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NC52684 | Spans the period from March 2018 when concerns relating to physical abuse by Child D's father and indicators of sexual abuse were raised until August 2020, when Child D's brother admitted sexually abusing his sister. Learning themes include: signs and indicators of child sexual abuse, especially the possibility of sibling perpetrated sexual abuse; cultural considerations; language barriers; the role of family members within a household; and no recourse to public funds. Recommendations for the Partnership include: seek assurance from partner agencies that work relating to child sexual abuse that has been undertaken in the past 12 months has been embedded; make information available to practitioners within their agencies for them to gain a better understanding of cultural considerations such as attitudes towards relationships, family life, child development and abuse; all agencies should ensure that the needs of children and families who have a limited understanding of English are met via the use of face-to-face interpreters, translated written material and additional time allowances for meetings; consider whether resources available to parents and families relating to safeguarding such as leaflets should be made available in additional language formats; seek assurance that existing tools such as genograms are utilised for the purpose of considering a family's composition and the roles that all family members play within a unit especially male family members; and make information available to practitioners within their agencies to improve their knowledge and skills in relation to the financial pressures and impact of having no recourse to public funds.
| Title: Child safeguarding practice review ‘Child D’. LSCB: Cambridgeshire and Peterborough Safeguarding Children Partnership Board Author: Cambridgeshire and Peterborough Safeguarding Children Partnership Board Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Cambridgeshire and Peterborough Safeguarding Children’s Partnership Board Child Safeguarding Practice Review ‘Child D’ 2022 2 Contents 1. Introduction .................................................................................................................................... 4 2. Methodology ................................................................................................................................... 4 3. Chronologies ................................................................................................................................... 5 4. Scope of the review......................................................................................................................... 5 5. Contact with family members ......................................................................................................... 5 6. Summary of Agency Involvement ................................................................................................... 6 Events of 2018..................................................................................................................................... 6 Significant event .............................................................................................................................. 9 Events of 2019................................................................................................................................... 10 Events of 2020................................................................................................................................... 13 7. Analysis.......................................................................................................................................... 17 1) How were risk and protective factors identified, assessed, and managed within the family? 17 Initial identification of risk ............................................................................................................ 17 Assessment of risk ......................................................................................................................... 18 Identifying other indicators of abuse: ........................................................................................... 19 No recourse to public funds .......................................................................................................... 19 Summary: identification, assessment and management of risk: .................................................. 20 2) How did practitioners and agencies that had contact with the family, work together to safeguard the children? .................................................................................................................... 21 Examples of good communication and inter-agency working: .................................................... 21 Areas for improvement: ................................................................................................................ 22 3) How well did agencies identify and respond to signs of child sexual abuse?........................... 22 Medical examinations ................................................................................................................... 22 Indicators of child sexual abuse: ................................................................................................... 23 Assessment of indicators of child sexual abuse: ........................................................................... 23 Barriers to disclosure: ................................................................................................................... 24 4) How was the voice of the child recognised and responded to within the case? ..................... 24 GP: ................................................................................................................................................. 24 Addenbrookes Hospital: ................................................................................................................ 25 Barriers to communication ........................................................................................................... 25 The child’s lived experience: ......................................................................................................... 25 Evidence of Child D’s voice: .......................................................................................................... 26 Family members: ........................................................................................................................... 26 5) Was Covid a factor in safeguarding and supporting Child D and did it have an impact on how agencies communicated and shared information? .......................................................................... 27 3 School non-attendance as a risk factor: ........................................................................................ 27 Presentation at A&E: ..................................................................................................................... 28 Inter-agency communication: ....................................................................................................... 28 6) Were there language or cultural barriers to the family accessing services and support? ....... 29 7) Can you identify any areas that you consider to be good practice? ........................................ 30 8. Summary ....................................................................................................................................... 31 9. Key areas of learning: .................................................................................................................... 32 Signs and indicators of child sexual abuse ........................................................................................ 32 Cultural considerations: .................................................................................................................... 32 Language barriers ............................................................................................................................. 32 The role of family members within a household .............................................................................. 33 No recourse to public funds .............................................................................................................. 33 10. Recommendations .......................................................................................................................... 33 Signs and indicators of child sexual abuse ........................................................................................ 33 Cultural considerations ..................................................................................................................... 33 Language barriers: ............................................................................................................................ 33 The role of family members within a household .............................................................................. 34 No recourse to public funds .............................................................................................................. 34 4 1. Introduction This report has been edited for publication to protect the identities of those involved. As a result personal information, beyond basic details, has not been included. Child D, her mother and two, now adult, siblings lived in a two-bedroom flat in the local area and had no recourse to public funds, the impact of which was significant financial pressure on Child D’s mother to support the family with her income. The family experienced overcrowding in their property which was located in an expensive part of the county, as well as social isolation. They frequently spent time in Europe with family members, including Child D’s father. Child D was assessed for additional learning needs and had an Education, Health and Care Plan. Child D’s mother may also have had additional needs. She was referred for assessment but was not felt to have met the threshold. This case was referred to the Child Safeguarding Practice Review (CSPR) subgroup for consideration of a rapid review by Cambridgeshire Constabulary in August 2020. The circumstances of the case were: Child D’s older brother provided details to the Police that he had been sexually abusing his sister, Child D. He was arrested and later sentenced to a custodial sentence for the abuse, having admitted numerous serious sexual and other assaults against her. There had been recurring and ongoing concerns with regards to the safeguarding and welfare of Child D since the family moved to Cambridgeshire. There had been previous concerns related to possible sexual harm and a medical examination was undertaken in April 2018 but no findings were noted. There were concerns relating to neglect, physical abuse perpetrated predominantly by her father and emotional harm, as well as consideration of Child D’s additional vulnerabilities due to cognitive and learning needs and the impact of English being a second language. Child D was made the subject of a Child Protection Plan in March 2018. 2. Methodology Following the CSPR referral a rapid review was undertaken. The case was discussed at a CSPR Subgroup meeting in September 2020 and it was agreed that the case met the criteria for a local CSPR. Relevant agencies were required to complete a “key events” chronology, which once completed, were combined into a single composite chronology. The chronology was used as the basis for a virtual multi-agency information gathering event with the chronology authors from the relevant agencies. Those present at this meeting were asked to consider the information within their own agency’s chronology and to participate in an in-depth case discussion regarding the safeguarding issues surrounding Child D in the timeframe of the review, which is outlined below. The aim of this discussion was to extract learning and good practice relating to Child D in order that practice might be improved across the safeguarding children workforce. A multi-agency practitioner information gathering event was also held which took place virtually and included those practitioners who had worked with Child D and her family both 5 during and after the timescale of the review. The aim of this meeting was to explore and understand the context of practice within the timescale of the review as well as considering questions posed within the terms of reference from the practitioners' perspectives. These processes have been the vehicle used for the review process alongside discussion and evaluation of this report for accuracy. As such the analysis included within the report has been either provided by or confirmed with this multi-agency group of author’s and practitioners. 3. Chronologies The following agencies were required to complete a chronology on an agreed template: Cambridgeshire Constabulary Cambridgeshire Children’s Social Care Cambridge University Hospitals NHS Foundation Trust: Addenbrookes Hospital Cambridgeshire Education Safeguarding Service SEND (Special Educational Needs and Disabilities) Service 0-25 Cambridgeshire Community Services NHS Cambridgeshire and Peterborough Integrated Care Board Sexual Assault Referral Centre (The Elms: Mountain Healthcare) 4. Scope of the review This review aims to consider those events specifically related to safeguarding within the time period from: 1st March 2018, the date that a strategy discussion was held as a result of concerns relating to physical abuse by Child D’s father and indicators of sexual abuse. An accumulation of concerns which had been shared with Children’s Social Care by Child D’s school were considered and a decision made for a section 47 inquiry to be carried out. To August 2020, when Child D’s brother made the disclosure of abuse. 5. Contact with family members As with all child safeguarding practice reviews, it is important to gain the views of the families of the subjects of these reviews. Attempts have been made to communicate with Child D’s mother via letter and text message using translation services. Whilst some of these attempts were responded to, the majority have been unsuccessful. Attempts to speak with Child D have not been made directly as it was felt by those having supported her most recently, that this would not be in her best interests. 6 As a result, neither Child D’s nor her mother's voice have been directly captured as part of this report and it is recognised that this is missing. Multi-agency records and practitioner feedback has been used to give some indication of their lived experiences through the timeframe of the review, as well as the inclusion of Child D’s voice via the Investigating Officer, who led the criminal case against her brother. Consideration has been given to making contact with Child D’s brother as part of this review, but it was felt that without Child D’s or her mother’s view this would not offer a balanced perspective. It has been agreed however, that the appropriate family members will be notified in writing of the completion of this report should they wish to obtain a copy. 6. Summary of Agency Involvement Events of 2018 According to Police and Children’s Social Care records, a strategy discussion was held on 1st March 2018 following Child D making a disclosure at school of physical abuse by her father. Records of the meeting show that an accumulation of concerns were considered which had been recorded by school and an after-school club, as well as concerns which had been raised in November 2017 by school resulting in a Strategy Discussion between Police and Children’s Social Care at that time, where it was agreed that a single agency section 47 enquiry should be undertaken by Children’s Social Care and an Initial Child Protection Conference should be held. It is not clear why an immediate medical examination was not considered at this point. On 8th March 2018, Child D attended her GP with her mother. The GP conducted a physical examination and found no visible injuries. The GP shared details of this visit with Children’s Social Care and the Police on the following day. A discussion was held in the multi-agency safeguarding hub (MASH) on receipt of this information on 9th March 2018 as to whether a child protection medical examination should be offered to Child D. The Social Worker spoke with the GP on 12th March and it was agreed that Child D should be seen by her own GP again the following day as she was still experiencing pain, representing another missed opportunity to refer Child D for a medical examination. It is unclear to what extent the GP was involved in the discussions on 9th March. On 12th March 2018 Child D told school staff that she was still in pain. The school staff informed the allocated Social Worker who spoke with Child D’s mother on 14th March and advised Child D’s mother to take Child D back to the GP. It does not appear that the potential indicators of sexual abuse, as indicated by the symptoms Child D described, were recognised as such. On 20th March 2018 Children’s Social Care record that Child D had not been taken to the GP by her mother despite her agreeing to do so. On the same date Child D was assessed by an Educational Psychologist in recognition of her additional needs. The outcome of this assessment was an Education Health and Care plan which is detailed later in the report. Child D reported again to school staff on 23rd March 2018 that she was still experiencing pain. School records evidence that this was communicated to the Social Worker and then discussed 7 at the Initial Child Protection Conference held on 28th March 2018. The Designated Safeguarding Lead from Child D’s school and a School Nurse were present. According to the records from Child D’s school, both of these practitioners noted a number of indicators of child sexual abuse. A number of other vulnerabilities were discussed at this meeting including additional educational needs, language barriers not just for Child D but also for her mother, domestic abuse, overcrowded housing and unexplained injuries. It was agreed, according to school records, by all professionals, that Child D would be supported under a Child Protection Plan for physical abuse as this appeared to be the most significant risk at that time. Records from Children’s Social Care suggest that indicators of sexual abuse were recognised within the plan and a child protection medical was requested to take place to explore this possibility. This was requested the following day and arranged for 5th April 2018. Child D’s sister was 17 years old and it was decided that she should be supported under a Child in Need Plan as it was perceived that the risk of physical abuse to Child D’s sister was not as high as she was not displaying the same indicators of abuse. As Child D is the subject of this review, the circumstances surrounding her have been the focus of this report, however it is acknowledged that Child D’s sister may have been vulnerable or subjected to abuse in her childhood also. During a home visit by the allocated Social Worker on 4th April 2018, a bruise to Child D was disclosed. The Emergency Duty Team was notified, which suggests the visit took place outside of office hours. No other action is recorded but the medical examination at the Sexual Assault Referral Centre (SARC) was due to take place the following day. Child D attended the SARC on 5th April 2018. Bruising was noted to various areas of Child D’s body but there were no abnormal genital findings noted. Sexually transmitted infection screening was refused by Child D’s mother. Later the same day, Child D’s Social Worker contacted her GP to request an appointment as Child D was still experiencing pain and required assessment for treatment, as suggested by the Doctor who conducted the examination at the SARC. On 6th April 2018 the Social Worker requested a strategy discussion with Police which took place in the MASH relating to the unexplained bruising to Child D observed on 4th April. It was agreed that Child D should have a child protection medical, but this appears to have been unnecessary given the analysis provided within the medical report produced by the Forensic Medical Examiner at the SARC. On 10th April 2018 Child D attended the GP with her mother. The appointment had been made with a female GP, the Social Worker attended, and a telephone translation service was used. An examination and tests were undertaken but no evidence of a cause for her symptoms could be found. Child D’s own words are well recorded in the records for this appointment but it is not clear whether the GP was made aware of Child D’s learning needs. Children’s Social Care records for 16th April 2018 include a discussion between the Social Worker and Child Protection Chair regarding the bruising noted on 4th April. Agreement was then sought from a Senior Manager for a Legal Planning Meeting, to determine whether the threshold for initiating care proceedings had been reached. This decision was based on the concerns that had been raised at the Initial Child Protection Conference, and particularly the bruising that had been observed on 4th April. This was agreed by the manager but there is no evidence within Children’s Social Care records that any further action took place. This is a significant missed opportunity to explore professional’s concerns further and impress upon Child D’s mother the level of risk that was perceived. On 3rd May 2018, an Education, Health and Care Plan assessment was agreed. 8 A Review Child Protection Conference was held on 5th June 2018, and it was agreed that Child D should remain on a child protection plan under the category of physical harm. Analysis provided within the chronology submitted by Children’s Social Care suggests that those in attendance at the meeting remained mindful of the possibility of Child D having experienced child sexual abuse, but it is clear from the records that the focus of professional's concerns was on the risk of physical abuse to Child D from her father and the contact that she had with him. The previous consideration of seeking legal advice due to the level of concern does not appear to be referenced at this meeting, nor is it clear whether any previous interventions of support had been achieved. There is no suggestion in the records that any lack of progress was challenged by those present. On 14th June 2018 there is a record within the school chronology of inappropriate behaviour by Child D at school which was recorded to be shared at the next Core Group meeting. On both 19th and 26th June, the school raised concerns with Children’s Social Care regarding a lack of supervision being experienced by Child D at home and then on 2nd July, the school again contact Children’s Social Care with concerns of inappropriate behaviour being displayed by Child D at school. It is not clear what action, if any, as a result of these concerns was taken. The next Core Group meeting was held on 25th September 2018, but these issues do not appear to have been raised and as such a further opportunity to explore Child D’s behaviour and to revisit the potential indicators of child sexual abuse, was missed. Child D attended the GP again with her mother and older sister on 10th July 2018. The GP advised plenty of fluids and a cautious diet. There was no interpreter available for this appointment, so the GP wrote advice on a note for Child D and her mother to take home. Again, on 13th July 2018, school records note concerns relating to a lack of supervision of Child D at home, after Child D reported to school staff that she had been left alone in the flat by her brother. This was a missed opportunity for the Core Group members to consider what role Child D’s brother might play in caring for, or at least supervising, Child D in her mother’s absence. On 27th July 2018, the records for Children’s Social Care note that advice was received from the Educational Psychology service relating to Child D’s communication needs. On 15th October 2018, the Special Educational Needs and Disabilities Assessment Team records show that an Education, Health and Care Plan (EHCP) was issued in recognition of Child D’s significant additional learning needs1. On 22nd October 2018, during case supervision the allocated Social Worker suggested that Child D could be stepped down from a child protection plan to support under child in need processes. Child D had expressed to the Social Worker that she was happy at home, felt ok about her brother and had not been left alone with her father during the holidays. The Social Worker felt that this was an indication that the risk of harm had reduced. Education records for 12th November 2018 show that bruising was noted to Child D on this date which did not match the explanation she gave for the injury. The allocated Social Worker was informed by the school but there is no corresponding information in Children’s Social Care records, demonstrating another gap in the recording in relation to this child. Equally there is no record that the school had chased Children’s Social Care on this occasion to determine what action they had taken. 1 This time span between the assessment and final ECHP plan is in line with Government guidance: https://www.gov.uk/children-with-special-educational-needs/extra-SEN-help 9 Child D attended her GP again with her mother and brother on 15th November 2018. The GP advised gastroenteritis. Significant event There are multiple entries in the combined chronology for the 19th of November 2018 from Police, Education and Children’s Social Care. Injuries are noted on Child D while she was in school but the staff member was unclear as to how the marks might have been caused. Child D could not provide an explanation for the injuries. There is insufficient detail within any of the agency records to be able to determine whether questions were being asked of Child D in a way that was commensurate with her learning difficulties. First aid was provided in school and the allocated Social Worker was informed. A strategy meeting was then held between the Police and Children’s Social Care and a single agency section 47 enquiry by Children’s Social Care and a child protection medical were agreed. An appointment was made with the GP later the same day because it was judged that immediate treatment for the injuries may be required. An opportunity was missed here to find out whether Child D could have had an immediate child protection medical with a Paediatrician, negating the need for her to be seen twice. Child D attended the GP appointment with her mother and the allocated Social Worker. Child D was unable to provide a clear explanation for the injuries. GP records are very detailed and include notes of Child D’s behaviour and the communication between Child D and her mother, in their first language. The GP undertook an examination of Child D’s injuries and her mother suggested, via a telephone translation service that the injuries were self-inflicted, although Child D herself denied this. The practice nurse dressed the injuries and provided spare dressings, but Child D declined further examination and requested a female doctor. Following the appointment, the GP sought advice from colleagues and arranged an appointment at Accident and Emergency with a Paediatric Registrar at Addenbrookes Hospital. Child D’s mother agreed to attend with Child D along with the Social Worker. Information within the combined chronology suggests that Child D and her mother did not attend this appointment as they were contacted by Addenbrookes to advise them to attend Hinchingbrooke Hospital on the following day instead. It appears that they did so and Child D was examined but that the details of this examination were not shared with the GP or Children’s Social Care. Had an immediate child protection medical been arranged, Child D and her mother would have only been required to attend one appointment and information sharing following that appointment might have been improved. Cambridgeshire Community Services records for the Community Paediatric service show that Child D was seen by a Consultant Community Paediatrician relating to the injuries on 20th November 2018. The Paediatrician noted that Child D’s injuries were likely to have been a combination of accidental and non-accidental injuries as well as possible self-inflected injuries. Child D‘s own explanation had been inconsistent. All injuries were photographed, and the Paediatrician also noted concerns of neglect. It is not clear from the combined chronology whether the details of this appointment were shared with other agencies or whether any action was taken. The following day, 21st November 2018, Child D made a comment to school staff which was then verbally shared with the allocated Social Worker but does not appear to have been recorded within Child D’s records. This comment should have triggered curiosity as to Child D’s relationship with her brother, and again the role he played in her care. On 22nd November 2018 there is a record of communication between the Social Worker and school relating to the injuries noted on 19th November to Child D and information that Child D 10 had said she was being bullied at school. It is around this time that a referral was made by the school to a Play Therapist from Cambridgeshire Women’s Aid. This referral was possible because Child D and her mother had previously resided in a women’s refuge. A Review Child Protection Conference was held on 28th November 2018 and all those present agreed that Child D should remain on a child protection plan for neglect. The concerns at this time were that Child D was not sufficiently supervised at home, her mother had not supported her to gain medical treatment and that Child D’s emotional wellbeing was suffering. The risk of physical harm was perceived to have reduced, despite the Paediatrician’s conclusion on 20th November that Child D may have been displaying non-accidental injuries. There does not appear to be consideration of any ongoing risk of sexual abuse. Child D attended the GP on 10th December 2018 but it was not noted who had attended with Child D. The following day, 11th December, the GP attempted to gain an update from the accident and emergency appointment arranged on 19th November, a demonstration of the GP’s level of concern. It was concluded that Child D had not been taken to the appointment. A number of missed opportunities can be noted throughout 2018, to explore Child D’s lived experience and the structure of her family. Additionally, during this period there were missed opportunities to arrange the SARC medical before this took place on 5th April and a further missed opportunity for acute health intervention via a child protection medical for the injuries in November 2018. Assessment of her education, health and care needs concluded that she had significant learning needs but there is no clear evidence of how practitioners working with her factored these needs into the contact they had with Child D. A lack of clarity in the records relating to health involvement via Core Groups and Child Protection Conferences, as well as inconsistent information sharing with the GP can also be found in this period. Events of 2019 On 1st January 2019 is it noted in the Children’s Social Care records that statutory visits were not being carried out according to procedures in this case because the home environment had not been observed and an understanding of Child D’s current home situation and potential risks could not be gained. This had resulted from Child D’s wish to see the Child Practitioner at school rather than in her home because of the limited space within the property. Whilst it was correct that Child D’s wishes were taken account of, home visits should have been carried out in addition to seeing Child D in school. On 4th January 2019, a School Nurse from Cambridgeshire Community Services reviewed the relevant records having received a copy of the minutes of the review child protection conference on 28th November 2018. At this point in time the School Nurse was an information only member of the Core Group, which could be considered as a missed opportunity for consistent health oversight of this case given the level of acute health involvement. However, this must be balanced with the pressures to this service at the time. The School Nurse then contacted the allocated Social Worker asking to be invited to the next Core Group meeting and to suggest that a health assessment be carried out, based on the concerns relating to self-harm and emotional health contained within the child protection plan. The GP contacted the allocated Social Worker on 14th January 2019 and was informed that Child D and her mother had been asked to attend Hinchingbrooke hospital on 20th November in place of the appointment arranged by the GP at Addenbrookes. The Social Worker had taken Child D and her mother to this appointment, but the GP was unable to gain details of the 11 appointment from the hospital despite making a number of attempts to contact them. It is unfortunate that the GP did not escalate this as the information may have added to the picture of Child D’s lived experience for the GP. Concerns were raised by the school on 6th February 2019 when Child D made a comment relating to her father’s behaviour towards her mother. This was shared with the Designated Safeguarding Lead in school but does not appear in Children’s Social Care records. Child D began working with the Play Therapist in school in February 2019. A health assessment was completed in school by a School Nurse with Child D on 7th March 2019. Child D’s mother was not present for the assessment. Child D described that she would have liked her own bedroom and did not believe that she could read or write as wll as her peers. Child D’s voice is described in the records as being captured throughout the assessment and the School Nurse used a variety of methods to engage Child D and gain her views. On 14th March 2019 there is evidence in the combined chronology of communication between Cambridgeshire Community Services and Children’s Social Care which confirmed that Child D’s older sister, her older sister’s husband and their baby, Child D’s niece were living at the same address as Child D, her mother and her brother. The baby, Child D’s niece, was later subject to an Early Help Assessment to consider her own needs and that of her parents. Child D attended the GP with her mother on 25th March 2019 for an emergency appointment. Observations and an examination of Child D were both normal. The GP booked an appointment for the following day with a female GP and an interpreter. Given the previous information both shared with the GP and observed through appointments with Child D, there was a missed opportunity here to pick up on a further possible indicator of child sexual abuse. Child D and her mother returned to the GP the following day, 26th March 2019. There is very good recording by the GP for this appointment, including observations of a respectful, comforting and supportive response from Child D’s mother towards her. Direct questions were asked by the GP of Child D relating to the potential causes for the symptoms she was experiencing but there is insufficient detail to determine whether these questions were appropriate to Child D’s level of understanding. Both Child D and her mother denied any concerns, but Child D was not seen alone. On 2nd April 2019, Child D made some concerning comments to a music therapist she had been seeing at school. This information is recorded in the school records as having been shared with the Social Worker. Unfortunately, despite several attempts to contact the company offering this service, no further information has been obtained. Child D was seen in her home on 17th April 2019 by a Health Visitor who was attending to see Child D’s sister and her sister’s baby. The Health Visitor noted Child D’s appearance and recorded that she had not seen any new bruises or injuries, a good demonstration of following the ‘Think Family’ approach. On 30th April 2019, according to the school records, Child D made further comments to the music therapist in school. This was communicated to the allocated Social Worker. A review of Child D’s Education, Health and Care Plan was undertaken on 22nd May 2019. At that time, Child D’s school was exploring a specialist placement for Child D with increased funding. It is also mentioned that the housing needs of the family were being assessed and that Child D would remain open to Children’s Social Care whilst this was ongoing. 12 A review Child Protection Conference was planned for 23rd May 2019, but the meeting was adjourned due to a lack of information provided by the new Social Worker to allow for consideration of both progress against and the impact of the child protection plan at the conference, despite the fact that the Social Worker was suggesting that Child D could be supported under a child in need plan rather than a child protection plan. It was also noted that the conference could not go ahead without an interpreter for Child D’s mother having been arranged. On 24th May 2019 Child D told the Play Therapist working with her at school of an unusual punishment used by her mother towards her. The allocated Social Worker was informed and Education records also suggest that a discussion with mum took place. When this event was explored with school staff, they spoke of mum’s shock and disbelief that Child D had made this disclosure. The review Child Protection Conference which had been due to take place on 23rd May, was held on 29th May 2019. Children’s Social Care records state that a representative from Child D’s school and the allocated Social Worker attended this meeting and it was agreed that Child D could be supported under a child in need plan. It was discussed that no further injuries had been reported and Child D’s mother had sought appropriate medical treatment for her when it had been necessary. Child D was not in contact with her father which it was felt reduced the risk of physical harm. Some areas of support remained but it was agreed by both agency representatives that these could be addressed within a child in need plan. The School Nurse had been unable to attend due to the meeting having been rearranged but had sent a report for the meeting. The report however had not included an opinion as to whether Child D should remain on a child protection plan or step down to a child in need plan and without this information, it cannot be evidenced that this meeting represented multi-agency decision making. The GP should have been invited to this meeting given the involvement she had had with Child D. Again, on 30th May 2019, the Conference Chair raised concerns to Children’s Social Care managers. These concerns were relating to the ‘quality of reporting and a lack of multi-agency oversight.’ There is no further detail relating to these concerns nor a recorded response. Child D attended the GP on 6th June 2019 with her mother. A telephone translation service was used. Child D described injuries which were itchy. She gave multiple explanations and the GP completed an examination and discussed concerns with Child D’s mother that the injuries were unexplained. The GP completed a referral to Children's Social Care and informed Child D’s mother of this. Comprehensive recording was completed again by the GP, which included observations of ‘good attachment and rapport between daughter and mum.’ The referral completed by the GP is recorded on Child D’s record held by Children’s Social Care but there is no record of a response. On 27th June 2019 a referral was made to the Community Paediatric Service for a review of the Education Health and Care Plan in place for Child D as it was felt that the plan in place was not adequate to meet her needs in school. A review was undertaken, and the result was that no additional medical diagnosis could be found, but genetic testing for Child D would be offered. The following day, 28th June 2019, Child D attended the GP with her mother: this was the fourth attendance for related complaints in the time scale of this review. There is good recording of behavioural observations within the GP’s records, and it was advised that Child D might have been suffering from growing pains. No other concerns were noted. It appears 13 from the records that Child D was seen by the same GP as on at least some of the previous occasions, who would therefore have been aware of Child D’s history. Child D’s case was reallocated by Children’s Social Care on 29th August 2019 to a Child Practitioner who spoke Child D’s and her mother’s own language in order to improve communication with Child D’s mother, who was unable to speak English. Until this point interpreters had been used for interactions with the family by Children’s Social Care. The practitioner made visits to Child D at school, as well as at home where it was noted that Child D was sharing a room with her mother. Contacts with Child D and her mother increased, according to the combined chronology, following this change of practitioner to complete the work within the child in need plan. A child in need meeting was held on 31st October 2019 and concerns were raised that Child D’s mother might be the victim of domestic abuse. She was offered support from Cambridgeshire Women’s Aid as well as support to obtain legal advice in relation to custody of Child D. Given the previous perceived risk of physical abuse to Child D from her father, there should have been consideration of this risk based on her mother’s injury. On 19th November 2019, Child D attended the GP with her mother for a respiratory related complaint. No concerns were noted from the examination but a follow up appointment was made to allow Child D and her mother to monitor her symptoms at home. Child D and her mother returned to the GP on 3rd December 2019. Monitoring of Child’s symptoms had been completed at home and the GP noted that the results were normal. Child D became upset but could not explain why. Despite offers from the GP, she did not wish to be seen alone or with her older sister. A further appointment was offered. On 13th December 2019, Child D was seen in school with an injury. First aid was provided in school, but it was felt that the injury required medical attention, so Child D’s mother was contacted and asked to take Child D to see the GP. Children’s Social Care were also informed and contacted Child D’s mother to reiterate the need for her to take Child D to the GP. Child D and her mother were seen by the GP later the same day. Child D gave an account of how she had sustained the injury, but her mother had given the school an alternative explanation. The GP noted that communication with Child D’s mother had been difficult due to a lack of interpreter. The wound was dressed by a nurse and Child D gave the same account to the nurse as she had given to the GP. The concerns communicated by the school at the practitioner's information gathering event were that Child D had been without supervision, which they believed would have presented a risk of harm to her, given her level of cognitive functioning. A strategy discussion at this point may have helped to gain a better understanding of this potential risk. It appears that this injury and the potential lack of supervision which might have resulted in the injury were give insufficient weight in the context of the identified risks to Child D. Events of 2020 Child D told a member of staff at school on 7th January 2020 that her father had been at the family home. Child D’s mother was spoken to but did not agree that Child D’s father was staying with them. It is recorded by the school that Children’s Social Care had been due to close the case, but it remained open based on this information. On 8th January 2020 Child D’s father attended one of Children’s Social Care’s offices and informed staff that he was not being permitted contact with Child D by Child D’s mother, but that Child D had been in contact with him. When the Child Practitioner saw Child D, she said 14 that she wanted to live with her father because she would not have to share a bedroom. Children’s Social Care planned to assess Child D’s father for his suitability to have contact with her at Child D’s request. Child D attended the GP with her mother on 14th January 2020 for a review following the last appointment. Child D reported breathlessness to the GP, but as Child D was acting as the interpreter for her mother, the GP recorded that it was difficult to gain Child D’s mother’s perspective. The GP asked about Child D’s previous presentation with an injury. There is again good recording by the GP of Child D’s own words and behaviour, particularly when the GP explained that Child D’s physical symptoms may be anxiety related. Child D became upset at this suggestion and despite offers of support by the GP, Child D left the appointment upset. On 17th January 2020, the GP contacted the Child Practitioner to discuss Child D’s injury, sustained in December 2019. It is unclear from the records what the delay had been in making this contact. The GP explained that her concerns related to the inconsistent explanations for the injury. The Child Practitioner informed the GP of the family's current situation in relation to Child D’s father and the impact that contact with him had had on the whole family, as well as the suggestion of Child D attending a specialist educational placement, which had been distressing for Child D. The GP and Child Practitioner agreed to share information to support the family. A child in need meeting was held on 12th February 2020, attended by the school and SENDCo (Special Educational Needs and Disabilities Co-ordinator). It was agreed at this meeting that the case could be closed with no step down to early help as the tasks within the child in need plan had been completed. However it does not appear, again, that this meeting was quorate. The GP was not invited and could perhaps have added to the picture of Child D’s lived experience having only seen Child D a month earlier. On 23rd March 2020, the UK went into a nationwide ‘lockdown’ of restrictions to activities and travel because of the Covid-19 pandemic. These restrictions included the closure of schools to all pupils with a number of exceptions. These exceptions included children open to Children’s Social Care and those with an Education, Health and Care Plan. On 25th March 2020 school records show that due to Child D’s Education, Health and Care Plan, she was eligible to continue attending school. However, Child D’s mother expressed that she wanted Child D to remain at home due to fears for Child D’s health. Weekly telephone calls were made to Child D’s mother during the period of school closure but only three of these calls were successful and Child D was spoken to once. School records suggest that Child D expressed that she would have liked to have returned to school but despite repeated offers of a school place, this was declined. The statutory annual review of Child D’s Education, Health and Care Plan took place on 16th June 2020. This was a virtual meeting which neither Child D nor her mother attended. Child D was due to start her secondary education in September 2020 and a specialist placement was agreed based on her level of additional needs. On 7th July 2020, a home visit to Child D’s address was undertaken by staff members from Child D’s school due to the infrequent contact that had been achieved and a lack of online learning being completed by Child D. It is unclear how Child D was being expected to complete the online learning nor whether she would have been eligible for a school funded laptop in order to access this. Child D was asleep when staff arrived at the address. Her brother woke her for what is described as a ‘short conversation’ and it was not recorded who else was present at the address. 15 Significant event Child D and her mother attended the accident and emergency department of Addenbrookes hospital on 3rd August 2020. During an examination, a mark was noted on Child D’s arm, a potential indicator of an assault. Nursing staff recorded a number of concerns relating to Child’s presentation and behaviour. Child D was also referred to the ear nose and throat clinic. Multiple bruises and other marks on Child D’s body were all noted in detail. A referral to Children’s Social Care was completed, samples taken for testing and antibiotics prescribed as well as the ear, nose, and throat appointment. Child D and her mother were in the accident and emergency department for several hours on this date. There is no suggestion in the records that Child D was seen alone. There was a missed opportunity for a Strategy Meeting here which would have allowed for immediate consideration of the potential risks, as well as involvement from the Police to determine whether the mark should be further investigated. One safeguarding strategy would have been to admit Child D to a ward within the hospital but given the context of the COVID-19 pandemic this may not have been possible or deemed to be an appropriate course of action on balance. Children’s Social Care records show that an initial referral was received from Addenbrookes on 3rd August. Child D was reopened to the original team for a duty visit, a Social Worker was tasked with seeing Child D within five days and completing a child and family assessment in line with section 17 processes2. Additional information was received by Children’s Social Care from Addenbrookes on 6th August 2020 relating to Child D’s attendance on 3rd August. Her presentation whilst in the hospital was described as ‘concerning’. The following day, 7th August 2020, a home visit was undertaken by a Social Worker to Child D’s home. Child D, her mother, and brother were present. Child D was not seen alone. She stated that she did not remember the mark observed in hospital four days earlier and her mother and brother described Child D as a child who bruised easily. No safeguarding concerns were raised as a result of this visit and a note was recorded for the case to be picked up on the following Monday: 10th August 2020. There is no further activity recorded on the case file until 17th August. Significant event On 17th August 2020 Child D’s older brother approached Police. Using a telephone translation service, he confessed to sexually abusing his younger sister, Child D. He was arrested and interviewed and following multiple contacts with Child D in relation to the information provided by her brother, an achieving best evidence (ABE) interview3 was conducted by Police Officers in the presence of an intermediary. 2 The Children Act 1989 Section 17 of the Act places a general duty on all local authorities to 'safeguard and promote the welfare of children within their area who are in need. ' Basically, a 'child in need' is a child who needs additional support from the local authority to meet their potential. https://www.scie.org.uk/publications/introductionto/childrenssocialcare/legalandpolicycontexts.asp#:~:text=The%20Children%20Act%201989&text=Section%2017%20of%20the%20Act,authority%20to%20meet%20their%20potential. 3 Achieving Best Evidence in Criminal Proceedings Guidance on interviewing victims and witnesses, and guidance on using special measures March 2011 16 Children’s Social Care records from the same date show a referral from the Police in relation to the above incident, which was recorded as a critical incident. A multi-agency Strategy Discussion was held, a joint section 47 enquiry was agreed and a medical assessment for Child D at the Sexual Assault Referral Centre (SARC) was planned. Records from the following agencies also include details of this meeting: Cambridgeshire Community Services, The Elms Sexual Assault Referral Centre (SARC) and Addenbrookes hospital. The Strategy Discussion included consideration of Child D’s one year old niece. An examination was booked at the SARC for 20th August 2020 and discussion also included consideration of Child D’s learning difficulties, historic domestic abuse concerns, the recent attendance at Addenbrookes hospital and physical abuse concerns. Child D did, later, make disclosures corroborating the information her brother had provided. https://www.cps.gov.uk/sites/default/files/documents/legal_guidance/best_evidence_in_criminal_proceedings.pdf 17 7. Analysis This section of the report aims to answer the following questions as posed within the Terms of Reference: 1) How were risk and protective factors identified, assessed, and managed within the family? 2) How did practitioners and agencies that had contact with the family, work together to safeguard the children? 3) How well did agencies identify and respond to signs of child sexual abuse? 4) How was the voice of the child recognised and responded to within the case? 5) Was Covid a factor in safeguarding and supporting Child D and did it have an impact on how agencies communicated and shared information? 6) Were there language or cultural barriers to the family accessing services and support? 7) Can you identify any areas that you consider to be good practice? 1) How were risk and protective factors identified, assessed, and managed within the family? Initial identification of risk The risk of sexual abuse to Child D was first identified on 22nd November 2017 when Children’s Social Care contacted Police to request a Strategy Meeting to discuss concerns from her school relating to possible indicators of abuse towards Child D. Attempts are recorded to have been made to contact Child D’s mother, but these were not successful. Additionally, there were previous concerns of physical abuse and emotional abuse, as well as concerns of inappropriate behaviour. The Strategy meeting involved Police and Children’s Social Care. There does not appear to have been a representative from health present. The outcome was for a single agency section 47 enquiry to be completed but no further detail has been explored as this event fell outside of the timescale of the review. There is evidence within agency records that these factors were discussed again on 1st March 2018 when a further Strategy Discussion was held. As a result of these discussions, it was agreed that an Initial Child Protection Conference should be convened. It is not clear why Child D had not been subject to a Child Protection Plan in the interim period. There was no evidence that protective factors were identified or discussed within this meeting. In addition, very few protective factors were identified by those agencies who had been involved in working with the family which suggests a lack of consideration of any strengths relating to Child D and her family or what was going well for them. A medical examination at the Sexual Assault Referral Centre (SARC) was arranged for 5th April 2018 which Child D attended with her mother. There is no indication within records of why the examination was not arranged until after the Initial Child Protection Conference. The examination was discussed in detail at the author’s multi agency information sharing session and it was agreed that it was unusual for a child to request to be seen alone, as Child D did. 18 It appears that that staff were concerned of the impact on Child D of agreeing for her to be examined without her mother present to support her, although a Crisis Worker would have been present. Child D did agree to have her mother present when this was explained to her. The result of the examination was that no abnormal genital findings were noted. The medical report produced by the Forensic Medical Examiner highlighted the possible indicators of sexual abuse in detail, as well as including: ‘A high proportion of children who have been sexually abused do not have genital or anal injuries at examination.’ The outcome of this examination appears to be significant in terms of the way the risks to Child D were perceived going forwards as the focus of multi-agency intervention shifted from possible sexual abuse to physical abuse. Learning point: Practitioners should feel confident to explore and fully record each of the presenting risk factors or indicators of abuse for a child or family and consider each of these indicators individually and as a collective when assessing risk and planning interventions. There was agreement from the multi-agency group that working with families where there are suspicions of sexual abuse but an absence of either disclosures or physical evidence, presents significant challenges and that this was particularly true for working with Child D and her family where there did not appear to be an obvious perpetrator. The concerns for Child D resulted in the Child Protection Chair and Social Worker discussing the case on 16th April 2018 and making the decision to seek agreement for a Legal Planning Meeting. However, records suggest that this meeting was not convened which was a missed opportunity for escalation of concerns at an early stage in supporting the family. There is no indication of why this meeting did not take place. Equally there is no evidence that the CP Chair escalated the fact that this action had not been progressed. Since the timescale of this review Children’s Social Care have added safeguards to practice which include a ‘Legal Tracker’ which facilitates the monitoring of such discussions and aims to decrease the likelihood of the circumstances observed in this case reoccurring. Learning Point: Practitioners must feel able to escalate a lack of progress or action against agreed outcomes within their own agency. They should be aware of relevant single agency procedures for raising such concerns. It appears that there was some early identification of possible sexual abuse, and certainly the risk of physical abuse was recognised and documented. However, the early recognition of sexual abuse was quickly overshadowed by the perceived indicators of physical abuse. Assessment of risk When the period following the examination at the SARC was discussed, it was agreed that whilst the risk of sexual abuse to Child D was recognised and discussed, it was not considered by those involved who might have been perpetrating this abuse. Professionals believed that Child D had ‘difficult’ relationships with both her brother and father: she was described as fearful of her father, but it was suggested that the idea of Child D’s brother posing a risk of sexual abuse was ‘almost unthinkable’ and as a result the risk he might have posed does not appear to have been considered. It was unclear at this time what role the brother played in the family, specifically how much time he spent with Child D and what their relationship was like. At the point at which it became clear that Child D’s brother was living with the family, this is something that should have been explored with Child D and her family members to allow professionals to gain a better understanding of the family’s situation and their relationships with one another. This might have supported a more thorough assessment of the potential risk to Child D. Research by the 19 Centre of Expertise on Child Sexual Abuse suggests that sibling perpetrated sexual abuse is likely to be ‘the most common form of intra-familial sexual abuse’ but that there is a ‘comparative lack of disclosure’ of this type of sexual abuse.4 Learning point: It is therefore an area of learning for agencies across the children’s workforce to be alert to the possibility of sibling perpetrated sexual abuse when working with families where child sexual abuse indicators have been identified but there is a lack of clarity relating to the possible perpetrator of abuse. This observation is also applicable to the risk of physical abuse as it appears from early on that Child D’s father was the perceived perpetrator following Child D’s disclosures and none of the other family members including her brother were considered, suggesting the possibility of confirmation bias and a lack of professional curiosity as to an alternative hypothesis. Identifying other indicators of abuse: Following Child D’s presentation at the GP on 19th November 2018 there are concerns recorded in the chronology that the injuries observed by school staff, and then the GP, might be self-inflicted, as well as Child D telling school staff that she was being bullied. Again, whilst there is recognition of the risks in relation to Child D’s mental health, it is unclear what support was offered to her, beyond monitoring her well-being in school, at this stage. It does not appear that the possibility that Child D was self-harming was responded to appropriately, nor is there evidence of any consideration of why she might have been doing so. There is evidence of consideration of risk from the chronology on 6th February 2019. Child D mentioned to a member of staff within school that she was not allowed to see her father because he was abusive towards her mother. Whilst this information was to be shared at the next Core Group meeting, there does not appear to be recognition of the impact of Child D’s experience of the domestic abuse between her parents or the lack of contact she was having with her father. Rather, the focus of support is on the mitigation of risk. In March 2019 there is mention in the chronology of Child D’s older sister’s partner living at the family address. The family were already living in overcrowded conditions and the impact that another adult moving in might have had on the family dynamics and the pressure on each person created by a lack of physical space and privacy does not appear to have been considered at this stage. There is mention later in the chronology of support relating to housing being offered. Child D was no longer subject to a Child Protection Plan on 29th May 2019 and was then being offered support under the child in need (section 17) framework. This appears to be in contradiction to the information shared on 24th May 2019 relating to Child D’s disclosure of physical punishment by her mother. School staff spoke of Child D’s mother’s shock and surprise when this event was discussed with her and it was felt at the time that this disclosure from Child D did not suggest a risk of harm to Child D from her mother but there was a lack of professional curiosity as to the reasons that Child D might have made such a disclosure and whether or not someone else could have perpetrated the punishment. No recourse to public funds: 4 ‘Sibling sexual abuse: a knowledge and practice overview’ Yates and Allardyce 2021 https://www.csacentre.org.uk/csa-centre-prodv2/assets/File/Sibling%20sexual%20abuse%20report%20-%20for%20publication.pdf 20 On 13th July 2018, there were concerns raised by Child D’s school pertaining to a lack of supervision by Child D’s mother at home due to mother’s working patterns. This would have been an opportunity to explore with Child D’s mother and the older siblings, what safeguards were in place for Child D when her mother was working, and Child D was not in school. Child D’s mother had no recourse to public funds and her lack of spoken English would likely have limited the employment options available to her. It is unclear to what extent Child D’s father offered any financial support, as he lived predominantly in Europe. As a result, Child D’s mother worked long hours to financially support her family which meant that she was away from the family home and Child D was left with her older sister and/or brother for much of the time that she was not in school. The school spoke of the fact that Child D’s mother had reduced her working hours in order to better support Child D in response the school’s and Children's Social Care’s concerns for her, but that this had a financial impact upon the family. It seems that whilst the risk to Child D of possible harm from neglect was considered on reflection of the case, there is no evidence in the records that a more holistic assessment was undertaken in 2018-2020 which considered the impact of financial pressures on the family. School staff also talked of the support they had sought to offer to Child D in the form of free school meals but that this had been unavailable to her because of the family’s lack of recourse to public funds. It was discussed at this meeting the challenge of this financial constraint on the family and the pressure it would have placed upon them. Additionally, Child D’s brother was thought to be sending some of the money that he earnt to his family members in his home country to support them, reducing the amount of money he was able to use to support his family in the UK. Whilst this area was discussed by the authors and practitioners involved in this review, there was no such consideration in the records of what this might have meant for the family at the time. Since 2020, a No Recourse to Public Funds Policy and Procedure have been in place within Children’s Social Care to support any such families and is available online for all social care practitioners. Learning point: Practitioners should have the necessary knowledge to consider the impact of financial pressure, poverty and specifically no recourse to public funds upon a parent, carer or family’s situation and their ability to act protectively. Summary: identification, assessment and management of risk: It has been difficult to make an accurate assessment of how the risk of harm to Child D in this timeframe was addressed and managed. The risks of neglect, physical, emotional and sexual abuse do appear to have been recognised at points throughout the timeframe, but it is the author’s opinion that, whilst the indicators of sexual abuse were explored when concerns for Child D were first presented, around November 2017, when there was not any corroborating evidence, the focus of support being offered to the family appeared to shift to possible physical abuse. It was suggested within the author’s learning event that a consideration of possible sexual abuse remained throughout the time that Child D was supported on a child protection plan and that Child D was asked questions relating to this possibility on multiple occasions. However, analysis provided by Children’s Social Care as part of the chronology suggests that there might not have been a complete understanding of the risk of harm to Child D due to a lack of home visits being completed. Whilst she was being seen in school at her own request, due to the overcrowding in her home environment, this meant that Child D’s mother was not as involved 21 as she should have been. Additionally, the relationship between Child D, her mother and her other family members could not be accurately observed and assessed, and it was unknown to what extent Child D’s mother was protective. Generally, the perception of the practitioners who had supported the family was that Child D’s mother’s understanding of the involvement of Children’s Social Care and the risks they were working to reduce was not clear. This may have been due in part to the fact that Child D’s mother did not speak or understand English or may have been reflective of cultural differences between the UK and her country of origin, or a combination of these factors. It is recognised within this analysis that the changes of practitioners and managers within Children's Social Care that Child D and her family experienced, were likely to have contributed to an incomplete picture of Child D’s experiences and may have compounded her vulnerability. Within the health sector, the GP had begun to build a picture of Child D’s needs and there is evidence of communication with Children’s Social Care but the GP received unclear messages from Child D and her mother, hindering the understanding of Child D’s situation and any risks to her. The school do appear to have recognised Child D’s needs and vulnerabilities and there is evidence of school staff seeking additional therapeutic support for Child D on multiple occasions. It is the author’s opinion that more reflective recording which sought to gain a clearer understanding of the level of risk to Child D would have been helpful. As recent research by the Centre of Expertise for Child Sexual Abuse states: professionals ‘need to understand CSA and the signs and indicators which signal that it may be occurring. In order to record that concern, they need the confidence to name it as such, and to address it.’5 This point is detailed further in this report. 2) How did practitioners and agencies that had contact with the family, work together to safeguard the children? Examples of good communication and inter-agency working: It is clear from the chronology and from both of the information gathering events held that the main agencies supporting Child D and her family during the time period of the review were Children’s Social Care and Child D’s school. Whilst health and therapeutic services were involved, this was usually for a time limited period. Those practitioners involved in this review agreed that inter-agency working was good in the later part of the time frame when the Child Practitioner had supported the family. Communication, particularly between the school and Children’s Social Care was also described as good. Core Groups and child in need meetings were run well and those involved were able to input their concerns. There is evidence of good information sharing and communication between the GP and Children’s Social Care. The school sought appropriate additional therapeutic support for Child D when her needs suggested this might be helpful. It was not always possible to secure support because of referral criteria or waiting times, but this did not result from a lack of effort on the school’s part. There were two periods of time when additional support was secured, and the information provided suggests that Child D responded well to the support and the activities she was offered and that communication between these support agencies and the school was good. 5 THE SCALE AND NATURE OF CHILD SEXUAL ABUSE: REVIEW OF EVIDENCE Kairika Karsna and Professor Liz Kelly (2021) https://www.csacentre.org.uk/documents/scale-nature-review-evidence-0621/ 22 Areas for improvement: There are some examples of difficulties in communication earlier on in the timeframe. Child D was seen by the GP and a Paediatric Doctor in relation to injuries to her body but there appears from the chronology to be some confusion in relation to which hospital Child D attended for additional examination of these marks. This resulted in the photos taken at the hospital of these injuries, not being shared with the GP. This was unfortunate as the GP went on to see Child D for a number of appointments in the following months and this additional information may have allowed the GP to explore the potential causes of these injuries further and gain a clearer understanding of Child D’s lived experience. There was then a further delay as the GP experienced difficulty in speaking with the Social Worker at the time about these injuries. When this did happen, it is unclear from the chronology how this issue was perceived and what possible support was considered for Child D, given that there was a suggestion that the lesions may have been self-inflicted – although Child D herself denied this – and she would have been only 10 years old at the time. Based on the information within the chronology, the decision made on 29th May 2019 to ‘step down’ Child D from a Child Protection Plan to support under section 17 child in need processes appears to have been made at a meeting that was not quorate. Records indicate only the Social Worker and school were present at the Review Child Protection Conference, although Child D was receiving support from a Play Therapist at the time, as well as having seen her GP on a number of occasions. Child D had made a disclosure to the Play Therapist on 24th May 2019 regarding a physical punishment by her mother. Given the previous concerns relating to physical abuse, it is difficult to understand why this disclosure was not given more weight: although records do suggest it was discussed at the conference. The strategy discussion held on 19th November 2018 in relation to injuries to Child D should have triggered a greater multi-agency response. Whilst Children’s Social Care took the lead as a section 47 enquiry was already underway, Police records show that no further information was shared with them in relation to the matter, nor was it chased by them. It was unclear at that point how the injuries had been caused and, in the author’s view, there should have been greater consideration given as to how and when these injuries might have occurred, as well as who might have inflicted them. The child protection medical which Child D attended at the time suggested that the injuries were a mixture of accidental, non-accidental and self-inflicted. There does not appear from the records to have been sufficient curiosity in relation to these injuries and whilst there is some consideration of Child D’s emotional wellbeing, there does not appear to have been a response to these directly. A review strategy discussion may have helped to pull information together from the child protection medical and facilitated a discussion between those involved about what action could be taken in response. 3) How well did agencies identify and respond to signs of child sexual abuse? Medical examinations: School staff spoke of ‘red flags’ and indicators of possible abuse. It is clear from the records and discussion held as part of this review, that the risk of child sexual abuse, as well as other forms of abuse were well recognised at an early stage and were recorded as such. 23 It was agreed at this meeting and the author’s meeting that there is limited awareness of the fact that forensic evidence of sexual abuse from medical examinations of children is extremely uncommon and should not be taken as evidence of the absence of abuse. ‘The consensus in published research6 is that, for children of all ages who have experienced sexual abuse of any kind at any time, an anogenital examination will commonly find no signs of injury.’7 In Child D’s case, there appear to have been a number of indicators of abuse which should have been given greater consideration, including behavioural manifestations and medical indicators. Learning point: to increase awareness of practitioners of the possible outcomes from a medical examination at the SARC and the context and likelihood of these potential outcomes. This information should then be used to inform the risk assessments in place for a child or family. Additionally, knowledge and understanding relating to child protection medical examinations and medical examinations undertaken at the SARC, including the differences between the two, should be increased amongst practitioners. Indicators of child sexual abuse: It was universally agreed that the current child protection processes place too great a reliance on a child or young person to make a verbal disclosure of abuse. This is a recognised systemic issue; the 2020 Joint Targeted Area Inspection Report into Child Sexual Abuse in the Family Environment states: ‘Professionals rely too heavily on children to verbally disclose.’8 It is also recognised that: “This is a heavy, and frankly unrealistic responsibility. Children cannot and should not be the only witnesses to the harm they experience; it is the responsibility of the adults around the child to respond to help-seeking behaviour and to safeguard them”i as stated by the Centre of Expertise for Child Sexual Abuse. Verbal disclosure was likely to have been an even less realistic expectation for a child with Child D’s additional needs, without considering the extent of the grooming behaviour she had been subjected to. Practitioners spoke of Child D’s interest in menstruation and particularly the idea of starting her periods herself. A discussion was held that explored the potential cultural aspects of these topics and it was agreed that this was not an area that had been fully understood or appreciated at the time by those working with the family. This area will be explored further later in this report, but it is mentioned here as it was believed by some of the group that in hindsight there may have been cultural influences on Child D’s behaviour particularly in relation to relationships, sex, boys and men which may have prevented a full understanding of the indicators of child sexual abuse. Assessment of indicators of child sexual abuse: There is no evidence within agencies records that practitioners completed a sexual abuse assessment tool. The Brook Traffic Light tool which was in place at the time but has since been replaced by a local child sexual behaviour assessment tool9, may have been useful. The 6 Sapp and Vandeven, 2005; Mollen et al, 2012; RCPCH, 2015 7 The role and scope of medical examinations when there are concerns about child sexual abuse A scoping review fDr Michelle Cutland (2019) https://www.csacentre.org.uk/documents/the-role-and-scope-of-medical-examinations-when-there-are-concerns-about-child-sexual-abuse-a-scoping-review/ 8 https://www.gov.uk/government/publications/the-multi-agency-response-to-child-sexual-abuse-in-the-family-environment/multi-agency-response-to-child-sexual-abuse-in-the-family-environment-joint-targeted-area-inspections-jtais 9 Cambridgeshire & Peterborough Safeguarding Children Partnership Board Child Sexual Behaviour Assessment Tool https://safeguardingcambspeterborough.org.uk/wp-content/uploads/2021/10/Child-Sexual-Behaviour-Assessment-Tool.pdf 24 tool may have provided an understanding of Child D’s behaviour in the context of what would be normal behaviour for someone of her age, as well as checking against the expected behaviours of a younger child given that Child D was functioning at a younger age. There is evidence in the chronology and from the information gathering events that Child D’s behaviour was noted by school and other professionals to be an indicator of concern, particularly the behaviour and language she displayed. The complexity of her chronological age, her level of understanding and the cultural considerations should have been examined alongside information relating to normal developmental behaviour relating to sex and relationships in order to plan interventions that aimed to reduce her vulnerability to grooming and abuse. Barriers to disclosure: Whilst there is evidence of recognition of the indicators of child sexual abuse at least early on, there does not appear to have been consideration given to what the barriers to disclosure might have been for Child D at the time. It was discussed by practitioners that it is recognised now that Child D was subjected to grooming behaviour by her brother from a young age but there appears to be no consideration of the possibility that Child D had been subjected to grooming in 2018. There could have been greater professional curiosity displayed in relation to the timing of when Child D’s behaviour changed, in order to build a picture to support the hypothesis of child sexual abuse. Questions such as ‘who does Child D spend time with and when?’ ‘When does Child D’s behaviour change and specifically when do the indicators of concern present? Do changes in her behaviour correlate with specific events such as when her father visits the family or when mum is at work or when she is in a safe environment?’ might have assisted in understanding the level and nature of risk to Child D. One of the barriers identified by practitioners in responding to Child D’s vulnerability to child sexual abuse were the difficulties experienced in communicating with Child D’s mother. This was partly related to the difference in language spoken by Child D’s mother and the professionals involved. But there were also difficulties in supporting Child D’s mother to understand the risks to Child D and her role in protecting her child from abuse. It was suggested that these challenges as well as regular absences of the family on trips out of the country may have meant that possible disguised compliance was not recognised and so went unchallenged. Additionally, it was felt by professionals that, whilst the risks of child sexual abuse were recognised early on, and Child D was spoken to on multiple occasions about what might be going on for her, it became inappropriate to continue with a repeated line of questioning. What should have appeared in the records of all agencies however was the continued hypothesis that Child D may have experienced child sexual abuse and that there may be an ongoing risk of that abuse based on the behaviour she had displayed and the other potential indicators that had been noted. Learning point: practitioners need to feel confident in not only identifying indicators of possible child sexual abuse but working with those indicators and their own concerns, particularly in the absence of a disclosure or medical evidence, to carry the hypothesis of sexual abuse throughout the work they complete with a child or family. 4) How was the voice of the child recognised and responded to within the case? GP: There is excellent recording of Child D’s own words and observations of her behaviour within the GP records for the time scale of the review. This is significant as Child D and usually her mother, presented to the GP an inordinate number of times within this period for a number of 25 different complaints. There is also evidence of direct questions posed by the GP to Child D relating to child sexual abuse and her responses are well recorded. On the occasion that Child D requested to see a female doctor, this was responded to, and the GP escalated their concerns by referring Child D to be examined by a Paediatric Registrar. Addenbrookes Hospital: On the occasion of the 3rd of August 2020 when Child D and her mother attended the emergency department of Addenbrooke's Hospital, it was established early on that something was concerning about Child D’s presentation and behaviour. Child D underwent a medical examination and a psychosocial assessment in response to this and Child D’s own words, as well as detailed descriptions of her presentation are recorded. Whilst Child D was asked direct questions relating to her presenting injuries, it is not clear if her behaviour was challenged with her, suggesting another missed opportunity for professional curiosity. There was also recognition that photographs had not been taken of the marks on Child D's body and this learning has been taken forward by the hospital. Barriers to communication: It is clear that Child D's voice, as well as her behaviour are noted early on in the time frame of the review. But as previously outlined, in the absence of a verbal disclosure of abuse by Child D the behavioural indicators appear to have been given less weight. Practitioners were clear however, that Child D was directly questioned by those working with her and provided with multiple opportunities to make disclosures of child sexual abuse. Indeed, she was perceived to have formed relationships with professionals and made verbal disclosures of physical abuse. Without Child D’s own perspective however, it is not possible to correlate whether she felt she had such opportunities. The complicating factor of Child D’s learning needs must also be considered. Although the relevant assessment information from the Education, Health and Care Plan can be seen from the records to have been shared, it is not clear to what extent this information was understood by each agency and therefore whether Child D was asked age-appropriate questions that she could be expected to understand. The child’s lived experience: It is noted by Children’s Social Care on reflection on this case that direct work with the family on ecomaps, genograms and the family story might have been useful in gaining an understanding of the family, as well as providing an avenue for Child D to give her perspective on those relationships and their impacts on her. There are recorded concerns relating to family relationships between Child D's mother and father, between Child D's older brother and sister, and Child D’s relationships with her siblings so it would have been a useful exercise to complete such tools with each member of the family and compile all the information to better understand their perspectives. The role of Child D’s brother particularly was not well understood, and he was agreed to have been largely ‘invisible’ by practitioners when they were working with the family in 2018 and 2019. This is a suggestion that resonates with both local and national child safeguarding practice reviews where the presence and role of particularly male figures linked to the family have gone unexplored. Discussion with those practitioners involved with this case as part of this review did include consideration of the lived experiences, both past and present of all of the family members within the household, particularly the impact of any abuse or trauma they may have experienced, but it was not clear that this had happened earlier. 26 Learning point: exploring the role of each family member within a household from the perspectives of each member is important in gaining an understanding of the dynamics and any potential risk within the family unit. Evidence of Child D’s voice: Other examples of where Child D’s voice was sought and captured were the assessment conducted by a school nurse on the 7th of March 2019. Records include drawings by Child D and her own words as well as observations of her completing various activities. The school had a particularly good understanding of not only Child D’s learning needs but the impact of those additional needs on her academic ability and social skills. Child D’s voice was well documented in school records as well as changes in her behaviour or any inappropriate behaviour that she displayed. There was one occasion on the 6th of February 2019 when Child D talked about her father in school. There could have been further exploration with Child D on this occasion about the context of what she said and the reasons why she had brought up that particular subject, but the impression gained from the records was that her school knew Child D well. Whilst the detail occurred outside of the time scale of this review, it is important to recognise within this report that during the information gathering event for practitioners, detail was shared relating to the police investigation and the efforts made by the relevant officers in engaging Child D and obtaining her perspective. This included significant rapport building and multiple home visits. It became apparent during the investigation that Child D was a victim of significant grooming by her brother, and this is highlighted here because of the impact that this will likely have had on Child D and her feelings of safety and confidence to speak with professionals about the abuse she suffered. Certainly, the views she expressed during the investigation and afterwards suggested that a verbal disclosure from her would have been extremely unlikely. There was also discussion relating to Child D’s perception of the relationship between herself and her brother which she expressed to the investigating officer and how what she had said and felt might be uncomfortable or unsettling for practitioners to consider or discuss, which was taken as a learning point from this case. Learning point: all practitioners should have support and opportunities to discuss any element of a case that is uncomfortable for them or ‘unthinkable.’ They should be supported to record their suspicions or feelings related to a case in an appropriate way that informs ongoing risk assessment. Both of these discussions highlighted the significant barriers to disclosure in place for Child D and why continuing consideration of her behaviours and general presentation were so important. Family members: What is missing from the records and to an extent from the information gathering event for practitioners, is Child D’s mother’s voice. Practitioners were able to describe her reaction to her son’s admission of abusing Child D and her feelings towards him in the immediate period following. There is also some evidence of assessment of her ability to be protective towards Child D but it is not until the Child Practitioner became involved in supporting the family that there is any evidence of Child D’s mother expressing her perspective. It is regrettable that attempts to make contact with Child D’s mother for the purpose of this review have been unsuccessful. 27 5) Was Covid a factor in safeguarding and supporting Child D and did it have an impact on how agencies communicated and shared information? At the point that the COVID-19 pandemic began to have a significant impact on everyday life in the UK, Child D was not being supported by any agencies beyond her school. Support from Children’s Social Care had ended when the case was closed on the 17th of February 2020, five weeks before the country experienced the first and most stringent lockdown on the 25th of March 2020. Shops, restaurants, leisure facilities and schools were all closed. Only essential services continued and only those working in those essential services who could not work at home were permitted to travel to work. School non-attendance as a risk factor: Schools were able to offer a small number of places for children to continue attending but these places were only available to children in specific categories. One of these categories was children who had an education health and care plan (EHCP), of which Child D was one. This meant that Child D was eligible to continue attending school, and a place at her school was offered to her. Child D’s mother turned down this offer, stating her concerns for Child D’s health and Child D remained at home. The school representatives stated that it had been suspected that Child D herself had also not wanted to attend school at least initially, due to feelings of anxiety in relation to COVID-19. The context of this time was that, as so little was known about the virus, and there appeared to be a substantial number of deaths across the population caused by it, there was widespread fear of contracting the virus. This was compounded by the severity of the restrictions placed upon the country. It is the author’s opinion that there should not be judgement placed upon Child D or her mother's decision-making in relation to Child D’s attendance at school during this time for these reasons. However, the impact of this decision was that Child D was believed to be at home for large amounts of time without the supervision of her mother as she continued to work to financially support the family. Weekly contact was attempted by the school via a staff member who was able to speak the same language as Child D and her mother, but this was most often unsuccessful. Child D also experienced difficulties accessing the virtual work provided by school and as a result, there was almost no contact with the family by any professionals. On the 7th of July 2020 school staff completed a home visit to Child D as they were concerned by the lack of contact with Child D and her mother and there was no evidence that Child D was completing any online learning. Child D was seen, although only engaged in a short conversation at the door to the property, having been woken by her brother. She was offered the opportunity to return to school but again refused. It was discussed that whilst this single contact with Child D in the three and a half month period since the COVID-19 restrictions began, might seem in hindsight to be an insufficient response from the school, it was over and above the guidelines in place at the time. It is known now that Child D’s mother had to change her job as a result of the closure of so many businesses during the period of restrictions and that this meant a change to her working hours but due to the lack of communication at the time, this was not known then. Had there been a clearer picture of the level of supervision present for Child D, a safeguarding referral or a referral to early help services may have been appropriate. 28 Presentation at A&E: The next contact that any agencies had with Child D was on the 3rd of August 2020 when she presented to the emergency department at Addenbrooke's hospital. As has previously been detailed, she was examined, and concerns were noted relating to the presenting injuries and her behaviour. The Consultant then commenced a safeguarding referral to Children’s Social Care because of her concerns relating to Child D’s presentation. A number of learning points and actions for the hospital were shared at the information gathering event for practitioners, including changes to the internal safeguarding referral process and dissemination of the Child Sexual Behaviour Assessment Tool. It was recognised that it had been difficult for the Consultant to assess Child D’s behaviour with a lack of contextual awareness of her learning needs on this occasion. As Child D was not being seen by any other professionals at this time because of the COVID restrictions, this contact stands alone in the records as the most detailed assessment, and therefore an important opportunity to gain an understanding of what Child D’s situation was at that time and how she might have been feeling. It does not appear from the records that she was seen alone which represents a missed opportunity to have explored her presentation with her directly. Children’s Social Care responded to the hospital referral by completing a home visit to Child D on the 7th of August 2020. Unfortunately, Child D was again not seen alone during this visit and the explanations provided by Child D's mother and brother were taken at face value. There is no further activity on Children Social Care records relating to Child D until the 17th of August 2020 which is the end of the time scale of this review. Given that Child D, like so many children, had such little contact with professionals during the period of COVID-19 restrictions, those occasions on which she was seen by practitioners were of even greater importance and should have been maximised by offering Child D the opportunity to speak to the relevant professionals on her own and by ensuring that appropriate measures were taken to support her to communicate. Addenbrooke's Hospital would not have had the benefit of access to records detailing historical concerns and Child D’s learning needs, but Children’s Social Care would have, and this information should have prompted a thorough assessment of Child D’s situation and presentation at that time. Inter-agency communication: When the topic of COVID-19 was discussed, there were no significant concerns expressed for the impact that COVID and the associated restrictions had had on information sharing or communication in relation to this case. Whilst it was recognised that telephone communication initially was more difficult, as particularly Children Social Care practitioners were working at home, this was quickly rectified, and email communication was unaffected. Face to face meetings were replaced by virtual meetings: not a wholly new concept, although it was recognised that this would have been significantly more challenging for children and families to have adapted to. Police Officers continued to work in communities in the same way and health staff largely continued to operate in their roles, albeit amidst significant additional pressure to the healthcare system. The final consideration is that related to the use of personal protective equipment (PPE). For the interactions that practitioners had with Child D after March 2020, face masks would have been worn by professionals and would have been required by members of the public, as well as other PPE such as gloves, aprons, or visors where appropriate. The authors and practitioners groups involved in this review expressed the view that whilst face masks 29 particularly could be seen as a barrier to communication, in their collective experience most children had quickly adapted to seeing other people wear them as their use was so widespread in society. The Police Officer present suggested that the achieving best evidence (ABE) interview conducted with Child D had been more awkward than might have been the case as both Child D and the interviewing officer wore face masks but didn't feel this had been significantly detrimental. All practitioners agreed that face masks have become a part of working practice at the time this review was taking place and that their use in the context of the pandemic was entirely appropriate. 6) Were there language or cultural barriers to the family accessing services and support? All agencies involved in supporting this family agreed that there were considerable communication problems. Child D herself was able to communicate to an extent in English, as well as her own language but she was described as fluent in neither language which, compounded with the fact that she was assessed as having been functioning significantly below her chronological age, meant that she had complex communication needs. Practitioners from Child D’s school described her as being aware of her own difficulties, particularly in comparison to her peers, and this would cause her to feel frustrated and impacted upon her self-confidence. Child D’s mother was not able to speak English, and had a very limited understanding of English and translation services should have been used each time any professional wished to communicate with her. There is little detail in the combined chronology relating to the use of translation services: the GP records are the clearest. It was universally agreed by practitioners that, for this family, the fact that all communication with mum required the use of interpreters was a significant barrier to engagement and must have been a significant challenge for Child D's mother herself. The school representatives described that it had been difficult to communicate with Child D’s mother using telephone-based interpreters and when a staff member provided some assistance, they experienced difficulty in understanding her. The possibility of Child D’s mother having learning or communication needs of her own was also discussed and it was agreed that this was a further challenge as it meant that even when translation services were used, verbally or for documents such as letters, Child D’s mother’s understanding of the information that was being translated could not be accurately determined. All practitioners agreed that communication with the family had become easier when the Child Practitioner who could speak the same language was allocated by Children’s Social Care. Additional interpreters were used for Child Protection Conferences to explain some of the more complex language. Indeed, it was apparent that Children’s Social Care had made significant attempts to ensure that Child D and her mother were provided with information in their own language in all their interactions. However, it was agreed that this case highlighted what might be ‘lost’ in terms of communication when using interpreters. Practitioners described that some interpreters they had worked with were better than others, but largely they did not check the understanding of the person they were translating for, rather simply translating ‘yes’ or ‘no’ answers. Additionally, the terminology so extensively used by safeguarding practitioners such as ‘child 30 in need’ or ‘public law outline’ do not directly translate if similar terms are not used in the family’s own language. It was highlighted that the culture within the family’s home country is vastly different to the UK in relation to safeguarding and child protection and this would have presented an additional challenge to Child D's mother in understanding the reasons for agencies’ involvement and concerns. The learning in relation to language and communication barriers is that time and effort should be taken to explain matters in a way that is accessible and to check the understanding of the person you are speaking with. Unfortunately, it was recognised that these considerations are often incompatible with time constraints and high workloads. It was also agreed that consistency in the interpreters used can assist when families are discussing difficult or personal information. Whilst it was agreed that having a practitioner engaged with the family who could speak their own language was undoubtedly beneficial, the challenge of that practitioner being required to fill two roles was also recognised. Learning point: when there are known communication difficulties, practitioners should feel able to modify time scales such as the length of meetings to meet the needs of the families they are supporting to better ensure their understanding and engagement. Beyond Children’s Social Care, it appears that face to face translation services were not consistently used by agencies. Whilst recognising the cost of these services it was agreed that in a case such as this where there are complex communication needs, face to face translation services provide the best opportunity to share information with families, assess their understanding and promote their engagement. Learning point: it should be the preferred default position that face to face translation services are offered to families who require these services for each face-to-face intervention for those family members. However, it is realised that there are barriers to this and that this target may be aspirational but the barriers to facilitating this should be recorded by the appropriate professionals. Finally, there were discussions held as part of this review relating to the cultural aspects of this case and it was agreed that practitioners had not sought to gain a better understanding of what the similarities and differences might have been between the culture of the family’s home country and the UK and how this might have impacted upon Child D, her mother and their family life. The Child Practitioner did appear to have explored this and demonstrated knowledge of Child D’s brother’s and sister’s upbringings as well as Child D's mother’s own experiences before she had moved to the UK. But there was not a clear understanding across agencies of how the families' previous cultural experiences might have affected their perception of risk, and therefore Child Ds mother's ability to be protective towards her. The result of the challenges in communication faced by both Child D and her family and those practitioners supporting them having not been fully explored is that it is not clear if the right interventions were offered to reduce the risk of harm to Child D. 7) Can you identify any areas that you consider to be good practice? Some examples of good practice have been noted in this report: extensive use of interpreters by Children’s Social Care, recording of the indicators of child sexual abuse at the Initial Child Protection Conference and recording, specifically in relation to Child D’s voice and behaviour 31 by the GP. In addition, the GP had made follow up appointments when Child D requested a female GP and where there had been concerns for Child Ds wellbeing. Recording by the school was also particularly good, making clear the concerns for Child D. Good multi-agency working has also been noted, and attendance at Core Groups appeared to be good. Practitioners spoke of the way in which Core Groups were led in the later part of the time frame to take into account Child D’s and her mother’s communication needs. Efforts were made by practitioners from her school, health, Children’s Social Care and voluntary agencies to build relationships with Child D and recording suggests that she was open to communication with those who were supporting her. There is some evidence of single agency challenge within the chronology. On the 23rd of May 2019, the Child Protection Chair adjourned the Review Child Protection Conference and escalated her concerns relating to the lack of information being presented to a manager. Again, on the 30th of May 2019, there is recorded challenge from the Child Protection Chair following the de-escalation of support for the family from child protection to child in need, relating to the quality of recording and a lack of multi-agency oversight. There is not however, a response recorded to this escalation from a manager. On 4th January 2019 a School Nurse on reviewing Child D’s records, contacted the relevant Social Worker to request an invitation to the next Core Group meeting and offer a health assessment for Child D due to the recorded concerns of possible self-harm. This was highlighted within the chronology as good proactive practice by the School Nurse. There are multiple examples throughout the chronology of occasions when Child D’s voice and her lived experience as interpreted through both her verbal and non-verbal communications are noted. Such examples can be found under question 4 within the Analysis section of this report. Finally, whilst it falls out of the time scale of this review, it was agreed that the response to Child D, her brother and her other family members following the disclosures made by her brother had been swift, appropriate and involved the necessary multi-agency partners. Consideration had been given to Child D’s needs and the relevant support had been put in place for her. 8. Summary It was agreed by those involved in this review, that this had been a complex case with a number of inter-relating risk factors such as the language barrier, Child D’s learning needs and the family’s living and financial situation. The case was also considered to have been unusual in the way that the abuse that Child D suffered came to light. Because of the information Child D’s brother shared with the Police during their investigation, significant detail was known of this abuse which offers the benefit of ‘absolute knowing’10 that the abuse had taken place in the time scale covered by this review. However, it must be acknowledged that this had not been the case in 2018/19 and all the learning highlighted within this review can be gleaned with the benefit of this information that had not been present at the time. 10 The myth of 'absolute knowing': when is the evidence enough? Anna Glinski 2019 for the Centre of Expertise on Child Sexual Abuse: https://www.csacentre.org.uk/resources/blog/the-myth-of-absolute-knowing/ 32 Whilst each case will be different as each child is unique, it is hoped that the key areas of learning outlined below might support practitioners to work with cases of child sexual abuse and specifically sibling perpetrated sexual abuse. Perhaps the most profound point of learning in this case was that, had her brother not admitted to abusing Child D when he had, it might still not be known that she was suffering this abuse. For those involved in this review, this highlighted the greatest challenge of working with children and young people in relation to child sexual abuse: how to support children and their families when abuse is suspected but not known? 9. Key areas of learning: Signs and indicators of child sexual abuse a. Practitioners should be open to the possibility of sibling perpetrated sexual abuse as the most common form of intra-familial child sexual abuse. b. Practitioners should have support and opportunities to discuss any element of a case that is uncomfortable for them or ‘unthinkable.’ They should be supported to record their suspicions or feelings related to a case in an appropriate way that informs ongoing risk assessment. c. Practitioners should be professionally curious within their roles when there are indicators of child sexual abuse but no clear perpetrator of that abuse. d. The possible reasons for non-disclosure should be considered where there are indicators of child sexual abuse and used to inform interventions with the child. e. There remains a reliance on verbal disclosure from children or the presence of medical evidence as confirmation of sexual abuse. When research suggests that either incidence is uncommon, greater consideration should be given to other potential indicators and non-verbal forms of communication. f. Similarly, practitioners should feel confident to carry a hypothesis of child sexual abuse i.e. keeping in mind that something may have happened when there is not clear evidence. g. Tools are available which might assist practitioners in understanding their own concerns in relation to child sexual abuse, including the local Child Sexual Behaviour Assessment Tool Cultural considerations: h. Cultural considerations such as attitudes towards relationships, family life, child development and abuse should be explored when this may impact upon a parent or family's ability to act protectively. Language barriers i. It is important to take time to ensure families who have language or communication needs can engage with agencies and processes in a way that is comparable to those families who do not. j. The preferred default position is that face to face translation services are offered to families who require these services for each face-to-face intervention for those family members. The barriers to facilitating this should be recorded by the appropriate professionals. 33 The role of family members within a household k. The importance of a family’s composition and the roles that all family members play within a unit should be considered as part of any risk assessment. No recourse to public funds l. Practitioners should have the necessary knowledge to consider the impact of financial pressure, poverty and specifically no recourse to public funds upon a parent, carer or family’s situation and their ability to act protectively. 10. Recommendations Signs and indicators of child sexual abuse It is recognised that since the commencement of this review, the Safeguarding Partnership in Cambridgeshire and Peterborough have undertaken significant amounts of work to monitor and improve practice relating to child sexual abuse across the children’s workforce. As a result of this, a recommendation will not be included within this report for additional work, rather the focus should be on determining the impact of the work already undertaken. 1. Cambridgeshire and Peterborough Safeguarding Children Partnership Board should: a. seek assurance from partner agencies that work relating to child sexual abuse that has been undertaken in the past 12 months has been embedded b. Consider how the impact of this work has improved practice in order to evaluate the effectiveness of this work. Cultural considerations: 2. Information should be made available to practitioners within their agencies for them to gain a better understanding of cultural considerations such as attitudes towards relationships, family life, child development and abuse, in order to support children and families who are impacted by cultural variances. Language barriers: 3. a. All agencies should ensure that the needs of children and families who have a limited understanding of English are met via the use of face-to-face interpreters, translated written material and additional time allowances for meetings involving the family. Any barriers to facilitating the family’s access to services should be recorded. b. The Safeguarding Children Partnership Board should consider whether resources available to parents and families relating to safeguarding such as leaflets should be made available in additional language formats. 34 The role of family members within a household 4. The importance of a family’s composition and the roles that all family members play within a unit should be considered as part of any risk assessment. The Safeguarding Partnership Board should seek assurance that existing tools such as genograms are utilised for this purpose and that the role of male family members particularly is highlighted. No recourse to public funds 5. Information should be made available to practitioners within their agencies to improve their knowledge and skills in relation to the financial pressures and impact of having no recourse to public funds. Where this impacts upon a family, this should be recorded and considered as part of any plan for support. i Don't wait for them to tell us: recognising and responding to signs of child sexual abuse Jane Wiffin (2019) https://www.csacentre.org.uk/resources/blog/disclosures-csa/ |
NC52344 | Sexual abuse of an 11-year-old child by their step grandfather over a number of years. Child Q1 was 11-years-old when their school made a referral to Children's Social Care due to concerns regarding child sexual abuse (CSA). Child Q1 was living with their parents and siblings at the time of the referral but had frequent contact with their grandmother and step grandfather. Child Q1 has Special Educational Needs (SEN) and attended a Free School in another borough. Following a social work home visit Q1 told Mother that they had been sexually abused by their step grandfather since the age of 4-years-old. Following inadequate Ofsted reports the Free School was closed in July 2017 and therefore staff could not be contacted for further information. Learning includes: prosecution for CSA, where a child has SEN where there is no forensic evidence, and the absence of evidence from a secondary source (in this case the teacher) is problematic; information sharing between and within agencies was not always in line with good practice, resulting in professionals not having all the information available when assessing the risks to Child Q1. Recommendations include: contact the Department for Education Skills and Funding Agency and the Regional Schools Commissioner to raise concerns and make suggestions to enable support from the local authority when Academies and Free Schools are identified as having safeguarding concerns; and raise concerns in relation to lost records/lack of information regarding HR records and possible breaches of the Data Protection Act when Free Schools and Academies are closed.
| Title: Child Q1 serious case review. LSCB: Manchester Safeguarding Partnership Author: Anne Morgan Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Manchester Safeguarding Partnership Child Q1 Serious Case Review This report was commissioned and prepared on behalf of the Manchester Safeguarding Partnership (previously Manchester Safeguarding Children Board) Independent Reviewer: Anne Morgan Published by the MSP on the 11th May 2020 MSP Child Q1 SCR Page i Contents 1.0 INTRODUCTION ................................................................................................................................ 1 2.0 RATIONALE FOR CARRYING OUT A SCR ........................................................................................... 1 3.0 REVIEW PROCESS ............................................................................................................................. 1 4.0 FAMILY COMPOSITION .................................................................................................................... 5 5.0 FAMILY HISTORY PRIOR TO PERIOD UNDER REVIEW ...................................................................... 6 6.0 NARRATIVE AND ANALYSIS FOR PERIOD UNDER REVIEW ............................................................... 7 7.0 RESPONSE TO RESEARCH QUESTIONS ........................................................................................... 12 8.0 LINES OF ENQUIRY ......................................................................................................................... 19 9.0 RECOMMENDATIONS ..................................................................................................................... 20 10.0 AREAS OF GOOD PRACTICE .......................................................................................................... 21 11.0 CONCLUSION ................................................................................................................................ 21 The Manchester Safeguarding Partnership published its new arrangements in June 2019 and in doing so took ownership of all Manchester Safeguarding Children Board (MSCB) reviews, strategies and policies. Find out more at www.manchestersafeguardingpartnership.co.uk The Manchester Safeguarding Partnership is a multi-agency partnership made up of a wide range of statutory, independent and voluntary agencies and organisations. These all work together to keep children, young people and adults, particularly those who are more vulnerable, safe from the risk of abuse, harm or exploitation. MSP Child Q1 SCR Page 1 of 21 1.0 INTRODUCTION 1.1 This serious case review has taken place because of MSP (formerly MSCB) having concern that there was a delay by Child Q1’s school in identifying and referring Child Q1 to children’s social care for possible sexual abuse. Additionally there was a concern regarding the effectiveness of multi-agency working both prior to and following the referral. 2.0 RATIONALE FOR CARRYING OUT A SCR 2.1 A meeting of Manchester Safeguarding Children Board’s Serious Case Review (SCR) Panel was held on the 01/09/2017 and a decision made to carry out a SCR. This decision was ratified by the MSCB chairperson on the 02/10/2017 and was based on the criteria as laid out in Working Together to Safeguard Children 2015 (Working Together)1, which refers to Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. “Cases which meet one of the criteria (i.e., regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii) must always trigger an SCR”. Child Q1’s abuse met regulation 5(2) (a), abuse is suspected, and 5(2)(b)(ii), the child has been seriously harmed2 and there is cause for concern as to the way in which the… (agencies)… have worked together to safeguard the child”. 3.0 REVIEW PROCESS 3.1 Scope and focus of the SCR The panel identified the following key areas to be explored as part of the review. They were: 1 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children March 2015 p 75: 2 Serious Harm in the context of SCR guidance includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following: A potentially life threatening injury; Serious and/or likely long term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. This definition is not exhaustive. In addition, even if a child recovers, this does not mean that serious harm cannot have occurred. MSP Child Q1 SCR Page 2 of 21 1. The period of time from when the school had initial concerns regarding Child Q1 to their referral to children's social care (CSC) in July 2017. 2. Child Q1 was reported to have learning difficulties. Did this have an impact on how the school managed their concerns? 3. The School’s safeguarding arrangements. 4. MASH threshold and assessment in cases of child sexual abuse (CSA). 5. Interagency Communication. The review panel were asked to incorporate the following lines of enquiry into the report. To attempt to provide a better understanding of the following aspects of service provision: cross boundary working, effectively sharing information regarding family members that can be resident in different local authorities to ensure that this is linked to the child to build a bigger picture the management of inter-generational sexual abuse and linking families members and other household members to the child to undertake a robust initial screening of the referral to adopt an appropriate level of assessment was Child Q1’s suggested learning needs and vulnerability referred to any health or education professional for a formal assessment. 3.2 Organisations involved in the Review 3.2.1 It was agreed that the following organisations would be required to contribute to the serious case review: Manchester City Council Children’s Social Care (CSC) Greater Manchester Police (GMP) Neighbouring Education Department3 Manchester City Council Education Department Manchester University NHS Foundation Trust GP Practice Bridgewater Community Health Care NHS Foundation Trust Manchester NHS CCG Neighbouring NHS CCG Manchester City Council Legal Department Free School (Records Only)4 The Regional Schools Commissioner (once identified as having governance responsibility for Free Schools) - no contribution received. 3 The Education Department, CCG, NHS Trust and Q1’s school have been anonymised to protect Child Q1 and their family 4 The Free School closed in July 2017 following an Inadequate Ofsted Report. There was minimal information available on the records transferred to Child Q1’s new school. No staff have been able to be contacted to be part of the review by either the local authority or GMP. MSP Child Q1 SCR Page 3 of 21 3.2.2 The review panel was made up of senior representatives from the following organisations with the SCR author as chair. The author was Anne Morgan, an Independent Safeguarding Children Consultant commissioned by MSCB. She has extensive experience in carrying out reviews and is trained in the use of a systems approach. The following table illustrates the agencies/professionals who were invited as panel members. Additionally contact was made on several occasions with the Regional Schools Commissioner to inform the review in relation to their role with Free Schools. No response to those contacts occurred. The neighbouring schools safeguarding lead provided information relating to education in the borough and attended the last review panel meeting. Agency Role Independent Author Independent Safeguarding Children Consultant MCC Education Department Education Case Worker MCC Children’s Social Care Service Manager (North assessment) Greater Manchester Police Service Detective Inspector Police Public Investigation Unit (PPIU) NHS Manchester CCG Designated Nurse for Safeguarding Children Neighbouring NHS CCG Head of Safeguarding & Designated Nurse for Safeguarding Children NHS Manchester CCG Designated Doctor for Safeguarding Children MCC Legal Department Deputy Head of Children and Families (Legal) Group Manchester University NHS Foundation Trust Named Nurse Safeguarding Children The panel was supported by the MSCB Safeguarding Board Co-Ordinator and Business Support Officer. The Practitioners involved were: Agency Role Children’s Social Care Manchester Multi-agency Safeguarding Hub (MASH) Team Manager Children’s Social Care MASH Social Worker Manchester University NHS Foundation Trust MASH Health Visitor lead for Safeguarding Children/MASH Manchester University NHS Foundation Trust School Nurse Team Lead Children’s Social Care Senior Social Worker Children’s Social Care Social Worker Greater Manchester Police Detective Inspector PPIU Greater Manchester Police Detective Constable MASH GP Practice GP Neighbouring Community Health Care NHS Foundation Trust Named Nurse MSP Child Q1 SCR Page 4 of 21 3.3 Time period to be covered 3.3.1 The period covered by the review is January 2016 to September 2017. 3.4 Methodology 3.4.1 Working Together 2015, Chapter 45 identifies the principles to be adhered to in carrying out any Learning Review. This includes the need for “Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children”. This review was carried out in line with those principles and is proportionate to the incident. 3.4.2 A chronology was produced by the agencies involved, and the professionals working with the family identified (see Footnote 3). 3.4.3 The model used was based on a broad systems approach. However due to the very limited and routine contact professionals had with this family a decision was made to meet with the professionals for an initial discussion and to explain the process and to enable practitioners to talk through their contact with the family and consider the scope and focus of the SCR in relation to their agencies’ involvement. A further meeting was held with this group to share a draft report, and discuss the report’s findings and recommendations. The process was hindered by the unavailability of any education staff from the Free School despite GMP and the local authority making concerted attempts to find their current location. 3.4.4 The process was supported by those panel members who were able to attend these meetings. 3.4.5 Family Involvement: Child Q1 and their parents were informed of the decision to carry out a SCR and invited to meet with the review author and a member of the review panel. Child Q1’s mother, paternal grandmother and aunt took up this offer to meet. A review team member was unavailable for the meeting therefore a social worker who had previously worked with the family attended to support the process. Child Q1’s mother said that her decision to send Child Q1 to the Free School was because of Child Q1’s learning needs and she thought Child Q1 would do better in a small school. Mother reported that this was also the view of Child Q1’s primary school. Once at secondary school she was concerned about the lack of educational support that Child Q1 had received. She advised that Child Q1’s teacher had remained the same for the whole of the school 5 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of March 2015 children p.75 MSP Child Q1 SCR Page 5 of 21 year and whilst she had not attended the parents evening, Child Q1’s mother had been into school to see the teacher in relation to Child Q1’s learning needs. She was therefore surprised that no concerns had been raised with her prior to the home visit. She felt that the home visit was inappropriate and talking to the neighbours about her unprofessional. This made her very angry and, along with the concerns that she had regarding Child Q1’s education she went into school to advise that Child Q1 would not be returning. Child Q1’s mother reported that she was unaware of previous concerns regarding her stepfather and was not aware of why she herself had been subject to a Child Protection Plan (CPP). She felt that the initial support provided by the social worker was good as was the police contact. Later contact was not as positive. She reported that Child Q1 could not understand why there was not going to be a prosecution (a view she and paternal grandmother and aunt also had) and felt that the way the family had been told was not helpful. The whole situation had caused a rift within the family and meant Child Q1 was unable to see her “aunt”. She reported that Child Q1 was now doing well at school and felt that the family were working well together to make sure that the children were ok. Child Q1 was not met as their parents felt it would be too distressing for them. However, when discussing the final report, the family were pleased to advise that Child Q1 was now doing well at school and was far more outgoing than they had been for many years. 3.4.6 Some of the learning identified was outside the terms of reference and timescale of the review. Where relevant this learning has been included in the analysis along with recommendations relating to them. 4.0 FAMILY COMPOSITION Age at time of Incident Relationship to subject Ethnicity Place of residence 11 years old Child Q1 subject White British Manchester 31 years old Mother White British Manchester 27 years old Father White British Manchester 5 years old Sibling 1 White British Manchester 4 years old Sibling 2 White British Manchester 43 years old Maternal grandmother White British N/A 46 years old Maternal step-grandfather White British N/A 13 years old Daughter of maternal grandmother and step grand-father White British N/A MSP Child Q1 SCR Page 6 of 21 5.0 FAMILY HISTORY PRIOR TO PERIOD UNDER REVIEW 5.1 Child Q1’s mother had been a Looked After Child (LAC)6 for a considerable part of her childhood, due to paternal abuse and neglect. She returned home in her late teens. 5.2 Child Q1’s maternal grandmother commenced a relationship with maternal step-grandfather who had a history of alcohol misuse and was known to the police because of a previous allegation made against him of child sexual abuse (CSA). In 2002 they had a child, a S47 investigation was commenced and a Child Protection Conference held. Their child was made subject to a Child Protection (CP) Plan, under the category of neglect. In 2003 when Child Q1’s mother returned home she was also made subject to a CP plan. Child sexual abuse (CSA) was added as an additional category. Both children remained on CP plans until December 2004 when they were no longer considered to be at risk. 5.3 At some time prior to December 2004 Child Q1’s mother and father had commenced a relationship and Child Q1’s mother was pregnant at the time of the December conference. There is no evidence however to suggest that an assessment of risk to her unborn child was considered as part of the conference decision making. 5.4 Child Q1’s was born in 2005. The parental relationship was at times fraught, with both parents suffering from mental health problems and misusing alcohol. There were also episodes of domestic abuse and in 2006 a Common Assessment Framework (CAF)7 was commenced because of concerns relating to Child Q1. Child Q1’s mother had severe post-natal depression and Child Q1 went to live with their father and paternal great-grandmother although contact was maintained. Child Q1 resided with paternal great grandmother until their (paternal grand-mother's) death in 2006 when child Q1 moved back to live with their mother. In 2009 child Q1 moved with her mother and siblings into paternal grandmother's house to be with Q1's father. 5.5 Child Q1’s siblings were born in 2011 and 2012. 5.6 Between 2012 and 2015 Child Q1 appears to have had four reported urinary tract infections (UTIs) and was seen by the GP on three occasions, however no consideration was given to following these up by referral to a paediatrician or whether there was a non- medical reason for the UTIs. Good practice is to refer after two such infections, and this would have provided an opportunity to do further investigations. 5.7 A further CAF was commenced in July 2015 by Child Q1’s primary school due to concerns relating to Child Q1’s learning difficulties and parental mental health (mother). Child Q1 had been assessed by an educational psychologist and received intervention from a teaching assistant to focus on areas of particular difficulties. A plan appears to have been put in place at the initial stage 6 A child becomes a Looked After Child (i.e. cared for by the by a local authority where a court has granted a care order to place a child in care, or where a voluntary agreement has been reached with the parents and council’s children’s services department has cared for the child for more than 24 hours. On reaching the age of 18, children cease to be considered looked-after by a council. 7 The Common Assessment Framework (CAF) is an early help inter-agency assessment. It offers a basis for early identification of children's additional needs, the sharing of this information between organisations and the coordination of service provision. MSP Child Q1 SCR Page 7 of 21 of the CAF including a referral to counselling for Child Q1’s mother and a referral to Big Manchester (a family support charity). As the Big Manchester referral was not accepted and the mental health referral made the CAF was closed. However the primary school continused working with Child Q1 regarding their needs; work included focusing on their confidence and transition to high school. 6.0 NARRATIVE AND ANALYSIS FOR PERIOD UNDER REVIEW 6.1 During March and April 2016 Child Q1’s maternal grandmother and step grand-father were seen by their GP. Grandmother was seen for low mood and anxiety, step grandfather with depression and alcohol misuse. No consideration was given by the GP to the impact this may have on their child. This is not examined further as not pertinent to the review and has been addressed outside of the review process 6.2 Between May and July 2016 Child Q1’s primary school attempted unsuccessfully to engage with their prospective secondary school regarding Child Q1’s educational needs. 6.3 In September 2016 Child Q1 transferred from primary to secondary school. The school chosen was a Free School, felt by both mother and their primary school’s head teacher to be the best choice for Child Q1, due to its small numbers and Child Q1’s identified educational needs. Following commencement at their secondary school Child Q1’s mother was provided with photocopies of Child Q1’s educational records to take into school. They did not appear to be part of Child Q1’s records at the time the school closed. 6.4 On the 6th March 2017 Child Q1’s younger sibling aged six years old talked to their teacher about loneliness and told their teacher that their younger sibling (aged five years old) was at home on their own whilst they, their parents and Child Q1 were at a party. Parents were seen in school; they were asked about this incident and advised that mum worked nights and is sometimes in bed but the younger sibling was not left alone. Given the clear concern from the child and the miss-match in information received this was not an appropriate response and should have resulted in a referral to Children’s Social Care (CSC) for investigation. It is not clear why this did not happen. 6.5 On Friday the 14th July 2017 Child Q1’s school made a referral to Manchester CSC where Child Q1 lived. This referral raised a number of concerns including Child Q1’s behaviour towards men… ”Child Q1 will happily approach the male teacher… wanting to hug etc.” They also reported that Child Q1 was “overly interested in sexual development, sexualised behaviours etc.” Child Q1 had previously reported to teachers that they ”shaves their pubic area” and also that they had been “sore in their genital area at times”. The referral identified that no direct disclosures had been made and there was no evidence to explain why Child Q1 behaved in the way they did. The referral stated that concerns had been noted over a 9-10 month period, since Child Q1 started the school and: MSP Child Q1 SCR Page 8 of 21 “Although no direct disclosures have been made Child Q1’s teacher… has a history of working with children who have been sexually abused and they began putting the information together and believes Child Q1 could be a victim of sexual abuse” The referral also stated that Child Q1 was one of the most vulnerable children in the school and had learning needs8. 6.6 The previous day a home visit had been carried out by Child Q1’s teacher to discuss the school’s concerns about Child Q1. The teacher was concerned about the home conditions and by information reported by a neighbour who said that there had been a lot of shouting from the house the night before. At that visit Child Q1’s mother became “very angry and aggressive” and was still reported to be upset when she visited school the following day to advise that Child Q1 would not be returning to the school as their needs were not being met. It was this visit by mother and the removal of Child Q1 from school that precipitated the referral. 67.7 Whilst it would appear that the referral from school was in relation to child protection this was not clear in the referral itself and the school did not discuss the referral with Child Q1’s mother or gain consent to share information. This was not acceptable practice unless the school were concerned that to do so would put Child Q1 at further risk or the child had disclosed sexual abuse. Their management of the referral reflected the concerns expressed by Ofsted in their May 2016 inspection which graded the school as inadequate. The inspection identified poor leadership within the school, a lack of Special Education Needs Co-ordinator (SENCO) as well as out of date safeguarding and child protection policies9. 6.8 It is not clear why the MCC Contact Centre agreed to accept the referral without the parents being aware a referral had been made. This is not normal practice unless to do so would put the child at further risk which was not evident in this case. This meant that when a social worker visited the family had no knowledge of the referral and could have reacted in a very different way. Working in partnership with parents is explicit within the Children Act 1989 and ensures their involvement in the process as well as clarifying which agencies are currently working with the family. 6.9 On Tuesday the 18th July 2017 the referral was transferred from the MCC Contact Centre to MASH for further gathering of information and to gain an understanding of what the sexualised behaviours were and why a referral had not been made previously. MASH enquiries commenced on the 19th July. The case did not go directly to a S47 investigation as no disclosure had been made, however the reported sexualised presentation, which can be indicative that a child has been sexually abused, was from an informant who was reported to be a professional with experience of direct work with sexually abused children This transfer to MASH was five days after the initial referral and outside of Manchester’s timescale for decision making and assessment. The review team were advised that this was due to workload, and whilst this was a clear perception it was not 8At the time of the review the school had pupils in Year 7, Year 8 and Year 9 attending, reflecting the time the school had been open. The proportion of pupils who were eligible for funding through the pupil premium was well above the national average. Many parents chose the school because of its small size and good pupil/teacher ratio (DfE Ofsted Inspection report: 11–12 May 2016) 9 DfE Ofsted Inspection report: 11–12 May 2016 MSP Child Q1 SCR Page 9 of 21 able to be tested for accuracy. The impact in this case was however that vital information from the school was lost due to its closure10; including what the specific expertise the teacher in question had in relation to CSA. Practice at the time of the review was for MASH to identify the level of concern and if a further assessment was needed for this to be carried out on transfer to the local team who would make a decision regarding the type of investigation required. 6.10 Enquires were carried out by all the agencies although not as effectively as they might have been. The MASH health enquiry collated information about Child Q1’s siblings and parents which contributed to the risk assessment that identified that further social work intervention was required. Health information was not requested from school health, as Child Q1’s school was outside of Manchester, to do so would have been good practice as Child Q1 was the subject of the enquiries. This would have identified the previous CAF raised by the primary school and the concerns raised in relation to Child Q1’s learning needs and mother’s need for support. Information relating to family history would also have been available. The health representative in MASH reported that at that time they did not routinely contact health providers outside of Manchester. This was due to a misunderstanding in relation to the process and partly due to the need to provide information quickly. In this case the MASH enquiry was already out of expected timescales so decisions were made with local information only. Subsequent amendments to the MASH health enquiry process, outside of this review, have focussed the MASH health enquiry to prioritise collation of health information proportionate to the presenting concern and risk. Information provided by GMP related to the immediate family and therefore it was not until wider family information was requested that important relevant information with regards to the family history was identified and shared. Initial searches within CSC did not identify the historical information relating to earlier domestic abuse referrals in 2005, mother’s past history or the previous CAFs in relation to the family. This was in part due to changes from paper to electronic records and the fact that CAFs at the time were not held within CSC. Had this information been readily available known risks to Child Q1 would have been identified earlier. However despite this because of the concerns identified within the referral a decision was made to transfer the case to the local team for further investigation. This was good practice. 6.11 The case was allocated to a social worker who was about to go on annual leave. This was ineffective management and has been addressed outside of the review. A colleague, realising the importance of prompt follow up and the delay that had already occurred, did an unannounced visit on the 28th July. Child Q1’s mother was unaware of the referral by school and reported to be concerned about the issues raised. Child Q1’s mother was accepting of the social worker talking to all three children on their own and having a discussion with Child Q1 of their understanding of appropriate and inappropriate touching. This showed a level of skill and competence from the social worker concerned and was excellent practice and resulted in Child Q1 disclosing to their mother later that day that they had been abused by their step grandfather. 6.12 Child Q1’s mother contacted the police later that day informing them of the disclosure, that Child Q1 had reported being sexually abused by their step grandfather since they were four years 10 Following an Ofsted Inspection 11–12 May 2016 and follow up inspection in December 2016 where the school was identified as inadequate a decision was made to close the school in July 2017 MSP Child Q1 SCR Page 10 of 21 old and the last time being the previous week possibly the 20th July 2017. This was two weeks after the initial referral and only came about because a social worker identified the risk, had the necessary skills to gain Child Q1’s mother’s confidence and the confidence knowledge and skill to carry out direct work with Child Q1 and their siblings. This was an excellent piece of work and highlights the importance of professionals who work with children having the confidence to talk to them in an age appropriate way and ask appropriate questions when their behaviour raises concerns. The need for this to occur is an area highlighted in previous Manchester SCRs11 as well as national research12 and is particularly important when CSA is suspected but when there has been no disclosure. 6.13 On the 29th July 2017 a strategy meeting was held in relation to Child Q1 and their siblings. A S47 investigation was commenced, decisions at the meeting included; appointments to be made for child protection medicals, an ABE interview and a referral to the Sexual Abuse Referral Clinic (SARC) by the police. This followed normal practice and was an appropriate response. The referral was received by the SARC on the 31/07/2017 and related to a serious sexual assault on the 20/07/2017 (11 days previously). Following further information received from the police on the 02/08/2017 relating to step-grandfather’s history, a disclosure was made by Child Q1’s youngest sibling regarding inappropriate sexual behaviour; and information was received from Child Q1’s mother advising that Child Q1 had disclosed that step-grandfather had sexually abused them on occasions since the age of four. A decision was made on the 04/08/2017 by the SARC to either see Child Q1 straight away and the two siblings at a later date, or see them all together in 2-3 weeks’ time. Child Q1’s mother made the decision for all the children to be seen together and an appointment was made for 23/08/17. 6.14 On the 7th August 2017 a further strategy discussion was held which included a representative from Manchester school health, Police and CSC. Actions agreed were: to follow up SARC medicals; ABE interviews which had not been actioned which caused delay; a further social worker visit; and a review strategy meeting to be held once all agencies returned from the summer holidays to assess the need to go to a CP conference. The school nurse for Child Q1’s school was not invited and no information was requested which again meant that previous information regarding the family was unavailable. Whilst it is not unusual to hold more than one strategy meeting when not all the information required to risk assess has been gathered, Working Together13 states that an Initial Child Protection Conference should be held within 15 days of the Initial Strategy meeting unless a decision has been made not to convene a conference. The decision to convene or not convene a conference was not formally made and led to some drift in the case. A third strategy meeting was planned but not held. Whilst the decision to cancel it may have been appropriate, with CSC making the decision that the children were Children in Need (CiN) rather than Children in Need of Protection, it would have been more appropriate to have held either the third strategy meeting or a professionals meeting to share information and agree whether or not there was a need for an Initial 11 Child G1 SCR 2018 and Child F1 SCR 2018 12 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick, University of East Anglia 13 DfE Working Together to Safeguard Children 2015 p40 MSP Child Q1 SCR Page 11 of 21 Child Protection Conference or whether they fitted the criteria for CiN (both parents had acted very appropriately once Child Q1 disclosed the abuse and the concerns raised by the school relating to neglect that do not appear to have been substantiated). A professionals meeting or strategy meeting would have provided an opportunity to explore these issues, ensure all relevant information was available and identify a clear plan of action. 6.15 ABE interviews were requested on the 08/08/2017 and took place on the 09/08/2017. 6.16 On the 23rd August 2017 Child Q1 and their siblings were seen at the SARC clinic. This was some time after disclosure, but due to Child Q1’s mother’s wish for all three children to be seen together. Psychological support was already being provided therefore the delay in this case did not affect the outcome, either from a forensic, physical or emotional perspective. 6.17 On the 18th September 2017, a CiN meeting was held, with representation from CSC and Child Q1’s school. Neither the siblings’ school, school health nor the GP were invited. There did not appear to be any consideration to some of the concerns previously raised in relation to Child Q1’s learning needs or any evidence of follow up in relation to this, i.e. referral to a developmental paediatrician to assess Child Q1’s learning needs and whether they were organic in nature or due to the abuse they had suffered. This was due to a lack of understanding of the role and presumed availability of school nurses. It has since been addressed and features in individual agency action plans and has therefore not been included as a specific recommendation. 6.18 At the time of writing the report the lack of records from the Free School, the inability to identify staff who were at the school and the lack of forensic evidence has hampered the CPS’s ability to provide sufficient information for them to consider a conviction in this case. A decision has therefore been made not to prosecute step-grandfather. This has caused distress to both Child Q1 and their family. MSP Child Q1 SCR Page 12 of 21 7.0 RESPONSE TO RESEARCH QUESTIONS 7.1 What factors affected the Free School’s response to their initial concerns in relation to Child Q1 to their referral to CSC in July 2017? 7.1.1 Free schools were given approval in the Academies Act 2010. The Act also stipulated that all new schools had to be academies or free schools. This meant local authorities lost their power to create new schools or monitor them in any way. A concern raised by many Local Authorities at the time of their inception and since. The Free School in this case was part of a business group of Free Schools which was approved by the DfE in 2013. Free schools are set up, through a specific application process, by groups of parents, teachers, charities, businesses, universities, trusts, religious or voluntary groups as non-profit making organisations and are funded directly by central government. Whilst legally they are academies’ and held accountable through the same mechanisms, i.e. the Funding Agreement between the Secretary of State for Education and the Academy Trust which operates the free school or academy, there are some requirements for free schools that are not the case for academies. Specifically free schools must be in response to local demand. For most schools that means there must be a petition from parents in the area naming the school as their first choice. Unlike local-authority-run schools, they are exempt from certain requirements including teaching the national curriculum and are able to use non- qualified teachers. Free schools are often also the school chosen by parents whose children are experiencing difficulties in school and who feel a small school would be more able to support their children’s vulnerability. This was the view of Child Q1’s mother at the time. 7.1.2 Lord Nash14 in his investigation into the effectiveness of Free Schools highlighted problems that new free schools were faced, problems that are often not educational in origin. They included: “New, inexperienced and often isolated trusts needing to upskill themselves to run a school for the first time; instability in principal appointments and senior leadership teams." All of these issues were present at the Free School in question along with the lack of up to date policies and procedures, inexperienced staff and lack of training as identified in the Ofsted Inspection15. Additionally the school did not respond to requests to attend meetings or to pick up Child Q1’s school file from their primary school. Child Q’s mother took a copy of their educational records to the secondary school. There is no evidence to show however that it was ever used to provide either education or social support and was not part of Child Q1’s files at the time of school closure. This lack of information would have contributed to staff at the school not identifying concerns relating to Child Q1 for some considerable time. 7.1.3 CSA can be difficult to identify unless there is a direct disclosure16, however a child’s behaviours may lead professionals to consider this as a possibility and ask appropriate questions and liaise with other professionals working with the child. This did not occur in Child Q1’s case, with education staff not sharing their concerns or liaising with school health or the previous school to 14 DfE Future Academy System: Lord Nash, Guardian Newspaper accessed 6th June 2018 15 DfE Ofsted Inspection report: 11–12 May 2016 16 Children’s Commissioner; Protecting Children from harm: A critical assessment of child sexual abuse in the family network in England and priorities for action Summary November 2015 p10 MSP Child Q1 SCR Page 13 of 21 acquire/share information regarding any previous concerns relating to Child Q1. They were dealing with a child who they knew had learning needs but had not received an assessment since being at secondary school. Lack of knowledge and challenge of Child Q1’s behaviour could have initially led staff to believe that some of their behaviours were caused by their learning needs rather than because they were being abused; however they should also have been aware that children with special needs are three times more likely to be abused than their peers17. It has not been possible to discuss with staff from the school due to the closure and the difficulty the police and other agencies have had in contacting them. Their view on the situation has therefore not been able to be sought. It would appear though that without the input of Child Q1’s teacher a referral may not have been made. 7.1.4 From the school’s inception the local authority provided support in relation to safeguarding training with various principals attending training for designated safeguarding children leads. Between 2014 and 2016 the school was offered and received whole school safeguarding training, Prevent awareness training and Local Authority Designated Officer (LADO)18 training. This was good practice, however it does not appear to have been embedded in practice as when Ofsted inspected the school in 2016 their report clearly identified poor safeguarding processes. Because there no requirement by Ofsted or the school to share any reports with the local Safeguarding Board it is difficult to identify and support schools with poor a safeguarding record unless picked up by safeguarding audits including such as S11/S175 audits19. 7.2 Child Q1 was reported to have learning difficulties. Did this have an impact on how the school managed their concerns 7.2.1 Disabled children are at significantly greater risk of physical, sexual and emotional abuse and neglect than non-disabled children.20 Some figures would suggest that they are three times more likely to be abused than their non-disabled peers. Those disabled children at greatest risk of abuse are those with behaviour/conduct disorders. Disabled children are also more likely to be abused by someone in their family compared to non-disabled children and the majority of disabled children are abused by someone who is known to them. Additionally disabled children may disclose less frequently and delay disclosure more often compared to typically developing children21. Ten of the children who were the subject of SCRs in the tri-annual review was identified as disabled with the report identifying that: 17 Ibid p8 18 Now known as Designated Officers: DfE; Working Together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children July 2018 19 DfE Education and Skills Act 2008 20 Sullivan, Vernon and Scanlan 1987; Cross et al. 1993; Sullivan and Knutson 2000; Kvam 2004; Spencer et al. 2005); Jones et al.2012 cited NSPCC David Miller and Jon Brown October “We have the right to be safe” Protecting disabled children from abuse 2014 21 NSPCC David Miller and Jon Brown October “We have the right to be safe” Protecting disabled children from abuse Main Report Prepared by 2014 MSP Child Q1 SCR Page 14 of 21 “physical injuries, challenging behaviours, developmental delays, poor growth, and unhygienic living conditions can all be left unchallenged or attributed to the child’s disability rather than identified as symptomatic of abuse or chronic neglect“22. And “Education practitioners need to be alert to the possibility of abuse or neglect with a disabled child, as with a non-disabled child”. The report also emphasises the importance of a child-centred approach in the context of prevention and effective safeguarding and the consequences of not hearing the voice of the child. 7.2.2 In this instance there is evidence that Child Q1 had learning difficulties including dyslexia and that their learning needs had been identified in Primary school. An educational psychology assessment had taken place in Year 4 and Year 6 with clear recommendations as how best to support Child Q1 both academically and socially. Child Q1’s secondary school did not respond to the primary school’s request to attend a transfer meeting or their further email or telephone contact requesting contact being made to enable transfer of records. There is no evidence that this advice was ever acted on once Child Q1 transferred to secondary school; nor is there evidence that a further educational psychology assessment was made or a clear education plan initiated so that changes in learning, mood and behaviour could be adequately assessed. Research identifies that children who have been sexually abused can shut down and present as though they have a learning difficulty. This and the lack of training/ skills within the school and no dedicated SENCO coordinator, all areas identified by the Ofsted inspection in 2016, would have impacted on the delay in a proper assessment of Child Q1’s needs and assessment of their behaviour despite the fact that they did have the same teacher for the period in question; a teacher with reported previous experience of CSA. It was this teacher who carried out the home visit and was responsible for the referral to CSC. 7.2.3 The possible late referral in this instance (without the benefit of records and staff involvement) because a young person has or is perceived to have learning difficulty is not something unique to this case and has been identified in a number of national SCRs as well as a recent Manchester SCR23. It is also not a problem just for education but for all agencies working with children24. However where staff are alert to concerns and able to demonstrate: “Professional curiosity and awareness of possible maltreatment and cumulative risk…..practitioners are able to challenge parents and explore a child’s vulnerability or risk while maintaining an objective, professional and supportive manner”25 timely and appropriate referrals are more likely to occur. 22 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick, University of East Anglia p70-71 23 MSCB Child I SCR 24 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick, University of East Anglia 25 Ibid p141 MSP Child Q1 SCR Page 15 of 21 7.3 Schools Safeguarding Arrangements 7.3.1 Schools have a responsibility to safeguard children. These responsibilities are set out in Primary Legislation26 as well as statutory guidance27. The guidance states that: School and college staff are particularly important as they are in a position to identify concerns early, provide help for children, and prevent concerns from escalating. All school and college staff have a responsibility to provide a safe environment in which children can learn. Every school and college should have a designated safeguarding lead who will provide support to staff members to carry out their safeguarding duties and who will liaise closely with other services such as children’s social care. All school and college staff should be prepared to identify children who may benefit from early help. Any staff member who has a concern about a child’s welfare should follow the referral process …. Staff may be required to support social workers and other agencies following any referral. The Teachers’ Standards 2012 state that teachers, including head-teachers, should safeguard children’s wellbeing and maintain public trust in the teaching profession as part of their professional duties. 7.3.2 Additionally school and college staff need to be aware of systems within their school or college which support safeguarding and these should be explained to them as part of staff induction. This should include: child protection policies the role of the designated safeguarding lead receiving appropriate safeguarding and child protection training including the types of abuse and neglect so that they are able to identify cases of children who may be in need of help or protection understanding the referral process to children’s social care and the need for multi-agency working know what to do if a child tells them they are being abused or neglected. 7.3.3 Both Ofsted and the Local Safeguarding Children Boards (LSCB) have a role in ensuring these responsibilities are met; Ofsted through the inspection process and LSCBs through their section 11 audits28. Whilst the majority of schools take these responsibilities seriously there have been a number of schools have failed their Ofsted Inspections and been found inadequate. For many of these this has included a failure in their safeguarding responsibilities29. Within the period under review only two schools Manchester were identified as inadequate in relation to safeguarding one 26 The Education Act 2002, Academies Act 2010 27 DfE Keeping children safe in Education; Statutory guidance for schools and colleges September 2016 DfE Working together to safeguard children; Statutory Guidance on inter-agency working to safeguard and promote the welfare of children 2015 28 Children Act 2004 29 Future Academy System: Lord Nash; Leaked to the Guardian April 2014 accessed 8th June 2107 MSP Child Q1 SCR Page 16 of 21 of which was a Free School. The other borough involved did not provide the number of schools found to be inadequate following Ofsted Inspection during the period of review. However they both identified the difficulty in being able to identify when a Free School was failing and the lack of any statutory responsibilities to intervene. This hampered them in providing support to non-local authority failing schools. Despite this the local authority when made aware of any failings they responded to those concerns in a timely manner. In this case the school concerned failed its Ofsted Inspection over a number of areas including leadership and safeguarding which put vulnerable children at risk. It also failed to respond to a request in March 2017 to provide their LSCB with a section 11 audit. Had they done so any failings identified could have been referred back to the Regional Schools Commissioner for action as it reflected the continued poor safeguarding arrangements at the school. Where there is poor leadership within a school and where schools do not take their responsibilities seriously the risk of a pupil not being identified as at risk of harm is increased. 7.4 MASH Threshold and Assessment in Cases of CSA 7.4.1 The LSCB has responsibility to agree with the local authority and its partners the levels for the different types of assessment and services to be commissioned and delivered within its boundaries and to publish a threshold document that identifies the agreed thresholds and the processes in place to access services30. Concerns about maltreatment may be the reason for a referral to local authority children’s social care or concerns may arise during the course of providing services to the child and family. In these circumstances, local authority children’s social care must initiate enquiries to find out what is happening to the child and whether protective action is required. Local authorities, with the help of other organisations as appropriate, also have a duty to make enquiries under section 47 of the Children Act 1989 if they have reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm, to enable them to decide whether they should take any action to safeguard and promote the child’s welfare31. 7.4.2 At the time of this review the Manchester process involved initial referral to the Contact Centre which then referred onto the MASH, for assessment. In most instances the child and family are informed of the action to be taken for this to proceed. This did not happen in this case. Transfer from the contact centre to MASH should occur within 24 hours. In this case the transfer was delayed and took two days. In cases of alleged sexual abuse where there is no direct disclosure, MASH information gathering is then passed onto the District Team who will use it to assess whether to continue to a S47 investigation or CiN assessment. This will takes into account the information available as well as the fact that children rarely disclose until they feel comfortable and able to trust the professional or family member. CSA includes contact as well as non -contact activities and not always will children know or understand that they are being abused which makes it even more 30 DfE Working Together to Safeguard Children 2015 31 Ibid MSP Child Q1 SCR Page 17 of 21 important that they are provided with information to enable them to talk about what is happening to them and that their voice is heard32. 7.4.3 In this case a further assessment was agreed following agency enquiries and being assessed as Amber33. In cases such as this where there was a lot of information provided which would suggest CSA consideration could have been given to Child Q1 being RAG rated Red34 which would have required a speedier response. The case was transferred for further social work assessment, however this was not actioned until six days later due to the allocated worker being on annual leave. The delay could have been longer had not a social work colleague used good professional judgement and carried out a home visit. This delay showed a gap in management oversight which has since been addressed and was not normal practice. 7.4.4 Whilst there is a clear need for policies and procedures and referral processes when this becomes overly bureaucratic there is little opportunity for professionals to use their knowledge and challenge decisions they do not agree with. 7.4.5 Since this review, MASH process has been made clearer for professionals, with cases that clearly meet S47 thresholds being passed straight to the area teams for assessment. This includes where the referral relates to possible CSA but no disclosure has been made. To do otherwise puts vulnerable children at risk. 7.5 INTERAGENCY COMMUNICATION: WITHIN AND BETWEEN AGENCIES 7.5.1 “Effective safeguarding work depends on collaborative multi-agency working: no one professional retains all of the required knowledge or skills”35 The Tri-annual report by Sidebotham et al also identifies the importance of good multi-agency working in which different practitioners: “Contribute knowledge and expertise, acknowledging their own priorities, while respecting the knowledge, expertise and priorities of other team members.36 32 Children’s Commissioner; Protecting Children from harm: A critical assessment of child sexual abuse in the family network in England and priorities for action Summary November 2015 p5 33 AMBER - Complex needs likely to require longer term intervention from statutory and/or specialist services. High level of additional unmet needs - this will usually require a targeted integrated response, which will usually include a specialist or statutory service. This is also the threshold for a child in need (S17 CA 1989) which will require a social care intervention. 34 RED - Acute needs, requiring statutory, intensive support. In particular this includes the threshold for child protection (S47 CA 1989) which will require Social care intervention. These cases may also require immediate police intervention as the child has been identified to be at risk of harm. 35 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham*, Marian Brandon**, Sue Bailey**, Pippa Belderson**, Jane Dodsworth**, Jo Garstang*, Elizabeth Harrison*, Ameeta Retzer* and Penny Sorensen** *University of Warwick **University of East Anglia p165 36 Ibid p. 153 MSP Child Q1 SCR Page 18 of 21 7.5.2 The report sees good communication as central to effective multi-agency working and that it depends on: practitioner skills effective systems and processes a culture that values and promotes information sharing a culture that enables shared information to be appraised and used to inform decision making and planning (p14). 7.5.3 Additionally Working Together to Safeguard Children 2015 (and more recently Working Together to Safeguard Children 2018) identifies the need for effective sharing of information between professionals and local agencies as essential for effective identification, assessment and service provision. It identifies early sharing of information as the key to providing effective early help as well as being essential to effective child protection services and that all organisations should have arrangements in place which set out clearly the processes and the principles for sharing information between each other, with other professionals and with the LSCB. 7.5.4 Serious Case Reviews (SCRs) have shown how poor information sharing has contributed to the deaths or serious injuries of children. Often it is a fear about sharing information that stands in the way, however in this case there was no agreed pathway for the GP to share information with school nurses which they felt would be a useful way forward. This is being addressed as a single agency action and therefore does not figure in the recommendations below. 7.5.5 The Free School’s failure to effectively access information from the previous school (they did not attend meetings or respond to email/telephone conversations relating to Child Q1) as well as their lack of understanding in relation to safeguarding and special educational needs put Child Q1 at risk. Additionally, there were no clear policies and procedures in place within the school to support this. Had the secondary school for instance attended the meetings at Child Q1’s primary school or responded to requests to contact them and pick up Child Q1’s records they would have known of the previous concerns and CAFA. The information would also have been available from school health records which would have recorded that there had been concerns relating to Child Q1’s development and enabled the school to meet Child Q1’s needs in a more pro-active way. 7.5.6 The transfer of records from one school to another can often cause problems when families move out of borough. It should not be a problem in borough or from feeder primary to secondary schools however it is dependent on the receiving school requesting them. In this instance Child Q1’s primary school were pro-active in advising the Free School of the need to have the records; however it was Child Q1’s mother who accessed Child Q1’s records and took them to their secondary school. Where a child is vulnerable it would be good practice to ensure the new school had access to those records prior to them changing schools. Failure to do so puts children at risk. There is currently no process for this to occur. 7.5.7 In this Free School’s case it would appear that their lack of action in relation to responding to Child Q1’s needs was not unique to this child, in that they do not appear to have made any records of Child Q1's or other children’s needs, with minimal information available to new schools once the Free School was closed. This lack of information sharing put not just Child Q1 but several other pupils at risk of not having their needs met. MSCB have alerted the relevant local authorities of this MSP Child Q1 SCR Page 19 of 21 fact to ensure that schools taking previous the Free School pupils are aware of the need for follow up. 7.5.8 MASH did not initially gain information from the school nurse for Child Q1’s secondary school as it was not a Manchester school. Whilst in this instance this was because of an individual’s lack of understanding of the process, the review panel were made aware that it often takes longer for health information to be made available to MASH professionals if the child is at a school outside of borough. This has been further exacerbated due to recent changes in the commissioning and provision of health services and lack of access to each other’s IT systems. 7.5.9 There was a delay in relation to information sharing in the initial referral to the SARC, however this was remedied at the second strategy meeting and an appointment made for all three siblings. Information regarding current intervention by other agencies was not passed to the SARC which meant that much of the information available at that appointment is recorded as coming from Child Q1’s mother. Joined up working/ sharing of information between agencies could have reduced duplication in offering of follow up services (counselling etc.) and provided a more joined up approach to the family’s needs. 7.5.10 The decision not to hold the third strategy meeting in September resulted in there being no multi-agency discussion in relation to risk or how the case should progress, i.e. whether Child Q1 and their siblings remained at risk of significant harm or whether a Child in Need meeting was more appropriate. When the CiN meeting was held health was not invited to the meeting which resulted in only school and CSC attending. There were a number of health professionals who would have had something to contribute and a more complete assessment could have been carried out. This failure to invite 'health' is in many instances due to CSC’s lack of understanding of the different roles that different health professionals may have. In this instance it was also in part due to a lack of understanding of the availability of school nurses and lack of involvement by GPs in the CiN process. Children’s Social Care are currently developing guidelines with their partners in relation to CiN which should address these issues. 8.0 LINES OF ENQUIRY The review panel were asked to incorporate the following lines of enquiry into the report: to attempt to provide a better understanding of the following aspects of service provision. They have been incorporated into the report but also highlighted below. 8.1 Cross boundary working - effectively sharing information regarding family members that may be resident in different local authorities to ensure that this is linked to the child to build a bigger picture 8.1.1 In this review Child Q1 resided in one borough and went to school in another, the same borough that maternal grandmother and step-grandfather resided in. Following the school's concerns regarding Child Q1 they referred appropriately to Manchester Children’s Social Care, the borough Child Q1 resided in. There does not appear to have been any delay in this because of any cross borough issues. There was however a delay in accessing the school nurse’s records due to the health MASH representative not contacting the school nurse as part of the information gathering. MSP Child Q1 SCR Page 20 of 21 This has now been addressed as identified in the narrative and should not in future cause any problems. Early access to historical information relating to the family was not immediately shared as it was not requested however once requested there was no delay in it being accessed and shared. 8.2 The management of inter-generational sexual abuse and linking families’ members and other household members to the child to undertake a robust initial screening of the referral to adopt an appropriate level of assessment 8.2.1 Initial requests for information depend on family information provided by the initial referrer and any information already on CSC’s files. It is unlikely, as in this case, that until further information is gathered and additional family members or an alleged perpetrator is identified that further checks would be carried out. 8.3 Was Child Q1’s suggested learning needs and vulnerability referred to any health or education professional for a formal assessment 8.3.1 Child Q1 had an educational psychology assessment prior to the period under review. This was passed onto their secondary school but no further assessment was carried out. There also appears to have been no regard given to following the recommended support identified in primary school. This meant that Child Q1’s vulnerability and educational needs were not adequately taken into account or risks adequately assessed during the period of time that they were a pupil at the Free School. 9.0 RECOMMENDATIONS 9.1 MSP review the current assessment processes to ensure risk factors relating to CSA are adequately covered. 9.2 MSP seek assurance that single agency CSA training is appropriate to the needs of that agency and feeds into the multi-agency training provided by the MSCB. 9.3 MSP reviews current training to assure itself that staff can recognise and been confident in addressing CSA. 9.4 MSP assure themselves that CSA training is embedded in local practice through audit. 9.5 MSP contact the DfE Education Skills and Funding Agency and the Regional Schools Commissioner to raise the concerns highlighted in this report with suggestions as to a way forward to enable support from the local authority when Academies and Free Schools are identified as having safeguarding concerns. 9.6 MSP contact the DfE Education Skills and Funding Agency and the Regional Schools Commissioner to raise the concerns highlighted in this report in relation to lost records/lack of information regarding HR records and possible breaches of the Data Protection Act where Free Schools and Academies are closed. MSP Child Q1 SCR Page 21 of 21 9.7 MSP share the learning from this review with the other borough involved for them to implement an action plan based on the recommendations. 10.0 AREAS OF GOOD PRACTICE 10.1 The Education Lead for Safeguarding in the area of the Free School was pro-active in offering and providing safeguarding training to the school following its inception in 2013. 10.2 The social worker who identified the need for a visit to be carried out whilst their colleague was on annual leave and then spoke to the children on their own showed a high level of professionalism and confidence in their practice. 11.0 CONCLUSION 11.1 Identification of CSA can be difficult and take patience and time. It requires skilled working with the ability to engage and listen and understand what a child is telling you. Additionally it requires supportive training, policies and procedures to be in place, good interagency working and sharing of information, with professionals respecting each other’s assessments and professional knowledge. This did not always happen in this case. |
NC046645 | Unexplained injuries to an 11-week-old baby in March 2014. Baby N was moved to a place of safety before being placed with the maternal grandmother. The father, JB, had a child from an earlier relationship who was also removed from his care following injuries. Following the injuries to Baby N, JB was charged with neglect/ill-treatment. Father had a history of domestic violence and involvement with childrens services due to concerns about neglectful and abusive parenting. Issues identified: the failure of childrens services to conduct a pre-birth assessment based on concerns reported by the health visitors; significant delays in childrens services conducting an initial assessment once Baby N was born; health professionals seeing their safeguarding role as primarily passing on or responding to information from childrens services and an over willingness amongst professionals to accept what they were told by the parents. Uses a systems methodology to analyse practice. Recommendations include: frontline practitioners should be reminded of unborn baby procedures and specifically told that where a previous child of either partner has been made subject to child protection procedures a pre-birth assessment is required for all subsequent pregnancies; where Initial Assessments are undertaken, referring agencies should be informed in writing of the outcome of referrals so there is clarity between agencies about the rationale for the decisions taken and referral forms and guidance should make clear the expectation that referring agencies gather background information from their own records.
| Title: Serious case review: Baby N. LSCB: Sunderland Safeguarding Children Board Author: Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Baby N (The SSCB has used a pseudonym to protect the identity of the child and family) Publication date 26 November 2015 Contents Page 1. Decision to hold a Serious Case Review (SCR) 3 2. Statutory Guidance 3 3. The approach used 3 4. Parallel Proceedings 4 5. Local Context 5 6. The Family’s Perspective 5 7. The Family as known to Agencies 6 8. Analysis of Practice 12 9. Summary 25 Appendix 1: Single Agency learning 26 Appendix 2: Recommendations for Sunderland Safeguarding Children Board 28 Appendix 3: Progress Report 30 1 Decision to hold a Serious Case review (SCR) 1.1 Baby N was born to parents JB and ST in December 2013. 1.2 In March 2014, when Baby N was 11 weeks old, unexplained bruising was found on the child’s abdomen. A skeletal survey revealed three healing fractures on ribs and another mid-clavicle fracture, possibly about 6-8 weeks old. Child Protection procedures were followed and Baby N was moved to a place of safety before being placed with the maternal grandmother. 1.3 JB had a child from an earlier relationship who, nine years previously, had been removed from the care of JB and his partner, following similar injuries to those found on Baby N. The view of the ‘Learning and Improvement in Practice’ Sub Committee was that the criteria for undertaking a Serious Case Review (SCR) were met and the Independent Chair of LSCB concurred with that view. 2 Statutory Guidance 2.1 A Serious Case Review is one where: ‘a) abuse or neglect of a child is known or suspected: and b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child.’ Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 require LSCBs to undertake reviews of serious cases in these specified circumstances and to ‘advise the Authority and their Board partners on lessons to be learnt’ 2.2 Statutory guidance requires SCRs to be conducted in a way that: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. 2.3 The guidance also stipulates that when undertaking reviews, LSCBs should ensure that frontline practitioners are fully involved in the process and are invited to contribute their perspectives without fear of being blamed for actions, which they took in good faith. Boards should also consider ways of involving family members and sensitively and appropriately managing their expectations. 2.4 The guidance is also clear that reports should be written in plain English and in a way that can easily be understood by professionals and the public alike. 3 The approach used 3.1 The review has used systems methodology supported by the use of short reports, and an integrated chronology from the agencies involved. An independent reviewer with experience of using a systems methodology and an internal reviewer from the LSCB were commissioned to lead the SCR process. 3.2 A Review Team of senior professionals representing the agencies that were or had been involved with the family was established. Their role was to provide a source of high-level strategic information about their own agency and their involvement with Baby N’s family through their contributions to the SCR process and through the submission of an Agency Learning Report. The Review Team, listed below, gathered and analysed data, appraised practice and agreed the content of this report. Linda Richardson Independent Lead Reviewer Lynne Thomas Business Manager-SSCB Deanna Lagun Head of Safeguarding Sunderland CCG (2nd Reviewer) Lay Member SSCB Lead Nurse Safeguarding South Tyneside NHS Foundation Trust (STNHSFT) Named Midwife Safeguarding City Hospitals Sunderland (CHS) Strategic Manager Sunderland Children’s Services1 Deputy Head of Safeguarding Northumberland Tyne and Wear NHS Foundation Trust Detective Inspector Protecting Vulnerable Persons Northumbria Police Education and Schools Lead Sunderland Council 3.3 Members of the Review Team also identified frontline practitioners and first line managers who were known to, or had worked with Baby N’s family. These practitioners formed the ‘Practitioner’s Group’ and they met on three occasions. They offered important details about the family and also provided a rich source of information about local systems and multi-agency procedures and processes. In addition, they helped the Review Team consider the extent to which the findings from this review were typical of practice elsewhere across the authority. 3.4 Data was collected through the examination of single and multi-agency records and individual conversations with practitioners and their managers. 3.5 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference. This helps the data to lead the key issues to be explored as opposed to the preconceptions of managers or a review panel. However, key lines of inquiry for this review quickly emerged around the central importance of quality assessments and how these are monitored; how significant information is collected, analysed and shared between agencies and the extent to which professionals understood the link between past and future harm. 3.6 This review examines practice and decision making of key agencies between May 2013 when ST first became pregnant to March 2014 when Baby N was admitted to hospital and injuries to the baby were observed. 4 Parallel Proceedings 4.1 JB was convicted of the offence of Neglect and ill treatment in August 2014. 1 Children’s Services membership of the Review Team changed three times during the review period, an issue picked up later in this report 5 Local Context 5.1 The Review Team were aware that this was the fifth Serious Case Review in Sunderland which related to the death or injury to a child under the age of 1 year old. Multi-agency learning looking at frontline practice between 2012 – 2014 centred around: a. The absence of good quality and robust assessments including assessments of parental abilities b. The lack of managerial oversight in Children’s Services c. An absence of critical thinking when key decisions were made d. Evidence that frontline practitioners especially in Children’s Services, repeated errors previously highlighted in research and local reviews e. The impact on frontline practice of poor leadership and ineffective supervision practice f. The absence of any robust performance management systems within Children’s Services g. Concerns that senior managers in Children’s Services did not ensure active and sustained participation by managers in SCR processes and how this impacted upon the depth and breadth of learning for that agency. 5.2 The Review Team shared concerns that the same lessons were being identified from each SCR with little evidence that changes were being embedded, quickly enough into frontline and managerial practices. As this SCR was nearing completion, Children’s Services was subject to an inspection by Ofsted and the findings from that inspection were of particular relevance to the findings identified in this SCR and which were related to that particular agency. Where the findings and required actions are similar these are noted and reflected in the report where appropriate. 6 The Family’s Perspective 6.1 The SSCB Business Manager and the 2nd Lead Reviewer met with Mother, ST, and Maternal Grandmother when the SCR began. They were keen to participate in the process but at the first meeting were unable to say how they could have been provided with any further support or advice from professionals. 6.2 Further attempts were made to make contact with these family members but they did not respond to letters or phone messages and so their perspective is sadly missing from this report. 6.3 The Lead Reviewer did however make telephone and email contact with the Paternal Grandmother who expressed distress at the fact that her son JB had not been given access to Baby N despite assurances by Children’s Services that supervised contact would be arranged. The Paternal Grandmother however felt she was unable to comment on professional involvement during the period under review. JB declined to meet or communicate with the Lead Reviewer and this again is a significant omission in this report. 7 The Family as known to Agencies 7.1 The Family2 Mother ST Father JB (and also father to Child D) Baby N 11 weeks (at the time of injury) Child D Half-Sibling (lives with Paternal Grandparents) under a Special Guardianship Order Mother of Child D FL Paternal Grandmother PGM Background Information prior to review period 7.2 Child D was born to parents JB and FL in September 2004. 7.3 At three months old, Child D was taken to baby clinic by JB. A bruise on the cheek and another on the baby’s arm was noted. The following week, the health visitor discussed the injuries on a home visit. FL said perhaps one bruise had been caused by a dummy and the other when the baby was being bathed. The health visitor then noticed another mark - an elongated bruise on the arm and she immediately made a child protection referral. The child was admitted to hospital where a bruise on the child’s left ear was also noted. A skeletal survey showed healing fractures to the forearm and old fractures to the lower end of both shinbones. 7.4 Child D was placed with the Paternal Grandmother on a voluntary basis in December 2004 and following a child protection conference, was made subject to a Child Protection Plan under the categories of Neglect and Physical Abuse. In 2006, the Paternal Grandmother, was granted Special Guardianship3 of Child D and Sunderland City Council obtained a 12 month Supervision Order in respect of the child. 7.5 The CAFCASS report presented to the Review Team stated that both parents accepted they were the primary carers of Child D and as such neither could be excluded as the perpetrator of the injuries. The CAFCASS report also identified that concerns were raised at the time about domestic violence within the parental relationship, the lack of routines and Child D being cared for by multiple carers. In addition there were some concerns noted in relation to JB’s learning needs. 7.6 The specialist reports filed for court included the findings from a Consultant Paediatrician which stated that Child D’s injuries ‘occurred as a result of pulling and twisting forces applied to a limb and these injuries rarely follow accidental injury’. The report concluded that the ‘infant had sustained repeated injury over time in the form of ……fractures and bruises’. A Psychological report was also filed which concluded that Child D would not be at risk in the care of JB ‘for short periods of contact’ but did not comment upon the risks of 2 Names, dates of birth and some family details have been changed to preserve anonymity. The ages given are the approximate ages at the time of the injury to Baby N. 3 A Special Guardianship Order (SGO) is an order made by a Court appointing one or more individuals to be a child's 'Special Guardian'. It is a private law order made under the Children Act 1989 and is intended for those children who cannot live with their birth parents and who would benefit from a legally secure placement. him sharing the same household as his child. At the time of the Final Hearing, JB was living with his parents who agreed to monitor his contact with his child. 7.7 Information recorded on Children’s Services information system (CCM) indicates that JB was later the subject of a Multi-Agency Risk Assessment Conference (MARAC) in 2008 and had a conviction for domestic abuse. 7.8 The Review Team specifically asked Children’s Services to review what was held on file regarding Child D and were informed that the same information as that provided by CAFCASS was on their system. Period under review: May 2013 – March 2014 7.9 In May 2013, ST presented for an antenatal booking appointment when she was 9 weeks pregnant. A ‘Vulnerability Assessment’4 was undertaken. ST advised that the father of her baby, JB, had “mild Aspergers”. There were no safeguarding concerns noted. 7.10 The ‘Vulnerability Assessment’ was received by the Health Visiting Team in late May and by ST’s GP in early June. Later that month, ST, at 16 weeks pregnant, was seen for a routine antenatal appointment and shortly after referred to the Family Nurse Partnership (FNP)5. 7.11 Despite contact with, and encouragement from, the FNP practitioner, ST was unwilling to engage with the FNP programme. The Review Team was told that not all parents agree to the intensive support offered, so this was not particularly concerning and health professionals did not consider that any additional agency involvement was required. ST attended for a routine antenatal scan in late July 2013. No safeguarding concerns were documented. 7.12 JB attended his GP in August 2013 with concerns about excessive sweating and weight gain after giving up smoking. This was a different GP practice to that of his partner ST. He was given smoking cessation advice and referred to a weight management and exercise programme. The GP records refer to JB as suffering from ‘anxiety/stress’ and although he rarely attended the practice, when he did, he was usually accompanied by his Mother, which the GP noted was unusual for a man of his age. The GP was aware of the previous child protection concerns related to Child D, but was unaware that JB was to be a father again. 7.13 In September 2013, ST attended a routine antenatal appointment with her midwife. No safeguarding concerns were documented. 7.14 After two no access home visits, in October, health visitor 1 (HV1) saw ST at home in early November 2013 for an antenatal assessment. ST was excited about her pregnancy, despite it being unplanned. JB was present at this visit and the couple discussed the support they had from extended family members. They reported that they lived apart but that JB spent most of his time with ST when he wasn’t working. During this visit JB disclosed how he was bullied at school and labelled as ‘slow’ but was later diagnosed with ‘Aspergers Syndrome’. He then disclosed that this had made it difficult to cope with Child D and the child had later been placed in the care of his mother (PGM) as a result of being injured by FL. JB explained he had been too young to care for his child and had remained living with his parents. HV1 4 These assessments seek to identify the potential needs of pregnant women who may be vulnerable and require additional services or support. 5 The Family Nurse Partnership is a voluntary home visiting programme for young mothers. A specially trained family nurse visits the parent on a regular basis, from early in pregnancy until the child is two years old. explained to the couple that she had a responsibility to share this information with Children’s Services and JB said he understood why this information should be shared. 7.15 HV1 telephoned Children’s Services later that day and spoke to an ‘assistant social worker’, (ASW1). She was advised that there was information on the CCM system, which confirmed that JB currently had supervised contact with Child D and there were also references to domestic violence towards a previous partner. ASW1 confirmed she would discuss the information with the Operational Manager (OM1) and a strategy meeting would be convened. HV1 followed up this conversation with a formal Child Protection referral, which was faxed through to Children’s Services and copied to the Safeguarding Team in STNHSFT. 7.16 Following her referral, HV1 contacted the Delivery Suite at CHS and advised the Midwifery Team of her referral to Children’s Services and that if ST should attend the hospital over the weekend the Duty Social Work Team should be contacted before discharge was considered. HV1 did not have a verbal conversation with the Community Midwife regarding this referral, she did however copy her referral to the Safeguarding Team in CHS. 7.17 Later that day CHS Midwifery Services received a fax, out of hours, from SW1 indicating that a Section 476 investigation was to be undertaken. A partially completed birth plan was included. This advised that should ST’s baby be delivered over the weekend mother and baby should be kept in hospital until the Monday, when the Section 47 investigation would continue. The fax advised that JB had a history of violence and was a risk to both mother and baby and also stated that Mother was to be informed that JB would only be allowed contact with the child under supervision by hospital staff. 7.18 Following her Child Protection referral the Health Visitor attempted to contact JB to discuss the referral. A message was left requesting he make contact with her. When he phoned back he was advised that a SW would be making contact with the couple to complete an assessment. During the conversation with the HV, she recalled that JB accepted that this would need to happen and he asked whether he would be assessed ‘like he was with his older child’. 7.19 Children’s Services records document that a few days later a no -access visit was made by SW1. This was followed up with a phone call to JB who advised that the Court Order related to Child D stated he could have unsupervised contact with his child. JB also informed SW1 that Child D had been injured not by himself but by the child’s mother, FT. The SW arranged to meet ST and JB the following day. SW1 received a telephone call from Paternal Grandmother later that day which confirmed she was the carer of Child D, via a Court Order and there were no concerns regarding her son having unsupervised contact with Child D. 7.20 SW1 visited the family home and both JB and ST were present. The home was reported to be clean and warm. The couple were documented as being prepared for the birth of their baby and had support from their families. No concerns were documented regarding drug/alcohol misuse or domestic abuse. SW1 recorded that ST was aware of the circumstances regarding Child D, and JB confirmed the injury was caused by the child’s mother. JB reported that he had regular contact with his child. According to Children’s Services records, the parents were informed that SW1 would contact the Police and if there were ‘no concerns to note’ there would be no further involvement by Children’s Services. 6 Under the Children Act 1989, a section 47 investigation takes place where there is reason to believe a child or young person may be suffering or is likely to suffer significant harm. 7.21 ST saw her midwife for a routine antenatal assessment the following day. There is no record of any safeguarding concerns. 7.22 The chronology from STNHSFT recorded repeated telephone calls and emails to SW1 from the HV1. Although she was able to speak with SW1’s colleagues, she did not manage to discuss the progress of her referral with SW1 until the end of November. Once contact was established, SW1 told HV1 that Children’s Services would not be taking any further action and the case was to be closed. She was advised that it was Child D’s mother who had caused the injury to Child D and JB had then assaulted the mother. HV1 records state that SW1 said that there was no risk to the baby and that ST was a protective factor. 7.23 HV1 accepted the decision of SW1, believing that the full history of Child D’s injuries had been accessed. She did not seek any advice or support from her safeguarding supervisor, as she had no reason to doubt that a thorough assessment had been undertaken. She shared the information from SW1 with the midwifery team and also with ST’s GP later that day. She reported that ‘SW1 has assessed the family and is taking no further action, but that health may need to offer additional support as necessary.’ 7.24 In early December 2013, there was a review of the Children’s Services case file by a temporary Operational Manager (OM2). The records state that SW1 had undertaken one home visit and concluded that there was no role for Children’s Services. OM2 however noted the health visitor’s concerns, contained in her November referral on 1.11.13 and decided that he and SW1 would prepare a genogram showing family relationships and SW1 would complete the Initial Assessment to ensure “that the correct conclusions are being drawn”. Children’s Services records show at this point, the Initial Assessment was already out of timescale. 7.25 ST did not attend a hospital appointment in December 2013, in relation to her anaemia. The Community Midwife attempted telephone contact with both ST and JB to advise of the need to attend the Midwifery Day Unit for review and although several attempts at contact were unsuccessful, ST did eventually attend hospital and was successfully transfused. The midwifery involvement at this point focussed on clinical presentation with no safeguarding concerns identified. 7.26 In late December 2013, ST went into labour. The Midwife contacted the Children’s Services Out of Hours Team to advise that ST had been admitted and queried whether JB could be present for the birth. She was advised that the unborn baby was not subject to a Child Protection Plan and there was nothing on the system to suggest that JB could not attend the birth. As they had not been notified of any concern, the duty officer said there was no information to suggest JB could not be present at the birth. 7.27 Baby N was born the next day, following a normal delivery and bottle-feeding commenced. The 24 hour Postnatal Vulnerability Assessment was completed by ST’s Midwife and this was sent to ST’s GP and HV. This document was not easy to read and was of poor quality, but it stated that Baby N could go home with Mum, but JB was not allowed unsupervised access, due to ‘previous concerns of violence’. 7.28 On the 21.12.13 prior to discharge, the Midwife contacted SW1 to clarify discharge arrangements. She was advised that mother and baby could go home, and although JB was not allowed unsupervised access, ST was considered a protective factor for Baby N. Mother and Baby N were subsequently discharged home. 7.29 ST and Baby N were seen on six occasions by the Community Midwife between postnatal day 3 and 11, five of these visits took place at home and one visit took place at clinic. Baby N was noted to be well, although slightly jaundiced. Both parents were present during the day 8 visit and were reassured about Baby N’s general development. No safeguarding concerns were identified. 7.30 On day 11, HV1 contacted SW1 requesting clarity on supervision arrangements regarding JB after receiving information from the hospital about the birth and JB not to have unsupervised contact; she was advised that he was allowed unsupervised access and SW1 was reported to state she didn’t know why hospital midwives thought otherwise. 7.31 Baby N was seen again by the Community Midwife on day 13, no concerns were recorded. HV1 undertook her primary visit to mother and Baby N on the same day. JB was feeding Baby N in the bedroom when she arrived. Both parents were noted to interact well with Baby N. JB questioned the HV about safe handling as he felt he had to be careful after what had occurred with Child D. The HV appropriately advised the parents about safe sleep arrangements and highlighted the risks and dangers of shaking babies. It was agreed that she would return in 2 weeks. The family were noted to be ‘level 2’ which meant they required additional support from health services. 7.32 In January 2014, a new and permanent Children’s Services Operational Manager (OM3) joined the team and found that despite SW1 being instructed to complete and close the Initial Assessment, it was still showing open and incomplete on the system. In response to concerns about work with this and other families, SW1 was made subject to disciplinary proceedings and was later dismissed from the authority. OM3 then instructed a SW (SW2) to prioritise the completion of the Initial Assessment and report back the following week to ensure that closure of the case was still the correct option. The Review Team was informed that due to a back log of open cases, Operational Managers were being told by their service leads, to review the open cases and where it was ‘safe’ to do so, close as many as possible on the system. The instruction to SW2 was in line with this strategy. 7.33 Baby N was seen at 18 days old by the Community Midwife and reported to be well and gaining weight. ST was documented as looking pale; however she said she was feeling healthy and felt well supported by JB and extended family. The Midwife arranged to return in one week. 7.34 HV1 visited ST at home mid April. Baby N was described as ‘clean and well-dressed’. JB was also present and described as responding to the baby well. The couple informed the HV that they were looking for a new home together. JB also advised that he was looking for a new job, as he wasn’t being treated fairly in his current position. HV1 advised that Baby N should be taken to see the GP regarding a rash and ST took Baby N to the GP 6 days later. 7.35 At the end of January 2014, Baby N was seen by the Out of Hours GP when parents were concerned that the baby was unsettled all day and crying more than usual. Colic was thought to be the problem and the parents were advised to use gripe water. Baby N was taken to the Baby Clinic the following day where the baby was stripped and examined which is usual practice, and was noted to be gaining weight. No concerns were identified. 7.36 HV1 undertook a 6-8 week assessment at the end of January 2014. ST was noted to handle her baby gently and was documented as having increased confidence with her baby, reporting that she ‘loved being a mam’. ST discussed the consultation with the OOH GP a few days earlier, stating she had used the gripe water and that Baby N had settled after a bowel movement. HV1 reinforced previous advice on safe sleep; recording that Baby N slept in a Moses basket. No safeguarding concerns recorded. The parents were invited to ‘baby days’ and a referral was made to the nursery nurse for baby massage. The HV reviewed her assessment of the family’s needs and downgraded the support needed to level 1 – universal services. 7.37 In early February 2014, ST attended her GP for her 6-week postnatal check and she was referred to the practice nurse for a contraceptive injection. No concerns were identified. 7.38 HV2 saw Baby N at the baby clinic in mid-February. Advice was given about increasing the amount of formula feed offered. HV2 contacted the named HV, HV1, regarding the clinic attendance. Nothing of concern was noted. From mid-February the nursery nurse visited the family at home to demonstrate baby massage techniques and support both parents in using these techniques. ST advised that they had found a new home and would be moving house in the next few weeks. 7.39 In mid–February, SW2 contacted HV1 by telephone and was updated on the progress that had been made by Baby N and both parents. The HV confirmed she had no concerns about the care of Baby N and agreed to the case being closed to Children’s Services. On the same day Baby N was taken to the GP surgery and the first vaccinations were given. 7.40 In early March 2014, the nursery nurse visited the family home, and saw Parents and Baby N. They were advised to talk and sing to their baby, and leaflets were left with them. The nursery nurse noted that Mum maintained good eye contact with her baby. The Parents were still awaiting the keys for their new property. 7.41 The following day a case note was entered onto the CCM system by OM3 in Children’s Services, stating that the previous SW had not completed an Initial Assessment as advised, so SW2 had been in contact with professionals involved with the family and as there were no concerns, the case would be closed. 7.42 On the 6th March 2014, the day after the above was recorded, Baby N was taken to the Baby Clinic by ST early morning, accompanied by a female friend. The HV at the clinic (HV3) noted an unusual bruise to the baby’s abdomen. ST could not explain how this might have occurred but wondered if the marks could have been caused by her nappy or by her acrylic nails. ST advised nobody else lived in the family home and that they had no pets. HV3 advised ST that as Baby N was immobile she would have to refer the baby to a Paediatrician and to Children’s Services. ST became upset at this point and said she would not ‘batter her baby’. HV2 tried to contact Children’s Services but the phone kept ringing out and then cutting off. A verbal Child Protection referral was eventually made to a call handler and HV3 requested an urgent response. 7.43 HV3, who did not know the previous history of this family, recognised that Baby N needed to be seen by a Paediatrician, because of a possible ‘non-accidental injury’. Due to the difficulty in contacting the duty SW, she requested that ST take Baby N straight to hospital and explained the need for a paediatric assessment with a Consultant Paediatrician. ST cooperated and took Baby N to hospital by public transport, accompanied by her friend and PGM. HV3 advised the Paediatric Emergency Department that she was sending Baby N in for a paediatric assessment and subsequently spoke to the Paediatric Liaison Nurse to ensure that the baby had been brought into hospital. 7.44 The Consultant Paediatrician, after examining Baby N also made a Child Protection Referral to Children’s Services. A strategy discussion was held between Police and Children’s Services and a Section 47 Investigation commenced. A SW (SW4) subsequently attended the hospital where the baby was seen in the care of ST, JB and PGM. 7.45 Baby N was admitted to a paediatric ward where further investigations showed multiple healing rib fractures, and a healing fracture of the left clavicle. The injuries were not compatible with the explanations offered by parents. Hospital staff were advised by the SW that Baby N should not be removed from the hospital by any family member and should they try, then security or police and Children’s Services should be informed. 7.46 During subsequent enquiries, JB questioned whether the harness of the car seat being too tight could have caused the bruising. He again stated that the injuries sustained by Child D were caused by Child D’s mother. Police records indicate that Police Powers of Protection were taken in early March and Baby N was discharged from hospital into a foster placement. 7.47 In mid-March 2014, SW4 contacted HV1 with an update; JB said he had fallen over when holding Baby N and the baby had fallen onto the arm of a chair. ST was reporting that she knew nothing of JB’s previous history and that the couple had subsequently separated. HV1 advised that ST had been present when JB had disclosed the circumstances around the injuries to his first child. 7.48 The Crown Prosecution Service took a decision in April 2014 to charge JB with neglect/ill-treatment. 8 Analysis of Practice 8.1 It is important to recognise how much hindsight can distort our judgement about the predictability of an adverse outcome.7 It should be appreciated that the prediction of events is not a straightforward matter; nevertheless it is important for any review to examine what happened and why actions and decisions may have made sense at the time. 8.2 The examination of single and multi-agency working leading up to the injuries sustained by Baby N has identified some single and multi-agency learning alongside some important reflections about partnership working. The analysis is structured around three specific areas of practice (ASP) listed below and further details follow. ASP1: The response of Children’s Services to the Health Visitor’s referral and the Initial Assessment undertaken in November 2011 ASP 2: The extent to which professionals understood their safeguarding responsibilities ASP 3: Supervision and Managerial Oversight ASP4: The SCR process 8.3 ASP 1: The response of Children’s Services to the Health Visitor’s concerns The information provided to Children’s Services by HV1 on November 1st 2013 should have prompted a pre-birth assessment in line with the Unborn Baby Procedures. This would have highlighted that the injuries sustained by Child D as a baby indicated a potential risk to Baby N. A pre-birth assessment was not however undertaken. 8.3.1 The Unborn Baby procedures in Sunderland clearly state that where a previous child has been made subject to child protection procedures, a pre-birth assessment is required for all 7 Munro (2011: 1.14) subsequent pregnancies. This is to ensure that any known or perceived risks are properly analysed and assessed within a multi-agency context, so babies who may be vulnerable are better protected and support can be targeted to parents who may be struggling. 8.3.2 The information in the Child Protection referral from HV1 to Children’s Services clearly highlighted information about past history, and this was corroborated by ASW1 when she accessed the Children’s Services system. This information stated that Child D had sustained unexplained injuries whilst a baby and had been removed from the care of JB and his then partner, FT. HV1 was told ‘the referral would be passed to her team manager and there would be a ‘strategy meeting’. Although this decision was one which should have been taken by a qualified social worker and not an ASW, the course of action, proposed by ASW1 was correct and in line with the SSCB multi-agency procedures. Her response to HV1 indicates that she had been able to access historical information relating to previous events with Child D. 8.3.3 HV1 appropriately contacted maternity services and was advised that should ST give birth over the weekend, the Duty Social Worker in Children’s Services should be contacted in order that a discharge meeting could be held. The midwives who attended the Practitioner’s meetings informed the Review Tea that where concerns about a baby have been identified, this would be their usual practice. 8.3.4 Children’s Services records indicate that the referral was passed to a locality team but despite the information given and the procedures in place at the time, no strategy meeting or pre-birth assessment was discussed or initiated. SW1 was allocated the case and asked to undertake an Initial Assessment. The Review Team could find no evidence that SW1 accessed Children’s Services records relating to Child D, either before or after her meeting with JB and ST and consequently, the significance of historical information was lost. 8.3.5 Clearly, there was concern on the part of Children’s Services and given that ST was then about 34 weeks pregnant, the need to act quickly was recognised. Although not documented in Children’s Services records, the labour ward received a fax from SW1 advising that a ‘s47 Enquiry’ was underway. The fax included a partially-completed birth plan advising that should the baby be born over the weekend, JB should not be allowed unsupervised contact and mother and baby should be kept in hospital until Monday morning. The Review Team was of the view that SW1 was unclear about what type of assessment she was being asked to complete and why, but as both she and the Operational Manager (OM1) have now left the authority, the Review Team was unable to explore this further and were left to examine the details through records made at the time. 8.3.6 The partially completed birth plan was not discussed with any health professional and the ‘instruction’ was unhelpful; hospital staff have no authority to insist that a mother and baby stay in hospital. The Review Team were informed that there is often a misconception by social workers that staff on maternity or neonatal wards generally ‘supervise’ parent/child interaction, but unless this part of an agreed multi-agency ‘safety plan’, they have neither resources nor capacity to undertake this role over a longer period. 8.3.7 The fact that such a direction ‘in relation to an unborn baby’ needed to be given should have alerted professionals to the Unborn Baby procedures and also reminded health professionals of their own agency guidance in place at the time.8 Although aware of the procedures, neither SW1, OM1 or any of the health professionals were familiar with the detail of these procedures and they did not refer to them to support their actions and decisions. 8.3.8 The reference to ‘s47 enquiries’ and ‘strategy meeting’ gave the impression to midwives on the delivery ward and to HV1 that child protection enquiries were underway. The Review Team was advised that the health professionals believed any concerns about risk to the unborn baby would be encompassed in those enquiries ‘in line with SSCB procedures’ and so they did not challenge the absence of a pre-birth assessment. 8.3.9 The fax from Children’s Services to the labour ward was received outside normal working hours and the ‘incomplete birth plan’ was not shared with the Named Midwife or the Community Midwife as is normal practice during ‘office hours’. It would be expected that existing communication protocols would refer to the importance of the timely sharing of information with key personnel as soon as possible on the next working day. This did not happen. Neither did staff on the labour ward seek any support or guidance from the Named Midwife who has considerable experience in developing or challenging the content and appropriateness of birth plans. The Review Team was informed that as staff believed that Children’s Services were involved there was no further action required on their behalf. The procedure for sharing information received by the labour ward including that received out of hours has now been reviewed and strengthened. Finding: Children’s Services staff and health professionals were unaware of the specific detail of the Unborn Baby procedures and the failure to follow these led to a single agency assessment which had unintended consequences. Recommendation 1 a. SSCB should seek assurance from partner agencies that frontline practitioners have been reminded of the Unborn Baby procedures and specifically informed that where a previous child of either partner has been made subject to child protection procedures, a pre-birth assessment is required for all subsequent pregnancies. (See 5.2.d of the Unborn Baby Procedures) b. SSCB should ensure that this message is clearly conveyed in multi-agency training programmes, where appropriate. 8.3.10 The Review Team was unable to evidence that Child D’s records were accessed before or after the home visit undertaken by SW1 in early November and it is assumed, therefore, that JB’s narrative of what happened to Child D, was accepted without question by SW1. The Review Team has not received any information to indicate that the police information was 8 Joint Guidance for the Supervision or restriction of Parental/Carer Contact to Babies and Children Admitted to Paediatric Wards where there is Actual or Suspected Deliberate Harm to a Child. (Revised 2015) requested to support the assessment being undertaken. There does not appear to have been any discussion between SW1 and her Team Manager (OM1) regarding the Unborn Baby procedures and there is no evidence to suggest there was any managerial oversight by OM1 at the time, in relation to the assessment undertaken. 8.3.11 OM1 left the authority and was replaced by another temporary operational manager (OM2). Almost 4 weeks later, OM2, reviewed the information gathered for the assessment and noted the details of HV1’s referral, Children’s Services records state that he wanted to be sure that ‘the correct conclusion had been drawn’. Records indicate that he and SW1 would prepare a genogram and SW1 would complete the assessment, which was already well outside the 7-day timescale. This work was however never completed. The Review Team commented that even if SW1 had not understood the significance of historical information or the need for a pre-birth assessment, her manager should have been aware of their importance and the need to follow SSCB procedures. OM2 was an interim manager but nevertheless should have been aware of the Unborn Baby procedures. 8.3.12 Following her referral, HV1 made several unsuccessful attempts to contact SW1 to find out the outcome of the assessment, but she was unable to make contact until the end of November. She accepted without question, the decision that there was no role for Children’s Services, believing that information about Child D’s injuries had been accessed and a full assessment had been undertaken by SW1 to inform the decision taken. HV1 was not however given information about the circumstances of the injury to Child D; the age when injured, or the injuries sustained by the child as a baby and neither did she ask for this information. The Review Team was told that HV1 had no reason to doubt that a thorough assessment had been undertaken and there was therefore no need for any discussion with her Safeguarding Team and she did not inform them of the outcome of her referral. 8.3.13 At this point, the only information given to HV1 was what she was told by SW1 and she did not receive any written confirmation relating to the outcome of her referral. The Review Team was told that despite statutory guidance,9 it is not common practice in Sunderland for referring agencies to be sent copies of Initial Assessments or to be given detailed feedback in writing. The Review Team concluded referring agencies need to be informed in writing about decisions taken in response to their referrals so they can better understand and where necessary, challenge, the rational behind the decisions taken. Finding: If the outcome of Children’s Services assessments and the decisions taken are not confirmed in writing to referring agencies, then the rational and understanding for those decisions is diminished. Even with busy schedules and increasing workloads, it is not only good practice to communicate key decisions in writing; it enhances partnerships working and engenders a sense of collaboration between professionals.10 9 Working Together to Safeguard Child 2015 10 http://www.scie.org.uk/publications/guides/guide34/ Recommendation 2 SSCB should ensure that where Initial Assessments are undertaken, referring agencies are informed in writing of the outcome of referrals so there is clarity between agencies about the rationale for the decisions taken. 8.4 ASP 2: How professionals understood their safeguarding responsibilities In a non-collaborative, stressful working environment there is always a risk that professionals defer too readily to colleagues in other agencies who they believe have greater knowledge or more experience than them and this makes challenges more difficult and less likely to take place. 8.4.1 The need for effective multi-agency working and information sharing in order to secure improved safeguarding outcomes is clearly stated in a number of reviews, policy documentation, and statutory guidance.11 8.4.2 Whilst the midwife noted at the booking appointment information regarding JB’s diagnosis of Aspergers there was no exploration of how this may impact on his parenting capacity, nor was any contact made with his GP (his GP details had not been recorded at this appointment). At this time there was no requirement for midwives to link with paternal GPs or share vulnerability antenatal or postnatal assessments. JB’s GP held relevant information about his previous involvement with Children’s Services, MARAC and his medical history - generalised anxiety disorder - and having met the criteria for an autism spectrum disorder. Following this review, midwives now routinely contact a father’s GP where the father’s details are provided and/or asked about. The Review Team were informed further work is being undertaken with GPs to improve partnership arrangements with midwives. 8.4.3 JB shared details with HV1 about Child D and the circumstances under which the child was removed from his care, several years previously. HV1 understood the significance of what she had been told and appropriately contacted Children’s Services, but did not pursue enquiries within her own agency to find out what had happened, for example by contacting the School Nurse for Child D or her Safeguarding Supervisor. School Nursing records held substantial information about Child D but HV1 did not consider the need to access this information as she was referring relevant information to Children’s Services and later, when informed that a strategy meeting was to take place, she saw no need to access the health information held by her own agency. HV1 also reflected that she had believed that JB was being truthful and had given her accurate details and therefore saw no need to be ‘curious’ about what she had been told. 8.4.4 There was some discussion in Practitioners’ Meetings about the extent to which health professionals should check out what was known in their own agency about what had happened to Child D. It was acknowledged that their own systems, had they been accessed, would have produced relevant background information as Child D was a Sunderland child. The view was expressed again that knowing Children’s Services were undertaking an 11 http://www.nfer.ac.uk/publications/MAD01/MAD01.pdf assessment reassured health professionals that background information would automatically be checked, although how health information would have been accessed without their assistance remains unclear. 8.4.5 The Review Team was told there is still confusion about what information can be shared and when, and accessing information from GPs remains a particular challenge. There was a helpful discussion about gathering information from pregnant women about fathers and this is reflected in the single agency learning identified by STNHSFT and CHSFT. In relation to JB, his GP had information that was very relevant to the Initial Assessment, but this was not accessed by health professionals and neither, significantly, by SW1. Finding: If professionals do not access their own agency records for background information when informed that a child known to them is the subject of a child protection or a child in need referral, important information can be lost or not accessed and this can leave children vulnerable. Recommendation 3 SSCB should review how the existing referral forms and guidance notes make clear the expectation that referring agencies gather background information from their own records to support child protection/ child in need referrals or the assessments that follow. 8.4.6 It became clear in individual and group discussions that health professionals in this review saw their safeguarding role primarily as passing on or responding to information from Children’s Services, as the “lead” statutory agency. They were of the view that they had fulfilled their safeguarding responsibilities in terms of sharing information, following up the outcome of the Initial Assessment and being persistent in pursuing Children’s Services for information 8.4.7 Once they had been informed that the assessment had been undertaken and no risks to Baby N were identified, the health professionals acknowledged, that they saw no need for them to take any additional actions to safeguard unborn Baby N. It is at this point that the training and experience of health professionals, should have led them to be more curious about the outcome of the assessment given that a previous baby had been injured whilst in the care of a parent with whom they were currently working. 8.4.8 Whilst HV1 and later, midwifery services, repeatedly contacted Children’s Services regarding outcome of the assessment and the contact/supervision arrangements, neither agency raised the issue of non-compliance with the procedures with their Named Professionals. The Review Team was told that the midwives and health visitors were unaware of the details of these procedures but assumed that if they were relevant Children’s Services, as the ‘lead’ agency would have advised them accordingly. 8.4.9 The question was asked about what stopped them being more curious about what had actually happened. Health professionals explained that competing demands for time and heavy workloads did not always allow them times to be ‘curious’, other than for families where there were emerging concerns or where safeguarding was already an identified issue. Health professionals described significant staffing issues during the period under review and the need to respond to a growing number of families with child protection concerns. These factors were felt to significantly impact on their workloads and influence what tasks they addressed and what they felt should be undertaken by partner agencies. 8.4.10 It was questioned in the Practitioners’ Group whether Children’s Services should be challenged given they were the ‘experts’. It was felt that they had to ‘trust’ their social work colleagues if they were told by them that checks had been undertaken and assessments concluded. The Review Team acknowledged these comments but are of the view that this approach clearly places the responsibility for ‘safeguarding children’ onto Children’s Services and did not reflect current thinking that every agency has a role to play in keeping children safe. Whilst the health professionals acknowledged this, it was pointed out that had there been safeguarding concerns noted, i.e. new or emerging issues, their practice may have been different. 8.4.11 Health professionals saw no reason to be concerned when told the assessment had been concluded and Children’s Services would have no further involvement. Careful parenting had been observed and the parents were engaging with professionals. Nevertheless, this was a family where a previous baby had sustained unexplained injuries and professionals needed to be both mindful and probing about that fact. Whilst it is not the responsibility of health professionals to do the ‘job’ of their social work colleagues, they are experienced practitioners and their knowledge and expertise should at least have led them to ask more details about the injuries to Child D and the role of JB. Had they questioned, sought appropriate advice they may have been supported to question the view that ‘there were no risks’ to Baby N, and the poor practice of SW1 and lack of managerial oversight might have come to light much earlier. However, in times of increasing workloads and busy schedules, the views were passionately shared in the Practitioners’ Group that the responsibility for challenging and addressing poor practice lay within the management structures of Children’s Services. 8.4.12 Between November and December, information from Children’s Services to HV1 and the Midwifery Team was confusing and contradictory but ST and Baby N were sent home without a discharge planning meeting. This was a missed opportunity, which could have been used to clarify the position regarding JB and supervised contact. It was apparent that midwifery were still concerned about the information contained in their hospital records and contacted SW1 to check that it was safe for baby to be discharged home with Mum, however no support was sought from the Named Midwife. 8.4.13 The Community Midwife did not question information about contact when the Mother and baby returned home and, despite JB being present during at least one of the post-natal visits, did not clarify or discuss how ST was supervising her Partner’s contact with their child. There was no meeting or telephone contact between the Community Midwife and Health Visitor around the supervision arrangements and no contact made with either ST’s or JB’s GP. 8.4.14 The confusion and misinformation around ‘supervision and access’ did not spark any concern from health professionals nor did it signal a need to refer this issue onto their Safeguarding team. HV1 did clarify supervision arrangements prior to her primary visit and again was reassured by Children’s Services that none were required; this was not shared with the Named Nurse or her team within STFT. 8.4.15 During later meetings with practitioners there was discussion about roles and responsibilities. Practitioners shared with the Review Team their frustration with colleagues in Children’s Services who did not return calls, meet timescales, or respond appropriately when they raised concerns. They were aware of how busy everyone was but stressed they too were working under pressure and could not spend their time always tracking progress of referrals or concerns. Finding: What is seen as consistently poor performance of Children’s Services has resulted in a loss of confidence by professional colleagues and this has a significant impact on partnership working and seriously compromises multi-agency working. This issue was identified in the recent Ofsted report. Recommendation 4 SSCB should consider how it might facilitate improvements in working relationships between professionals and so enhance multi-agency practice. 8.4.16 Whilst there was an acceptance that all agencies had safeguarding responsibilities to ensure that practice within and across agencies was robust and to challenge where accepted standards were not met, health professionals in the practitioner’s group continually stressed that they had no concerns about the care of Baby N. Children’s Services was not however the only agency holding information about what actually happened to Child D; whilst the facts surrounding the unexplained injuries on Child D were not shared by SW1, the information would have been available from the school health Child Records had the HV1 liaised with her School Nurse colleagues. It was not until much later the review process that health professionals recognised the similarities between the injuries of Child D as a baby and Baby N. 8.4.17 The decision to allow the Baby to be taken from the clinic by her Mother was potentially unsafe and a Consultant Paediatrician appropriately advised HV3 that she should have ensured that the Baby remained in clinic until a SW arrived. Later that day the HV discussed the day’s events with a Safeguarding Supervisor and understood that she should have considered alternative arrangements to transport Baby N to hospital, for example by discussing with the police, given she was unable to speak to a SW. It is unfortunate that she did not consider liaising with her Safeguarding Supervisor or the Named/Lead Nurse in STFT at a much earlier point about the difficulties she was having in contacting Children’s Services. HV3 accepted these comments and shared the difficulty in managing such a sensitive issue in a clinic full of other parents and with no easy access to a private room. During the individual conversation with HV3, she advised she was relatively new to the Sunderland area and did not have access to the SSCB procedures in the clinic setting. She had to arrange support from her colleagues to relieve her from her clinic responsibilities and returned to her office to complete the necessary paperwork and fax it to Children’s Services. She had reflected on her actions and recognised earlier support from the STFT Safeguarding Team should have been sought to ensure all aspects of the referral and medical management were safely considered. 8.4.18 SW2 advised the Review Team that she saw her responsibility as responding to her Manager’s instruction to check with the Health Visitor before closing the case and she did just that and no more. She did not check the background files for Child D and clearly did not access the incomplete Initial Assessment. She described how the Team were under considerable pressure at the time and she just did as she was told. The Review Team were concerned at this response from SW2 as it suggested a lack of confidence in being able to challenge her Manager about what she was being asked to do, but it also highlighted that from a professional perspective, SW2 demonstrated poor practice in closing a case on file without reviewing records or checking that all that should have been done to ensure the safety and welfare of a child had been done. 8.4.19 The case was closed without any challenge from HV1, although it is difficult to determine on what grounds HV1 could have argued for it to remain open. Although the couple were moving house to live together, HV1 did not share this information with SW2 and clearly did not think of it as the ‘significant’ event it was. The Review Team were of the view that this information would have been highly unlikely to have impacted on the decision to close the case, given the circumstances under which that decision was taken. 8.4.20 HV1 did identify that she could recall having a ‘gut’ feeling about ST and Baby N. In conversation, HV1 said she couldn’t clearly identify what was troubling her and knowing that Children’s Services were closing the case, felt she had no strong evidence for her ‘feeling’. She therefore agreed to the case being closed. Had she been aware of the circumstances and nature of the injuries sustained by Child D, HV1 said she would have pursued this instinct further. HV1 also indicated that with hindsight, it would have been useful to share her feelings with her safeguarding supervisor as this may have offered an objective pair of eyes to help her step back and review her thinking. In practitioner meetings, the challenge of knowing when and whether to seek support for concerns which don’t meet the child protection threshold was acknowledged and views expressed that this was often made more difficult by the fragility of relationships and lack of confidence in other agencies. 8.4.21 The Review Team were left with a sense that professionals in this review had a narrow view of their safeguarding responsibilities. In the present climate, however health professionals found it difficult to accept that their safeguarding responsibilities extended beyond sharing or responding to information or in the case of SW2, doing more that they were told. This perspective can leave children vulnerable but also highlights the vulnerabilities of a multi-agency system designed to safeguard children. 8.5 ASP 3: Supervision and lack of effective management oversight; During this review it was revealed that there was not a thorough understanding by frontline professionals and managers of the Unborn Baby procedures. The initial child protection referral was shared with the safeguarding team in STNHSFT and CHSFT but neither they nor the Operational managers in Children’s Services picked up the significance of the information shared. 8.5.1 Whatever the state of their work environment, frontline practitioners must constantly assess situations and make judgements while working on their own or in teams. However, supervision sessions should both support and challenge practitioners - helping them to avoid the temptation to slip uncritically into either an analysis skewed by bias and unfounded assumptions, or simply defaulting to an entrenched ‘agency view’. 8.5.2 The Review Team were informed that the experiences of supervision and managerial oversight varied across agencies; in health settings high caseloads often meant only higher risk (i.e. Child Protection) families were discussed, whilst in Children’s Services, supervision depended on other pressures and too often sessions, at that time, were cancelled or led by agency workers who were not familiar with local procedures. The lack of robust supervision arrangements for social workers and concerns about management oversight were highlighted in the recent Ofsted report. 8.5.3 In the professionals’ meetings, health professionals were varied in their responses to when and under what circumstances they would contact their Safeguarding Team s or Named leads where concerns did not reach the child protection threshold. The Named Professionals provide a statutory role for their employing organisations and are expected to function at level 4 competency as outlined in the Intercollegiate Guidance, 12Health Visitors and Midwives must demonstrate safeguarding children competency at level 3 and this requires them to use their professional judgment when making safeguarding decisions. The Health Visitor complied with her agency’s safeguarding procedures by copying the Safeguarding Team, Midwifery, and the GP into her child protection referral in November, she did not however advise the outcome of that referral. 8.5.4 It is usual practice that when a child protection referral is copied into the Safeguarding Team at STNHSFT, a safeguarding advisor reviews the information and checks for any additional information on the system which may support the frontline professional. Using a tracking tool, there is usually a follow up with the referring professional after 5 days to monitor progress if they have not been informed by the referring professional. Where a referral remains outstanding with no recorded outcome, the tool is used to alert the safeguarding advisor/referring professional for the need for remedial action. It became evident in this 12 /Safeguarding Children Roles and Competences for Healthcare Staffed review that the absence of any follow up from the safeguarding team in STNHSFT in relation to the referral was directly linked to capacity issues. The safeguarding team consisted of three and then later two safeguarding advisors, the original team having been composed of seven and this appears to have impacted upon the team’s ability to respond to STNHSFT procedures for routine safeguarding practices. The Review Team were informed that this issue is currently being addressed as a matter of some urgency through a ‘Business Continuity Plan’ for the Safeguarding Team. 8.5.5 The Named Professionals and safeguarding advisors were unaware that no further action was being taken by Children’s Services and this clearly was a missed opportunity to challenging procedural non-compliance and the decisions taken by Children’s Services. Finding: This review highlighted that the roles and responsibilities of Named Professionals and their respective teams would benefit from clarification and dissemination amongst health professionals. Finding: Where capacity issues impact on the ability of these teams to respond effectively to the material passed to them, important information can be overlooked. Recommendation 5 SSCB should seek assurance that the Named Professionals and their safeguarding teams are well equipped to effectively monitor and respond to safeguarding information forwarded to them. 8.5.6 The review team were made aware that the STNHSFT Safeguarding Team still do not have an electronic system to support the Named Nurse and the supervisors in their daily work – this was a recommendation in the Child X SCR in 2010, and reportedly remains high on the STNHSFT Risk Register. Some health information on Child D will have been archived off-site by the Safeguarding Team, but could have been requested when the initial child protection referral was reported to them when ST was pregnant. It has been acknowledged that the School Nurse would have been able to provide the historical information regarding the incident and subsequent events with Child D. Additionally if the outcome of the referral had been shared by the Health Visitor, with her Safeguarding Team, the absence of pre-birth would have likely been identified and support offered to the HV to ensure procedural compliance. 8.5.7 The STFT Agency Learning Report advises that the above should have been the core response from the safeguarding team, but highlights that in addition to capacity issues mentioned previously , the team at STNHSFT also became responsible for Safeguarding Adults which was also not without impact on practice. 8.5.8 Clearly, there were significant and concerning shortcomings in the quality of the Initial Assessment, which by January was several weeks outside of timescale. A new Operational Manager (OM2) appointed in January instigated disciplinary proceedings against SW1 in relation to her work with this and other families and she was subsequently dismissed her by the Local Authority. OM2 instructed SW2 in February 2014 to contact other professionals and if they had no concerns about Baby N to complete a summary and close the case. SW2 placed a closure note on file in March 2014, having been informed by HV2 that she had no concerns about the care of Baby N. 8.5.9 The Review Team requested additional information on what SW2 had been asked to do and were clearly informed she had been asked to just check with the professionals involved, i.e. the HV, whether there were any current issues. She was not asked to review the files held by Children’s Services on Child D or revisit the Initial Assessment itself. SW2 advised the Review Team that the records indicated that the historical files had had been checked by SW1 so she saw no reason to revisit previous records for Child D. The Review Team have learnt that the Initial Assessment although ‘open’ on the CCM system, contained no details at all. Whilst the records relating to the home visit were on the Family’s file, there was no analysis to support to the judgement that there was no risk to Baby N. The Review Team was unable to explore why historical records were not accessed and how the decision was made that there were no risks involved. No supervision records for SW1 have been located. The ‘warm and comfortable home’, the disclosure, and self-reported history by JB together with his willingness to engage appear to have influenced SW1 and highlight a level of professional naivety/professional optimism when faced with what was likely disguised compliance by the family. 8.5.10 The Agency Learning Report from Children’s Services described drift and delay, resulting from sickness, change of SWs and the involvement of 3 Operational Managers, the first being a temporary agency worker. The very evident poor practice of SW1 was compounded by a lack of management oversight and supervision; and although the Review Team were assured that an appropriate review of her caseload was undertaken, it is clear that the shortcomings related to the ‘Baby N’ assessment was not picked up. Finding: Organisational restructuring, inadequate IT systems, increasing workloads and reduced staffing are significantly impacting upon the work of frontline professionals and their managers and compromises their capacity to safeguard children effectively. Recommendation 6 SSCB should establish a system whereby the board is kept informed on a regular basis by partner agencies about any organisational constraints which impact or are likely to impact on their safeguarding responsibilities. 8.6 ASP 4: The SCR Process 8.6.1 This review has been delayed in completion due to a range of factors: change in Review Team membership, incomplete individual agency learning reports and action plans, rescheduled meetings due to the Ofsted Inspection and other review processes impacting on managers, the SSCB Business Unit and the 2nd reviewer. The number of SCRs being undertaken in Sunderland has a significant bearing on the extent to which practitioners and managers from all agencies can realistically sustain their active involvement in multiple SCRs. 8.6.2 The Review Team recognised the significant pressures influencing Children’s Services and the challenging climate in which both managers and practitioners are currently working. The number of temporary leadership posts within Children’s Services has been commented upon by partner agencies and there has been a consequential impact of these on this and other SCRs. During the process of this review, 4 different Children’s Services Managers attended at various times, as members of the Review Team and were not always well prepared to contribute to discussions. This compromised the ability of the Review Team at times to work effectively but it also created tensions as managers from other services attended regularly and met the required deadlines for information and action plans. This issue has been raised in previous SCRs. 8.6.3 It is clear that when managers in temporary positions attend as team members of a Review Team, they struggle to commit to the SCR process, as they were not in post during the period under review, and they are often unable to account for practice in their service at that time. Neither, however, can they always reassure the Review Team, that the necessary changes will be introduced and embedded. Finding Partners have expressed their frustration at what they regard as a continued lack of commitment by senior and middle managers within Children’s Services to SCRs and are of the view that their failure to ensure continuity of membership compromises the learning from, and the integrity of, the SCR process. 8.6.4 Sunderland LSCB has completed a number of case and serious case reviews over the past 3 years and there are many common themes emerging from these reviews. This would suggest that whilst lessons are being learnt, they are not being embedded quickly enough into frontline practice. The challenges highlighted by the recent Ofsted report in respect of Children’s Safeguarding Services and the LSCB clearly compound this issue even further. The following recommendations are respectfully offered to assist the LSCB to move forward in learning from SCRs in the light of improvement plans already identified. Recommendation 7 The single agency action plan template used in SCRs is reviewed so the Board can more easily audit and monitor progress of single agencies in implementing agreed actions. Recommendation 8 The Board reconsiders the way in which operational and strategic learning from SCRs is disseminated across the workforce and between Board partners. Recommendation 9 SSCB should review the capacity of the SSCB Business unit to respond to and manage existing and future SCRs especially given its increased responsibility to also support the Adult Safeguarding Board. 9 Summary The historical information relating to a previous child of the father should, in line with Sunderland’s Unborn Baby procedures, have led to a multi-agency pre-birth assessment once it became known that the male was to become a father again. Whilst this may not have prevented the injuries sustained by Baby N, it would have identified the potential risks posed to a vulnerable baby and allowed agencies to consider how or if these risk could be managed and the need for protective action agreed. Health and social work professionals observed careful and sensitive parenting and had no concerns about the safety or welfare of Baby N, although they were aware of some concerns with a previous child several years previously. Their willingness to accept what they were told by both parents highlights how, without good supervision, a measure of curiosity and a degree of healthy scepticism, professionals can be influenced and to some extent disarmed, by parents and grandparents who appear helpful and persuasive. This review is also a stark reminder to professionals of the importance of not only sharing information, but also questioning what is being shared and on what basis decisions and actions are undertaken. This requires the continued acceptance that safeguarding children is a responsibility shared by all agencies. During the period of 2013 -2014 a number of case and serious reviews in Sunderland have highlighted the impact of workforce instability and poor managerial oversight in Children’s Services on staff morale, both within the organisation and on other agencies. This SCR again reinforces the importance of clear direction from managers and safeguarding supervisors in all organisations and illustrates how a variety of factors can result in procedural non-compliance which can lead to unintended consequences. Appendix 1 Single Agency Learning (Information below is taken directly from the Agency Learning Reports which were endorsed by the Chief Officers in each agency) City of Sunderland Children’s Services All Front Line Staff in Children’s Social Care must be supported to deliver high quality practice: Children’s Services have developed a new framework for supervision to ensure that all front line practitioners and managers receive regular (4 weekly), good quality supervision. Supervision is monitored through regular reporting to both Children’s Services and the monitored and reported to the improvement board on a monthly basis. The caseloads of all social workers are monitored and reported weekly. Ensuring front line practitioners are aware of and understand the Unborn Baby Procedures. Children’s Services staff have been reminded of these procedures through briefings and the procedures will be part of the induction for new staff. Management information to assist front line manager to manage workloads will be developed. A weekly and monthly performance management data set has been developed and this is available to all front line managers and staff. This will enable Managers to have oversight of all the work of their team, including assessments out of time. There is a weekly Improvement meeting with all Managers chaired by Head of Safeguarding. The Performance Information Team which supports Children’s Services is being strengthened and Children’s Services are commissioning a new Recording System which will enable managers and practitioners to have access to a range of performance information. Ensuring that all staff in Children’s Services have access to statutory guidance and procedures. Children’s Services have commissioned TriX which will give all staff access to online statutory guidance and procedures. The system will be operational in January2016. Ensure that referrers are informed of the outcome of assessments Children’s Services has undertaken a range of work to strengthen and improve the process for managing and responding to referrals. New processes to ensure that referrers are informed in writing of the outcome of referrals and assessments are being developed will be fully operational as of 1.12.15 Sunderland Clinical Commissioning Group • Where a father to be or father is known to be registered with a different GP to the other family members information will be shared with them about any safeguarding concerns by midwifery and health visiting services • GPs have been requested to consider the parenting/caring role of men when taking histories from male patients to ensure they can liaise with other practitioners involved in safeguarding children to prevent issues about “hidden/invisible fathers” • The SSCB will ensure that all safeguarding procedures are explicit regarding information sharing with GPs for males who are Fathers or carers South Tyneside NHS Foundation Trust (STNHSFT) • STNHSFT should ensure that all baby clinics have Children’s Services contact numbers and body maps accessible frontline professionals • The awareness of the ‘masking’ influence of tidy, well presented and appropriately responding parents on the perceptions of health professionals should be revisited through supervision and training • STNHSFT Safeguarding Procedures should be amended to reflect the process for safe transfer of a child to the local hospital when a paediatric assessment is required • STNHSFT new starters safeguarding supervision should reinforce how to deal with suspected NAI within the community settings • The use of STNHSFT tracking tool, which has been recently reviewed, should be audited within 6 months • The role of the Safeguarding team and the information they may hold should be highlighted to all front line health professionals • Staff will be reminded of the importance of promptly escalating concerns to, or seeking advice from, the Safeguarding Team at STNHSFT City Hospitals Sunderland • A more holistic discussion should be undertaken by Midwives with both parents including the completion of a genogram to provide a robust risk assessment and analysis • The Vulnerability assessment needs to be updated to include key factors for inclusion including who is present at booking, name of fathers even if not currently in a relationship, contact made with GP • Contact should be made with the father’s GP to ascertain any unknown risks to improve information sharing between agencies regarding ‘invisible’ fathers • Midwives need to escalate cases where safeguarding procedures are not being followed • The maternity safeguarding Team need to have oversight of all cases • Internal processes for sharing information received OOH needs to be robust • In view of the lack of birth arrangements and concerns raised by the midwives a discharge planning meeting should have been held. This is particularly important where post- natal arrangements needed a multi - agency approach. During this time period pre discharge planning meetings were not robustly embedded in practice • Capacity issues within the Maternity Safeguarding team need to be addressed Appendix 2 Recommendations for Sunderland Safeguarding Children Board Recommendation 1 a. SSCB should seek assurance from partner agencies that frontline practitioners have been reminded of the Unborn Baby procedures and specifically informed that where a previous child of either partner has been made subject to child protection procedures, a pre-birth assessment is required for all subsequent pregnancies. (See 5.2.d) b. SSCB should ensure that this message is clearly conveyed in multi-agency training programmes, where appropriate. Recommendation 2 SSCB should ensure that where Initial Assessments are undertaken, referring agencies are informed in writing of the outcome of referrals so there is clarity between agencies about the rationale for the decisions taken. . Recommendation 3 SSCB should review how the existing referral forms and guidance notes make clear the expectation that referring agencies gather background information from their own records to support child protection/ child in need referrals or the assessments that follow. Recommendation 4 SSCB should consider how it might facilitate improvements in working relationships between professionals and so enhance multi-agency practice. (See SCR Baby A and Child C) Recommendation 5 SSCB should seek assurance that the Named Professionals and their safeguarding teams are well equipped to effectively monitor and respond to safeguarding information forwarded to them. Recommendation 6 SSCB should establish a system whereby the board is kept informed on a regular basis by partner agencies about any organisational constraints which impact or are likely to impact on their safeguarding responsibilities. Recommendation 7 The single agency action plan template used in SCRs is reviewed so the Board can more easily audit and monitor progress of single agencies in implementing agreed actions. Recommendation 8 The Board reconsiders the way in which operational and strategic learning from SCRs is disseminated across the workforce and between Board partners. Recommendation 9 SSCB should review the capacity of the SSCB Business unit to respond to and manage existing and future SCRs especially given its increased responsibility to also support the Adult Safeguarding Board. ` Appendix 3 PROGRESS REPORT Outlined below is some of the improvement work undertaken by individual agencies and by the SSCB partnership: Sunderland Clinical Commissioning Group Where there are Safeguarding concerns about an unborn baby, GPs to share appropriate and proportionate information about fathers to assist in information gathering by midwives and enabling appropriate referrals to Children’s Services • Ongoing work continues with the Head of Midwifery to develop a plan to ensure patient confidentiality is respected and Safeguarding concerns in respect of the father of the unborn baby are shared; this will inform the risk assessment process. • Risk assessment and referrals in respect of the unborn baby are undertaken in a timely manner in the antenatal period. • The pre-birth assessment will include father’s information. • The impact of this will be reflected in such cases being discussed at MDTs which will improve information sharing. GPs have been required to consider the parenting/caring role of men when taking histories from male patients to ensure they can liaise with other practitioners involved in Safeguarding children to prevent issues about hidden/invisible fathers. • This recommendation is being covered in the GP locality training sessions which began in November 2015; dates have been planned until March 2016. • GPs recognise the importance of understanding the relevance of sharing Safeguarding concerns in respect of fathers in order to safeguard the unborn baby City Hospitals Sunderland NHS Foundation Trust • Ensuring robust, respectful challenge when safeguarding procedures are not followed. • The Unborn Baby Procedures have been highlighted with Midwives. • Midwives will be aware of the timescales for actions under the procedures and understand the key points where challenge may be required. The role of the Maternity Safeguarding Team and the need to escalate any delays to the team has been reinforced. • From October 2015 there are now 5 teams with dedicated community midwives who will provide continuity of care to the women ensuring that the midwives have a robust understanding of the case. Where drift and delays are highlighted the Midwife will be able to challenge and escalate as required. Impact to date has been evidence through challenge by Midwives. An audit will be undertaken in December 2015 to further evaluate impact. Strengthened oversight by the Maternity Safeguarding Team The Maternity Safeguarding Team should have an oversight of all safeguarding cases and where there are concerns in respect of the case they are reviewed by the Team. All referrals are quality assured by the Maternity Safeguarding Team and concerns are feedback to the referring Midwife and discussed in supervision. This ensures improved professional quality of referrals, challenge as required. Improving information sharing during Out of Hours (OOH) Arrangements for secure transfer of information via secure email have been strengthened. Staff are aware of the requirement to prioritise information sharing and a more robust recording system is in place. These processes are closely scrutinized and any issues are raised with the Maternity Safeguarding Team. This ensures robust management oversight. Improved capacity of Maternity Safeguarding Team Additional resources have been provided that is 0.5wte dedicated admin. This has enabled a robust process for internal procedures to be implemented. A further 1.0wte is being considered. An additional temporary Safeguarding Midwife has been appointed and a further 1.0wte Named Midwife is being considered. Both posts will strengthen the capacity of the team. Strengthen Pre discharge planning meeting CHSFT and Children’s Services have strengthened the use of the pre-discharge planning meetings. This ensures a robust secure discharge home and is evidenced through minutes etc. Embedding Learning and Improvements into every day practice All actions from this SCR have been considered and will be implemented from January 2016. These improvements will strengthen the continuity of care for women and their babies from dedicated Midwives who have knowledge of the safeguarding concerns regarding the family. Sunderland Safeguarding Children Board The SSCB has instigated the following improvement work: • Reviewed and updated the Safeguarding the Unborn Baby - to strengthen the requirement for the Pre-Birth Child in Need Assessment to include information from other professional assessments including the Vulnerability Assessment Protocol. The assessment will therefore be multi-agency and include the expertise of partners. The Pre-birth Child in Need Assessment must also be copied to all professionals working with the family to ensure a shared understanding of what the child’s plan is based on • Reviewed and updated the SSCB Vulnerable Baby Training - This is delivered to multi-agency staff and includes the learning from SCRs • Raised awareness of the learning from the SCRs - developed SCR briefing sheets and delivered multi-agency learning and improvement workshops. Staff attending the sessions report that they have learnt from the sessions and are applying this to their practice. The impact of this learning will be audited through a further post course evaluation audit • Reviewed and agreed a robust action plan format for future SCRs which will require agencies to demonstrate what improvements they intend to make and how they will measure the impact of the improvement work on children and their families • Reviewed and updated the Child Protection/Child in Need Referral form - To strengthen the requirement to access and consider historical family information prior to submitting referrals - To remind professionals that their responsibility does not end once they have made a referral - To remind professionals that they have a professional responsibility to challenge drift/delay using the SSCB Escalation and Challenge Process when required - To require referring professionals to identify fathers and/or any other adult male in the child’s life and clarify their role in relation to the child The intended impact of the improvements is to ensure that referrals to Children’s Services contain robust historical information and a full outline of the family of a child including any adults they have contact with, remind multi-agency staff of their responsibility to continue to work with families even if they have made a referral to Children’s Services and when multi-agency professionals don’t receive a response to their referral or they don’t agree with the action taken in response to their referral they must escalate issues to ensure children and young people are safeguarded. • Reviewed and updated the SSCB Escalation and Challenge Function and highlighted the process to multi-agency staff - The impact of this is to ensure that multi-agency frontline staff and managers are aware of their responsibility to escalate issues of concern, the process is put into action when required and use of the process safeguards children and young people |
NC52401 | Severe neglect and abuse of a large group of siblings by their mother and father over many years. Care proceedings concluded in 2017 and the children are no longer under parents' care. Six of the siblings are now adults. Evidence of the children suffering significant neglect and abuse by their parents between 2007-2017. Home environment was overcrowded, chaotic, dirty and unsafe. Evidence of physical abuse, domination and coercion, and failure to prevent physical and sexual abuse between siblings. Failure to ensure that the children received medical care or attended school regularly. Parents were uncooperative; aggressive to professionals with some disguised compliance and manipulative behaviour. Several of the children made subject to child protection plans for neglect in 2007-2009; in July 2016 police protection was taken on all the children under 18 living with the parents and interim care orders were granted. Learning includes: overwhelming nature of the complexity and scale of the problems and of the oppositional, hostile behaviour of the parents; responses from all agencies to concerns and interventions were generally short-lived and episodic; children's lived experience was not fully appreciated. Ethnicity and nationality not stated. Recommendations include: develop a model for interagency practitioner supervision for complex cases where working together closely and consistently is of paramount importance; ensure that the use of the Public Law Outline is being used effectively to give local authority and social workers sufficient leverage with families which are deliberately obstructive by clarifying their concerns in a 'Letter before Proceedings' or further action.
| Serious Case Review No: 2020/C8262 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Serious Case Review Conducted Under Working Together 2015 Children’s Case W Overview Report Lead Reviewer Amy Weir MA MBA CQSW 2 | P a g e Final 12.09.2018 SCR CASE W LIST OF CONTENTS 1. INTRODUCTION AND BACKGROUND TO THE REVIEW 3 2. REVIEW PROCESS 3 3. NARRATIVE OF KEY EVENTS 7 4. The EXPERIENCE of the CASE W children 15 5. THEMATIC ANALYSIS & EVALUATION OF PRACTICE and THE WAY AGENCIES WORKED 19 6. Summary Thematic ANALYSIS 26 7. FINDINGS 28 8. CONCLUSIONS 30 9. RECOMMENDATIONS 31 Appendices Appendix A - List of References 3 | P a g e Final 12.09.2018 1. INTRODUCTION AND BACKGROUND TO THE REVIEW 1.1 This Serious Case Review (SCR) was commissioned following concern about the neglect and abuse experienced by the children of Family W over a period of many years. It considers the circumstances in which services were provided to the children and their family and seeks to identify learning about how practice could be improved. 1.2 All the names in this review have been anonymised and the children are known as W within this review report. The case review considers the experience of the children but also of the older children of the family who are now adults. 1.3 There were care proceedings in relation to some of the children. These were concluded in 2017 and the children are no longer in the care of their parents. 1.4 The circumstances of the neglect and abuse experienced by the children of this family led to the decision in September 2016 by the Chair of the Local Safeguarding Children Board to undertake a serious case review. The criteria for commissioning a SCR, as set out in Working Together 2015, were met. 2. THE REVIEW PROCESS 2.1 This review has been conducted with due regard to the principles of fairness, impartiality, thoroughness, accountability, transparency and above all with a focus on the children. The consideration of their interests and experience has been the central focus of the review. The significance of the circumstances in which they were abused and neglected has affected all those involved in the review. 2.3 Amy Weir, who is an experienced independent safeguarding expert, was appointed as the independent reviewer. A panel of senior managers 4 | P a g e Final 12.09.2018 was formed to support the process. Amy Weir wrote this report with the support and advice of the SCR Panel. 2.4 Critical points in the case were considered in the SCR. Possible reasons for actions taken at the time and learning and improvements that are now still needed have been identified – including the significance of these insights for current practice. Where there was evidence of good practice in the case, this has also been noted. These findings will inform the LSCB’s Learning and Improvement Plan and they have already led to progress in improving local practice. 2.5 This investigation has examined key documents and involved experienced senior managers who have had no direct involvement in this case. The root cause analysis “fishbone” approach to identifying key contributory factors has been used. The aim of this has been to gain an understanding of how the interaction between the various factors influenced the way practitioners responded to the children and their family. 2.6 There have been several other serious case reviews conducted by the LSCB in the last 2 years which have found that there were issues for all agencies about the effectiveness of the identification of, and addressing of, the severe and chronic neglect of children. This review also looked across these other reviews to ensure that the learning from each of the others is considered within the findings of the Case W review. 2.7 A key focus for this review has been to ensure that the voice of the children, their wishes and feelings have been taken fully into account. This is a very large sibling group and the children’s experiences of being parented have varied considerably but it is clear that there has been significant harm and suffering for the children as a result of the compromised and inconsistent parenting they received from their parents. 5 | P a g e Final 12.09.2018 2.8 The family have not been contacted about this SCR. It is not the intention to advise them that this case has gone through the review process because of the complexity of the relationships and the conflicting and differing views of family members. The parents are confrontational and have never demonstrated an understanding of their children’s needs and have not cooperated fully or honestly with the support provided to them. There are also outstanding criminal investigations which are unlikely to be resolved for a considerable period. 2.9 There have been other proceedings in this case. The children have been subject to care proceedings. The Police are still investigating the neglect of the children by mother and father and prosecution may follow. 2.10 The main time period covered within this Serious Case Review is from 2012 to 2017. Any additional historical information relevant to the review going back beyond these dates (e.g. within the family history) has been fully considered in the review as important contextual history. 2.11 The Judge in the care proceedings was consulted about the review. It has been agreed that the information should be anonymised, and that there should be consideration given to not publishing this SCR, given the concerns about the sensitive nature of this case and the high likelihood that the children would be identifiable. This review is an anonymised thematic review, which does not provide the full details of the family or the issues faced by individual children. The critical points considered are: 2.12 Following scoping of the case and the issues arising from it in January 2017, the SCR Panel was asked to summarise the key practice episodes within their agencies. The Panel met on 27th July 2017 to review the findings to date. 6 | P a g e Final 12.09.2018 2.13 There are three key periods of involvement in 2009, 2012 and 2016 when there was significant involvement with the family and an increased concern about the care of the children and the poor quality of parenting. 2.14 The report considers the Terms of Reference and is structured to describe and discuss the major themes arising from these. • The effectiveness of the child protection system and case management processes in identifying the needs of the children, in addressing poor parenting and in improving the circumstances of each child. This is particularly of interest for the two younger children who have additional medical needs. • The impact of the size of the sibling group on identifying and addressing the needs and maintaining focus on each child whilst working with this family. • Appreciation and understanding of the differential parenting provided and the expectations attributed to different children which characterised how different children were cared for. • The impact of, and the management of the parents’ oppositional behaviour and non-engagement with services and professionals. The response of professionals and their mindsets and how this was affected by parental behaviours. • Effectiveness of the professional engagement with the children to ensure their voice is heard and acted upon. This is a particular issue in relation to understanding the experience of each child and in protecting them within a context of domineering, uncooperative parents, who exert coercive control and influence on the children’s behaviours and opportunities to communicate. 2.15 The possible reasons for actions taken or not taken at the time were considered: • What factors contributed to practice decisions at the time? • What could have been improved? • What worked well? 2.16 The significance of these insights for current practice. 7 | P a g e Final 12.09.2018 • If the same event occurred now – what factors would influence the response? • What learning, and improvements have already been implemented? • What is working well now and what still needs to be improved? 3. NARRATIVE OF KEY EVENTS The scope of the review includes historical information with a focus on events from November 2012 when the first child with an additional medical condition was born. Any significant relevant events outside of this period have also been considered. 3.1 Family History 3.1.1 This is a very large sibling group with a wide age range. Six of these are now adults; three of them had been in care as children, did not return home and are living independently. 3.1.2 In July 2016, the remaining children under 18 years, who were still living at home, were taken into care because of further and significant concerns about physical and emotional abuse of the children as well as both long term and immediate neglect. This was precipitated by a crisis point which was reached when it became clear that the parents were unable to meet the continuing and substantial medical needs of two younger children who both suffer a significant congenital condition. Essential medical follow-up appointments were arranged for the children but the children were frequently not taken to these. The youngest child became acutely ill at which point her condition required immediate medical intervention. 3.1.3 Legal proceedings were started, and these were completed in 2017 with none of the children returning to the care of their parents. 3.2 Agency involvement with the family 3.2.1 Universal services – health services and schools - have known the family for more than twenty years. 8 | P a g e Final 12.09.2018 3.2.2 The incidents set out below are illustrative samples of significant events during the years 2007 to 2017. 3.2.3 Throughout the whole period there is evidence of the children suffering significant harm caused by the parents: • Oppositional, uncooperative and aggressive responses to professionals with some misleading disguised compliance • Manipulation of professionals – favouring some over others. • Children cared for in overcrowded, chaotic, dirty and unsafe conditions • Evidence of physical abuse and undue domination and coercion of the children. • Lack of parental care and supervision • Inappropriate expectation that older children would look after the younger children to the detriment of the needs of those older children • Encouraging rivalry between the children and failing to prevent physical and sexual abuse between some of the children • Children displaying inappropriate sexualised behaviour • Inconsistent and differential parenting of the children with some children being favoured and others being scapegoated • Neglect of the children’s needs with children dirty, smelly, hungry and inappropriately clothed • Lack of parental warmth and empathy towards the children • Not promoting children’s developmental needs resulting in developmental delay particularly in relation to speech and language. • Failure to ensure children attended nursery and school regularly or to encourage and promote their educational progress • Failure to ensure children received prompt, acute treatment or regular appointments for medical care 9 | P a g e Final 12.09.2018 3.2.4 Events in 2007 and 2008 The first recorded indication of significant difficulties occurred in 2007 when one of the girls – then aged 14 years – became the subject of a child protection plan as a result of concerns about likelihood of sexual harm from an 18 year old male and her allegation that she was being physically chastised by her father; her parents refused to become involved or to discuss the issues but father did agree for her to be accommodated into care in October 2007. She remained in care thereafter. From November 2007 to June 2008, as a result of further concerns about neglect of the children and the poor quality of parenting, several of the children still at home with the birth parents were made subject to child protection plans under the category of neglect. The assessing social worker recorded that when she visited “all the children presented with frozen watchfulness” in the presence of their parents. The parents were said to show no emotion or empathy towards the children when they spoke to them. 3.2.5 Events in 2008 and 2009 After June 2008, the children were subject to child in need plans. The social work report to the child protection conference stated that there was no evidence that the children were at any identified risk of harm from their parents and it described this as “a fairly private family”. As a result the Child Protections Plans were ended and the intervention reduced to the level of Child in Need plans which given the family’s non-cooperative behaviours meant a very limited intervention and engagement. The high level of difficulty in working with this family does not appear to have been fully considered so for this reason reducing the level of required engaged from the parents was questionable. This social work report is likely to have led to an over-accepting mindset for the parental behaviours as it provided a family style / right to privacy explanation for those behaviours. 10 | P a g e Final 12.09.2018 A few months later in September 2008, another daughter aged 11 years came into care. During 2008 and 2009, she disclosed several abusive and neglectful incidents about her parents’ care of her and other children. She alleged that she had also been hit – as had her siblings – by mother as well as father. She alleged that her brother, when a baby of nine months, had been hit for moving whilst he was having his nappy changed. She stated that she and her siblings were subject to neglect and having to care for the younger children and not having enough to eat. Further in April 2009, this 11-year-old stated that prior to coming into care in 2008, she had been sexually abused by her eldest brother and that she had also seen him having sex with another sibling before that sibling was 12 years old. These allegations were formally investigated with ABE interviews and a physical examination, but the findings were inconclusive. This child remained in care and continued to raise concerns about the welfare and safety of her siblings at home. There is evidence that the parents were increasingly uncooperative, and father was aggressive and refusing to allow social workers to see the children. The seven-year-old was seen with injuries consistent with her having been hit and it appears that an application for child assessment orders was made to the court in April 2009. A seven-day child assessment of the children was ordered by the court; the children were seen and assessed but the outcomes were inconclusive, and it seems that father was present when the children were being seen. In July 2009, six of the children were again made subject to child protection plans under the category of neglect; the youngest child then was not made subject to a plan. The analysis in the social work assessment completed in July 2009 states that there have (previously) been significant concerns around the welfare of the older children and around incidents and injuries to the younger children. The parents were recorded as having a history of non-engagement with children’s services therefore, despite children previously being on child protection plans, there are no assessments of parenting capacity or children’s well-being on record” There was an insufficiently 11 | P a g e Final 12.09.2018 planned, objective and systematic approach to examining what the experience of each child was and a comprehensive overview of the parenting capacity would have provided this. Decision-making as hampered by the lack of clear and specific evidence of the concerns and incidents. In October 2009, the children at home were no longer subject to child protection plans and moved onto child in need plans which lasted until September 2010 though the parents were not cooperating with these plans. The challenging behaviour of father and the parental non-cooperation concerned professionals but they could not see how to overcome it and rather they adapted their ways of working to accommodate it. The risks to, and impacts on, the children of this aggression were identified by professionals but they appeared to be unable to articulate sufficiently and on an interagency basis to act more decisively and to maintain the child protection focus. 3.2.6 Events in 2010 During this year, the health visitor was the main professional involved in visiting the home and the parents allowed her to come in. Her focus was on the younger children. Mother had a miscarriage and was quite depressed; at one point, she gave the health visitor a letter saying she wanted to leave father, but this did not happen, and she was soon pregnant again. There was a pattern already established of the parents not ensuring that the children attended health appointments including remedial speech and language therapy. The health visitor worked hard to continue to engage the parents, but it was also clear that she was worried about the cumulative impact of the home situation and that she had had concerns about the children. 3.2.7 Events in 2011 The case was closed in children’s services. 12 | P a g e Final 12.09.2018 The then 5-year-old boy fractured his clavicle, but no medical intervention was sought for five weeks from the day of the injury. His 13-year-old sister took him to the GP which was further evidence of the older children caring for the young ones. Father blamed one of the older children for this injury, but it was not reported to children’s services or investigated by the GP. This was an important missed opportunity for the real experience of the children to be exposed. The fact that the child was brought a long time after the injury and, not by a parent, should have raised the alarm. This matter should have been referred to Children’s Services as per the local policy and procedures. Then, a thorough child protection investigation could have been carried out providing an opportunity, in particular, for the children to be seen alone. Another child was born, and all the focus of the parents was on the new baby. Father was not challenged about the injury to the 5-year-old. 3.2.8 Events in 2012 There were eight separate events of concern from February to June 2012. Two of the children were talking to school staff about the problems at home; they were not being given breakfast; one of the older boys then 14 years was hitting these two younger children aged 9 and 7 years. In June 2012, the 7-year-old broke his wrist and had to be taken to A and E by a neighbour and one of his sisters three hours after the accident because his father had refused to take him to hospital because he said, “he shouldn’t have climbed up there in the first place”. The nurse, who saw the boy, told the EDT social worker that the boy’s physical state was very poor; he was described as “filthy, smelly and shaven-headed”. The next day a social worker visited the home. Initial assessments were completed after a referral from the primary school about the welfare of the children at home. The mother told the social worker that she cancelled appointments for the children because of having panic attacks about leaving the home and she said she had had agoraphobia for more 13 | P a g e Final 12.09.2018 than 20 years. Chronic and widespread neglect of all the children living at home was the social worker’s assessment. In August 2012 after the initial assessment of the children, the case was closed by children’s services as “there is no role for children’s services at this time” and “other agencies continue to work with the family”. This represents a completely disjointed and an incoherent view given the evidence there was. There were several different social workers involved with the family and a stop-go approach therefore impaired the capacity of the service to understanding the needs of the children and the poor, abusive parenting being provided to them. In September 2012, further concerns were raised by the primary school about one of the children coming to school with odd shoes, wearing dirty clothes and with black fingernails and saying he was hungry and thirsty. In October 2012, a strategy meeting was held with the Police and it was recorded that the family have a long history with children’s services, long-term recurring concerns of neglect, concerns about lack of supervision and physical abuse allegations against father and sometimes against other siblings since 2006. Concerns continued about the older children being carers for by the younger ones. The house, which only had 3 large bedrooms and one very small one was now even more overcrowded, and the health visitor was very concerned. She and a social worker contacted the housing association to see what could be done. The parents told the heath visitor that they had been told they could not get help to move and this was not true. In November 2012, another child was born. She was born with substantial congenital condition - additional medical needs requiring care and attention. Mother had not used antenatal services so there was no 14 | P a g e Final 12.09.2018 evidence of any preparation for this new child. The hospital staff were concerned about whether she would be appropriately cared for at home; the health visitor is said not to have been concerned. There were subsequently many missed follow up appointments for her; the health visitor had then become concerned about the parents’ ability to understand the seriousness of this child’s condition. The last social work assessment of 2013 states that the family circumstances are “not child protection”, even though it is recorded that the parenting is neglectful. There was clearly a lack of understanding or appreciation of neglect as causing children significant harm. 3.2.9 Events in 2013 There were several referrals to children’s services including an anonymous one. Social work assessments were undertaken in August and again in October 2013. The home was described as in a poor state with fire hazards and rubbish outside. The second recorded assessment was started because of concerns that the children were being physically abused. 3.2.10 Events in 2014 Initial assessments were completed in January 2014 for all the children. Although some of the children were seen alone at school, they disclosed nothing. When two of the children had started at primary school they appeared to be electively mute and did not communicate for some time. Despite concerns about poor school attendance, the case was closed in children’s services. There was no chronology in place and there was a lack of tracking of events including the high numbers of referrals so that the accumulating and continuing risks were not identified. Events and behaviours were somehow seen as “typical” of this family and “normalised”. 3.2.11 Events in 2015 15 | P a g e Final 12.09.2018 In 2015, there were further referrals to children’s services including an anonymous one – later found to be from a family member. In one referral it was alleged that a photograph of one child with her head in a plastic bag had been posted on social media. In March and April, further assessments of the children were planned but instead the case was closed. In July, father agreed that the children at home should be made subject to child in need plans. In September, father told the health visitor to stop visiting which raised further concerns and led to another social work assessment; no concern was raised, and the case was closed. There was a three-month period during which the health visitor was denied access, but this does not appear to have been escalated. In November 2015, the hospital made referral to children’s services after father did not respond to calls about his daughter. Father had tried to consent by telephone for two operations on 13-year-old daughter who had broken both her legs in a road traffic accident. She had been run down by a car crossing the main road on the way to school. A referral to MASH by one of the adult children in December about the children being neglected was recorded for information only. 3.2.12 Events in 2016 A further child was born by emergency caesarean in January suffering from substantial congenital condition which required continual monitoring. Mother had not attended for antenatal care and she went into labour at home before being transferred to hospital. Although GP and health service were aware of the increased risk of congenital problems for a further child, mother’s pattern of not reporting she was pregnant and not using antenatal services limited the capacity of those professionals to raise the alarm earlier. Children’s services decided through the MASH not to assess the hospital’s concerns because it was said that the family would not engage. In March 2016, health professionals raised concerns at the child’s discharge meeting that they felt the parents could not meet the 16 | P a g e Final 12.09.2018 child’s needs given the history of failed appointments for her older sister who also had the same significant congenital condition. In early June, the then 13-year-old daughter, who had previously been involved in the car accident and broken her legs, stated at school that she had been held by the neck against a wall by her father. She also said she was hit regularly by him and she said her parents are “not very nice”. She appeared thin and unkempt and there were scratch marks on her. This child came into care with parents’ agreement and remained in care. By June it was clear that the youngest child was not being cared for appropriately and her head circumference was increasing. The family were not listening to the health visitor. By the end of June, the child had to be admitted to hospital and she was made subject to a child protection plan. In June 2016, all of the children, who were living at home, were made subject to child protection plans under the category of neglect. It was also decided that there should be emergency protection for the youngest child and interim care orders sought for the other nine siblings. The parents did not attend this child protection conference. In July 2016 Police protection was taken on all the children under 18 living with the parents and interim care orders were granted. None of the children have returned to the care of the parents and plans for new families for them have been implemented. 4. The experience of the children 4.1 The children of the family have endured considerable suffering and harm at the hands of their parents. There is considerable evidence of this from the accounts given to professionals by the children over time. The harm caused, and their experience included: 17 | P a g e Final 12.09.2018 • Lack of basic care – dirty, ill kempt, crowded chaotic living • Lack of food – hungry • Not taken to access acute health care by parents and not being brought to important medical appointments • Fear and frozen awareness from parental violence and threats • Dirty, overcrowded living conditions • Lack of parental supervision and exposure to risks outside the home and resultant injuries • Lack of warmth, empathy and emotional care • Developmental delay including speech not stimulated or promoted • Differential relationships with children with some being favourites, others being scapegoated • Acrimony and bitterness and recriminations between the siblings which continues • Physical violence and sexualised behaviour not prevented between the siblings • Being required to care for younger children 4.2 Professionals appear to have been unable to focus sufficiently on what the children were saying or to piece together all the various strands of information which provided tangible evidence of what was happening in this household. On many occasions, the overwhelming control and aggressive behaviour exercised by the parents seems to have prevented professionals from challenging what they were doing. 4.3 Some of the older children came into care when they were able to escalate the issues for themselves. Once out of the home they did not return and continued to tell professionals directly, and through anonymous referrals, how terrible was the existence of their siblings still at home. It is remarkable how many of the older children once out of the home tried to alert the agencies to the suffering of their siblings who were still living at home. There is some evidence in the records that the 18 | P a g e Final 12.09.2018 allegations from the children in care were sometimes seen by professionals as attention seeking behaviour and not valid. 4.4 Even when children suffered significant harm through direct physical abuse from father or as a result of the lack of supervision provided, decisive action was not taken to protect the children. When one of the children broke his wrist and the parents did not take him immediately for treatment, this was not even referred or investigated. When one of the daughters was involved in a car accident resulting in breaking both legs, this was not fully investigated nor followed up in relation to the known and recorded problem of the parents not ensuring the children were supervised to get to school safely. There are many examples of the children not attending important medical appointments and of children being taken by siblings to hospital or the GP even when they had suffered fractures. 4.5 There was little consideration of the extra pressure and impact on each child as each new child was born. As children grew older they were expected to provide care to the younger children to their own detriment. In each child protection or child in need meeting – most of which the parents did not attend, there was insufficient consideration of each child’s needs. When child protection plans were put in place they did not always relate to every child in the household even though each of those children was experiencing the same environment of harsh and inappropriate parenting. 4.6 Numerous reports about, and direct evidence of, neglect were not followed up robustly. For at least ten years the high level of neglect and the non-compliance and disengagement of the parents was known and recorded. Although earlier in the history in April 2009, children’s services had sought child assessment orders which were granted; this attempt ‘to get a grip on the situation’ did not succeed and the children remained at 19 | P a g e Final 12.09.2018 home in the care of their parents. It does not appear that further legal advice was sought after this. 4.7 During assessments of need and during the child protection and child in need processes, it is difficult to see in the records that the views, wishes and feelings of each child were fully elicited and considered. There is no evidence of direct social work with the children individually. The children were assessed through child assessment orders in 2009 and later some of the children were seen alone at school but this was not the normal practice in this case. One of the children who came into care was interviewed by a police officer and social worker through ABE interviews but the outcomes from these interviews were not robustly pursued. Within the health visiting records, the individual health needs of the children were often not identified with each child’s needs tending to be lost within the context of the wider family. 4.8 It is of significant concern that it was recorded by a social worker in October 2013 that the repeated referrals by older siblings should be regarded as ‘bordering on abusive’ when they had resulted in the younger children at home being repeatedly subject to social care intervention. This is a really worrying perspective and was a great disservice to the children and showed no insight into the dreadful circumstances in which we know the children were living. There is no evidence that there was effective supervision in place to challenge the view taken by the social worker. 4.9 Their childhoods were significantly impaired by the lack of care and abuse the children suffered. During the ten-year period to 2016, the primary school recorded multiple incidents and concerns. There are twenty-nine records relating to observed physical injuries ranging from facial bruising to cuts, scratches and at least one cigarette burn. Often the children had no explanation for their injuries or they blamed older siblings for them. The children were often dirty and hungry, and they came to school with the wrong and worn shoes and sometimes without underwear. 20 | P a g e Final 12.09.2018 On four occasions, members of the public contacted the school because they were worried about road safety and the children running out on front of cars and crossing at red lights. 4.10 The children’s school attendance was poor – there was sporadic attendance with some periods of good attendance though this was not sustained. There is limited evidence that the children were spoken to about why they were not at school. In July 2016, there was successful court action to prosecute the parents for the children’s irregular school attendance. 4.11 Some of the children have experienced and continue to have poor outcomes into adulthood. For example, in 2015, two of the children then teenagers were taken to hospital with suspected overdoses of painkillers and having self-harmed. Some of the children have been involved in criminal activity including assaulting others. However, some of the children have flourished in care and are progressing well in their new families. 5. Thematic Evaluation of agency responses and practice 5.1 Some good and determined practice to make a difference with the family did take place at times – though this was in isolation. 5.1.1 The recorded assessments early on, and indeed, later in children’s services do identify and name the long term serious problems in this family. For the most part, the seriousness of the children’s situation and the recalcitrant behaviour of the parents was identified and known. In 2009 legal advice was taken and court proceedings were initiated. The children were made subject to Assessment Orders. However, no further follow-up action occurred to pursue further court involvement; therefore, the seriousness of the harm being caused to the children did not result in further court proceedings. As far as the assessments which were 21 | P a g e Final 12.09.2018 completed in 2009 are concerned, it is very likely that the children were constrained by threats from father to keep quiet about what was happening and therefore they did not disclose the harm they were suffering. 5.1.2 The health visitors tried very hard to stay in touch with the children – certainly the under five-year olds – and to ensure that the parents let them have access to see the children especially when other agencies – particularly the social worker – were prevented by the parents from engaging with the family. Understandably they did their best to appease the parents in the children’s best interests though this was clearly stressful to them and a pragmatic compromise. 5.1.3 The schools tried hard to make improvements for the children at school and through working with the other agencies. The parents would not work with them at all and even refused to walk the children to school even when, for safety reasons, they should have done. Teachers listened to the children when they would speak and followed up with making referrals about what they had been told. This was important support for the children who were very isolated and fearful of the consequences of sharing their lived experience at home in the care of their parents. 5.1.4 After the birth of the youngest child and the continuing worries about the parents’ inability to take her additional medical needs seriously, a new approach was taken, and the then-allocated social worker led a concerted effort to focus on the harm not only to this child but also to the other children who were still living at home. This marked a considerable step change in the practice which had occurred previously. The fact that the youngest child had a life-threatening event because her medical needs were not being met by the parents, who did not give her the care and attention she required, meant that a vital and crucial tipping point for action was finally achieved. The social worker was challenging of previous assessments of the family and was child-centred in practice. A chronology 22 | P a g e Final 12.09.2018 of events and the time-line of the decades of abuse and neglect enabled that practitioner to see the pattern of events. Legal advice followed and a clear plan was made for future plans for the children. This resulted in 2017 in an effective, successful removal of the children through legal proceedings. 5.2 Overwhelming nature of the complexity and scale of the problems and of the oppositional, hostile behaviour of the parents 5.2.1 Even from 2007 this was already a very large family with many children each with different needs and concerns about their safety and welfare. For individual professionals – social workers, health visitors and teachers – it was hard to keep focus on every single child and their needs as individuals. Within this large family of children, the parents’ practice of differential and inconsistent parenting towards different children was a challenge to track. The parents made efforts to concentrate on their care of, and behaviours towards, the babies with mother breastfeeding them, for example; they were apparently more able to provide a show of warmth and care to this younger group. This was however, in stark contrast to the harsh and punitive regime they employed with the older children who were expected to look after their younger siblings and were expected to fend for themselves. The medical needs of the last baby were too much for the parents to cope with and they neglected her care to the extent that it resulted in a life-threatening event. 5.2.2 There was a lack of effective challenge to the parents and of pursuing and setting consequences for the parents in relation to their defiance in not following the advice of professionals and their overall non-compliance. They would “try” harder for a while to feign compliance in order to seek to persuade professionals that they were listening. This was difficult because the parents usually absented themselves from meetings such as child protection conferences. When they were seen – father in particular - could be aggressive and attacking of professionals with 23 | P a g e Final 12.09.2018 threats though he stopped short of actually assaulting any staff even was extremely intimidating. Not only did they refuse or ignore invitations to meetings but they at times refused all access to the home and the children for extended periods; they refused access to some social workers and some health visitors even when the children were subject to child protection plans. 5.2.3 There was a lack of professional curiosity and determination to see the children’s needs. There was so much activity, coercive control of the children, rivalrous activity between the children and so much distraction and anger and unpleasantness from father that these incapacitated the professionals’ ability to do their best. 5.2.4 There is an impression in the records of professionals “buckling” under the parents’ aggressiveness and resistance to all advice which was given to them. It was not easy to manage and to feel validated in your practice when father banned you from visiting and made threats and nasty comments about you. This could be very isolating for professionals and could lead to their views being marginalised. 5.2.5 For most of the period under review, professionals appeared to be “stuck” and this resulted in them avoiding and skirting around the difficulties presented by the family. For example, when in 2015 father refused access by the health visitor and there was already considerable evidence of neglect and poor care, the agencies did not work either singly or together to escalate matters. 5.2.6 The Bridge Childcare Development Service in their report (1997) into the death of Rikki Neave in 1994 recommended that: “recognition be given by managers to the impact on social workers and other staff of parental aggression and any fear that is aroused in them and the consequences for decision making and practice. Adequate professional supervision and support must be given in these situations”. 24 | P a g e Final 12.09.2018 5.3 Responses from all agencies to concerns and interventions were generally short-lived, episodic and occurred as a reaction to particular issues and concerns as they arose. 5.3.1 Even though it was clear as early as 2008 that there were long term, chronic and serious problems with the parenting of the children being identified and recorded, the activity tended to be about single events – lack of an overarching focus and identification of patterns of neglect and harm being caused to the children. 5.3.2 There were multiple assessments of need for some children, sometimes for most of the children and several had plans for periods – child protection and child in need plans. These did not lead to effective action even when there was no resultant improvement in the parenting or the circumstances of the children. These safeguarding processes did not result in any improvements for the children and, even when this was apparent to everyone involved, the consequences of this were not followed through even with consideration of further legal proceedings until 2016. 5.3.3 Even when, at different points three of the children came into care, the links to, and the fate and treatment of, the other children was not made strongly enough and the children in care’s views were ultimately not taken seriously enough. Father blamed the children who had left and scapegoated them to make them the problem to confuse matters further and to sow seeds of doubt about the veracity of what the older children were saying. 5.3.4 A great deal of information was collected about the children from referrals, assessments made, meetings held and in contacts from and within other agencies. However, this information was not organised and analysed to provide a framework of understanding 25 | P a g e Final 12.09.2018 what was happening in the family over time. Keeping the full history of a family is essential to avoid slipping into over optimistic views when they are not justified by the full evidence. There were frequent changes of social worker / supervisor and a lack of continuity of practice. Chronologies and timelines of events for analysis were not created to assist with the analysis and planning. In addition, legal advice was not sought even at times when it was justified. Throughout much of the history of the case, Children’s Services were regarded by Ofsted as inadequate and in need of improvement. There were frequent changes of social worker / supervisor and a lack of continuity of practice. Chronologies and timelines of events for analysis were not created to assist with the analysis and planning. In addition, legal advice was not sought even at times when it was justified. The assessments which were competed were superficial for the most part being immediate and brief responses to events and incidents which occurred within the family without appropriate investigation and resolution. Throughout much of the history of the case, Children’s Services were regarded by Ofsted as inadequate and in need of improvement. 5.3.5 There was a high, perhaps, over-reliance on schools and Health Visitors to support the children accompanied by opening and closing of the case in children ‘s service. For example, in August 2012 after the primary school had referred further concerns in June about the care of the children, assessments were carried out but then the case was closed with the justification – “no role for children’s services at this time” and “other agencies continue to work with the family”. 5.3.6. At some points practitioners tried to be more optimistic and focused too much on small improvements made by the family and they lost sight of the full history and the extent of chronic neglect. Some of the health visitor efforts to engage the family were very impressive but for 26 | P a g e Final 12.09.2018 the most part as soon as she had left behaviours and parenting did not improve. Schools monitored the care of the children and recorded concerns and passed these to children’s services and tied hard to reassure the children they were being heard when they said anything. However, for the most part this involvement did not result in he required escalation with other partners. Often too the children would not or did not disclose anything, even when it was clear they were worried. 5.4 The enormity of the tasks and the level of conflict and obstruction of the parents resulted in a mindset of passivity, hopelessness and helplessness and sometimes complacency for professionals. Some professionals became “acclimatised” to the poor circumstances of the children which hindered their ability to escalate matters. 5.4.1 Despite direct acknowledgement as early as 2009 of the inadequacy of the parenting and of the harm being suffered by the children, and no evidence of any significant acceptance of this by the parents or improvements made, both decision-making and practice were ineffective in protecting the children from further harm. 5.4.2 The lack of engagement by the parents and the hostility expressed affected the practitioners’ decision-making capacities and ability to follow through with assessments and plans. It was difficult for practitioners to see the children alone; even at school the children were reluctant to talk about what happening at home. As mentioned above, in October 2013, the reports made by the older children in care were being disregarded and seen as a “nuisance” and perhaps even as malicious and causing harm of themselves. The circumstances of the younger children were apparently seen as acceptable despite all the indications to the contrary and despite the significant numbers of referrals from other agencies and neighbours. 27 | P a g e Final 12.09.2018 5.4.3 In May 2015, at a supervision session in children’s services, it was decided to close the case even though it was formally recorded that “this family will always be of some concern”. This was after a member of the family anonymously reported concerns about the children not being taken to school and the risk of road traffic accidents from this. In fact, in November 2015, one of the children had a road traffic accident and was hit by a car which broke both her legs. 5.4.4 Neighbours’ referrals were not always taken seriously enough or followed through. For example, when a neighbour had to take the child with a broken wrist to hospital because the father refused to do so no effective challenge was made, or action taken. Legal advice was obtained but no specific action followed. 5.4.5 There are many examples in this case of either no action being taken by agencies and / or of inadequate responses being made to referrals received by children’s social care. Not all child protection issues received an appropriate response or were even referred to children’s services. For example, father nailed up the windows of the house so that the children could not get out; he said that he did this in response to complaints about anti-social behaviour from neighbours when they complained about the lack of parental supervision. It does not appear that any action was taken to questions this or to ask further questions about the impact of this on the children. On several occasions, the children came into school wearing the wrong shoes and ill-kempt, but these referrals were not followed up effectively. 5.4.6 There was very often an acceptance of lower parenting standards and unacceptable care for the children because this was seen as typical of and acceptable for this family. The individual needs of each child were lost sight of and the parents’ intimidation and lack of cooperation with professionals meant that the focus on the children was impaired. The GP did not refer to children’s services the child who was taken to the surgery by his sister, with no parent present, several days after the injury. 28 | P a g e Final 12.09.2018 5.5 There was a lack of a full appreciation of the children’s lived experience; professionals do not appear to have put themselves “in the children’s shoes” or to visualise what their lives were like. 5.5.1 Although the children were occasionally seen alone, there was generally a lack of creative direct work with the children individually to establish wishes and feelings. Even when the Court Assessments were carried out, father was present when most of the children were seen by the paediatrician with one child sitting on his lap during it. 5.5.2 It is likely that the parents would have opposed this work, but it should have been tried. The parents’ refusal would have been a further test of the ability to put their children’s needs first and to reflect on their own parenting. 5.5.3 The Bridge Childcare Development Service in their report (1997) into the death of Rikki Neave in 1994 recommended: - “when a parent is considered to be threatening or hostile any presumption that they are different with their children should be rigorously tested”. 5.6 There is no evidence of any formal assessment of parenting capacity in the family. 5.6.1 This is a further example of lack of focus and challenge to the parents. Clear standards were not being considered in relation to what was happening and even when no progress was being made with the children on child protection plans, there was insufficient professional challenge and no escalation. 5.6.2 In July 2009, the summary analysis of assessments of the children in that year records that there had previously been significant concerns around the welfare and safety of the children. It is also stated that the 29 | P a g e Final 12.09.2018 parents had a long history of not engaging with children’s services but “despite the children being previously on child protection plans, there are no assessments of parenting capacity on record.” 6. SUMMARY THEMATIC ANALYSIS 6.1 The effectiveness of the child protection system and case management processes in identifying the needs of the children, in addressing poor parenting and in improving the circumstances of each child. This is particularly of interest for the younger children who have additional medical needs. The child protection system was not effective in improving the outcomes for the children over many years. When the younger children, who were born with additional medical needs, arrived this increased the stress on the family and further tested the parents’ parenting capacity. They were not able to prioritise the needs of the most vulnerable child and, as a result, the child’s condition worsened providing immediate evidence of the parenting shortfalls. When this was identified in 2016 the system was effective, and the children were removed. 6.2 The impact of the size of the sibling group on identifying and addressing the needs and maintaining focus on each child whilst working with this family. As described above the size of the family and the number of children made it very difficult to focus on each child individually. The allocation of a single practitioner – health visitor or social worker – was unlikely to deliver positive intervention. 6.3 Appreciation and understanding of the differential parenting provided and the expectations attributed to different children which characterised how different children were cared for. This links to the sheer complexity of the family circumstances and the large number of children and distractions in place including the hostile and uncooperative behaviour of the parents. 6.4 The impact of, and the management of the parents’ oppositional, manipulative behaviour and non-engagement with services and professionals. The response of professionals and their mindsets and how this was affected by parental behaviours. 30 | P a g e Final 12.09.2018 This was very stressful for practitioners. The turnover and shortfalls in professional staffing and high levels of demand on services during this period also hampered effective practice particularly in children’s services. 6.5 Effectiveness of the professional engagement with the children to ensure their voice is heard and acted upon. This is a particular issue in relation to understanding the experience of each child and in protecting them within a context of domineering, uncooperative parents, who exert coercive control and influence on the children’s behaviours and opportunities to communicate. There were significant shortcomings in the professional engagement with the children even when the children in care were trying to persuade children’s services to intervene to protect their younger siblings. In summary, the practice was characterised by: • There were multiple, repeated assessments which lacked depth and analysis. They were stop/go responses to the issues. Multiple assessments without coherent outcomes and levels of risk and impacts on the children not fully considered • Confused and incoherent practice – even when no progress or worsening conditions for the children, there were no clear consequences • The history, patterns of events were not fully analysed and acted upon with focus • Minimisation of serious concerns occurred • Even when the children were subject to child protection plans, there was drift even when progress and improvement was not happening • Child protection processes were not attended by parents and they were not directly challenged or given targets and consequences to meet; their parenting was not assessed formally. • Agencies did not always refer or escalate serious concerns to children’s services • The children were not the focus of the intervention and they were not heard; there was a lack of child centeredness. • There is little evidence of senior management oversight or of effective, challenging supervision which may have led to a more focused approach and earlier escalation of concerns. 31 | P a g e Final 12.09.2018 7. FINDINGS 7.1 There was some positive effort and conscientious practice in this case to support and safeguard the children. The amount of involvement by professionals was enormous but it was generally ineffective in achieving improvement for the children. The primary school recorded multiple incidents and concerns and made referrals to children’s social care but most of these did not receive the level of response required. The health visitors tried to engage with the parents and at times they were the main point of access to seeing the younger children. 7.2 The parents of the children were deceptive, uncooperative and aggressive in their relationship with the professionals. They played professionals off against each other – health visitors, school staff, GPs and social workers refusing to engage with anyone who raised concerns. For a time, they would cooperate with a particular professional such as the health visitor but then they would refuse access to the children by the same person. Father was verbally abusive to one social worker who visited, and the police had to be called. 7.3 This was a family where interventions provided by professionals did not result in timely, improved outcomes for children whilst the children remained in their parents’ care. A variety of different forms of support were offered to the family including the involvement of the children’s centre and even grants to help them to get the children to school but the parents did not engage with these offers of help. The parents attended a few child protection conferences but generally refused to do so which meant there was at time a delay; for example, one child protection conference was adjourned because they had refused to attend. 7.4 All the children experienced abuse and neglect which has affected their development and outcomes for life. There is much evidence to show how the children were intimidated by the parents but also manipulated by them. When the children disclosed physical assaults by father, they usually withdrew these allegations and told professionals how afraid they 32 | P a g e Final 12.09.2018 were of recriminations. Father used Facebook to name call some of the children. Boundaries within the household were not clear and often inappropriate and there were incidents of violence and inappropriate sexualised behaviour between the children. 7.5 The professionals and the agency network were overwhelmed by the enormity and complexity of the issues in this case – the number of children, the open aggression and recalcitrance of the parents. For the school there were considerable dilemmas about how best to resolve the major concerns they had about the children’s care and safety; the parents were hostile and threatening and this was hard to manage. 7.6 Professionals dealt with problems reactively and worked in isolation and did not work together to coordinate their views and to agree what action was required. The Housing provider had several opportunities to share information about the care and safety of the children, but the significance of the information was not appreciated and so it was not always shared. For example, it became too difficult to carry out the repairs to the house because of its dilapidated state but this was not considered in relation to the children’s safety. 7.7 The lived experience and suffering of the children was not appreciated and the attempts by the older children to intervene and to protect their younger siblings were not fully acted upon in a timely way. 7.8 There is no evidence of any senior management challenge or awareness of the serious and significant harm the children were suffering over a very long period within each agency or between agencies. 8. CONCLUSIONS 8.1. This was a very challenging and overwhelming case for the agencies and practitioners to manage. 8.2 It was an extremely “stuck” situation and research evidence is that positive outcomes are difficult to achieve in the circumstances of such 33 | P a g e Final 12.09.2018 compromised parenting. Bentovim (Bentovim et al 1987; Bentovim 2004) argues that parents’ failure to take responsibility for their children’s maltreatment, their dismissal of the need for treatment, their failure to recognise their children’s needs and the maintenance of insecure or ambivalent parent–child attachments are all key indicators of a poor prognosis following maltreatment. 8.3 Practitioners need very strong support and highly focused supervision to overcome the obstacles to practice in such situations. They may even need to seek specialist consultancy. Signs of Safety, for example, may have provided a workable framework for managing this case and for challenging the parents. 8.4 Professionals and each agency became compromised by the deflections engineered by the parents which were intended to and succeeded in preventing agencies from tackling the sheer enormity and scale of the abuse of so many children over such a long period. 9. Recommendations for the LSCB to consider and action: The following recommendations are made to the LSCB as an overview and summary of all the recommendations which have arisen from this review. They reflect the key learning from this review. The Local Safeguarding Children Board should: 9.1 Establish a senior group of multiagency professionals to identify and scrutinise cases where children have been subject to multiple child protection plans and continuing concerns without significant improvement spanning over more than three years. 9.2 Update and improve the existing LSCB policy to provide specific advice and learning from this case for practitioners in working with parents who use hostile and threatening behaviour, are non-compliant/uncooperative behaviour as well as exhibiting disguised compliance (Apparent Co-operation). 34 | P a g e Final 12.09.2018 9.3 Conduct an interagency review of current frontline practice with children who are subject to significant harm through neglect, where parental behaviour is hostile or uncooperative, to identify good practice to share but also cases which require improvement for action. This should include a specific focus on large sibling groups. 9.4 Develop a model for interagency practitioner supervision for complex cases where working together closely and consistently is of paramount importance. 9.5 The LSCB to seek assurance, from an audit of current PLO cases, that the use of the Public Law Outline is being used effectively to give the local authority and social workers sufficient leverage with families which are deliberately and unreasonably obstructive by clarifying their concerns in a ‘Letter before Proceedings’ or further action. 9.6 Develop an interagency protocol through the LSCB for managing future interagency actions and interventions when care proceedings do not result in legal protection for children, against whom it is believed that significant harm continues to be happening. 35 | P a g e Final 12.09.2018 Appendix A - List of References Action for Children – The state of child neglect in the UK, Action for Children and University of Stirling, 2013; www.actionforchildren.org.uk/media/5120220/2013_neglect_fullreport Bentovim (Bentovim et al 1987; Bentovim 2004) Journal of Family Psychotherapy Volume 15, 2004 - Issue 1-2 Working with Abusing Families General Issues and a Systemic Perspective Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black - Analysing Child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 The Bridge Childcare Development Service in their report (1997) into the death of Rikki Neave in 1994 C4EO Safeguarding Knowledge Review - Effective practice to protect children living in ‘highly resistant’ families NCB 2010 Child Abuse Review (2015) – Vol 24: 155-158. May-June 2015. Various articles on neglect and the importance of listening to children. Peter Dale, Murray Davies, Tony Morrison Dangerous Families Assessment and Treatment of Child Abuse Paperback – 1 Dec 1990 Department for Education – Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of Children – 2015 Horwath, J & Tarr, S; Child Visibility in Cases of Chronic Neglect: Implications for Social Work Practice British Journal of Social Work (2015) 45, 1379–1394 Ofsted - Learning lessons from serious case reviews, 2009–2010 (100087), Ofsted, 2010; www.ofsted.gov.uk/resources/learning-lessons-serious-case-reviews-2009-2010. 36 | P a g e Final 12.09.2018 Ofsted - In the child’s time: professional responses to neglect – March 2014 Reder, Dr Peter, Duncan, Sylvia, Gray, Moira - Beyond Blame: Child Abuse Tragedies Revisited (1993) |
NC52815 | Fatal stabbing of a 17-year-old in 2021. At the time of his death, Lilo was a Child in Need who had a diagnosis of autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), as well as limited mobility because of a moped accident. Learning themes include: access to education and delays in assessments for Education Health and Care Plans (EHCPs) and the experiences of neurodiverse Black boys in education; recognising and responding to risk in the context of extra-familial harm; understanding the impact of trauma in the context of extra-familial harm and wider trauma; and understanding the impact of trauma on the workforce. Recommendations include: education must undertake a review of the EHCP process; the local safeguarding children's partnership should commission further learning to improve professional understanding across all agencies to ensure a better understanding of trauma, intersectionality, adultification bias and neurodiverse children in the context of extra-familial harm, always considering language and framing of children; ensure that the voice of the child is heard and integrated into planning; ensure that all social workers and managers can recognise and respond to extrafamilial harm, especially for children with additional needs; improve the quality of support and child protection responses, with increased understanding of the role of a statutory safeguarding partner; improve the quality of record keeping and assessments; child and adolescent mental health services should introduce multi-disciplinary review meetings when a child is referred more than three times and does not meet threshold for intervention as well as monitor and improve access and support for Black and ethnic minoritised children.
| Title: Child safeguarding practice review: Lilo. LSCB: Lewisham Safeguarding Children Partnership Author: Jahnine Davis Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review: Lilo June 2023 Independent Reviewing Author: Jahnine Davis 2 My Son My son was a caring, loving, cheeky and sensitive child who wore his heart on his sleeve. He had alopecia from an early age which was a sign of his sensitivity. He was a good listener who wanted to help others but often kept his own feelings to himself. He was very close to me and when we were alone together going to hospital appointments in the car, he would talk deeply about life and the future for himself. I knew him well to know what he liked and disliked. Because of my son’s ASD and his ADHD, he was sometimes misunderstood, and he could get frustrated if he didn’t quite get the grasp of what was being asked of him. My son had multiple sports activities after school to help him to use it to manage his ADHD, as an alternative to giving him medication from CAMHS, which neither myself nor my son wanted to do. He was sometimes very innocent about how the world works and struggled to grasp some concepts. This made him very vulnerable. He would always need one instruction at a time and struggled to process two things at once. He was a very family orientated child who loved his siblings and enjoyed playing with them, plaiting his little sister’s hair etc. He had many interests including sports and he loved to travel and had been to Egypt, Spain and the Caribbean. He loved nature and the freedom of being outdoors. He was studying a multi-trades course and wanted to build houses. He had a clear plan to build his own house, wanting a family business in housing, marrying his girlfriend and starting his own family. His girlfriend was important to him. They met at college. She was Bengali and he was learning the Koran. He was accepted by her family and her community, who felt that he had really helped to calm their daughter and helped her on her journey. She is now studying Criminal Law. Her family feel that my son was instrumental in that for her. My son was a very positive child that impacted many lives. His death has had a real impact on our family, his friends, and his local community, and he is greatly missed. 3 Contents 1. Introduction 2. Family and Case Context 3. Parent views: Professional Network 4. Thematic Analysis 5. Emerging positive practice 6. Conclusion 7. Recommendations 1. Introduction 1.1 This Local Child Safeguarding Practice Review was commissioned by Lewisham Safeguarding Children Partnership1. The review is in respect of a Black British Caribbean male, who died at the age of 17 in 2021. He died as a result of being stabbed, in the context of extra-familial harm 2(harm outside of the home). At the time of his death, Lilo was a Child in Need who had diagnosis of Autistic Spectrum Disorder (ASD) and Attention Deficit Hyperactive Disorder (ADHD). A few years prior to his death he sustained a life changing injury which affected the way that he walked and limited his mobility. This became significant at the time of this death, as he was unable to flee from the those that fatally stabbed him. The combination of Lilo’s needs arising from his neurodiversity3 and limited mobility, left him extremely vulnerable to extra-familial harm. 1.2 This review will show thematic learning across four overarching themes, which are listed in section 4. All themes of learning relate to the key lines of enquiry which were created by members of the review panel and signed off by the Lewisham Safeguarding Children Partnership Executive. 1.3 The four themes identified include: o Access to education and delays in assessments for Education Health and Care Plans and the experiences of neurodiverse Black boys in education o Recognising and responding to risk in the context of extra-familial harm o Understanding the impact of trauma in the context of extra-familial harm and wider trauma o Understanding the impact of trauma on the workforce 1 Jahnine Davis is the lead reviewing independent author, she has extensive experience in child protection and Black and minoritsed children and is the leading UK subject matter expert in adultification bias and the impact on child protection. Siobhan Burns provided specialist advice in her expertise of children’s services and children with complex needs and disabilities 2 Extra-familial harm is defined as risks to the welfare of children that arise within the community or peer group, including sexual and criminal exploitation. See www.contextualsafeguarding.org.uk 3 Neurodiversity is a concept where neurological differences are seen as natural variations of the brain. These neurological differences are recognised and respected, celebrated and allow people to be themselves. These differences can include those diagnosed with Autism Spectrum Disorder, Dyspraxia, Dyslexia, Attention Deficit Hyperactivity Disorder, Dyscalculia, Tourette Syndrome and others. See https://childrenandfamilyhealthdevon.nhs.uk/wp-content/uploads/2020/04/1-minute-guide-neurodiversity.pdf 4 1.4. The review then concludes with a summary of the most significant learning and recommendations to improve practice. Key learning includes the following: ▪ Professionals must consider how services support neuro-diverse children that do not always have the capacity to comprehend risk, potentially increasing vulnerability and exposure to extra-familial harm. When a child is known to several agencies, it is important that any offer of support is joined up and co-ordinated, reducing siloed responses rather than a holistic and collaborative approach. This includes considering how agencies understand extra-familial harm and their role as statutory safeguarding partners. ▪ Individual professionals, agencies and the wider partnership must demonstrate how they consider a child’s intersecting identity4 , always remaining curious in exploring how and to what extent does the race/ethnicity/gender and neurodiversity of a child impact decision making, assumptions and attitudes. This is important because this group of children may experience more punitive informed approaches when they present with behaviours which may be symptomatic of their unique educational needs5. ▪ Black boys (and girls) are also at a greater risk of adultification bias, this must be understood as a manifestation of racism6. This means that professionals are more likely to overlook the vulnerability and impact of traumatic experiences of Black children, due to racist assumptions that Black children are either complicit in the harm they experience or somehow able to safeguard themselves, more than other children. Thus, reducing a child protection response whilst increasing the chances of interventions to control behaviours or especially for Black boys to become known to Youth Justice services rather than providing trauma informed and a needs led approach7. ▪ It is critical to understand the impact of trauma on children, who have experienced both direct and indirect harm. This includes physical injury (whether caused by extra-familial harm or by any other means), life changing injuries, emotional impact of living in fearful circumstances and experiencing bereavement. Trauma can present through both physical change and behaviour. Due to negative stereotypes about Black boys being perceived as more ‘aggressive’, ‘mature’ and ‘difficult’8, it is important to consider how trauma is interpreted by professionals when the child is Black, male and neuro-diverse. ▪ All children deserve the opportunity to thrive and be the best they can, regardless of their race/ethnicity/gender and neurodiversity. Research shows us that children who 4 The interconnected nature of social categorizations such as race, class, and gender, regarded as creating overlapping and interdependent systems of discrimination or disadvantage; a theoretical approach based on such a premise – Oxford English Dictionary 5 Davis, J, (2022). Adultification bias within child protection and safeguarding. His Majesty’s Inspectorate of Probation (See https://www.justiceinspectorates.gov.uk/hmiprobation/wp-content/uploads/sites/5/2022/06/Academic-Insights-Adultification-bias-within-child-protection-and-safeguarding.pdf ) 6 Davis, J. and Marsh, N. (2020). ‘Boys to men: the cost of ‘adultification’ in safeguarding responses to Black boys’, Critical and Radical Social Work, 8(2), pp. 255-259 7 Davis, J, (2022). Adultification bias within child protection and safeguarding. His Majesty’s Inspectorate of Probation 8 ibid 5 receive consistent and high-quality education, where their special educational needs are identified and responded to in a timely manner, can meet their full potential9. ▪ Education and safeguarding systems are complex and co-ordination between these services must be improved. It is good practice for professionals to come together to problem solve, particularly for children with a combination of needs, that cannot be met by any one service. Child in need meetings and strategy meetings are key opportunities for this to happen in a multi-agency way. ▪ It is important that all professionals working with children understand their responsibilities in respect of safeguarding and are aware of their duties to work in partnership and share information. ▪ There is important learning from this review for CAMHS around the accessibility of services for young Black boys that require therapeutic interventions, particularly, how trauma is acknowledge and understood when extra-familial harm is a feature. 1.5. Scope and methodology: 1.5.1. This Child Safeguarding Practice Review has considered multi-agency practice between December 2018- April 2021. Although, to provide further context some learning falls outside of the above dates, to support future learning and practice improvement. Professionals were asked to contribute to practitioner meetings and 1:1 sessions. Family members (mother, stepfather and father) were also offered the opportunity to speak with the independent author. Lilo’s father was unable to participate in this review. However, his mother and stepfather’s voices have been included in section 3. 2. Family and Case Context 2.1. Lilo and his family are of Black British Caribbean heritage. He lived at home with his mother, stepfather, siblings and resided in the London Borough of Lewisham. He also had a relationship with his biological father, which was at times inconsistent, but nonetheless they had a relationship. Lilo had a girlfriend who he loved deeply. Lilo was immensely loved and cherished by all his family members and his death has had a deep and profound impact. During the review, it was evident that the death of Lilo also deeply saddened the professional network. 2.2. From a young age Lilo started to present with behaviours that reflected a child who did not have the capacity to always understand risk. Lilo was a child who was easily led and wanted to ‘fit in’. His diagnoses of ASD and ADHD impacted his capacity to identify harmful and risky situations. His wish to ‘fit in’ left him especially vulnerable to grooming and exploitation outside of the family, despite his mother’s attempts to keep him safe. Lilo was sensitive to his mother’s feelings and felt sad that his injuries and at times his behaviour left her worried. The voice of Lilo was rarely documented in case notes, most of his experience was verbalised through the voice of this mother and some professionals in the system. 9 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2022/11/cc-beyond-the-labels-a-send-system-which-works-for-every-child-every-time.pdf 6 2.3. Lilo’s mother was a significant protective factor throughout his life. She recognised from an early age that her son needed further support to address some of the difficulties he started experiencing. Lilo’s mother dogmatically sought support and reached out to agencies, particularly during his adolescence. At times it seems that the mother was expected be the Lilo’s parent, his advocate and the conduit for sharing information between agencies. These included: ▪ Three requests for an education health and care plan needs assessment. ▪ Requests for support from services for Lilo in relation to his neurodiversity. ▪ Requests for help from children’s services (children’s social care and children with complex needs and disabilities). ▪ Offering elective home education to safeguard her child and to provide a safer education provision. ▪ Sharing information with the professional network, for example communicating concerns about extra-familial risk and harm, both in respect of Lilo and his younger siblings. 3. Parents views about professional network 3.1. I wish to personally thank Lilo’s mother and stepfather for holding space with me and having the courage to contribute to this review. Lilo’s mother and stepfather shared their perspectives and experiences of the professional network. The following excerpts are verbatim. 3.2. Mother and Stepfathers view 4. Thematic Analysis 4.1 The learning from this review was produced by the information and perspectives in agency reports, practitioner events and parent involvement. The review includes an intersectional analysis throughout. All themes align to the key lines of enquiry as per the Terms of Reference: Services, they need to listen, they don’t listen, we were crying out for help. My son would always say, my mum is my role model, support and professional. That’s because I literally did everything. I felt like I was on my own. There were so many professionals in his life, it was so overwhelming. They did not understand my son, they did not understand his needs. Professionals should intervene where it matters, give young people the resources for them to be able to move on. Stay guiding them, as adults we seem to forget that even when a child is 14,15, 16 or 17, they still need guidance We set up a provision in his name, which is a preventative programme for children who need support in their community. Parents know what needs to be done, not the institutions, they just focus on problems and solutions rather than having the understanding that you need to preserve first and foremost 7 o Access to education and delays in assessments for Education Health and Care Plans and the experiences of neurodiverse Black boys in education o Recognising and responding to risk in the context of extra-familial harm o Understanding the impact of trauma in the context of extra-familial harm and wider trauma o Understanding the impact of trauma on the workforce 4.2 Access to education and delays in assessments for Education Health and Care Plans and the experiences of neurodiverse Black boys in education. 4.2.1. Inconsistent and Fragmented Access to Education 4.2.2. Education was an unpredictable experience for Lilo, and he was not provided the opportunity to reach his full potential. The impact of Lilo’s ASD and ADHD coupled with the multiple school moves (including primary settings), made his secondary education an even more challenging experience. It is evidenced that children with ASD struggle more than their counterparts to manage change and form strong peer relationships. 4.2.3. Between the ages 13-16 years, Lilo had moved across four education provisions. In addition, one period of elective home education (placement two) was due to his mother’s concerns regarding his first school. She was concerned that they were not meeting his needs and providing a safe and nurturing environment. He had become involved in fights in the school, and he had begun to get drawn into low level criminal activity10. School Placement dates Length Secondary School 1 September 2016 – March 2017 6 months Elective Home Education April 2017– October 2017 6 months Alternative Provision 1 (this included two sites for different key stages movement from 3-4) October 2017 – December 2018 1 year and 2 months Not accessing or being provided education due to ill health January 2019 – June 2019 6 months Alternative Provision 2 June 2019 – December 2019 Less than 6 months College 1 February 2020 Leading to lockdown in March 2020 EHCP finalised August 2020 4.2.4. Lilo’s father reported that he had been ‘beaten up badly’11 by a student from School 1 in October 2017. Given Lilo was harmed by a pupil from his previous school, a managed move was agreed for a temporary placement in an alternative learning provision. 4.2.5. The purpose of the temporary placement to Alternative Provision 1 (third placement) was for the school to undertake a six-week assessment to establish whether Lilo could function 10 Taking and driving away, in possession of a stolen motorbike 11 Account of LILO ’s father 8 in mainstream education12 following a period of elective home education and experiencing two fixed term exclusions in School 1. This placement exceeded the initial assessment duration and was the longest period Lilo experienced in education, a total of a one year and two months. It is unclear why he did not return to a mainstream school following his assessment period or, if his needs were such that he could not return to a mainstream school and why an education health and care plan needs assessment was not triggered. 4.2.6. There is a lack of evidence that Lilo’s wishes, and feelings were sought about being in this provision and what aspirations he had for the future. 4.2.7. Lilo’s fragmented access to education impacted on his educational achievements, the continuity of SEN provision and his capacity to build a trusted, positive peer network. 4.2.8. Significant traumatic experiences and the impact on education 4.2.9. Lilo experienced significant trauma during ages 14-16 years, which happened in tandem with changes in his education placements. Whilst a student at Alternative Provision 1, Lilo experienced two significant traumatic events. ▪ The murder of a close friend who was also a child impacted by extra-familial harm. ▪ A month following the death of his friend, Lilo was stabbed by another pupil from his alternative learning provision. This student lived on the same road as Lilo, and he had regarded him as a friend. 4.2.10. Lilo left Alternative Provision 1 due to experiencing extra-familial harm from a school peer. He missed learning and was not provided access to education between January 2019 and June 2019 due to poor health, arising from the incident in December 2018. The receiving schools request for a full assessment of his needs further contributed to the delay in him starting. 4.2.11. There is no evidence to suggest that Lilo was offered any professional support following the death of his friend. Concerningly, the education provision was aware of the death13 of his friend and yet without professional support, it remains unclear how Lilo’s mental health, wellbeing and sense of safety were acknowledged. Furthermore, there was a lack of understanding and professional curiosity regarding the impact of Lilo’s ASD and ADHD and the way in which this increased his risk of extra-familial harm. The stabbing and the occasion when he was ‘badly beaten’ both occurred when either at school, or by peers from his same educational setting. 4.2.12. Lilo struggled with peer relationships in both his first secondary school and first alternative provision. The difficulty to navigate and understand peer relationships was exacerbated due to his ASD and ADHD diagnosis, which increased his vulnerability to extra-familial harm 14. However, this was not understood across the safeguarding system due to a lack of exploration and co-ordinated understanding of contextual risk. Professionals in the children’s social care practitioner event shared that contextual risk was a new and emerging issue at the time of these critical incidents in 2018, which may have impacted how risk to Lilo was understood in the professional network. This will be discussed further in the section ‘Understanding risk in context of extra-familial harm’. 12 Information taken from Education IMR and practitioner learning events 13 Account of LILO ’s mother and Stepfather – shared verbally with independent author Dec 2022 14 Notes from ADHD and ASD diagnosis 2012 9 4.2.13. Unfortunately, Lilo did not get the opportunity to settle into his fourth education placement; Alternative Provision 2 in June 2019, as he was involved in a serious moped incident a few weeks later, which resulted in life changing injuries and a long and difficult recovery. Lilo was not able to continue with his education until later in the year. This was provided using a combination of online and some face-to-face support. This was challenging for Lilo as it was a new provision for him, and he had to travel across boroughs to access learning. During the practitioner events, professionals shared that they did not fully understand Lilo ’s needs and his vulnerability, due to a lack of information sharing between agencies. An example of this was the last college he attended. They were not aware that he had a social worker and their exclusion from the child in need processes resulted in missed opportunities for information sharing and interagency communication. 4.2.14. Evidence provided in the review suggests that Lilo was struggling to come to terms with the life changing injuries he had sustained and was showing signs of trauma. For children who experience significant trauma, compounded with neurodiversity, Lilo would have likely had trouble in comprehending the harm caused to him. 4.2.15. The way in which Lilo processed and experienced trauma will have had an impact on his recovery, both physical and emotional. 4.2.16. Impact of Covid and Education 4.2.17. In February 2020, Lilo started his fifth education provision, whilst awaiting his Education Health and Care Plans (EHCP) assessment outcome. However, in March 2020, the Covid Pandemic resulted in a national lockdown. Lilo was left without consistent support and finding it difficult to respond to online education. During the practitioner event, professionals shared that they understood his learning needs. However, given that education was offered online and without minimal support it is unclear if and how his new provision fully grasped his needs. 4.2.18. Impact of unassessed special educational needs 4.2.19. Due to inconsistent and fragmented education, professionals did not get to know Lilo or fully understand his needs to support the development of a coherent SEN plan to either meet his needs or evidence the need for an ECHP needs assessment. There was a lack of effective information sharing between schools which meant that the early recognition in 2015 that he had sufficient additional needs to require him to be placed on the school’s SEN register, was not passed on. This created a ‘start again syndrome’ in each of his new schools each time he moved. 4.2.20. Due to this lack of information sharing, his additional educational needs were not assessed, and he was not offered education tailored to his specific needs across any of the provisions he attended between 2017 to January 2020. This includes Primary education, as Lilo was 9 years old when he diagnosed with ASD and ADHD, as such there should have been a transfer of his plan from primary to secondary education. There were multiple missed opportunities to establish a coherent plan. Secondary School 1 Lilo was on SEN the register, however it is unclear if and how his plan was implemented. 10 2018 – mother’s request for EHCP declined. (aged 12) Alternative Provision 1 SEN plan was not shared from Secondary School 1 – Lilo had no SEN plan in place, and this was longest placement in education. Alternative Provision 2 In Autumn of 2019 a request for EHCP is made and declined on the same day. Lilo’s mother follows up the request for ECHP to be fast tracked two days later due to changes in his health – (Lilo aged, 16). College 1 February 2020 (a month before the Covid Pandemic lock down – Lilo’s EHC needs assessment is agreed. 4.2.21. Lilo’s EHCP was eventually finalised in August 2020 a month before his 17th birthday. 4.2.22. Lilo’s mother advocated strongly for him and made numerous attempts to get an EHCP needs assessment, so that his additional needs could be recognised, and a tailored package of support could be devised addressing his needs arising from his neurodiversity, health and social care needs. Despite these requests for an EHCP needs assessment by his mother, the threshold for an assessment was not met until January 2020. During this period Lilo’s mental health and overall wellbeing had declined following his moped incident and subsequent life-changing injury. When the decision to undertake an assessment was made in 2020, it appears that his additional health needs were a factor in the decision that the threshold was met to trigger this statutory assessment. Prior to this, his needs relating to ASD and ADHD were never perceived to be enough to meet the threshold. 4.2.23. Whilst an EHCP may not always be required for children with a diagnosis of ASD and ADHD, Lilo still should have received a high-quality SEN plan15 to ensure that he had the best opportunity to achieve. When it became evident that Lilo required an EHCP, there had already been multiple missed opportunities to provide Lilo with the specialist educational, health and social care support he required. 4.2.24. Black, male and neurodiverse in school education 4.2.25. Some professionals considered Lilo as being a ‘danger to others’ and having ‘irrational angry outbursts’16. This language denotes the image of the ‘angry Black boy’. During his education Lilo experienced both fixed term exclusions and periods of being excluded from the classroom17. 4.2.26. In the Ofsted Inspection (2016) of School 1 where Lilo experienced the most fixed term exclusions, the school was found to be inadequate. The key issues highlighted included: inadequate safeguarding, inability to manage behaviour and over-use of school exclusions and a lack of pastoral care and welfare support. 15https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/398815/SEND_Code_of_Practice_January_2015.pdf 16 Documented in EHCP needs assessment review case notes, 2020 and GP notes 2011 17 Based on the information provided it is unclear if these periods outside of the classroom were categorised as internal exclusions 11 4.2.27. As a Black neuro-diverse male, in the context of a school that was found to over-use exclusions and struggling to manage behaviour, it is probable that Lilo was perceived as the issue, rather than a consideration that he might have been responding to the conditions created within the school environment. It is not clear how these perceptions of Lilo impacted on how he perceived himself as a Black neuro-diverse child when excluded from lessons and activities. However, Autism UK (2019) found that exclusions can leave autistic children feeling sad, angry and let down18. 4.2.28. When the focus shifts to responding to a child’s behaviour, without the consideration of critically reflecting what might be the cause of behaviour, professionals are at risk of overlooking the vulnerabilities and difficulties neuro-diverse children experience in education settings19. 4.2.29. Given that Lilo was a Black British Caribbean male, who are more likely to experience punitive responses and expulsion from education20 and where autistic pupils are three times more likely to be excluded from schools than their neurotypical peers21, it is likely that his behaviours were not always considered to be symptomatic of his neurodiversity. 4.2.30. Lilo’s lack of educational progress and negative perceptions about his behaviour could be suggestive that Lilo had started to experience the hallmarks of the school to prison pipeline. This is the movement of Black working-class boys from mainstream education to alternative learning provisions and/or pupil referral units (PRUs) to the criminal justice system, due to lower aspirations for Black boys in education22.This is an important consideration because ‘the proportion of PRU’s and Alternative learning provisions in the capital is almost double the national rate, with young boys from Black Caribbean heritage overrepresented in the sector’23. 4.2.31. The movement of education provisions, significant traumatic experiences, the deterioration of Lilo’s mental health and the limited understanding of his vulnerabilities and learning needs in the professional network, leaves questions about how Lilo experienced his final years before his death. From reviewing Lilo’s experience of secondary education, in tandem with his trauma, it can be best described as an unsafe and unstable period. 4.2.32. Learning Points: ▪ Moving children between multiple education settings can result in feelings of instability in relationships, in both peer and professional spaces. It is incumbent on schools to understand and be responsive to the needs of neurodiverse children. This requires information seeking, sharing and clarifying information and providing high quality special educational needs plans to ascertain if and what support a child requires. 18 Autistic pupils and exclusions (autism.org.uk) 19 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2022/11/cc-beyond-the-labels-a-send-system-which-works-for-every-child-every-time.pdf 20 https://thecommissiononyounglives.co.uk/commission-on-young-lives-calls-for-an-end-to-exclusions-culture-as-part-of-a-new-era-of-inclusive-education-to-tackle-the-scourge-of-teenage-violence-and-exploitation-and-help-all-children-to-succe/ 21 https://www.autismeducationtrust.org.uk/exclusions. 22 https://irr.org.uk/article/beyond-the-pru-to-prison-pipeline/ 23 ibid 12 ▪ Negative stereotypes about Black children can reduce professional curiosity to explore the extent to which presenting behaviours are symptomatic of neurodiversity. Professionals must always consider how bias and assumptions about Black boyhood can impact children receiving the best opportunity to thrive in education. ▪ Risks of extra-familial harm increases for children who experience fragmented education. This risk is heightened when children are placed in alternative provisions and pupil referral units. Children who are neuro-diverse and not always able to comprehend risk and healthy relationships and require education settings which provide nurture, understanding and boundaries. Recommendation 1: Education must undertake a review of the EHCP process o Education must gain assurance that when a child has an SEN plan it always follows the child throughout each educational setting. o It must be expected that SEN plans are updated and where they are not meeting the needs of children, an EHCP needs assessment is progressed. o Education must gain assurance that SEN plans are robust, effective and provide a clear understanding of the needs of the child in order to ascertain if and what further support is required, such as an EHCP. Recommendation 2: Identifying, acknowledging and challenging bias within the education system Lewisham Safeguarding Children Partnership to commission learning and development for Adultification bias and review its current training offer on trauma, neurodiversity and extra-familial harm. 5.3. Understanding risk in context of extra-familial harm 5.3.1. Children’s Social Care Services: 5.3.2. Lilo was assessed twice in February and August 2017 by the referral and assessment team. Notifications had been made to the service following his arrest in August 2016 when he was stopped and searched by the police who found Lilo with a screwdriver, balaclava and pair of gloves24. Another notification was made to children’s social care later that year when Lilo had been involved in a fight which involved groups of boys from two schools. No further action was taken by children’s services following these notifications. 5.3.3. Children social care became involved with Lilo again in 2018 after he had been stabbed. An assessment was triggered, and it was later decided that Lilo’s case would close in June 2019. At the time of the stabbing there was important knowledge held in the professional network showing signs of significant risk to the family. This included: 24 In total Lilo was stop and searched 5 times by the police all resulting in no further action 13 ▪ Lilo’s close friend had been murdered and Lilo was wearing his friend’s coat at the time of the death ▪ Lilo’s mother told the YOS worker that Lilo had said he did not feel safe ▪ Lilo’s mother told a Redthread25 worker that Lilo had been approached on a few occasions to sell drugs ▪ A group of males were reported to have been seen outside the home address and school There were several agencies in contact with the family at this time, which included: ▪ The school, who had requested CAMHS support for Lilo ▪ Redthread, who had been informed of signs of extra-familial harm by the mother ▪ Family Functional Therapy, offering support for Lilo and his mother to develop their communication ▪ The police, who had responded to the stabbing and report of the threat to the home ▪ YOS due to the offences involving motorbikes. ▪ The GP, who held the family’s history and diagnosis of ASD and ADHD and stress related Alopecia ▪ CAMHS who were offering remote medication provision 5.3.4. The risk to Lilo in December 2018 was recognised to be significant and a strategy meeting26 was held. However, this meeting was not recorded and the planning from this meeting was unclear. This was a critical missed opportunity to bring together all the information known about Lilo, to set out his vulnerability and lived experience and to take steps to secure the immediate safety of Lilo and his siblings. 5.3.5. A further incident happened at the end of December 2018, where a ‘blue light’ had been shone through the letterbox of the family home and this made the family fearful about further violence or harm. There is no evidence that a strategy discussion took place and the only response to this incident was to advise the mother to move out of the family home. To note, if his mother had moved out of the local authority permanent home, her secure tenancy and the rights attached to this would have been compromised, leaving the family ‘intentionally homeless’. 5.3.6. Since this review Lewisham Housing have updated their housing needs assessments and this now includes the impact of extra-familial harm. It is important that housing associations are updated with any changes or new information regarding this assessment. 5.3.7. Notes from a multi-agency meeting in February 2019 show that there was some recognition of the risk to Lilo from extra-familial harm. However, Lilo had multiple changes of social worker and in June 2019 the decision was made for his case to close as there were: Practitioner case notes: 25 Redthread provide youth violence intervention programmes in identified hospitals in London, including one where Lilo was an inpatient in 2018. See (https://www.redthread.org.uk ) 26 A strategy meeting is a multi-agency meeting, hosted by children’s services to identify levels of risk and plan for the immediate safety of the children involved. 14 ‘No parenting concerns, Lilo had a school placement, and he was working with the Youth Offending Service and health27’ 5.3.8. This decision implies that extra-familial harm was not well understood at the time, a view that has been reflected by practitioners that took part in this review. 5.3.9. A month later Lilo was involved in a moped accident which triggered a fresh referral to children’s social care and a new assessment of need in August 2019. The outcome of the assessment was that Lilo should be offered services from the Safe Space Team. This was a new team designed to meet the needs of children at risk of extra familial harm. A decision was later made that Lilo should be held by the team who cater for children with complex needs and disabilities. This was a perplexing decision given that children with complex needs and disabilities teams usually have high thresholds and do not usually serve children with needs arising from neurodiversity - unless acute, such as non-verbal. 5.3.10. Feedback from practitioners was conflicting when this decision making was explored. One explanation was that the Safe Space team did not have capacity to take Lilo at the time as the criteria for services from this new team were not clear and it had been flooded with referrals. Another explanation was that the decision was made from a service manager level whereby the Local Authority felt the complex needs and disabilities team was most suitable. 5.3.11. Lilo transferred between social work teams until November 2019 where a request had been made for support in meeting Lilo’s needs arising from the injuries, he sustained in the motorbike accident. He was allocated for a child and family assessment by a social worker in the children with complex needs and disabilities team to see if he met the threshold for services from this team. The supervision notes at this time indicate that Lilo blamed himself for some of the issues he was experiencing due to ‘hanging around the wrong peer group’28. Although it is unclear how professionals supported Lilo in exploring these feelings. 5.3.12. The child in need planning following this assessment did not highlight the risk Lilo was experiencing due to extra-familial harm. This planning was focussed on his physical needs and his mother’s need for breaks from providing care to him. Lilo’s voice was not present in case planning. If he had attended his reviews in person or his voice represented by his mentor29 or mother, it is highly likely that his sense of feeling unsafe would have helped to focus the attention of the other professionals contributing to the planning. As a result of this important gap the planning was not linked to his need for protection. 5.3.13. It is expected practice that a boy of Lilo’s age would contribute to planning and be given the opportunity and support to express his wishes and feelings about his life. It is also expected that all professionals working with children are either invited to attend reviews or consulted on their views. 5.3.14. It is also expected that where significant harm has been identified that basic child protection processes are followed: e.g., strategy discussions and safety planning. 5.3.15. Child and Adolescent Mental Health Services (CAMHS) 27 This note is taken from the children service’s record. 28 Supervision notes dated 22.11.2019 29 A mentor from Young People Relate Mentoring Service was commissioned by the children with complex needs and disabilities service to additional support to LILO 15 5.3.16. Lilo disclosed concerns about his safety a few months after he was stabbed in December 2018, in his initial medication assessment appointment in March 2019. 5.3.17. Lilo told the professional undertaking the assessment that he had carried weapons as means to protect himself from harm, indicating concerns regarding safety. This information was not shared with children’s social care or any other professional, at the time Lilo was subject to a Child in Need plan. Upon reviewing the assessment notes, the focus was on Lilo needing to understand the risk of carrying weapons, rather than the underlying issue – his fear and lack of safety. The assessment concluded that there were no known safeguarding issues, although his risk of external harm was recorded as ‘moderate30. This is despite his disclosures of not feeling safe and the evident extra-familial harm that Lilo and his family were exposed to in December 2018. 5.3.18. It is important to note that CAMHS were not informed about the stabbing incident in December 2018 by children’s social care but were informed at the medication review meeting by his mother. This illustrates there was a lack of effective information sharing across the partnership which was exacerbated by the fact that Lilo did not have a care co-ordinator in place until March 2021. It is the role of the care co-ordinator to ensure that planning is holistic and co-ordinated across agencies. 5.3.19. As part of the review, information in the SLaM IMR into CAMHS suggested that professionals did not have an understanding Lilo’s risk of harm. The assessment of his needs endorses the view of the IMR author. There were, however, contradictory views about this as SLaM’s serious incident report31 does not share the same perspective as recorded - ‘the risk assessment forms…. were not detailed. However, the team consultant who also provided care coordination demonstrated a detailed understanding of the issues...’ It is difficult to understand this view based on the limited information on the medical assessment form and poor practice seen in this review. 5.3.20. Records of the medication assessment show that records were copied and pasted from previous assessments which indicates a lack of vigour and exploration of his changing needs. 5.3.21. Since Lilo’s death further concerns have been raised about how CAMHS understand their role in child protection. During a CAMHS practitioner 1:1 meeting a senior professional stated that they were not assured that issues like those identified with Lilo, including poor assessment and understanding of risk had improved following the death of Lilo. Practitioner comments: ‘I still do not feel assured that SLaM have an understanding of child protection and our role within that...’ ‘There was no risk management plan and no sharing of information’ 5.3.22. Race, racism and other biases and Extra-familial Harm 30 Medication assessment notes 27th March 2019 31 SLaM undertook an investigation in line with the NHS Serious Incident Framework: NHS England » Serious Incident framework the investigation was a joint investigation with Oxleas NHS Foundation Trust. 16 5.3.23. Black children are at an increased risk of extra-familial harm32as such, services must feel able to critically reflect how assumptions about Black boys can impact safeguarding responses and decision making. 5.3.24. To better understand if and how Lilo’s identity impacted safeguarding responses and decision making, during the review, professionals were asked to complete an online anonymous questionnaire which included questions about if and to what extent racism and bias potentially influenced safeguarding decisions. A total of 17 responses were received with over 90% from one service, overwhelming practitioners felt that racism was not an influencing factor. Practitioner comments: ‘I feel confident that racism did not impact services responses to Lilo ’ ‘Our services are open and inclusive and the LSCP has a good understanding of racism and discrimination’ 5.3.25. However, during a 1:1 meeting with the lead reviewing author and LSCP interim strategic safeguarding lead some practitioners felt that racism had impacted on safeguarding responses to Lilo. Practitioner comments: ‘He was a Black boy at the bottom of the well, adultification bias impacted how Lilo was responded to as child’ ‘Racism was a compounding factor he was just another Black boy’ ‘Talking about racism is not easy for our services which is frustrating as it constantly shapes how Black children are safeguarded’ 5.3.26. In addition, during practitioner events there appeared to be some discomfort in talking about racism. Periods of long silence occurred. Talking about racism can be challenging for several reasons; this includes, practitioners not feeling confident or safe, including concerns of causing offence. As such, services need to create the conditions so that conversations about race and inequality are normalised and part of everyday practice. The National Panel’s report into extra-familial harm; It was Hard to Escape33 identified that Black boys are at a heightened risk of being victim to this form of harm. Therefore, it is imperative that individuals and agencies feel able to talk about identity, in particular race and ethnicity. In addition, findings from a recent review into extra-familial harm and Black boys in a London Borough, identified naming racism as one of the difficulties in service provision34. 32 Hard to Escape (2020). National Children Safeguarding Practice Review Panel 33 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/870035/Safeguarding_children_at_risk_from_criminal_exploitation_review.pdf 34 https://www.contextualsafeguarding.org.uk/resources/toolkit-overview/building-safety-safeguarding-black-young-men-and-boys-in-lambeth/ 17 5.3.27. Learning points: ▪ It is important that children who are at risk of or experiencing extra-familial harm are provided with timely and effective support. This requires professionals to recognise risk and refer children to the services which can best meet their needs. This includes, reflecting on bias and being able to talk about racism in child protection when considering the experiences of Black boys in the context of extra-familial harm. ▪ It is important that all practitioners and managers across all agencies, including specialist service areas (CAMHS and Children with Complex Needs and Disabilities) are alert and responsive to extra-familial safeguarding risk and harm. This includes understanding the increased vulnerabilities for children who are neuro-diverse and/or with physical disabilities ▪ CAMHS practitioners must understand their role as a statutory safeguarding partner and their duty to share information as well as recognise safeguarding concerns. ▪ Strategy meetings are important vehicles in identifying risks, developing plans and sharing and analysing multi – agency information. It is critical that these meetings take place, involve the relevant partners and are recorded. ▪ Where a child has complex needs and is being served by a range of agencies it is important that a care co-ordinator is allocated in a timely manner. ▪ Children’s voices are important to help us understand their lived experience and to inform planning. Recommendation 3: The importance of the voice of the child that is heard and integrated into plans. Lewisham Children’s services to ensure that staff are aware of expected practice across children’s services regarding child in need planning and reviewing processes. Namely, o it is expected that children (where possible) are involved in planning and reviews o It is expected that all professionals working with children are invited to attend or contribute to child in need planning meetings and reviews. o It is expected that all professionals working with children receive the outcome of CIN planning meetings and reviews. Recommendation 4: Recognising and responding to extrafamilial harm. For Lewisham children’s services to take steps to ensure that all social workers and managers working with children can recognise and respond to extra-familial harm, especially for children with additional needs that increase their vulnerability to grooming and exploitation. Recommendation 5: Improving the quality of support and child protection responses, with increased understanding of the role of a statutory safeguarding partner o The Lewisham Safeguarding Children Partnership must gain assurance that there is regular management oversight of children who are open to CAMHS service but do not have an allocated care co-ordinator and performance around this expectation is 18 reviewed in the Lewisham Safeguarding Children Partnership Monitoring Evaluation and Service Improvement subgroup o To gain assurance that CAMHS (South London and Maudsley) understands their role as statutory safeguarding partner and provide assurance of their capacity to recognise and respond to children at risk of and experiencing harm. Recommendation 6: Improving the quality of record keeping and assessments Lewisham Safeguarding Children Partnership must gain assurance that CAMHS assessments of extra-familial risk meet expected standards. Lewisham Safeguarding Children Partnership must gain assurance that: o Strategy meetings are happening when risk or potential risk is identified o These meetings are attended by all relevant partners o These meetings are recorded, and a copy of the plans are shared with all agencies working with child 5.4. Understanding the impact of trauma and mental health in the context of extra-familial risk, harm and life changing injuries Children who are worried about potential risk of harm from others, or those who have already experienced harm, may not always feel able or safe to share how they are feeling, which can result in poor mental health and wellbeing.35 It is important that individual professionals and agencies understand trauma in the context of extrafamilial harm, considering children impacted by this harm may be perceived as being complicit or having increased agency to manage their own risk.36 When considering Lilo’s identity as a Black neuro-diverse male, it is likely that assumptions about increased capacity and agency impacted professional curiosity. During the undertaking of this LCSPR some professionals used language which could be considered as Lilo being complicit in the harm/risk he was experiencing, without due consideration of his lack of capacity to comprehend risk, due to his ASD and ADHD diagnosis. Some language used included ‘he put himself at risk’. This is an unhelpful narrative and erases the innate vulnerability of a child and not one which considers how Lilo’ s neurodiversity presented when grappling with potential risk or trauma. 5.4.1. There were notable episodes during Lilo’s adolescence where is started to present with trauma and poor mental health, some of which were related to extra-familial harm and other with reference to the impact of life changing injuries experienced outside of the home. 5.4.2. Child and Adolescent Mental Health Services (CAMHS) 5.4.3. Between 2018 -2021, Lilo was referred to CAMHS on seven occasions, this included both external and internal referrals. The rejection of internal referrals within and across CAMHS services, did not trigger follow ups or professional queries. Lilo, his mother and agencies reported concerns regarding his mental health over a two-year period to CAMHS. However, none of these met the threshold for CAMHS intervention. Although Lilo was receiving 35 https://chscp.org.uk/portfolio/child-c/ 36 Mapping the policy and practice landscape of safeguarding young people from extra-familial risks and harms (EFRH), 19 support from the family functional therapy service37; CAMHS missed opportunities to be responsive to Lilo’s trauma and declining mental health. 5.4.4. A brief timeline below provides some insight to Lilo ’s experience over a 12-month period: 2018 ▪ Lilo experienced an unexpected bereavement following the death of his friend ▪ When Lilo was stabbed, he experienced alopecia, difficulty in sleeping, reported low mood and struggled hygiene 2019 ▪ March 2019, 3 months after Lilo was stabbed, he discloses at his medication review meeting that he feels unsafe and has carried weapons as means to protect himself38. During this period, Lilo has a ‘mild to moderate depressive episode’39. Although, this is not recorded on the assessment form. ‘Trauma’ as so far as it relates to PTSD or medical diagnosis was not present according to the assessment’40. ▪ May 2019, YOS shares concerns regarding Lilo’s mental health with CAMHS, following an episode in custody. IMR indicates that following this concern, a meeting between Lilo, his mother and a CAMHS Consultant Psychiatrist took place where outcome of both Lilo and his mother’s mental health questions and signifies major depression. However, this has since been disputed.41 ▪ June 2019, Moped incident resulting in life changing injuries ▪ July 2019, Lilo ’s mother and Redthread Youth workers visiting Lilo in hospital raise concerns regarding his mental health and trauma, however CAMHS do not accept referral ‘he was not acute of high-risk enough in his presentation’42 5.4.5. In addition, Lilo experienced auditory hallucinations whilst in police custody in 2020. 5.4.6. It is deeply troubling and difficult to understand how a child who was a victim of stabbing, involved in serious vehicle incident and consequently left with a life changing injury within a period of six months did not meet the threshold for CAMHS and his mental health was deemed moderate. 5.4.7. Referral, acceptance and waiting times for Black and minoritised children requiring CAMHS support 5.4.8. During the undertaking of this review, third party disclosures were shared with the lead independent reviewing author, regarding concerns that Black boys referred into the Local Authority CAMHS service experience longer waiting times for support and intervention than their white counterparts. 5.4.9. At request of the independent reviewing author, CAMHS were asked to provide their most recent referral, acceptance and waiting time data. The data highlighted that in 2021, Black 37 Lilo was referred to the family functional therapy service 38 Medication Assessment 27.03.2019 39 Record from CAMHS Chronology submission to review 40 The Consultant Psychiatrist record on review template December 2022 41 The Consultant Psychiatrist emailed the independent reviewing author -stating Lilo was not diagnosed with major depression. It is unclear if and what case notes this alleged diagnosis was recorded. 42 Recorded on Redthread Lamplight record 17.07.19 – information provided by Clinical Nurse Specialist Children’s Safeguarding 20 boys waited 114 days for initial contact from CAMHS upon acceptance of referral, in comparison to 76 days for their white counterparts. Meaning Black boys had to wait one and half times longer for support. This was similar for Asian boys (115 waiting days). 5.4.10. In that same year, Black children had proportionally fewer referrals accepted than white children estimate of 72% vs 78% for girls, and 71% vs 78% for boys. The proportion of accepted referrals for children of mixed heritage is even lower estimate of 63% for boys and 62% for girls. There was no waiting list data provided for mixed heritage children. Whereas Asian children had the highest acceptance rate estimate of 83% males and 86% females43. 5.4.11. Given the disparity presented in the data, CAMHS must explore and reflect on why this disproportionality exists within its service provision and how it is assured that bias and discriminatory practice is not influencing which children are more likely to receive therapeutic support in a timely manner. 5.4.12. Key professionals from CAMHS who were involved in the decision-making regarding Lilo’s needs, were invited to participate in the review and share their perspectives. However, after more than several requests to meet, none of the invited practitioners were able to participate in the practitioner learning events or attend 1:1 meeting with the independent reviewing author. However, the independent reviewing author met with two members of the Senior Management Team within CAMHS who provided some level of insight following a review of Lilo’s case file. 5.4.13. There were missed opportunities to undertake a multi-disciplinary review of Lilo’s needs, as he had multiple referrals into the service. This was exacerbated by absence of a co-ordinated approach and fragmented information sharing across agencies within and external to CAMHS. 5.4.14. Referrals for Lilo tended to focus on his behaviour as the core issue, rather than trauma and his mental health. This raises questions about the lens in which professionals viewed and understood Lilo’s trauma and vulnerability. 5.4.15. Research suggests that traditional therapeutic services do not always consider the experiences of racialised communities44, and that the very foundation of mental health provision in the United Kingdom is underpinned by Eurocentric45 and neurotypical ideas and assumptions about the presentation of trauma and mental health46. Therefore, being a Black neurodiverse male likely resulted in a misinterpretation of Lilo’s behaviour and without consideration of how interpretations might be steeped in professional bias and negative racial gendered stereotypes. 43 CAMHS provided a graph with no actual percentages or numbers. Therefore, referral and acceptance information are estimates based on the interpretation of the independent reviewing authors analysis. However, the waiting time information is factually correct as CAMHS provided actual numbers for this data. 44 Therapeutic Intervention for Peace Report: Culturally Competent Responses to Serious Youth Violence in London. See www.powerthefight.org.uk 45 Oxford dictionary defines Eurocentric as’ an attitude that focuses on European culture or history and regards it as more important than the culture or history of other regions’ 46 https://doi.org/10.1080/13648470.2021.1949892 21 5.4.16. Learning Points: ▪ Where there is a history of more than three referrals into CAMHS, which are not accepted, this should trigger a multi-disciplinary meeting to evaluate why the referral does not meet the threshold for services and to agree an alternative provision where the referral can be better redirected. ▪ Children who experience, or who are at risk of extra-familial harm can experience trauma. There is a risk that children impacted by this kind of risk, may be overlooked due to assumptions that they are complicit in the harm experienced or have increased agency and capacity to safeguard themselves. Language such as ‘children putting themselves at risks’ denotes a lack of understanding of the innate vulnerability all children possess and can lead to adultification bias. ▪ Children who have social communication difficulties are at a greater risk of exploitation and extra-familial harm, whereby presentations of trauma are not always identified. Leaving children who already have limited capacity to navigate complex issues. Consequently, services are at risk of exacerbating the poor mental health and wellbeing of children, instead of providing the appropriate therapeutic support required. Racial biases also contribute to misinterpretations of behaviour and risk. ▪ CAMHS must demonstrate how they provide an inclusive service which considers the intersectional needs of children whose experiences of trauma span across various contexts, including extra-familial harm. Recommendation 7: Reviewing repeated referrals into CAMHS not meeting the threshold for intervention The learning from this review must be considered in how South London and Maudsley CAMHS service supports and responds to children impacted by extra-familial harm. CAMHS must ensure that a multidisciplinary review is triggered when a child is referred into more than 3 times within a 12-month period and does meet the threshold for intervention. Recommendation 8: Improving understanding trauma in the context of intersectionality Further learning and development is required for all agencies – with a particular focus on CAMHS and Children with Complex Needs and Disabilities. All learning and development must be underpinned by intersectional thinking. This requires high quality facilitation, to ensure that professionals better consider how they understand and offer their curiosity to children trauma related to experiencing, or at risk of extra-familial harm and who fall within intersecting categories e.g., race, ethnicity, neurodiversity, gender etc An evaluation of all learning must be revisited within three months of the initial training/development, evidencing next steps, improvement and areas for development. Recommendation 9: Improving access and support to CAMHS The learning from this review has highlighted that there is a disparity in which children are referred into CAMHS, including the waiting times for first contact. CAMHS must monitor and improve the inclusivity and accessibility of its services for Black and minority ethnic children. 22 This includes improving the quality of data and ensuring data is used to improve service design and provision 5.5. Understanding the Impact of trauma on the workforce 5.5.1. The impact of trauma on practitioners working with children impacted by harm can be significant. During this review practitioners shared how the death of Lilo had impacted their mental health and ability to remain hopeful and positive that youth violence can and will get better47. Professionals working closely with children who experience extra-familial risk and those who die as a result of this form of harm struggle with burn out, fatigue and require support to acknowledge the impact of loss48. It is important that professionals have access to supportive spaces where they can share, reflect and be provided with support during difficult times, when a child they may know directly or indirectly is harmed. 5.5.2. Fatigue, hopelessness and trauma 5.5.3. During this review it became apparent that the professionals across the safeguarding system, including those from the youth offending service, were becoming somewhat used to receiving traumatic news about the children and families they work with or have supported in the past. 5.5.4. Practitioners also shared that at times, it is the same professionals called upon to participate in joint agency review meetings (JAR)49 and other multi-agency meetings about the death or serious injury of a child. It was evident by the emotion displayed during this review, that practitioners felt a sense of hopelessness, pain and exhaustion. Sadly, some practitioners blamed themselves for Lilo’s death. 5.5.5. Some practitioners shared that they were not provided any wellbeing support following Lilo’s death and were left to manage the impact of the bereavement in isolation, further impacting their mental health, with other sharing similar examples. All practitioners across the safeguarding partnership, including other external agencies must have access to and, or be informed of support services available to them, particularly when experiencing trauma. 5.5.6. In 2021, the year Lilo tragically lost his life, London documented the highest number of deaths related to youth violence on record, 30 teenagers between 14-19 years of age50. Most of these victims died as a result of knife crime. 5.5.7. Some of these themes in this review have been identified in other incidents involving Black boys such as, ‘Chris’: London Borough of Newham,51 ‘Child C’: London Borough of Waltham Forest,52 Child C: London Borough of Hackney.53 As such, it is important to recognise the re-occurring themes of Black boys impacted by violence. This is crucial to understanding why and how practitioners might feel overwhelmed. 47 Accounts taken from practitioner learning events held in June 2022 48 https://www.contextualsafeguarding.org.uk/resources/toolkit-overview/building-safety-safeguarding-black-young-men-and-boys-in-lambeth/ 49 A JAR meeting occurs following the unexpected death of a child as per Chapter 5 in Working Together to Safeguard Children 2018 50 https://data.london.gov.uk/dataset/serious-youth-violence?_gl=1%2adyethe%2a_ga%2aMTA4Mzk1MjE4OC4xNjcwNTA4NTMw 51 https://www.newhamscp.org.uk/wp-content/uploads/2018/10/Serious-Case-Review-Chris-.pdf 52 https://www.walthamforest.gov.uk/sites/default/files/2021-11/WFSCB%20-%20SCR%20Child%20C%20May%20final_.pdf 53 https://chscp.org.uk/wp-content/uploads/2022/07/CHSCP-SCR-Tashaun-Aird-Child-C-Report-PUBLISHED-FINAL2.pdf 23 5.5.8. Examples of positive practice 5.5.9. Throughout the review, the Youth Justice Service (YJS) (previously known as the Youth Offending Service), demonstrated an in-depth understanding of the impact of trauma on the workforce. This is reflected in their Therapy Hub provision. The aim of the Therapy hub is to provide (consultation) to professionals when in need of support. This is a multidisciplinary service is delivered by YJS practitioners, (Family Therapists, Speech and Language Therapists and the co-located Forensic CAMHS team). This is small and unique service where capacity is limited, as such it is important that leadership consider how to sustain it, without unintentionally absolving the responsibilities of other inter-agencies to provide a similar provision. 5.5.10. Learning points: ▪ The impact of trauma following the serious injury or death of a child known to the safeguarding system can be profound. It is important that front facing practitioners are safeguarded and supported to manage the impact of trauma. ▪ The impact of youth violence in London is profound. Professionals working within the context of extra-familial harm may experience burn out, fatigue and vicarious trauma. Access to effective wellbeing services must be standard practice. Recommendation 10: Understanding Trauma for Practitioners working within the context of Extra-familial harm o Lewisham Safeguarding Children Partnership must provide wellbeing support to all practitioners working front face with children and families impacted by extra-familial harm. This should include reflective practice and high-quality supervision to ensure practitioners feel supported and able to share concerns regarding their mental health and wellbeing o Lewisham Safeguarding Children Partnership must gain assurance the need wellbeing and mental health needs of professionals are being met. It must undertake review to explore what current wellbeing provision is available to practitioners, with a plan improve provision where needed. Including utilising learning from the YJS Therapy Hub. 6. Emerging Positive Practice 6.1. Whilst the review has highlighted challenges within the safeguarding system and individual agency practice. There were some examples of positive and improving practice. 6.2. Increased awareness of contextual risk and extra-familial harm 24 6.3. There is evidence in this review that there is now better understanding of the purpose and referral pathway for the adolescent safeguarding service (Safe Space). In addition, the development of consultation surgeries focused on contextual safeguarding. The purpose is for professionals to increase understanding about extra-familial risks and discuss potential concerns with experienced practitioners. 6.4. The development of the Safeguarding Partnership Multi-Agency Child Exploitation (MACE) panel provides an opportunity for a more focused consideration of extra-familial harm, enabling for a more improved and collaborative partnership approach. 6.5. Relational Practice 6.6. The Youth Justice Service and Lilo’s allocated mentor had a good and consistent relationship with both Lilo and his mother. Relationships are not mandated and therefore when practitioners nurture positive relationships with children and families, it should be recognised and celebrated. Hard to Escape (2020) highlighted the importance of relationship-based practice for children at risk of or experiencing exploitation. 6.7. Out of all the agencies who met the family, it seems that YJS had most in-depth understanding of the family needs and functioning, including the lived experience of Lilo. 6.8. YJS and the GP both demonstrated the importance of agencies having a good and communicative relationship with parents. Lilo’s mother shared that she felt able to reach out to individual practitioners in YJS, where a relationship remains. 6.9. Redthread 54acknowledged the challenging dynamics Lilo’s mother experienced when trying to safeguard her child but also managing with multiple difficulties which required wider support outside of the Redthread offer. Therefore, having a better understanding of a whole family approach rather just focusing on the individual child. 6.10. A trusted adult who builds aspiration - Lilo ’s mentor Practitioner account: ‘I seen and treated Lilo like my son, I would’ve done anything for him, he was one of the most caring and beautiful young men I ever had the privilege to know’ (Mentor) 6.11. A mentor from Young People Relate Mentoring Service was commissioned by the Children with Complex Needs and Disabilities service to provide additional support to Lilo. 6.12. Having a trusted adult, such as a mentor, who role modelled consistency, boundaries and care, provided Lilo with a space he could access if and feeling unsafe, worried and overwhelmed by the realities of the difficulties he experienced in his external surroundings. 54 Combined Agency Chronology V5 25 6.13. Lilo’s mentor was allocated 5 hours of mentoring support per week55. During the period Lilo received mentoring, he did not miss any sessions and seemed to really enjoy the relationship he and his mentor had developed. From his mentor’s perspective, Lilo felt safe and able to be himself when they were together; this included Lilo using his crutch which he needed to aid his walking. Lilo had shared with his mentor that he did not always feel comfortable using his crutch when out with his friends, as he had a desire to ‘fit in’.56 6.14. During the period Lilo received mentoring support, he achieved several AQA’s57, including one focused on meditation to help Lilo with his anxiety. His mentor was concerned that he was not accessing appropriate education for his needs and learning, so decided to provide Lilo with 1:1 tuition, alongside his enrichment activities. From Lilo’s mentors’ perspective, this increased confidence and belief within Lilo that he could achieve and do something positive with his life. Lilo’s mother and stepfather both shared a deep gratitude to his mentor and acknowledged the support and care provided to him. 7. Conclusion 7.1. Lilo was a vulnerable child whose needs were not always understood and considered by professionals across the safeguarding system. Lilo did not have the capacity to always understand risk and comprehend unsafe situations. This was exacerbated due to many professionals interacting with him not being able to recognise that his neurodiversity compounded his risk and vulnerability to extra-familial harm. 7.2. As a Black neuro-diverse boy with a physical disability, Lilo navigated the intersections of gendered racism and ableism. This was prevalent in aspects of his educational experience, negative racial stereotypes and the lack or delayed curiosity of the wider professional network to engage and consider the impact trauma was having on his life. 7.3. Adultification bias was present which means racism influenced how Lilo was protected as a child. There was an overlooking of Lilo’s need for safety when at risk of and experiencing harm. Apart from one supervision record in children’s social care, the primary focus of children’s social care , education and CAMHS was on his ‘risk taking behaviour’ rather than his vulnerability to risk and harm. 7.4. The difficulties of meeting the threshold for an EHCP needs assessment, should not hinder or absolve the responsibility of schools to provide high quality SEN plans. The lack of support and understanding of Lilo’s needs meant for most of his education he went without the expected effective support to assist him in fulfilling his potential. Furthermore, this lack of understanding, influenced how professionals perceived Lilo, in terms of his risk, vulnerability and how that presented through his behaviour. 7.5. For any child protection system to work, professionals must share and analyse information to inform the best possible outcomes for children. Whilst information sharing continues to be a perennial issue, at different points all agencies had knowledge of Lilo’s vulnerability to risk; this includes direct disclosures from Lilo and his mother. Therefore, the challenge was not solely about the sharing of information, it was how agencies analysed and responded to the information they had sight of. 55 Support provided as part of short breaks via children with complex needs and disabilities service 56 Account taken from 1:1 meeting between independent author and LILO ’s previous mentor 57 Assessment and Qualifications Alliance 26 7.6. The voice and experiences of parents must be included in planning and decision making, where they are recognised as experts. Where there are no concerns about parental abuse or neglect, the professional network must make every effort to include parental experience and insight in the child protection system. This includes meeting them where they are at, centring this within a Think Family approach. 7.7. Understanding extra-familial harm has increased over the past several years across safeguarding systems in England. At the time of Lilo’s death, practitioners shared that contextual risk was a new and emerging issue. However, even without a good understanding of this type of harm, opportunities were missed to safeguard Lilo due to basic child protection procedures not being adhered to. This includes the lack of coherent strategy meetings, planning and record keeping, failures to act upon disclosures and not sharing information when concerns regarding the potential risk to safety became apparent. 7.8. The role of the local authority CAMHS as a statutory safeguarding partnership requires improvement. Whilst this review highlights issues across most agencies including children’s social care, it became increasingly evident during the review that CAMHS does not fully understand its role and duty in child protection. The medicalised focus seemed to obscure the child protection issues and his wider emotional needs arising from trauma. The issue is not one of the past but present based on concerns raised during the undertaking the review which are endorsed by the independent reviewing author. 7.9. Thresholds for CAMHS support and waiting times is a national issue, however, this review found that Black boys waited one and half times longer for support in comparison to white boys in this London Borough. This is concerning and raises serious questions about the inclusivity, accessibility and discriminatory practice in mental health provision. For Lilo, he experienced significant trauma, but this was not reflected in the support he received. 7.10 Whilst Lilo did not always have access to therapeutic support, outside of his family network, he had some professionals, including his mentor and those in YJS, who understood him and provided care, nurture and support. However, without the wider system providing wrap around support for Lilo, it was easy for him to fall out of sight and receive an ineffective response to the harm he was suffering. 7.11 The death of a child has a reverberating impact on loved ones, including the professional network. Leadership must reflect and act on ensuring that practitioners have access to support when working with children impacted by extra-familial harm. 7.12 Since the death of Lilo, new and emerging positive practice has started to shape professional understanding regarding extra-familial harm. This is an important step towards building safety for children impacted by contextual risk. However, this review also found examples of practice and attitudes which require further improvement. Therefore, even with the death of Lilo occurring two years’ ago, it must not be assumed that the partnership including Education does not have more to learn. The professional network must be assured that the safeguarding system can prevent and overt risk as best as possible. For Lilo the partnership must reflect if the response and support he was provided was good enough for a child who needed its help. 27 8. Recommendations: All 10 recommendations must be included in a partnership action plan related to learning from this review and any other related LCSPRs. Recommendation Responsibility When by? Recommendation 1: Education must undertake a review of the EHCP process. The LSCP must gain assurance from relevant education services that when a child has an SEN support plan it always follows the child throughout the different educational setting It must be expected that SEN support plans are updated and where they are not meeting the needs of children, an EHC Needs Assessment is progressed by the education setting. Education and the LSCP must gain assurance that SEN support plans are robust, effective and provide a clear understanding of the needs of the child and how these needs are met in order to ascertain if and what further support is required, such as an EHC Needs Assessment. (See para 5.2.33) Education within 6 months Recommendations 2 and 8: Review workforce development offer and commission further learning to improve professional understanding across all agencies to ensure a better understanding of trauma, intersectionality, adultification bias and neuro-diverse children in the context of extra-familial harm always considering language and framing of children. Identifying, acknowledging and challenging bias within the education system: (see para.2.32) Improving understanding trauma in the context of intersectionality (See para 5.4.17) LSCP Updated learning and development programme: within 3 months Evaluation of impact: within 8 months Recommendation 3: The importance of the voice of the child that is heard and integrated into plans. Children’s Social Care to ensure that staff are aware of expected practice across children’s services regarding child in need planning and reviewing processes. Namely, • it is expected that children (where possible) are involved in planning and reviews • It is expected that all professionals working with children are invited to attend or contribute to child in need planning meetings and reviews. (See para 5.3.25) Children’s Social Care Ongoing 28 Recommendation 4: For Lewisham children’s services to take steps to ensure that all social workers and managers working with children can recognise and respond to extrafamilial harm. Especially for children with additional needs that increase their vulnerability to grooming and exploitation. (See para 5.3.25) Children’s Social Care Within 6 months Recommendation 5: Improving the quality of support and child protection responses, with increased understanding of the role of a statutory safeguarding partner o Lewisham Safeguarding Children Partnership must gain assurance that there is regular management oversight of children who are open to CAMHS service but do not have an allocated care co-ordinator and performance around this expectation is reviewed in the LSCP Monitoring Evaluation and Service Improvement subgroup o To gain assurance that CAMHS (South London and Maudsley) understands their role as statutory safeguarding partner and provide assurance of their capacity to recognise and respond to children at risk of and experiencing extra-familial harm. (See para 5.3.25) LSCP & CAMHS Immediate Recommendation 6: Improving the quality of record keeping and assessments Lewisham Safeguarding Children Partnership must gain assurance that CAMHS assessments of extra-familial risk meet expected standards. Lewisham Safeguarding Children Partnership must gain assurance that: • strategy meetings are happening when risk or potential risk is identified • These meetings are attended by all relevant partners • These meetings are recorded, and a copy of the plans are shared with all agencies that are contributing to the safety plan. (See para 5.3.25) LSCP & CAMHS Within 3 months Recommendation 7: CAMHS must introduce multi-disciplinary review meetings when a child is referred more than three times and does not meet threshold for intervention CAMHS Immediate 29 The learning from this review must be considered in how South London and Maudsley CAMHS service supports and responds to children impacted by extra-familial harm. CAMHS must ensure that a multidisciplinary review meeting is triggered when a child is referred more than 3 times and does meet the threshold for intervention. This will enable a review of the child’s needs and potential signposting of other support services (See para 5.4.17) Recommendation 9: CAMHS must monitor and improve access and support for Black and ethnic minoritised children The learning from this review has highlighted that there is a disparity in which children are referred into CAMHS, including the waiting times for first contact. CAMHS must monitor and improve the inclusivity and accessibility of its services for Black and minority ethnic children. This includes improving the quality of data and ensuring data is used to improve service design and provision (See para 5.4.17) CAMHS Within 12 months, including a 6-month progress report shared with the LSCP Recommendation 10: Improve workforce wellbeing and mental health offer to professional network • Lewisham Safeguarding Children Partnership must gain assurance the need wellbeing and mental health needs of professionals are being met. • Lewisham Safeguarding Children Partnership must undertake a review to explore what current wellbeing provision is available to practitioners, with a plan improve provision where needed. Including utilising learning from the YOS Therapy Hub (See para 5.5.9) Single Agencies with LSCP oversight Within 6 months |
NC047848 | Harmful sexual behaviour and death of 17-year-old in 2015 as the result of stab wounds. Child F lived with his mother, and experienced uncertainty related to the family not having their residence in the UK regularised, poverty and poor housing which affected his health. Maternal history of abuse, domestic violence and mental health problems. Father deported in 2006 following imprisonment for serious drug offence. Assessed as child in need in 2011. Behaviour and attendance at school erratic, and several incidences of involvement with others in minor and serious offences, including rape of a 12-year-old and 14-year old. Decision made that prosecution relating to first rape was not in public interest. Learning points identified include: when cases are not pursued in the public interest it is still necessary for the young perpetrator to be given a full understanding of the implications of his actions face to face; lack of support for mental health needs due to referrals to and fro between agencies; good chronologies of key events would help spot risks; impact of long bail periods should be recognised and support should be provided to young person; agencies should take great care when describing sex as consensual when in law it cannot be; young teenagers are often unclear about consent. Recommendations include: review safeguarding approach to child perpetrators of sexual abuse and harmful sexual behaviour; encourage education providers to ensure law around consent is explained clearly; ensure that a young person's stated concern about violent risks to them is taken seriously by agencies.
| Serious Case Review No: 2017/C6344 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. SERIOUS CASE REVIEW INTO SERVICES PROVIDED TO CHILD F and FAMILY Independent Reviewer- Alan Bedford Section Page 1 INTRODUCTION 1 1.1 Background to the Review 1.3 Terms of reference 1.7 Review process 2 1.10 Independent reviewer 1.11 Family involvement 1.12 Anonymity 3 1.13 Agencies participating 1.14 Report structure 1.16 Family structure 2 HISTORY 4 2.1 Introduction 2.3 Case History 2.34 Summary 11 3 ANALYSIS and LEARNING 13 3.1 Introduction 3.2 Was the harmful sexual behaviour preventable? 3.7 Pathway to the death: preventable? 14 3.14 Decisions about Offences 16 3.21 Consent 17 3.27 Was there sufficient understanding about ethnic, cultural and family background issues? 19 3.28 Gangs 3.32 How much was known about F? 20 3.40 Agency Responsibility 21 3.47 Coming up to 18 23 4 CONCLUSION 24 4.2 What was (or could have been) known about Child F by local agencies, and was sufficient action taken as a result? 4.4 Could S’s harmful sexual behaviour been prevented, and was his ultimately fatal involvement with gangs preventable 4.6 Was there sufficient understanding about ethnic, cultural and family background issues? 25 5 RECOMMENDATIONS 26 App 1 Collated learning points 27 App 2 Acronyms 29 1 1. INTRODUCTION 1.1 Background to the Review: This is a Review into the services provided to F, a 17 year old child who died of stab wounds in 20151. The Chair of the Local Safeguarding Children Board (LSCB) was asked to consider if circumstances of this case met the statutory requirements for a Serious Case Review (SCR) as set out in statutory guidance.2 These are that there should be an SCR for every case where abuse or neglect is known or suspected and either a child dies or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child. 1.2 The LSCB took the advice of the Secretariat of the National Panel on SCRs3 as the case was not similar to most SCRs where the harm is committed inside the family, and was advised that the criteria were indeed met. 1.3 Terms of Reference (ToR): The 2015 guidance no longer provides core terms of reference for SCRs, but provides overall guidance on the purpose of Reviews. The following were agreed as the summary ToR 1.4 This SCR will : • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; • recognise the complex circumstances in which professionals work together to safeguard children; • seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. 1.5 Whilst the key issues should emerge from the Review explorations, the SCR Panel is particularly interested in the following overall questions: • What was (or could have been) known about Child F by local agencies, and was sufficient action taken as a result? • Could F’s harmful sexual behaviour been prevented, and was his ultimately fatal involvement with gangs preventable? • Was there sufficient understanding about ethnic, cultural and family background issues? 1.6 The five years leading up to Child F’s death were set as the core timeframe for study but learning was more important than precise start and finish dates, so key earlier 1 Two men were convicted of his death, and both are serving very long sentences 2 Working Together to Safeguard Children (DfE, March 2015) 3 National Panel of independent experts on serious case reviews which is to support LSCBs in ensuring that appropriate action is taken to learn from serious incidents in all cases where the statutory criteria are met and to ensure that those lessons are shared through publication of final SCR reports. The panel reports to the Government their views on how the SCR system is working’. Its remit includes advising LSCBs about the application of the SCR criteria, the appointment of reviewers and publication of SCR reports. 2 information which threw light on the core period was relevant. Agencies could use their judgement to add information which they felt relevant to learning as it was important to learn from whatever emerged from looking at the events and the family in the case.. 1.7 Review Process: The Review used the flexibilities contained in the guidance to follow a methodology which maximised staff involvement and kept the depth of inquiry proportionate to the complexity of the case. Agencies contributed to a combined chronology of professional involvement with the case. There was a ‘staff group’ of professionals who knew the family, or could represent the agency if their front line staff were not available. (A feature of this Review was that very few professionals who worked with the family were still locally employed) The group, which saw summaries of each agency’s involvement, clarified the history, identified the key points of agency interaction with the family for specific focus, and also identified key themes for the Reviewer to explore. This was helpful in both engaging staff in thinking about the possible learning, but also making best use of Review time by agreeing focus. Thereafter, the Reviewer followed up some key issues for clarity, but there was no need for either major agency reports or a comprehensive programme of interviews. 1.8 To support the process there was an SCR Panel of senior staff from involved agencies which the reviewer could use as a sounding board, and if necessary to facilitate any stumbling blocks in the process. The Panel met with the author to discuss the initial draft and help shape recommendations 1.9 The staff group reconvened to consider the draft SCR, to advise on whether it was describing appropriately the facts and issues, and to consider what recommendations would be most helpful for their work. The Reviewer would like to thank staff for their openness and commitment to the learning process. All agencies were fully cooperative. 1.10 Independent Reviewer: Alan Bedford was asked by the LSCB to undertake this Review. He has a background in child protection social work with the NSPCC, where he was also national training manager. Following this he spent 18 years in the NHS, the majority of the time as a CEO in Trusts and Health Authorities. He has worked independently as Alan Bedford Consulting on a range of issues from infection control, to emergency health care, and to safeguarding. From 2009-11 he was Director of Safeguarding Improvement for NHS London, leading a London wide peer review programme, and from 2009-13 was chair of the Brighton and Hove Safeguarding Children Board. He has conducted many SCRs, is accredited as a SCIE Systems Reviewer, and completed the 2010 and 2013 national training for SCR authors/chairs. Sadly, Alan passed away in October 2016 shortly after completion of this SCR. 1.11 Family Involvement: The family declined the opportunity to contribute to the Review but were kept informed throughout the process. 3 1.12 Anonymity: As the focus of SCRs is about learning, it is inappropriate to identify the child and family concerned. Additionally the National Panel agreed that to protect the family, the report could be published anonymously to the local authority area. 1.13 Agencies Participating: All involved agencies participated. These included: • Council1 Children’s and Young People’s Service ( CYPS) - Children’s Social Care - Youth Justice Services ( formerly Youth Offending Service) 4 • Academy School • Further Education College • Local Victim Support • Local Mental Health NHS Trust (MHT) • Local NHS Trust Hospital 1 • Local NHS Trust Hospital 2 • Local NHS Trust Hospital 3 • Local NHS Trust Hospital 4 • Clinical Commissioning Group (CCG) • General Practice (GP) • Ambulance Service NHS Trust (The ambulance service) • Police Service • Council 2 Children’s Services (CS) 1.14 Report Structure: This report describes the history in Section 2, appraising professional practice in key events. In Section 3 there is ‘Analysis and Learning’ which identifies the key themes of professional practice and where possible why those patterns of work occurred. The ‘Conclusion’ in Section 4 summarises the learning, and answers the key question about whether protection could have been quicker. 1.15 There are in Section 5 recommendations for the LSCB to consider. They are addressed to the Board rather than each agency separately, given the Board’s collective responsibility for assuring the quality of child protection systems. 1.16 Family Structure. F, who was 17 when killed, lived mainly with his mother (‘mother’). F and his mother had arrived from the Caribbean in 2000, seeking asylum from violence which mother said had lost her several relatives. F had two much older half siblings Y (his mother’s child) and Z (his father’s child) who lived elsewhere. The father (‘father’) was deported in 2006 following imprisonment for a serious drugs offence. 1.17 The Review wishes to make it clear that F was never convicted (for reasons set out below) of the serious sexual offences for which he was charged, but the SCR Panel 4 In this SCR the phrases Youth Offending Service (former title) and Youth Justice Service (current title) are the same service 4 agreed that reference needed to be made to the alleged offences because of the major learning to be achieved for agencies 2 HISTORY 2.1 Introduction: This section looks at the history of the case. Most analysis and appraisal is in Section 3, but there are some comments on professional work here. The chronology has around 200 entries setting out agency work. The Review was asked to focus on key issues and so every event is not covered in full detail. Sufficient is set out below to illustrate the themes that were identified in the Review. 2.2 In order to set the context within which professionals worked with F, there are some critical comments about his behaviour or attitude. Section 3 will explore the degree this reflected him being a victim or perpetrator, as guidance is clear how blurred are those concepts when dealing with children (as F was up to his death) who may be both. 2.3 Case History: At the beginning of 2006 there is a record of a social worker assessing for Probation the wisdom of the father returning to the home after a jail sentence for supplying class A drugs. The CYPS conclusion, having talked to mother of F and an older sibling was that the father could return home, and no further action was decided. That year the police report to CYPS that an older sibling had made some complaints against the mother. There was a strategy discussion between a CYPS manager and a police officer, which heard that the sibling did not wish to pursue the matter, and would be living elsewhere. The CYPS submission to the SCR criticises F not being seen alone as part of the deliberations. Three weeks earlier S’s school expresses concerns to CYPS about his late collection from school, mother not attending appointments with the education welfare officer, and that he might not be getting sufficient adult care. There is no record of how this was processed. Father was deported at some point in 2006. 2.4 Agencies reported nothing more to the Review until early 2011 when mother referred herself (and F) to Council 1 as she was to be evicted. She was passed to the No Recourse to Public Funds5 Team. She said she suffered from domestic violence before the father’s deportation. The assessment identified the threat of deportation6 , the potential accommodation needs, and F described himself as depressed and using the school counsellor. No help was to be offered until she attempted to regularise her stay by applying to the Home Office. 2.5 The same month F, with other boys, was a witness to a robbery, but police notes say ‘the boys and their mothers are unwilling to participate’. Two month later F was robbed of his mobile phone. F was said to have cooperated, but suspects were not 5 No Recourse to Public Funds (NRPF) is an immigration condition restricting access to public funds, including many mainstream benefits such as welfare and housing 6 They had now overstayed the visitor’s visa by 11 years. 5 found. Police noted that F ‘found it hard to express himself’. Around the same time the school were reporting home to the mother poor punctuality. 2.6 CYPS appropriately challenged the Home Office when they said they had no record of mother, despite the UK Border Agency (UKBA) having been involved earlier. A home visit by CYPS in April found home conditions very cramped, and the rent in arrears, but mother could still not show she had applied to the Home Office. In June 2011 the CYPS case was closed due to that non-application, and because ‘no child protection concerns were identified’. 2.7 In November 2011 the mother reported to Council 1 that she had now applied to the Home Office, that her home was soon to be demolished, and that conditions were ‘very bad’. An initial assessment was planned, and the accommodation found to be quite unsuitable7. The damp was a threat to F’s asthma. F said he had been mugged, and threatened by young people in a neighbouring local authority. His mother said this was reported to the police and he had since been provided with a personal alarm. F was said to ‘have been exposed to local gang culture’. The mother was depressed, and spoke of childhood abuse and violence from several partners. F had been a witness to father’s domestic violence to mother. F was assessed as a ‘child in need’ (CIN). Alternative accommodation was offered in the same neighbouring local authority that he said he had been threatened in. Mother rejected this as she said F had been threatened by boys from there twice and he was too scared to move. She told CYPS about the April robbery. Further accommodation was offered funded by the NRPF team, with subsistence payments made to his mother. This seems to have been appropriate service. The assessment itself has been seen by the Review. It was thorough and exceptionally detailed about F as a person. 2.8 A home visit, the month after the move, noted concerns about mother’s mental health (she was referred for counselling), but that F was doing better. At home visits a social worker gave him advice about drugs and sex education. The CIN Plan created in January 2012 was about exploring his contact with the local gang culture, ensuring he had drugs and sex education, and supporting his mother. By March 2012 the social worker reported the mother having attended several counselling sessions and the family ‘doing well’. Two months later, without further interim contact, at a CIN Review8 “The Social Worker concludes that the family are much more settled and F’s behaviour has markedly improved. Mother is receiving treatment for depression. Home Office response still outstanding. The family continues to receive subsistence and accommodation”. CYPS report that the CIN Plan was ‘stepped down’, as mother was getting treatment and was awaiting the Home Office decision on immigration status. The case was to be ‘held on duty’. Very 7 Rat and cockroach infestation, no hot water, the boy sharing a bed with his mother, and that S’s emotional and social development was being affected. The GP records show a range of chest infections 8 Only mother, F and the social worker attended. 6 shortly after this the school were concerned about F’s ‘poor behaviour’ and phoned the mother about this. 2.9 In February 2013, when 15, F was arrested for the rape of a 12 year old girl. Although the event is described as ‘consensual’ in agency records9, in law a 12 year old is deemed incapable of consent. CYPS was not informed by the Police for 19 days. F was bailed and re-bailed until September 2013 when the Crown Prosecution Service decided it was not in the public interest to take him to court. It is understood that the ages of the children, his having no prior conviction/caution, the victim’s behaviour, and that there was social services intervention for both the victim and F, were among the reasons for non-prosecution. It was also said that prosecution would ‘have a disproportionate adverse impact on his future prospects’. The explanation of what the decision meant for F10 was not explained to him directly but via his mother when he was not in when Police called at his home. This should have been face to face given the magnitude of the circumstances. 2.10 CYPS did know before the Police notification arrived as mother reported it to them, saying F was very confused. He was ‘very clear’ the sexual act was ‘consensual’. The mother came in for an appointment, but apparently F did not wish to see anyone. Nothing further is recorded after that discussion with mother. Around this time the CYPS NRPF team chased the UKBA as they had been supporting the family so long. Interestingly, on F’s arrest, in February 2013, the Police had found out from the Home Office that F had been given leave to remain from 25.1.13 to 25.7.15. The UKBA only told CYPS seven months later in September 2013 that leave to remain had been granted, without recourse to public funds. CYPS asked UKBA to reconsider. The only other record in 2013 is of the school being concerned on occasions about punctuality, truanting, and a confrontation with a member of staff. 2.11 In early January 2014, the mother told the Council that she could not find anywhere to live as she could not pay the rent. The social worker made an access to benefits request to the Home Office, as the council was still providing financial support. That month F was given detention for poor punctuality at school, and he also had a fight during a lesson. Mother supported school sanctions. By April, the Home Office was saying it could not decide on their immigration status as there was to be a ‘judicial review’. 2.12 In May 2014, a 14 year old girl said she was ushered away from friends and raped in a park by four youths at around 11pm. F handed himself in to the police, and CYPS and the Youth Justice Service were told 4 days later. F denied forcing anyone to have sex. The case was not put to the CPS until spring 2015, and their decision to proceed was made in the summer 2015. In autumn 2015 he pleaded not guilty and 9 This is discussed further in Section 3 10 That the fact of being accused would remain on record and could be used if any future repetition etc. 7 was bailed. He was awaiting an early 2016 trial at the time of his death, having been on bail and re-bailed for 19 months. 2.13 In June 2014, a strategy meeting was held11 to discuss the rape incident. From the minutes, it appears that the focus of the meeting was the victim and two of the alleged perpetrators including F. The minutes incorrectly say F was 13 at the previous rape allegation when he was 15, and that the victim was 11 when she was 12. Information from the school at the meeting was that there were concerns about disruptive behaviour, truanting, and possibly smoking cannabis. It was decided to assess F. When seen, he said he was ashamed, upset and anxious. He presented as having a ‘very low mood’, but said he had a good support network at school and from his mother and an older sibling. 2.14 The assessment concluded that F had been deeply affected by the incident, that he had a difficult history including witnessing domestic violence and concern over two rape arrests in a year. The social worker, who had helped F with a College application, concluded “I do not feel that there is a further role for Children’s Services at this time as there are no safeguarding concerns, however F will still be linked to NRPF, CAMHS and possibly YOS in future. I recommend the case close to Children’s Services”. As it happened, the NRPF team were off the case by August 2014, and nothing came of the CAMHS referral. 2.15 The social worker had referred F to the Child and Adolescent Mental Health Service (CAMHS), and mother for counselling. CYPS says he was referred to the Multiagency Sexual Exploitation group (MASE)12. However, the Review has identified that it was the victim (about whom there was already concern) who was referred, not F specifically. It was regarded as an assault, not CSE13 and so it seems unlikely this was of any benefit for F. The Youth Justice Service noted their statutory arm could not be involved as he was not on a court order. The referral to CAMHS was accepted but with a 3 month wait, with a plan to transfer to the Youth Offending Service (YOS) if formally charged.14 2.16 However, CAMHS decided that F would be better served by CYPS referring to The National Clinical Assessment and Treatment Service (NCATS) which offered assessment and treatment for children and young people who show high risk of harmful sexual behaviours. The GP was copied into this decision. The referral did not happen as the costs to CYPS were deemed prohibitive. It seems no other option was pursued. 11 Present were CYPS, F’s academy school and the victim’s school, YOS, NRPF rep, Police and a community paediatrician 12 The Multiagency Sexual Exploitation group (MASE) is where child sexual exploitation victims, offenders, locations and themes are discussed. It comes under the multi agency Community Safety umbrella 13 Child Sexual Exploitation 8 2.17 F left school in July 2014. He had been there 5 years. On arrival he was noted as having special educational needs, although at the lowest level. His attendance was 86% in year 7, and did not improve in year 8. Education Welfare contacted the mother in April 2011 concerned about attendance and detentions for punctuality. In year 9 his behaviour was a mix of debits and credits, and he was at the nationally expected level 5 at English maths and science. In year 10, 2012-13 his attendance was ‘improved markedly’ to 95%, and in his last year 2013-14, 11, attendance was 98%. As noted elsewhere there were concerns about behaviour and punctuality, but not at a high level. He obtained 7 GCSEs, although 6 of them were at D or E. The school reported that no agencies raised child protection concerns, nor did it need to refer such concerns. 2.18 In a positive step, in August 2014 the UKBA granted the family leave to remain with recourse to public funds. This meant they left the NRPF accommodation, and NRPF team support. The same month the YJS allocated the case. The case was closed to the NRPF team in September 2014. It appears that it was also effectively closed to CYPS after the June 2014 assessment and onward referrals, as no activity is recorded until October 2014 when a manager’s decision to close the case is noted ‘as F is working with YOS and the immigration matter resolved’. 2.19 Between August 2014 and June 2015, F and his mother were supported by the YJS Prevention Team, and F engaged well, keeping his appointments where he was given the opportunity to discuss and learn about sexual health and substance misuse. He had sexual health checks. He was also offered support around further possible criminal activity (see below). The mother was also supported. The worker made an assessment that there were ‘improvements in terms of being able to form age appropriate relationships, demonstrate an understanding of victim empathy, thinking through the consequences of his actions and demonstrating remorse for his behaviour.’ In June 2015 it was deemed that all scheduled work to be done was completed, and the case was closed. The rape charge was still outstanding. 2.20 Alongside this ongoing work, there were continued concerns about F’s behaviour and vulnerabilities. In early 2015 he was arrested for possession of cannabis and failing to stop for Police. He was referred to the Youth Offending Team as an alternative to prosecution. Council 1 MASH15 was informed but the Merlin16 only went to the YJS and not CYPS. The Police assessed the concern as the second highest level of need on the local Safeguarding Board Thresholds.17 The Police submission notes he attended the Youth Offending Team for assessment and was “deemed suitable for the matter to be disposed of by means of triage (Youth Restorative Justice).” In February, F told the YOS that he had serious concerns 15 Multi Agency Safeguarding Hub - a which brings together a variety of agencies into an integrated multi-agency team, where they can share information around vulnerable children, families and adults 16 The Police notification of a child involvement with a police matter 17 Local Thresholds Guidance. “ Level 3: Complex needs likely to require longer term intervention from statutory and/or specialist services. High level additional unmet needs -this will usually require a targeted integrated response, which will usually include a specialist or statutory service. This is also the threshold for a child in need which will require Children's Social Care intervention.” 9 about his safety as he was being targeted by boys from one particular area as his friends were from another area. This was passed on to the YOS Police link. 2.21 In spring 2015 F was stopped and searched with another youth suspected of robbery, but no further action was taken. Also in March the YOS referred him to the Gang Action Group18. The referral contained F’s own words which are repeated here to give him a voice in this Review: “The people that are from x area have something against me because the friends I have all live in y or z area, the only reason I know all of my friends is because the primary school I went to was in y area and that’s where most of them lived. Also the friends I knew in secondary school lived in either w, y or z area , and these were the people I grew up around so my face became known and the boys from x area have something against my friends, and because I associate with people from other areas the people from x area see me as one of the y area boys so they try fight me every time I see them Dangers of living here? I fear that they might find out where my actual house is, which means that I won’t even be safe in my own house and also this will put my mum in danger and I don’t like seeing her stress or frightened. Every time I leave my house, they will see me waiting at the bus stop and will approach me. By the way, I don’t want to get the police involved because the situation will get worse, I just want to move away from this location because the longer I stay here, more of them will start to recognise my face and carry on coming after me even though I have nothing to do with their beef.” 2.22 The referral added that F’s mother has told YOS that he had been attacked a few months earlier causing swelling to ear and mouth. The YOS worker submitting the referral said that F had reported a knife being pulled on him because of where he lived, but concluded ‘In my professional opinion, F does not present as being involved in gang activity’. It said he was studying mechanics at College. 2.23 (F attended College through 2014-15 and achieved a level 1 qualification in motor vehicle maintenance and repair. He returned in September 2015 for level 2 courses. The College says ‘he was making steady progress until his death. He was a popular student with classmates and staff. His attendance reached 55% in term one’. The College said it was in regular contact with his mother about this. The College did not know about his offending history or stabbing in autumn 2015) 2.24 The response from the Gang Action Group was that he was a victim, ‘with no concrete evidence’ that he was gang member and that he should be referred to Victim Support. A referral to the Young Victims Worker, (part of Victim Support) a few days later used the same information. Two months later, apparently without having had any contact with F, Victim Support referred F to Victim Support as his bail address was there (his sibling’s home). He attended one appointment in the summer, where he said he was scared to leave his house as he had been threatened by a gang from x area, and also referred to a fellow pupil at College 18 A three weekly multiagency panel that looks at gang activity and associations, and to agree multiagency actions and plans. It is under the Community Safety Partnership. 10 whom he believed watched him for the x area gang. Fearing repercussions he did not want Police involvement. He was given a personal alarm. Four attempts to call him across the summer were not successful but in early October he was contacted. F said he was fine, and no longer needed support. He said he had the Victim Support number if necessary. The case was closed. 2.25 In autumn 2015, aged 17, F was treated in Hospital 1 for a stab wound to the thigh which required stitches. He refused to cooperate with police inquiries. The Police say this was the first time they recognised that he may be involved with gangs. As he provided a Council 2 address – his sibling’s house – the Police notification went to Council 2, who had no record of him. He was again assessed as Level 3 on the continuum as need. Council 2 CYPS was going to do a child protection assessment, but when they discovered during the assessment that his main address was in Council 1 he was referred to Council 1 CYPS. In the course of Council 2’s initial inquiries they say they were told there was no further action on both the rapes and the possession of cannabis, but this was wrong on the second rape where trial was awaited. F attended Council 2 CYPS twice which Council 2 said suggested ‘he was willing to engage in services’. Both F and his mother denied he was involved with gangs. 2.26 Although Council 2 had in good faith started to assess the case, Council 1 CYPS did know about the incident as they were told almost straight away by Hospital 1. The hospital’s referral included “There are concerns that F is at risk of serious injury or death”. Four days after the stabbing, it was discussed (like other similar cases) at the paediatric unit’s weekly child protection meeting where the feedback received from the Council 1 CYPS19 was that ‘there was no information to suggest that (F) is at continued risk of harm. Management decision – the referral will be used as information only’. The outcome was that the referral was taken off the discussion sheet. Council 1 CYPS told this Review that they should have called a strategy meeting on hearing of the stabbing. 2.27 The detail of his attendance was passed to the Hospital 1 Gangs Youth Outreach Worker. At the time of attendance the youth worker was commissioned for young people who resided in Council 3 which is served by the same hospital, only as part of the Council 3 Gang Strategy and therefore would not have had any direct contact with Child F. 2.28 Council 2 realised this was really a Council 1 case, and referred back to its neighbour nearly a month after the injury but, as seen above, Council 1 already knew. The Council 1 MASH was also involved as the GP records the MASH Team sought information from them. Council 1 had decided ‘no further action to be taken by Council 1 CYPS as no child protection concerns identified at this current time’. 19 Although not told by the Police, A&E told Council 1 CYPS the day after the attendance. The GP was also informed. 11 Section 3 will look at whether this response accorded with guidance. Neither Council 2 nor Council 1 were therefore involved at the time of his death. 2.29 A few days after the stabbing the CAMHS referred F to a Clinic, a solicitor having asked the GP in July to get a psychological assessment of F. The Clinic was commissioned to take 18 cases a month from CAMHS. The GP was informed that the case had been allocated to the Clinic. By the time F died a letter had been sent offering an assessment but no contact had yet been achieved. 2.30 The School Nursing service was informed of the incident by the Hospital 1 paediatric liaison nurse. The referral form had the name of F’s school on it, but he had left there 15 months before. An unaddressed letter to CYPS to find out what had happened after the hospital referral is on school nursing notes, but whether anything was actually sent is unclear. There is no record that the nurse checked the academy to see if it was the right school, or of any chasing to find out the outcome of the referral to CYPS. Hospital 2, which runs school nursing services in the area, told the Review that this should have been done. 2.31 In late 2015, there was an altercation at the College between F and another pupil. F told the College “he knew the other student from x area and that the other student has it in for him because the people he hangs about with are from y area”. The College said a “report was then sent to the Head of School, and the College Police Officer was also informed because of the student mentioning the x/y area issue”. The College was unaware of the recent stabbing. 2.32 Two months later in 2015 F was arrested in possession of a mask, and with a friend who had an 8” bladed knife. A victim’s handbag was found when F was arrested. He was bailed not to associate with (a named person); an 8pm to 6am curfew; not to enter the area and to live and sleep at his mother’s address. F was aggressive throughout his dealings with Police and made no comment. The Merlin notification was prepared, and provided to Council 1, but again only to YJS and not CYPS. 2.33 One month later20 it is understood that whilst trying to purchase cannabis with an acquaintance, there was an altercation with two men resulting in F receiving two stab wounds – to back and thigh, the latter proving fatal. He was attended quickly by ambulance and helicopter and conveyed to Hospital 4, but was pronounced dead less than an hour after arrival. Two men were charged with his murder and drug offences and subsequently tried and convicted. 2.34 Summary: F was a child brought up in a family where the mother had experienced abuse and violence for much of her life, where his father had apparently perpetrated domestic violence and was jailed for drugs offences. He experienced the uncertainty that went with him and his family not having their residence in the UK regularised, and poverty and poor housing which exacerbated his chest complaints. Although 20 This was during the curfew period 12 showing some signs of wanting to do well, his behaviour and attendance at school were erratic and he increasingly became involved, always with others, in minor and serious offences, notably rapes of a 12 and 14 year old. He was also the victim of offences such as mugging, and then a stabbing. There were signs of a serious escalation in what was happening to and with him in the last year of his life, with arrests relating to drugs and robbery, and the stabbing. 2.35 The family received good support when the concern was around immigration, housing, and the need for financial support. An issue for discussion in the next section is whether public services did enough, or in a coordinated enough way, to prevent the escalation of his lifestyle to one of real danger – to both others and himself. 13 3 ANALYSIS AND LEARNING 3.1 Introduction: This section looks at the degree to which, if at all, the harmful sexual behaviour and criminal death were preventable, and then explores the issues raised in the conclusion in more detail. It looks at what happened with the public services which had responsibilities relating to the family, how well they worked and, if there were problems, why they occurred. 3.2 Was the harmful sexual behaviour preventable? F was involved in two incidents where, with others, he is alleged to have raped firstly a 12 year old when he was 15, and then a 14 year old when he was 16. It can be concluded quickly that it would be unreasonable to think that services might have prevented the first rape in 2013. There were no indications that he might behave in such an extreme way. The family had been given some good practical help around their immigration status, housing and finances, and both mother and F had been given some personal support and advice. CYPS had closed the case in 2012, but even had their work been more intensive or longer it is hard to see how this could have prevented the first offence. Even if his knowledge about ‘consent’ had been better, he is unlikely to have been deterred when (apparently) by the statement of the victim some of the sexual acts were volunteered21 and he was in a like- minded group of boys. 3.3 It is not so easy to reach the same conclusion on the second rape. It might be argued that the decision on the first rape that it was not in the public interest to prosecute gave F a mixed message about how ‘bad’ his actions were. The Police reported that the reasons for that decision, and the implications, were never conveyed face to face with F but only via his mother. He never had any specific therapeutic or educative input around this offence which he undoubtedly committed. (His belief that the victim acted consensually is negated by her age). F was not seen by CYPS between the two rapes. There is no evidence that any agency spoke with him about it, and it is understood that neither the GP nor school (which had been dealing with some behaviour and attendance problems between the two offences) were aware of the offence. CYPS was informed by the police, and mother was seen twice but F declined to be involved. 3.4 The fact that there was no prosecution did not mean the offence did not exist (albeit not proven in court). Local Child Protection Procedures require a strategy meeting around a child who harms another. This did not happen. The procedures emphasise multiagency knowledge about such offending, but this did not happen either as it did a year later with the second rape. Maybe the absence of a charge deflected thought from F’s needs and prevention. 21 Although in law the victim at 12 was deemed incapable of making informed consent. 14 3.5 It cannot be proven that the absence of any work with the 15 year old F about sexual behaviour or peer pressure after the first rape led to or failed to stop the second, but at the least its absence may have contributed to his understanding of right, wrong and consent being unimproved. (With the second rape he similarly saw the sexual act as a mutually consensual one). 3.6 Learning Points: • When cases are not pursued in the public interest, it is still necessary for the young perpetrator to be given a full understanding of the implications face to face • Guidance that there should be a strategy meeting around safeguarding a young offender should be followed even if there is, in the public interest, no prosecution. • No further action by the CPS does not mean in itself that other agencies should act as if there has not been a serious offence 3.7 Pathway to the death: preventable? The second question is whether the journey of escalating criminality/violence could have been halted or slowed. The following is a table of his contacts with the law. Date Event Comment Feb 2011 Victim of a robbery when stopped by older boys and mobile phone stolen Feb 2013 Arrested age15 for rape of 12 year old girl In Sep 2013 the CPS decided it was not in the public interest to prosecute May 2014 Arrested age16 for rape of 14 year old girl Charged in July 2015, and due in court in early 2016. F was killed late in 2015 2015 Age 17, arrested for possession of cannabis, and failing to stop for police Referred to the Youth Justice Service as an alternative to prosecution 2 months later 2015 Stopped and searched with another youth suspected of a robbery No further action 5 months later 2015 Charged with rape, he appeared at Crown Court Pleaded not guilty to rape. Trial set for early 2016 one month later 2015 Age 17, stab wound to thigh requiring stitches Refused to cooperate in any police investigation of the assault. Police believe he is involved in gangs, and might have been present at another stabbing the previous day. two months later 2015 Still 17, arrested on suspicion of robbery. Had a mask. With another youth who had a knife Investigation ongoing at the time of F’s death. Bailed on condition of 8pm-6am curfew, living at family address, not going to certain parks, 15 3.8 The first event in 2011 will sadly not be that unusual, and both mother and son reported being supported by the Police at the time. The first rape did indicate he was acting with a group of youths, and the previous paragraphs have described how no action was taken with F over his behaviour. This was a missed opportunity. After the second rape, there was the required strategy meeting and an assessment of F’s needs. Although seen by CYPS it seems that the fact that he was denying the offence and had made ‘no comment’ was seen as a reason not to discuss the offence itself with him. CYPS soon decided there was no further role for them and closed the case having referred F to CAMHS. They in turn wanted him referred to NCATS, so the case was referred back to CYPS but apparently it was decided this could not be funded. He therefore ended up with no specialist emotional support about his then predicament. He also lost the support of the NRPF team, although for the positive reason that the family had been given leave to remain in the UK. 3.9 From August 2013 CF did have the support of the YJS, which was on a voluntary basis as he was not charged until after they ceased involvement. This seemed to be a positive involvement. However, during this period he was arrested for possession of cannabis and failing to stop and was referred to the YJS as an alternative to prosecution. He had a number of sessions with YJS about sexual health and drugs. CYPS was not informed by the Police so did not have the opportunity to consider re-opening the case. F told YJS about his fears for his own safety which were passed to the Police, and he was referred to the Gang Action Group and, with his consent, to Victim Support. 3.10 In 2015 F was stopped and searched regarding a possible robbery. 3 months later, YJS closed the case as it was deemed all scheduled work was done. This seems questionable given the CPS had yet to decide about prosecution for the second rape. At that point no CYPS, YJS, or mental health services were involved at all. While it would be unreasonable to say that this led to the later escalation of violence, it does raise the question about whether there should have been no involvement when he was still on bail for a second rape, had had a drugs arrest that year, and had been expressing fears for his safety. The issue of which agency needs to take an overview of a young person’s needs in this sort of situation is discussed later. 3.11 By the time he was stabbed in 2015, he had been arrested twice for rape (and awaiting trial on one rape), been arrested for a drugs offence, and suspected of a robbery – which might suggest that he was getting into serious circumstances. Yet there was no strategy meeting, and CYPS saw no need to become involved. Whilst not associating with (named) person. One month later 2015 Stabbed in thigh and back, the thigh wound proving fatal. With an associate, F was apparently in an altercation with older drug dealers. This was during the curfew period. 16 again it could not be concluded that the lack of involvement led to his death, it would be fair to say that as far as F was concerned he was on his own after the stabbing, and with a trial hanging over him too. Of course, he may not have accepted any help or intervention offered. 3.12 There was one more opportunity when, a month before his death, F was arrested on suspicion of robbery with another youth. Between them they had a mask and knife. He was still at 17 technically a child. Again Council 1 YOS but not CYPS was informed of ‘an arrest for possession of an offensive weapon’. No action by YOS is recorded22. Even if CYPS had been told there can be no assumption that doing ‘something’ would have stopped the late night altercation over drugs a few weeks weeks later, but it does highlight again the question of who takes overall responsibility for the safety of a teenager in these circumstances and those around him. 3.13 Learning Points: • The ease with which a teenagers mental health needs can go unsupported as referrals go to and fro between agencies • Good chronologies in each agency of key events would help spot accumulating and escalating risks 3.14 Decisions about offences: Getting a case to a position where there is evidence to put before the Crown Prosecution Service (CPS) is not easy, especially when there is limited cooperation from the young person/s concerned. And even after the decision there are inevitable waits for court hearings. However, it is worth reflecting on the length of time that F spent waiting for a decision or a trial, and on the impact of the decision not to proceed. 3.15 F was arrested for the first rape at age 15 in February 2013, and was bailed and re-bailed until September 2013 when the CPS decided not to prosecute, a period of 7 months. The mother was told and had the implications explained in October, but F never had a direct explanation. Given we know that F did not understand the law on consent (he thought a 12 year old girl appearing to him as willing made it all right) it is possible that he saw the no further action as vindication of his position. It is also possible that he saw the no further action as meaning he did not commit an offence. This is speculation, but there was a need to try and ensure F was well guided on his future behaviour. In the future, in similar circumstances, the Police must make sure the young person has a full explanation of the implications. 3.16 The second rape case had not been heard when F was killed, 19 months after the offence. A hearing was due the following month. The wait for forensic evidence/phone analysis amongst other things meant the case was not put to the CPS for evidential review until March 2015, ten months later, and the CPS decision 22 By this time Council 1 YOS had a very limited service for anyone not on a court order 17 was not taken until a further four months, when he was charged. Trial was booked for early 2016, which would have been 20 months after the offence. The time from offence to trial would have amounted to almost 10% of his life. The Review has not examined the decision process, but raises the issue of the impact on F, the child concerned. 3.17 It is known that F was (not surprisingly) low about the process. He had expressed remorse to the social worker. He would inevitably be anxious about what it was all leading to. But when the CPS decided to prosecute he had not been seen by CYPS for a year, and the YJS work had stopped the month before. Council 1 CYPS had also decided not to be re-involved after his drugs arrest in 2015, or the stabbing later that year, and the YOS did not get involved after the robbery arrest in late 2015 – all before he had got to trial for the rape. When there are such delays in decisions about prosecution, or long waits for trial should not one of YJS or CYPS be providing some sort of support, or even a watching brief? 3.18 The fact that he denied an offence, and later pleaded not guilty at the preliminary hearing, may have acted as a disincentive for agencies to act as if he was ‘guilty’ by proactively trying to engage. But he was a child in law, and whatever the technicalities of what can or cannot be discussed about a specific offence before trial, there is a need to do whatever is possible to protect him from himself or others. It was not as if his life was going smoothly while on the extended bail, as four of the events listed in the chart in 3.7 above occurred during this time, two of which were when no agency was involved. The SCR Panel also identified the issue that children might still need services even if there is a decision not to charge, and therefore it is important that a no prosecution decision does not blind services to a child’s needs. 3.19 CPS guidance is that children of 13-15 years old, of the same or similar age are highly unlikely to be prosecuted for engaging in sexual activity, where the activity is mutually agreed and there is no abuse or exploitation. It is interesting that the ages in the first rape were 15 and 12, which are not really ‘the same or similar’. See ‘Consent’ below. 3.20 Learning Points: • When a case is not taken forward as not in the public interest it is essential the alleged perpetrator is provided with a thorough explanation of the implications, and that it does not mean that no offence may have been committed. • No prosecution does not necessarily mean a child has no service needs. • The impact on a child/young person of long bail periods must be recognised, and support provided especially to those with known vulnerabilities. • Agencies should be wary of closing cases whilst major decisions about offences are still pending. • Denying an offence, does not negate the need for the child/young person to be supported or worked with to protect themselves or others. 18 3.21 Consent: In law, no one under 16 can consent to sexual activity, although, if the child is aged between 13 and 16, and the adult reasonably believed the child to be 16 or over there may be a defence. There is no such defence if the child is under 1323. A child under 13 is deemed unable to give consent. It is interesting that several Police entries in their chronology and in other agency files the act for which F was arrested in 2013 was described as ‘consensual’ when the law deems it impossible for a 12 year old to consent. It is also interesting that although at 12 the victim was in law unable to consent, the CPS decision considered how the victim behaved in its decision not to prosecute F. 3.22 The Review understands what is meant in agency files by ‘consensual’, that is that apparently the victim claimed the sexual activity was as a willing participant, but the point of the law is to protect young children from situations where they engage in sexual activity at an age when they are deemed unable to consent. This being the case it would be better if agency records did not describe the activity as consensual sex, as in law it was not. The risk is that by so describing the activity, it somehow becomes less serious, but the offence is the same (‘rape’) regardless as to the motivation and behaviour of the victim. There is also a risk that the perpetrator may also see it as somehow less grave if professionals deem that the activity can be consensual. F could not understand that he had offended because he saw the victim as consenting but a 12 year old cannot consent. 3.23 With the second rape, the victim said she had gone to the park for consensual sex with a friend, but had then been orally raped by three strangers (one of whom was F). F’s statement was that he did nothing forcibly, and again he presumably did not know that such sexually activity was an offence, forcible or not as she was under 16. In this case the CPS must have disagreed with his assessment or they would not have decided on a prosecution. 3.24 The local Child Protection Procedures24 says there is a high incidence of rape of girls involved with gangs. “Some senior gang members pass their girlfriends around to lower ranking members and sometimes to the whole group at the same time”. It says girls can be groomed at school using drink and drugs which act as a disinhibitor. This Review does not know enough about the rapes in this case to know if they were connected to this dynamic, and neither case was heard in court. 3.25 At the Staff Group, the need for schools/colleges to ensure that the law around consent was covered well was emphasised. 3.26 Learning Points: 23 Sexual Offences Act 2003, section 5-15. 24 Local Child Protection Procedures- Section 12 ‘Safeguarding Children Affected by Gang Activity/Serious Youth Violence’. 19 • Agencies should take great care when describing sex as consensual when in law it cannot be. This helps avoid the risk of such offences being seen as less serious than they are, and to avoid any possibility of that message reaching the perpetrator. • Young teenagers are often very unclear about the law around consent. • Schools and colleges are well placed to ensure the law around consent is clearly explained to pupils. 3.27 Was there sufficient understanding about ethnic, cultural and family background issues? CYPS had on file a very good assessment of F’s family background and his own interests and attitudes. Similarly with his mother. There is no indication that agencies which worked with the family were unaware of his own background, which was of course highlighted by the immigration issues. The YOS was also well aware. The services which F’s family required as immigrants with NRPF seemed to have been well provided by Council 1. 3.28 Gangs: National guidance on safeguarding and gangs25 chooses the following definition: “A relatively durable, predominantly street-based group of young people who see themselves (and are seen by others) as a discernible group for whom crime and violence is integral to the group’s identity”. It gives a three tier description. Level 1 ‘peer group’- a relatively small unorganised group where involvement in crime is not integral to its identity. Level 2 ‘street gangs’, more durable groups, street based, and seen as a group where crime and violence is integral to identity. Level 3 ‘criminal gangs’ where crime is so integral it could be seen as the members’ occupation. The guidance focusses on Level 2 which seems to be the highest level with which F was involved. And, as described in section 2, the YOS concluded that F, at 17, did not seem to be involved in gang activity. However his contribution to the referrals to Council 1 Gang Action Group, and Victim Support, described quite well how he was involved in a culture where geographically based groups were violent to those from other areas, simply because of residence. The Gang Action Group decided he was more of a victim than a gang member. 3.29 The national guidance emphasises the overlap between being victim and perpetrator. For example, victims of violence can take revenge later. Perpetrators can become the victim of revenge attacks. Both may well have the same disadvantaging features in their past. The local guidance says “Potentially a child involved with a gang of serious youth violence could be both victim and perpetrator. This requires professionals to assess and support his/her welfare and well-being needs at the same time as assessing and responding in a criminal justice capacity”. The importance of a good assessment is emphasised in the guidance but, after he was stabbed, Council 1 CYPS decided without assessment that there were ‘no child protection concerns’, both at the time and later when Council 2 realised he was living in Council 1 and referred back there. There should have been a strategy meeting, or 25 ‘Safeguarding children and young people who may be affected by gang activity’. HM Government 2010 20 assessment or both. F was still a child at 17, was well known to agencies, and had been wounded in an assault. When, not long after the stabbing F was arrested with a knife and believed to be planning robbery, the YOS apparently took no action when informed by the Police. As within a period of two months he was seen as both a victim and a potential perpetrator, this should have been a sign of him being pretty heavily involved in a violent world. (CYPS was not informed). 3.30 Whether or not someone is said to be involved in ‘gangs’ and any other subcategory that might appear in guidance, is to some extent not relevant. What matters is simply what is happening to and with the child, and what the risk is of being a victim or perpetrator. Being in a gang may enhance the risks, but not being in one and being part of much less formal activity, does not necessarily mean less risk- as this case shows. 3.31 Learning Points: • In the violent world of some young groups, workers at assessment must consider that being a victim and being a perpetrator is very closely related. • Assessment needs to work out the respective risks and to determine what intervention/pathways may be best to reduce those risks. • What is actually happening to the young person in the round needs to be the focus - an approach not deflected by a ‘no-gang’ conclusion. 3.32 How much was known about F? From information supplied to the Review, it seems that what was currently known receded as he became older and the risks grew. The CYPS assessment in 2011 was excellent, and YOS worked hard with him between summer of 2014 and summer 2015. But by the autumn of 2015, when his stabbing and then the offensive weapon/robbery arrest were not followed up by either CYPS or YOS (who were both by then not involved at all) neither would have an up to date understanding of risks to him. He was at College from September 2014 to his death, but the College had no idea about his offense related issues, and it does not seem that other agencies informed the College of anything. The College did report to the College police officer the turf related altercation F had in late 2015, but this was presumably not seen as significant enough for the officer to log an intelligence report. It appears that the school nurse who was informed did not identify that F was now at college in a neighbouring borough. 3.33 In October 2015, Council 2 Children’s Services, after the stabbing when they thought he was permanently in the borough, did start an assessment- which was not completed and referred back to Council 1. Council 2 did find out from F’s GP who had seen him in July, that F had said ‘he has had history of stress and anxiety for long time (though presented for the first time at the surgery) and has deteriorated over the last two years, with poor concentration, feeling depressed and poor sleep, though not suicidal’. 21 3.34 The GP’s last contact was in summer 2015 when he saw F as he was asked to make a CAMHS referral. F reported being sexually abused as a child (but by whom is unknown) and gave the history reported in the previous paragraph. The hospital did tell the GP about the stabbing but seems just to have been noted. The GP was asked by the MASH and by Council 2 Children’s Services for a briefing after the stabbing, but nothing extra more was known by the practice after the July contact. 3.35 As the College did not know about his involvement with violence/offending (although it did know about the geographically based altercation F was involved with) it means that, other than Council 2’s fleeting involvement, F’s predicaments and risks were pretty unknown or unrecognised in the last few months of his life. 3.36 Although the school attended the strategy meeting in June 2014 which discussed the second rape, there is nothing in school records about this and the College which he moved to that autumn had no knowledge about his alleged history in relation to younger girls. The SCR Panel debated whether say the police should have told the school/college so they could be alert to possible risks to other pupils, and this Review recommends that the LSCB explore with agencies the ethics around such an exchange of information. 3.37 As this Review shows, there was quite a lot to be known about F, and a need to assess what it all meant. Other than one strategy meeting, focussing on the victim, there was no multiagency meeting at any time to discuss F. This meant that there was never a forum where all the information could come together. If say after the stabbing there had been a multiagency meeting, it is possible that the combined information from two CYPSs, hospital, YOS, Police, GP, CAMHS/onward referral agencies, Victim Support, and College might have identified the growing risks. Local agencies will need to consider how this might be achieved in future cases. 3.38 F made a number of references to agencies about the geographically based conflicts of which he was nervous. It does not seem this was ever analysed for the real risk. 3.39 Learning Points: • This case shows how a teenager can drift off the radar, even with a serious offence still pending • The absence of multiagency discussions can make it much more likely risks are not fully assessed. • Agencies need to consider what might trigger such a meeting in future cases • When a child or young person says they are at risk this should be taken seriously and explored 3.40 Agency Responsibility: At the Staff Group and Panel, those present were struck by the range of services involved to one degree or another, but also the lack of clarity about which if any had the responsibility to take the overview on F. There are two related issues. 22 3.41 The first is the contrast between apparent good intentions and in the end very little seeming to happen. At some point F was referred to CAMHs, MASE (or was said to have been), Victim Support, and Council 1 Gang Action Group, and there was a plan to refer to NCATS. He was also referred to the Clinic. This Review has been unable to identify that anything of any significance occurred as a result of these referrals- and it all seems to wither away. As said in the previous paragraph there was never any multiagency discussion about F to pool knowledge, assess risks, and plan how to minimise them. Each agency carried out what it understood to be its own role, but none seemed to be pulling it all together and answering the question ‘is what we all doing, put together, are making a difference?’ 3.42 The second issue is who was responsible for holding it all together? At 17 F was still the child protection responsibility of Children’s Social Care under CYPS, and guidance is clear that referrals of concern about under-18s involvement in gang (or similar) related violence needs to use child protection procedures as it involves protecting the young person or others from the young person. The Youth Offending Service, which is also part of the Council, is responsible for supervising young offenders in the community or custody, and through its preventive arm supporting ‘children, young people and their families who are at risk of offending’. CYPS had closed the case in July 2014 (but knew YOS was involved) and the NRFP team (properly) stopped in August 2014. CYPS declined to reopen it after the stabbing in the autumn of 2015. YOS had formally closed the case in summer 2015 while F was still awaiting trial for rape, and did not become re-involved after the late 2015 robbery arrest. When things seemed to be getting violent in the autumn of 2015, neither department initiated an assessment, which seemed warranted under national and local guidance. 3.43 At the Staff Group and Panel, given that there cannot be a major response to every youth that gets into trouble, there was a discussion about just how common was the cluster of events with which F got involved? (See chart in 3.7). There was no consensus at first, but the more that emerged about F the more the conclusion was ‘not that common’. The lesson that emerges from this is the need for one agency to ensure there is a proper overview of a case like this, and to ensure a full assessment. To achieve this there needs to be greater clarity of the respective roles of Children’s Social Care and YJS which are part of the same organisation. This should include being clear which is going to have responsibility for assessing the whole young person and reaching conclusions about the overall risk. In other words, taking everything into account what is the risk to or from this child/young person? 3.44 Staff involved in discussing this case with the Review were struck by the range of organisations involved, and it is hard to understand where each fits and what is the limit of their involvement. It is probable that this is even less clear when the person concerned varies between being a victim and a perpetrator, where the person’s status as an offender is not yet clear as there have been no ultimate hearings to 23 determine this, where the age is close to adulthood, and where it is not clear if ‘gangs’ are involved or not. 3.45 There was also a communication weakness about the police notification system for children and young people coming to notice. Procedurally these should go to CYPS, but in this case on some occasions they only went to the YOS component. Police may have expected that as both are in the Council they were in effect communicating with both, but this was not the case. And YJS would have assumed that Children’s Social Care knew as per procedure. CYPS for example did not know about the offensive weapon/possible robbery shortly after the stabbing, and only knew of the stabbing as other agencies, not the Police, informed them. It is important that both internally and externally the relationship between children’s services and youth justice services within Council 1 are clear. 3.46 Learning Points: • It is important to be clear what referrals to other organisations have led to, and not to assume they have made a difference. • One agency, presumably Council 1 through either its CYPS Social Care and Youth Justice Service, needs to be take the lead in maintaining the overview of the child/young person’s progress, and assessing the accumulating and overall risks. • There needs to be clarity of the respective roles of within CYPS around older children. • There are many organisations set up to support children like F but their respective roles, and the connections between them may not be clear. • Police, Children’s Social Care and YJS need to clarify communication routes about young people coming to the notice of police involving offending. • Is there a need to clarify school nursing responsibilities on over 16s in college, and what information they should receive? 3.47 Coming up to 18: At both the Panel and Staff Group meetings concern was expressed that as a teenager approaches 18, and adult services, there is an increased chance of service response being less than ideal. F would have been 18 the month after his death. It was in the months leading up to his death that services several times declined to become involved. This is not just a matter of service attitude as teenagers of that age can act in an adult way and appear to be, so to speak, young criminals rather than wayward children who are very hard to engage. Nevertheless Children’s Services have legal responsibility for the protection of children up to 18. The Review will recommend that the LSCB reviews with its members the service response to older teenagers. 3.48 Learning Points: • Care needs to be taken that statutory responsibilities are considered appropriately when a teenager approaches 18. 24 4. CONCLUSION 4.1 In terms of the three main questions asked of this Review, there are no absolute answers, but rather issues identified for further thought and possible learning. 4.2 What was (or could have been) known about Child F by local agencies, and was sufficient action taken as a result? The Review has shown that quite a lot was known about F and his family, but how this diminished the older he got. The sum total of his inherent vulnerabilities from his childhood history, what he conveyed to agencies about his fears of geographically related violence, and his ongoing brushes with the law including some very serious incidents, would if ever put together at least have identified significant risk. It would also have showed in the last few months an escalation of concern. Help was appropriately given by the Council around immigration and housing, and later by YOS on drugs and sex education, but later he had no special support, and onward referrals including for emotional support seemed to come to nothing. One factor in this was that he was not seen to be involved in ‘gangs’ so this limited intervention/support. It does not appear that his references to inter area conflicts were ever studied to assess the depth of the risk 4.3 One of the questions that was discussed at the staff group/panel was whether, if F was one’s own child, would we have thought enough was done given the serious situations he kept being involved in? The general view was no. It is important to point out that doing more would not have been easy. On some occasions F declined support, on others he specifically asked for no Police involvement, and on others he clearly would not have volunteered information about his own offending. On the other hand, at 17, he was still deemed in law to be a child, and needed whatever help, protection, or control which might have made a difference. 4.4 Could S’s harmful sexual behaviour have been prevented, and was his ultimately fatal involvement with gangs preventable? The Review concluded that his first sexual offence was not preventable, as it was out of the blue. However, it can be argued that lack of action on that first offence, or at least the failure to explain to him in person what taking no further action meant, did nothing to lessen the chance of reoccurrence. F had just the same misunderstanding of consent when he committed the second rape, and there had been very little discussion with him about 25 the first offence. As far as we know he did not commit a third sexual offence after YOS provided educational input so it may have made an impact.. 4.5 The Review cannot conclude that F’s death was preventable, but does raise issues about the lack of follow through of agencies, and that he was essentially without any agency monitoring or support in his last few months. This seems related to there being no clear process for pooling information about the accumulation of concerns, especially when the teenager is not deemed to be involved in ‘gangs’. Whether he was or not can be debated, but his own accounts were of geographically related threats from other groups. The case will provide much food for thought for local agencies on how they work together to assess and work with teenagers caught up in risky behaviour, whatever label is given to it. However, any conclusion that more might have been done, does not imply a conclusion that the death would have been prevented particularly as the criminal trial found no connection with his murder and his history. 4.6 Was there sufficient understanding about ethnic, cultural and family background issues? There was on CYPS file an excellent assessment of F’s family background issues. YOS also had a good understanding of this. There was enough information available for his vulnerabilities from parental background and early childhood to be known. If there was an area not explored enough, it was his references to the geographically based violence of which he was afraid. 4.7 One of the striking features of the evidence gathered in this Review is the lack of reference to ethnic issues, other than as they related to his origin in Caribbean. No agency has made any reference to this as an issue for this Review, nor has anyone suggested his ethnicity impacted on how agencies did or did not respond to him. Local services to the family with NRPF in the UK from the Caribbean seem to have been good 26 5 RECOMMENDATIONS 5.1 Introduction: The recommendations here are in addition to the learning points in section 3 which the LSCB and agencies can use as they see fit to focus learning from the review. The recommendations are on the more overarching issues and are addressed to the LSCB to oversee. It is for the LSCB to prioritise the recommendations in light of its own assessment of how widespread locally are the issues seen in this case. 5.2 Recommendations: The LSCB should…. (1) Ask Council 1 to clarify the relationship between, and the mutual responsibilities of, its Children’s Services and Youth Justice Service in relation to older children. (2) Review with member agencies the safeguarding approach to child perpetrators of sexual abuse and harmful sexual behaviour, including support when the decision is not to prosecute. (3) Seek assurance that strategy meetings are considering the needs of both child victims and child perpetrators. (4) Review with member agencies how children can get ongoing support during long waits for prosecution decisions or trials. (5) Review the process of referrals and access to child mental health services to ensure proper and timely decisions and care. (6) Consider with Police, CYPS and Education as to what information about offences (including those not proceeded with) should be appropriately given to, or passed between, schools, colleges and related health services. (7) Emphasise to all agencies the benefits for chronologies of key events to help identify patterns of behaviour and increasing risks. (8) Encourage education providers to ensure that the law around consent to sexual activity is explained clearly to pupils. (9) Ensure a young person’s stated concern about violent risks to them is taken seriously by agencies. 27 Appendix 1 Collated Learning Points This appendix collates the learning points listed in section 3 Analysis and Learning. On was the harmful sexual behaviour preventable • When cases are not pursued in the public interest, it is still necessary for the young perpetrator to be given a full understanding of the implications face to face. • Guidance that there should be a strategy meeting around safeguarding a young offender should be followed even if there is, in the public interest, no prosecution. • No further action by the CPS does not mean in itself that other agencies should act as if there has not been a serious offence. On- Pathway to the death: preventable? • The ease with which a teenager’s mental health needs can go unsupported as referrals go to and fro between agencies. • Good chronologies in each agency of key events would help spot accumulating and escalating risks. On decisions about offences • When a case is not taken forward as not in the public interest it is essential the alleged perpetrator is provided with a thorough explanation of the implications, and that it does not mean that no offence may have been committed. • No prosecution does not necessarily mean a child has no service needs • The impact on a child/young person of long bail periods must be recognised, and support provided especially to those with known vulnerabilities. • Agencies should be wary of closing cases whilst major decisions about offences are still pending. • Denying an offence, does not negate the need for the child/young person to be supported or worked with to protect themselves or others. 28 On Consent • Agencies should take great care when describing sex as consensual when in law it cannot be. This helps avoid avoid the risk of such offences being seen as less serious than they are, and to avoid any possibility of that message reaching the perpetrator. • Young teenagers are often very unclear about the law around consent. • Schools and colleges are well placed to ensure the law around consent is clearly explained to pupils. On gangs • In the violent world of some young groups, workers at assessment must consider that being a victim and being a perpetrator is very closely related. • Assessment needs to work out the respective risks and to determine what intervention/pathways may be best to reduce those risks. • What is actually happening to the young person in the round needs to be the focus - an approach not deflected by a ‘no-gang’ conclusion. On how much was known about F? • This case shows how a teenager can drift off the radar, even with a serious offence still pending. • The absence of multiagency discussions can make it much more likely risks are not fully assessed. • Agencies need to consider what might trigger such a meeting in future cases. • When a child or young person says they are at risk this should be taken seriously and explored. On agency responsibility • It is important to be clear what referrals to other organisations have led to, and not to assume they have made a difference. • One agency, presumably Council 1 through either its CYPS Social Care and Youth Justice Service, needs to be take the lead in maintaining the overview of the child/young person’s progress, and assessing the accumulating and overall risks. • There needs to be clarity of the respective roles of within CYPS around older children. • There are many organisations set up to support children like F but their respective roles, and the connections between them may not be clear. • Police, Children’s Social Care and YJS need to clarify communication routes about young people coming to the notice of police involving offending. 29 • Is there a need to clarify school nursing responsibilities on over 16s in college and what information they should receive? On coming up to 18 • Care needs to be taken that statutory responsibilities are considered appropriately when a teenager approaches 18. Appendix 2 Acronyms MHT Mental Health NHS Trust CAMHS Child and Adolescent Mental Health Service CCG Clinical Commissioning Group CIN Child in Need CPS Crown Prosecution Service CYPS Children and Young People’s Service LSCB Local Safeguarding Children Board MASH Multiagency Safeguarding Hub NCATS National Clinical Assessment and Treatment Service NHS National Health Service NRPF No Recourse to Public Funds SCR Serious Case Review ToR Terms of Reference UKBA United Kingdom Border Agency VS Victim Support YOS Youth Offending Service YJS Youth Justice Service |
NC52560 | Suspected non-accidental injury to a 4-month-old-infant in 2018. Learning themes include: offering families early help; considering the nature of engagement and the refusal to engage with early help; understanding parental risk factors such as parental learning disability, domestic abuse, parental mental health, and parental drug use; considering new information regarding risk including anonymous concerns; environmental difficulties such as housing, homelessness and poverty; neglect and its impact upon child development; seeing patterns of neglect and understanding changes in families in relation to neglect; and communication and information sharing. Recommendations include: consider how to enhance practice and processes to offer the right support to families in cases where early help is refused and unmet need results in repeated contacts being reported; ensure that practitioners respond to new information in the light of the possibility of cumulative harm to a child; revise and refresh the procedures, practice guidance and training in identifying, assessing and making effective interventions where there is suspected parental learning disability or difficulty; ensure that practitioners understand the specifics of the parental risk factors as described in the local neglect strategy when working with any family; when responding to anonymous concerns to any agency, practice should be on a par with other contacts in terms of the scrutiny and weight given to the likelihood and impact of the risk identified by the anonymous referrer and should always be considered within the broader context of what is known about the family; and ensure that information sharing in safeguarding work is effective and serves to support the safety of children.
| Serious Case Review No: 2023/C9825 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Child K –Serious Case Review report v4 30.08.19 1 Serious Case Review in respect of Child K Independent Reviewer Josie Collier Child K –Serious Case Review report v4 30.08.19 2 Index 1.0 Summary of the case _________________________________________________________ 3 2.0 Summary of Learning _________________________________________________________ 3 3.0 Methodology _______________________________________________________________ 4 4.0 Practitioners’ understanding of the family – history and relevance to the period under review. _____________________________________________________________________________ 4 5.0 The context of practice _______________________________________________________ 7 6.0 Theme One: Offering Early Help and responding to the refusal of the offer _____________ 7 7.0 Theme One B: Considering the nature of engagement and the refusal to engage with early help _____________________________________________________________________________ 8 8.0 Theme Two: The specifics of our concern – understanding each parental risk factor and ‘low-level’ concerns. ________________________________________________________________ 9 8.1 Theme Two A: Parental learning disability _______________________________________ 10 8.2 Theme Two B: Domestic abuse and violence. ____________________________________ 11 8.3 Theme Two C: Parental mental health __________________________________________ 12 8.4 Theme Two D: Use of substances – cannabis _____________________________________ 13 8.5 Theme Two E: The specifics of the concerns of others – anonymous referrals, new information and decision-making: ___________________________________________________________ 13 9.0 Theme Three: Environmental difficulties: Housing, Homelessness and Poverty. _________ 14 10.0 Theme Four: Neglect and its impact upon child development - seeing the lived experience of the child. ____________________________________________________________________ 15 11.0 Theme Four: Neglect: Seeing patterns and understanding changes in families. ________ 16 12.0 Theme Five: Communication and information sharing ____________________________ 17 13.0 Conclusion _______________________________________________________________ 17 14.0 Feedback from practitioners _________________________________________________ 18 15.0 Recommendations _________________________________________________________ 19 16.0 References _______________________________________________________________ 20 17.0 Appendix One – Learning Points for Practitioners ________________________________ 21 Child K –Serious Case Review report v4 30.08.19 3 1.0 Summary of the case 1.1 This Serious Case Review (SCR) was initiated by a Safeguarding Children Board in 2018, following a suspected non-accidental injury to a child aged 4 months old. In order to preserve anonymity this child will be referred to as Child K. Child K was brought by the mother to the GP who sent them to the hospital due to the child’s presentation. Child K was found to have a head injury and there was evidence suggesting similar but older injuries; however, this could not be verified due to a lack of evidence. Practitioners who cared for Child K at hospital described the child’s physical presentation as ‘filthy’ with thick cradle cap and with very sore skin on their neck. Child K’s blanket was smelly, and their dummy was broken. At the time of these injuries the family had three small children, Child K was the youngest and the eldest child, Sibling 1 had just turned two years old. 1.2 The review covers a period of two and a half years commencing from the mother’s presentation to midwifery services regarding the first pregnancy with Sibling 1. The family lived in a neighbouring area (Area 1) but became homeless and moved to the area that commissioned the review (Area 2). The family were known to a range of health and care agencies engaged in preventative and responsive safeguarding in both areas. The family received midwifery and health visiting services throughout the period under review. Sibling 1 was known to Area 1’s Children’s Services. Sibling 2 was born as the family moved from Area 1 to Area 2, and whilst the father, mother and Sibling 1 were staying at the home of paternal relatives. When Sibling 2 was born, the family became known to a range of Area 2 services and their intervention continued for a time when Child K was born. 1.3 In total there were 10 contacts made to social care services in Area 1 and Area 2 and at least an additional 3 calls reporting concerns regarding the children to the police in Area 2. Over this period of time 4 Child and Family (social work) assessments were completed, however it is important to note that at no point did the family receive intervention supported by a multi-agency plan, either as an Early Help plan or under s.17 or s.47 of the Children Act 1989. The family were said to have been referred/notified once to Early Help and Preventative Services (EHPS) in Area 2. Two of the Child and Family assessments recommended that the family could benefit from these services and there were 4 other occasions where early help was suggested to the family. Additionally, there were ‘Concern and Vulnerability’ forms raised by midwifery regarding this family during the first two pregnancies, neither of which resulted in a pre-birth assessment as the mother was not considered eligible under the Area 1 Pre-Birth protocols in place at the time. 2.0 Summary of Learning 2.1 Each agency contributed an agency report regarding their work with this family. There are learning points and recommendations in these reports for the individual agencies to take forward. 2.2 This report provides an analysis of some of the learning themes for multi-agency safeguarding practice in Area 1 and Area 2. In summary these are: • Offering families early help/ early intervention. • Managing families that refused early help. • The nature of engagement by the family. • The specifics of safeguarding concerns – understanding parental learning disability; domestic abuse; parental mental health; parental use of cannabis; new information regarding risk including anonymous concerns. Child K –Serious Case Review report v4 30.08.19 4 • Working with homelessness and poverty. • The impact of neglect and the child’s lived experience. • Communication and information-sharing. There are also a number of learning points for practitioners to consider and reflect on as to the significance to their current practice. 3.0 Methodology 3.1 A total of 11 agencies completed agency reports as required by the SCR’s Terms of Reference. These were submitted and a combined timeline of multi-agency safeguarding work was drafted. There was a practitioner learning event, facilitated by the lead reviewer in order to reflect on practice and develop this analysis of multi-agency practice in the case. Area 1 and Area 2 Safeguarding Children Board’s will disseminate and embed the learning from this case in order to promote effective multi-agency safeguarding practice in the future. 3.2 This report has been reviewed by the Area 2 SCR Panel for the case and was then submitted to Area 2 Board for the learning to be disseminated in practice. The date of publication of this report is not yet known and is dependent on the outcome of the current criminal investigation. 3.3 It would always be the aspiration of the Area 2 Safeguarding Children Board to include the family’s perspective of intervention in the SCR process, however at the time of writing, criminal and public law processes are still underway and so this precludes the involvement of the family in the review. 3.4 This iteration of the report is drafted with publication in mind and thus is anonymised fully. However, some details of the family and events are included in order to emphasise some of the learning points. This analysis seeks to identify aspects of the safeguarding system which might not work well to promote the most effective practice. 3.5 The independent reviewer is a qualified social worker and works independently as a social work and safeguarding consultant. She has not worked in Area 2 previously. 4.0 Practitioners’ understanding of the family – history and relevance to the period under review. 4.1 4.2 As per the Terms of Reference, agencies were requested to share any known information from the time prior to the start of the review period deemed significant to subsequent agency involvement with the family. The immediate family structure depicted above was known to practitioners in most of the agencies during the period under review, however there was more Mother (aged 24) Sib. 2 (aged 15 months) Father (aged 31) Sibling 1 (aged 25 months Child K (aged 4 months) Child K –Serious Case Review report v4 30.08.19 5 information about the extended family. (N.B. Family members are recorded with their approximate age at the time of the injury to Child K.) 4.3 The agency reports gave details of the father and the mother’s own experience of caregiving as children that potentially impacted upon their own ability to offer care to their children. The extended family and their history were discussed with practitioners – a more fragmented understanding of the family emerged with some agencies knowing about different parts of the family and some agencies knowing nothing. There was information which evidenced the presence of a range of risk factors in the wider family. These factors may have led to ‘cumulative harm’ in terms of the impact on the children.1 There was also evidence to suggest that several relatives had children known to social care. Whilst this might not directly impact upon the quality of parenting in this case it suggests family patterns of maltreatment. It also may mean that the experience of statutory intervention in the wider family network might contribute to how the family regard intervention by different agencies. This historic information was not fully considered together as part of an analysis of risk during the period under review. 4.4 The father was from a minority community and had grown up in Area 2, the mother was also, from Area 2. Both the father and mother had been known to Area 2 children’s social workers as children, due to suspected neglect and physical abuse. The father was recorded as having received input from Youth Offending Services and Education Welfare Officers as a young person and adult and had 18 criminal convictions for 29 offences, including public order, theft, robbery, burglary, damage and violence towards people including assault on police officers. His last criminal conviction was in 2016. 4.5 Upon request, after queries arose at the Practitioner Learning Event, the Area 2 police agency author retrieved information regarding domestic abuse incidents where the father was the alleged perpetrator. Between 2007 and 2015 he was known to be involved with 5 different women, each of whom had been subject to at least one domestic abuse incident allegedly perpetrated by the father, as well as other behaviours such as harassment. He was arrested on at least 4 occasions and on another was issued a harassment warning. 4.6 Several of these women had had domestic abuse risk assessments (preceding the implementation of Domestic Abuse, Stalking and Harassment (DASH) assessments) or DASH assessments completed around the risk posed by the father. There were 9 risks assessments recorded: 8 concluded that the woman was at medium risk of harm and 1 recorded a ‘standard’ level of risk. Two of these women were known to be mothers. The first of these women had a child. This child was said to believe that the father was her father. However, the father subsequently told practitioners that this was not the case. The second of these women stated to Area 2 police officers in 2014 that she had agreed with Area 2 SCS in 2013 that she would not let the father have contact with her child. This was not known to the practitioners involved in the review process regarding this child. 4.7 There is information held on agency records that as a child the mother was known by different agencies to have, as variously described, a diagnosed learning disability/a global developmental delay/ learning difficulty. Further information sought showed that the mother had a statement of Special Education Needs from 2002, when she was 8 years old. This showed her as a child to have general learning difficulties, manifesting in cognitive function and an inability to understand information. During the period under review, the mother informed various practitioners that she had “learning difficulties” which impacted upon her ability to read and 1 Sidebotham and Brandon et al: 2016: 75 Child K –Serious Case Review report v4 30.08.19 6 write. When the mother was 16, a doctor reported that she was not able to fully consent to sexual activity as she was not “fully Fraser-competent”, suggesting her learning needs had a significant impact upon her understanding. 4.8 As a child, the mother was alleged to have been sexually abused by her brother (aged 13). The mother also featured as part of domestic abuse incidents involving the maternal grandmother and her husband. They were both recorded to be alcoholics and from aged 10-15 the mother was alleged to have been subject to physical and emotional abuse and threats from various family members. The mother moved homes between her mother (the maternal grandmother) and her aunt. 4.9 The mother and father are believed to have started their relationship during 2013. In Jan 2015 the maternal grandmother reported to the police that the father had assaulted the mother. The mother did not want to engage with police, however safety planning was considered and offered. She was assessed as being at medium risk of harm, using the DASH assessment. The police agency report offered the rationale behind the medium risk assessment was that it was clear from relatives that this was not the first incident of assault or abuse in which the mother was the victim. No further action was taken against the father due to conflicting accounts and the mother’s refusal to engage with the police. There were also two reported domestic incidents between the mother and maternal grandmother in 2015, indicating that the volatile and difficult relationship between the two women had continued into the mother’s adulthood. This indicates that the mother, as a parent, may not have had an extended family network to rely upon, which was further exacerbated by a sense that the father was not liked by her family, possibly due to domestic abuse in the relationship. 4.10 In 2013 the father was arrested and charged for an assault on a man whom the father perceived was attacking his partner. This incident took place whilst they were under the influence of alcohol. The mother was on the floor and shouting for help to get up, the victim went to assist her, and the father assaulted him. The father received a conviction for Actual Bodily Harm and a suspended sentence. At the beginning of the period under review, the father was known to the Community Rehabilitation Company (CRC) due to the subsequent sentence. 4.11 From the background information, a picture emerges of a family characterised by a range of challenges. This information was already available in parts of the professional safeguarding system. The family’s experience has elements of all of the list of contributory factors to child neglect as outlined in the Area 2 Safeguarding Children Board Neglect Strategy (published in 2017): • Parental mental health problems • Parental substance misuse • Households where there is domestic abuse • Unemployment • Poverty • Poor parental functioning (including learning disabilities) • Inadequate housing • Homelessness The analysis will focus on some of these areas in terms of how they were understood in this family during the period under review. Child K –Serious Case Review report v4 30.08.19 7 5.0 The context of practice 5.1 The socio-economic context in which practice in this case took place is one where there have been significant changes over the past few years in how services are delivered. For example, in this case the midwife only saw the expectant mother in clinic rather than at home. Other challenges in service provision that time also appear to have directly impacted upon the family in that it had been possible for them to become homeless, a situation which hopefully would now be avoided due to the implementation of The Homelessness Reduction Act (2017) and the resultant statutory duty upon key agencies to prevent homelessness. 5.2 From the agency reports there is some information shared by some agencies that reflects the impact of working within a very busy safeguarding system upon practice e.g. taking up opportunities for supervision and reflective opportunities in safeguarding practice; the need to use temporary staff which was shown to impact upon the effectiveness of service provision. 5.3 Conversations with practitioners regarding this case also reveals good practice and effective systems around safeguarding work with this family – for example, there was evidence of the implementation of expected practice frameworks in Health Services; joint visiting during the case between health visitors and social workers and a good handover from Area 1 to Area 2 for Children’s Services, Midwifery and Health Visiting. 6.0 Theme One: Offering Early Help and responding to the refusal of the offer 6.1 This is the defining theme in this case and is one which arises from the legal and statutory safeguarding system. On at least seven occasions, professionals recommended or recorded that the family would benefit with intervention from early help services in order to support their parenting, including at the end of the second and fourth social work assessment. Within the Area 2 threshold document in operation at the time, the application of that threshold between preventative and responsive safeguarding services did not ensure that the family got the right support in a timely way as the family refused, and were not required to, take up the offer of early help. Therefore, the need for parenting intervention was not met. An observation by practitioners was made that it is sometimes difficult to explain what the concept of ‘early help’ means to families and that there is a skill in helping families identify for themselves that they might need such help. The approach to this has now changed in Area 2: a continuum of need and risk is best supported by a continuum of evidence-based support; therefore, the new Area 2 Support Levels appear as a framework which address this learning theme. 6.2 Towards the end of the period under review at the end of the fourth Child and Family assessment, the father researched the requirements of families regarding acceptance of the early help suggested and established that engagement with any early help service was voluntary. This rejection of early help was made at the same time as ongoing positive engagement with health visiting which offered reassurance to the professionals that the family were receiving some support. The health visitor understood from the mother that she was visiting the GP. The GP noted that he was re-assured to hear from the mother that she was seeing the health visitor regularly. There was no discussion between these practitioners to identify what shared support was being offered, only what was reported by the mother herself. 6.3 Due to issues in health intra-agency reporting systems in Area 1, this family also did not benefit from joint working between midwifery and health visiting in terms of receiving early intervention during the first pregnancy. It was felt that this system problem would not occur now in Area 1. Child K –Serious Case Review report v4 30.08.19 8 6.4 Some decisions were made not to intervene with the family when subsequent safeguarding concerns were reported suggested possible ‘fixed thinking’ in that they were based on the fact that there had been a recent Child and Family assessment completed, even though two previous assessments had also identified unmet need. 6.5 In managing the refusal by a family of an offer of early help, practitioners were fully aware that the family could be re-referred due to that unmet need. When this occurs, there is a need to balance the avoidance of repeated referral and assessments of families with ensuring the safety and wellbeing of children in families. There is also a need to avoid ‘start-again’ syndrome through building an analysis on the existing information. It would not be wise to recommend setting up a new process to monitor families refusing early help which could become a bureaucratic burden; however, some solutions may lie in practice; some practitioners reported that they utilise these already. For example: • Highlighting unmet need and identifying the ‘weight’ of already known information where there is a refusal of early help. • Recording clear contingencies in responding should new information about the family should be reported within a certain space of time. • Monitoring re-referrals and unmet need within the MASH/ Front Door. • Reinforcing useful practice frameworks – for example, utilising Signs of Safety in Area 2 or Strengthening families in Area 1 to ensure more effective mapping of strengths/ risks or danger/safety and what might need to change at the point of ending the assessment or updating the Graded Care Profile assessment at the point of case closure. • Pro-actively supporting engagement by families with other services to meet need and sharing with consent the assessment of unmet need with universal services that participated with this assessment e.g. the G.P. and health visiting. Recommendation One: Both Area 1 SCB and Area 2 SCB should consider how to enhance practice and processes to offer the ‘right’ support to families in cases where early help is refused and unmet need results in repeated contacts / concerns being reported. This will include ensuring that practitioners respond to new information in the light of the possibility of ‘cumulative harm’ to a child or young person. In some families, repeated refusals of help to meet need and risk without evidence of positive change should be seen as a ‘red flag’ by those in practice. 6.6 Overall, it appears as though the support given, and interventions offered made with this family sat most at the ‘right’, but fairly rigid, level within the threshold document given what was known to practitioners at the time, with some need identified. There were at least two decisions made that agencies have identified as opportunities to intervene which were not taken. The family never engaged with any early help service beyond appointments in clinic with midwives; home visiting by the health visitor; and visits to the GP. There is no evidence of any attendance at ante-natal or post-natal groups; parent and toddler groups or parenting groups. 7.0 Theme One B: Considering the nature of engagement and the refusal to engage with early help 7.1 Engagement by the family with health visiting and midwifery was reported as good, practitioners were very committed, and this acted as a protective factor for the children in this family. However, engagement was perhaps more conditional for the family with other agencies Child K –Serious Case Review report v4 30.08.19 9 such as housing and social care. It was reported that on occasion the father was evasive regarding giving requested information to housing services towards whom he had shown some animosity. The health visitor and the social worker did try to explore their refusal of early help with the family but were often met with the response from parents that they would “think about it”. Negative experiences of intervention can often prevent future intervention, and reluctance and blocks to engage can arise from a fear of something new or unknown.2 Examining these areas with families requires a skilled approach by practitioners. One social worker described how she tried with all families to support their engagement with early help in creative ways which appear as good and tenacious practice. 7.2 Though the family appeared accepting of social workers during the earlier part of the period under review, the social worker involved towards the end of the period under review suggested that the father appeared to dislike her and requested that she was removed from the case. It was also reported by her manager that this social worker had begun to challenge the family a little bit more regarding their lifestyle and parenting. It was also reported that the father had been heard being openly racist about the social worker. Participants suggested that a family’s racist views might be an obstacle to their engagement, but it was also suggested that such behaviour from service users should also be considered as a possible hate crime and should also be considered relevant in terms of decision-making around the safety of the child. 7.3 During the Practitioner Learning Event, practitioners demonstrated some culturally competent thinking in their consideration of the father’s ethnicity, and this is noted in some but not all of the agency reports. They reflected upon his sense of pride in his family, showed their understanding of some of the family’s ‘ways’ and discussed how they had tackled some of these issues sensitively with the family, for example acknowledging the importance for the father of providing food to his children within the context of his culture, whilst at the same time challenging the less than healthy food that he was providing. Practitioners were also aware that as she did not share the same heritage and so the mother was isolated from some of the paternal extended family and was said not to like them. What is not clear is whether there was any explicit discussion with the father and mother about the father’s cultural background and what that meant for their parenting style and sense of family as well as for the family’s willingness to engage with services. 8.0 Theme Two: The specifics of our concern – understanding each parental risk factor and ‘low-level’ concerns. 8.0.1 This case offers a worrying but very real perspective on the potential for the lack of a shared understanding of risk in the family arising from parental factors, where families present as requiring lower levels of support. There was historical and current evidence regarding risk factors such as parental mental health, domestic violence, possible parental learning disability 3 in this and the previous generation of this family. All of the contacts regarding concerns about the family made to Area 1 and Area 2 social care services are based on elements of recognised risk factors and appear as appropriate contacts or referrals. The decision to initiate assessments on 4 referrals was appropriate, although there were other contacts where the decision making did not appear to match the reported risks. It is relevant to emphasise the number of concerns raised to social care and police by practitioners (9) and members of the public (4) in less than 2 Ferguson (2011:175) suggests a range of blocks to intervention including a dislike of the system, worker or offer; fear of criminalisation; or personal characteristics in the family arising from their own trauma. 3 Sidebotham and Brandon et al: 2016: 75 Child K –Serious Case Review report v4 30.08.19 10 three years of the period under review. Whilst the family may not have stood out against other families using services, they clearly looked to others like a family that needed help and support. 8.0.2 How much detail about these parental factors might have been expected to be understood or explored with the family by practitioners working at levels 2 and 3 of the Area 2 Inter-agency Threshold Criteria (now replaced) is debatable, although such detail would be desirable in order to inform intervention. Some agency reports noted a shortfall in meeting agency expectations around understanding these factors, for example the lack of exploration of the wider family with the agency’s Family Health Needs Assessment by Area 1 Community Health or not giving consideration to the father’s family by the CRC. 8.0.3 The family were subject to four social work Child and Family assessments under s17– two by Area 1 Children’s Services and two by Area 2 SCS, and social workers worked with health visitors. Whilst none of these assessments appear to have led to a ‘Child in Need’ plan, a Child and Family assessment would be expected to deepen an understanding of the family’s needs and the possible risks to a child. In this case, agency concerns around these different family challenges varied, and relied mainly upon the information offered by the family themselves. Some information was ‘checked out’ by social workers but information regarding the family’s history was not fully utilised to assess risk. A social worker at the Practitioner Learning Event noted how much information came to light at the event that they had not been aware of. To develop this learning theme further, this analysis will examine how practitioners worked well with each risk factor or concern in order to identify good practice and what might be done differently in future practice. 8.1 Theme Two A: Parental learning disability 8.1.1 The father was known to have had low educational attendance, which some practitioners attributed to a cultural norm of not attending school in adolescence. He was thought to have a diagnosis of ADHD, although this was self-reported. The mother was variously described in agency reports as having some form of learning disability. There was no shared understanding of this as a possible challenge to parenting capacity. The GP reported having no information about this diagnosis on his records. An Area 2 social worker recorded their concern regarding mother’s cognition and level of understanding after the first home visit in 2017. She was accompanied by a friend or relative to nearly all of her ante-natal appointments when pregnant with Sibling 1. What is unclear is the extent to which the historical information regarding this type of diagnosis might be expected to ‘travel’ as a child becomes an adult without a formal transition from children to adults’ service or without support from the family for it to do so. 8.1.2 Practitioners identified that there was clearly some level of impairment to the mother’s understanding and described their sensitive and intuitive practice, both in pitching the advice they gave at a particular level so the mother could understand it and in ‘checking back’ to ascertain her understanding of their advice. In response to this, practitioners noted that the changes that they had suggested were often made quickly, indicating some understanding on the part of the parents. The GP said that the mother was able to follow his advice around treatment. Practitioners did not feel that the parents ‘stood out’ in terms of their cognitive functioning. However, there is also some evidence regarding how parents may well have misunderstood some of the advice or information shared by practitioners. Examples include not understanding healthy eating advice, providing evidence for housing application processes; the father misunderstanding a letter from the council which requested information regarding housing benefits to recover unpaid council tax, but was understood as a demand from the Child K –Serious Case Review report v4 30.08.19 11 bailiffs by the father; and the couple building up rent arrears even with the council’s Floating Support service in place. Additionally, the mother repeated her understanding to practitioners that her children were subject to ‘Child in Need’ plans in Area 1 and in Area 2 on several occasions despite this not being the case. 8.1.3 Although checks were done by an Area 2 social worker to ascertain whether the mother had had input from adult services, it is not clear as to whether practitioners followed the advice of Area 2 SCB procedures to access sources of information about the mother’s possible learning disability4 and therefore the possible limitations on her parenting and so the resultant risks appear as only vaguely understood. Learning disability can impact different areas of functioning to varying degrees and so understanding a parent’s strengths, needs, relationships and barriers they face is vital5. The efforts of practitioners to make improvements to parenting may not have been appropriate to the mother’s learning disability. The concept of families moving through a system of intervention from having a problem to resolution and positive outcome might not have been helpful for this family where the parents have a learning disability. National practice guidance suggests that long term support may be required6 – firstly as a cognitive impairment does not go away and secondly because the needs of children change as they develop and so the parent may need to learn new parenting skills to respond to these needs. Recommendation Two: Area 2 SCB to revise and refresh the procedures, practice guidance and training in identifying, assessing and making effective interventions where there is suspected parental learning disability/ difficulty. 8.2 Theme Two B: Domestic abuse and violence. 8.2.1 From the agency reports and the practitioner learning event, it is apparent that the level of risk to the children from domestic abuse does not appear to have been understood or shared across the professional network in terms of the father’s behaviour. The mother was open that there had been some domestic violence in the past. During the period under review there were no reports to the police of incidents between the couple. The second Child and Family assessment was initiated by a police notification that father had been released from prison and was a ‘known serial domestic abuse offender’ and so the Area 1 social worker identified that she had checked his history as a perpetrator. There was a wider range of information held by Area 2 Police about the father’s violent behaviour as described at paragraphs 4.5 and 4.6. 8.2.2 Practitioners identified that the ‘vague’ terms to describe the assessed risk in several different agencies (i.e. low, medium and high) did not support developing a shared understanding of risk amongst practitioners both between and within agencies, and probably would mean nothing to the general public. There was also a shared view at the practitioner event that the CAADA DASH risk assessment could give a subjective picture of possible harm. The police had put warnings on the father’s record as he had been the subject of more than one call out to more than one victim. He was also known for aggression towards police officers, but this was not known by other agencies. This could have compromised the safety of practitioners from other agencies visiting the family home. 8.2.3 This evidence of father’s propensity to violence more broadly was not considered as possibly symptomatic of an inability to self-regulate and manage his anger. There are incidents where 4 (Area 2 SCB Procedures 2.2.14 Parental Learning Disability) 5 Working Together with Parents Network (WTPN) 2016. 6 Ibid. Child K –Serious Case Review report v4 30.08.19 12 father’s anger and hostility are clearly visible and aimed at practitioners. The period under review is ‘book-ended’ by an incident at the beginning where the father is arrested after criminal damage upon being breached for failing to comply with his community order. Towards the end of the period under review, the police are called to an occasion when the father was smashing property at the family home whilst the children were in his sole care. The father reported to police that he was ‘venting his anger’. These instances appear to have been considered in isolation and thus as ‘low-level’ but should have appeared as more significant when considering that the father was caring for his infant children during some of these times. 8.2.4 Despite little understanding across agencies of the previous severity of risk to women arising from domestic abuse by the father, practitioners were mindful of evidence of past domestic abuse in the couple’s relationship and were able to evidence their activity and resultant rationale for not feeling that domestic abuse by the father to the mother was a risk during their involvement. There appeared to be a number of appropriate direct conversations or ‘safe enquiries’ conducted by practitioners in several agencies, with the mother on her own, regarding the risk of domestic abuse. The agencies where practitioners did not speak with the mother about domestic abuse have identified this as learning. 8.2.5 Practitioners, especially the health visitor, saw the couple together on home visits. This helped to develop a deeper but still partial understanding of the couple’s relationship e.g. how they communicated; that mother had a fear that the father would leave her; that the father was proud of his family and spoke of their plan to marry. During the course of visits to the home there were no observed changes in the mother’s behaviour when the father was absent or present. It was described that on visits when the father was there, he tended to ‘take over’, however, this may have been a cultural behaviour whereby the men in the family tended to lead on working with ‘authority’ figures. There may well have been a difference in intellectual capacity which might have led to a dependency by the mother upon the father. There is also the possibility of the mother not recognising abusive behaviour. A challenge in understanding the risk of domestic abuse is in balancing what a practitioner sees in front of them versus less tangible evidence, for example, historical information or concerns reported by family members. 8.3 Theme Two C: Parental mental health 8.3.1 Currently there is no information available to this review regarding the father’s mental health. It is confirmed that there was no engagement by the father with mental health services or the GP regarding this. 8.3.2 The mother was very open with practitioners regarding her anxiety and depression and cooperated fully with the standard screening and assessment activity with each new birth regarding her post-natal mental health. Mother told the health visitor about her engagement with the GP regarding her mental health and around her use of prescribed anti-depressant medication. She also informed the health visitor when she had unilaterally stopped taking medication during pregnancy. The mother refused suggestions that she access counselling and some agencies did not have knowledge of the vulnerabilities arising from the mother’s childhood. The mother’s openness about her depression during the period under review seems to have led to an over-reliance on the mother’s self-reporting rather than an assessment of how her mental health impacted on her capacity to care for her children which drew on multi-agency information and professional judgement. The lack of communication by the health visitor with the GP treating mother for depression may have been useful at the point of the end of the Child K –Serious Case Review report v4 30.08.19 13 targeted regular visiting by the health visitor as the mother had reported an increase in her medication to the health visitor. 8.3.3 The GP reported that the mother attended surgery twice in early 2018 regarding her mental health. Mother reported herself to be ‘stressed out and moody’. She also reported being stressed about the break-up of her relationship with the father, a fact which was not known by other agencies. On the first visit there had been some confusion with her receiving the right medication and so she wanted her prescription to be altered. The GP described his thorough approach in exploring how her mental health impacted upon her, asking her about possible self-harm and any ideation of harm towards the baby. It appears as though the mother was able to appropriately seek help and manage her medication for depression. 8.4 Theme Two D: Use of substances – cannabis 8.4.1 The father’s use of cannabis and any resultant risk to the children was the focus of proportionate professional inquiry by staff from a range of agencies. The father was very open about his use of cannabis and when practitioners responded to reports made to the police and to social workers regarding cannabis, the father explained to attending officers that he had smoked away from the house in the garden. Some practitioners examined the specifics of the extent of his use with the father and the effect it had on him (e.g. he felt that cannabis calmed him down) and were specific in how they established that this did not pose a risk to children, for example the frequency, location and intensity of his use of cannabis. It was noted that his use of cannabis cost £40 a week, which could present a challenge to a family with limited financial resources. 8.4.2 More broadly, there are some instances and descriptions of an often-busy household from practitioners. Some of these also include examples of social drinking and from the perspective of a neighbour who made reports, the misuse of alcohol and drugs which posed a threat to the children of the household. However, the practitioners in this case were clear that they did not see signs of the use of substances influencing parental capacity in this case, comparing this to other cases where substance misuse is more obvious and clearly harmful. Practitioners asked mother about her use of substances: she does not appear to have used cannabis or other drugs. Recommendation Three: Area 2 SCB should ensure that practitioners understand the specifics of the parental risk factors as described in the Neglect Strategy when working with any family. Understanding some of these unwanted behaviours or situations in terms of severity (frequency, intensity, duration, and onset) and their impact on children is important. 8.5 Theme Two E: The specifics of the concerns of others – anonymous referrals, new information and decision-making: 8.5.1 During the course of intervention there were several anonymous contacts made to the police and to social care regarding alleged parenting behaviours which potentially could have added to professional understanding of already identified concerns. There are anonymous referrals which are malicious and those which do prompt an appropriate safeguarding response – for example, a welfare check by police. But in this case, there were instances where anonymous referrals were perhaps not examined with the same degree of rigour as other referrals and were considered in isolation from existing knowledge of the family. Some referrals were felt by practitioners not to have had a robust enough response. These include allegations that the dog was sleeping in the child’s cot in Area 1, and that there was a neighbour who had seen a baby Child K –Serious Case Review report v4 30.08.19 14 being dangled from the family’s balcony in Area 2. New information, even when reported anonymously, can add to the professional understanding of the risks in the family. 8.5.2 In this case, there are instances where the rationale for the decision to close the contact / notification/ referral made regarding new concerns to the police, to both social care services and to the maternity hub in Area 1 was that there had been a recent Child and Family assessment completed. This is despite the identified need for early help input being refused. Risk is dynamic, circumstances do change and asking the question about what might be different in that instance as compared to the information already known is an important one, especially where there is identified unmet need and the presence of risk factors. In the example of the referral regarding the father’s anger and destruction of property, the Out of Hours service made a decision not to progress the contact based on the recent Child and Family assessment, a decision that was reviewed the next day and approved by the team who had most recently worked with the family. Recommendation Four: Area 2 SCB should assure itself that practice in responding to anonymous concerns to any agency is on a par with other contacts in terms of the scrutiny and weight given to the likelihood and impact of the risk identified by the anonymous referrer. This should always be considered within the broader context of what is known about the family. 9.0 Theme Three: Environmental difficulties: Housing, Homelessness and Poverty. 9.1 This family were homeless or living in less than suitable accommodation when Sibling 1 and Sibling 2 were born. There were occasions where the father was said to be at work very early in the morning, but it is not clear that his employment was regular. The family were known to struggle with debt. The family’s homelessness was the key concern for practitioners when the family moved to Area 2 from Area 1 and prompted the third Child and Family assessment (the first assessment by Area 2 SCS). During the period under review, the family lived in two different addresses in Area 1 and the tenancies were in the mother’s name only. The second of these tenancies was terminated whilst the mother was pregnant with Sibling 2. Area 1 Strategic Housing were candid in sharing that despite it not yet being a statutory duty at the time of their involvement, their housing officers were expected to prevent or relieve homelessness. In this case the housing officer had not made efforts to do so. The family were then seen by practitioners whilst they lived at two different homes of family members in Area 2; then moved to a temporary address for just under 3 months before moving to a permanent address. Research findings suggested that homelessness is potentially harmful to an infant child’s development. 7 9.2 Descriptions of the 2-bedroom property on the second floor of a housing development that became the family’s permanent tenancy were that it was a challenging environment for families. Practitioners reported that the floors were hard and there was damp and mould in many of the flats. There was no lift. There was no outdoor play space for children. The efforts of practitioners were often focussed on ensuring that the family had enough of some of the 7 ‘An Unstable start for Babies’ (NSPCC 2015), the NSPCC and Anna Freud centre note that “homelessness and temporary accommodation during pregnancy are associated with an increased risk of preterm birth, low birth weight, poor mental health in infants and children, and developmental delay. All of these factors are, in turn, associated with the risk of poor outcomes in later life” (p17-8). Child K –Serious Case Review report v4 30.08.19 15 basic items required through making referrals to local charities. In this case, it appears as though practitioners showed sensitivity and kindness and were sympathetic regarding the challenges that the family faced regarding housing and poverty and were supportive in trying to access practical resources on their behalf. What is not clear is how the family coped in this environment with two, then three small children, and how they overcame potential isolation. 10.0 Theme Four: Neglect and its impact upon child development - seeing the lived experience of the child. 10.1 The key risk that practitioners are managing when working to safeguard children is that a child’s development will be impaired or significantly harmed by the behaviours of others. In the case of infants that are seriously physically harmed, this is most likely to be within the family setting. 8 10.2 The injury to Child K is believed to have arisen from physical abuse through shaking. There was also some evidence identified in the hospital of Child K failing to thrive, however the trajectory of this failure is not clear, as the work of practitioners in monitoring physical signs of this appears as robust during their intervention. From the outset of professional involvement, a main concern for the children was the possible developmental impact of neglectful parenting and some practitioners gave detailed accounts of observations they had made regarding parent-child interaction and around the physical care and presentation of the children. The parents were seen to be warm towards the children and on the whole, the children were clean. The GP reported that the mother was attentive to Child K, and able to follow the treatment advised for nappy rash and presented the child for a follow-up appointment. On only one occasion did the health visitor in Area 2, who visited on a monthly basis for over a year, note her concern regarding Sibling 1 appearing as ‘lost’ amongst adults in a busy household. She described the parents missing basic cues and signals from the child e.g. failing to respond to the child being thirsty and more generally needing their attention. On two other occasions, the police may have witnessed an angry parent on their last visit during the period under review; and a temporary housing provider had reported the father as mishandling Sibling 1. 10.3 There was not always a consistently positive assessment of the children’s development – Sibling 2 was slow to grow after having tummy bugs, possibly arising from poor hygiene around feeding at around 8 weeks old. The weight of Child K did not give cause for concern during the first two months of life although the infant had dropped one centile at the 6-8-week health visiting review (a drop of two centiles would prompt concern and action). After this point, there is no evidence that Child K was weighed for 11 weeks prior to the injury, and upon admission to hospital as a result of that injury, there were signs of poor weight gain/ weight loss. Sibling 1 was noted as showing signs of developmental delay in his communication and fine motor skills towards the end of the period under review. 10.4 Some agencies noted that there were limitations in their practice in understanding the child’s lived experience in this case. This included social workers having limited time to observe parent-child interaction and the frontline police focussing on the physical signs of neglect rather than gaining an understanding of the emotional impact on children of maltreatment. However, there was also some very good practice in making joint observations of the children in this family by health visitors and social workers. Particularly striking was the in-depth description 8 Sidebotham and Brandon et al 2016: 65. Child K –Serious Case Review report v4 30.08.19 16 of aspects of the children’s presentation that the social worker and health visitor observed on the last joint visit that they made. 10.5 In summary, most practitioners were looking in the right direction when trying to understand the children’s lived experience, but again the intermittent nature of some agencies’ case involvement and the refusal by the family to engage in further intervention meant that the opportunity to really understand the child’s lived experience was not taken. 11.0 Theme Four: Neglect: Seeing patterns and understanding changes in families. 11.1 As outlined in the previous section, there were developmental indicators that when looked at together appear indicative of repeated patterns of impairment to development arising from parenting, where suggested changes by practitioners were not sustained. In this case it is not clear whether agencies were thinking about change in and changes to the family which had an impact. In most agencies the purpose of intervention is to bring about some form of positive difference – whether that is assisting parents to help a child move through the series of developmental tasks in order to progress9 or to ensure that parental behaviour changes in order to reduce harm. 11.2 There were patterns in the signs of neglect in this family which could have been recognised. All three children developed a flattening on the back of their heads (plagiocephaly) and with each child this was addressed by giving the same health messages about how to give the child ‘tummy time’ and not leave them lying down too often in a buggy or bouncy chair, however flattening was evidenced in each child. This is suggestive of a lack of ability to apply the messages around the child’s needs in each successive child. Another example of a pattern not changing appears regarding the need to give subsequent advice regarding hygiene, for example, around baby bottles and cleaning dummies after the birth of Sibling 2 despite this being the subject previous concern when Sibling 1 was born. The broken and dirty dummy features again when the third child, Child K, presented at hospital with head injuries. 11.3 It is acknowledged that it is often hard to stand back and look at these patterns when in the midst of a busy working environment. The use of tools or frameworks that map change and progress in families and their care-giving behaviour across Area 1 and Area 2 differ and the extent to which they are ‘embedded’ in practice are varied between and within these two areas. A simple tool is a multi-agency chronology, especially around the point of decision making or in resolving professional disagreements. As a reflective tool, the chronology can support recognising patterns and responses to change, and whether change is sustained. The NSPCC suggest that practitioners do not always look for recurring patterns in a family or children’s presentation, rather they look for small improvements that engender optimism as does positive engagement 10. In this case, messages were acted upon after challenges were made to parents by practitioners, thus giving that sign of a small improvement, but one which was not maintained. 11.4 There was a positive change noted by practitioners in that becoming a parent had had a positive effect on the father. It was understood to have stopped him in terms of his pattern of domestically abusive behaviour towards partners and violent to others. He was reported as a ‘changed man’. This idea sat alongside with the father’s sense of pride in his family as identified 9 Cicchetti, D., & Valentino, K. 2006 10 Infants: Learning from Case Reviews Nov 2017 Child K –Serious Case Review report v4 30.08.19 17 by practitioners. The mother had also been able to identify on several occasions that arguments and violence were not good for children and during the course of intervention there were no reported domestic incidents. 11.5 The birth of a third child is a significant change for any family. There was an indication that the third pregnancy was not wanted by the father or his family, as the mother informed the health visitor when she became pregnant that they had wanted her to have a termination of the pregnancy. There was perhaps not the level of caution by practitioners as to the implications of Child K being the third child born in 20 months and the parents’ ability to cope with this. Services to the family either ended or were reduced less than two months after the birth of Child K.11 11.6 There was a significant change in Child K’s circumstances in the two weeks prior to the injuries being reported. The GP reported the baby generally as being well and observed an “easy baby”. The baby was not weighed by the GP on the last two presentations in mid-April 2018 as there was no cause to do so. In the two weeks after this there was a rapid change in Child K’s experience which is not yet understood. It is not for this review to hypothesise around that, but to draw from this that negative change in an infant’s health and wellbeing can be rapid in the light of the reports regarding Child K’s physical presentation at hospital. 12.0 Theme Five: Communication and information sharing 12.1 Information sharing is repeatedly identified as a challenge to effective safeguarding and deeply entrenched systemic issues can prevent effective information-sharing 12. In this case, there appears to be a real variability in practice regarding the sharing of information between practitioners and agencies. In some parts of the system it worked very well, and in others, perhaps due to the lack of a legal imperative to share, key information does not seem to have been sought or forthcoming around significant risks (see section 8), and perhaps this is to be expected due to the status of the case as ‘low-level’. 12.2 From Child K’s GP records there is no evidence that the GP sought any information with other health staff involved, despite Child K presenting with a condition that the health visitor could have been support the parent in managing. This is despite the fact that Child K had been identified within the GP’s medical notes as a ‘vulnerable child’ and mother was known to have a mental illness which was managed by the GP. However, the GP did not feel that there was the need: the mother’s engagement was seemed to be positive and she followed the GP’s advice and treatment. Recommendation Five: Given the national evidence and local evidence from previous safeguarding reviews and current practice, Area 2 SCB should assure itself that information-sharing in safeguarding work is effective and serves to support the safety of children. 13.0 Conclusion 13.1 Whilst the physical injuries to Child K were not predictable, this case has significant learning arising from it for individual agencies around working families where there is the presence of several risk factors. Agency reports on the whole have been candid and informative and there 11 The NSPCC (2016) found evidence in other case reviews that suggest that the birth of a baby “can lead to a tendency to see the birth of a new baby as an opportunity for a fresh start. Sometimes this may hinder practitioners from recognising pre-existing patterns in parents’ behaviour which pose a risk to the baby” 12 Brandon et al 2016: 164 Child K –Serious Case Review report v4 30.08.19 18 is evidence of an impact upon practice from this review. Details of this can be found in the single agency reports and summary of learning and in the ongoing processes within agencies to embed the learning from the agency reports. 13.2 There are some families who despite identified need and professional signposting do not take up the offer of preventative support, from the more structured interventions that might be offered by district services or from more flexible offers that might be on offer through children’s centres or voluntary/ community groups. This type of refusal can in itself be seen as a potential vulnerability and should be explored in order to avoid unmet need and risk to children escalating. 13.3 The evidence suggests that it is more difficult to identify and understand the level of risk in families without formal processes such as CAF/ Team around the Family/Early Help plans/ Child in Need or Child Protection being in place, or shared practice tools being implemented effectively e.g. (Signs of Safety or the Graded Care Profile 2). Different agencies had different understandings of what ‘risk’ meant and the identification and response to risk remains vague without robust assessment and intervention plans. 13.4 This family was not one where there were only emerging signs of risk. Agencies held information which signified potential significant risk to children, however it was never pulled together in a comprehensive enough multi-agency assessment in order to inform appropriate intervention. This family did not stand out during the period under review, but there was information regarding known risk and vulnerability in the past which was not explored for the relevance to the children in the family. Working with and understanding child neglect appears to pose a series of challenges around understanding the severity and impact of neglect especially where the family composition changes. 13.5 In this case, during the last few weeks of the period under review, something significantly changed for Child K in terms of the caregiving he was receiving. The child’s physical presentation had changed radically from that witnessed by practitioners not long before the injuries were known. Change in families and the circumstances for children can be very rapid and unpredictable. 14.0 Feedback from practitioners 14.1 As part of their contribution to this review, practitioners were asked to give their summary analysis of multi-agency safeguarding practice in this case through answering the following questions: What aspects of multi-agency practice in this case went well? • Good engagement with family and practitioners although it is clear there was selective engagement. However, it was acknowledged that this could be cultural. • Good evidence of joint working between agencies including communication and shared activity between midwifery and health visiting in Area 2; social workers and health visitors in Area 1 and in Area 2; and across the two areas of Area 1 and Area 2. • Triangulation of information when the child presented at hospital. • Referrals and reports of concern regarding this family were appropriate. Child K –Serious Case Review report v4 30.08.19 19 What might have been done differently in multi-agency practice in this case? ▪ There was a lack of information to some agencies about what was known. Information-sharing continues to be a challenge to effective practice. ▪ There were several contacts within a short period of time, but the case did not reach the threshold which would lead to statutory intervention. ▪ Applying the thresholds on these types of cases are challenging (NB – these are now known as support levels. ▪ There was no engagement with services for adults. ▪ There is a gap in service provision when working with families with low level learning difficulties. Parents may not recognise the difficulties that arise. ▪ Decision-making around the last referral. What might need to change and what need to happen to bring about this change for future practice? ▪ Considerations when working with non-verbal children. ▪ Practitioners working in a multi-agency system should meet following single-agency assessments to pull information together. 15.0 Recommendations Recommendation One: Both Area 1 SCB and Area 2 SCB should consider how to enhance practice and processes to offer the ‘right’ support to families in cases where early help is refused and unmet need results in repeated contacts / concerns being reported. This will include ensuring that practitioners respond to new information in the light of the possibility of cumulative harm to a child or young person. In some families, repeated refusals of help to meet need and risk without evidence of positive change should be seen as a ‘red flag’ by those in practice. Recommendation Two: Area 2 SCB to revise and refresh the procedures, practice guidance and training in identifying and making effective interventions where there is suspected parental learning disability/ difficulty. Recommendation Three: Area 2 SCB should ensure that practitioners understand the specifics of the parental risk factors as described in the Neglect Strategy when working with any family. Understanding some of these unwanted behaviours or situations in terms of severity (frequency, intensity duration onset) and their impact on children is important. Recommendation Four: Area 2 SCB should assure itself that practice in responding to anonymous concerns to any agency is on a par with other contacts in terms of the scrutiny and weight given to the likelihood and impact of the risk identified by the anonymous referrer. This should always be considered within the broader context of what is known about the family. Recommendation Five: Given the national evidence and local evidence from previous safeguarding reviews and current practice, Area 2 SCB should assure itself that information-sharing in safeguarding work is effective and serves to support the safety of children. Child K –Serious Case Review report v4 30.08.19 20 16.0 References Brandon, M et al 2008 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005. London: Department for Children, Schools and Families, DCSF-RR023. Brandon, M et al 2011 Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews. London: Department for Education, DFE-RR110 Cicchetti, D., & Valentino, K. 2006. An ecological transactional perspective on child maltreatment: Failure of the average expectable environment and its influence upon child development. In D. Cicchetti, & D. J. Cohen (Eds.), Developmental psychopathology (2 ed., Vol. 3, pp. 129-201). New York, NY: Wiley. Ferguson, H Child Protection Practice Palgrave Macmillian, Basingstoke, England. Horwarth, J 2016 ‘Making a difference to the neglected child’s lived experience’ pp 70- 93 in Gardner, R. and Howe, D. (Eds) 2016 Tackling Child Neglect: Research, Policy and Evidence-Based Practice Jessica Kingsley NSPCC (2015) An Unstable start for Babies: www.nspcc.org.uk NSPCC (2017) Infants: learning from case reviews: Summary of risk factors and learning for improved practice around working with children aged two and under accessed on www.nspcc.org.uk Sidebotham, P et al 2016 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Department for Education Working Together with Parents Network (WTPN) 2016 Update of the DoH/DfESGood practice guidance on working with parents with a learning disability (2007). Accessed http://www.bristol.ac.uk/media-library/sites/sps/documents/wtpn/2016%20WTPN%20UPDATE%20OF%20THE%20GPG%20-%20finalised%20with%20cover.pdf Child K –Serious Case Review report v4 30.08.19 21 17.0 Appendix One – Learning Points for Practitioners Learning point 1 (para 4.3): Whilst many practitioners may not be in the position to gather in-depth information, understanding the wider family and family history cannot be over-emphasised. There are useful tools and resources for practitioners to do so in an engaging and creative way (SCIE communication skills 2008), in order to identify possible risk factors. Learning Point 2 (para 6.2): In order to understand more fully the experience of the family, practitioners should not rely solely on the family’s perspective of help and services when trying to identify if and how the family are being helped. Learning point 3 (para 7.2): Practitioners should utilise opportunities such as professional conversations and supervision to consider the nature of engagement, whether it feels positive or negative. How resistance to intervention manifests itself may have a significant impact on staff and should always be considered in supervision as part of the duty of care for staff. Learning Point 4 (para 7.2): When possible, practitioners should consider exploring the family’s experience of past intervention with the family. and actively facilitate engagement with another service if they are suggesting it to a family. This might mean making a phone call; facilitating an initial meeting or accompanying a service user to an appointment. Learning Point 5 (para 7.3): Practitioners should be curious regarding how families from different communities might regard services and consider how services might be offered in a more culturally sensitive way. Learning Point 6 (para 8.3): Assessments should draw upon information from a range of sources both family and professional, current and historical. The past is an indicator of possible future risk; and the family’s history may indicate the risk of cumulative harm to the child/ren. Practitioners should be mindful of what they don’t yet know. Learning Point 7 (para 8.1.3): Any family where there is a suspected learning disability is assessed to understand the impact upon parenting. This does not require a specialist assessment but an understanding of the specifics of that parent’s capacity around strengths, needs and risks through an assessment that utilises clear mapping techniques and focus on evidence of good practical parenting skills. Learning Point 8 (para 8.2.2): There are many risk assessment processes that exist in single- and multi-agency safeguarding practice which must be clearly explained as to the specifics of the possible risk of harm rather than using agency ‘shorthand’ or ‘labels’. The use of a shared risk assessment models or frameworks will support developing a shared understanding of risk. Learning Point 9 (para 8.2.6): Practitioners may need to reflect on domestic abuse and violence within a broader frame of reference, beyond physical assaults in to considering how a child might experience a parent’s uncontrolled rage or anger or their coercive controlling behaviour. Learning point 10 (para 8.3): Understanding the specifics of the nature of mental illness and the impact of it upon parenting is vital – practitioners can always ask to check with the GP where the GP is managing the mental health condition of a parent. Learning point 11 (para 8.4): The assessment and management of the possible risk arising from cannabis use appears as balanced and proportionate. This type of curiosity in inquiry into the specifics Child K –Serious Case Review report v4 30.08.19 22 of possible concerns should be applied across practice. Practitioners were confident in ascertaining how cannabis is used, the frequency of its use and where use takes place in order to understand if there is a risk to children. Learning Point 12 (para 8.5): Information from an anonymous source can take on more significance when seen in the broader family context or when reviewing past intervention that has taken place in the case. It can add to the understanding of the specifics of our concern in terms of understanding the frequency, intensity, duration and onset of the unwanted behaviour which might cause harm to a child. Learning Point 13 (para 8.5.2): Effective decision making requires practitioners to weigh up new information, including that from anonymous sources, and to consider it in the light of the family history. These reports add to a picture of cumulative harm. Previous case closure does not always mean that all of the risks have been managed or completely reduced. Learning point 14 (para 9.2): Homelessness should be considered as a vulnerability and can be a risk factor for the development of young children. Consideration of how homelessness and housing interact with parental risk factors and the child’s development is central to practice. Learning point 15 (10.4): At this level of intervention, practitioners should always be curious and respectfully uncertain regarding the ‘lived experience’ of the child. This would include considering the actual details of the child’s daily routine and the impact of parental behaviour upon them. Learning Point 16 (11.1.5): Focussing on the changes that practitioners hope to support in a family and how they might recognise that they have taken place is central to safeguarding. Practitioners should use supervision and peer support to consider the impact of circumstances and changes in and upon the family as well as asking the family as to how changes might be protective or how they might be complicating and adding vulnerability to the children’s situation. Learning Point 17 (para 12.4): Practitioners should not assume that information has been shared or received, and so if proportionate and legitimate, practitioners should take the opportunity to share information if it means getting the right support to children and their families, as well as seek advice if they are not sure. This is particularly relevant within the health system for GPs, health visitors and midwives who each offer interventions to new-borns which should as a whole add up to a comprehensive offer to the family. Effective practice can be supported by utilising the procedures on the Area 2 SCB website. |
NC042386 | Death of a baby, a few months old, in July 2011. Child W was found dead by his/her mother, after the child had been brought to bed by the mother's partner and placed between the couple as they slept. Prior to Child W's birth, mother and older siblings had been assisted by the Police Public Protection Unit to relocate to Coventry, from Birmingham, following incidents of domestic abuse. Older siblings of Child W had been subject to child protection plans in the past when the family had been living in Birmingham. Child W and his/her siblings had been removed from the family home following an incident of suspected violent assault against the mother by her new partner, however there was insufficient evidence of concern to progress to child protection plans. Makes recommendations covering: the provision of residential accommodation to those fleeing domestic violence; patterns of multi-agency working; and, risk assessment processes and tools used by professionals.
| Title: Serious case review: Child W. LSCB: Coventry Safeguarding Children Board Author: Coventry Safeguarding Children Board Date of publication: 2012 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Coventry Safeguarding Children Board Serious Case Review Child W May 2012 This is the report of the Serious Case Review concerning the death of Child W, which was commissioned by Coventry Safeguarding Children Board. It was conducted using the Learning Together / Social Care Institute of Excellence systems learning methodology. 2 Coventry Safeguarding Children Board Learning Together Systems Review Child W May 2012 3 Report of the Learning Together Review of Child W Contents Page Introduction / Background to the review 4 Succinct summary of case 4 Process and structure of the review 5 Scope and terms of reference 5 Sources of data 6 The Findings 8 Appraisal of professional practice in the case – a synopsis 8 Management system 14 Patterns of multi-agency working 16 Processes and tools used by practitioners 20 Summary of the seven findings 26 Bibliography 27 CSCB response to the seven findings 28 4 1. Introduction Background to the Review 1.1 Child W was a few months old when he/she died in July 2011. The death of Child W was referred to the Coventry LSCB and the Chair of the LSCB decided that the case met the criteria for holding a Serious Case Review. The Chair commissioned this review. Ofsted was notified of the decision and following correspondence and discussion with the Department for Education (DfE) permission was granted for the case to be reviewed using the Social Care Institute for Excellence (SCIE) „Learning Together‟ methodology. Summary of the case 1.2 Child W was found dead by his/her mother in July 2011. The child had been brought to bed by the mother‟s partner and placed between the couple as they slept. 1.3 In early 2011, following concerns expressed by the local family support and universal services‟ professionals and following anonymous allegations that the three older siblings of Child W were witnessing domestic abuse; Coventry Children‟s Services undertook a Core Assessment of the family and judged that continued support from the Common Assessment Framework (CAF) team was sufficient to support the children. 1.4 Child W was born in late May 2011 following a normal pregnancy and birth. Four weeks after the birth of Child W, a serious incident took place. Both the mother and her partner were intoxicated with alcohol and the partner was suspected of a violent assault on the mother. Children‟s Services and the police became involved and judged that neither parent was capable of looking after the children at that time. 1.5 A strategy meeting was held. Those professionals present decided that there was insufficient evidence of concern about the care of the children to proceed to case conference and child protection plans. The decision reached by members of the meeting was that a further six week period of assessment was required. A week following the strategy meeting Child W was found dead by his/her mother, the child having been brought to bed by her partner and placed between the couple as they slept. 1.6 The inquest was held on 16th December 2011 and the Coroner recorded an open verdict 1.7 The family had previously lived in Birmingham. In 2009, the mother of Child W was seriously assaulted by her then partner and she, and her children, fled to Coventry with the support of local police. The family initially lived in hostel accommodation in Coventry and some months later the family was given a tenancy in Coventry. Support was provided to the family by a local Domestic Violence Support Project and the local family support and universal services professionals. 5 1.8 While she was in the hostel the mother met Child W‟s father with whom she had a transient relationship resulting in the pregnancy. Later, when she was in her own independent tenancy, the mother became involved with a new partner who had a history of alcohol and drug abuse and domestic violence. She was living with this man at the time of Child W‟s death. Process of the Review 1.9 The scope of the review was agreed by the Review Team as being from 1 December 2009 to 15 July 2011. This covers the period when the family moved to Coventry from Birmingham and the date of the death of Child W in July 2011. 1.10 The mother of Child W and her partner were informed both verbally and in writing that a Serious Case Review was to be undertaken and their involvement through taking part in individual conversations was requested. Both declined the invitation to be involved. Review team - Who was involved? 1.11 The Review Team was led by an Independent Professional from a voluntary agency and an Independent Safeguarding Consultant who has undergone training on the SCIE „learning together‟ methodology. These two reviewers were assisted by a review team of representatives from relevant local agencies. Structure of the review process - What was done? 1.12 The Review Team met on six occasions on the following dates: 7 November 2011, 28 November 2011, 12 December 2011, 9 January 2012, 30 January 2012 and 2 April 2012. 1.13 The Review Team met with the Case Group (the professionals who had worked directly with the family) on two occasions on the following dates: 20 January and 16 March 2012. 1.14 In addition members of the Review Team held individual conversations with members of the case group on 14 November 2011, 18 November 2011 and 5 January 2012. Scope and terms of reference 1.15 In line with qualitative research principles, reviewers endeavour to start with an open mind in order that the focus is led by what they actually discover through the review process. This replaces terms of reference that have a specific focus of analysis before the review process has begun. 1.16 The use of Individual Management Reviews is not part of the SCIE „Learning Together‟ methodology. However prior to gaining the permission from the Department for Education to depart from some of the requirements of Working Together (2010) in respect of Serious Case Reviews, the Coventry LSCB had commissioned Individual Management Reviews from the following agencies: 6 University Hospitals Coventry and Warwickshire Coventry City Council ,Children, Learning and Young Peoples Directorate Children's Social Care Services Children's Multidisciplinary Team School and Education Service West Midlands Police The Supported Accommodation Provider Specific information was also provided by Birmingham City Social Care Services in the form of a summary report. 1.17 When approval was gained from the Department of Education to use the SCIE methodology a decision was taken to draw upon the Individual Management Reviews as an additional source of data to supplement the content of the individual conversations with key staff that were subsequently conducted. Sources of data: Data from practitioners 1.18 Information was provided by members of the Case Group who were directly involved with the family through a process of individual conversations. A total of sixteen conversations were held with individual practitioners. Individual management Reviews (IMRs) 1.19 Information was also obtained from the Individual Management Reviews together with various agency records. The Review Team has considered Individual Management Reviews from the agencies listed above at 1.11 Documentation 1.20 The following documents were reviewed by the review team: Minutes from relevant Multi-agency Risk Assessment Conference for domestic abuse (MARAC) meetings Core Assessment - March 2011 E mail information provided by hostel E mail information from the Police Information provided by local nursery Signs of Safety Assessment 7 Background information from the local domestic abuse project Data from family, friends and community 1.21 The mother of Child W and her partner were informed both verbally and in writing that a Serious Case Review was to be undertaken and their involvement through taking part in individual conversations was requested. Both declined the invitation to be involved during the course of the review. In November 2012, the mother of Child W met with one of the lead reviewers following the completion of the review to discuss the findings and was invited to contribute any comments she may have. She was informed of the publication arrangements for the report on the LSCB website. She was able to endorse the concerns expressed in the report about some of the unregulated accommodation she was placed in; saying she felt unsafe and unsupported there. She also recognised that from her own experience women in violent relationships need longer term support than she had received in order to avoid falling back into pre-existing patterns of behaviour, particularly when moving into a new area. She was thanked for her contribution which will be fed into the action plan for further consideration. Data from Birmingham 1.22 Birmingham Children‟s Services did not complete an IMR in accordance with the terms of reference as the timescale of the case review commenced after the family had left Birmingham. Nonetheless, it became apparent that agencies in Birmingham would have valuable information that shaped how the family were received into Coventry and initially influenced the provision of services. The Birmingham LSCB provided a summary report which has been considered during the review process. It has not been possible to hold individual conversations with the staff in Birmingham who were involved with the family at the time. This has left the review team with some unanswered questions about how the case was managed and what information was transferred to Coventry services in late 2009. Methodological comment and limitations 1.23 Attendance at the first meeting of the review team and case group was excellent and the results provided a good level of information. Unfortunately, some agencies were unable to attend the second of these meetings due to competing operational priorities and leave commitments. The review team has therefore significantly relied on information gained from those staff in those agencies provided in the individual conversations. 1.24 The underlying patterns in the safeguarding system discussed in the findings have been identified by members of the case group during the review process. These are based on their views and experience. In order to determine the frequency of these patterns and the extent to which they are applicable across all the local services, the LSCB may want to undertake action or further investigative work. 8 The ways in which this case provides a useful window on the systems in Coventry 1.25 A number of systems were influential in the way that the case unfolded; the way in which cases are considered by the Children‟s Services, the relationships between professional groups involved in the Common Assessment Framework, the way cases are assessed and the thresholds for subsequent intervention are all key features of the case under review. The examination of these systems and the way they interact with each other has provided an opportunity to gain insight into the strengths and areas for development in those systems and forms the content of the findings below. 2. The findings 2.1 A key feature of the systems model is the endeavour to make the particular case being reviewed act as „a window on the system‟. This involves moving from the analysis of intricate details of the case (via the key practice episodes and their contributory factors), to a deeper level of analysis. The nature of a systems review process is to seek to answer questions about actions and events, which seemed reasonable to those involved at the time but with hindsight now seem questionable based on all the information available. 2.2 This deeper level is about what can be learnt from this particular case, which may be relevant to professional practice more broadly. In terms of service improvement the Review Team is seeking to identify patterns in the way that workers interact with and are influenced by different aspects of single and multi-agency systems, as opposed to issues unique to this case. While these influences on practice may manifest slightly differently in different cases, the underlying factors are the same. SCIE call these the „underlying patterns of systemic factors‟. As stated above, the LSCB may want to undertake action or further investigative work to determine the frequency of these patterns and the extent to which they are applicable across all the local services. 2.3 The systems model that SCIE has developed includes six broad categories of underlying issues. In this review, three of these have been particularly relevant to the analysis of the information and data considered: – management system, patterns of multi-agency working, and processes and tools used by practitioners. 2.4 Each pattern features interactions between people and aspects of the system, including other people. Each category may have many different subcategories and it is hoped these will be developed and expanded as more case reviews using this model are developed. There is, of course, overlap between categories. 2.5 A critical final step in the case review process is to both identify and prioritise the main underlying patterns. This has drawn from discussions both among review team members and with contributions from the case group 9 Appraisal of professional practice in this case – a synopsis 2.6 The family of Child W moved to Coventry from Birmingham fleeing domestic violence and were assisted in doing so by the Police Public Protection Unit (PPU) staff in Birmingham and Coventry. The children of the family had been subject to child protection plans in the past in Birmingham. An initial assessment was completed at the time the family were placed in hostel accommodation in Coventry. 2.7 The police public protection arrangements across the two local authority areas worked well and the prompt intervention by domestic violence officers evidenced that domestic abuse and a speedy response to it is a priority in the two areas. However, Children‟s Social Care Services in Birmingham and Coventry were not involved in the move and were therefore unable to assess the situation in respect of the children and this was potentially compromising to their safety. 2.8 Birmingham Children‟s Social Care Services tried on two occasions to transfer this open case to Coventry Children‟s Services for help. The Referral and Assessment Service (RAS) in Coventry refused to take the case on the basis that it was early days into their move and the family did not have a permanent address in the Coventry area. The high volume of workload also precluded their involvement. There were clearly child protection concerns at the time of the move to Coventry as it has emerged that Birmingham Children‟s Social Care Services were considering removing the children if the mother had refused to move due to the dangers presented by her ex-partner, although it appears that the children were not subject to child protection plans as might have been expected. The case was transferred to Coventry after a short delay but the Review Team was particularly interested to understand why the Coventry service had not immediately taken over responsibility for the case. 2.9 Finding suitable refuge accommodation for the family proved difficult for PPU officers. The hostel where the family were initially placed may have contained residents who were a danger to the children and no comprehensive checks were carried out regarding the background of those people resident at the hostel. This raised questions for the review team about how local commissioning of appropriate provision occurred and how compliance with quality and safety standards was achieved. 2.10 The case was referred promptly to the Multi Agency Risk Assessment Conference (MARAC), which is part of the Multi Agency Public Protection Arrangements (MAPPA) in Coventry. Members of the conference initiated an immediate move of the family to another DVA supported accommodation provider, which is commissioned by the local community safety partnership arrangements in Coventry. This was good practice particularly as this hostel provided the family with appropriate security and support including psychological assistance for one of the children who, in the past had witnessed domestic abuse taking place. 2.11 From the safety of the DVA supported accommodation, the mother felt able to disclose to the Coventry Police that during the incident of abuse which had necessitated her move to Coventry, one of her children had also been assaulted by her ex-partner, something she had previously denied. The police reviewed the 10 information in the case and referred it back to the Birmingham area as there is a police protocol that offences are investigated in the area where they happened. The case was allocated to inexperienced officers and administrative mistakes were made in both the Birmingham and the Coventry Police areas and as a result the case was dealt with inappropriately. This had the effect of concealing the mother‟s inability to prioritise the needs of the children over her own, potentially exposing them to future risk. 2.12 Six months after becoming resident at the DVA supported accommodation the mother met a new partner; staff become aware of this new relationship in May 2012. In September 2010 the mother notified staff that she was five weeks pregnant with Child W by which time the relationship had ended. 2.13 While resident in the DVA supported accommodation, the staff there were concerned about the mother‟s ability to prioritise her children‟s needs and tried to persuade her to stay resident there allowing the time for her to develop life and parenting skills. A Common Assessment Framework (CAF) procedure was put in place providing a simple structure for local professionals involved with the family to meet and access appropriate services for the family. Unfortunately, the mother chose to find her own independent tenancy and left the hostel after nine months, in October 2010. Before doing so she split up with Child W‟s father and began to see someone else. 2.14 After leaving the DVA supported accommodation, the service allocated a worker from the Teenage Parents floating support in November 2010, to support Child W‟s mother in her new home, alongside active input from a Children‟s Centre family support worker. The Common Assessment Framework arrangements remained in place which was helpful to the mother and allowed for a level of monitoring. However, this type of support was voluntary which meant that the mother did not have to access it if she chose not to. The type of support offered by them seemed appropriate at the time, but in hindsight it was insufficient to ensure the safeguarding of the children, as its function was to focus on the needs of young parents. 2.15 It became evident that the mother‟s new partner had a history of alcohol abuse and drug abuse and had been physically abusive to a previous partner. The adolescent child of this man was also subject to a CAF. However, the professionals involved made no attempt to undertake a formal assessment of the partner‟s possible risk to the children, or to co-ordinate the interventions between the CAF‟s 2.16 Over time and on a number of occasions the professionals involved in the CAF had suspicions that domestic abuse was being perpetrated against the mother and challenged her to disclose which she refused to do. The voluntary nature of the support she was receiving through the CAF process did not support the workers to be assertive and to challenge the mother. Professionals found it difficult to find supporting evidence of actual abuse in the face of the mother‟s denial that there was a problem. 2.17 The local family support and universal services professionals involved in the CAF attempted to escalate the priority of the case by trying to engage Children‟s Social Care Services with their concerns about the probability that mother‟s new partner was perpetrating domestic violence against her. The requests by the local family 11 support and universal services professionals for more formal intervention by those in the Children‟s Social Care Service were not initially accepted. The workers in Children‟s Social Care Services believed there was a lack of clear evidence of risk to the children on which to take further action. This raised questions for the review as to why the concerns of local family support and universal services professionals were not fully understood or acted upon immediately. 2.18 However, shortly afterwards, following an anonymous referral from a neighbour, the Children‟s Social Care Service did intervene and escalate the case to Child in Need status and undertook a core assessment of the family over a three month period. The assessment was completed during a period of stability in the family. The assessment recommended no further action except for continued support from the local family support and universal services professionals. However, the basis of the assessment was unclear, gave a poor analysis of the risk factors contained in the family situation and did not consider the effect that the mother‟s current pregnancy may have on the situation at the time or after the birth of the baby. The Review Team wished to discover why the assessment process had produced that result. 2.19 Child W was born normally in May 2011 and suitable advice was given, both verbally and in writing to the mother by both hospital and health support staff in respect of the safe care of the newborn child which included safe sleeping arrangements. Subsequent to Child W‟s death Child W‟s mother confided in a member of the Review Team that she had remembered being given advice about safe sleeping and not taking Child W to bed and had understood the advice. However, she acknowledged that she and her partner had ignored the advice on a number of occasions. 2.20 A month after Child W‟s birth the police and Children‟s Social Care Services were called to the family home. Both of the parents had consumed large amounts of alcohol and they had had a violent argument in which the mother had sustained an injury. They were both judged to be incapable of looking after the children at that time. Temporary arrangements for looking after the children were agreed jointly by the police and Children‟s Social Care Services but were unsatisfactory in that they did not ensure that the violent partner would not return to the house therefore this insufficiently safeguarded the children. 2.21 Following this incident Children‟s Social Care Services intensified visits to the family and all those local family support and universal services professionals involved in the CAF were asked to provide information and attend a professionals meeting. This provided a good opportunity for information sharing. A few days later a strategy meeting was held to consider the case going forward to a child protection case conference. 2.22 A suitably experienced senior social worker in the absence of the team manager took the chair. The meeting considered the case and used a risk assessment tool to guide members of the meeting in their decision making in respect of the next steps in the case. The results from using the tool were inconclusive. 2.23 The chair of the meeting was unconvinced that the risk factors outlined by the professionals in the meeting were based on hard evidence and believed that the 12 family were being co-operative in working with the services involved. The chair, mistakenly with hindsight, believed there to be a consensus for the decision to „defer a move to case conference for six weeks pending further assessment and support of the family‟. The decision not to take immediate formal safeguarding action was agreed by those at the meeting and no dissenting views were recorded at the time. Again with the benefit of hindsight it is arguable that there was sufficient evidence at the time to move more directly into more formal child protection processes. Given the available information the Review Team were keen to understand why such a result had occurred. 2.24 At the strategy meeting arrangements were made for a child in need meeting to be held with the family as it was thought important to ensure that the family were clear about the level of concern held by local professionals. The family arrived very late for this meeting saying they could not stay as they had another appointment. The meeting was cancelled and a further meeting set for two weeks after that. The couple had attended but this situation should perhaps have raised more concerns about whether the couple were taking the professionals' concerns about their children sufficiently seriously. 2.25 One week after the strategy meeting, the mother and her partner had been consuming alcohol and Child W was taken into bed with them by the partner. The mother awoke in the morning to discover that Child W was lying in between them and was not breathing. An ambulance was immediately called but the child was subsequently pronounced dead. It is the view of the Review Team that while the potential for some form of harm to Child W may have been predictable, the death was not preventable. Systemic Issues 2.26 The „Learning Together‟ methodology has allowed the Review Team, working with the Case Group to identify and explore the issues raised above where they manifest themselves not only in this case but perhaps more widely in other instances across the safeguarding system. In accordance with the „Learning Together‟ methodology these wider „systemic‟ issues seek to provide a „window‟ into the safeguarding system and allowed the review team the opportunity to analyse a number of underlying patterns in the system. 2.27 It should be stressed that the issues that the review examined which were felt to be peculiar only to this individual case under review were not included as part of the findings as they were not felt by the Review Team to be manifest in the wider safeguarding system. This approach is a feature of the SCIE systems methodology. An example of an issue believed to be peculiar to this individual case was safe sleeping arrangements. Following a thorough examination and discussion of the issue, the Review Team were confident that the matter had been dealt with properly by the agencies involved in the safeguarding system. Those involved in the case were found to have appropriately used written information, verbal prompts and suitable advice and support to the mother of Child W and her partner in respect of safe sleeping. The Review Team concluded that because the mother of Child W and her partner had chosen to ignore the advice that they were given that this issue was 13 an individual aspect of this particular case alone, albeit that it led to the circumstances of Child W‟s death. 2.28 The likely underlying patterns in this case are listed below and then discussed: a) Management System i) High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority. ii) Workflow through the children‟s social care teams may not always occur within agreed timescales because of the overall competing high levels of demand in the City. b) Patterns of multi- agency working i) There is a perception that the timing and appropriateness of transfer of cases from and to the local multi-disciplinary family support teams who use the Common Assessment Framework (CAF), a system known as „stepping up‟ or „stepping down‟ cases needs to be further refined to clarify expectations. ii) Consistent and comprehensive quality assurance standards for the provision of residential accommodation to those fleeing domestic violence are not in place. iii) The role of the agencies providing accommodation, support and counselling for domestic abuse cases is not sufficiently clear and potentially concentrates attention on adult victims with insufficient focus on safeguarding vulnerable children. c) Processes and Tools used by practitioners i) Does the current system for identifying the levels of need and support to families, along with the expectations of the role and responsibilities of professionals and agencies, require reconsideration by Children‟s Social care? ii) Considering risk using any tool including the „Signs of Safety‟ model may lead to ambiguous judgements and decision making. The implications of this need to be considered to ensure there is a standardised implementation of the use of the tool. There should be sufficient knowledge of the tool to allow professionals to challenge decisions which flow from the use of the tool. iii) Assessments of need, particularly core assessments, are potentially insufficiently multi agency in production and may lead to gaps in the information required to complete a comprehensive assessment. a) Management System i) High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority. 14 2.29 When Birmingham Children‟s Social Care Service made requests to Coventry Children‟s Social Care Service for transfer of the case between areas this was not immediately agreed. The refusal by Coventry on both occasions was justified by a different rationale. On the first occasion Birmingham were told that evidence of the family being permanently resident in Coventry was required and that hostel accommodation did not indicate that the family were permanently housed locally. On the second occasion Birmingham were informed that excessive workload precluded the service taking on responsibility for the case at that time. This transfer difficulty was regrettable but the case was accepted shortly afterwards. 2.30 Participants in the Case Group described that there was a general expectation that neighbouring authorities within reasonable driving distance, wishing to transfer complex cases to Coventry would be asked to hold and to continue to work with those cases for a period. The rationale for this being that the other authority would be able to continue to visit the family, and experience had shown that families frequently move back to their original home town. There was a lack of clarity about whether this understanding was explicitly stated in regional procedures. 2.31 The Review Team discussed the issue of cross border transfers and noted that, while regional procedures in the West Midlands had existed in respect of case transfer arrangements these were no longer current and required revision to take into account changing legislation and organisational structures. 2.32 In Northamptonshire County Council v Islington LBC (1999) and C (a child) v Plymouth City Council (2000), the Court of Appeal gave authoritative guidance on the test to be applied when determining which local authority is to be designated under Section 31(8) of the Children Act 1989. It was held in these cases that a child is ordinarily resident where the parent of a child with parental responsibility resides. Further to these legal provisions the Children Act 2004(S11) (1)/ (2) lay duties on authorities to safeguard children and co-operate together to do so. Therefore in this case, the mother and her children who were resident at a hostel in Coventry should have perhaps been provided immediately and without any delay with a social care service, if the appropriate level of need was reached. 2.33 In many respects the exact legal position is a moot point, what is of relevance and concern is the need for a focus on the welfare of children moving over the boundary into the Coventry LSCB area. FOR CONSIDERATION BY THE LSCB High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority. This case review illustrates that on some occasions cases moving into the Coventry LSCB area that would be eligible for transfer into the Coventry Children‟s Service may not be given immediate priority. 15 While it is a reasonable stance that children and their families „in transit‟ should remained connected to staff in the local area that has been working with them, a change of address, albeit temporary does change the situation. Professional staff from another area working across a boundary will probably not know or have access to local resources once a family has moved, thus potentially causing operational and communication difficulties when working in that different area. The Review Team is aware that the lack of current protocols, understood and supported by Children‟s Services staff in Coventry and published more widely within the region is a barrier to efficient case transfer. It is a challenge to the LSCB to ensure the safe and timely acceptance of children‟s cases from external authorities into the Coventry area. It is a challenge to the LSCB to ensure protocols are developed which apply to local and regional transfers of cases into Coventry and when in place, that the procedures are publicised and supported by management action. ii) Workflow through the children’s social care teams may not always occur within agreed timescales because of the overall competing high levels of demand in the City. 2.34 The high level of demand on the Coventry Children‟s Social Care Services, Referral and Assessment Service (RAS) was given to Birmingham Children‟s Social Care Service as a reason why the service was unable to respond to the request for immediate transfer in respect of the family in this case review. 2.35 The Review Team was told that a large numbers of cases were being handled by the RAS in mid 2011 and a commonly held view in the case group was that there was a resource versus demand mismatch at that time. The RAS staffing comprises of twenty five social workers, five senior practitioners, five team managers and one integrated service manager (ISM). The average caseload within the service is twenty five cases per full time equivalent social worker. Some cases remained in the service longer than the agreed six weeks duration due to problems with transfer to longer term teams. Many cases reached second child protection and looked after children reviews before it was possible to transfer them into other teams. In 2010-2011 the service dealt with: Contacts 13,478 Referrals 3655 Initial assessments 3100 Core Assessments 1097 Section 47 enquiries 567 Initial child protection conferences 384 FOR CONSIDERATION BY THE LSCB Workflow through the children’s social care teams may not always occur 16 within agreed timescales because of the overall competing high levels of demand in the City. The RAS plays a crucial role as an initial access point to children and families requiring service and represents the „front door‟ of the children‟s service. Decisions about whether or not to grant access to services take place in the service as do initial and core assessment s of children and their families. Clear operational protocols are in place to govern the throughput of cases ensuring that the team holds cases for a maximum of six weeks before cases are moved on to longer term or specialist teams. However, there is a wide acknowledgement that those protocols have not always been adhered to because of the high number of cases the RAS is dealing with caused by a backlog of cases which should move on to other specialist teams. The nature of the work is such that the demand for referral or re referral cannot be estimated or the ebb and flow of cases being presented accurately calculated. In these circumstances of a demand versus resource mismatch in this service there is a potential for staff to become stressed and their abilities of assessment and decision making to become impaired. The LSCB will want to consider whether workflow through the system is still a difficulty and what can be done to alleviate any difficulties. It is a challenge to the LSCB to satisfy itself that contingency plans are in place to ensure that those children who require services from the RAS receive them. It may be advantageous to consider the issues in respect of RAS in the context of the whole of the Children‟s Services. b) Patterns of multi-agency working i) There is a perception that the timing and appropriateness of transfer of cases from and to the local multi-disciplinary family support professionals who use the Common Assessment Framework, (CAF), a system known as ‘stepping up’ or ‘stepping down’ cases needs to be further refined to clarify expectations. 2.36 A number of the local multi-disciplinary family support professionals were involved in giving support to and monitoring the progress of the family in the case being reviewed. It is clear from the evidence gained during both the individual conversations and the Case Group meetings that those operating the CAF arrangements encountered difficulties in escalating the case under review for the involvement of Children‟s Services. The rationale given for this by Children‟s Services was that there was still insufficient evidence to warrant further action. 2.37 Those local family support and universal services professionals involved in this case felt that there was what they perceived to be a more general reluctance on the part of Children‟s Social Care Services to become involved directly in a case unless there was a clearly identified significant worsening of the situation or a crisis. This may 17 also reflect a lack of clarity on the part of these professionals about their roles in managing the CAF plan and helping the family. 2.38 Those involved in the review from Children‟s Services pointed out that the CAF process was nationally designed to provide early intervention and involves „everyone whose job involves working with children and families to keep an eye out for their well being and be prepared to help if something goes wrong‟ The Common Assessment Framework for children and young people: a Practitioners guide 2006. Using this ethos the expectation of Children‟s Services staff is that cases will be effectively contained and worked with at a CAF level unless there was a clear crisis or rationale for their intervention. These differing viewpoints did not seem to be aided by current procedural guidance and management arrangements and potentially left a gap where CAF professionals needed support with their concerns and easier access to children‟s professionals with a greater level of expertise. 2.39 Case Group members from Children‟s Social Care Services were keen to point out that they had limited resources and were often not in the best position to intervene as to do so would have the unintended consequence of elevating a case beyond the levels of intervention that were warranted or beneficial to the children. FOR CONSIDERATION BY THE LSCB There is a perception that the timing and appropriateness of transfer of cases from and to the local multi-disciplinary family support who use the Common Assessment Framework (CAF) a system known as ‘stepping up’ and ‘stepping down’ cases needs to be further refined to clarify expectations. The CAF system is a valuable method of accessing early intervention for a large number of children and families. However, those involved in the CAF process need clarity of role and the confidence to carry out that support role effectively. There is a misperception by some of the professional staff using the CAF that it is in some way a method of diverting cases that otherwise would or should receive attention from the Children‟s Services. This misperception is reinforced by case examples, such as the one under review, where CAF professionals experience a difficulty in „stepping up‟ cases where they feel there is genuine concern and where the expertise of a social worker is required. While it is difficult to quantify these perceptions they do exist and potentially may prevent the smooth operation of the CAF system which in turn potentially frustrates the aim of the CAF system to provide coordinated early support and intervention to families. It is a challenge to the LSCB to ensure that professionals in all agencies are fully equipped and confident to perform their roles within the CAF process and that assistance and support for more complex case situations is available to staff who require it. 18 ii) Consistent and comprehensive quality assurance standards for the provision of residential accommodation to those fleeing domestic violence are not in place. 2.40 Domestic violence was a significant feature in the case under review. Child W‟s mother‟s attempts to flee domestic violence brought her into contact with residential accommodation which provided temporary sanctuary from the violence she was subject to. The Case Group members described to the Review Team variability in the quality and safety of the establishments she took refuge in. In the first hostel in which the mother of Child W stayed she received threats from other residents. This is an independent non-commissioned hostel. The second DVA Accommodation provider is a properly commissioned DVA service subject to contractual monitoring by their commissioner, Coventry City Council. 2.41 The Review Team were concerned about the lack of comprehensive arrangements for the regulation and monitoring of independent non-commissioned establishments both locally and nationally. The Review Team remained unconvinced that the needs of the children who accompany women fleeing domestic violence, as in this case, were fully considered and safeguarded. 2.42 The Review Team discovered that in the absence of national regulations and quality standards applicable to the operation of residential hostel accommodation dealing with domestic violence that effectively anyone can set up such accommodation as a private landlord. The implication of this situation is that it is not possible for those agencies assisting in placing women and children in such accommodation to be reassured that it complies with general children‟s safeguarding principles. It can also be difficult to know with certainty if staff working in the establishments have the professional expertise to provide services such as counselling and support to vulnerable women and children. The Review Team believe that this is an issue of national significance and should be noted for potential action by the relevant government departments such as the Department for Education and the Home Office. 2.43 At a local level the Review Team believe it is essential that those professional staff and police personnel involved in responding to and assisting those subject to domestic violence should satisfy themselves that the residential accommodation in which they place vulnerable women and children is safe and provides the level of expertise required to respond to the needs of its residents, both adults and children. iii) The role and expertise of agencies providing accommodation, support and counselling for domestic abuse cases is insufficiently clear and potentially concentrates attention on adult victims with an insufficient focus on safeguarding vulnerable children. 2.44 Members of the Case Group described how difficult it can be to work with adult women who are often in denial about the abusive relationships they are in. The case under review highlighted the need for staff in both supported accommodation and family support services, dealing with domestic violence and abuse, to be confident in 19 identifying, challenging and responding appropriately to signs of domestic abuse and to be mindful that small children who are present in the household can be potentially vulnerable. 2.45 The Review Team were struck by the paradox that certain types of work such as statutory child protection interventions usually attract a mandatory response from well qualified and experienced professionals, whereas domestic violence and abuse situations which also demand high levels of skill and investigative abilities tend to be dealt with by less experienced and qualified staff. The Review Team were further struck by the tendency in agencies for whom child safeguarding was not a primary focus, when responding to the needs of adult victims, sometimes allowing themselves to be distracted from the needs of potentially vulnerable children. FOR CONSIDERATION BY THE LSCB Consistent and comprehensive quality assurance standards for the provision of residential accommodation to those fleeing domestic violence are not in place. The role and expertise of agencies providing accommodation, support and counselling for domestic abuse cases is insufficiently clear and potentially concentrates attention on adult victims with an insufficient focus on safeguarding vulnerable children. In the absence of prescribed national standards for the quality and safety of residential accommodation dealing with victims of domestic violence, it is a challenge to the LSCB, working in partnership, to ensure the safety of children in these facilities. The LSCB will want to consider how best it can do this both through direct commissioning and through individual agency practice. In respect of direct commissioning, the LSCB activity is likely to overlap with that of the local Community Safety Partnership in order to ensure that contracts reflect the needs of both adult victims and their children. It will be a challenge to both of these partnership bodies to ensure that contracts not only reflect quality and safety standards but also, as part of ongoing contract monitoring, that those standards are maintained. With respect to individual agency practice, it will be a challenge to both the LSCB and the Community Safety Partnership to ensure that individual professionals making referrals to residential accommodation are aware of the safeguarding needs of children and ensure that they are not compromised when placing their adult carers. c) Processes and Tools used by Practitioners i) Does the current system for identifying the levels of need and support to families, along with the expectations of the role and responsibilities of 20 professionals and agencies, require reconsideration to take into account the Munro recommendations? 2.45 The circumstances in which professionals become involved with children and their families and the level of that involvement is often referred to as a threshold of intervention. On a number of occasions in the case being reviewed the local family support and universal services professionals identified instances where they believed that domestic abuse was being perpetrated within the family and that this was likely to be affecting the wellbeing of the children. When they made attempts to escalate their concerns to colleagues in Children‟s Social Care Services they were told that they had insufficient evidence on which to take further action. The effect of this was that on some occasions the case was inappropriately maintained by the CAF professionals outside of the formal safeguarding system in local family support and universal services. The Review Team believes that this links into the issues described above in relation the timing and appropriateness of transfer of cases from and to the local multi-disciplinary family support professionals. 2.46 Some members of the Case Group felt that the application of thresholds may not always be as consistent as they would like to see. Coventry Local Safeguarding Children Board (CLSCB) have developed and published procedures and processes in respect of how thresholds of intervention should operate taking into account the skill mix of the workforce involved, available resources and the need to promote the welfare of children and ensure their safety. 2.47 The tool used to govern this is known as the „Promoting Children and Young People‟s Welfare Model‟. The model works on the principle of four levels, level one being access to universal services usually characterised as those which are normally available to all children such as playgroups or nurseries, through to level four where specialist intervention such as situations requiring action to prevent significant harm or the need to provide alternative care. Within the model the CAF process is located between levels two (life chances may be impaired without services) and three (life chances will be impaired without services). 2.48 The Review Team agreed that the formulation of thresholds and their publication is a helpful aid to multi agency understanding of child safeguarding but the existence of written tools will not in themselves ensure that levels of need will be correctly identified. Munro (2011) notes „procedures are always incomplete and require skills and the use of judgement to implement them.... When the organisation does not pay enough attention to these skills, then procedures may be followed in a way that is technically correct but is so inexpert that the desired result is not achieved‟. 2.49 Despite the existence of the agreed thresholds contained in the „Promoting Children and Young People‟s Welfare Model‟ there may remain a lack of understanding about what referral information would elicit a particular response from Children‟s Social Care Services. This led to some staff becoming frustrated when they did not get the response they expected. On occasions this led to referrers over emphasising the importance of certain pieces of referral information in order to gain the required response and trigger intervention. 21 2.50 This phenomenon has been observed in other places, White et al (2008) note that “Often referrers 'talk up' referrals to avoid the threat of being blamed for inaction. The introduction of the Common Assessment Framework (CAF), a standard process designed to support early intervention and encourage other professionals to continue working with families rather than refer to children's social care, may be sometimes having its own unintended impact. In a high blame, high risk environment, rather than encouraging other agencies to work with families for longer CAF has sometimes increased referral rates to children's social care”. 2.51 Children‟s Social Care Services staff were innately aware of this tendency for referrals “to be talked up” and believed that they sometimes under-reacted in order to compensate for what they believed was information bias. However, that situation has the potential effect of undermining and altering the agreed threshold levels from all perspectives with potentially unsafe consequences. FOR CONSIDERATION BY THE LSCB Does the current system for identifying the levels of need and support to families, along with the expectations of the role and responsibilities of professionals and agencies, require consideration to take into account the Munro recommendations? The consistent and safe application of thresholds of intervention is crucial in maintaining the safety of children and young people and ensuring that services are provided at the appropriate level according to assessed need. The Promoting Children and Young People‟s Welfare Model provides an agreed multi agency approach to thresholds of intervention. The review discovered some issues of concern in the consistent and appropriate application of thresholds for intervention. While the review team acknowledge that considerable efforts have been made to illustrate, raise awareness and train professionals about the agreed threshold levels there remains a degree of inconsistency which is problematic. It is particularly essential to ensure that those referring into Children‟s Services are clear, accurate and open about their concerns and that those receiving referrals respond appropriately as required by the levels of the agreed model of thresholds. It is a challenge to the LSCB to ensure that children are dealt with at the most appropriate level of the service in order that they can access the part or parts of the children‟s service that effectively promotes their welfare and safety. In order to meet this challenge staff in the children‟s service, particularly those who interface with CAF professionals require support and supervision facilities to provide checks and balances in the decision making process. ii) Considering risk using any risk assessment tool such as the ‘Signs of Safety’ model may lead to ambiguous judgements and decision-making. The implications of this need to be considered to ensure there is a standardised 22 implementation of the use of the tool. There should be sufficient general knowledge of the tool to allow professionals to challenge decisions which flow from the use of the tool. 2.52 The „signs of safety‟ tool was used in the review case at a key juncture, the strategy meeting in July 2011, when determining the risks present in the family. It produced a variable result showing signs that on the numerical scale used by the tool risks were between three and five on a scale of zero to ten where zero represents an unsafe situation and ten a safe one. The interpretation of this result, while acknowledged at the time as uncertain, was insufficient to trigger the case being referred on for discussion at a child protection conference. 2.53 The „signs of safety‟ tool is in widespread use within services for children in Coventry and elsewhere in the country and has recently been introduced for use by CAF professionals such as those within the multi-disciplinary team. Those teams of professionals using the tool have received training on how to operate it. 2.54 The tool depends on the use of questions around a number of domains and the answers to those questions lead on to the numerical score previously described. In the case under review there was a wide variation in the results the tool provided which case group members, attending the strategy meeting found confusing. 2.55 The tool is based on research, Turnell (1997) and was first introduced in Coventry around 2006 and “uses the ethos of solution-focused work, building on strengths and enabling families to find their own solutions. It encourages the use of solution-focused techniques, including scaling questions and goal-setting as the vehicle for obtaining good quality assessments.” The tool is well thought of and features in The Munro Review of Child Protection (2011) as a practice exemplar. 2.56 Members of the Case Group indicated that it gave confidence to those using it when a clear result at either end of the scale is obtained but it is less effective when mid-range more ambiguous scores are indicated. 2.57 Clearly the use of the tool can be extremely beneficial by focusing on what works well within a family rather than what does not. Chapman and Field (2007) describe the tool as „assisting with moving from „conveyor belt‟ practice characterised by getting cases through the system to more reflective practice characterised by critical reflection of the issues‟. 2.58 The Review Team concluded that problems resulting from the use of the tool were likely to be due to its application when the scoring is not clear-cut rather than a fundamental problem with the tool itself. FOR CONSIDERATION BY THE LSCB Considering risk using any tool including the ‘Signs of Safety’ model may lead to ambiguous judgements and decision making. The implications of this need to be considered to ensure there is a standardised implementation of the use of the tool. There should be sufficient general knowledge of the tool 23 to allow professionals to challenge decisions which flow from the tool. The „signs of safety‟ tool has much to commend it and is now in widespread use in Coventry and elsewhere. The case under review revealed the possibility of ambiguous interpretation of its findings and a lack of confidence in some staff regarding results in the mid range of its scale where there was an indefinite indication of risk. It is a challenge to the LSCB to ensure that those staff using the tool have had adequate training and possess the skills to operate it correctly through the use of appropriate questioning and a critical appraisal of the answers received. It is also a challenge to the LSCB to ensure that appropriate management oversight, support and supervision is in place to provide failsafe checks to the results obtained from tools such as the „signs of safety‟. iii) Assessments of need, particularly core assessments, are potentially insufficiently multi agency in production and may lead to gaps in the information required to complete a comprehensive assessment. 2.59 The core assessment undertaken and completed in March 2011 appears to have been too optimistic in its conclusions with respect to the family‟s functioning. It insufficiently considered the likely effects of the birth of Child W and while acknowledging a number of risk factors, discounted their importance in respect of the safety of the children. 2.60 Members of the Case Group were of the view that, in respect of assessments there was a formal link to thresholds of intervention. The formal system of applying thresholds is discussed above. However, the application of those thresholds is a matter for professional assessment and judgement and is ultimately a subjective activity. 2.61 Core assessments in Coventry Children‟s Social Care Service use the National Framework for the Assessment of Children in Need and their Families and are carried out by social workers from Children‟s Social Care Services. Part of the emphasis of this type of assessment is the notion that assessments take a multi disciplinary approach to both the assessment and provision of services. This approach can manifest itself in a number of forms. However, one of the strengths of a collaborative approach to assessment is that different agencies not only contribute information to an assessment but also a level of analysis and a different perspective on the functioning of a particular family. This approach can lead to a more balanced assessment of risk with the fullest information possible and which is less likely to be skewed by the priorities, bias or resources of one particular agency or professional. 2.62 The view of the Case Group was that joint assessments were not being regularly undertaken in this way and general practice was more, as in most authorities nationally, about the act of gaining information from participating agencies or professionals. This method had the effect of isolating some professionals from the decision making process contained in the assessment. Munro (2011) notes that 24 „Different social workers often undertake each assessment and a second one frequently starts the whole process again rather than building on a common assessment submitted by another agency or the initial assessment‟. 2.63 The review team were unable to access the CAF assessment completed by the local family support and universal services professionals for the case under review. The Review Team have been subsequently reassured that the initial CAF undertaken by the DVA accommodation provider was completed in March 2010 and placed on the shared electronic database then in use (and therefore assessable to most agencies). Regular Family Support meetings were held in March, May, July and November 2010. 2.64 Children‟s Social Care Services staff need assessments from those involved in the CAF about what plan has been implemented and with what outcome. That information can then form the beginning of a specialist “core” assessment. The reviewers questioned whether those processes were satisfactorily in place and, if not, whether this was a major barrier to closer working with Children‟s Social Care Services, illustrated by Children‟s Social Care Services staff feeling CAF professionals relied too much on „gut‟ instinct rather than clearly articulated, written evidence. 2.65 Adding to the above issues, the current restricted timescales for the production of assessments does not aid multi-agency assessment. Indeed in the case under review the social worker was keen to finish the assessment quickly as it had already stretched beyond the statutory timescale for completion. This pressure to complete assessments within tight prescribed timescales was highlighted by Munro (2010) in part one of her review. She notes „a significant concern among social workers, non-social work professionals working with children, and leaders of Children‟s Services about what is said to be over-prescribed guidance on assessment, the restrictions placed upon practitioners by the associated timescales, and the perceived ambiguities concerning the purposes of the Common Assessment Framework (CAF)‟. The acceptance by the government of a relaxation of timescales for assessments may assist this problem in the future. FOR CONSIDERATION BY THE LSCB Assessments of need, particularly core assessments, are potentially insufficiently multi agency in production and may lead to gaps in the information required. The assessment function, particularly in respect of core assessments, is a key piece of activity when safeguarding children as such assessments are a major building block in decision making. In order that a wide range of information can be gathered, debated and analysed the best assessments are completed on a multi agency basis and should include the views and analysis from a range of professionals involved with the family. Due to time constraints and practicalities it can often be difficult for professionals to meet in person to carry out joint assessments. However, the sharing of written 25 information needs to be supplemented by contact in other ways to facilitate debate, analysis and to form joint recommendations. It is a challenge to the LSCB to promote the use of joint assessment techniques allowing for debate and conflict resolution within the process where necessary. 26 Summary List of the Findings of the Review Finding 1 Lack of clarity about responsibilities in relation to transfer of cases between neighbouring authorities. Finding 2 High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority. Finding 3 Workflow through the children‟s social care teams may not always occur within agreed timescales because of the overall competing high levels of demand in the City. Finding 4 The mechanism for the timing and appropriateness of transfer of cases between the local multi-disciplinary family support teams who use the Common Assessment Framework (CAF) and Children‟s Social Care; a system known as „stepping up‟ or „stepping down‟ cases needs to be further developed to ensure all agencies understand how to use this system effectively to protect children. Finding 5 Consistent and comprehensive quality assurance standards for the provision of all residential accommodation used by those fleeing domestic violence are not in place. Finding 6 The role of the agencies providing accommodation, support and counselling for domestic abuse cases is not sufficiently understood by partner agencies and potentially concentrate attention on adult victims with insufficient focus on safeguarding vulnerable children. Finding 7 The current system for identifying the levels of need and support to families, along with the expectations of the role and responsibilities of professionals and agencies, need to take into account the Munro recommendations. Finding 8 Considering risk using any assessment tool including the „Signs of Safety‟ model may lead to ambiguous judgements and decision making. The implications of this need to be considered to ensure there is a standardised implementation of the use of the tool. There should be sufficient knowledge of the tool to allow professionals to challenge decisions which flow from the use of the tool. Finding 9 Assessments of need, particularly core assessments, are potentially insufficiently multi agency in production and may lead to gaps in the information required to complete a comprehensive assessment. 27 Bibliography Munro, E. (2011) The Munro Review of Child Protection: Final Report A child-centered system. London: The Stationary Office. Munro, E. (2010) The Munro Review of Child Protection: Part One: A systems analysis. London. The Stationary Office 2010. Turnell, A. and Edwards, S. Aspiring to Partnership: the signs of safety approach to child protection: Child Abuse Review Vol 6 1997. Pages 19-190. Department for Education and Skills (2006) The Common Assessment Framework for Children and Young People: Practitioners Guide. London: The Stationary Office. Children‟s Workforce Development Council (2010). Present position and future action: Children‟s Workforce Development Council. White, S., Hemming, J and Norman, A. (2011) „Social workers cannot be out seeing families when they are inputting data‟: Comment Section, Family Law Week 15 November 2011. Chapman. M and Field, J. (December 2007) Strengthening our engagement with families and increasing practice depth: Social Work Now Volume 38 28 Coventry Safeguarding Children Board Response to the Findings of the Review concerning Child W Coventry Safeguarding Children Board met on 5 April, 24 May and 8 October 2012 to consider and discuss the implications of this review for current and future practice with families and children in the City. The Coventry Safeguarding Children Board has accepted the findings of the report in principle and committed at its meeting on 5th April 2012 to progress actions against each finding. has continued to consider the extent to which the findings are applicable across all the local services and it will be undertaking further investigative work in relation to all the findings. is determined to respond promptly and effectively to the findings of the review. It wants to improve practice and will use the findings to do so. Some immediate responses have already been put in place. A clear focus on action from learning is being adopted to ensure that the required changes happen following this case review. The findings of the Review have and are being taken forward using the Learning Together system. A. Issues with clear cut solutions that can be addressed locally and by all relevant agencies. Finding 1 Lack of clarity about responsibilities in relation to transfer of cases between local areas. Action 1 The West Midlands Regional Protocol for the transfer of cases – child protection and children in need - to be reconsidered and developed by LSCB Chairs and DCSs. This has already been discussed regionally and will be taken forward. To be completed by March 2013 29 B. Issues where solutions cannot be so clearly described because they are complex issues where there may be competing priorities and inevitable resource constraints and there are no easy answers. Finding 2 High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority. Action 2 Coventry Children‟s Services have recently undertaken a fundamental service review to ensure that needs and demands can be more appropriately provided for. As a result there has been an increase in social work capacity in Neighbourhood teams in order to strengthen services at the front door of the service. The LSCB has been kept appraised by the DCS of these developments. The LSCB has requested an additional report concerning activity and response during 2011/12 to identify what progress and improvements have been made. More frequent monthly monitoring of the demand of CAF activity across all agencies and on children‟s social care will now be required by the LSCB. Finding 3 Workflow through the children‟s social care teams may not always occur within agreed timescales because of the overall competing high levels of demand in the City. Action 3 As above, the Coventry Children‟s Services fundamental service review was set up to consider the increases in demand on children‟s services and how best these might be addressed. The LSCB has recently received a baseline report about staffing and caseload sizes in children‟s social care. It has also sought a baseline report concerning the efficiency of transfer of cases between the RAS and the longer term teams in Coventry. This information is part of regular performance updates to the Board. The LSCB will be monitoring more regularly the size of caseloads across children‟s social care against the staffing establishment as part of its performance framework. 30 The LSCB Chair carried out a visit to the RAS service in mid-2011, this visit will be repeated again with other LSCB members every 6 months. Framework to be agreed by September 2012 Reporting schedule to be in place by January 2013 C. Issues that require further research and development in order to find solutions, including those that would need to be addressed at a national level. Finding 4 and Finding 7 There is a perception that the timing and appropriateness of transfer of cases from and to local multi-disciplinary family support services who use the Common Assessment Framework (CAF), a system known as „stepping up‟ or „stepping down‟ cases needs to be further refined to clarify expectations. And Does the current system for identifying levels of need and expectations of the role and responsibilities of levels of support to families and children need to be reconsidered taking account of the Munro recommendations? Action 4 and 7 The CSCB has reviewed its subcommittee structure and this finding will be taken into account. The LSCB will refocus the work and role of the current Promoting Children‟s and Young People‟s Welfare sub-group to provide a means of more effectively monitoring the effectiveness and capacity of all early intervention services as required by the Munro Review. The LSCB will carry out an independent review of the current mechanisms for the management of the interfaces between different levels of service and intervention. The LSCB will take forward the recommendations and outcomes of this review with partner agencies. To be completed by March 2013 31 Finding 5 and 6 Consistent and comprehensive quality assurance standards for the provision of residential accommodation to those fleeing domestic violence are not in place. Role of Agencies providing accommodation, support and counselling for domestic abuse cases is not sufficiently clear. Action 5 and 6. Coventry City Council and Community Safety Partnership is undertaking a review of all aspects of service delivery for domestic violence and abuse. The LSCB will refer this issue to that review and will monitor progress. To be referred immediately and progress monitored 3 monthly. Finding 8 Considering risk using any tool including the „Signs of Safety‟ model may lead to ambiguous judgements and decision-making. The implications of this need to be considered to ensure there is a standardised implementation of the use of the tool. There should be sufficient knowledge to allow professionals to challenge decisions which they do not agree with. Action 8 The LSCB will review the current multi-disciplinary arrangements for risk assessment including the use of the signs of safety tool and for recommendations, if required, for improving practice. To be completed by September 2013. Finding 9 Assessments of need, particularly core assessments are potentially insufficiently multi-agency in production potentially and may lead to gaps in the information required to complete a comprehensive assessment. Action 9 The arrangements for assessment are currently subject to national review and update as the National Assessment Framework is being reframed. There are pilots of different ways 32 of conducting assessments across the country. Some of these are achieving better inter-professional engagement with and contribution to core assessments in particular. The LSCB will be holding workshops for partner agencies to consider the implications the national pilots and of the new framework when this is issued by Government. The LSCB will ask for an update from Board members on the current arrangements and systems for ensuring that all assessments undertaken from CAF to Core Assessment are sufficiently inter-professional and shared with all relevant partners. To be completed by March 2013. |
NC50864 | Death of a 3-month-old boy in September 2017 whils in his mother's care. Child E was taken to hospital in cardiac arrest having been left unchecked for 12 hours overnight in a pram with heavy blankets. Mother had a history of drug misuse. An anonymous referral to children's social care raised concerns about mother's drug use and home environment. A common framework assessment (CAF) meeting was held in relation to Child E's siblings. This was closed as professionals felt mother had worked honestly with the service and was no longer misusing drugs. However, mother later disclosed to the midwife that she had used multiple drugs during the pregnancy of Child E. Criminal investigation is ongoing. Ethnicity and nationality of family not stated. Learning includes: the rationale for closure of CAF should identify trigger points to review necessity for further multi-agency sharing of information; understanding multi-agency referral pathways is crucial to professionals' sharing information with purposeful intent; specialist midwives are best placed to support the pregnancy of women with a known drug history; health agencies need to work together in order to ensure that new born babies are registered with a GP practice. Recommendations include: review guidance ascribed to cessation of CAF to include a risk indicator to support single agency identification of risk to initiate further multi-agency consultation; ensure that the role of specialist midwifes is developed and promoted amongst the wider health economy; use this review as an instructive case scenario to support early help services to understand barriers to best practice.
| Title: Serious case review report: Child E. LSCB: Rochdale Borough Safeguarding Children Board Author: Rochdale Borough Safeguarding Children Board Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Report Child E 2 1. Introduction 1.1 This Serious Case Review (SCR) concerns Child E, a baby who died aged 3 months old whilst in the care of his mother ME. Child E was taken to hospital in cardiac arrest having spent twelve hours unchecked overnight in a pram containing heavy duty blankets. 1.2 Child E is the third born child to ME, he had two older maternal half siblings. FE, the father of Child E did not live in the family home but remained in a relationship with ME throughout Child E’s life. 1.3 Eight months before the birth of Child E, an anonymous referral was made to Children’s Social Care which raised concern about ME misusing substances and about the adequacy of the home conditions for the children. A child and family assessment was completed in the Early Help Service and family support services worked with ME for a period of two months within the Common Assessment Framework (CAF). ME was considered to have worked honestly with the service and no longer using substances when the case was closed to CAF. 1.4 Child E was known to universal services only and was never subject to a multi-agency plan. 2. Scope and Terms of Reference 2.1 The circumstances of the death of Child E clearly met the criteria for Serious Case Review given that a child had died, and abuse or neglect was a suspected factor. 2.2 Once the decision to conduct a review was made by the Chair of the Rochdale Safeguarding Children Board, all partner agencies were asked to provide a chronology of interventions and an analysis on their agency activities between November 2016, the date the pregnancy of Child E became known to agencies, and September 2017, the date of the death of Child E. 3 2.3 A serious case review panel was established with an independent reviewer appointed. The serious case review panel was mindful that Rochdale had two other concomitant Serious Case Reviews that were specifically considering thresholds of intervention and the approach to step up and down through the application of threshold criteria. The panel, supported by the Local Safeguarding Children Board Chair, made a decision to conduct a lighter touch review in respect of Child as the two other cases (Child Z and Child X1 and X2) were addressing similar issues. Specific to this review, three specific lines of enquiry were identified: 1. To what extent ME was educated in respect of safe sleeping arrangements for babies; 2. The effectiveness of risk assessment by agencies that had single agency contacts with Child E and ME; 3. The extent to which opportunities to share information were taken across the safeguarding partnership. 2.4 Unusually, but within the context of this being a third Serious Case Review with some similarity and in light of the agreement for a lighter touch review, practitioners were engaged through the agency panel leads and written reports only. 2.5 The review was conducted alongside an ongoing police investigation for neglect, and the potential for practitioners to be called for evidential purposes to a criminal trial also precluded direct involvement in the review in a timely fashion. 2.6 The Review was conducted through three meetings, written reports from agencies and the debate of panel members and the independent author. 2.7 The criminal investigation is ongoing. 3. Overview of what was known to Agencies 3.1 Prior to the timeframe for this review, in September 2016 ME self-referred to a Rochdale drug service. After an initial assessment, ME missed one and attended four 4 sessions with a keyworker. ME asked for her contact to be closed in November 2016, shortly after the closure if the child in need plan, at which point she stated that she was no longer using cannabis but was exhausted looking after two children. 3.2 A CAF meeting in respect of Child E’s elder siblings took place in early November 2016 with ME present. This meeting followed a two month period of intervention by the Early Help Service using the graded care profile as a tool to support ME to address the vulnerabilities that were present for the children. A decision was made to close the CAF because it was believed that ME had addressed the issues of concern. The issues of concern included the effects of ME using drugs on her parenting, and specifically the children missing health appointments. 3.3 The CAF meeting outlined the following: that ME could initiate contact with a nursery parent liaison officer if she required support in the future; that ME would be referred to the Children’s Centre and Home Start in order for ME to access low level support to get her and the children out of the house; the health visitor would continue with routine developmental checks ME had already confirmed the pregnancy of Child E with the GP prior to this meeting but did not share this information. There was no further multi-agency meeting. 3.4 One week after the meeting, ME attended a midwifery booking appointment for her pregnancy with Child E. ME shared a previous history of drug misuse, stating that she had used cocaine in the past and last smoked cannabis six months previously. ME shared with the midwife that she and had recent involvement with Children’s Social Care. ME told the midwife that she lived alone with her two children and that FE visited the home on his days off work. 3.5 The booking midwife contacted Children’s Social Care MASH Team to verify what ME had told her and this was confirmed as accurate. The midwife completed a special circumstance form for sharing of information with other health professionals and 5 Children’s Social Care. The special circumstances form was received by Children’s Social Care as information only, and although the midwife recommended that further early intervention may be required, this was not clear from the way in which the information was shared because no multi-agency referral form was completed. 3.6 Two weeks later, the health visitor involved in the previous multi-agency meeting undertook a home in relation to Child E’s half sibling and was advised by ME that she was pregnant. FE was present during the visit 3.7 In late January 2017, the health visitor made a home visit to complete an 8-12 month developmental review of Child E’s half sibling. During this visit, the lounge was noted to be cluttered with toys but safe for playing. FE was present during the visit. Child E’s half sibling was not yet walking and the health visitor planned to visit further in three months’ time. 3.8 The health visitor made a home visit in May. The developmental assessment of Child E’s half siblings was reviewed with a plan to revisit in three months. The lounge was noted again to be cluttered with toys but safe to play. 3.9 Child E was born in June 2017 at 37 weeks. The GP was sent a notification of birth. The midwife in hospital, aware of ME’s history with multi-agency services contacted Children’s Social Care who confirmed that no actions were required before discharge. Prior to leaving hospital, safe sleeping advice was given to ME. 3.10 Nine days after the birth, ME contacted the police for advice and assistance stating that the father of her eldest child was refusing to return Child E’s half sibling to her care. ME stated that the child normally stayed with the father two days per week, but he felt it was too soon for his child to return after the birth of Child E. ME advised that she was not concerned for the welfare of her child as the father was a good father, but also stated that she did not know where he lived. The police agreed that they could conduct a safe and well check however ME made the decision to manage the situation without police intervention. 6 3.11 The health visitor arranged a visit for twelve days after Child E’s birth, however no one was home to receive the visit. A further visit was made three days later whereby it is recorded that Child E was observed with both ME and FE who were bonding well. Safe sleeping advice was discussed for a second time as was the effects of passive smoking. The home was seen to be clean, warm and welcoming. No concerns were identified in regards to ME’s emotional health and the health visitor planned for the next visit to be a routine 6 – 8 weeks assessment four weeks later. 3.12 No one was home to receive the next scheduled health visitor appointment nor a subsequent attempt. Calling cards were left re-arranging each missed appointment and it was the third attempted visit when the family were seen at the home. Child E was asleep in a moses basket when the health visitor arrived, lying with a quilt nestled around the sleeping area. ME was advised to remove the quilt as it posed a risk to overheating and suffocation. Safe sleep advice was re-affirmed at length for a third time and written information was also provided. ME reported herself to be physically and emotionally well but finding three young children demanding. ME was encouraged to access the local sure start children’s centre with the children. The health visitor planned a further appointment for a routine 8-12 month development assessment. 3.13 Child E did not attend a pre-appointed GP appointment at two months old for post-natal check and first immunisations. The appointment was sent alongside a standard letter sent to all new mothers congratulating on the birth of their baby and advising of the requirement to register the baby with a GP and attend for the eight week check and immunisations. Child E was registered with an alternative GP practice three days before death. 3.14 The eldest sibling of Child E commenced full time school in September 2016. The school had been made aware by the nursery that a CAF had been in place, however, the safeguarding file had not transferred to the school as is standard procedure. 7 3.15 Aged three months, Child E was taken to hospital in cardiac arrest mid- morning. Police investigation has revealed that Child E was put to sleep in a pram at 11 pm and was not checked until 11am the following morning. At which point the baby was unresponsive with a blanket over his head. The police investigation established that ME had been using cannabis the night prior to the death, and that she had left the house between 1 and 2 am in the morning to go to a local garage. 4. Analysis 4.1 Child E was born into a family where two children had been parented for three years without being known to children’s services beyond those universally accessed by all children. The referral to Children’s Social Care in 2016 was a first referral and the undertaking of a child and family assessment through the Early Help Service was proportionate to the nature of concern, the age of the children and ME’s willingness to engage. 4.2 When challenged about the content of the anonymous referral, ME admitted that she had used cannabis and other drugs, but advised this was no longer a feature of her life. Over the two months period, ME was considered to have engaged in the assessment and early help process by accepting that continued use of substances was not compatible with her responsibilities as a parent. ME’s willingness to accept professional advice and level of insight into the impact of cannabis use on her parenting was accepted as an indicator that she was motivated to change her behavior and prioritise parenting her children. Within twelve months however, and with the addition of a third child, it is now known that ME continued to misuse cannabis and that this this was a contributory factor to the neglect of Child E. 4.3 ME disclosed to the midwife that she had used multiple drugs during the pregnancy of child E, this information would confirm that ME had not ceased using drugs as she had stated to the professionals involved in the CAF. Such information would normally lead the way to a referral to a specialist midwife who works with substance abusing mothers, however this did not happen because ME had indicated her drug 8 use was a past concern. The information was not accepted at face value by the midwife who did show a degree of caution by checking the facts as told with Children’s Social Care to ensure that ME had given a truthful account. The fact that the case no longer remained open to Children’s Social Care influenced the subsequent actions, in that there was an acceptance that the issues of concern were no longer present. In effect, because the CAF had been closed, ME was seen a woman without a current or ongoing substance misuse problem. The information available to the midwife, just one week after the closure of the CAF, was however critical to reviewing the analysis of potential for risk which was supported by the belief that ME was no longer using drugs. 4.4 The multi-agency meeting that took place in November 2016 was attended by the health visitor, nursery and a key worker from the supporting families’ team who had provided a short prior of intervention to address the issues of concern. The meeting was convened prior to ceasing the supporting families’ team involvement which demonstrated good practice with regard to information sharing across the agencies involved at that time. The outcome of the meeting focused on assisting ME to access local support networks. The CAF did not continue and therefore there was no further plan to continue multi-agency working. 4.5 At the point of closure, no specific risk was perceived to be present. The risks from substance misuse were accepted as resolved and this was supported by the improved attendance of the children at nursery and health appointments which indicated increased stability and organisation within the family. ME did not share that she was pregnant, although had known this. Her actions would suggest therefore that her level of engagement was superficial, and that she was not working in the open manner that professionals had believed. The actions beyond the CAF meeting were designed to increase ME’s support networks but it was ME’s choice whether to participate. Significantly, ME also ceased the drugs counselling after the closure of the CAF, and her engagement with the service lasted only the length of the multi-agency work. 9 4.6 Had ME worked honestly with services, undoubtedly the process of CAF would have continued to ensure a longer period of support to assist ME to address the issues that were impacting on her parenting. Similarly, had the professionals known that ME was pregnant, they may well have continued the support plan under CAF arrangements. Although ME was considered to have a high motivation for change, she had not been willing to participate in parenting groups such as Webster Stratton, and did not want to access options for community support networks beyond nursery care for the children. Her engagement with drugs services did not result in any sustained change of attitudes or behavior, whilst her attendance alone may have falsely reassured professionals that she was committed to change. 4.7 The information available to the review would suggest that ME had a history of recreational and habitual drug use rather than an addiction. To professionals this implied that ME could and had made a choice to maintain a substance free lifestyle, free from the challenges of addiction. This review therefore begs the question about how well professionals can be reassured that substance misuse that impacts on parenting is ever really resolved or whether some level of risk will always remain. 4.8 MT reported cannabis to be her drug of choice to be cannabis and cocaine less frequently. It is true that many parent’s use of drugs does not present a risk of harm to their children. It is also true that many parents who use drugs have chaotic and unpredictable lifestyles that do impact on their ability to maintain stability and safe parenting of their children. For child care professionals, the most common drug use leading to problematic parenting is cannabis and cocaine, and less common is heroin. The use of cannabis has become an increasingly common factor when working with families in early help and higher thresholds of need, to the extent that professionals need to mitigate against becoming de-sensitised to the fact that it remains an illegal drug, and one which when used even intermittently can have highly detrimental consequences for family life. 4.9 The time within which professionals were reassured by ME that risk related to substance misuse was reduced may be a significant factor in the accuracy of their 10 probability judgement. Using a model of change to support the analysis of how effectively change is achieved, professionals are reminded of the significance of the maintenance phase as the route to ensure that change is embedded. While there was evidence to support that the children were experiencing improved standards of care, the ability to sustain this was somewhat untested by the CAF ceasing within two months of commencement. The risk of re-occurrence was not articulated in the cessation of the CAF, and therefore not addressed in a way which facilitated a pathway for single agency identification of risk factors to lead to a further multi-agency communication. 4.10 The opportunity to review how significant the fact that ME had continued to use drugs was to the welfare of the children was lost to the multi-agency partnership. The three barriers to achieving this was the lack of clarity by the midwife about whether the special circumstances form was intended to be a referral for early help, the absence of a decision to refer to the specialist midwife for substance abusing mothers, and the absence of a clear analysis at the point of CAF closure about the risk and potential impact of continued drug misuse. 4.11 The substance misuse by ME contributed to her impaired ability to provide safe care for Child E who was left for twelve hours without checking in an unsafe sleeping environment. This case is a salutary reminder that abstinence from substances is not always a static factor which means that parenting capacity can change and deteriorate very quickly. The presence of a specialist midwife for substance misuse would have continually re-enforced the messages that ME required and may have eroded her conscious and subconscious attitude to the use of drugs alongside the care of children. A specialist midwife would also have undertaken an ongoing risk assessment which identified the risk and resilience factors including the lifestyle of the partner. 4.12 The chronology shows that ME was slow to respond to GP invitation for Child E to access immunisations. Non-attendance at medical appointments had been an indicator of the deteriorating functioning of the family leading up to the CAF, and 11 was attributed as an indicator of the effects of ME using drugs. Given the short period of time concerned, it was not possible to identify a pattern, but had this continued, it was likely that a CAF would have been further invoked. Pennine Care Foundation Trust identified that given the history of CAF, further collaboration with other professionals should have been considered by the health visitor when engagement by ME started to decline and some concern was noted at the 6-8 week development assessment. 4.13 It is evident from the chronology that on three occasions ME was given detailed advice on safe sleeping. This provides a positive picture of how safe sleeping is being promoted in hospital, midwifery and health visiting services. ME did not heed this advice with fatal consequences for Child E. 5. Findings and Recommendations 5.1 The early help intervention was agreed by the panel to be a proportionate response appropriately placed within the threshold of need. A short intervention resulted in some positive progress in respect of the children which gave professionals reassurance that ME was committed to changing the factors that were impacting on her parenting, primarily her drug use. 5.2 Shortly after the cessation of the CAF, there was information available within the multi-agency partnership which confirmed that ME had not worked openly and moreover that her drug use had continued. The particular areas of learning can be outlined as follows: 1. In order to optimise single agency identification of risk following the cessation of CAF, the rationale for closure should identify trigger points to review necessity for further multi-agency sharing of information 2. Understanding multi-agency referral pathways is crucial to professionals’ sharing information with purposeful intent 12 3. Specialist midwives are best placed to support pregnancy of women with a known drug history 4. Professionals must be ever mindful of the cycle involved in achieving lasting change and that motivation, action and maintenance have equal importance when seeking reassurance that change has occurred 5. Professionals must ever mindful of repeated indicators of concern and act collaboratively with other agencies to review indictors of risk 5.3 The review has identified that safe sleeping is firmly embedded into relevant health services. 5.4 The lessons learnt by individual agencies, supported by actions plans are as follows: 5.4.1 HMR CCG Health agencies need to work together in order to ensure that new born babies are registered with a GP Practice 5.4.2 Pennine Acute Hospital Trust The need for a clear pathway or assessment for early help referrals by Midwives. 5.4.3 Pennine Care Foundation Trust The need to engage in early help assessment at the first point of concern when there is a history of previous concern The need for recordings to give a whole picture of the adults who present with children and to record reasons for non-engagement 5.5 Multi-agency recommendations 13 1. Multi-agency partners to review guidance ascribed to cessation of CAF to include a risk indicator to support single agency identification of risk to initiate further multi-agency consultation 2. The Board to be provided with assurance about how the role of specialist midwifes is developed and promoted amongst the wider health economy 3. That this review is used as an instructive case scenario to support early help services to understand barriers to best practice |
NC52709 | Death of a child in 2019. At the time of death Child AA was known to several agencies. Review concludes that the death could not have been predicted prior to or at the point of the mother's mental health assessment during the critical period. Recommendations to the safeguarding partnership include: work with the local safeguarding adults board to oversee the review of approaches to the assessment and interventions with whole families where the criteria for a referral to adult services is met; promote the learning from this review across relevant partner agencies, and hold a multi-agency workshop in order to increase working relationships and practitioner awareness; work with the local safeguarding adults board to maximise practitioners' skills in the assessment of parental mental health and the impact on children including an audit of single and joint training with a view to strengthening arrangements across agencies; oversee the review of multi-agency policies, procedures and protocols relating to parenting capacity and mental illness; work with the local safeguarding adults board to review and update its information sharing code of practice, including the value of working closely with and seeking information from extended family members.
| Title: Serious case review: Child AA: summary report. LSCB: Buckinghamshire Safeguarding Children Partnership Author: Mark Jowett Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Child AA Summary Report Mark Jowett, Independent Author Introduction Buckinghamshire Safeguarding Children Board (now known as Buckinghamshire Safeguarding Children Partnership) decided to undertake a Serious Case Review in relation to the death of Child AA in 2019. At the time of death Child AA had been known to a number of agencies. Process for conducting the review Buckinghamshire Safeguarding Children Partnership commissioned Mark Jowett1 to author the report. Mark Jowett is fully independent of Buckinghamshire Safeguarding Children Partnership. In addition, a multi-agency Serious Case Review Panel was established to oversee the Serious Case Review. No professionals who formed part of the panel had any operational responsibility for agency working in relation to Child AA. Alongside the Serious Case Review, NHS England commissioned a Mental Health Homicide Review2, and that report informs some of the learning in this report. The Mental Health Homicide Review followed a Comprehensive Root Cause Analysis Investigation Report (Oxford Health NHS Foundation Trust) which reviewed the care that Child AA’s mother received from Oxford Health NHS Foundation Trust. In terms of methodology which conforms with statutory guidance3, the Panel planned to undertake the review by gathering agency4 chronologies and analysis of learning, and then conducting a multi-agency workshop whereby members of the Panel shared learning from their specific agencies. Unfortunately, it was not possible to hold a frontline practitioner and manager event as anticipated, as some key staff members remained very distressed following the tragic death of Child AA. However, in order to understand perspectives in relation to 1 Mark Jowett is an independent Safeguarding Consultant and has extensive experience in Children’s Services and Local Safeguarding Children Boards and has authored numerous Reviews including Serious Case Review. 2 Mental Health Homicide Review: A Mental Health Homicide Review was commissioned by NHS England and authored by Anne Richardson. The purpose is to review the care and treatment received by the patient so that the NHS can be clear what (if anything) went wrong with the care of the patient; minimise the possibility of reoccurrence of similar events; and make recommendations for the delivery of health services in the future. 3 Working Together to Safeguard Children expects case reviews to be conducted in a way that; recognises the complex circumstances in which professionals work together; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did ; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform findings. 4 Agencies that have contributed to this review are; Oxford Health NHS Foundation Trust, Buckingham Children’s Social Care, Thames Valley Police, Buckinghamshire Health Care Trust, Buckingham Clinical Commissioning Group, Hightown Housing Association, Oxford Health NHS Foundation Trust, South Central Ambulance Service, Frimley Health NHS Foundation Trust. learning, key adult mental health professionals were interviewed as part of an internal review and the wider the Mental Health Homicide Review. In addition, the author of the Serious Case Review and the Mental Health Homicide Review jointly interviewed the Children’s Social Care frontline manager. The Serious Case Review author also spoke with the social worker who had been allocated to Child AA. Finally, the Panel reconvened to consider the draft of the Serious Case Review report, with recommendations for multi-agency learning discussed. Whilst the Panel identified that critical events took place over a period of 4 months, the review considered a wider timeframe over 2 years in order to capture any previous information that may be helpful in terms of providing a wider context to the family history and inform learning. The Review considered the detailed, chronological history of Child AA and the family’s interaction with services over this period, as well as a detailed review of key episodes, informed by the multi-agency chronologies and analysis and the author’s interviews with key personnel. Good Practice The focus of a Review is to learn and improve services. As such, it is important to learn from examples of good practice that support good outcomes for children. Good practice from a number of agencies and professionals was identified during the course of the Review including: • The allocated social worker identified that the mother required debt counselling and sign-posted her to relevant services. The social worker also offered the mother ongoing support via Child in Need or Early Help. • SCAS, Police and Children’s Social Care Out of Hours liaised and responded quickly to a family member’s call during the critical period. • The Children’s Social Care team attempted to encourage the GP to make the referral to the Adult Mental Health Team and showed tenacity in getting the Adult Mental Health Team to respond urgently. • The Adult Mental Health Team responded quickly and made several attempts to engage the mother. This included an un-announced visit. • The Adult Mental Health Team arranged an assessment of the mother as soon as the mother was willing. • The Mental Health Assessment was carried out by experienced practitioners and was viewed by the Independent Mental Health Homicide Review to be thorough and of good quality. • The Housing Association offered the mother good support with her debt management and housing issues, and this included helping her to successfully apply for a Homeless Prevention Fund. Conclusion The Serious Case Review concluded that the death of Child AA could not have been predicted prior to or at the point of the Mental Health Assessment during the critical period. Whilst no specific acts or omissions were identified by the Review as leading directly to the death of Child AA, there are some aspects in terms of joint working and sharing of information that could have been stronger. A full mental health assessment conducted by an experienced team was completed during the critical period. This did not elicit any evidence that the mother was suffering from a mental disorder. The Mother did not have any formal psychiatric history, and on the basis of this information and within the context of the earlier Children’s Social Care assessment and information, the view of Children’s Social Care was that there was no evidence of risk to Child AA. The view of the Mental Health Homicide Review was that the NHS clinicians fulfilled their responsibilities and completed a good and thorough assessment of the mother. It is clear from accounts of family members that they were seeing some evidence of mental health symptoms in the mother, though not all of this information was known to professionals until after Child AA’s death. If the mother had been experiencing psychotic symptoms at the time, then she was adept at hiding them and the experienced NHS clinicians were not able to find evidence of what appears may have been a psychotic state. The Serious Case Review concluded that whilst the tragic incident which resulted in the death of Child AA could not have been predicted and no blame should be attributed, improved system wide communication and assessment between professionals, with greater involvement of the family would have been valuable. Recommendations The Review made the following recommendations which were accepted by the Buckinghamshire Safeguarding Children Partnership: Buckinghamshire Safeguarding Children Partnership to monitor the implementation of actions from single agency action plans. This includes the actions and recommendations detailed in the Mental Health Homicide Review. The Serious Case Review Panel makes the following multi-agency recommendations to Buckinghamshire Safeguarding Children Partnership: Whole family approach i. Buckinghamshire Safeguarding Children Partnership to work with Buckinghamshire Safeguarding Adults Board to oversee the review of approaches to the assessment and interventions with whole families where the criteria for a referral to Adult Services is met. Promote learning ii. Buckinghamshire Safeguarding Children Partnership to promote the learning from this review across relevant partner agencies, and to gain evidence in relation to dissemination and embedding of learning. Buckinghamshire Safeguarding Children Partnership to hold a multi-agency workshop on the issues coming out of the Serious Case Review in order to increase working relationships and practitioner awareness. Training iii. Buckinghamshire Safeguarding Children Partnership to work with Buckinghamshire Safeguarding Adults Board in overseeing a review of how to maximise practitioners’ skills in the assessment of parental mental health and the impact on children. This should include an audit of single and joint training with a view to strengthening arrangements across agencies. Policies & procedures iv. Buckinghamshire Safeguarding Children Partnership to oversee the review of multi-agency policies, procedures and protocols relating to parenting capacity and mental illness, to ensure learning from this Serious Case Review is included. v. Information sharing Buckinghamshire Safeguarding Children Partnership to work with Buckinghamshire Safeguarding Adults Board in overseeing the review and update of its information sharing code of practice. This should include the value of working closely with extended family members. Information should be sought from extended families and carers to inform assessments as a matter of course unless there are clear reasons why it is not appropriate to do so. |
NC50713 | Death of an adolescent boy by apparent suicide in May 2017. Laurie and siblings had been looked after by the local authority since 2011. Laurie refused to return to foster care placement and moved to mother and stepfather's home. Children's social care undertook a placement with parent ("P") review, recommending that return home should be supported but closely monitored. Laurie was arrested three times between 2015 and 2016 following threats to mother and stepfather. Assessed by Child and Adolescent Mental Health Services (CAMHS) but declined further involvement. Case was transferred to the leaving care service as Laurie approached sixteenth birthday. Several instances of self harm but no referrals to CAMHS or GP. Inquest into Laurie's death pending. Ethnicity and nationality not specified. Findings include: family support for Laurie's mother and stepfather was overlooked; the leaving care service's assumption of primary responsibility was premature; there is no evidence that any agencies looked into why Laurie did not engage with services; and responses to self harm and suicidal ideation were inconsistent. Recommendations include: obtain assurance that the looked after child review process is robust; request that children's social care share the outcome of their placement with "P" procedures review; disseminate the learning from this case review to stress the importance of recording and appropriately responding to incidents of self harm; develop a multi-agency policy for services experiencing difficulty in engaging children and families; and learning from this case review should inform any review or process for developing the local suicide prevention strategy.
| Title: Executive summary of a serious case review in respect of a young person ‘Laurie’. LSCB: Wakefield District Safeguarding Children Board Author: David Mellor Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Executive Summary of a Serious Case Review in respect of a young person ‘LAURIE’ David Mellor Review Facilitator & Author August 2018 2 1. Introduction 1.1 On 1st May 2017 a young person who will be referred to in this report as Laurie died after apparently taking his own life. At the time he had been in the care of Wakefield Council since 2011 although placed in the care of his mother and step father since 2015. An inquest into Laurie’s death will take place in due course. 1.2 Following Laurie’s death, Wakefield and District Safeguarding Children Board decided to conduct a serious case review (SCR). The Safeguarding Children Board commissioned David Mellor to be the lead reviewer for this SCR. He has several years experience of conducting SCRs and has no connection to Wakefield or any of the agencies involved in this case. 1.3 Laurie’s mother and step father, his girlfriend and Laurie’s previous foster carers contributed to this review. 2. Brief summary of the case 2.1 In 2011 Laurie and his siblings became looked after by the local authority. Laurie spent almost five years in a successful foster care placement. During the early months of 2015 Laurie began to express the wish to have more contact with his birth family and talked of returning to them permanently. 2.2 In July 2015 Laurie refused to return to his foster care placement and moved to his mother and step father’s home. This led to the urgent completion of a Placement with Parent (“P”) assessment under the Care Planning, Placement and Case Review (England) Regulations 2010. Given Laurie’s age and understanding together with improvements within the life of mother and step father, it was recommended that Laurie’s wishes should be supported but that his return home closely monitored. 2.3 Laurie continued to be supported by the Looked After Children (LAC) team and statutory visits and reviews took place as previously. It was recommended within the Placement with P report that six weekly multi disciplinary meetings should be held to closely monitor Laurie’s placement, identify any support needs and provide additional support if required. 2.4 The view of Laurie’s independent reviewing officer (IRO) had been obtained which was that she would have preferred that Laurie remained in foster care and moved back to his birth family in a planned way. 2.5 During August 2015 a LAC review chaired by a new IRO took place at Laurie’s home. Laurie was said to be happy in the placement although ‘pushing boundaries’. 2.6 On 1st September 2015 Laurie was arrested by the police after threatening to stab mother and step father. Laurie was released from custody but re-arrested after making further threats to mother and step father. Whilst in custody Laurie was assessed by the child and adolescent mental health services (CAMHS) crisis team after threatening self-harm. 3 Laurie subsequently declined further involvement with CAMHS. Laurie was referred to the youth offending team (YOT) for a youth conditional caution for an offence of affray arising from this incident. 2.7 During a LAC review in November 2015, Laurie was said to have settled back into the family home, was doing well in education and engaging with YOT. Support for mother and step father to manage Laurie’s behaviour was to be explored by the social worker. 2.8 The leaving care service became involved with Laurie as his sixteenth birthday approached. An assessment of Laurie’s needs took place in order to determine the advice, assistance and support to be provided after he left local authority care. A pathway plan was prepared and personal advisor appointed. Laurie’s case was transferred to the leaving care service in February 2016. 2.9 Also in February 2016 Laurie’s educational placement noticed marks on his arms and legs which were said to have been self-inflicted following a split with his then girlfriend. Although support was offered, no referral to CAMHS, the LAC nurse or Laurie’s GP appeared to be considered. 2.10 In April 2016 an IRO chaired LAC review took place at which Laurie was said to remain happy to be living at home and mother said that their relationship had improved. However, a referral to the intensive support team (IST) to provide family support to mother and step father remained outstanding but was not followed up. 2.11 In early May 2016 Laurie posted images of self-harm marks on his arm on Facebook accompanied by comments which suggested he was making progress in overcoming difficulties. His post generated largely positive responses but also attracted criticism. Laurie’s leaving care worker became aware and advised him to remove the images which were said to be ‘from three weeks ago’. No referral was made to CAMHS or Laurie’s GP. 2.12 The following day Laurie attended the local NHS Hospital Emergency Department with cutting wounds to his arm and chest following the end of a relationship with his then girlfriend. The wounds were diagnosed as superficial and he was discharged. Laurie’s GP received a notification in which the injuries were described as “trivial self-harm”. Laurie was referred to the emotional wellbeing team (EWBT) by his leaving care worker, although Laurie’s engagement with the EWBT was short lived. 2.13 In May and June 2016 mother sought support from NHS 111 and her GP to address Laurie’s behaviour which included self-harm. Laurie again declined a referral to CAMHS. 2.14 Also in June 2016 Laurie’s previous foster carer contacted children’s social care to express concern about Laurie’s relationship with mother. A period of respite was arranged for Laurie during which he stayed with the foster carer’s son in Chichester. 4 2.15 In September 2016 an IRO chaired LAC took place at which it was said that Laurie was happy to remain in the family home and that arguments had decreased. 2.16 In December 2016 Laurie was arrested after threatening mother and step father with a knife. He later appeared at court and a pre-sentencing report was requested. It was also agreed that Forensic CAMHS would complete a structural assessment of violence in youth (SAVRY) assessment followed by a review of Laurie’s mental health. (This assessment was completed just prior to Laurie’s death). Laurie was also referred to the young person’s drug and alcohol service and the YOT supporting families lead practitioner. 2.17 In January 2017 Laurie was sentenced to a referral order for 12 months and his case was allocated to the same YOT worker who had previously worked with him. YOT work with Laurie was to focus on controlling temper, knife awareness and family relationships. 2.18 Later the same month Laurie asked his college for a referral to a counsellor but there is no record of whether he saw a counsellor or not. 2.19 In early February 2017 Laurie declined his annual LAC health assessment for the third consecutive year. Around the same time a drugs worker conducted initial screening with Laurie during which he disclosed regular drug misuse. 2.20 The YOT supporting families lead practitioner visited Laurie, mother and step-father during February 2017 but mother and step father were said to be unwilling to engage at that stage. Around this time Laurie’s YOT worker and his leaving care worker began to feel that Laurie’s home circumstances were contributing to his risk of further offending and it was suggested that independent living should be considered. 2.21 A March 2017 LAC review was attended only by the IRO, mother and the leaving care worker. Significant conflict between Laurie and his mother was noted. Whilst it was concluded that Laurie should remain in his current placement, checks would be carried out into the suitability of Laurie staying at his girlfriend’s address. Laurie had been in a relationship with his girlfriend since before Christmas 2016 and had begun to stay at her house for several nights each week. There was no discussion of independent living for Laurie. 2.22 Later that month Laurie was assessed by the drugs worker who identified that Laurie may have been experiencing symptoms consistent with panic disorder (panic disorder is an anxiety disorder characterised by recurrent unexpected panic attacks). 2.23 During April 2017 Laurie was present during an incident of domestic abuse involving a sibling and her partner which Laurie reported to the police. Later that month Laurie’s girlfriend called an ambulance when Laurie was struggling to breathe after a panic attack. 5 2.24 During the late evening of 1st May 2017 step father contacted the ambulance service to say that Laurie had hanged himself from a tree not far from their address. Laurie was taken to hospital but was found to be dead on arrival. 3. Analysis 3.1 Placement with “P” Assessment Against very tight time pressures the placement with “P” assessment carried out by children’s social care was thorough and comprehensive in many respects. However, the potential impact of mother’s emotional difficulties on her parenting of Laurie should have been more fully explored. This may have led to more detailed consideration of the support mother needed to parent Laurie effectively. 3.2 The decision to place Laurie with his mother and step father Whilst children’s social care had several misgivings about the placement with mother and step father and the haste with which it became necessary to implement it, this placement was considered to be the lowest risk option available. Legal disruption of Laurie’s unauthorised presence in mother and step father’s home (e.g. harbouring notices) was rejected on the grounds that this course of action might prove counterproductive and could be harmful to Laurie. 3.3 Laurie’s foster carers were critical of the decision to place Laurie with mother and step father as Laurie’s contact with them had always been supervised and he had not had weekend leave with them either. In their view, going from this position to returning to live permanently with mother and step father seemed ‘too big a jump’. 3.4 Review of contact arrangements The need for an assessment of contact arrangements between Laurie and mother was identified in 2014 following concerns that mother was putting her needs ahead of Laurie. This assessment did not take place. Had it taken place, the assessment may have helped to improve the relationship between Laurie, mother and children’s social care and may have reduced the extent to which children’s social care found themselves reacting to events when Laurie’s foster care placement broke down. 3.5 The extent to which Laurie’s ‘voice’ was heard. Laurie’s return to the care of mother and step father accorded with the preference he expressed. Children’s social care arranged for the children’s advocacy and participation service to advocate for Laurie, although they were not asked to provide advocacy to Laurie during the placement with “P” assessment. 3.6 Monitoring of Laurie’s placement with mother and step father The placement with “P” regulations make it clear that where the child’s welfare is not adequately safeguarded and promoted by the placement, the local authority must review the case. (Regulation 30) There were several occasions when it was apparent that Laurie’s welfare was not being adequately safeguarded and promoted by the placement but there is 6 no evidence that the placement was reviewed as a result or that implementation of the placement breakdown contingency plan was considered. 3.7 Support for Laurie’s mother and step father The placement with “P” assessment recognised the possible future need for relationship work between Laurie and mother. Relationship work became necessary when the placement came under strain. The November 2015 LAC review proposed a referral to the intensive support team (IST) to provide family support to mother and step father with parenting strategies to manage Laurie’s behaviour but this was said to be ‘still outstanding’ during the April 2016 LAC review and not followed up thereafter. 3.8 Relationship work did not begin until the referral to the YOT supporting families lead practitioner following Laurie’s arrest in December 2016. This work was unsuccessful primarily because mother and step father were of the view that the work should be directed towards Laurie solely. 3.9 Children’s social care did not initially appreciate that Laurie’s return home fundamentally changed mother’s role from a parent who had only supervised contact with their Looked After Child to full time carer for that Looked After Child. The placement with “P” regulations state that the local authority must provide such services and support to the parent(s) as appear to them to be necessary to safeguard and promote the welfare of the child (Regulation 20). 3.10 The Looked After Child review process The IRO chaired LAC review process was the crucial point of collaboration between practitioners, Laurie and mother and step father. The process began constructively but meetings were not always fully informed of all relevant issues. When concerns were more fully shared, the actions proposed did not match the level of those concerns. Over time, attendance dwindled to mother and Laurie’s leaving care worker. Health practitioners including LAC nurses were not represented at any of the LAC reviews, nor was the YOT. 3.11 Laurie’s transfer to the Leaving Care service The point at which the leaving care worker became the primary worker for Laurie was premature. Laurie’s subsequent pathway plan lacked insight into Laurie’s background and the context of mother’s care. Despite moving to independent or semi-independent accommodation being identified in Laurie’s pathway plan in November 2016, no meaningful searches or services had been identified at the time of Laurie’s death in May 2017. 3.12 Engagement with Laurie and his family Children’s social care experienced difficulty in engaging consistently with Laurie. The placement with “P” regulations state that on each statutory visit the social worker must speak to the child in private. It is unclear whether this always happened. Children’s social care were unable to prevent some visits being taken up with discussing Laurie’s mother’s concerns. 7 3.13 The YOT worker’s approach involved taking Laurie away from the home environment which appeared to be successful. Consistency of worker also appeared to be an important factor in Laurie’s positive engagement with the YOT. Children’s social care have reflected on how their service could have considered engaging with Laurie differently and outside more traditional routes. 3.14 Laurie appeared to be resistant to engaging with therapy offered by CAMHS. It is unclear whether any practitioner explored why Laurie was unwilling to engage with therapy. CAMHS respected Laurie’s wishes and discharged him from the service and provided information on how to refer back. The question of whether this is sufficient arises. Should ‘duty of care’ considerations indicate a need to go further? ‘Hard to engage’ procedures adopted by some local safeguarding children boards (LSCB) require cross agency communication at the point that an agency ceases to offer a service as a result of disengagement. (1) 3.15 The involvement of the LAC Nurse Service When Laurie began to decline annual LAC health assessments from 2015 onwards, the ‘LAC refusal pathway’ should have been followed. This pathway requires the exploration of all possible options to complete the assessment and the gathering of information about the child’s health from the information systems of agencies in contact with the child. Unfortunately, the pathway was not followed and the LAC nurse service took a narrow view of Laurie’s health needs, placing less emphasis on his mental wellbeing. 3.16 General Practitioner involvement Laurie registered with mother’s GP shortly after he returned to the family home. The GP practice was not informed about Laurie’s placement with “P”. The GP practice was also unaware of the Laurie’s lack of engagement with the LAC nurse. Had the GP been aware of this, they could have undertaken a more detailed assessment of his health needs to support the LAC health care plan. 3.17 Agency responses to self harm and suicidal ideation. The response of agencies to incidents of self-harm and suicidal ideation by Laurie was inconsistent. Some incidents were not fully documented or appropriately shared, one incident was trivialised and some incidents were referred to CAMHS whilst several were not. The risks that Laurie presented to others appeared to mask his risk of self-harm on occasions. Additionally, there is no evidence that Laurie’s accumulating history of self-harm and suicidal ideation was reviewed by any agency. This might have assisted practitioners to clarify triggers for self-harm such as relationship breakdowns which could have informed subsequent work to support Laurie. 3.18 A 2017 University of Manchester study Suicide by children and young people found that over half of young people who die by suicide have a history of self-harm (2) and although there are many antecedents of suicide in young people, the study considered self-harm to be a crucial indicator of risk which should always be taken seriously, even when the physical harm is minor. (3) 8 3.19 Good Practice Examples of good practice include Laurie’s successful long term foster placement and the support the foster carers provided to Laurie after the placement ended; children’s social care prompt and largely comprehensive placement with “P” assessment; efforts to support Laurie to remain engaged with education and training; the high degree of persistence and tenacity several practitioners demonstrated in engaging with Laurie and his family; the continuity of worker achieved by the advocacy service and the YOT; the voluntary engagement offered to Laurie by YOT when their formal engagement with him ended. 4. Findings and Recommendations 4.1 Support to, and monitoring of, Laurie’s placement with parents Laurie’s placement with parents was not successful. Children’s social care had misgivings from the outset but placing Laurie with mother and step father accorded with Laurie’s stated wishes and was considered to be the only viable alternative in the circumstances. 4.2 The placement got into difficulties from an early stage but family support was overlooked and was only finally put in place as a result of the referral order imposed nearly eighteen months after the placement began. This was far too late. Any optimism there may have been at the outset of the placement had long since dissipated and the YOT supporting families lead practitioner was unable to make progress. Overall, the perception that children’s social care held of mother as a parent who had problematic contact with Laurie, did not shift quickly enough to an appreciation that she was now parenting Laurie full time. 4.3 The leaving care service rightly became involved when Laurie reached 16 but that service’s assumption of primary responsibility for Laurie’s case was premature. This seemed to be a largely ‘automatic’ decision making process which would have benefitted from more careful consideration. Once the leaving care service began to manage Laurie’s case exclusively, the focus shifted to planning for independence when much work remained to be done to enable Laurie to thrive in his placement with mother and step father. 4.4 The IRO chaired LAC review process was not an effective vehicle for monitoring Laurie’s care plan. Multi-agency engagement fell away alarmingly and one of the consequences of this was that the LAC review meetings were not always fully informed of Laurie’s needs. However, the final LAC review was largely aware of the escalating concerns in Laurie’s life but the actions proposed were limited. 4.5 Practitioners who contributed to this SCR expressed the strong view that the IRO should be better supported to ensure the LAC review process effective and inclusive. They did not perceive the weaknesses in the LAC review process disclosed by this review to be limited to this case only. Additional administrative support may be required as well as an attitude shift amongst partner agencies to see LAC reviews as ‘must attend’ events. 9 Recommendation 1: That Wakefield and District Safeguarding Children Board obtains assurance that the LAC review process is robust and involves all relevant parties. 4.6 Children’s social care is to conduct a review of placement with “P” procedures with a particular focus on placement breakdown and family support. The LSCB may wish to be made aware of the outcome of this review. Recommendation 2: That Wakefield and District Safeguarding Children Board requests children’s social care to share the outcome of their placement with “P” procedures review with them so that the Board can obtain assurance that placement with “P” procedures are applied effectively to ensure that placement, care and pathway plans fully meet identified needs. 4.7 Engagement with Laurie Engaging with Laurie and his family proved extremely challenging at times. Some agencies were more successful than others. Continuity of worker and the presence of statutory orders appeared to be important factors. When Laurie did not engage, agencies only infrequently considered working with those agencies with which Laurie was engaging successfully. One agency – the LAC health team - did not follow their non-engagement policy. Those agencies which found difficulty in engaging with Laurie could have considered alternative approaches. 4.8 There no evidence that any agency explored with Laurie the reasons why he did not want to engage with services. When Laurie decided not to engage, his wishes were respected and he was discharged from the relevant service. This resulted in Laurie’s needs being unmet. Some LSCB’s have multi-agency policies which provide guidance on approaches to be adopted in order to address difficulties in engaging. Such policies are not limited to Looked After Children. The LSCB may wish to consider developing a multi-agency policy along similar lines. Recommendation 3: That Wakefield and District Safeguarding Children Board should consider developing a multi-agency policy to provide guidance on action to take when services experience difficulty in engaging with children and families. 4.9 Self harm and suicidal ideation Agency responses to self harm and suicidal ideation were inconsistent. No agency in contact with Laurie appeared to have a complete understanding of his self harm history, and the triggers for his self harm, including Laurie’s difficulty in coping with intimate relationships coming to an end. 4.10 Although the University of Manchester study considered self-harm to be a crucial indicator of risk which should always be taken seriously, the following additional thirteen antecedents of suicide in people under the age of 20 were also identified (4); contact with social care/local authority services; contact with CAMHS (at any time); self-harm by cutting; psychiatric diagnosis; Looked after Child; bereaved; experienced abuse; bullied; self harm 10 by self poisoning; contact with youth justice/police (at any time); excessive alcohol use; illicit drug use and no service contact. 4.11 In Laurie’s case, several of these antecedents were present, specifically contact with children’s social care; Looked after Child; CAMHS contact; youth justice/police contact; self harm by cutting; bereaved (step father advised the review that a paternal uncle of Laurie’s had committed suicide); experienced abuse (exposed to domestic abuse between birth father and mother and had been present during domestic abuse incident involving elder sibling and partner shortly before death) and illicit drug use. It is unclear to what extent professional practice is informed by these antecedents of suicide. 4.12 It is proposed that the LSCB widely disseminate the learning from this case and make use of it as a vehicle for stressing the importance of recording and appropriately responding to all incidents of self harm (no matter how apparently superficial) and suicidal ideation and raising awareness of the antecedents of suicide in children and young people. Recommendation 4: That Wakefield and District Safeguarding Children Board widely disseminate the learning from this SCR in order to stress the importance of recording and appropriately responding to all incidents of self harm and raising awareness of the antecedents of suicide in children and young people. 4.13 The provision of support to parents of children and young people should also be informed by awareness of the antecedents of suicide in children and young people. 4.14 This case has confirmed the extent to which social media is a factor in cases involving the suicide of children and young people. Laurie posted images of his self harm on Facebook which exposed Laurie to unkind comments indicating that it may have been unwise to compromise his own privacy in that manner. 4.15 Ensuring appropriate support for parents of children and young people at risk of suicide or serious self harm and raising practitioner awareness of the role that social media can play in suicide and serious self harm are just two of the issues arising from this review which should inform the local suicide prevention strategy. It is therefore recommended that the learning from this case is made use of to review the local suicide prevention strategy. Recommendation 5: That Wakefield and District Safeguarding Children Board ensure that the learning arising from this serious case review informs any review or process for developing the local suicide prevention strategy. 11 References: (1) Retrieved from http://pandorsetscb.proceduresonline.com/files/working_harder_engage_families.pdf (2) Retrieved from http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/cyp_2017_report.pdf (3) ibid (4) ibid Glossary Independent Reviewing Officers (IRO) have a duty is to ensure the care plans for children in care are legally compliant and in the child’s best interest. All local authorities have a duty to appoint an IRO to every child in care. IROs are required to oversee the child’s care plan and ensure everyone contributing to the care plan fulfils their legal obligations to the child. A Looked after child (LAC) is a child who is being looked after by their local authority. They might be living with foster parents; at home with their parents under the supervision of social services; in residential children's homes or other residential settings like schools or secure units. They might have been placed in care voluntarily by parents struggling to cope or children's services may have intervened because a child was at significant risk of harm. A Person Education Plan (PEP) is a statutory tool to ensure that everyone involved is actively prioritising the education of the Looked After Child. Placement with “P” Regulations When parents have their own children returned to them after being in local authority or social services arranged care, it’s known as ‘placement with parents’. This process is governed by the The Care Planning, Placement and Case Review (England) Regulations 2010. Youth Community Resolution is the resolution of a less serious offence through informal agreement between the parties involved as opposed to progression through the traditional criminal justice process. Children aged 10 – 17 years old can be given a Youth Conditional Caution if they admit a criminal offence. Youth conditional cautions are a caution with one or more conditions attached. All children who receive youth conditional cautions are referred to the YOT. Referral Order Where a young person is before a court charged with a criminal offence for the first time and pleads guilty, the Court must pass (in most cases) a referral order. Under the order the young offender agrees a contract with the youth offender panel which can include reparation or restitution to their victim, as well as undertaking a programme to address their offending behaviour. |
NC52799 | Fatal stabbing of a 16-year-old-boy by a 17-year-old boy in November 2020. Child N and Child O knew each other through peers but had no contact until a few days before the murder. Learning themes include: agency responses to both boys criminal activity; the complexity of working with vulnerable children with links to gangs, who have police, social work and youth offending service (YOS) involvement, especially when a child is in care and moves placements between local authorities; the importance of education as a protective factor for children; and the importance of practitioners having strong relationships with young people as a significant factor in reducing offending behaviour and improving outcomes in general. Recommendations for the Partnerships include: supporting the development of arrangements which will result in detailed operational multi-agency, multi-disciplinary risk management pathways for individual children most vulnerable to being involved in violent incidents due to their involvement in gangs, including children moving areas for their own protection; supporting the development of more alternative educational and training options for children who have disengaged or been excluded from school; reinforce with practitioners the importance of young people having strong and enduring relationships and recognising the impact on young people when practitioners change; ensure risk assessment checks are completed for every potential change of address prior to accommodation being confirmed; improve information sharing arrangements between the Criminal Justice Liaison and Diversion (CJLD) service and the YOS; and improve the availability of placements for children at risk in the community.
| Title: Child safeguarding practice review report: Children N and O. LSCB: Milton Keynes Together Safeguarding Partnership and Northamptonshire Safeguarding Children Partnership Author: Karen Perry Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD SAFEGUARDING PRACTICE REVIEW REPORT Children N and O Lead Reviewer: Karen Perry Publication Date: 7 June 2023 1 CONTENTS 1. Introduction page 2 2. Learning page 2 3. Details of the families and case context page 3 4. Story of each child: Child N page 3 5. Story of each child: Child O page 5 6. Summary of both children’s stories page 7 7. Thematic analysis page 8 8. Child O’s comments page 25 9. Positive Practice page 26 10. Conclusions page 27 11. Recommendations page 28 2 INTRODUCTION 1.1. This Child Safeguarding Practice Review is in respect of Child N, age 16 years, who was stabbed three times in the street and fatally injured by Child O age 17 years. Child O has been convicted of murder. Child N and Child O knew each other through peers within their social network but had no contact until a few days before the murder. They had had an argument over the phone a few days before the murder because of contact between respective friends. The meeting in the street which resulted in Child N’s death occurred by chance. 1.2. This review involves two Safeguarding Partnerships: LA1: MK Together Safeguarding Partnership where the victim lived and LA2: Northamptonshire Safeguarding Children Partnership as the perpetrator was a child in the care of LA2 although placed in LA1. LA1 took the lead for this review although relevant staff from both areas participated. Both partnerships will ensure that learning is widely disseminated locally and publish the full report on both Safeguarding Partnership websites. To avoid unnecessary disclosure of sensitive information, details in this report regarding what happened focus only on the facts required to identify the learning. The Child Safeguarding Practice Review takes into account multi-agency involvement: for Child N: from April 2019 (decision-making that Child N no longer needed to be the subject of a child protection plan) to the time of his death in November 2020. For Child O: from March 2019 (when Child O returned to a placement in LA2) to the time of Child N’s death in November 2020 1.3. The safeguarding partnerships agreed to undertake this review using a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted as they did at the time. Family members and Child O were also offered the opportunity to speak to the lead reviewer. Child O agreed to do so; his comments have been included in section 8 of this report. 2. LEARNING 2.1. All learning points are listed in section 5, at the end of each theme. What follows is a summary of the most significant learning from this review. 2.2. Partnership working with vulnerable children who have police, social work and youth offending service (YOS) involvement due to offending and links to gangs is inherently complex. This complexity is exacerbated when a child is in care and moves placements between local authorities. It is important that practitioners and agency records are clear about which local authority is responsible for a child and that arrangements to ensure that information is shared promptly with that local authority are effective. Where children have moved areas to keep them safe from gangs it is important to have reciprocal information sharing arrangements between police forces if they are different in the host and home authorities. When the Criminal Justice Liaison and Diversion (CJLD)1 service practitioners are involved there would be benefits to improved information sharing arrangements that enable CJLD to have access to background knowledge about a child and for them to share information about their involvement with the Youth Offending Service (YOS). 1 The CJLD service identifies those who have mental health, learning disability, substance problems or other vulnerabilities when they first meet the criminal justice system. Staff will assess needs, inform criminal justice decision making and help the individual access the right health and social care support as you move through the criminal justice system. 3 2.3. Children vulnerable to being involved in violent incidents due to their involvement in gangs need to be supported by detailed operational multi-agency, multi-disciplinary risk management plans which are reviewed at key points eg when they move placements or when incidents indicate increased risk or vulnerability. Deterioration in behaviour and increase in risk can be very swift if young people involved with gangs in one area connect with gangs in a new area. This needs to be considered in any re-housing of families and requires both social workers and housing authorities to have arrangements to ensure they have or can obtain sufficient local knowledge to make good judgements. Care plans and statutory reviews for looked after children in care who have been placed with their parents should include consideration of the vulnerability of the parent and any risks they pose. 2.4. Being engaged in education is a protective factor for children, and when a child is not in school for any reason this needs to be addressed promptly. There needs to be a range of choices of work experience and other education and training-based opportunities for older children who have disengaged from education or been excluded from school. These children can be highly motivated to obtain employment. They benefit from support to assist getting and keeping a job e.g. work experience, careers guidance, mentoring to develop foundation and interview skills, and practical and financial support. 2.5. Practitioners having strong relationships with young people is a significant factor in reducing offending behaviour and improving outcomes in general, and there is a need to manage the impact when these relationships are disrupted for any reason. When practitioners have raised concerns about a child’s safety that are not resolved they should escalate the difference of opinion through their own agency or by using their safeguarding partnership’s policy. 3. DETAILS OF THE FAMILIES AND CASE CONTEXT 3.1. Family members will be referred to by their family relationship to each child eg Child N’s or Child O’s Mother, Sibling etc. At the time of his death Child N was living with his mother and three younger siblings. Child N was described as good to work with once a relationship had been established; he could be insightful and had a good sense of humour. He was said to have hidden his sensitivity with bravado. He had a strong initial defensive reaction to being challenged or when he thought he had got things wrong/when receiving negative feedback. He was loyal and very protective of his family. He was good with his hands, at making things for others and DIY, and was keen to have a career in construction work. 3.2. At the time of the murder Child O was subject to a care order and living in supported accommodation commissioned by LA2 but located in LA1. Child O was described by practitioners as seeming quite vulnerable and wanting people to like him and to “fit in”. He was also described as having a good sense of humour, and could be caring, kind and thoughtful, and he had several friends. He was reported to be very protective of his younger sibling, with whom he was very close. Child O had enjoyed family picnics in the park and supported a premier league football team. He was keen to obtain employment and was interested in specific types of construction work. 4. EACH CHILD’S STORY: CHILD N (victim) 4.1. Some history prior to the scoping period is relevant. Child N had four younger siblings. During his childhood he was exposed to domestic abuse, alcohol and drugs misuse by his mother who also suffered from mental ill-health. From mid-2015 to mid-2017 Child N lived with his father because Mother could not manage his behaviour. During 2016 and 2017 Child N was offending, went missing several times and was assaulted twice in the community. Father and Child N did not accept offers of 4 help from the Early Help and Targeted Support services and he moved to live with his mother in 2017. 4.2. Child N was subject to a child protection plan (category neglect) from December 2017 to April 2019 because there were concerns about him offending, being involved in gangs, going missing overnight on several occasions, and being vulnerable to violence in the community, all coupled with the inability of Mother to offer adequate care and protection. 4.3. In May 2018 Child N had transferred from Academy 1 to Academy 2. Prior to April 2019 Child N refused to attend school. For the summer term of 2019 Academy 2 provided him with weekly one-to-one tutoring. His first application to a college was rejected due to his offending history and he was Not in Education, Employment or Training (NEET) at the end of October 2019 despite a second college interview. 4.4. From April 2019 a Child in Need Plan replaced the child protection plan, records show this was because Child N was engaging well with the LA1 YOS; there had been no recent missing episodes, he had been working, was motivated to seek further work, and there had been good engagement with Mother. 4.5. LA1 YOS had become involved in February 2019 to provide Bail Support after Child N was arrested for two offences of assault and four offences of intimidating a witness committed between May 2018 and February 2019. These offences were thought to be gang related. Whilst on bail Child N was subject to a curfew from 7pm until 7am, monitored by a tag from February to August 2019. This intervention by the YOS and the tag was successful; by April 2019 it was felt that Child N should no longer be subject to a child protection plan. In June 2019 Child N was made subject to a Referral Order2 for six months for a robbery committed in September 2018. In August 2019 this was extended by six months due to the other offences committed in 2018/19. 4.6. Public Law Outline (PLO)3 proceedings were instigated in August 2019, for Child N and his siblings due to concerns that Child N’s Mother continued to misuse drugs, was not consistently engaging with the relevant specialist service and that the school attendance of the siblings was poor. The PLO ceased due to Mother’s reduced drug use. 4.7. Child N’s behaviour deteriorated quickly in August 2019, with missing episodes restarting. Child N missed a referral panel meeting in December 2019, as well as a YOS appointment in January 2020, which meant he was told about a risk of being returned to court by the Referral Order panel. During 2020 Child N was referred twice by police to the Criminal Justice Liaison and Diversion (CJLD) team for a welfare check when he was in custody. 4.8. In early May 2020 the social worker ceased involvement after a Signs of Safety4 reflective discussion in supervision. Records show that all members of the Team Around the Child including Mother agreed with the decision to cease social work involvement with Child N, especially as statutory involvement by the LA1 Youth Offending Team was continuing. 2 A referral order is the community sentence most often used by the courts when dealing with 10 to 17 year olds, particularly for first time offenders who plead guilty. Referral orders require that an offender must appear before a local panel of trained volunteers to agree a contract of rehabilitative and restorative elements to be completed within the sentence, and attend the panel every 3 months for reviews. 3 Public Law Outline (PLO) meetings are called if the Local Authority is concerned about the care that a child is receiving where consideration is being given to the potential or actual necessity of starting care proceedings. These are attended by social worker and team manager with the parents who should be encouraged to bring a solicitor; unless the risks are so serious that an immediate application is required their purpose should be to explain to the parents what they need to do to avoid proceedings. 4Signs of safety system of working which engages child and parents alongside practitioners to plan and deliver intervention after analysis; What do you think is going well?” “What are you worried about?” “What needs to change?” 5 4.9. In May 2020, because of a new initiative, the police identified Child N on police records as being at serious risk of youth/gang violence. In June 2020 Child N was arrested for driving a car without a licence and insurance. Because he was still subject to a Referral Order an out of court disposal was not an option. Child N subsequently pleaded guilty at a court hearing in August 2020 and received a conditional discharge and six points on his provisional licence. 4.10. In early July 2020 intermittent compliance with LA1 YOS requirements over a few weeks had resulted in a warning letter. Records show that by July 2020 Child N was getting frustrated with continuing to have YOS involvement although he did recognise that it had helped him. At the end of July 2020, the Referral Order panel discharged his order. 4.11. Between September and early November 2020, Child N came to police attention three times. The first two were for threats to commit criminal damage and robbery. The third occasion was in early November when his girlfriend accused him of assaulting her and her two friends in her home causing minor injuries. Referrals were made to the Multi-Agency Safeguarding Hub (MASH) on both occasions resulting in letters to Mother, the first (after consultation with the previous social worker) suggesting Mother contact them for help if needed and the second advising her of agencies that may be able to assist. Whilst consideration could have been given to contacting Child N directly this would not likely have been successful as he had disengaged from services at this time. 4.12. In mid-November 2020 a chance encounter in the street between Child N and Child O resulted in the stabbing for which Child O was convicted of murder. Both families have been given support by agencies since. 5. EACH CHILD’S STORY: CHILD O (perpetrator) 5.1. Some history prior to the scoping period is relevant. Child O has one considerably younger sibling. From an early age Child O was neglected and witness to domestic abuse and violence between extended family members. His parents misused substances and he was physically abused by his father who had an extensive criminal history. Before Child O reached the age of 10 years records show that his school and Mother were having difficulty managing his behaviour which included physical aggression. In 2016 Child O was permanently excluded from school aged 12 years for aggressive and threatening behaviour; he had assaulted a pupil. As a result of this he was admitted to specialist provision for children with Behavioural Social and Emotional Disorders (BSED). 5.2. In June 2017 Child O became the subject of an Interim Care Order (ICO) due to neglect and was placed with kinship foster carers. In October 2017 the LA2 Youth Offending Service (YOS) became involved due to Child O being subject to a Community Resolution Order5 after committing two assaults. In January 2018 he was shot with a shot gun; the police believed the perpetrators were from a rival gang. Via a local emergency foster placement, Child O moved to residential care. He was moved to another set of foster carers in May 2018 and then had three residential placements out of county in the north of England between June 2018 and March 2019. He then came back to LA2, where he had three further residential moves. 5.3. During 2018 - 2020 strategy meetings were held in response to Child O going missing on three or more occasions. These meetings were regularly attended by Police, Social Workers and Education professionals. Attempts were made to mitigate the missing episodes. 5 A Community Resolution Order requires the subject to admit guilt where the victims have agreed they do not want the police to take further action. These do not give someone a criminal record although they can be taken into account by the police if the person commits further offences. 6 5.4. In April 2019 Child O was the victim of a stabbing by a peer which required stitches. In April 2019 Child O appeared in court for the first time when he was sentenced to a 9-month Referral Order for an offence of possession of an offensive weapon. The Team Around the Child thought it was crucial to get him out of LA2, away from gangs, to keep him safe. In May 2019 Child O was placed with his mother, initially in a hotel in LA2 for about a week pending a family assessment placement being set up in LA1. This was initially a temporary placement for 12 weeks. 5.5. By now attempts to secure a place at a specialist school had been successful, unfortunately it was an hour’s journey away in LA2; Child O requested nearer provision in mainstream school. In mid-November 2019 Child O was offered a place in specialist provision in the sixth form (although he was still year 11). Child O was permanently excluded and removed from roll in June 2020 after assaulting another student. In September 2020 Child O secured a place at college but he refused to attend. 5.6. Between mid-August and November 2019 records show consideration was given to an application for a secure order for Child O, because he was going missing and the relationship with his mother had deteriorated. However, the situation had improved, and social work staff thought such a decision was difficult to justify as he was not offending. Although he was going missing, there was no evidence at that time of gang affiliation locally or renewing contacts in LA2. 5.7. At the beginning of January 2020 Child O and his mother were placed in temporary accommodation in LA1, after presenting as homeless. Soon afterwards there were further signs of the relationship between Child O and his mother breaking down including Mother calling the police during an argument after refusing his request for money. At the end of January 2020 came the first report that Child O might be keeping a knife for self-protection. Child O went missing overnight for the first of several times during the remainder of the scoping period and he was also leaving school premises. Over the next few weeks Child O reported threats, including with blades, and an assault. In February 2020 Child O reported an attempted robbery in the street where one of the three people involved threatened him with a knife. At the end of February 2020, Child O was arrested and bailed (but not subsequently charged) regarding an incident for stabbing another young person in their leg and arm. He was seen while in custody by the Criminal Justice Liaison and Diversion (CJLD) team and the only issue of concern was flashbacks for which he declined support. 5.8. In early March 2020 a complex strategy meeting was held due to concerns about whether Child O’s placement was meeting his needs and the risks posed by the geographical area he lived in given the level of gang activity. For the first time intelligence had been received that Child O might be pressurised into drug dealing activity in LA2. A move to supported accommodation was being considered, which occurred a week later, and a safety plan was put into place. Child O’s social worker made a referral to the National Referral Mechanism (NRM).6 5.9. In April 2020 a final Referral Order panel was held, and Child O’s Order was signed off as successfully completed. LA 1 YOS offered involvement on a voluntary basis, as they routinely do to avoid an abrupt step down in support. This ceased at the end of July 2020 because Child O had not engaged with this, despite several attempts made by LA1 YOS to contact him. 5.10. In May 2020 Mother returned at short notice to live in LA2 as she did not feel safe where she was living. Whilst in supported accommodation Child O consistently told practitioners that he did not feel supported, and he wanted to live with his mother. 6 The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. 7 5.11. In May 2020, because of a new initiative, the police identified Child O on police records as at serious risk of youth/gang violence. In early June 2020 Child O was arrested twice, once in another part of the country, after being missing from placement for nearly a week, in possession of a large amount of class A drugs and cash, and once for Grievous Bodily Harm7 after an assault on a fellow student. 5.12. At the beginning of September 2020 Child O attended the A&E department for treatment with a laceration to his finger said to have been caused at work laying bricks. This was confirmed by his support worker, so the hospital staff accepted an accidental explanation and concluded there were no safeguarding concerns. 5.13. At the end of September 2020 Child O was seen with a knife and threatened someone with it. In mid-October 2020 he was presenting as very down and unhappy as he had split up from his girlfriend and lost his job, he hadn’t got the college course he wanted, and his request (at a LAC review) to live with his mother was refused. The supported accommodation worker took him to be seen by nurses at the local Urgent Care Centre who provided information and reassurance. 5.14. At the end of October 2020, the national Single Competent Authority declared that Child O was a victim of modern slavery; this meant that the identified exploitation would be considered and may influence whether any criminal proceedings against him continue and be used by him as a statutory defence. 5.15. During October 2020 Child O went missing from his accommodation on a couple of occasions. He was then allowed to stay overnight with his mother without permission from his social worker (this had been requested by email). 5.16. The next contact agencies had with Child O related to the murder of Child N. 6. SUMMARY OF BOTH CHILDREN’S STORIES 6.1. The children had very similar backgrounds; neglect, exposure to domestic abuse and parental substance misuse. Neither child had a positive role model. Child O’s father physically abused him and had an extensive criminal record for violence and drug offences. From an early age he influenced Child O to be anti-police. Both children had extensive involvement with social workers, and their parents had difficulty managing their behaviour. For Child N this meant moving to live with his father for two years and then moving back to live with his mother. When living with his mother Child N was made subject to a child protection plan. Child O was made subject to a care order and had had multiple placements, mostly outside of his (home) local authority (LA2), until May 2019 when he was placed with his mother in LA1 to keep him safe. Mother did not settle there and after about 12 months returned to LA2 and Child O then went into supported accommodation. 6.2. Youth Offending Services were involved with both children, and each was made subject to Referral Orders for offences which included violent or intimidating behaviour. Both children were involved in gangs, and at risk of violence. The precipitating factor for Child O to move to LA1 was being stabbed by a peer. Prior to coming into care, he had been shot with a shot gun, probably by rival gang members. Moving to LA1 did not keep Child O safe from gang involvement, especially after he moved to an area of LA1 known for gang activity and, after he was found a long way from home with a large amount of cash and drugs having gone missing for a few days, a successful referral was made to the National Referral Mechanism (NRM). 7 The offence of GBH means causing extremely serious injuries which severely affect the health of the victim. These can include broken bones or permanent disfigurement. 8 6.3. Both children had disengaged from education, including being excluded from school/college. They each had a strong desire to obtain employment in a trade using their hands. Although Child O had a long history of vulnerability to criminal exploitation, each child had periods of relative stability and progress during the scoping period, with sudden deterioration in behaviour. During the two months before the murder, with the benefit of hindsight, Child N became more vulnerable due to disengagement with the YOS after the completion of the Referral Order and Child O was heading for a crisis due to not wanting to be in supported accommodation, not having a college place or work and having broken up with his girlfriend. 7. THEMATIC ANALYSIS 7.1. The learning from this review was identified from information and opinions provided in the agency reports and at the practitioner event and from Child O. The themes are: • Exploring the relationship between Child N and Child O • Response by agencies to both Child N and Child O’s criminal activity including risk of Child Criminal Exploitation and involvement in gangs and knife crime • Decision-making and information sharing about Child O’s placement with his mother, their move to LA1 and his subsequent placement in supported accommodation • Meeting educational and health needs • Continuities of service including complexities of cross border working • Impact of Covid and any other relevant organisational contexts Theme: Exploring the relationship between Child N and Child O 7.2. Child N and Child O knew each other through contacts within their social networks. They had had an argument over the phone a few days before the murder because of contact between their respective friends. Whilst evidence given to the court suggests that Child O had threatened to kill Child N during that phone call, the murder occurred during a chance meeting in the street. Child O subsequently claimed that the person threatening him with a knife during the attempted robbery in the street in February 2020 was Child N, and that this was why he was carrying a knife because he assumed Child N carried one. Neither Child N, nor either of his two friends who were with him at the time of the murder, were carrying a knife at the time. Child O had not co-operated with the police investigation at the time of the assault against him and declined to do so during the police investigation after the murder. Theme: Response by agencies to both Child N and Child O’s criminal activity including risk of child criminal exploitation and involvement in gangs and knife crime 7.3. Both children were associated with gangs. Gang membership can range from as little as using a hashtag on social media, or living in a particular street, to serious involvement in crime including violence. In 2010 government guidance identified three different categories. Being in a transient “peer group” (which may, or may not, describe itself as a gang), being part of a “street gang” with a specific identity (and where crime and violence are part of that identity) and being part of an 9 “organised criminal gang”.8 The relationships between these categories are complex and fluid, for example gangs might compete or merge. However, the three elements that tend to be consistently present for street gangs that link back to organised criminal gangs are violence, drugs and defined geographical location. When children move area they often retain their gang membership and are regarded by other gang members to do so. Agencies were aware of the potential risks to Child O arising from a rival from a gang in LA2 who had also relocated to LA1. After the murder consideration was given about keeping Child O safe in custody. 7.4. The 2019 British Crime survey data9 suggested that 27,000 children and young people in England identify as gang members. In a recent study published in 2019 the Children’s Commissioner for England and Wales estimated there were 313,000 children aged 10-17 years linked to gangs, including 33,000 who are a sibling10 of a gang member and 34,000 who have been the victims of violent crime in the last 12 months and are either a gang member or know a gang member. It is this latter group of 34,000 victims of violent crime about whom the Children’s Commissioner feels authorities should be most concerned. Both Child N and Child O fell into this definition. When remanded in custody Child O described his gang links in terms of the one he was most closely affiliated to, another he had links with and two others from whose members he would be at risk. Child N was also believed to be associated with a gang, but practitioners told this review his links were weaker. 7.5. From May 2019 when Child O was living in LA2, until December 2019 after he moved to LA1, Child O was supported by staff from the Community Initiative to Reduce Violence (CIRV) which is a LA2 police led multi-agency gang intervention programme designed to reduce gang violence and help those involved in gangs to live a life free of crime. This included mentoring from an ex-gang member and other support to provide an alternative pathway to successful adulthood. After a strategy meeting in early July 2019, which was convened to discuss missing episodes, Child O agreed to voluntarily wear a Buddi tag11. However, records show that within days he was requesting it be removed. He only had it for less than three weeks, and half of this time it was not charged. Records show there was a recognition of his desire for work experience and then employment in the construction industry, which would require basic literacy and numeracy skills. This was followed up by a focus on support to get a national insurance card (which is less straightforward for children in care) in time for his sixteenth birthday and foundation skills (eg health and safety, first aid) for getting a Construction Skills Certification Scheme (CSCS) card. The involvement of the CIRV co-ordinator was most intensive in the first few weeks, which included liaison with LA1 Neighbourhood Policing Team, and after that she remained in occasional touch with Child O until December 2019 because of the risk of him going back to LA2. 7.6. A child involved with gang related activity is often a victim and an offender over time, and possibly at the same time. When children are found in possession of controlled drugs consideration should be given as to whether they are victims of trafficking; Crown Prosecution Service (CPS) guidance reflects that for all but the most serious sexual or violent offences there is a statutory defence for children accused of possession of controlled drugs; that their action was a consequence of being exploited and that a reasonable person with the same characteristics in the same circumstances would have done the same. Police, local authorities and Youth Offending Services can all make 8 Children’s Commissioner (2019) Keeping children safe; improving safeguarding responses to gang violence and criminal exploitation Children’s Commissioner 9 Children’s Commissioner (2019) Op cit 10 As well as being at risk of being recruited into the gang, siblings are at also risk of reprisal physical and sexual violence 11 The tag is designed to be worn securely around the ankle and provides GPS location data on a continuous basis 10 referrals to the National Referral Mechanism (NRM). The threshold for a referral is low; “suspect but cannot prove” is included in the criteria. 7.7. In March 2020 Child O’s social worker made a referral to the NRM. By the time the Single Competent Authority declared that Child O was a victim of modern slavery he had been arrested in another part of the country, after being missing from placement for nearly a week, in possession of a large amount of class A drugs and cash. Practitioners told this review that although there were concerns that Child N was involved in a gang, the associated behaviour and risks had not put him near the threshold for referral to the NRM. 7.8. In June 2019 Child N was made subject to a Referral Order for 6 months for a robbery committed in September 2018. In August 2019 this was extended by 6 months due to other offences. The LA1 YOS worker provided an intensive package of support: understanding consequences, managing conflict, being organised, sharing problems to find solutions, victim awareness, positive peer relationships grooming, and reparations activity. In May 2019, whilst Child N was on bail, a YOS police officer had begun offering support for Child N to get a Construction Skills Certification Scheme (CSCS) card,12 the application for which children’s social care subsequently agreed to fund. 7.9. Child N’s behaviour deteriorated quickly in August 2019, with missing episodes restarting. This seems to have been a combination of him no longer being on a tag and believing he could do as he wished now as he was aged 16. Mother asked for help, in particular for YOS to convene a meeting with the social worker. While it was unclear what specifically had been the outcome of that request, practitioners told this review that there had been several joint meetings with the social worker and YOS officer and that the social worker had offered support to Mother. 7.10. After Child N had been refused a college place due to his history of offending, and particularly because he needed help to obtain the Construction Skills Certificate Scheme card, his engagement with YOS improved for a while. However, he missed a referral panel meeting in December 2019, as well as a YOS appointment in January 2020, which meant he was told about a risk of being returned to court by the Referral Order panel. The Information, Advice and Guidance (IAG) worker helped him get a National Insurance Card and arranged work experience from early 2020. 7.11. Once the Covid pandemic started Child N began disengaging again. Practitioners told this review this was because he was demotivated due to not being able to get a job and contact with his YOS officer only being by phone. Practitioners told this review that he had missed a couple of appointments and panel could have returned him to court for sentencing for the original offences. However, in practice the order had only a few weeks to run, he had completed the work required and a return to court would have likely resulted in a fine, which would have had to have been paid by his mother. When discharging his referral order in July 2020 the panel recognised the importance of being in Education, Employment or Training and they hoped that he would continue to engage with the Information Advice and Guidance (IAG) worker; everyone recognised that Child N was much happier when in work. 7.12. Child O’s Referral Order was made in April 2019 in LA2. Where children in care are placed in another local authority it is not unusual for the YOS in that local authority to be asked to caretake the order. However, for a few weeks after the order was made it was unclear where Child O would be living and then, because Child O’s initial placement with his mother in LA1 was for a 12-week assessment period, LA2 YOS continued to hold responsibility for the RO. This, and Child O not attending assessment meetings, even at his home address, meant that there was a delay in holding the first referral panel until mid-July 2019. Child O did not attend this as his social worker was worried about 12 CSCS cards provide proof that individuals working on construction sites have the appropriate training and qualifications for the job they do on site. 11 the risk from others if he went back to LA2. LA2 YOS had had previous experience of making a request for caretaking and then Child O moving before intervention could start so the caretaking request was not made until October 2019. There was a further delay in holding a panel meeting involving both YOS teams until just before Christmas 2019. This was due to a need to confirm the input required from LA1 YOS and that Child O would be staying in LA1 with his mother and remaining subject to a care order. While a service had begun to be offered by LA2 YOS the delay in requesting and finalising the caretaking arrangement meant that Child O did not benefit from LA1 YOS’s local knowledge in managing risk. 7.13. The handover in December 2019 involved a review panel where both YOS officers were present. Caretaking arrangements usually include conducting assessments and holding review panels in the area where the child is currently living, however they continued to be held in LA2 at the request of LA2 YOS, because he had engaged with the panel in LA2 and because LA2 YOS had had experience of Child O refusing to engage with previous caretaking arrangements. At the time it was also anticipated that this would best provide continuity of YOS officer (although that was later disrupted by Covid related issues). It also meant that the referral panel did not know LA1 and the characteristics of the local community which made them more dependent on the YOS officers’ recommendations for suitable content of the order. 7.14. At the review panel meeting in December 2019, it was discovered that, despite Child O engaging with the contract of work from July 2019, and with subsequent panels, perhaps because he did not attend the first one in July 2019 and had never actually signed the contract of work the order had technically never started until December 2019.13 Although he would have known the alternative was to return to court for resentencing, it was positive that Child O agreed to continue working with YOS in LA1, despite having to engage for several more months than he had anticipated. 7.15. Work done by LA1 YOS with Child O included intervention about knife crime, gang involvement, peer influence, substance misuse, obtaining education and relationship building between Child O and his mother. Given his involvement with gangs had affected his motivation and capacity to change, practitioners believed he may have benefitted from more specialist intervention, e.g a programme on criminal exploitation which could include access to a gang mentor. After the Referral Order finished in April 2020 LA1 YOS offered voluntary intervention, which Child O declined to take up. 7.16. A report14 produced by the inspectorate for probation services about Referral Orders (RO) provides a relevant context for this review. These community orders are said to provide an ideal opportunity to help young people cease their offending behaviour before it becomes entrenched. The report stated that ROs are believed to be consistently more effective than other sentences and that YOSs generally performed well. However also that some issues were evident. The report identified two relevant to Child O; the importance of engaging young people in agreeing the intervention and of managing the period after sentence well up until the panel met, to avoid loss of impetus and meaning for the Referral Order. Child O had never signed the contract from the panel meeting in July 2019 and the subsequent panel, when LA2 became formally involved was not until December 2019. 7.17. The Referral order was the main form of intervention to tackle Child N’s offending behaviour. His risk level was identified by LA1 police as well below the threshold for involvement by the Problem-Solving Team. Due to involvement in an alleged robbery and an alleged assault in October 2020, he was offered support from another part of the police service; officers from the Violence Reduction 13 The referral order finished in April 2020, in line with intended timing when the court originally made it as both YOS felt Child O had completed the necessary work 14HM inspectorate of Probation (2016) Referral Orders, do they achieve their potential? HM inspectorate of Probation (2016) 12 Team visited him and his mother to offer support to get him involved in constructive activities. They were told he had just started a new job and was not interested. Practitioners told this review that perhaps more police proactive support could have been offered during the previous 6 months, when there were some signs his behaviour was escalating, but his circumstances did not distinguish themselves significantly from the other 250 local young people then regarded as at serious risk of youth/gang violence. 7.18. Child O also had contact with and support from the two different police forces covering LA1 and LA2. While the police force from LA2 promptly notified police force in LA1 that Child O had moved to LA1, this was done by sharing of intelligence rather than a formal notification to the police force. This should then have resulted in the neighbourhood policing team and the Problem-Solving Team being proactively aware of his arrival as soon as he had moved, for safeguarding and risk assessment purposes. During May, June and July 2019 there were five brief missing from home episodes. In June LA1 police received intelligence that Child O may be used as a “money mule” which prompted the first contact from the Problem-Solving Team.15 In early July 2019 LA2 police requested a flag on his address due to a threat to kill from another gang member. This was treated as an administrative matter rather than prompting a conversation between the two police forces, as it should have done. In Mid July 2019 the Problem-Solving Team created a Risk Management Occurrence to manage the risks around Child O. This was two months after Child O had arrived in LA1 and, given his history and vulnerability as a looked after child, this review was told that this should have been considered earlier. 7.19. At the end of July 2019 Child O was discussed at a multi-agency Strategic Exploitation Panel (SEP) meeting. At that time LA1 YOS were not aware whether there was YOS involvement and were tasked to find out, this was still not clear at the time of the next SEP meeting in September 2019, for reasons that are not known. From August 2019 the frequency of missing episodes increased and by September 2019 this has resulted in another Risk Management Occurrence, which was running alongside the one created in July 2019. There is no evidence that the two Single Points Of Contact (SPOCs) liaised, and it would have been preferrable if oversight had been maintained by one person rather than two. Notes from the Strategic Exploitation Panel (SEP) meeting in October 2019 suggest there was no evidence of gang affiliation in LA1, by this stage it was also known that he was subject to a Referral Order to LA2 YOS so his name was removed from the SEP agenda. For the same reasons the RMO raised in July 2019 was also closed. For reasons that are not known there was no liaison with the police force in LA2, or the police officer dealing with him as a repeat missing person. 7.20. A summary of the international research prepared in 201616 found a range of features of intervention that had consistent positive (or negative) outcomes. The majority of the studies were from the US rather than the UK. However, whilst some of the programmes of intervention might not be transferable given the different legal systems, the principles on which they are based are. Effective intervention considers: the individual’s risk of re-offending, matching the intensity and type of services to that level of risk; the needs of the individual, focusing attention on those attributes that are predictive of reoffending; the individual’s ability to respond, taking into account their learning styles, motivation, abilities and strengths. The literature review found that although some young people will always need to be sentenced to custody, the evidence suggests ccommunity-based 15 The police Problem-Solving Team (PST) in LA1 work intensively with ten young people at any one time. They are identified through scoring criteria for the number of times someone had been a victim, suspect, and missing, considering how seriousness and how recent incidents were. The PST was involved with Child O from June 2020 through the rest of the period covered by this review. 16 Adler J et al (2016) What works in managing young people who offend? A summary of international evidence. Ministry of Justice 13 interventions tend to be more effective. In addition, diversionary approaches, including restorative justice, which direct these individuals away from the formal justice system, may be appropriate for some young people because drawing young people who commit low level offences into the formal youth justice system may increase their offending. In the UK diversionary activity involves judgements about the likelihood of desisting criminal activity, the safety and wellbeing of the child and risk of harm to the public. There were some decisions made by LA1 police not to proceed against Child O for relatively minor offending, e.g., possession of small amounts of cannabis, and damage at the supported accommodation. 7.21. The literature review also identifies the benefits of multiple services: addressing a range of offending related risks and needs rather than a single factor. It is important to consider the wider offending context: considering family, peers and community issues. There is evidence that each of the agencies working with both children took a risk-based approach and considered the individual circumstances of the children. For example, each YOS held internal risk management meetings at key points. However, the multi-agency approach for Child O at key points was fragmented and there is no evidence of an overarching closely managed operational, multi-agency, multi-disciplinary risk management plan which the national panel report previously mentioned noted was effective in the local authorities seen to be using them. If the thinking was that due to his “looked after” status the care plan and statutory review function should have served that purpose, this was not effective. At a basic level it became clear during the review that agencies did not have the same addresses for him while he lived in LA1. More importantly, there was no statutory review before Child O moved in with Mother. The next statutory review was held in August 2019, by coincidence at crisis point, which was attended by a LA2 YOS worker who described the referral order as unworkable, for reasons that are not recorded, and who was considering taking it back to court. Records for the statutory review in October 2019 show that Child O was much more settled, but there was no attendee from YOS, or reference to their involvement, which one would have expected given the situation in August 2019. For the August and October 2019 statutory reviews there was no police representative in attendance, and reference to continued involvement from CIRV (LA2), but no reference to liaison with or involvement by the LA1 police force. This was despite evidence in CIRV records of attempts to arrange a multi-agency meeting because of the level in risk in September 2019. There were difficulties in contacting a social worker or practice manager, who were then unable to attend. The next statutory review in March 2020 was held just before the move to the supported accommodation as it should have been, the records are more detailed and holistic than the previous ones. The YOS officer was in attendance, there is evidence of liaison with the LA2 police and recognition that Child O may be more vulnerable when his referral order comes to an end. By the next statutory review in June 2020 Child O had been permanently excluded from school due to the assault. He was working with the Problem-Solving Team (PST) police officer who was in attendance.17 7.22. Practitioners told this review that close working relationships between police, YOS and social workers were key to success in their experience of working with the highest risk children. LA1 police felt that one area for improvement to support this would be more consistency by PST team members in producing and sharing chronologies with YOS and social workers which included all incidents and intelligence. There is evidence of close working relationships for both children. However practitioners were not supported by systems and arrangements to promote this, and a co-ordinated approach to risk management, which facilitates multi-agency discussions and planning at key points. For Child O examples of these would be: at the point he moved into LA2; when the placement with Mother appeared to be breaking down; when he was excluded from school; when he moved to the supported accommodation and when he was found in another part of the country with cash and drugs. Children 17 All the statutory reviews from August 2019 until the end of the period covered by this review were attended by the relevant placement provider and an education representative when he was in school as they should have been. 14 like Child O are subject to several separate, but potential duplicatory, meetings to manage risk and plan care: meetings because of a legal status (statutory reviews) or a risk of significant harm (strategy meetings) or going missing. None of these operated successfully to bring all the right people together to produce and monitor a holistic risk management plan. 7.23. Young people who had stopped offending who contributed to a report from the probation inspectorate18 put great store on a trusting, open and collaborative relationship with a YOS worker or other professional, seeing it as the biggest factor in achieving a reduction in offending. This was also a finding from the 2020 National Safeguarding Panel report about children involved with gangs and vulnerable to criminal exploitation.19 It can be difficult to build trusting relationships with children like Child N and O due to them often having been let down by adults. This can often be even more challenging for children in care, who may have had many changes of placement and changes of practitioners, sometimes at short notice, and without any control. 7.24. Despite their histories of poor care and changes in placements, multiple times for Child O, both children were able to respond to practitioners’ attempts to build relationships. There was evidence that several practitioners had persevered with this, but also of a significant impact when those relationships ended for some reason. However skilled the practitioner, building relationships with young people takes time, requiring time spent in understanding the history as well as engaging with the child, and there is evidence that sometimes changes in practitioner adversely affected Child O’s engagement in particular. 7.25. More than one SPOC made a determined effort to establish and maintain a relationship with Child O. He engaged particularly well with one and he expressed dissatisfaction when that person was no longer involved. This review has been given different reasons for that police officer ceasing involvement. From Child O’s perspective the critical issue is that he no longer had regular contact with him. Whilst Child O did engage with the successor, this was at the point his overall engagement was reducing. The timing of the change was unfortunate as this was the beginning of a very difficult period for Child O. The previous SPOC stayed in touch20, attempted to follow up with Child O a report he had made about his phone being stolen. The new SPOC contacted him after he had “stormed out” of the LAC review in October 2020. On this occasion Child O expressed frustration at all the “help” he was being offered and “all the people involved in his life” that he had not necessarily asked for. 7.26. During the period under review there were discontinuities of staff, due to workers changing jobs and the Covid pandemic (see section below). Just prior to the period under review the social worker who had been allocated to Child O for the previous two years changed. From March 2019 until the end of the scoping period Child O had four more social workers. Two of these were involved for less than three months. Social worker 5 became involved in June 2020 after Child O had been found with cash and drugs in another part of the country shortly after moving into the supported accommodation. This was because the previous social worker was absent from work, and it was good practice to re-allocate given the escalating risks. 7.27. SW5 built a good relationship with Child O. However she reflected that for young people recently allocated to her who were new to supported accommodation in future, she would visit more frequently to build up a relationship which might better enable young people to confide when they felt unsafe. Having said that the report from the national panel previously mentioned described that 18 HM inspectorate Probation 2016 Desistence and young people 19 National safeguarding Panel 2020 It was hard to escape; safeguarding children at risk from Criminal Exploitation 20 Contacts between the end of September and November 2020 were not recorded until after the murder. They should have been recorded contemporaneously to keep the Problem-Solving Team updated 15 many young people involved with gangs are not able to be honest about their circumstances, as this may put them at more risk. The careers advisor at the academy changed jobs in October 2019 which was unfortunate timing for Child N as her normal practice would be to stay in touch in the Autumn term. This is because it is not unusual for young people to experience setbacks with planned destinations, and it is very hard for a new person to support young people as effectively without the benefit of a previous relationship. 7.28. From March 2020 neither child was able to see their usual YOS officer face to face due to the Covid pandemic. Practitioners told this review that this had a huge adverse impact on the children’s previous good levels of engagement. They suggested that rather than attempt to introduce new people who did not have a relationship with them it might have been better to be more flexible and offer virtual contact with the original officer once the arrangements were up and running. Learning Points: • Partnership working with vulnerable children who have police, social work and YOS involvement due to offending and links to gangs is inherently complex. This complexity is exacerbated when a child is in care and moves placements between local authorities. • Young people who have disengaged from education can be highly motivated to obtain employment. They benefit from support to assist getting and keeping a job e.g. work experience, careers guidance, mentoring to develop foundation and interview skills, and practical and financial support. • Referral orders can be very effective in supporting young people and reducing their offending behaviour, but this is undermined if referral panels are not convened promptly. • When a child involved with gangs moves to live in another area the importance of o Prompt and effective liaison between police YOS and Children’s Social Care in both local authorities o The police force in the new area having effective force wide arrangements to provide monitoring of risk and support • Children vulnerable to being involved in violent incidents due to their involvement in gangs need to be supported by detailed operational multi-agency, multi-disciplinary risk management plans which are reviewed at key points e.g. when they move placements or when incidents indicate increased risk or vulnerability. • The importance of all key practitioners being involved in statutory reviews. • The importance of practitioners having strong relationships with young people, and the need to manage the impact when these relationships are disrupted for any reason. Recommendations A and C Theme: meeting educational and health needs 7.29. Receiving appropriate education is an important protective factor for young people. Apart from improving their employment opportunities and impacting on a range of other life chances, being in school or college provides access to supportive adults who are positive role models and someone 16 to turn to in times of difficulties. It also provides constructive occupation which reduces time at a loose end and opportunities to get into trouble. Research consistently shows that risks for children significantly escalate when they are permanently excluded from school, partly due to the difficulties of providing alternative full-time education.21 7.30. Both children had chequered educational histories. Between May 2018 until April 2019 Child N refused to attend Academy 2. From April 2019 Academy 2 provided him with weekly one to one tutoring. Out of a possible 43 sessions he attended almost two thirds. When present, the tutor thought Child N was engaging well and making academic progress and he obtained GCSEs in Maths and English. The Academy has since reflected that it would have been helpful to have included more diverse educational opportunities including work experience alongside the tutoring. Practitioners told this review that there were very limited choices for young people in LA1 to provide alternatives to school or college placements when children either won’t attend, or are prevented from being offered a place, due to level of risk. These could also enhance and support educational placements by providing work experience, or other practical learning opportunities for older children who struggle to engage with more academic options. Those children might be more accepting of the need to achieve a basic level of literacy and numeracy if delivered by an alternative provider. More leisure activities would also be helpful to occupy children at risk of offending behaviour. 7.31. In June 2019 Child N completed his secondary education at Academy 2 with a destination confirmed with the Careers advisor, who intended to stay involved until October 2019. Child N achieved his wish for a practical job with relatives in July 2019; the careers advisor believed he was still employed in October 2019. However, the job had ended because, although relatives were keen to offer him work, Child N had not wanted to make it a work experience placement. His first application to a college was rejected due to his offending history and he was Not in Education, Employment or Training (NEET) at the end of October 2019 despite a second college interview. YOS records show he was highly motivated to find work, accepted help to produce a CV and applied for jobs on his own initiative in the Autumn 2019. Unfortunately, the work experience placement he started enthusiastically in early 2020 closed due to Covid, and subsequently he was discouraged by the lack of response to job applications. 7.32. Child O’s education had been severely disrupted by the number of placement moves he had after coming into care. He was the subject of an Education Health and Care Plan which meant that the lead agency for securing provision was the Special Educational Needs (SEN) service in whichever area he was living at the time. Whenever he moved across local authority boundaries, which he did several times, the responsibility changed, which built in discontinuity and delay. Records suggest that more than one social worker and the IRO were not clear who was responsible for leading on securing educational provision. They both mistakenly thought it was the Virtual School. The role of the Virtual School is to advocate for children in care to support activity to secure appropriate provision. There is also evidence of misunderstanding that it is SEN teams rather than the Virtual School being responsible for reviewing Education Health and Care Plans. Records for statutory reviews show that social workers did not know when the EHCP had been last reviewed. 7.33. The education placement Child O had when first placed in LA1 was in fact one which had been secured after he had returned to LA2 in 2019. It was in LA2, which was an hours’ journey, and located in the local authority from which he had moved away to ensure his safety. There is no evidence that this was considered in the placement planning led by children’s social care (see placement theme below). It was not until June 2019, some weeks after he had moved to LA1, that the social worker informed LA2 Education Health and Care (EHC) Team that Child O could not return 21 National safeguarding Panel 2020 It was hard to escape; safeguarding children at risk from Criminal Exploitation 17 to the LA2 school and requested alternative provision because other pupils were frightened regarding his gang connections and threats of violence. 7.34. In July 2019 the LA2 SEN team asked the SEN team in LA1 to take over responsibility for finding provision. Because he could not attend the site due to his bail conditions and had not previously engaged with tutoring, they also removed Child O’s name from the school’s roll. This meant the school no longer had responsibility for providing some form of education. This should not have happened until alternative arrangements were in place, especially as this was near the end of term and meant nothing was in place for the next academic year. There were some delays for the SEN staff in LA1 getting involved because they had not had all the necessary information from LA2; staff told this review that in future similar circumstances they would get involved more quickly, perhaps by convening a meeting of relevant people rather than waiting for written information to be supplied. In mid-September 2019 Virtual School staff requested a tutor be provided; this did not start until mid-October and ended within three weeks as Child O would not co-operate. Children in care should have a Personal Education Plan which is reviewed every six months with consideration of it being done at the same time as the EHCP for children who have those. PEP review meetings should still be held irrespective of whether children are on a school/college roll. PEPs were held for Child O in October 2019, December 2019 and Jan 2020, i.e. more than minimum frequency because he was not on a school roll. 7.35. Child O had requested a place be found in a mainstream school, because being in a special school made him feel different. Practitioners told this review he did not understand that he was not ready to thrive in mainstream education. However, they also told this review that, for a child of Child O’s age, attempting a placement if the setting thought it was safe could be the difference between a child having some education as opposed to none. In mid-November 2019 Child O was offered a place in specialist provision in the 6th form (although he was still year 11). The school requested a professionals’ meeting to discuss risks which was held in the last week of the autumn term. Child O commenced attending three days a week mid-January 2020. This is the standard level of attendance for all students in sixth form, which is less than would have been expected for a pupil in year 11. Despite poor attendance/going missing during the school day, by May 2020 he had managed to achieve a level 1 certificate in construction, engage in work experience and obtain a place at college. 7.36. Practitioners told this review they had significant engagement with the college to get Child O a potential place there because of the perceived risks. Unfortunately, not only was he placed on a construction course of a type that he was not expecting that started with bricklaying, no-one was informed of this in advance of his first day at college. Practitioners told this review that this change of course may have been because he did not have the entry requirements for the specific course he wanted and so was placed on an access course with a wider range of activities, which unfortunately had not started with the one he wanted. The outcome was Child O refused to attend college, and the assault at the school in June 2020 meant he had no backup plan. The social worker and LA1 police Problem Solving Team continued to support him to find a college place; he obtained a constructions skills course place to start after the October half term 2020. 7.37. Both children were seen while in custody by the Criminal Justice Liaison and Diversion Service (CLJD). Child N was seen in February 2020. Discussion and use of a mental health screening tool identified that the only concerning issue was the daily use of drugs. Child N declined a referral to substance misuse services. In September 2020 the worker was unable to contact Child N the police or Mother by phone despite confirming the numbers with the MASH (and checking no social worker was involved). Mother did not respond to two further attempts to contact her, or to a message left the following day. 18 7.38. Child O was seen by CJLD twice; in February 2020 and after being arrested for the murder. The only issue noted to be a particular concern was periodic anxiety and flashbacks to traumatic events which he said he coped with by using distraction techniques. The worker reported his daily use of cannabis to the social worker, this was believed to be funded by money given by, or taken from, his mother. 7.39. The CJLD practitioners told this review it would have been helpful to have had some background information about both children and that this can be particularly difficult to access outside of office hours including weekends. They said they are reliant on those NHS records which they can access, which may not be detailed, or what the investigating officer can tell them, which is sometimes not very much. Phone calls to MASH usually result in a worker’s contact details rather than actual information and then practitioners being busy means they often don’t respond for a few days. Some organisations will tell them that they cannot share information without the consent of the chair of a particular meeting. 7.40. Practitioners from LA1 also told this review that it was not standard practice for CJLD staff to contact the YOS after seeing children; there is no evidence they contacted them regarding either child. YOS practitioners felt this would be useful. If the child is known, then having information from the assessment would be helpful. If the child is not known this would act as an early warning regarding young people who had moved into or were offending in LA1. Since the beginning of 2022 CJLD have been emailing a dedicated YOS email with information about children seen in custody who they know are involved with YOS LA1. However, no-one directly involved in this review knew what happened to these messages and whether they were getting through to allocated officers. This system does not include all children, and this is practice used by the daytime service. There is another commissioned service for weekday evenings and nights and no-one involved in the review knew if they had equivalent arrangements. 7.41. Both children were regular users of cannabis by their early teens. In April 2019 Child N attended a first session with a YOS drugs worker but was late to the second and missed the third. Records show sessions with his YOS worker were more difficult when he was asked about his drug use and he declined intervention for this. Records for Child N in February 2020 show reflection by CJLD about how he was funding a daily drug habit without a job, but there is no evidence of any liaison with YOS about this. During an annual health assessment in April 2019 Child O stated he had been smoking cannabis since age 13. 7.42. At the beginning of September 2020 (age 16) Child O attended the A&E department for treatment with a laceration to his finger said to have been caused at work laying bricks. This was confirmed by his support worker. The hospital staff accepted the injury was caused by an accident and concluded there were no safeguarding concerns. A nurse from the health trust reviewed the hospital summary about a week later, noted the lack of safeguarding concerns and concluded there was no role for the school nurse. Neither agency considered whether working as a bricklayer was appropriate, or enquired about the nature of the working environment, for reasons that are not known. Both agencies could have made enquiries to check whether his social worker knew he was working. The social worker did in fact know he was working, had checked it appeared to be a reputable company and had tried to contact the owner, but he did not respond to phone messages. Practitioners were not aware of the employer’s responsibility to do a risk assessment for any employee working in construction who is under 18. 7.43. In September 2020 Child O seemed low in mood. He refused to attend his annual health assessment with the LAC nurse despite several contacts from her. He also refused a referral to the LAC mental health team but agreed to see his GP. Unfortunately, the GP had removed his name from their patient register. This was because after making unsuccessful attempts to contact him, they assumed that when his mother moved that he had gone with her. The GP practice has since put in place 19 systems to prevent children being removed from the patient register without being registered at another practice. The supported accommodation worker took Child O to the local urgent care centre. The nurses there appeared sympathetic and reassuring, clarified he was not self-harming, encouraged him to “think positive” and gave him information about a range of online resources. Learning Points: meeting educational and health needs • Being engaged in education is a protective factor for children, and when a child is not in school for any reason this needs to be addressed promptly. • The importance of a range of choice of work experience and other education and training based opportunities as substitutes for, or enhancement to, school placements. • The need to raise awareness amongst social work staff of the responsibilities of the SEN team for identifying school placements for children who are subject to Education, Health and Care Plans, including when they are looked after. • The potential usefulness of better arrangements for the Criminal Justice Liaison and Diversion service (CJLD) to have timely access to background information about the children they see in custody. • The potential usefulness of CJLD staff sharing information with YOS about the children they see in custody as standard practice. This would provide YOS with helpful early warnings about any children newly moved to the area as well as support their work with children known to them. • Practitioners need to be aware of the employer’s responsibility to do a risk assessment for any employee working in construction who is under 18. Recommendations B, E and F Theme: Decision-making and information sharing about Child O’s placement with his mother, their move to LA1, including subsequent placement in supported accommodation 7.44. Understanding the timing and decision-making for some of the placement changes for Child O during the period under review has been difficult due to a combination of some characteristics of the social work electronic record (where some key details are only visible in contact records) plus gaps or lack of detail in contact records, coupled with social workers and team managers who were involved before March 2020 not being available to participate in this review. In addition, some agencies who had provided placements or support for Mother were not identified until a late stage in the review and have not provided any information.22 7.45. In January 2019, a meeting was held involving social care staff and a legal representative due to concerns regarding Child O’s risk-taking behaviours within LA2, alongside the breakdown of placements. The outcome of the meeting was that Child O did not meet the criteria for a secure order application23 at that time. Advice given by the then Assistant Director, was that all other placement 22 The provider of the supported accomodation placement and substance misuse services in both local authorities 23 Secure orders are made under section 25 of the Children Act 1989. The order allows children’s services to place a looked after child under the age of 16 in secure accommodation on welfare grounds if one of two conditions applies: the 20 options needed to be considered/exhausted prior to going down the secure accommodation route. This is in line with national and local guidance. After he was stabbed, a second legal planning meeting was held in May 2019. This led to a Secure Panel meeting being arranged by LA2 two months later in July 2019 (no reason for the delay is recorded) where it was agreed that the threshold was met to make an application to court for a secure order for Child O. Agreement was given by the Director of Children’s Services that, pending an application to court, Child O should be placed in secure accommodation without an order for 72 hours. Unfortunately, no placement of any kind was available which could meet his needs. Because of this the Assistant Director agreed it was appropriate to explore the possibility of a placement with Mother. There is no evidence of anyone considering trying to find a bespoke unregulated placement for supported accommodation for Child O, for reasons that are not known. However, given the level of risk and need it might have been difficult to keep him safe in such a placement. Emerging concerns nationally about the use of unregulated accommodation for children under 16 years might also have been a relevant context. 7.46. By this time, Child O’s mother had been engaging in support services to address her substance addiction and was willing to care for Child O. Child O was very clear that he would not return to any placements ‘Out of County’ as he missed his mother and the regular contact he was having with his sibling. Child O’s mother was willing to leave her council flat, in order for Child O to be placed with her in LA1. A suitable placement was identified in LA1 which could undertake a specific parenting assessment, and the court responsible for the care proceedings directed that it would be safer for Child O and his mother to move into a hotel (family room) in a town in LA2 for a few days rather than live in Mother’s flat until the placement was ready. Records show that Child O was in court on the day of the move to LA1 and that the judge had made clear that if this placement was not successful then it might be necessary to consider secure accommodation. 7.47. Records show that the schedule 3 report assessing the suitability of the placement with Mother was signed by a senior manager before the family moved to LA1, but three days after they had moved into the hotel together in mid-May 2019. Whilst this may have been an emergency placement, which was endorsed by the court, approval should have been given beforehand, although it is clear from the schedule 3 report that information gathering for it had begun sometime previously and that there had been discussions with senior managers. References to YOS noted the need for ongoing involvement due to the recent making of the Referral Order but did not consider which YOS service would provide this. The report stated Child O had an education placement in LA2 due to start in a few weeks. Whilst this was not in the town where he had previously lived there was no evidence of reflection on whether its location was suitable given that it was still in LA2, where it was not deemed safe for him to live, nor on the fact that he had previously expressed reluctance to attend there. It is not known whether anyone considered whether any of the other pupils might have knowledge of him via involvement in gangs. The report indicated that they would have sole use of a family sized home during the parenting assessment and that the police had been involved in a risk assessment of the safety of the location. 7.48. This review was told that the IRO endorsed the decision for Child O to live with his mother, alongside an extensive support package, which included intensive family support, specialist input to help Mother continue to stay drug free, CIRV, NRM and education outreach, but there is no evidence that a statutory review took place either prior to this move or shortly afterwards as it should have done.24 child has a history of running away. The order may be made if the child is likely to run away from any other type of placement, and they would be likely to suffer significant harm if they did run away; the child is likely to injure himself or someone else if they were kept in any other form of placement. 24 https://northamptonshirechildcare.proceduresonline.com/p_look_aft_rev.html Children Act 1989 Guidance and regulations (2021) Volume 2 care planning placement and case review Chp 3 DfE 21 There is no requirement in the schedule 3 report to indicate the view of the IRO or the date of a statutory review to endorse the placement. Although the care plan was sanctioned by a court and the plan indicated the IRO’s agreement with it, local procedures indicate that a statutory review should be held soon after placement. The absence of a statutory review before August 2019 meant there was no opportunity for all the agencies involved with Child O to get together and discuss the plan. This would have been particularly useful just after the family had moved to LA1 as it would have enabled the staff delivering the parenting assessment to meet other practitioners and for everyone to have an opportunity to discuss their roles and nature of their intended involvement. This might have made more visible the challenges faced by YOS in initial delivery of the referral order and the complexity of the potential involvement of both police forces and their need to be kept informed. 7.49. Between May 2019 and July 2019, most of the occasions of police involvement with Child O involved him going missing for brief periods (five times). Otherwise, records show the placement seemed to be going well from the point of view of family relationships and engaging with the social worker and YOS. 7.50. LA1 was only 30 minutes travelling distance from Child O’s previous address, and therefore placed a heavy reliance on him to co-operate with keeping himself safe. Overall, for a few months Child O’s situation seemed relatively stable in terms of not offending in the community. However, records show that concerns about him going missing between mid-August and October 2019 had been at a level where consideration was given to an application for a secure order. Some agency records show a belief that secure accommodation was appropriate without necessarily having a detailed understanding of the legal requirements, however records also show that at least one agency tried, without success, to get an understanding of why a decision by LA2 to pursue a secure order had changed. No secure panel was arranged as the situation had improved; social work staff thought seeking secure accommodation was difficult to justify as he was not offending. In addition, practitioners told this review that secure orders could only usually be justified for a few months. Whilst they might be necessary sometimes to protect children, without a good transition plan they were not long enough to do much more than provide a safe pause to try and engage the child who would revert back to the previous behaviour if there was not a good follow-up plan once they were released. 7.51. From August 2019 his relationship with his mother deteriorated, including him asking for money with threats and aggression. In fact the statutory review record shows that the placement was considered to be breaking down in August 2019 to the extent that Mother returned to her accommodation in LA2 while Child O remained in the placement with 2:1 staff support pending an application for secure accommodation. This was unsuccessful for reasons that have been described previously and Mother agreed to return to the placement and resume caring for him. By the next statutory review in October 2019, it was clear that things had improved considerably in terms of family relationships. In addition, three potential school placements had been identified, although the only educational input imminently available was two hours a day tutoring. 7.52. The final care plan produced for court in November 2019 indicated that the outcome of the parenting assessment had been sufficiently positive for Child O to remain in the care of Mother, but that he needed the ongoing protection of a care order to ensure his needs were met. It also stated that Mother had engaged “meaningfully” with the substance misuse service in LA2 and proposed that Child O be supported to understand living with a parent with an addiction. It is unclear what “meaningful engagement” meant, but whilst it is accepted that a person’s struggles with substance misuse may mean relapses, by August 2019 there was evidence that Mother was using drugs again. The fact that the family assessment placement had to frequently provide food vouchers, at least 22 partly because Mother was spending money on drugs, suggests the protection assumed from engagement with services implied more optimism than was warranted. There is also no evidence of any work with Child O on living with a parent with addiction. 7.53. Managers from the family assessment placement told this review that, looking back, they believed that all the practitioners focussed too much on Child O improving his behaviour and overlooked the risk his mother posed. There needed to be a holistic plan that also looked at mother’s functioning and risky behaviour and there is no evidence that this was considered after the care plan was presented to court. As is the case nationally, the local authority’s recording tools for care planning and statutory reviews are designed for most children in care who are living with foster carers, or in children’s homes or supported accommodation. The starting point is therefore that the actual placement is safe and the carer(s) protective, so these documents are not well suited to placement with parents arrangements where, by definition, since the threshold of significant harm has been met in a court, there are likely to be some risks associated with the parent. 7.54. It is unclear which agencies knew that Mother had started using drugs again by August 2019 and appears to have continued to do so throughout the time caring for Child O. There is some evidence in agency records of individual practitioners sharing information and concerns about mother’s substance misuse with other individual practitioners. However, there is no evidence of any multi-agency discussion (including at statutory reviews) about what drugs she was using and how often, how she was getting them, what the impact on Child O might be (e.g on household income, contact with people dealing drugs etc) or what support she might need to cease using again. There is a fleeting reference to Mother possibly taking up substance misuse services in LA1. It has not been possible to gain any information about this from the agency concerned as they have been taken over and the records archived. 7.55. The parenting assessment provider allowed Mother and Child O to live in one of their properties after the assessment had finished, pending them finding an alternative. During a social work visit in mid-December 2019, when only Child O was at home, Child O stated that the provider had given them 28 days to find somewhere else to live and that Mother had an appointment with housing in LA1 that week. Records show that the social worker was intending to attend with Mother. It is not clear whether they did, but housing records show that the housing authority was aware that police and social workers from LA2 were involved, and that it was not safe for Child O to return to LA2. Although the property was not available indefinitely there is no evidence that the social worker had planned ahead for follow on accommodation. 7.56. Records suggest it was necessary for Mother to present again at housing early in the new year when she was accompanied by the LA1 YOS officer. The family were offered temporary accommodation that the housing authority deemed suitable and affordable. Unfortunately, this was in a part of LA1 where gangs were operating. There is no evidence of a detailed discussion about the nature of the risks which might have enabled housing staff to recognise that there could be parts of LA1 which would not be suitable for the family. In addition, housing staff told this review that they did not have a detailed understanding of risks in different areas of LA1, and that one of the constraints in rehousing people was the limited amount of temporary accommodation available. 7.57. The LA1 YOS officer had raised his concerns with housing and was informed this was temporary housing. The concerns were also shared by LA1 police and the LA1 Exploitation Lead. Challenges were made to LA2 social workers querying why they had not taken action to house the family and instead the family had to present themselves as homeless to housing which then had potentially increased the risks to Child O in relation to gangs and exploitation, both in terms of the nature of the local area and because insecure housing makes children more vulnerable. Records show this was 23 escalated to the team manager whose response repeated that the accommodation was temporary and described Mother as having support from the parenting assessment provider to complete some unspecified tasks to secure permanent accommodation. The team manager did not directly address the concerns about the nature of the area itself. This reply seems to have been accepted as there is no evidence of any further escalation. Records show that SW2 was aware that this was a “poor area” where Child O would be at “greater risk” and had in fact asked colleagues to provide evidence and challenge to the housing authority, but this was after the accommodation had been offered. 7.58. The care planning regulations and the Schedule 3 report previously referred to require consideration of the safety of the area in which a child in care is going to live. At the time of the original placement in LA1, there is evidence that SW1 had sought reassurance from the LA1 police that the proposed address was a safe area for Child O to live. There is no evidence of a proactive approach by social work staff in late 2019 to identifying which would and wouldn’t be safe areas for Child O and Mother to be offered accommodation. After the family had moved into the temporary accommodation there was no evidence of consideration being given to any options for moving them, for example, by providing financial support to enable the family to rent accommodation elsewhere in LA1, despite the YOS officer passing on Child O’s fears to the social worker about being approached in the area where he now lived to deal drugs. It may be relevant that Mother soon became more committed to the solution being to move back to LA2. Records show she was worried about losing her tenancy there and finding it hard due to Covid restrictions to have contact with Child O’s younger sibling. 7.59. During this review practitioners expressed differing views about the impact of Child O being housed in an area where he was vulnerable to becoming involved again in gangs. Whilst deterioration in Mother’s ability to care for him might have been expected after the cessation of the additional support and monitoring provided by the parenting assessment provider, the nature of the area was a compounding factor which could have been avoided. 7.60. By March 2020 agencies had serious concerns about several things: Child O offending, the risks the behaviour posed to others and himself; Mother’s ability to supervise him and to prioritise her finances to ensure there was sufficient food in the house for him; and the two of them were not getting on. In addition, Mother wanted to move back to LA2. Child O moved to supported accommodation in March 2020. This was after risk assessments had been completed which took into account that other residents were in stable circumstances and included seeking confirmation from LA1 police that the address was in a safe area. 7.61. Within two weeks of entering supported accommodation missing episodes increased, including overnights, with at least one being known to be outside of LA1. Child O was upset about how the impact of the Covid pandemic prevented in person contact with his mother and sibling. There was also the issue of getting used to a new group of staff, which was a challenge for both parties given his history. Social work practitioners involved with Child O during his stay in supported accommodation told this review that, especially as he had only been 16 years old when he had moved into supported accommodation, they should have reviewed the nature, level and purpose of the purchased care package (seven hours per week, with 24-hour access to a staff member on site) during his stay. They also felt that perhaps the level of support had needed increasing, and that in future they would monitor packages more frequently, and review them more proactively, for other young people in similar circumstances. 7.62. Since the murder Child O has spoken to his social worker about his time in LA1. He said that he was worried about informing practitioners that he was scared and unhappy, for fear of being moved 24 further away from his family. Child O had previously been moved to placements in other local authority areas which affected his close relationship with his sibling and family members. Ideally Child O would have felt confident to raise such concerns without the fear of being moved away from his support network. If this worry had been shared, consideration could have been given to ensuring he remained close to important family links. Learning Points: • A requirement to add the IRO’s opinion or the date of a statutory review which had endorsed the placement of a child subject to a care order back with their parent on the schedule 3 report may assist in ensuring that the care plan is updated to include all multi-agency involvement. • When children subject to a care order are placed with parents at short notice, including at the direction of a court, a statutory review should be held promptly to discuss this and ensure the meeting and care plan includes attendance or a contribution from all practitioners actively working with the child and parent. This is particularly important when children are placed outside their home authority. • Some children in care who have not thrived in multiple residential care placements can do better when placed with their families if there is a good package of support. • Care plans and statutory reviews for looked after children placed with their parents should include consideration of the vulnerability of the parent and any risks they pose. • Deterioration in behaviour and increase in risk can be very swift if young people involved with gangs in one area connect with gangs in a new area. This needs to be considered in any re-housing of families and requires both social workers and housing authorities to have arrangements to ensure they have or can obtain sufficient local knowledge to make good judgements. • When practitioners have raised concerns about a child’s safety that are not resolved they should escalate the difference of opinion though their own agency or by using the relevant safeguarding partnership policy. Recommendations D, E and G Theme: Continuity of services, including complexities of cross border working 7.63. Working with children who offend, who may be victims as well as perpetrators, and who also have social workers brings with it a lot of complex partnership arrangements. This applied to both children. Both Child O and the practitioners working with him also had to deal with the challenge of cross border arrangements. These meant more people were involved, sometimes with overlapping roles, or a change from someone familiar to someone who was not because Child O had moved to LA1 requiring a change in agency delivering a service. Records show more than one example of Child O feeling there were “too many people” involved in his life. This was exacerbated by agencies’ uncertainty about whether the move to LA1 was going to be more than temporary. This resulted in some duplication or delay in YOS, SEN and police services. 7.64. Whilst there is evidence of strong partnership working with both children there is also evidence of misunderstandings and gaps. Agencies in LA1 were not always clear that the responsibility for the 25 care order lay with LA2 rather than LA1 as it would for most young people living in LA1. Nor were they aware that police in LA2, needed to be consistently kept informed due to the risk that Child O might be drawn back to previous activity with gangs there. The police in LA1 needed to be kept informed regarding any incidents that came to the notice of LA2 police. The communication with and by Child O’s social workers about incidents and changes in plans was not always consistently good. Police officers told this review that, when there was an incident in LA1 requiring notification, although they always tried to communicate directly with Child O’s social worker because of the intensity of the police Problem Solving Team involvement, in practice LA1 police would share information with the local MASH in LA1 (who should contact their counterparts in LA2 so Child O’s social worker was aware). Taken as a whole, police records in LA1 show some confusion as to which local authority was responsible for Child O. This makes the MASH-to-MASH communication important as a safety net. Learning points: continuity of services including complexities of cross border working • The importance of practitioner and agency records being clear which local authority is responsible for a child in care and that arrangements to ensure that information is shared promptly with that local authority are effective. • Where children have moved areas to keep them safe from gangs the importance of reciprocal information sharing between police forces if they are different in the host and home authorities. See recommendation A 7.65. Impact of Covid and any other relevant organisational contexts 7.66. The Covid pandemic is known to have had a huge impact on services and young people. Both children engaged best with practitioners in person, but engagement with practitioners was often limited to phone and video conferencing, which took a while to put into place. Overall service continuity and capacity was reduced due to staff sickness and vulnerability to infection and the need for redeployment to meet service priorities. These things also had a big impact on individual staff; they increased the challenges of what are already demanding roles. 7.67. Child N was not able to re-sit the test for the construction skills card. Nor was he able to get a job or engage with a training agency which closed due to Covid restrictions. He was also not living at home for a while when he would not comply with Covid restrictions because Mother worried this would put a vulnerable family member at risk. Child O found restrictions due to the Covid pandemic on his contact with his mother and younger sibling particularly upsetting. 8. CHILD O’s COMMENTS 8.1. Child O agreed to have a virtual meeting with the author in the company of his current probation officer. When talking about relationships with practitioners, there were a number who Child O felt he had a good relationship with; the YOS workers from both LA1 and LA2, a police officer from LA1 and two of the supported accommodation staff. Characteristics he identified which helped build his confidence in these people included: having a long term relationship with them; their taking time to seek him out; their being friendly and interested in him and his family and in what he was doing; feeling he could chat about anything without being judged; and practitioners being “straight up” (honest) with him. He also appreciated sometimes being brought snacks and drinks. Child O’s top 26 tips for practitioners working with young people would be to “Listen to them, relate to them and put yourself in their position”. Mostly he felt listened to, two occasions where he didn’t were decisions about placements: when being placed in a particular part of LA2 in 2019, and in temporary accommodation in LA1 (circumstances discussed in section 7 above). 8.2. He was pleased to be able to live with his mother and thought it was a good idea to go to LA1 in the family assessment placement where he could have a fresh start and they could get used to living with each other again. The YOS worker and the police officer in LA1 both tried to get him into clubs to do activities and make friends to avoid getting in with the wrong crowds, but this was prevented by the Covid pandemic. He felt being placed in temporary accommodation was a big mistake because the area was unsuitable for both him and his mother because they were “surrounded by gangs and drugs”. He confirmed there were times when he felt very unhappy and scared but had found it hard to tell people that because he thought he would be removed a long way away from his family, because this was what had happened when he had previously confided being unsafe. 8.3. In talking about his experiences in education Child O was sorry that he had been out of education for so long after returning to LA2. He wanted to be in a mainstream school as he thought this was more likely to be an environment where he would make more progress with his learning. He would have been enthusiastic about more practical learning opportunities to help him get a job in the construction trade. He was disappointed with the college course offered as it was not what he thought he had signed up to. He had done bricklaying before, and he did not want to do art as he feels he is not artistic. He would have liked to have done more carpentry, to build on what he had learnt at school, and gained other skills relevant to the construction trade his uncle and grandfather engaged in. 9. POSITIVE PRACTICE 9.1. When undertaking a review, it is important to also consider the kind of positive practice that might have broader applicability to protecting or supporting other children and families. A number of examples have been previously referred to, others are listed below. Protective and supportive actions by practitioners Children’s Social Care asked the GP for information which was provided promptly to social workers and the child protection conferences When Child N was made subject to a Referral Order confirmation of allocation of the YOS worker he knew was prompt. Information Advice and Guidance worker was able to motivate Child N to improve his CV and apply for a number of jobs Addiction services changed provider in 2020. Arrangements were made for Mother to continue her treatment with the same worker Child N attended the child protection conference and acted as scribe School staff attended the police station with Child N to find out the outcome of his bail Educational provision was provided for Child N to sit his GCSEs YOS police officer assisted Child N to prepare and practice to obtain a Construction Skills Certification Scheme card 27 IAG worker engaged with Child N and helped him complain about unfair treatment at the test centre, which was the context for him failing the test the first time. The complaint resulted in him being given a free resit Police officer from the Problem-Solving team knew Child N well and visited his mother to offer support and liaised well with his social worker, including calling in at the office and attending core group meetings LA1 social worker provided support even though Child N was no longer open to her e.g. helping get a birth certificate, which helped with funding support activities The post 16 centre staff built sufficient rapport with Child O that he was able to be honest about his current circumstances and feelings including anxiety and panic attacks Regular liaison by college staff with supported accommodation staff, SW and YOS and Mother Supported accommodation worker was persistent in helping Child O to obtain support when he was feeling low in October 2020 Strong working relationship established between SW5 and police officer from PST who engaged well with Child O CIRV co-ordinator stayed engaged after Child O moved to LA1 Child O’s LA1 YOS officer engaged well with him, and provided him with cooked food and food parcels and liaised well with LA2 YOS Child O has had the same IRO since 2017 The referral to the NRM was made as a matter of routine practice by the local authority and LA1 YOS at an appropriate moment There was a close working relationship between LA1 and LA2 YOS which benefited Child O 10. CONCLUSION 10.1. Several practitioners were persistent and thoughtful in the support they provided to each child. Both children responded particularly well to help that they thought would give them a future in terms of obtaining employment. As well as disrupting some key relationships with practitioners, the actual timing of the Covid pandemic was unfortunate at their age in reducing their opportunities for training and employment. Having said that, even without the pandemic, practitioners told this review that training and work experience opportunities for children who have disengaged from education or who have been excluded from school are limited in LA1. 10.2. It is It is striking that for both children a quick deterioration in behaviour could follow periods of relative stability. Placing Child O with his Mother out of LA1 to protect him from violence from gangs in LA2 was both a last resort due to the lack of any alternative viable placement, and a positive move with potential for better outcomes given that he was, initially at least, highly motivated to live with his mother. The deterioration in Mother’s ability to care for him eventually resulted in him living in supported accommodation with a low number of hours of proactive support at a young age. This deterioration, and his involvement in further offending behaviour, might have been expected after the cessation of the additional support and monitoring provided by the parenting assessment provider. However, the nature of the area where they moved to was a compounding factor which could have been avoided. 10.3. These children barely knew each other. It was tragic for Child N that they met at a time in Child O’s life of significant stress, when, with the benefit of hindsight, it is clear there was a risk of some kind 28 of serious incident but without any practitioners either knowing how precisely that might present itself, or about the conflict between the children which led to the murder. 11. RECOMMENDATIONS. 11.1. The individual agency reports have made single agency recommendations. Both Safeguarding Partnerships have accepted these and will ensure their implementation is monitored. To address the multi-agency learning, this Child Safeguarding Practice Review identified the following recommendations. A. That each partnership supports the development of arrangements which will result in detailed operational multi-agency, multi-disciplinary risk management pathway for individual children most vulnerable to being involved in violent incidents due to their involvement in gangs. These arrangements should always include children moving areas for their own protection and risk management plans should be reviewed at key points e.g. when children move placements or when incidents indicate increased risk or vulnerability. B. That MK Together Safeguarding Partnership supports the development of more alternative educational and training options for children who have disengaged or been excluded from school. C. That both partnerships reinforce with practitioners the importance of young people having strong and enduring relationships with practitioners and the risk of changes, especially if these are more than one practitioner at the same time. Partnerships should seek assurance from all agencies that they recognise the impact on young people when practitioners changes so that this is avoided where possible and steps taken to mitigate the impact where it is not. D. For children who have moved areas for their own protection. I. That each partnership supports the development of arrangements which will support the nature of the local community being risk assessed for every potential change of address prior to accommodation being confirmed. Such checks are a regulatory requirement for looked after children. II. That MK Together Safeguarding Partnership seeks assurance from Milton Keynes City Council that housing staff are aware of the learning from this review and supported to develop arrangements to ensure such checks are completed for looked after children. E. That Northampton Safeguarding Children Partnership seeks assurance from the Children’s Trust that: I. Work has been done to review the attendance at LAC reviews to ensure that the right people are in attendance II. Work has been done to ensure social workers and IROs understand the respective roles of the SEND service and the Virtual School in securing educational provision and reviewing Education, Health and Care Plans (EHCPs) for looked after children 29 III. That the learning from this review is used to improve the quality of the care planning, monitoring and review for looked after children who are placed with their parents F. That MK Together Safeguarding Partnership supports the development/review of information sharing arrangements to I. Provide timely information to the Criminal Justice Liaison and Diversion (CJLD) service about the backgrounds of children they see and II. For Youth Offending Service to receive timely information from CJLD about the children CJLD see G. To improve the availability of placements for children at risk in the community I. That the two Partnerships consider together whether there are any mutually beneficial joint commissioning arrangements that could be made. II. That the two Partnerships jointly draw the attention of the national panel to the learning from this review about the difficulties in finding placements for young people who meet the criteria for secure accommodation and seek their view on whether they can do anything to improve this situation. H. That each Partnership seeks assurance from each agency involved in this review that learning points have been identified and action has been/or is being taken to address and disseminate them. I. That each Partnership agrees what arrangements will monitor the impact of action arising from addressing these recommendations. |
NC044988 | Death of a 2-year-7-month-old boy in January 2013 as the result of drowning in the bath whilst left unattended. Post-mortem examination revealed hot water burns to Child T's body, caused after his death. Mother was convicted of manslaughter and received a 3 year custodial sentence. Mother and father were both on methadone programmes; tests conducted after the incident showed mother had also recently taken Diazepam, Temazepam, Nitrazepam, Heroin, Cocaine and Cannabis, along with Methadone, Tramadol and pain-killer Pregabalin. Family were well known to agencies including children's services. Both parents had a significant history of drug misuse, there was a history of domestic abuse and father had spent time in prison for drugs related offences. Issues identified include: insufficient focus on father's role in Child T's life; and poor prescription control practices leading to the over-prescription of medication to father. Makes recommendations including that the local Public Health Service should undertake a targeted public awareness campaign highlighting the risks associated with consuming a mixture of substances. Uses the Significant Incident Learning Process (SILP).
| Title: Serious case review: Child T: born: May 2010: died: January 2013: overview report. LSCB: Hull Safeguarding Children Board Author: Paul Tudor Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. HULL SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW CHILD T Born: May 2010 DiedJanuary 2013 OVERVIEW REPORT Lead Reviewer: Paul Tudor September 2014 CONTENTS 1. INTRODUCTION 1.1. Introduction to the Circumstances 1.2. Introduction to the family 1.3. Introduction to Serious Case Reviews and SILP 1.4. Introduction to the Lead Reviewer 1.5. Introduction to the process for this Serious Case Review 2. A BRIEF TIMELINE 3. FAMILY HISTORY AND BACKGROUND PRIOR TO NOVEMBER 2009 4. KEY PRACTICE EVENTS IN THE PRE-SCOPING PERIOD 5. KEY PRACTICE EVENTS AND EPISODES FROM NOVEMBER 2009 WITH SYSTEMIC LEARNING 6. SYSTEMIC LEARNING IN RELATION TO DOMESTIC ABUSE 7. AN UNDERSTANDING OF THE SUBSTANCE MISUSE SERVICES AND SHARED CARE OFFERED TO THE PARENTS WITHIN THE SCOPED PERIOD 8. THE ROUTINE AND UNIVERSAL SERVICES OFFERED TO THE FAMILY WITHIN THE SCOPING PERIOD 9. CONCLUSIONS (including the specific Terms of Reference) 10. AN OVERVIEW 11. FINDINGS FOR THE HULL SAFEGUARDING CHILDREN BOARD 12. RECOMMENDATIONS Appendices i. Terms of Reference and Project Plan ii. Agency Author Report Template iii. Glossary of Terminology iv. Drug Treatment System Referral Guidance v. HSC letter to all GPs regarding Pregabalin 11. INTRODUCTION 1.1. Introduction to the circumstances On 5.1.13 the subject child T (then aged 2 years 7 months) was brought into hospital by ambulance. He was in cardiac arrest. Resuscitation was unsuccessful, and he died shortly afterwards. He had severe scalding to his body and the Pathologist later recorded the cause of death as “consistent with drowning and post-mortem scalding injuries”, i.e. the burns were caused after he had drowned. His mother (Adult V) had woken from sleep at home to find Child T face down in the bath water. His father (Adult W) was asleep in bed. Both parents were on Methadone programmes. Toxicology tests indicated that other substances were also in both their systems at the time of the incident (see below). Initially both parents were arrested and bailed; subsequently Adult W was released from bail; and Adult V faced charges of manslaughter. On 4.7.14 Adult V was convicted of manslaughter and received a 3-year custodial sentence. Evidence presented at the trial indicated that she had left Child T unattended in the bath probably for up to 2 hours. Blood and urine tests showed she had taken Diazepam, Temazepam, Nitrazepam, Heroin, Cocaine and Cannabis, along with Methadone, Tramadol and pain-killer Pregabalin; The judge at the Trial made it clear there was never any suggestion Adult V was responsible for the burns, which he accepted happened after Child T drowned. He accepted that once Adult V fell asleep Child T switched on the hot tap. He then tried to get out when the temperature increased but fell back in and drowned. Mr Justice Coulson accepted that Adult V had been a good parent before Child T’s death. He told Adult V: “You did not intend this to happen. You were a good mother to Child T with good maternal instincts”. 1.2. Introduction to the family Adult V Mother (*37 years) Adult W Father (42 years) 2 (*Ages at time of incident *) The family are White British with no known disabilities or special needs. Children X and Y were twins. In 2001 Child Y died of natural causes (bronchial problems) aged 9 months. For much of the period covered by this Serious Case Review, Adult V and her two older children (Child X and Child Z) lived with maternal grandmother. In November 2009 she secured her own tenancy. Child X (then aged 8½ years) came with Adult V to the new tenancy; Child Z remained living with maternal grandmother by choice as she had lived with her for most of her life; but Adult V’s new tenancy was within 5 minutes walking distance of maternal grandmother and Adult V reported that she saw Child Z most days. The relationship between Adult V and Adult W was volatile (see incidents in Sections 4 and 5 of this report) and when he was released from prison in early 2007, Adult V had said she wanted nothing more to do with him. However, during the latter part of 2007 they re-established their relationship and he was spending more time with his daughters, Child X and Child Z. 1.3. Introduction to Serious Case Reviews (SCR) and Significant Incident Learning Process (SILP) Serious Case Reviews have operated for many years, until recently under 2010 guidance “Working Together To Safeguard Children”. Child X (11 years) Child Y Deceased Child Z (13 years) (9 months) Subject: Child T Deceased (2½ years) 3 This guidance contained mandatory and discretionary thresholds for holding Serious Case Reviews and prescriptive advice on processes, on Individual Management Reports (IMR) and Overview Report templates. In April 2013 new guidance was issued1 and Chapter 4 of this guidance emphasises the importance of a Learning and Improvement Framework2, of which reviews on specific cases is one element. Regulation 5 (2)(a) of the Local Safeguarding Children Board (LSCB) Regulations 2006 still requires Serious Case Reviews to be undertaken in defined circumstances; but the new guidance stipulates that reviews should be completed in a way which: - recognises the complex circumstances in which professionals work - seeks to understand the reasons that led individuals and organisations to act as they did - seeks to understand practice from the viewpoint of individuals and organisations at the time - is transparent about the way in which data is collected and analysed. The guidance also advises that any learning model may be used, consistent with the principles contained in the guidance at para. 11. In 2010 Paul Tudor and Leicestershire & Rutland Safeguarding Children Board devised a methodology entitled Significant Incident Learning Process (SILP). The key principles of SILP are: - proportionality - learning from good practice - the active engagement of practitioners - engaging with families - systems methodology. 1 Working Together To Safeguard Children April 2013 2 Chapter 4 Learning and Improvement Framework, para. 10 4These principles and the SILP methodology (including Learning and Recall Events) are entirely consistent with the 2013 Working Together To Safeguard Children guidance, particularly “to hear the voice of the practitioner” as advocated by Professor Eileen Munro following the Serious Case Review on Daniel Pelka (Coventry Safeguarding Children Board 2013). 1.4. Introduction to the Lead Reviewer After a 20-year career with the NSPCC primarily focussed on Child Protection systems, Paul Tudor has had a further 22-year career as an independent Safeguarding Advisor. His portfolio has comprised a significant number of Serious Case Reviews, locum contracts as a Child Protection Conference Chair and Independent Reviewing Officer and offering training on a range of safeguarding issues. 1.5. Introduction to the process for this Serious Case Review The decision by the Independent Chairperson of the Hull Safeguarding Children Board to initiate a Serious Case Review was made in early October 2013. This was a considerable time after the death of child T. The reason for the delay was due to the period required for parental toxicology results to be confirmed. Prior to this point the Chair assessed that there was insufficient information to reach an informed view as to whether the criteria for a Serious Case Review were met. The Police were also investigating the circumstances to determine whether any charges were to be made against one or both parents. The Post Mortem results on child T ruled out death by natural causes. When, at the end of September 2013 there was still no final decision about whether either or both parents were to be charged in relation to the death, a decision was reached to initiate this Serious Case Review. Subsequently in November 2013, Adult V was charged with manslaughter. The National SCR Panel were kept up-to-date throughout about the decision-making process. 5The Lead Reviewer met with the Chair and the Manager of the Hull Safeguarding Children Board in early October 2013 and commissioning took place on 11.10.13. The Lead Reviewer then met with members of the Serious Case Review Sub-Committee on 8.11.13 to undertake a scoping exercise. The full Terms of Reference, a Project Plan and an Authors’ template were developed and appear as Appendices (i) and (ii). It was decided that the scope of the Serious Case Review would be from November 2009 (the confirmation of the pregnancy with Child T) to 5.1.13 (the date of the fatal incident). However, agencies were also asked to review and report on significant events and any safeguarding issues prior to November 2009 in order to set the context of family life in which Child T lived. A briefing for authors took place on 22.11.13 and during early December further negotiations took place with CPS and Police as there were concerns about potential witnesses in a criminal trial coming together and discussing the case in a Learning Event, with a risk of possible contamination of the evidence. As Lead Reviewer I am very grateful to all parties for the way in which a compromise was negotiated, i.e. three practitioners had to be excluded; but otherwise a full Learning Event took place on 24.1.14 (30 participants); and the three excluded professionals were subsequently interviewed and contributed to the review after Adult V’s trial had been completed. An early draft of this report was shared at a Recall Event on 28.2.14. Again, it was well attended (24 participants) and further debate and analysis took place. Subsequently a further draft of this report has been circulated to participants with an opportunity for them to offer consultative comments electronically; and a Serious Case Review Panel (comprising of Hull Safeguarding Children Board members and lead agency authors) was held on 11.8.14. 6Letters of explanation were prepared for both parents but it was established that Adult W did not wish to receive it or to hear anything about the Serious Case Review at this stage. The letter to Adult V was received by her in prison a few weeks after the trial and she agreed to meet the Lead Reviewer and the Professional Practice Officer of the Hull Safeguarding Children Board . An interview was conducted on 21.8.14 at which Adult V was supported by an Offender Supervisor. Adult V’s views and comments are woven into the text of this report at relevant points. The whole process has been very efficiently and thoughtfully administered by the Hull Safeguarding Children Board Administrator, to whom my thanks. 7 2. A BRIEF TIMELINE This is designed to assist the reader in gaining a quick and early understanding of the events and issues which are to be described in this Overview Report. Father – Adult W; born May 1970 Mother – Adult V; January 1976 December 1994 Birth of Child Z 11.7.96 Referral to Children’s Social Care from Health Visitor 1.8.96 Anonymous referral to Children’s Social Care 22.8.96 Referral to Children’s Social Care from Police 12.3.97 Referral to Children’s Social Care from maternal grandmother 3.4.00 Police call-out to a domestic incident March 2001 Birth of twins – Child X and Child Y 17.3.01 Referral to Children’s Social Care from Special Care Baby Unit December 2001 Death of Child Y aged 9 months from natural causes 31.10.03 Police call-out to a domestic incident 6.8.04 Police call-out to a domestic incident 11.10.05 Anonymous referral to Children’s Social Care 25.5.06 Health Visitor made a home visit and found Child X home alone; referred to Children’s Social Care and Police 5.6.07 Child with Additional Needs Meeting (CWANM) 17.9.07 Review CWANM 3.4.08 Adult V arrested for Possession with intent to supply 6.5.09 Adult V arrested for breach of the peace 24.09.09 The GP referred Adult V to the maternity service, for pregnancy in relation to child T. 13.1.10 The first of monthly Substance User Assessment Tool (SUAT) meetings in relation to Child T 24.3.10 A reconvened CWANM 8May 2010 Birth of Child T 30.6.10 Child X reported to school a scratch under her eye 16.9.10 Child X reported to school that she cares for Child T (feeds him and changes his nappy) 9.10.10 Police called out to a verbal argument between parents 19.1.11 Police called out to a domestic incident 3.2.11 Parents arrested for burglary, Adult V cautioned for possessing Cannabis. A Section 47 enquiry was conducted on a single agency basis by a social worker 3.7.11 Police called to a domestic incident 19.7.11 The case discussed at Families Affected By Domestic Abuse (FABDA)Panel Meeting 5.11.12 Adult V referred to Compass, but she failed to attend the Preparation Group on 22.11.12 and 6.12.12 January 2013 Death of Child T 93. FAMILY HISTORY AND BACKGROUND PRIOR TO NOVEMBER 2009 3.a. Context The evidence suggests that the family’s living arrangements changed from time to time, but as already stated at Section 1.2, for most of the period of the pre-scoped period (i.e. up to November 2009) Adult V and the two children (Child Z and Child X) were living with maternal grandmother; and for a 2-year period up to 2007 Adult W was serving a prison sentence. Adult V and Adult W were known to the Police for convictions and other matters. 3.b. Child Z Within the scoping period she has lived with maternal grandmother for most of her life and no information relevant to this Review has been brought forward. 3.c. Child Y Child Y died of bronchial problems at the age of 9 months (in December 2001). 3.d. Child X Child X is the surviving twin. There is one noteworthy entry in medical records: On 26.8.04 the GP recorded “not sleeping, witnessed assault by dad on mum; advised needs support and contact”. There is no evidence that any action arose from this; and it may be regarded as a missed opportunity for checks to be made by the GP, e.g. contact with the Health Visitor. The Home/School Liaison Officer from the Primary School made a home visit in the autumn of 2006 following up concerns about Child X not being collected from school at the end of the day (the family were living with maternal grandmother). Information that Adult V shared regarding being the victim of domestic abuse and Adult W serving a substance misuse-related prison 10sentence were noted and shared with the school Child Protection Co-ordinator. Child X is the subject of some of the Key Practice Events at Section 4; but otherwise there were no reported concerns and Child X appears to have been making satisfactory progress. Indeed the school records analysed for this Serious Case Review note the emotional warmth between Adult V and Child X. 3.e. Adult W (father) Since the birth of Child Z in December 1994 Adult W has given the Police 17 different addresses and several aliases. In 1996 the Probation Service made a referral to Adult Services for a drug rehabilitation placement. Following a custodial sentence he was supervised by the Probation Service for 5 months from February to July 2007. The Probation Officer and Adult W were both advised about the Community Care Assessment process at that time From 1996 he was receiving regular prescriptions for medication. In August 2003 a urine test proved positive for opiates (although none had been prescribed for a year) and for Benzodiazepines (also not prescribed). Adult W had reported that he had first started using Heroin aged 21 (1991) and he received support from Compass between May 2007-April 2009 in the form of Methadone prescriptions, whilst the care-coordination remained with Drug Intervention Programme (DIP). He was also accessing other unprescribed opiates and Benzodiazepines. In February 2009 he appeared to be stable (self-reported); and he was on a supervised prescription of daily Methadone at 100mgs3 and results of tests by the GP showed that he had been free of illicit substances for 6 months. 3 The dosage is expressed in terms of 1mg of Methadone per 1mg of fluid. The figures appear as mgs. 11In April 2009 the prescribing was transferred from Compass to GP Shared Care. During the rest of 2009 he only reported smoking Cannabis; otherwise he reported that he was free of illicit substances. Between April 1996-October 2007 he had six contacts with Hull & East Yorkshire Hospitals NHS Trust (HEYHT); of which five were attendances at Accident & Emergency and one planned admission. Four of the six contacts related to complications associated with substance misuse. 3.f. Adult V (mother) In June 1996 she presented at hospital with a broken nose, having been head-butted four days previously (the identity of the assailant was not recorded). During her pregnancy with twins Y and Z in 2000/2001 she was on daily Methadone of 28-30mgs and attended 7 out of 11 antenatal appointments. In September 2003 she attended hospital following an alleged assault by “a man she knows, not her husband”. She sustained a suspected fractured cheek bone. Appropriately, she was given a “Violence Card” produced by Women’s Aid to signpost her to support services. There was a history of having been referred to and then discharged from Specialist Substance Misuse Services within the hospital from 2005. She reported having commenced using illicit substances in 1997 and having commenced on a Methadone programme the same year. When seen in 2005, her daily prescription was 55mgs Methadone daily with 5mgs Diazepam at night. Three non-attendances for appointments led to her discharge from the service which was normal practice. A urine test at the GP surgery in August 2006 evidenced illicit substance misuse. However, there is no record of either direct safeguarding concerns or 12of the possible impact of Adult V’s substance misuse on her parenting ability being considered. Substance Misuse Services started to work with Adult V in 2006, at which point she was living with maternal grandmother ; Adult W was in prison. She was described as lacking confidence, was withdrawn and was heavily dependent on maternal grandmother to help care for the children. In 2007 her GP had advised that she should receive Mental Health/Bereavement services regarding the death of Child Y; but she declined. At that time she was using illicit Benzodiazepines but stated that she was not using Heroin. Over the next two years (2008 and 2009) reports from Substance Misuse Services suggest that Adult V began to regain some stability; she appeared more positive, more focused and she reportedly stopped using illicit substances. She is described as wanting to reduce both her prescribed Diazepam and her prescribed Methadone. 13 4. KEY PRACTICE EVENTS IN THE PRE-SCOPING PERIOD 4.1. On 11.7.96 a neighbour (who wished to remain anonymous) passed her concerns to a Health Visitor, relating to parental substance misuse, shoplifting and taking Child Z (aged 19 months) out late at night. In turn, the Health Visitor referred this to Children’s Social Care. 4.2. A home visit was undertaken by a member of Children’s Social Care staff on 15.7.96 at which Adult V confirmed Adult W’s substance misuse and that he had left the family home and she did not allow him to have contact with Child Z when he was under the influence. Child Z was seen and no concerns were raised and a decision was reached by Children’s Social Care that there was no assessed need for any further Children’s Social Care involvement. 4.3. A second referral to Children’s Social Care came anonymously from a neighbour on 1.8.96 alleging that Child Z was “covered in bruises 3 weeks previously”. Concern was also expressed in the referral about both parents misusing substances and frequent visitors to the house. Checks were carried out by Children’s Social Care with the Health Visitor and the Police and 3 no-reply home visits took place. There is no record of any further action. Comment On the one hand this is clearly unsatisfactory as the child should have been seen in the light of the referring information. However, it is acknowledged that the child had been seen 2 weeks previously (see above) which is after the alleged sighting of bruises three weeks previously (but before the referral). Nevertheless, the visit on 15.7.96 did not focus on bruising as this was not the subject of that first referral, as it was on the second referral. 4.4. The Police referred to Children’s Social Care on 22.8.96 following a home visit at which Adult V was considered by a Police Officer to be “as high as a kite” albeit described as being capable. Child Z was said to look OK though grabbing a bottle which might indicate she was hungry. 14A no reply home visit was made by a social worker the same day, followed by two further no reply visits until a successful home visit on 30.8.96. Child Z was seen to be well dressed; and Adult V insisted she was only taking sleeping tablets at night. The case was closed to Children’s Social Care. 4.5. A caller made a referral to Children’s Social Care on 12.3.97. She expressed a concern that Adult house was “full of drug users” and thought that Adult V had started using substances again. She was worried about Child Z living in that environment. In a home visit by a Social Worker Adult V stated that she was not misusing substances and that even though her friends did use, she would not allow taking or supplying in her house in front of Child Z. 4.6. On 3.4.00 the Police were called to a domestic abuse incident. Adult V told the Police that she had refused Adult W entry to the house, that he had kicked the door off its hinges and had assaulted her while she was holding Child Z. Adult W was arrested and interviewed but Adult V withdrew her complaint. Children’s Social Care were notified (14.4.00) and made a successful telephone call with Adult V on 27.4.00 after 3 failed home visits. Adult V explained that she and Child Z were now living with maternal grandmother. A check was made with Child Z’s school who reported no concerns and the case was closed to Children’s Social Care. 4.7. Adult V was the subject of discussion at monthly substance misuse meetings at the Maternity Hospital between December 2000 and March 2001 in relation to her pregnancy with twins (Child X & Child Y). These meetings were newly established and chaired by the Hospital Social Worker; they are a multi-agency forum for sharing information about pregnant women who are known to be using substances (see Systemic Learning after Key Practice Episode 1, para. 5.8a). At that time Adult V and Adult W were believed to be living with their respective parents; and by the time of the March 2001 meeting Adult V had reduced her Methadone use from 30 to 28mgs per day. 154.8. Despite Adult V being discussed at the monthly substance misuse meetings (described above), 2 days after the birth of the twins (March 2001), the Special Care Baby Unit made a referral to Children’s Social Care based on the history of substance misuse by both parents. This resulted in an Initial Assessment. Adult V was visited on 20.3.01 and reported that she was not living with Adult W. No concerns regarding parenting capacity were reported by Special Care Baby Unit staff, nor by the school who were contacted in relation to Child Z. Adult V declined any further support and as no safeguarding concerns were identified, the case was closed to Children’s Social Care. Comment This was a missed opportunity to see and assess Adult W. The issue of the invisibility of men/fathers is discussed at later sections of this report. 4.9. Child Y died from natural causes (bronchial problems) in December 2001; and subsequently two visits were made by a social worker to assess how the family were coping and to offer support, but the family declined any further help and Child Z and Child X appeared to be well-cared for. It is recorded that the Health Visitor also offered support to the family. 4.10. On 31.10.03 the Police were called to the house when Adult W refused to leave. The caller had stated that Adult V and the children were threatened by Adult W, but when the Police spoke to her at the house she stated that there were no threats, just a verbal argument and no complaint was made. A Form 913 was submitted to Children’s Social Care by the Police (see Glossary at Appendix iii for an explanation of this form). 4.11. On 6.8.04 the Police were called by Adult V alleging that Adult W had dragged her out of a chair by her hair, had kicked and punched her repeatedly, had bitten her leg and then wrecked the house. The Police could not locate Adult V and the children despite numerous visits to the home address; but the Police made a referral to Children’s Social Care and a social worker was allocated to carry out an Initial Assessment. 16Adult V and the children were staying with maternal grandmother and Adult V told the social worker that her relationship with Adult W (who was now in custody) was over. The Initial Assessment concluded that Adult V had taken appropriate action to protect the children and there was no further role for Children’s Social Care. 4.12. Children’s Social Care then received an anonymous referral in October 2005, suggesting that Adult V and Adult W were using and dealing in illicit substances at the family home; but when Adult V was seen, she stated that she and the children had been living at maternal grandmother’s home since 2004. Checks with other agencies raised no concerns and no further action was assessed as being required. 4.13. On 25.5.06 the Health Visitor made a home visit and received no reply from Adult V but found Child X (aged 5 years) home alone. After waiting 10 minutes at the home address the Health Visitor made a referral to Children’s Social Care and the Police. Prior to the attendance by the Police and Children’s Social Care Child Z (aged 11 years) returned to the property, about 40 minutes later, saying she thought her mother was visiting a neighbour and Child Z then took Child X to the neighbour’s house. The Health Visitor confirmed that the mother was at the neighbour’s house. Both Police and Children’s Social Care subsequently visited and spoke to Adult V after the Health Visitor had left. 4.14. A first day absence home visit (to maternal grandmother’s house) was made in April 2007 by the Home/School Liaison Officer in relation to Child X. 4.15. There was evidence of strained family relationships between Adult V and maternal grandmother (verbal altercations and Child X crying). Adult V seemed emotionally distressed and maternal grandmother was concerned that Adult V was using illicit substances again. The outcome was that the Home/School Liaison Officer reported to the school Child Protection Co-ordinator, who, in turn, spoke to the School Nurse about initiating a Common Assessment. 174.16. The Common Assessment Framework (CAF) Co-ordinator was consulted and recommended that a Common Assessment should be completed; and the school nurse was identified as the most appropriate person to do this. With Adult V’s consent, the School Nurse did so; submitted it to the CAF Co-ordinator and an initial Child With Additional Needs Meeting (CWANM - see Glossary) was held on 5.6.07. Whilst it was agreed that Child X had no significant additional needs, it was identified that Adult V did need support regarding her substance misuse and mental health. According to the records, Family Group Conferencing and bereavement counselling were offered (but subsequently not taken up); and bereavement counselling had also been suggested by the GP. Comment There were no issues identified which would suggest that a referral to Children’s Social Care was required. Therefore this was an appropriate response and focus, demonstrating good practice. However, it should be noted that the decisions were based on Adult V’s self-reporting of her substance misuse. According to records it should also be noted that she did not access any of the additional services offered. However, in her interview with the Lead Reviewer, Adult V recalled having contact with someone whom she found to be very supportive and it is believed that this person was from the Family Group Conference Service. Interestingly, she also said in her interview that she did not receive support at the time of Child Y’s death. She could not remember the Social Worker visits (see paragraph 4.9); and she advocated the importance of counselling in these circumstances. 4.17. Adult V was present at this first CWANM but did not attend the review on 17.9.07. The home situation appeared more settled to those present and the school expressed no concerns about the care of Child X. Maternal grandmother was providing good support and it was decided that there did not need to be any further meetings. 184.18. On 3.4.08 Adult V was arrested by the Police on suspicion of “possession with intent to supply” (a Class C drug); and she tested positive for opiates and Cocaine. She also admitted to the Police at that time to using Crack Cocaine and Heroin occasionally; and she had Methadone (55mgs) and Diazepam prescribed. She received a conditional discharge plus costs. The context for this incident is that Police Officers were on their way to interview Child Z about another matter when they saw Adult V in the street. Comment Whilst a Form 125 (see Glossary) was submitted in relation to Child Z, a separate Form 125 in relation to the adult substance misuse was not raised and should have been. This is a missed opportunity for consultation and communication between the Police and Children’s Social Care (and potentially other agencies) in order for them to exercise professional judgement on any risks to the children from parental substance misuse. 4.19. Nevertheless, a referral was made to Compass in the context of a Post-Arrest Referral. Compass have confirmed that they used an internal form to confirm they had contacted Children’s Social Care to ascertain whether the family was known. They were informed that the School Nurse was Lead Professional in a CAF. 4.20. A copy of the form was also sent to and filed by School Health, but there is no evidence that it was seen by the School Nurse (due to staffing levels at this time impacting on the reviewing and recording of information within the Health record). Comment There should have been a 2-way discussion between Compass and the School Nurse (as CAF Lead Professional) to ensure clarity re: follow-up. The particular form used by Compass has subsequently been altered to promote that clarity of information and expectations. 194.21. The Police notified Children’s Social Care of an incident in May 2009 in which Adult V had been causing a disturbance in the street (after drinking some vodka). She was arrested for a Breach of the Peace, and this was witnessed by Child Z and other family members close to the house. The CAF Co-ordinator later notified the School Nurse (as Lead Professional) of the disturbance. 20 5. KEY PRACTICE EVENTS AND EPISODES FROM NOVEMBER 2009 – JANUARY 2013 WITH SYSTEMIC LEARNING Context 5.1. This section now addresses events and episodes within the scoped period from November 2009 (when Adult V booked in with Child T’s pregnancy) to January 2013 (the death of Child T). From the beginning of this period Adult V and Child X were living in their newly-acquired tenancy, having moved from living with maternal grandmother. The narrative will be broken down into key practice events and episodes.4 Key Practice Episode 1 – Antenatal contacts and joint working between professionals 5.2. Adult V was referred from her GP to Maternity Services when the pregnancy with Child T was 4 weeks; and she was seen on the same day as her booking appointment by the Obstetric Consultant (11.11.09). This is an enhanced service for substance misusing women and represents good practice as this Obstetrician takes a particular interest/specialism in substance misusing pregnant women, most of whom are booked under his care. A copy of the booking summary including information on Adult V’s substance misuse was sent to her GP and the Health Visitor and again this represents good practice. 5.3. In January 2010 the Substance Misuse Midwife shared information on Adult V with the Hospital Social Worker resulting in the family being discussed for the first time in this pregnancy at the next multi-agency Substance User Assessment Tool (SUAT) meeting (see Glossary for an explanation). This occurred on 13.1.10 and thereafter monthly through to May 2010 (i.e. 5 times) and on a 6th occasion in June after Child T had been born, but before he was discharged. 4 Some are designated as events, i.e. a very specific incident; others are described as episodes as they stretched thematically over a short period of time. 21 5.4. Antenatally Adult V was described by professionals working with her as making good progress, i.e. a relatively low dose of Methadone and Diazepam prescribed by her GP. She self-reported that she used Cannabis. During the pregnancy she achieved a further reduction in her Methadone use from 50mgs to 25mgs. 5.5. She was offered 11 appointments with the Maternity Services. Being under the care of an obstetrician requires hospital attendance as well as antenatal care in the community; and this represents good practice. A Paediatric5 alert and a plan of care for the unborn Child T was made by the Paediatrician on 4.3.10 (i.e. 27 weeks gestation). The plan identified that Child T may be withdrawing from substances following delivery. 5.6. Initially Adult V’s attendance at antenatal appointments was slightly erratic (i.e. 2nd, 5th and 6th being failed attendances, the reasons were not recorded). 5.7. Latterly in the pregnancy Adult V attended on a regular basis. At no stage during the course of the pregnancy did the Hospital Social Worker consider that the threshold for a referral to Children’s Social Care was met; nor, indeed, at the point of Child T’s discharge as he did not require any special care withdrawal of substances. 5.8. However, the very significant information (both historic and current) relating to Adult W was missing and this was very relevant as Adult V had reported that although she and Adult W did not live together, he was the father of Child T and they had quite a lot of contact (as evidenced by the Police). It would have been productive for these meetings to discuss Adult W’s own substance misuse and the nature of his relationships with Adult V and the children. 5 Paediatric alerts are generated by a paediatric referral being made to a paediatrician if there is a potential concern for the unborn child, for example, maternal drug use/heart defect. The paediatrician then reviews the referral and if assessed as necessary writes a paediatric alert for the records which incorporates a plan of care which is filed within the maternity notes. A copy is also placed within the paediatric records for when the baby is born, (it can be seen as an example of good communication between departments within HEYHT). 22Systemic learning from Key Practice Episode 1 a. Due to time constraints and the volume of cases, cases are not discussed in great depth at the SUAT meetings and, it was reported at the Learning Event that, pragmatically, there is not sufficient time to discuss fathers/partners. Additionally, the Substance Misuse Services involved in the SUAT meetings expressed concerns about sharing such information on the men/fathers without consent. In the light of the historic information and the longstanding relationship, it would have been good practice to seek his consent to discuss relevant information about him, to aid an assessment of the impact of his needs on the family, and of his own parenting capacity. b. The lack of knowledge and information on fathers/partners raises issues about potential unknown risks to other children in the household, to the new born and regarding staff safety (.e.g. the risk of lone home visiting). c. There was no evidence of information-sharing between practitioners outside the meeting. There was no documentation from the meeting within the Hospital Maternity records, or record of sharing information with the Community Midwives. This practice has now altered to ensure that information from the meetings is shared with Community Midwives and filed within the Hospital Maternity records so that practitioners involved with the maternity care in both the community and hospital settings are aware of the content of discussion from the SUAT meeting. d. At the time of Adult V’s pregnancy with Child T, the minutes of SUAT meetings were not recorded on Carefirst (i.e. the Children’s Social Care database) in cases where there were no safeguarding concerns about the unborn child. The minutes were distributed to the representatives of the agencies attending the meeting, who in turn were responsible for distributing them as appropriate within their agency. The Hospital Social Worker also retained the minutes and was the point of contact for requests for information-sharing with Children’s Social Care (for example following a referral to CSC from another source). 23e. In mid-2013 this changed, and since that time all minutes from SUAT meetings have been recorded on Carefirst although clearly identified as for information only in circumstances where there are no safeguarding concerns about the unborn child. f. Whilst the multi-agency SUAT meetings are clearly valuable in their own right (i.e. information-sharing), there has been no consistent use of a Common or an Early Help Assessment in a more structured and co-ordinated way. Moreover the meetings do not consider the views of the parents. g. The Hull Safeguarding Children Board currently has a working group looking at Pre-birth Pathways; and one stream of work relates to the SUAT meetings. Consideration needs to be given to their scope, their practice, the recording by all agencies and the distribution of minutes. Key Practice Episode 2 – Multi-agency working and decision-making under the Common Assessment Framework (CAF) 5.9. In addition to the substance misuse meetings (Key Practice Episode 1 above), on 24.3.10 Child X was the subject of a CWANM which was part of the CAF process at the time. It was chaired by a CAF Co-ordinator and attended by a Hospital Midwife, the Hospital Social Worker, a Health Visitor, the School Nurse, the Child Protection Co-ordinator for Child X’s school and by Adult V herself. However, it is noteworthy that there was no representative present from the Substance Misuse Service. 5.10. The Common Assessment completed in relation to Child X in 2007 (with the School Nurse as Lead Professional – see para. 4.16) had been brought to the attention of the Common Assessment Team by the Hospital Social Worker when she was notified of Adult V’s new pregnancy with Child T and she felt it appropriate to review whether there was any need for any further help and support under the Common Assessment Framework. 245.11. The minutes of the meeting describe a positive picture both regarding Child X’s progress (no concerns expressed by school) and the needs of unborn Child T, e.g. good family support. Child X saw Adult W regularly; and, although reportedly not living together, Adult V and Adult W reportedly had a more positive relationship; Adult V supported Child X well at school and was attending her antenatal appointments. The conclusion was that Child X had no additional needs. The allocated Health Visitor had tendered her apologies and requested minutes of the meeting; but another Health Visitor had attended in her place. The allocated Health Visitor then carried out an antenatal contact with Adult V on 23.4.10. The outcome was that the level of need was Universal6 requiring only routine core contacts. 5.12. There is no specific learning from this episode, other than that there is evidence that key professionals considered the needs of Child Z and unborn Child T and reached a reasonable professional judgement that there were no unmet needs which required additional support. Key Practice Episode 3 – Child T’s Discharge 5.13. Adult V and Child T stayed as inpatients in the Maternity Hospital from birth to discharge 7 days later. Child T had health assessments on each day by the Advance Neonatal Nurse Practitioner or Paediatric Doctor due to the risk of Neonatal Abstinence Syndrome (i.e. withdrawing from substances). The plan had always been that Child T would stay in hospital for 5 days from birth for observation. Child T had a weight-loss of more than 10% on the fifth day so it was advised that Adult V and Child T would remain in-patients for a further 2 days, Adult V agreed to this plan. 6 Health Visiting services are delivered in line with the national Healthy Child Programme 2010. This follows a model of a universal core programme of service delivery to all antenatal mothers and fathers progressing to a programme of care and service that meets different levels of need and risk (progressive universalism). The Assessment takes place at each contact with the service user. It takes into consideration identified current need and future risks which inform the level of service provided. The three service levels of need are: Universal which, as stated, is a core programme of care; Universal Plus, where a short time-limited increase in service is provided in response to an assessment of additional need, for example support with breast feeding; and Universal Partnership Plus programme of care which is provided where an assessment of health need has identified a child or their carer as having an additional health need, physical need and/or where there are safeguarding concerns around an unborn child or a young person (Health Visitor Implementation Plan, DoH 2011). 25This represents good practice by the Midwifery team and also shows Adult V being responsive to her baby’s needs. Key Practice Event 4 – First report to school 5.14. On 30.6.10, shortly after the birth of Child T, Child X reported to a member of school staff that Adult V had scratched her under her eye the night before. Child X stated that it was caused because she refused to come in. Information was passed to the Child Protection Co-ordinator who recorded they would contact Adult V. Although there are no records of the conversation with Adult V, the Child Protection Co-ordinator recalls having a conversation with Adult V. The Child Protection Co-ordinator is confident that if, during the conversation they had identified any concerns, she would have consulted and/or referred to Children’s Social Care. Key Practice Event 5 – Second report to the school 5.15. A further record was made by the Primary school on 16/9/10 after Child X disclosed to a member of staff during a 5-day residential school trip that when Adult V is asleep she (i.e. Child X) “does not recognise her” (i.e. Adult V) and that Child X looks after Child T. When asked how Child X looks after Child T, Child X said she gives Child T his dummy and bottle and changes his nappy. This information was passed on to the Child Protection Co-ordinator once the trip returned the following week. The Child Protection Co-ordinator recorded that they would speak to Child X. However, there are no recordings of this action taking place. Nevertheless, the Child Protection Co-ordinator recalls having the conversation with Child X, and is adamant that if they had had concerns they would have shared information with Child T’s Health Visitor with whom there was a strong working relationship. Systemic Learning for this particular school from Key Practice Events 4 & 5 5.16. It is unsatisfactory that on both occasions there is no recording of the outcomes. The Education Officer (Safeguarding) has addressed the issue of safeguarding recording in this school and shared her findings at the Learning Events as follows: 26i. Since 2010 the school Child Protection recording system has improved to ensure the system is more robust. ii. All Child protection files now have key information attached to the front cover, which clearly indicates the case status, a chronology sheet and a synopsis of events. The cross referencing on the front cover assists with easy navigation to relevant documentation in the file. iii. All records of Child Protection, safeguarding or behavioural concerns are forwarded to the Child Protection Co-ordinator in a timely manner for them to action accordingly. Having one contact point within the school ensures consistency in decision-making and enables the Child Protection Co-ordinator to have a complete overview of concerns raised. All records are shared and signed by the Headteacher as an additional measure to ensure appropriate actions have been taken. iv. The school acknowledges that there are never any guarantees that systems will not fail. However, they continue to maintain a self-critical approach in challenging their working practice by conducting internal audits to help identify and discuss decision-making. v. Previously domestic abuse incidents were not shared with the school (see Section 7). However, practice has since changed and been strengthened, i.e. the school acts on information received as necessary; and therefore there are no specific recommendations for the school. However, the Chair of the Hull Safeguarding Children Board will ensure learning from this review is communicated to all local schools. Key Practice Episode 6 – First Police call and resulting follow-up actions 5.17. On 9.10.10 the Police were called by Adult V following a verbal argument with Adult W whom she alleged had been kicking the door after she had locked him out; and he had a brick in his hand. The two children Child X and Child T were in the house at the time. He had remained outside the house for 2 hours. 27By the time the Police arrived Adult W had left and no damage or assaults had occurred. However, the attending Police Officers were told that Child X had shown signs of being distressed as a result of this incident. Both children were seen and appeared well. 5.18. A form F125 was submitted by the Police (i.e. a concern about a child); and a Case Administration Tracking System (CATS) record was created. This record confirms that Domestic Abuse Partnership (DAP) booklets were sent to Adult V offering support if she wished it. (For explanations of processes see Glossary of Terminology at Appendix iii.) The information from the CATS record was then shared with the Children’s Social Care Central Duty Team (CDT) and Health via City Health Care Partnership (CHCP) Safeguarding Team the following day (10.10.10). The CDT decision was that there was no need for Children’s Social Care involvement. 5.19. The Health Visitor and School Nurse were also notified of this incident and the Health Visitor made a follow-up home visit on 1.11.10 which generated a discussion with Adult V regarding the incident. From that discussion the Health Visitor had no safeguarding concerns but at the same time there was no particular challenge to the information regarding Adult W nor to the incident as described in the notification. 5.20. The School Nurse, having been notified of the incident, recorded that Child X had been distressed as a result of the incident. There is no evidence in records that this was followed up by gaining Adult V’s consent to speak to Child X. There is no evidence as to whether or not this incident was discussed between the School Nurse and the school. Systemic Learning from Key Practice Episode 6 a. The decision for no intervention by Children’s Social Care was a reasonable one, despite the children being present and the apparent distress by Child X over the incident. Best practice would have been for Children’s Social Care to liaise with the Children’s Centre, the Health Visitor and the school as part of their decision-making. 28At the very least Adult V should have been advised of the services for wide-ranging support offered by the Children’s Centre. b. It was good practice by the Health Visitor to make a follow-up home visit following receipt of the domestic abuse notification. Key Practice Event 7 – Second Police call 5.21. The Police were called by Adult V on 19.1.11 as Adult W was refusing to leave after he had stayed overnight. She claimed that he had hit her and smashed the TV and she was unsure whether he was under the influence of drink or illicit substances. When officers attended Adult W was still present and there was damage to the television but no assaults were reported and Adult W was removed from the property. Child X was at school. Child T was in the house but he was seen to be safe and well before the Police left the home. Adult V was aware of domestic abuse support available. 5.22. There is no particular learning from this event. Key Practice Episode 8 – Third Police intervention 5.23. On 3.2.11 both parents were arrested for burglary and then released unconditionally, though Adult V was cautioned for possession of Cannabis. When searching the house in the context of the alleged burglary, the Police reported finding 40+ uncapped needles, spots of blood and bloodied tissues strewn around the house, including in the children’s bedroom. Police representatives attending the Learning Events highlighted that having possession of substance misuse paraphernalia does not in itself constitute an offence and no substances were found. Moreover, none of the children were present as they were with relatives. Adult V’s Comment She was very disquieted by this description during her interview with the Lead Reviewer and she insisted that she has never used needles in the house. 29She is adamant that this description relates to the home of a couple living next door whose little girl was playing in their garden (see 5.25 below). 5.24. A Form 125 was submitted and a CATS record created; and the risk was assessed as medium. There was direct liaison between an officer from the Public Protection Unit and the manager of the Central Duty Team the following day (4.2.11). The decision was to proceed to a Section 47 enquiry on a single-agency basis by Children’s Social Care. 5.25. For this Serious Case Review the CSC author has reported that whilst a Social Worker visited unannounced the same day (4.2.11) neither the contact, referral nor consultation on the joint decision with the Police are recorded on the CSC database; and there is no record of an assessment of the children’s needs. The recording is limited to brief diary notes. 5.26. The Social Worker was present at the Learning and Recall Events and confirmed that there was no detailed recording but she could recall the visit in which Adult V was “very engaging”. The Social Worker saw Child T who was clean and well-presented. Adult V disputed the information given by the Police, i.e. a child’s name on the form was not related to this family; and she refuted the reference to uncapped needles. The Social Worker checked each room and there was no sign of any substance misuse paraphernalia. 5.27. The state of the house was good and there was food in the fridge and cupboards. Again in her interview, Adult V confirmed that Adult W was not living at the house and her explanation for any bloodied tissues found was that one of the children would have had a nosebleed. 5.28. The school Child Protection Co-ordinator was contacted by the Social Worker and reported back after Child X had been spoken to in school, stating that no concerns regarding Child X were identified. Additionally, the school Child Protection Co-ordinator described that they knew Adult V well and had a good relationship with her. The Substance Misuse Worker supporting Adult V was also contacted and reported no concerns. 305.29. A Children’s Social Care colleague updated the CATS record on 14.2.11, reporting that Adult W was living with paternal grandfather; and Adult V and Child T were safe and well with Adult V reportedly accepting help from Domestic Abuse Partnership (DAP). From the Police perspective, the risk assessment was lowered to Standard and the incident was closed. 5.30. However, it has subsequently emerged when the records were checked that Adult V in fact declined DAP support. Systemic Learning from Key Practice Episode 8 a. Monitoring of progress of Children’s Social Care assessments did not work sufficiently well in this case, so that the absence of recording in relation to the referral and joint decision-making with the Police was not highlighted, and no assessment was completed. Given the length of time which has elapsed, it has not been possible to establish the cause of this situation, but the Learning Event heard that the likely context was a higher than average rate of new work into the Central Duty Team at that time and a particularly pressured period in terms of work demands for the individual worker involved. b. An immediate unplanned visit was made to the family in response to the referral from the Police, and contacts made with some other agencies, which provided no immediate cause for concern about the safety of the children. Nevertheless, an opportunity to undertake a full assessment of the children’s needs, together with an analysis of risk, was missed, and this was not good enough practice. The assessment work that was carried out was not formally recorded. These two dimensions (i.e. the lack of a full assessment and the lack of formal recording) meant that information which may have informed decision-making in respect of a subsequent contact about the family was not available. c. There is no evidence of robust challenge to the parents by the Police in response to them finding substance misuse paraphernalia. Also, in the process of lowering their risk assessment, there was a false assumption that Adult V was accepting DAP support (see Glossary). 31This information had come initially from Adult V herself and then through the Social Worker update of the CATS record. Key Practice Episode 9 – Fourth report to the Police 5.31. On 3.7.11 Child Z called the Police reporting that Adult V and Adult W were arguing with Child T present. On arrival at the house Police Officers confirmed that no offences had been committed and Adult W agreed to leave the address. Child T was seen to be happy, clean and well nourished. A Form 913 was submitted and the domestic abuse risk was assessed as medium. 5.32. The Police made another referral to DAP via a Form 913 on 9.7.11 because during the course of the home visit on 3.7.11, Adult V had told the Police Officers that Adult W was very controlling, by. making her wear a ring on her wedding finger even though they were living together and objecting to her going to a SureStart centre. A DAP Duty Worker made three telephone calls to the home (11th, 15th and 19th July) and on each occasion Child Z stated that Adult V was out or not available. 5.33. Meanwhile the DAP Social Worker brought the family for discussion to the Families Affected By Domestic Abuse (FABDA) panel meeting to be held on 19.7.11 (see Glossary). This meeting recommended that DAP try again to contact Adult V. When the attempt to contact Adult V failed again, DAP sent a letter and booklet later the same day (19.7.11). The case was then closed to the FABDA Panel and DAP informed the Police they have been unable to contact Adult V. 5.34. The record of the FABDA meeting was copied to the CHCP Health Safeguarding Practitioner who established that there were no actions for Health and then sent copies of the notes to the Health Visitor and School Nurse respectively for information. 5.35. There is no specific systemic learning from Key Practice Episode 9. 32 6. SYSTEMIC LEARNING IN RELATION TO DOMESTIC ABUSE (All the acronyms that are used in this section are expanded and explained at the Glossary – See Appendix iii) 6.1. Case Administration and Tracking System (CATS) forms are sent to the Central Duty Team (CDT) (which was established in May 2008) where a decision is made about the most appropriate response, for example, whether or not the child is in need under Section 17 Children Act 1989, or whether the threshold is met to initiate enquiries under Section 47 Children Act. During the period within the scope of this Review those domestic abuse cases assessed by the Police as high risk were directed to a Team Manager at CDT who liaised with a Police decision-maker about the response, in accordance with Child Protection Procedures. Medium-Lower risk cases were directed to a Senior Practitioner for a decision about whether to discuss the child and family at the FABDA panel. All notifications from the Police were inputted onto CareFirst (CSC database) as an initial contact by an administrator. 6.2. Copies of the CATS forms are also sent to Education where the Education Officer (Safeguarding) redirects them to the appropriate school; and the school involved in this case confirmed at the Learning Event that they found these notifications very important and useful in maintaining a child focus within the context of understanding the family. 6.3. Until November 2013, copies of the CATS forms were also directed to the City Health Care Partnership (CHCP) CIC Safeguarding Children’s Team and, when the incident involves pregnant women, a further copy is sent to the Hospital Midwifery Service. However, at governance level a decision was made (1.11.13) that Health (CHCP) could no longer receive the CATS forms as there were concerns about third party information being inputted into a child’s health record. Some of the issues raised are the consent of the subjects, confidential storage, and a considerable quality assurance exercise to confirm the accuracy of information received. 336.4. The inability of agencies across the partnership to resource full minute taking meant that the decision was taken in 2011 to stop providing full minutes of FABDA meetings and each agency present took their own notes. The operation of the FABDA panel was reviewed during the early part of 2014 in relation to its position within the partnership’s Early Help Framework. As a result the role of the Panel has been integrated into Early Help Action Meetings within each locality rather than operating as a standalone panel. This is an appropriate and positive development in that the partnership arrangements have changed and developed in the three years since FABDA was introduced. Adult V’s Comment In her interview, Adult V was surprised that this report focuses on domestic abuse, claiming that her partner was not a violent man, that she had never been severely assaulted and that she invariably felt safe. Moreover, she described that he has always taken a keen interest in the children, including by being present at the birth of each child and accompanying them to appointments. 34 7. AN UNDERSTANDING OF THE SUBSTANCE MISUSE SERVICES AND SHARED CARE OFFERED TO THE PARENTS WITHIN THE SCOPED PERIOD 7.1. On the basis of the parents’ lifestyles and in particular the circumstances surrounding the death of Child T, it is important to understand the services that they received; albeit that much of the information contained here is based on self-reporting. 7a. Context 7.2 10 out of 57 GP practices in Hull have chosen to offer Shared Care. It means that when a patient has stabilised, they can receive the management of their prescribing and testing can be delivered by the GP in conjunction with the Substance Misuse Service who focus on psycho/social support. Adults V and W had separate GPs, both of whom offered Shared Care. There are many advantages, e.g. treatment locally and in the community and back into Primary Care services; less stigma; and the GP taking a holistic approach. There may be also some disadvantages, e.g. patients not engaging in group work activity and psycho-social interventions which J2R offer centrally. Adult V’s view In her interview she suggested that she found it better to receive the service in the community rather than mix with groups of substance misusers centrally, when, inevitably, there are risks and temptations. She feels that her own shared care worked very well. 7.3 Systemically there are issues in relation to recording, i.e. two separate systems being used in different GP practices (EMIS and SystmOne); and J2R workers not having access to either system for reading or recording purposes. 357.4 The respective Substance Misuse Worker and GP for Adult V worked closely together and the Substance Misuse Worker devised a practice whereby she would make her records available to the GP practice who would then scan them into the medical records. In the absence of Shared Care Monitoring Group meetings across the city (which used to take place), practice issues such as this good example are no longer shared – see Recommendation at Section 12. 7b. Adult V 7.5. From the point in September 2009 when Adult V became pregnant with Child T, she began to describe wanting to reduce her Methadone, not wanting her baby to be dependent on Methadone when born. Plans were made to reduce her Methadone and Diazepam during the second trimester. The assessment by the Substance Misuse Worker was that she engaged well and started to make positive changes in her lifestyle. The GP reports that multiple urine samples confirmed no other substances present. 7.6. Following Child T’s birth in May 2010, Adult V presented to Substance Misuse Services as being stable and free of illicit substances and she quickly established routines with the support of Adult W and maternal grandmother . At appointments she appeared relaxed and happy; and extra support was offered around the time of the anniversary of Child Y’s death which was, historically, a difficult period for her. 7.7. In January 2011 Adult V decided to concentrate on reducing her Diazepam with a view to detoxification during 2012. Generally throughout 2011 she was stable and she achieved her milestone of coming off Diazepam by January 2012. However, in November 2011 she was angry and upset with the GP who refused to prescribe Pregabalin. (This medication can lead to a high addiction and can be very problematic; see Health & Social Care Board (HSC) letter at Appendix v.) 367.8. She admitted to the GP that she had been using maternal grandmother’s Pregabalin to manage lower back pain; but she declined the alternative offered by the GP. 7.9. Adult V’s attendance at J2R deteriorated in the early part of 2012, e.g. only attending 2 appointments instead of 4 between February and April 2012; though she maintained appointments with the GP and she did continued with her planned reduction of Methadone, gradually reducing down from 25mgs to 15mgs. In May 2012 the J2R worker made a no reply home visit in the light of continued failed appointments; and in June 2012 there is evidence of good communication between J2R and the GP and then with Adult V, discussing alternative plans if Adult V continued to fail appointments, e.g. to consider supervised consumption at the pharmacy. This prompted her attendance at her next appointment in June, but she felt that she had reduced too quickly and she was stabilised back on 20mgs of Methadone. 7.10. In July 2012 she asked her GP for sleeping tablets and this was declined. There was also evidence of good practice in the shared care between J2R and the GP by co-ordinating and bringing in line the issue of prescriptions and the J2R appointments, in order to counteract the pattern of failed appointments. This had the desired effect of improving her attendance from September 2012 to December 2012, i.e. 5 attendances out of 7. 7.11. There was a 3-way clinical review (J2R/GP/Adult V) in October 2012 at which she disclosed she had missed her collection of Methadone for 5 days due to illness; but she had used Adult W’s Methadone. It is noteworthy that Adult V had informed neither her J2R worker nor her GP of her failure to pick up her Methadone from the pharmacy; nor had the pharmacy informed the GP on the 4th day as per protocol. This would have allowed the GP to make a review, a result of which could potentially be a decision to stop the prescription, or to revert to supervised consumption. 377.12. Routine home assessments are carried out by J2R with service users who are parents and these were conducted with Adult V in October and November 2012 with no concerns raised. The purpose of these visits is to see the home and observe the environment in which the service user and children are living. They are not considered to be formal parenting assessments. For this Serious Case Review it has been established that Adult V was provided with safe storage information (May 2012 and October 2012) and she was also issued with a lockable safe storage medication cabinet. 7.13. Adult V had been on Methadone for over 8 years and the treatment plan was to complete detoxification preparation work before Christmas 2012 with a view to entering an in-patient detoxification in early 2013. Hence she was referred to Compass (5.11.12) in order to undertake the Transitions Group work programme and to be offered 1:1 support (see Glossary at Appendix iii). 7.14. Adult V attended an induction meeting at Compass on 7.11.12 at which she reported occasional Cannabis use but she was confident she could abstain for the next 6 weeks in order to attend the group. She agreed to attend the group which was starting the following day and the plan was for 6 x weekly group sessions. However, she did not attend. An agreement between J2R/Adult V/Compass confirming that the start date would be postponed by a week (i.e. commencing on 15.11.12) again led to a failure (she reported that Child T was clingy following an accident requiring hospital treatment). Despite telephone contact and texts to encourage her and also information-sharing with J2R, she then failed 3 further dates up to 3.1.13. Having not responded to communications, when she did not attend again on 3.1.13, she was discharged from the Compass programme. Reflection in the Learning Event identified that it would have been good practice to hold a 3-way meeting comprising Compass/Adult V/J2R to facilitate her engagement. 387.15. Meanwhile, two planned home visits by J2R were unproductive; Adult V changed the date of the first appointment and was out for the second; but when the J2R worker spoke to her on 2.1.13 she reported she had had a good Christmas and New Year; there were no concerns about her presentation and she had coped well with the build-up to the anniversary of Child Y’s death (end of December). A 3-way review (GP/Adult V/J2R) was planned for later in January. 7.16. Meanwhile, 3 days before the fatal event, Adult V had been given a 1 day prescription with a request that she come back into the GP surgery the following day to collect a 4 day prescription. She failed to do so. This Serious Case Review has explored whether GP surgeries could or should be proactive in “chasing” patients who have not collected their prescriptions. The GP who was interviewed after the Learning Events considered that it was not proportionate or desirable to do so, partly due to limitations on resources and partly because assessing the motivation of the patient is crucial. This position is accepted. Adult V’s view Adult V believes that users should be tested weekly rather than fortnightly because there are many strategies for still misusing substances and yet at the same time producing “clean” samples. 7c. Adult W 7.17. From the point when J2R took over the contract in July 2011 (see Glossary) Adult W attended appointments with his Shared Care (J2R) worker focusing on his relationship with Adult V, his benefits, and seeking accommodation. He stated that he could not imagine coming down from the 100mgs of Methadone which he had been on for a long time; and he declined the offer of a referral for group work. He confirmed that he smoked Cannabis. 397.18. However, from November 2011 to March 2012 he failed many appointments, despite arrangements being changed so that he could be seen at the Shared Care Practice which would have been easier for him. He stated that he did not have a phone, so contact had to be by letter. Home visiting was considered but it was deemed not suitable as there was no current risk assessment regarding staff safety available. 7.19. In March 2012 Adult W’s J2R worker and Shared Care GP discussed Adult W and the GP agreed to adjust prescription dates to coincide with J2R appointments. This strategy was effective in that Adult W did attend an appointment with the J2R worker in April 2012, at which the main feature that was identified was that he was not taking his epilepsy medication and he was advised to speak to the GP about this. 7.20. In May 2012 a 3-way review was held (GP/J2R/Adult W) at which Adult W agreed to try a reduction of 5mgs and to recommence taking medication for a pre-existing medical condition. Additionally, he admitted that he was taking illicit Benzodiazepines occasionally and he had missed Neurology appointments. In July he was continuing to reduce his Methadone by 5mgs per month. After careful planning for a J2R worker to make a home visit (Adult V’s consent, the purpose, etc.) it was a no reply visit and Adult W later made clear his objection to a home visit despite J2R’s policy to undertake home visits for everyone with children. His Methadone reduction continued through the autumn and he appeared stable, reporting that he was enjoying the time he spent with Child T; he seemed brighter, more alert and stated he wished to explore detoxification options. 7.21. The key feature of the November 2012 appointment with his J2R worker was Adult W reporting that he was using acquired Pregabalin which had not been prescribed and about which there is significant concern (see Appendix v). 40He claimed that it helped his medical condition; but he was advised of the risks of doing this and it is noteworthy that he had asked the GP for Pregabalin 12 months earlier and had been refused. 7.22. The two J2R workers supporting Adult V and Adult W respectively liaised to discuss a home visit to which Adult V had agreed. Also at this time a safeguarding referral was considered by one of the J2R workers with a colleague; but, on balance, it was felt that there were no current risks to the children. At the time of Child T’s death, Adult W was on supervised consumption, and had been for the entire period of time covered by this Review. 7d. The Learning i. A J2R Did Not Attend (DNA) policy was introduced in November 2011 i.e. three consecutive Did Not Attend can lead to the suspension of treatment and discussions held to determine the appropriateness of continuing prescriptions and treatment in shared care, based on clinical risk and assessment. A review of possible options will form the basis of this such as a reversal back to supervised consumption may be considered. ii. The Agency Author suggests that this policy should have been used with more rigour in relation to Adult V; but the J2R worker and the GP accepted that Adult V was generally a rather poor attender, with no increased risks identified; she was not demanding or manipulative; she was not a persistent substance-seeker; and her Methadone dose of 20mgs was considered as a low dose. iii. It was totally appropriate and commendable that the GPs in both practices did not accede to the requests for Pregabalin indicating that they recognised that this would potentially be detrimental to patient care. However, no overt description of this as substance-seeking behaviour was recorded; and there are no records of child safeguarding considerations having been made in relation to this. 41It may be significant that both parents were asking for this medication from their respective GPs at the same time (September-November 2011). iv. There were occasions when the pharmacy did not alert J2R or the GP if Adult V and Adult W independently failed to collect their Methadone doses; policies and practice are that when there are 3 consecutive failed collections, the pharmacy should inform J2R. v. In her interview with the Lead Reviewer Adult V gave an insight into the ease of availability of substances in her local area and in particular Pregabalin. She acknowledged that its “effects are weird”, i.e. potentially dangerous. 428. THE ROUTINE AND UNIVERSAL SERVICES OFFERED TO THE FAMILY WITHIN THE SCOPING PERIOD Introduction 8.1. Sections 5 and 6 of this report have described particular interventions and offered a commentary on them. Additionally, members of the family also received universal services within the scoping period and these are briefly summarised here. 8.a. Subject – Child T 8.2. Following discharge, 2 out of 4 Community Midwife appointments were kept and no adverse effects from the missed appointments were identified. Adult V reported that she had been to the GP. 8.3. The Health Visitor had seen Adult V at an antenatal appointment at34+ weeks gestation based on the Health Visitor attending the CWANM (24.3.10). Following Child T’s discharge, the Health Visitor made a Primary visit when he was 12 days old; and another visit when he was aged 23 weeks, as a follow-up to a domestic abuse notification. 8.4. A Nursery Nurse visited 4 times (30.6.10, 13.7.10, 31.8.10, 5.7.12). The last visit comprised a 2-year development review. There were no health concerns, Child T had no unmet health needs, and his developmental assessment was age-appropriate. 8.5. Additionally, the GP conducted a routine postnatal review at 6 weeks old. Comment At no stage were any health, development or safeguarding concerns identified. The relationship between Adult V and Child T was reported to be good; as also was the care she offered him. There is evidence of good interactions. 43Health Visiting services were delivered in line with standards and expectations within the Child Health Promotion Programme (2008) and the Healthy Child Programme (2010) – see footnote 6 under para. 5.11. 8.6. The only other intervention for Child T was on 10.11.12 when he was brought by Adult V to A&E. The history given was that he had been running around with a bottle in his mouth, had fallen over and cut his lip. He needed to stay in overnight for suturing under general anaesthetic by a surgical team. He was discharged the following day. No safeguarding concerns were raised because the explanation of the injury was reasonable and accepted. The hospital staff observation was that Adult V was meeting all of Child T’s needs while he was in hospital therefore there were no concerns identified about parenting at this time. 8.7. Procedurally, the A&E attendance and admission information and discharge letter were sent to and reviewed by the Health Visitor and again no safeguarding concerns were identified. However, there is no evidence of information or a discharge letter in the GP notes and therefore the GP could not undertake any follow-up (though of course the letter may have been sent and gone missing). 8.b. Child X 8.8. She presented as a happy, sociable child in Primary school where she made steady progress under School Action (see Glossary at Appendix iii). The only concerns centred on how she was collected from school and some absences. In her interview with the Lead Reviewer Adult V spoke warmly of the school and its consistency of the Class Teacher, good relationships and support. 8.9. Poor attendance in the first term at Secondary school (Autumn 2012) resulted in letters to Adult V and a home visit by a School Nurse on 19.11.12 (no reply) and another on 21.11.12 when she spoke to Adult V. 448.c. Adult V 8.10. Out of the 11 antenatal appointments offered by the Maternity Service, Adult V attended 8 and she received continuity of care from a core group of staff. On each of these 8 appointments she attended, she was requested to produce urine samples for the detection of proteinuria, but she actually only produced three. She claimed that the GP had tested the urine samples and the results were negative. However, at each antenatal appointment her current reported substance misuse and medication were described by Adult V and recorded in the maternity records; notably her reported reduction of Methadone from 50mgs to 25mgs during the pregnancy. Learning Urine samples will have been needed but for two different purposes and processes; testing for illicit substances and pre-eclampsia/diabetes. There is a risk that both professionals and patients could be confused without clarity and communication between all parties. The learning is for Midwives and GPs to be explicit and clear to women the purpose of particular urine samples. Although the multi-agency SUAT meetings did represent one aspect of sharing information, professionals challenging information with parents and across agencies may be both necessary and appropriate. There will often be a need for separate and specific communication between agencies such as GP, Substance Misuse Services and the Maternity Service outside the SUAT meeting process. 8.11. The local Children’s Centre contacted Adult V three times in the first two months of Child T’s life, comprising an initial postnatal baby visit (30.6.10) and two further home and safety check visits (12.7.10 & 13.7.10). 45The visits were carried out by a Nursery Nurse based at the Children’s Centre and although Adult V was given information about services available in the local area, she did not access any Children’s Centre services, other than a holiday activity in July 2011. 46 9. CONCLUSIONS (including the specific Terms of Reference) 9.1. Is there evidence of disguised compliance? Defining disguised compliance as a deliberate attempt to draw attention away from potential harm to children, the analysis from this Serious Case Review is that this feature cannot be established. It is certainly evident from the preceding text that Adult V was, at times, reluctant to engage with services (e.g. DAP and Children’s Centre); that she failed appointments on many occasions (GP, J2R); and that she gave misleading information regarding the status of her relationship with Adult W. On several occasions, particularly following domestic abuse incidents, she said that the relationship was over or that he was not living at the family address, whereas it is clear that they maintained their sometimes volatile relationship. There was insufficient challenge by agencies at that time and also when Adult W was obviously present on many occasions at the family home (Police call outs and at the time of Child T’s death). Nevertheless, Adult V has consistently been described in the agency reports, at the Learning Events and indeed by the Judge, as a good mother. The agencies never assessed that the children (including child T) were at risk of significant harm. Her mis-information (e.g. stating that she was engaged with the Domestic Abuse Partnership which was not true) and keeping herself somewhat distant from agencies are much more likely to be related to her lifestyle and her involvement in illicit substances culture rather than deliberate attempts to draw attention away from any potential harm. 9.2. Is there evidence that for those agencies and services which are adult-focussed, they maintained a “think family/think child” agenda? There is good evidence that the two Substance Misuse Workers (who sometimes saw Child T at appointments) did record in their assessment work with both parents that they were considering the potential impact of parental substance misuse on Child T. 47Adult V and the children were registered with one GP practice and there is no evidence that there was not an appropriate child-focus. Indeed, in her interview the GP specifically commented on the good care Child T was receiving and on the close bonding and rapport between Adult V and Child T. Additionally, Adult V had reported to her Substance Misuse Worker that she made strenuous efforts to give all three children (i.e. including Child Z) individual play-time and attention. 9.3. Is there any evidence that agencies heightened their thresholds or lowered their sensitivity, i.e. the “accommodation syndrome”? A careful study of all the agency reports and the debates (conducted over the two Learning Events) reveals much good practice and no evidence that sensitivity to safeguarding fell below expected standards, e.g. on all the Police call outs there were checks on the children and appropriate forms submitted; antenatal and postnatal services were of a high standard; the Health Visitor followed up the notification of a domestic abuse incident. However, the self-reporting from both parents (e.g. relating to their substance misuse and the status of their relationship) was not sufficiently checked or challenged by agencies. 9.4. Was there sufficient focus on and assessment of Adult W? There are several examples of occasions when agencies were insufficiently curious about Adult W’s role in the family and in the home in general, and when Adult W should have been contacted and his role should have been assessed. • The 3.4.00 allegation that Adult W assaulted Adult V while she was holding Child Z. Even though she had left to live with maternal grandmother, this could and should have been assessed by contacting Adult W. • Initial Assessments on Child X and Child Y in 2001. Parents had been mis-using substances for at least 5 years by this time and Adult V was indicating that Adult W planned to move in. 48 • Initial Assessments regarding Child Z and Child X in 2004. This was an opportunity to make contact with Adult W and therefore assessments fell below required standards. • The February 2011 Section 47 investigation; a lack of contact and therefore a missed opportunity to assess strengths/risks in his relationships with Adult V and the children. • On 9.7.11 Adult V told Police that Adult W had a controlling influence over her but he was not included in any assessment and therefore the nature of their relationship was never explored and remained unknown. • Adult W was seen by a Health Visitor at the primary birth visit on 2.6.10; but when a Health Visitor visited on 1.11.10 Adult V reported that she and Adult W had been together for 20 years and that the incident had been taken out of context. There is no evidence of any exploration or challenge to this information. • Partners are not discussed in SUAT meetings. • There was never any assessment of Adult W as a significant other by any agency. • There is no evidence of Children’s Social Care making contact with Adult W’s Substance Misuse Worker to explore the implications of his substance misuse on his parenting capacity. • Adult W’s J2R worker was unable to complete a Home Assessment. This is a recurring theme in local and national enquiries7,8,9 7 There is a tendency for agencies to overlook the role of fathers/male partners/men both regarding the risk they pose and regarding the information they hold, in order to help understand the child’s situation. “This Serious Case Review highlighted the need for those working with children and their families to demonstrate how the role of fathers and men in households is considered in service provision and assessment. This appears to still be an issue and requires further review.” Hull Safeguarding Children Board Serious Case Review Child F 2011 499.5. Was “the voice of the child” heard? There is good evidence that Child X was spoken to by a number of the school staff prior to the CWANM on 24.3.10. Therefore her views were conveyed to the meeting through the school Child Protection Co-ordinator. Child X was not seen by a Social Worker but was spoken to by the Child Protection Co-ordinator as part of the February 2011 Section 47 Enquiry. (NB: the Social Worker and the school had a very strong and trusting relationship and the decision for the Child Protection Co-ordinator to speak with Child X rather than the Social Worker was a considered and appropriate one.) Throughout the period described in this Serious Case Review there is no evidence of Child X or Child Z being spoken to other than in school; but the study and analysis that has been undertaken does not identify that any other professional should have done so. Key Practice Episodes 4 and 5 have identified that again Child X was spoken to directly in school on the basis of the concerns which were raised. The observations of mother/child relationships, and particularly the interaction between Adult V and subject Child T, come mainly from Health (GP, Special Care Baby Unit, home visits by Health Visitor and Nursery Nurse). Additionally, it is noteworthy that J2R workers made records which were scanned into the GP notes referencing observations on Child T. Also, the brief record of the Social Worker’s home visit on 4.2.11 does comment on the presentation of Child T, although not on the mother/child interaction. 8 An Ofsted report identified gaps in Serious Case Reviews where information from or about fathers, whether living at home or elsewhere, and other adults living in the home might have contributed to a better understanding of the children and their families. Learning Lessons from Serious Case Reviews 2009-10 (Ofsted 2010) 9 There was, yet again, scanty information about men in most reviews, particularly in relation to an understanding about past history. This pattern reflects the wider problem of the lack of information about and lack of engagement with men in child health and welfare more broadly (Haskett et al 1996). The information that was available sometimes highlighted the tentative engagement by and with men and fathers. Understanding Serious Case Reviews and their impact – Biannual Analysis 2005-2007 Department for Children, Schools and Families – June 2009 509.6. Is there evidence of both compliance with expected practice and of good practice? There are several examples in the text of sections 3-7 which are highlighted as comments. Additionally, there are some further examples highlighted below: • The Police policies and procedures were followed in response to domestic abuse incidents. • The Domestic Abuse Partnership (DAP) and Public Protection Unit have a good internal working relationship and worked well with partner agencies. • J2R’s effective individual case management of their respective clients and perseverance helped support the parents to move from hectic and chaotic lifestyles and ambivalence, to change and want to reduce their dependency. • J2R were aware of vulnerability around the anniversary of Child Y’s death and proactively offered extra support. • Effective inter-agency communication and work between school and School Nurse at the point of initiating a CAF in June 2007. • The meeting between Primary and Secondary Child Protection Co-ordinators prior to transfer in order to share background information, notably the CAF. • Social Workers visiting the family shortly after the death of Child Y in 2001 to offer support. • There is evidence to support that Adult V was asked the Routine Enquiry Questions by her Health Visitor and her responses were recorded appropriately. 51• An additional visit to Child T was completed by the Health Visitor for further assessment following the receipt by the Health Visitor of the DV report from the Police on 1.11.10. • The early referral to a consultant-led clinic for women misusing substances during pregnancy by midwifery. • The fast-tracking of children in the A&E unit who require plastic surgery. • Both GPs recognising the risks of prescribing Pregabalin. 9.7. Is there evidence of effective multi-agency working together? Again there are several examples commented upon in the text of this report. Additionally: • The system of Police Form 125 and CATS being shared with Children’s Social Care Central Duty Team works well in general and did so in this case. • It was confirmed in the Learning Events that the system of Police Form 913 being screened by Domestic Violence Co-ordinators and then the links to the multi-agency FABDA meeting was effective in this case. • The multi-agency SUAT meetings are a good example of early intervention and the co-ordination of planning (see Key Practice Episode 1). • When Adult V was admitted to the antenatal ward the Midwife contacted the Hospital Social Worker to inform her of Adult V’s admission. • The pre-birth plan from the hospital was filed in the maternity records (6.5.10); and a copy of the plan was shared with the Community Midwives and Health Visitor and placed in the unborn Child T’s records. • Hospital Social Worker was informed of the discharge of Adult V and Child T on 27.5.10 (in accordance with the pre-birth plan and the Paediatric alert). 529.8. Are there practices and procedures described in this report which reveal that there are Areas for Development and Learning Opportunities? i. In conducting the review of Adult W’s records, the author of the agency report covering GP services has become aware that there is an issue of significant over-prescription of addictive medication by the practice to Adult W. This extends back for at least one year prior to Child T’s death and therefore he received more potentially addictive, and other prescribed, medication than was intended. Poor prescription control practices in the surgery have been raised by the Agency Author. This was raised and addressed by the agency report author. ii. J2R did not establish links with the Health Visitor or the school in order to triangulate information or share assessments of the parents’ functioning. Conversely, the Health Visitor did not initiate any contact with J2R for similar purposes. Although the two J2R workers (managing each parent individually) did exchange information frequently, they might have attempted to manage both parents and their potential risks more collectively. Substance Misuse Service assessments must consider the individual in the context of them being a parent/carer for children. iii. Adult V received antenatal care from the Substance Misuse midwives and Obstetric medical staff, with the shared care arrangements managing the reduction of Methadone programme. The midwives relied upon self-reporting from Adult V (on substance use and the results of urine samples) rather than seeking validating information from the GP and Substance Misuse Service before entering the information into recording systems. iv. Although Compass only saw Adult V on one occasion, they could and should have explored and recorded the risk assessment question on DV which was answered in the affirmative. Compass might also have checked whether Adult V required childcare support to obviate her failed appointment. Compass’ Safeguarding children and Safeguarding adults policies have both been reviewed and were distributed in July 2014. 53Compass single agency training has been delivered to staff around the new policies, and processes relating to safeguarding have also been reviewed with staff. This will include the expectation that Children’s Social Care will be contacted when it has been identified that a service user has children/is residing or has significant relationships with children under 18 years, to check the status of the child/service users/family. v. There were no clear national or HEYHT guidelines for substance misusing pregnant women in place in 2009. As a result, the package of midwifery care received by Adult V would appear to be basic with no identifiable enhanced midwifery care or effective enhanced communication with partner agencies. There was no documentation of an assessment of Adult V’s awareness/understanding of potential problems for her unborn baby in regard to her substance misuse. There was no record of any conversations regarding coping strategies in respect of caring for new born and other children whilst still using substances. There was no record of any discussion regarding the safe storage of medication to prevent accidental ingestion by any of the children in the household. The Serious Case Review has been informed that a new dedicated 15 hour per week Substance Misuse Midwife post became operational from 8.9.14. Additionally, a draft job description for a full-time post is under review and will be completed by 1.12.14. vi. There is no evidence of enquiry into domestic abuse within the Maternity records for Adult V. During 2009 to 2010, ‘routine enquiry’ on whether a woman was experiencing domestic abuse was a recommendation from the Department of Health, Responding to Domestic Abuse (2005) and the HEYHT Individualised Antenatal Care for Pregnant Women guideline (2008). The ‘routine enquiry’ did not occur in this case, and the authors are unable to ascertain why this was so. The HEYHT Children and Domestic Violence Guideline (2012) states that domestic violence data is to be collected by all midwives, health visitors and A&E staff. 54Routine enquiry is asked by all midwives and health visitors when they come into contact with a woman. Ideally this should be done antenatally and between 1-3 weeks postnatally. The practitioner must also ask routine enquiry (if deemed safe to do so) if he/she suspects or has evidence of domestic abuse. Yearly training on routine enquiry is now mandatory for all midwives. Compliance with recording routine enquiry is monitored via the supervisors of midwives spot check which is done on a monthly basis. The HEYHT key performance indicator (KPI) target is 80% for this being recorded, with exception reporting to NHS Hull Clinical Commissioning Group (CCG) if the compliance rate falls below 80%. Compliance from August 2013-August 2014 has been between 80-100% with the exception of 1 month (June 2013) at 70%. This has been investigated and no trends were identified. Subsequently, the following month audit showed 100%. The figures for routine enquiry are reported to the HEYHT Children’s Safeguarding Committee and the maternity managers on a monthly basis and also to the Hull Safeguarding Children Board Serious Case Review Sub-Committee. This process has implications for the Police. If a Health Visitor or Midwife is asking a victim “Who is responsible for assaulting you?” and possibly even the circumstances and mechanism of any injury, and then making a record of this conversation, the Police may need to seek access to such records and also take a statement from the Health professional. As a result of this Serious Case Review the Police intend to inform all their staff of this process via the Force Intranet and through safeguarding training. vii. In relation to the learning from key practice episode 8 (the Section 47 Enquiry in February 2011), Children’s Social Care has subsequently embarked on a ‘whole systems review’ of social work. This review is known as ‘Reclaiming Frontline Practice’. With effect from January 2014 the Central Duty Team is now known as the Access & Assessment Team. 55As part of the overall changes there has been a substantial increase in the number of social workers within ‘Access & Assessment’ together with a restructuring so that social workers work within small units (known as pods) led by a Consultant Social Worker. Each pod is supported by a Pod Co-ordinator with responsibility for business support and administration. One pod is responsible for the initial receipt of, and decision making about, all referrals, and this has introduced a high degree of consistency and monitoring of referrals when compared to previous arrangements. viii. The principle of shared responsibility within each pod for a number of assessments is important for ensuring that ongoing assessments remain ‘live’ and that there is support for joint working to minimise the overload of any individual worker. In addition, assessment practice has been improved through the introduction of a Children’s Social Care single assessment, which replaces previous systems of initial and core assessments from January 2014 onwards. ix. At the time under review Health Visiting and School Nursing worked with paper-based records and they had no system for determining which children lived together within a family, especially if children had different surnames or had transferred from Health Visiting to the School Nursing service before the next child was born. With the implementation of the electronic Health Care record (SystmOne) for School Nurse services in September 2012 there has been a considerable improvement in the recording of the groups and relationship of significant others within a child’s records. From February 2014 Health Visitors now use the same system and gain the same advantages. x. Within the time period of this report universal core contacts could be delivered by Health Visitors, Community Staff Nurses and Nursery Nurse within the team. This practice was revisited in March 2012 following the Health Visitor Implementation Plan (2012) and was fully implemented by October 2012. Assessments at 6-8 weeks, 7-12 months and 2 years are now completed by the Named Health Visitor. 56In addition, children assessed as requiring a universal service provision are now routinely offered two appointments. If they fail to attend they are followed up by the Named Health Visitor. xi. There is no record of an assessment of Adult V’s emotional wellbeing during the postnatal period. The current HEYHT Perinatal Mental Health Guideline (2012) now advises enquiry into maternal mental health at both antenatal and postnatal assessments. There is no HEYHT record of assessment of emotional attachment within the postnatal period as suggested in NICE Guidance for Routine Postnatal Care of Women and their Babies (2006), this area of practice was identified as collateral learning within a local Serious Case Review in 2013. Midwives are to receive additional training regarding maternal mental health, within the “Caring for the Vulnerable Women” training and an explanation of the need to implement enquiry into maternal mental health: The programme includes • Honour-based Violence and Domestic Abuse (DAP) • The Emotional Impact of Pregnancy on the Vulnerable Woman • Substance Misuse (ReNew) • Female Genital Mutilation (FGM) • Asylum Seekers. Refugees Six sessions will be available through the Autumn of 2014. The recording of enquiry into maternal mental health will be audited in May 2015 when all midwives have received the above update and the Maternal Mental Health enquiry will have been embedded in practice. 57xii. Systems to enable earlier engagement by Children’s Centres with pregnant women from more vulnerable groups have also been established. During 2013 an information-sharing protocol was agreed between Hull City Council and the Hull and East Yorkshire Hospitals NHS Trust. The purpose was to facilitate liaison between the hospital and the Children Centres. The process is that, with written consent from women at the point of the booking of a pregnancy, information is shared with their local Children’s Centre at the 16th week of pregnancy, so that early contact can be made and additional support offered to potentially vulnerable women. However, this Review has also highlighted the need for more routine feedback to the multi-agency substance misuse meeting at the Women and Children’s Hospital as to whether individual women have engaged with their local Children’s Centre. xiii. The issue of the dissemination of CATs records to Education and Children’s Social Care but not Health agencies was recognised at the Learning Event as a significant information-sharing and governance issue for wider discussion, including partner agencies and the Hull Safeguarding Children Board. Two multi-agency meetings have been held with future meetings planned. Initial agreement has been reached that the Police will no longer share the CATS records and will use the 913 forms. City Health Care Partnership will review the information received in the first instance via an audit which will be reported to the next meeting. Information governance leads will work together on an information-sharing protocol. Further meetings, convened by the Clinical Commissioning Group, will review sharing with other agencies including health organisations and education. xiv. On 18.8.14 a well-attended multi-agency meeting was held to begin to develop a Pre-birth Vulnerability Assessment Pathway. A draft pathway description and diagram have already been prepared for further consultation. 5810. AN OVERVIEW a. Serious Case Reviews should attempt to identify whether the tragedy could have been predicted or prevented. b. Sections 3 and 4 of this Report have analysed the family history and the key events up to 2009. Whilst there were some significant substance misuse-related and domestic abuse incidents, that period concluded with Child X being the subject of a CAF. c. The scoped period from November 2009 is characterised by multi-agency working antenatally and postnatally (Child T), three further reports of domestic abuse and one Section 47 enquiry; together with ongoing substance misuse services to both parents. d. It is now clear from information revealed during this Serious Case Review that Adult W was in fact living at the family home consistently over the last 18 months of Child T’s life; but he chose to identify another address for official purposes. However, there is no evidence that the earlier dishonesty of Adult V saying that the relationship with Adult W was over and then him remaining a constant feature in her life, or her reluctance to engage with agencies, had any direct or major adverse effect on the children. e. The last involvement of Children’s Social Care/Police/Domestic Abuse Partnership/FABDA was in July 2011, i.e. 18 months before Child T’s tragic death. For the remaining services involved with the family during that 18-month period (Nursery Nurse, GP, two J2R workers) no concerns about Child T in his own right, nor about the parents’ care or handling of Child T ever emerged. Indeed there are reports of good interaction between Adult V and Child T; and this reinforces the Judge’s comments quoted at Section 1.1. Additionally, there were no significant concerns from the school in relation to Child X. f. Adult W was reported to be “hands on” with all three children. The home environment and the parents themselves appeared more settled. 59Indeed, the 18-month period prior to Child T’s tragic death was the most stable period in the parents’ adult lives. Therefore the J2R workers’ decision that there were no safeguarding issues to justify a referral (see para. 7.21) was a reasonable and defensible one. g. Based on the levels of need and risk identified in the Child Health Promotion Programme (2008) and later the Healthy Child Programme (2010), Child T was always assessed as needing health visiting services at the Universal level, i.e. the core programme. This was an appropriate assessment in the circumstances. h. Despite the long history of mis-use of controlled substances, a history of low level dealing, and other risk factors such as domestic abuse and other health complications, up to Child T’s death there is no evidence that the children were ever subjected to significant harm by the parental substance misuse. i. Whilst this Serious Case Review has identified some learning, the conclusion is that the fatal incident could not have been predicted and therefore could not have been prevented. 60 11. FINDINGS FOR THE HULL SAFEGUARDING CHILDREN BOARD 11.1. The assessment and management of substance use in pregnancy The current guidelines under the auspices of Hull & East Yorkshire Hospitals NHS Trust, Hull City Council Social Services Department, and Hull & East Riding Community Health are dated April 2000. However, in addition, there is detailed guidance issued by the Hull Safeguarding Children Board entitled “Substance Misuse in Pregnancy” (Section 7.13). This includes communication and confidentiality, SUAT meetings, record keeping, etc. At Key Practice Episode 1 and at 9.8(xiv) of this report reference is made to work that the Hull Safeguarding Children Board is currently undertaking on Pre-birth Vulnerability Assessment Pathway. In the light of the findings of this Serious Case Review, the Hull Safeguarding Children Board will want to be reassured that this stream of work is robust. In particular reassurance will be needed that the ownership and effectiveness of Multi-agency Vulnerability Meetings (previously SUAT Meetings) is established. The HSCB accepts this finding and is leading on work to develop a comprehensive pre-birth vulnerability pathway. This work will be concluded by 31st March 2015. 11.2. Overlooking the role of fathers/men/significant others “If professionals do not enquire about or assess the role of fathers, possible risk factors and possible protective factors could be missed.”10 10 Hull Safeguarding Children Board Serious Case Review Child F 2011 61The Hull Safeguarding Children Board will want to assure itself that assessments, ongoing work, and professional curiosity with children and families maintains an appropriate focus on and engagement with fathers/men/significant others (e.g. grandparents) both in relation to the risk they may pose and/or in relation to the information they may hold. The HSCB accepts this finding and recognises that a lack of focus on the role of fathers/men/significant others has been a feature of other local and national serious case reviews and local learning from practice. The HSCB will lead on a focused piece of work with partners to understand the issue and identify the most effective means of improving local practice. This work will be concluded by 31st March 2015. 11.3. Information-sharing relating to domestic abuse and child concern The current guidance issued by the Hull Safeguarding Children Board is entitled “Considerations when contacting another agency/service” (Section 8.1). In the light of this Serious Case Review the Hull Safeguarding Children Board needs to oversee, scrutinise and challenge how information is effectively shared: i. the dissemination of CATS records to Education and Children’s Social Care but not Health and the governance and duty of care implications that lie behind this decision (although this is currently being discussed see 9.8 [xiv]) ii. the current guidance does not constitute a multi-agency information-sharing protocol. This has been recognised locally and work is underway to develop a specific protocol for sharing domestic abuse notifications. The HSCB accepts this finding and is leading on work to develop an information sharing protocol in relation to domestic abuse. This work will be finalised by 31st January 2015. 6211.4. The Lead Reviewer is satisfied that single agency recommendations and action plans, which agency authors identified, are accurate and reflect the internal findings and learning. The Hull Safeguarding Children Board will monitor the implementation and impact of these single agency recommendations. 63 12. RECOMMENDATIONS There are four specific recommendations which have emerged from the work of this SCR: i. That the Independent Chair of HSCB should write to all local Head Teachers informing them of the learning from this and other reviews about the need for accurate recording in relation to safeguarding issues - by 15th November 2014 ii. That a forum is established by the Strategic Substance Misuse Manager to enable General Practitioners involved in delivery of shared care arrangements to come together and identify areas of concern or barriers to effective joint working and also to share current best practice - by 31st January 2015 iii. That the local Public Health Service should undertake a targeted public awareness raising campaign highlighting the risks associated with consuming a mixture of substances - by 31st March 2015 iv. That the Strategic Substance Misuse Manager should write to pharmacies and substance misuse service providers reminding them of the need for clear communication about repeated failure to collect prescriptions – by 31st December 2014 Appendix (i) Terms of Reference and Project Plan HULL SAFEGUARDING CHILDREN BOARD TERMS OF REFERENCE & PROJECT PLAN SUBJECT : Child T D.O.B. 20.05.2010 D.O.D. 05.01.2013 64 Appendix (i) Terms of Reference and Project Plan 651. Introduction The 2½ year old male child was pronounced dead shortly after he arrived at hospital on 5.1.13. An ambulance had been called by the child’s father when the child had been found floating face down in a bath of very hot water. There has been a delay in making a decision regarding a Serious Case Review (and the methodology to be used) due to awaiting toxicology reports on both of his parents (in relation to drugs) and on the outcome of further tests and enquiries in the police investigation. The Chair of the Hull Safeguarding Children Board, in consultation with members of the Serious Case Sub‐Committee, has decided to invoke a Serious Case Review and to use SILP methodology; and the Department of Education and Ofsted have been advised accordingly. 2. Purpose The purpose of a SILP remains the same as that for a Serious Case Review, namely: • To establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children • To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • Improve intra‐ and inter‐agency working and better safeguard and promote the welfare of children. (Working Together to Safeguard Children, March 2010) Appendix (i) Terms of Reference and Project Plan 663. Framework Serious Case Reviews and other case reviews should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings (Working Together, para. 10, March 2013) 4. Specific Scope The subjects: • the deceased child ‐ Child T • both parents ‐ Adult V (mother) ‐ Adult W (father) • the younger sibling ‐ Child X (collectively as Family U) The time period – from 4th November 2009 (antenatal dating scan) up to 4th January 2013 23:00pm (date and approx. time emergency services were called to the family home). Appendix (i) Terms of Reference and Project Plan 675. In addition Agencies are asked to review and report on significant events and safeguarding issues on both parents and children prior to November 2009, eg. domestic violence episodes, substance misuse and treatment, referrals to Children’s Social Care, the use of CAF, etc. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points. 6. Agency Reports Agency reports will be commissioned from: • City Healthcare Partnership CIC for Health Visiting and School Nursing • Hull & East Riding Hospitals NHS Trust for Midwifery and Acute services • North Yorkshire & Humber Area Team, NHS England for GP services • Journey to Recovery and Compass for substance misuse services • Humberside Police • Adults, Children and Family Services: o Children’s Social Care (to include an overview of involvement with CAF, FABDA and the Children’s Centre) o Learning & Skills (Primary school involvement with sibling) • Domestic Abuse Project 7. Generic Analysis 7.1. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. Were there missed opportunities or episodes when there was sufficient information to have taken a different course? Were assessments conducted effectively and appropriate conclusions drawn? Appendix (i) Terms of Reference and Project Plan 687.2. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. 7.3. Demonstrate whether your agency/service heard and responded to the child’s voice. 7.4. Identify and explain if your agency/service believes that other agencies/services should have been sought and/or provided. 7.5. Identify good practice. 7.6. Were professionals proactive in escalating concerns and effecting challenge where appropriate? 7.7. From an inter‐agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other? 7.8. Did your agency identify any issues of ethnicity, diversity, language, culture (e.g. poverty)? If so, how did your agency address these issues? 8. Particular Areas For Consideration 8.1. Was there evidence of disguised compliance on the part of parents in their dealings with agencies and services? 8.2. Is there evidence of “Think Family/Think Child” in the way adult‐focused agencies and services conducted their management of the case? 8.3. Is there evidence of “an accommodation syndrome”, i.e. an acceptance of normality and high thresholds in responding to substance‐misusing parents? Appendix (i) Terms of Reference and Project Plan 699. Engagement with the family A letter will be sent from the Chair of the Board informing parents of this Review and its purpose. A little while later Paul Tudor will write to them again as a follow‐up and invite them to participate in the form of a home visit/interview/correspondence/telephone conversation. Their contribution will be woven into the text of the Overview Report; and they will be given feedback at the end of the process. We will keep an open mind regarding siblings and significant others. Hopefully any interviews will take place prior to the Learning Event so that their voice will be heard at the Learning Event. 10. Documentation The “bundle” for the Learning Event will comprise: • Integrated Chronology (prepared from CDOP information and updated with SCR agency report information) • Agency reports • Any minutes of meetings (FABDA, CWAN, etc.) 11. Timetable w/c 18 November 2013 Commissioning letters to agencies for Authors 22 November 2013 11am‐12pm Brunswick House (HQ‐Adults, Children & Family Services) Briefing for Agency Authors by Paul Tudor By 10 January 2014 Deadline for Agency Reports 13/14 January 2014 Quality assurance of Agency Reports by Paul Tudor/Neil Colthup Appendix (i) Terms of Reference and Project Plan 16 January 2014 Distribution of Agency Reports and integrated chronology for Learning Event 24 January 2014 9am – 3:30pm Brunswick House Learning Event 12 February 2014 10am – 12pm Brunswick House Reference Group/SCR Sub‐Committee 28 February 2014 9am – 3:30pm Brunswick House Recall Day 19 March 2014 Presentation of report/sign off at HSCB meeting 8 April 2014 Deadline for completion of Overview Report/submission to Department for Education (subject to conclusion of any criminal proceedings) 70 Appendix (ii) Agency Author Report Template HULL SAFEGUARDING CHILDREN BOARD AGENCY REPORT (*Name of the agency*) SIGNIFICANT INCIDENT LEARNING PROCESS SUBJECT : Child T 71 Appendix (ii) Agency Author Report Template 1. Please see Terms of Reference and Project Plan document for: • Introduction • Purpose • Framework 2. Specific Scope The subjects: • the deceased child ‐ Child T • both parents ‐ Adult V (mother) ‐ Adult W (father) • sibling ‐ Child X (collectively as Family U) The time period – from 4th November 2009 (antenatal dating scan) up to 4th January 2013 23:00pm (date and approx. time emergency services were called to the family home). 3. In addition Agencies are asked to review and report on significant events and safeguarding issues on both parents and children prior to November 2009, eg. domestic violence episodes, substance misuse and treatment, referrals to Children’s Social Care, the use of CAF, etc. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points. 72 Appendix (ii) Agency Author Report Template 4. Within the Scoping period (4.11.09 – 4.1.13 11pm) a. Summarise in narrative form the key information on the child and parents from your agency/service. b. Summarise the services offered and/or provided to the child and parents; and the decisions reached. 5. Generic Analysis 5.1. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. Were there missed opportunities or episodes when there was sufficient information to have taken a different course? Were assessments conducted effectively and appropriate conclusions drawn? 5.2. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. 5.3. Demonstrate whether your agency/service heard and responded to the child’s voice. 5.4. Identify and explain if your agency/service believes that other agencies/services should have been sought and/or provided. 5.5. Identify good practice. 5.6. Were professionals proactive in escalating concerns and effecting challenge where appropriate? 5.7. From an inter‐agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other? 5.8. Did your agency identify any issues of ethnicity, diversity, language, culture (e.g. poverty)? If so, how did your agency address these issues? 73 Appendix (ii) Agency Author Report Template 6. Particular Areas For Consideration 6.1. Was there evidence of disguised compliance on the part of parents in their dealings with agencies and services? 6.2. Is there evidence of “Think Family/Think Child” in the way adult‐focused agencies and services conducted their management of the case? 6.3. Is there evidence of “an accommodation syndrome”, i.e. an acceptance of normality and high thresholds in responding to substance‐misusing parents? 7. Key Learning Points 7.1. What did we do well which we need to keep doing? 7.2. What didn’t we do so well that needs to stop? 7.3. What things need to be done differently to lead to improvements and how should this be done? 7.4. What is to be learnt about improving multi‐agency working? 8. Recommendations You may make in‐house/single agency recommendations (but are not obliged to do so). If you are making recommendations please make them SMART, i.e. Specific Measurable Achievable Realistic Timely 74 Appendix (ii) Agency Author Report Template 9. Sign‐Off (Neither the reviewer nor senior sign‐off person has had any direct involvement with this case prior to the death of the child.) Agency Reviewer: Date: The reports of all reviews must be signed by the relevant senior officer, indicating that the review has been: • carried out to the required standard and • the learning points are accepted by the organisation • the recommendations/action plan will be implemented The Senior Officer accepts that: • The review has been carried out to the required standard. • The learning points reached in the review are accurate. • The recommendations/action plan will be implemented. Senior Officer: Job Title: Date: On completion, please send or deliver the completed report by 10th January 2014 at the latest to: Cathy Eccersley Hull Safeguarding Children Board Midmere Centre Dorchester Road Hull HU7 6BD or [email protected] 75 Appendix (iii) Glossary of Terminology CAF Co-ordinator With the introduction of the Common Assessment Framework (CAF) in Hull in 2006, a number of CAF Co-ordinator posts were established by the Children and Young People’s Strategic Partnership to work in local areas in the City. Their role was to work alongside and support agencies to develop the use of the CAF, to support decision-making and to provide training across the partnership. CAF Co-ordinators also acted as Chair for more complex Child With Additional Needs Meetings as part of the CAF arrangements. The role of CAF Co-ordinator was deleted in 2011. Case Administration and Tracking System (CATS) Humberside Police use a system called CATS for the recording of all information sharing; F125s, Section 17 and Section 47 referrals. Not all F913s are recorded on CATS, i.e. as some parties involved in domestic incidents may not have children. The CATS system can create a computer generated form from information contained within a CATS record. Humberside Police have used CATS since 2008. City Health Care Partnership Community Interest Company (CHCP) City Health Care Partnership CIC (CHCP) provides community health services to the City of Kingston upon Hull and surrounding areas. City Health Care Partnership CIC (CHCP), previously NHS Hull provider services, officially formed on 1st June 2010 as an independent health services provider separate to the commissioning organisation, NHS Hull. Amongst other services, CHCP provides community paediatric nursing, health visitors, school nurses, dentistry, public health and GP practices in a community setting. Compass (Compass Open Access and Harm Reduction Service) A service which will take referrals from professionals and also self-referrals. CWAMN Child With Additional Needs Meeting (CWANM). As part of the implementation of the CAF framework in Hull, the title given to a multi-agency meeting to discuss the co-ordination of support to a child and family following a CAF assessment. National guidance referred to such meetings as Team Around the Child (TAC) meetings, and with the development of whole family approaches Team Around the Family (TAF) is now the commonly used terminology. 76 Appendix (iii) Glossary of Terminology Domestic Abuse Partnership (DAP) This is a multi-agency partnership which is co-located in a Police Station. Staff are seconded from Police (Domestic Violence Co-ordinators and MARAC Administrator), Children and Young People Services (social workers), Women’s Aid (DAP Manager), Housing (Housing Officer), CHCP (Health Practitioner and administrator), J2R (Addictions Workers and Citysafe), 7 Domestic Violence Support Workers and Men’s Worker. The Domestic Abuse Partnership sits in the same office as the Police Public Protection Unit and those cases screened as high risk will automatically be passed to DAP for a secondary risk assessment and consideration of a MARAC. Any consideration of victim consent will be overridden in these cases. Drug Intervention Programme (DIP) From 2006 Compass was responsible for most of the programme. This comprises key elements such as resettlement, Housing support, Clinic, needle exchange, Choices, Outreach. In 2008 another service became involved in parts of the programme, i.e. City Health Care Partnership. Prior to July 2011 Substance Misuse Services were provided by two providers, Humber Foundation Trust and CHCP CIC. The services provided by CHCP CIC used a tiered approach to provision from complex to less complex patients/presentations. The services provided a mixture of substitute prescribing options alongside psychological interventions. Families Affected By Domestic Abuse (FABDA) A multi-agency forum for case discussion in relation to children and families affected by low level domestic abuse. The purpose of the meeting was to co-ordinate an early response in those cases which did not meet the threshold for a response by Children’s Social Care or MARAC. During 2014 the FABDA panel was discontinued and low level domestic abuse contacts are now discussed at multi-agency Early Help Action Meetings which take place in each locality of the city. Form 125 Juvenile Report For Police Officers to complete where any contact with a child under 18 raises concerns of a safeguarding nature; in circumstances of being a victim, a witness, an offender or “of interest or concern”. The form is to be submitted to the Public Protection Unit. The Officer submitting the form is required to complete a risk assessment grading and selecting the relevant category Standard/Medium/High. 77 Appendix (iii) Glossary of Terminology Form 913 For Humberside Police the definition of domestic abuse is: “Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological, physical, sexual, financial and emotional.” It is Force policy that when Police Officers or staff attend a domestic abuse incident where one or both of the parties are 16 years or older a F913 form submission is required. The form includes a risk assessment for the Police Officers to complete. The form is sent through to a Domestic Violence Co-ordinator located within the Public Protection Unit where a secondary risk assessment takes place. For the Police, Form 913 is the recording tool for all officers to submit a record of incidents of suspected or actual domestic abuse. For Hull alone, Humberside Police attend approximately 500 per month. These are initially screened using a national risk assessment code. The Form 913 is sent through to a Domestic Abuse Co-ordinator within the Public Protection Unit for a secondary risk assessment. Journey to Recovery (J2R) A non-criminal justice service to assess and assist individuals for both prescribing and structured interventions to support and enhance individuals with substance related problems becoming free of illicit substances and maintaining recovery. J2R took over from CHCP in July 2011. School Action School Action of the Special Educational Needs Code of Practice (2001) is provided when a child has been identified as making little or no progress despite a differentiated curriculum. Children are given extra support using internal resources, and progress is monitored via an Individual Education Plan. 78 Appendix (iii) Glossary of Terminology School Health Plus The universal school health service delivers the service required by the Government following the Healthy Child Programme. School Health Plus is an enhanced service provided by three City Health Care Partnership (CHCP) School Health Teams which can be procured by individual schools, bespoke to their needs or by a cluster group of schools collaboratively. Enhanced support packages include: attendance booster; emotional health support package; sex and relationships education programme; personal health and social education support and individually tailored programmes to a child or family’s needs. In this case the School Nurse undertook home visits to encourage parents to improve their child’s attendance. SUAT Meetings Hospital Social Workers employed by Children’s Social Care have been located within the Hull Women and Children’s Hospital for the last 13 years; and they have co-ordinated, chaired and recorded monthly substance misuse multi-agency meetings, which are held in the hospital. They are known as SUAT meetings as they use a Substance User Assessment Tool. Attendance at the SUAT meeting can include Compass, DIP, SCBU, two Safeguarding practitioners (representing Health Visiting and Hospital Trust respectively), Substance Misuse Midwives (when in post), Postnatal Ward Midwifery Sister; and more recently J2R.The purpose is to share information on pregnant substance misusing women and to ensure that support and intervention in individual cases is appropriate to the needs of the unborn child. 79 Appendix (iv) Drug Treatment System Referral Guidance 80 Appendix (v) HSC letter to all GPs regarding Pregabalin 81 Appendix (v) HSC letter to all GPs regarding Pregabalin 82 |
NC52308 | Death of a 7-month-old-baby girl in August 2017 as a result of a non-accidental head injury. Mother was found guilty of manslaughter and child cruelty and sentenced to imprisonment. Learning includes the need to: have a holistic approach which considers the needs of the whole family; record the child's developmental milestones and the family's support networks; be mindful of the parents' culture and its potential impact on childcare. Recommendations include: hospitals should hold discharge planning meetings for children with complex needs; health providers should consider the need for a lead professional and shared clinical care plans for children with complex health needs; safeguarding leads should make evidenced referrals to the Multi-Agency Risk Assessment Conferences (MARAC) and the MARAC coordinator should provide feedback to referrers regarding the outcome of any referral; all professionals working with non-mobile babies need to be alert to, and suspicious of, physical injuries to this vulnerable group; hospitals should take Kennedy samples when a child dies; if it is not safe for staff to visit an address, other workers should be notified.
| Title: Serious case review, Baby A: (born January 2017, died August 2017). LSCB: Essex Safeguarding Children Board Author: Felicity Schofield Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review, Baby A (Born January 2017, died August 2017) Final report Independent reviewer: Felicity Schofield August 2020 2 1. Introduction 1.1 The subject of this Serious Case Review (SCR) is Baby A, a baby girl of Asian origin, who died as a result of a head injury in August 2017, aged 7 months. Baby A had a twin brother who was not injured and is now living with his paternal family. 1.2. Following her death, a number of other injuries were found on Baby A, all of which were deemed to have been non-accidental. The earliest of these was concluded to have occurred approximately four to six weeks before her death. The other injuries were found to have occurred in the days leading up to her death. 1.3 There was nothing about this family that might suggest that their daughter would be deliberately harmed. The parents were not previously known to any safeguarding service and no safeguarding concerns had come to light during the ante-natal period, whilst Baby A was in hospital or whilst she was living at home. 1.4 Baby A was born prematurely and with significant health problems which required her to remain in hospital for the first four months of her life. Once she had been discharged from hospital, she continued to require some nursing care and was fed through a naso-gastric tube. 1.5 This Review covers the time period from June 2016, when the mother first became known to ante-natal services, through to August 2017 when Baby A’s brother was removed from the care of his parents. 1.6 The Review has sought to describe and analyse the professional activity in the weeks leading up to Baby A’s birth, during her stay in hospital and especially during the short time that she lived with her parents. 1.7 This SCR has been delayed because of the criminal investigation into Baby A’s death. The mother has always, and continues to, deny hurting Baby A, however, in July 2019, the mother was found guilty of manslaughter and child cruelty and sentenced to 6 years imprisonment. 2. The Process 2.1 In February 2018, The Chair of the LSCB decided that this case met the criteria for a SCR as described in Working Together to Safeguard Children 2015. The reason for this decision was because 3 Baby A had died as a result of a head injury. In addition, a post-mortem had established that there was evidence of multiple old and recent injuries to the head, eyes and musculoskeletal system which were consistent with several episodes of non-accidental injury. 2.2 On the advice of the Crown Prosecution Service and the police, the Chair of the LSCB decided to delay the SCR because both family members and key practitioners were required as witnesses in the criminal trial and could not contribute to the SCR until after the conclusion of the trial. Following the conclusion of the trial, both the father and practitioners were able to contribute to the Review. 2.3 The detailed terms of reference are attached as an Appendix. The purpose, framework, agency reports to be commissioned and the particular areas for consideration are all described there. Ten agencies contributed reports to this Review. Not all of the areas for consideration included in the Terms of Reference are explicitly referred to within the report but they have contributed to the analysis, findings and recommendations. 2.4 Working Together to Safeguard Children 2015 states that SCRs should: • understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight; • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; • be written in plain English and in a way that can be easily understood by professionals and the public alike HM Government (2015:74) 2.5 The lead reviewer, Felicity Schofield, is independent of all the relevant professional agencies in the Essex area, has had no previous direct involvement with or knowledge of the family who were subject to the review and has had no previous involvement in a professional capacity with safeguarding practice in Essex. She is a social worker by profession. 2.6 Both the father and practitioners who knew the family well have contributed to this review. Their contribution has enabled the lead reviewer to understand better the events leading up to Baby A’s death. Their input is greatly appreciated. 4 3. Period Covered by the Review The ante-natal period (July 2016 to 6 January 2017) 3.1 Baby A and her twin brother were conceived by IVF after the parents had tried to conceive for a period of about 5 years. Both parents spoke good English and were described as a professional couple. The mother was in the UK on her husband’s visa and had no recourse to public funds. 3.2 The maternity booking was made when the mother was 9 weeks pregnant. The issue of domestic violence appears to have been raised as a matter of routine by the midwife with no concerns identified, although the partner was present at the time, which would make such a conversation difficult. 3.3 The mother attended all her ante-natal appointments. From an early stage, routine scans identified that whilst one twin was growing normally, the other twin was much smaller although without any obvious abnormalities. The parents understood that the smaller twin may have complications when born. 3.4 The twins were born at 36 weeks gestation. Their paternal grandmother was staying with the parents in the period immediately before and after the births. Baby A was born with a defect in her oesophagus and a heart problem. Her birth weight was very low. Her brother was significantly heavier and was in good health. 3.5 Baby A was transferred to a neonatal intensive care unit in a neighbouring County the day after her birth. When she was just a day old, she underwent surgery to repair her oesophagus. As a result of this surgery she needed to be tube fed. 3.6 In the first few days after the twins’ birth the parents showed appropriate concern about the welfare of both babies. The mother and twin brother were discharged from hospital after 6 days. The mother remained anxious about Baby A, who was being visited by her father. Analysis 3.7 Both parents were involved in the ante-natal period and attended all the relevant appointments. They were prepared for the fact that Baby A was likely to have some additional health needs after her birth, although the nature of those needs could not be identified in the ante-natal period. 3.8 There was nothing about the behaviour of either parent which raised any concerns with health staff and after Baby A’s birth the parents showed appropriate concern for her welfare. 5 The period when Baby A was in hospital and her brother was at home (January – May 2017) 3.9 Throughout Baby A’s 4 month stay in hospital, she was regularly visited by her father although not every day. These visits were recorded as being short visits, approximately 15 minutes. Sometimes the paternal grandparents accompanied the father. In the first few weeks of her hospital stay, the father would ring the ward if he was unable to visit. The father has questioned the reference to the length of his visits, saying that whenever he visited, it was at least 45 minutes to one hour. He emphasised the circumstances for the family at that time; he was working in Central London and had to dash to Cambridge after finishing work at 6.00p.m, travelling one hour, then spending time with the baby, and often getting back home late at night, with work the next day. 3.10 The mother visited Baby A approximately once every three or four days. She was advised by hospital staff that she could either bring the other twin with her to visit Baby A or stay in the hospital so that she could spend more time with baby A. However, the mother did not drive and there were no family or friends who were able to drive her to and from the specialist hospital, which was 50 miles from the family home. 3.11 Ward staff recorded some concern both about the mother’s less frequent visits and about the length of visits by both parents, which were considered to be too short to get to know Baby A. Some four weeks after her admission, the parents were asked to visit earlier in the day and for longer periods of time. The records highlight the likely impact of the short visits on the parents’ attachment to Baby A. It is not recorded whether the reasons for needing to spend more time with Baby A were made explicit, and if they were, the parents’ response was not recorded. However, their pattern of visiting did not change. The family were also offered support from a psychologist although they did not actually meet with the psychologist because their ward visits did not coincide. The parents were given leaflets regarding the psychology service but they did not follow them up. The father said that the parents were not given any leaflets or indeed offered the psychology service. 3.12 The father has explained that he took responsibility for Baby A whilst his wife looked after her twin brother. He ensured that he visited Baby A 5 days a week. The father regarded the point of his visits as being to check on Baby A’s welfare and progress rather than to spend time with her. He worked in central London and therefore he had little option but to visit in the evenings. 3.13 At the beginning of February a health visitor visited the family home. The mother advised her that the paternal grandmother was expecting the mother to do all the housework, cooking etc whilst 6 the grandmother fed the baby. The mother also said that whilst her husband was generally supportive, he had changed since his mother had come to stay from India. 3.14 By the middle of February the parents, but especially the mother, were visiting baby A less frequently, for example the mother did not visit her for a period of over 2 weeks and the father did not visit for a period of 7 days. The length of their visits continued to be short. The father has explained that they visited Baby A less because she had recovered from her surgery and she was making good progress so they were less worried about her. 3.15 During this same period the mother attended the GP surgery for her post-natal check-up. The GP was unaware of the mother’s unhappiness at home because the health visitor did not record her visit on the shared information system, Systmone, until two months later. 3.16 In March the health visitor visited the family home and the mother was more positive about the home situation. There were no concerns about the brother’s care. The mother advised the health visitor that she and her husband played music to Baby A and took in pieces of clothing so that the baby would become more familiar with her family. 3.17 Throughout March the parents continued to visit once every few days, the mother less so. The parents were keen to speak to medical staff about Baby A’s progress and often rang for updates, but spent little time with Baby A. At the end of March, the hospital records state that a speech and language therapist would contact the parents to ask them to visit more frequently and to establish whether there was anything the hospital could do to facilitate this. There is no record of such a conversation having taken place. The following day the same concerns were discussed in a multi-disciplinary meeting but there is no record of a conversation with the parents. 3.18 In April the police attended the family home after a call from the mother stating that her husband had beaten and manhandled her. However, on arrival the police were advised that there had been a verbal argument with her husband about her mother-in-law’s critical attitude towards her. The mother had not been assaulted. No offence was recorded. The police offered the mother safeguarding advice. No further action was taken. 3.19 Information about the domestic abuse incident was passed to the health visitor on the same day and followed up with a phone call to the mother a few days later. The mother stated that the problems had been caused by her mother-in-law who had now returned to India. The mother advised the health visitor that she felt safe and that the baby was safe. 3.20 Towards the end of April, Baby A was able to begin feeding more normally, although she still needed to be tube fed as well. The parents continued to visit her once every few days but the mother 7 began to spend longer on the ward and to feed Baby A herself. The parents said they could not visit more often because of the distance to the hospital but the mother began to stay overnight. 3.21 Baby A transferred to a local hospital at the beginning of May. Hospital staff advised the father that ideally, they would like a family member on the ward with Baby A most of the time. The father said that he had not realised that this was their expectation. From then on, the parents visited Baby A more frequently and for longer. They received ongoing advice and support from both the nursing staff and speech and language therapists. Feeding was not easy but both parents persevered. No concerns about their approach were identified. 3.22 Baby A was discharged from hospital two weeks later. The father has described the discharge as ‘chaotic’. Both parents had been trained in her specialist feeding regime and were regarded as competent to undertake it within their own home. They were keen to take Baby A home. No concerns had been recorded by the local hospital regarding the care given by either parent or about their relationship with each other. Analysis 3.23 There is little information in the hospital records regarding either parent, essentially because there were no significant concerns. The recording was focussed almost exclusively on Baby A’s health needs. The length of parental visits was not always recorded nor was the parents’ response to conversations with hospital staff. 3.24 The concerns which had been identified about the timing and frequency with which the parents visited Baby A were raised early on with the father but were not pursued, even though the parents did not alter their visiting patterns to any significant degree and in fact visited less once Baby A was known to be making a good recovery. Practitioners have advised that no further action was taken because the concerns, whilst having been noted, were not considered to be serious. The father has advised that he was not aware that hospital staff were concerned that the parents were not spending enough time with Baby A. He believed he was visiting as often as possible in what were very challenging circumstances. The importance of spending time with Baby A in order to form an attachment to her was not an issue he considered or which he remembers being raised with him. 3.25 If the health visitor had liaised more frequently with the specialist hospital, she could have been made aware of these concerns and discussed them, together with Baby A’s needs generally, with the mother at home in a less stressful environment. She could have explained to the parents the importance of forming an attachment to a baby as soon as possible. 8 3.26 It is noticeable that when Baby A transferred to the local hospital and expectations about parental visits were made explicit, the parents spent more time in the hospital. In addition, the practical problems of caring for the other twin should not be under-estimated, especially when the mother did not drive and there was no extended family support. Once again, the health professionals could have usefully discussed this dilemma during their home visits. 3.27 The community health records also do not include information about the parents and how they were coping with the demands of twins and hospital visiting or what their feelings were about Baby A’s not insignificant health needs. There was no information in the records about the mother’s support needs and who might be meeting them, especially given the difficulties she had reported to be experiencing with her mother-in-law. Practitioners have advised that whilst they did recognise that the mother was isolated, their absence of recording was a consequence of the mother’s apparent ability to cope and the lack of any identified concerns. 3.28 When the parents started to become more involved in Baby A’s care, once she had transferred to the local hospital, they presented as caring committed parents. They took it in turns to stay with Baby A and appear to have coped well with her care. 3.29 There was no discharge planning meeting before Baby A was discharged from the local hospital. Given that Baby A was to receive services from three different professional groups in addition to her GP and the specialist hospital, it would have been helpful to get the relevant professionals together to ensure that the professionals and the parents were clear about their respective roles and responsibilities. Baby A’s time at home (mid-May to mid-August 2017) 3.30 Baby A left hospital in mid-May aged four months old. Over the next three months, Baby A was seen by health workers from three different professions (the health visiting service, the children’s nursing service and the speech and language service) at least twice a week. Each profession monitored different aspects of Baby A’s health. No concerns about Baby A’s care or her brother were identified. 3.31 The naso-gastric tube kept coming out during the first week. The parents sought advice on each occasion and health staff visited in response. The feeding problems continued and advice was sought from the GP, with the father taking Baby A to the surgery. Four days after the visit, the GP emailed the paediatrician seeking specialist advice. 3.32 The father has described this period as ‘overwhelming’. He ensured that every appointment was kept but by taking time off work to attend appointments, he was having to work at home through the evenings. He and his wife had no time to talk. He said they had so many appointments that when they 9 were advised by the nurse to consult their GP, they could not find time to attend for a period of four days. 3.33 At the end of May, both the health visitor and the mother were concerned about Baby A’s weight loss. The father had to take Baby A to the emergency department of the local hospital to get a replacement naso-gastric tube fitted after the original one had been accidentally damaged. The following day, the parents took Baby A to the GP regarding her weight loss. The GP had yet to receive a response from the paediatrician following her email two days earlier. 3.34 By the beginning of June, Baby A was recorded as having put on weight, although her weight remained very low (below 0.4 centile). There had been regular liaison between the various health professionals about her feeding problems. 3.35 The health visitor referred the family to a local children’s centre for support. The referral included the information about the earlier incident of domestic violence and also stated that the mother now described her relationship with her husband as satisfactory. Baby A was described as being alert and smiling. 3.36 This referral was responded to three weeks later with a joint home visit from a children’s centre support worker and the health visitor. During that visit, the mother said that she was a victim of domestic abuse in the form of arguments and controlling behaviour by her husband. These arguments tended to be about her mother-in-law who the father was skyping every week. The mother told them that her mother-in-law had sent over a white powder to put in the baby’s feed. She did not put the powder in the feeds but was worried about what her husband would say if he found out. In response, the health visitor contacted the father to advise him not to give the powder to Baby A and it was discarded. 3.37 At a second visit, the mother agreed to a referral to the local multi-agency risk assessment conference (MARAC). Based on the available information, the risk assessment score was significantly below the threshold for referrals (5 v 15), however, professionals can still refer to the MARAC if they have concerns. Whilst unable to be specific, the health visitor was worried that honour-based violence might be an issue, especially when the mother returned to India. However, no further action was taken by the MARAC coordinator because the risk assessment score did not meet their threshold. This decision was not fed back to the health visitor who, in turn, did not follow up her referral. 3.38 As part of the criminal investigation, the father told the police that he took Baby A to see his GP in connection with her reflux medication. At the same appointment the father sought advice about Baby A’s leg. The father had noticed that she could not put weight on it and that she seemed in pain 10 when he touched her toes. He had asked his wife who had said it might be cramp. The father has stated that the GP said there was no time to discuss this second concern and that he should raise it at his forthcoming appointment at the specialist hospital. 3.39 The GP records do not reflect this discussion. At interview, the GPs who saw Baby A during this time period confirmed that any reference to a painful limb would have been recorded. It should also be noted that there was no GP appointment in the days leading up to the appointment at the specialist hospital, which was at the beginning of July. The father remains adamant that he raised this matter with his GP but was content with the response because of the forthcoming appointment at the specialist hospital. 3.40 The parents and Baby A attended the appointment at the specialist hospital where a plan was agreed for her continuing feeding problems. The father advised the doctor that Baby A appeared to have some pain in her leg. Her legs were examined and nothing abnormal was identified. It is now known that Baby A probably had two fractures to her leg at this time. Expert witnesses in the subsequent court proceedings confirmed that as a result of this injury, Baby A would have been in pain with reduced movement to her leg. 3.41 In the four weeks before she died, baby A was seen by health professionals on 18 occasions, including two brief inpatient stays in two different hospitals. No concerns were recorded about either parent’s care of Baby A by any professional during this period. 3.42 Even with the benefit of hindsight following Baby A’s death, practitioners reported that there was nothing about the mother that gave them cause for concern. She was always welcoming, the flat was clean and tidy, and she was equally responsive to both babies. 3.43 The mother attended baby massage with both twins at the local children’s centre for the first time. She discussed with the support worker how she felt about meeting the babies’ needs and her relationship with the father. She said he checked her phone. The mother was given general support and advice about domestic abuse and the action she could take if she felt unsafe. The mother said she would like continued support with her emotional needs although there is no detail about why she wanted this additional support (presumably because of her ‘controlling’ husband). 3.44 Three days later the mother made a 999 call to the local police force, alleging domestic violence. The violence was alleged to have been part of an argument where the father had told the mother to leave the family home and that he did not want her looking after the children. 3.45 When a police officer arrived, the mother told the officer that she had been raped repeatedly by her husband over the last 7 years and that the twins had been conceived by rape. The last occasion 11 was said to have been 4 months earlier. The father has advised the lead reviewer that during this same visit he raised with the police officer the fact that the mother had smacked Baby A. There is no reference to this matter in the police records. The father was arrested and later released on bail with conditions not to contact the mother. 3.46 The mother and children were moved firstly to a police station and then to a hotel in a neighbouring County because she said she had no family or friends with whom she could stay. A community nurse visited them at the police station and again at the hotel because Baby A’s naso-gastric tube had come out and needed to be re-inserted. The mother appeared to be coping well in what were clearly difficult circumstances. The police notified Children’s Social Care (CSC). 3.47 On the same day as the mother’s allegation, the father also rang the police and alleged that the mother had smacked Baby A. The call was wrongly diverted to the Metropolitan police. This information was not passed on to the Essex police, who were only notified of it as part of the investigation following Baby A’s death. These two systems issues have been referred to the Independent Office for Police Conduct. The outcome is awaited. 3.48 Information was shared between the community nursing service, health visitor and GP, enabling Baby A’s specialist feed to be supplied to the hotel where the mother had been temporarily placed. The GP practice updated their records for the mother and children but not the father. 3.49 Within days the mother had formally withdrawn her complaint to the police and refused to make a statement. 3.50 In a phone conversation with the children’s centre support worker, the mother said that she did not want to be a single parent. She also said that her parents had encouraged her to return home because within her culture she would bring shame on her family. 3.51 Following that telephone conversation, the children’s centre support worker rang the duty social worker who was already aware of the domestic abuse allegation. The support worker shared her concerns about the mother’s vulnerability due to her isolation and Baby A’s special needs. The children’s centre support worker then made a referral to CSC which described the recent events and which also stated that ‘there is no concern for the children’s health and care needs being met’. 3.52The children’s centre decided that following the allegation of domestic abuse, it was no longer safe for children’s centre staff to undertake home visits alone to the mother and her twins. As a result, a further appointment was cancelled because there was no second worker available. 12 3.53 The case was allocated to a social worker who undertook a joint visit with the health visitor. CSC had had no previous involvement with this family. Baby A was undressed and weighed by the health visitor. There were no visible signs that Baby A had suffered any injuries. The mother repeated her allegations of rape and controlling behaviour by the father. The social worker noticed that the mother’s attitude to Baby A was more negative than it was towards her twin brother. The mother said that she wanted her husband to return home, believing that he had ‘learnt his lesson’. 3.54 Following the visit and the mother’s reported desire for the father to return to the family home, the social worker put arrangements in place for a child protection strategy meeting. 3.55 The community children’s nurse also visited that day at the mother’s request in order to re-insert the naso-gastric tube which had, once again, been pulled out by Baby A. 3.56 In the early hours of the next day, the mother made an emergency call for an ambulance. Baby A was reported to have stopped breathing. Baby A was taken by ambulance to a hospital in a nearby London Borough where she died shortly afterwards. The mother had been advised how to undertake CPR by ambulance control but when the ambulance arrived there was no evidence of her having followed this advice as Baby A remained in her cot. Analysis 3.57 The parents received significant amounts of help and support from community health professionals during the three month period that Baby A was cared for at home. It is evident from the records that community health staff responded promptly to the parents’ requests for practical help and communicated regularly with each other. They used the same electronic recording system (Systmone) which meant that all those involved with the family could see what information was recorded. 3.58 What is absent from the records is information both about how the mother was coping with the demands of caring for Baby A together with her twin brother and also about either twin’s developmental progress. The reason for this absence is because there were no concerns either about the parenting of the twins or about their development. 3.59 Baby A was consistently difficult to feed which, for a first time mother with no apparent support from either extended family or friends, a husband who was reported to be verbally abusive and controlling and a mother-in-law who she believed was being repeatedly undermining, must have been very difficult. However, the mother did not speak about her feelings and presented as coping well. She never complained. 13 3.60 The various professionals who were visiting the home did recognise the mother’s isolation but were limited in their ability to address this issue. The referral to the children’s centre was an appropriate response in the circumstances. 3.61 The four day delay in taking Baby A to see the GP in May was a good example of how demanding life was for this new family. The father said they had so many appointments that they just could not find the time to go. This delay in seeking medical advice could have been an opportunity for health professionals to consider the impact of their service provision from the family’s perspective. 3.62 The GP should have sought more direct advice from the specialist hospital regarding Baby A’s feeding difficulties. An email a few days after the consultation was not an appropriate response in the circumstances. 3.63 The father is adamant that he had raised concerns about Baby A’s leg with her GP a few days before it was examined by a paediatric surgeon at the specialist hospital. However, that appointment has not been identified as part of this review and whilst the GPs who saw Baby A in the broad timeframe remember seeing her, neither remembers a reference to a painful leg and it is not recorded in their notes. It is not therefore possible to comment further on this matter. 3.64 The failure of the doctor at the specialist hospital to identify an injury to the leg at the beginning of July was a missed opportunity to safeguard Baby A. Further enquiries should have been made with the parents in order to establish why they thought Baby A’s leg was painful. Whilst the reason for the appointment was the problem with her oesophagus, all doctors should be mindful of the potential for a non-accidental injury. The vulnerability of non-mobile babies to non-accidental injuries has been repeatedly identified in serious case reviews. Medical opinion has subsequently confirmed that at this time Baby A’s leg would have been painful and her movement would have been restricted. 3.65 During the last four weeks of her life, when we now know that Baby A sustained other injuries in addition to her broken leg, there were 18 contacts with health professionals. At no time did the mother express any difficulty in caring for the twins. If Baby A was unsettled and/or grizzly, this was attributed to the difficulties with her feeding tube. 3.66 A more coordinated approach across the health professionals with a named Lead Professional and a single clinical care plan which identified lines of accountability and areas of responsibility would have helped the family. A lead professional could have taken overall responsibility for ensuring that all Baby A’s health and social care needs were being met. 3.67 It would also have been helpful to identify when Baby A should be taken to her GP and when specialist advice should be sought from either the local or the specialist hospital. For example, at the 14 end of May when there were concerns about Baby A’s feeding problems, approaching the hospital direct may have been more appropriate. 3.68 There was an appropriate and timely response to the mother’s initial allegations of domestic abuse, although a referral to MARAC was not appropriate given that the risk assessment score was considerably below the threshold for such referrals. The health visitor’s safeguarding lead should have advised the health visitor to seek more information if she was worried about honour-based violence before making the referral. Nevertheless, the MARAC coordinator should have provided feedback to the health visitor regarding the decision to take no further action. It was good practice for the GP to update the records, but this should have included the alleged perpetrator as well as the victim. 3.69 The support from the children’s centre would seem to have been precisely the right approach for supporting this isolated mother but unfortunately there had been no opportunity to establish the support before the second allegation of domestic abuse which effectively ended the children’s centre’s involvement with the family. The centre’s risk assessment, which indicated that two workers were required for a home visit, resulted in support not being offered to the mother and was at variance to other services where lone workers were continuing to visit the family home. 3.70 It is now known that the father made a counter-allegation concerning the mother smacking Baby A on the same day that the mother alleged rape. The local police were unaware of the father’s telephone call, however, the mothers more serious allegation would have taken priority at least in the first instance. Immediately after Baby A’s death 3.71 In line with multi-agency procedures for child deaths, Baby A’s body was examined by both a paediatrician and a police officer shortly after she had arrived at the hospital. The paediatrician was aware of Baby A’s extensive medical history although the hospital could not access her records. No concerns were identified during this examination. Any marks on the body were attributed to Baby A’s medical condition. Other evidence, such as the taking of blood and urine samples, known as Kennedy samples, was only partially gathered, despite a challenge to the paediatrician from the attending police officer. 3.72 The family home was visited by a police officer, two social workers and a specialist nurse on the day that Baby A died. Her death at that stage was regarded as ‘unexplained’. Nothing of concern was identified within the home environment. 3.73 A strategy meeting was also held on that day and because the death was unexplained, it was agreed that there should be a daily visit to the family home by either the social worker or the health 15 visitor pending the outcome of forensic tests. The father was taken to see Baby A, released from his bail conditions and allowed to return to the family home with the mother’s agreement. 3.74 Both parents wanted to resume their relationship and agreed to work with CSC. The father denied the allegations of rape. He also told the social worker that on occasion he had seen the mother smack baby A on the bottom and that sometimes the mother had become angry with Baby A because she was not as quick to learn as her brother. The social worker shared this information with the police. 3.75 Nothing of concern had been found at the examination immediately after the death of Baby A. A skeletal survey was then undertaken three days later and found multiple injuries which had occurred at different times, mainly but not exclusively in the few days prior to Baby A’s death. The skeletal survey was completed on a Friday but the results were not passed on to either the police or CSC until the Monday, potentially leaving the brother at risk of significant harm over the weekend. The post-mortem was completed nine days following the death of Baby A. 3.76 A child protection strategy meeting was held on the same day that CSC were notified. Both parents were arrested and the twin brother was removed from their care six days after his sister had died. A child protection medical subsequently found no evidence of any bruising or injuries to the brother. Analysis 3.77 The brother was potentially at risk in the six days between Baby A’s death and CSC being informed of the outcome of the skeletal survey and his subsequent removal from his parents’ care. 3.78 Expert evidence from the criminal trial confirmed that the facial bruising to baby A would not have been obvious at the time of death and was only found as part of the post-mortem process. 3.79. The local child death procedures required certain samples to be taken immediately after an unexplained death: ‘Where the cause of death / collapse or factors contributing to it are uncertain, investigative samples should be taken immediately on arrival and after death is confirmed. Full guidance is provided to hospital staff on the taking of samples.’ (Paragraph 18.1) 3.80 A strategy meeting was rightly held on the day of Baby A’s death because her death was unexplained. The decision to introduce daily visiting pending the outcome of the post-mortem was an appropriate response. 3.81 There should not have been a delay of three days between the identification of the fractures and both the police and CSC being notified. The reason for the delay is not fully understood, possibly a 16 misunderstanding regarding the availability of child protection services at weekends. The process has since been reviewed and procedures changed to ensure that such a delay would not happen again. 4. Baby A’s lived experience 4.1 Baby A had a traumatic start in life being born prematurely and spending her first four months in hospital. During that period her parents did not spend a great deal of time with her, both because she was in a hospital at some distance from the family home and also because the parents had her twin to care for. 4.2 Feeding was very difficult for Baby A, firstly because of the problems with her oesophagus and later because of the naso-gastric tube. She was reported to be averse to feeding orally even when it was possible and desirable. 4.3 Baby A was repeatedly recorded as having pulled out her naso-gastric tube. Whenever the tube came out, a nurse was required to re-insert it. These incidents account for the very high level of visits from community nurses. Sometimes it took several attempts to re-insert the tube. On one occasion Baby A was described as being exhausted by these attempts. 4.4 When Baby A was first discharged from hospital, she had delayed gross motor skills as a consequence of her health problems and prolonged stay in hospital. This delay in her development was temporary. 4.5 Baby A was injured on at least three separate occasions before her death. Her leg was broken in two places between 4 and 6 weeks before her death, her skull was bruised between 3 and 7 days before her death, her ribs were broken between 2 and 4 days before her death and her skull was fractured in the final 12 hours of her life. She had therefore experienced considerable physical abuse during those last weeks of her life. 5.0 The Parents 5.1 The parents had tried to conceive for a number of years and were looking forward to the birth of the twins. 5.2 Following the birth there was a difficult period when Baby A was in hospital at a considerable distance from the family home. During this time the father took the main responsibility for visiting Baby A, whilst his wife cared for the twin brother. Once Baby A had left hospital, the father took her to her many appointments. The father regarded this approach as the best way to cope with the practicalities of their situation. 17 5.3 At no time, either whilst Baby A was in hospital or when she was at home, did either parent advise any of the workers who visited them that they were experiencing difficulties in caring for the twins, although the father has subsequently described the situation as a whole as overwhelming. They just managed as best they could. 5.4 The mother continued to deny any difficulties during both the care proceedings and in the criminal trial, where she pleaded ‘not guilty’ to the charges against her. During the criminal trial, the mother’s friends also stated that the mother appeared to be coping well. 5.5 The parents’ relationship was strained. Divorce proceedings were said to have been commenced in India, although this was not known prior to Baby A’s death. The mother made allegations of coercive control and domestic violence, which the father denied. Although she did involve the police, the mother decided not to pursue her allegations. Some of her allegations were later proven to be untrue. At the time of Baby A’s death, the mother had wanted her husband to return home but he was prevented from doing so by bail conditions. 5.6 After Baby A’s death, as part of the subsequent court proceedings, the father said that from around July he had noticed that the mother was short-tempered with Baby A because she was developmentally behind her brother, occasionally ‘tapping’ or ‘smacking’ her bottom. When Baby A did not want to take a bottle, both parents called her ‘lazy’. 5.7 The father has expressed his concern to the lead reviewer that his views were not sought before a referral was made to the MARAC and that his concerns about the mother’s treatment of Baby A were not considered at the time that his wife made the serious allegations of rape and domestic abuse. 5.8 During the criminal trial, it was suggested that the mother had ‘played down’ the extent of Baby A’s problems, describing both twins as ‘the same’ in conversations with both her husband and members of the extended family. However, practitioners who had visited the family home did not perceive the mother’s attitude towards Baby A as a cause for concern, reporting that it is not unusual for parents to ‘normalise’ their children’s special needs. 6. Changes in Service Delivery since Baby A’s death 6.1 The three health professions and the children’s centre are now all managed as a single Children and Family Wellbeing Service with a single set of policies and procedures. As a consequence of this reorganisation, the response to referrals for additional support is quicker. 18 6.2 If a similar domestic violence allegation was made to a health visitor today, an independent domestic violence adviser (IDVA) would be allocated within 24 hours. 6.3 The same lone working policy now operates across the Children and Family Wellbeing Service. 6.4 The local hospital has introduced discharge planning meetings for children with complex health needs. 6.5 A more robust procedure for taking Kennedy samples has been introduced by the hospital where Baby A died. 6.6 The London hospital which undertook the skeletal survey after Baby A’s death has reviewed and changed its procedures regarding communication with the police following the identification of safeguarding concerns. 7. Lessons learned and findings Overall: 7.1 There was nothing about this family that might suggest that their daughter would be deliberately harmed. The parents were not previously known to any safeguarding service and no safeguarding concerns had come to light either during the ante-natal period, during the four months that Baby A was in hospital or in the short period that she lived at home. 7.2 The parents were Indian with the mother having moved to this country relatively recently and having no recourse to public funds. She had no family living in this country. Both parents’ English was good. However, practitioners could have been more enquiring about the parents’ culture and its potential impact on their care of the twins. Practitioners have reported that they were mindful of the potential impact of the parents’ culture but did not identify any issues or concerns, which is why their records contain so little reference to culture. 7.3 The parents did not tell anyone that they were struggling with the care of the baby A, if indeed they were. However, the parents were managing a stressful and demanding situation with very little support from either friends or family. The focus of the recording by health professionals was on Baby A’s complex needs. A more holistic perspective which considered the needs of the whole family, including the recording of developmental milestones for both babies and a description of the family’s support networks should have been included. 7.4 It would appear that in the absence of her husband, the mother found it difficult to care for Baby A. The mother never said that caring for the twins on her own might be a problem but this possibility should have been considered and discussed with her once the couple were separated. 19 7.5 A number of health staff did examine Baby A after she had sustained injuries, however, in the absence of any concerns about the way she was being looked after, it seems that if she was fretful or upset, her behaviour was attributed to her health problems. The possibility that she had been deliberately harmed was not considered. Specifically: Discharge meetings for babies and children with complex health needs 7.6 A discharge planning meeting could have established a more coordinated response to service provision at an early stage. Recommendation: Hospitals should consider holding discharge planning meetings for children with complex needs. (This has already been actioned by the local hospital). Coordinating services for babies with additional health needs & the need to identify a lead professional 7.7 Baby A was seen by health professionals at far greater frequency than would be the case for a baby without her health needs. During the three months that she lived with her parents she was generally seen at home at least twice a week by representatives of one of the three professional groups that were delivering direct services to her. In addition, she had appointments with two local hospitals, a specialist regional hospital and her GP. 7.8 The records evidence very regular information sharing between the various professionals. However, there was no lead professional and no coordinated approach to the provision of services, the liaison with the hospitals and with the GP. 7.9 The level of visiting was intrusive to the family, even though it was often requested and never complained about. A lead professional could have discussed the overall situation with the parents and developed a better understanding of how they were managing. Recommendation: Health providers should consider the need for a lead professional and shared clinical care plans for babies and children with complex health needs. Responding to allegations of domestic abuse 7.10 The allegations of domestic abuse were responded to promptly and sensitively. A risk assessment was undertaken and the mother was given appropriate advice. The health visitor consulted her safeguarding lead and made a referral to the MARAC, despite the fact that the risk assessment score was significantly below the threshold for referrals (the score was 5, the threshold was 15 or above). 20 7.11 Whilst it was good practice for the health visitor to consider the risk of honour-based violence there was insufficient information to enable the police to take any further action. 7.12 Thresholds are in place in order to ensure that scarce resources are directed towards those families who are most in need. There is provision for professionals to refer cases to the MARAC which fall below the threshold based on professional opinion. In this case there do not appear to have been exceptional reasons which warranted such a referral. The safeguarding lead should have advised against making a referral at that time and encouraged the health visitor to acquire a more detailed understanding of the situation. If there were exceptional circumstances which warranted a referral despite the low risk assessment, the safeguarding lead should have identified and agreed the reasons before the referral was made. 7.13 The MARAC coordinator should have advised the health visitor of the outcome of her referral so that she was aware that no further action was being taken. Similarly, if the health visitor had no response from the MARAC following her referral, she should have followed it up. Recommendation: Safeguarding leads should be reminded of the importance of ensuring evidenced referrals to the MARAC. The MARAC coordinator should be reminded to provide feedback to referrers regarding the outcome of any referral 7.14 After the second allegation of domestic abuse, the children’s centre decided that it was no longer safe for their workers to visit the family alone. This decision was made in isolation of the other services being provided to the family, all of whom continued to send lone workers to visit the family home. Recommendation: If an agency decides that it is not safe for their staff to visit an address, they should notify their decision to other workers who are also known to be visiting the same address. Injuries to non-mobile babies and children 7.15 A few weeks before her death, the parents advised a paediatric surgeon that Baby A’s leg appeared to be hurting her. How would a parent know that a baby’s leg was hurting her? The paediatric surgeon failed to seek further information from the parents. Whilst the leg was examined, fractures to the tibia and fibia were not identified. Recommendation: All professionals working with non-mobile babies to be reminded of the importance of being alert to and suspicious of physical injuries to this vulnerable group. 21 Timely Communication between police forces 7.16 Essex police only became aware that the father had alleged that the mother had smacked Baby A after her death because the allegation was wrongly reported to the Metropolitan police and not subsequently passed on to the Essex police force. Recommendation: The Safeguarding Partnership should consider the implications of the Independent Police investigation once the outcome is known. Compliance with Child Death procedures 7.17 A strategy meeting was rightly held on the day of Baby A’s death and because her death was unexplained, the decision was taken to introduce daily visiting pending the outcome of the post-mortem. This was an appropriate response. There were no grounds to take any additional safeguarding action at this stage. 7.18 Some Kennedy samples were not taken at the time of Baby A’s death, despite the procedures being clear that this is a requirement for all unexplained and unexpected child deaths. The failure to do so appears to have been the result of a misconstruing of the coroner’s directions by the hospital in a neighbouring London Borough. 7.19 There was a delay of three days between the identification of the fractures at the skeletal survey and Police and CSC being notified. The reason for this delay has been explored but remains unclear. However, the procedures have been changed to ensure that such delays will not happen again thereby reducing the risk of harm to siblings. Recommendation: The Strategic Child Death Overview Panel ensures that Kennedy samples are now being taken as required by the Child Death procedures. 8. Recommendations: 8.1 Hospitals should consider holding discharge planning meetings for children with complex needs. 8.2 Health providers should consider the need for a lead professional and shared clinical care plans for babies and children with complex health needs. 8.3 Safeguarding leads should be reminded of the importance of ensuring evidenced referrals to the MARAC. 8.4 The MARAC coordinator should be reminded to provide feedback to referrers regarding the outcome of any referral 22 8.5 The Safeguarding Partnership should consider the implications of the Independent Police investigation once the outcome is known. 8.6 All professionals working with non-mobile babies should be reminded of the importance of being alert to and suspicious of physical injuries to this vulnerable group. 8.7 The Strategic Child Death Overview Panel should ensure that Kennedy samples are now being taken by all hospitals in the area, as required by the Child Death procedures. Addendum to the Serious Case Review report – Baby A Introduction During the process of this report being quality assured by the Essex Safeguarding Children Board, it was widely considered that the report lacked a degree of balance as a result of Mother’s perspective and experiences not having been included in the SCR report. Two previous letters sent by the Essex Safeguarding Children Board in July 2018 and September 2019 to Mother’s solicitor, informing Mother about the Review and inviting her to contribute to the Report, had not elicited a response. However, following a third attempt to make contact with Mother in January 2020, this time via the prison, Mother said that she would like to be involved. She said that she had not received the first two letters. This addendum report provides a summary of information obtained from Baby A’s Mother following a face to face meeting between her and two senior representatives from the Essex Safeguarding Children Board on 24 February 2020, which enabled her to go through the report and ask questions. In addition, she was allowed to keep a copy of the draft SCR report to further reflect on the content and so that she could provide written comments for inclusion in the published version as an addendum report, and the Essex Safeguarding Children Board received this on 16 March 2020. A further meeting was held with Mother on 9 July 2020 via conference call to agree the final content. Mother’s input has been very helpful in helping us to understand her experiences and to help clarify certain points. There is no doubt that taking part in this process was extremely upsetting for Mother and she was visibly distressed during the meeting at the prison. However, we are grateful for her contribution and also for the support offered to Mother from the HM Prison Service. 23 Mother’s perspective Mother went to University in India to study for a Master’s degree in Social Work. All her family live overseas and she has no-one in this country outside prison to support her or argue her case for her. She married Baby A’s father in 2009 and this was an arranged marriage. Once married she came to the UK on her husband’s passport but she herself had no recourse to public funds. Mother described her husband as being very wealthy and as such he held the money and the passport. The children were conceived by IVF after 7 years of marriage. From the first scan the doctor was very concerned about Baby A and had told the parents to be prepared anytime for their unborn daughter to die. Both parents asked the doctor numerous questions about what the problems might be, but the doctor was not able to say with any certainty at that time. The twins were born by emergency C-section on the 6th January 2017. Mother explained that Baby A was born prematurely with significant health issues which required her to remain in hospital for the first four months of her life. Baby A underwent an operation on her oesophagus the day after she was born which was unsuccessful and the doctors were reluctant to undertake a further operation due to the potential risks involved. The reason why Baby A needed to remain in hospital for the first four months of her life was to allow the hole in her oesophagus to heal. In those four months Baby A went through six constructs in the radiological department. Throughout Baby A’s 4 month stay in hospital, Mother said that her husband used to visit the child regularly. If he was not able to visit both parents would make sure that they called the hospital to enquire about their daughter’s well-being (at least 3 times a day). When Mother was unable to visit her daughter in the hospital with her husband, he ensured that she had contact with Baby A via FaceTime, in addition to sending her pictures and videos of their daughter. Mother said that once discharged from hospital, Baby A continued to receive nursing care every other day and was fed through a naso-gastric tube. In addition to the home visits by health practitioners, (47 in total), her daughter also had various GP and hospital visits within this three-month period. Mother said she herself was also experiencing a lot of post-operative pain at that time. (The SCR report - 1.4 refers to the family being overwhelmed with appointments). Baby A’s father would usually take their daughter to the hospital while her mother would arrange all Baby A’s appointments and make sure that everything was organised. Whilst both parents would try 24 to take Baby A together to the hospital, this was not always possible and they did not feel this was the right environment for their son. However, Mother emphasised that they did not miss any appointments or any phone calls from the health professionals involved in their daughter’s care. Mother said that both parents were always worried about their daughter and continued to ask questions of medical staff about her health. The mother maintained that if any of the medical staff had had any concerns about them as parents, then she was sure that they would have raised this with the GP or the health visitor or indeed with themselves. The mother has no recollection of being offered any support from a psychologist either before, during or after giving birth. (The SCR report refers to the hospital offering this support via giving the parents an information leaflet about their psychological services. However, it would appear that handing out an information leaflet was not considered by Mother to be an offer of psychological support). Baby A’s naso-gastric tube kept coming out almost every other day. Both parents raised concerns with the Speech and Language Therapist regarding their daughter not having any paediatric appointments which they thought was really important. The mother believed the Speech and Language Therapist had then raised this with the GP. Mother recalled an occasion when her husband having returned home from work lifted up their daughter and helped her to stand however she looked as though her leg was in pain. The mother observed that Baby A used to wriggle about a lot and wondered if it might be cramp, so they agreed to monitor her overnight with a view to discussing their concern with the G.P. the following morning as they already had an appointment to discuss her reflux medication. When Baby A’s father took her to the G.P, the father said that he had raised his concern about her leg, however the G.P was reported to have told him that he would have to make another appointment as it was a different issue . The following day both parents (and the twins) attended an appointment for Baby A to see a health specialist in an out of county hospital and they raised their concern with him about her leg. Mother said that the doctor did ‘a throw test’ on her leg and concluded that he was not concerned.Mother raised the issue and her concerns that the doctor missed whether there was anything wrong with Baby A’s leg. Mother said that she does not know and is concerned why no health professional picked up that her daughter was in pain, especially as health visitors used to check Baby A’s weight every week and she 25 was fully undressed at that time . The health professionals used to hold Baby A all the time to make sure that she was alright. Similarly, Mother said that she attended baby massage with both her children at a local Children’s Centre. She would massage her daughter and a nurse would massage her son. However, Baby A did not appear to like the massage and would cry throughout. When the nurse asked her why Baby A was crying, Mother explained that her daughter would always cry when being massaged or bathed. Mother feels strongly that her daughter’s health problems were more significant than initially thought by professionals. Mother confirmed that she did make a 999 call to the police, as described in the SCR report due to an argument with her husband. She said that it came about when her husband was on Skype with his parents overseas and he was showing the twins to them. The call coincided with the time for Baby A’s medication which was very important to her. Baby A’s Mother asked her husband a couple of times to allow her to give their daughter her medication (which she had to administer through a tube), however he did not comply and continued holding their daughter which started the argument. Mother said that her husband did not tell her to leave (as recorded in the SCR report) and that he wanted her to look after their children. She is clear that she did not have any contact with her mother-in-law when she returned to India (following her stay with them in the UK) and it was her own mother who had advised her not to bring up her children without a father and it was nothing to do with her culture or shaming her family. Following the argument she remembers her husband telling the police officer that she had smacked their daughter. The mother said that she only affectionately tapped Baby A’s bottom while cradling her as a soothing gesture. Baby A’s Mother said repeatedly and consistently that she did not know how her daughter sustained her injuries and that she felt that Baby A’s health issues were much more significant than was initially thought by professionals. She said that she has not been able to grieve for either of her children and “can still smell them”. Her distress is compounded by the fact that her own parents did not have the chance to meet either of their grandchildren. |
NC52227 | Death of a 3-month-old infant in August 2019. Jason had been co-sleeping with a sibling and his mother. Jason had already died when Mother contacted emergency services and he was taken to hospital. Skeletal surveys found no injuries beyond evidence of attempted resuscitation. Siblings were subject to child protection plans and children in need plans at different points from 2008. Parents had been looked after children and experienced adverse childhoods. Mother had a history of self-harm, low mood and domestic abuse and was subject of a child protection plan for several years. Mother had difficulties regulating emotions and could be very hostile and aggressive with practitioners and the public. Father was remanded in prison at the time of Jason's death. Parents are White British. Learning includes: some parents have difficulty assimilating and consistently following advice and the circumstances under which children's needs are neglected; the way parents respond to their children's needs is influenced by their own childhood experiences; parents who have experienced unstable or adverse childhoods can learn to just focus on their own needs because they have learnt not to depend on others. Recommendations include: ensure multi-agency training includes curiosity about where children are sleeping as part of assessments; develop safe sleeping procedures emphasising the importance of ongoing risk assessment about safer sleeping for all services; consider how the use of the neglect toolkit is used routinely by services; encourage every GP practice to have a written protocol for discussing safeguarding concerns and follow-up.
| Title: ‘Jason’: the overview report. LSCB: Wakefield Safeguarding Children Partnership Author: Peter Maddocks Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 21 A local child safeguarding practice review (LCSPR) commissioned under The Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018 ‘Jason’ The Overview Report May 2021 Page 2 of 21 Index 1 Introduction and context ........................................................................... 3 1.1 Purpose and circumstances of the review ........................................... 3 1.2 Agencies who provided information to the review ................................ 3 1.3 Family contribution to the review ...................................................... 4 2 Overview of information ........................................................................... 4 Research and national learning relevant to the review ...................................... 10 3 Summary of learning from this local child safeguarding practice review ........... 13 4 Assessment of systemic or underlying reasons for what happened .................. 15 5 Summary of recommended improvements to be made to safeguard or promote the welfare of children ............................................................................ 19 The methodology and terms of reference ....................................................... 21 Page 3 of 21 1 Introduction and context 1.1 Purpose and circumstances of the review 1. This review was commissioned following the tragic death of three-month-old Jason in August 2019. It examines the involvement of ten organisations from 1st February 2017 until Jason’s death. Jason had already died when his 29-year-old mother contacted the emergency services and he was taken by ambulance to the hospital. A subsequent skeletal survey found no injuries over and above the evidence of attempted resuscitation. Jason had been co-sleeping with a sibling (Child 2) and his mother. The eldest sibling (Child 1) was not with the mother or the two younger children and has lived with the paternal grandparents since May 2019. Jason’s 37-year-old father was already remanded to prison at the time of Jason’s death for an offence of grievous bodily harm (GBH) with intent. The family live in an area of high deprivation1. Jason’s parents are white British and English is their language of communication. Father was employed before going to prison. His job involved working away from home for most weekdays and nights. There is no record of any faith-based affiliation for either parent. 2. For clarity, the use of acronyms is kept to a minimum. Jason is the name used for the child whose tragic death is the subject of the review. Child 2 is a 19-month-old full sibling and 10-year-old Child 1 is a half-sibling with a different father. Any birth family members are referred to by their relationship to Jason as mother, father or grandparent for example. Professionals are referred to by their job titles or role such as GP, health visitor, police officer, probation officer, social worker or teacher. 1.2 Agencies who provided information to the review 3. The following agencies have provided information including agency learning and contributed to a virtual learning event for the LCSPR: a) Bradford District Care Foundation Trust (BDCFT) (community health service); provided health visiting services in Wakefield and District; b) Wakefield MDC Children’s Services (social work services); statutory children’s assessments c) Mid Yorkshire Hospitals NHS Trust; provided midwifery services; d) NHS Wakefield Clinical Commissioning Group (CCG); provided primary care services through the GP practices; 1 94.4 per cent of post codes in England are less deprived. ONS Postcode Database http://geoportal.statistics.gov.uk/ Page 4 of 21 e) Primary school (unnamed to preserve the anonymity of Jason and his family); f) South West Yorkshire Partnership Foundation Trust; offered access to mental health services; g) West Yorkshire Police; involvement over several years about allegations of anti-social and violent behaviour, repeat offending, substance misuse, sexual abuse, h) West Yorkshire Community Rehabilitation Company Ltd; supervised father following his conviction for a drink driving offence in 2018 and was imprisoned in summer 2019 following a violent assault i) Yorkshire Ambulance Service who also provide the NHS 111 service as well as emergency services; had contact in February 2018 about mental health concerns when the response crew made a safeguarding referral about the children; attended a road traffic accident in 2018 when father was convicted of drunk driving and in January 2019 were called when the mother was assaulted by a member of the extended family. 1.3 Family contribution to the review 4. The parents were advised about the review and invited to provide information. The mother made no response. Father asked for a meeting with the report author at the prison but declined to have a discussion when the author visited him. 5. The parents were advised the review was due to be completed and have received copies of the final report ahead of publishing. Both parents chose not to provide any comment. 2 Overview of information 6. The family had contact with universal and specialist services over several years dating back to the childhood of both parents when both had been looked after in local authority care at different times. Both parents had adverse childhoods although much less information is recorded about the father. Jason’s mother has presented with evidence of self-harm (cutting and overdoses), low mood and domestic abuse. She experienced traumatic experiences in her childhood and was the subject of a child protection plan as well as being looked after for several years. She experienced several disrupted placements in residential and foster care. Mother has difficulty in regulating her emotions and can be very aggressive and volatile; this occurred for example at GP surgeries, with housing officers and social workers as well as in the general community. She struggled at times with understanding and responding to the needs of Child 1 her eldest child. An example is the mother’s insistence that Child 1 had ADHC (attention deficit hyperactivity disorder) and poor behaviour despite the school not observing any evidence of ADHC or particularly problematic behaviour compared to peers. Both parents used alcohol and drugs which aggravated and Page 5 of 21 contributed to incidents of significant antisocial and violent behaviour. Child 1 was subject to a child protection plan (CPP) between December 2008 and February 2010 due to concerns about emotional abuse. The case was closed to social work involvement when the CPP ended although very soon afterwards Child 1 was injured and there had been verbal and physical confrontations between mother and Child 1’s father. There was a social worker assessment and the case was closed. In the summer of 2013 Child 1’s school attendance was poor; this has remained a factor up to 2019 when Child 1 moved to the grandparents. There was the third assessment in 2015 and the Early Help Service were involved for a short time. In June 2015 mother received hospital treatment following an overdose. Following a short Child in Need (CIN) plan social work involvement was closed in 2015. 7. Child 1 became the subject of a further CIN (child in need) plan in March 2017 following a referral from the police in respect of domestic abuse and an assessment was completed by Children’s Social Care (CSC) who closed their involvement when the assessment was finished and the CIN plan was stepped down to the Early Help Service through the HUB. The closure and stepping down was not discussed with other services. 8. In early February 2018, the school made a home visit; this was not the first and the school was regularly in contact with the mother and visiting the home in an effort for example to improve Child 1’s attendance at school. The mother reported difficulties with managing Child 1’s behaviour and persisted in her assertion that Child 1 had ADHD despite the school not seeing evidence of this in behaviour at school. From their contact with Child 1 and mother, the school had a range of information about the family’s circumstances; mother was receiving anti-depressant medication through the GP and she acknowledged low mood; she also disclosed information that Child 1 was being used as a carer in the family for Child 2 and which was probably a contributory factor in Child 1’s poor level of school attendance. 9. Less than a week after the home visit Child 1 told the school that she was worried that her mother might have self-harmed. The school visited the home and spoke with the mother who acknowledged having thoughts of self-harm but had no plans to do so. The mother described Child 1’s behaviour at home as being a significant stressor. When Child 1 did not come to school the following day the school visited the home but could get no answer and therefore involved the police who gained entry to the property. They found drugs during their search for the mother and the children who were not in the house. Subsequent contact by phone established that the mother and the children were at the maternal grandmother’s home. The only service to make a referral relating to the incident was the ambulance service who had been called to attend in anticipation of the police entry into the family home. None of the services requested a strategy meeting although CSC completed an assessment. The assessment was an opportunity to make enquiries with other services and to collate relevant history as well as the more recent concerns. Page 6 of 21 This did not occur and is discussed later in the report. A combination of physical standards not causing concern, mother’s lack of engagement and insufficient attention to the lived experiences of the respective children were significant factors in professionals not recognising the level of neglect. The assessment recorded Child 1’s school attendance as good when it was a persistent concern. 10. The YAS made a second referral in April 2018 when they attended a road traffic accident (RTA) after the father had collided with another vehicle and tested positive when breathalysed. Mother and the children were in the vehicle with him. They had not been in any approved child restraint seating. The police did not make a referral. There were other incidents when for example father had assaulted a taxi driver in February 2018 and reports of drug dealing from the house were not reported. 11. In May 2018 the police received the first of what would be several further contacts from the local community reporting concerns about drug use and supply from the house. There were also complaints of intimidating text messages with a threat to harm from mother against people making complaints. Those contacts which did not result in any police checks as to where children were in the household did not result in any discussion in or referral to the MASH. 12. In May 2018 father began his 12-month community supervision order. There was contact from the probation officer to the social worker at the outset of the supervision; this included advising the social worker about planned work on binge drinking which was seen as a factor in his offending behaviour (having been convicted of drink-related motoring offence) and 1.1 work on the impact of domestic abuse on partner and children. The supervising officer identified from the first session that the father’s relationship with Jason’s mother and with previous partners had been characterised by domestic abuse. Father claimed he did not use drugs and that he had managed to move from being alcohol dependant to controlled drinking. Information was exchanged with CSC after the first session which ensured that CSC was aware of the court directed work and for CSC to inform the supervising officer that the children were known to CSC but were not subject to a child protection plan. There is no recorded evidence that the safeguarding concerns identified as part of the offender assessment were discussed with CSC and considered alongside their long history of contact with both parents and the children. 13. The police sent a copy of a DASH2 risk screening to the MASH3 in June 2018 after they responded to a report of the parents being intoxicated and fighting at the family home. This was triggered by an argument about how to handle the baby (Child 2). The DASH provided little detail about the incident. 2 Domestic abuse, stalking and harassment (DASH) risk identification and assessment tool 3 Multi-agency safeguarding hub (MASH) Page 7 of 21 Significantly, within the context of a review following the sudden death of an infant, the mother was asleep when the police arrived and could not be roused and the baby Child 2 was asleep on the bed beside her. Child 1 was worried that her parents would not wake during the night when the baby needed feeding. As discussed later in the report the use of substances and co-sleeping presented a very significant risk of harm to infants under six months; there was also evidence of potential emotional and physical harm to all the children as well as neglect. There was no strategy discussion requested by any of the services. There was a CIN meeting although the records do not confirm who participated. The police would not have been in attendance nor the GP; both of these services had significant and relevant information that should have informed a discussion about need and risk. The meeting resulted in a written agreement with the parents that they would not drink when the children were present and there would be no domestic abuse. The reliance on such a written agreement without any substantial exploration and understanding about what was driving the behaviours and concerns was ill-advised. 14. The police were still responding to incidents of aggression in the community. For example, in August 2018 there were reports from members of the public observing the parents having a violent confrontation outside a supermarket and a relative also raised concerns about another incident. Some of this information was treated as intelligence rather than being recognised as potential safeguarding concerns that should have been processed through the police safeguarding team and the MASH. The school also saw the father collect Child 1 from school when smelling of drink and the mother was also observed to be intoxicated when she was pregnant. This did not result in any follow-up action at the time. 15. Although a follow-up CIN meeting was told that Child 1’s attendance at school was 89 per cent, was working below expected age and ability levels and was displaying difficulties in concentrating and seeking attention, CSC planned to appropriately step down to universal services. 16. The mother continued consulting the GP about her low mood and was regularly seeking to have her medication of Tramadol increased. The GP made a referral to the IHBTT4 in late summer 2018; the referral was declined by the service because the mother’s symptoms did not meet the levels of concern and need for a service intended to respond to patients with evidence of developing more severe mental illness. 4 The intensive home based treatment team (IHBTT) provides assessment and treatment to adults who are experiencing the onset of, or relapse of severe mental distress. The service provides a gatekeeping role to inpatient services, signposting people to appropriate services, facilitating and coordinating admission to hospital where necessary. Page 8 of 21 17. In late September 2018 mother was admitted to the hospital via the ambulance service with severe abdominal pain. She admitted drinking heavily and had been looking after the children on her own. The ambulance service described the house as smelling of cannabis. No referral was raised by the ambulance service or by the hospital. The information was sent to the GP but there was no discussion at a GP practice safeguarding meeting5. The use of alcohol and cannabis with the prescribed medication including Tramadol and sole care of the children had safeguarding implications including safe sleeping. It is a significant point of learning given that at about the same time CSC believed that the mother was complying with her agreement to not be drinking while the children were with her. 18. In the first half of October 2018, there were two incidents when the parents displayed very extreme levels of verbal aggression to housing staff who were showing a property for the family to rent (the family were living in temporary accommodation). Mother, in particular, showed very little self-restraint and they continued arguing with each other outside the property. Although the incidents were reported as abuse of housing staff there was no discussion within the housing service or with the MASH about the potential safeguarding issues given the uncontrolled behaviour being witnessed by a child. Around the same time, the police had been called to deal with an argument at the family home and although a DASH was completed it provided little detail and there was no discussion in MASH to consider the pattern of call outs and other concerns about the family. 19. The health visitor also reported that the mother was very frantic and aggressive in her speech during a home visit in late October 2018. There was no discussion with the GP practice about whether for example the behaviour was a symptom of psychological or psychiatric distress or related to the use of substances; the health visitor along with other health professionals did not have anything like a complete picture of the substance misuse. The health visitor contacted CSC to speak with the social worker although it was not for another two weeks in mid-November 2018 that the social worker and health visitor were able to speak by phone. The case was closed to CSC in October 2018. 20. The midwife booking in early November 2018 with Jason’s pregnancy included a discussion about the maternal family’s history of mental health and anxiety. None of that history was disclosed or explored in assessments by CSC and was 5 Monthly dedicated GP safeguarding meetings throughout the year should include a GP who is the safeguarding lead for the practice (or their deputy), the link health visitor and midwife. The meeting should not be restricted to children subject of a child protection plan but an opportunity to review patients about whom there are concerns (or family member concerns). This can be further informed by interrogation of the patient IT system. Good practice would place a record of any discussion on the patient record for a health professional to read during a patient consultation. Page 9 of 21 not referred to in the referral to CSC that was made for a pre-birth assessment for example. 21. In November 2018 there were several anonymous referrals to CSC from people in the community who knew the family. The referrals described concerns about physical assaults on Child 1, use and supply of drugs from the family home and anti-social behaviour. There was not a strategy discussion to discuss any of the referrals which represented allegations of criminal and safeguarding concerns. A social worker discussed concerns with the mother who interpreted them as the malicious gossip of an ex-friend who would subsequently report being the target of the mother’s concerted and abusive texting. The mother, in turn, made a complaint to the police that the person was harassing her. Case recording by the social worker in December 2018 described the allegations made against the mother as malicious and the Early Help Service was asked to provide support. 22. An assessment, the third since 2017 and the sixth since CSC had first become involved with any of the children in 2009, again relied on the parents agreeing not to use alcohol when with the children and that there would be no domestic abuse. There was little evidence of direct or indirect input of information or analysis by any other professional outside of CSC. 23. The closing summary included significant inaccuracies; it asserted that there were no health concerns although there was a recent history of Child 2 needing hospital assessment and treatment and the mother had enduring mental health needs of low mood and were prone to thoughts of self-harm. There was no mention of Child 1’s school attendance or attainment and interaction at school. Child 2 was described as ‘not presenting with any emotional or behavioural issues because of their young age’. The parents were described as accessing community resources. It was an optimistic description that was not based on accurate and verified information but reflected what the mother was describing. 24. In February 2019 the midwifery service requested a pre-birth assessment which was declined by CSC at the beginning of March 2019. The referral was a one-sentence request for the pre-birth assessment. 25. In late March 2019, the midwifery and GP services were told in a letter about the outcome of a single point of access (SPA) referral to the mental health service. The letter described the mother’s disclosures about trauma in her childhood that included physical and emotional abuse by her parents and been removed from their care at the age of ten. She reported having multiple placements including residential homes. With the benefit of hindsight offered by this review, some discrepancies are highlighted about the mother’s ability to respond to the needs of her children. During this SPA assessment, she cited her children as protective factors yet one of her increasing stressors had been identified as her daughter Child 1 and her reported ability to ‘press mother’s Page 10 of 21 buttons to initiate a reaction. The information was not discussed at a GP safeguarding meeting and CSC was not aware of the consultation or the disclosures until much later. A follow-up session with the psychologist identified increasing stressors in the mother’s life and that she wished to have support. This was not followed up in letters to the GP or the MASH. 26. It was not until an initial child protection conference in June 2019 discussed information from the services participating in this review that the full picture of what life was like for any of the children began to be understood more completely. The quoting of an individual professional or from recorded minutes is not a practice encouraged in a review such as this. However, in this case, the words of the chair of the conference in the record of the ICPC that summarised what had happened at that meeting deserve including: “It has become clear at the meeting today based on all information shared that there are multiple issues which may be impacting on mother (sic) and father’s (sic) ability to parent their children safely and meet their needs appropriately long term. We have heard extensive evidence of substance and alcohol misuse, domestic violence, parental mental health issues, criminal and anti-social behaviours and chaotic family functioning. It is extremely worrying that despite the level of social work involvement over the years that all of this information was only learned by professionals involved today at the conference. Although it was a single incident criminal allegation that led to the conference today, professionals must not be side-tracked and realise that there a multitude of issues which expose all three children to a combination of risks. Alongside police history about both parents, Child 1’s (sic) presentation, poor school attendance and the missed health appointments have been discussed as well as the history of disguised compliance from mother who has historically used lots of different ways to detract professionals involved from the issues that are impacting on parenting capacity and causing a risk of harm to her children. Such tactics include numerous complaints about professionals and requests for changes of professionals being upheld. It is extremely important that this is considered in future assessment and planning and the children’s needs always remain the priority and the focus of assessment and intervention”. 27. Even at this initial child protection conference and for several weeks after there were people who still did not share the level of concern expressed in the summary of the conference chair. Jason and Child 2 were made the subject of a child protection plan because of neglect in the face of opposition from some professionals who later challenged it without success. Research and national learning relevant to the review 28. The sudden unexpected death of an infant (SUDI) which is also referred to as sudden infant death syndrome (SIDS) was relatively common in the 1980s, affecting about 1 in 500 live-born infants. Recognition of the importance of the infant’s safe sleeping position led to a dramatic fall in the rates of SUDI Page 11 of 21 throughout the world. Presently, less than one in every 2,000 babies in the UK dies from SUDI. Almost nine out of ten (88 per cent) SUDI deaths happen when the baby is six months or less6. Of the babies who die whilst sharing a bed with an adult, 90 per cent died in hazardous sleeping conditions. There is an adult who has recently consumed alcohol, they or a partner smoke, have taken drugs that cause drowsiness and/or the baby was a premature birth or weighed less than 2.5kgs at birth7. These are factors present in this case. SUDI is still a leading cause for infant mortality in the UK despite the significant reduction in cases since the 1990s. 29. The National Institute for Health and Care Excellence (NICE) Guidelines for postnatal care8 recommend that parents should be made aware of the associations between co-sleeping and SUDI and be informed that the risks from co-sleeping may be greater when parents smoke or consume alcohol or drugs, or where babies are born with low birth weight or premature. This reflects the practice shown by midwifery and health visiting services in this case. 30. As the incidence of SUDI has declined the association with social deprivation has become more marked. For example, in Avon in South West England, during 1984-88, 23 per cent of SUDI occurred in the 10 per cent most deprived communities, whereas by 1999-2003 this had risen to 48 per cent of SUDI cases9. 31. Factors associated with an increased risk of SUDI; a) Co-sleeping after alcohol or drugs have been consumed are a significant risk10; was observed and recorded by the police although sleeping arrangements were not seen by most services; b) Unsafe sleeping positions (prone or side); c) Smoking; both parents smoked; 6 https://www.lullabytrust.org.uk/safer-sleep-advice/what-is-sids 7 Safer Sleep: saving babies lives a guide for professionals https://www.lullabytrust.org.uk/wp-content/uploads/Safer-sleep-saving-lives-a-guide-for-professionals-web.pdf 8 National Institute for Health and Care Excellence. Addendum to clinical guideline 37, Postnatal Care: Routine postnatal care of women and their babies. UK: National Institute for Health and Care Excellence, 2014. 9 Blair PS, Sidebotham P, Berry PJ, Evans M, Fleming PJ. Major epidemiological changes in sudden infant death syndrome: A 20-year population-based study in the UK. Lancet. 2006; 367(9507):314-19. https://doi.org/10.1016/S0140-6736 (06)67968-3. [PubMed] 10 Blair, P. S., Sidebotham, P., Evason-Coombe, C., Edmonds, M., Heckstall-Smith, E. M., and Fleming, P. (2009). ‘Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England’. BMJ, 339, b3666. Page 12 of 21 d) An unsafe sleeping environment with particularly high-risk circumstances being co-sleeping, temperature and overwrapping, loose bedding and mattresses, keeping head covered; not commented upon; e) Use of alcohol or drugs during pregnancy; mother denied but was using alcohol and drugs; f) Poor ante-natal care. 32. There is an overlap with other sources of risk such as abuse and neglect which is reflected in this case and the findings of the Child Safeguarding Practice Review Panel’s report11 published as the review was being completed. 33. Factors that contribute to effective work with families experiencing higher levels of difficulty and adversity include; a) A dedicated worker who can build a relationship; this was not achieved in this case; b) Practical hands-on approach; offered through the Early Help Service as a step down from social work involvement that did not recognise the level of neglect; c) A persistent, assertive and challenging approach; was not achieved and when there were some attempts mother was able to block it; d) Considering the family’s circumstances as a whole; not achieved in this case; e) Common purpose and agreed action; was not achieved in this case; the ICPC in June 2019 was the first occasion when a multi-agency discussion of all services took place but still did not reflect a common purpose until some weeks later. 34. Adverse childhood experiences (ACE) describe things that cause harm during childhood and into adulthood. It encompasses abuse including neglect, domestic abuse in the household, mental illness and problematic substance misuse of a parent or carer. Experiencing ACEs as well as experiencing hate crime, community violence or not having supportive adults exacerbate longer-lasting damage and is sometimes referred to as ‘toxic stress’. 35. Adults who have experienced significant ACEs in their childhoods are more likely to present with a range of needs and difficulties such as poor learning and employment records, illness and substance abuse and have an influence on how they meet the needs of their children which can bring them into 11 The Child Safeguarding Practice Review Panel (2020) Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm, London, HMSO. Available from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf [Accessed 30th July 2020] Page 13 of 21 conflict with people and services focussed on safeguarding children. There is no recorded evidence that the evidence of significant ACEs in the history of both parents was considered and explored in education, health and social care assessments with the family. 36. Resistance to professionals demonstrated by parents is a common theme in reviews over many years. It is behaviour manifested in different ways including open hostility, ‘disguised compliance’ and sabotage12, and is a significant obstacle to establishing more open and effective relationships. Although there can be particular reasons such as a fear of losing children to care that can drive the behaviour it is often a manifestation of parents who have had poor cumulative experiences as children and adults. The co-existence of poor physical and mental health, substance misuse that can be denied or disguised as seems to have happened in this case, poverty, learning difficulties and domestic abuse are factors that contribute to inconsistent parenting and disorganised lifestyles that are harmful to children. It leaves parents with difficulty in controlling their emotions and problems for the parent in providing adequate emotional care for their children. It is why good taking a good history is important when completing an assessment, something which is not evident in this case. 37. Interventions by health and social care services, in particular, have to develop responses that can help adults address the impact of an adverse childhood experience and prevent children from suffering harm. This has implications for how assessments of parents and children are completed and for encouraging greater curiosity and routine enquiry by people such as primary health care professionals and for providing access to appropriate help which can include trauma-informed care. 3 Summary of learning from this local child safeguarding practice review 38. There was poor sleeping practice at the time of Jason’s death despite the repeated advice provided by the health visiting and midwifery services. There was a high reliance on the parents implementing the advice and guidance being given including when subsequent examples of unsafe practices showed this was not being followed. This case shows that some parents have difficulty assimilating and consistently following the advice and are the circumstances under which children’s needs are neglected. The way that parents respond to the needs of their children is influenced by many factors including their childhoods. Parents who have experienced unstable or adverse childhoods can mean that they have learnt to just focus on their own needs because they have learnt not to depend on others. They can exhibit the disorganised neglect 12 Reder, P. Duncan, S. and Gray, M. (1993) Beyond blame: child abuse tragedies revisited. London: Routledge. Page 14 of 21 described by Horwath and others13 that is driven predominantly by emotion which as in this case can be exacerbated by the influence of alcohol or drugs. Their needs take precedence over anybody else including their children. Although there may be occasions when the needs of the parent and the child converge there will be other times when that is not the case. It is behaviour that can be perplexing and provide false positives and assurances when for example discussing safe sleeping or an agreement to stop drinking. If the parent is more focused on their own emotions and needs their attitude for example to where their children sleep will be inconsistent and lack routine. 39. The neglect and risk of emotional and physical harm, in this case, were not sufficiently recognised by any service largely because the information was processed as single separate events or incidents. The issue of cumulative risk of harm when different parental and environmental risk factors are present in combination and over extended periods is an issue identified in serious case reviews for several years. It applies particularly to domestic abuse, parental mental ill-health, and alcohol or substance misuse as well as adverse childhood experiences. Most of the services worked without enough knowledge of the family’s history. For example, the child protection conferences relating to Child 1 in 2009 described the care history of the mother as a child, the difficulties she had with substance abuse and anger. It was a behaviour that continued during events up to 2019. CSC and the 0-19 service (as well as the other services such as school) did not use a chronology. The extent of involvement by services such as CSC over many years beginning with both parents in their childhoods was largely hidden. The absence of multi-agency discussion and decision making at the point of referral or before case closure is significant. The development of a multi-agency pregnancy liaison and assessment group (MAPLAG) postdates the events examined in this case; it provides a multi-agency forum and opportunity for coordination although its current remit would not include a mother who is not declaring current substance misuse. 40. Safeguarding work represents a challenge and can present issues and difficulties that contribute to less effective practice. These can range from professionals becoming overwhelmed by the intractability of difficulties that a particular family presents; becoming intimidated by the aggression or behaviour of an adult or be misled by the apparent cooperation and compliance. None of the services has described their various staff as ever being overwhelmed although it is self-evident that the scope of difficulties that the family faced extend beyond the capacity of any single person or agency to address. The level of need and risk presented by the family needed a well-informed multi-agency response that was led effectively and could provide intensive involvement and work. Mother made complaints against 13 http://www.safeguardingshropshireschildren.org.uk/media/1250/j-horwath-working-with-child-neglect-during-the-covid-19-pandemic.pdf Accessed on 20th July 2020 Page 15 of 21 professionals when she felt they were beginning to challenge and show curiosity about what was happening. 41. Despite the level of difficulty and long-term indicators about neglect, this was a family where help and support were largely episodic and focused on responding to specific incidents, not all of which got the level of response that would be expected and was hampered for example by not using strategy discussions between services. There was insufficient coordination or a sense of common purpose. When a statutory assessment was completed it was largely conducted as a single agency activity by CSC. Decisions by CSC to step down their involvement for example in January 2019 from CIN to involvement by the Early Help Hub was accompanied by the 0-19 service stepping down their level of contact to a universal service offering on the basis that the services did not have safeguarding concerns. The school nursing service likewise stepped down to a universal service level for the eldest child. 4 Assessment of systemic or underlying reasons for what happened 42. These include: a) Seeing the world of the child through their eyes and giving them a voice of influence in enquiries, assessment and decision-making; reflecting upon and asking about the impact the behaviour of the parent has on the child is important for a child of any age; silence or the absence of any disclosure is not evidencing that all is well; children who are too young to have language can still provide important information to people with an understanding of age-related child development who spend enough time with parents and child can observe the interaction of parents with their children and show curiosity; for example about Child 1 being used as a carer for younger siblings and a potential factor in the poor school attendance; Child 1’s need for adult attention; children witnessing extreme levels of abusive behaviour; b) Chronology and history that gives context to single incidents; seeing and understanding the complexity and significance of history and cumulative harm eluded professionals until the child protection conference in the summer of 2019; even at that stage some people could not see the significant harm being done to the children through the emotional abuse and neglect and risk of physical harm; a student social worker had collated a chronology in March 2017 but the significance of the history was not sufficiently understood at the time and it did not draw information from other services; this is not a criticism of the individual student social worker and it was the only time a chronology was collated; Page 16 of 21 c) Using multi-agency systems for processing and discussing safeguarding concerns about children including MASH that include the police and GP in multi-agency discussion of risk such as occurred at the child protection conference in June 2019; the systems would have been relevant such as the incident of domestic abuse in June 2018 that resulted in the oldest child being injured was not discussed in a strategy discussion or subject of specific child safeguarding enquiries and assessment; although the police requested a strategy discussion there was no escalation or referral when there was no response from CSC; this was in part reflected by the organisational stress that was having an impact in CSC but it also indicates organisational passivity on the part of other services who did not escalate concerns to more senior managers or within the MASH; there were occasions at school, at the GP, within the police and social care as well as in MASH to recognise and respond appropriately to evidence of concerns; some important safeguarding information was not reported to the police and social care; d) Developing relationships of support for families; high levels of complex need and vulnerability are less likely to be understood enough through single or time-limited home visits; people who have the time to develop an understanding of underlying history and issues and to build a relationship of trust are more likely to provide effective help; underestimating the level of need contributed to the family not being encouraged to use a children’s centre for example; relationship-based and practical work with families dealing with multiple challenges needs to be well-grounded in systems of professional support and safeguarding practice; the early help service was the only service attempting to provide practical hands-on assistance but did not recognise important indicators of risk; some of this was missed by other people as well; e) Being curious enough about finding out the underlying drivers for concerns and risk14; the verbal and physical violence, emotional and psychological difficulties and the use of substances were not just markers of an anti-social lifestyle that represented a risk for children; the deep-rooted implications of the parents’ adverse childhoods; these are not easily addressed or amenable to exhortations to behave better and to keep to agreements; not understanding the significance and implications of history undermines developing more effective help; 14 It is acknowledged that the CRC offender risk assessment did explore and record drivers but it was not used in any multi-agency or other services assessment. Page 17 of 21 f) Barriers and control of narrative and professional reaction; professionals are less able to help families effectively when important interaction is controlled by parents who are unable or not motivated to make necessary changes; many of the problems that were described when Jason was born and was described when he died were longstanding concerns; avoidant strategies that block communication or minimise concerns are manifested in different ways; professionals can be closed down by outright confrontation and hostility or be manipulated into false states of reassurance; mother had a ‘toolbox of behaviours’ to manage her interaction with various professionals; she was described by one as being able to display outright hostility and rejection through to presenting as being compliant and needy; it was a behaviour that reflected her history of abuse and trauma and behaviour learnt and unchallenged over many years; when mother sensed a professional was more assertive and curious about what was happening with the children she would make complaints; this happened in CSC on more than one occasion as well as at the school; one of the social workers had the case taken off them against their professional judgment following a complaint by mother; the mother showed the same behaviour to people in the community whom she suspected of trying to raise concerns with CSC or the police; g) Community and neighbourhood networks are often aware of what is happening in a complex household; this case shows the importance of giving attention to information coming from people who may see far more of the family and what is happening with children than any of the services; ignoring or dismissing as malicious the concerns of people who are not part of a recognised profession or service; taking concerns seriously and making robust enquiries that involve all relevant people; h) Recognising the impact of domestic abuse on children and exploring it as part of assessments; Child 1’s disclosures of drinking and fighting between the parents did not result in concerted follow-up; there were other occasions such as reports from the community to police and social care; there is no evidence of the GP considering domestic abuse as part of mother's presentation for low mood; the probation risk assessment was not factored into any other assessments of risk and was the only one to highlight coercion and control as a particular risk; i) Assessments being rigorous enough in terms of the investigatory process and age-related child development; on more than one occasion a social worker wrote that a preverbal child ‘does not present with any emotional or behavioural difficulties given their (sic) age’; the processing of referral and Page 18 of 21 conduct of assessments were not curious and aware of why parental history was critical and included all relevant people to give information and contribute to analysis; none of the assessments that were complete resulted in the level of social work involvement that was required along with other services; not using tool kits and frameworks designed to help inform professional judgment about issues such as neglect or a child’s attachment; the neglect toolkit in the 0-19 service was not used in 2018 when evidence of potential neglect began to emerge; this was despite specific advice given by a safeguarding nurse practitioner. The service also found that when completing reports for the initial child protection conference in 2019 the scaling of risk was not completed by health visiting or school nursing services and at the time danger statements were not being used; mother’s low mood and self – harming behaviour was not meaningfully explored in assessments; the GP was peripheral to the work being done through other health and social care services. j) Pre-birth assessments; requests being accompanied by a summary of concerns highlighted for example during a booking appointment with midwifery services; a good pre-birth assessment could have taken into account the factors that had a negative impact or implication for Jason and set that against any protective factors which in this case were very limited; k) Written information and advice about safe sleeping is not equally effective for all parents; the high reliance by health professionals providing SUDI advice to parents to act appropriately even when there were repeated occasions when unsafe practices were observed; more attention to how parents understand, retain and can act on the information is important and seeing where children are sleeping; l) Preventing SUDI as a public health and child safeguarding issue; early years and social care practitioners need to demonstrate a good understanding of the risk of SUDI and their role in assessing and reinforcing safe practice advice; this includes seeing where children are sleeping; police officers who visit households where there is evidence of substance misuse and co-sleeping have a role in giving immediate advice and reporting information through the MASH; m) Poverty and social deprivation are overrepresented in the profile of children dying from SUDI; this does not mean those factors cause SUDI but do need to be factored into risk assessment and are relevant to a wider consideration of children’s welfare and resilience; there was no recorded evidence of this being considered and explored in assessments with the family; Page 19 of 21 n) SUDI and neglect as co-existent risks; neglect is not a one-off incident or event; it is cumulative and has a corrosive impact on the health and wellbeing of children; tool kits help collate, analyse and understand underlying patterns of neglect; adversity in parents childhood and the co-existence of issues such as substance misuse, mental ill-health contribute to inconsistent and ineffective parenting and a chaotic and disorganised lifestyle; they will struggle to implement advice such as safe sleeping; it has an impact on how they control emotions and an inability to provide emotional warmth for their children; o) Separate help for adults who have been significantly damaged by their childhood and life experiences. 5 Summary of recommended improvements to be made to safeguard or promote the welfare of children I. The WDSCP should ensure that all multi-agency training includes the need to be curious about and to understand where children are sleeping as part of assessments and intervention. II. The learning from the review should be referred to the local multi-agency task and finish group for the prevention of overlay that is developing a risk assessment. III. The WDSCP should develop a safe sleeping procedure that emphasises the importance of ongoing risk assessment about safer sleeping for all services. This should include a specific risk of overlay assessment tool identifying that modifiable factors exist which are known to contribute to SUDI due to overlay15. The procedure should direct that routine safe sleeping risk advice is always joined up with an overlay risk assessment. This should be part of the core ongoing contact delivered by midwives at booking and ante-natal checks; health visiting mandatory contacts and visits; six-week checks by the GP; early help workers, social workers and police enquiries; chairs of child protection conferences or CIN meetings. IV. The WDSCP should consider how the use of the neglect tool kit is promoted and used routinely by services. The WDSCP should review whether the strategy and provision of training in respect of neglect is giving sufficient understanding to professionals about the different types of neglect which include disorganised neglect, emotional neglect and, passive and physical neglect. The current neglect toolkit should be amended to include intentional unsafe sleeping practices 15 https://www.nottinghamshire.gov.uk/media/1494648/safer-sleeping-risk-assessment-tool.pdf Page 20 of 21 and /or no provision of safe sleep space for infants as indicators of neglect. V. The CCG should continue encouraging every GP practice to have a written protocol for discussing safeguarding concerns and follow up. This should include routinely referring notifications and requests for information from the MASH in respect of statutory CIN or child safeguarding assessments and recording in relevant patient records. VI. The CCG should encourage GP practices to develop and use assessment templates that routinely explore domestic abuse with patients presenting with symptoms of low mood or other mental health needs. VII. The Director of Children’s Services should ensure that within MASH all information or reports about safeguarding concerns are processed under the safeguarding partnership’s protocols for strategy discussions, enquiries and investigation. VIII. The Director of Children’s Services should remind social workers when completing enquiries or assessments to verify where children are bathing and sleeping as a matter of routine and are using appropriate age-related frameworks to inform assessments about children’s development. IX. The Education Safeguarding Advisor should ensure that a summary of learning outcomes is provided to the chair of governors, head teachers and designated safeguarding leads. This should include promoting the use of the neglect tool kit, systems for recording safeguarding concerns, supervision of staff who conduct home visits, the use of referral pathways to Early Help and MASH. X. The Health and Wellbeing Board should consider the learning from this review in respect of how local services respond effectively to the needs of parents with a history of adverse childhood experiences and the need for strategies to reduce poverty and health inequalities that support systemic arrangements for prevention and early intervention to support more vulnerable families. Page 21 of 21 The methodology and terms of reference Agencies were requested to produce summaries of learning drawing on agency records and the direct involvement of practitioners who worked with the child and family to reflect on practice issues and demands. In this way, the reports reflected learning for the system in which the professionals were working. A virtual learning event involved people from the services involved although many of the practitioners who had direct involvement in the events since 2017 were not available. Peter Maddocks, the independent reviewer, also had individual discussions and had access to copies of assessments and records of meetings (where they were available) and the child protection conference. The review considered the impact of the following areas of multi-agency practice in the case to inform learning and future practice: i. Awareness of reducing SUDI and overlaying risk. ii. The scope and organisation of enquiries and assessments, (including pre-birth) and the extent to which they gathered sufficient information from relevant sources and about the risk to the children and provided analysis and how this contributed to an understanding of neglect or other abuse. iii. Information sharing between agencies and the use of chronologies and awareness of history in decision making about need and risk. iv. Challenge or escalation when concerns were referred to children’s social care resulting in No Further Action. v. Understanding of the lived experience of all of the children including how the voice of the older child (D) was sought and taken into account. vi. Recognition of the ongoing domestic abuse and violence within the household and its impact on the children and the evidence of substance abuse. vii. Different presentations of neglect and emotional abuse. viii. The impact of adverse childhood experience (ACE) on the adults and the impact on their parenting. Consideration of how this impacted each of the children. ix. Understanding and responding to the emotional wellbeing of the mother. x. The impact of working with hard to engage parents on safeguarding children, including hostility, non-compliance and disguised compliance. |
NC52446 | Death of a 7-year-old boy from asthma in November 2017. Hakeem's mother was convicted of gross negligence and manslaughter. Findings include: confusion by professionals around significant harm thresholds for neglect where a child has a chronic medical condition that is being poorly managed by a parent; a lack of communication between those responsible for non-school attendance and children's social care which resulted in the two processes not taking account of the neglect that Hakeem was experiencing; little professional understanding of the daily lived experience of the child, resulting in a lack of assessment of what Hakeem's reality was like and the level of neglect experienced; failure by agencies to consult and inform the birth father of the growing concerns for the child, resulted in professionals not adequately taking account of his ethnicity and background, alongside the potential for extended family support. Recommendations include: where children have had hospital admissions for chronic conditions there is a robust discharge plan that includes identifying if any other agencies are involved; improvement work on engaging fathers includes those who may be on remand or serving prison sentences and makes appropriate reference to their ethnicity and family support networks; need for pharmacists to have specific safeguarding training that makes links between parental drug misuse, prescription medical equipment and childhood asthma.
| Title: Serious case review (BSCB 2017-18/03): Hakeem. LSCB: Birmingham Safeguarding Children Partnership Author: Jenny Myers Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review (BSCB 2017-18/03) Hakeem Lead reviewer and independent author - Jenny Myers MA CQSW Publication date: 1st September 2022 2 Contents Glossary of abbreviations and terms used in the report ............................................................... 3 Introduction ........................................................................................................................... 4 Scope of the Review ............................................................................................................. 5 Methodology ......................................................................................................................... 5 Brief family background and synopsis of the case ................................................................. 6 5. Summary and analysis of professional involvement with Hakeem ......................................... 7 Ability of professionals to understand what the daily lived experience was for Hakeem. ..... 12 Effectiveness of multi-agency working, compliance and communication including compliance with procedures, information sharing, supervision and support. .......................................... 13 8. Working with resistant parents and non-engagement. ......................................................... 17 9. Identification of risk of significant harm leading up to ICPC in November 2017. .................. 19 10. Social Work Practice ........................................................................................................... 20 11. How non-compliance issues by parent and drug treatment were managed ......................... 23 12. Adequate assessment and management of child’s asthma, including prescribing practice. 25 13. Role of school nursing in management of Hakeem’s asthma. ............................................. 29 14. Findings and Conclusion ..................................................................................................... 31 15. Key findings and recommendations .................................................................................... 32 16. Post-script ........................................................................................................................... 35 17. References ......................................................................................................................... 36 Appendix 1 ................................................................................................................................. 37 3 Glossary of abbreviations and terms used in the report Hakeem Subject of the SCR Mother Laura Heath SW Social Worker DSL Designated Safeguarding Lead MGM Maternal Grandmother HV Health Visitor MW Midwife NSA Non School Attendance CGL Change Grow Live CASS Child Advice and Support Service BSCB Birmingham Safeguarding Children Board (from April 2019 BSCB became Birmingham Safeguarding Children Partnership BSCP Birmingham Safeguarding Children Partnership MASH Multi Agency Safeguarding Hub ICPC Initial Child Protection Conference BCSC/BCT Birmingham Children’s Social Care (from April 2018 BCSC became Birmingham Children’s Trust). SCR Serious Case Review ED Emergency Department NICE National Institute for Clinical Excellence BWCHFT Birmingham Women’s and Children’s Hospital NHS Foundation Trust CIN Children in Need CPP Child Protection Plan ToR Terms of Reference BTS British Thoracic Society CDOP Child Death Overview Panel WMAS West Midlands Ambulance Service CCG Clinical Commissioning Group 4 Introduction 1.1. This overview report summarises the findings of an independently led Serious Case Review (SCR) commissioned by the Chair of Birmingham Safeguarding Children Board (BSCB) in 2018. It concerns Hakeem, a seven-year-old boy, described by his father as well behaved, bright and independent and by his mother, as a very bright loving boy who loved to dance. Hakeem was of mixed heritage with a White British mother and Asian father of Muslim faith. The report was completed in 2019, however, due to ongoing criminal proceedings it was prevented from being published until the outcome of the court case was resolved. Hence the significant delay in publication until 2022. The learning from the review has however been implemented by Birmingham Safeguarding Children Partnership (BSCP) and actions tracked to ensure there was no delay. 1.2. This (SCR) was conducted in accordance with Government statutory guidance entitled 'Working Together'1 following Hakeem’s death on November 26th, 2017. It was commissioned prior to changes to statutory guidance that evolved since 2018. 1.3. On November 26th, 2017 West Midlands Ambulance Service attended an address (not the child’s home address) and on arrival found Hakeem unconscious in the garden. The initial account provided by the child’s mother was that he had been unwell the previous day and she believed that during the night he went into the garden due to his asthma. The ambulance service confirmed that Hakeem was deceased and had been so for some considerable time. The post-mortem confirmed that Hakeem had died of asthma. However, photos of the family home, and the house where Hakeem was found dead, which belonged to a registered sex offender, show evidence of chronic neglect, prostitution, and drug use. There was also a stockpile of inhalers used to smoke crack cocaine. 1.4. Throughout Hakeem’s life there was sporadic multi-agency professional involvement with his family. He was placed on a Child Protection Plan (CPP) for neglect because of pre-birth concerns about his mother’s substance abuse and her previous history where three of her children were removed from her care. This was discontinued in January 2011. A second CPP commenced at the end of 2011 again for neglect and ceased in August 2012, when it was felt the situation had improved. In July 2017, Hakeem became subject to a Child in Need Plan (CIN) as concerns about Hakeem’s welfare were once more increasing. These concerns continued to escalate and, on the 24th November 2017, (sadly two days prior to death), he was made subject to a Child Protection Plan under the category of neglect. 1.5. This case has received local and national media attention following the high-profile coverage of the criminal proceedings and subsequent conviction of Laura Heath, Hakeem’s mother, for gross negligence and manslaughter for which she received a 20-year sentence on April 28th 2022. 1.6. Hakeem’s death follows a number of deaths of children which have been asthma related. There is a need to understand more about the quality and effectiveness of multi-agency practice involved with Hakeem and his family, leading up to his death. 1.7. This SCR identifies some key themes for learning and improvement through an appraisal and analysis of practice, in light of what was known at the time and the subsequent information received through the information reports, interviews and a practitioner event. The recently published recommendations in the national practice 1 Working together to safeguard children, HM Government 2015. 5 review into the murders of Arthur Labinjo-Hughes and Star Hobson (Crown Copyright 2022) and the Independent Review of Children’s Social Care (MacAlister, J. 2022) make many recommendations for action that resonate with this review. Scope of the Review 2.1 The review covers the period from July 2015 until the death of Hakeem on November 26th, 2017. Other significant information that relates to the review outside of this timeframe is summarised. 2.2 Full terms of reference for the Review can be found in Appendix 1. As part of the initial phase of the review ten agencies identified internal learning to help improve safeguarding practice. This early learning has been acted upon and the BSCP have verified that all actions have been fully implemented. The key lines of enquiry focused on the following issues: a) The professional understanding of neglect and ability to recognise and respond to it and other risk factors (wider risk, substance abuse). b) The level of effective multi-agency working and communication including compliance with procedure, information sharing, supervision and support etc. c) The ability by professionals to really understand what the lived experience of the child was (including other factors: racial, cultural, linguistic etc). d) Where there was non-compliance with a drug treatment programme, was supervised consumption and/or drug testing considered? e) Was there adequate assessment and appropriate management of the child’s asthma, including prescribing practice? Methodology Jenny Myers MA CQSW, a highly experienced independent reviewer, was commissioned to undertake the serious case review. Jenny is a qualified social worker, safeguarding sector specialist and independent safeguarding children’s partnership chair, experienced in leading complex reviews and one of the pool of national reviewers for the Child Practice Review Panel. She is entirely independent of any of the Birmingham agencies. 3.1 A multi-agency SCR review team established by BSCB supported the review. There were representatives from: • Birmingham Children’s Social Care (now provided by Birmingham Children’s Trust) • Birmingham City Council Education • Birmingham South Central NHS Clinical Commissioning Group (CCG) (now called NHS Birmingham & Solihull CCG) • Change Grow Live (CGL) • West Midlands Police 3.2 Sources of data. All agencies reviewed their records and provided timelines of significant events and a brief analysis of their involvement; these timelines were then merged to create an inter-agency chronology. This was carefully analysed by the lead reviewer alongside the 10 commissioned information reports in order to identify key 6 lines of inquiry/practice and organisational issues to be further explored with the practitioners who had worked with the family, at the practitioner event. 3.3 In addition, the author of this report held two separate meetings with the information report authors, accessed other key documents, and conducted interviews with the social worker and team manager. The author also met with the BSCB chair and CEO of BCT. 3.4 A number of key texts have informed the lead reviewers analysis and references to these documents can be found at the end of the report. 3.5 Practitioner involvement. The practitioner event took place on 13th September 2018, facilitated by the lead reviewer and was well attended by 19 multi-agency practitioners who had been involved with Hakeem and his family. Significant information was gained about how it had felt to work with the family and what the professional mind-set and understanding of the situation was at the time. This is reflected in the analysis section of the report. 3.6 Family involvement. The lead reviewer appreciates the involvement of those members of the family who chose to meet with her. It has been a difficult time for them and there is no doubt that the loss of Hakeem has been felt deeply by those who loved him. Where possible any feedback from these family members is incorporated into the text in order to gain their perspective on the effectiveness of the multi-agency support given to Hakeem and his family. The author met with Hakeem’s father whilst he was in prison in 2018 and met with mother in May 2022. Their views have been incorporated into the report. 3.7 Limitations. The review was not given consent to access mother’s medical records, there was delay in receiving full chronology and some other key texts from BCT, and delay in seeing family due to the parallel criminal investigation. Some key practitioners had left their roles or were on long term sick leave. Brief family background and synopsis of the case 4.1 Family Composition Immediate family • Mother • Father • Maternal grandmother (MGM) • Sibling 1 - Older Half-sister • Sibling 2 - Older Half-brother • Sibling 3 - Older Half-brother Significant others • The Baby (niece to Hakeem) 4.2 The family have been known to Birmingham Children’s Social Care (BCSC) since 2008. Hakeem’s mother as stated, had three older children, removed from her care in 2008 due to her misuse of drugs, poor home conditions and domestic violence. The two oldest children (sibling 1 and 2) were made subject of a Residence Order and placed with their Maternal Grandmother. Whilst sibling 3 went to live with their father when very young. Sibling 1 and sibling 2 have sporadically returned to live with their 7 mother over the years, but relationships have been turbulent, including allegations of sibling 2 being physically abusive towards their mother. 4.3 Due to the family history and concerns about mother’s use of heroin, Hakeem was made subject of a pre-birth Child Protection Conference and Child Protection (CP) Plan in 2009 with both his parents completing a residential parenting assessment in 2010. Family support was offered, mother reportedly successfully detoxed, and the case was closed to Birmingham Children’s Social Care (BCSC) in February 2011. Hakeem was subject to two other CP plans under the category of neglect, each being linked to issues of sustainability of care and impact of parental substance misuse. The CP plans were deemed necessary mainly due to mother’s lack of engagement with services to ensure Hakeem was appropriately safeguarded. The second CP plan was discontinued in August 2012, on the grounds that mother was assessed as working well with professionals. The last one ceased following Hakeem’s death. 4.4 In March 2014, when Hakeem was 4 and had started school, the school became concerned about a range of issues, including his poor attendance, the fact that he smelled of cannabis, lack of timely collection from school, and allegations by Hakeem that he had been hit by his grandmother. Further referrals from the school followed later in 2014 and in 2015. Referrals were followed up but there was not thought to be evidence that mother was not parenting Hakeem appropriately. At this point it was believed that mother was well supported by Hakeem’s father. In 2015, father was arrested for a sexual assault against a 19-year-old woman, and after a period of remand, received a six-year custodial sentence. Although they did not continue to live together after his arrest, he was actively involved with the care of Hakeem until going to prison. 5. Summary and analysis of professional involvement with Hakeem 5.1 The next few sections provide a summary and analysis of the professional involvement with Hakeem, establishing not just what happened but where possible understanding why. It focuses on the significant periods or events over the two years where key aspects of the terms of reference are addressed including where agency practice was below expected standards. The discussion aims to inform learning and improvement across the whole system and reference is made to local practice, other reviews and literature. The analysis of practice is informed by the information reports by the key agencies involved. Learning points for the review and key findings are then highlighted in more detail in the final section. 5.2 The professional understanding of neglect and ability to recognise and respond to it and other risk factors. 5.3 Hakeem was seven years old when he died. The post-mortem shows that the cause of death was asthma-related. However, the circumstances in which he was found indicate that he was experiencing significant neglect. 5.4 Neglect, as described in the Inform Overview Practice Guide (Community Care online) is complicated and difficult to define. The threshold for neglect is somewhat vague, and a determination of whether or not a child is being neglected often requires judgement rather than meeting a set of specific objective criteria. This can cause confusion when trying to establish if a child is, a child in need or a child in need of protection. For Hakeem, the confusion appears to have arisen as there was a lack of understanding about the importance of appropriate management of his asthma, alongside the impact of a decline in his home circumstances, and deteriorating school attendance. Working Together (2015) states that neglect is, “The persistent failure to 8 meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development…… and may involve a parent or carer failing to: provide adequate food, clothing and shelter, protect a child from physical and emotional harm or danger; ensure adequate supervision…., ensure access to appropriate medical care or treatment. The definition has been criticised as it is too focused around the caregiver rather than being child-focused and should centre not on the acts or omissions on the part of adults but on what the experience of neglect means for the child. As Beckett (2007) argues, it is not that “neglect is impossible to define, but that it cannot be defined in absolute terms. Like other forms of child maltreatment, neglect needs to be interpreted in context”. 5.5 BSCB have over the last few years disseminated information and delivered training on recognising and responding to neglect, including training on strengthening families and the graded care profile. There is a clear threshold strategy in place called the Right Help, Right Time and all professionals are expected to make use of it when considering how to respond to concerns. Practitioners at the event on 13th September 2018 were aware of the guidance and most had done some training and were also familiar with Strengthening Families Framework model of social work practice though may not have experienced it themselves in case conferences. However, it was clear from the professional practice described in the information reports that some of the basic premises of identifying and responding to neglect in the last years of Hakeem’s life were not always recognised as such and this resulted in delay in providing an adequate response for Hakeem. The author of this report would suggest that confusion about definition and thresholds as described above might have contributed. Evidence of this is outlined in a number of ways. 5.6 Although we would expect that social workers and health professionals should be able to make professional judgements to determine which of a child’s needs are basic, and assessments should be able to determine “seriousness”, perhaps it is these aspects of the definition that are responsible for some of the confusion about thresholds, and the uncertainty as to the level of neglect required to trigger a referral, or to cross that threshold between “a child in need” and “a child in need of protection”. This is the first learning point for the review and may be something which BSCB might want to explore further. Learning Point 1: There may still be confusion about significant harm thresholds and the level of neglect required to trigger a referral or cross between a child in need and a child in need of protection. 5.7 The crucial issue is what did the experience of neglect mean for Hakeem? What were the consequences of not having the right medication, of not getting to school, of not being fed and being hungry at times, of living with a drug dependent mother? Hakeem made it clear to school staff what it felt like - these are just some of the quotes from his school of what he said to them when he was six years old. “I am 5% happy, 100% angry and 1000% scared.” “I have not had any dinner, I sometimes have breakfast, sometimes lunch, but not during Saturdays and Sundays.” “I don’t wash regularly as there is no money for gas and electric.” 9 “My mum sleeps all day, and no one takes me to school”, “I take care of myself whilst mum is asleep.” 5.8 Medical neglect, missed appointments and the correlation between non-school attendance and his mother’s drug use and the fact that Hakeem himself was telling school how unhappy and scared he was, should in the author’s view have triggered an earlier and more robust response. Hakeem’s mother’s own reflection in her recent interview with the author of the review was to say that she felt “if a parent has an active addiction, the child should be removed”. 5.9 In May 2017, the SW began a family assessment for Hakeem as the school had continued to report their growing concerns for his welfare to BCSC. However, as the information report author highlights, it was of poor quality and was in fact never properly written up or informed by wider professional views and information. The author of the BCT information report concluded that whilst the SW felt suitably competent and trained in neglect issues that this was not evidenced in either the family assessment or their interventions. Sadly, the last time that the SW saw Hakeem was in school in July 2017 some four months before he died. There was no evidence of any analysis in relation to multiple neglect factors that were present such as: • Physical and emotional neglect, including observations of Hakeem being unkempt and shabby, his complaints about being hungry, not able to wash as there was no gas, and that he had been hit by his grandmother and mother, and general level of violence between mother and her other two children. • Educational neglect, including adequate supervision by his mother, in relation to getting him to school on time, failing to pick him up, which impacted on his performance at school, his behaviour and frustration at going from being a ’gifted and talented’ child to getting behind. • Medical neglect – mother’s failure to provide appropriate health care, missing hospital appointments or ignoring medical recommendations, such as the correct use of inhalers, and provision of inhalers to the school. • Increasing parental substance misuse. 5.10 As the BCSC report points out, there is ample evidence in research and previous reviews about how neglect is a cumulative concern, rather than a one-off event, and how the combined effect of various factors, including substance misuse, chaotic lifestyle and domestic abuse can impact on parenting. The Joint Targeted Area Inspection (JTAI 2018) into the neglect of older children observes that there needs to be a coordinated strategic approach across all agencies and that both adult and child-focused services need to look holistically at the whole family, and this was not evident in Hakeem’s case. Recent research in Adverse Childhood Experiences (ACES) would also have benefitted the SW assessment both of Hakeem and his mother. 5.11 There was not sufficient analysis of what was happening in this household from the point of allocation onwards (May 2017), but also in considering the history of this case. This included what accounted for the changes, given that mother’s parenting up until that point was apparently ‘good enough’, the impact of the older siblings and a baby moving back to the household, of her partner being in prison and whether she had made a new relationship. In interview with the author mother described herself as, ‘spiralling out of control’ once the relationship with her partner disintegrated following his conviction. 10 5.12 Part of the explanation provided by the SW is that he was the case worker for sibling 1 and her baby, and that was his primary focus. As concerns regarding Hakeem escalated, they were coming through to him rather than Hakeem being considered as an individual child in his own right. Reflections from both the SW and team manager have concluded that Hakeem should have had a separate social worker. The social worker for sibling 1 and the baby already had a busy case load and was struggling to keep on top of written work and recording due to dyslexia, which hugely impacted on his ability to carry out more structured written tasks that might have better informed the assessment. The wider observations about social work practice are discussed later in the report. Finding 1 - This review has found there is a confusion amongst professionals around significant harm thresholds for neglect, which increases where a child has a chronic medical condition that is being poorly managed by a parent. There is a need for professionals to become more aware of the correlation between poor parental management of medication for children with chronic health conditions such as asthma, and wider childhood neglect. It is essential that where children have had hospital admissions for chronic conditions there is a robust discharge plan that includes identifying if any other agencies are involved. A reliance on parental self-disclosure may not always be best practice. 5.13 Non School Attendance (NSA) and Neglect. Hakeem was a bright child who had been identified early on by school as being potentially gifted and talented. He became increasingly affected by his non-school attendance (NSA) and upset at getting behind in his studies, which resulted in some more difficult and challenging behaviour when he was in school. By 2016-2017 Hakeem’s overall attendance was only 58% with authorised absences of 7.5% and unauthorised 34.4%. He was brought to school late 18% of the time. Only 7.5% were attributed to illness and none to attending medical appointments. Non school attendance and the significance of this as an indicator of neglect was not considered enough. 5.14 Hakeem had been diagnosed with asthma when he was around three years old and did miss nursery and school as a consequence of sporadic episodes of breathing difficulties, some which had resulted in hospital admission and a number of GP appointments. However, the mindset at the time of some professionals appears to be that his NSA, if they were aware of it, was related to ill-health rather than anything else, though as the above statistics demonstrate this was not the case. Medical professionals have as part of this review confirmed that with routine asthma care and good parenting children should not be regularly missing school. There was not enough professional curiosity as to what else was happening to Hakeem. His mother frequently said that his asthma prevented him being in school and this went unchallenged by children’s social care and health professionals. 5.15 The Designated Safeguarding Lead (DSL) at the Academy Trust was persistent in her attempts to raise her concerns about possible neglect of Hakeem with BCSC and in January 2017 submitted a Request for Support, a process which had replaced previous MARF (Multi Agency Referral Form). The form outlined very clearly details of neglect, stating that Hakeem had poor attendance but when in school was seen to be tired and unkempt, have sad sunken eyes, no breakfast or lunch, and was often late. This was the beginning of a series of ongoing contacts and debates with BCSC asking for better support for Hakeem and a ‘ping pong’ of communication that left Hakeem living with neglect without adequate multi-agency response. Whilst it is clear the school sought support from their National Safeguarding Advisor, closer links to the Education 11 Safeguarding provision within Birmingham would have brought about a more co-ordinated response to this case (see Learning Point 4). 5.16 The Academy Trust Hakeem attended at the time employed the services of an organisation called Big Community (which has since closed), which at the time offered pastoral and family support to schools in Birmingham and was also commissioned to oversee attendance issues. The attendance officer attempted to discuss issues with Hakeem’s mother in December 2016, but she was dismissive of support. As his attendance continued to worsen, legal action was taken by the education authority and mother was fined twice, once in July 2017 and then again in November 2017. However there does not appear to have been any linkage made by the attendance officer within the school, the social worker, school nurse or other medical professionals such as the GP or even Hakeem himself to establish what the reality of life was like for him. Bearing in mind that Hakeem was on a CIN plan at the time, this is concerning. In fact, Hakeem told school on one day that his mother could not bring him as she was asleep in the dog basket. Additionally, at no time was Hakeem’s birth father, who by July 2017 was in prison, informed of any concerns regarding the deteriorating situation at home or the legal action re NSA. The wider implications of excluding father are discussed next, but the principle of keeping absent fathers informed is one that should be recognised: see Finding 4. 5.17 In clarifying what expected practice would be in a case like this, the Head of Service confirmed that once a school has a concern about attendance every effort should be made to firstly contact parents to establish what the reason is for NSA, then follow up by letters and informal meetings to try and resolve any problems. Where it becomes evident that parents may require an early response, then school staff are trained to complete early help assessments which may result in request for social work or family support. The ‘Spotlight on Attendance’ programme is a time-limited intervention to warn parents of legal consequences of NSA rather than the safeguarding impact of such non-attendance on the child. If parents still fail to engage, or additional support does not result in attendance improvement, then legal action can be considered. In Birmingham this is after a child has accumulated 20 sessions of unauthorised absence within a calendar year, something Hakeem clearly had done. 5.18 If Hakeem had a medical condition that had been assessed as preventing him from being in school regularly, then there should have been an expectation that all the professionals involved with Hakeem should work together to explore why his asthma was preventing him from being in school and if necessary, looked at what additional education support was available. A systemic finding from this review is that the consequence of previous cuts to the Education Welfare service and the devolvement of attendance management to individual schools appears to have resulted in a lack of join-up and consistency in how attendance and welfare issues are managed and communicated. Finding 2: In this case it was evident that there was a lack of join-up and communication between those responsible for Hakeem’s non-school attendance and children’s social care, which resulted in the two processes not taking account of the neglect that Hakeem was experiencing. In future there must be a better process to ensure communication between the school attendance officers and other professionals to establish more about the daily lived experience for children. They must clarify which absences are authorised or unauthorised, especially if they are on a CIN/CP plan and recognise that persistent NSA is seen as a potential indicator of neglect. Additionally, children with chronic conditions such as diabetes or asthma which may result in NSA should be adequately assessed and supported. It should be 12 noted that properly managed, asthma should not impact greatly on a child’s school attendance. It was also clear that Academy Trusts who employ their own safeguarding support need to ensure that more formalised strategic links are made between themselves and local authority support officers to ensure better guidance and support when they arise. 5.19 Medical neglect - discussed under the section on management of childhood asthma. 5.20 In conclusion there is strong evidence that the professional ability to recognise, assess and respond to evidence that Hakeem, who was only six years old and living with a multitude of factors that indicated neglect, was inadequate. Following the continued raising of concerns by the school in May 2017, BCT have reflected in their own assessment of the case, that if they had looked at the facts holistically, rather than piecemeal, then it should have triggered at least a complex case discussion, where all the different agencies, from health, hospital, GP, school were brought together to concur on whether thresholds for significant harm had been reached. Expected practice may also have considered a legal planning meeting to consider thresholds and perhaps a period of pre-proceedings, as opposed to being managed as a child in need. 5.21 Having spoken to all parties concerned, one of the striking features was the continued lack of authoritative practice and challenge to mother’s refusal to engage with professionals which appears to have had a significant influence and is discussed more later, but most concerning is the lack of consultation with Hakeem about what a day in his life felt like to him. Ability of professionals to understand what the daily lived experience was for Hakeem. 6.1 It is clear from undertaking this SCR that very few people had any idea what Hakeem’s true daily lived experience was like and that is a sad reflection considering the number of people who had contact with Hakeem and his family over the two-year time period of this review. If anyone was trying to tell what the reality of life was like for him, that was Hakeem. From the school records alone, he described vividly what was happening to him and how scared he was and what loss he had suffered. In the last years of his life, his father had been sent to prison, his dog of which he was very fond, and paternal grandmother had died, his mother was repeatedly not taking him to school, and he was observed, as discussed, to be tired, hungry and unkempt. The school did their level best to try and obtain help for Hakeem, and as discussed there were many contacts with BCSC regarding their growing concerns. 6.2 The review has established that had the concerns from school been directed via the CASS route, rather than straight into the safeguarding team, then this may have triggered a more proactive response. As mentioned previously the contacts from school were directed to the SW who was already working with sibling 1 and her new baby, both of whom were on CIN plans. Too much emphasis was also given to mother not giving her consent for a further assessment of Hakeem in his own right. The SW reflected in interview with the lead reviewer that he was trying hard to keep the relationship with mother and sibling 1 open, to make sure the baby was not at risk and that when he showed any signs of concern about Hakeem, mother refused to discuss it, feeling strongly that had it not been for sibling 1 he would not be coming around. The SW described how he tried hard to build positive and strength-based relationships with mother but that in reflection he lost sight of Hakeem and was unduly influenced 13 by mother, who continually stated that his non-school attendance and appearance was due to his asthma and poor health, and this went unchallenged. Learning Point 2: Where one child is on a CIN plan and there are growing concerns about another in the family with very different needs, there is a need to ensure that the child is assessed in their own right and a separate plan and social worker allocated. 6.3 In conclusion, the allocation of the same SW to both Hakeem and sibling 1 and the baby was not helpful. There appears to be have been only one attempt at direct work with Hakeem and further attempts by the SW were stopped by mother being out, away, or Hakeem saying he did not want to speak to him. There was a lost opportunity to explore further some of the things Hakeem had said about being 1000% scared, unhappy, hurt, or hungry. There was also no link made between what it felt like to have asthma and other allergies, how these were affecting him, his school attendance or what support he felt he needed. 6.4 At the practitioner event it was surprising how few professionals had actually seen Hakeem. The midwife for sibling 1 was one of the only ones who was able to describe him, and her impression at the time was of a sweet natured, happy chatty little boy who was clearly besotted by sibling 1’s baby. The GP practice described him as a gentle and caring child. The HV was also able to describe a positive interaction between him and his mother. She stated that he appeared at this time (Oct 2016) to be well looked after, with plenty of toys and a mother who doted on him. The home conditions were cramped and cluttered and though concerning for a new baby she felt were adequate for Hakeem, though he was sharing a bedroom with sibling 2 and witnessing volatile episodes between his mother, sibling 1 and sibling 2, as described by a number of police call-outs. Although home conditions at this time were not great, there does seem to have been a significant deterioration from Oct 2016 to Nov 2017. Finding 3: In this case there was little professional understanding of the daily lived experience of the child. This resulted in a lack of assessment of what his reality was like through the day and night and the level of neglect experienced. Going forward it is essential that supervision processes and multi-agency assessments are required to clearly describe a day in the life of each child. Most importantly there also needs to be clear and robust processes for ensuring that visits to CIN are done in line with BCT guidance and are monitored as closely as for those on a CP plan. The work on ACES (Adverse Childhood Experiences) may be something that BCT and other partners want to explore further in order to strengthen practitioner understanding and impact when undertaking assessments. Effectiveness of multi-agency working, compliance and communication including compliance with procedures, information sharing, supervision and support. 7.1 This SCR has not identified a pattern of multi-agency non-compliance around LSCB safeguarding procedures, or an endemic lack of support, but there are some concerns about management oversight of the case through formal rather than informal or group supervision. Reviews of this kind can always find improvements and things that could 14 or should be done better, and each agency has analysed its own practice and suggested actions that will increase compliance with their individual protocols. 7.2 The effectiveness of multi-agency working in this case has to be considered in the wider context of improvement work being undertaken by Birmingham Children’s Trust. A number of initiatives have been introduced over the last three years to tighten up on compliance and improve social work practice, supervision and partnership working. Whilst in general these have been positive, there are still areas of practice that are inconsistent. 7.3 The Ofsted monitoring letter (October 2017) found that, “considerable work needs to be done to ensure that services for children in Birmingham are of a standard at which outcomes for children are consistently good.” It judged that the standard of management oversight, in affirming case direction and the quality of work done, remained too variable and clear guidance on case direction in many cases was not provided or clearly recorded. All of the above was evident in this case. Whilst there was adequate supervision and support for the social worker (who spoke positively about the team ethos), group supervision and line management support, at times this was too informal in nature and decisions and actions to be taken were not recorded as they should have been. The team manager reflected in interview with the lead reviewer that at the time there was a huge push for social work managers to undertake more reflective and systemic supervision. As a consequence, she felt she had lost her way a little and as a result some of her previous and more robust management oversight of social work practice was weakened in her attempts to try out new systemic supervision models. 7.4 In addition, it is the lead reviewer’s opinion that the introduction of strength-based models and relationship social work, alongside more systemic and reflective supervision have at times had some unintended consequences which have resulted in a less authoritative approach to families where non-engagement and a lack of compliance is an issue. This is discussed further in the section under social work practice. 7.5 In CGL the change in commissioning and then sickness of the lead support worker resulted in significant drift in the case and it was not until the worker returned that support and supervision of the case improved. For the school, the designated safeguarding lead for the academy was very supportive, but the support was detached from the local authority systems and processes as discussed in the previous section. 7.6 West Midlands Police (WMP) identified six incidents of note in their information report. These included domestic abuse, allegations relating to physical assault between mother and her older children, and concerns regarding neglect, parental drug misuse and registered sex offenders. The first one that directly concerned Hakeem took place on May 15th, 2017, following a report that he had been missing from school for almost three weeks. The matter was risk assessed as priority status and although somewhat delayed due to a wider community emergency, Hakeem and his mother were located and seen, and information was then shared appropriately. The one area of concern regarding the police response followed ten days later when a further report was made regarding Hakeem’s general welfare, living standards and possible parental assault. The concerns were shared via the MASH (Multi-Agency Safeguarding Hub) and the incident recorded by the WMP MASH representative as a non-crime number, therefore not resulting in a robust response. Given the circumstances reported in the MASH referral and disclosures made by Hakeem using hand puppets of physical assault and being ‘1000% scared’, this should have resulted in Hakeem being seen by a child abuse police officer. Had this taken place it could have provided an opportunity to 15 explore more about the exact nature of his disclosure and provide him with an opportunity to talk about his experience of living at home. At the time the WMP representative had not attended any specialist child abuse investigation training or other core modules. The WMP report concluded that risk indicators at the time were not understood and the referral report was filed despite an outline of possible criminal offences and risk. WMP have now addressed this as part of their action plan in response to this review. 7.7 At the practitioner event, the multi-agency issues discussed tended to be systemic ones where there are no easy solutions, for example not having joined up IT systems, the changes in commissioning of services, difficulties in getting to multi-agency meetings and organisational change. It is important to stress that practitioners did describe the impact on them of the above issues; working under increased pressure, becoming desensitised so that working with families and neglect becomes the norm, having higher workloads, and the difficulty in keeping their records up to date. The impact of these issues on the level of effectiveness of multi-agency working is explored in more detail below. 7.8 Communication and information sharing. It became clear during the review that a significant amount of information on Hakeem and mother was not easily available to those involved. The continued split between adult-focused services and their IT systems, the hospital ED, respiratory clinic and GP, school and school nursing resulted in no one having the full picture of Hakeem and his family. These are not new messages and have continued to be written about in SCRs. At the practitioner event it was clear that for many attendees, this was the first time they had sat in the room with all the facts. Mother’s history and dependence on drugs and involvement of CGL was just not known by many of the professionals involved. Despite there being such a wealth of previous information very few people had access to this. In fact, even at the multi-agency meeting held November 2016, for the unborn child of sibling 1, who was now living back with her mother and Hakeem, neither the health visitor nor midwife were aware of mother’s increasing or previous drug dependency, and it was not considered when deciding to place the baby and sibling 1 on a CIN rather than a CP plan. The consequence was that mother’s ability to parent and the potential impact of her drug use on her whole family, not just Hakeem, was not well understood. 7.9 Some of this can be explained by the original assessment on sibling 1 being undertaken by the ASTI (assessment short term intervention team). The significant information on mother was not considered as, at that time, sibling 1 was living permanently with her grandmother. Learning Point 3: When assessments are carried out in the ASTI team and then the responsibility for the child moves into the longer-term safeguarding team, there is a risk that unless a short review of the assessment and plan is undertaken by the new SW then any significant changes in family circumstances, may not be reflected in CIN/CP plans and shared with the other agencies involved. 7.10 The CGL worker only had very scant information on mother’s wider history and it was not until April 2017, some 18 months after he became involved, that he realised that there was a child living in the household with an allocated social worker, it was not until this point he made contact with the Social Worker. He had no knowledge of the baby and sibling 1. This was explained partly by mother’s reluctance to share and her avoidance of face-to-face meetings, but also as described further on in this report, by the change in commissioning of drugs and alcohol services and a transfer from paper records to an electronic system, where previous details on mother had existed. In 16 interview with mother she said that she felt she had had poor support for her drug addiction and that when she had reached out for help after returning from, in her words, ‘doing cold turkey’ in Ireland in August of 2017, the worker from CGL failed to turn up to a planned visit and so she never met him. 7.11 As discussed, the SW for sibling 1 and later the baby became Hakeem’s social worker by default. As concerns for him were escalated by his school the SW was asked by his team manager to take on responsibility for Hakeem as well, but his primary focus was on the new baby and young teenage mother. The SW was not aware of CGL’s involvement and the deterioration in mother’s drug management and her lack of engagement with their support service. The GP was also not aware of much of the family history, or mother’s drug dependency and due to different names did not make all the connections about who was in Hakeem’s family until after his death. 7.12 Birmingham Women’s and Children’s Hospital Foundation Trust (BWCHF) staff at the practitioner event described how they rely heavily on parental disclosure when routinely asking if the family has a social worker. When Hakeem was brought into ED at BWCHFT in September 2017, initially mother did not disclose and there was no system of flagging to identify that Hakeem had previously been on a CP plan or latterly was on a CIN (something that has been raised in previous SCRs (Polly, Derbyshire LSCB 2017). The CP-IS (child protection information service) only shows that a child is on a CP plan or is a looked after child. As the Consultant described, ED is busy, and they see many parents who have a range of multiple and complex issues, Hakeem and his mother did not stand out especially. The priority, not surprisingly, is always to treat the sick child rather than identify social history and neglect. Neither the GP practice nor any other agency had received any formal notification that Hakeem had been placed on a CIN plan. 7.13 There were other occasions described in the BWCHFT information report where information that was gained from mother about her history and situation should have triggered further seeking of advice from the hospital safeguarding team and been recorded within the hospital electronic handover system to ensure that the ED consultant shared information with the consultant paediatrician. The lack of compliance with the Trust safeguarding policy was explained by the use of peripatetic services2, and the lack of written records. The staff nurse on the high dependency unit, where Hakeem was staying, was advised by the internal Early Help lead to contact the school nursing service, but it was eight days before a message was left, and there was further delay and a lack of ownership by nursing staff to follow up. This was partly explained by work pressures and partly by the difficulty in getting anyone to speak to in the school nursing team. 7.14 West Midlands Ambulance Service (WMAS) received five 999 calls in relation to Hakeem over the two-year time period, all relating to him having breathing difficulties. Each time he was taken to Birmingham Children Hospital (BWCHFT), the final time being on November 26th when he was found not breathing. WMAS were not aware of any involvement with children’s social care as at the time they had no access to records as CP-IS was not fully implemented. 7.15 Professional understanding of escalation process. From January 2017 there was a significant increase in communication between the school and BCSC as their concerns for Hakeem’s welfare increased. They believed they had sufficient evidence of what they felt to be neglect to warrant statutory involvement and the support of a 2 High Dependency Plus – paediatric consultants who outreach across the hospital to support and manage high dependency patients to reduce their need to be transferred to Paediatric Intensive Care Unit. 17 social worker. The difficulty the school staff had in getting any helpful response to their concerns regarding Hakeem’s welfare was both frustrating and not in his interest, although eventually the family assessment commenced, and Hakeem was deemed to be a CIN in July 2017. 7.16 The school’s concerns were significant, especially as the school holidays loomed and they knew that their oversight of Hakeem would not be there. Support for school was sought from the regional strategic safeguarding leads employed by the Academy chain and they appropriately considered the thresholds in the Right Service, Right Time document. BCSC continually advised that the threshold for significant harm had not been reached as they felt there was no immediate safeguarding risk (see previous discussion in section on neglect) and see Finding 2. The safeguarding leads advised the Academy that the BSCB escalation policy should be employed in contesting the assessments and view of their social work colleagues that the case should remain at CIN. This escalation never progressed beyond Stage One of the process. The information report for Education concluded that there was some confusion by the school about how to escalate appropriately and evidence their concerns, this was partly caused by the way the Academy Trust provided their safeguarding advice regionally. Learning Point 4: There was a lack of understanding and application of the escalation procedure by the Academy Trust when there were persistent safeguarding issues, which resulted in concerns raised not being appropriately escalated and resolved. 7.17 When practitioners were asked about why they did not use the BSCB escalation process, they described that they felt it to be ineffective, requiring an enormous amount of persistence. The cumulative effect of getting a negative response from BCSC was both frustrating and had the unintended consequences of making them feel it was not worth it. This was not just within the school: the ED Consultant felt thresholds for child protection varied between Birmingham and other authorities (Solihull) and that she had received a more negative response from what is now BCT, which affected her confidence in them responding when concerns were raised. This is something that BSCB may want to explore further. 8. Working with resistant parents and non-engagement. 8.1 Research and evidenced based practice give us clear information about working with resistant families. In this case this should have been better understood and addressed by the SW, team manager, and the multi-agency team to both identify mother’s pattern of behaviour and the causes of this, and then consider how to engage and work with her over the long term. At the practitioner event, those professionals who had worked with mother or who had come across her collectively and individually described her as difficult, challenging, rude, ranting, abusive (verbally or via text), and demanding, she was also at times intelligent, articulate and when not high on drugs, lucid. The impact of this behaviour as described by them, was to meet her demands and to get her out of the building as quickly as possible, to prevent further disruption or upset to others. Receptionists at school and the GP practice all felt the same. The school described letting Hakeem go home with his mother after she arrived intoxicated at school, their rationale being to avoid confrontation and that they had to consider the wider welfare needs of staff and school community. Her volatility caused, not surprisingly, huge apprehension. The real impact on Hakeem was not fully recognised or considered. In previous SCRs by the author of this report (Polly, Derbyshire LSCB 2017), working with this non-engagement and difficult parental behaviour has been discussed and a key learning point from that review was that non-engagement should be recognised 18 not as frustrating, but as carrying the potential to harm the child and central to a child's welfare. It is a parent’s choice, not a child’s choice, to not keep appointments, to be difficult to pin down, to not be seen alone, something recognised in the DfE Triennial analysis of SCRs (May 2016). It calls for authoritative professional practice, defined as an ability to demonstrate professional curiosity, respectful uncertainty and being able to challenge parents and other professionals (Tuck 2013). 8.2 As discussed, BSCB introduced an overarching practice framework for the city in 2013. Called “Right Service Right Time” (refreshed in 2018). This was a conceptual service guide for the city’s practitioners and aimed to help them define particular levels of need, harm and risk for children and families using a strength-based approach based around Signs of Safety (Turnell, A, & Edwards, S (1999). Previously Birmingham had had a confusing number of different assessment tools for early help which were proving ineffective. Researchers from Kings College London found that Signs of Safety is "workable" where authorities make the necessary commitment of trust in their staff at all levels, backed up by time resources and reflective supervision (Ref Children and Young People Now, July 13th, 2017). 8.3 Signs of Safety is based on honest relationships between the worker and families and between all professionals involved to achieve a shared understanding of what needs to change, and critical thinking to minimise error and create a culture of reflective practice. However, where parents consistently fail to engage, are resistant and/or manipulate and demand things on their terms only, then this approach needs to have some clear safeguards in place. (see ref Fox, L 2016, Applying Signs of Safety in high risk cases, Community Care inform Children). After the CGL worker had reported to BCSC his concerns around safeguarding, mother then sent abusive texts. A plan was devised to ensure that a different drugs worker complete the drug test to keep her engaged but she never attended. The significance of mother’s drug dependency and her historical reliance on drugs was never fully assessed or understood in the context of her ability to parent safely. 8.4 It is well documented that in such cases maintaining focus on the child can be particularly challenging, the problems of the adult often eclipsing those of children (RIP 2012). Typically, such cases can involve a downgrading of referrals from school, viewing incidents in isolation with no recognition of cumulative harm, possibly becoming desensitised to the child’s difficulties, and with a potential for workers to over-identify with the parent. These issues were all evident in Hakeem’s case. 8.5 In interviews for this review the SW believed that he was working well with mother, that she was at times engaging with him, and that he had a good relationship with Hakeem but the evidence to support this assumption is weak. He saw Hakeem alone on only a couple of occasions: the last time he recorded that he had seen Hakeem alone and had a reportedly reasonable conversation with mother was in June 2017. The team manager in interview with the lead reviewer said that she was not aware that Hakeem had not been seen, and if she had she would have acted upon it. There were opportunities during the group supervision in August (and later in November) or at the CIN meeting on 28 September 2017, that mother did not attend, for the practitioners involved to discuss this in a better-informed way and arrive at a set plan of intervention, timescales and contingencies, but this did not happen. Learning Point 5: Where parents are persistently not engaging in relationship-based practice, there is a role for social work supervision to intervene to consider a more authoritative approach ensuring that the child is adequately assessed, seen and safeguarded. 19 9. Identification of risk of significant harm leading up to ICPC in November 2017. 9.1 At the end of May 2017 there was, as discussed previously, ample evidence that Hakeem may be suffering neglect once more. In the space of six weeks, the school had shared with BCSC multiple concerns about Hakeem’s living environment and the detrimental effect it was having on him. This included him disclosing that life at home was miserable, his mother and sibling 1 were fighting, and he had witnessed his sibling 1 screaming and throwing the baby on the settee in frustration. (It is not clear how this was responded to or shared in the light of the vulnerability of a young mother and baby.) He was also presenting as hungry in school. His inhaler at school had run out, and his mother had not supplied a replacement and had failed to attend a school nursing appointment. 9.2 By July 2017, the school were rightly anxious that appropriate support be put in place before the school holidays. Whilst the concerns had been noted by BCSC, the decision to place Hakeem on a CIN plan, not a CP plan, did in the lead reviewer’s opinion result in a lesser degree of action and protection. It is not clear to the lead reviewer what process was used to determine that a CIN plan was appropriate and how and if this decision was made in agreement with other key agencies as the plan was only written up posthumously. The SW acknowledged that he himself was anxious about the decision at the time but was re-assured by his team manager that a robust CIN plan with clear timescales for action would be the best option to keep mother engaged. BCSC should instead have undertaken a Strategy Discussion and then brought the case to an ICPC for a multi-agency decision to have been made. 9.3 The information that Hakeem had been missing from school for two weeks in September 2017, and then on November 10th allowed to go home with his mother from school who arrived late and intoxicated, rather than risk a confrontation, was not properly shared by the school, so the opportunity to trigger a home visit was lost. 9.4 In October 2017 a formal decision was taken for the case to be taken to a child protection strategy meeting and then onto an ICPC, though this had initially been suggested in August through group supervision. The expectation by BCSC at the time was that this should happen within 15 working days, however given it was now four months since the SW saw the child, and had had any contact with his mother, it should have been held earlier. The delay appears to have been caused by a number of unrelated factors. Firstly, it was presumed during the summer holidays that mother and son were in Ireland, though this was never properly validated, secondly Hakeem’s NSA was coming to court and it was hoped this would improve the situation and lastly the SW was on annual leave and had not yet written up the family assessment or completed the conference attendance form which triggers an ICPC. 9.5 It would seem from the point of allocation of Hakeem as a case in his own right in May 2017 until the ICPC in November 2017 that there was little evidence of any effective social work intervention or management oversight of the case. The team manager reported that she was not aware that Hakeem had not been seen: she had assumed that the SW knew the case well and that appropriate visits were taking place. The SW reported that although he felt supported and spoke regularly to his team manager, he only received one formal supervision between May 2017 and Nov 2017. 9.6 It was clear from the minutes of the ICPC that the decision then to make Hakeem subject to a CP plan was the right one. However, the scaling from professionals who attended the conference rated him as between 0-2 on the scaling safety scale, which is very low. At the practitioner event one attendee at the ICPC said she left the meeting 20 feeling extremely anxious for his wellbeing. There is a learning lesson here for all agencies: firstly that if a practitioner feels unhappy or significantly concerned for a child’s welfare after an ICPC, then they must speak to their manager, or designated safeguarding lead and consider escalation, and secondly that there must be some action taken by BCT and the ICPC chair to assess the perceived level of immediate risk. Learning Point 6: The review found that there was an absence of guidance for ICPC/Review Chairs when a review or strategy meeting register a child as having a safety scaling at 2 or lower (0 = no safety, 5 = moderate safety, 10 = high level of safety). In this case, the level of risk should have triggered consideration of the immediate removal of the child or the development of an appropriate safety plan to minimise and manage the risk. 9.7 In this case whilst there may have not been enough evidence to seek legal action to remove Hakeem, at a minimum there should have been a safe and well check to see him. The lead reviewer has learnt that at the time the ICPC took place on a Friday afternoon, and that this influenced what actually happened as it was late and the end of the working week. In response to learning from this this case ICPCs are no longer held on Friday afternoons. 10. Social Work Practice 10.1 The analysis of social work practice has to be set in the context of wider improvement work that Birmingham Children Trust are undergoing. In 2010 Children’s social care services in Birmingham were graded ‘Inadequate’ by Ofsted. Government intervention, along with the appointment of a series of commissioners, has reflected the national concern for these services. In the Ofsted inspection in 2016, improvements were noted, but the overall judgement was still inadequate. 10.2 SCRs should attempt not to allocate blame but to understand the root cause of any problematic practice to determine more about why rather than what happened. However, it is important to not shy away from naming practice that falls below expected standards where these have had a significant impact on the management of the case. In this case there were a number of issues, many of which are being addressed internally by BCT, but some of which need some explanation. The issues listed below summarise the practice concerns which have been identified during the course of this review; they are not necessarily systemic or widespread but were a significant feature of this case. • Not actively engaging with or seeing Hakeem alone from June 2017 until his death in November 2017, despite him being on a CIN plan. • Not in any way engaging with Hakeem’s father in prison or his extended paternal family. • Allocation of one social worker to the two siblings and a new baby all on CIN plans with very differing needs. • A poor-quality family assessment which took no account of the family dynamics. • Drift in timescales and lack of urgency to hold an ICPC when the situation deteriorated over the summer of 2017. 21 • Failure to adequately write up social work records and complete the written CIN plan and share with others until after Hakeem’s death. 10.3 Use of Children in Need. The decision to place a child on a CIN plan rather than CP Plan continues to cause concerns and this case once again shows how difficult it is to get it right. This issue is highlighted in multiple SCRs including the Birmingham LSCB SCR into Keanu Williams (Jan 2011). The BCSC practice guidance on CIN (2015) clearly identifies that there should be a holistic assessment, that the child should always be seen in the context of their community, ethnicity, culture and that the parents must accept the findings of the assessment. It also states that any CIN plan must be formulated with the child, family and any relevant partner agency within 10 days of the completion of the assessment. All plans must then be ratified by the team manager and children seen at a maximum of six weekly intervals and more frequently where intensive support is necessary. In reality almost no CIN meetings took place, or if they were recorded as CIN they were actually only professional meetings, as mother was never present and other professionals were not fully aware or included in the assessment, and mother was not engaged in the work in any way. 10.4 The team manager described her team at the time as holding quite high caseloads, where children on CP plans tended to be the priority as they were being closely monitored in terms of compliance as part of the DfE improvement work and that there was a backlog of recording needing to be done. The SW at the time had a case load of 22, had a backlog of recording, not helped by his dyslexia. The team manager stated that CIN plans were often not written up in such a timely way, and this sometimes resulted in them not being properly shared with other agencies often until just before the next CIN meeting. Recent audits of CIN cases in the team did verify that timescales were not always robustly met. As a result of issues raised in this review, BCT has re-issued practice guidance stating that CIN plans must be written up within 10 working days and shared with the family. 10.5 The lead reviewer has determined that the SW felt he was in a difficult position, he was trying hard to maintain the relationship with mother, sibling 1 and her baby, alongside beginning to build trust with Hakeem. Mother was determined that no one was going to take Hakeem from her, and therefore was very reluctant to let the SW see him, enter the house, or engage in any meaningful work. Hakeem himself was not that willing to see the SW and told him he did not want a social worker. However, part of the social work role is to have the skills and confidence to use authority and professional competence to overcome these issues, and where necessary seek support from managers to find solutions to being blocked by a child or family. Hakeem was a child in need and if there was an issue with gaining access to him, then that in itself should have warranted further urgent intervention. Mother was at the same time keeping the CGL worker at a distance as she was not wanting to acknowledge the state of the house, nor the number of drugs that she was back on, or indeed how she was funding her drug addiction. As we have heard from all other professionals, she was volatile and difficult and trying to keep her on board rather than confront her was the easier option. The impact on professionals of working with complex, resistant and difficult parents should not be underestimated and can, if not managed well, result in the unintended consequence of preventing the child being the primary focus. The SW as discussed should not have been holding the two cases with very differing needs in the family alone, see Learning Point 2. 10.6 The author of the report has sought to examine factors behind the problematic practice to ascertain if the social worker and team manager felt adequately supported, were regularly supervised and had received adequate training. All of the above were deemed to have taken place, including the use of group supervision and peer support. 22 The SW took Hakeem’s case to group supervision for discussion in August 2017 and was advised by his peers to take the case to ICPC. However, the BCT information report does suggest there was some slippage in formal supervision which may, if it had taken place, have identified how long it had been since the SW saw Hakeem alone and alerted the team manager to the need to hold an urgent ICPC. 10.7 Some local authorities or Trusts appear to have a lesser degree of scrutiny of CIN plans than CP plans and as discussed, identifying neglect and seeing the risks associated with it from the child’s point of view must influence decision making in a more authoritative way. BCT have sought as a consequence of this review to audit CIN practice to assure themselves that this is not now the case. 10.8 Lack of Engagement with Father and his extended family. There are two very striking concerns about the professional response to Hakeem and his paternal family. Firstly, at no time was there any evidence that their racial background was ever considered. His father was from a Muslim Asian background and until going to prison said that Hakeem had regular contact with his paternal British Asian family. There is no reference in any professional meetings or notes of the significance of this for Hakeem which resulted in his extended paternal family not being consulted or asked if they could offer support, or help with getting him to school, or any other aspect of his case, as things began to deteriorate. 10.9 The second point is that once he was convicted, there is no evidence that any agency including BCT, made any attempt to seek his views, describe the deteriorating conditions or inform him that his son was on a CIN plan, much to his regret. Hakeem’s father described in an interview with the lead reviewer whilst he was in prison that although he did not live full time with Hakeem, he was a “hands on dad” who was very involved with his care. He regularly saw Hakeem, describing him as the best thing that ever happened, had been part of the residential parenting assessment when Hakeem was born and was very concerned for his health, often taking him to the GP and hospital appointments, as evidenced in all health records. Father had a good awareness of his partner’s drug dependency and was clear that whilst he was there, he felt her use of methadone was kept under control. 10.10 At the practitioner event not one agency could really describe why this was, other than that they still focus significantly on mothers as the primary carer. Mother had been very vocal about her disgust at the allegation against her partner and that she wanted no agency to contact him, Hakeem was not consulted on this. The social worker acknowledged that his normal practice would be to involve a father, and consider cultural and racial backgrounds, whatever the circumstances and that he was unduly influenced by the offence he had committed which had been widely reported in the press, and mother’s volatility towards any contact with him. 10.11 BCT have recently undertaken further work around this and established that there is a pattern of social workers concentrating most on whoever is the primary carer rather than involving both parents, so it not solely about just not engaging with fathers. 10.12 Basic good practice would expect that a birth father, especially one who had been so involved with his son, would be consulted even if they were in prison for a serious offence. He had not offended against a child. It was never recognised that Hakeem’s overall care, happiness, medical and physical neglect began to seriously deteriorate once his father had gone to prison. BCT are now actively encouraging a better engagement of fathers and expecting to see it as part of assessments and plans for children. 23 Finding 4 - In this case the failure by all agencies to consult and inform the birth father of the growing concerns for his son’s welfare resulted in professionals not adequately taking account of his ethnicity and background, alongside the potential for extended family support or wider engagement and support from the family’s wider community. It is vital that the improvement work on engaging fathers progresses and includes those who may be on remand or serving prison sentences and makes appropriate reference to their own ethnicity and family support networks. It is recommended that any assessment should include the impact on the child, in terms of possible loss of support, guidance and wider family contact when a parent goes to prison, not just the risk the parent may have posed. 11. How non-compliance issues by parent and drug treatment were managed 11.1 As discussed, parents who do not engage with services for themselves or their children present a significant challenge to professionals, particularly for those who are working with strength-based models. The lack of any meaningful engagement of mother by both adult-facing and children’s services was a consistent theme in this case. 11.2 Analysis of CGL involvement. Mother only attended one key working appointment during her treatment episode with CGL from 1 March 2015 to 26 November 2017, missed 16 and cancelled four. She attended five medical appointments and missed four. The CGL key worker arranged three home visits, but she was always out, or cancelled so they never actually met her and only communicated with her by text or telephone. Historical information from Birmingham and Solihull Mental Health Foundation Trust stated that mother did not feel she needed to attend appointments, so this was not a new pattern of behaviour. 11.3 In October 2016, mother was initially prescribed methadone (50ml) on a supervised daily basis as she admitted that she had stockpiled some of her prescribed dose and had recently used heroin and a small amount of crack. She was later assessed by a CGL doctor to have more protective factors in place having described herself as a busy working mother, having a non-substance abusing partner, and using a safe storage box for her medication, though these facts were never verified, which would have been good professional practice. This led the doctor to agree to her collecting methadone three times a week rather than daily, which was not in line with CGL policy. 11.4 By March 2016, mother was not engaging in her treatment package, so her prescription was rightly changed back to daily collection. The focus of the work by CGL key worker was purely on engaging mother. They only became aware of Hakeem and his asthma-related problems and other siblings in August 2016. After case discussion with his CGL team leader he agreed to ascertain from mother what support she had in place for her children and to refer to children’s social care as he felt there may be safeguarding issues. Unfortunately, the worker from CGL, before taking any action, went off sick, not returning to work until January 2017. The case drifted and was not reallocated in his absence so no information about CGL involvement with mother was shared with BCSC, something which is a learning point for CGL. 11.5 Mother was seen by CGL doctors twice in this period and there was some exploration around risk to children in the first appointment, however she refused to provide the CGL medic with the children’s names when asked, which should have led to further action. At the second appointment she attended with the seven-week-old grandchild, who she said was now living with her. The baby was observed to be well cared for, but again it should have triggered a contact with the CASS to follow up on the information provided; this did not happen. It was not until April 2017 when mother was requesting 24 a late holiday prescription that she provided the names and dates of birth of her children and shared that BCSC were involved because the father of the baby was a convicted sex offender. The CGL worker contacted BCSC and spoke to the allocated social worker on the same day. This was, according to the SW, the first time he became aware of mother’s medication, trips to Ireland, poor engagement, and previously reported drug use. This is extremely worrying practice as by this time sibling 1, her new baby and Hakeem aged six were all living with mother and sibling 1 and the baby were on CIN plans, which had taken no account of mother’s current drug dependence or potential risk. 11.6 In May 2017 at her appointment mother was asking to come off supervised daily subscription. However, she tested positive for methadone and opiates, admitting she was now smoking heroin and cannabis, spending about £100 a week on drugs. The CGL doctor rightly recognised potential risk to children and suggested a transfer from methadone to buprenorphine, which is considered safer as the risk to children from accidental overdose is reduced. This was the only option to off-supervised prescription and was in line with the CGL family-focused prescribing policy. A plan was made to review daily supervision in a month if mother could refrain from heroin use, but again the significance of this information appears not to have been considered in the family assessment that the social worker was undertaking at the time. This pattern of non-attendance by mother continued and in August 2017 the CGL worker was informed by the pharmacist that she had not collected her methadone for two weeks. CGL escalated concerns to the duty team as the SW was on leave at the time and again later in the month when he heard that mother was moving to Ireland. He received no response from BCSC. He was appropriately concerned that there must be an increase in mother’s illicit use of drugs and was aware there were children in the house. 11.7 It is important to understand practice by CGL in the context of wider changes. Birmingham City Council re-commissioned substance misuse services in 2014 with a planned 36% reduction in the budget. CGL were awarded the contract but as the CGL information author reported, over 5,000 service users, and 300 staff from 26 different contracts transferred across. Staff at the time had a mixture of skills, experience and backgrounds. The new model of funding impacted on staff as there was new IT, more flexible working, a reduction in locally based buildings and this impacted on staff morale and stress levels. The changes took time to bed in and although there was a plan to support the safe transition of service users around safeguarding, the outgoing provider for mother did not record any current safeguarding concerns and no electronic marker was placed on her electronic case file. This was significant as the case was not perceived to be safeguarding and the historical record that documented the previous risk assessment and history regarding Hakeem and his siblings was not included, so was never seen by the CGL workers who only had access to electronic records. 11.8 The information report into the practice of CGL concluded that there was evidence in the first 18 months that the focus was adult-orientated with the primary aim being to engage mother, and many attempts were made to get her back into treatment including offering psychosocial interventions. However, there was only minimal curiosity initially into the risk associated with drug use and children. The CGL safeguarding policy stated that where service users with children of school age are prescribed opiate substitute medication a home visit needs to be conducted and a parental needs assessment undertaken. Although four planned visits were arranged including an announced joint visit with the social worker, there should have been more efforts made to locate mother to undertake a home visit, seek management advice at her continual absence, and share information with school around concerns. Mother confirmed in her recent interview with the author that from her perspective she felt she never got any proper 25 support from her CGL worker and that when she requested help on her return from Ireland after, “doing cold turkey” the response was to forward her text to the social worker, rather than contact her directly to offer help, so she lost trust in them. 11.9 The role of pharmacists in supporting the prescribing of substitute opiates is important and this review suggests it is not well understood by professionals outside of drug treatment services. There is an expectation that pharmacists will contact CGL when a service user has missed three days of their dose. This did not always happen which meant that the CGL key worker was sometimes unaware that mother was without her prescribed medication. This is significant as it can be an indicator that she was getting her drugs elsewhere and was using class A drugs again; to obtain them needs substantial amounts of money. What we know now is that after Hakeem’s death it was clear that mother had been using drugs for some time and was potentially funding this via prostitution from the same premises where Hakeem was sleeping. CGL drug testing policy states that service users should be tested every 12 weeks. In general, when mother attended, she was drug tested on most occasions, but as she missed many appointments the testing was irregular and positive tests alone should not be the only method of assessing how much someone is using. The crucial point is understanding the wider implications of such use. A second point was that mother was also requesting additional asthma inhalers for Hakeem, which she got from the pharmacist. It was discovered after Hakeem’s death that she was stockpiling and using these inhalers for smoking crack. The review has established that pharmacists do not receive specific training around substance misuse and therefore it would be unlikely that they would make the link between alternative use of inhalers and dispensing prescribed opiate substitute medication. This may be something that the commissioners of pharmacy services may want to consider as part of their action plan (see Finding 5). 12. Adequate assessment and management of child’s asthma, including prescribing practice. 12.1 Medical history. Hakeem seems to have had an early diagnosis of asthma and by the age of five had received steroid injections twice and was taking Beclomethasone (a steroid preventer inhaler) and using a salbutamol inhaler up to four times a day. He also had extreme reactions to nuts and eggs and had episodes of childhood eczema. 12.2 Hakeem was seen once within the timeframe by Heartlands Hospital Birmingham in July 2015 when he was brought into ED by his father. He was treated for asthma and discharged with prescription and advice to see his GP. It was noted that there was a family history of asthma and that he had not been using his preventative inhaler. The GP had recently referred Hakeem for a chest X-ray, but he had not been brought for it. There was no further explanation of why he had not been brought during the consultation at the hospital. The ED practitioner did not check electronic records as part of the routine triage, so was not aware of the family history. If they had, it would have identified a previous safeguarding alert on Hakeem’s electronic records dating back to his previous CP plan for neglect in 2013. As Hakeem presented as well cared for, no further questions were asked. At this time compliance with record checking in the hospital was not good, and this was later subject to an improvement plan. The Trust reports that compliance in 2017-18 is now 97%. 12.3 In October 2015 Hakeem was taken by ambulance to BWCHFT and was admitted as he needed oxygen. The Paediatric registrar recorded that Hakeem had poorly controlled asthma with a concerning history and that an outpatient appointment was required. The respiratory nurse assessed wider medical and social needs and 26 recorded that mother said she smoked cannabis and had previously been a heroin user. The nurse sent a letter to the GP and parents summarising her assessment and advising that the school should be provided with more information to support Hakeem’s education and health needs but did not consult with the hospital safeguarding team for advice or support following mother’s disclosure, which would have been expected practice. She did however speak to the then Common Assessment Framework Coordinator (CAF) for advice and established there was no current involvement with the family from children’s social care. 12.4 Hakeem was not brought to his follow up appointment in October 2015 but did attend with his father in November 2015 when his asthma was deemed to be more under control. The December appointment was also missed, and no explanation was sought so the Consultant Paediatrician sent a discharge letter to parents and the GP. No consideration was taken at this time into social history or curiosity as to why Hakeem was not brought, or the impact upon him. 12.5 Hakeem had one more hospital attendance in November 2016 but was not admitted. The real build up to concerns was in the September of 2017, a few weeks before Hakeem’s untimely death. 12.6 It is expected practice by BWCHFT, that for each child with asthma, a holistic assessment is completed of health and social care needs. Whilst there was some evidence that this was undertaken by the respiratory nurse at BWCHFT, it was not undertaken at any of the ED attendances. The ED consultant at the practitioner event said that it would be unlikely that this would be actioned as in ED priority is on life saving activity and once the child is stabilised, they are quickly moved elsewhere. 12.7 From the records it is clear that his father played a key role in supporting the early treatment and oversight of Hakeem’s asthma, a fact confirmed with the author of the report when she visited father in prison as part of this review. He described how hard it was to understand what was required and his frustration that more could not be done by the hospital and GP to prevent Hakeem from suffering. Both parents smoked, and the hospital doctor had talked to the father about stopping to prevent Hakeem’s breathing difficulties becoming worse. The significance of father’s imprisonment on the management of Hakeem’s asthma as his health deteriorated was never considered by any of the professionals involved, in fact it is unclear if there was any knowledge of it by health professionals until mother disclosed the fact when Hakeem was in hospital in September 2017. Mother stated in recent interview with the author that she felt neither parent had really understood the life threatening seriousness of Hakeem’s asthma and that medical professionals should be more transparent and direct when talking to parents. 12.8 The GP practice saw Hakeem 11 times during the period of review, eight times by the GP and twice by a practice nurse, and once by both on the same day. In general, the CCG information report concluded that the management of Hakeem’s asthma did conform to national British Thoracic Society (BTS) guidelines, however it has identified some local practice points and wider learning. The GP practice works with many vulnerable and disadvantaged families and the ethos of the practice was described by the report author as trying to establish good partnerships with families, even those who are difficult and demanding. However, there is an important lesson for them to ensure that within this ethos and culture they do not fail to identify children who may be a significant risk of harm or parental medical neglect. There are a number of other specific learning points for the GP practice development that have come out of learning from this review and the information report. 27 12.9 Hakeem was prescribed the appropriate inhalers with spacer devices and given courses of steroids and antibiotics as required. There was a full asthma assessment with the practice nurse on 12 April 2017 and a written asthma management plan including written advice on how to use his inhalers. The GP also assessed his asthma on four other occasions the last being the 22 September 2017. Mother told the author that although on paper there was an asthma plan, she felt it was not helpful as it did not really spell out or explain the difference between the different drugs and how to use them, or the consequence of getting it wrong. Mother looked at the internet and felt there was different advice and treatment options available. 12.10 By July 2017, the GP had registered some concern about the number of inhalers being requested by mother, along with nebules, declining to prescribe any more nebules, stating that Hakeem must be seen when a prescription was collected. This did not happen, and no explanation could be given as part of this review as to why. They also then did not investigate when Hakeem was not brought to a follow up appointment six days later. The GP noted that Hakeem’s asthma was poorly controlled due to poor adherence to preventer therapy. 12.11 The practice would say that mother insisted she knew best how to handle the asthma and because of previous discussions about her volatility this went unchallenged. Hakeem’s inhaler technique was only checked once because mother did not allow staff to get any further in their assessment. The combination of poor control and mother’s resistance to further medical input is, as the CCG information report author suggests, a cause for concern. The GP practice made no mention of mother’s behaviour, or their concerns about it, when responding to information request from BCSC on Hakeem. This is a learning point for the GP practice and the CCG. Learning Point 7: The GP Practice, when sharing information with BCSC, only shared medical advice and did not include important information regarding obstructive parental behaviour and drug use, which would have enhanced professionals’ understanding of the wider issues facing this family. 12.12 The need for a better understanding by all professionals around the lack of parental cooperation in the context of poor health, and consideration of the impact on the child is a significant learning point from this SCR. It was also apparent at the practitioner event and within the review team that apart from a few medical professionals, very few professionals understood anything about asthma and what good management of it looks like. 12.13 The national review of asthma deaths (NRAD) makes some strong recommendations about the importance of children taking their preventer inhalers (brown ones) as well as the blue ones (reliever inhaler). In the last six months of his life Hakeem was dispensed more reliever inhalers and fewer preventer inhalers than is recommended. He was also prescribed nebules twice. The information report for the CCG identifies that nebules are used in a nebuliser (a machine that delivers the medication through a mask) and it is not generally recommended practice in UK for use by patients at home as they can be dangerous, and result in a reliance on them which stops the patient using preventer medicine. Nebulisers can be bought on the internet and in interview with the author Mother described how she had purchased one as she felt it might help Hakeem, though admitted she had no idea it could be so harmful if used wrongly. Thus, it is concerning practice that Hakeem was prescribed by the GP on two occasions (May 2017 and Sept 2017) salbutamol nebules (the liquid used in a nebuliser). There is no record of the GP exploring with mother where she had obtained it, or the dangers of using one. Normal practice would be that if a nebuliser was prescribed it would be part of a hospital treatment plan. The social worker observed on a visit to the house 28 Hakeem wearing the nebuliser and presumed it was part of his normal asthma medication. Learning Point 8: In this case the child, who was suffering from asthma, was prescribed nebules by the GP for use with a nebuliser. This course of treatment should only form part of an agreed asthma treatment plan with the child’s local hospital. 12.14 Hakeem was admitted to a high dependency unit at hospital with poorly controlled asthma in Sept 2017 and Oct 2017. On his discharge from BWCHFT, the level of concern about Hakeem’s asthma was high and increased efforts were made by the GP and practice staff to contact mother and ask her to bring Hakeem in for review, but they never got hold of her. This concern was not shared with BCSC as the GP believed they needed the consent of mother to share information with other agencies. They were not, as mentioned, aware that Hakeem was on a CIN plan, nor of the growing concerns about Hakeem’s wider welfare. There appears to have been no formal discharge plan for either time Hakeem left hospital. 12.15 Hakeem was prescribed four preventer inhalers in the last six months of his life (each one is supposed to last approximately one month, slightly fewer than ideal), and eight reliever inhalers, as children often lose them or need an extra one at school. While this alone does not give a clear picture, nevertheless the use of more than one reliever inhaler a month should raise clinical suspicions. The review has also identified that inhalers were issued by the pharmacist in October 2017, prior to prescriptions being given; this can happen legitimately at the discretion of the pharmacist but caused concern for the GP practice, who were rightly worried that mother was obtaining more reliever inhalers for Hakeem, without preventers or him being medically assessed. The CCG information report says that the approach of the pharmacist was not helpful and undermined the attempts by the GP practice to see Hakeem in person. There was some discussion between pharmacy and the GP over the issue and the GP practice took advice from the medicines management team of the CCG to clarify the issue. The pharmacists argued that they had a duty to provide inhalers on patient safety grounds, whether or not prescribed by the GP. This is accepted practice and in line with medical guidance. Whilst it may be accepted practice, it potentially leaves a situation where a child’s poorly managed asthma is not recognised and therefore not acted upon in a timely way. 12.16 The management of asthma by parents is complicated and BSCB and CDOP (Child Death Overview Panel) have recently completed further research and issued publicity to raise the profile of it to parents and carers following four other asthma related deaths of young people and an unpublished learning lesson review which highlights many similar issues found in this case and summarised in the briefing note, (ref Asthma can Kill, Nov 2017, BSCB). 12.17 Asthma is a common condition affecting around 1 in 11 children. With effective control, hospital admissions and premature deaths should be avoided. A national review of asthma highlighted some avoidable factors which have a role to play in three quarters of asthma-associated deaths (Birmingham CDOP review Jan 2016). One of the most important factors that the CDOP report, BTS and NICE guidelines highlight is ensuring that there is an appropriate clinical review carried out by primary care, when a child’s asthma becomes problematic, or within two working days of receiving treatment in hospital or via the out of hour’s service for an acute exacerbation. 12.18 All children should also have an annual review and individual personal asthma plan. This personal plan should include structured education on how to recognise an asthma 29 attack, when to seek help and how to prevent a relapse. The importance of this being developed and shared with families, hospital, GPs, school nurses and any other relevant professionals is crucial. It also ensures that further encouragement is provided to children who are not brought to ensure any preventable harm to the child is avoided and problematic asthma is dealt with early. 12.19 In this case, whilst the hospital and GP had regular contact with Hakeem and there was an annual review of his asthma, there was little awareness among other professionals of the significance and risk associated with poor asthma care nor a well-developed personal asthma care plan for Hakeem which should, had it existed, have been incorporated into his CIN plan. It is also a concern that his mother did not feel the asthma plan helped her understand the different medications and the significant of Hakeem’s asthma. Finding 5 - This review has found that there is a lack of professional awareness around the appropriate use of medication for children with asthma that can result in a failure to identify patterns of over-prescribing of inhalers. In addition, there needs to be awareness that asthma medications can be misused where there is parental drug misuse. There must be a wider dissemination of the messages from the previous Asthma Kills Learning Lessons Briefing note in Birmingham with a suggested update of lessons from this SCR. For GPs and other medical staff, there must also be an expectation that all children with asthma have a personalised asthma action plan which includes structured education on the medications prescribed and how they should be given, how to recognise an asthma attack, when to seek help and how to prevent a relapse. This plan must be shared with families, hospital, GPs, school nurses and any other relevant professionals. There is also a need for pharmacists to have specific safeguarding training that addresses the wider safeguarding issues that by parents continuously requesting emergency medicine they may be unable to plan or meet the basic needs of their children. The training content also needs to make a link between parental drug misuse, prescription medical equipment and childhood asthma, especially where there is a tendency for parents to request emergency medication for their children. Communication between GPs and pharmacists in these types of cases is essential. 13. Role of school nursing in management of Hakeem’s asthma. 13.1 The school health advisory service commenced in April 2016. Each primary school had a fortnightly visit and gave an opportunity for the school health advisors to talk with school staff regarding children where there were concerns. At the time of Hakeem’s death, there were significant issues with sickness in the team in the area covering the school. 13.2 Like many of the other professionals in this case, the school nurse never met Hakeem or mother. In trying to understand why there was no more proactive involvement with Hakeem, the information report author concluded that one of the main explanations was that when Hakeem started school, his mother never returned the health questionnaire to the school health advisory service, which, had she done so, should have identified his medical condition. The consequence of this was that they were unaware of his asthma and other allergies or that he had any specific needs for support. 30 13.3 There appears to have been little communication between any of the health professionals and school regarding Hakeem’s asthma, and they actually were not made aware of Hakeem until after his admission to BWCHFT in October 2017, when they were informed he had been admitted twice in the last two weeks with an exacerbation of asthma almost to the point of collapse, and which resulted in high dependency intervention. The doctors were concerned that mother did not seek medical attention until Hakeem was very ill. The Sister for medical complexities at the hospital rightly requested the school health advisers follow up in school and with mother, to look at the possibility of early help intervention. They were not aware that Hakeem was already on a CIN plan. This follow up, although recorded, did not take place, so no health assessment was undertaken, and no medical care plan developed. This delay in response by the school health advisory service is of serious concern. The interaction between health and education is crucial to ensure that children can succeed in school. It would have been expected that the school nurse advisor’s role would have been to liaise with the GP, the mother, and the school to ensure good partnership working. Other than sickness there is no obvious other explanation for such a poor response. 13.4 It is not clear from the information report or practitioner if the role of school nurse is clearly understood by the wider medical professional or social workers. In interview with the lead reviewer the team manager said until the practitioner event she was not aware of the cuts to school nursing and presumed that every school still had regular access to a school nurse. Until July 2018, Birmingham Community Healthcare Trust (BCHC) commissioned the school nursing and health visiting service. In this case, as the information report highlights, there was no joined up working between health visiting and school nurse services and assumptions were made that each was aware of the other’s involvement with Hakeem and his family. 13.5 One of the areas of concerns was the lack of timely response when information was received from BWCHFT in relation to Hakeem’s acute admissions. It would appear that the school nurse at Hakeem’s school had been off sick and only limited cover was provided. There was no obvious child health care plan, though it was suggested that one was developed but not signed off. Finding 6: This case has highlighted that liaison across health providers is not as robust as it could be. It is speculated by agencies involved that the practice in this case of not routinely sharing information about chronic health conditions and wider welfare concerns is not a one off and that there is a pattern of poor communication between health (GP, hospitals, health visiting and midwifery) and a decreasing school nursing provision. There is a concern that with more cuts to school nursing services that there will be even more difficulty in ensuring information is appropriately shared and acted upon in a timely manner, which will continue to leave children without adequate support. 13.6 Was not brought (WNB)/missed appointments for Hakeem. Whilst there were 11 presentations at the GP practice and five at ED, there were only a few times when Hakeem was not brought to appointments at the asthma clinic in 2017, and therefore no real pattern can be found. If Hakeem was unwell then either his mother asked for emergency treatment at the GP, or if he was very unwell called 999. The real issue was the lack of persistence in following up after asthma reviews to see if there had been compliance and if health had improved. The CCG reported that they did recognise the importance of GP follow up after acute asthma attacks however, if the family are difficult to get hold of via phone, then follow ups may not happen due to pressure of work. The key point is how well supported are parents to manage childhood 31 asthma and what should happen if they are not complying with treatment plans and that this is seen in the context of possible medical neglect, and that the Think Family approach is embedded in all health practice, both primary and secondary. 14. Findings and Conclusion 14.1 This SCR has sought to address the key elements of the terms of reference as specified over the two-year period of the review. This review has, through the practitioner event and via other documentation and interviews, identified a number of practice and organisational issues which need to be considered by the BSCB, and individual agencies, in order to ensure that there is systemic learning and improvement. The SCR highlights six findings and some additional single and multi-agency learning points that the BSCB and agencies should take into consideration when considering their recommendations. 14.2 The findings from this SCR reflect to some extent the wider findings of the latest Ofsted inspection monitoring visit (August 2018) which followed the City Council’s transition to a Children Trust in April 2018. The published Ofsted letter states that the Trust is continuing to make some progress in improving services for its children and young people. However, a number of areas continue to require improvements, which include the quality of the Trust’s evaluation of social work practice, the consistent engagement of partners in contributing to multi-agency meetings and ensuring that in cases of neglect, over optimism does not lead to inaction. More work is required to ensure that plans for improvement in children’s circumstances are easily understood by parents and that plans detail what the next steps will be when no progress is being made. All of these aspects are found to be the case in the analysis of practice with Hakeem. 14.3 Hakeem died of an acute asthma attack, but in the months leading up to his death there were a number of opportunities for professionals to have identified wider neglect factors that may have supported a more robust and protective professional response. The consideration of his welfare and care needs should have been assessed in light not only of his own health needs, but also of the reality of living with a substance misusing parent. The NSPCC Learning document on Parental Substance Misuse (Sept 2018) reflects how parents and carers who misuse substances can have chaotic, unpredictable lifestyles and may struggle to recognise and meet their children’s needs which may result in their children being at risk of harm. A good assessment must involve both protective factors but also risk, be collaborative and seek the views of other agencies who are involved with the family, such as health professionals, teachers, substance misuse services and criminal justice agencies (Bogg, 2013; Cleaver, Unell and Aldgate, 2011; Cornwallis, 2013; Home Office, 2003). Following Hakeem’s death as the West Midlands Police information report and photographic evidence identified, mother admitted her addiction was costing over £55.00 daily, she smoked heroin in the bedroom where Hakeem slept, and made makeshift crack pipes out of his prescription inhalers. If the drug key worker or social worker had gained access to the house or been more inquisitive about mother and her drug addiction they would have seen this for themselves. 14.4 We know that professionals have been deeply affected by this case and no one set out to fail to protect Hakeem, but collectively they did fail to see him or experience his lived and daily life, which had been deteriorating rapidly and was not hidden. Indeed, Hakeem himself told us on many occasions that life was not good for him. 32 14.5 As discussed, the review identified problematic professional practice which should be seen in context of changing organisational systems and performance at that time. It must also recognise the potential for professional de-sensitisation to conditions and level of poverty and neglect, to the extent that parental non-engagement becomes the norm, preventing the child being seen as central. This was a significant observation made by the lead reviewer following the practitioner event and other meetings. 15. Key findings and recommendations 15.1 The review identified 6 findings and 8 learning points that relate to issues that will, if addressed, impact on improvements in current professional practice. Findings: Finding 1 This review has found there is confusion by professionals around significant harm thresholds for neglect where a child has a chronic medical condition that is being poorly managed by a parent. There is a need for professionals to become more aware of the correlation between poor parental management of medication for children with chronic health conditions such as asthma and wider childhood neglect. It is recommended that where children have had hospital admissions for chronic conditions there is a robust discharge plan that includes identifying if any other agencies are involved. A reliance on parental self-disclosure may not always be best practice. Finding 2 In this case it was evident that there was a lack of join-up and communication between those responsible for Hakeem’s non-school attendance and children’s social care which resulted in the two processes not taking account of the neglect that Hakeem was experiencing. In future there must be a better process to ensure communication between the school attendance officers and other professionals to establish more about the daily lived experience for children. They must clarify which absences are authorised or unauthorised, especially if they are on a CIN/CP plan and recognise that persistent NSA is seen as a potential indicator of neglect. Additionally, it is recommended that children with chronic conditions such as diabetes or asthma which may result in NSA should be adequately assessed and supported, it should be noted that properly managed, asthma should not impact greatly on a child’s school attendance. It was also clear that Academy Trusts who employ their own safeguarding support need to ensure that more formalised strategic links are made between themselves and local authority support officers to ensure better guidance and support when they arise. Finding 3 In this case there was little professional understanding of the daily lived experience of the child. This resulted in a lack of assessment of what his reality was like through the day and night and the level of neglect experienced. Going forward it is essential that supervision processes and multi-agency assessments are required to clearly describe a day in the life of each child. Most importantly there also needs to be clear and robust processes for ensuring that visits to CIN are done in line with BCT guidance and are monitored as closely as for those on a CP plan. 33 The work on ACES (Adverse Childhood Experiences) may be something that BCT and other partners want to explore further in order to strengthen practitioner understanding and impact when undertaking assessments. Finding 4 In this case the failure by all agencies to consult and inform the birth father of the growing concerns for his son’s welfare resulted in professionals not adequately taking account of his ethnicity and background, alongside the potential for extended family support or wider engagement and support from the family’s wider community. It is vital that the improvement work on engaging fathers progresses and includes those who may be on remand or serving prison sentences and makes appropriate reference to their own ethnicity and family support networks. It is recommended that any assessment should include the impact on the child, in terms of possible loss of support, guidance and wider family contact when a parent goes to prison, not just the risk the parent may have posed. Finding 5 This review has found that there is a lack of professional awareness around the appropriate use of medication for children with asthma that can result in a failure to identify patterns of over-prescribing of inhalers and use of asthma medications that may indicate parental drug misuse. There must be a wider dissemination of the messages from the previous Asthma Kills Learning Lessons Briefing note in Birmingham with a suggested update of lessons from this SCR. For GPs and other medical staff, there must also be an expectation that all children with asthma have a personalised asthma action plan which includes structured education on how to recognise an asthma attack, when to seek help and how to prevent a relapse. This plan must be shared with families, hospital, GPs, school nurses and any other relevant professionals. There is also a need for pharmacists to have specific safeguarding training that makes links between parental drug misuse, prescription medical equipment and childhood asthma, especially where there is a tendency for parents to request emergency medication for their children, communication between GP’s and pharmacists in these types of cases is essential. Finding 6 This case has highlighted that liaison across all health providers is not as robust as it could be. It is speculated by agencies involved that the practice in this case of not routinely sharing information about chronic child health conditions and wider welfare concerns is not a one off and that there is a pattern of poor communication between health (GP, hospitals, health visiting and midwifery) and a decreasing school nursing provision. There is a concern that with more cuts to school nursing and other health services that there will be even more difficulty in ensuring information is appropriately shared and acted upon in a timely manner, which will continue to leave children without adequate support. Learning Points: 34 Learning Point 1 There may still be confusion about significant harm thresholds and the level of neglect required to trigger a referral or cross between a child in need and a child in need of protection. Learning Point 2 Where one child is on a CIN plan and there are growing concerns about another in the family with very different needs, there is a need to ensure that the child is assessed in their own right and a separate plan and social worker allocated. Learning Point 3 When assessments are carried out in the ASTI team and then the responsibility for the child moves into the longer-term safeguarding team, there is a risk that unless a short review of the assessment and plan is undertaken by the new SW then any significant changes in family circumstances, may not be reflected in CIN/CP plans and shared with the other agencies involved. Learning Point 4 There was a lack of understanding and application of the escalation procedure by the Academy Trust when there were persistent safeguarding issues, which resulted in concerns raised not being appropriately escalated and resolved. Learning Point 5 Where parents are persistently not engaging in relationship-based practice, there is a role for social work supervision to intervene to consider a more authoritative approach ensuring that the child is adequately assessed, seen and safeguarded. Learning Point 6 The review found that there was an absence of guidance for ICPC/Review Chairs when a review or strategy meeting register a child as having a safety scaling at 2 or lower (0 = no safety, 5 = moderate safety, 10 = high level of safety). In this case, the level of risk should have triggered consideration of the immediate removal of the child or the development of an appropriate safety plan to minimise and manage the risk. Learning Point 7 The GP Practice, when sharing information with BCSC, only shared medical advice and did not include important information regarding obstructive parental behaviour and drug use, which would have enhanced professionals’ understanding of the wider issues facing this family. Learning Point 8 In this case the child, who was suffering from asthma, was prescribed nebules by the GP for use with a nebuliser. This course of treatment should only form part of an agreed asthma treatment plan with the child’s local hospital. 35 16. Postscript In the intervening period since the tragic death of Hakeem in November 2017 there has been significant development and improvement in the multi-agency safeguarding arrangements in Birmingham. This section focuses on some of the key changes that have taken place that directly relate to the emerging learning and findings from this case. On the 1st April 2019 the former Local Safeguarding Children Board was replaced by new multi-agency partnership arrangements where statutory responsibility for leadership of the arrangements is shared equally between West Midlands Police, Birmingham City Council and Birmingham & Solihull Clinical Commissioning Group. The crucial leadership role that Birmingham Children’s Trust plays in the new arrangements, since their creation in April 2018, cannot be underestimated. Since 2017 there have three independent reviews of Children’s Social Care undertaken by Ofsted. In January 2019 services for children in need of help and protection were no longer judged to be inadequate. Ofsted commented “the delegation of statutory functions to Birmingham Children’s Trust has enabled the revitalisation of both practice and working culture, and, as a result, progress has been made improving the experiences and progress of children. Subsequent focus visits by Ofsted in January 2020 and November 2021 have provided further evidence of progress. The BSCP will continue to focus on improving leadership and partnership practice in tackling childhood neglect. The BSCP has funded a Neglect Programme Manager to work alongside the Neglect Operational Group in piloting new models of working to support children and vulnerable families in the city. The BSCP will launch the Childhood Neglect Strategy for 2022-24 at a practitioner conference on the 26th September 2022 focusing on tackling childhood neglect. In September 2021, NHS England and Improvement (NHSEI) published the national bundle of care for children and young people with asthma. Phase 1 of this national plan seeks to provide support for the new Integrated Care Systems in delivering high quality asthma care. In Birmingham there are two pilot projects that have these national standards at their core in engaging primary and secondary care together with key frontline practitioners from a range of agencies to achieve better outcomes for children with asthma. The city’s Child Death Review Arrangements will continue to review all cases involving deaths through asthma to maximise the opportunity to learn and promote good practice. 36 17. References Bogg, 2013; Cleaver, Unell and Aldgate, 2011; Cornwallis, 2013; Home Office, 2003). Fox, L 2016, Applying Signs of Safety in high risk cases, Community Care Inform Children Child Protection in England (2022) National review into the murders of Arthur Labinjo-Hughes and Star Hobson: Crown Copyright MacAlister, J (2022) The Independent Review of Children’s Social Care NSPCC (2015) Hidden Men: Learning from Case Reviews NSPCC (2018) Parental substance misuse NSPCC (2016) Lessons from SCRs, https://www.nspcc.org.uk/preventingabuse/childprotection-system/case-reviews/learning/ Sidebottom P, Brandon M & Co (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case review 2011 to 2014: DfE Turnell, A., & Edwards, S. (1999). Signs of safety: A solution and safety-oriented approach to child protection casework. New York, NY: Norton RIP (2012) Engaging Resistant, Challenging and Complex Families Beckett, C., (2007) Child Protection and Introduction: Sage Advisory Council on the Misuse of Drugs: Hidden harm (2003) responding to the needs of children of problem drug users: Home Office Asthma can Kill, Nov 2017, BSCB Summary briefing Joint Area Targeted Inspection into the neglect of older children (2018) HM Working Together to Safeguarding Children (2015) BSCB SCR :Keanu Williams (2011) BSCB Learning Lesson review 2017 37 Appendix 1 SERIOUS CASE REVIEW TERMS OF REFERENCE Introduction This Serious Case Review has been commissioned by Birmingham Safeguarding Children Board in accordance with guidance issued under Regulation 5(1)(e) and (2) of the Local Safeguarding Children Boards Regulations 2006. A serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child Aim The aim of a Serious Case Review is to undertake a rigorous, objective analysis of what happened and why, so that important lessons can be learnt, and services improved to reduce the risk of future harm to children. 3 The Serious Case Review should evaluate the quality of professional practice and the way in which professionals worked within their own agencies and with other agencies in order to identify the needs of the family. The final report should: Provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence Be written in plain English and in a way that can be easily understood by both professionals and the public Be suitable for publication without needing to be amended or redacted. Background On 26th November 2017 an ambulance was called to an address where a 7-year-old child had been found unconscious in the garden. The initial account provided by the child’s mother was that he had been unwell the previous day and she believed that during the night he went into the garden due to his asthma. The ambulance service confirmed that Hakeem was deceased and had been for a considerable amount of time. West Midlands Police were conducting an investigation into the circumstances surrounding the death of this child. The child’s three older siblings had all previously been removed from mother’s care due to domestic violence and alcohol abuse. Hakeem had been subject of a Child in Need (CiN) Plan, which had been put in place in May 2017 following the completion of a family assessment. During the period of May to October 2017 Hakeem remained open to Children’s Services and was subject of a CiN Plan. There 3 Working Together Chapter 4: Learning and improvement framework, HM Government March 2015 38 were on-going concerns during this period in relation to mother co-operating with agencies to meet the needs of Hakeem. Hakeem’s school attendance and behaviour whilst at school were worrying as both had deteriorated further. Mother was not engaging with her drug support worker, nor was she taking Hakeem to health appointments in relation to the management of his asthma. On the 24th November 2017 (two days prior to Hakeem’s death) Hakeem was made subject of a Child Protection Plan under the category of neglect. Process At the Serious Case Review Sub Group on the 8th December 2017 it was established that the case met the criteria for a Serious Case Review as abuse and neglect is suspected to be a factor in the child’s death. The Independent Chair of the BSCB was formally notified and ratified the decision to commission a Serious Case Review on the 21st December 2017. The commissioning of chronologies and agency reports, once requested, will have four weeks for completion. Presentation of the SCR report and learning is to be presented to the Executive Board at the conclusion of the criminal investigation. The Executive Board has appointed an Independent Lead Reviewer to oversee the completion of the Serious Case Review, supported by a Review Team of safeguarding experts from: • Birmingham Children’s Social Care • Birmingham City Council, Education • Birmingham South Central CCG • West Midlands Police • Change, Grow, Live This case, at that time, was subject to an ongoing investigation by West Midlands Police. The Serious Case Review would not be finalised until the outcome of the Police enquiries are known to enable any additional information to be incorporated within the review. The Serious Case Review Sub-Group will ensure that any emerging findings are acted upon as soon as possible by agencies to ensure that any early lessons are fully implemented. The Review Team will consider the most appropriate way of involving family members in the review process. The Independent Lead Reviewer will be responsible for arranging liaison with the family with the support of West Midlands Police Family Liaison Officer. The Review Team will consider all aspects of the racial, cultural, linguistic and religious background to this case. There do not appear to be any factors that impact on immigration status. BSCB will obtain legal advice as necessary. The review will adhere to the Board's current legal advice relating to serious case reviews and other publications. The Clinical Commissioning Group (Birmingham Cross City CCG) will notify the Local Area Team of NHS England of the serious case review through the "Sudden Untoward Incident" system. The Review Team will take into account any relevant information that emerges from the Police investigation. The Police representative on the Review Team will be responsible for liaising with the Senior Investigating Officer and the Crown Prosecution Service. 39 The Social Care representative will be responsible for provision of information from family proceedings. The Strategic Health Forum will oversee implementation of learning across the Health network in Birmingham. The final overview report will take into account information from any other independent enquiry being held in relation to this case. The final draft report will be presented to the Serious Case Review Sub-Group to quality assure and endorse the key learning, prior to presentation to the Executive Board for ratification and effective dissemination of learning. The Executive Board will be responsible for the publication and media strategy. 5. Scope of the Review 5.1 Time Period The Review Team concluded that the Serious Case Review should focus on the period from the 1st July 2015 (to incorporate the decision made by Children’s Social Care to close the case) until the date of the child’s death on the 26th November 2017. 5.2 Individual Agency Reports And Chronologies All agencies that had contact with the family should complete a key events chronology using the chronolator software provided. Each agency will review their records and files relating to the case to prepare an information report on the template provided identifying emerging learning and action that will be undertaken to take forward any improvements. All agencies are required to provide analysis of their agency’s intervention with the subject child and family members, taking account of the below key issues. Guidance notes are provided for the use of the chronolator and content of information reports. Consideration will be given to a briefing for Information Report Authors by the Independent Lead Reviewer. The session will cover the purpose and aim of serious case reviews. It will also provide guidance about analysing their agency's involvement in the case and any specific issues detailed in the terms of reference. 5.3 Practitioners Learning Event Agencies will need to prepare a full list of those professionals and line managers who had direct operational involvement with the child and family to enable them to be invited to a practitioners learning event. The Independent Lead Reviewer will send out invitations providing plenty of notice, highlighting the importance of attending and explaining the purpose. 5.4 Key Issues To Be Addressed Within The Review The review process will focus on the below key issues: 1. The professional understanding of neglect and ability to recognise and respond to it and other risk factors (wider risk, substance abuse). 2. The level of effective multi-agency working and communication including compliance with procedure, information sharing, supervision and support etc. 3. The ability by professionals to really understand what the lived experience of the child was (including other factors: racial, cultural, linguistic etc). 40 4. Where there was non-compliance with a drug treatment programme, was supervised consumption and/or drug testing considered? 5. Was there adequate assessment and appropriate management of the child’s asthma, including prescribing practice? |
NC52535 | Suspected non-accidental head injury to an 8-day-old infant. At the time of Child R 's birth all of the children in the household were the subject of child protection plans. Learning themes include: knowing and considering the parent's history and vulnerabilities when working with a family; understanding a child's lived experience and what they may be communicating by their behaviour; the likelihood of child neglect coexisting with other forms of abuse; the impact of 'growing families and growing children' on the ability of parents' to cope; the cumulative impact of long-term neglect; awareness among professionals of control and coercion and non-violent domestic abuse; need for professionals involved with adults to be aware of plans for the children in the household; the effect of COVID-19 on families and services received; considering making older siblings aware of safe handling and careful behaviour around a new born baby; child protection procedures regarding parental contact following an injury. Recommendations to the safeguarding partnership include: ensuring improvement actions are taken, including seeking assurance that the learning from this review is considered by those responsible for ICON training, and that ICON recognises the need for bespoke plans about safe handling for parents with learning difficulties and where there are older children in the family; ensure that services are aware of the need to follow child protection procedures when a non-mobile child has injuries; and ensuring that when children are the subject of a plan, this is recorded on the GP record of any adults in the household.
| Title: Child safeguarding practice review: learning identified from considering Child R. LSCB: Wolverhampton Safeguarding Together Author: Nicki Pettitt Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Version 10 FINAL 1 Sensitivity: RESTRICTED Child Safeguarding Practice Review Learning identified from considering Child R Contents 1. Introduction page 1 2. Process page 1 3. Learning page 2 4. Recommendation’s page 11 1 Introduction 1.1 The Wolverhampton Safeguarding Together (WST) agreed to undertake a Child Safeguarding Practice Review (CSPR) by considering a case to be referred to as Child R . 1.2 Child R was 8 days old when they were taken to A&E with significant head injuries1. There had been ongoing concerns about parental neglect of Child R ’s older siblings. At the time of Child R ’s birth all of the children were the subject of child protection plans. 1.3 Both parents had learning needs and some mental health issues and there was known to be conflict in their relationship. Allegations of historic domestic abuse2 were not made by the parents until after Child R ’s injuries. 1.4 Learning has been identified in the following areas: • Knowing and considering the parent’s history and vulnerabilities when working with the family • Understanding a child’s lived experience and what they may be communicating by their behaviour • The likelihood of child neglect coexisting with other forms of abuse • The impact of ‘growing families and growing children’ on the ability of parents to manage • The cumulative impact on children of long-term neglect • The need for professionals involved with adults to be aware of plans for the children in the household • How COVID-19 effected the family and the services received • Bespoke safe handling and coping with crying advice, to include older siblings • Following child protection procedures regarding parental contact following an injury 2 The Process 2.1 An independent lead reviewer3 was commissioned to work alongside local professionals to undertake the review. Information provided to the rapid review meetings was considered and additional information was requested from individual agencies, including the identification of single agency learning and any improvement actions required. 1 The police investigation concluded without any charges. The children are the subject of care proceedings. 2 Professionals were aware of regular parental arguments which were thought to be an unhealthy feature of their relationship, this was not considered to be domestic abuse at the time. 3 Nicki Pettitt is an independent social work manager and safeguarding consultant. She is an experienced lead reviewer and entirely independent of the WSP. Version 10 FINAL 2 Sensitivity: RESTRICTED 2.2 Professionals involved at the time were involved in discussions about the case and the wider system. Due to the on-going response to Covid-19, the practitioner participation session was held in January 2022 using video technology. 2.3 The lead reviewer met with the parents of Child R to identify any learning from their perspective. This is included in the body of the report. 3 The Learning 3.1 The learning identified for the safeguarding system and partnership is highlighted below, followed by detailed and case specific analysis. When undertaking assessments and making plans for children, there must be a full understanding of the parent’s histories and vulnerabilities, and consideration of the impact on their functioning and parenting ability 3.2 It was evident to all of those working with Child R ’s parents that they had learning needs. The interventions were sensitive to this and included careful and particular consideration of how best to ensure that both parents understood what was being discussed and what was expected of them. There was no evidence that the professional input was purely mother focused, with both parents being assessed and worked with by those involved including the social workers, the IFS workers and the health visitor. There was also evidence that the professional input was provided equally to both parents, which was good practice. 3.3 What was not entirely clear was the extent of their learning needs. Since the injuries to Child R , there have been cognitive assessments undertaken on both parents. The review was told that the father has an ‘extremely low cognitive ability4’ with ‘extremely poor verbal comprehension and working memory and no functional literacy’. This was likely to have had a significant impact on his parenting ability and understanding about how to implement the changes being requested by the agencies working with him in regard to the children. The mother was also assessed to have ‘extremely-low cognitive ability5’ with ‘just about functional literacy’. Both meet the criteria to be described as having a ‘learning disability’. It appears that the father attended a special school. The GP information shared during this review states that the mother attended a mainstream school with provision for children with learning needs, and she told the review she had a lot of one to one support in school. 3.4 Those working with the family at the time told the review that while it was evident that the parents had learning needs, they were shocked about how severe these needs were. The school recognised that the children’s father was lacking in ‘common sense’. He reportedly had very little traffic awareness and did not seem to retain much of the information and advice the school provided. Neither parent seemed to recognise the psychological impact on the children of things like them wearing dirty or inappropriate clothing and poor personal hygiene. None of those involved fully appreciated how limited their cognitive ability actually was. It is not routine practice to undertake cognitive assessments when there are concerns about the learning ability of the parents, although in this case the ICPC which was held during the pregnancy with Child R stated that this should be requested as part of the child protection plan (CPP). They were requested but not agreed. The PAMS6 assessment that was also planned went ahead however, and it was hoped that this would give a clear indication of the parents learning needs and the impact on their care of the children. 3.5 The PAMS model does not give any early results or feedback, with the need to complete all sessions before a ‘result’ is available, 12 weeks after it commences. However, the IFS worker 4 His full scale IQ is in the range 54-62 which places him at the 0.2nd percentile and thereby below 99.8% of the population. 5 Her full scale IQ is in the range 60-685 (1st percentile) which places her below 99% of an age-matched population. 6 PAMS stands for ‘Parent Assessment Manual’ a guide that takes into account parents with learning difficulties or disabilities. Version 10 FINAL 3 Sensitivity: RESTRICTED completing it was experienced and noted that the couple both had identifiable learning needs prior to the results of the completed assessment being available and ensured that her input to the family reflected this. PAMS are undertaken jointly on a couple and the results consider them this way, as it is recognised that one can compensate for the other in some areas. There had not been consideration of undertaking the assessment when there were past concerns about the older children. 3.6 There was undoubtedly awareness across agencies of the need to work with the parents in a way that took their evident learning needs into consideration. Those involved used visual aids for example and were aware of the need to regularly repeat advice and instructions. Good practice was evident from a number of professionals who provided a significant level of support to the parents with the aim of improving the care of the children. This included the health visitor and intensive family support worker, both of whom worked hard to build relationships with the parents. Both parents had the support of advocates at key meetings such as child protection conferences, with the referral form stating this was due to their learning needs. The CP process was difficult for them to understand and those involved worked hard to ensure that the plans were outlined in a way that enabled them to make sense of what was being asked and what was expected of them. Those involved reflected that despite this, there were concerns about the lack of impact and minimal sustained improvements. This may have been due the true extent of their learning needs not being known. 3.7 Those involved due to child in need (CiN) and child protection plans (CPP) during 2020 and 2021 had very little information about the experiences of the parents during their own childhoods. An ACEs (Adverse Childhood Experiences) assessment was completed with the parents by the social worker at the time of the ICPC in 2021 and the school completed ACE work with the children as suggested at the ICPC. The parents provided very limited information, specifically stating that they did not want to speak about their history due to their upset at recent bereavements in both families. This impacted negatively on the assessment. While it is important to speak to the parents about their childhood, there is also a need to seek out information from historic records and from other agencies, such as the GP, when undertaking assessments or work with a family. This is to check out what the parents are reporting and to provide additional information. During this review it was established that the children’s father had a number of periods of CSC involvement during his childhood that had not been considered by those working with the family in 2020-21. The robust and detailed consideration of this type of involvement is required, even if it requires a request for paper files from archives, which can be time consuming. In father’s case the neglect and physical abuse he experienced as a child is likely to have had an impact on his well-being as an adult and on his parenting. 3.8 Research into ACEs show that when a person experiences abuse or neglect as a child, and the longer they experience it, the worse their physical, mental and social outcomes are likely to be. This includes the possibility that their children will be known to safeguarding services, and that they will require support in the future with their longer-term mental health. Professionals were aware that both of the parents had issues with ‘low mood’. The mother had contact with Healthy Minds7 on four occasions prior to 2017 but the referrals did not progress due to her non-engagement. She was historically prescribed antidepressants by her GP and during 2016 received some support from the out-patients clinic of the mental health home treatment team. She confirmed this to the review. There was initially no information about the parent’s mental health shared with this review by the couple’s GPs, due to information sharing concerns. As this limited the potential learning for the GP service and for the wider review, a recommendation has been made in respect of this issue. It is acknowledged that after challenge from the lead reviewer, some helpful information was provided prior to this report being completed. This confirmed that the father has been prescribed 7 Healthy Minds provides talking therapies for people struggling with their mental health Version 10 FINAL 4 Sensitivity: RESTRICTED antidepressants for low mood a number of times over the years. He was registered at a different GP to the children so it appears that his GP record does not include any information about his children being on a CP plan. This is a systemic issue that has been raised nationally in a large number of reviews and can lead to a significant gap in knowledge if information is not shared with and noted by the parent’s GP as well as the children’s when there are any safeguarding concerns. In Wolverhampton it is customary for the health professional in the MASH to check all adult health information when a referral is made and for the parent’s GP to be contacted as part of any assessment. When a plan is made there needs to be information sharing with the GP for any adults in the home to ensure that they are able to flag that the adult lives with a child/ren on a plan. 3.9 The father had contact with mental health services just prior to the pregnancy with Child R when the couple briefly separated. The police were involved as the father was reported to be suicidal. He agreed to mental health support initially, and a Healthy Minds assessment was completed over the telephone. Father reported anxiety and low mood due to family bereavements and relationship difficulties with his wife. He was referred for counselling and anger management, but there is no evidence he attended. He did agree to work with IFS around his anger and emotional regulation however, and his good relationship with the IFS worker means he has been provided with good support. It was known to some professionals prior to the birth of Child R that there was a parent with issues relating to anger and aggression in the household. There were a number of reports that the older children regularly used aggressive and racist language, which they appeared to get from their parents. The Healthy Minds assessment identified a need for anger management support, but it appears this was not considered a specific risk to the children as there is no evidence that this was shared. It is not known if Healthy Minds were aware that a new baby was due. Neither parent’s GP appear to be aware of any concerns about anger or aggression, however as stated there was a difficulty in gaining access to the GP records for the parents for this review. 3.10 The identified need for a pre-birth social work assessment when the pregnancy with Child R was confirmed was appropriate and proportional showing recognition of the factors impacting on parenting capacity and ongoing concerns about the care of the older children. It was recognised that a growing family is an increased risk in a family where there are safeguarding concerns, which is good practice, also that as babies become toddlers and toddlers become children their needs change. Parents need to alert to, and able to adapt to, the increasing demands. Professionals need to explore and understand a child’s lived experience, including considering what they may be communicating by their behaviour. When a baby is expected, there needs to be specific consideration of their likely lived experience 3.11 As well as understanding the parent’s vulnerabilities, all professionals need to be aware of the impact of this on the children, with particular regard to the lived experience of the children within their family. The importance of professionals having a child centred approach is well recognised in safeguarding work, and there is evidence of a commitment to this in Wolverhampton. In the case considered, it is noted that professionals worked hard to provide the older children in this family with opportunities to speak to them about their home life and to consider their views, including at school. While speaking directly to children is essential, it is also important to understand that children may not be able to express themselves or that they may feel conflicted and/or concerned about sharing too much about their lives or any concerns they have. It is therefore necessary and important to also consider a child’s behaviour and what they might be saying without words.8 There were on-going and regular concerns about the behaviour of the older children who were described as ‘out of control’ and ‘unmanageable’ when with their parents, sometimes in the school setting, and when visited at home by professionals. 8 The voice of the child: learning lessons from serious case reviews. Ofsted 2010 Version 10 FINAL 5 Sensitivity: RESTRICTED 3.12 There were two known incidents of physical injuries to the two eldest siblings when they were very young. These were investigated at the time and determined to be accidental, with issues identified about the parent’s management of the children and concern about lack of supervision. (This is considered further below, from 3.17.) Those involved throughout the children’s lives noted that the parents struggled to put boundaries in place, and did not respond to advice about how to ensure the children were adequately supervised and kept safe. The school told the review that they were regularly concerned about the children while they were being taken to and from school and about their dangerous behaviour around a main road. Poor supervision by the father, who did most of the school runs, was regularly raised as an issue with him and shared as a concern with other professionals. 3.13 The children’s school attendance was poor, and when in attendance they often spoke to the school about their home life, including making allegations about domestic abuse, rough handling, and the inappropriate ways that their parents coped with poor behaviour.9 Staff at the children’s school built good relationships with the children and they were able to capture their voices and notice changes in their behaviour. The parents always denied what the children had shared when they were challenged. Those involved were clear that the children’s exceptionally boisterous behaviour in the home, at school and when in the community was due to a lack of boundary setting and inconsistent parenting. This also led to lack of supervision being seen as the reason for any injuries seen on the children, with the alternative possibility of physical abuse not considered. 3.14 Overcrowded housing and poverty were also issues for the family, which is well known as a source of stress. The children spoke of monsters coming to the house wanting money (thought to be debt collectors), food parcels and food bank referrals were regularly provided by professionals and there was often noted to be a lack of nappies, toiletries and toilet paper in the home. The children did not appear to know how to use soap and were often dirty. While none of this was necessarily an unusual factor for the most deprived families in the city, it is an indicator of neglect and professionals need to ensure that they are not desensitised or that indicators of neglect are accepted the normal. The lack of understanding or acknowledgement from these parents about the impact on the children of the physical neglect that was evident was noted at the time and contributed to the concerns. 3.15 The property was private rented and it was recognised that it required repairs and essential maintenance10. The poor state of the accommodation was felt to be largely down to the family rather than the landlord and there was a notable lack of motivation from the couple to improve the conditions without a lot of encouragement and support from the professionals involved. Those involved were concerned about the impact on the children’s lived experience of their home environment. The family were on the waiting list for a social housing/council property and professionals worked hard to support them with this. However there was confusion about the bidding process for suitable properties. Learning has been identified about the need for professionals to ensure that the relevant housing agency is invited to child in need or core group meetings when a housing issue is impacting on the progress of a child’s plan. There was some confusion amongst professionals about which housing department needed to be contacted to ensure that the re-housing need was prioritised. Wolverhampton Homes is an organisation which provides allocation of social housing, whereas the private sector housing team11 is part of the City Council, which is confusing and hard to negotiate for busy non-housing professionals. Wolverhampton Homes is in the process of updating their website and training their staff to ensure 9 For example alleging that they are locked in the bathroom when they are naughty, and stating that their father told the children ‘if you kick me, I will kick you back.’ 10 This included a lack of working locks on the windows, which was an issue as it was an upstairs property and the children had been seen leaning out of the windows. 11 The review was told that the family could have privately rented a larger property, but did not have access to a deposit. Version 10 FINAL 6 Sensitivity: RESTRICTED that effective advice and support is given to other professionals who require support in helping families with a housing need. 3.16 It is important to consider the voice and the likely lived experience of the unborn and then new-born baby as well as the older children. When a baby is on a child protection plan, the conference can be a good place to ensure that this is evident in assessments and plans. There has been helpful reflection from the conference chair and their team about the need to provide particular focus on the unborn child in conferences, particularly when there are older children whose needs may otherwise dominate the meetings. Professionals need to recognise and consider the cumulative harm to children who experience long term neglect 3.17 A new social worker had taken on the case in 2021 and she recognised that the children’s continued poor lived experience, a lack of sustained progress, and the likelihood of a further deterioration when the expected new baby arrived, warranted a child protection response and an ICPC. Her ‘fresh pair of eyes’ and assertive decision making was what the case required. There were well known and reported incidents of concern about the care provided to the children over a long period of time. When the decision was made to make the children subject to a CP plan this was acknowledged and there was a good awareness of the impact on the children of their lived experience. Poor home conditions and the physical neglect of the children and self-neglect by the parents had been regularly evident. (As well as their neglect of the children, the parents also struggled with their own personal hygiene and dental health.) While the neglect concerns fluctuated, with improvements in the home and the children’s presentation often linked to a period of sustained professional intervention, by the time of the ICPC it was acknowledged that the children were suffering ‘significant harm’ due to the long-term nature of the neglect concerns and the inability of the parents to maintain any improvements. 3.18 The national Safeguarding Practice Review Panel’s annual report published in May 202112 states that ‘the recognition of cumulative13 neglect and its impact continue to be a key challenge for practitioners’ nationally’. There is a danger when working with cases of neglect that professionals wait for a serious one-off incident to happen to provide evidence that the children are suffering significant harm on a given day. With neglect, a large number of smaller issues when collated, may show significant harm over time. Recognising this fact does not always lead to sustained change for the children however. The review is aware that the courts both locally and nationally rarely support care plans that request removal of a child from their parent’s care, despite evidence of significant cumulative harm from neglect. This can lead to a systemic disincentive for those working in these complex cases, and an issue that is recognised in Wolverhampton. 3.19 The decision to make the children subject to a child protection plan, along with unborn Child R , was also due to the recognition that the care of the children would be impacted by a new baby in the home and concern about how the parents would manage. There was no consideration of any immediate risk of harm to the new-born baby, with the risks thought to be longer term and in relation to neglect and a lack of parental boundaries and control. The ICPC and resulting CPP did not include consideration of safe handling and the ICON programme being used in Wolverhampton or safe sleeping advice, and single agency learning for the safeguarding service has been identified in regard to this. 12https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984767/The_Child_Safeguarding_Annual_Report_2020.pdf 13 The terms ‘cumulative risk’ and ‘cumulative harm’ were first identified by Bromfield and Higgins in Australia in 2005. They defined cumulative harm as ‘the effects of patterns of circumstances and events in a child’s life which diminish their sense of safety, stability and wellbeing. Cumulative harm is the existence of compounded experiences of multiple episodes of abuse or layers of neglect.’ Version 10 FINAL 7 Sensitivity: RESTRICTED 3.20 Working with cases where there is long term neglect can be particularly difficult for professionals. As well as families being overwhelmed by their circumstances, professionals can also struggle to know how to proceed. Balancing the needs of the children and the parents is difficult and exhausting work. This can lead to drift and delay for the children and a risk that plans will be ineffective. The issue needs to be considered within a context of large case loads and high demand for services. Professionals can also effectively become immune to the child’s life experience due to an acceptance of poor home conditions and the needs of the child not always being met. ‘Poverty blindness’ can also occur where professionals are working in areas of high deprivation. Because poverty is widespread in Wolverhampton, there can be an ‘associated desensitisation to poor hygiene, dirty clothes and poor dental hygiene.’14 There was a degree of sympathy among professionals for Child R ’s parents due to their circumstances, and an accepted view that they were willing to work with professionals and wanted to improve. It was not straightforward however as there was evidence of the father being defensive, unapproachable and aggressive when challenged. Focused, reflective and challenging supervision for the multi-agency team working with a case like this is a way of ensuring that being overwhelmed by a case is less likely, and that the cumulative impact on the children is considered. In Wolverhampton they are introducing a system where a place is available for professionals to have a reflective and creative discussion about how best to work with a family, which will be very helpful in cases that require it. 3.21 There has been a positive focus on child neglect by agencies in Wolverhampton in recent years and this continues. The safeguarding partnership is about to relaunch its ‘We Can’ Tool Kit and is planning to review the city’s Neglect Strategy. The Local Authority have a new neglect Share Point that provides details of resources and services available to help in the identifying and planning where child neglect is an issue. Domestic abuse can be subtle. All professionals need to understand how it may manifest 3.22 As well as the cumulative impact of physical and emotional neglect, there were concerns about the impact on the children of the problematic relationship between the parents. While there was an awareness of difficulties between the couple, the criteria for a DASH risk assessment was not met at any stage prior to Child R ’s injuries. Domestic abuse was not identified despite the children sharing concerning information, including in November 2020 when one of the older children stated at school that his father had punched his mother. 3.23 In January 2021, when the children had been on a child in need plan for around ten months, their father reported feeling suicidal because the mother stated that she wished to separate from him. This was not seen as a sign of domestic abuse at the time, although such a threat is a well recognised controlling behaviour and is emotionally abusive. Those involved, including the police who undertook a safe and well check, were concerned about father’s mental health and the impact of this on the children, but did not identify it as a symptom of a domestically abusive relationship. The review found that there is a need for increased awareness of this aspect of coercive and controlling behaviour among police officers and other professionals. In this case the children’s mother was seen as the dominant partner, and she tended to be the one to take the lead when speaking to professionals. This may have provided a false sense of security about her potential vulnerability in the relationship. When neglect is a known issue for children in a family, consideration should also be given to the risk or occurrence of other types of abuse 3.24 A published study of all the case reviews undertaken following the death of a child between 2005-201115 found a context of known neglect more often than known physical abuse prior to the child’s 14 Serious Case Review (SCR) analysis for the education sector: Neglect. SCiE 2020 15 Brandon, M., Bailey, S., Belderson, P.and Larsson, B (2013) Neglect in Serious Case Reviews, NSPCC/UEA. https://www.nspcc.org.uk/Inform/resourcesforprofessionals/neglect/neglect-scrs-pdf_wdf94689.pdf Version 10 FINAL 8 Sensitivity: RESTRICTED death. Neglect alone is rarely associated with the death of a child, but the case reviews undertaken at the time show that both physical abuse and neglect often coexist in a family, as they did in almost half of the reviews considered. In the cases where non-fatal injuries were present, as was the case for Child R , the co-existence of neglect was found to be higher than 50%. This is something that is not always considered when professionals are working with children where the primary concern is neglect. It is acknowledged that neglect is more prevalent as a safeguarding concern than physical abuse and that the two types of abuse do not necessarily co-exist, but having an open mind to this as a possibility is good practice. In the report, Brandon et al considered why the risk of physical abuse is often missed when working with a case where neglect has been identified. Some of their findings were evident in the work undertaken with Child R ’s family. They include optimism about the family appearing to engage with professionals, efforts not to be judgemental, the impact of increased family size being underestimated, injuries readily being accepted as accidental and a ‘this is only neglect’ mindset. Neglect is often seen as a passive form of child abuse, where the parents unintentionally harm their children. A child being harmed by a direct violent action may not then be considered as something that these particular parents are likely to do. 3.25 When injuries to the older children were considered in 2016 and 2017, it can now be seen that physical abuse may have been identified had more rigour and curiosity been applied to considering the injuries and the parent’s explanations. For example during the response to injuries in 2017 there is evidence that the A&E doctor had concerns about bruising to the eye and thighs of the then two year old child, and about the father’s explanations and demeanour. An appropriate referral was made and a child protection medical was undertaken. On balance the consultant paediatrician felt the injuries could be accidental and identified a lack of parental supervision as an issue. This led to a period of child in need planning then early help support, including parenting work. 3.26 There is no doubt that there were long term and on-going issues about the parent’s management of the children and the state of the home. This focus can lead to the risk of or coexistence of other forms of abuse being overlooked. Nationally, neglect is the most common reason for a child to be made the subject of a child protection plan. In Wolverhampton around 70% of children are on a CP plan for neglect. The parent’s issues in this case led to neglect of the children and while there were indicators of anger control being a concern, statements by the children that could indicate a risk of physical abuse, and past suspicious injuries, any concerns about the risk of further physical abuse were either not acknowledged or secondary to the concerns about the poor physical and emotional care of the children and the state of the home. Those involved in the case were shocked at the extent of Child R ’s injuries and that serious non-accidental injuries should occur in this particular family. There is a need to ensure that safe sleeping and safe handling information is shared in an appropriate way with families by all involved professionals 3.27 It is not known how Child R ’s injuries were caused or who the perpetrator was. However this review is a good opportunity to consider how safe handling and coping with crying information is shared with families around the birth of a new baby and in the weeks following the birth. It is clearly recorded that information was shared both in the hospital and when Child R and the mother were discharged from hospital in regard to both safe sleeping and safe handling. This was specifically shared despite them having older children, and with an awareness of their need for information to be shared in a way that was understandable to them. Mother told the review that during sessions with the family support worker, both safe handling and safe sleeping were discussed with both parents. The father confirmed he was aware of the need to avoid unsafe sleeping. Version 10 FINAL 9 Sensitivity: RESTRICTED 3.28 The ICON16 programme has been launched in Wolverhampton and professionals are being trained in the methods. Health workers were trained and using it at the time of Child R ’s birth. It was in the process of being rolled out further but this had yet not happened. ICON is a programme developed to help professionals provide consistent and accessible advice and support to families to prevent shaking and abusive head trauma. The rolling out of the programme needs to ensure that it equally includes the fathers or co-parents as well as mothers, that older siblings are considered in any advice given and that all professionals are aware of how to give and reinforce the advice. In families like this, where there are additional challenges, there needs to be careful consideration to how safe handling information is provided, how to reinforce that it must always be adhered to and an exploration of the family specific challenges. This was particularly necessary during the COVID-19 pandemic where there was less direct contact with parents from a number of agencies. 3.29 In the case of Child R ’s parents, while programmes like ICON are helpful, the messages given need to be bespoke and regularly reinforced and provided by all professionals working with them. There are interesting parallels in the area of safe-sleeping, where provision of advice verbally and in written form (often a leaflet) at key points during antenatal and postnatal care is expected practice nationally. The Lullaby Trust17 state that ‘for some in more vulnerable situations, additional support in understanding and implementing safer sleep practices is required.’ This is relevant to, and should also be required, when it comes to safe handing and coping with crying. This case shows that consideration also needs to be given to the risk the older children in a family may pose to the baby on a case by case basis. 3.30 Specific consideration needed to be given to how to ensure that any ICON plan considered the need for the older children in the family to be made aware of the need for safe handling and careful behaviour around the new born baby. Given the chaotic environment, lack of boundaries and the children not attending school on occasions during the pandemic, there was a possibility that the baby could be harmed by their older siblings and this needed to be considered and part of any plan, although this is not something that is usually part of the ICON programme. COVID-19 had an impact on the family stressors and on the support provided 3.31 The national Child Safeguarding Practice Review panel published a briefing paper last year that considered serious safeguarding incidents reported to them during the initial COVID-19 outbreak (March – September 2020). Their analysis shows that COVID-19 exacerbated risk due to an increase in family stressors (including an increase in domestic abuse and mental health concerns alongside less wider family support), children not being seen as regularly, school closures, and difficulties with the requirement for ensuring safe professional practice. As stated by the health visitor in this case, there is an anxiety about what you may be missing when predominantly contacting families by phone. The national panel agree, by noting that ‘virtual visits are not always effective in assessing changing needs and risks.’ 3.32 In the case of Child R and her siblings, COVID-19 had a further impact. Although they largely continued to receive services despite the pandemic, the parents did not wish the older children to attend school due to fear of them catching COVID-19 and bringing it home. While most schools remained open for the most vulnerable children from day one of the first national lockdown and these children were invited to attend, they did not. The family reportedly had extended family members die from COVID-19 and Father had a long term health issue that they felt made him more vulnerable. This increased their fears and lessened their ability to manage during the national lockdowns. They were also living in overcrowded housing with no outdoor space, which was reportedly an additional stressor. Mother told the review that it was very hard managing the 16 ICON stands for Infant crying is normal, Comforting can help Okay to walk away and Never ever shake a baby 17 A charity that raises awareness of sudden infant death syndrome (SIDS) and provides expert advice on safer sleeping Version 10 FINAL 10 Sensitivity: RESTRICTED children with no break. The school were aware of the vulnerabilities and worked to ensure contact, including undertaking door step visits to the family with food and school work for the children. 3.33 Children’s social care and IFS continued to visit the most vulnerable children throughout the national lockdowns. This was the case even if there was COVID-19 in the home as they had access to some PPE (personal protective equipment) if needed. A red, amber, green assessment was undertaken in all cases, and this determined the risk to the children if a visit was not undertaken to a particular family. The children in this family were referred to CSC just prior to the first national lockdown in March 2020 and an assessment was undertaken regardless of the pandemic. A child in need plan followed which remained in place until the ICPC was held just less than a year later, during another lockdown. 3.34 It is relevant to note that recently published research shows that abusive head injuries in children have increased nationally over the period of the COVID-19 pandemic.18 This is apparently due to the risks associated with children spending more time at home, less professional interaction, and the associated increase in parental mental health concerns. The NSPCC has highlighted the heightened risks to children of a non-accidental injury during the pandemic due to the increase in social isolation, and a lack of access to services and the ability for professionals to pick up on early warning signs. Financial insecurity19 has also been a pressure for many families, which has historically been linked to an increase in non accidental injuries in children20. Data from April to September 2020 outlines a 31% rise in reported incidents of death or serious harm to children under 1 when compared with the same period in 2019.21 The family of Child R were under increased pressure at the time, including from their experience of COVID and non-COVID related bereavements. 3.35 The rolling out of the ICON model of working with families to help them to cope with babies crying has been impacted by the pandemic, as it was a new model and not yet embedded at the time of the first national lockdown. The ICON message is not as powerful on the phone, tends to only be shared with the baby’s mother, and there is no guarantee they will pass it on to others who may be caring from the baby, including fathers. By the time Child R was born, families were being visited and community midwifes and health visitors who were sharing the ICON coping with crying and safe handing / sleeping advice. Following a hospital birth is another good time to share the ICON message. In this case the father was unable to visit in hospital, so the ICON discussion and leaflet was shared with mother only in this setting. When a baby is on a child protection plan, as was the case with Child R , it is good practice for the conference chair to use the opportunity of the pre and post birth conferences to check that the ICON programme has been delivered, that the information was appropriate for the particular family’s needs and to reinforce the ICON messages. 3.36 There was a particular impact on social workers across Britain who were often the only professionals going into family homes during the initial COVID-19 lockdown22. While guidance was clear that social distancing and basic PPE was required, social workers in the UK have reported that this is very difficult when visiting families in crowded housing, particularly when younger children initiate physical contact with the worker. There was also personal anxiety due to the expectation that social workers take health risks to try to protect children during the pandemic. There was also a capacity impact in CSC and other services when colleagues needed to shield due to health conditions or isolate for a period. For example just after the birth of Child R , the allocated social worker was isolating and a duty social worker had to undertake a planned visit to the family. 18 Sidpra J et al (2021), Rise in the incidence of abusive head trauma during the Covid -19 Pandemic. 19 Both parents in this case were said to be stressed about their financial predicament and housing situation. 20 Huang, MI et al (2011) Increased incidence of non-accidental head trauma in infants associated with economic recession. 21 Child Safeguarding Incident Notification System, 2021 22 Harry Ferguson, University of Birmingham. Professional Social Work magazine 6.12.21 Version 10 FINAL 11 Sensitivity: RESTRICTED 3.37 Not all services were undertaking direct work at the time due to COVID-19. The family were referred for a family group conference (FGC) when plans were being made for the arrival of the fourth child. This was appropriate as the wider family were known to be supportive and to have an awareness of the professional concerns. The IFS worker had a good relationship with family members and were aware they had concerns about the family. The school had also been told that the family were worried about the children. The FGC meeting was held on the telephone using group call functionality. The family plan was also reviewed without a face to face meeting. Those involved acknowledged this was not ideal and was likely to have been particularly difficult due to the learning and communication needs of the parents in this case. It may also have had an impact on the willingness of family members to share their concerns, and indeed they did not do so. How much this is due to the FGC model generally or the impact of attempting it remotely in the early days of the pandemic is not clear. All professionals need to be reminded that when there is an injury to a non-mobile baby, child protection procedures need to be followed23 3.38 Prior to the non-accidental injuries being identified at the hospital, Child R ’s mother contacted one of the midwives known to the family to report that the baby had a lump on their head, and that they did not know why. The midwife visited later the same day and described it as a ‘grape sized lump’. The midwife sought advice and confirmed that the lump was not due to the birth. They suggested that the baby should be taken to the hospital and spoke to the paediatric medical assessment unit at the hospital to ask them to expect the baby. As she was aware that the baby was on a child protection plan and that there was an allocated social worker, this information was shared with the medical assessment unit. The family took the baby to hospital themselves. The midwife did not deem it necessary clinically to call an ambulance. She did not consider that that the baby should not be alone with its parents due to the potential of it being a safeguarding issue, and for the same reason did not consider informing out of hours children’s social care of the injury (it was gone 5 pm by the time they visited the family). She did ring and leave a message on the allocated social worker’s mobile phone. This message was not retrieved by the social worker until she returned to work some days later. 3.39 The relevant health trust have considered this matter and will reinforce how professionals need to respond to a non mobile baby with an injury and the need to follow child protection procedures in such cases even if it is an allocated case. This will include the process that should be followed to ensure that the baby remains safe until they are medically examined. The West Midlands procedures are clear that the health professional that identifies an injury needs to be frank and honest with parents/carers about the need to make a referral, and that they need to ensure that the baby is safe and not left alone with their parents/carers in the meantime. It is the responsibility of children’s social care to arrange the medical and they need to be informed immediately to ensure that this happens as soon as possible. 3.40 When EDT24 were contacted by the hospital sharing their concerns that Child R had presented with serious unexplained injuries, the hospital were asked to ensure that the parents had no unsupervised contact with Child R . However they returned home to care for the younger children. This was the case until 8:30am when the hospital safeguarding team and daytime CSC staff were made aware of what had happened and ensured that the parents were not unsupervised with the older children. This has been addressed with those involved in each agency and single agency learning has been identified. 4 Conclusion and recommendations 23https://westmidlands.procedures.org.uk/pkyzyz/regional-safeguarding-guidance/injuries-in-babies-and-children-under-2-years-of-age 24 The EDT function is now (since June 2021) provided by the MASH 24 service. Version 10 FINAL 12 Sensitivity: RESTRICTED 4.1 This CSPR has considered the learning from Child R ’s case and identified learning that will be helpful for the wider system. It shows that when long-term neglect is an issue due to the vulnerabilities and needs of the parents, support needs to remain in place25 and there needs to be optimum communication between professionals and regular consideration of whether the children’s needs can be met, even when a high level of support is being provided. The learning from serious case reviews and CSPRs shows that all professionals need to recognise neglect, understand the long term and cumulative impact of neglect and take timely action to safeguard children. This review has found this, along with the need to consider the possibility that other forms of abuse often co-exist alongside neglect. 4.2 Single agency learning has been identified during the review and recommendations have been agreed to address these, including single agency SMART action plans. There has been excellent cooperation with this review from the majority of partner agencies, which was essential in establishing the learning from this case. 4.3 Having considered the learning not addressed in the single agency actions, the following additional recommendations are made to ensure improvement actions are taken: Recommendation 1 WST and the CCG to consider how GP information on parents is appropriately and helpfully shared with any CSPR, as this is a local issue that impacts on the timeliness of reviews. Recommendation 2 WST to seek assurance that the learning from this review is considered by those responsible for ICON training and support, and that ICON recognises the need for bespoke plans about safe handling for parents with learning difficulties and where there are older children in the family. Recommendation 3 That the Task and Finish Group reviewing the WST Neglect Strategy consider the learning from this review. Recommendation 4 WST to request an update from partner agencies on improving awareness of control and coercion and non-violent domestic abuse, including the aim for more cases of this kind to be presented at the MARAC.26 Recommendation 5 WST to seek assurance from MASH 24 (who now provide the out of hours function) and the relevant health trust that action has been taken to ensure that services are aware of the need to follow child protection procedures when a non-mobile child has injuries. Recommendation 6 WST to request that the CCG and WCC work together to ensure that when children are the subject of a plan, this is recorded on the GP record of any adults in the household. 25 It was raised during the review that the support provided to the parents from their advocates is only funded while children are on child protection plans. The relevant representative on the panel has responded to the advocacy agency regarding this. 26 There is a current review of the MARAC and the learning from this review should be considered. |
NC049439 | Death of a 17-year-old girl in June 2016. An inquest recorded a verdict of suicide. Child KA was a victim of robbery with sexual overtones and serious sexual assault in 2011 and 2012 which were investigated by police. No suspects were identified although the perpetrator of the second incident was a similar aged child to KA and could be identified by KA and mother. A further, gang-related incident, took place in 2015. KA began to self-harm and had low mood. In late 2015, GP agreed to refer KA to the local Child and Adolescent Mental Health Service for her mental health to be assessed, but the referral was closed. KA received services from a number of agencies between March 2011 and June 2016. Ethnicity of the family not specified. Learning: the need to raise awareness of complexities of self-harm for children and young people and take episodes seriously; the need for information sharing protocols between schools, including timescales for the effective sharing of school records when children move schools; a need to develop local suicide prevention strategies and action plans. Recommendations include: to conduct an audit to examine referrals received specifically relating to sexual abuse of children age 12 and above, to explore strategy meetings are being held for these cases and that the statutory and local requirements for strategy meetings are being met; to consider ways to improve awareness of children and young people and professionals working with them about issues linked to child sexual exploitation and gangs, particularly safe/healthy relationships, consent and bullying.
| Title: Serious case review report: re: Child KA. LSCB: Newham Local Safeguarding Children Board Author: Amanda Clarke Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 NSCB_SCR KA_Final_02May2017 Newham Safeguarding Children Board Serious Case Review Report Re: Child KA Date: 2 May 2017 Review Process This serious case review was commissioned by the Independent Chair of Newham Safeguarding Children Board (NSCB) on 12th July 2016, in agreement with the recommendation of the NSCB Serious Case Review Sub Group that the circumstances surrounding the death of a child met the criteria for a serious case review. Subject of the review: Child KA: Died aged 17 years. The Mother of KA has provided valuable information to this serious case review. Her contributions are included where relevant within the report. KA was described by Mother as “a wonderful, caring and special child”. The true initials of the subject child are not KA to protect the identity of the child and family. KA’s Mother was consulted on her preference for what her child should be called in this serious case review report. The initials KA were the choice of the family and will be used throughout the report. Circumstances and history resulting in the review KA had lived locally in a close family. KA’s birth mother (to be referred to as Mother throughout the report) was the primary carer. KA had older adult siblings, a stepfather and a birth father, all of whom shared good relationships with KA. The timeframe for the review will be explained later in methodology. At the start of the period under review KA attended a secondary school which was not the local school to KA’s home. In early 2011 KA reported to the school being attacked by an unknown perpetrator whilst on the way to school. The allegation was a robbery with sexual overtones and the Police were informed. As a result a referral was made by the Police to Children’s Social Care. An investigation was completed but a suspect was not identified. Around the same time of the robbery incident KA had reported a separate physical assault by some similar aged children. This was also investigated but no suspects traced. KA moved to a different local school nearer to the family home in the spring term of 2012 and remained as a student there until leaving for college in 2015. KA attended college only briefly before taking up employment. In late 2012 when aged 13 years KA attended a local youth club. It is alleged that KA was a victim of a serious sexual assault after the youth club. The alleged perpetrator was a similar aged child to KA and 2 NSCB_SCR KA_Final_02May2017 could be identified by KA and Mother. The day after the sexual abuse Mother reported KA missing to the Police as KA failed to return home during that day after being out with a friend. The sexual abuse was mentioned by Mother to the Police in the initial missing report. After being missing for only a short period KA returned and was taken to the Police station for an officer to complete a safe and well check, which is a routine occurrence when a missing episode has occurred. During the safe and well check the sexual abuse is not recorded as being discussed, and no action was taken to commence an investigation at that time. The full circumstances surrounding this incident, including Mother’s recollection of what happened, will be explored later. Two days after the alleged sexual abuse Mother and KA attended the GP and the sexual abuse incident from the youth club was disclosed. It was suggested that the abuse was gang related, that KA was fearful of repercussions and did not want to involve the Police or make a formal complaint. Within 24 hours the GP referred the information to Children’s Social Care, including the fears which KA and Mother had shared and that the perpetrator was known. Subsequent action, which will be scrutinised later, included a strategy meeting/discussion between the Police and Children’s Social Care two weeks after the referral, followed by a number of contacts between the Police and Children’s Social Care to progress the actions agreed. A single agency visit by Children’s Social Care did take place to see KA and Mother. Records for the visit indicate that KA was clear about not wishing to make a formal complaint to the Police, but that some details were shared about the alleged perpetrator with the visiting Social Worker, which could enable further checks regarding the perpetrator’s identity. After the social work home visit, liaison took place between the Social Worker and a Police Officer on an unrelated matter involving a different child. The Police Officer worked on the Sapphire unit which is a specialist sexual offences investigative team. As a result of the contact the Social Worker mentioned the allegation made by KA, and the Police Officer subsequently recorded the information on a crime report. The Children’s Social Care involvement regarding the sexual abuse incident of KA was closed early in 2013 with no ongoing safeguarding concerns highlighted. There was no Police investigation regarding the alleged perpetrator and no action was taken by Children’s Social Care regarding the perpetrator also being a child. The School Pastoral Centre provided ongoing support to KA during KA’s time at the school. The School Pastoral Centre at the time provided support for students with emotional or behavioural difficulties. Support was required for KA for a number of issues including low self esteem, peer relationships, bullying and anxiety. In early 2014 as a result of a theft allegation, KA spent a brief time detained in police custody. Whilst there KA suffered a panic attack which is noted on Police records. In early 2015 after a gang related incident when KA was spat at, KA spoke of taking seven pain killers in an attempt to self harm. This was disclosed to the School Pastoral Centre. The School Pastoral Centre had already referred KA for one to one mentoring sessions with Gangsline which is a non-profit organisation providing help and support to young men and women involved in gang culture. The Gangsline involvement for KA was to continue periodically throughout the next two years and KA made frequent reference to the alleged sexual abuse incident in 2012, during the sessions. In Spring 2015 KA reported concerns to the school of alleged inappropriate behaviour by a school staff member towards a friend of KA. Allegations against Professionals procedures were properly instigated and Children’s Social Care and the Police interviewed KA as a possible witness. At the time school had some concerns for KA of risk of possible sexual exploitation. A referral was made to Children’s Social Care but Mother declined any further support for KA. After an assessment the referral was closed. In late 2015, after leaving school in the summer, KA attended hospital with a superficial cut to the arm disclosing feeling “low about life”. Reference was made by KA to the sexual abuse incident when aged 13 3 NSCB_SCR KA_Final_02May2017 and feeling suicidal as a result. A false name was provided by KA and unfortunately KA absconded before treatment could be completed. The hospital referred the incident to Children’s Social Care and the Police were informed. When the correct details were traced the Police attended KA’s home to conduct a follow up as part of a missing person safe and well check. KA again made reference to the sexual abuse incident and the Police flagged this information on their records from the visit. Children’s Social Care received the Police safe and well check information. Due to Mother being supportive of KA, a decision was made that there were no safeguarding concerns and, after signposting to the GP and the Child and Family Consultation Service, no further action was taken. The Child and Family Consultation Service is the name for the local Child and Adolescent Mental Health Service (CAMHS) which is part of East London Foundation Trust. The day after the hospital attendance Mother and KA attended the GP to discuss KA’s low mood, the self harm episode and the sexual abuse. The GP agreed for a referral to the Child and Family Consultation Service for KA’s mental health to be assessed. Unfortunately, due to an error which will be explored later, the referral was closed and there was no assessment or intervention regarding KA’s mental health. There was no further service involvement with KA and family until six months later when sadly KA was found dead at home. Subsequently an inquest has recorded a verdict of suicide. Legal Context: A serious case review was commissioned by Newham Safeguarding Children Board, following agreement at Newham Serious Case Review Sub Group in accordance with Working Together to Safeguard Children (Department for Education 2015). Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely: 5. (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1)(e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Cases which meet one of the criteria (i.e. regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii)) must always trigger an SCR. Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. Where a case is being considered under regulation 5(2)(b)(ii), unless there is definitive evidence that there are no concerns about inter- agency working, the LSCB must commission an SCR. The methodology used was based on the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). This is a formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for Local Safeguarding Children Boards to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. 4 NSCB_SCR KA_Final_02May2017 However, because a review has been held, it does not necessarily mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of Safeguarding Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final review report or in an action plan as appropriate. The opportunity to conduct serious case reviews in this, and other ways, is as a result of the change in statutory guidance following The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011. Munro suggests that Local Safeguarding Children Boards should use any learning model which is consistent with the principles in the Working Together to Safeguard Children Guidance: Learning and Improving, HM Government 2015. Methodology: Following notification of the circumstances of the death of Child KA in this case, and agreement by the chair of the Newham Safeguarding Children Board to undertake a serious case review, a Review Panel (known as the Panel) was established in accordance with guidance. This was chaired by Susannah Beasley-Murray, Head of Child Protection, Newham. The Panel included representation from relevant organisations within Health, Children’s Social Care, Education, the Police, the Youth Offending Service and the voluntary sector. Amanda Clarke, an independent reviewer (the Reviewer) from Derbyshire was commissioned to work with the Panel and to undertake the review. The Panel identified the review timeframe as commencing from March 2011 which is when the first allegation occurred, and ending June 2016 when the death was reported. Full terms of reference for the review are attached as Annex 1. All relevant agencies reviewed their records and provided timelines of significant events and analysis of their involvement. These were considered by the Panel and provided opportunity for Panel members to raise questions and clarify understanding of the circumstances of the case and of the separate services provided. The agency timelines were merged and used to produce an interagency timeline. This was carefully analysed by the Reviewer with the Panel and informed of the areas of interest that required further exploration and consideration. The process also allowed for the identification of the key practitioners required to attend a learning event in order to understand the detail of the single and interagency practice in this case. The Reviewer met with Mother of KA to gain an understanding of the family’s experiences of the services offered to them, and services provided to KA during the review timeframe. A further contact was made with Mother to clarify certain points raised at the practitioner learning event. Mother’s thoughts are summarised at relevant points throughout the report. This valuable insight into KA’ and the family’s experiences was shared with practitioners at the learning event, and with the Panel at draft report stage. Account was taken of the views when writing the final report and formulating recommendations and the Reviewer is grateful for Mother’s contribution. The learning event was held in December 2016 and was attended by 15 professionals who had had direct involvement with child KA and the family, or who were representing agencies with involvement. The Reviewer facilitated the session assisted by the Partnerships and Workforce Development Manager, Newham and officers from Newham Safeguarding Children Board. The learning event was organised in line with Welsh Government guidance (Child Practice Reviews: Organising and Facilitating Learning Events, December 2012) and notes were recorded. With the support of Panel members and the Newham Safeguarding Children Board team, further enquiries were made with professionals who were unable to attend the learning event, and this information is included in the report. 5 NSCB_SCR KA_Final_02May2017 Following the learning event, the Reviewer collated and analysed the learning to date for discussion with the Panel. Practice issues originally identified by the Panel were re-examined in the light of the findings of the review. A draft report was provided to the Panel in advance of the Panel meeting in January 2017. In reviewing the findings, the Panel gave consideration to what could be done differently to further improve future practice. The Reviewer will offer to meet again with the Mother of KA to provide an opportunity to see a copy of the report when agreed by the Newham Safeguarding Children Board. Learning from the full report will be made publically available after consideration by the Newham Safeguarding Children Board of any issues affecting publication. A Health Overview Report was completed as a result of KA’s death. This is a task undertaken within Health when a serious incident occurs. The purpose of the Overview Report is to evaluate how (i) health organisations are working together to deliver services and (ii) meeting their statutory duties to safeguard children. The Reviewer has considered the findings of the Health Overview Report and has referenced these where necessary throughout the serious case review report. NHS agencies are required by statute to participate and contribute to a serious case review when requested by a Local Safeguarding Children Board. Clinical Commissioning Groups are required to provide a panel member who will maintain oversight of the health involvement. In addition the Clinical Commissioning Groups Panel representative for the KA serious case review has shared information from the Health Overview Report to ensure robust analysis of the known circumstances. Learning from both reviews will be disseminated across the NHS locally. The Newham Safeguarding Children Board will require assurance that actions identified in the Health Overview Report have been completed. ANALYSIS: Practice & Organisational Themes Identified Child KA had received services from a number of agencies during the period of the review. Scrutiny of the timeline, information shared and reflections at the Panel meetings and the learning event have highlighted areas of good practice and also provided an opportunity for wider learning to emerge about the ways in which services work together. The following is an analysis of the themes identified: 1. Responses to child sexual abuse During the agreed timeframe of the review the child, KA, made allegations of crimes which were reported to the Police. The separate circumstances involved a physical abuse incident by peers, a robbery with a possible sexual motive, and a third incident which involved serious sexual abuse. The third crime reported is referenced by KA through much of the review timeframe and has been the main focus of the Panel’s scrutiny. The physical assault was alleged to have taken place the day before the robbery incident in early 2011. This circumstances involved peers and KA was not injured. A full investigation took place which included liaison with KA’s school and home, but suspects were not identified. Details of this incident were shared by the Police with Children’s Social Care. The robbery allegation was reported by KA to the Police via the (first) school. The crime was fully investigated but no perpetrator was traced. The robbery and the assault the day before were unconnected. Children’s Social Care were informed about the robbery, and provided information as appropriate to the investigation, but this was minimal due to limited service involvement previously. The contact was recorded by Children’s Social Care but no further action was taken, which was expected practice due to the details of the crime. Mother told the Reviewer she recalled the Police taking the 6 NSCB_SCR KA_Final_02May2017 robbery allegation seriously. GP records show that KA and Mother shared details of the robbery incident during a GP appointment around ten weeks after the crime occurred, and that the Police had facilitated victim support involvement. This was positive practice by the Officers involved who had noted that KA reported being unhappy around that time. The serious sexual abuse was brought to the attention of services in late 2012. The incident occurred when KA was aged 13 and the alleged perpetrator was known, including by name and address and said to be a similar age to KA. At the time the crime was not reported directly by KA to the Police but Mother states she did speak about the allegation to an Officer at a Police station within 24 hours. This was at the same time when Mother was reporting KA missing, the day after the abuse had taken place. Mother and KA returned to the Police station later the same day and a different Police Officer conducted a safe and well check in response to KA’s return from being missing. Mother’s recollection, and opinion, is that the second officer spoke firmly to KA. The Police record regarding the safe and well check indicates there was no specific follow up with KA regarding the sexual abuse despite Mother disclosing this earlier the same day when reporting KA missing, and a note having been made on the missing report by the first Officer seen. The responses to the sexual abuse allegation are explored below: I(i) Joint working An appropriate referral was made to Children’s Social Care by the GP after the incident in late 2012 was reported by KA and Mother in a GP consultation. Information was shared between Children’s Social Care and the Police Child Abuse Investigation Team (CAIT) via the standard 87a form two weeks after the referral had been received by Children’s Social Care. The reason for the delay is not known and due to time elapsed cannot be explained. However, the delay in sharing the allegation with the Police is unacceptable. Significant harm to a child (KA) was suspected and an immediate strategy meeting or discussion should have taken place. The 87a form, which was eventually used by Children’s Social Care to share the allegation is a method used by Children’s Social Care to refer cases into the Police. In 2012 the Child Abuse Investigation Team (CAIT) was, and still is, the single point of contact for referrals. This was, and is, the position even when referrals do not meet the CAIT’s own criteria of familial abuse. CAIT is then required to direct referrals to the relevant Police team. In late 2012, the referral for KA should have been transferred to the Police Sapphire team, the specialist team for serious, non familial sexual offences. It is unclear from records available why there was no attempt by officers in CAIT to involve the Sapphire team at this initial stage, despite the type of allegation being referred meeting the Sapphire team’s criteria for investigation. In records from the Havens sexual assault referral centre, which have been scrutinised for the review, Sapphire reported no record of the incident on their system after a contact from a Havens centre over a month after the offence took place. The arrangements that CAIT are responsible for initial Police management of referrals remain the same now, with cases being transferred from CAIT to other Police teams as necessary. At the learning event and at Panel meetings an issue was raised of the apparent disconnect which is still seen to exist, in the view of some professionals, within the Police service between CAIT and Sapphire. This may help to explain the lack of coordination between the teams in 2012 which appears to have resulted in a lack of ownership of KA’s case. It was explained that the Metropolitan Police Service is in a process of change, which will help address this issue, with the introduction of pilot Police Safeguarding Hubs which will better direct referrals to the appropriate team (see below). What is known is that records for late 2012 show a strategy discussion took place regarding the incident 7 NSCB_SCR KA_Final_02May2017 as soon as the Police CAIT received the 87a referral from Children’s Social Care. This was actually two weeks after the initial referral by the GP. This was followed by a number of contacts between Police and Children’s Social Care to track progress. Working Together to Safeguard Children, HM Government, March 2010 was the guidance in place at the time and was consistent with the current Working Together to Safeguard Children guidance, 2015 which states “Whenever there is reasonable cause to suspect that a child is suffering or likely to suffer significant harm there should be a strategy discussion”. Two agencies were involved in the strategy discussion; Children’s Social Care and the Police Child Abuse Investigation Team (CAIT). A decision is recorded that a single agency visit should be undertaken by a Social Worker to obtain more information including details of the alleged perpetrator. The record shows that a strategy meeting would be reconvened once the home visit had taken place. This second strategy meeting, when the latest position regarding the allegation and the perpetrator would have been discussed, did not take place but a record indicates that the Police (CAIT) signposted the Social Worker to the Sapphire Team who should have continued the investigation. An email contact did take place between the Social Worker and a named Sapphire officer soon after the Social Worker’s visit to KA and a conversation subsequently took place between the two professionals. Newham now has a local protocol known as the Newham Safeguarding Children Board Child Protection Strategy Meeting Protocol, 15.01.15. This reflects the requirements from Working Together to Safeguard Children, HM Government 2015. The protocol states when identified risks include “sexual abuse/exploitation, and gangs/serious youth violence, strategy meetings must be held”. In KA’s case, which did involve sexual abuse and possibly gangs, records indicate an initial strategy discussion did occur. However other requirements of Working Together to Safeguard Children 2010 were not met. The guidance states strategy discussions should, as a minimum, involve a local authority Social Worker and their manager, Health professionals and a Police representative. Other relevant professionals will depend on the nature of the individual case. In KA’s circumstances in late 2012, this should have included school involvement, but did not. The Police have advised that there are clear procedures in place for strategy discussions between the Police Child Abuse Investigation Team (CAIT) and Children’s Social Care. However there are no formal arrangements between the Police Sapphire Teams and Children’s Social Care. A new system will be piloted in 2017, which will involve the restructuring of police arrangements for protecting vulnerable people. This will ensure all referrals go the new Police Safeguarding Hub to manage a merge of MASH (Multi Agency Safeguarding Hub) and CAIT referrals. Strategy meetings should then take place regarding all vulnerable persons and dependant on the outcome cases will then be referred, as appropriate to the relevant investigation team. Timescales are not specifically outlined as to when a strategy meeting or discussion should take place but two weeks after the initial referral, as in KA’s case is not an acceptable delay. The reason for the delay in Children’s Social Care sharing the referral with Police is unclear, but this explains why the strategy meeting was overdue. It is recorded that the initial meeting took place within hours of the Police receiving the 87a form for KA. The current Working Together guidance, March 2015, and all earlier versions, suggests timely action in all responses to safeguarding, but particularly when significant harm is known or suspected. Regarding KA’s case the record and outcome of the Social Worker’s visit indicates that KA provided a detailed account of the incident including the location of the offence, ‘street name’ of the perpetrator and suggestion that the same perpetrator may have sexually assaulted another similar aged child to KA, with some details provided to the Social Worker. Despite the information shared by KA and Mother it is clearly recorded that their wishes at the time were for no Police action. A formal strategy meeting was not reconvened by Children’s Social Care to discuss the position and to share the further information which had been obtained. Other safeguarding agencies were not provided with the opportunity to become 8 NSCB_SCR KA_Final_02May2017 involved in the case, to offer support to KA, and to explore reasons for not wanting to pursue a complaint to the Police. This is examined further below, as is the position regarding the alleged child perpetrator. The schools which KA and the perpetrator attended were not included in any information sharing or discussion about the incident, which meant safety planning for KA, and wider safeguarding considerations for other children did not take place. In Newham now, since mid 2015, all referrals to Children’s Social Care come through Newham’s Triage which includes the Multi Agency Safeguarding Hub (MASH). The current arrangement is that the referrals are processed by duty managers and decisions are made on whether to allocate for assessments, step across to early help services or subject the referral to MASH checks. A decision may also be made to undertake a screening visit if the information on a referral is unclear or warrants a quick but more in depth check. There are several partner agencies involved with the MASH team and the core roles include; Social Care, Police, Health, Education and Housing. There are other agencies that provide their services and support to MASH from their satellite locations. These extended partners include; CGL (drugs and alcohol support work), Probation, ANCHAL (independent domestic violence support), Shelter, Early Help, Youth Offending Service and Families First. These extended agencies sit within MASH every Tuesday for relevant meetings and input. Under the Triage arrangements described above referrals requiring assessment, either under Section 17 (child in need) or Section 47 (child protection investigations), are immediately progressed through to the assessment teams based within local areas and allocated promptly. Cases that require further multi agency checks are identified and are subject to multi agency discussions within Triage which assists in decision making regarding thresholds of need. The Reviewer was told by the Triage manager that strategy meetings are currently undertaken by the Social Worker who has been allocated in the relevant area’s assessment team, and their manager. In some local safeguarding children board areas arrangements are in place to enable strategy meetings to take place within the ‘front door setting’ (Triage/ MASH) to utilise the partners who are available on site due to their co-location. Due to different ‘front door’ processes being in place in 2012 when KA’s referral was received and being managed the new opportunities for multi agency working at the front door to services were not available. Despite positive changes, particularly regarding joint working and co-location within the Newham Triage Service, there may still be a lack of true multi agency involvement in strategy discussions and possible delay, due to the arrangements in place to hold strategy meetings in assessment teams out in areas. The pilot Police Safeguarding Hubs which are being introduced, see above, should help to improve strategy meeting arrangements. The Newham Safeguarding Children Board should conduct an immediate audit of strategy meetings convened in the last three months to include scrutiny of agencies involved, timeliness of meetings and decisions and actions recorded. Newham Safeguarding Children Board should conduct an audit to examine referrals received specifically relating to sexual abuse of children age 12 and above, to explore that strategy meetings are being held for these cases and that the statutory and local requirements for strategy meetings are being met. The audit sample should include some cases where the sexual abuse is allegedly gang related and peer on peer abuse. 1(ii) Police enquiries As stated above, KA did not want to make a formal complaint to the Police regarding the sexual abuse. This is consistently recorded by both the GP who made the initial referral to Children’s Social Care, and 9 NSCB_SCR KA_Final_02May2017 by the Social Worker who visited KA over two weeks after the incident took place. Reasons recorded for the lack of a formal complaint were fear of reprisals by the alleged perpetrator and associates, as there was an indication that the offence on KA was gang-related. There is an indication that there was confusion regarding ownership and allocation of the enquiry and which Police team had overall responsibility. The case should have been investigated by the Police Sapphire team but was not formally transferred to them. Whichever Police team was to continue the investigation, a crime report should have been submitted about the known circumstances at the earliest opportunity. This is explored below, but as soon as an allegation of crime is received by the Police, it should be recorded. This did not happen until six weeks after the date when the incident was first reported. This is a practice issue for the Police as protocol and guidance regarding timescales and expectations for crime recording is already in place. There was no Police visit to KA at all regarding the allegation, despite this being a serious crime against a 13 year old child with an identified suspect. Whilst it is accepted that KA had a voice and a right to make decisions there is no evidence that a multi agency strategy discussion explored this aspect of the case; what action was required or that the rationale for no action being taken was recorded. Strategy meetings are discussed above. There is no record of any efforts being made to trace other possible witnesses but this was unlikely to occur without ownership of the investigation. The incident was only shared with Sapphire when the Social Worker who visited KA and a Police Officer happened to be speaking about another unrelated incident a short time after the home visit took place. This was not a planned formal discussion about KA specifically but did result in an email being sent by the Social Worker to the Officer to confirm details. The Police Officer was a specialist in sexual offences attached to the Police Sapphire Unit and as a result of the contacts, after establishing whether the crime was already being investigated and completing other intelligence checks and preliminary enquiries, recorded KA’s allegation as a crime, with a note that the child (KA) did not want to make a complaint themselves. A link was also made to KA’s missing report of the same time period. The enquiries to track the investigation and high case load of the Sapphire Officer meant there was a delay of a further two weeks from the Children’s Social Care/ Sapphire contacts taking place to the crime report actually being submitted. Records indicate that this was the first point that Sapphire had any involvement with the case. After being recorded as a crime over a month after the date of the incident, no further investigation or action to supplement the initial enquiries by the Sapphire Officer took place. It is apparent throughout the review timeframe that KA was able to share some details about the allegation with different professionals. Therefore if options had been explored and support offered, KA’s view regarding a formal complaint may have been different. Unfortunately it seems KA and family were not provided with advice, options or support regarding the situation. The decision to “not complain” was taken at face value and the case from a Police perspective was not progressed. There was no evidence of consideration of forensic opportunities, regarding the victim or the crime scene, details of which had been provided by KA. However, opportunities to obtain meaningful forensic evidence, commonly referred to as the ‘forensic window’ would have closed, due to the length of time elapsed. The Crown Prosecution Service (CPS) has issued Guidelines on Prosecuting Cases of Child Sexual Abuse, CPS, 2013, which includes information on additional support available to children via special measures and other guidance relating to specific models of child sexual abuse including gangs and peer on peer abuse. The allegation by KA related to both such models. Special measures are a range of measures that can be used to facilitate the gathering and giving of evidence by vulnerable and intimidated witnesses, Youth Justice and Criminal Evidence Act 1999. 10 NSCB_SCR KA_Final_02May2017 The CPS guidance was not in place at the time of the allegation in late 2012 but special measures for vulnerable and intimidated witnesses had been available for the Police to consider using for many years prior to that date. Furthermore, supporting victims and witnesses of serious crimes, who are presenting as frightened and unwilling to make formal complaints, and finding solutions for such scenarios, is a task which Police Officers, particularly child abuse investigators, are routinely required to face. There is no record of consideration of the involvement of an Independent Sexual Violence Adviser (ISVA) if such a resource was available in the area at the time. An ISVA could have been a valuable source of support for KA and family. An Independent Sexual Violence Adviser supports victims of sexual violence, including child sexual abuse. They are independent from the Police and are victim focused advocates. The Metropolitan Police were inspected by Her Majesty’s Inspectorate of Constabulary (HMIC) during 2016 and findings, published in Metropolitan Police Service – National child protection inspection, HMIC, 25 November 2016, indicate that there were concerns about the quality of some aspects of some child protection investigations. The case of KA in late 2012 was not a case example examined for the HMIC inspection but the findings of this serious case review indicate that there are concerns regarding the Police response to KA’s allegation of child sexual abuse. A number of recommendations have been made by the HMIC to the Metropolitan Police Service as a whole, and it is positive that the Newham Safeguarding Children Board has already considered the local Borough policing response to the inspection findings. Furthermore, as mentioned earlier, the local Police’ commitment to the new Triage Service arrangements in Newham, with co-location of operational specialist officers to enable immediate collaborative working is to be commended. The Metropolitan Police response to the HMIC inspection includes the formation of a Gold Group at Deputy Assistant Commissioner level, with representation from Children’s Social Care. This Group, and other new leadership and governance arrangements (internal and independent) aims to scrutinise the inspection recommendations and action plan, and to ensure learning is shared as appropriate. Newham Safeguarding Children Board through the Local Improvement Board should request a further opportunity to scrutinise the local Police position in Newham as a result of the findings of this serious case review, and in conjunction with the findings of the HMIC inspection to ensure the identified local Police response and improvement plan is accurate and actions are robust. The Chair of the Newham Safeguarding Children Board should request assurance from the Metropolitan Police after the Police Safeguarding Hub pilots are implemented that the interface and working arrangements between Child Abuse Investigation Teams and Sapphire Teams in Newham and elsewhere, regarding management of referrals and subsequent investigations of child sexual abuse is effective. 1(iii) Sexual health and support after an allegation is made In the London area the Havens are a network of specialist sexual assault referral centres jointly funded by NHS England and the Metropolitan Police Service. Self referrals are accepted by Havens but the majority of referrals are made by professionals. The GP advised Mother to make contact with a Havens site and Mother did attend with KA three weeks after the sexual abuse had taken place. A similar account of the circumstances was provided by Mother as had been shared previously to the GP. At the time in 2012 not every Havens site had resources for managing cases involving children, and records indicate that the site Mother and KA contacted did not then have capacity to see children. Alternative provision and support was arranged within a sexual health unit which KA and Mother were signposted to. Records indicate an attempt was made initially by the Havens to clarify the Police involvement in the case 11 NSCB_SCR KA_Final_02May2017 as Havens routinely work closely with the Police on sexual abuse investigations. However, as stated earlier, the Police Sapphire team at that time had no recorded knowledge of the incident or of KA. It is positive that the GP provided information to Mother and KA regarding the Havens service and that Mother acted on this advice. Not all parents or carers would have acted as proactively as Mother did in taking responsibility to self refer KA to the Havens service and in those circumstances children alleging sexual abuse may possibly not have received the care and support needed. There was an assumption by the GP that Police involvement in the investigation would occur triggered by the referral to Children’s Social Care. As discussed earlier, this did not happen until almost two weeks after the initial referral, but the GP was right to assume that the Police would have been informed. A further expectation from the GP’s perspective was that the Police would also liaise with Havens regarding KA and any forensic evidence opportunities. This is one of the key functions of the Havens, but due to the delay in Police involvement and the subsequent confusion over Police ownership of the case this liaison did not happen. Within the Health Overview report completed as a result of KA’s death, as explained earlier, a need was identified for awareness-raising for GPs of sexual assault referral centre pathways to ensure children and families receive accurate information and effective support. The Newham Safeguarding Children Board should obtain assurance and evidence from Health partners that all recommendations made as a result of the Health Overview Report regarding sexual assault referral centres have been completed. 1(iv) Safeguarding enquiries regarding child perpetrators The alleged perpetrator was identified by name and address, and the age of this child was said to be near to the age of KA, who was 13 at the time. Furthermore there was a suggestion that the same perpetrator was already known to Children’s Social Care and may have been involved in a similar gang related, but unconnected incident against another child. Research by Berelowitz et al, 2012 found “the majority of sexual exploitation within gangs was committed by teenage boys and men in their twenties”. In Newham there is now a Police Gangs Unit which works closely with other agencies to respond to child sexual exploitation. Nationally current figures demonstrate an increase in recorded cases of children committing sexual offences against other children, with a rise by 78 per cent in England and Wales between 2013 and 2016. “The number of alleged offences reported to Police forces in England and Wales rose from 5,215 in 2013 to 9,290 in 2016”, Barnardo’s press statement, 3 February 2017. In late 2012 and early 2013 when KA’s referral had been received none of the information regarding KA’s perpetrator was the focus of any other safeguarding referral or enquiry by Children’s Social Care or the Police. As a consequence no assessment of risk or needs of the alleged child perpetrator or consideration of any wider safeguarding issues took place. Children who are suspected of committing sexual offences are as much in need of a service from all safeguarding agencies as those who have offences committed against them, and a statutory child protection referral should have been made regarding KA’s identified perpetrator, leading to a multi agency strategy discussion highlighting the sensitive nature of the specific circumstances, including the wishes of KA. As stated earlier the local protocol in place now regarding strategy meetings identifies sexual abuse and gangs/ serious youth violence as risks for when strategy meetings must be held. No professionals involved at the time recognised that the alleged child perpetrator had safeguarding needs themselves, and the reason for this is unclear. This is a practice issue to be highlighted for all partners as distinct safeguarding procedures were in place, prominently available, and should have been 12 NSCB_SCR KA_Final_02May2017 used, regarding statutory requirements for action when abuse is known or suspected. Other guidance regarding children who display sexually harmful behaviour was also available. Raising awareness and providing information to all children and young people, and the professionals working with them, regarding healthy relationships, consent and other related issues is explored later. 2. Information sharing with/ between/and internally in schools KA moved schools during the timeframe of the review and spent a brief period out of school whilst Mother considered education options. The school which KA attended when the first allegation was made had only limited information to contribute to the serious case review due to the short time KA was a student there and the time elapsed since KA left. Representatives from the main school where KA was a student, which included the period when the 2012 allegation occurred up until KA left school at age 16, attended the learning event and have provided additional information to the Reviewer. It is a concern that there is no information of the first allegation in KA’s school records which were the responsibility of the school attended at the time. The second (main) school had no knowledge of that incident and therefore any support provided to KA was not informed by the previous allegation, other than information shared by KA them self. Keeping Children Safe in Education, Department for Education, Part 2: September 2016 (first published March 2015) states “as part of meeting a child’s needs, it is important for governing bodies and proprietors to recognise the importance of information sharing between professionals and local agencies”. This guidance was not implemented at the time of KA’s allegations but Section 175 of the Education Act 2002 was, and still is, relevant. This places “a duty on local authorities (in relation to their education functions and governing bodies of maintained schools) to exercise their functions with a view to safeguarding and promoting the welfare of children who are pupils at a school”. By not sharing the specific safeguarding issues which had related to KA whilst at the first school, there was a missed opportunity to allow the second (main) school to make proper arrangements to support KA. Of more concern is that the second allegation which occurred when KA was attending the second (main) school, but out of school hours, was not shared formally with the school by the safeguarding agencies initially involved. It is apparent that KA mentioned to school staff that “something had happened at the weekend” but the detail and seriousness of the allegation was not known by the school, despite a referral having been made to Children’s Social Care by the GP within days of the incident occurring. As a result in the early period that the incident had taken place the school were unable to properly plan for the safety of KA and any possible repercussions relating to the allegation. Newham Safeguarding Children Board should work with Education partners to ensure there is sufficient awareness in every education setting, and specifically the two schools involved in this review, of information sharing protocols, including timescales for the effective sharing of school records when children move schools. Children’s Social Care did eventually make contact with KA’s school in early 2013, over two months after the actual incident, to complete agency checks for the core assessment to be completed as a result of the allegation and referral. It transpired that the alleged perpetrator, whilst not a pupil at the same school, was known locally around the school and therefore may have been a risk to other students. Soon after the agency check with school the Children’s Social Care case regarding KA was closed, with the assessment highlighting that Mother was supportive and able to protect KA. As described earlier the Newham Triage, which currently receives and manages all referrals to Children’s Social Care, includes representatives from Education. Therefore information sharing to and from schools 13 NSCB_SCR KA_Final_02May2017 and between other agencies, should be more robust, and relevant education information should be available immediately to inform decisions and assessments. The situation where a particular school is not aware of a serious safeguarding concern about a student at the school should not occur. KA at this point and during 2013 had accessed support from the School Pastoral Centre, within the main school. As stated earlier the School Pastoral Centre operated similarly to a pupil referral unit, but internally, by providing educational and behaviour support to those students with emotional or behavioural difficulties, sometimes through complete withdrawal from the mainstream setting or partial support whilst still in the mainstream. KA had reported incidents of bullying and issues related to gangs, and eventually in Spring 2013 a referral from the School Pastoral Centre to Gangsline resulted in one to one sessions for KA with a Gangsline mentor. Gangsline is a non-profit organisation providing help and support to young men and women involved in gang culture. Throughout 2013 and 2014 KA received regular support via a Gangsline mentor, a relationship which Mother described very positively to the Reviewer. Mother said KA “spoke highly” of the Gangsline mentor. The mentor attended the learning event and recalled KA, early on in the mentoring sessions, reflecting on the alleged sexual abuse from 2012, and the impact this had had on KA. Other issues discussed included bullying, and later as the mentoring relationship developed, low self-esteem and self- harm. The mentor described how any pertinent safeguarding information from the one to one sessions was shared with the School Pastoral Centre but it was unclear where and how much information was shared on from that point, or what formal recording systems were in place. The school population were organised into school year teams with every student allocated a school year team. At the time the relevant school year team to which KA was attached, would have been aware that KA was receiving support but not the reason why or other details. There was a change in leadership at the school in September 2014. The Deputy Head explained the current position regarding safeguarding in the school and that a dedicated child protection team had been developed since the end of 2014/ early 2015. The team meets weekly and the Head of the School Pastoral Centre attends to share information and discuss any concerns. Specific staff in each school year team, who manage lower level safeguarding issues and early help intervention, are linked into communication as relevant. Panel meetings with each school year team take place once every half term (bi-termly). Vulnerable students are identified through a number of indicators, and interventions for these students and the impact of these interventions are reviewed. The new arrangements offer improved information sharing opportunities across all sections and levels of safeguarding within the whole school setting. Regarding School Health involvement in the new arrangements within school, it was explained that currently School Nurse time allocated to the school is extremely limited due to staffing shortages. Time allocated is currently around half a day a week and this is affected if there are pressures elsewhere. The limited capacity means that it is almost impossible to ensure that there is the opportunity for proactive planning of interventions for students and planned attendance at meetings. Efforts are made to liaise effectively via messages in a log book, emails and the open invitation for School Nurses to visit the child protection team office whenever a School Nurse is onsite. It was highlighted at the learning event that the Newham Triage system is not benefiting from a consistent presence by the School Nursing Service and vice versa. However Health and Education information is normally accessible via the agency professionals located in the Triage service. School Nurses are said to receive ‘Merlin’ information, see below, on children, which will provide details of incidents where vulnerabilities have been identified and, as described later, School Nurses do receive notifications of children attending the accident and emergency department with a follow up protocol in place. 14 NSCB_SCR KA_Final_02May2017 The Help and Protection for Children, Young People and Families Practice Guide: A guide to services in Newham explains Police ‘Merlin’ forms as being created when a child comes to the notice of the Police, including when reported missing, and there are concerns about the child’s vulnerability. There are currently over 4,000 Merlin forms created in Newham a year. However, if School Nursing presence within schools is minimal due to resource issues there is limited opportunity for relevant safeguarding information which School Nurses do receive, such as Merlin forms as above, to be shared with schools. In the Health Overview Report conducted after the death of KA it is concluded that the school health record for KA was “uneventful”. This indicates a different awareness of the issues KA faced possibly explained through lack of availability of School Nursing professionals to work regularly with the school and access the full information available. If the School Nurse had been aware of the involvement which the School Pastoral Centre and Gangsline had with KA, an “uneventful” school health record would not have been an accurate reflection of the circumstances. Unfortunately due to the lack of a presence of the School Health services in the support package planned and being provided to KA throughout the time at the main school the involvement of, and any subsequent benefit from the School Nurse for KA was minimal. From detail now known from the timeframe of the review it is positive that KA felt supported enough to share sensitive personal information with some professionals, in particular the Gangsline mentor whose relationship with KA has been commended by Mother. However schools who commission external services, such as Gangsline, must be assured that clear protocols are in place for safeguarding information to be properly recorded and shared particularly when relating to children in receipt of additional support arranged by a school. This will ensure appropriate, timely action is taken if and when required and records can inform assessments as necessary. Furthermore all professionals involved in supporting children who may disclose issues relating to safeguarding, must be aware of, and follow when required, the child protection procedures of the relevant Local Safeguarding Children Board. This is mandatory with clear procedures already in place, and therefore a practice issue for all safeguarding agencies and professionals. It is encouraging that the main school involved with KA, and its School Pastoral Centre have developed more robust child protection processes including for recording, which are hopefully now fully embedded. Designated staff can now focus solely on managing child protection within the school setting. The Chair of the Newham Safeguarding Children Board should request a report on the current position of School Nursing provision within secondary school settings in order that an adequate and consistent service in terms of resource and frequency is available. 3. Consideration of Early Help Support The Help and Protection for Children, Young People and Families Practice Guide, 2014 sets out Newham’s approach to supporting families across all levels of need. The key elements of Newham’s offer of support are universal services, early help and statutory intervention. Child KA mainly accessed universal services such as education and routine healthcare. However, the allegation of sexual abuse in late 2012 resulted in a statutory intervention, which was eventually closed. Professionals supporting KA particularly after the 2012 incident did not formally identify KA as requiring early help support. This is despite concerns of low self esteem, self harm, bullying, gang related pressures, possible mental health issues all of which were examples of Indicators of Need levels 1(b) and 2(a) in the Help and Protection Practice Guide, levels which meet the criteria for early help support. 15 NSCB_SCR KA_Final_02May2017 Working Together, HM Government 2015, 1.1, emphasises that early help means providing support as soon as a problem emerges, at any point in a child’s life which can also prevent further problems arising. However for early help to be effective local agencies need to work together to identify children and families who would benefit from early help and to undertake an assessment of the need for that support. Earlier versions of Working Together, which were in place throughout the review timeframe, gave similar consistent messages regarding the timing and processes for early help. Whilst it is acknowledged that some support was being provided to KA through the School Pastoral Centre and Gangsline, the coordinated approach which a formal early help process should bring was not initiated. In Newham there is now an Early Help Partnership team made up of coordinators and practitioners who advise and guide professionals in their responsibility of providing safeguarding and early help support. For the period within the timeframe when the Early Help Partnership support was available there is no evidence that professionals involved with KA requested assistance from the service, to help implement formal early help support for KA. It should be highlighted that when the Early Help Partnership service was introduced initially there was just one officer providing support. In early 2015 KA disclosed to school of being spat at in a gang related incident which resulted in an attempt to self harm by taking seven pain killers. Two other episodes of anxiety and dizziness had also been reported by KA to separate professionals around the same time. Despite such incidents clearly being examples of concern at early help level on the Help and Protection Practice Guide Indicators of Need there is no recorded consideration of instigating early help processes. Response to the self harm incident will be explored in more detail later. At the learning event early help support did not appear to be a consideration for the professionals who had been involved with KA. In Spring 2015 KA reported a concern for a friend regarding alleged inappropriate behaviour by a member of school staff on the friend. This was investigated but unsubstantiated. As a result of KA being interviewed as a possible witness, and due to concerns from the school, at this time KA themselves was referred by a senior member of school staff to the Children’s Triage Service, the ‘front door’ for all requests for support or protection of Newham children, as described earlier. As there were concerns regarding possible child sexual exploitation of KA at the time that the concerns for the friend were raised the level of need for KA was identified as level 2(b) on the Help and Protection Practice Guide Indicators of Need. This level, as before, was categorised as eligible for consideration for early help support. As a result of the school’s referral to Triage, an invitation was made to meet with Mother to discuss concerns for KA. Children’s Social Care was undertaking an assessment on KA due to the current concerns and the previous sexual abuse allegation. Mother refused to engage with the Social Worker as, in her view, KA was worried for a friend and there were no issues or concerns for KA. Mother felt she was a supporting factor in KA’s life and also said that KA was accessing support in school. It is not clear whether formal early help processes were considered as an option for the family at this point, but family engagement and consent is a requirement for early help support to be of benefit, as services and families work together collaboratively to find solutions for the concerns identified. The Children’s Social Care assessment was completed and closed; school support was highlighted as being in place and no other concerns were identified through agency checks. However records indicate that the school shared details about the overdose and the continuing disclosure by KA of the 2012 sexual abuse when providing information for the assessment. The 2(b) level Indicator of Need had been identified but formal early help support was not considered, possibly due to the support in place for KA through the school. Advice was not requested from any specialist services by Children’s Social Care, school or Gangsline, regarding the self harm or other concerns, and this will be explored below. 16 NSCB_SCR KA_Final_02May2017 Despite the emphasis in statutory guidance, as in Working Together 2015, of the importance of early help, and the best efforts of many Local Safeguarding Children Boards to ensure the early help offer is properly embedded, early help processes again appear not to have been considered by professionals as an option. The lack of coordinated early help support offered to KA and family, or a team around the child approach, is another example of a missed opportunity for such support to be provided to an individual in circumstances which meet the criteria of identified levels of need for early help. The Newham Safeguarding Children Board may want to consider whether further promotion and raising awareness for professionals is necessary to ensure the Early Help strategy and what support is available locally is widely known across the partnership and in all agencies. 4. Thresholds regarding self harm During the timeframe of the review there is evidence that KA suffered with low self esteem. This was discussed with the Gangsline mentor and her professional opinion, as early as autumn 2013, was that KA appeared “low, lost and unsure of them self”. Around this time, which was one year after the 2012 sexual abuse allegation, the school had asked for support for KA from Gangsline regarding possible gang related child sexual exploitation. In early 2014 as a result of a theft allegation, KA spent a brief time detained in police custody. Whilst there KA suffered a panic attack which is noted on Police records but no further action was taken regarding an assessment of KA’s presentation and needs. No referral was made to Children’s Social Care. Thurrock Safeguarding Children Board published a serious case review in December 2016 regarding ‘James’, which included a recommendation for the Metropolitan Police Service to “remind custody officers to ensure any vulnerabilities disclosed to a Forensic Medical Examiner (FME) by a child in custody must be risk assessed. Furthermore if the assessment highlights concerns these must be referred to appropriate agency partners”. In KA’s case a FME was not involved but more robust action should have been taken to share information to ensure other professionals had opportunities to offer support. Newham Safeguarding Children Board should consider requesting an update from the Metropolitan Police Service of progress against the recommendation in the Serious Case Review “James”, December 2016. In the Spring of 2014 dizziness, exam stress and a fainting episode was reported resulting in an attendance at hospital from school, but medical tests were noted as unremarkable. It was explained at the review’s learning event that the School Nursing service safeguarding team do receive notifications of accident and emergency hospital attendances but follow up for a teenager fainting was unlikely. Three attendances of a child at an accident and emergency department within six months would trigger an automatic follow up by the School Nursing service. In late 2014 there is a record that KA discussed the 2012 sexual abuse allegation with a member of the School Pastoral Centre. Into early 2015 dizziness was reported to the GP, and KA suffered a panic attack in school after a problem with a staff member. Soon after, KA disclosed to school of “taking seven pain killers at the weekend” in an attempt to self harm. As described earlier this was as a result of an alleged gang related incident. The disclosure was recorded by school staff and a re-referral made for further support for KA with Gangsline. The incident of self harm was not referred to the Child and Family Consultation Service (CFCS), but at the learning event representatives from CFCS said that such an incident of self harm would have been expected to be referred to the Service for an assessment. Newham CFCS is a multi-agency specialist mental health service for children and young people with complex, severe or persistent emotional, behavioural or developmental problems. Referrals are accepted from birth to 18th birthday. School did not pass on KA’ disclosure of self harm or seek advice from other specialists in mental health services, or the Early Help Partnership Officer. However, as well as the referral for further Gangsline support a request for support was also made to the school counselling service. Records show that this 17 NSCB_SCR KA_Final_02May2017 request for school counselling was agreed by KA. It is positive that the same Gangsline mentor was able to quickly re-commence one to one sessions with KA, and once again low self esteem was noted. There was again no consideration of referring KA for a specialist mental health assessment, or as discussed early, for coordinated early help support. It was explained at the learning event by those who had been involved that as KA was being supported by both a Gangsline mentor and school counsellor, and due to KA’s reluctance to trust other professionals, this arrangement was considered to be appropriate in terms of supporting the child at the time. Despite the ongoing support via the school, and the good intentions of professionals already involved, it is important to understand that self harm is a complex issue particularly in children and at a minimum a consultation with a Child and Family Service professional should have taken place after the overdose self harm disclosure. In Truth Hurts: Report of the National Inquiry into Self Harm among Young People, Mental Health Foundation 2006 it is suggested that “at least one in fifteen children are self harming and some evidence suggests that rates of self harm in the UK are higher than anywhere else in Europe”. Obtaining accurate figures on children who self harm is difficult as most children do not tell anyone about what is going on. However, in 2014 figures were published by the National Institute for Health and Care Excellence (NICE) suggesting a seventy (70) per cent increase in ten to fourteen year olds attending accident and emergency departments for self harm related reasons over the preceding two years, The facts: self harm statistics, www.selfharm.co.uk. The school where KA was a student, and other schools, now work closely with a CFCS clinical nurse who completes consultations with pastoral staff when concerns are raised regarding mental health. A self harm disclosure such as the one made by KA would now be followed up through the consultation process. Early feedback from the school regarding the new consultation arrangements is very good. The decision by Children’s Social Care not to consult with or seek any specialist support regarding the overdose disclosure, when this was eventually shared by the school in late Spring 2015 is a concern. The information came to the attention of Children’s Social Care during the assessment agency check requested by Triage when KA was referred to them (after raising the concern for a friend regarding the staff member). This was over three months after the actual self harm overdose incident. In Fundamental Facts About Mental Health 2015 Executive Summary, The Mental Health Foundation, it is noted that “ten per cent of children and young people (aged 5-16 years) have a clinically diagnosable mental problem, Mental Health of Children and Young People in Great Britain: 2004. Office for National Statistics, “yet 70% of children and adolescents who experience mental health problems have not had appropriate interventions at a sufficiently early age”, The Good Childhood Inquiry: Health Research Evidence, London, The Children’s Society (2008). Due to the school and associated support network deciding to manage internally KA’s developing mental health issues there was no opportunity for a clinical assessment of KA’s needs. This was at a time when KA’s exams and leaving school were imminent, and the trusted and supportive relationships built at school would no longer be available. After leaving school in Summer 2015 then starting a college course for a brief time, it is now known that in late 2015 KA attended hospital accompanied by a friend. KA had superficial injuries which had been self inflicted and during the consultation disclosed a previous incident of self harm (an overdose). It is unclear if this was the same incident as disclosed to school in early 2015. KA also told the hospital of “feeling low about life” and records state “sometimes suicidal after being sexually abused when aged 13”. Unfortunately a false name was provided to the hospital, and KA and friend left before being seen by the Child and Family Consultation Service. This should have been the next stage in treatment having received an initial mental health assessment, as specified in the East London NHS Foundation Trust 18 NSCB_SCR KA_Final_02May2017 Pathway for under 18s with self-harm or other psychiatric emergencies- out of hours- age 16 to 18 birthday, pre January 2016 version. In the Health Overview Report an issue was identified that KA “was an unaccompanied vulnerable minor left without supervision in a health setting” for a period of seventy-five minutes prior to the absence being noticed. This linked to concerns noted in the Health Overview Report about older children (age 16 and 17) being cared for within an adult setting (the adult accident and emergency department) without paediatric input into their care. The Newham Safeguarding Children Board should obtain assurance and evidence from Health partners that all recommendations made as a result of the Health Overview Report regarding the attendance of KA at hospital have been completed. On realising the patient (KA), had absconded, an appropriate report was made by hospital staff to hospital security, and a referral made to the Police and to Children’s Social Care. Through intelligence checks the Police managed to trace KA to the correct name and home address on the same evening. During the missing person safe and well check KA again referenced the sexual abuse allegation, which was noted as a concern by the officer on the Merlin report. The Merlin report completed after the visit requested follow up for KA by ‘the Social Worker’. Unfortunately there was no allocated Social Worker at the time as the case was not open. The Merlin form regarding the self harm and subsequent missing incident was considered in Triage within required timescales. The Police record clearly referenced that “all problems (KA) was having were as a direct result of ‘that incident’ (the sexual abuse)”. The Triage outcome was for no further action with “no safeguarding concerns” and “Mother’s continuing support” being noted. A standard letter with signposting information on local support services was sent to the family and the case was closed. This point in the chronology of the case could be identified as a missed opportunity by Children’s Social Care to offer more proactive support to KA if the full history of the circumstances and information on record had been properly considered and assessed. This included in the same year of the self harm and missing episode, a previous self harm incident which became known via a referral for Triage for possible child sexual exploitation and gang related issues. In addition, on record were the two non-recent sexual abuse allegations, significantly one of which was still being referred to by the child as a reason for the self harm. It is acknowledged that Mother had informed the Police of her intention to seek medical help for KA but the specialist support did not materialise, for reasons explored below. Therefore KA did not receive any further specialist or other support, apart from that provided by Mother. Sadly KA was found dead at home six months later. The Newham Safeguarding Children Board drawing on the expertise of partners, should explore ways of raising the awareness of all children’s practitioners of the complexities of self-harm for children and young people and the requirement to take self-harm episodes seriously and to clarify pathways for professionals to consult specialist mental health services for advice and support. 5. Referral processes to CAMHS The review timeline shows that Mother and KA did attend a GP appointment one day after the late 2015 self harm and missing episode, as described above. The GP notes indicate that sexual abuse was referenced at the appointment and that KA had “felt low in mood over several years”. An appropriate examination of the minor self harm injury took place and the GP made a referral to the Child and Family Consultation Service (CFCS). Mother and KA were aware that a referral had been made, and in her 19 NSCB_SCR KA_Final_02May2017 meeting with the Reviewer, Mother recalls assuming they would be on a waiting list but that KA would have eventually been sent an appointment. Unfortunately only minimal demographic information was recorded on the referral form with no additional information attached, so the explicit reason for the referral was not included. Therefore the actual details of KA’ full circumstances at the time of the referral were not included by the GP, although the referral was marked as ‘urgent’. The Health Overview Report highlighted that clinical information is usually attached to the referral form but it is unclear why that did not occur on this occasion. It is known that the referral was received in the Child and Family Consultation Service and was sent to the administrator of the Front Door (Referrals) Team. It was discussed in the Front Door Referrals meeting and as the referral contained no clinical information an action was made for this to be obtained. The action was emailed for allocation but no clinician was identified specifically to follow up. Consequently the case was closed at the Front Door Team but no further action was being taken by any clinician which resulted in no further communication with the GP. The outcome was KA never being contacted or seen by a professional from the CFCS. Mother explained to the Reviewer that, at the time during early 2016 and prior to KA’s death, she just presumed that the lack of contact from any mental health services was due to high demand and long waiting lists. Only after the death did she realise the referral had been closed soon after it was made. It is encouraging since July 2016 that a revised Operational Policy for Front Door/Duty has been in place for the Child and Family Consultation Service. A detailed process is included from a referral being received to the point of allocation, and a system for liaison when there is insufficient referral information. As part of the new operational policy a duty system is in place which aims to ensure prompt response to queries from potential referrers and to advise on alternative services for referrals not meeting the threshold for CFCS. The Newham Safeguarding Children Board should seek assurance and evidence from East London Foundation Trust that the Child and Family Consultation Service Operational Policy for Front Door/Duty is fully embedded in the Service, is providing an appropriate initial response to all referrals and that the updated Policy has been circulated widely across all potential referrers. In addition, NSCB should seek evidence that an audit has been conducted, as highlighted in the Health Overview Report, regarding quality and content of referrals made to the Child and Family Consultation Service since July 2016, and that any further action/improvement identified as a result of the audit has been taken. 6. Contact with children who return after being reported missing KA was reported missing twice during the review time frame. The first missing episode was reported on the day after the sexual abuse incident had taken place, in late 2012. KA was missing for a brief time before coming home. Mother recalls attending a Police station with KA soon after KA returned and that this was when KA was spoken to about being missing. Mother’s opinion is that she (Mother) assumed this conversation related to both the sexual abuse and missing incidents but there is no record of any specific discussion or questioning about the alleged sexual abuse in the Police safe and well check which took place with KA from the 2012 missing episode. The note regarding KA’s lack of any further sexual abuse allegation was made after the Officer had completed the safe and well check and had chance to see the earlier recording about Mother reporting the sexual abuse. The position at the time was that information gathered from a Police safe and well check, after a missing child had returned, would inform the Children’s Social Care response but the safe and well check for KA included no actual reference to the sexual abuse, albeit the missing report, completed afterwards, did. The Police explained that during a safe and well check, basic questions would be asked including; “Where have you been?” “Why have you been missing?” “Did anything happen to you whilst missing?” This 20 NSCB_SCR KA_Final_02May2017 would have given KA opportunity to tell the Police about anything that may have happened, but KA chose not to. There was a reference to the sexual abuse on the missing documentation completed earlier after Mother’s initial report to the Police, but this was not mentioned in conversations during the safe and well check with KA carried out by a different Officer. It is noted within the safe and well report that KA “did not make any allegations in relation to the sexual abuse”. The Officer recalls not asking KA directly about a specific allegation as the Officer did not notice that an incident of sexual abuse had been mentioned by Mother on the initial missing report. On completing the documentation to share on to Children’s Social Care, the second Officer saw reference to the sexual abuse on the missing report and therefore added that KA had not disclosed any abuse in the safe and well check, although KA had not been questioned in more detail other than the standard safe and well questions as above. Had the information on the report been read thoroughly prior to the safe and well check, more questioning of KA could have taken place to explore what Mother had already reported. Consequently the information shared by Police with Children’s Social Care regarding the sexual abuse, but as part of the missing report, was minimal. Children’s Social Care did not act on the brief information about the sexual abuse in the missing report. The sexual abuse of KA was referred in full after the report from the GP two days later. No follow up, immediate or otherwise, took place by Children’s Social Care regarding the late 2012 missing incident, and as stated earlier, no visit took place with KA regarding the sexual abuse until more than two weeks after the GP’s referral. The second missing episode was in late 2015 when KA absconded from the hospital after reporting self harm. The Police visited KA at home for a missing person safe and well check, and KA referenced the sexual abuse in 2012. The officer added the information to the Merlin report for the missing episode and this was shared, as was protocol, with Children’s Social Care. In 2015 the process for Children’s Social Care follow up after a missing/return incident was as in 2012. If the Police debrief identified safeguarding concerns then Children’s Social Care follow up would be considered. However as explored earlier, despite the officer highlighting clearly the reference to the 2012 sexual abuse as a result of what KA had said, the decision by Children’s Social Care was not to initiate follow up, other than in writing signposting to support for self harm. At the time in 2015 there was no formal process in Newham for children returned after being missing, and who were not already involved with Children’s Social Care, like KA was not, to be seen and supported by a professional other than a Police Officer conducting a safe and well check. This was a gap in service provision for children who were not classed as open cases, when a follow up contact would be required to take place by the allocated Social Worker. In 2015, a risk indicator of possible child sexual exploitation had already been identified nationally as children being missing from home, care or education, Signs, Symptoms and Effects of Child Sexual Exploitation, NSPCC, and in the individual case of KA sexual exploitation had already been reported. Since September 2016 Families First have been commissioned in Newham to undertake return interviews with children who have been missing and who are not open cases to Children’s Social Care. At time of writing this report a supporting policy and procedure is awaiting publication. The new arrangement is positive and should enable vulnerabilities, risks and additional support needs to be identified, across all groups of children who have been reported missing. The lead for Child Sexual Exploitation (CSE) and Missing in Newham explained the number of return home interviews has significantly increased over the last six months with no notable increase in children going missing. Return interviews are being completed in a timely way and children are being offered the choice of who should conduct the interview. A positive outcome from the new arrangements is that themes and triggers are now being identified for missing episodes which will be shared with frontline professionals to inform practice. The Newham Safeguarding Children Board through the CSE and Missing sub group should audit the new 21 NSCB_SCR KA_Final_02May2017 arrangements for return visits by Families First after nine months of the service being introduced. The audit should include focus on interface between Families First and the Police regarding information shared from Police safe and well checks, and that appropriate referrals are being made as necessary by Families First or the Police when safeguarding concerns are identified. 7. Child Sexual Exploitation involving Gangs and Groups There is a link to gangs which is evident throughout this serious case review timeline. The allegation of sexual abuse in late 2012 was said to involve a gang member as the perpetrator. The main reason for KA not wanting to pursue a formal Police complaint was due to fear of gang related intimidation and reprisals. Other issues throughout the timeline relating to gangs include concerns of verbal and physical abuse, bullying, and peer/friendship problems. The school were aware of some of the gang culture which was impacting on KA. It is positive that KA felt secure enough to confide in some school staff, and the School Pastoral Centre identified the need for a referral to Gangsline, which was a resource available to the school at the time. As mentioned previously the Gangsline mentor is praised by Mother for the relationship which developed with, and the support provided to, KA. Extensive research has been conducted regarding exploitation and gangs, including “I thought I was the only one in the world” (interim report) November 2012 and “If only someone had listened” (final report) November 2013, The Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation In Gangs and Groups, Sue Berelowitz et al. What is now known about the experiences of KA, which coincidentally were happening at the exact time the research above was underway, highlights two areas for development in particular from recommendations within the Final Report (November 2013) of specific relevance to services in Newham. Problem-profiling involves information and data being collated and assessed to inform strategic decision making and local practice development. By including all aspects as recommended in the research above and as relevant to the experience of KA will ensure a more rounded and effective response due to the fuller profile of exploitation in the area being obtained and scrutinised. Therefore the local problem profile should include detailed information and data about victims, perpetrators, gangs, gang-associated girls, and neighbourhoods. A CSE audit was undertaken in Newham in 2016 which highlighted the overlap with CSE and gangs as an emerging theme within Newham. This will inform the local problem profile. The audit recommended that the Youth Offending Service produce an action plan detailing how the gangs overlap will be addressed locally and how the findings will supplement the CSE problem profile. Reporting areas include ensuring that those victims associated with gangs through social networks are identified and adequately safeguarded; data on cross border activity specific to CSE is provided regularly; the overlap between harmful sexual behaviour and CSE offending is monitored. These recommendations were approved by the Newham Safeguarding Children Board and progress will be overseen by the CSE and Missing sub-group. This continued local scrutiny of the links between CSE and gangs is reassuring. The theme of gangs and sexual exploitation within the timeframe of this review starts with the significant incident of sexual abuse in 2012, which was alleged to be gang related. In particular the School Pastoral Centre and Gangsline worked hard to provide help and guidance to KA in response to this and a number of other issues. Sadly KA was not the only student requiring support and there was, and still will be, others affected by similar life experiences and concerns in the same and neighbouring school(s), and in the local area. The changes in approach to child protection in KA’s last school have been outlined earlier and responses now should be more robust. However such a framework for responding to actual safeguarding and child protection concerns needs to be underpinned by an holistic/whole school approach to managing and 22 NSCB_SCR KA_Final_02May2017 raising awareness on a wide range of issues linked to exploitation and gangs, including safe/healthy relationships, all forms of bullying and harassment, the getting and giving of consent, and online safety. In an environment where messages of respect, confidence and safety are consistently promoted, and where responses to concerns are appropriate and strong, children and young people will be more equipped to at least identify concerns and seek support as necessary. The school reported that these issues are taught to students through the Personal, Social and Health Education (PSHE) curriculum and the Information Technology (IT) curriculum. Current research by Barnardo’s shows that recorded cases of children committing sexual offences against other children rose sharply by 78 per cent in England and Wales between 2013 and 2016. Furthermore Barnardo’s research suggests that age-appropriate compulsory sex and relationship education (SRE) would better protect children and help them understand consent, respect and what a healthy relationship should look like, Barnardo’s, 3 February 2017. The school where KA attended explained that the suggested areas are covered comprehensively within that school but there is inconsistency around what other settings are including for PSHE and SRE. In the Tackling Child Sexual Exploitation: A Progress Report, HM Government February 2017 the Government has shown a commitment to provide further funding for the Disrespect NoBody campaign which educates young people in respectful and safe behaviour and how to access support. The Newham Safeguarding Children Board should consider ways to improve the awareness of children and young people, and the professionals working with them, about issues linked to sexual exploitation and gangs particularly safe/healthy relationships, consent and bullying. Provision should be consistent across all educational settings, including secondary and post sixteen sites, for those not in full-time education, and in other hard to reach categories. 8. Suicide prevention planning An inquest into the death of KA has recorded a verdict of suicide. Statistics regarding numbers of children and young people known to have taken their own lives are very difficult to collate. However what is known is that each day in England around 13 people take their own lives, Suicides in the UK in 2014. London: Office for National Statistics, 2016 with each death being a tragedy. Despite the conclusion of this serious case review being that KA’s death could not have been predicted there is a need to develop local suicide prevention strategies and action plans that engage a wide network of stakeholders in reducing suicide. A local suicide prevention plan will combine actions by local authorities, mental health and health care services, primary care, community and voluntary agencies, police, employers, schools and colleges, prisons and others. Public Health England has issued Local suicide prevention planning: A practice resource, October 2016 which is a useful resource for development of local suicide prevention strategies. The Newham Safeguarding Children Board should collaborate with Public Health and other local strategic bodies to ensure a proactive and effective approach to suicide prevention within Newham is underway. Practice issues Practice issues were highlighted for individual organisations as a result of the review. These issues are not subject to separate recommendations as policies, procedures and training are already in place, but the individual governance arrangements of organisations will need to monitor that issues have been, and continue to be resolved: The Metropolitan Police Service must ensure the protocol of recording crimes at the earliest opportunity is followed by all Police officers and relevant staff; 23 NSCB_SCR KA_Final_02May2017 All professionals involved in supporting children who may disclose issues relating to safeguarding, must be aware of, and follow as required, the child protection procedures of the relevant Local Safeguarding Children Board. In addition, of particular relevance to this case are existing procedures and guidance relating to strategy meetings and managing referrals where the alleged perpetrator is also a child. Good Practice Identified Good practice is highlighted when it is judged that more than ‘expected practice’ has taken place; it is acknowledged that many professionals worked hard to support KA but practice is highlighted where professional commitment, persistence and/or professional curiosity resulted in an enhanced service. Mother identified the support provided by the Gangsline mentor to KA throughout the timeframe as good practice. Mother said KA had valued the time spent with the mentor and that this often made a positive difference to KA. Conclusion The findings of this serious case review do not indicate that the outcome of the case could have been predicted by any individual or organisation involved at the time. However, there were missed opportunities to fully investigate the sexual abuse and to coordinate the wider support being provided to KA. Information about the health and wellbeing of the child was not properly shared and specialist advice was not requested to enable a clinical assessment of specific mental health needs. Scrutiny of practice always provides an opportunity to reflect on ways in which services can be further enhanced. As a result of the significant incident(s) involving KA there is an opportunity to ensure that services and practice continue to be developed and assurance will be obtained that change and improvement, if required, has occurred. Recommendations, as below, have been made based on the learning from the case: Recommendations In order to promote the learning from this case the review identified the following actions for Newham Safeguarding Children Board (NSCB) and its member agencies: 1. The Newham Safeguarding Children Board should conduct an immediate audit of strategy meetings convened in the last three months to include scrutiny of agencies involved, timeliness of meetings and decisions and actions recorded Intended outcome: Evidence is obtained of the current position regarding procedural compliance relating to strategy meetings, enabling direct action, and development of staff where required to ensure effective initial responses to all referrals where significant harm is known or suspected; 2. Newham Safeguarding Children Board should conduct an audit to examine referrals received specifically relating to sexual abuse of children age 12 and above, to explore that strategy meetings are being held for these cases and that the statutory and local requirements for strategy meetings are being met. The audit sample should include some cases where the sexual abuse is allegedly gang 24 NSCB_SCR KA_Final_02May2017 related, and peer on peer abuse Intended outcome: Allegations of sexual abuse by older children are taken seriously, including in referrals involving gangs and peer on peer abuse, with robust multi agency responses enabling the needs of all children to be appropriately assessed and support provided; 3. Newham Safeguarding Children Board through the Local Improvement Board should request a further opportunity to scrutinise the local Police position in Newham as a result of the findings of this serious case review, and in conjunction with the findings of the HMIC inspection to ensure the identified local Police response and improvement plan is accurate and actions are robust 4. Intended outcome: Additional scrutiny and challenge of the current local Police position regarding responses to actions form the KA Serious Case Review and the HMIC inspection of the Metropolitan Police Service will allow for, and lead to, a more effective service in child protection investigations in the future; 4. The Chair of the Newham Safeguarding Children Board should request assurance from the Metropolitan Police after the Police Safeguarding Hub pilots are implemented that the interface and working arrangements between Child Abuse Investigation Teams and Sapphire Teams in Newham and elsewhere, regarding management of referrals and subsequent investigations of child sexual abuse is effective Intended outcome: The Safeguarding Hub structures enable improved joint working arrangements within the Police Service internally which in turn enhances partnership working externally regarding management of referrals, improving outcomes for children and families involved; 5. The Newham Safeguarding Children Board should obtain assurance and evidence from Health partners that all recommendations made as a result of the Health Overview Report regarding sexual assault referral centres have been completed Intended outcome: GPs are better informed of sexual assault referral pathways to ensure appropriate information is provided to children and families to facilitate attendance at centres, meaning support can be provided in a sensitive and timely way to those affected by sexual abuse; 6. Newham Safeguarding Children Board should work with Education partners to ensure there is sufficient awareness in every education setting, and specifically the two schools involved in this review, of information sharing protocols, including timescales for the effective sharing of school records when children move schools Intended outcome: Information held by education settings, including safeguarding records, is transferred securely and quickly when children leave one setting, enabling the receiving setting to be fully aware of all circumstances relating to a child’s journey. This allows for a more holistic assessment of the child’s needs and for any future interventions to be informed by what has happened in the past; 7. The Chair of the Newham Safeguarding Children Board should request a report on the current position of School Nursing provision within secondary school settings in order that an adequate and consistent service in terms of resource and frequency is available Intended outcome: A review of the School Nursing offer within secondary school settings is completed with actions identified as necessary to enable an effective, resourced service across the area; 8. The Newham Safeguarding Children Board should obtain assurance and evidence from Health partners that all recommendations made as a result of the Health Overview Report regarding the 25 NSCB_SCR KA_Final_02May2017 attendance of KA at hospital have been completed Intended outcome: Older children aged 16 and over, attending hospital unaccompanied by an adult and waiting to be seen by Mental Health Services, are reviewed at regular intervals to ensure they are being appropriately supported whilst waiting, and reassured that further mental health assessment will take place as soon as possible; 9. The Newham Safeguarding Children Board drawing on the expertise of partners, should explore ways of raising the awareness of all children’s practitioners of the complexities of self-harm for children and young people and the requirement to take self-harm episodes seriously and to clarify pathways for professionals to consult specialist mental health services for advice and support Intended outcome: All professionals working with children have sufficient awareness of self harm thresholds and pathways for referrals, and are confident to access specialist support. This will ensure those children and young people identified as possibly in need of mental health support are managed appropriately and receive a specialist response where necessary; 10. The Newham Safeguarding Children Board should seek assurance and evidence from East London Foundation Trust that the Child and Family Consultation Service Operational Policy for Front Door/Duty is fully embedded in the Service, is providing an appropriate initial response to all referrals and that the updated Policy has been circulated widely across all potential referrers. In addition, NSCB should seek evidence that an audit has been conducted, as highlighted in the Health Overview Report, regarding quality and content of referrals made to the Child and Family Consultation Service since July 2016, and that any further action/improvement identified as a result of the audit has been taken Intended outcome: All requests for services for children and young people referred to the Child and Family Consultation Service are made, received and allocated in accordance with the Front Door/Duty Operational Policy ensuring an improved service for children and families by requests for service being responded to in a timely manner and all referrals receiving a documented response; 11. The Newham Safeguarding Children Board through the CSE and Missing sub group should audit the new arrangements for return visits by Families First after nine months of the service being introduced. The audit should include focus on interface between Families First and the Police regarding information shared from Police safe and well checks, and that appropriate referrals are being made as necessary by Families First or the Police when safeguarding concerns are identified Intended outcome: Children and young people who are not open cases to Children’s Social Care are given safe opportunities to talk about their experience of being missing, which will provide time and space for safeguarding concerns to be identified. An audit of the arrangements will ensure that when safeguarding issues have been raised appropriate action has been taken by professionals; 12. The Newham Safeguarding Children Board should consider ways to improve the awareness of children and young people, and the professionals working with them, about issues linked to sexual exploitation and gangs particularly safe/healthy relationships, consent and bullying. Provision should be consistent across all educational settings, including secondary and post sixteen sites, for those not in full-time education, and in other hard to reach categories Intended outcome: All children and young people are provided with consistent messages for safe and healthy relationships, in a coordinated way, which improves individual awareness and ultimately affects and improves how children and young people view and treat themselves, and others; 13. The Newham Safeguarding Children Board should collaborate with Public Health and other local strategic bodies to ensure a proactive and effective approach to suicide prevention within Newham is 26 NSCB_SCR KA_Final_02May2017 Statement by Reviewer REVIEWER Amanda Clarke (Independent) underway Intended outcome: Issues relating to suicide and suicide prevention are considered in a local multi agency forum enabling national and local data and themes to be explored with the aim of helping to reduce levels of suicide and to learn from, and better support, families affected. References Working Together to Safeguard Children Guidance, HM Government 2015 Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012 The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011 Child Practice Reviews: Organising and Facilitating Learning Events, Welsh Government, December 2012 Working Together to Safeguard Children, HM Government, March 2010 Newham Safeguarding Children Board Child Protection Strategy Meeting Protocol, 15.01.15 Guidelines on Prosecuting Cases of Child Sexual Abuse, Crown Prosecution Service, 2013 Special measures: Youth Justice and Criminal Evidence Act 1999 Metropolitan Police Service – National child protection inspection, HMIC, 25 November 2016 “I thought I was the only one in the world” (interim report), Sue Berelowitz et al, November 2012 Barnardo’s press statement : reported offences, 3 February 2017 Keeping Children Safe in Education, Department for Education, Part 2: September 2016 (first published March 2015) Section 175 of the Education Act 2002 The Help and Protection for Children, Young People and Families Practice Guide 2014: A guide to services in Newham Thurrock Safeguarding Children Board Serious Case Review ‘James’ , December 2016 Truth Hurts: Report of the National Inquiry into Self Harm among Young People, Mental Health Foundation 2006 The Facts: self harm statistics, www.selfharm.co.uk 2014 Fundamental Facts About Mental Health Executive Summary, The Mental Health Foundation, 2015 Mental Health of Children and Young People in Great Britain: Office for National Statistics 2004 The Good Childhood Inquiry: Health Research Evidence, London, The Children’s Society 2008 East London NHS Foundation Trust Pathway for under 18s with self-harm or other psychiatric emergencies- out of hours- age 16 to 18 birthday, pre January 2016 version Child and Family Consultation Service Operational Policy for Front Door/Duty, July 2016 Signs, Symptons and Effects of Child Sexual Exploitation, NSPCC, 2015 “If only someone had listened” (final report), The Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation In Gangs and Groups, Sue Berelowitz et al, November 2013 Tackling Child Sexual Exploitation: A Progress Report, HM Government February 2017 Suicides in the UK in 2014. London: Office for National Statistics, 2016 Local suicide prevention planning: A practice resource, Public health England, October 2016 27 NSCB_SCR KA_Final_02May2017 Statement of independence from the case Quality Assurance statement of qualification I make the following statement that prior to my involvement with this learning review:- I have not been directly concerned with the child or family, or have given professional advice on the case. I have had no immediate line management of the practitioner(s) involved. I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review. The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. Reviewer (Signature) A.Clarke Name Amanda Clarke Date 2 May 2017 Chair of Review Panel (Signature) Name Date 28 NSCB_SCR KA_Final_02May2017 ANNEX 1 KA Serious Case Review Terms of Reference Reason for undertaking the SCR KA, a 17 year old, was found dead at home in June 2016. KA was known to a number of services and had been the victim of assaults and had been referred to the CAMHS service. There is also a reported history of bullying during KA’s school years. SCR criteria and decision for commissioning the review Working Together 2015 sets out the SCR criteria where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. In this instance the young person had died and the members of the SCR panel considered that the previous abuse, and the effect that is had on KA, may have contributed to the circumstances which appear to have led to KA taking their own life. The panel recommended that an SCR was commissioned and the Independent Chair confirmed this decision on 28th July. Communication Ofsted, the DfE and the National Panel of Experts have been informed and an overview writer, Amanda Clarke, has been confirmed. A panel of multi-agency partners will work with Amanda to see this review through to its conclusion. The expectation is that the review will be complete within six months and that, once it has been signed off, it will be published on the LSCB website. There has been contact with the Coroner’s office and an inquest is scheduled for November (date tbc). It is possible that there will be media interest at this point. KA’s mother has been informed about the review and was visited on 9th September. She has confirmed that she would like to be involved in the review. Communication about the SCR, including any media enquiries, should be through the LSCB office who will liaise with the council’s media and communications team. Review terms of reference 1. To understand the factors that led to KA’s death and the extent to which any vulnerability was recognised and understood by those close to KA. 2. To consider what opportunities there were during the period leading up to KA’s death for KA to seek and receive help and the outcomes of this. 29 NSCB_SCR KA_Final_02May2017 3. To analyse what impact the reported historic sexual abuse and bullying of KA (and any other risk factors that come to light during this review) had on KA’s ability to function and enjoy life. 4. To review the protective and preventive actions taken by all relevant agencies in response to the reported incidents of victimisation and the effectiveness of these. 5. To review how well agencies worked singly or together to meet KS’s needs and support the family in keeping KA safe and well; and the views of KA’s family about the effectiveness of agency involvement. 6. To explore whether there are any other reviews, including the recent review undertaken by Sunderland LSCB, whose learning may have a bearing on KA’s case. Scope of the Review To start from the date of the first reported sexual assault in 2011 to the present . Involvement and support of KA’s close family / friends KA’s mother has said that she would like to be part of the review. It is possible that wider family members and some of KA’s friends would also wish to be involved. This is to be confirmed. Involvement and support of staff All agencies that had contact with KA in the period the review is considering: Bart’s Hospital Children’s Social Care Education settings ELFT Community Child Health ELFT Child and Adolescent Mental Health Services Gangs Line GP Police Information and evidence to be gathered To be confirmed at first panel meeting Are there any learning points and/or recommendations that have already been enacted? If so, are these being achieved and sustained? Dissemination of learning The LSCB will ensure that the learning and any recommendations from this review are disseminated within the partnership through the LSCB training programme, specific briefing events and information on the LSCB website. |
NC51389 | Sexual abuse of three girls by their male foster carer. The victims, Grace, Lisa and Carey provided evidence to convict the perpetrator, who was sentenced to 9 years imprisonment. Perpetrator and his wife were approved foster carers from 1998 until their deregistration in December 2014. They had 38 children placed with them; 28 were placed prior to 2011. Grace made several disclosures from 2011 but no action was taken. She was contacted by police investigating disclosures by Lisa and Carey in 2014. Learning includes: mishandled or ineffective investigation of child sexual abuse is especially damaging for the victims and leaves them in greater jeopardy; presentation of perpetrators as pillars of the community and hiding in plain sight; foster carers who have well-established and long relationships with people such as social workers and teaching staff will undermine a child's confidence in talking with anybody about sexual abuse or other maltreatment by that those foster carers; role of local authority designated officer (LADO) has a significant role in regard to any criminal investigation, enquiries and assessment as to whether a child or children are at risk or in need of services. Recommendations to LSCB include: ensure that an apology and an appropriate account of the lessons learnt is provided to the three 'children'; ensure that all practicable steps have been taken to identify and contact any other children who were placed with the perpetrator. Recommendations relating to national policy include: professional bodies and regulatory authorities have a role in promoting improved awareness of child sexual abuse and exploitation and the responsibilities of professionals in regard to the protection of victims and prevention of crime.
| Serious Case Review No: 2019/C7991 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. CONFIDENTIAL Page 1 of 42 A serious case review (SCR) commissioned under Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006 Independent reviewer and report author Peter Maddocks, MA, CQSW. May 2019 CONFIDENTIAL Page 2 of 42 Index 1 Introduction and context of the review ............................................................... 3 1.1 General context ....................................................................................... 4 1.2 Grace, Lisa and Carey’s contribution to the review .......................................... 6 2 Narrative summary of key information ................................................................ 9 3 The learning and analysis from this review ......................................................... 12 3.1 Summary of research .............................................................................. 12 3.3 Impact of poor attachment and neglect ...................................................... 17 3.4 Summary of learning from the agency reviews of practice .............................. 18 3.5 Good practice identified through the review ................................................ 21 3.6 The views, wishes and feelings of the children and responding to their experiences and presentation of behaviour ............................................................................ 21 3.7 Effectiveness of the statutory mechanisms in overseeing and influencing the quality of care provided for the children in placement. ............................................ 24 4 Conclusions and recommendations .................................................................. 29 4.1 Promoting prevention and awareness ........................................................ 29 4.2 The LADO .............................................................................................. 31 4.3 Supervision of foster carers ...................................................................... 33 4.4 Recommendations .................................................................................. 33 4.5 Issues for national policy .......................................................................... 34 5 The methodology of the review ....................................................................... 36 5.1 The agencies who provided information for the review ... Error! Bookmark not defined. 5.2 The key lines of enquiry ........................................................................... 38 6 Summary of the relevant legal and regulatory arrangements ................................. 40 6.1 Supervision, support and review of foster carers .......................................... 40 6.2 Role of independent people ..................................................................... 41 6.3 The local authority designated officer (LADO) .............................................. 42 7 Individual agency action and/or recommendations . Error! Bookmark not defined. 7.1 Children’s social care .................................. Error! Bookmark not defined. 7.2 Child Advocacy and Participation Service ....... Error! Bookmark not defined. 7.3 Clinical Commissioning Group (CCG).............. Error! Bookmark not defined. 7.4 Virtual School ............................................. Error! Bookmark not defined. 7.5 Hospital NHS Trust ..................................... Error! Bookmark not defined. 7.6 Mental Health Trust ................................... Error! Bookmark not defined. CONFIDENTIAL Page 3 of 42 1 Introduction and context of the review 1. This serious case review was commissioned by the Safeguarding Children Board following the conviction of a male foster carer (referred to as the perpetrator) on thirteen counts of sexual assault of three female children who had been placed at various times with the perpetrator and his wife whilst approved as a foster carers. He was convicted by a unanimous jury verdict and was sentenced to nine years imprisonment, Sex Offender Registration indefinitely and was made subject of a Sexual Offences Prevention Order (SOPO). 2. The three victims who provided the evidence to convict the perpetrator and to halt his abuse of children are given the names Grace, Lisa and Carey for the purpose of the review. Although all the victims are now over 18, the phrase child or children is used throughout the report. 3. The timeframe for the review is from 2011 when the perpetrator was the subject of allegations by Grace. This provided the first opportunity to undertake enquiries and investigation. The review took account of relevant information prior to 2011 that could or should have caused concerns to be raised about the perpetrator and his wife as foster carers as relevant to the key lines of enquiry described in the appendix to this report, and the extent to which these were known and understood by those involved with the 2011 and the subsequent 2014 investigation. All of the services were highly reliant on the detail and quality of information that had been recorded in their systems given many of the people who were involved in contact, decisions or events even as recently as 2014 have moved on. 4. Most of the agencies have archiving policies that set a limit on how long information can be retained; for example the NHS retains a child’s health record until the 25th birthday (or 26 if they are 17 when an episode of treatment ends). This means for example that information regarding any contact in regard to school nursing or Children in Care health assessments for the oldest of the children have been destroyed in compliance with the policy. There is therefore for example, limited information in regard to the circumstances of emergency hospital attendances as a 15 and 16 year old with self-harming injuries in 1995 and 1996. This is the time when subsequent disclosures in 2014 described sexual abuse by the perpetrator. 5. As will become very clear through reading this report, children like Grace, Lisa and Carey face many barriers and inhibitions to reporting sexual abuse. Two of the girls had been sexually abused by other men and the third had witnessed significant physical and sexual violence committed against her mother who was a high risk MARAC1 victim of domestic violence and abuse. All three girls were subjected to intimidation by the perpetrator and were frightened by him. The perpetrator presented himself as a respectable and trusted adult and this, combined with the needs and vulnerabilities the girls had for example in regard to learning difficulties, had the cumulative effect of isolating them from potential sources of help. 6. Child sexual abuse often does not get disclosed at all. When children (or as adults) begin to disclose what has happened, it often does not occur as one complete, consistent and coherent account. This reflects the profound and long lasting damage that is done to children who may also not have the emotional and verbal language to express what has happened or is happening to them. 1 Multi-agency risk assessment conference CONFIDENTIAL Page 4 of 42 7. In 2011, when Grace as an adult made disclosures about being abused by the perpetrator, there was a partial mind-set that treated the information as reflecting ‘inappropriate behaviour’ involving adults. The police were not involved in an investigation in 2011 on the basis that there was no criminal act, leaving it to the local authority to determine what action to take2. The foster carers were temporarily suspended from having children placed with them but had resumed accepting placements after it had been concluded that the allegations had not been substantiated. 8. A second investigation in 2014, this time led jointly by the police and the local authority’s children’s social work services, responded to further similar allegations made by 13 year old Lisa and 15 year old Carey. Grace was contacted as part of that 2014 investigation and subsequently made a statement to the police about the sexual abuse that she had suffered between January 1995 and December 1995 from the perpetrator. It was this second investigation that led to the subsequent prosecution and conviction of the perpetrator. 9. It is particularly concerning that any child could be sexually abused by a person entrusted and approved to provide care for them and it represents a gross sexual exploitation of a child. Many children needing the care of foster carers already have very adverse childhoods that have involved abuse and neglect. This is reflected in the respective histories of the three girls in this review. 10. The concern felt for the three children in this case is magnified by the fact that the investigation in 2011 did not stop the perpetrator’s abuse at that stage. This review provides the information and analysis about what factors contributed to that occurring. The organisations and people who work to protect children and young people want to learn any lessons from this case to help ensure that individuals who represent risk can be found out and stopped. This is the reason and motivation for conducting this review. 11. The perpetrator was in a position of trust which created the imbalance of power for him to be able to coerce, manipulate and deceive the three girls when they were under 18 into sexual activity. This meets the first part of the national definition of child sexual exploitation3. The exploitative nature of the offence, together with the impact of undermining the girls’ sense of trust and confidence in other people in positions of trust allowed his crimes to remain undetected for many years. There is no evidence that the perpetrator was part of any network of perpetrators involved in child sexual abuse or child sexual exploitation. 1.1 General context 12. In the spirit of establishing an appropriate context for the review, it is relevant to point out that several important developments have taken place since 2011 that influence how for example child sexual abuse and exploitation is now dealt with and understood. 2 According to social care records the behaviour had involved attempted touching by the perpetrator; the police do not have this information recorded. It is accepted that the allegations should have been investigated by both services. 3 Child sexual exploitation is a form of child sexual abuse where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. CONFIDENTIAL Page 5 of 42 13. In 2011 national guidance was more limited. In general, children vulnerable to sexual exploitation often fell outside the scope of specialist services and teams who were more focussed on interfamilial abuse. Prosecutions were often seen as problematic because witnesses were viewed as potentially vulnerable to being presented as unreliable and susceptible to cross examination by lawyers defending the accused perpetrator. This was part of the contributing background to how Grace’s initial disclosures were processed in 2011; if there was a poor prospect of achieving a prosecution there was less imperative to conducting an investigation. This reflects an old style mind-set that is nationally being challenged through the development of new approaches to how investigations are undertaken. 14. The investigations in Oxfordshire, Rochdale and Rotherham since 2012 along with other reports have contributed to a far clearer public understanding in the UK about the extent and nature of child sexual abuse and child sexual exploitation (CSE). The Independent Inquiry into Child Sexual Abuse was set up because of the serious concerns that some organisations including individual local authorities have failed and were continuing to fail to protect children from sexual abuse and child sexual exploitation. 15. In 2011, the Child Exploitation and Online Protection Centre (CEOP) published a thematic assessment analysing 2,083 victims of child sexual exploitation4. In that report, which was focussed on localised grooming networks following a series of high profile prosecutions in various towns and cities across the UK, a number of findings were reported. Children subjected to CSE were frequently going missing from home or care, were disengaged from their schools and education, exhibiting a range of behaviour and were often victims of bullying. The victims feared violence from their abuser if they failed to comply or made reports to the police or social workers. This reflects some of the experience that the three girls reported who were sexually abused by the perpetrator who did not commit his sexual abuse as part of a network. The report highlighted that offenders frequently exacerbated vulnerabilities such as disengagement from families and detachment from services. 16. In November 2012 the Children’s Commissioner for England published the interim report of inquiry into child sexual exploitation5 which followed the publication in July 2012 of their report concerning the particular vulnerability of children in public care. 17. As a result of the various reports and inquiries, the barriers that face any child, and in particular children who have additional vulnerabilities in disclosing sexual abuse should be becoming much better understood along with the importance of professionals having the training, knowledge and motivation to proactively look out for any signs or symptoms that may indicate a child is being abused. 18. For example children’s behaviour and interaction and their emotional and physical presentation are some of the ways in which trusted and competent adults can be alerted and therefore be curious about what might be happening to a child. This is why it is important for children’s social workers to have the time and aptitude to spend time with children, to develop relationships of trust and for people such as primary health care professionals and teachers 4 Out of Mind, Out of Sight Breaking down the barriers to understanding child sexual exploitation CEOP thematic assessment June 2011. 5 Berelowitz, S. et al (2012) Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation in Gangs and Groups London: Office of the Children’s Commissioner. CONFIDENTIAL Page 6 of 42 to have the capacity to identify potential warning signs about abuse. Research is providing a growing body of information to help identify potential sexual exploitation. Self-harm, eating disorders, substance abuse, going missing are the potential manifestations that a professional with appropriate levels of curiosity and time to invite discussion can try to follow up. 19. The purpose of this preamble is to remind ourselves that the people who were processing information in 2011 will have been working within different guidance and understanding and this no doubt influenced the mind-set that they brought to their task of processing information. The review attempts to distinguish between things that could and should have been dealt with better at the time irrespective of this different context of knowledge and understanding. Put at its plainest, it is about helping people to do the basic things well enough in regard to keeping children safe. 20. In the words of Carey, one of the three children subject of this review, asking children if they are all right and giving them time to talk is one of those basic things. 21. Disclosure rather than detection is the most reliable route to identifying perpetrators of child sexual abuse and exploitation. An ‘invitation to tell’ for young people and making them feel cared about and building trust is highlighted in research key messages described later in the report. 1.2 Grace, Lisa and Carey’s contribution to the review 22. Grace, Lisa and Carey were informed of the review following the initial planning meeting. In view of their ages, particular attention was given to seeking their consent to access relevant information from the various agencies relating to their care as well as consulting them about the scope of areas of enquiry for the review. This was done through providing information verbally and in a written format to them. 23. They were encouraged to meet with the independent reviewer who is the author of this report. Grace and Carey initially agreed to meet in late February 2018 although those meetings were postponed at their request due to their respective illness. At the time of preparing the draft report Grace still felt unable to meet the reviewer but has been kept informed about the review. 24. The independent reviewer met Lisa in early March 2018 who was supported by her social worker and current foster carer. 25. Lisa was placed with the perpetrator and his wife when she became looked after. There were no introductory meetings. Lisa stated that she was never happy in this placement although nobody realised this at the time. She thinks they should have been able to see that she was not happy and thinks that they could have been more curious and inquiring about her feelings at the time. The perpetrator used threats made to Lisa against her family to prevent her from disclosing what was happening. Lisa had a social worker who she could talk to and also had an independent visitor and advocate. Lisa also had two teachers that she felt able to talk to; it was one of the teachers that Lisa eventually told about the sexual abuse. Lisa described how the CONFIDENTIAL Page 7 of 42 sexual abuse and its effect on her had all been going over and over in her mind and built up to a point when she needed to talk to a trusted adult and after that happened this led to action being taken promptly. 26. Lisa was unable to describe what made the difference between the various adults who she came into contact with from the different services; she described having a good relationship with all of them although did say that much of the contact with the social worker for example was at the foster carer’s home with little opportunity for talking away from the foster carers. Lisa stated that nobody asked her whether she was happy at the foster carer’s and feels that would have made a big difference. 27. Lisa could not remember being asked to provide information for a LAC review which she described as being ‘rubbish’ and ‘boring’. It has not been possible to find any of the consultation forms that are used to record the views, wishes and feelings of children for Lisa or for Carey. Lisa talked about the number of people who could come to the meetings and for example being asked to organise drinks for everybody could mean that when she came back into the room it was difficult to understand and pick up what people were discussing. She had limited recollection of ever being asked to provide comments into foster carer reviews; the occasion when it happened the carer gave her the form and Lisa gave the form back to the same carer and this therefore limited any opportunity for independence. 28. Lisa, at the prompting of her social worker, described how she had provided a Power Point for a meeting and how this had felt much more creative and useful for Lisa. We talked about how Lisa tends to understand pictures and what people say rather than reading information and how this is important when thinking about how to seek the views and involvement of young people such as Lisa6. 29. Carey agreed to a short telephone discussion with the independent reviewer rather than have a face-to-face meeting. Carey said that her sexual abuse had gone on for about four months and it was only after a chance conversation with Lisa that revealed that another girl was also being abused by the perpetrator. Up until that point Carey had felt unable to speak to anybody. She confirmed that her social worker visited at least fortnightly and she had a good relationship with the social worker. She also had a good relationship with a school staff member (thought to be the learning mentor). 30. The reasons that Carey felt unable to speak to anybody was a fear of not being believed and that she would be left in a worse position as far as the perpetrator was concerned. The perpetrator had a grandchild at the school and he would regularly be at the school. 31. When Carey was able to disclose what was happening, the social worker responded quickly and took appropriate and effective action. 6 The wishes and feelings form used by the CAPS service uses a picture format as does the All About Me form. CONFIDENTIAL Page 8 of 42 32. Carey said that waiting for court was hard and also having to give evidence which she did by video link. 33. As regards lessons to be learnt Carey said that seeing children regularly, talking to them and asking them if they are ‘OK’ is important. Carey wanted to know if there was some way that carers could be more thoroughly checked. CONFIDENTIAL Page 9 of 42 2 Narrative summary of key information 34. The perpetrator and his wife were approved foster carers from 1988 until their de-registration in December 2014. They had 38 children placed with them; 28 were placed prior to 2011. 35. Grace was in placement between 1988 and 1997. Grace was eight years old when she was initially placed. She continued to have contact with the perpetrator and his wife after she left the placement. Lisa was in placement for about 12 months between 2013 and 2014. Carey was in a foster placement with a relative of the perpetrator who was also an approved foster carer from late 2011 until the spring of 2014. Grace 36. In early October 2011, Grace then an adult, during a visit to the GP discussed being abused when she was in foster care. The GP recorded that they ‘discussed problems’ although nothing more specific was recorded and there is no evidence that Grace was advised to raise a complaint or for the GP practice to make a report about allegations under the LADO protocols7. 37. In early December 2011 Grace made her first specific disclosure about the perpetrator during a discussion with a social worker. This information was reported to the LADO who in turn reported the information to the police. The LADO also reported that Grace was concerned about ‘repercussions’ from the perpetrator. The LADO was uncertain if Grace wanted to pursue a complaint or not. Whether Grace wanted to make a complaint or not would not prevent an investigation taking place both in regard to the allegations that Grace was making and in regard to the fact that the perpetrator was an approved foster carer with his wife. The information was passed to the specialist police adult safeguarding unit. 38. Two strategy meetings chaired by the LADO in December 2011 discussed the allegations. The police did not attend either of these meetings (13th and 21st December 2011). The second meeting concluded that the allegations ‘had been explored’ and that the perpetrator was not a risk to children. There was no investigation undertaken by the police who recorded that this related to inappropriate behaviour and there were no offences to investigate. The police recorded that CSC would conduct a single agency investigation to establish what ‘concerns that the perpetrator may present’. The meeting concluded that there was no evidence of the perpetrator behaving inappropriately. The foster carers were reinstated and their fostering limit was raised from two to three children. An apology was provided to the perpetrator. 7 The national requirement for local authorities to appoint a designated officer (LADO) to manage allegations against adults who work with children was introduced in Working Together (2006) and in Safeguarding Children and Safer Recruitment in Education (2006), Managing Allegations Department for Children, School and Families (2009). CONFIDENTIAL Page 10 of 42 39. It was just over two weeks later that Grace consulted the same GP she had spoken to in October 2011. Grace made further disclosures about sexual abuse whilst in foster care (the foster carer was not named; there is no record of a name being sought or given) and Grace told the GP that she had informed children’s social care services. The GP offered counselling which was declined by Grace. As on the previous occasion there was no other follow up or check with children’s social care services to establish if they were aware of the disclosures being made by Grace. The GP was not aware of the LADO’s investigation and did not consult the LADO. The importance of using the LADO is highlighted as a central learning point for the review and as will become clear later in the report there were other professionals on other occasions who could and should have made contact with the LADO. 40. In March 2012 a social work assessment referred to Grace making disclosures about her abuse from the perpetrator. During a discussion in late 2013 with an independent psychologist, Grace made disclosures that she had been abused between 14 and 17 years of age. This information was not discussed with any other professional or service but was included in a psychological report that was subsequently completed for court proceedings that are not related to the circumstances of this review. The local authority had a copy of that report at the time. It would be expected practice that the local authority’s legal representative at the time would have reviewed the report. No action was taken either by the psychologist in terms of making a referral to the LADO or by any of the children’s social care services or by anybody in the legal service who had access to the psychologist’s report. 41. The report was not scanned into the children’s social care services electronic record system until January 2017 and therefore would not have been accessed as part of any routine checks or inquiries that might have been made after this date. 42. Grace was contacted by the specialist police officer investigating disclosures by Lisa and Carey in March 2014. Initially Grace was reluctant to have any contact but eventually agreed to provide a statement although cancelled several meetings before the statement was taken. This should not be read as criticism of Grace; making any sort of disclosure at any stage would have caused profound emotional and psychological distress and the fact that she made previous disclosures that had resulted in her account not resulting in more effective action compounded by an apology being given to the perpetrator in 2011 makes Grace’s reticence very understandable. Lisa 43. Lisa was placed with the perpetrator and his wife in 2013 and remained there until she was removed in 2014 after her disclosure of abuse by the perpetrator. An independent visitor and a children’s advocate were to be appointed but there was a delay in being able to match Lisa with an independent visitor. The independent visitor was introduced to Lisa in February 2014. CONFIDENTIAL Page 11 of 42 44. In March 2014 Lisa had made a disclosure to her learning mentor that the perpetrator had sexually assaulted her. It was recorded that Lisa had been in constant fear of what the perpetrator and his wife might do. Lisa was also worried about what the perpetrator might do after any criminal trial; Lisa was designated as a vulnerable witness and had the support of the intermediary who had been involved from the initial assessment. Carey 45. Carey was looked after by the local authority from 2011 but was not placed with the perpetrator. Carey was aged 15 when she was interviewed following Lisa’s disclosures. Initially Carey was unaware of the reason why she was meeting the detective and she was accompanied by her social worker. The detective asked Carey if there was anything she needed to tell them about the perpetrator. Carey initially said ‘No’ but when she was told that Lisa had said she thought she would want to speak to the police, Carey got upset and said there was something she needed to say. 46. Carey had never told anyone about this and the first time she disclosed was to the detective and to the social worker during the video recorded interview. Carey said that this was because the perpetrator had told her if she said anything he would be stopped from fostering and he would be sent to jail. 47. It was following these allegations by Lisa and Carey, the police sought contact with Grace having reviewed the information she had reported in 2011. 48. The two children in placement with the perpetrator and his wife were removed in March 2014 and a LADO meeting was held on the 21st March 20148. The LADO was a different officer from 2011. There were four strategy meetings between April and August 2014 to share information and to co-ordinate the investigations during which disclosures about the perpetrator’s abuse were made. 8 Local authority designated officer (LADO) describes the individual or team of individuals who have responsibility for receiving and co-ordinating action in response to allegations made against individuals in positions of trust. This includes carers as well as officers employed by the local authority. The role and function is described in national guidance contained in Working Together to safeguard children and relates to the duties under section 11 of the Children Act 2004 for organisations to safeguard and promote the welfare of children. CONFIDENTIAL Page 12 of 42 3 The learning and analysis from this review 3.1 Summary of research 49. Learning from this review relates to perpetrator behaviour, disclosure and the impact of sexual abuse on children and improving systems and arrangements for the protection of children from sexual abuse and exploitation. 50. Of the adults who disclose childhood sexual abuse, surveys consistently show that between 46 and 59 per cent of those adults abused as children had never disclosed it in their childhood. Given that it remains a fact that it is only a minority of adults who ever disclose their experience of sexual abuse in their childhood, the proportion of children who never tell anybody at any stage about sexual abuse is many times larger. An adult disclosing childhood sexual abuse is therefore very significant information that has implications for the health and well-being of the adult making the disclosure of being a child victim of sexual abuse and represents a vital opportunity to help identify and deal with a perpetrator especially if there is any indication that they are in a position of trust such as in this case. 51. The nature of sexual abuse means that it is largely a silent and witness free crime and rarely leaves visible physical signs although the emotional and psychological trauma is consistently harmful and has serious and life changing consequence; it is a crime that is actively hidden by the perpetrators who persuade and coerce their victims of the abuse to keep it ‘their secret’ and can manipulate their victims into feeling they have responsibility for what happens. 52. It is how and why sexual abusers such as the perpetrator seek to hide within the systems where children already face multiple adversities and are the children least likely to either disclose that abuse is happening to them or are more likely to be disbelieved or discredited if and when they do say anything. Grace learnt that nobody believed her in 2011 and Lisa and Carey both said they feared not being taken seriously. The perpetrator selected child victims who were particularly vulnerable and were unlikely to be believed if they ever did make disclosures about abuse that was happening to them. 53. The research evidence set out in The Spiral of Abuse9 in relation to sex offenders provides a conceptual framework to understand the gradual process by which perpetrators of child sexual abuse offend. The spiral describes how perpetrators, when confronted, will deny, rationalise, and minimise their actions, so that the normal moral inhibition that prevents people from acting on their arousal to children is overcome. Fantasising about sexual contact with children can further reinforce their arousal and their cognitive-distortion through a type of behavioural conditioning. 9 Sullivan J; The Spiral of Sexual Abuse’ 2002 CONFIDENTIAL Page 13 of 42 54. The next stage is realising the fantasy by preparing or “grooming” a child by, for example, giving treats or special attention but also by intimidation. This process can also include building up, for other people such as social workers, an image or reputation of the child as an attention seeker or troublemaker, who is subsequently less likely to be believed should the child allege abuse. It is notable that the Virtual School describe how one of the girls was reported to be presenting ‘challenges’ in their placement although there was no similar presentation at school. The gains which perpetrators experience from abuse will vary from sexual excitement and satisfaction to enjoying a sense of power and control that can extend to deceiving various professionals. 55. The term “cognitive distortion” is commonly used to describe the type of rationalisation which allows someone to go beyond barriers set by guilt or fear in this type of situation. Thus the spiral of abuse continues. 56. Sullivan also describes in other work that is quoted later, how sex offenders use manipulation techniques on both children and the practitioners that they may come into contact with. This was evident in this case. 57. In most instances, the only people who know about the abuse are the child and the abuser, and this situation may continue for a prolonged period as it did in this case. The research evidence shows that only a minority of children who are abused can tell a protective adult and it is for this reason that there is a general consensus and growing evidence that child sexual abuse is a widely under reported crime. 58. The reasons for this are numerous but include; intimidation generated by blackmail or threats, fear of being disbelieved and guilt or dread of official intervention. Drawing children into secrets, colluding with them about what stories to tell and the excuses to make, can force a child to assume some responsibility and culpability for the sexual relationship. 59. Sexual abuse of children remains one of the most complex areas of work for any of the professionals who have responsibility for identifying, responding and investigating allegations or suspicions that a child is being sexually abused. 60. Anger, aggressive and hostile attitude and significant behaviour problems are the potential indicators of abuse although can go unrecognised when for example education and health professionals are being consulted about children’s difficulties. The challenge for all the professionals is being able to distinguish for example between the anguish and distress that may reflect earlier abuse a child has suffered prior to becoming looked after and being in a position to understand that abuse could be a current issue in regard to the care being provided for example by a foster carer or other trusted adult. As Munro10 comments the ‘Behavioural evidence [of sexual abuse] also tends to be indeterminate…many victims show no behavioural signs at the 10 Munro, E (2008) Effective Child Protection (2nd Edition). Sage Publishing, London pp 83-89. CONFIDENTIAL Page 14 of 42 time of abuse…behavioural signs reveal the possibility of abuse…most however are non-specific and can be seen in any child under stress’. 61. Care and expertise is needed to achieve a balance between not seeing child sexual abuse in every aspect of ‘difficult’ behaviour but equally having arrangements in place that can identify, discuss and hypothesise about possible underlying reasons for children’s distress and behavioural turmoil. 62. It is a fact that children face very significant barriers in disclosing their abuse; the majority only disclose their childhood sexual abuse when they have become adults and either feel safe enough to disclose or they are for example becoming overwhelmed by the emotional and psychological consequences on them and for their children. This reflects the circumstances that Grace faced in 2011. One can only imagine the acute stress and distress that she must have felt when talking with the GP and the psychologist about her childhood experiences. 63. Non-disclosure and silence about childhood sexual abuse is therefore unsurprisingly far more common than disclosure or detection during childhood or at the time that the abuse is actually taking place. Drawing on his clinical experience, Summit (1983)11, for example, argued that while children who have experienced sexual abuse may tell others about it gradually or incrementally, many children remain silent about it, deny that it actually happened, or produce a series of disclosures of abuse followed by recantations. Summit’s observations were an important development, because he raised questions about relying solely on children’s statements in forensic investigations such as occurred in 2011 in this case; if children do not readily disclose abuse, then convictions for abuse are more difficult to obtain and as in this case if the person accused is a trusted adult the impetus for investigation is swiftly diluted and lost. In this case it contributed ultimately to the foster carer receiving an apology and thereby conferring increased power and protection from further disclosures. 64. Summit’s model termed child sexual abuse accommodation syndrome describes five components: (a) secrecy; (b) helplessness; (c) entrapment and accommodation; (d) delayed, conflicted, and unconvincing disclosures; and (e) retraction of disclosure. Summit argued that children who have been sexually abused may respond with self-blame and self-doubt. They may fear the perpetrator and the possible consequences of disclosure. All three girls described such fear and consequences. Hence, in order to survive sexual abuse by a trusted person, children make accommodating efforts to accept the abuse and to keep the abuse secret. Furthermore, according to Summit, when children do reveal their abuse, disclosure will be incremental over time, a process that often includes outright denials and recantations of prior disclosures, and then reinstatements of the abuse. It is important to keep in mind that there are two separate aspects of this model, each with its own components. The first stipulates the psychological consequences of abuse (fear, blame, and accommodation). The second 11 Summit, R. (1983) The child sexual abuse accommodation syndrome. Child Abuse and Neglect (7): 177-193. CONFIDENTIAL Page 15 of 42 aspect stipulates the consequences that these psychological states have on behaviour (secrecy, denial, and recantation). 65. On the basis of this understanding of sexual abuse disclosure, new strategies for interviewing children were developed with the aim of enabling them to disclose abuse more easily. There is now a substantial body of literature on forensic interviewing, and an emphasis on the importance of having specially trained interviewers in police and social work services available to undertake this work with a good enough understanding about helping children disclose information and being sufficiently well informed about current guidelines for interviewing within criminal proceedings for example. The evidence given to the review is that those people overseeing the original allegations in 2011 did not have this level of knowledge and insight or at least did not apply it sufficiently well to be effective. 66. Disclosure of child sexual abuse takes different forms as occurred in this case. Children can disclose information directly. These apparently clear disclosures will in themselves represent considerable complexity for the specialist police and social work staff who have responsibility for investigating the child’s statements and developing their understanding with the child of what has happened to them. 67. Individual factors that influence an individual making a disclosure have been identified in a review of the literature by Featherstone and Evans (2004)12 regarding the barriers that must be overcome by parents/carers, professionals and support agencies if children are to feel safe enough to disclose abuse. Children report feeling that there is no-one to talk to who will listen and can be trusted; that they will not be believed or taken seriously; and that nothing will change if they tell someone. In this particular case for example one of the children made a complaint about a passport not being organised and which was not resolved in a timely fashion; that would have left a residual feeling of nothing happening even when a formal complaint was made. They also report feeling embarrassed; reluctant to burden others; fearful of getting themselves or someone else into trouble; fearful about a loss of control over the information that is shared and how that information will be acted upon by adults; and that there is a stigma of involvement with formal agencies. They also have limited knowledge of available services and what those services can do to help. 68. Child sexual abuse can and is committed against children by both men and women. It is not confined to any particular social or economic group. The work of specialist assessment and treatment services has revealed the complex belief and value systems that abusers develop. Revealing the activity relies heavily on a victim, as a child or in adulthood more likely, disclosing that they are or have been abused. The abusers will not disclose information; they will seek to conceal their behaviour and will seek to divert or undermine detection of their behaviour. 12 Featherstone, B.and Evans, H. (2004) Children experiencing maltreatment: who do they turn to? London, NSPCC. CONFIDENTIAL Page 16 of 42 3.2 Factors that inhibit children from disclosing sexual abuse 69. The factors that influence whether a child discloses sexual abuse include; a) Their relationship with the perpetrator, the age at which the abuse began; the use of physical coercion; the type, severity and extent of the child sexual abuse. Other factors also include whether the child has any form of disability or learning difficulty that can influence their understanding of what has happened to them. Factors such as ethnicity or religion can also be a factor; the children understand that the child sexual abuse is wrong but face additional barriers in feeling able to tell someone what has happened to them. Gender is also a factor; for boys in particular, disclosing child sexual abuse can be seen as a display of weakness or emotional vulnerability and this can be especially pronounced within a dominant subculture of masculinity and how young men in particular believe they should behave; b) Some research suggests that long-term abuse by a parent, relative or similar trusted adult such as a foster carer that starts at a very young age for the child is the least likely to be disclosed; c) Children who are able to disclose will frequently talk to a friend or to a sibling; for children who are looked after away from their family and their siblings may face additional problems in finding a trusted person to disclose information. Of all family members to whom children disclose child sexual abuse, mothers are the most likely person they speak to; again for children who are looked after may face additional barriers in feeling able to talk with a parent and especially if the abuse has involved a partner. d) Historically, some professionals have believed that false accounts are frequent; although there have been cases including some brought before courts where doubt has emerged about the veracity of disclosures, these are not part of a common pattern; research has provided no systematic evidence that false allegations are common. Some of the proceedings that have been problematic have revealed shortfalls in how children’s statements and evidence was listened to and recorded. e) Research also indicates that children do not seek help from agencies and professionals because they do not know that the services exist. 70. Research also provides compelling evidence about the variety of reasons for children not making a disclosure about their sexual abuse. These include; CONFIDENTIAL Page 17 of 42 a) Barriers in asking for help. These are most frequently children being able to identify a trusted adult who can help; having confidence in that person to be able to offer help; a person who has the time and motivation to help; the adult that one of the children used worked at the school; b) Children frequently feel they will not be believed or taken seriously; this was a significant issue for at least one of the children who made disclosures; c) Children worry about confidentiality and they fear losing control of what will happen as a result of disclosing information. This has implications for how professionals such as police and social workers in particular plan and handle their formal enquiries. 71. Children who need to be looked after are particularly vulnerable to sexual abuse due to the adverse circumstances many will already have experienced including poor attachment and neglect and represent additional opportunity to a perpetrator who is able to pass the vetting and assessment process for becoming a foster carer. 3.3 Impact of poor attachment and neglect 72. Attachment describes an emotional bond to another person. Psychologist John Bowlby as the first attachment theorist, described attachment as a "lasting psychological connectedness between human beings13". Bowlby believed that the earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life. According to Bowlby, attachment also serves to keep the infant close to the mother, thus improving the child's chances of survival. Understanding the significance of that missing link for children who become looked after forms part of the insight into why they become even more vulnerable to an individual giving them attention. 73. Since Bowlby’s early work, further research and literature has developed to help develop an understanding about children’s needs, parenting behaviour and the impact of poor attachment for children’s subsequent development. 74. Attachment theory provides a framework to understand that attachment is characterised by different behaviour that are referred to as secure attachment, ambivalent attachment and avoidant attachment. 75. Many children14, who become looked after, and especially at an older age, will be children with an avoidant attachment and tend to avoid parents or caregivers. When 13 Attachment and Loss: Bowlby J. (1969). 14 This statement is open to some challenge; the quality of assessing a child’s attachment varies and depends on the particular knowledge and experience of people such as social workers undertaking appropriate assessments CONFIDENTIAL Page 18 of 42 offered a choice, these children will show no preference between a caregiver and a complete stranger and this represents additional risk from predatory adults. Research has suggested that this attachment style might be a result of abusive or neglectful caregivers. Children who are punished for relying on a caregiver will learn to avoid seeking help in the future and leads in turn to making them even more isolated from potential help. 76. The combination of sexual abuse and neglect combined with difficulties in attachment represent a great obstacle for being able to seek help. 3.4 Summary of learning from the agency reviews of practice 77. Key messages identified by the review include: a) Given the number of children that the perpetrator had placed over the years, there can be no confidence that he has not abused other children who have not yet been able to disclose what happened to them; the steps taken to contact other children is described in the final chapter; b) The placement of children with foster carers is an act of trust; it requires rigorous and continual monitoring and supervision at all parts of the system for the carers and for the professionals involved in supporting the carers and the children and the cultivation of open and varied communication opportunities with children; in this case it was the relationship with a learning mentor that was critical to the abuse being disclosed; c) Mishandled or ineffective investigation of child sexual abuse is especially damaging for the victims and leaves them in greater jeopardy; it helps give additional power to the perpetrator and makes it less likely that other children will disclose information; d) Presentation of perpetrators as a pillar of the community and hiding in plain sight; the perpetrator was an active member of a church and therefore assumed to have the appropriate ethics and values required and was a longstanding foster carer who was able to use his standing in a relatively small community to create the veneer of respectability; perpetrators thrive on a sense of power and control and he was aware of the power his role and reputation gave him in comparison to the girls whom he abused and in manipulating various professionals; the girls he abused had all suffered great adversity before being placed with him and he made clear to them that he was far more likely to be believed in the event of any allegations being made by any of the girls; this was demonstrated in 2011 when Grace made her allegations which resulted in apologies being extracted for the perpetrator; with other professionals. The prevalence of neglect in these and other children who become looked after has led the overview author to assert that many children who become looked after will present with avoidant attachment or ambivalent attachment. It is notable in this case that more than one of the children had strongly protective feelings of duty to their mothers rather than feeling they could rely on care and protection. CONFIDENTIAL Page 19 of 42 e) Interviewing a suspected perpetrator needs a different mind-set and set of skills that is informed and supported by a research aware interview strategy; predatory abusers will have developed and mastered a repertoire of approaches for keeping victims quiet and professionals distracted and at a distance; f) Foster carers who have well-established and long relationships with people such as social workers and teaching staff will undermine a child’s confidence in talking with anybody about anything as sensitive as sexual abuse (or other maltreatment that is not visible) by that foster carer or other ‘trusted adult’; g) Victims are selected or are more susceptible to a perpetrator because of particular vulnerabilities; the three children all had a need for acceptance and adult contact; they had various difficulties in learning and cognitive abilities; had already suffered abuse and were susceptible to threats to keep them silent about the abuse inflicted by the perpetrator; h) Children and young people living in care who have had to overcome adverse early childhood experiences or neglect can be left unable to form trusting relationships15; they have great difficulty using other people’s help; they have difficulties in developing alliances with helpful people and this can place them at a disadvantage16; low self-esteem associated with experience of abusive relationships and low educational participation can exacerbate this; this needs to be addressed as part of ongoing routine care planning; i) Evidence from major inquiries and reviews across the UK have shown that the extent of child sexual abuse and exploitation has been poorly understood until relatively recently; children need time and the support of people who can help them disclose information; this includes being sensitive to clues and indicators in the child’s behaviour and health as well as showing proper curiosity and interest in listening and understanding when children or adults begin taking about abuse; it highly probable that there will be further learning to emerge for example from the Independent Inquiry into Child Sexual Abuse; j) Social workers who do not have the workload capacity or aptitude to spend time with children in developing trust based relationships are unlikely to understand the needs of a vulnerable child well enough and are even less likely to be the recipient of accurate information about the true views, wishes and feelings that children have; this includes children being able to alert trusted adults such as social workers to risk and significant harm; children need professionals who have time to spend with them outside formal settings or care placement; this has implications for example in how workloads are assessed and prioritised; children will only disclose abuse to people they trust and can be confident will act effectively; this requires having the time, motivation and skills to build those relationships; k) Great caution needs to be applied to relying too much on systems such as consultation forms for statutory reviews as a means for getting a good enough insight into children’s needs, views and wishes; 15 Stein, M. and Wade, J. (1986) Leaving Care. Oxford: Blackwell 16 Downes, C. (1992) Separation Revisited. Aldershot: Ashgate CONFIDENTIAL Page 20 of 42 l) Providing good and child focussed care for vulnerable children requires access to effective supervision and support; this applies to a home based carer (who is not a family and friends carer17) as much as to professionals working in a different setting; good supervision should be challenging and provoke reflection; an inability to use supervision and reflection or to heed advice in regard to development should be a cause for further inquiry and scrutiny; foster carers have to be open to training development opportunities and to recognise the value and importance of participating in support activities; m) Lower level concerns about the quality of care were insufficiently collated and used to inform the ongoing supervision of the foster carers; the views of children placed with the foster cars or from their social workers were not recorded as part of the annual review n) Effective chronological records are essential for identifying patterns in regard to the behaviour of children as well as carers; persistent lapses in good care practice should not be treated as one off incidents; o) The role of LADO has a significant role in regard to any criminal investigation, enquiries and assessment as to whether a child or children are at risk or are in need of services and in regard to considering whether disciplinary action is indicated; their role should be ongoing until all processes including a conviction have been completed; part of that role is actively promoting opportunity for other victims to come forward; p) For the LADO to be effective requires all relevant professionals and organisations to be aware of the purpose and role of the LADO and to ensure that consultation and information sharing is well understood; people in positions of trust should expect to maintain appropriate standards of private and personal conduct; arrest or other evidence of inappropriate behaviour such as dishonesty or violence is relevant to share with the LADO; q) All professionals have a responsibility to support and cooperate with all processes relating to the protection of children and effective management of perpetrators; this includes ensuring effective participation in criminal and prosecution arrangements; there were long delays in some social work staff making themselves available to make statements to the police as part of the criminal proceedings; r) Contact for all three children with important professionals such as social workers did not provide enough time to develop relationships or take place away from the influence or interference by the carers; s) All professionals have a duty and responsibility to raise concerns either about a child they believe could be at risk of significant harm or a person who poses a risk of harm to children (or vulnerable adults); the GP, an independent psychologist, a solicitor and social work supervisor all missed evidence at different times given by Grace regarding sexual abuse that could have been instrumental in helping to identify the perpetrator’s sexual abuse prior to 2014; t) All professionals in direct contact with children need a basic awareness of child sexual abuse and an understanding of how a child’s trauma can be exhibited through their behaviour for example; children who present with difficult and 17 Adults who become carers by virtue of being a friend or a relative of a child. CONFIDENTIAL Page 21 of 42 confrontational behaviour may be exhibiting the effects of traumatic experiences that include abuse; children who have been sexually abused and have attachment disorders are highly unlikely to disclose their abuse and be highly susceptible to abuse. 3.5 Good practice identified through the review 78. To support the learning from the review the panel looked for examples of good practice. To constitute good practice, the panel looked for action or decision making that went beyond compliance with local and national policy, procedures and guidance. 79. Examples of good practice identified by the review include; a) The recognition in 2014 that Grace, Lisa and Carey were vulnerable witnesses and the effort made to use special measures and support particularly in preparation and participation in the criminal proceedings; b) The planning and conduct of the enquiries and investigation in 2014 displayed a much clearer understanding and empathy about the needs of Grace, Lisa and Carey in for example how interviews were scheduled; c) The effort and persistence in making contact with Grace in 2014 and apparently having better understanding about how little confidence and trust Grace could have and the deployment of a specialist police officer with specialist training; Grace was also offered support through a specialist sexual abuse support service in 2014 which she declined. 3.6 The views, wishes and feelings of the children and responding to their experiences and presentation of behaviour 80. Giving children the opportunity to speak freely and to have the confidence that they will be listened to, is an important part of promoting safer cultures and systems of care and to make it less likely that an abuser can hide their criminal behaviour. However good the vetting and recruitment procedure for becoming a foster carer, perpetrators can and do hide their true motivation and behaviour for becoming approved and trusted to care for children. 81. Any family based care is by the very nature of the arrangement a far more private experience than for example living in a residential setting. A great deal of the care giving will be done out of sight and will be done on the basis of trust that the carer is ethically motivated and able to understand and have insight about the needs of a child. Care systems that promote the safety of children will be pro-active about checking routinely on whether that trust is well placed or not. CONFIDENTIAL Page 22 of 42 82. Children who have been neglected who crave basic attention and care giving or have experienced sexual abuse and have damaged perceptions about what constitutes healthy relationships and care will be vulnerable to predatory or exploitative attention. 83. More than one of the agency reports acknowledge that seeking the views of children as part of routine practice was not a widespread or strong part of local arrangements until relatively recently. The CCG agency report for example comments that there was no evidence that the views, wishes and feelings of any of the children were routinely sought during consultations with primary health care staff. The point is made that as far as Grace is concerned, general safeguarding and primary health care practice in regard to listening to children was far less developed than would be expected now. 84. Lisa said that she had never been happy in the placement and she felt that people should have been able to pick up on this; Lisa says that nobody ever asked about her feelings in regard to the placement. Improvement was recognised as being required and the implementation of practice models have promoted a clearer emphasis on bringing the child’s voice into routine professional practice across agencies. 85. The respective learning difficulties of the individual girls was not generally well recorded particularly in respect of measures that could help promote their voice being heard as part of routine practice and it certainly was not adequately considered when the first disclosures were made in 2011; the preoccupation at the time was in regard to evidential issues if ever put before a court. The police routinely record information that might have an impact on the ability of an individual providing information although were not involved in the 2011 inquiries. 86. When Grace first disclosed being sexually abused by the perpetrator in 2011 there was little recorded evidence about how her views wishes and feelings were considered over and above her saying she did not want to make a formal complaint to the police. This reflects old style investigatory mind-sets that cannot understand the circumstances of the victim, the various barriers and inhibitors to victims feeling able to cooperate in investigations and the level of control and coercion that is a powerful dynamic between a perpetrator and a victim. 87. The facts of Grace’s earlier experience of sexual abuse, the awareness that she was particularly vulnerable and the history of difficulties she had through adolescence and early adulthood were all factors that deserved closer exploration and understanding in terms of implications for how the disclosure was handled and is acknowledged as areas of learning in the respective agency reports. 88. The fact that the allegations concerned a currently approved foster carer who had cared for many children over several years gave additional gravity. The early decision that there were no grounds to investigate whether a crime had been committed or not was premature and demonstrated a lack of basic curiosity about the potential implications for other children already placed over several years. It certainly suggests CONFIDENTIAL Page 23 of 42 that the individuals involved in the discussions and decisions at the time did not have a good enough understanding that childhood sexual abuse was more likely to be revealed in adulthood or an understanding about the way in which disclosures are made as described for example by Summit and discussed at the start of this chapter. 89. Disclosures about child sexual abuse often occur incrementally and inconsistently over time. The investigation strategy could have been better informed with consideration as to which agencies and individuals should be contacted as part of the inquiries. Disclosures cannot be relied upon as providing sufficient evidence and therefore thought is required about how to triangulate evidence as much as possible from different sources of information and evidence. If contact had been made for example with the GP practice, it is highly likely that the information about Grace consulting the GP less than two months previously during which she talked about being abused in foster care would have been disclosed. The CCG agency report acknowledges that the GP practice should have considered using the LADO procedures in October 2011 and also draws out the lack of detail that was apparently sought and certainly recorded at the time. 90. The Advocacy service that was available to Lisa and to Carey was not in place when Grace was a looked after child. The service is an explicit and independent service designed to ensure that the views, wishes and feelings of a child are promoted particularly during formal processes such as child protection conferences, LAC reviews or changes in placement arrangements. It was not this service that heard Lisa’s first disclosure about sexual abuse; it was a learning mentor. Children (and adults) will choose the person they feel they can talk to. Grace had initially gone to the GP. Unlike Grace’s experience with the GP, the learning mentor ensured that the information was followed up with children’s social care services and with the LADO. 91. The Advocacy service acknowledges that there was a long delay between the decisions to allocate an independent visitor for Lisa in May 2013 until the first introductory visit in February 2014. The reason for the nine month delay is attributed to staff changes, a shortfall in volunteer visitors, although there had also been delay in processing the service referral forms as well. Giving children access to adults who have the time and aptitude to form relationships and to encourage children to talk and communicate (such as play and art for example) is one of the foundations of promoting and hearing the child’s voice. 92. There was a far more robust and empathetic approach to seeking information from Lisa and Carey as well as from Grace in 2014. There is good evidence that there was much clearer focus on the respective needs of Lisa and Carey when their initial disclosures were made in 2014. The fact that Lisa had moved placement and the impact that could have upon her was considered when scheduling interviews to ensure that she was settling into her new placement and support an effective collection of evidence. The fact that the children were fearful of repercussions and CONFIDENTIAL Page 24 of 42 their need for support as the investigation continued led to the use of the specialist intermediary. 93. It is not surprising that Grace had difficulty in initially agreeing to speak with any investigating officers in 2014. It is good practice that specialist officers made such concerted effort to speak with Grace and she was also given support through the Witness Care Officers. These officers kept very regular contact with Grace and it is believed that this helped in having Grace’s attendance at court. 94. Although children’s behaviour can be a manifestation of abuse it can be problematic for professionals to determine or understand what the behaviour represents; as Munro observes, behaviour can be ‘indeterminate’. In general there was an absence of sufficient curiosity about the respective experiences and presentation of Grace, Lisa and Carey. 95. With the benefit of hindsight, some of the recorded information about behaviour presented by the girls whilst in placement could have been symptomatic of being sexually abused. For example, between February 1995 and November 1996 there were eight overdoses which were generally alcohol and paracetamol. There is no record of these being discussed by the GP practice. Although the expectation now would be for this to have occurred it was not the same expectation in 1990’s. The GP practice was also aware that the mental health service were involved and might have felt they had little to add at that stage. Similarly there was far less developed focus generally on the specific circumstances and needs of children who were looked after. The issue of self-harm was far less recognised by any of the services than it is today. Other evidence such as poor eating and of going missing from home was not the subject of any significant enquiry or reflection at the time of the incidents. 3.7 Effectiveness of the statutory mechanisms in overseeing and influencing the quality of care provided for the children in placement. 96. The CSC agency report described a number of shortcomings in regard to how the respective system of safeguards was applied. a) Visits were made by social workers to the children, although the majority took place in the foster carer’s home and probably with the foster carers present; in the case of Carey, there is only evidence that 12 of the 17 statutory visits being completed; none of the children were visited more frequently than the legal minimum requirement; b) Although the records of the LAC reviews confirmed that consultation forms were used by Lisa and Carey, no copies are retained on file; there were copies of the wishes and feelings consultation forms used by the Advocacy service on that service’s files; c) A report from the respective child’s social worker was not always available for reviews concerning the children in placement or for the annual review of the CONFIDENTIAL Page 25 of 42 foster carers; this suggests systemic issues rather than just reflecting individual practice; d) There are gaps in information from education and health services; e) Only Carey was offered direct support to access support from the Advocacy service although Lisa also used the service although there was a long delay in processing a referral and then matching an independent visitor; f) There was limited evidence about advocacy and complaints procedures being promoted with the young people; the system for complaints was originally established with the implementation of the Children Act 1989 and associated guidance; g) The occasions when children’s social workers raised issues about the care practice of the foster carers this did not result in formal supervisory requirements; likewise during the 2011 investigation of Grace’s disclosures included reference to shortcomings in practice although no formal and enhanced supervision requirements were considered or implemented but rather provision of an apology to the carer; h) The fostering panel and the chair of the panel were not informed and consulted as part of the LADO and children’s services 2011 investigation; changes have already been made to ensuring that any allegations and complaints are reported to the fostering panel. 97. Social workers need the time and the motivation to spend time with children away from their placement to get to know the child, to promote trust and to give the child opportunity to talk about their views, wishes and feelings. The CSC agency report highlights that in April 2014 the looked after children social work team was reduced by seven whole time equivalent social work posts. 98. Although the statutory reviews provide opportunities for children to record their views there is no record of evidence in regard to any of the children for example in regard to any of the consultation forms. Similarly, there is no evidence that they were given appropriate information and support to use complaints processes. There was delay in appointing an independent visitor. Lisa and Carey were given access to an advocate; Lisa provided placement feedback when she left the placement with the perpetrator; she described not feeling part of the family, did not feel listened to and did not see her social worker enough. There is no formal mechanism for ensuring that when such information is forthcoming it then leads to effective follow up action. 99. The agency report from CSC found that although there were no formal allegations or complaints made prior to 2011 there were issues that had been identified. This had included the foster carers’ response to challenging behaviour, offensive and discriminatory attitudes and language and standards of some care. The fact that none of the children felt able to speak out at the time or that anybody was able to have any indication of their daily lived experience with foster carers has to be a significant area of learning from the review. CONFIDENTIAL Page 26 of 42 100. The agency review confirms that although there was evidence of annual reviews of the foster carers in accordance with regulation and agency standards, the quality of recording and rigour was inconsistent. The personal development plans were not comprehensive and the pattern of relatively lower level concerns and shortfalls were not identified and followed up. For example, the carers were not participating in training and this was probably contributing to their inappropriate response at times to children with enhanced levels of emotional need. The agency report highlights that there were occasions when there were problems in having the appropriate capacity for training and development; such shortages help create the latent conditions where carers who are motivated to keep their training and development updated will take up any available opportunities. 101. The predictors for the maltreatment (not child sexual abuse) of children living in family foster care were sought by a research study to identify the characteristics of riskier foster homes18. Of four characteristics that presented increased risk were homes about which case‐workers had reservations; the other three factors were homes that had younger foster mothers, homes in which children shared bedrooms with other family members and homes that were restricted for placement of certain children. 102. The perpetrator and his wife were supervised by longstanding fostering social workers. This consistency and long term involvement would often be seen as a strength although it may have contributed to professional staff becoming too familiar and less able to identify the foster carers’ shortcomings. The established relationship that the perpetrator had with social workers and at the school would have been a significant factor in any child feeling they would not be believed. The agency report describes a ‘start again’ syndrome where isolated events or incidents of practice were not collated and viewed within the context of longer term attitudes and behaviour. 103. The agency report acknowledges that when Grace made her allegations in 2011, and the history of care practice issues, there would have been cause to elevate the level of oversight of the carers. 104. The information about Grace’s allegations or the apparent shortcomings in care practice were not apparently reported to and discussed by the agency fostering panel. It is not apparent that a formal review of the carers was undertaken before the decision was made to increase their fostering limit. The role of the fostering panel is to be available to provide advice and recommendations given the range of experience and knowledge that a panel should have amongst its membership. The panel are now routinely informed when an allegation or complaint is raised in regard to a foster carer. 18 Zuravin. S, Mary Benedict, Somerfield. Child Maltreatment in Family Foster Care, Am J Orthopsychiatry; 63(4):589-96 October 1993. CONFIDENTIAL Page 27 of 42 105. The police and CSC were the only two agencies made aware of the allegations by Grace in 2011. The police involvement in the 2011 investigation is unclear. The police had no record of a strategy meeting taking place and although the LADO meeting in December 2011 records that a detective constable visited Grace there is no corresponding record on the police system. There is no recorded evidence that anybody from the police safeguarding service spoke with Grace. There is no evidence about what account was given to the exploitative nature of the abuse being disclosed by Grace or of the perpetrator having access to children as a trusted adult. The police had no record of any outcome from the CSC investigation. CSC concluded that the perpetrator was’ not a not a risk to children’ and there was ‘no evidence that he had acted inappropriately’. There is little recorded evidence about how the investigation was undertaken and the factors considered in reaching the conclusion in 2011. 106. The disclosures that Grace made to a psychologist in 2012 appear to refer to incidents of abuse between 14 and 17 years of age. These allegations were not entered into the CSC system until January 2017 and do not appear to have been investigated at any stage. There is no record of the psychologist having used the LADO or MASH referral systems. The disclosure should have been recorded and processed as a LADO referral by the psychologist. The information contained in the report should have been recognised as a LADO issue with implications for the protection of other children. The report will have been read by several people including the social worker, the social worker’s supervisor, and the solicitors and CAFCASS officer. The information was not shared with the fostering service. 107. In 2014 it was the police and CSC jointly who were primarily involved in conducting investigations. Information was sought and shared with other services in regard to collating evidence and co-ordinating safeguarding arrangements. The investigation was more robust and a more complex investigation. There was joint investigation between the two services involving specialist interviewers. There was explicit consideration about the vulnerability and additional needs of the victims. This included using the Code of Practice for Victims of Crime to guide support arrangements when the decision was made to prosecute the perpetrator. 108. The LADO convened strategy meetings ended before the criminal proceedings had been completed. A significant learning point to come from this review is emphasising that the LADO role should continue until all related processes have been completed. For example, the police had difficulty in arranging for some social work staff to be available to provide statements as part of the criminal process. The LADO could have helped facilitate that more effectively. There were ongoing support needs for the three victims of the perpetrator’s abuse during and after the criminal proceedings. It remains the case that it is more likely rather than less likely that there are other victims of the perpetrator’s sexual abuse who have not yet disclosed information. 109. The LADO is a critical part of the system for ensuring that individuals who have positions of trust are subject of appropriate monitoring. Evidence of abuse is only likely to emerge incrementally. In December 1995 the perpetrator had been arrested CONFIDENTIAL Page 28 of 42 in relation to a complaint of GBH. Although the CPS decided that no charge would be processed through court, the allegation of violence and the suggestion of coercion in the report of the incident was relevant to the perpetrator’s role as a foster carer. The information was not shared at the time of the offence or during the 2011 or 2014 LADO strategy discussions. The police have given assurance that such offences would now be reported. Currently, the Common Law Police Disclosure (CLPD)19 provides for the police being able to disclose known information regarding an individual in order to enable a third party such as a LADO to consider risk mitigation in respect of an employment or voluntary role believed to be undertaken by the individual. This common law power enables the police to share personal sensitive information with a third party where there is a “pressing social need”. A pressing social need encompasses safeguarding or protecting from harm an individual, a group of individuals or ‘society at large’. The CLPD provisions endorsed by the chief constables in March 2014 did not become operational advice until March 2015 following the withdrawal of the Home Office’s previous guidance. 110. A CLPD is not reliant on a conviction or a charge. When a person is released from custody, either after arrest or having attended as a voluntary attendee for a violent, sexual or drug related offence the Information Management Team are automatically notified of these offences electronically. This team will then undertake a review of the offence and determine if a CLPD should be made. 111. Other local organisational changes occurred after 2011 that contributed to improved co-ordination. The MASH brings together the local authority, education, health and police in the same location with virtual links to other services as necessary. Referrals, including LADO notifications, are discussed by a multi-agency group which feed into strategy discussion or meetings when enquiries are to be undertaken under s47. 19 Common Law Police Disclosures (CLPD) – Provisions to supersede the Notifiable Occupations Scheme (NOS), National Police Chiefs’ Council March 2015 CONFIDENTIAL Page 29 of 42 4 Conclusions and recommendations 112. Regrettably, the perpetrator is not the first foster carer to be convicted of sexually abusing looked after children placed by a local authority. The sexual abuse of children (including child sexual exploitation) is a highly complex issue; more seems to be known about what does not work well in safeguarding rather than what helps people and organisations to be more effective in safeguarding children. 113. The objectives of this learning review are; a) Prevention; stopping child sexual abuse happening and particularly in a regulated and supervised care arrangement such as a foster care placement; b) Improving the protection for children and young people who are placed with carers through better identification, disclosure, reporting and response to information. 4.1 Promoting prevention and awareness 114. There is learning that applies to all children and young people for keeping them safer from sexual abuse. Research from North America indicates that preventative education delivered in schools can help increase the knowledge and awareness of all children and help to change culture, attitudes and environments in which child sexual abuse can take place. Age and developmentally appropriate pre-school and school-based education programmes on child sexual abuse can be effective at teaching children and young people to recognise inappropriate behaviour and to improve their knowledge of self-protection20. 115. The PSHE Association provides a helpful checklist of 11 points for effective implementation of PSHE which could be used to inform the implementation of sex and relationship prevention education21. Schools can also provide a safe space for sexual abuse disclosure to take place22, taking into account the systemic and organisational 20 Baker, C. K., Gleason, K., Naai, R., Mitchell, J., and Trecker, C. (2013) Increasing knowledge of sexual abuse: A study with elementary school children in Hawaii. Research on Social Work Practice, 23(2), pp.167-178. Pulido, M. L., Dauber, S., Tully, B. A., Hamilton, P., Smith, M. J., and Freeman, K. (2015). Knowledge gains following a child sexual abuse prevention program among urban students: A cluster-randomized evaluation. American Journal of Public Health, 105(7), pp. 1344-1350. Walsh, K., Zwi, K., Woolfenden, S., and Shlonsky, A. (2015) School-based education programmes for the prevention of child sexual abuse. The Cochrane database of systematic reviews, 4, Article No: CD004380. Zwi, K. J., Woolfenden, S. R., Wheeler, D. M., O'Brien, T. A., Tait, P., and Williams, K. W. (2007) School-based education programmes for the prevention of child sexual abuse. Cochrane Database of Systematic Reviews, 3, 21 PSHE Association (2016) Key Principles of Effective Prevention Education. London: CEOP/ThinkUKnow/PSHE Association. Available at: https://www.pshe-association.org.uk/system/files/PSHE%20Association%20report%20to%20CEOP%20April%202016%20FINAL.pdf [acessed on 09/07/18] 22 Office of the Children’s Commissioner (2015) Protecting Children from Harm, London: Office of the Children’s Commissioner. Available from: https://www.cscb-new.co.uk/wp-content/uploads/2015/12/Child-sexual-abuse-protecting-children-from-harm-Nov-2015.pdf [Acessed 09/07/18] CONFIDENTIAL Page 30 of 42 factors that make disclosure difficult (and already mentioned) as well as the research into children’s experiences of trying to tell and not being heard23 (Cossar et al, 2013). 116. Perpetrators of child sexual abuse (and sexual exploitation) are able to commit their abuse in secret and often without detection because children and young people do not disclose what is happening to them. It is a minority of people who ever disclose child sexual abuse; a greater number of those who do disclose are adults when they make the disclosure. 117. Children who are placed away from their families face additional vulnerability. Giving children regular and independent access to people outside of their care placement and independent from their carers is essential. This does not mean relying on specific arrangements such as independent visitors; children choose who they confide in and it is about having the various professionals sufficiently knowledgeable about the child’s circumstances and what to do if they are given the sort of partial and incomplete information that a disclosure may represent; this includes education and health practitioners who have routine contact with children (and with adults who may disclose childhood abuse). 118. Compliance with statutory standards as to the frequency of visits to a child in placement is merely achieving the minimum standards and does not in itself provide any information about the utility and quality of the contact with the child. Information and reflection about the manner in which children communicate, the people they choose to communicate with should be a starting point to measuring the effectiveness of contact with a child in placement and of routinely reviewing the quality of care arrangements. A clear and appropriate record of contact that provides evidence and information about the child’s views, wishes and feelings should be a benchmark standard. 119. Supporting and encouraging a broad community of professionals to improve and develop their awareness, knowledge and understanding about child sexual abuse is essential. This begins with achieving a broader understanding that child sexual abuse is widespread and under reported, that silence and non-disclosure in childhood is very common, that children face many barriers in talking about it at all and that when disclosures do occur they can be subject to retraction and inconsistency and be incomplete. 120. Adults such as Grace who disclose childhood abuse are providing an opportunity to identify perpetrators and to protect children they may have contact with; the abuse is never ‘historical’ and it is highly likely that there will be other victims of the perpetrator to be identified. The disclosure can be prompted by a crisis such as 23 Office of the Children’s Commissioner (2013) It takes a lot to build trust, London: Office of the Children’s Commissioner. Available from https://www.uea.ac.uk/documents/3437903/0/OCC+Recognition+and+Telling+report.pdf/923aec11-0221-4d54-8c77-f83189e9e02d [accessed on 09/07/18] CONFIDENTIAL Page 31 of 42 appears to have been the trigger for Grace in adulthood beginning to speak about what had happened to her over several years in her childhood. 121. It is essential to provide support to the victim who is very likely to have been living with the emotional and psychological damage that is manifested for example in substance abuse, poor mental and physical health. These are the type of factors that investigators and prosecutors may say indicate unreliability as potential witnesses in a court for example. 122. The sentencing of the perpetrator following his conviction was widely reported in the media at the time of his conviction and sentencing; no further victims came forward following that media coverage. 123. In May 2017, the Police Serious Case Review Co-ordinator researched Police local systems and completed Serious Incident Information Gathering Reports for 27 children who had been formerly fostered by the perpetrator and his wife. This was to identify if other children who had been placed with the perpetrator and his wife wished to make a complaint and if they would need including in the scope of this review. This information report was submitted to the SCR subcommittee for consideration as part of the commissioning of this review. 124. There are special measures available at court for vulnerable victims and witnesses. Child witnesses under the age of 18 will automatically be eligible for special measures by virtue of section 16 of the Youth Justice and Criminal Evidence Act 1999. A vulnerable or intimidated witness will be eligible for special measures under sections 16 to 33 of the YJCEA 1999. In the case of Grace, Lisa and Carey, they were identified as vulnerable by the police and special measures were applied for and granted by the court. The special measures included an intermediary for Lisa to assist with cross examination at court, the use of screens for Lisa and Carey preferred the use of a video link to give her evidence. Grace indicated that she would prefer to give evidence with the use of screens. Pre- court visits were also arranged for Grace, Lisa and Carey and subsequently were undertaken with Lisa and Carey accompanied by the intermediary. 125. An independent sexual violence advisor service was launched in 2015 and the Sexual Assault Referral Centre (SARC) was also launched in 2015 and would be offered. 4.2 The LADO 126. Widely promoting the purpose and role of the LADO is important and goes wider than the work of carers and professionals working directly with the local authority and encompasses for example volunteer organisations and activities; clear understanding by health professionals, teachers and learning mentors, criminal justice and legal practitioners as well as more widely across the community. In dealing with sexual abuse, the LADO can play a vital role in collating intelligence that on its own has little CONFIDENTIAL Page 32 of 42 significance but can begin a process of joining up different elements of evidence and concern. 127. The LADO needs to be a role undertaken by somebody who has sufficient awareness, understanding and knowledge about sexual abuse and exploitation and maintains and develops that expertise through refresher training and research updates with peers. 128. The LADO will often have to challenge people and organisations who may be reporting information about an individual who has an established reputation or status that is valued or well regarded. Recognising the potential for human bias and cognitive influence in how information is processed about that individual is an essential part of the LADO function. Ensuring there is clear differentiation and definition of roles in regard to the investigation of information and how support is provided to the respective parties. Professionals who feel their role is to provide support to a carer for example is unlikely to have the level of sceptical and challenging curiosity to contribute effectively to an investigation that is suitably robust and thorough. 129. Social workers and police officers who do not have sufficient understanding about child sexual abuse are unlikely to have the necessary mind-set, knowledge and skills to conduct the type of inquiries and investigation that is required. 130. The Police have committed to investing in training of Safeguarding Staff. Multiple Specialist Child Abuse Investigators Development Programme (SCAIDP) courses have been held in 2018. Capacity on the SCAIDP courses has been increased from 8 student places to 12 student places. Following attendance on the SCAIDP course, each student is provided with a tutorial development plan and is required to complete and submit a portfolio to satisfy the criteria of the course. In order to be fully accredited as a specialist investigator, students must also attend and complete the Initial Crime Investigators Development Programme (ICIDP). The training to become a specialist abuse investigator is intensive and rigorous. 131. The Police have specially trained officers (STO’s) who are responsible for the first response for sexual offences. These officers are both male and female and every attempt is made to ensure that the victim is offered a choice of gender of officer who attends. STO’s receive extensive training in line with College of Policing standards and are given the opportunity for refresher training on a regular basis. 132. The LADO has a responsibility for ensuring that a sufficiently informed and clear strategy is developed for responding to information and ensuring that agencies are not solely relying on a victim’s disclosure for example. 133. The LADO has a role until all processes are completed. This includes facilitating and supporting the respective agencies in ensuring that support and protection is being given to the victim, that attention is given to identifying victims who have not come forward and the strategies required to deal with this and to ensure that the police and CPS are appropriately supported in any prosecution of the perpetrator. CONFIDENTIAL Page 33 of 42 134. The LADO investigation in 2011 did not identify the risk that the perpetrator represented to girls placed in his care and was compounded by the fact that it resulted in the carers being given an apology and having their fostering limit increased. This would have had powerful implications for any child who had concerns about the perpetrator wanting to raise them. 135. The level of collective response in 2011 relied on the statements by Grace and the interview of the perpetrator and his wife by social workers. The decision by the police that there was no crime to be investigated was both premature and removed an important input by specialist police officers to be instrumental in conducting an interview with the perpetrator under caution. 4.3 Supervision of foster carers 136. The supervision of foster carers needs to be robust. Where relationships have developed over several years between carers and social workers and other professionals, children who have concerns or are being abused will feel even more that they are unlikely to be believed or taken seriously. 137. Ensuring that children are asked for their views, wishes and feelings independent of their carer; ensuring that their social workers are required to provide information for the foster carer review; maintaining a chronology of concerns or issues raised in regard to the carer; assessing the carers attitudes to training and personal development; the extent to which they can demonstrate appropriate empathy and understanding about the behaviour and needs of children. 4.4 Recommendations I. The LSCB should ensure that an apology and an appropriate account of the lessons learnt is provided to each of the three ‘children’. The LSCB should also ensure that arrangements for ongoing support and counselling are being facilitated by the relevant organisations. II. The LSCB partners should satisfy themselves that all practicable steps have been taken to identify and to make contact with any other children who were in placement with the perpetrator to ensure that those children are aware that the perpetrator has been prosecuted and to give opportunity for any further information to be provided and to offer advice, help and support as may be appropriate. III. The LSCB should consider what information it receives about the delivery of PSHE in local schools and to consider if there is further scope to promote better awareness for children and young people about relationship education and of sexual abuse. CONFIDENTIAL Page 34 of 42 IV. The LSCB should support the LADO to promote improved awareness, knowledge and understanding about the role and function of the LADO with relevant local organisations, including local medical and legal stakeholder organisations. This should include written guidance about the role of the LADO. V. The chief officers of all of the member organisations of the LSCB should ensure that there is appropriate written guidance for staff to cooperate with any criminal investigations relating to safeguarding children (and vulnerable adults) including the giving of statements and other evidence and information to the relevant investigating and prosecuting agencies. VI. The LSCB should encourage the chief officers of partner organisations that commission independent specialist or expert services in relation to children in need or at risk of harm, to ensure that there is written guidance provided to those professionals as part of their contract outlining the circumstances and their responsibilities for reporting any relevant concerns to the LADO that may emerge during the course of their work. VII. The LSCB should consider whether the review indicates any further development of training and professional development in regard to child sexual abuse; in particular in relation to the recognition and response to child sexual abuse. VIII. The LSCB should consider if they should have any further information that arrangements for contact and visits with children who are looked after are providing sufficient quality and regularity and that there are effective arrangements for evaluating this in the relevant services. IX. The Common Law Police Disclosure (CLPD) should be included in any updated local child and adult safeguarding protocols to ensure clarity of understanding about the purpose of such information being shared by the police. X. The LADO, in consultation with children’s social care services, should formally review whether any agency has any grounds to consider making a referral to any of the relevant professional bodies regarding the processing of information contained in the professionals report in 2013. XI. The independent chair of the fostering panel should be provided with a copy of the review and be invited to make a formal response to the LSCB regarding any further development in regard to the panel’s role in proving oversight and advice and the robustness of supervision, support and review of foster carers. 4.5 Issues for national policy 138. Professional bodies and regulatory authorities have a role in promoting improved awareness about child sexual abuse and exploitation and the responsibilities of professionals in regard to the protection of victims and the prevention of crime. Education, health, and social care as well people working in civil and criminal law need CONFIDENTIAL Page 35 of 42 to know and understand the circumstances under which the LADO must be consulted and informed of information that indicates a person in a position of trust is a perpetrator of sexual abuse. The national panel may wish to consider whether professional bodies such as for example The Law Society or the Medical Royal Colleges have a role in promulgating learning at a national level. 139. National guidance issued by the National Police Chiefs’ Council provides for the police being able to disclose known information regarding an individual in order to enable a third party such as a LADO to consider risk mitigation in respect of an employment or voluntary role believed to be undertaken by the individual. This common law power enables the police to share personal sensitive information with a third party where there is a “pressing social need”. A pressing social need encompasses safeguarding or protecting from harm an individual, a group of individuals or ‘society at large’. A CLPD is not reliant on a conviction or a charge. There is no corresponding guidance to other organisations who may be in receipt of, or party to such information. CONFIDENTIAL Page 36 of 42 5 The methodology of the review 1. This SCR used the principles and requirements set out in the government national guidance (Working Together to Safeguard Children 2015). a) Recognises the complex circumstances in which professionals work together to safeguard children; b) Seeks to understand who did what and the underlying reasons that led individuals and organisations to act as they did; c) Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than relying on hindsight; d) Is transparent about the way information is collected and analysed; e) Makes use of relevant research and case evidence to inform the findings; f) Specifically considers all relevant equality issues related to ethnicity, religion, disability and diversity; g) Is able to develop a multi-agency action plan in light of the findings. 2. A review panel was convened of senior and specialist agency representatives to oversee the conduct of the review and agreed case specific terms of reference. 3. The purpose of this review is to identify in particular: a) The extent to which the views, wishes and feelings of the three children were sought, considered and acted upon in regard to any concerns explicitly disclosed or represented in their behaviour or other presentation such as self-harm; b) The extent to which agencies could have identified concerns about the care or abuse of children in the care of the perpetrator prior to 2014 and the subsequent conviction of the perpetrator; c) The quality and rigour of professionals’ response at single and multi –agency level; this includes how any significant information, observations or incidents were dealt with through contact, assessment and action planning; d) The extent to which the relevant legal frameworks were applied for reviewing of the care arrangements for the children and the quality of the foster carers in meeting the needs of the children, the processing of any concerns or complaints, and the invocation of multi-agency child safeguarding procedures including LADO; e) The level of understanding about any particular factors in regard to the vulnerability of the children and includes any disability or learning difficulty, cognitive understanding and/or legacy of maltreatment prior to placement with the perpetrator; CONFIDENTIAL Page 37 of 42 f) The quality of advice, support and supervision for professionals and the general oversight of arrangements for vulnerable children looked after on behalf of the local authority; g) Identify any issues in regard to the capacity or resourcing of services. 4. The approach to this review reflects a duty of candour. Any young person looked after by the local authority has the right to expect that the care provided to them will be appropriate to their needs and will protect them from abuse. 5. The review takes account of the reality of arrangements for complex multi-agency working involving organisations over several years, some of which no longer exist or their responsibilities had been transferred as result of changes to organisational, legal or commissioning arrangements. It considers the extent to which relevant legislation and guidance was applied with the aim of understanding why the systems for safeguarding children placed with the perpetrator did not operate effectively enough particularly in 2011. 6. As far as has been possible given the circumstances of the review, the aim has been to understand why those involved with the children and foster carers, or who received information about the children and foster carers, took the action or made the decisions they did at that time in regard to any evidence or indicators of concern or abuse. 7. The agencies known to have had involvement with the children were asked to produce an agency report addressing the key lines of enquiry described in paragraph 21. Through a collaborative learning process the review identifies evidence of strengths and good practice, and supports the development of an action plan to address the learning arising from the review. 8. The LSCB commissioned Peter Maddocks as an independent person to lead the review and to provide this report. He does not and has not worked for any of the organisations who are party to the review, and does not hold and never has held elected office in the district. Similarly he is not related in regard to personal or professional matters to any person working for or responsible for the provision of services. 9. The fact that the review is examining events that occurred over several years means that many of the people who were involved at the time of critical events or decision making were no longer available to participate in any aspect of the review. This meant that the SCR has been reliant on collating evidence and information from agency records without the benefit of being able to include practitioners in developing the analysis and understanding about how for example information was understood and processed at the time. CONFIDENTIAL Page 38 of 42 5.1 The key lines of enquiry 10. Agencies were asked to provide a critical evaluation of their services and practice against each of the following: a) How did your agency seek evidence and information about the views, wishes and feelings of the children and to what extent was it appropriately considered in any enquiries, assessment, consultation, decision making and action. Can you identify any barriers or obstacles that may have hindered good enough understanding about any evidence or information from any of the children? b) Did relevant staff demonstrate sufficient professional curiosity and maintain an appropriate focus on the child in responding to the experiences and presentation of the children? Comment on the level of understanding about any particular factors in regard to the vulnerability of the children and includes any disability or learning difficulty, cognitive understanding and/or legacy of maltreatment prior to placement with the perpetrator that inhibited disclosure of abuse. c) What involvement was there from your agency in ensuring any of the statutory mechanisms (Foster Carer Reviews, LAC reviews, Pathway Planning, promoting access to the complaints process) were effective in overseeing and influencing the quality of care provided for the children in placement? Can you identify any learning? d) What involvement was there from your agency in the conduct of the investigation in 2011 or in 2014? Was the involvement by your agency as effective as it should have been? What learning can you identify to ensure that investigations are thorough and robust? e) Can you identify any examples of where the care or response by the foster carers required challenging or further enquiry? What action was taken or not taken and can you identify any learning for the review? f) Can you identify any learning about the relationships professionals develop with long term established foster carers and their ability to retain a child-focus and to challenge poor care? g) Did your agency ever have cause to use the child protection mechanisms relating to the reporting and responding to concerns about quality of care and allegations of abuse from the children by the foster carer; were they appropriately utilised and robust in their application? What learning can you identify? h) Can you identify any opportunities that were missed to challenge and to intervene earlier to reduce risks to the children from abuse or inappropriate care? What learning can you identify? CONFIDENTIAL Page 39 of 42 i) Was inter and intra-agency communication and information sharing by or involving your agency sufficient and appropriate, and are there any gaps evident and can you identify any learning? j) Can you identify any issues in regard to the capacity of your service resulting from your review of the three cases? k) Even in the most difficult of circumstances there can be examples of good practice. Can you identify any in your own service or with any other organisation? l) Comment on any changes that have already been made that make it less likely that the perpetrator would be able to remain undetected or any changes that you believe are still required to improve the detection and protection of children from similar poor care and abuse CONFIDENTIAL Page 40 of 42 6 Summary of the relevant legal and regulatory arrangements 1. A system of statutory checks and ongoing oversight arrangements of the child’s care and progress are intended to ensure that care is not just safe but that it nurtures the overall development of the child. The arrangements that are now in place in 2018 for the approval, monitoring and care of children are more rigorous and extensive than when the perpetrator was first approved in 1988. 6.1 Supervision, support and review of foster carers 2. Foster carers have a central role in providing the family based care that is so critical for providing security, stability and a strong sense of identity to children who have often suffered great adversity in their lives. The foster carer is one of the people who will spend the most time with a child and the nature of the role means that much of that contact is done within the privacy of the carer’s home and out of sight of any professional. 3. Once a foster carer is approved they will be agreeing to provide care in line with national and local standards and will have a social worker who is responsible for supervising and supporting them in their role as foster carers. The expectations of that supervision role are spelt out in standard 21 of the Fostering Services; National Minimum Standards in England. This includes; a) Each approved foster carer is supervised by a named, appropriately qualified social worker who has meetings with the foster carer, including at least one unannounced visit a year. Meetings have a clear purpose and provide the opportunity to supervise the foster carer’s work, ensure the foster carer is meeting the child’s needs, taking into account the child’s wishes and feelings, and offer support and a framework to assess the carer’s performance and develop their competencies and skills. The frequency of meetings for short break foster carers should be proportionate to the amount of care provided. Foster carers’ files include records of supervisory meetings. (21.8) b) There is a good system of communication between the fostering service social workers and the child’s social worker. The fostering service social workers understand the role of the child’s social worker and work effectively with them. (21.12) 4. As part of the routine support and supervision, the foster carer is subject to reviews that are described in regulations and statutory guidance the latest version of which is regulation 28 of the Fostering Services Regulations 2011 as being at least once a year. These regulations were in force at the time of the 2011 allegations made by Grace. In conducting the annual review the fostering service must seek and take into account the views of the foster carer, the child placed with the foster carer and the placing authority (the child’s social worker). The review has to determine if the foster carer continues to be suitable to provide care and the terms of the approval. 5. The later sections of the report describe how aspects of the review and monitoring of the perpetrator and his wife were not sufficiently robust. CONFIDENTIAL Page 41 of 42 6.2 Role of independent people 6. There are separate regulations governing the placement of the child which include arrangements for statutory contact with the child in placement by the social worker, holding statutory reviews and for this to overseen by an independent reviewing officer (IRO). Since 2004 all local authorities have been required to appoint Independent Reviewing Officers (IROs) to protect the interest of children throughout the care planning process. The requirement to appoint IROs arose from concerns that looked after children could 'drift', with care plans that either did not meet their needs or were not implemented. Even where care plans had been agreed by a court, they had no ongoing role in ensuring that the local authority put them into practice. Given these concerns, it was decided that every looked after child should have an IRO: an adult with oversight of their care plan and empowered to act on their behalf in challenging the local authority. Although IROs were to be appointed by the local authority, they must be independent from the immediate line management of the case. In April 2011, revised government regulations and statutory guidance about care planning came into force, which (amongst other things) strengthened the IRO's role. 7. The Children Act 1989 (sec 23ZB) requires a local authority to appoint an independent visitor when either the criteria are met or the local authority consider it is in the child’s interest to have an independent visitor. 8. The two main criteria are that it appears that communication between the child and a parent or any person who is not a parent but has parental responsibility for the child has been infrequent; or the child has not been visited (or has not lived with) a parent or any person who is not the child’s parent but who has parental responsibility for the child, during the preceding 12 months. 9. The guidance is explicit that the independent visitor does not provide skilled advocacy in complex matters and draws attention to using specialist schemes operated locally.24. 10. An additional set of statutory arrangements created by the Children Act 1989 and The Children Act 1989 Representations Procedure (England) Regulations 2006 brought in arrangements for children (and other people) to raise complaints or representations about the care of children. The system allows for independent investigation at stage two. 24 The National Standards for the Provision of Children’s Advocacy Services, issued as section 7 guidance in November 2002, set out standards for the commissioning and delivery of advocacy services. The standards provide a framework for the planning, development and review of advocacy practice at all levels. In implementing this guidance, local authorities with social services responsibilities should ensure the standards are followed. Further guidance was issued through The Advocacy Services and Representations Procedure (Children) (Amendment) Regulations 2004 with a focus on children having access to advocacy support as part of the complaints and representation arrangements for looked after children. . CONFIDENTIAL Page 42 of 42 11. Children who are looked after and of school age are expected to receive additional support to promote their achievement and participation at school. Because of the passage of time there was little recorded information in regard to Grace; a fire in 2007 had destroyed historical records. Carey and Lisa were both supported at school with a personal education plan (PEP) and education health care plan (EHCP). 6.3 The local authority designated officer (LADO) 12. The role of the local authority designated officer (LADO) was introduced in 2006 and is set out in Working Together to Safeguard Children (2018) and is governed by the local authorities’ duties under section 11 of the Children Act 2004 and LSCB inter-agency policy and procedures. This guidance outlines procedures for managing allegations against people who work with children who are paid, unpaid, volunteers, casual, agency or anyone self-employed. The LADO must be contacted in respect of any person who has behaved in a way that has harmed or may have harmed a child, possibly committed an offence against or related to a child, or behaved towards a child that indicates that they may pose a risk of harm to children. The LADO has a role in regard to any criminal investigation, enquiries and assessment as to whether a child or children are at risk or are in need of services and in regard to considering whether disciplinary action is indicated. 13. Overarching all of these arrangements are the various Acts, regulations along with statutory guidance described in Working Together to Safeguard Children for raising concerns about a child at risk of harm and for the sharing of information, planning and conduct of enquiries and assessment under section 47 of the Children Act 1989. |
NC045403 | Death of a 1-year-old girl in May 2013 whilst in the care of her mother, recorded as unexplained death but treated as suspicious. Parents grew up in Africa, mother was a naturalised UK citizen, but father was not. History of: allegations of domestic abuse first reported in pregnancy; mother's suggestion that she may put the child up for adoption at birth but later changing her mind; marriage breakdown; and mother moving around with no stable accommodation. Residence Order was granted in favour of father due to fear of mother leaving the country with Child N. The day after the order was granted mother left the country and Child N was found dead in her flat. Issues identified include: need for improved multi-agency management of risks arising from domestic abuse; learning for Cafcass in relation to private law cases, including undertaking a review into how it presents recommendations of a change of residence; engaging fathers in services; and service provision for minority ethnic populations. Recommendations are made for Thames Valley Police, Cafcass, children's social care, health services, and legal services.
| Title: Serious case review into the death of Child N: overview report. LSCB: Oxfordshire Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final 05/08/2014 Oxfordshire Safeguarding Children Board Serious Case Review into the death of Child N Overview Report Oxfordshire Safeguarding Children Board Independent Chair Maggie Blyth SCR Panel Independent Chair Paul Kerswell Independent Overview Report Author Keith Ibbetson Final 05/08/2014 1 Serious Case Review CONTENTS Page 1. Arrangements for the Serious Case Review 2 2. Steps taken to undertake the SCR 7 3. Narrative of key events 10 4. Evaluation of the services provided and the wider implications for professional practice and service provision 39 4.1 Introduction 39 4.2 Was there evidence that the mother might pose a risk of serious harm to Child N? 40 4.3 The pattern of agency involvement with Child N and her parents during the period under review and the nature of the assessments that were undertaken 45 4.4 Assessment and provision made in relation to allegations of domestic abuse 50 4.5 Assessment and provision made in relation to the mother’s mental health 55 4.6 Assessment and provision made in relation to homelessness 55 4.7 The role of Cafcass in private law cases where the residence of children is disputed 57 4.8 The work of agencies with fathers and other male carers 63 4.9 The response of agencies to ethnicity, religion and cultural factors 64 5. Summary of findings and recommendations 65 Appendices I Membership of the SCR review team 69 II Documents and reports considered by the SCR panel 70 III Principles from statutory guidance informing the SCR methodology 71 IV Policy and research documents informing the SCR 71 V Additional single agency recommendations 72 2 1 ARRANGEMENTS FOR THE SERIOUS CASE REVIEW Introduction 1.1 This report was prepared for Oxfordshire Safeguarding Children Board (the LSCB) in order to fulfil the requirements of the statutory guidance Working Together to Safeguard Children 2013.1 The guidance sets out the arrangements for the local interagency review of serious child protection cases. The LSCB is required to undertake the review in order to identify opportunities to improve the provision of services for vulnerable children. This report sets out the findings of the Serious Case Review (SCR). 1.2 In keeping with statutory requirements the LSCB has published the SCR Overview Report in full. Reasons for conducting the SCR 1.3 The SCR concerns the services provided for a child aged one who is subsequently referred to as Child N. In May 2013 Child N was found dead in the flat where she had lived with her mother. 1.4 Child N had been the subject of contested proceedings for residence and contact in the family court between her mother and the father. She is believed to have been in her mother’s care during the last days of her life and her mother is known to have left the UK in the hours following the child’s death. The initial post mortem examination of Child N was unable to ascertain the cause of her death; however it noted that Child N did not have the commonly observed symptoms of unexplained sudden infant death. The death of Child N is therefore being treated as suspicious and is the subject of a continuing criminal investigation. As yet there has been no inquest. 1.5 Working Together 2013 states that the LSCB in the area where the child lived should conduct a SCR when a child has died and ‘abuse or neglect … is known or suspected’.2 The recommendation to hold the SCR was made by the LSCB SCR group meeting in June 2013. Andrea Hickman, who was at that point the Independent Chair of the LSCB, judged that the circumstances met this criterion and made the decision to undertake the SCR on 20th June 2013. Work began at that point to agree the scope and focus of the review. The scope and focus of the Serious Case Review bearing in mind the circumstances of the death and the involvement of agencies with other family members 1.6 The purpose of the SCR is set out in Working Together 2013. It is to provide a ‘rigorous, objective analysis’ of the services that were provided to the child and family ‘in order to improve services and reduce the risk of future harm to children’. The LSCB is then required to ‘translate the findings from reviews 1 HM Government, Working Together to Safeguard Children – 2013. Chapter 4 2 LSCB Regulations 2006 (Regulation 5) 3 into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. 3 1.7 It is the responsibility of the LSCB to determine the scope and focus of the SCR. In its initial discussions the SCR panel agreed that agencies would be asked to consider the following aspects of their practice: How well potential risks to the child arising from parental vulnerabilities had been identified and understood, including possible concerns about domestic abuse, parental mental health, marital conflict and unstable accommodation Whether assessments and decisions had been reached in a timely, informed and professional way The actions taken to safeguard Child N in relation to any identified risks and how effectively agencies had worked - both individually and collectively Whether there had been effective communication and working between agencies in Oxfordshire and those in other local authority areas Whether any safeguarding risks had been identified and acted upon in the private law proceedings in relation to residence and contact arrangements Whether appropriate local single agency and inter-agency procedures and professional standards were in place and were implemented in an effective fashion Whether practitioners were sensitive to the specific characteristics and needs of the child and other family members arising from race, culture, language or religion. 1.8 Individual agencies that had provided services to the family made enquiries about all of these areas. This report summarises the findings of those enquiries and focuses on the matters judged to be the most significant. These findings are set out in detail in section 4 of this report. 3 Working Together 2013 4.1 and 4.6 4 Findings and recommendations 1.9 The SCR has made recommendations to individual agencies or to the LSCB on areas where it found that services could be improved because the findings in this case highlighted a wider weakness in services. In some instances the SCR has produced findings which require further work of the LSCB and member agencies before deciding what action to take. The time period covered by the SCR 1.10 The SCR has taken account of events during the period between January 2011 and May 2013, covering the mother’s pregnancy with Child N and the child’s life. Agencies involved 1.11 The SCR considered the work of the following agencies and contracted health professionals who had the most significant involvement with the family: Children and Family Court Advisory and Support Service (Cafcass) Oxfordshire Clinical Commissioning Group in relation to GP services Oxford Health NHS Foundation Trust - in relation to health visiting and a service providing community based psychological therapies Oxfordshire University Hospitals NHS Trust – which provided antenatal services Oxfordshire County Council o Children’s Social Care including hospital based social workers o Early Intervention Service o Legal Services Northamptonshire County Council - Children, Families and Education Directorate – which had dealings with the family when the mother and Child N lived briefly in Northants Thames Valley Police. All of these agencies prepared individual management reviews describing and evaluating their involvement with the family in detail. Other agencies (all outside of Oxfordshire) which had only very brief contacts with the family assisted the SCR by providing chronologies of their involvement. Engagement with the parents’ solicitors 1.12 The father represented himself throughout the family court proceedings. The mother was represented by two solicitors. There was a break and a change in her legal representation due to the availability of funding from the Legal Services Commission (‘legal aid’). The LSCB approached the solicitor who was representing the mother at the time of Child N’s death in order to seek information about his actions. This would have enabled the SCR to have a better understanding of the advice given to the mother during the latter part of the proceedings. The solicitor told the LSCB that he was unable to 5 disclose information about the case because it was subject to professional privilege, an aspect of common law embodied in Chapter 4 of the Solicitor’s Regulatory Authority (SRA) Principles and Code.4 He had taken specific advice from the SRA on this which supported his understanding. 1.13 The SCR recognises that this leaves a gap in its understanding of events which cannot be filled. This is apparent from Section 4.7 of the report. However it is hoped that the learning from the SCR will be of value to this solicitor and to others working in the family courts. Parallel processes that have impacted on the conduct of the SCR 1.14 Thames Valley Police has conducted a criminal investigation into Child N’s death. The SCR panel has been kept informed of relevant information gathered during the course of the investigation. Careful consideration has been given to the contents of material published by the LSCB and its potential impact on the criminal investigation. Agreed extensions to the normal timescale for completion of the SCR 1.15 The SCR has taken longer to complete than the six months set as a guideline in Working Together 2013. This was largely due to two factors: the impact of the work being taken by agencies in Oxfordshire on another SCR which was being conducted at the same time and delays caused by the need to take account of the progress of the criminal investigation. The Independent Chair of Oxfordshire LSCB has been briefed about the progress of the review. Where it was possible to take action in relation to shortcomings in practice identified during the course of the SCR, participating agencies have done so. Involvement of family members 1.16 The whereabouts of Child N’s mother remain unknown, making it impossible to inform her about the SCR or to involve her in it. The child’s father was informed about the decision to undertake the SCR and invited to contribute. He has done so through an interview with the overview report author. The views of the father about the involvement of agencies are incorporated in the report at relevant points and a number of his concerns are addressed in Section 4 of the report. Agreement of the SCR findings and arrangements for publication 1.17 A draft SCR overview report was discussed by the SCR panel and agreed after amendments. Staff who were had direct contact with the family have been involved in the review and have been offered feedback about their work as the review has progressed. 4 http://www.sra.org.uk/solicitors/handbook/code/part1/content.page 6 1.18 The Overview Report was presented to the LSCB on 28th July 2014 and its findings were accepted by the Board. The Overview Report will be published in full as required by Working Together 2013. 1.19 Other documents prepared by member agencies and for or by the review panel, the notes of interviews with members of staff and family members and the records of service users will not be published or disclosed. 7 2 STEPS TAKEN TO UNDERTAKE THE SERIOUS CASE REVIEW 2.1 Working Together to Safeguard Children 2013 sets out a series of principles that should inform the methodology for SCRs. These are reproduced in Appendix 3 of this report. The review process and methodology 2.2 At the time of Child N’s death, Oxfordshire LSCB and member agencies were involved in substantial work undertaking a SCR in relation to the sexual exploitation of a number of children in Oxford. Given this consideration the LSCB Independent Chair decided that the LSCB would conduct this SCR in line with the method of enquiry set out in the previous (2010) version of statutory guidance.5 This would enable member agencies to carry out a thorough review, in a timely manner, using a familiar approach rather than have to commit substantial additional resources to training members of the review team in an untested review method. 2.3 In order to comply fully with the requirements of current statutory guidance particular care has been taken by member agencies to involve staff in the review as fully as possible in the SCR. 2.4 Paul Kerswell acted as the Independent Chair of the SCR panel. Keith Ibbetson wrote the SCR overview report. Both have substantial experience of conducting SCRs and are independent of the agencies involved in the review. 2.5 A full list of the roles and job titles of SCR panel members is contained in Appendix 1 of this report. Panel team members are experienced clinicians or managers in member agencies or designated health professionals with substantial experience of safeguarding children. None of the panel members had had any previous contact with Child N or other family members. 2.6 The SCR panel team met on 4 occasions in order to review the materials prepared by contributing agencies to evaluate the provision made by agencies and to discuss and agree a report to be presented to the LSCB. 2.7 The overview report findings were circulated to participating agencies for formal comment and agreement before being submitted to the LSCB for discussion and agreement. 5 HM Government (2010) Working Together to Safeguard Children, Chapter 8 8 The framework for making judgements about the actions and decisions of professionals 2.8 Self-evidently there is value in reviewing the history of professional involvement with a child, with an overview of events and knowledge of the outcome. However along with the clarity that hindsight brings the SCR has taken account of the danger of what is termed ‘hindsight bias’. This arises when the evaluation is unduly influenced by knowledge of the outcome because ‘looking back the situation faced by the clinician is inevitably grossly simplified’.6 In the investigation of serious incidents in health services, air accident investigation and other high risk industries the dangers of this are recognised. It is easy to criticise the decisions and actions of professionals because they can now be seen to be part of a chain of events that had a tragic outcome. 2.9 If decisions and actions are judged out of the context in which they occurred it is likely to reduce the value of the investigation. It may also be unfair to the individuals who were involved. More valuable learning can be obtained by seeking to understand and explain why decisions were made and actions taken taking full account of the influences over professionals arising from the circumstances within which they were working. The SCR has therefore sought to take advantage of hindsight whilst avoiding hindsight bias. 2.10 In keeping with this approach judgements about actions and decisions take into account the information that was available to the professionals who took them. At certain points it is necessary to evaluate the overall service provision in relation to information that was known to the network of professionals as a whole or ought to have been available if relevant information had been shared. 2.11 The review has sought to judge the actions of professionals and agencies against established standards of good practice as they applied at the time when the events in question took place. Nevertheless where the actions of individuals, groups of professionals or agencies as a whole are found to fall short of established professional standards this will be stated, together (where it is possible) with an explanation of why that happened. 6 Charles Vincent (2010) Patient Safety (second edition ) Wiley-Blackwell BMJ Books, pages 50-52 9 An organisational or systems approach 2.12 As well as focusing on the actions and decisions of the individuals who were directly involved, the SCR has tried to understand and distinguish the influence of a range of organisational factors in the decisions and actions taken. The additional focus on the team, the service, the agency as a whole and the collective actions of agencies together does not diminish the responsibility of individuals to act professionally and to work effectively. It explains the factors that sometimes make it harder for them to do so. Recognition of strengths in professional practice 2.13 Research points to the value of identifying strengths in practice and ordinary things that were done well. Agencies need to learn from these and promote them as well as learning from shortcomings. When these are judged to be significant, they have been highlighted, either in Section 3 or 4 of this report. Recommendations and challenges to the LSCB and member agencies 2.14 The review has distinguished in its findings between the following: Practical actions that the agency concerned has already or may swiftly act on to ensure compliance with an established procedure or professional approach Firm recommendations that the agency or the LSCB has agreed to implement Areas where more information or research is required before the LSCB can decide what action to take. 10 3 NARRATIVE OF KEY EVENTS 3.1 This section contains a detailed narrative of the main professional contacts with family members and events reported to professionals. In Section 4 key episodes are evaluated in more detail where this assists in understanding important aspects of the provision made for Child N and her family or where it offers an insight into the wider working of safeguarding services. Contacts with agencies prior to the period under review 3.2 In 2010 Child N’s mother and father made a joint application to Oxfordshire County Council to act as carers for vulnerable adults under a project known as ‘Shared Lives’. They were approved following the normal assessment process and two vulnerable adults spent short respite periods in their shared household. After this trial period they decided not to continue with this work. One of the stays ended ahead of schedule but there was no indication of any concern about the couple’s conduct. This occurred some 12 months before the birth of Child N and is not considered to be relevant to main findings of the SCR. Information about this was not known to the local authority children’s service during its involvement with Child N and her parents because records of it were stored on a separate adult services database dealing with carers. As there might be occasions when information such as this would be relevant to children’s services the local authority has agreed to review its arrangements for checking the ‘Shared Lives’ database when undertaking an assessment of a child’s circumstances. The local authority has adopted a recommendation in relation to this. 3.3 In May 2010 an allegation was made against the father who at that time was employed as an agency worker in a residential school. This was investigated by the police who decided that there were no grounds for further action. The police judged that the allegation did not meet the criteria for reporting to the Local Authority Designated Officer (LADO) – who should coordinate the response to allegations of abuse against those working with children in a professional capacity. Again agencies dealing with the Child N subsequently had no knowledge of this event. This incident occurred 18 months before the birth of Child N and was judged by Thames Valley Police not to require further action as a criminal matter or under inter-agency safeguarding arrangements. There is no indication that this was not a legitimate judgement. Nor is there any indication that it adversely affected the way in which Child N’s circumstances were dealt with. There is no evidence or reason to suspect 11 that Child N was ever caused any harm by her father. The parents’ personal background and family history 3.4 The mother is approximately 40. She grew up in Africa but had lived for almost all her adult life in the UK and was a naturalised UK citizen. The father is in his mid-thirties. He grew up in a different part of Africa and he is not a UK citizen. None of the agency reports state the date of the parents’ marriage. There is no significant background information in the GP health records about either parent. Neither parent had a criminal record in the UK. 3.5 In general agency records contain descriptions of contemporary events but very little background information about either the mother or the father. There is no work or social history and there is almost no information about either parent’s life in their own family or country of origin, or their reasons for coming to live in the UK. The lack of background information obtained by agencies and the reasons for this are discussed further in Section 4.3. This describes the nature of the various assessments that were undertaken by the agencies involved and considers why they obtained so little information about the parents. Professional involvement with the mother during her pregnancy 3.6 In early January 2011 the mother was referred for antenatal care by her GP. She stated that she was very happy to have conceived. The referral contains no significant medical or social information. 3.7 In February 2011 the mother attended her antenatal booking appointment at John Radcliffe Hospital. At the first appointment the midwife undertook a medical, obstetric and social assessment. This highlighted some medical concerns making the pregnancy ‘high risk’ from a medical perspective and requiring monitoring by the Consultant Obstetrician. 3.8 The assessment dealing with social issues scored the mother as being ‘low risk’. This assessment had included standard enquiries about any history or current concerns about domestic abuse, to which the mother answered ‘no’. The mother gave details of the father’s identity and reported that he was involved and supportive, even though the couple were now separated. There is no record that the father attended and it is assumed that he did not as the questions about domestic abuse would not have been asked in his presence. 3.9 The mother later gave 15 March 2011 as the specific date of her separation. This contradicts the information provided at the booking appointment. It is not clear if she was providing misleading information on either occasion or was simply mistaken. 12 3.10 The GP and community midwife subsequently shared routine aspects of the mother’s medical care, entering information on the mother’s hand-held antenatal care record with basic details also entered into the mother’s GP records. This is normal practice. The mother attended the scheduled appointments and followed treatment suggestions and plans. The mother was also reviewed by the hospital consultant on three occasions prior to the birth because of the potential medical complications. 3.11 Midwives did not record details of whether the father attended each appointment because they were not expected to do so. They remember the father attending some appointments at the hospital, but not the majority. Midwives have no specific recollection of his attendance at the children’s centre where the community appointments were held. The question of how professionals relate to fathers during pregnancy and early childhood is considered further in Section 4.8. 3.12 On 14 April 2011 the mother went to a police station and reported having had an argument with her husband in which he had shouted and screamed at her. This was categorised as a domestic incident and a risk assessment was carried out using the standard format employed by Thames Valley Police.7 The assessment questions ‘prompt’ for information about aspects of the incident that could point to a higher level of risk. The mother reported being frightened and it was noted that she was pregnant and that the couple had separated during the past year (all of which are factors found in research to raise risks associated with domestic abuse). 3.13 The incident was classed as ‘no crime’ (because there was no allegation of any crime) and the risk assessment was passed to the police force Domestic Abuse Investigation Unit (DAIU) in order to screen the details of the incident and establish what information (if any) needed to be shared with other agencies. Noting that there had been no criminal offence alleged or committed but also noting that the mother was pregnant the DAIU assessed the risk as ‘standard’ and arranged for emails containing summaries of the incident to be sent to the local authority (children’s social care) and the maternity service. 3.14 Oxfordshire County Council social care service reviewed and noted the incident and decided to take no further action. 3.15 The hospital antenatal service has no record of having received this notification and as a result it did not become part of the hospital’s records. Records have been thoroughly reviewed and the trust cannot identify the reasons for this. The management report provided by Thames Valley Police has identified a 7 This is the DASH- CAADA Risk Identification Checklist template which is the standard approach used in most police forces and many other agencies nationally 13 number of aspects of the response made to this domestic abuse report and subsequent ones which did not fully comply with its internal procedures. None of these are considered to be significant in relation to the overall findings of the SCR. They have led to a number of internal recommendations which are set out in detail in Appendix 5 of this report. On the basis of the information available to the local authority at this point the SCR takes the view that there was no need for the local authority to seek further information about the circumstances. However it is noted that the local authority would have assumed that the maternity service had received the notification (because that was the standard procedure) and would be able to take that information into account in its further contacts with the mother. Section 4.4 of this report evaluates the response of agencies to reports of domestic abuse in detail. 3.16 On 4 May 2011 the mother phoned the local authority’s social work service based at the hospital and spoke to a trainee social worker. The mother stated that she was 23 weeks pregnant and wanted to discuss relinquishing her baby. An appointment was made for the following day, which the mother did not keep. 3.17 During a second phone call two days later the mother spoke to the same worker about domestic abuse saying that she had recently reported it to the police for the first time and that it was ‘getting worse’. During the call the mother alleged that her husband had ‘only married her to remain in the country’. However, the mother had no current concerns about domestic abuse telling the worker that the father was no longer speaking to her and that the locks on the former family home had been changed. 3.18 The mother was seen by the same worker for an initial assessment on 14 June 2011. By this time the worker had access to the police notification of the alleged incident on 14 April 2011. The mother stated that the main reasons for considering giving up her baby were her financial insecurity and her desire for the baby to have the kind of stable family life that she had experienced; however prior to her separation she had been relishing the prospect of becoming a mother. The worker formed the view that the mother was an intelligent and articulate woman who already had an emotional attachment to the unborn baby. 3.19 During the assessment discussion the worker provided advice about financial and practical supports that might be available to address the mother’s concerns and enable her to bring up the child, including social contact with other new mothers and parents mothers. The mother was given some informal advice and advised to see a solicitor over the custody of the baby. 14 3.20 Initially it was agreed that the worker would make a follow up visit prior to and after the birth of the baby in order to see that arrangements were in place. In the event following further positive phone contacts the worker – having written up her assessment and twice consulted her supervisor – decided to close the case and offer further contact if the mother requested it. 3.21 During these contacts no checks were made of other agency records and no information was provided to the midwives in the antenatal team. This contact is evaluated in Section 4.3 of the report which deals with professional assessments. 3.22 On 23 August 2011 the father phoned the police and stated that during a phone call the previous night the mother had started screaming and shouting at him. He explained that she was heavily pregnant. He was concerned that she might call the police and make trouble for him. He believed that he had been offering practical support to the mother. He stated that he intended to contact his solicitor about the situation the following day. The father told the SCR that he had a particular concern that he was very vulnerable to a false allegation of domestic abuse because of his job in a caring profession and his immigration status and that this was why he had contacted the police before the mother could. 3.23 Police officers visited the father the following day and undertook a risk assessment along the standard lines set out in Section 3.12 above. This revealed an additional comment by the father that the mother had threatened suicide two years previously. 3.24 Records of the contact were reviewed by the Thames Valley Police DAIU which agreed with the grading of the contact as ‘standard’. On this occasion no notification was made to the local authority. The Thames Valley Police management review has commented on this episode and identified some learning for the police service. In particular it highlights possible learning about the value of 1) investigating historic allegations of crimes – even if they are minor and tenuous and 2) seeing both parties in a dispute to obtain a full account and give advice. The fact that this was not done in this case has no bearing on the final outcome. Overall the SCR has found that the police reacted in a thorough way and operated a low threshold in response to episodes that most people would consider barely constituted domestic abuse. Section 4.4 of this report addresses the wider problem of how agencies should view current approaches to domestic abuse, especially in relation to 1) those incidents that are less serious but fall within current definitions 2) whether agencies attempt to see both parties or seek additional information 15 in order to corroborate accounts. 3.25 With the exception of the mother’s routine involvement with the antenatal service there was no further professional contact with the mother or father prior to the birth of Child N. Early weeks 3.26 Child N was born in September 2011. The delivery was uneventful and she was in robust health. There were six follow up contacts with midwives in the community, during which no significant problems were identified and the infant was noted to be thriving. 3.27 Health Visitor 1 made her primary birth visit (the first home visit to assess the needs of new born child and family circumstances) on 5 October 2011. This covered routine areas of advice about the child’s health and the mother was signposted to a range of services. It was noted that the mother had ‘some good support networks’ but it was not recorded what that meant. The mother was advised to attend the local child health clinic and other services. 3.28 Aside from a minor medical complaint there were no significant professional contacts with Child N or the family during the remainder of 2011. The baby was taken to the 6-8 week health check which was noted to be positive. Routine immunisations were given. Application for Prohibited Steps Order and subsequent court decisions: December 2011 – May 2012 3.29 On 15 December 2011 the parents attended a mediation session as part of an attempt to arrive at amicable divorce arrangements. 3.30 The notes of the session indicate that this was the first time that the parents had agreed contact arrangements. Until the New Year there would be two contact sessions per week (but flexibly arranged – presumably because of the holidays). Subsequently there would be two four-hour contact sessions per week at specified times at the father’s home. Neither parent made allegations of domestic abuse in the session. 3.31 The mother was considering taking Child N to her country of origin to meet her family. At this point the father indicated his agreement to this provided that it was only for a month. The mother also stated that she was experiencing some financial difficulties, in particular funding the mortgage on the family home. She was to seek advice about her eligibility for state benefits. Consideration was to be given to the financial support that the father should provide. 3.32 Subsequently the mother spoke to a Community Staff Nurse (CSN1) who was a member of the Health Visitor’s team to report her fears that the father ‘may be thinking’ about taking Child N out of the country. The mother referred to ‘general’ comments and threats made by the father, but there 16 were ‘no physical threats’ and ‘nothing to go to the police with’. This had not been noted in the record of the mediation session. 3.33 CSN1 advised the mother of agencies who could offer relevant advice and consulted Health Visitor 1, who decided that no additional action was required. 3.34 On 1 January 2012 the mother phoned the police and reported that the father had been threatening and aggressive towards her at her home. The police attended and found only the mother there. There was no sign of injury or damage to property. Officers completed the same standardised information gathering exercise during which the mother offered the additional information that the father had previously threatened to commit suicide. The officers assumed that the father had been present and had left and gave the mother advice on how to make better contact arrangements. They did not attempt to see the father to verify the mother’s account or offer advice. 3.35 Police records indicate that details of the incident were forwarded to ‘all child agencies’ though those agencies were not listed. The SCR has confirmed that only the local authority received the notification. The Thames Valley Police management review has noted that in the circumstances (this was the third reported domestic incident in 8 months) it would have been wise to see the father in order to give him advice. With hindsight and in the light of all the information available from other agencies doing so might also have served to test out whether the incident had happened in the way that the mother had described (or even whether it had occurred at all). It would certainly have highlighted some aspects of the mother’s account that were not consistent with the facts and with versions given to other agencies. It is not possible to be certain which agencies were notified but if an alert was sent to health agencies it is further evidence that the arrangements for alerting health agencies of domestic incidents were not reliable as this was the second of two alerts in this case which had not successfully become part of health service records. This is addressed in Section 4.4. 3.36 The local authority initially decided to take no action, but the decision was reviewed by a senior practitioner who decided that the case should be ‘monitored’ because of the baby’s age and vulnerability. This meant that it was recorded on the file that should there be another domestic abuse referral enquiries would be made, even if it were not an incident that in its own right would normally merit that response. In making the decision not to seek to be actively involved the social care service is likely to have assumed that the health visiting service – which would have been in contact with Child 17 N – would have received a copy of the same notification, though this had not happened. 3.37 During the following month the mother took Child N to two baby groups at a children’s centre, before ceasing to attend. On 20 January 2012 the father made an application for a Prohibited Steps Order (PSO) in order to prevent the mother from taking Child N out of the jurisdiction of the court.8 His supporting statement claimed that the mother was preventing him from having the agreed contact. The application did not raise any safeguarding concerns or mention allegations of domestic abuse. 3.38 The court heard the application at a Directions Hearing on 23 January 2012 and granted the PSO. At this point Cafcass was notified of the proceedings and the requirement to undertake safeguarding checks prior to a scheduled full hearing. These were undertaken promptly. During the course of telephone contacts the mother advised a member of Cafcass staff that she had stopped the contact because of the heated arguments between the parents which she did not want Child N to witness. 3.39 The Cafcass officer categorised this as a case of possible domestic abuse and as a result initiated the enhanced checks required by family court private law proceedings practice guidance. These revealed the information held by the police and the local authority already set out in this report which Cafcass subsequently made available to the court. In doing so Cafcass made clear to the court the limited value of such checks when either party had lived in the UK for only a limited time. 3.40 According to information which she provided to Oxfordshire children’s social care in May 2012 the mother rented out the former family home on 12 February 2012 as she could not pay the mortgage. She said that from that date she and Child N had moved to live with friends in Northamptonshire. It is not possible to verify this information and in the agency records there is no account of the mother living anywhere other than at her established address until May. 3.41 The next significant court date was on 4 April 2012. Prior to this the mother contacted her Health Visitor and (in effect) asked for a reference, stating that the father was alleging that she was not a fit parent and asking her for a report to the court. The advice of the Named Nurse for Safeguarding was that in a private law case the trust would not provide a report unless it was requested by the court. 9 The Health Visitor emailed the mother to tell her this. 3.42 At the hearing the court made Child N a party to the proceedings. The case was transferred to the Family Division of the High Court to be heard by a more senior judge, largely as a result of the international dimension to the 8 Section 8, Children Act 1989. This enables the court to prohibit a person from taking any specified action in relation to the child 9 A specialist child protection advisory post in the health trust 18 case. The court directed Cafcass to appoint a Children’s Guardian to report on the merits of an application made by the mother to take Child N to her country of origin, the progress of contact and any other pertinent welfare issues. The report was to be filed by 4 July 2012. 3.43 Cafcass allocated responsibility for the work to a Family Court Adviser (FCA 3) the following day.10 However she did not have the space in her caseload to begin work on it in earnest for some weeks. A solicitor was appointed by FCA3 to represent Child N’s interests independently of the views of the FCA. Both remained involved in the case until the death of Child N. 3.44 At the court hearing on 4 April 2012 the judge ordered that contact should take place each week at a contact centre (which would provide a neutral venue, but no observation or assessment of the contact arrangements). The parents were asked to file statements for a future hearing; including proposals for contact should the mother take Child N to her country of origin. The decisions of the court and Cafcass at this stage were consistent with the case law and practice guidance. The appointment of the FCA as the Children’s Guardian being particularly relevant to a case with an international dimension. It is important to recognise that neither party in the proceedings raised concerns about safeguarding in relation to Child N. The father was concerned that at certain points the mother’s care of Child N was less than satisfactory because she had no permanent home; however his main concern about this was his belief that the mother was using this as a ploy to disrupt contact arrangements. There is evidence from phone calls made to the child’s solicitor of the Guardian planning her assessment so as to take account of the potential international complexities, the significance of Child N maintaining a relationship with both parents and the previous allegations of domestic abuse. The case had been categorised as one which featured domestic abuse as a result of reports of low level incidents which might be indicative of a larger problem and so merited more detailed background checks. This was an entirely correct approach in the circumstances Contact with agencies when the mother and child had no stable accommodation: 3 – 31 May 2012 10 A Family Court Advisor is a Cafcass employee who provides advice to the court (sometimes in the form of a written report). FCA is a job title. In this case the FCA was appointed as a Children’s Guardian. Children’s Guardian is a legal term with defined responsibilities appointed by the courts. To simplify matters the member of staff concerned is subsequently referred to by the abbreviated job title FCA. 19 3.45 On 3 May 2012 the mother registered herself and Child N at a GP practice in Luton. Initial health screening was undertaken by the Practice Nurse who noted relevant medical information. The mother gave a local address and indicated that she was a single parent, staying in the town temporarily. There were no concerns about Child N and GP routinely alerted the child health database in order to notify the health visiting service. There was no further contact with this surgery and the patient was deregistered on 16 June 2012 when the mother registered at a new practice. 3.46 Between 14 May and 2 June 2012 the mother was reported to have moved with Child N between a number of different addresses and locations. The following paragraphs reconstruct events and contacts with professionals as they were known at the time to the professionals involved. 3.47 On 14 and 15 May 2012 the mother had telephone contacts with the social care service in Luton. She said that she was moving between different locations and planned to stay with a friend in Cambridge and that she would then be returning to seek accommodation in Oxfordshire. Her initial contact was with the Luton out of hours service and she did not keep appointments offered with the normal duty service the following day. 3.48 On 15 May 2012 the mother informed FCA3 that she had been sleeping in her car with Child N. She was homeless as she had been staying with her brother in Luton, but they had had a dispute. Her intention was to send for money from her family to buy a ticket to travel to her country of origin. FCA3 advised her to present herself at a police station and seek accommodation, but the mother said that she would be staying with a friend in Cambridge. 3.49 A Luton social worker (who had spoken to the mother on the phone but not met her face to face) discussed the circumstances with FCA3 who undertook to make a safeguarding referral to Oxfordshire children’s social care. The referral was made on the morning of 16 May 2012 and copies were sent to the local authorities in areas where it was understood the mother had stayed or visited over recent days. It was completed on a Cafcass template for child protection referrals headed ‘URGENT Referral for Child Protection Services under Section 47 of the Children Act (1989)’; however the content related to the lack of stable accommodation. 3.50 FCA3 also notified the court of her concern and considered asking the court to insist that the mother surrender her passport because of the perceived risk of her fleeing the UK. 3.51 During this time FCA3 was given different information by the parents about contact arrangements. The father said that there had been no contact for substantial periods and the contact that had taken place was unsatisfactory as the mother forgot to bring basic items that he needed for Child N. The mother said she also wished to avoid confusion and possible breach of the court order by confirming which venue should be used for contact. 20 3.52 At about midday on 16 May 2012 the mother took Child N to a children’s centre in Luton where she was seen during a child health clinic. The health visitor had details of the GP registration in Luton referred to above. Height, weight and head circumference measurements were taken. No concerns were noted and the mother said that Child N had previously had her developmental check-up. 3.53 Later the same afternoon the mother presented at the Oxfordshire County Council social care office in Oxford. She described her recent stays with relatives and reported that she had stayed in her car the previous evening. The mother was told to go to the Banbury team office (which covered her previous home address) and to try to make temporary arrangements pending her tenants being given notice to quit the former family home. The mother later phoned the Banbury office and was advised to seek temporary housing. She agreed to present herself to the District Council office as homeless. The District Council had responsibility for housing assessments. 3.54 Oxfordshire County Council closed the social work contact a few days later on the grounds that the only concerns expressed had related to homelessness, over which the authority could not take further action. The District Council housing officer referred the mother to a women’s refuge in Luton which decided not to offer her a place on the basis that there was no actual evidence of any imminent risk of domestic abuse. The social care management review has noted that the staff involved responded in a limited way by treating the contact with the mother as being exclusively about housing issues and not assessing any potential risks to Child N caused by the mother’s mobility. The review recognises that this was the approach that staff generally feel a pressure to adopt and that this may create difficulties when there is a potentially vulnerable child involved. This is considered further in Section 4.6. 3.55 On 18 May 2012 the father phoned Thames Valley Police to express his concern about recent events and report that the mother had threatened that she would take Child N to her country of origin so that he would never see her again. The police established the mother’s whereabouts and Hertfordshire police visited the hotel where she was staying to check on the child’s wellbeing, reporting back that there were no concerns. 3.56 The mother next had contact with professionals at the family court on 24 May 2012. It is not clear where Child N and her mother spent the intervening eight nights. The mother later told Oxfordshire social care that she was staying with a friend in Northamptonshire and that she stayed for some time at the hotel. She subsequently admitted that she had never slept in her car, though she had come close to doing so. At the court hearing orders were made for the mother to surrender her passport and for weekly contact. The 21 father made clear his intention to apply for a Residence Order (which would mean that his daughter would live with him and that he would have control over the main decisions about her). FCA3 was instructed to address this issue in her assessment and report. 3.57 On 28 and 29 May 2012 there were a large number of phone calls between Oxfordshire children’s social care, the FCA, housing services managed by a district council and a women’s refuge in Northamptonshire in order to establish the whereabouts of Child N and her mother and to seek to provide suitable accommodation and advice to the mother. The mother refused the offer of a refuge place. The mother was offered but did not take up a further duty contact with the local authority social care service in Oxfordshire. 3.58 During this period the FCA and Child N’s solicitor discussed whether it would be necessary to ask the court to make an order under Section 37 Children Act 1989 requiring the local authority to assess Child N’s circumstances and the potential need for a Care Order to safeguard her. Court decision to make an Interim Care Order 3.59 By 31 May 2012 the mother and Child N were living in privately rented accommodation in Northamptonshire. At a court hearing that day the judge made a direction under Section 37 Children Act 1989, instructing the local authority to undertake a detailed assessment of Child N’s welfare. The judge viewed the mother as being a ‘flight risk’ due to her failure to hand over her passport. He determined that he had found her to be unreliable in her accounts and felt that the care of Child N had been inconsistent. He accepted at face value accounts of the mother and child sleeping in a car. Very unusually the judge also made an Interim Care Order, despite the fact that neither the local authority nor the FCA had sought such an order. He gave the local authority the power to remove Child N immediately if judged necessary. 3.60 Oxfordshire immediately asked Northamptonshire children’s social care to make a welfare visit to check that Child N was not at immediate risk and notified various agencies of the need to prevent the mother from leaving the country. Oxfordshire also sought to find ways of preventing the mother from removing Child N from the country, which had been a major concern of the court. It established that none of the agencies concerned (such as the Border Agency) could ‘flag’ individual details in a way which would have prevented the mother from leaving the UK unless specific travel plans (such as a flight number) were known. 3.61 Northamptonshire social care service did not undertake the welfare visit because the local service decided that it did not have sufficient capacity and could not prioritise the task. The Northamptonshire County Council review of this episode has found that whilst this judgement was properly considered it gave insufficient weight to 22 the potential risks to a child about whom the authority had no direct knowledge and was not justified by the other pressures on the service at the time. A visit should have been made. 3.62 Thames Valley Police did make contact with the mother and Child N later that day, though the mother refused to disclose where she was living. The next day two members of social work staff from Oxfordshire social care visited the mother in Northamptonshire after she disclosed her address. There were no immediate concerns about Child N and the mother signed a written agreement that she would remain in her current accommodation and participate in the assessment ordered by the court. 3.63 On 6 June 2012 the mother surrendered Child N’s passport to her solicitor and registered with a local GP. The Oxfordshire children’s social care Team Manager directed a Senior Practitioner to begin an assessment in order to present a report to the court hearing scheduled for 22 June 2012, providing specific guidance as to how to undertake it. Contacts with children’s centre and health services in Northamptonshire during June 2012 3.64 On 11 June 2012 Child N was seen by a health visitor at a drop in clinic. The mother said that she had recently moved to the area and gave details of her circumstances (i.e. that she had wanted to take her daughter to the mother’s country of origin but this was being prevented by proceedings in the family court). The health visitor was satisfied with Child N’s development and presentation and the mother’s account of her feeding and behaviour and allocated her to the universal service (contacts would be determined by the mother and take place at the child health clinic). Enquires were to be made about a further immunisation linked to the mother’s proposed travel plans. 3.65 On 15 June 2012 the health visitor was informed by the local children’s centre that Child N had been made the subject of an Interim Care Order. The police had made a welfare visit and that – apart from financial worries – no immediate concerns had been identified. On her next working day (18 June 2012) the health visitor made contact with Oxfordshire social care and the allocated senior practitioner explained the reasons why the interim order had been made. She stated that Oxfordshire social care had no concerns about the parenting that was being provided by the mother. There had been concerns about the lack of stable accommodation and the mother had been strongly advised to find permanent accommodation, which she had now done. 3.66 The health visitor heard from Oxfordshire social care on 25 June 2012 that the court had decided not to make any further order that required the local authority to be involved and that Oxfordshire would confirm this in an update to Northamptonshire social care. The health visitor contacted the mother to 23 discuss the outstanding immunisation and she said that she would not continue with it at this point as she had not realised that she would have to pay for it. The health visitor confirmed that she had made an application for a financial grant under the Healthy Start programme. The health visitor’s next involvement was in July 2012 when Northamptonshire social care undertook a child protection enquiry. Local authority core assessment 31 May - 22 June 2012 3.67 The Senior Practitioner saw the father on 7 June 2012. This was the first face to face contact that he had had with the local authority. He gave background information about the parents’ relationship, which had begun in 2007, stating that the marriage had broken down due to the mother’s controlling and bullying behaviour and her dishonesty. His account was that he had separated from her during the pregnancy (early 2011) but remained supportive. 3.68 The account given by the father to the SCR in early 2014 was entirely consistent with this record. 3.69 The father’s view was that the mother’s behaviour had deteriorated in November 2011 because she had discovered that he was having a relationship with one of her neighbours and it was suggested that this person might play some role in Child N’s life by child minding her. Since then contact had been very difficult with the mother cancelling visits at short notice and mediation had been unsuccessful. The father alleged that the mother had subsequently disregarded court orders and placed numerous obstacles in the way of him spending time with his daughter. 3.70 The father explained his understanding of the financial position and the support he provided. His view was that between his support and the mother’s benefits there was sufficient money for the mother and child to live comfortably. He denied ever having behaved abusively towards the mother. 3.71 The worker was satisfied that Child N was genuinely at the centre of his concerns. As the cause of concern in the case was framed as being about 1) relationship difficulties between the father and mother and 2) there was no evidence that Child N was at risk of immediate harm, the social worker noted that the father had not been observed with his daughter so the quality of the relationship had not been assessed but recorded that she ‘could see little advantage’ in the Interim Care Order remaining in place. 3.72 This constituted the initial assessment. The local authority decided at this point that there were no grounds for an application for the local authority to seek a Care Order and that the concerns could be resolved satisfactorily within the private law proceedings. This decision was made prior to the completion of the core assessment. The timing and implications of this decision are considered further in Section 24 4.3 which considers this assessment further. 3.73 At this point the social worker sought legal advice. Despite the social worker reporting that the mother’s interaction with the child was ‘brilliant’ the County Council legal advisor confirmed that the local authority was required to complete the Section 37 report for the court. 3.74 During the course of the core assessment the social worker had contact with or received information from the following individuals and agencies: Children’s Centre Health Visitor Contact centre The parents Citizen’s Advice Bureau (CAB) A member of the mother’s extended family 3.75 The Health Visitor informed her that when Child N was an infant the family had received a ‘universal’ service and that there had been no concerns. 3.76 The children’s centre listed the activities that the mother and child had attended but as she had been using universal services, rather than a targeted individual support programme, there were no detailed records of contacts.11 There were no records of any concerns at all about Child N. 3.77 The Children’s centre Manager passed on information that had been provided to the centre by the CAB about the mother’s financial difficulties; her housing problems; the mother’s aspiration to take Child N to her country of origin and the support and advice that had been provided. It was reported that Child N was clean and well presented and that there was a ‘beautiful bond’ between the mother and her child. It was noted that the mother appeared to listen to advice offered. 3.78 Entries in records show the social worker trying unsuccessfully to phone other professionals who were for one reason or another not in their offices or at work. A number of pieces of information were obtained by the social worker on 21 June 2012, the day before the court hearing but after the written report based on the core assessment had been submitted to the court. 3.79 There was no successful contact with the GP surgery, though it is clear from the GP records now available to the SCR that there would have been nothing negative to report had contact been made. The relevant health records would also not have been at that surgery as they would not at that point have arrived from the mother’s last GP in Luton. 11 Between July 2011 and January 2012, the mother had taken Child N to: 2 parent craft group; 3 mediation sessions at Bicester Mediation Clinic; 2 baby groups; a baby weighing group and the “breast feeding café” (once). There had been one introductory visit to the family home which was a standard part of the universal provision. 25 3.80 The contact centre (which was run by a local church) stated that its role was not to provide an assessment and that it needed to remain ‘neutral’ in its dealings with the parents. However it had identified no concerns about the child or the contact. 3.81 The records show that the mother was not interviewed again because she could not attend appointments offered, though there were email and phone contacts. The social worker planned to conduct an ‘observational assessment’ of father and child together but this did not happen because the social worker had a period of leave and the father was unavailable on the days that the social worker suggested. 3.82 The core assessment was completed and authorised on 18 June 2012. It concluded that because she had moved so often the mother had failed to provide her daughter with a secure and stable environment. She had failed to comply with court directions and appeared not to be taking the court proceedings sufficiently seriously. Financial pressures if not managed would adversely affect Child N’s basic care. 3.83 The assessment also highlighted the apparently strong emotional attachment between mother and child. It noted that the mother had cooperated with the social care assessment team and had prioritised Child N’s needs. The father told social care that he believed that mother had moved around in order to create obstacles to him seeing his daughter and reported his fear that the mother would remove Child N from the country. He alleged that the mother was dishonestly manipulating professionals in order to get the outcome she wanted. 3.84 The overall assessment was that Child N’s physical, health and emotional needs were being met whilst in her mother’s care and that she was not at risk of significant harm. 3.85 On 21 June 2012 the social worker had a conversation with a man who was said to be the mother’s uncle. He said that he had provided support since her brother had asked her to leave his home and that he had visited the mother and Child N. He confirmed that his niece took excellent care of her daughter and that he would contact the local authority if he had any concerns. He suggested that the father was placing undue pressure on the mother. He was firm in his opinion that there was no reason to remove Child N from the mother’s care. 3.86 The findings of the core assessment were presented to the court on 22 June 2012. The local authority also reported the actions planned by Oxfordshire social care in order to share information with services in Northamptonshire (where the mother was now living) which would remain in touch with the family. The judge thanked the local authority for providing a thorough assessment in such a short time. 3.87 Oxfordshire social care staff wrote to the agencies in Northamptonshire and on 25 June 2012 Oxfordshire closed the case. The parents were told this. 26 The father expressed his dissatisfaction at the outcome because he felt that the mother had been dishonest and misleading. 3.88 The following day the FCA observed a contact session between Child N and her father. Her observation was that this had been very positive and there was clearly a good relationship between them. As a result the FCA filed a recommendation for the contact to be changed to a three hour, unsupervised session. 3.89 There was no significant professional contact with the family for the next four weeks. Episode of possible abuse or neglect in Northamptonshire 3.90 On Thursday 26 July 2012 the mother’s landlord reported to Northamptonshire social care that 2- 3 weeks previously she had left Child N alone in the flat without supervision; he also said that the baby had no cot and had bruises caused by falling off the bed. A telephone strategy discussion the same day between Northants Police and the local authority led to the decision that Northants social care would pursue this as a single agency investigation. 3.91 An urgent home visit was made during which the mother admitted that she had left the baby alone – but that it was for only a few minutes and the landlord had been in the property for the whole time. The episode was categorised as ‘concerns substantiated’ (as the event had been admitted) but the mother had promised not to repeat her behaviour. This was treated as an acceptable outcome in the absence of any other current concerns. 3.92 At no point was consideration given to the bruising mentioned in the referral. 3.93 The Northants social worker involved contacted Oxfordshire at the beginning of the following week seeking background information from the core assessment previously conducted, which was provided over the phone. This was recorded by Northants as offering positive views on the mother’s parenting. The local authority also made contact with the Northamptonshire health visiting service and the local children’s centre. The health visiting records refer to discussions about Child N being left alone ‘for ten minutes’ and falling out of bed. The health visitor noted that she had shared information from her notes with the local authority. She gave details of the GP and suggested that the social worker made contact. 3.94 As a result of the visit and the discussions with other professionals Northamptonshire decided to take no further action. Letters were written to the mother, the health visitor and to the Children’s centre confirming this. No information about the reported incident was provided to Cafcass (which the authority knew from its earlier contacts had been involved). The SCR is concerned that the investigation focused exclusively on the 27 episode when the baby had been left alone and did not address the reference in the referral to bruising. The contact with the health visitor refers to Child N ‘falling out of bed’ which strongly suggests that the landlord’s explanation for the bruises had been accepted. The mother admitted leaving the child alone and said she regretted it. There is no account given about whether the child had had bruises and if so how they had been caused. Even though this was said to have happened some days before the referral and even though the referrer gave an account of how he thought it had happened, it should have been recognised that the presence of bruising on an infant under the age of one (even one who could crawl and walk and so might have caused the bruises accidentally) was a potentially concerning presentation. The authority has told the SCR that it cannot find a reason for this happening, other than the fact that it was not considered. The staff involved were experienced and knowledgeable and the office was not one that was unduly busy making it hard to explain that this was anything other than an oversight leading the staff to focus on just one of the presenting problems. In the context of the review as a whole however this is an important and concerning episode, since this is the only point in the case history when there was any professional knowledge of a sign or symptom that might have been indicative of physical mistreatment of Child N while she was in her mother’s care. The SCR is also concerned that information about the outcome of this Section 47 enquiry was not made known to Cafcass (which may have found the information relevant in the private law proceedings) and Child N’s father (who had parental responsibility). The SCR has made a recommendation to Northamptonshire LSCB in relation to this episode. 3.95 The health visitor next tried to make contact with Child N and her mother on 19 September 2012. She found the rented accommodation empty and renovation work being carried out. She established from the children’s centre that the mother might have moved back to her address in Oxfordshire. The health visitor was unable to contact the mother to establish her forwarding address so decided to pass details of the case and the records to her safeguarding advisor. She in turn tried to establish a forwarding address. She but could not do so as the mother had not by then registered herself or Child N with a new GP. She retained the records until she was contacted by colleagues from Oxfordshire in October 2012 (see paragraph 3.102 below) Court hearings and further developments during the period 4 September 2012 – 26 November 2012 28 3.96 There is no record of further professional contact with the mother between 26 July and 4 September 2012, the date of the next court hearing. 3.97 At that point it was noted that the mother had moved back to the former family home in north Oxfordshire and that contact with the father in recent weeks had remained problematic. For example the mother had phoned the police when the father returned Child N fifteen minutes late after a contact visit. 3.98 The final family court hearing was listed for mid-December. This included allowance for professionals to be consulted who could offer advice about the position of the child should the mother be allowed to take her to her country of origin. However this hearing had to be postponed as some of the professionals could not attend. 3.99 On 30 September 2012 the father contacted Cafcass and reported that the contact arrangement seemed to be working better and his fears that the mother wanted to take Child N out of the country had diminished. 3.100 On 3 October 2012 a specialist safeguarding advisor in the Oxfordshire contacted her counterpart in Northamptonshire health visiting service and obtained information about the health visiting contact that there had been with Child N and her family when they had been in Northamptonshire. 3.101 On 12 October 2012 the mother spoke to a GP over the phone. She reported being low and depressed because of the court case and not being allowed to travel to visit her family. The mother described sleeping poorly, overeating and low motivation, but said she had no suicidal thoughts and was not thinking about running away with the child (as the court would prevent her from doing this). She was encouraged to make an appointment and the GP recorded his intention to contact the Health Visitor. There is no evidence in the medical record that the GP did discuss the family with the Health Visitor; however the Health Visitor did start to become involved from this point on because of information shared by colleagues in Northamptonshire. 3.102 On 15 October 2012 two Oxfordshire health visitors who had had contact with the mother spoke in order to review the position of Child N. This conversation detailed knowledge of the episode from Northamptonshire and confirmed that there were no other known concerns. 3.103 On 17 October 2012 the mother’s allocated Health Visitor (who had also dealt with her before she moved away from Oxfordshire) made an unscheduled visit to the family following unsuccessful attempts to contact the mother by phone. The mother was seen. Child N was recorded as being asleep upstairs and reported to be well. 3.104 The mother stated that she was tearful about having to go to court and that she was not well enough to attend. She repeated her allegation about the father’s reasons for marrying her and that she was upset that he was now 29 having a relationship with her neighbour. She was not prepared to attend the local Children’s centre as her husband’s partner attended there too. The Health Visitor recorded that the mother was ‘very depressed’ and offered to look into the services available at another centre to see if legal advice could be obtained. She advised the mother to see her GP to get a sick note for the court and the health visitor agreed to call back in a week’s time. 3.105 The mother missed a scheduled court appointment on 19 October 2012 on the grounds that she was off work for two weeks due to stress. At this hearing it was noted that some progress had been made in understanding the legal position in the mother’s country of origin. Advice received suggested that the mother would need to apply for an order, mirroring any order made in the family court in the UK, setting out the father’s right to contact and the practical arrangement. Section 4.7 considers the international aspect of the case, taking account of the advice obtained by the court, the practicality of implementing it and the process for obtaining it. 3.106 On 24 October 2012 the mother attended an appointment at her GP surgery. She reported that things were ‘much the same’ as recorded in the previous phone consultation. She had been in touch with her Health Visitor and was keen on the idea of contacting the Talking Space psychological therapy service, though she had not done so yet. 12 She asked for medication on the grounds that this would lift her mood and was prescribed a standard anti-depressant medication. 3.107 The same day she took Child N to the child health clinic and referred herself to Talking Space. After an initial telephone screening interview the mother subsequently missed two appointments before attending one face to face appointment and then taking up one phone appointment. This contact took place over a period of six months. 3.108 On 29 October 2012 the mother saw a number of health professionals. Further contacts and referrals resulting from these appointments set the pattern of the mother’s contact with professionals between this point and the death of Child N. The GP notes mistakenly state that on this day the mother was seen in ‘psychiatry clinic’ but it has been established that this was a mistaken reference to the telephone therapy and treatment service. 3.109 The mother had an initial assessment (carried out over the phone) with a therapist from Talking Space. She stated that she had been unable to cope (for herself or with Child N) since July 2012 when the court had barred her 12 Talking Space is a community based therapy service using cognitive and behavioural approaches. Its purpose is to treat patients with minor mental health problems, particularly anxiety and depression. Much of the work of the service takes place by phone as this allows more clients to be seen, some service users prefer this and it improves take up of services. 30 from taking Child N out of the country. She described her former husband as emotionally abusive and that he had threatened to hit her and had broken ‘objects’. However he had never hit her. She described a low mood, lack of motivation and loss of control and the feeling that her partner was getting on with his life, whereas she was not. The father was described as ‘totally unreasonable’. She was hurt by the fact that he was having a relationship with one of her close neighbours. 3.110 The mother stated that she was currently taking an anti-depressant and that she had had a previous episode of depression when she had been made redundant. Her aims in treatment were to ‘gain back my self-esteem’ and cope with ‘emotional abuse’. 3.111 Following the consultation the mother was sent welcome letters and information about Talking Space and her GP was informed. She was signposted to Women’s Aid and the EVE Wellbeing Project.13 The Oxford Health NHS Trust summary of this assessment was that it did not identify any specific risks (either to herself or to others) arising from the mother’s account of her circumstances and needs. 3.112 On the same day (29 October 2012) the Health Visitor saw Child N and her mother at the GP surgery. Child N was recorded as being well presented, a happy and articulate toddler. There were no concerns about her health or development and she was up to date with her immunisations. The mother also looked smart and seemed well. She said that she had financial worries and also a real concern that the father was attempting to gain custody of Child N. 3.113 The Health Visitor made a referral to the Children’s centre describing the mother as feeling ‘very low’. It was felt that she would benefit from access to the centre and the crèche, the Freedom Programme (which is a programme for women who have been victims of domestic abuse) and the opportunity to make new friends. A referral was also made for a service called ‘floating support’ (which offered welfare benefits and financial advice). 3.114 On 31 October 2012 health visiting notes from Northamptonshire were transferred to the local service. 3.115 On 5 November 2012 the court issued a penal notice in order to enforce the order for contact previously made. It also refused the mother’s request for adjournment of the final hearing date (at that time fixed for 26 and 27 November) due to her ill health, on the basis that the sick note she had supplied did not say that she was unfit to attend court hearings. 3.116 The same day Child N was taken to the crèche at the children’s centre. She subsequently attended on nine occasions during November 2012, and at no 13 EVE is a voluntary organisation that offers to support to women affected by sexual abuse, domestic abuse and mental health concerns http://evewomenswellbeing.org/ 31 point was there any concern about her appearance or behaviour or the mother’s interaction with her. 3.117 On 6 November 2012 a centre worker visited the mother at home. This was a normal part of the centre’s work to support referred families. The mother gave a similar account of her worries about her situation and her mood was described as being ‘OK’. It was noted that the house was very bare and that Child N had no cot. Mother explained that she had been staying with relatives ‘up north’ and had had to sell furniture to pay her legal fees. The centre worker said she would get the mother a cot and confirmed the plan of support and activities described above. 3.118 On 7 November 2012 the mother saw her GP for a review. It was the same doctor who had seen her a week before. She reported feeling a lot better as a result of the positive impact of the medication, the psychological therapy service and contact with her Health Visitor. She also saw her Health Visitor with Child N at the GP surgery to provide an additional immunisation that was part of the normal health care regime in the mother’s country of origin. The mother said she felt more in control than when they had last met and that she had seen her solicitor which was helpful. 3.119 On 14 November 2012 FCA3 visited the mother and child at home. She had no concerns. The mother informed her that the reason some contact sessions had been missed in September was that the father had been on holiday. There is no evidence that this assertion was checked. 3.120 The same day the mother asked her GP for a letter to the court explaining that she could not attend and the impact that the court case was having on her. The mother subsequently withdrew the request as on the advice of her solicitor she attended. 3.121 On 19 November 2012 the mother saw her GP again and reported continuing small improvements as a result of the support she was receiving from the children’s centre and the Health Visitor. 3.122 On 22 November 2012 FCA3 filed a court report for the forthcoming hearing. This set out her view that Child N should remain in the care of her mother. She noted her concern about contact arrangements and how they would be maintained should the mother leave the UK, especially as the current (relatively straightforward) contact arrangements were not working successfully. FCA3 recommended that the parents should be directed to attend a Separated Parenting Information Programme (SPIP) in order to understand the impact that their behaviour might have on Child N. This service is provided by a separate organisation. 3.123 The planned court hearing on 26 November 2012 was not in a position to make a final order. Instead it required both parties to file updated statements and ordered disclosure to the court of information from the police and the mother’s bank. On the advice of FCA3 the court asked the Office of the Head of International Family Justice to provide clarity about the possibility of 32 obtaining a court order to secure the father’s contact. This was to be done by 8 February 2013.14 The role of this body is considered in Section 4.7. 3.124 FCA3 interviewed both parents at the court. The father stated that he was seeking a Residence Order and wanted overnight contact in the meanwhile. The mother was opposed to this on the grounds that she was still breastfeeding. FCA 3 took the view that overnight contact was not in Child N’s interest given her age and attachment to her mother. 3.125 The judge agreed with the recommendation to direct the parents to attend the SPIP. FCA3 was directed to file a report specifically to consider the issue of overnight contact with a further final report to be filed by 13 May 2013. A review hearing to decide the application for overnight contact was listed for March 2013 and the final hearing was listed for 13 May 2013. 3.126 On 28 November 2012 the mother cancelled her first face to face appointment with Talking Space saying that she was ‘stuck in floods’. An alternative appointment was offered for 11 December and the mother was sent further paperwork and self-assessment questionnaires to complete. Court hearings and other key events from December 2012 until the death of Child N 3.127 On 4 December 2012 the mother and Child N were seen at the child health clinic and the infant was observed to be thriving. The mother had a minor concern about ‘noisy breathing’ which she attributed to the father smoking during contact visits and having pets. Practical advice was given on this and the mother was offered a review with the GP if reassurance was needed. 3.128 The mother took Child N to the crèche at the children’s centre. On 3 December 2012. She subsequently attended on six further occasions during December 2012, and at no point was there any concern about the child’s appearance or behaviour or the mother’s interaction with her. 3.129 On 12 December 2012 the mother attended the Freedom Programme. 3.130 On 10 and 19 December 2012 the mother had contact with the GP (on the first occasion by appointment and on the second by phone) about minor health matters and she was given advice. During the first consultation she claimed to be a nurse. No particular significance was attached to this. 14 This is a small team of members of the judiciary supported by civil servants http://www.judiciary.gov.uk/about-the-judiciary/international/international-family-justice According to its annual report it has 2 or 3 members of staff and received 253 referrals during 2012. A significant part of the workload of its judicial and professional staff is to attend international conferences and workshops, sometimes making presentations. The Annual Report for 2012 shows that during that year staff associated with the office spent over 40 days attending conferences in locations including Hong Kong, Bermuda, The Hague, Paris, Switzerland, Barcelona, Madrid and Nicosia. The report refers to assistance being provided by an overseas judge in relation to the country to which Child N’s mother proposed to remove her. 33 3.131 On 20 December 2012 the mother had a telephone consultation with her worker at Talking Space. This appears to have been another rearranged appointment possibly due to the mother’s attendance at the Freedom Programme on 12 December 2012. The mother reported the decisions made by the court and her disappointment that the court appeared to want to prevent her taking Child N to her country of origin. The therapist discussed the potential value of Cognitive Behavioural Therapy and sent the mother further material in relation to depression.15 3.132 There is no indication in any agency record as to how or where the mother and Child N spent Christmas 2012. The father told the SCR that at some point over the Christmas period he noted that there were lights persistently on at the mother’s home when she had said that she and Child N were going to be away. He says that he phoned to local social care office to ask for advice about this. The local authority has no record of the contact which suggests that he could have been given informal advice which (given that he had not reported a specific concern which the local authority could have acted on) appears not to have been recorded. 3.133 On 7 January 2013 attended the GP for a review of her depressive symptoms. She again reported the positive effect of her medication and the GP noted the value of continuing it for at least six months. The mother also discussed other medical matters. 3.134 The mother had much less contact with services during January 2013. Child N attended the crèche on only three occasions. On the last occasion it was noted for the first time that Child N was upset when her mother left and was generally uninterested during the session. When this was shared with her mother she stated that Child N had been a bit more ‘clingy’ recently. Nothing in this was outside the range of normal age-appropriate behaviour and it was entirely appropriate that it was discussed with the mother in the way that it was. 3.135 On 18 January 2013 the mother missed another phone appointment with Talking Space. She was phoned and sent a text and letter to ask her to make contact within two weeks if she wanted to continue to be seen by the service. If not she would be discharged. Subsequently the mother contacted Talking Space on 15 February and attended a further appointment on 14 March 2013. 3.136 On the same day the father brought Child N to the GPs because of thrush on the child’s vulva. He was noted to be concerned about this, but had ‘no 15 CBT is an approach which seeks to enable the patient to think about and understand their circumstances differently in order to enable them to try to implement different strategies for dealing with day to day problems. 34 concerns about abuse’. There had been an earlier similar presentation in August 2012. No treatment was recorded on either occasion. This can be a symptom of child sexual abuse, but also has benign causes in infants. There is no reason to believe that there was reason for concerns about sexual abuse in this case. 3.137 Child N was left at the crèche on five occasions during February. On the first – when she had not attended for over two weeks - it was noted that she took some time to settle. 3.138 On five occasions between 12 and 19 February 2013 the mother had contact (either by phone or urgent appointment) with GP practice staff in relation to Child N suffering from vomiting and diarrhoea. Her contacts with health professionals appear to have been routine and do not raise concerns. 3.139 On 19 February 2013 two workers from the local authority Early Intervention Service met with a worker from a charity known as Parents and Children Together (PACT) to discuss the possible involvement of the mother in a programme known as the Recovery Tool Kit. This is a 12 or 24 week educational programme to support victims of domestic abuse, who are no longer living with the abusive partner. A programme was due to commence the following day at the children’s centre and a member of staff from PACT had assessed the mother as being suitable for the course. 3.140 The PACT service had at that time been commissioned by the District Council to provide services for victims of domestic abuse and had been put in contact with the mother by the local housing service. Subsequently the District Council awarded the contract for services to another organisation and the worker from PACT stopped attending the group. This worker did not provide the local authority workers with details of their assessment of the mother, leading to the belief that no assessment (or at best a very scant assessment) had been undertaken. 3.141 Subsequently the mother attended four programme sessions during February and March 2013 with her last attendance being on 13 March 2013. She missed two further sessions on 20 and 27 March 2013 (the fifth session having been focused specifically on the impact of domestic abuse on children). At that point it was reported that she would no longer be attending due to ‘other commitments’ (which were not defined). 3.142 The only unusual or noteworthy comments made by the mother at the group sessions were recorded on 6 March 2013 during the course of a discussion among the women about handing over children for contact sessions with violent partners. In contrast to other group members, who reported high levels of anxiety about this, the mother made it clear that she had no concerns and that if anything happened to her child during a contact visit it 35 would be the father’s responsibility. During this session the mother also reported having met a new partner via the internet. The mother’s involvement in domestic abuse services is discussed in detail in Section 4.4 3.143 On 21 February 2013 the Health Visitor saw the mother and Child N at the GP surgery. The mother said that she was still feeling ‘very down’ about going to court over the custody dispute. She said that she was still taking anti-depressants and attending the domestic abuse programme, which she was finding helpful. The mother claimed that the court was telling her to give up breastfeeding and the Health Visitor advised the mother of World Health Organisation recommendations to continue breast feeding until the age of two years. 3.144 The Health Visitor noted that the mother had no thoughts of self-harm or harming Child N, though she was very angry with the court and her husband. It was suggested that the mother write down all the things that were making her angry and take the opportunity to discuss them at the children’s centre the following week. The Health Visitor obtained the mother’s agreement that she could discuss her situation with the children’s centre worker, but there is no recording to indicate that this discussion took place. It is not certain whether what the mother was saying about continuing to breast feed was truthful. There is no evidence that the court had discouraged her from doing so and it certainly could not prevent her. In fact FCA3 had been influenced by the mother’s account of continued breast feeding to be cautious about granting overnight contact visits. At no point was there any contact between Cafcass and the health visitor or the other professionals who were in contact with the mother and Child N at this time. This is considered in detail in Section 4.7 3.145 The Health Visitor next saw Child N and her mother on 27 February 2013. At this stage the mother was noted to be much calmer and more positive about her situation and observed to be interacting happily and warmly with Child N. The mother reported her continued concern about being asked by the court to stop breastfeeding in order for the father to have overnight contact. However this had not been required and there had been no court hearing since the last Health Visitor contact. Again the Health Visitor did not know this. 3.146 On 1 March 2013 the father took Child N to the GP surgery and asked if he could have access to her medical records on the grounds that the mother was not keeping him informed about Child N’s health. He made it clear that both parents were seeking Residence Orders in relation to the child. No 36 specific response was recorded. This visit coincided with the mother visiting the surgery and she was angry that the father was bringing Child N for appointments. The GP told her that the appointment had been for the father and that no details could be provided. Mother stated that she ‘could not think clearly’ because of the custody dispute and went home. This was the last significant GP contact with Child N. 3.147 In contrast to these contacts with health professionals in which negative feelings about the court process had been expressed, on 8 March 2013 at a court hearing all parties (including the mother who was legally represented) agreed to a planned overnight contact stay with the expectation that a second overnight stay would be agreed before the next scheduled court hearing. 3.148 At this hearing the mother reiterated her plan to take Child N to her country of origin and confirmed her intention to live with and marry a man she had met on the internet. FCA3 and the child’s solicitor reiterated their opposition to Child N being removed from the UK until such time as there was an order in place to protect the father’s right to contact. The final court hearing was listed for 17 June 2013. 3.149 On 14 March 2013 the mother had a telephone session with Talking Space. Standardised assessments were undertaken and the mother was asked questions about any thoughts or intention to harm herself or others. The therapist identified no concerns. The mother said that she continued to take the same medication. 3.150 Records indicate a session in which the mother spoke mainly about the practicalities of her current situation including progress with the court case. At this point the mother suggested that lawyers were establishing if there was a way for her to move overseas with Child N, which she preferred to do as she had ‘no support here’. 3.151 She reported that there had been one overnight contact stay and that arranging contact can be ‘a nightmare’. However they have two day stays per week and are working towards stays of two nights per week. The notes state that the mother ‘gets on well with him (the father) and his partner and trusts God that it goes well’. 3.152 She described her relationship with a new partner, currently living in her country of origin. 3.153 The mother described feeling a residual anger towards Child N’s father as he had ‘abandoned’ her during the pregnancy. 3.154 She spoke of having attended the domestic abuse programme sessions and reiterated some of the contents. She stated that this allowed her to ‘let things go’; however she had lost all faith in the legal system. 3.155 The mother spoke of a possible business opportunity in London. The notes conclude by stating that her anger is the main destructive thing and that 37 there are times when she can get upset and not know ‘what to do with it’. The therapist suggested some relaxation techniques, which the mother agreed to follow. 3.156 The mother’s next telephone session with Talking Space took place on 11 April 2013. The same standardised screening assessments were used and again the mother denied any thoughts or intentions of harming herself or anyone else. Once again the session notes suggest that the mother spoke a lot and provided updates on her views on all aspects of her current situation. She appears to have stated that she was now able to be more accepting of her current circumstances; however she aspired to return to her country of origin, but feared the financial cost in legal fees of making the necessary arrangements. She reported that her new partner would be attending the next significant court hearing which was scheduled for 7 May 2013. 3.157 The mother agreed to continue practicing the relaxation techniques previously sent to her. A further appointment was made for the 10 May 2013 but was cancelled by Talking Space on the day of the appointment due to staff sickness. The appointment was rebooked for 17 May 2013. 3.158 On 3 May 2013 the parents notified FCA3 and the solicitor acting on behalf of Child N that they had agreed arrangements for the second overnight contact visit. The records show that the mother had asked the father to care for Child N whilst she was abroad for two (or according to one record three) weeks from 23 May. The interim contact arrangements appeared to have gone well so that Child N had been able to stay overnight with her father from Thursday morning until 8pm on Saturday. 3.159 FCA3 remained of the view that Child N should not be allowed to move abroad without safeguards in place to ensure contact would continue to take place with her father. Advice provided on the overseas legal issues had confirmed that there was no provision under child care law in the country concerned to adopt a foreign order so an application would need to be made afresh in that country. This is considered further in Section 4.7 3.160 On 10 May 2013 the FCA observed a further contact session between the father and Child N. She was satisfied with the outcome believing that there was evidence of warmth and a strong attachment between them 3.161 On 14 May 2013 FCA3 had supervision with her Service Manager and discussion about the final recommendation to be made to the court. The Service Manager advised FCA3 to make a firm recommendation in order to avoid further delay in what had become protracted proceedings. 3.162 Although there was evidence of growing cooperation between the parents over contact arrangements the report focused its deliberations on the applications that had been made to the court. The mother had a long standing application to remove Child N from the jurisdiction of the court in order to bring her up in her own country of origin. The mother proposed to form a new family unit with her new partner and his son (whom she had met 38 on the internet but who had never been to the UK or met Child N). The mother’s legal representative had undertaken enquiries in order to establish how contact arrangements for the father might be arranged and secured via an order in the court in her country of origin. 3.163 The report set out the father’s reservations that he feared that Child N would not be well looked after if she left the UK, that the mother would not facilitate contact and that he would not be safe if he travelled to visit his daughter. The report considered how contact arrangements might be secured, either through a court in the mother’s country of origin making an order for contact, or the mother agreeing to bring Child N to the UK for contact and posting a substantial sum in the UK which would be forfeited if contact did not take place. Any orders made would not be mutually enforceable in the courts of the different countries because the country concerned was not a signatory to The Hague convention. 3.164 In contrast the father’s application for residence was based on the assumption that he would live in the UK and allow contact with the mother. He envisaged his new partner playing a role in Child N’s life. 3.165 After further reflection the FCA decided to recommend that the court should make a Residence Order in favour of the father. Her report recorded her assessment that ‘both parents are equally capable of meeting Child N’s needs’ and that had the case not involved the mother’s application to remove Child N from the jurisdiction of the court FCA3 would have recommended an order in which residence was shared by both parties. 3.166 FCA3 recorded her lack of confidence in the mother’s willingness and ability to facilitate contact should she be allowed to take Child N to her country of origin. Her judgement was that Child N had a significant relationship with her father which would be jeopardised if she moved to live with a new family in a different country. This recommendation in favour of the father and the process by which it was arrived at are discussed in Section 4.7. This also considers the issue of how best to tell parents in a contested case that Cafcass has recommended a change in residence. 3.167 On 14 May 2013 FCA3 completed her report and emailed it to the father (who was representing himself) and to the solicitor acting for the mother to share and discuss with her. The mother’s solicitor forwarded the Cafcass report to the mother by email. On 15 May 2013 the father alerted the police to the possible flight of the mother because she had failed to take Child N to a scheduled contact handover. Subsequently it was established that she had left the UK that evening. 3.168 The following day Child N was found dead in the family home. 39 4 EVALUATION OF THE SERVICES PROVIDED FOR CHILD N AND HER FAMILY 4.1 Introduction Working assumptions about the circumstances of Child N’s death 4.1.1 In conducting its work the SCR has not had the benefit of 1) definitive information about the cause of Child N’s death 2) a detailed understanding of the circumstances in which it occurred or 3) clear evidence about who – if anyone – caused it. These are unusual circumstances in which to conduct a SCR. Whilst it is not the function of the SCR to investigate or to determine any of these matters the SCR has had to take account of possible explanations of events in order to direct its enquiries. 4.1.2 Given the information that is known about the circumstances of the death set out in Sections 1.4 – 1.5 of this report the SCR’s work has therefore proceeded on the basis that it is likely that Child N’s mother was implicated in some way in her death. There is no evidence to suggest that the father had any involvement and at the time of writing there is no evidence to implicate anyone else. 4.1.3 Whilst this assumption has no legal standing it is difficult to see how the SCR could have proceeded on any other sensible basis. The evaluation of services in this section of the report therefore focuses in part on whether there was evidence – in her interaction with the child, with the father or with professionals - that the mother might have posed a risk of serious harm to the child and if there was, how the agencies responded. Focus of the evaluation 4.1.4 This section of the report addresses the aspects of practice that offer the most important opportunities for learning and service improvement, as follows: 4.2 Whether there was evidence that the mother might pose a risk of serious harm to Child N and if so what action was taken? 4.3 The pattern of agency involvement with Child N and her parents during the period under review and the nature of the assessments that were undertaken 4.4 Assessment and provision made in relation to allegations of domestic abuse 4.5 Assessment and provision made in relation to the mother’s mental health 4.6 Assessment and provision made in relation to homelessness 4.7 The role of Cafcass in private law cases where the residence of children is disputed 4.8 The work of agencies with fathers and other male carers 40 4.9 The response of agencies to ethnicity, religion and cultural factors 4.1.5 Each section of the evaluation refers back to specific episodes described in Section 3 of the report. 4.1.6 In relation to each aspect of practice the report evaluates whether the findings are significant in relation to the outcome for Child N and in wider service provision for vulnerable children. 4.2 Was there evidence that the mother might pose a risk of serious harm to Child N? Introduction 4.2.1 This section of the report summarises the findings of the SCR about whether overall professionals had grounds to be concerned that the mother might have posed a serious risk to her child. Episodes when there was potential concern about the quality of care that was being provided for Child N by her mother 4.2.2 During her pregnancy Child N’s mother made contact with the social care service at the hospital where she was receiving antenatal care to say that she was considering relinquishing the unborn child for adoption. After meeting with a member of the hospital social work team and being told about the sort of financial and practical support that would be available she changed her mind. This episode is described in detail in Section 3.16 – 3.21 above and evaluated in Section 4.3. Neither the mother’s presentation nor her account of her feelings could have been viewed as being an indication of any serious risk to her future child. 4.2.3 On three occasions between April 2012 and January 2013 the parents separately reported domestic disputes (rows, arguments, threats and past threats). These were treated by agencies as falling within the definition of domestic abuse and responded to as such. As a result Cafcass and the court treated the private law proceedings over Child N under the guidelines for domestic abuse cases and accordingly made additional local authority and police checks on the parents which highlighted these episodes. However neither parent ever formally made allegations about reported domestic abuse in the court proceedings. In late 2012 - 2013 the mother continued to refer to historic domestic incidents in which her husband had threatened her and she attended services for women who had suffered domestic abuse in north Oxfordshire. 4.2.4 There has never been corroborative evidence of domestic abuse and it remains unclear whether 1) the reported incidents took place 2) how serious they were and what impact if any they had on Child N and 3) if there were incidents, who the perpetrator was. Many professionals who worked with the mother have subsequently expressed serious doubts as to whether she was a victim of abuse, though none recorded doubts or challenged her accounts 41 at the time. Some considered that she was more likely to have victimised her husband. 4.2.5 The responses of professionals to these reported episodes are evaluated in Section 4.4. There is no indication that Child N was at risk of harm as a result of domestic abuse. 4.2.6 In May 2012 (when Child N was 8 months old) her mother had no stable accommodation and stayed temporarily with a family member and then with a number of friends. She said at the time that she had slept in her car with the baby though she subsequently reported that this was untrue. The child’s father believed that the mother was moving frequently in order to frustrate his attempts to have the contact ordered by the family court. As a result of the instability the court made Child N the subject of an Interim Care Order and ordered the local authority to undertake an assessment. This episode is evaluated in Sections 4.3 and 4.6. 4.2.7 There is no indication that the mother’s presentation or her account were indicative of any serious risk and once the mother found stable accommodation observations made by professionals of Child N with her mother indicated that the baby was being well cared for and thriving. 4.2.8 Between October 2011 and the death of Child N the parents were involved in protracted court proceedings over the residence of their child. One member of staff from Cafcass had contact with the parents and was able to observe Child N on many occasions over this period. With the exception of the period of instability due to the mother’s housing problems – when she was concerned - this professional identified no signs or symptoms of abuse or neglect. Indeed along with all of the other professionals involved she always observed and recorded that Child N was well cared for, by both parents, almost always in a happy mood and meeting all of her expected developmental milestones. 4.2.9 Between October 2012 and May 2013 the mother spoke to her GP and a therapist about feelings of depression and anxiety, linked in the main to the custody dispute. The GP prescribed anti-depressant medication, which was regularly reviewed. The mother made use of face to face and telephone therapy and treatment services. Her symptoms were within the range of commonplace and moderate presentations and she appeared to respond well to these interventions (which are evaluated in detail in section 4.5 of this report). At no time did there appear to be any indication that these problems might impair the mother’s capacity to parent Child N or cause professionals any concern. 4.2.10 In July 2012 Northamptonshire social care received a report that Child N (who at that time 10 months old) had bruises from falling off the bed and had been left alone in the mother’s bedsit. Northamptonshire visited the mother, observed Child N and asked other professionals if they had concerns. The mother admitted briefly leaving her child alone but claimed that the landlord 42 had been on the premises at the time. She undertook never to do this again. Northamptonshire social care overlooked the need to investigate the account of bruises caused by falling off the bed and so did not examine Child N to see if there were bruises or ask her mother about this aspect of the report. 4.2.11 At this distance it is impossible to be certain whether or not this was significant. Child N was mobile at this point and so could have fallen or been bruised accidentally. However any report of bruising in a child under the age of one is of potential concern and the reported concerns should have been investigated and tested. Given the subsequent history it is important to note that this was the only point at which any concern about a symptom of possible physical assault was ever noted. It is also a concern that the outcome of this episode was not reported to the father or to Cafcass. Overall assessment 4.2.12 Unless the bruises to Child N described in the episode referred to above were inflicted deliberately, there was no evidence known to professionals who were working with the family that the mother might pose a risk of serious harm to Child N. In fact the opposite is true. Even though the mother experienced practical and emotional difficulties at some points and there were occasions on which some professionals found the mother demanding and difficult to work with, the unanimously held view of professionals who had contact with Child N was that she was in good health, extremely well cared for and flourishing. 4.2.13 This was the professional assessment during the period under review and nothing has emerged in the collation of evidence since the death of Child N which has shown evidence of risks that were missed at the time to contradict this picture. 4.2.14 It was a view shared by the father who told the SCR that he ‘never, ever worried’ about the way in which she looked after Child N. 4.2.15 There may of course have been aspects of the mother’s behaviour or events in her earlier life history that – had they been known – might have would have pointed to potential risks. But if they existed they were not known. Section 4.3 of the report recognises that professionals had opportunities to ask for more information about the background and life histories of both parents and did not do so. The reasons for this are explored below. 4.2.16 In the circumstances it is not possible to see how professionals working with the mother could have predicted that she would harm her child or have taken any action – that would have been justified by the circumstances – that would have prevented it. 43 Wider research and practice experience 4.2.17 The SCR has also considered whether there is wider research or practice experience that would have highlighted potential risks to Child N and therefore should have been taken into account. 4.2.18 Research about the killing of children in the context of custody disputes and domestic abuse has identified that this is a very serious risk but a very rare one. The only major study of the phenomenon covers a 10 year period and identified 29 cases.16 However even detailed knowledge of this research – which is well known in Cafcass – would not have led to specific concerns about this case. All of the perpetrators in the study were men and all of these cases occurred where there had been serious domestic abuse (of which there is no evidence in this case). 4.2.19 Cafcass has recently published an overview of the organisation’s involvement in SCRs over the period 2009 – 2013 and a detailed analysis of more recent cases.17 This provides useful additional information about children who have been killed or seriously harmed in the context of disputes about residence or contact or care proceedings. The study notes the very low proportion of private and public law cases in which the organisation is involved in which there is a child death (approximately 1 per 3800) and again describes a picture in which in the overwhelming majority of deaths there was previous evidence of risk factors such as domestic abuse (90%); substance misuse (78%); neglect (38%) mental health problems (33%) or physical abuse (33%). 4.2.20 The report recognises that there are cases in which children are killed without there being any previous indication of risk and notes that this is ‘a useful reminder that fatal abuse does not always occur within the context of recognised high risk indicators’. Identifying this as a problem does not mean that there is a solution. Whilst highlighting that children can be killed in cases where there are no known indicators of heightened risk (i.e. in 10% of the deaths) this also serves to underline the fact that it is close to impossible to successfully identify risk in every case. 4.2.21 The circumstantial evidence about Child N’s death indicates that it was an extremely unusual and rare event. This makes it naturally less likely that anyone would conceive that it was a possibility. Even if this had happened no one has suggested a way in which the tiny number of such events (approximately 1 event in every 3800 cases) could be screened or assessed to identify every possible risk. If such a method were devised it would probably be so time consuming and expensive and have such an adverse impact on the operation of the courts that it would never be implemented. 16 Hilary Saunders (2004) Twenty-nine child homicides: Lessons still to be learnt on domestic abuse and child protection, Women’s Aid 17 Cafcass (November 2013) Learning from Cafcass Individual Management Reviews (IMRs) - Case Dynamics: Executive Summary 44 4.2.22 This raises the question of whether wider research should be conducted given that the findings cited above have a very specific focus and may not be comprehensive in its coverage. The knowledge held by Cafcass will not be comprehensive as serious harm may have occurred in the course of custody disputes in which the organisation was not involved or after it has ceased to be involved. Issues raised by the father of Child N. 4.2.23 The father of Child N has raised a number of concerns about the conduct of agencies in relation to the child’s mother. In particular: 1) He feels that the failure of the mother to comply with court orders (even when there were penal notices) should have been dealt with more firmly. 2) Recommendations from Cafcass should just be sent to the judge, rather than all the parties. 3) The Section 37 report conducted by the local authority should have included more visits and especially unannounced visits to the mother 4) He should have been told that there had been social care involvement in Northamptonshire 4.2.24 These matters are referred to in the remaining sections of the report. The SCR shares the concerns of the father in relation to the final two. However it remains the view of the SCR that even if all of these matters had been addressed differently they would not either individually or in total have substantially altered the picture that everybody involved had of the care that Child N received from the mother. Nor are they likely to have altered the outcome of events. Identified areas for improvement 4.2.25 The remainder of this report needs to be understood in the overall context of the finding that Child N’s death could not have been foreseen. In reviewing their involvement with the child and her parents contributing agencies have understandably identified errors in practice and individual actions which might fall short of the standard that agencies normally deliver or aspire to. Such episodes will be found in all cases, including many in which there has been a positive outcome for the child. 4.2.26 The SCR identifies some weaknesses in systems and practices. However there is no evidence that any of these placed Child N at risk or led to a failure to identify risk. The burden of all the evidence is that – with the exception of the brief period when she was homeless – the mother’s care of Child N was good and usually that it was very good. Breaking bad news in court cases where residence and other aspects of the care of children are disputed 4.2.27 The Police investigation suggests that Child N may have died shortly after the mother’s solicitor informed her by email that Cafcass intended to 45 recommend that the father should be granted a Residence Order. However the final decision rested with the court which would hear other evidence and opinion and it was by no means certain that the court would accept this recommendation. 4.2.28 It is not possible to know whether this news triggered the events that led to the death of Child N. However Cafcass has taken seriously the possibility that it might have. As a result it has given further thought to the question of how all of those in the family justice system might in future break unexpected bad news to parents where the court is considering or has decided to order a change in residence for a child when this has been disputed. Section 4.7 considers this further and it is the subject of a recommendation to Cafcass. 4.2.29 This may be the subject of wider learning for all professionals. It may for example now be widely assumed that it is reasonable to impart potentially disturbing news via an email, where there is no scope to judge or respond to the recipient’s reaction, rather than face to face. It is hard to turn this into a practical recommendation, but it is something that all professionals might usefully reflect on. 4.3 The nature and quality of the assessments undertaken Introduction 4.3.1 This section considers the quality of the following assessments and the resulting service provision: Antenatal service assessment of health and social risk factors Pre-birth initial assessment by local authority social work staff New birth health assessment by the Health Visitor Local authority Section 37 / core assessment in June 2012 4.3.2 The following assessments are evaluated separately: Assessments in relation to alleged domestic abuse (Section 4.4) Assessments in relation to mental health (Section 4.5) Cafcass assessments (Section 4.7) Antenatal assessments 4.3.3 The antenatal assessment of health and social risk factors took place at the hospital maternity service early in the pregnancy. The mother did not delay referring herself. The management review provided by the health trust indicates that the assessment covered all of the expected areas. The midwife identified some medical risk factors which were addressed by referring the mother for consultant-led medical care. No social risk factors were identified at that point. 4.3.4 Since circumstances can change during the course of a pregnancy the trust management review has recommended that it would be beneficial if, in 46 future, midwives repeated the assessment of social vulnerability factors later in the pregnancy. The trust has also noted that there was very limited contact with the father during the pregnancy, who might have provided an additional source of information. The trust has undertaken to carry out further work in order to consider how it can involve fathers better. The SCR endorses both of these recommendations. The question of the father’s involvement is considered further in Section 4.8 of this report. 4.3.5 The mother referred herself to the hospital social work department in May 2011 initially stating that she wanted to relinquish her child at birth. Having been informed about the kind of practical and financial support that would be available she reported in a subsequent discussion that she wanted to keep the child. The social worker who saw her was aware of the police notification of a row between the parents. 4.3.6 It appears that this contact with the mother was categorised as an initial assessment of need in relation to the unborn child, but was viewed by the professional involved as a counselling contact with the mother. No further background information was sought because by the time of the mother’s second contact the presenting problems had been resolved. The assessment was that the mother had been panicked by the prospect of becoming a single parent but had become more positive and confident and was now completely committed to preparing for and keeping the child. 4.3.7 The social care management review has noted that this contact was unusual in two respects. First, it was a self-referral. Second, it was unusual for a mature woman with a healthy foetus to seek advice about relinquishing the child at birth. It comments that this should have led the staff involved to be more curious as to the circumstances and background. 4.3.8 Taking a wider view it is easy to understand why this contact was viewed as being a less significant piece of work in relation to the range of tasks undertaken in a busy paediatric and medical social work service. In most local authority areas this case would not have met the threshold for allocation to a worker for assessment. In many it would not have come to the attention of a social worker at all as the local authority does not have an active presence in antenatal services. 4.3.9 The staff involved considered whether to share information about the contact with the antenatal service but decided not to do so on the basis that this had been a minor episode. Whilst this was a considered decision the SCR is clear that even on the basis of the information known at the time, it was not a correct one. A short note summarising the contacts should have been shared with the antenatal service in order to inform future contacts by the midwives. Had this happened it would not have changed the interventions that were made because the mother subsequently kept all of her antenatal appointments and complied with suggestions for care without causing anyone any concerns. 47 The Health Visitor new birth assessment and subsequent contacts 4.3.10 The Health Visitor and other members of the community health team had three face to face contacts with the mother and Child N during the first eight weeks of her life, in keeping with the normal arrangement to provide a universal child health service. There were no concerns at all about Child N’s health or development. 4.3.11 During the course of the contacts the mother’s current social circumstances were explored and she was signposted to relevant support services. No information was obtained about the mother’s background, which was seen as being less relevant than her current circumstances. 4.3.12 The assessments undertaken met the health trust’s expectations, given the fact that there were no current difficulties or concerns in relation to Child N. Possible concerns about domestic abuse were explored, but the mother was clear that this was not currently relevant. 4.3.13 Almost a year later (October 2012 onwards) the same health visitor had a short series of contacts with Child N and her mother after they moved back to Oxfordshire. Again there were no concerns about the safety, health or development of Child N. At this time the Health Visitor was covering some additional work as the second Health Visitor in the locality (who worked part time) was not at work. 4.3.14 The focus of activity at this point was on the reported impact of the court proceedings on the mother’s mood and mental health. Once again there was no concern that this was having a negative impact on the health or development of Child N. 4.3.15 The Health Visitor referred the mother and child to the local children’s centre and to the Freedom Programme (for support around domestic abuse), financial and legal advice and advised her to see her GP about her reported depression and anxiety. The reasons for referring the mother to the Freedom Programme (given that she had not reported current or recent domestic abuse) were not recorded. 4.3.16 The Health Visitor had four further contacts with the family between October 2012 and February 2013. During this time she discussed the family with the children’s centre but she had no contact with the other professionals she knew to be involved i.e. Talking Space (mental health psychological therapies) or the GP. This is not surprising given that the Health Visitor was covering the work of a colleague and that she did not have pressing or unresolved concerns to discuss. The Health did not know that Cafcass was involved, though she did know about the private law proceedings. 4.3.17 In its individual management review the health trust recommends that there should be greater information sharing between health visitors and other 48 professionals involved. It indicates that staff in community health services should have a greater awareness of the role of Cafcass in private law proceedings that involve young children. 4.3.18 The SCR endorses this approach recognising that the extent to which professionals can share information about their involvement with families will always be shaped by the time they have available, their judgement of the value that it will add and competing priorities. This mirrors a recommendation made that Cafcass should provide more comprehensive information to the agencies represented in the LSCB about its role and responsibilities in private law cases. Potential use of the Common Assessment Framework 4.3.19 In principle the Common Assessment Framework could have provided a means of coordinating help for the mother and child. This was not used because the mother was separately cooperating with individual agencies and there did not seem to be the need for meetings or shared assessments to coordinate the help that was being provided. 4.3.20 Given the presentation of the family and the lack of any concern about the health and development of Child N it is not surprising that none of the professionals involved felt that there was a need to undertake a CAF. There is no reason to think that if one had been undertaken it would have altered the pattern of service provision made or offered any greater protection to Child N. Social care core assessment in June 2012 4.3.21 Oxfordshire social care undertook a core assessment in order to inform the report required by the court when it made an order under Section 37 Children Act 1989. This required the local authority to investigate the child’s circumstances with a view to determining whether it should (a) apply for a care order or for a supervision order with respect to the child; (b) provide services or assistance for the child or his family; or (c) take any other action with respect to the child.18 Unusually the court made an Interim Care Order at the same time (without either Cafcass or the local authority proposing or seeking the order). 4.3.22 The local authority presented its Section 37 report, based on the core assessment, at the court hearing on 22 June 2012. The judge was complimentary about the quality of the report and grateful that it had been prepared so quickly. Based on the reassurance that it provided the judge decided that Child N was not at risk of significant harm and that there was no need to make an order to remove Child N from her mother’s care. 4.3.23 Sections 3.59 – 3.80 set out the steps taken by the local authority social worker to prepare the report, including a range of contacts with 18 Children Act 1989, Section 37. http://www.legislation.gov.uk/ukpga/1989/41/section/37 49 professionals and family members. During the period under review Child N’s mother was living in Northamptonshire 4.3.24 It is clear that the major concern of the local authority was to establish whether there were grounds to remove Child N from her mother’s care. It was quickly determined that there was no reason to do so and that the legal criteria for removal were not met. The assessment then focused on the recent history of the family and the standard of care being provided to Child N. It addressed the fact that the mother had moved several times and the impact of this on her daughter. The mother was left in no doubt about the need to maintain stability of accommodation for Child N and made a commitment to stay in her current accommodation in Northants. 4.3.25 The management review prepared by the local authority noted some weaknesses in the assessment undertaken. For example there was no detailed consideration given to the concerns reported by Cafcass about the mother’s mood being ‘up and down’. Little information was gathered about that the parents’ family histories or the mother’s support network or to understand in more detail the reports about alleged domestic abuse. It noted that the mother appeared to have ended the problem of unstable accommodation but it did not establish why this had come about in the first place. In addition there was no specific consideration given to the cultural or international aspects of Child N’s circumstances, bearing in mind that her parents came from different countries, were of different racial origin and different religions, the potential impact of these factors might have been of concern. 4.3.26 These criticisms rely more on a comparison between this core assessment and the ‘ideal’ standard that the local authority aspires to, rather than setting out why the core assessment had these shortcomings. 4.3.27 The circumstances in which this assessment was carried out led to its very specific scope. The report was narrowly focused on the question of whether a Care Order was required and whether Child N needed to be removed from home. This was established through observation of the parents and child and seeking corroborative information about the current care of the child from other professionals who were involved. Once the chief purpose of the report had been accomplished little further background information was sought. 4.3.28 There was no doubt that from the local authority viewpoint the circumstances of the case as they currently presented fell far below the level that would normally have been required to merit an Interim Care Order. Had it not been for the court order the local authority would have been unlikely to have initiated a core assessment at all. 4.3.29 Nor were there grounds at that point to remove Child N from her mother’s care and place her with her father. The threshold to remove an infant who 50 had only ever been cared for by her mother and was still (according to the mother) breast feeding would rightly have been extremely high. 4.3.30 At the time the mother and child were already living in another local authority area and the mother had given an undertaking to remain there. This meant that the case would probably not be the long term responsibility of Oxfordshire. The local authority believed that a fuller assessment would be undertaken by Cafcass and presented to the court before any lasting or final decision would be made about the long term welfare of Child N. It believed that there would be ample opportunity for others to evaluate in much more detail the child’s needs and the capacity of each of her parents to meet them. 4.3.31 The assessment was required and undertaken within a very short timescale. This was dictated by the level of concern that the FCA and the judge had felt at the time of the hearing on 31 May 2012. Looked at from a different perspective it could equally be said that the report was more superficial than it might otherwise have been had the judge not needed to make a decision about whether Child N needed immediate protection. 4.3.32 It is very likely that all of these factors would have influenced the mind set and judgement of the social worker undertaking the assessment. They would also have shaped the judgements made by managers about the level of detail required on issues that the court had not asked the local authority to address, particularly when set alongside the needs of other cases and workload for the individual and the team. 4.3.33 Child N’s father told the review that there should have been more visits to the mother and more unannounced visits. In an ideal world the SCR has some sympathy with this view, however there is nothing to suggest that had this been done anything else the findings of the assessment would have been different. 4.3.34 When the court received the report on 22 June 2012 the judge thanked the local authority for presenting the report such a helpful report so quickly, as it addressed the immediate concerns that he had had when ordering it. 4.3.35 In all the circumstances it is right to recognise that this report should have been more analytical, asking more questions about the family backgrounds of the parents and seeking more information about the mother’s environment and support. Its shortcomings were understandable and a product of the unusual circumstances that led to it being prepared. 4.3.36 The local authority has made a recommendation making clear its expectations for the quality of core assessments and noting the need for managers to be more challenging of the scope and rigour of these assessments in future. The SCR endorses this approach. 51 The overall pattern of assessment and service provision 4.3.37 The assessments undertaken by agencies were very specific in their focus and oriented to particular tasks and services. Knowledge about the family captured in assessments did not accumulate as the case history progressed. Assessments were not informed by the family history or the outcome of previous assessments. 4.3.38 This is a frequent finding in SCRs where a large number of agencies are involved. It is a feature of the way that many agencies expect their staff to operate. Except for local authority core assessments it is rare for professionals to gather significant amounts of information from other agencies when undertaking their assessments. Often they do not probe for background information or seek information about what other agencies have been involved and what services have been provided. 4.3.39 Unless there are serious concerns about a child’s health or welfare there is little coordination of work by agencies except when it is undertaken by the local authority. This case followed that pattern. Agencies came into contact with the family at specific points in order to undertake certain tasks and no one felt that the circumstances merited action to coordinate the input made by different agencies. 4.4 Assessment and provision made in relation to allegations of domestic abuse Introduction 4.4.1 This section of the report considers the allegations made in relation to domestic abuse and the response of professionals. It focuses on two areas: The response of agencies to reports of less serious incidents of domestic abuse Service provision made to the mother. It is not the responsibility of the SCR to determine whether there was domestic abuse. 4.4.2 The police received three allegations of possible domestic abuse, two during the pregnancy and one shortly after Child N was born. The allegations made by the mother were about incidents best described as ‘rows’ and there was no allegation of physical assault. The father’s allegation about the mother was made in order to pre-empt and protect him from false allegations he feared would be made by the mother. 4.4.3 There was no corroborative evidence of any domestic abuse. Whenever allegations were put to the father he denied having abused the mother and in turn alleged that the marriage had broken down because of her aggressive and unreasonable behaviour. He firmly maintains this position. 4.4.4 Some professionals who knew the mother did not have the impression that she behaved in a way that indicated that she had been a victim of abuse, though they accepted her word that she had. No one sought to corroborate 52 the accounts given and no one involved attempted to speak to both parties together about the allegations. 4.4.5 When the parents were seen together (through mediation and parenting services associated with the court applications) the allegations were not mentioned. 4.4.6 The family court was aware of the allegations of abuse because the mother mentioned them to Cafcass at an early point. The court took the allegations seriously though neither party sought to bring evidence of allegations into the court, where they could have been tested. The court did not feel that they reached the threshold where a fact finding was required to determine what, if anything, had happened. 4.4.7 The mother repeated her allegations to her health visitor and mental health therapist and she was referred to local support services. During early 2013 she attended group support meetings, though again no steps were taken to corroborate her accounts. The mother stopped attending the group meeting two months before the death of Child N, saying that attendance was not a priority. Initial responses to allegations of domestic incidents 4.4.8 The incidents of alleged domestic abuse that might have affected children or pregnant women were taken seriously. In the main they were responded to in line with local procedures and protocols, even when they were of a less serious nature and there was no firm evidence to support or corroborate them. For example the police attended promptly and took the expected steps to record and respond to alleged incidents. 4.4.9 Agencies receiving information generally ensured that it was recorded and considered properly. Social care considered the need for an initial assessment and judged (correctly given the circumstances) that the referrals did require an intervention. In one instance a social care manager decided because of the accumulation of incidents that the authority would respond positively to the next incident, even if it was not itself a serious one. Given the number of incidents and the age of the child this was a measured and sensible reaction. 4.4.10 District Council housing services responded by making offers of temporary accommodation, pending a fuller assessment of the circumstances. 4.4.11 However the management reports provided by agencies have identified a number of ways in which the response to domestic abuse reports which did not fully comply with local procedures and expectations. In two instances it was not possible to find confirmation that information had been passed by the police to health agencies (whereas the same information had been sent to social care). In one instance it appeared likely that this was because it had been shared but not recorded or filed by the ante natal service. In the second the evidence that information had been sent was less clear. 53 4.4.12 The police management review identified one incident where it would have been better if the offers concerned had spoken to both parties in order to given them both advice and to corroborate the accounts. In another instance it was found that further consideration should have been given to investigating historic allegations as possible crimes. 4.4.13 Taken together these were minor shortcomings, which had been addressed through the individual management reports and lead to a number of recommendations which are set out in Appendix 5 of this report. None of these are considered to be significant in relation to the overall findings of the SCR. 4.4.14 The SCR has noted that local agencies and partnerships have gone to great lengths to make systems for sharing information about domestic abuse as reliable as possible, including the systems in the antenatal service. This incident confirms how hard it is to achieve that. Since the events under review, additional systems to track domestic abuse notifications have been introduced in the antenatal service. These should lead to greater reliability. 4.4.15 Discussion in the SCR panel has identified a wider concern about the very large number of referrals which are currently shared between referrers (most often the police) and other agencies. This has led to the danger that systems for risk assessment have become overloaded. Agencies wish to take this opportunity to consider collectively whether current arrangements are as effective as they could be, especially at the lower level of risk. 4.4.16 The SCR notes that in 2014 Oxfordshire agencies will collaborate in the introduction of a multi-agency unit to screen and evaluate referrals and contacts.19 The review has therefore recommended that in the design and implementation of the MASH attention should be paid to the arrangements for sharing and responding to incidents of alleged domestic abuse so as to ensure that there is an effective response to cases where there are a number of minor incidents. Agencies will need to ensure that thresholds are at a level which protects children whilst at the same time ensuring that agencies are not overloaded with information about relatively minor incidents. Services provided to the mother because she was believed to be a victim of domestic abuse 4.4.17 A number of professionals who worked with the mother felt it was unlikely that she was a victim of domestic abuse, or that if there had been abuse the mother may have instigated it. Nevertheless her allegations were taken at face value by all of the professionals who dealt with her and she was referred to attend an educational and support group. 19 Nationally such arrangements are commonly referred to as a multi-agency assessment hub or MASH 54 4.4.18 The initial assessment of her suitability for the group was carried out by an organisation called PACT, though when asked for details of the assessment by the local authority nothing was provided. The main commissioner of the service was the District Council, as part of its housing and community safety responsibilities. However the service was de-commissioned during the period under review. The mother attended briefly and suddenly stopped doing so, indicating that the group was not a priority for her. 4.4.19 The SCR is concerned that information was not shared between the original service provider and the local authority when it took over the service. This is a matter that should have been built into the contract and monitored to ensure that it occurred. The relevant partnership will be asked to remind commissioners and providers of this. 4.4.20 It is also a concern that services are currently commissioned in a way which would allow for a woman to attend a group work service (which then appears not to have met her needs especially well) on the basis of a very limited assessment without any reference to corroborative information from other agencies to establish if she had actually been a victim of abuse. 4.4.21 This points to the need for professionals to be more curious about the details of events, to share information about allegations of abuse with one another and to seek corroboration of their nature and seriousness. 4.4.22 However this approach also presents a potential difficulty. It would not be right to ignore allegations and in accepting accounts at face value professionals feel that they are properly guided by research that shows that victims find it hard to disclose abuse and tend to under-report it. It is inevitable that in any sample of people who claim to be victims of domestic abuse there will be some false positives. Possibly this is a risk that has to be taken and not a major concern in the overwhelming majority of cases. 4.4.23 This points to the need for a recommendation to the agencies that commission domestic abuse services to take account of the need for professionals to obtain a more detailed account of the incidents of domestic abuse and its impact on children before making referrals for services, while at the same time not losing sight of research about the prevalence and nature of domestic abuse. 55 4.5 Assessment and provision made in relation to the mother’s mental health Provision made for the mother 4.5.1 The health visitor was aware of the mother’s self-reported symptoms of depression and anxiety and advised her to consult her GP and the primary care mental health service. 4.5.2 The mother was seen by her GP and by the Talking Space service, which provided evidence-based psychological therapies. The GP provided medication and reviewed it periodically. The therapy and treatment service undertook regular standardised assessments and counselling either over the phone or face to face. 4.5.3 There is no evidence that the mother had any significant mental health problems. Her accounts of mild symptoms of anxiety, depression and loss of self-worth were consistent with the experience of many people going through contested divorce cases where the residence or contact arrangements for children are disputed. The standardised assessments point to low level / moderate concerns and suggest that there was some improvement over time as a result of the interventions offered. 4.5.4 At no point was there any concern that the mother’s mental health problems were impacting negatively on her capacity to care for Child N, less still that they posed any risk to her. There was no evidence that signs and symptoms of more serious problems were missed. Information sharing between professionals 4.5.5 At no point did the professionals who were aware of these difficulties share information with one another about their work with the mother. This would have been useful and easily done and should be part of normal working practice when a referred patient is responsible for the care of potentially vulnerable children. 4.5.6 The Oxford Health NHS Trust management review has made a recommendation to address this in relation to Health Visiting and Talking Space which the SCR endorses. When a person with small children has accessed a service for mental health problems, GPs should naturally be part of arrangements to share information about progress and any concerns. 4.6 Assessment and provision made in relation to homelessness 4.6.1 In May 2012 the mother was referred to Oxfordshire County Council because she had reported that she had no permanent accommodation and the Family Court Advisor was concerned about the welfare of Child N. The mother presented to the Oxford social care office (where she was seen by a 56 housing worker and a member of the social work team) and was referred on to the District Council in the area where she had previously lived in north Oxfordshire. The workers involved did not feel that the mother was in need of accommodation but that if she had been and had she also been responsible for the care of a child, funding for short term accommodation would have been made available while a fuller assessment was carried out. 4.6.2 The approach taken in this case was justified by the circumstances. Nevertheless the local authority management review sets out concerns about the wider picture in which ‘many of the workers who were interviewed stated that having the ‘housing’ or ‘homelessness’ label resulted in what was referred to as a ‘blanket approach’, namely: to outline the duty local authorities have in relation to homelessness; to explore options of staying with friends/family; to advise the family to refer themselves to the homelessness section of their local District Council. The housing options that are at CSC’s disposal are very few, and funding is limited. In such circumstances ‘providing money or housing is a last resort’. 4.6.3 Taken together with the large volume of work dealt with by assessment teams there is always a pressure in what are defined to move through and close ‘housing’ cases. 4.6.4 The local authority management review recommends that there is a need for clearer guidance to staff as to how to deal – jointly with housing colleagues – with families in more complex situations including those who have experienced multiple moves. The SCR endorses this proposal. 57 4.7 The role of Cafcass Introduction 4.7.1 Cafcass was involved with Child N and her family from January 2012 (when it received a copy of the application for a Residence Order from the father) until 14 May 2013 when the FCA filed a report prepared to assist the final court hearing which was scheduled for mid-June 2013. 4.7.2 The responsibility of Cafcass in Child N’s case was twofold. In all contested private law cases involving children Cafcass will undertake checks with the police and the local authority, in line with guidance.20 4.7.3 At the hearing in April 2012, the judge made Child N a party to the proceedings because of the potential complexity of the case (i.e. the concern about allegations of domestic abuse and the international dimension to the case). As a result Cafcass was directed to appoint a Children’s Guardian to report on the merits of the mother’s application, the progress of contact and future arrangements and any pertinent welfare issues.21 The role of the organisation is to advise the court, taking account of the welfare checklist in Section 1(3) of the Children Act 1989 as well as any other matters required by practice directions, required by the judge or raised by the parties.22 4.7.4 Cafcass prepared a comprehensive individual management review for the SCR which finds that in its work Cafcass complied fully with its internal procedures and with family court practice directions. However the case raises wider professional issues for Cafcass and others working in the family court system dealing with private law applications about children. These are set out in the following paragraphs. 20 This is described in the Cafcass individual management review as follows: 1) Screening – obtaining information from the police and children’s services 2) Risk identification – making an initial assessment of risk based on screening and separate interviews with both adult parties and 3) Reporting of this initial work to the court’s first hearing. 21 See footnote 10 22 Section 1(3) of the Children Act 1989 a) The ascertainable wishes and feelings of the child concerned (considered in light of his age and understanding); b) His physical, emotional and/or educational needs; c) The likely effect on him of any change in his circumstances; d) His age, sex, background and any characteristics of his, which the court considers relevant; e) Any harm which he has suffered or is at risk of suffering; f) How capable each of his parents and any other person in relation to whom the court considers the question to be relevant, is of meeting his needs; g) The range of powers available to the court under the Children Act 1989 in the proceedings in question. 58 Working arrangements between Cafcass and other professionals 4.7.5 In private law cases Cafcass will always make standard checks with the local authority and the police. Those checks will be enhanced (more detailed and thorough) in cases where concerns about domestic abuse have been identified. However Cafcass does not automatically access and report on the full range of information that might be available to other professionals and agencies that are in contact with the child. It will only contact others - such as health professionals – if it is apparent that they have information that is relevant to the issues that Cafcass is required to address or if the court directs that specific information is obtained. 4.7.6 During the course of SCR panel discussions it was established that this was not apparent to members of the panel. It is reasonable to conclude that it is also very unlikely to have been known to professionals who were involved with Child N who might have had information that could have assisted the court. For example information held by the GP, the mother’s Health Visitor and the Talking Space service about the mother’s depression and anxiety was never known to Cafcass or to the court. As a result the FCA did not form the view that the mother had any mental health problems, beyond the stresses and strains likely to be present when a parent is involved in a dispute over plans for the child’s future. 4.7.7 In this case knowledge of the mother’s reported symptoms of mental health problems was unlikely to have affected the recommendations made by Cafcass in its report to the final hearing. The mother’s problems were minor and there was no evidence that they had impacted negatively on her care for Child N. If anything, knowledge of the mother’s contact with professionals is likely to have reinforced the assessment that it was in the interests of Child N to live with her father. 4.7.8 However the current approach might create a risk in other cases, where for example there are mental health concerns about a parent that are not known to the other parent and not apparent to the court or to Cafcass. 4.7.9 This needs to be addressed from both sides. It may not be necessary, possible or proportionate for Cafcass to undertake a more comprehensive set of agency checks in all cases, however the agency should consider how it can ensure that within the framework of guidance laid down by the court, its staff can become more proactive in seeking information from agencies other than the local authority and the police. 4.7.10 It would also be beneficial if professionals in other agencies were more widely aware of the normal approach taken by Cafcass in obtaining information from other agencies. In some cases this might lead professionals to be more proactive in finding out whether Cafcass was involved and providing information to the organisation. In order to facilitate this Cafcass has agreed to adopt a recommendation that it will begin to make systematic presentations to local safeguarding boards in order to 59 assist in making professionals in other agencies more aware of its role (and of any limitations in that role). That work is under way. Decision making leading to the decision to recommend a Residence Order in favour of the father and the approach taken when informing parties of the proposal for a change of residence in a contested case 4.7.11 The report for the proposed final hearing was filed by Cafcass on 14 May 2013. 4.7.12 At that point the agency records suggest that cooperation between the parents was increasing and working in Child N’s interests. For example the parents had successfully negotiated longer contact including overnight stays which were reported to have worked well. The mother had overcome some of her suspicions and fears about the father to the extent that she had asked him to care for Child N for two or three weeks while she travelled to her country of origin. This may of course just have been because she could not take Child N out of the UK so it suited her for the father to have the child. 4.7.13 Although there was evidence of growing cooperation between the parties, the final hearing was scheduled to consider the applications before the court (details of these have been set out in Sections 3.154 – 3.162 above) rather than the recent changes in the parents’ behaviour. 4.7.14 In the face of severe practical difficulties and some reasonable and obvious objections from the father, the mother would need to overcome a number of substantial hurdles in order to achieve her ambition of taking Child N to live in her country of origin. In hindsight these difficulties appear almost insurmountable but it is not clear how well the mother was being advised and whether she was aware how unlikely it would be for her application to be successful. 4.7.15 It is not hard to see why the FCA chose to recommend that the court should make a Residence Order in favour of the father. This was in keeping with the case law and principles that the court would be required to follow. Because there were so many unknowns and uncertainties attached to the mother’s proposal to take Child N to Africa granting a Residence Order to her father appeared to be the least risky option. 4.7.16 However there is nothing to indicate that this was the preferred option for the FCA until the final supervision session with her Service Manager. Nor is there evidence that the FCA had discussed this possibility with the mother, prior to her solicitor sending her the report containing the FCA’s recommendations. 4.7.17 Earlier in the proceedings the mother had been warned by the judge that if she did not cooperate fully with the required assessments, consideration would be given to granting residence to the father. It may have been clear to the mother that if she persisted in her intention to take Child N overseas she 60 risked losing the right to have her daughter live with her. However this is not clear from the material seen by the SCR. 4.7.18 At this point the mother was represented by a solicitor. However for the reasons set out in Section 1.13 he has not contributed to the SCR. It is therefore impossible to judge how well he prepared the mother for the Cafcass recommendation or whether he had concerns about its potential impact on her or her child. 4.7.19 A recommendation or court order for a full change of residence in a disputed case is inevitably distressing for the party ruled against. Whilst the number of such recommendations is relatively small Cafcass has recognised the need for further detailed consideration to be given to the question of how the findings of reports recommending a change in residence should be made known to parents in these cases. 4.7.20 Regardless of the role of Cafcass it would be reasonable to assume that a parent’s advocate would explain the decision and enable the parent who faced losing custody of a child an opportunity to consider his or her options. It would always be natural for Cafcass to be more concerned about the potential reaction of a parent who was not legally represented, or had a history of threatened or actual violence. International aspects 4.7.21 Legal consideration of Child N’s circumstances was made more complex because of the international dimension. The country to which the mother proposed to take Child N is not a signatory to the relevant sections of The Hague Convention (which seeks to achieve agreements on aspects of law between different countries, including family law). As a result a legal order made in the UK would not automatically be mirrored and could not be enforced through the court system in the country where Child N would have been living. 4.7.22 At the hearing in July 2012 the court ordered that the child’s solicitor obtain information about the legal system in the mother’s country in order to determine whether an order made in the UK could be enforced there. After some delay it was confirmed (in October 2012) that this was not possible and the onus was then placed on the mother’s solicitor to establish how a separate court order could be obtained in the overseas court to do this. 4.7.23 On 26 November 2012 the court invited the Office of the Head of International Family Justice to provide more definitive advice on this matter by 8 February 2013. It is not clear when this body was contacted or what action if any it took. In May 2013 the court considered sending further information to this body, but it appears not to have done so before the death of Child N. 4.7.24 At the time of the preparation of the Cafcass report to the final hearing the court did not have the benefit of reliable, neutral or comprehensive advice 61 on the international aspects of the case to enable it to chart the best course of action. It is not clear whether in these circumstances the responsibility of Cafcass is to seek out a viable, practical solution or whether the onus is on the parties to make proposals. 4.7.25 In her report for the final hearing the FCA suggested (as one possible solution) that if Child N was taken to her mother’s country of origin the mother should be asked to post a surety with the court in London which would be forfeited if orders setting out contact arrangements were breached. The report indicates that this was a solution that had been implemented in another case. It is not clear whether this had been discussed with the mother before the report was written or whether in practice it would have been possible to implement. 4.7.26 Alternatively the mother had been encouraged to apply for an order in an overseas court granting contact rights in favour of the child’s father (who did not live in and was not a citizen of that country). It remains unclear how it could ever have been practical for the mother to do this or how in practice the father might enforce the order if the mother failed to comply with it. Overall the proposed steps and measures may have appeared to those involved to have carried some hope of success but it is extremely difficult to believe that they would have worked in practice. 4.7.27 The inability of the parties and the court to resolve this issue contributed to confusion and delay. Child N was too young to be aware of the uncertainty and in fact her parents appeared to be working better together as time passed. However in other cases this sort of delay and uncertainty might not be in the best interests of a child. 4.7.28 Cafcass has legal advisors who it says could have assisted by providing advice on international issues, but it did not seek their advice in this case. Reliance was placed on the parties to propose solutions. 4.7.29 The judiciary at present relies on the Office of the Head of International Family Justice.23 This is a tiny body which according to its Annual Report has two or three members of staff and received 253 referrals during 2012. The Annual Report provides seven case studies demonstrating its contribution but beyond that it is not clear what role was played in relation to the 253 referrals or how many of them were successfully resolved as a result of the information and advice provided. 23 http://www.judiciary.gov.uk/about-the-judiciary/international/international-family-justice Its judicial and professional staff devote a considerable amount of time in promoting international collaboration through attending and making presentations at international conferences and workshops. The Annual Report for 2012 shows that during that year staff associated with the office attending conferences in locations including Hong Kong, Bermuda, the Hague, Paris, Switzerland, Barcelona, Madrid and Nicosia. According to the annual report a judge in the country to which Child N’s mother proposed to remove her ‘has continued to provide the Office with invaluable assistance throughout 2012’. 62 4.7.30 Given the growing numbers of international private cases being brought before the courts (an inevitable consequence of international migration and the greater diversity of the UK population) there appears to be a need for Cafcass (and possibly others in the family court system) to learn wider lessons from this and to devote more resources to the problems created by disputed cases with an international dimension. 4.7.31 The SCR has therefore recommended that Cafcass should consider how it should strengthen its own capacity to work in international private law. It should also discuss the issues raised by this with the President of the Family Division in order to consider whether the judiciary and the private law system as a whole is properly equipped to deal with the likely need to manage international family law cases. 63 4.8 The work of agencies with fathers and male carers 4.8.1 The management reviews prepared by individual agencies found the involvement of the father to be an area of weakness in the practice of the midwifery and health visiting services. 4.8.2 The health visiting service had all of its contacts with the mother and did not seek to establish the father’s views or role, nor to corroborate of challenge the mother’s account by speaking to the father. The antenatal service had a small number of contacts with the father, but did not record his presence or views. 4.8.3 This is a common problem likely in this instance to have been exacerbated by the fact that this was treated as an ‘unproven’ case of domestic abuse where current professional culture is not to seek to check facts and allegations. 4.8.4 The engagement of fathers is identified in the community health management review as an area of potential learning, given that recent government guidance places stress on identifying fathers, assessing their involvement in the family and encouraging greater involvement with children and services. 24 4.8.5 Guidance sets very high expectations about the involvement of both resident and non-resident fathers highlighting the value of direct communication with fathers, assessment of fathers and arranging appointments at times when fathers can attend. At present there is often a gulf between the guidance produced by government and its implementation. 4.8.6 It is recognised that there are particular practical difficulties in applying this approach in midwifery, not least because midwives are also expected to exclude male partners from part of the antenatal assessment while they ask required questions about domestic abuse. 4.8.7 If it is to be successful the work to engage fathers requires a significant development in culture, expectations and working practice. Guidance and training may be beneficial because it is clear that many practitioners find it hard to know how to broach the issue of father’s involvement with mothers and to find out more about fathers in a way which does not appear to be intrusive. It is recommended that health trusts need to provide a much more comprehensive approach. This could include: issuing clear guidance; offering training; and monitoring the extent of engagement with fathers and the effectiveness of contacts. 4.8.8 Staff will need to be consulted so that there is a shared understanding of why this aspect of practice is so difficult and to have an opportunity to contribute their own ideas. Many of the ideas suggested in national guidance (such as offering appointments when it suits fathers) will clearly 24 Department of Health (2009), Healthy Child Programme – pregnancy and the first five years of life. 64 have resource implications and trusts need to decide at a senior level whether they are prepared and able to ask staff to prioritise this area of activity. 4.8.9 Both the health agencies referred to have agreed to adopt the recommendation that they revisit their current strategies for the involvement of fathers in service provision, examine their success and make further recommendations for action. 4.9 The response of agencies to ethnicity, religion and cultural factors 4.9.1 The ethnicity of family members was potentially of significance, as the parents came from different ethnic, cultural and religious backgrounds. 4.9.2 With the exception of the concern that Cafcass had in relation to the international aspects of the family’s situation (described in the Section 4.7) there is no evidence from notes and records that agencies paid attention to the potential significance of factors such as ethnicity and religion, the extent of the support that family members had in the UK or the potential for conflict between them over this. 4.9.3 It appears that the mother was viewed as being Westernised and therefore treated as if she were English. It is recognised that she was very forceful in her dealings with professionals and that she did not make it easy for professionals to seek background information or explore issues such as this. 4.9.4 For there to be such a shortfall in practice in a case where the ethnic and religious background of the parents may have had a significant impact should be a concern for the safeguarding board and member agencies. The SCR will therefore recommend that the LSCB revisits its current thinking and strategy on this issue in order to identify ways in which service provision can better reflect the needs of the changing population of Oxfordshire. 65 5 Summary of findings and recommendations Overall assessment of the provision made for Child N and other family members 5.1 A central concern of the SCR has been to establish whether there was evidence that the mother might have posed a risk of serious harm to Child N and if so whether professionals took the right action. The following paragraphs summarise the findings of the review in relation to this. 5.2 There were a small number of episodes during Child N’s life when there was potential concern about the quality of care that was being provided by her mother. However none of these could have led professionals to anticipate that her mother presented a risk of serious harm to her. 5.3 During her pregnancy Child N’s mother made contact with the social care service at the hospital where she was receiving antenatal care to say that she was considering relinquishing the unborn child for adoption. Neither the mother’s presentation nor her account of her feelings could have been viewed as being an indication of any serious risk to her future child. 5.4 On three occasions between April 2012 and January 2013 the parents separately reported domestic disputes (rows, arguments, threats and past threats). These were treated by agencies as falling within the definition of domestic abuse and responded to as such. There has never been corroborative evidence of domestic abuse and there is no indication that Child N was at risk of harm as a result of domestic abuse. The SCR has identified some minor shortcomings in the way in which agencies responded to the reports of domestic abuse, but they have no bearing on the death of Child N. 5.5 Between October 2011 and the death of Child N the parents were involved in protracted court proceedings to obtain a Residence Order in relation to their child. One member of staff from Cafcass had contact with the parents and was able to observe Child N on many occasions over this period. With the exception of the period of instability due to the mother’s housing problems – when she was concerned - this professional identified no signs or symptoms of abuse or neglect. Indeed along with all of the other professionals involved she always observed and recorded that Child N was well cared for, by both parents, almost always in a happy mood and meeting all of her expected developmental milestones. 5.6 When Child N was 8 months old her mother chose to rent out the family home and as a result had no stable accommodation. As a result of the mother’s behaviour the family court made Child N the subject of an Interim Care Order and ordered the local authority to undertake an assessment. Whilst there were some gaps in this assessment there is no reason to believe that the circumstances at that time merited removing Child N from her mother or making her subject to a child protection plan. Once the mother found stable accommodation observations made by professionals of Child N with her mother indicated that the baby was being well cared for and thriving. 5.7 Between October 2012 and May 2013 the mother spoke to her GP and a therapist about feelings of depression and anxiety, linked in the main to the 66 dispute. The GP prescribed anti-depressant medication, which was regularly reviewed. The mother made use of face to face and telephone therapy and treatment services. Her symptoms were within the range of commonplace and moderate presentations and she appeared to respond well to these interventions. At no time did there appear to be any indication that these problems might impair the mother’s capacity to parent Child N or cause professionals any concern. 5.8 In July 2012 Northamptonshire social care received a report that Child N (who at that time 10 months old) had bruises from falling off the bed and had been left alone in the mother’s bedsit. Northamptonshire visited the mother, observed Child N and asked other professionals if they had concerns. It is impossible to be certain whether or not this was significant. Child N was mobile at this point and so could have fallen or been bruised accidentally. However it is a concern that this report was not investigated properly. It is the only incident during which any concern about a symptom of possible physical assault was ever noted. 5.9 Taking the history as a whole there was no evidence known to professionals who were working with the family that the mother might pose a risk of serious harm to Child N. In fact the available evidence suggested the opposite. Even though the mother experienced practical and emotional difficulties at some points and there were occasions on which some professionals found the mother demanding and difficult to work with, the unanimously held view of professionals who had contact with Child N was that she was in good health, extremely well cared for and flourishing. Although he was in conflict with the mother over Child N the father told the SCR that he had no reason to believe that Child N’s mother would ever deliberately harm her. 5.10 In the circumstances it is not possible to see how professionals working with the mother could have predicted that she would harm her child or have taken any action – that would have been justified by the circumstances – that would have prevented it. 5.11 It is known, though very rare, for children to be killed in the course of a dispute about contact or residence. There are also no pointers in the wider research on this topic which would have highlighted risk in this case. When children are killed as part of such a dispute it is almost always by the male protagonist and almost always where there has been a history of violent domestic abuse, neither of which applies in this case. The wider implications for services to safeguard children and proposals for further action to improve the safeguarding of children 5.12 Agencies with safeguarding responsibilities could neither have predicted Child N’s death nor taken action to prevent it. However the review has identified a number of areas in which services could be improved. Whilst there is no reason to believe that the minor weaknesses identified had any impact on the outcome for Child N they should be addressed as they highlight potential areas of vulnerability in services which might impact negatively on other children and their families. 67 5.13 The SCR has made the following recommendations arising from the analysis and findings in Section 4 of this report. Recommendations made by individual agencies which arise from the learning from their separate internal reviews are set out in Appendix 5. Standard of Section 47 Investigation in Northamptonshire 1. Northamptonshire County Council should undertake regular scrutiny of the conduct of Section 47 enquiries so as to ensure that the response of the local authority and the police service fully addresses all of the referred concerns. Multi-agency management of risks arising from domestic abuse 2. Oxfordshire LSCB and the member agencies involved in the design and implementation of the proposed MASH attention should ensure that it provides an effective arrangement for dealing with incidents of alleged domestic abuse, including cases where there is a sequence of apparently less serious incidents. The response to cases should be effective and matched proportionately to the likely risk to children and vulnerable adults. 3. Oxfordshire LSCB should ensure that agencies that commission and provide domestic abuse services take account of the need for professionals to obtain relevant factual information about incidents of domestic abuse and its impact on children before making referrals for services, while at the same time not losing sight of established research about the prevalence and nature of domestic abuse. Recommendations for and relating to the work of Cafcass in private law cases 4. Cafcass and OSCB should review the current programme of presentations on the roles and responsibilities of Cafcass to ensure that they address the learning from this SCR and also meet the needs of both operational staff and strategic managers in member agencies. 5. Cafcass should undertake a review of the way in which it presents the recommendations of reports in private law cases in which it is recommending a change of residence (or other potentially challenging recommendations) in contested private law proceedings 6. Cafcass should consider how best it can strengthen its ability to work in complex international private law cases, taking account of the growing international mobility of families and the growing number of cases coming before the courts. 7. Cafcass, with the OSCB, should seek to enhance the capacity of the family court system to deal with complex international private law cases taking account of the growing mobility of families and the growing number of international cases coming before the courts through discussion with 1) relevant members of the judiciary and 2) local Family Justice Boards 68 Engagement of fathers and other male carers in service provision 8. Health trusts working with families in Oxfordshire should revisit their current strategies for increasing the involvement of fathers and other male carers in their services in order to test their effectiveness and review approaches as necessary. Service provision to children and families from minority ethnic populations 9. Oxfordshire LSCB should review how it monitors and challenges member agencies over their policy, procedures and practice in relation to children and families from minority ethnic groups in order to ensure that all aspects of the planning and delivery of services reflect the needs of the changing population of Oxfordshire. 69 Appendix I SCR REVIEW TEAM MEMBERSHIP SCR Panel Independent Chair: Paul Kerswell Agency: Designation: Oxford Health NHS Foundation Trust Acting Head of Nursing Children and Family Services Children’s Social Care & Youth Offending Service, Oxfordshire County Council Deputy Director Children’s Social Care, Oxfordshire County Council Safeguarding Manager Education & Early Intervention Service, Oxfordshire County Council Deputy Director Legal Services, Oxfordshire County Council Head of Law and Governance Thames Valley Police Detective Chief Inspector Oxford University Hospitals and Oxfordshire Clinical Commissioning Group Designated Doctor Safeguarding CAFCASS Head of Service for Avon, Gloucestershire, Wiltshire and Thames Valley. 70 Appendix II List of documents and material considered by the SCR review team Individual Management Reviews Children and Family Court Advisory and Support Service (Cafcass) Oxfordshire Clinical Commissioning Group (formerly NHS Oxfordshire) Oxford Health NHS Foundation Trust Oxford University Hospitals NHS Trust Oxfordshire County Council Children’s Social Care and Early Intervention Service Oxfordshire County Council Legal Services Northamptonshire County Council - Children, Families and Education Directorate Thames Valley Police Chronologies of brief involvement Luton Borough Council – Children and Learning Department Cambridge Community Services NHS Trust (in relation to the health visiting service in Luton) Luton Clinical Commissioning Group 71 Appendix III Principles from statutory guidance informing the SCR methodology 1. The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. 2. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed 3. Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. In addition Serious Case Reviews should: Recognise the complex circumstances in which professionals work together to safeguard children. Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Be transparent about the way data is collected and analysed. Make use of relevant research and case evidence to inform the findings. Appendix IV Policy guidance and research references HM Government (2013) Working Together to Safeguard Children HM Government, LSCB Regulations 2006 HM Government (2010) Working Together to Safeguard Children Charles Vincent (2010) Patient Safety (second edition ) Wiley-Blackwell BMJ Books DASH- CAADA Risk Identification Checklist http://www.caada.org.uk/marac/RIC_without_guidance.pdf Annual report of the Office of the Head of International Family Justice http://www.judiciary.gov.uk/about-the-judiciary/international/international-family-justice Hilary Saunders (2004) Twenty-nine child homicides: Lessons still to be learnt on domestic abuse and child protection, Women’s Aid Cafcass (November 2013) Learning from Cafcass Individual Management Reviews (IMRs) - Case Dynamics: Executive Summary Children Act 1989 http://www.legislation.gov.uk/ukpga/1989/41/section/37 Department of Health (2009), Healthy Child Programme – pregnancy and the first five years of life. 72 Appendix V Recommendations arising from individual agency management reviews Rec No. Agency Rec 1 Thames Valley Police Thames Valley Police to include guidance in the new Domestic Abuse Standard Operating Procedure regarding the importance of contacting the other party in domestic abuse incidents. 2 Thames Valley Police Thames Valley Police to circulate guidance to all front line staff explaining the importance of considering making contact with the other party in domestic abuse incidents as part of a ‘Positive Action’ response. 3 Thames Valley Police Thames Valley Police to remind front line staff of their duty to record and investigate any disclosures of a crime on a DOM5 form. 4 Thames Valley Police Thames Valley Police to ensure that front line staff understand that Positive Intervention in relation to domestic incidents includes when the victim perceives that an incident is domestic related and that their concerns should be fully investigated and positive action taken. 5 Thames Valley Police Thames Valley Police to instruct front line staff to consider whether there are any safeguarding issues evident in ‘Fear for Personal Welfare’ incidents and ensure that they are recorded on CEDAR. 6 Thames Valley Police Thames Valley Police to remind staff within the Protecting Vulnerable People Referral Centres to record all actions in CEDAR. 7 Thames Valley Police Thames Valley Police to evaluate the effectiveness of local policing area domestic abuse initiatives in relation to standard graded victims and consider the viability of rolling them out across the whole of Thames Valley Police. 8 CAFCASS Learning and themes from the Cafcass IMR to be disseminated throughout the agency. 9 Children’s Social Care Ensure consistency of practice so that self-referrals are managed in the same way as referrals from other sources and proceed to assessment where necessary 10 Children’s Social Care Senior Managers should assure themselves that C&F Assessments include an understanding of wider environmental factors and analyse the impact on the risk to the child. 73 Rec No. Agency Rec 11 Early Intervention Service Review the quality of referrals received by children’s centres and the use made of the Common Assessment Framework (CAF) both at the referral stage and when a family’s situation becomes more complex. 12 Early Intervention Service / CAFCASS Cafcass and EIS to ensure good practice with families in private proceedings, especially where both parents are (potential) users of the same hub or children’s centre. 13 Police / Children’s Social Care / Health The system of domestic abuse notification should be reviewed and taken into account in the design of the Multi-Agency Safeguarding Hub in order to: Ensure that the risks to children and families are assessed in a timely way and that there are appropriate and consistent responses from agencies, including the children of ‘standard risk’ victims. Ensure that resources are used efficiently across agencies without over-reliance on children’s social care. 14 OSCB Domestic Abuse training should ensure that ‘listening to what victims say’ is not interpreted as accepting statements at face value without probing, assessment or challenge. 15 Legal Services International law and port alerts , knowledge of emergency action procedure when there is a risk of abduction, to be added as team training event for the Child Care Solicitors. 16 Legal Services Child Care Team to be reminded of responsibilities to properly scrutinise adequacy of Court Reports and particularly S37 Reports. 17 Legal Services Child Care Team to ensure cultural, religious, racial and other characteristics properly considered and addressed in Court Reports. 18 Legal Services Diarise reminders if Social Workers complete S37 Reports with NFA required in private law proceedings and if there are issues to inform CAFCASS. 74 Rec No. Agency Rec 19 Clinical Commissioning Group GP records should represent a summary of primary care provision for a patient GPs must actively contribute to planning and agreeing communication arrangements with other relevant co-professionals to ensure this happens. The GP practice must have a clear communication process with Health Visitors and other co-professionals to ensure that the GP is kept up to date with all issues and actions for the patient. Formal arrangements such as being a “Looked After Child” must be notified to GP Practices and recorded in patient’s GP notes. GPs must ensure they have in place a clear system that this happens and is kept up to date. 20 Oxford University Hospitals NHS Trust The OUH midwives need to ensure that vulnerability is assessed on more than one occasion to maximize the opportunity to identify any concerns, vulnerability or risk 21 Oxford University Hospitals NHS Trust The maternity service needs to give further consideration on the best way to assess and record the involvement of and interactions with the father in pregnancy. 22 Oxford Health NHS Foundation Trust To improve information sharing between the Talking Space and the health visiting service in relation to patients with children under five to ensure a shared understanding of a parent’s mental health and any impact on the child is assessed and a shared plan of support is in place. 23 Oxford Health NHS Foundation Trust RIO rules/documentation guidelines to include guidance for health visiting staff on the documentation of father’s details and their role within the family and to be monitored via the annual documentation audit. 24 Oxford Health NHS Foundation Trust Health visiting services to ensure that recording of domestic abuse enquiry and maternal mental health is completed by practitioners and monitored via audit. 25 Oxford Health NHS Foundation Trust To provide updated information to Trust staff on the private law court process and role of CAFCASS. Recommendations for Child N 07/08/14 Serious Case Review for Child N Recommendations for the Oxfordshire Safeguarding Children Board The recommendations from the Serious Case Review of Child N for Oxfordshire Safeguarding Children Board (OSCB) are detailed below. These recommendations have been used to produce an action plan for OSCB, which is monitored on a quarterly basis by the Quality Assurance and Audit (QAA) subgroup of the board. Actions and progress made against them will be reported in the OSCB Annual Report and a 6 month update will be produced. Recommendations: 1. Multi-agency management of risks arising from domestic abuse - Partner agencies involved in the design and implementation of the proposed MASH should ensure that it provides an effective arrangement for dealing with incidents of alleged domestic abuse. 2. Commissioning Domestic Abuse Services - OSCB should ensure that agencies that commission and provide domestic abuse services take account of the need for professionals to obtain relevant factual information about incidents of domestic abuse and its impact on children before making referrals for services. 3. Service provision to children and families from minority ethnic populations - Oxfordshire LSCB should review how it monitors and challenges member agencies over their policy, procedures and practice in relation to children and families from minority ethnic groups in order to ensure that all aspects of the planning and delivery of services reflect the needs of the changing population of Oxfordshire. Actions: OSCB Independent Chair has written to the MASH project board to enquire of the effective arrangements in dealing with alleged incidents of domestic abuse The OSCB QAA subgroup to test the effectiveness of multi-agency working in domestic abuse cases in 2015/16. Oxfordshire Domestic Abuse Sub Group (ODASG) sit on the Board and they will help inform this work OSCB Independent Chair has written to the Oxfordshire Community Safety Partnership to request a review of pathways into domestic abuse services and what information is required from professionals making referrals OSCB are currently developing a new Section 11 Audit Tool to make the process more suitable for commissioners OSCB have requested that member agencies provide an update on their work/planned work with minority ethnic groups. |
NC045621 | Death of a female child in June 2013 as the result of asphyxia caused by ligature strangulation. Child X's father was convicted of manslaughter. Family were known only to universal services. Child X's parents separated in 2008 but father remained living in the family home as a lodger. Father was due to move out on 1st June 2013 but, after failing to find alternative accommodation, it was agreed that he could remain in the house for a further month. Child X was killed during this month. Following Child X's death, father was found with substantial injuries after his car had crashed; no other car was involved in the crash. Mother reported a change in father's behaviour over a period of years, from being outgoing and gregarious, to becoming more home-based and socialising very little. Mother stated that father had a very close relationship with Child X, which was at times overprotective and controlling and that father and Child X shared a bedroom. Mother maintains that, despite noticing a change in father's behaviour, she had no concerns about his ability to care for Child X. Makes recommendations, covering: record keeping and safeguarding training for GPs; and the need for a meta-analysis of research and reviews involving the death or serious injury of a child in the course of residence and contract disputes. Includes the response of the Hertfordshire Safeguarding Children Board
| Title: Serious case review: Child X. LSCB: Hertfordshire Safeguarding Children Board Author: Donald McPhail Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review into the Death of Child X – the Response of the Hertfordshire Safeguarding Children Board 1. The Background to the Serious Case Review Following the killing of Child X by her father and his attempted suicide, a Serious Case Review was commissioned into agency involvement with the family prior to the child’s death. The review was carried out by an experienced independent reviewer, Donald McPhail, with the specific purpose of: “evaluating the provision made [to the family by agencies] and identifying any missed opportunities for risks to have been appreciated or any good work about which there might be learning for the future.” As set out in the SCR report, the family had no involvement with agencies other than for normal primary schooling and routine visits to their GPs. Unknown to any agency, including her school, the parents had separated a number of years earlier but had continued to live in the same house with their daughter. The death occurred when the father had agreed to move out of the matrimonial home. There is no evidence of impropriety or previous violence within the family. The father was convicted of manslaughter. The review was carried out using Independent Management Reports (IMRs) submitted by the school and the surgery, together with an interview with the mother. As there were parallel criminal proceedings, the father was not interviewed. The Review’s approach was designed to fulfil the Working Together 2013 (WT 2013) guidelines including that “the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined.” (WT 2013, p66). The final report of the Review was received and discussed by the Board in April 2014. The Board’s response to the Report is set out below and together with the Serious Case Review Report (attached at Appendix A) is being published in keeping with the Working Together guidelines. 2. The Findings of the Review The reviewer found that the death was neither predictable nor preventable by agencies and that there were no actions which could have been reasonably taken to have altered the course of events for Child X. However, as a result of the submission of the management reports and his analysis of the case, he made two recommendations for the Board to consider. These are set out in the following paragraphs together with the Board’s response. 2.1 Recommendation 1: Further research into child homicide and parental suicide The reviewer was concerned that the unusual circumstances of Child X’s death should not be seen in isolation of other cases, where matrimonial separation or disputes have resulted Page 1 of 11 in child homicides and parental suicide. He therefore recommended that further national research should be carried out into such cases - “Hertfordshire Safeguarding Children Board should request the Department for Education to consider the need to commission a meta-analysis of research and reviews involving the death or serious injury to a child in the course of residence and custody disputes, to establish if there is any learning that could help prevent future deaths or serious injuries.” This potential research has been discussed with the Department of Education. Unbeknown to the report author, since the death of Child X, two research reports have been published which explore child homicide and parental suicide in circumstances of family breakup and family justice proceedings. References for the research are set out at the end of this report. The research generally highlights the unpredictability of child homicide in such cases, although the work by the Child and Family Court Advisory and Support Service (Green and Jeapes, 2013) identifies a correlation between parental suicide (rather than child homicide) and milestones in family court proceedings. The parents in the Child X case were settling their matrimonial matters without involving court processes. The Department of Education is already aware of the publication of these research reports. In addition, in recent months the NSPCC Library has established a repository of Serious Case Reviews. This gives safeguarding professionals and case reviewers the opportunity to learn from significant cases and is supported by the NSPCC’s own analysis of themes within reviews. HSCB Response to Recommendation 1: In light of the research reports and the NSPCC approach, it is not considered appropriate by the Board to ask for additional meta-research or analysis. The Board has therefore decided that rather than request new research, it will make other Safeguarding Boards and Local Authority Children’s’ Services Departments aware of the existing research so that it can be built into local learning and development frameworks for professionals. This is being achieved through the networks of the National Association of LSCB Chairs and the Association of Directors of Children’s Services. The Board is also sending a copy of the Child X report and this response to the NSPCC library for inclusion in the repository. 2.2 Recommendation 2: GP note-taking The Independent Management Report carried out into the family’s contact with their GP surgery identified that in the years before her death, the GPs had not always followed best practice standards in note-taking during their routine consultations. There is no suggestion that the GPs had failed to appropriately assess risks to Child X when they saw her. Considering the IMR, the reviewer made the following recommendation: “Hertfordshire LSCB should monitor the way in which the learning points for GPs identified in this review will be addressed by NHS England, Hertfordshire and South Midlands Area Team.” This ‘learning point for GPs’ is that “safeguarding training for GPs should encourage safe, accurate, precise record keeping with use of codes”. HSCB Response to Recommendation 2: The local ‘named’ doctor for safeguarding has worked with the GPs in Child X’s surgery to ensure that practitioners are fully aware of the latest national standards and comply with them. In addition, all GPs now receive annual ‘level 3’ training in safeguarding, which includes a component on report writing and the use of codes and Page 2 of 11 chronologies in note-taking. This training was not in place at the time that Child X visited her surgery. The Hertfordshire and South Midlands Area Team of NHS England, who are represented on the Board, now carry out randomised audits of GP records to ensure that the standards are achieved with advice or additional training being given as appropriate. In future, the results from these audits in Hertfordshire will be reported to the Safeguarding Board so that they can be considered with other auditing and case review information to identify any learning needs in future. Bibliography Green R. and Jeapes H. (2013) Learning from Cafcass Individual Management Reviews (IMRs) Case Dynamics: Executive Summary. https://www.cafcass.gov.uk/media/181560/learning_from_cafcass_individual_management_reviews_case_dynamics.pdf Yardley, E., Wilson, D. and Lynes, A. (2013) A Taxonomy of Male British Family Annihilators, 1980-2012. Oxford: John Wiley & Sons Ltd. http://onlinelibrary.wiley.com/doi/10.1111/hojo.12033/fullPage 3 of 11 Appendix A Serious Case Review - Child X Independent report author Donald McPhail HSCB independent chair Phil Picton Contents Title Page 1. Decision to undertake a serious case review (SCR) 5 2. Criteria for undertaking the SCR 5 3. Independent author of the report 5 4. The circumstances of the death of Child X 5 5. Terms of reference 5 6. Process of the review 6 7. Family contribution to the review 6 8. Agency contact with the family 7 9. Information from mother of Child X 8 10. Analysis 9 11. Conclusion 11 12. Recommendations 11 Page 4 of 11 1. Decision to undertake a serious case review (SCR) 1.1 The circumstances of Child X’s death were reported to the Hertfordshire Safeguarding Children Board (HSCB) and it was decided that the Serious Case Review (SCR) sub-group would review the details of services provided to her and her family and make a recommendation to the independent chair of HSCB. The SCR sub-group considered the case on 26th June 2013 and recommended to the chair of HSCB that the criteria for undertaking a SCR were met. The chair decided on 20 July 2013 that a SCR should be undertaken. 2. Criteria for undertaking the SCR 2.1 Working Together to Safeguard Children, 2013 requires that a SCR is undertaken ‘where abuse or neglect is known or suspected and a child has died’. This case fits this criterion. 3. Independent author of the report 3.1 The board commissioned Donald McPhail, an independent consultant, to review individual management reviews prepared by agencies that had provided services to Child X and other information provided by agencies and to write the overview report. Donald McPhail had had no involvement with the agencies contributing to this review. 4. The circumstances of the death of Child X 4.1 Child X was found dead at her home in June 2013. The cause of death was established by the paediatric forensic pathologist as Ia) asphyxia and Ib) ligature strangulation. Shortly after Child X’s death her father was found with substantial injuries after his car had crashed. No other car was involved in the crash. In January 2014 Child X’s father was convicted of her manslaughter. 5. Terms of reference 5.1 The review focused on the involvement of agencies over the two years prior to Child X’s death, but included any other events thought significant in previous years. The review’s remit was to evaluate the provision made and identify any missed opportunities for risks to have been appreciated or any good work about which there might be learning for the future. Page 5 of 11 6. Process of the review 6.1 Following the decision to commission the SCR, the LSCB requested all agencies with a legal requirement to safeguard children to review their records to establish if Child X or her family were known to their agency and to set out their involvement with the family. The only agencies that were able to identify contact with Child X or her family were: • Family GP • School • Police These agencies provided written individual management reviews to the SCR. 7. Family contribution to the review 7.1 The overview report writer met with Child X’s mother to establish her view of services provided to the family. Her views are expressed in the body of the report. There was no contact with Child X’s father who was awaiting criminal trial for murder. 7.2. Family details: Child X was born in 2002. Her parents were both approximately 50 at the time of her death. The family is white British. Child X was the couple’s only child. 7.3 Family circumstances: although Child X’s mother and father separated in 2008, they continued to live in the same house. Child X’s father became a lodger in the house after his share of the house had been bought out by Child X’s mother. This was not planned to be a permanent arrangement, but it was a practical arrangement that allowed Child X’s father to have continuing substantial contact with his daughter. The plan had been that Child X’s father would move out of the house to accommodation he was to find for himself on the 1st June 2013, but as that date approached he still had not found alternative accommodation and it was Page 6 of 11 agreed he could have a further month to find accommodation. During that time Child X was found dead. 8. Agency contact with the family 8.1 It was established by the SCR sub-group that only universal services were involved with the family. 8.2 GP practice: the GP records for both mother and family do not indicate any issues that relate to the possible development of difficulties which could have been anticipated as contributing to safeguarding risks for the child. In particular there was no evidence of domestic abuse, mental health difficulties or substance abuse. All of the GP surgery contacts by Child X predated the two year time period of this review, but details of earlier contacts were provided by the internal management review because of practice issues that emerged. Child X was seen twice in 2010 and 2011 in relation to asthma, and while the details of her medical condition were well documented, there was no recording of who attended the surgery with her, her demeanour, or the effect of her asthma on her lifestyle or education. There was no recording of the school that she attended. Earlier Child X had attended the GP practice on two occasions, once as an 8 month old, and again as a 5½ year old. As a baby Child X attended for a dressing by the practice nurse of a laceration to the left temple. There is no recording of the explanation for the injury. Child X had been seen in February 2003 at a hospital accident and emergency department with an injury to the temple while in the care of her mother. Police statements from both parents give a history of the injury occurring as a result of a fall from a car seat. At age 5½ Child X’s medical notes indicate the negative results of a vaginal swab, but no detail of the reason for the swab was found in the records. The GP was later able to confirm that there were investigations for a urinary tract infection, but all results were negative. The school nursing service had had no significant contact with Child X. 8.3 School: Child X’s school had no record of concerns for her before her death. Child X attended her school from year 1, her parents choosing not to send her to the reception class. It is reported by the school that the parents would have preferred her to be home schooled, but, in the event she attended school. Page 7 of 11 The school perceived the parents to be very caring and protective of her, and they described her as being a very ‘precious’ child. Both parents usually attended parents’ consultation evenings, and Child X was brought to school and picked up from school every day by either her mother or her father. Child X did not attend year 5 or 6 residential trips but she was taken on holiday by her parents at her birthday time during the academic year. The school indicated that permission would no longer be given for such absences in term time. The last contact with the school was when Child X’s father phoned the school on the day before she died to say she had an upset stomach and would not be in school. The school had no concerns about Child X: she was achieving well academically and working at or above age appropriate expectations in all her assessments. She was a quiet girl who always appeared well cared for and happy, and had friends in the school. 8.4 Hertfordshire Constabulary: there had been no contact between the police and any member of the family in the two years before Child X’s death. There were two reported contacts with the police with the father in 2008 and 2010 which have no bearing on the incident being investigated. 9. Information from mother of Child X 9.1 Child X’s mother provided insight into family life. She described a change in her husband’s behaviour, from whom she had been separated for about five years, although living in the same household. He had originally been outgoing and gregarious, but over the years became more home-based and socialised very little. He had a very close relationship with Child X, and was at times overprotective and controlling. Child X shared a bedroom with her father, while her mother slept in the other bedroom. There had been an amicable agreement between Child X’s mother and father when they split up to remain in the same household for a while, with Child X’s mother buying out his share, and he becoming a lodger in the house. This arrangement was due to end on the 1st June 2013, but child X’s father needed more time to find suitable accommodation. Child X’s mother is clear that although she could recognise a change in the father’s behaviour over the years, she had no concerns about his keeping Child X safe, and she recognised also that anyone outside of the family, Page 8 of 11 including professionals, would not have perceived him to present any concerning behaviours. 10. Analysis 10.1 While the school had daily contact with her, Child X presented very positively with no signs of stress or behavioural reactions. The school had no concerns about the care she received and her parents were seen as being involved and caring. Although the school did not approve of her being taken out of school for holidays, and they noted that she did not attend school residential trips, they also recognised that this did not make her stand out from other pupils and did not cause them to be concerned about parental support. The family had very little contact with the GP practice and there was nothing within the two year time period before Child X’s death that would have enabled any professional from the GP practice to identify the danger to Child X in June 2013. However, the review has identified a number of issues regarding the recording of visits by the GP practice to address as there was limited information available about some consultations that should have been more fully recorded. In particular the two contacts in 2002 and 2008 should have been more fully documented to demonstrate that there was an understanding of the context of the injury and infection and to explicitly recognise if any risks were considered or identified. The 2010/11 GP consultations with Child X did not raise any issues of concern in relation to her medical care, but insufficient attention again was given to her attendance and the social implications of her illness. The importance of recording these factors was addressed in guidance issued by the Royal College of Paediatrics and Child Heath in 2010 1. The GP individual management review identified four learning points from the review of these consultations: • GPs must be encouraged to be well trained in use of their electronic systems to record sufficient accurate information at each encounter, to enable other health professionals reading the records to understand why the patient consulted at that time and the reasons why specific actions were taken. 1 Safeguarding Children and Young People: roles and competencies for health care staff’, Intercollegiate Guidance September 2010 Page 9 of 11 • When children are seen it is important to record who accompanied the child to the appointment and the relationship to the child. • It is important that GPs and their staff make an effort to communicate directly with children if they are old enough and have sufficient mental capacity to respond. • Safeguarding training for GPs and their staff must emphasise that it is possible to code safeguarding concerns using nationally agreed codes. The GP individual management review has made a recommendation to address these issues. The insights provided by Child X’s mother raise the possibility that, in retrospect, there was a hidden dynamic developing out of the father’s fear of losing his parenting role with his daughter. This has been a feature of other SCRs into the deaths of children in the course of difficulties over residency and contact and specific research by Women’s Aid. 2 It is however important to note that in all of the cases in that study the man who killed the child had previously been violent to the partner. This research, while very useful, is now a decade old and the SCR believes that it would be valuable if it could be updated, to take account of more recent child deaths in the context of disputes over residence and contact. 11. Conclusion 11.1 Review of the facts set out above: it is evident that there are unusual features of the way in which this family lived, such as the parents’ decision to continue to share a home after their divorce and the sleeping arrangements. The purpose of the SCR is not to speculate on the possible significance of these but to evaluate the practice of professionals who were involved with the family taking into account information that they possessed or might reasonably have known. The judgement of the SCR is that none of the professionals involved with Child X and her family had information to enable them to be able to predict or prevent the tragic outcome for her. Although the SCR has identified some weaknesses in practice these have no bearing on Child X’s death or to the possible identification of risk to her. Recommendations arising from this 2 Hilary Saunders, (2004) Twenty-nine child homicide: Lessons still to be learnt on domestic violence and child protection, Women’s Aid, Page 10 of 11 evaluation are designed to strengthen the quality of service provision for other children. 12. Recommendations 12.1 HSCB should request the Department for Education to consider the need to commission a meta-analysis of research and reviews involving the death or serious injury to a child in the course of residence and contact disputes, to establish if there is any learning that could help prevent future deaths or serious injuries. 12.2 Hertfordshire LSCB should monitor the way in which the learning points for GPs identified in this review will be addressed by NHS England, Hertfordshire and South Midlands Area Team. Page 11 of 11 |
NC52268 | Injuries to a 4-month-old baby boy in 2019 inflicted by his mother who was mentally unwell. Learning includes: there is some inconsistent understanding regarding statutory guidance in the child protection procedures about undertaking pre-birth assessments related to mental health risk factors; coordinated work, robust information sharing and effective strategic oversight will better ensure all children are safeguarded; children are best protected when the local system of management oversight in supervision and meetings is strong, resulting in well-coordinated risk assessments, interventions, and planning; professional curiosity is best supported when working with families and other professionals if there is a local culture of collaboration and professional challenge; confident and open practitioners work better with families if their professional views are challenged, and all practitioners at times struggle to communicate with some families; families do well when they have a good understanding of their rights and responsibilities, and can make informed choices. Recommendations include: ensure that all local multi-agency pre-birth risk assessment tools and protocols and information sharing comply with child protection procedures and local guidance, and that staff are aware of, and trained, in using these; seek assurance of the quality of individual agency supervision and management oversight; consider how empowering staff and supervisors in exhibiting professional curiosity can be encouraged in training and supervision, so that staff feel confident to have challenging conversations.
| Serious Case Review No: 2021/C9117 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Official Baby D Child Safeguarding Practice Review 2021 Executive Summary 1. This systems’ Child Safeguarding Practice Review considers a time period of 17 months in 2018-19 leading to a serious incident involving Baby D, a White European 4-month-old baby boy. His mother became mentally unwell and consequently Baby D was injured by his mother. The family was a professional family, and the mother was a professional working with families. This incident was raised by the Mental Health Trust, as a serious incident and they completed a Root Cause Analysis. However, despite the family being known to several other local agencies, none notified the LSCP of the serious incident. This would have been expected, given the serious nature of the incident. 2. The family was firstly known to agencies before pregnancy as the mother had a long history of significant mental health difficulties. They were living in County A. They had regular support from Mental Health services, midwifery and GP during the pregnancy. Shortly after discharge from the acute Hospital when Baby D was born, the mother became unwell and threatened to kill him. She was brought into A&E (Accident and Emergency) by Ambulance to the same acute Hospital in County A; she was detained under the Mental Health Act and she and Baby D went to a Mother and Baby Unit over 100 miles away. 3. There were confusions over which county was responsible for the family as the family had been living temporarily in County B, a neighbouring county. County B Children’s Social Care carried out a Section 47 investigation and closed the case after several weeks; County A Children’s Social Care was informed of the open case but not of the threats to harm the baby, and was not included as part of that assessment. County A Children’s Social Care carried out a single assessment under Section 17 and closed the case 10 weeks later without meeting the family or meeting with most professionals, as the family did not wish to meet them. Professional relationships working with the family were not always straightforward; the father did not feel he was informed of his parental rights and was told he could go to prison for being obstructive at one point. 4. Mental Health professionals working with the family, continued to have concerns regarding the mother’s deteriorating mental health in the community and the family agreed that she would not be left alone with the baby. Six weeks after the closure by 2 Official County A CSC, the mother was alone with Baby D and dropped him on the floor. They were taken to the same acute Hospital in County A and the mother was again detained under the Mental Health Act. The baby was treated and discharged into the father’s care. 5. Professionals at times found it challenging to maintain a professional relationship with the father. It is hypothesised that he was trying to advocate for his wife. No professionals were able to have a conversation with the father regarding how his behaviours were impacting on their work. 6. Now after considerable support and evaluation, Baby D is thriving in the care of his parents. After the period the review has examined in detail, there was stronger multi-agency involvement: for example a well-represented Strategy Meeting took place, leading to an Initial Child Protection Conference where Baby D was made subject to a Child Protection Plan, and joint supervision took place between the Health Visitor, Social Worker and their managers, which was good practice. 7. This report makes five findings and provides questions to our local Strategic Leadership Groups and Boards regarding supervision, pre-birth risk assessments, staff confidence in working with challenge from families, and information sharing. 3 Official Contents Methodology 4 Baby D’s parents’ comments 4 Appraisal of Practice 7 Findings 18 Conclusion 28 4 Official Methodology 8. This review uses a SCIE (Social Care Institute of Excellence) systems’ methodology. A Review Team was made up of senior multi-agency professionals, who had no direct involvement with the family. The team met seven times virtually over a nine-month period, plus there were individual agency meetings to agree this report, which was drafted by the lead reviewer. A virtual practitioners’ day was held in October 20201 to go through chronological events, and individual meetings with those practitioners unable to attend also took place. Some of the practitioners completed workbooks with their reflections. The family was invited to meet with members of the review group and met once with members of the Review Team. After collating and scrutinising the multi-agency chronology and practitioners’ feedback, this report consists of an appraisal of practice looking at four periods of time, ranging in total over seventeen months, findings, and questions to local senior leaders. Practitioners gave positive feedback in relation to their experience of the practitioners’ day. 9. The parents have suggested that this Review might have benefitted from having a perinatal psychiatrist as subject expert on our Review Team. This is accepted learning for us and this report has been considered in its sign-off process by a consultant perinatal psychiatrist, who had no involvement in the family’s story. Baby D’s parents’ comments 10. Our local and national principle is that families should be involved in Child Safeguarding Practice Reviews and there should be a portrait of the child and a focus on his experiences at the centre of the Review. We do know that Baby D is thriving in the care of his family. The parents met members of the Review Team in January 2021 and were given the draft report. The parents gave their account of events before they read the report, and we are grateful for their time and insight-their words are in italics. The mother said that she had felt let down from the perinatal appointment she attended before Baby D was born and considered that she should have been given anti-psychotic medication before the baby was born to mitigate against any deterioration in her mental health. The mother felt that she had been given questionable medical advice. This is addressed in paragraph 22 below. The parents said that the time since had been very traumatic, which affected them now. The parents said that people did not seem to care, and it felt like professionals had run away when the family had wanted help. From the beginning, the mother said that she felt that she had had no continuity of care. 1 Police, County A and County B Children’s Social Care, Perinatal Mental Health Team, Acute Hospital Midwifery and Paediatrics Teams, County A Health Visitor, Separate contact was made with the GP, Mother and Baby Unit, GP Surgery Nurse. 5 Official 11. The parents told us that after Baby D was born, the mother had needed to see the specialist team midwife as she was unwell- she was disappointed that her voice was not heard as she did not see this midwife. She said that she had struggled to sleep and to feed Baby D. The parents felt that the midwives should have kept a closer eye on her. She was discharged from the Maternity Ward at 9:30pm on a Friday evening and was visited the next afternoon at 5pm by a Midwife. The parents said that there was no contact from the mental health team. The parents told us that as they left hospital, they were given contraceptive advice, but instead they had needed someone to reach out to them, to care and coordinate. 12. The father said that he then called 999 on the Sunday as they had no other telephone number to call. He first called the Maternity Ward, but they said they did not have anything to do with this. The mother was then admitted to the Maternity Ward. The parents thought that professionals did not understand the mother’s history and would not give her any psychiatric medication. The parents felt that it all got out of hand, as the professionals did not understand the mother’s psychiatric history, even though she was treated at the same hospital. The mother said she was very stressed. 13. The parents said that no-one communicated to the family about the planned Mental Health Act Assessment. The parents said that the mother had not been subject to a Mental Health Section in the past. They said that there were five people in the room, it was a crisis and it was pointless and too late. The father said that he lost confidence and the situation was out of his hands. The parents said that they had a new baby, and this should have been the best time, but it was the worst time. The father said that he was not able to look after his wife, and she was not well enough to understand fully what was going on. The father said that common sense would have been to keep the family together – people were trying to tear them apart. 14. The mother remembered that an ambulance with a blue light took her and Baby D to the MBU (Mother and Baby Unit). The mother found this an awful experience. She said that she was very confused and thought she was going to prison. The mother felt that there was a take it or leave it attitude that they had to go to the MBU- the father said that he did not know they had other options. The father thought that the transfer to the MBU was illegal; he said that the mother was distressed, and two men moved her. The father was also trying to work. The parents said that the family had offered to care for the baby at home so that the mother could go to a local psychiatric hospital and to bring Baby D in every day to see his mother. Things, the parents said, were not managed by the NHS. 15. The discharge from the MBU seemed too early for the father. He said that he had lost confidence in professionals. The father said that the mother was determined to be discharged. The parents said that the Psychiatrist at the MBU had not understood the mother’s history or risks. 6 Official 16. The parents said that the support from the Home Treatment Teams had varied and they had not been supportive in the crisis before Baby D’s injury. The father said that he had not wished to consent to the 78 x-rays (the skeletal survey) prescribed for Baby D when he was injured, as he feared for his future health and development. To the father, that had seemed a reasonable response, but this had led to him being seen to be obstructive and CSC moving towards legal proceedings. 17. The parents said that after Baby D’s injury, they found that the Police had little knowledge of mental health issues. They said that the mother was arrested but she had no capacity. It was obvious. The father said that he tried to plead that they go to Hospital, so that the mother could be assessed there. The parents said that the mother was in the Police station for 11 hours until 5am. For them, this did not seem to be the right place as the mother was no risk to anyone. No one explained the process to them, they told us. The mother said that she would not have tried to run away. She said that she was treated as a criminal and should not have gone to a medium secure forensic unit. 18. The parents said that the first time they met the social worker after Baby D was injured, the social worker said they had to comply, or the child would be taken away. The parents said that the social worker did not understand. They said that the professionals were more used to broken families and did not take it well when people questioned them. The family said that they had five different social workers. The father said that he stood up to professionals, but they lived in fear and had to sign up to agreements. They felt that if Baby D fell over, tripped, they would have to bring him to hospital. The parents now had a fear that Baby D would be taken away. They said that they had seen what had happened in the past. 19. The father said that he had found some professionals helpful and he would latch on to them. He said that he was looking for someone he could trust; someone patient and relate-able. He liked people to talk and listen to him. The father said that he liked to understand the process of what was going on and to ensure his wife had the best treatment. He acknowledged that he was vocal about that and would try to decipher things in his head to make sense. It was better when they did not need to retell their story. The father said that he had been dealing with caring for his wife for 12 years, and they had friends and family who were always there. Some family members lived close by. He said that he reached out to them. He said that he was high functioning and kept going. They both worked and played very hard. The father said that he would always challenge and ask questions to understand things. They had never gone against consultant’s advice. 20. The parents told us that communication was key and there had seemed to be a lack of common sense. They felt that professionals were from so many different backgrounds; they could not work together collectively. The parents said that professionals did not understand or appreciate mental health issues. The parents hoped the conclusion of this report may help someone else. 7 Official 21. When we met them, the parents had not yet received the Root Cause Analysis Report from the Mental Health Trust, and this was sent to them shortly after the meeting. The parents said that they thought that there was a cover-up. Appraisal of Practice Pre-birth Planning 22. The family initiated and attended a mental health pre-conception meeting which lasted 30 minutes longer than usual, which was a positive. This meeting was very good practice. The consultant psychiatrist noted that the meeting was sensitive, and it lasted nearly two hours. The mother had impressive insight into the likelihood of her mental health deteriorating and accepted additional support would be likely when she was pregnant; the father had many questions. On reflection, the psychiatrist considered that the pre-conception counselling protocol could be improved to focus more on fathers - their hopes and fears, attitudes to services, treatment, and their own mental health. The mother has expressed that she should have been given anti-psychotic medication in pregnancy. In hindsight, this is a valid point and maybe the outcome after Baby D was born could have been different, but this does not mean that the decision at the time was wrong. This was investigated in the Mental Health Trust Root Cause Analysis report and it was found that the mother’s care and treatment had been appropriate. 23. Information was shared with the GP. The mother became pregnant swiftly after this meeting and was booked for her pregnancy very early and identified at booking with the maternity team as high risk due to her significant history of mental illness. She had the support of the same specialist midwife in the specialist team at the local acute Hospital throughout the pregnancy. This was good practice. 24. The mother’s health was discussed monthly at the maternity concerns’ meetings at the local acute Hospital. A decision to refer to County A Children’s Social Care at the first meeting was not made after supervision. We have not been able to clarify the rationale for this. This decision was not challenged or reconsidered by the maternity concerns multi-agency group. The lack of contingency planning and assessment before birth was a missed opportunity. This would have been a chance to plan for a safe delivery and after-birth care from a multi-agency perspective and work in partnership with the parents in a transparent way about strengths and risks. The father’s assistance, family and support network could have been clarified. A Mother and Baby Unit option could have been discussed at an early point, and maybe one closer to home identified, if needed. 25. There was good liaison between the midwife and GP- consistent parties throughout the pregnancy. The mother remained under the care of the Consultant from the 8 Official Mental Health Team, who was having 3 monthly reviews with the mother and sent letters to the GP. GP Correspondence was filed by an Administrator; Midwifery and Health Visiting also wrote to the GP. Now safeguarding correspondence is read by a safeguarding lead in the GP practice and flagged. 26. All midwives at the acute Hospital are trained to use the risk assessment tool and Whooley questions. The local perinatal mental health guideline 2017 is available on the Hospital’s intranet but this was not followed. 27. All letters were received from Maternity by the Health Visiting team. In this case the mother was not contacted as usual at 28 weeks pregnancy by the Health Visitor. This is likely to have been an administrative error. The local provider’s Standard was not met; this is discussed in paragraph 101 below. This was a missed opportunity. 28. At times during the pregnancy, “work stress” was noted for the mother by GP and midwives, which was seen as a potential trigger for exacerbation of mental health symptoms. At times, the mother had a sick note, excusing her from work. This was not escalated to the Mental Health teams by the GP or known by other professionals to be taken into account at the maternity concerns’ meetings. 29. The birth plan was made by the midwife in good time: it was about the birth itself, not mental health risks, and was not shared with other agencies. It would have been helpful for there to have been a mental health review after the birth. Now as the Perinatal Mental Health Team is well established with more staff, this would be considered. There was a collaborative mental health crisis plan made several months before birth with the mother by the Recovery Team – this was standard good practice but this was not shared with the midwifery team, GP and family; this would now be shared with the Perinatal Mental Health team. 30. Above all, in this pre-birth period, despite good family and considerable professional engagement, the local Child Protection Procedures, local peri-natal mental health guidance and our local pre-birth protocol were not followed for a mother with a history of psychotic episodes and more consideration could have been given to assess risk and strengths. Baby D’s Birth and Hospital Discharge 31. Baby D was born in the A County Acute Hospital where the pregnancy had been booked and monitored, a healthy boy, and the plan was for the mother to stay in the post-natal ward in hospital for several days, as she had some high-risk factors. In planning for the discharge, it seemed a surprise to practitioners that the family was 9 Official living temporarily in a neighbouring county in the grandmother’s home, County B, as their home was being renovated If it was known the mother would be going out of county postnatally, the midwives in County B would have been involved beforehand. 32. Whilst waiting for discharge, the mother asked three times to see the specialist midwifery team. Normally, the specialist team can review cases as requested or a Consultant from psychiatric liaison could have been involved. It was recognised that the maternity specialist team was exceptionally busy at the time, which included several high-risk safeguarding cases. Whilst the specialist team is not available out of hours, there is always a senior midwife on call. The psychiatrist had last seen the mother a week before hospital discharge, 2 days before the Baby’s birth. It is not known how the mother’s anxieties to see the specialist Team and worries about going home were viewed by staff in the context of her history, nor how the father was involved in being a protective factor, as this was not recorded. This was a missed opportunity and may have afforded the mother reassurance or delayed her discharge. There was a flag on the electronic record to remind staff to check the mother’s care plan and that she needed to be seen by the specialist team midwife prior to discharge. Specialist team records are now stored on the electronic record relating to safeguarding and mental health, so there is now greater access to records, and they are more up to date. 33. The mother and Baby D were discharged on a Friday to County B Community Midwives; information was sent by email by the acute Hospital Administration staff and was not received or confirmed by the sender. This discharge summary had scant mental health information. 34. Good practice when a mother has a history of mental illness, and is known to the specialist maternity team if they are moving out of county, would be for the Maternity Unit to telephone through to the Community Midwives in the other county for a formal handover, to confirm receipt of discharge, and to request an early visit which would have ensured a visit over the forthcoming weekend by Midwives. There are no records of this in the Community Midwifery Team in County B but the parents have told us they were visited by a Community Midwife shortly after Baby D’s birth. 35. A discharge planning meeting would have helped- this could have involved the family, Health Visitor, GP, mental health team and midwives from both counties. Since January 2020, there are now discharge planning meetings involving post-natal midwives, if there is high risk of deterioration in maternal mental health. A newly established Perinatal Mental Health team was launched mid-January 2019 in County A, and it works collaboratively with the specialist midwifery team to review mothers with a history of severe mental illness 10 Official An electronic discharge summary was sent to the GP and Health Visitor, and the mother was given a discharge summary for the community midwife, GP and Health Visitor. Secure transfer was made of records to County B community midwives. 36. There was no communication with the Mental Health team that the mother had had the baby and no perinatal mental health care plan; she could have been becoming unwell. Currently, there is joint work ongoing around discharge planning with Mental Health teams and midwifery. Ensuring this information is shared in accordance with NICE guidance will be part of this Review’s action plan. 37. In this instance, Baby D was not registered with his GP until early March- no agency checked on this, including the Mother and Baby Unit, where a history was taken on admission. Mother and Baby D returned to Hospital 38. There was no formal professional contact at home, and two days after discharge, the father called 999 on the Sunday at 10:30pm, as the mother was threatening to kill the baby. We do not know how long the mother’s health had continued to decline, perhaps during that day, or why the Mental Health services or midwifery team were not contacted by the family. Mental health can decline very quickly. 39. The Ambulance Service attended and conveyed the mother and Baby D to the local acute Hospital, where he was born, noting that the family was living in a temporary address, but not noting that address. The Ambulance Service made a safeguarding referral to County B CSC, where the family was staying, as they should have. However, the Ambulance Service Patient Report Form did have both addresses. This was a missed opportunity to share and clarify addresses. 40. County B Children’s Social Care (CSC) began a Section 47 Child Protection Enquiry and did not ascertain this was a County A child or send any record of it to County A CSC at that time. This significant confusion about area responsibility began a long train of confusing events for the family and those working with them, which could easily have been remedied. County A CSC did not receive the Police notification and were not aware of the threats to harm the baby. The Police notification only went to County B CSC as is practice, and it wrote of the mother wishing to smother the baby. Police was aware of the temporary nature of the address in County B, as the County A address was in their research. 41. In County B, there was a timely telephone strategy meeting with Front Door Health in attendance, but no information was gained or shared regarding the mother’s mental health, nor was the family’s County A address known. This is a serious oversight. 11 Official Now the picture is very different in County B as changes have been made at the front door to CSC, and Police are based in the team. 42. In County A, two days later, the acute Hospital referred to CSC and a single agency assessment under Section 17 began; there was no strategy meeting despite the mother having threatened to harm the baby, as Children’s Social Care was not made aware of this. This would normally take place in County A, if CSC were made aware of risks. In County A CSC, the Head of Service contacted the safeguarding midwives querying why information was being sent to County B, concerned that key information was not being shared, that would impact their assessment. At the same time, the Health Visitor was trying to gain contact with midwifery to make a new birth visit and was not made aware of the incident- the Health Visitor had already contacted the parents about a new birth visit and had not heard back from them. It is not clear how the mental health team and GP were informed. Good practice would have seen a joint strategy meeting involving both counties and all other agencies taking place, and ensuring key people were invited. This does take place in Counties A and B. 43. A Mental Health Assessment took place on Monday by County A Mental Health Social Care Team. The father felt strongly that he did not want his wife detained under the Mental Health Act; he did not want his wife to be interviewed by the Adult Mental Health Team and was observed by staff to be obstructive. The mother was not initially detained under the Mental Health Act and there was agreement for voluntary admission to a Mother and Baby Unit. 44. The mother was subject to a further Mental Health Assessment, the following day, which recorded the potential high risk to Baby D, including the mother talking of smothering the baby and being unresponsive to Baby D’s needs. It was agreed that the mother should be detained under the Mental Health Act. The family were against formal detention, the father was articulate and persuasive with the psychiatrist during the first mental health assessment, presenting the counter argument that mother had the capacity to consent to voluntary admission. This led to a delay in formal detention, which the Hospital advised. In hindsight, the Assessment could have been challenged as a day later, the same doctor reconsidered the decision and the mother was detained under Section 2, of the Mental Health Act. 45. County B CSC notes that the case was allocated for assessment in County A CSC. County B CSC attempted to contact the father for 5 days to no success; they wrote about his confusion about consent and his parental rights. Medical staff found it hard to engage with the father and he talked of finding a private psychiatric unit for the mother, and caring for the baby himself, which would have been possible. County A contacted the father twice with no reply, and a third time he contacted the social worker himself but the contact was limited as the social worker was not sure of his identity and the father shared limited information. 12 Official There was very little consideration of concerns about the father’s anxieties and behaviour, despite many professionals finding the situation difficult. Professional curiosity did not extend to asking why the father was so surprised by the mother’s mental health presentation or what help he needed. 46. In the meantime, the mother and baby stayed on the maternity ward with nursing observations. There were conflicting professional views of the mother’s ability to care for the child. The mother spoke of feeling abandoned by the specialist team midwife and wondered if she should have phoned the Team before. The Hospital contacted County A CSC. And County A CSC tried to contact the Hospital in return, leaving six phone and email messages. A conversation would have led to a better understanding of matters for both sides and a sharing of strengths and risks. 47. County B CSC had 12 minutes’ notice from the Hospital maternity unit, before the mother and Baby D were transferred to the MBU (Mother and Baby Unit) out of the area, and County B CSC requested a discharge planning meeting. This did not occur and would have presented another opportunity to clarify roles and responsibilities, not least addresses. That same day, County A CSC had contact with the maternity team in the Hospital to discuss the family’s address and plan to go to the MBU. 48. The GP practice were notified of mother’s attendance at A&E, including her detention under the Mental Health Act by a summary document. The summary did not include that mother had had thoughts of harming her baby. At this time there would have been no active role for the GP, as she was an inpatient on the Mother and Baby Unit. The Mother and Baby Unit 49. The confusion of owning locations and areas spread to the Mother and Baby Unit (MBU), where it was recorded that “County A and B CSC” was carrying out an assessment. This added to the disadvantage of the MBU being approximately two hours away from home. 50. The MBU assessed the situation, and considered that there was no impression there was a risk to Baby D. In the MBU, a history was taken from the father; he said how the mother had not wanted to have the baby and said that the baby was better off dead. It was not clear if this information and stress for the father was shared with any party, and how it informed the MBU’s risk assessment and subsequent work with both parents. 51. The mother did not voice any threats towards the baby in the Unit and the Unit based the mother’s discharge on this. This would seem to be overly optimistic and not taking into account context, multi-agency involvement and history. This assessment seemed 13 Official centred on the mother. Children’s Services’ involvement and future planning, including contingency plans should have been clarified whilst the mother and baby were safe, and good practice would have led to a multi-agency meeting to achieve this. 52. The mother wanted to go home and was discharged from her Section after 6 days by a new doctor to the Unit. She requested discharge home a week later- in the meantime, the MBU and County B CSC had found it hard to contact the father, as he was working. He was concerned about the mother being discharged and becoming unwell again. Home leave then began. 53. Home leave was not ideal at this time in the MBU’s hindsight opinion, due to the mother’s health, and the mother’s bed was left open in case it was needed again. It was hard for the Unit to liaise with local professionals in the home area. They routinely updated the Health Visitor but not the GP-this would only have happened on discharge. The Health Visitor, but not the GP are invited to CPAs (Care Programme Approach Meetings) and discharge meetings, which was what happened in this case. The Health Visitor did not attend the discharge meeting, as it was out of county, and a significant distance, which was understandable. The County A social worker was on the way to the discharge meeting and it took place without her; unfortunately, her train was delayed. It would have been good practice for the Unit to have updated the local GP and Mental Health Trust with details of any home leave, and for the discharge meeting to have waited for the social worker. 54. For local residents, MBU home leave is staged with short periods at home, Occupational Therapy visits and support from the Unit. This could not happen due to the distance for this family. The transfer to Mental Health services was not straightforward as the Home Treatment Team can only be referred on discharge and do not attend discharge meetings or CPAs. Shortly after this, there was a transfer between perinatal teams as the mother moved back from County B to County A. 55. There was a slight deterioration in the mother’s health before home leave, but the mother was an informal patient. The father was concerned regarding the deterioration. But the mother would not agree to stay. At this point, County B CSC closed the case. County A CSC met the MBU but not the family, as they would not agree to this. There was an MBU agreement that the father or maternal grandmother would always be with the mother and baby. There was no plan shared with the family or other agencies, with contingencies. At Home 56. Following leave from the Mother and Baby Unit, the family lived at home, firstly with the maternal grandmother in family accommodation in County B, and then back to the family home in County A for the next two months. Two weeks later, the mother 14 Official was discharged from the MBU by a series of telephone calls. Had she been a local resident, a lot more outreach would have taken place. Normal best practice would have been a sit-down discharge meeting from the MBU involving the family and other agencies. 57. During this time, many mental health professionals were involved: the MBU, the Perinatal Mental Health Team, the Recovery Team and the Home Treatment Team. This was confusing to professionals and family members and no lead Mental Health professional was identified. Sometimes joint visits were carried out by the Perinatal Mental Health Team and the Home Treatment Team, which was good practice. The professionals did ask to see the mother alone, which was good practice, but both parents declined. In hindsight, this could have given another picture as to her wellbeing. Mental Health practice guidelines have been developed independently of this review by which practitioners are expected to try to see a client alone on at least one occasion, to allow for the use of routine enquiry about Domestic Abuse. 58. The family had found the Home Treatment Team visits disruptive due to different staff members attending; there were two occasions where the family cancelled visits – this was due to the Team being late for appointments and therefore was not unreasonable. On both occasions, the mother was seen the following day. 59. Risk was often assessed as low to moderate and included that Baby D should not be left alone with the mother. The family declined informal re-admission to the MBU. There was reassessment under the Mental Health Act, and it was assessed that mother was not detainable. The Review Team could not identify if there was consideration or discussion with the family around the reasons for not wanting to return to the Mother and Baby Unit. We acknowledge that the Unit was a two-hour drive from the family home, and this could have been a substantial barrier. This potentially highlights the challenges of finding local MBU placements. 60. There was no evidence that the father was offered the option of a Carer’s Assessment by any agency, to identify what support could have been available for him as he was in what could be imagined a stressful situation balancing the needs of caring for his new-born baby, unwell partner and juggling work commitments. Whilst consent would be required for this assessment, the local carers’ network would have carried this out in County A. This would be expected as good practice, so that the father could engage in services in his own right. This is not always remembered by staff in general in our local safeguarding system. He could have been offered Carers’ support some years ago as well before the baby was born, or he could have approached the network himself. 61. At times, it was noted that mother was trying to calm the father and grandmother at visits. This was not a matter for professional reflection. 15 Official 62. There was good communication between the Health Visitor and the Perinatal Mental Health Team. The Perinatal Mental Health Team updated the GP after visits. Professionals found the father stressed and at times challenging to work with. The Home Treatment Team professionals visited in pairs following a decision they had made together regarding working with the father- there were no physical risks. They informed the Perinatal Team of this but did not inform other agencies of this decision. No agency or professional thought of the effects of the father’s behaviour on the baby. The Mental Health Home Treatment Team nurse thought that father was aware of any risks, due to mother’s previous relapses during their relationship. 63. The mother’s mental health fluctuated. The mother was seen three times by the Health Visitor, and the mother and baby were seen once by the GP at a 6-week check. The mother was transparent at this meeting, informing the GP of her ill-health and admission to the MBU. The GP had not met the father. On reflection, following the mother’s 6-week review, a case discussion between the Health Visitor and GP would have been helpful; this would have enabled discussion about the potential impact of the mother’s mental health on Baby D. 64. During this period, the Perinatal Mental Health Team’s concerns rose for the mother’s deterioration in mental health. County A CSC closed the case with the social worker on the manager’s direction, contacting the Mental Health Nurse, Health Visitor and Psychiatrist in advance. The CSC Team Manager completed the single assessment. A telephone call was made afterwards to the GP, and letters were sent to the family, mental health nurse, Health Visitor and GP with the outcome of the single assessment. Maybe there was a false sense of security that the family was engaging with the Mental Health Teams. At the time this was a new Perinatal Mental Health Team. On reflection, the Team was in its infancy and today this case would have been followed up with CSC by them, which could have potentially stopped case closure. 65. The CSC closure seems to stem from the family declining to work with County A CSC and the involvement of mental health services. This should have been seen as a warning signal, and professionals should have been invited to a meeting to share the full history- this would have been good practice. The mother’s thoughts of harming the baby when she was very unwell were not taken into consideration, as County A had not known of this. The single assessment was completed and the recommendations with a letter were shared with other agencies. This is normal practice. The single assessment and a letter were sent to the family. There was no context or analysis around the mother’s fluctuating insight and mental health. The family had expressed, they did not need support. 66. Five weeks later, the baby was injured. It would seem professionals assumed CSC was involved- we do not know why professionals did not escalate this at the time nor challenge when the case was closed despite risks rising, as the Perinatal Mental Health Team informed the social worker regarding their concerns. That Team spent 16 Official considerable time finding out how to contact the social worker and there was no feedback. The Social Work Team manager completed the single assessment and closed the case, giving the management oversight of this decision in CSC, detailing mental health and Health Visitor support. The social worker had left. We question the effectiveness of supervision received at the time for all involved agencies. We ask if there was a false sense of security for professionals working with the mother. 67. We note the vulnerability of two different parties in the family dynamic and at risk at home, particularly at weekends. There was a wish for the mother to continue life as normal and care for the baby. There was a focus on the mother, and not on Baby D. Baby D was injured 68. The family did not initiate contact - it was always at the initiation of the Perinatal Mental Health Team. In the week before a bank holiday Monday, the Perinatal Mental Health Team noted a further decline in the mother’s wellbeing. The Perinatal Nurse had previously been on leave. The Health Visitor and Care Coordinator were informed. A safely plan was developed by the Perinatal Mental Health Team and revisited with the family; the Home Treatment Team could have been engaged over that weekend. At every visit, the safety plan was updated with the family. The care coordinator in the Recovery Team and the consultant psychiatrist were informed. The Perinatal Mental Health Team brought the consultant’s appointment forward to see the mother. All agencies who were involved and the local CSC should have been informed. 69. When the mother was alone with the baby in the family home in County A on a Friday of the forthcoming bank holiday weekend, her mental state deteriorated and as a result she dropped Baby D deliberately. She subsequently informed the maternal grandmother of this, as she was in another part of the home, and the maternal grandmother called 999. 70. Ambulance attended the home and the mother, maternal grandmother and Baby D were brought to the A&E Department at the acute Hospital in County A (the same hospital as noted above). The Ambulance Service called Police to assist. The mother was subsequently arrested and taken to Police custody; she was not placed in a cell, but she was sat in the charge area with the father. She was checked every 30 minutes. This was evidence of compassionate policing. In Hospital, the maternal grandmother remained with the baby. A Mental Health Act assessment was carried out in police custody as is police policy, and the mother was detained at a psychiatric hospital in County A. This was appropriate practice in a crisis situation for the mother. 71. Baby D was admitted to a ward as a place of safety at the acute Hospital in County A. The father denied consent for additional photographs to be taken of the 17 Official baby. Hospital staff wanted to take photographs of a possible stork mark. A skeletal survey was carried out, which is standard procedure for an infant fracture according to NICE guidance in these circumstances, evidenced by the Royal College of Paediatrics and good practice. Professionals found the father’s behaviour challenging. He suggested involving a solicitor. This made professionals feel anxious when working with the family and medical staff told him that he could be imprisoned for being obstructive. This type of encounter would only raise anxieties for a parent and for staff members. On reflection, staff noted how this tension inhibited their practice and how fearful the father must have felt. Some spoke of how they felt controlled and unable to function; one person said that the father had berated them. Some noted that the father seemed to prefer to work with more highly qualified professionals. This was seemingly not picked up in their professional supervision and addressed. 72. The strategy meeting four days later was tense, partly as the father was on the ward, although he was not involved in the strategy meeting itself. The meeting was chaired by a County A CSC Team Manager, and ten professionals attended, which was appropriate. Police attended the acute Hospital and assessed that the father was suitable to care for the baby, following Police intelligence checks. A discharge plan was made. A LADO (Local Authority Designated Officer) referral was made by the Mental Health Trust Named Nurse three days later, due to the mother’s professional status. The father’s fear and resistance were not discussed, which was a missed opportunity for both the family and professionals. There was no discussion of staff safety. Professionals were invested in developing a good working relationship with the family, and so avoided addressing their concerns of safety and resistance. There was no sense of assessing the daily lived experience of a four-month-old baby with such relationship dynamics going on around him. The safety plan was discussed with the father at a subsequent home visit the following day by the social worker. There was also a discharge planning meeting. 73. Following examinations, Baby D was discharged into the care of his father four days after the incident, that same day. Plans were also made for an Initial Child Protection Conference to take place. Debriefs were held for staff in the mental health teams. This was good practice. 74. The quality of information sharing could have been improved. There was no request for information from the GP by CSC until over a week after the injury. The Hospital discharge letter was received by the GP surgery over a week after discharge, informing them that Baby D had been admitted following a Non-Accidental Injury. 75. No one informed the GP Surgery of the incident or discharge planning meeting- and Baby D attended the GP a couple of days afterwards for immunisations with the Practice Nurse. The Practice Nurse was not aware of the injury and as a result of learning, Practice Nurses at this surgery now note who brings a child in to appointments. 18 Official 76. The Mental Health Trust raised the incident as a serious incident within their own agency and carried out a Root Cause Analysis, raising this incident with the CCG in a timely manner. Best practice would have been for each agency to have raised this as a serious incident immediately. This was subsequently raised as a serious incident with the LSCP by the CCG - a significant delay of eight months. Findings and Recommendations 77. We have outlined five improvement recommendations for our local Partnerships to consider. We have identified several safeguarding contributory factors, which led to the serious incident in 2019 for Baby D using the themes of Tools, Information Sharing, Management Systems and Staff Interactions with Family Members. Rather than one cause or a concern for any one agency, these are system wide improvement issues. These issues for improvement take us beyond Baby D’s story to our local safeguarding systems. Recommendations are made to both the Local Safeguarding Children and Adults Partnerships in the three local areas. Tools Pre-birth assessments and protocols 78. There are several local tools to aid risk assessment and information sharing. The LSCP Pre-birth Protocol was first launched in 2015 and has been refreshed during this review period, and the Think Family Protocol was updated in 2019. We have found that many local practitioners are unaware of these documents, as well as the local Child Protection Procedures or the local Perinatal Mental Health Guidance (2017) which outline pathways to assessment when there are pre-birth concerns. The Child Protection Procedures states “ Or s/he could be an unborn child: Of a pregnant woman with any previous major mental disorder, including disorders of schizophrenic, any affective or schizo-affective type; also, severe personality disorders involving known risk of harm to self and / or others.” Our multi-agency local Threshold Document follows local guidance and outlines required action where there are pre-birth concerns of mental ill-health. If these procedures had been followed, there potentially would have been adequate pre-birth planning for Baby D. Findings are in common with the Child O Serious Case Review, around a need to strengthen a coordinated multi-agency approach, and to include the voice of the child. 79. A pre-birth referral could have been made before 12 weeks’ pregnancy in this case, despite the mother being in good health, based on any single health agency assessment of risk. The Child Protection Procedures advise that best practice is for a pre-birth assessment to be completed by 20 weeks pregnancy. In this situation, the clock would be ticking for CSC, but a decision could have justifiably been made to go over the 45-day single assessment timescale, thus not placing pressure on CSC to 19 Official close the case. Later, in the MBU, the threshold would have been made for a referral to CSC, if they had not been already involved. 80. Since this time, the acute Hospital’s maternity concerns meetings have been reviewed and their format changed, as at the time of our review, large numbers of pregnant women were discussed - every woman on the list. Local guidance has been refreshed to triangulate with the Child Protection Procedures and local protocol. Now fewer vulnerable women are discussed each month - only new and high-risk women are discussed. This is a busy maternity unit serving approx. 5,600 women per year and several counties. Currently not all other counties attend this meeting for their cases, but they receive lists. The Perinatal Mental Health Team are planning to attend. The County A CSC Front Door Team, Drug and Alcohol and Health Visiting teams attend consistently. This meeting can now work effectively as a virtual and offline model to bring in other counties and services. 81. Maternity concerns meetings’ minutes are now recorded on an Excel database, which ensures easier searching and reads more succinctly for everyone involved in the meetings. All agencies who usually attend, are emailed prior to the monthly meeting to enable them to access any further updates to bring to the meeting. Rather than discussing every woman, only the recognised high-risk women are discussed or if there have been any updates from any agencies or individuals. The action tab, on the database, is updated after each meeting with the relevant information on what action is required, which individual or agency is actioning and the results of these actions. 82. We have found that the mental health risk assessment focussed on the adult not the child. The Mental HealthTrust’s risk assessment guidance is comprehensive and includes consideration of everyone in the household, children at risk, family support, guidance around carers, home leave, discharge, contingency planning, and an equality impact assessment tool. Risk guidance should be clear on action and information sharing if the adult deteriorates in health or access cannot be undertaken to see the individual. A decline can happen very rapidly. As the social work team is now not part of the local mental health service in County A, a possible check and balance is missing. Local CSC Teams since this time has provided considerable staff development around pre-birth assessments. 83. Practitioner understanding of Baby D’s vulnerabilities pre-birth could have been stronger. The national picture 2supports our local analysis and search for improvement in working pre-birth and with infants. The Child Safeguarding Practice Review Panel has outlined that they have seen 137/500 cases for babies harmed or killed by non-accidental injury since its inception in June 2018 to December 2020. More than half appeared to have involved weak risk assessment and poor decision making. Between the beginning of the pandemic in March 2020 and October 2020, 2 Child Safeguarding Practice Review Panel January 2020-Thematic review into non-accidental injury in children under one; Amanda Spielman 6th November 2020 speech at the NCASC 2020 (National Children & Adults’ Services Conference); Children’s Commissioner Lockdown Babies May 2020 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2020/05/cco-lockdown-babies.pdf 20 Official Ofsted saw 40% of their serious incident notifications for babies; a fifth more than in the same period last year - 8 babies died. Information Sharing in short and longer-term work 84. Information sharing is a local systemic issue for us to improve, as partners have told us of instances of not knowing information pre-birth, post-birth and regarding child protection enquiries and serious incidents. In this case, not all key agencies knew most importantly that the mother had threatened to harm Baby D when first admitted to Hospital when he was 7 days old. Those agencies who were aware of this risk did not reflect on this or share the information, ensuring partners were aware. In this case, there are many other instances where important information was not shared or reflected on within or between agencies, such as the mental health team visiting the family in pairs, when County A closed the case despite the Perinatal Mental Health Team raising concerns, or the GP noting the mother was suffering from work stress in pregnancy, which was a potential trigger for a decline in mental health. 85. There needs to be consideration that when a child is discharged from Hospital, the ward telephones or emails involved agencies to inform of any Non-Accidental Injury, other serious issues, and discharge into the community, as appropriate. This will address the time lag between discharge and receipt of the discharge notification. Baby D had attended the GP surgery for his third set of immunisations the day before the discharge notification arrived. Birth discharge notifications are also still handed to mothers to give to the Health Visitor and GP; details of babies are not routinely taken by GP Practices when electronic notifications of births arrive from hospitals. This is being addressed by ongoing strategic work between the CCG, GPs and Maternity Services. 86. The hospital or urgent care centre treating children for Non-Accidental Injuries or any other suspected abuse should make sure the GP and other relevant professionals are aware of serious incident, and invited to attend discharge planning meetings and receive any notes and safety plans immediately. GPs should be routinely invited to FINDING 1 There is some inconsistent understanding regarding statutory guidance in the Child Protection Procedures about undertaking pre-birth assessments related to mental health risk factors QUESTION 1The Partnerships are asked if they are assured that all local multi-agency pre-birth risk assessment tools and protocols comply with Child Protection Procedures and local guidance, and if staff are aware of, and trained, to use them. 21 Official attend strategy meetings by CSC and information requested if they are unable to attend. They should not need to wait for the normal discharge summary, as in this instance and in general, this can take some days to arrive. 87. GP surgeries have differing local practice in flagging records and sharing information regarding vulnerable patients. The GP Safeguarding Lead would have expected the records to be flagged and initiated discussion regarding next steps. The process outlined above whereby the safeguarding lead in each practice reviews all correspondence regarding safeguarding would have ensured a more robust response. A standard recording of who brings a child to appointments would also have been helpful and has been put in place at the GP surgery involved. 88. Information was not clear to the family or professionals regarding the Mental Health lead for the mother, nor the rationale for staff visiting the home in pairs. The Mental Health Teams seem to have asked family members to ensure that the mother was not alone with Baby D and to have informed them when her health declined. This did not fully take place. The father seems to have been unaware of his rights as a parent, and as Nearest Relative to the mother as a mental health patient. 89. It would seem that assumptions are made that information is known to other agencies, particularly when CSC is involved; agencies assumed County A knew about the mother wishing to harm the baby at the first Hospital admission. In some agencies, supervisors do not seem to systematically check the involvement of other partners. It could be pressure of work that prevents practitioners reflecting and thinking widely, but supervision should be a check on this. We address the issue of supervision below. 90. The need to strengthen information sharing from frontline to strategic levels was evident in our local counties. Strategic leads were not always identifying serious incidents within their agency, addressing this within their own system and alerting the Partnership to potential learning. Protocols in place were not being used. County A CSC refreshed the serious incident guidance in June 2020 and the Partnership itself in October 2021. In County B, there have been improvements to the safeguarding front-door when cases are transferred to another county- this has been assured by a dip-sample audit of cases. “Think Family” has been disseminated as a concept for our working together since this review has begun, with a webcast being developed in February 2021 and plans being made for a summer virtual Conference with all the local Safeguarding Adults’ Boards. FINDING 2 Coordinated work, robust information sharing and effective strategic oversight will better ensure all children are safeguarded. Our local information sharing within and between agencies can be further strengthened. QUESTION 2 The Partnerships are asked if they are assured that all local multi-agency and single agency information sharing complies with the Child Protection Procedures and local guidance, and if staff are aware of and comply with this. 22 Official Expectations of families 91. We note that the father requested information about his parental rights to care for Baby D, as is understandable. Confusions about local area responsibility, would not have helped the family’s working relationships and we can imagine they will have sometimes felt very frustrated, alone, and afraid. This may have led to them wishing to work with more senior professionals in the network. Management systems Staff oversight 92. Staff supervision is an extremely useful tool to help a practitioner reflect on their work with a family and other agencies and should provide an objective view to ensure any safeguarding issues have not been overlooked: it should be a system check. Supervision was taking place across all agencies in this review but was not always effective. The Mental Health Teams had regular supervision including daily clinical supervision for the Home Treatment Team. We wonder whether better staff oversight could have helped professionals to see the baby, and hear his voice, instead of focussing on the adults, with possible associated unconscious bias around the family’s professional status and ethnicity. 93. This review has found supervision at the acute Hospital led to a referral not going to CSC from the maternity concerns’ meeting. Subsequently there has been training of midwives in supervision and the process has been strengthened. In the acute Hospital, there is a safeguarding supervision policy and a form is completed together in supervision for individual case holders, finalised by the Named Nurse or Named Midwife. This is then put in the case records by the professional and a plan is agreed between the supervisor and supervisee. It is down to the professional to bring cases they wish to discuss. Best practice would be for previous actions to be discussed too, and clear documentation made of changes of plans. 94. From summer 2019, there has been monthly open peer group or individual supervision session for ward staff and A&E at the Hospital for anything they wish to discuss, undertaken by the Named Nurse or Named Doctor. 95. In County A, there were some changes in CSC teams, and the social worker left, meaning the manager completed the single assessment. It was a busy time in the 23 Official team due to staff turnover issues. Supervision would have noted that risks were rising as the case was being closed and multi-agency views were required. 96. The County A CSC Supervision Policy was updated in January 2021. A lot of work has gone on around supervision in CSC. Timescales are clear within the policy and included within the policy is joint supervision with other professionals, including Health and Education. Case discussions are held at least every eight weeks. There is a 10-day management oversight for all new assessments. In this instance, there was management oversight and case review three times in the first month. Reflective supervision applying the Signs of Safety approach is used. After the Review period, there was a joint supervision with CSC and Health Visiting, where they used a discrepancy matrix to reflect on the work with the family and consider next steps. This was good practice. Group / peer supervision happens between weekly to monthly in CSC, and learning groups take place monthly. Practitioners are encouraged to have informal supervision whenever there are difficulties. 97. In separating the Adult mental health and social work teams in County A in 2017, the review has found that information sharing, and management oversight have fragmented in more than this one case. Good supervision would have helped staff develop relationships with other agencies working with this family and allowed for more professional challenge each agency’s decisions. It would have helped practitioners focus on the child and risk. 98. Supervision in Maternity at the acute Hospital in County A has changed over the last year. Originally, every member of staff in maternity would undertake a yearly inhouse update surrounding safeguarding and mental health. They would also undertake an external multi-disciplinary update session every 3 years. As well as this, the Band 7's in the specialist team would have a quarterly supervision with the Named Nurse for Safeguarding, who had the requisite Level 4 qualification. The Safeguarding Midwife and the Link Midwife for Domestic Violence also had this qualification. Last year the Safeguarding Midwife and the Deputy Director of Midwifery, undertook this Level 4 training. The idea of extending this training was to be able to provide supervision to a recognised group of midwives who would benefit from this extra support. This group of midwives were the Antenatal Clinic, Community and Examination of the Newborn Midwives. Therefore, as from January 2020 quarterly supervision was started for these extra midwives alongside the previously mentioned updates for everyone else. The aim is to provide supervision for 100% of these midwives every year. 99. The Health Visiting team has a standard to ensure vulnerable women identified in pregnancy are followed up pre-birth- this did not happen for Baby D, and we do not know why. Baby D was not identified as being in the higher tier (Universal Plus) for support. 100. The Health Visiting service in County A receives many specialist Hospital maternity team referrals with very few being opened to the specialist maternity team itself. There is now a health visiting triage system as part of its Practice Standard to determine if the pregnant woman’s support should be opened or supported under the Universal offer. This Standard was introduced in January 2019. The first audit of this 24 Official Standard was due in January 2021. There is currently no checking process to determine if the contact with the pregnant woman is undertaken following the triage. Health Visiting is currently considering if a check could be implemented at 34-36 weeks pregnancy. 101. There should have been a strategy meeting at the first admission of the mother into hospital with significant mental health concerns, and where, in addition, the mother was threatening to harm the baby. County B had opened a Section 47 child protection enquiry but did not include any health professionals in the strategy meeting, save the front door health lead. Work has commenced by County A CSC to improve the quality of referrals from other agencies. Management oversight of professionals involved did not notice missing information, nor the confusions regarding addresses escalated to ensure this was resolved in a timely way. In comparison, the strategy meeting at the time of the baby’s injury was comprehensive three months later and shows good practice. We want to improve the identification of risks pre-birth and encourage professional curiosity to ask more questions. 102. One agency informed the LADO (Local Authority Designated Officer who oversees allegations made against staff and volunteers) of the mother’s professional role, and before Baby D’s birth, her anxiety was seen as “work stress”. We have asked ourselves if a non-professional or non-white family would have received the same response. 103. We are pleased that there is now as a result of this learning, a process of identifying the lead Mental Health Professional in place. The Root Cause Analysis report was very good, and identified care and service delivery problems in its learning. It found that there was a lack of a multi-agency approach in the working between the Recovery and Support Team, the Perinatal Community Team, and Children’s Services; and that the Recovery Team were delayed in providing a care coordinator, who would have been the lead mental health professional and a point of contact for the family and professionals. 104. One agency picked up the serious incident and non-accidental injury at a strategic level and ensured strategic oversight and learning. The reporting of serious incidents is a nation-wide matter of discussion at present. Locally, there has been a decrease in reporting over recent years in our sharing of serious incidents within the Partnership; the policy has been refreshed after our Independent Scrutineer reviewed the process in summer 2020, and more recently we have seen an increase in reporting. There is discussion in the Designated Doctor network how the STEIS (Strategic Executive Information System) relates to the local reporting system as a national issue. Currently, supportive and reflective models of supervision are being considered to support local practitioners in understanding cases which seem “stuck” or challenging. Joint supervision took place between CSC and Health Visiting and their managers after this review time period, which was good practice. We will be ensuring single agency and our Partnership escalation and resolution policies are embedded further. 25 Official Practitioner interactions with family members The family seems to have found some professionals hard to work with, and similarly, some professionals found it challenging to work with the family at times. Understanding was needed on both sides. This working situation was hampered by incomplete information sharing and at times the confusions about lead professional and county. If professionals had communicated more effectively, the family would have had a better experience of professional support, and professionals would have been able to address any concerns of challenge in working with the parents more effectively. 105. Working with professional and or affluent families sometimes requires practitioner confidence to face challenging conversations. This has been evidenced in others of our local learning reviews over time, and there have been multi-agency action learning sets to develop skills. 106. Practitioners sometimes find it hard to explain in words how they feel about the families they work with. In this case, practitioners’ assessments did not outline the difficulties they encountered in engaging with the family at times, and the effect of this FINDING 3 Children are best protected when the local system of management oversight in supervision and meetings is strong. This leads to well coordinated risk assessments, interventions, and planning. RECOMMENDATION 3 The Partnerships are asked to assure themselves on the quality of individual agency supervision and management oversight. FINDING 4 Professional curiosity is best supported when working with families and other professionals if there is a local culture of collaboration and professional challenge. RECOMMENDATION 4 The Partnerships are asked to consider how empowering frontline staff and their supervisors in exhibiting professional curiosity can be encouraged in induction, training and supervision, so that staff feel confident to have challenging conversations, challenge their own stereotypes, and reflect on their work. (Burnham Social Graces) 26 Official on the baby’s care, and safeguarding. This could stem from the impact of family’s ethnicity, culture and professional status on workers, and workers’ lack of confidence. 107. Local professionals often struggle to work with challenge- they modify their behaviour at times and are better equipped to deal with physical hostility instead. Professional supervision, and multi-agency supervision to reflect would help. Professional curiosity could have been strengthened in understanding the family, their ethnicity and culture, and to use the prompts in agency guidance and templates. These gaps in knowledge were not always identified or addressed. This style of working meant that the baby’s experience and needs, and the support for the family were not comprehensively considered. This is not new learning in our local learning reviews and multi-agency audits. Practitioners sometimes find it hard to consider issues of ethnicity and culture, and perhaps find it uncomfortable to ask, maybe particularly so with professional families. County A CSC is doing work on identity and culturally sensitive practice. 108. Agencies had varying amounts of information about ethnic identity, religion, and its impact. In many cases, family is a critical support to any new mother and support and its availability should be discussed. Assumptions were made around the mother’s profession and education and working with professional parents. We have asked ourselves how staff are prepared for encounters and manage possible challenge. Work around identity and support was work which could have been undertaken during the pregnancy without any sense of urgency yet was never fully completed in approximately 18 months of intervention. Only one lead in the network would have needed to ask the questions, so that there was no duplication of effort. In County A CSC the front door teams now have packs for families with information about consent, which is good practice. FINDING 5 Transparency is key when working with families. Confident and open practitioners work better with families if their professional views are challenged, and all practitioners at times struggle to communicate with some families. Families do well when they have a good understanding of their rights and responsibilities, and can make informed choices. RECOMMENDATION 5 The Partnerships are to assure themselves that local practitioners have sufficient understanding, supervision, resources, and training to engage with families with professional curiosity, and resilience. 27 Official Conclusion 109. This report is presented to the LSCP in Counties A and B. It has been sent to the National Panel and the What Works Centre for Children’s Social Care. 110. We acknowledge some limitations in this Review as all meetings have all been virtual due to the ensuing COVID-19 pandemic. Our local learning has corresponded with national learning in terms of risks of non-accidental head injury in babies 3, information sharing, the importance of supervision and the need for thorough assessments for parents with mental health concerns. 111. The Review Team would wish to thank the family and all practitioners who have taken part in this review and brought such helpful learning and reflection about our local systems, especially during a time of crisis working. We trust together with the parents that this report may make a difference to the safeguarding of future local children and their families. 3 https://learning.nspcc.org.uk/media/1351/learning-from-case-reviews_perinatal-healthcare-teams.pdf; https://learning.nspcc.org.uk/children-and-families-at-risk/parental-mental-health-problems#heading-top |
NC52240 | Significant burns to a 5-and-a-half-year-old child in August 2019. Child AI suffered burns to 26 per cent of her body while in the care of her mother. Child AI was taken to the regional burn centre and underwent surgery. Following discharge, the family were placed in a family assessment unit, with Child AI and her sibling subsequently being placed in foster care. Child AI had been managed under Section 47 and a child in need plan for neglect. Reports from neighbours about anti-social behaviour (ASB) at Mother's flat. Child AI presented with injuries on several occasions at nursery at school. Ambulance services attended the family home on two occasions before the incident. There was no contact with Child AI's father. Ethnicity and nationality not stated. Learning includes: staff should consider when families use emergency departments, whether it is because they do not want professionals to visit the family home; ASB officers should consider the impact of ASB in a safeguarding context when a child is present and share with appropriate agencies; the number of perceived minor injuries to a child should be viewed in relation to parenting capacity and the ability to keep children safe. Recommendations include: equip frontline staff with the skills to work with clients who may have a 'learning difficulty'; promote the Family Network programme, to build relationships with the wider family and support families when services are no longer needed; develop guidance for transferring safeguarding records from Early Years to schools to facilitate appropriate information sharing at the point of transition.
| Title: Child safeguarding practice review regarding Child AI. LSCB: Norfolk Safeguarding Children Partnership Author: Ann Duncan Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child Safeguarding Practice Review regarding Child AI Author: Ann Duncan PUBLICATION: September 2020 2 Contents Circumstances that led to this SCR Page 3 Methodology and Terms of Reference Page 3 Practice Summary of the Review Period - Key Events Page 5 Analysis of Practice Page 12 Areas of Good Practice Page 21 Conclusion and Recommendations Page 21 Appendix 1: Methodology and Terms of Reference Page 23 Appendix 2: NSCP Thematic Learning Framework from SCRs Page 25 Appendix 3: Learning Event Page 26 Appendix 4: Acronyms Page 28 3 1. Circumstances that led to this Child Safeguarding Review. 1.1 In August 2019 Child AI, then aged five and a half suffered significant burns to 26% of her body while in the care of her mother. At the time of the incident, the case was still open to Children’s Services but a Social Work Assessment (SWA), completed two days before the incident, had recommended that the case should be stepped down to Early Help. Child AI had previously been managed under Section 471 of The Children Act (April – November 2018) and then for a short period of time managed under a Child in Need Plan (Section17). AI has one younger sibling, aged 10 months at the time of the incident. 1.2 AI was taken to the local Emergency department and was then transferred by air ambulance to the Regional Burn Centre, where AI underwent surgery. Following discharge from the Burn Centre the family were placed in a family assessment unit. This placement ceased and AI and her sibling were placed in foster care. 1.3 The case was considered by the Norfolk Safeguarding Practice Review Group (SPRG) on 02.09.19, where it was agreed that the case met the criteria for a Child Safeguarding Review (CSR), that is: o Abuse or neglect of a child is known or suspected o The child had been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child o The child sustained a potentially life-threatening injury o The child is likely, i.e. on the balance of probability, to suffer serious and permanent impairment of physical and/or mental health and development. 1.4 The Safeguarding Practice Review Group formally recommended to the Independent Chair of Norfolk Safeguarding Children Board (NSCB), now the Norfolk Safeguarding Children Partnership (NSCP) that a CSPR is commissioned to review this case, in line with Chapter 4, Working Together.2 1.5 The Police investigation is ongoing with regard to the injury sustained by Child AI. The Care Proceedings have concluded. 1.6 At the time of Child AI’s injury there were a number of agencies involved with the family. 2 Methodology and Terms of Reference. 2.1. Full details of the review process are included in Appendix 1. In summary, an independent lead reviewer worked alongside a review team, composed of senior managers and facilitated by the NSCP Business Manager. The purpose of the CSPR was to review the involvement of the agencies involved with the family to understand how professionals had understood the cause and nature of the family’s difficulties, and how effectively professionals had responded. The focus of the review was to learn about how the local safeguarding systems are operating and if any changes may be required as a result of the wider lessons from this case. The CSPR considered the work of the following agencies: 1 The Local Authority have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or like to suffer significant harm. 2 Working Together to Safeguard Children, HM Govt 2018.The CSPR was commissioned whilst arrangements were in transition. 4 • Local Authority Services (including: Children’s Services, Early Years) • Education • Health agencies (including: Community Health Services, Midwifery Services, General Practice, Emergency Services at a local hospital) • Ambulance Service • Housing • Norfolk Constabulary. 2.2 The timeframe for the review was from January 2018 when Child AI sustained her first burn injury to August 2019 when Child AI presented with 26% full thickness burns to the chest and abdomen. The possibility of Child Sexual Exploitation (CSE) relating to the household was initially identified however, it was agreed that the review should be appropriate, proportionate and that CSE was not explicit within the case and was not key to the case. 2.3 The Child Practice Review Panel identified specific lines of enquiry grouped against expected standards and procedures, and a particular focus on the management of cases of neglect and the impact on the lives of the children. The terms of reference were as follows: • How well are parents’ potential learning disabilities understood and their parenting capacity assessed in light of any cognitive limitations? • Did the professionals have a view on the bonding between mother and child? How was this assessed? • If a child is frequently arriving at a nursery/early year setting with bruises, scratches and other minor injuries how is this monitored and shared with other professionals working with the family? • What does the use of A&E services tell us about the way families understand and access health provision? How does this impact on our safeguarding systems? • Are staff desensitised to indicators of neglect and how does this impact on their ability to effectively assess risk? • What are the similarities and differences between this case and other neglect cases in the local area? (Ref Case AF, AG and the local ‘deep dive’). 2.4 The CSPR was also asked to use the NSCP Thematic Learning Framework (see Appendix 2) and to consider learning that has already been identified within a number of recent Norfolk reviews. 2.5 Contribution of Family Members. The involvement of key family members in a review can provide particularly helpful insight into the experience of receiving or seeking services. The lead reviewer and NCSP Business Manager met with the maternal grandmother and mother separately. It was difficult to get engagement with both the maternal grandmother (MGM) and mother in order to elicit a meaningful dialogue. The family moved from London about twenty years ago and her three children had attended school locally with no identified problems. She reported that the mother and her younger brother fought like “cats and dogs” but she left them to sort it out between themselves. The mother and Child AI lived with the grandparents until they moved into their own property at the end of 2016. The MGM did not have any concerns about her daughter’s ability to look after Child AI. She described her relationship with her daughter as close, however she was unaware of the ASB, alleged cannabis smoking and that there had been a risk to the mother’s tenancy. Child AI was 5 described as an inquisitive child and was always “doing things she shouldn’t be doing, I was always right behind her.” In the interview with the mother she was unable to articulate what the professionals working with her had concerns about and had not found any of the professionals/ agencies working with her helpful, she “didn’t get any support.” The mother told us that she had been bullied at school but could not remember about what, she described her time at college as being better. The mother had studied child care at college and when asked if this had been helpful in parenting her own children she replied “I don’t know where the paperwork is” (she hadn’t brought it with her when she moved). The mother struggled to tell us what Child AI was like or what she enjoyed doing. The only incident that both the mother and maternal grandmother described (and the mother showed us a photograph on her phone) was when Child AI had ‘flipped out and trashed her bedroom.” The mother thought that Child AI had autism or Attention Deficit Hyperactivity Disorder and wanted help to get a diagnosis, but “no one would give it to me.” The mother had asked her brother to help her look after her nieces and nephews (the children of her older brother) over a weekend and that she had been frightened of her brother at the time. It was clear that neither the mother nor the maternal grandmother had a clear understanding of what the professionals were concerned about in relation to the mother’s ability to safely parent the children. 3 Practice Summary from the review period – Key Events. At the end of each Key Event practice learning points have been captured, these are not recommendations but serve as a summary of where systems and practice can be improved. Background prior to the review period: Child AI and her mother lived with her grandparents until December 2016 when the mother signed a tenancy agreement with a local housing provider for a two bedroomed flat, located in the local town. The mother reported that the father of AI lived in London and that there was no contact with him. From September 2017 there were reports from neighbours to the Housing Association that raised concerns about the level of rubbish and Anti- Social Behaviour (ASB) associated with the mother’s property including; a large number of teenagers visiting the flat. The mother’s 16-year-old brother was staying with her at the time and it was thought that it was his friends that were causing the disturbance and ASB. One of the callers to the Housing Association expressed concern for AI at this time. The mother was advised that ASB could have an impact on her tenancy and she was advised to stop her brother visiting or staying at the flat. AI attended the Emergency Department (ED) at the local hospital 16 times from birth to December 2017. The reasons for attending the ED were for minor accidents following trips and falls and seeking advice for minor illnesses such as fever and cold like symptoms. 3.2 An ambulance was called to the family home on two occasions between January and February 2018. Both visits by the Ambulance Service resulted in safeguarding referrals being made to Norfolk Children’s Services. The ambulance service attended the family home in early January 2018 following a referral from the NHS 111 service3 for a thermal burn to AI’s hand as mother was unable to take Child AI to the local Emergency Department. The burn consisted of 3 NHS 111 is available on line or by telephone 24 hours a day, seven days a week for advice and management of cases. 6 small blisters to the palm and the pads on her fingers; she had no loss of sensation. It was reported that the injury had been sustained when AI reached up to the hob after it had been switched off. The ambulance crew noted that AI was just tall enough to reach up to the oven hob. The incident had happened some hours prior to the callout; the pharmacist had given the mother something to treat the burn with, but also advised her to contact 111. The ambulance crew made a safeguarding referral to Norfolk Children’s Services due to the state of the flat, Child AI being described as unkempt, and that although the burn was possibly accidental it happened because of a lack of parental supervision. One month later an ambulance crew attended the flat, this time it was reported that AI had fallen and hit the back of her head, and had sustained some minor bruising. Another safeguarding referral (the second within a month) was made due to the state of the home environment: there was no light in AI’s bedroom, broken toys scattered over the floor, and it was reported that AI had run her own bath that morning. Learning points: • At the time of the review the Safeguarding Team within East of England Ambulance Service NHS Trust (EEAST) did not have the capacity to feedback to crews following safeguarding referrals. Crews are always able to contact the safeguarding team if they wish to receive feedback to a specific incident. • Whilst some agencies are routinely included in social work assessments, not all referrers have the same experience. This is particularly true of those that are not routinely involved in every case for example some housing providers, the Ambulance service amongst others. It is clear that CADS ensure all professionals are informed of the outcome of their contact, if it has been referred to a locality for a SWA. However, at this point not all referrers are contacted or included to contribute to the social work assessment. This is a missed opportunity for both the completeness and accuracy of the assessment and also ongoing learning of all agencies involved in the safeguarding of children. • Currently all NHS111 Services are live with CP-IS and it is hoped that all Ambulance Services will be live before March 2021. • Staff need to consider when families use the Emergency Departments is it because they do not want professionals to visit the family home? 3.3 The behaviour of young people associated with the family escalated, leading to complaints being made to the housing provider and the police being called. (Housing and Anti-Social Behaviour). At the end of January 2018, the police were called by neighbours due to Anti-Social Behaviour (ASB) by associates of the family including: setting the fire alarms off, smoking cannabis, leaving condoms in the lifts and making lots of noise. The Housing Officer visited the property to advise the mother that this behaviour needed to stop as the future tenancy of the flat was at risk. The police were called again in early February by a neighbour as they were concerned about the number of youths smoking ‘weed’ and drinking at the family address and were concerned about the impact of this on Child AI. The police visited the property and found Child AI in the care of two males 7 (the uncle and a friend). The mother was called back to the property and spoken to. The Housing Association served a Section 21 notice4 on 26.02.18. In March another Section 21 was served and a plan was put in place which would allow the mother to remain in her home, take steps to alter her behaviour which would help her to keep the tenancy of the flat. The agreed plan allowed more options to be put in place and was seen as a positive action. At the time ASB housing officers were looking at the level of compliance with the tenancy agreement; it was more about enforcement rather than taking an holistic approach5. The police visited the family home on 11.03.18 as it was believed that the flat was being used for Child Sexual Exploitation (CSE) and drug use. When the police visited the address, it was found to be in an “atrocious state, with rotting food, used nappies and clothing items strewn across the floor.” The police made a referral to Children’s Services that described the home conditions as extremely poor, with very little food in the home, and that Child AI was seen wearing only a dirty long-sleeved T-shirt. Learning points: • ASB officers should consider the impact of the ASB in a safeguarding context when a child is present and share with appropriate agencies. • To review membership of the Anti-Social Behaviour Action Group (ASBAG) and to strengthen the safeguarding response within the local community. 3.4 Following the police referral, the case proceeded to an Initial Child Protection Conference in April 2018 and AI was made subject to a Child Protection Plan under the category of neglect. Following a strategy discussion on 21.03.18 it was agreed that the case should proceed to an Initial Child Protection Conference (ICPC). The concerns were: • risk of CSE; • unknown males attending property (police intelligence); • poor home conditions; • lack of parental supervision for AI; and • the possible eviction of the family due to anti-social behaviour at the address. The mother disclosed that she was pregnant due to deliver in October 2018; the father of the unborn child was unknown. Child AI was made subject to a Child Protection Plan under the category of neglect. The mother was to be referred to the Adult Learning Disability Services as there was concern about whether the mother had learning difficulties and lacked the capacity to parent effectively. There is no record of this referral being made. The statutory child protection visits (fortnightly) and the core meetings took place monthly from April to October 2018. The professionals continued to be concerned about the mother’s level of supervision and keeping AI safe. It was reported that Child AI had no ‘stranger danger awareness’6 In late August 2018 an 4 A 'Section 21 Notice of Possession' operates under section 21 of the Housing Act 1988, is the legal eviction notice template notice a landlord can give to a tenant to regain possession of a property at the end of an Assured Shorthold Tenancy (AST 5 The role of ASB Officer is currently being reviewed and is likely to be called something different moving forward to more accurately reflect the safeguarding work these members of staff undertake. 6 'Stranger Danger' is better referred to as a small part of teaching children protective behaviours as 85 per cent of danger or abuse to children occurs with someone known to the child or trusted by the child. The aim is to teach children to be safe, to be aware of predatory strangers, and to be self- protective. 8 ICPC was convened for the unborn baby; the decision was that the unborn child would be managed under a Child In Need Plan. 3.5 AI attended Nursery prior to commencing at the local Primary school in September 2018. Following the burn that AI had sustained in January (2018) the nursery staff noticed that AI’s behaviour changed and it was observed that she was taking additional snacks and food from other children’s plates, had repeated head lice infestations and would come to nursery with minor cuts and bruises. The mother was always up-front about the injuries. There were 19 pre-setting forms completed7 between January 2018 – July 2018. AI was described as a child who found it difficult to relate and play with her peers, and the other children were fearful of AI at times. AI sought out her key workers and would play more with adults than the other children. The nursery had put in place a Target Support Plan8 which was regularly reviewed. AI started in the reception class of a local primary school in September 2018. It was reported that AI settled well into school, however AI was not good at reading social cues from the other children and was “in other children’s faces.” The records from the nursery were transferred to the school but although there was a copy of the CPP included in the records, it was unclear whether the plan was still in place or whether there were any future meetings planned. The Designated Safeguarding Lead (DSL) at the primary school developed a good working relationship with the mother. The DSL described the mother as” needy, vulnerable and more like a teenager” The mother frequently talked to staff at the beginning and end of the school day to seek basic parenting advice and to report any concerns. Learning Points: The safeguarding guidance for Early Years settings should be reviewed to inform practice in the following ways: • By keeping chronologies of injuries to children in Early Years and schools, staff understand the importance of using them to analyse patterns and identify the cumulative risk and where appropriate consult with CADS in order to ensure the needs of the child are being met. The number of perceived minor injuries to a child should be viewed in relation to parenting capacity and the ability to keep children safe • Early Years Settings are supported to explore different methods of providing support and management oversight of the safeguarding function so that Safeguarding Lead Practitioners (SLPs)have dedicated time to reflect on and analyse case records in an non-reactive way to build an understanding of children’s needs and respond accordingly. This will support settings to create safe cultures for everyone in the setting’s community. 3.6 A Review Child Protection Conference was held the day before the birth of AI’s sibling; the decision was to manage the case under a Child In Need plan. 7 These forms mark any injuries on a child when they arrive at the nursery, including a body map and description of the injury. 8 Plan identifying key areas of child’s development that required additional support. 9 In September 2018 the mother attended her GP due to low mood, anxiety and reportedly finding it difficult to leave the house. An urgent referral was made to the local mental health trust but no further follow-up was deemed necessary after a telephone consultation. During this telephone consultation the mother divulged that she had a social worker and it would have been an ideal opportunity for the mental health practitioner to explore more about her current situation. The mother was offered Cognitive Behavioural Therapy9 via her GP; it is unclear from the records whether this offer was ever taken up by the mother. A Pre-birth Initial Child Protection Conference concluded that the unborn baby would be supported via a Section 17 and that SW1 would recommend that Child AI would be also supported by a Section 17 at the Review Case Conference (scheduled for October 2018). The Headteacher became concerned about AI’s behaviour and it became evident that AI required support on a 1:1 basis. A week later the Designated Safeguarding Lead at the school received a telephone call from SW1 and informed her that Child AI was on a Child In Need Plan. This information was incorrect as Child AI was still subject to a CPP. The review Child Protection Conference was brought forward and it was a unanimous decision by the professionals to step the case down to a Child In Need Plan (Child AI’s sibling was born the following day.) The view expressed by the professionals was that the risks had been reduced although some concern about how the mother would manage after the birth of the baby but it was hoped that the family would have been rehoused and be closer to the maternal grandmother. The management overview was that the case would be referred to Early Help and then closed in 6 weeks. The intervention and support provided by family support teams (early help) is invaluable to many families if it is an accurate assessment then the case should be stepped down after any form of statutory intervention. This must only happen if the assessment is an accurate summary of presenting risk and robust management oversight has analysed all available information. Stepping down must not be used as a means of moving cases out of statutory social work team if it is evident that child protection or child in need planning is more appropriate to meet the assessed need. At the first Child in Need home visit SW1 recorded that AI had a couple of bruises; there was no explanation of where the bruises were or how Child AI had hurt herself and therefore no consideration given to seeking medical advice. It was also recorded that AI did not want to talk about school and again there was no exploration as to why this might be, or any strategies used to engage with AI. This was the last visit made to the family by SW1. The HV made three home visits following the birth of AI’s sibling and the mother was observed to be meeting the needs of the baby with support from the maternal grandmother and a friend. A month after the birth of AI’s sibling a cause for concern was reported to the Designated Safeguarding Lead (DSL) regarding AI hitting other children for no reason. It was noted that there had been a change in AI’s behaviour over the past two weeks. This was raised at the CIN meeting a week later; but despite this, the case was closed and stepped down to Early Help (EH). At the point of managing the risks under a CIN plan a Family Network meeting10 should have taken place - this did not happen. The Family Network approach was a new initiative and was not fully embedded in practice. However, it is now required practice that all workers across the Social Work and Family Support services embed the Family Networking Approach into their practice and offer to children and families, so that it becomes “business as usual” in underpinning all their 9 Talking Therapy that can help manage problems by changing the way people think and behave. 10 Family networking is an overarching approach to identifying and engaging with the whole family – immediate, extended and anyone important in a child’s life. Family Network Meetings (FNM) should be offered to any family whatever the level of intervention, and whether children are living with their families, in care or leaving care. 10 interventions In December 2018, EH made a referral to the Children’s Centre11 to support the mother in getting out of the house and interacting with other adults due to low mood, anxiety and isolation. The Parental Mental Health (PMH) worker from the Children’s Centre visited the family home on three occasions and put together a programme for the mother which included: baby massage, yoga and music. The mother attended a total of four sessions prior to the closure of the Children’s Centre. It was reported by the PMH worker that the mother appeared to struggle with the sessions, she didn’t know what she needed to do, and was anxious about being in a group. The second home visit was done jointly with the DSL, the home conditions had deteriorated, dirty clothes everywhere and mother appeared to be struggling. Child AI was described as “bouncing off the walls”. The DSL reported the concerns to Early Help. Learning points: • It is required practice that all workers across the Social Work and Family Support services embed the Family Networking Approach and as part of this Family Network Meetings, into their practice and offer to children and families, so that it becomes “business as usual” underpinning all interventions. • FNMs [or Rapid Family Network Meetings] must be actively considered, promoted and implemented where possible in all stages of casework planning from initial referral, through the key stages of the assessment process, in Multi-Agency Strategy Discussions, in CP conferences and in all other statutory review processes – Family Support/Child in Need/Child Protection/ Looked After Children. • Staff working within Adult Services must remember to “Think Family.” • The importance of robust systems of management oversight and supervision which will allow reflective analysis and development of outcome focused plans to evidence real change for the children. 3.7 Following police intelligence that vulnerable young people may be at risk of CSE at the family home the police visit and made a referral to Children’s Social Care (the second police referral) The local frontline police visited the mother’s flat in May 2019 following information received from the CSE team within Norfolk Constabulary. At the time of the visit there was an Object marker12 on the address The police had been given information concerning missing persons (aged 17) who were believed to be at the family home. The missing persons were not found at the address but the flat was described as “untidy, food had not been cleared away, the bathroom was filthy” and Child AI’s bedroom was “not great” with either no bed covers or a very dirty bed. There was also a screwdriver left lying around in the living room. There was no food in the house but the mother was expecting her benefits to come through the following day. The mother and her brother were described as “very drowsy” and AI was “overfamiliar’ with the officers. The view of the officer was that there was a high level of concern and 11 The Children’s Centre was part of the Great Yarmouth Community Trust- the centre closed on 30.09.19. 12 Key information is put on the IT system for particular addresses- at the time the information was that children at risk of potential drug use at the property and undesirable visitors. 11 submitted a Child Protection Investigation.13 The referral was forwarded to Children’s Social Care. Following this referral, a Social Work Assessment (SWA) was instigated. SW2 made a joint home visit with HV1. Child AI was at school but her sibling was seen at this visit. SW2 observed that the mother always stood by the window on her mobile phone and thought that this was a sign for her friends / visitors for them not to come to the flat. SW2 discussed with the mother that her brother should only visit the flat for a limited time (two hours) and no more than three times a week. SW2 advised the mother that “he must ring the bell and you provide access.” SW2 made an evening visit to the flat when Child AI was at home, SW2 observed that AI was over familiar and sat on her lap and pulled her hair, the mother did not respond to AI’s behaviour or try to get AI to sit with her. It was also reported that AI sometimes stayed overnight with a friend to help the mother out, SW2 advised mother to stop doing this. On the 17.06.19 a rapid response meeting was held at the family home where it was identified that the mother required ongoing support to help her sustain the improvements that she had made whilst AI was subject to a CPP. It was suggested that a Graded Care Profile 14should be undertaken (the previous one had been completed in 2016). It is unclear whether this took place as a copy of it cannot be located within the records however it is important that individuals do not decide to ignore a direction given to undertake a piece of work. The social work assessment was not completed within the timeframe15 due to high numbers of assessments to be completed by SW2 in the same timeframe. The outcome of the social work assessment was to step the case down to Early Help with support from the Children’s Centre. The last SWA gives a clear assessment of what needed to change for AI and her sibling, and what their mother needed to do to achieve this. Unfortunately, this was based on observation and discussion with their mother during visits and makes no mention of whether their mother had the mental capacity to make these changes or understand why they needed to happen. Learning points: • The importance of including the family history in the assessment to include the parent’s own childhood experience and the impact it may have on their current parenting ability. 3.8 An ambulance attended the family home due to a significant burn Injury to Child AI. The Social Work Assessment was completed and the decision was that the case would be managed under Early Help and Family Support. Two days later the ambulance service was called to the family flat. The call handler had advised the mother to “douse Child AI with water and await the arrival of the ambulance”. On arrival the mother was described as “deadpan” with very little emotional response. It was reported that the mother had been in the kitchen when she had heard AI scream from the living room. The mother did not respond immediately to the scream so AI made her way from the living room to the kitchen, whilst on fire. It was reported that AI had found a cigarette lighter in the living room and had started playing with it. The mother had scooped AI 13 Child Protection Investigation notices are submitted on any police call out where there is a safeguarding concern; the CPIs are then populated on Athena, the central police data base. 14 Graded Care Profile. A practice tool that gives an objective measure of the care of children across a range of needs. 15 Social Work Assessment should be completed within 45 working days of the referral being received by the Local Authority. 12 up and put her in the shower and removed any remaining clothing before the ambulance crew had arrived. The crew found AI in the bath and that they could see that the burn was serious and covered a large body area. AI was transferred to the Emergency department at the local hospital and later transferred by air ambulance to the regional burn centre. 4.0. Analysis of Practice 4.1 Introduction. This section of the Review assesses the quality of multi-agency practice at the key points that are considered to provide the most significant learning. In doing so, the Review considers the information that was known, or could have been known, at the time of the events alongside the individual agency practice standards. Where there is information about why practice may not have met required standards, this is explained. By understanding why things happened in the way that they did, rather than simply what happened, the CSPR is seeking to achieve a greater depth of learning about safeguarding systems within Norfolk, and beyond the individual case. The review has been conducted and written with the benefit of hindsight, which often distorts the reader’s view of the predictability of events, which may not have been evident at the time. Despite robust systems being in place, there were some gaps in practice which need to be considered in order to learn from them. 4.2 How well are parents’ potential learning disabilities understood and their parenting capacity assessed in light of any cognitive limitations? Much has been written about the negative professional conceptualisations and stereotypes of parents with learning difficulties and even the ‘system abuse’ they face when they come into contact with child protection processes.16 There is also substantial evidence concerning the range of problems that can impair parental capacity to meet the needs of children17 including: mental illness, problem drug and alcohol misuse, learning disability and intimate partner violence. It is also well documented that children may be at increased risk where a parent/carer has a learning disability. Professionals need to carefully consider the implications of relying on individual parents to follow through on advice or recommendations, bearing in mind that they may be unwilling or unable to do so. Professionals should consider whether the failure of the individual to follow through on advice or recommendations, and the ability to sustain the change is an additional level of concern. The professionals working with the mother had different professional opinions as to whether the mother had a learning disability/need, and lacked the capacity to parent effectively. The mother’s behaviours were also associated with depression, low mood and anxiety and she found it difficult to leave the family home at times. The Mental Capacity Act 18 (MCA) is routinely used in Adult Social Care and across Health Services but not routinely in Children’s Services. The MCA is designed to protect and empower people who may lack the mental capacity to make their own decisions about care and treatment. Part of the two-stage assessment is to determine whether the person understands the information relevant to the decisions, retain the information, and use the information to weigh up that information as part of the process of making the decision. In a safe child protection system obtaining agreement from parents means that professionals must appreciate the vulnerabilities of a parent, and ensure that consent is a process of appreciative enquiry and respectful enquiry. The view 16 Aunos and Feldman2002; McConnell and Llewellyn2002. McConnell etal2006. Sigurjónsdóttir and Rice 2018). 17 Cleaver et al,2011; Brown and Ward,2012 18 Mental Capacity Act 2005 legislation.gov.uk 13 expressed at the learning event from frontline staff was that the label given to someone often sticks, but the narrative does not always support the label. The professionals working in the nursery and school settings told the lead reviewer that they had developed a relationship with the mother and she would seek the key workers out at the start and end of each day. The mother found it difficult to make decisions and sought reassurance on a daily basis. It would appear that the mother found it difficult to firstly make decisions and then lacked the ability to execute the decision.19 The mother was able to follow clear instructions when given and the lead reviewer was told that story boards and picture boards were used when working with the mother.20 The mother did not attend a special school and told the lead reviewer that she did not remember having any problems with school work or extra time when taking exams. A learning disability is defined as; A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence); with a reduced ability to cope independently (impaired social functioning); which started before adulthood, with a lasting effect on development.21 A learning disability is usually identified with an IQ score below 70, and this is typically the criterion against which eligibility for local authority adult learning disability services is assessed in England. We now know that the referral to the adult learning disability service was never made, however the view from the adult AD was that it they had received a referral it is unlikely that she would have met the criteria for an assessment or service. Parents with learning difficulties may have been assessed as having IQ scores above 70 overall, but often struggle with literacy, everyday practical tasks and abstract concepts such as time, as well as the wide range of social disadvantages common to adults with learning difficulties/disabilities such as poverty, poor housing and social exclusion and a lack of social support22 When parents with LDs come to the attention of children’s social care, concerns are typically and primarily in relation to neglect - which may include failure to offer appropriate protection or meet children’s basic needs.23 During the care proceedings the mother underwent a Psychological Assessment24 where she was found to be in the borderline range of adult intellectual ability, and therefore falls outside the range whereby the mother would be considered to have a learning disability. However, it was identified that the mother would find it difficult to process complex verbal information and would find it easier to understand when information was presented visually. Following the incident leading to the review the residential placement for the family broke down due to significant concerns about the mother’s capacity to keep the children safe and sufficiently meet their needs. The mother struggled to provide the daily personal care of both children despite frequent prompts from staff. Cognitive and parenting assessments are a fundamental part of any plan and should be completed at an early stage. Assessing the likelihood of a parent being able to make sufficient changes in their lives to ensure the child’s safety and wellbeing is part of assessing whether the parent has the capacity to change. The importance of and the need to support social workers to determine how long to spend on individual cases 19 Executive capacity-the ability to execute one’s decisions. 20 NSCP illustrated Threshold Guidance updated 2019. 21 Department of Health 2001 page 14 22 Cleaver and Nicholoson; McConnell and Llewellyn 2002. 23 Understanding ‘Successful Practice/s’ with Parents with Learning Difficulties when there are Concerns about Child Neglect: the Contribution of Social Practice Theory 2019Beth Tarleton & Danielle Turney 24 Psychological Report 2019 14 and to balance ‘thoroughness and depth’ and ‘timeliness and proportionality’ in the conduct of assessments becomes critical. When services are configured for adults and children separately there is a danger that the impact of risk within the whole family may not be fully understood. It is evident from this case that the professionals working with the mother never fully understood the possible implications and limitations of how successfully the mother was able to parent and keep her children safe on a daily basis. 4.3 Did the professionals have a view on the bonding between mother and child? How was this assessed? Research25 on attachment theory suggests that early intervention with care givers can dramatically affect your beliefs about yourself, your expectations of others, and the way you process information, cope with stress and regulate your emotions as adults.26 What researchers call a child’s attachment style develops in particular through the parent or other caregiver’s response at times when the infant is distressed, for example when the child is ill, physically hurt or emotionally upset . From around six months, infants are able to anticipate their parents’ responses to their distress. They adapt their behaviour in turn, finding ways to manage their feelings. Researchers27 also tend to agree that birth to three is a particularly crucial period of development, with attachment developing in particular from six months. Frontline staff stated that there was evidence that the mother did provide a level of care and love but there was a lack of intimacy and physical contact. There was little understanding of what the bond between the maternal grandmother was and how this may have an impact when the mother and AI moved to their new flat. There was an absence of fathers, the mother told the professionals that both the father of AI and the father of her sibling had left her when she was in the early stages of her pregnancy- they had moved to London and there was no contact. This was accepted with little challenge or further exploration of what this might mean. From an early stage the professionals were concerned about the “bonding” between the mother and Child AI. AI had spent the first two years of her life living with her mother and maternal grandparents, who provided a level of support to them. The family were offered a two bedroomed flat in the local town, which they accepted. The mother continued to visit the grandparents’ home on a daily basis either taking the bus or walking if she did not have the bus fare. When families are given accommodation away from the family (albeit a short distance away) does this have an impact on the family bonding and the level of support that is being provided? The mother’s younger brother was seen as causing problems with ASB however, he may have provided a level of support that the network was not aware of. The mother had told us that she had asked her brother to come and help her when she was looking after her nieces and nephews over a weekend. The mother found it difficult to remember much about her own childhood apart from telling the lead reviewer that she had been “bullied” at school, although she could not remember about what. The psychological assessment identified that there was a disconnect between the mother and her early childhood years and described a “vagueness, cut off from any emotional connection when thinking about family and experiences.” Professionals need to consider how the wider 25 Baby Bonds Parenting, attachment and a secure base for children Research by Sophie Moullin, Jane Waldfogel and Elizabeth Washbrook March 2014 26 Benoit, 2004 27 Benoit,2004 15 family network may offer some ongoing support to help sustain the changes that the family have started to make. The importance of observing the mother child relationship is key to gaining a better understanding of their lived experience and emotional world. This work is often compromised when workloads are high and there is reduced capacity within the service. In this case the concerns were about the lack of supervision provided by the mother towards child AI in order to keep her safe. The use of the Signs of Safety28 approach in child protection has led to improvements, however, in some cases there has been an over emphasis on the concept of safety and what works well resulting in the importance of good risk assessment being lost.29 The child protection plan identified three danger or risk areas to help keep Child AI safe, including supervision. Progress on improvements to the supervision of Child AI were measured by a reduction of injuries sustained by AI within the family home. It was noted in the plan “that the mother was using the locks on the bathroom and kitchen doors to help keep her safe, and that she was being supervised at all times.” AI was described as a child that was “attention needing” and a very inquisitive child that was unaware of any risks or dangers. AI found it difficult to pick up on social cues, lacked social skills, and overwhelmed other children within the school setting. As previously noted AI had no awareness of “stranger danger,” and the risks associated with that. It was noted that the mother did not have the capacity to understand the risks either. Although professionals identified the risk there was little evidence of understanding the impact on AI. The mother raised concerns with the school in February 2019 that she thought that AI was being bullied by another child and that AI no longer wanted to come to school. The response from the school was that they felt this was more about children learning to socialise with one another rather than bullying. The mother struggled with some of AI’s behaviours, AI had a poor attention span and was not engaged with learning. It was reported that AI struggled to follow instructions and the view from the school was that AI demonstrated some traits associated with Attention Deficit Hyperactivity Disorder (ADHD) that needed to be explored. There is evidence that early and long-lasting severe and extreme neglect and deprivation, coupled with major disruptions of care, is associated with disinhibited attachments; quasi-autism; and inattentivity, overactivity and impulse control problems30 This population of deprived children shows high rates of inattention/overactivity that share many features with ADHD. A referral was made by the family GP to the Newberry Child Development Centre in June 2019. At the time the GP did not contact the school to discuss whether they had any ongoing concerns surrounding AI’s behaviour. The referral was refused as AI was too young to undergo an ADHD assessment. A diagnosis of ADHD can be considered but will not usually be confirmed until a child is around six years old. The input of teachers as observers in a structured school environment is crucial and it is good practice for teachers’ observations to be incorporated into an assessment. The ambulance staff commented that there was very little emotional response from mum when they attended the incident in August 2019, and considered whether she might be under the influence of something as she was slow to react to things, if at all and only cried on one occasion. The mother did not appear to grasp the severity of 28 The strengths-based and safety-focused approach to child protection work is grounded in partnership and collaboration. It expands the investigation of risk to encompass strengths and Signs of Safety that can be built upon to stabilise and strengthen a child’s and family’s situation. 29 NSCB thematic Review Case AF, p31 Sept 2019 30 Kreppner et al.2001 16 the situation asking ‘will she be going into hospital.” AI was described as quite calm, crying with the pain, and shivering. She was quite clingy towards the ambulance crew member who carried her to the ambulance and wanted to be held and hugged. AI only asked for her mum once. The ambulance crew had to ask the mum to hold AI’s hand. The way that the mother and extended family responded to the injury was seen as detached and lacking emotional response and was perceived by the professionals working with them at the time as “not necessarily how we would behave.” The mother stated that she was scared to hold AI’s hand or touch her as she didn’t want to cause her more pain. Where there is an ambivalent relationship, or attachment difficulties between the primary care giver and the child, this has the potential of compromising the safety of a child from danger/risks posed by the environment in which they live or from other adults. 4.4 If a child is frequently arriving at a nursery/early year setting with bruises, scratches, and other minor injuries how is this monitored and shared with other professionals working with the family? Staff working in Early Years settings use Pre-setting Forms to record any marks or injuries on a child when they come into the setting (on a daily basis). This includes using a body map to pinpoint the exact position of the mark and a description of the injury. Pre-setting Welfare Forms are used to report any safeguarding concerns and are shared with the Designated Safeguarding Lead (DSL) immediately. The mother was reported to be open with the staff working in these settings and would alert them to various scratches and bruises on AI and give an explanation as to how they had occurred. It was also reported that Child AI had “lots of accidents at the nursery too” so AI was seen as a clumsy child. At the time the nursery had a number of low-level concerns but they didn’t think it would meet the threshold for intervention and had experienced a number of Multi Agency Safeguarding Hub (MASH) referrals being ‘bounced back.” Since the introduction of Children’s Advice and Duty Service (CADS) in October 2018 professionals reported that they feel empowered to contact the service and have a conversation about the children that they are worried about. The CADS service is made up of senior social workers who provide advice and support and talk through concerns and solutions, it allows early help and support to families. The importance of keeping a chronology in order for staff to identify the frequency and nature of the reported and recorded injuries is essential. By keeping a log of injuries in date order it allows practitioners to identify any underlying patterns and the possible cumulative effect of these on the child. It also allows practitioners during supervision to explore that although the explanation given by the mother as to how the injuries happened may be plausible, does it identify that the level of supervision and possible neglect within the home setting requires more support to the family? Early Years settings relationships with partner agencies is seen as positive but it is also dependent on individual working relationships and experience of working together. The lead reviewer was told that the staff working directly with Child AI did not have access to the records (they were kept in the office) and a verbal update was obtained by the safeguarding lead prior to the core group meeting. Attendance at core meetings is critical in developing an outline of the child protection plan, set out what needs to change and by how much and by when in order for the child to be safe, and have their needs met. Core groups must implement and refine the child protection plan and it is therefore important to ensure the key agencies involved with the child are present and feel equal partners in any decisions being made. It is critical that all of the agencies involved with the family are heard on an equal footing and feel that their contribution is as valid as any other partner agency. The importance of supervision 17 becomes key in allowing time and space to reflect on the case and emerging patterns in order to be able to articulate the current concerns as well as any improvements or family strength. 4.5 What does the use of A & E services tell us about the way families understand and access health provision? How does this impact on our safeguarding systems? Nationally the number of adults and children attending A&E services has risen dramatically over the past decade due to changing patient expectations and ease of access; it is perceived to be easier to attend an A&E department than obtaining a GP appointment. The NHS 111 telephone service is the NHS’s non-emergency number and, in many areas, encompasses the GP Out of Hour Service. The number of people calling NHS111 that have been advised to attend their local emergency department, or been sent an ambulance, increased from around 150,000 a month to 200,000.31 The reasons why parents bring their children can be split into five broad categories: • Parental worry • Perceived advantages of Paediatric Emergency Departments • Perception of other healthcare services • Social network influence, and • Lack of confidence and low health literacy. The mother did use the local emergency department for both Child AI and her sibling as well as attending her own GP. Each time a child is reviewed in the emergency department consideration will be given as to whether the presentation of the child raises any safeguarding concerns. For every attendance at the emergency department an electronic notification is sent to the family GP informing them about the attendance and treatment given. All correspondence for children under the age of 12 received by the GP surgery is sent directly to the lead GP for safeguarding who reviews and will act on the information accordingly. The ambulance service and NHS 111 service also share information with the family GP about any call outs or treatment given where a safeguarding referral has been made. The health visiting service are reliant on receiving this information from the GPs. The GP Surgery work in a child centred and 'think family' way and work collaboratively with other agencies including the Healthy Child Programme (HCP) 0-19 service. The HCP practitioners, the safeguarding lead GP and the practice manager meet on a regular basis at a liaison meeting to discuss cases that they are worried about. The discussion around cases involves a reflective account of the situation and robust plans and actions are agreed, these meetings are formally documented. By working in this joined up way children and families of concern are able to be discussed in a transparent way and child centre decisions are made HCP has a robust system in place across the county which is supported by a care pathway to inform GP liaison meetings. The organisation also has clear escalation routes if the GP liaison meetings are not taking place so that this can be quickly resolved. Information sharing both within organisations and between organisations is critical in keeping children better protected. The term information sharing may suggest that this is a passive action rather than an active exchange and dialogue between agencies and professionals within the multi-agency network. Information Technology (IT) systems are not uniform within health agencies or across the multi-agency 31 Dyan, M. (2017) ‘Winter Insight: NHS111?’ Nuffield Trust briefing,22 February 2017. https://www.nuffieldtrust.org.uk/resource/winter-insight-nhs-111. 18 safeguarding network. This means that information sharing in ‘real time’ can become difficult as was demonstrated in this case. Currently children who are subject to a Child Protection Plan and Looked After Children will be on the National Child Protection Information System (CP-IS) that is shared with A&E departments by Children’s Social Care, so that when children are seen in this setting clinicians can check to see if they are subject to a plan. Those children who are subject to a CIN plan are not included on the CP-IS and staff are reliant on parents telling them. This system is not currently shared with the ambulance service (there are plans for this to be implemented by March 2021). The current service landscape with fragmentation and outsourcing of services, service cuts and corresponding high caseloads and high staff turnover, has profound practical and emotional impacts on staff who are struggling to work effectively with families in complex circumstances.32 Managers and commissioners need to recognise these impacts and put in place structures to provide support, time and guidance for front-line practitioners33. 4.6. Are staff desensitised to indicators of neglect, and how does this impact on their ability to effectively assess risk? Neglect remains a NSCP priority. The coexistence of issues such as: physical or mental ill-health, substance misuse, poverty, criminal behaviour, learning difficulties and domestic abuse can result in inconsistent and ineffective parenting and a disorganised lifestyle. It may mean parents have difficulty in controlling their emotions and experience apathy and disengagement, resulting in an inability to provide adequate emotional warmth to their children or essential supervision.34 Complexity and cumulative harm was almost invariably a feature of families where children experience neglect.35 Emotional desensitisation means that with repeated exposure to the same sort of thing we tend to react less intensely. It is a normal response to become more tolerant to something that you are regularly exposed to. Familiarity with that experience often reduces (or alters) the emotional response to that experience. In the context of safeguarding it would not be unreasonable to accept that practitioners who are exposed regularly to a set of circumstances (poor home conditions, low level chronic neglect) will become familiar with the experience, and as a consequence, their emotional response may lessen. Continued exposure can lead to a state of no longer being shocked by what is in front of you as this becomes the ‘norm.’ By the nature of their work, safeguarding professionals are exposed to highly emotional and distressing material. Exposure to such material takes a psychological and emotional toll on the professionals and they are of increased risk of developing secondary traumatic stress. The steady ‘drip, drip, drip’ effect of seeing trauma on a daily basis can cause demoralisation, pessimism and apathy36. Professionals become defensive when the term ‘desensitisation’ is used rather than accepting that this is a possibility, and that critical thinking and reflective supervision will help to support and build resilience within the workforce. By building resilience and containment with frontline practitioners, 32 Basarab-Horwath & Platt, 2019 33 Complexity and challenge: a triennial analysis of serious case reviews 2014-2017, March 2020 DfE. https://assets.publishing.service..._SCR_REPORTS_2014_to_2017.pdf 2014- 2017, 34 Cleaver, Unell & Aldgate,2011 35 Complexity and challenge: a triennial analysis of serious case reviews 2014- 2017, March 2020 DfE.https://assets.publishing.service..._SCR_REPORTS_2014_to_2017.pdf 36 What an Auschwitz survivor taught NHS safeguarding leads about resilience. Mike Drayton, Jessica memerzia and Sarah Robinson. 19 supporting them in acknowledging their own emotional response will lead to better assessments, identification of risks, and a better understanding of what the lived experience is for the child on a daily basis. 4.7. What are the similarities and differences between this case and other neglect cases in the local area? (Ref Case AF, AG and the local ‘deep dive’). This Children Safeguarding Practice Review (CSPR) was conducted in the east of the county and was the second review that the lead reviewer had carried out in the area. The lead reviewer was struck by the strong narrative that was repeated and re-told about how difficult it was to work in the area with high levels of poverty and deprivation, coupled with high volumes/numbers of safeguarding cases, and a high level of vacancies in both health and social care services. The reputation of the area makes it difficult to recruit and the focus had been on recruiting rather than thinking about the effectiveness of how the services were working together. Problematic multi-agency working can result in lost opportunities for protecting children from harm.37 “A respectful organisational culture is crucial to Safeguarding”.38 The challenge for the multi-agency safeguarding network is how the different mindsets of partner agencies can be broken down in order to work collectively. Organisational culture is often described as the personality of that organisation; “the way we do things around here”. It encompasses the underlying values, beliefs and codes of practice that make an organisation what it is. It can be seen through behaviour, language, customs, rules, group interactions and habits. Handy39describes four types of culture which the organisations follow: • Power - power remains in the hands of a few people • Task - teams are formed to achieve the targets or solve critical problems • Person – employees feel more important than their organisation, and • Role – delegated roles and responsibilities according to specialisation. Changing organisational cultures takes time and a commitment from all that change is required. Relationships are critical to build trust across the multiagency safeguarding network and a recognition and support from leaders that this is important. This becomes more difficult when there is a high staff turnover. It is not enough to co-locate agencies in the same building, there has to be a shared goal and a willingness to work collaboratively. This is sometimes helped with appointing a different operational manager who is seen to be independent and acts to bind agencies together towards a shared culture.40 There are some early signs that professionals are starting to have courageous and positive dialogue in order to start building bridges and relationships. This needs to be supported so that healthy challenge and disagreements can take place in a safe environment at an early stage in cases which should then result in less cases being escalated. The term “escalation” can be perceived as negative and seen as going above someone in a hierarchy, resulting in a defensive reaction. In the Thematic Review41 recently completed it was stated that, “relationships between professionals has an important impact on practice and service delivery, identifying the importance of this and establishing how relationships can be built and nurtured within the multi- agency safeguarding network [is crucial].” 37 Complexity and challenge: a triennial analysis of serious case reviews 2014- 2017, March 2020 DfE.https://assets.publishing.service..._SCR_REPORTS_2014_to_2017.pdf 38 Anneta Williams 2018. 39 Charles Handy, Model of Organisation Culture 1999. 40 Joint health and social care appointment for Stronger Families in Breckland 41 NSCB Thematic Review Case AF- September 2019 20 Table comparing key features of cases: AF, AG and AI. Case Neglect LD label Substance Misuse Domestic Abuse Prematurity Bruising AF X X X X X AG X X X X X X AI X X X X The three local cases all involved children who had been subject to a child protection plan under the category of neglect and with poor attachment as a feature. The cases had been stepped down from a CPP to a CIN plan relatively quickly. Relationship and attachment are important in the understanding of neglect. Research shows that neglectful mothers are more likely to have a history of unstable, hostile and non- nurturing childhoods42 to have a history of disrupted or discordant relationships in adulthood43 and to be less responsive and sensitive to their own children.44 Attachment theory is therefore a useful basis for understanding neglect, as it demonstrates linkages between a carer’s own childhood and their adult mental health, their approach to relationships and their parenting style. Neglect is often chronic in nature, involving a complex interplay of entrenched family difficulties. There is not likely to be a ‘quick fix’ remedy available. Therefore, services working with neglectful families must recognise the need to work with some families on a long-term basis. In all three cases the cases were stepped down from a CPP to CIN plan after a short period of intervention, “long-term working as an approach is ‘out of favour’ in the current climate of limited resources and a government preoccupation with short-term targets”45. However, services need to be aware of and make provision for a proportion of families for whom prolonged involvement with professional help is necessary for lasting solutions. Despite the volume of work undertaken across Norfolk around neglect and the promotion of the Multi-Agency Neglect Strategy and the Graded Care Profile tool there is still much work to be done in ensuring that all professionals are aware of and competent in using the strategy and tools to enhance and evidence the work that they do in partnership with families. The Neglect Strategy (2017) is currently being revised and will be published over the next few months. An app is also being developed for families to enable them to monitor their own progress. Norfolk Children Safeguarding Partnership are currently reviewing the Graded Care Profile (GCP) tool to make it easier for frontline staff to complete it. The feedback has been that the tool is cumbersome and time consuming to complete. The outcome of this is that only two domains are to be completed rather than all of the domains and identify: what are we most worried about, and what is working well 5. Learning Event for frontline staff and managers. A Learning Event was held for key staff and managers in March 2020 to share the key findings from the case and identify any additional learning. The full details of the event can be seen in Appendix 3. The Learning Event was an holistic process which allowed staff to reflect and challenge one another in both a positive and safe environment. 42 Stevenson, 1998 43 Horwath. 2007 44 Crittenden, 1993 45 Stevenson, 2005 21 The independent reviewer would like to acknowledge the honesty and contributions that all attendees made in difficult and emotional circumstances. Some staff attended in their own time and on their ‘rest days’ which would not be reimbursed. The learning that emerged was: • The need for organisations to help and support staff dealing with trauma and build emotional resilience. • To review sickness policy and ensure that the mental health of staff is managed appropriately and compassionately. • Organisations need to be confident about permissions required in order to share information both internally and between partners. • Use some of the key points discussed throughout the day as a basis for safeguarding supervision sessions. • Raise discussions about family background and time to reflect on cases more - identify the missing information. 6. Conclusion and Recommendations Neglect continues to be a serious and ongoing safeguarding issue in Norfolk as evidenced by recent reviews undertaken: for example, cases AF, AG and AI. These cases have highlighted that there is a strong commitment by the partner agencies to: reflect, learn and change practice to improve the lives and lived experience of children growing up in Norfolk. The systems in which professionals work are complicated. Over time, working practice has become reliant on Information Technology (IT) and all too often the IT systems have little or no inter-connectivity; the outcome of this is that the exchange of information becomes more challenging and is very much reliant on developing trusted working relationships with other partners. Building these relationships requires both time and a stable workforce. There should be a clear understanding of everyone’s role and responsibilities to enable an optimum outcome for the children that they are working to protect. The aforementioned challenges are certainly not unique to Norfolk. However, the positive commitment and the willingness shown by the multi-agency safeguarding network to get things right and learn from the reviews conducted in Norfolk is a real positive going forwards. NSCP is currently reviewing the Neglect Strategy and the Graded Care Profile tool so there will be no specific recommendation on neglect. Recommendation 1. NSCP as part of a workforce development plan, identify and equip frontline staff with the confidence and skills to work with clients who have, or may have a ‘learning difficulty’ including the use of visual aids in order to communicate effectively. Recommendation 2. NSCP requires assurance that social workers and frontline practitioners working with children are equipped to make full use of the Mental Capacity Act to test both an adult’s understanding of the required changes, and probability of being able to successfully achieve these required changes. 22 Recommendation 3. CSC and Cambridge Community Trust (Healthy Child Programme) should provide assurance to NSCP that working relationships within the east of the county continue to improve resulting in a positive outcome for children. Recommendation 4. NSCP to promote the Family Network programme, in order to identify and build relationships with the wider family to better support families when services are no longer needed. Recommendation 5. The NSCP should oversee the development of guidance for transferring safeguarding records from Early Years settings to schools to facilitate appropriate and timely information sharing at the point of transition. 23 Appendix 1: Methodology and Terms of Reference. The Child Safeguarding Practice Review will be carried out in accordance with the requirements as set out in Working Together 2018. The aim of this CSPR will be: • To investigate what went wrong and why as well as what went well in the case • To identify any learning and resulting recommendations for action • To invest in providing opportunities for practitioners to learn from their own and others’ experience, building confidence and empowering effective safeguarding practice for the future • To provide a CSPR report for publication. The case meets the criteria for a CSPR because: • Abuse or neglect was known or suspected • The child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child • The child sustained a potentially life-threatening injury • The child is likely, i.e. on the balance of probability, to suffer serious and permanent impairment of physical and /or mental health and development as a result of neglect. Terms of Reference 1. All Safeguarding Practice Reviews should consider themes and questions to provide an analysis of practice and to identify learning. The CSPR Lead Reviewer and Panel members are asked to consider why events occurred as they did, based on a clear account of what took place and the actions of the practitioners and others involved, including an analysis of any factors considered important. 2. Working Together 2018 sets out the criteria, purpose and process for conducting a child Safeguarding Practice Review. 3. The CSPR will be required to consider learning that has already been identified within a number of recent Norfolk reviews. Where this review identifies learning that had been previously identified in the earlier SCRs, the focus will be on how learning has been translated into practice in the intervening period. General Terms The CSPR will take into account the NSCB’s Thematic Learning Framework as part of the general terms of reference. See Appendix 2 Specific issues to consider in the review of this case. In this case the following have been identified as key issues for consideration that should be examined by each agency. However, the Lead Reviewer and agency authors should not limit their review to those issues already identified. There may be other more important themes for each agency which are different from these. Consideration for specific focus on: • How well are parents’ potential learning disabilities understood and their parenting capacity assessed in light of any cognitive limitations? • Why are staff desensitized to indicators of neglect and how does this impact on their 24 ability to effectively assess risk? • What are the similarities and differences between this case and other neglect cases in the local area? (Ref AF, AG and the local ‘deep dive”) • Neglect being overlooked in the context of other safeguarding concerns, i.e. Child Criminal Exploitation / Sexual Exploitation (CCE/CSE). The Review Process and Framework The review methodology will be proportionate to the scope of the review. The investigation will include: • Reviewing and collating detail of practitioner experience and explanation from interviews and document reading • Specify ‘why’ questions when considering critical path events • Revisiting the experience of staff locally – using single interviews and group discussions in each agency to ask ’why’ questions and seek answers to any issues of concern identified, as well as detailing positive practice • Seeking the views of the family on the services provided • Collating and analyzing responses – contrast how it was at the time and how the service is now – use gap analysis to reach findings • Considering any relevant research or other SCR evidence applicable to this review • Writing up SCR report for publication • Disseminating lessons / findings and actions required. Methodology The lead reviewer worked alongside a panel made up of senior managers from the agencies involved. The panel met on four occasions, two of the times were done using IT Team Meetings (due to Covid -19 pandemic). Ann Duncan was commissioned by NSCP to write the overview report and was independent of the case. The panel met with 17 frontline staff and one focus group. The following documentation was made available to the lead reviewer: • Integrated chronology • NSCP Policies and Procedures • Chairs reports of CP conferences • Child Protection Plans • Psychological Report • Access to Liquid Logic records (Children Service) • MASA Plan • Thematic Review Case AF • Family Safeguarding Networks Members of the panel. Job title / role Organisation Detective Inspector Norfolk Constabulary Head of Quality, Performance and Systems Manager Norfolk Children’s Service Named Nurse Safeguarding Cambridge Community Service Deputy Designated Nurse Clinical Commissioning Group Improvement and Inclusion Officer Early Years Safeguarding Specialist Practitioner for Children and Young People East of England NHS Ambulance Trust 25 Litigation and Anti -Social Behaviour Flagship Housing Safeguarding Advisor for schools Norfolk Education Named Nurse Safeguarding James Pagett NHS Trust Safeguarding Lead Norfolk Suffolk Foundation Trust Board Manager Norfolk Safeguarding Children Partnership Business Support Officer Norfolk Safeguarding Children Partnership Lead Reviewer Ann Duncan . 26 Appendix 2: NSCP Thematic Learning Framework from SCRs The NSCP Thematic Learning Framework has been developed to enable us to think about the recurring issues and barriers to effective working together. The framework was introduced to Board in December 2015 and has subsequently been tested with partners within Norfolk, through the Public Protection Forum (PPF), with the support of partnership board business managers, as well as nationally. The thematic learning framework, focuses on four key learning areas: 1. Professional curiosity – how can the Board encourage and support appropriate curiosity with families, and between professionals? 2. Information Sharing and Fora for discussion – how can the Board ensure that we use opportunities for discussion effectively, include all relevant parties, act promptly and clearly; and share information well? 3. Collaborative Working, Decision making and Planning – how can the Board improve timely and collaborative planning and get strong and shared decisions? 4. Leadership: Ownership, Accountability and Management Grip – how does the Board give effective leadership and champion better safeguarding, locating clear accountability? At the heart of all learning is the child or young person, and sitting underneath everything we do is the recognition that safeguarding requires people at all levels to manage risk and uncertainty. Appendix 3. 27 Case AI Practitioners Event 3 March 2020 Registration at 9.00am – 4.00pm Venue: Great Yarmouth Race Course, NR30 4AU Agenda Welcome and Introductions Outline of Learning Event Norfolk SCR activity and background Outline of Serious Case Review Process Whole group consideration of timeline Whole group consideration of research questions Identification of gaps/additional information required Identification of learning & recommendations The event was attended by 28 staff and managers including panel members and 25 evaluation forms were completed at the end of the event. A total of 23 attendees found the day useful, comments included: • Really useful to listen to different perspectives, points of view in a safe environment. • I know very little about the processes of social care despite regularly referring into it, so it is very useful learning and I was personally affected by this opportunity to gain closure. • Discussing questions with other professionals / services was very insightful and provided learning. 28 • Informed me of local services and pathways that I am not party to. Felt I was part of a solution, part of a whole rather than solo. Highlighted different aspects / indicators of neglect. • Always useful to hear perspective of other agencies, very affirmative as most agencies are not too far away in agreement. • It was good to understand other agencies barriers and challenges to multi-agency working. • The conclusion and recommendations touched on the support for practitioners working with neglect – there needs to be more open discussion about the impact on workers and support to enable workers to continue to affect change with this work. Key Learning from the day: • Use of language when explaining situations to family, root causes, working with trauma • How other services safeguard and communicate with others. • Understanding cultural genograms of families, reason why the issue may occur • Neglect – important to act on, keep low thresholds – refer even with symptoms. Holistic referrals instead of injury descriptions etc family dynamic etc • To be able to involve other agencies such as housing and education in the planning for the child. • The importance of working together and being open to challenge. • Thoughts around desensitisation specifically with regard to neglect, also the discussions of learning disability. • Culture of a family – the importance of looking into the family background and the benefit this can have. • Systems approach – useful to be able to reflect on wider processes and how they impact on decision making (especially impact of service re-organisations etc on leadership of teams) • Clarity of communication to parents how and in what form? Are key messages clear? How will you implement learning in to your everyday practice? • Be more aware of neglect when visiting and not become desensitised to neglect. Share information and be able to challenge decisions and accept challenge. • To connect and communicate with other agencies to gain trust and consent of families to enable this to happen. • Continue to support practitioners to identify neglect. Encourage reflection and clinical supervision. • Re-visit with teams the value and importance of enough protected time for reflection and ‘slower thinking’ about cases. • To ensure neglect interventions are robustly identified, not just a plan to assess. • More awareness of the long-term impact of childhood trauma as parents and need to consider how to support this. 29 Appendix 4 Acronyms AD Assistant Director ASB Anti-Social Behaviour ASBAG Anti-Social Behaviour Action Group CADS Children’s Advice and Duty Service CSE Child Sexual Exploitation CIN Child in Need CPIS Child Protection Information System CPP Child Protection Plan CSPR Child Safeguarding Practice Review DSL Designated Safeguarding Lead EEAST East of England Ambulance Service Trust ED Emergency Department GCP Graded Care Profile GP Family Doctor HV Health Visitor HCP Healthy Child Programme ICPC Initial Child Protection Conference MGM Maternal Grandmother MASA Multi Agency Safeguarding Arrangements NSCP Norfolk Safeguarding Children Partnership PMH Parental Mental Health Worker SLP Safeguarding Lead Practitioner SPRG Safeguarding Practice Review Group SW Social Worker SWA Social Work Assessment |
NC52843 | Life changing injuries to a baby, thought to be non-accidental. The incident is subject to an ongoing police investigation at the time of the review. Learning includes: parental vulnerabilities and the potential impact on parenting; the need to consider if neglect is an issue when a child has emerging special needs; maintaining a focus on the child and their lived experience over time; processes and practice that safeguards babies who have unexplained bruising; the impact on children of a parent's mental health difficulties; the effective and robust consideration of fathers/non-birthing partners; and parental engagement, including understanding the barriers to meaningful engagement. Recommendations to the Partnership include: seek assurance from partner agencies about the impact of the on-going focus on working effectively with fathers and non-birthing partners; seek assurance that professionals understand and assess the impact of mental health and trauma on parenting, including the development and use of a clear mental health pathway for safeguarding in pregnancy and after the birth of a child; ask the relevant partner agencies for an update on the work undertaken to improve the response to bruising in non-mobile babies; seek assurance on how agencies are balancing high support with high challenge when required; request an update from the relevant partner agencies on work being undertaken in respect of using chronologies which incorporate the history of siblings and parents to inform safeguarding work; seek assurance from agencies regarding work being undertaken to ensure increased use of the Graded Care Profile by trained professionals, and for this to be monitored and appropriately challenged.
| Title: ‘Dylan’: local child safeguarding practice review – summary of learning. LSCB: Stockport Safeguarding Children Partnership Author: Stockport Safeguarding Children Partnership Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. ‘Dylan’Local Child Safeguarding Practice Review – Summary of LearningCompleted June 2023The CSPR ProcessThe Stockport Safeguarding Children Partnership has undertaken a Local Child Safeguarding Practice Review (CSPR). It has identified about the professional involvement with a family where a young baby sustained life changing injuries that are thought to be non-accidental.The incident leading to the injuries is the subject of an on-going police investigation. Therefore, the full review cannot be published until this has concluded.An independent lead reviewer worked with a panel of local managers and safeguarding leads and met with the professionals involved directly with the family prior to the injuries. This provided the review with the opportunity to reflect on both the case and wider systems and practice in Stockport.The family were invited to meet with the lead reviewer. They chose not to engage at this time. Learning has been identified in the following areasThe need for all of those working with the family to know about parental vulnerabilities and to consider the potential impact on parentingThe need to consider if neglect is an issue when a child has emerging special needsPractice needs to focus on the child and their lived experience over time, including speaking directly to older children Processes and practice that safeguards babies who have unexplained bruisingThe need to specifically consider the impact on children of a parent’s mental health difficultiesPractice and systems must ensure the effective and robust consideration of fathers/non-birthing partners Identifying and considering issues with gaining parental engagement, including understanding the barriers to meaningful engagementRecognising the impact on practice where a parent has significant needs, and the need to maintain a focus on the childThe review made the following recommendations, and an action plan is being progressedThat the Partnership, considering the learning from this review and the previous CSPR Child A, seek assurance from partner agencies about the impact of the on-going focus on working effectively working with fathers and non-birthing partners. The Partnership should seek assurance that professionals understand and assess the impact of mental health and trauma on parenting. This should include developing and using a clear mental health pathway for safeguarding in pregnancy and after the birth of a child, that is understood and used by all relevant professionals. The Partnership to ask the relevant partner agencies for an update on the work undertaken to improve the response to bruising in non-mobile babies. The Partnership to ask agencies to provide assurance on how they are quality assuring the need to balance high support with high challenge when required. The Partnership to request an update from the relevant partner agencies on work being undertaken in respect of using chronologies* within and across agencies, which incorporate the history of siblings and parents, to inform safeguarding work. The national CSPR Panel, should also be asked to consider whether there is a need nationally for more guidance in respect of this. The Partnership to seek assurance from agencies regarding work being undertaken to ensure increased use of the GCP by professionals who have been trained, and for this to be monitored and appropriately challenged. |
NC049500 | Death of a 16-year-old girl in 2015. Her step-brother and his partner were convicted of her murder and manslaughter respectively. A Domestic Homicide Review is addressing the circumstances in which Becky died. Becky had lived with her father and step-mother since age three. At the time of her death, her step-brother and his partner lived outside the family home. Becky had complex needs, including anorexia nervosa. When Becky was 13 her step-mother requested support from children's social care citing Becky's behaviour and poor relationship with her father. There were concerns about Becky's school attendance, mental wellbeing and sexual exploitation, and she received support from CAMHS and the Hospital Education Service (HES). In May 2014 HES made a referral which was passed to Early Help, who in turn made a referral to the youth service and a commissioned family support service. Learning includes: the absence of an evidence-based understanding of the needs and circumstances of adolescents can lead to adolescents being seen as troublesome rather than troubled; the tendency of professionals to take parent/carer perspectives at face value without triangulating information from other sources can lead to a limited understanding of a young person's needs; professionals are less challenging of the lack of engagement of fathers in child welfare practice. Makes no recommendations but puts a number of questions for the Local Safeguarding Board to consider.
| Title: Serious case review ‘Becky’. LSCB: Bristol Safeguarding Children Board Author: Bridget Griffin and Jane Wiffin Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Bristol Safeguarding Children Board Serious Case Review ‘Becky’ Bridget Griffin & Jane Wiffin December 2017 1 | P a g e The Reviewers would like to extend their condolences to Becky’s family and all who knew her. 2 | P a g e Contents 1. Introduction ........................................................................................................................................ 3 Why This Case Is Being Reviewed......................................................................................................... 3 The Lead Reviewers ............................................................................................................................... 3 The Review Team ............................................................................................................................... 4 The Case Group .................................................................................................................................. 4 Structure of the Review Process ......................................................................................................... 4 Methodological Learning .................................................................................................................... 4 Terms of Reference for the Review .................................................................................................... 5 The Family .......................................................................................................................................... 6 Family Involvement ............................................................................................................................ 6 2 The Findings of the Serious Case Review ......................................................................................... 8 Introduction ......................................................................................................................................... 8 Appraisal of Professional Practice in This Case ................................................................................. 8 Becky’s Step-mother Seeks Support ................................................................................................... 8 Initial Assessment ............................................................................................................................... 8 Services Provided by FISS ................................................................................................................ 10 Referral to CAMHS .......................................................................................................................... 11 Referral to Hospital Education Service ............................................................................................. 12 Referral to Family Therapy ............................................................................................................... 13 Referral to Eating Disorder Clinic .................................................................................................... 15 CAMHS work finishes ...................................................................................................................... 15 HES Referral to First Response ........................................................................................................ 16 Early Help Response to Referral ....................................................................................................... 17 Visit by Action for Children ............................................................................................................. 18 Involvement of Youth Services ........................................................................................................ 19 3. The Findings .................................................................................................................................... 20 Finding 1 ........................................................................................................................................... 20 Finding 2 ........................................................................................................................................... 24 Finding 3 ........................................................................................................................................... 27 Finding 4 ........................................................................................................................................... 28 Finding 5. .......................................................................................................................................... 30 References ........................................................................................................................................ 32 3 | P a g e 1. Introduction Why This Case Is Being Reviewed 1.1 This serious case review (SCR) was commissioned by Bristol Safeguarding Children Board (BSCB) as a result of the murder of Becky. The criteria contained within Working Together 2015i makes it clear that it is mandatory to carry out an SCR where a child dies, and abuse is known or suspected. The evidence of abuse in this case is the murder itself. Becky was reported as missing on the 19th February 2015 and her body was found on the 3rd March 2015. Becky’s Step-Brother stood trial for her murder, and in November 2015 was convicted and received a custodial sentence of life imprisonment with a minimum term of 33 years. His partner was convicted of manslaughter and received a custodial sentence of 17 years. 1.2 This review looks at the three and half year period before Becky died where professionals were involved in providing services to her and her family. The review does not consider the circumstances in which Becky died or the contributory factors related to her Step-Brother and his partner, as this is being addressed by a Domestic Homicide Review (DHR) as would be expected in line with current guidanceii. Methodology 1.3 This Serious Case Review has been undertaken using systems methodology, based on the Learning Together approach developed by SCIEiii. The focus of a case review using a systems approach is on multiagency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why – to identify the deeper, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case, and changing them should contribute to improving practice more widely. Data came from semi-structured conversations with the involved professionals (the case group), documents, contextual documentation from organisations and the family. A fundamental part of the review was talking to professionals to try and understand what they thought and felt at the time they were involved in the case, avoiding hindsight as much as possible. The review has sought to try and make sense of what factors contributed to their actions at the time and to the decisions they made. The Lead Reviewers 1.4 This review was undertaken by Jane Wiffin and Bridget Griffin who are both SCIE accredited Reviewers. Jane and Bridget are qualified Social Workers who have extensive experience of working in safeguarding. Both are experienced Serious Case Review Authors and Chairs, and are independent from all the agencies. 4 | P a g e The Review Team 1.5 The Review Team consisted of a team of senior representatives from local agencies who had no direct dealings with the case. They analysed the conversations and documents, identified key practice episodes and contributory factors and helped to make sense of the key Findings. This report is the shared responsibility of the Review Team in terms of analysis and conclusions, but was written by the Lead Reviewers. Review Team Members Service Manager, Additional Learning Needs (Education) Safeguarding in Education Team Manager Service Manager (South), Child and Family Support (Social Care and Early Help) Deputy Designated Nurse Safeguarding Children (Bristol CCG) Named GP Safeguarding Children (Bristol CCG) Child and adolescent mental health services (CAMHS) Safeguarding Board Manager Avon and Somerset Constabulary (Police) The Case Group 1.6 The members of the Case Group are the professionals who worked with or made decisions about the family, and who had individual conversations with the Lead Reviewers. The Case Group comprised of 22 people (although not all these people were able to attend the case group meetings). They met with the Review Team on three occasions to share in the analysis, identification of contributory factors, and to comment and contribute to the final report. Structure of the Review Process 1.7 The Review Team met on five occasions, and three times with the Case Group. They worked on the data, analysis of practice and the identification of the Findings and issues for Bristol Safeguarding Children Board consideration. Methodological Learning 1.8 Throughout the review period it was often difficult get hold of agency records and to make sense of them; some of these difficulties were caused by the way case recordings were made in agency records, some were hand written and were difficult to read, some took a very long time to access, and some were so poorly written that it was never possible to make sense of them. Ultimately all records were accessed and so the only 5 | P a g e impact was that it caused some delay. The concerns regarding poor recording practices can be found in Finding 2. 1.9 This SCR was one of a number of reviews into Becky’s death. The Child Death Overview process, a Domestic Homicide Review and one agency’s own internal review of practice have also been conducted. The decision to undertake a Domestic Homicide Review was made by the Bristol Community Safety Partnership ‘Safer Bristol’ two years after Becky’s death and when the SCR process was significantly advanced. This decision was helpful as it provides analysis of professional involvement with Becky’s Step-Brother and his partner, however the completion of the SCR has been delayed as the SCR reviewers have triangulated the information provided to the DHR by agencies to ensure that there is consistency across the two processes. 1.10 It is very important that there are clear linkages between different review processes, to ensure that all learning and knowledge is shared. An agreed process to do this was not in place at the start of the SCR. This was subsequently addressed, and all information shared. Going forward it is essential that the BSCB SCR process makes clear the need for, and facilitates, formal links where different types of reviewing mechanisms coexist. Terms of Reference for the Review 1.11 The SCR was commissioned to consider the following two research questions: • How is the psychosocial history of family members (with particular reference to early trauma) held in mind in multi-agency assessments and service provision? • How do agencies and services work together to understand the day to day life of a young person with complex needs and how are services co-ordinated when there is limited multi-agency involvement? 1.12 The review was commissioned to consider the involvement of professionals in Becky’s life in the three and a half years before her death. It is not the remit of this Serious Case Review to review the involvement of organisations in Becky’s early years, but the review did seek to understand how professionals considered and assessed the impact of Becky’s early life on her needs and difficulties in the period under consideration. 1.13 This Serious Case Review report will refer to Becky’s early experiences of trauma and abuse. Becky’s parents were separated when Becky was born, and Becky spent her early life living with her mother. When Becky was a young child her Mother struggled to meet Becky and her Older Brother’s needs on her own. Mother told the review she requested a two week respite placement from Children's Services when Becky was 3 6 | P a g e years old. This led to a period when Becky was on the Child Protection Register1 and following respite Becky was taken into the care of the local authority at age three due to concerns about neglect. She was placed in foster care whilst her Father’s parenting was assessed. Her Father was granted a Residence Order and she lived with him until her death. Further details related to this period are not relevant to the content of this report. The Family Becky – 13 at the start of the review period Maternal Grandmother - with whom Becky stayed at weekends Father - with whom Becky lived Brother – lived with Mother Becky’s Step-mother - with whom Becky lived Step-brother – lived independently Mother - with whom Becky stayed Step-brother’s partner – lived independently The Family are White/British Family Involvement 1.14 The Lead Reviewers met with Maternal Grandmother, and spoke to Mother, Father and Becky’s Step-mother on the telephone. This was difficult for all of them and we are grateful for their time. All were positive of the services they and Becky had received. There remained many questions for Maternal Grandmother and Mother and the reviewers have attempted to clarify several uncertainties for them. The views of all have been integrated into the appraisal of practice and the Findings that follow. 1.15 Having read the report family members were given the opportunity to comment on its findings. Mother and Maternal Grandmother said that it was important for the public and professionals to hear how important it was for children and young people to be believed when they talk about their worries and that they were not blamed for their behaviour. They said that the review had shown that Becky was expected to engage and meet with too many different professionals and so could not build the trust she needed to speak out and they hoped that systems would be changed as a result of this. They said they did not know about many of the worries and concerns Becky had and so could not support her as well as they would have wanted to. They asked that professionals consider all family members, including those who do not live with the child full time, when providing services to children and young people. 1 This is now known as a child subject to a plan https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 7 | P a g e 1.16 Becky’s Father and Step-mother said that in hindsight they could see that the behaviour from Becky which they found challenging to manage was worse at times when her Step-brother was around. They said they wished they had realised the bullying she was experiencing from him at the time so they could have intervened to keep her safe. Father said he was not included by professionals and was not given the parenting support he needed so relied on strategies such as telling Becky she would have to move out of the home if she did not behave to manage her behaviour. He said he now understood that this behaviour was partly as a result of what Becky was experiencing from her Step-brother. He asked that professionals offer services at times working parents can attend so they can be more involved. 8 | P a g e 2 The Findings of the Serious Case Review Introduction 2.1 This section begins with a summary and appraisal of the professional response to the needs of Becky and her family over a three-and-a-half-year period. This sets out the view of the Review Team about the quality of the professional response provided. Care has been taken to avoid hindsight bias and to focus on what was known and knowable at the time. The report then discusses in detail priority findings that have emerged from the SCR. Appraisal of Professional Practice in This Case 2.2 All those professionals who knew Becky were shocked and saddened to hear of her murder; the subsequent criminal trial and SCR have been difficult for all those involved particularly because these processes required people to think back to time they had spent with Becky. All the professionals involved in this review have contributed fully and been open and reflective about the professional response to Becky and family. This SCR has found no evidence that the murder of Becky could have been predicted or prevented by any professional working with her. However, inevitably, in any review of the professional response to a young person there will be lessons to be learnt and so it is here; these are outlined below and in the Findings section. Becky’s Step-mother Seeks Support 2.3 The review period starts when Becky was just turning 13. Records show that Becky’s Step-mother visited the local Children and Young People Services (CYPS2) office to ask for help. She reported that Becky was finding it difficult to go to school, that she had anxieties about being outside of the family home as well as there being conflict between Becky and Father. The records say that Father had “not smacked her” but described him as being at “breaking point”. Appropriately this self-referral was accepted, a social worker allocated and an Initial Assessment (IA)3 commenced in a timely manner. Initial Assessment 2.4 The quality of any assessment at this stage is important, and although the completed Initial Assessment contained a reasonable amount of information, it was more descriptive than analytical and drew almost exclusively on the one perspective provided by Becky’s Step-mother who was the only person seen. Becky’s Step-mother provided information about family history, the circumstances in which Becky came to live with 2 The CYPS has now been subject to notable change – see https://www.bristol.gov.uk/documents/20182/239407/CYPS+is+changing+2013_06_25.pdf/818c0733-0bd4-44eb-8adf-c912fbe61976 3 The initial assessment is a short assessment of each child referred to Children's Services focusing on establishing whether the child is in need or whether there is reasonable cause to suspect that the child is suffering, or is likely to suffer significant harm. 9 | P a g e her Father and concerns about Father and Becky’s poor relationship. There was a lack of recognition or reflection that as a “blended” family with a complex past there might be differing family perspectives. Little information was sought regarding the current role played by Mother and Maternal Grandmother or the relationships between siblings. 2.5 Overall, this meant that there was neither an accurate nor objective picture of the complex family dynamics. Becky’s Step-mother’s engagement with professionals was caring and often very thoughtful, but unintentionally her perspective dominated, and an objective or holistic view was not formed. This over reliance on what adults said about the past and present (adult self report) emerges as a theme across the review period and is discussed in Finding 4. 2.6 The initial assessment was also negative in the language used about Becky who was described as “controlling”, “lacking aspirations” and “not engaged in the assessment” without an analysis of what this meant regarding Becky’s current circumstances. She was not seen alone and there was no sense that the assessment considered circumstances from Becky’s perspective. This suggests a lack of understanding regarding the needs of a 13-year-old adolescent - who reported feeling isolated with significant fears about the outside world - for whom the process of meeting new people might be difficult precisely because it focused on Becky as the problem. This issue of the difficulties in professionals recognising the needs and circumstances of adolescents is discussed in Finding 1. 2.7 There was clearly a need for an in depth (core) assessment, indicated by the number of concerns which remained unexplored, such as the reported risk of physical altercations and the impact of Becky’s past trauma and neglect on present attachment relationships. The absence of this meant that there was no clear analysis or formulation4 and no understanding of the nature of the overall family difficulties or bringing together of all the available information to make sense of what were the underlying issues and develop a holistic plan for addressing them. From this point on the focus was on Becky being problematic and having problems, without a consideration of what was the cause and what, therefore, might be the solution. This was a theme across the review and the importance of a holistic formulation or analysis which does not just focus on young people as the problem is discussed further in Finding 1. 2.8 The conclusion of the assessment was that Becky was considered to be a Child in Need (CIN). This should have meant that a CIN plan was formulated in partnership with the multi-agency network, and there should have been CIN meetings and regular reviews of the plan5. This did not happen, and this meant that there was no lead professional or 4 Formulation is the process of making sense of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. 5 A child is in need if s/he is under 18 and either s/he needs extra help from Children’s Services to be safe and healthy or to develop properly; or s/he is disabled. Children’s Services decide if a child is in need by assessing their needs. If they decide the child is in need they will normally draw up a plan setting out what extra help they will provide to the child and their family. This is called a child in need plan. The plan should also say when and how the plan will be reviewed. 10 | P a g e process for overseeing the multiagency work and coordinating the different services offered. This inconsistency in the approach to planning, setting of goals, sharing thinking across the multi-agency group and a lack of a clear review process across agencies is echoed across this review and is discussed in Finding 2. Services Provided by the Family Intervention Support Services (FISS6) 2.9 A month after the initial assessment was completed the family were offered services by FISS and this support would continue for the next 6 months. It was helpful that there was a focus on the whole family as a starting point, but in reality, as the plan continued, there was an over emphasis on Becky’s needs and on what was described as her problematic behaviour. A family support worker was to offer parenting support and explore the reported conflict between Becky and her Father and there was an individual support worker for Becky who was to focus on supporting her return to school and increasing her confidence. A social worker was tasked with overseeing the work and also engaging with Becky about her anxieties. The confusion about the need for a CIN plan appears to have been caused by the involvement of FISS who generated their own plan of action. This was important, but it was not multi-agency in nature and so served only as a single agency plan. This team does not exist anymore, and significant action has been taken since the time under review to strengthen CIN arrangements. 2.10 This plan of work was agreed during a home visit, but the expected outcomes of the interventions offered were not articulated making it unclear what was hoped to be achieved and therefore hard to monitor or evaluate progress. The records of the planning session describe Becky negatively, but the family support worker was proactive in finding a way of speaking to Becky alone. Becky reported feeling scared about a lot of things, including going back to school and being out alone, caused, she said, by reading about abduction cases and watching horror movies. The social worker was charged with addressing these concerns, but Becky did not attend any of the planned sessions. These anxieties were addressed in part through the work with the individual support worker, but the issue of what action Father and Becky’s Step-mother could and should have taken to limit the watching of these programmes was not addressed because the parenting sessions did not happen. This meant the meaning of these films for Becky and why she watched them was never established. The lack of an initial analysis/formulation or subsequent reviewing mechanism meant that this gap was never addressed. 2.11 Becky’s Step-mother reported that there were continued concerns about Becky’s relationship with her Father, and although this was discussed with Becky’s Step-mother and Becky, Father did not engage with any of the sessions with the family support worker (and never really engaged with any other services). There was no analysis or comment regarding this at this time which meant that there was no focus on the role 6 FISS is a specialist service within Children’s Services with the overall aim of preventing family breakdown through the provision of intensive support services. This team no longer exists. 11 | P a g e that Father played in his relationship with his daughter or an outline of what he could and should do to help change the situation. This is discussed in Finding 5. 2.12 The individual work with Becky focussed on getting Becky back into mainstream school; although there was a clear plan of action put in place this was not achieved. The individual support worker was successful in engaging Becky in weekly activities and enabled her to feel more confident in going out. Referral to CAMHS 2.13 The FISS team made a referral to Child and Adolescent Mental Health Services (CAMHS)7 at the start of their involvement because of concerns around Becky’s social anxiety. Four weeks later CAMHS organised a meeting8 which was attended by the family support worker, the individual worker for Becky, Becky’s Step-mother and CAMHS professionals. Most of the information was provided by Becky’s Step-mother and there was no exploration of the wider family’s view or any reflection on the circumstances from Becky’s perspective given that she was not present. CAMHS agreed they would make a referral to Hospital Education Service (HES) and the clinical psychologist would meet with Becky to undertake an assessment of mental health needs and plan future work. 2.14 There were no formal minutes produced, but professionals were copied into a letter from CAMHS to Becky’s Step-mother summarising what had been covered at the meeting, what actions would happen next and handwritten notes were kept in the CAMHS files. There were several problems with this approach to record keeping and updating the referring agency (Children’s Social Care) of future plans. The handwritten notes9 are hard to read, and the content of the letter was focussed on Becky’s Step-mother’s views/description of Becky’s circumstances, as opposed to a more robust professional analysis. This inadvertently added to the professional overreliance on Becky’s Step-mother’s view of the family circumstances which is discussed in Finding 4. The issue of different styles and approaches to report writing and record keeping and its impact on multi-disciplinary work is discussed in Finding 2. 2.15 The lack of a child in need meeting/process meant that there was no overall coordination of the services provided by CAMHS with the existing package of support being provided by FISS. Consequently, there was overlap in the support offered, and Becky was required to engage with a number of different professionals. Some discussion was needed about how these different services would dovetail together and how Becky’s acknowledged uncertainty about engaging with a number of new adults would be overcome. This is discussed in Finding 2. 7 CAMHS stands for Child and Adolescent Mental Health Services. CAMHS are specialist NHS services. They offer assessment and treatment when children and young people have emotional, behavioural or mental health difficulties. 8 CAMHS call this a complex case meeting 9 This approach to recording was part of established custom and practice internally at CAMHS at this time because of capacity and resource issues. This is currently in the process of change. 12 | P a g e 2.16 The first meeting with the clinical psychologist at CAMHS took place a month later and was attended by Becky and Becky’s Step-mother. There were seven further meetings over a 14-week period, attended by Becky and Becky’s Step-mother or Becky’s Step-mother alone and a number of telephone calls prompted largely by non-attendance at a number of appointments. Becky’s Step-mother tried to support Becky to attend these meetings. Becky’s Step-mother provided information about her knowledge and perspective of the family history, but this was not checked with Mother who had a different view of the past family history. The information shared by Becky’s Step-mother was that Becky was neglected when young, she was fearful of the outside world and had concerns about being abducted and had problems with eating. There was no formulation developed as would be expected at this point and the subsequent sessions were designed to focus on Becky’s anxieties and she continued to be highlighted by the family as the person with problems and no wider formulation was developed. 2.17 Goals were not set and there was a lack of clarity of what was to be achieved. The cause for this lack of a clear focus appears to be Becky’s lack of engagement in the sessions and refusal to be seen alone. Given that the social worker also expressed concerns about not being able to engage Becky there should have been a review of focus and progress, and the meaning and expectations explored. The meaning of this lack of engagement and participation needed further analysis and exploration. This is discussed in Finding 1. Referral to Hospital Education Service 2.18 At the same time as the CAMHS work started a referral was made appropriately to the Hospital Education Service (HES10) because Becky was out of education at this time. HES met with Becky and Becky’s Step-mother at home, and a clear personalised education plan was agreed with a gradual and staged approach to attendance. This plan was effective and with the support of the FISS individual worker, HES staff, and Becky’s Step-mother, Becky started attending HES lessons three months later. 2.19 Six months into the work with the FISS team they evaluated that their intervention had been successful; Becky was settled in HES school provision and reported feeling more confident to go out. FISS worked much longer with Becky than they would normally do so, but the conclusion focussed exclusively on Becky and although the closing summary acknowledged that conflict between Father and Becky had been an issue it did not acknowledge that work regarding this had not been undertaken and parenting support had not been engaged with. FISS informed all agencies of the closure, but did not provide a copy of the brief closing summary and therefore those agencies did not know what progress had been made, what issues remained unresolved or what needed to be addressed in the future and by whom. This lack of a clear handover process is addressed in Finding 2. 10 Hospital education services is specialist educational provision designed to support young people who are unable to access mainstream education because of medical needs. 13 | P a g e 2.20 On case closure FISS asked HES to undertake a CAF11, and a member of HES staff was designated as the lead professional. It is not clear what the purpose of this was or what was hoped to be achieved. CAMHS were still working with Becky and her family and there was a lack of coordination with those services. It would have been expected that given that the FISS services were being provided under the auspices of a CIN process that there would have been a CIN meeting to coordinate the transition to what was supposed to be a new organising framework. 2.21 At this time, the CAF work was overseen by a panel and the CAF process took place separately from the other services. There were three meetings of the CAF panel. Another agency, Action for Children12 were asked to provide services and support as part of the CAF over a six-month period, but it is not clear exactly what these services were because there are no written records (this issue of very poor recording practices is being addressed by Action for Children as outlined in their internal review), but they included some home visiting and some attempts to work individually with Becky. What is clear is that once again there was some overlap with other services being provided and a lack of coordination. There were no multi-agency meetings of everyone involved. 2.22 This lack of coordination between the CAF panel, services delivered by Action for Children and other services such as CAMHS meant that at the same time as Becky, her Father and to some extent Becky’s Step-mother were not fully using existing services and support, new services were being offered. This highlights some confusion about how services should be coordinated in the context of the CAF and when there is no obvious framework such as a child in need plan/involvement of CYPS. This is discussed in Finding 2. 2.23 HES also reviewed progress, something they did regularly over the next 18 months. This review was attended by HES and CAMHS staff which enabled there to be a discussion about both educational and psychosocial issues; something that was lost when agencies were no longer involved and HES were working with Becky alone some months later. The importance of full support to HES and the complexity of their work is discussed in Finding 3. Referral to Family Therapy 2.24 CAMHS also held a case discussion, four months after the work with the clinical psychologist had started. This included a full summary of the family history and current concerns were said to be related to Becky’s social anxiety, eating problems, possible depression, insecure attachment and her difficult relationship with her Father. The 11 The Common Assessment Framework (CAF) is a process for gathering and recording information about a child for whom a practitioner has concerns, identifying the needs of the child and how the needs can be met. It is intended to help to identify in the early stages the child’s additional needs and promote coordinated service provision to meet them. 12 Action for Children is national charity who are commissioned within Bristol to provide support services to children, young people and their families. 14 | P a g e outcome of this discussion was a referral to the Family Therapy service 13 within CAMHS. 2.25 This was an appropriate referral and represented a further opportunity to encourage all those adults responsible for Becky’s care to consider the impact of the past and the present on her. In part this was achieved in the five sessions attended (Becky and Becky’s Step-mother attended all the sessions, and Father came to one and Mother to another). A lot of family information emerged; this included Becky talking about significant conflict with Father and early worries for Becky that Father did not want her at home. Becky also talked about significant conflict with her older Brother and being unkindly teased about her weight by her Step-brother. Becky discussed the impact of the past on her, the complex family relationships and her worries about Becky’s Step-mother and Father who were both unwell and undergoing tests. The conclusion of the Family Therapists was that all the adults in Becky’s life faced challenges which meant they could not fully focus on Becky’s needs, an important conclusion that moved the focus from Becky having problems, to a more holistic and family focused view. 2.26 The family therapy sessions took place over a five-month period and in the final session Becky talked about still feeling afraid of people and places and the conclusion was that this was likely to be connected to her traumatic past and current complex family circumstances. This was an important point, as up until this moment Father, Becky’s Step-mother and Mother had not acknowledged that the complex family circumstances and relationships could be having a negative impact on Becky’s emotional wellbeing. Unfortunately, at this time there were significant concerns about Becky having an eating disorder, Becky’s Step-mother was becoming very unwell, Father was also physically unwell and these pressures meant the family felt unable to continue to attend family therapy. 2.27 This important family focussed formulation and analysis was not discussed with any of the other agencies or with the other professionals within CAMHS who were working with Becky and her family. This meant that the progress made in moving fixed family and professional thinking from Becky having problems to there being complex family relationships which were impacting on her was lost and this is discussed in Finding 1. 2.28 The effectiveness of this work was also not supported by appropriate recording (notes of all the sessions being handwritten and difficult to read), there was limited evidence of reflection or analysis, and there was no closing summary or final analysis of the work undertaken and this is discussed in Finding 2. 13 Family Therapy enables family members, couples and others to express and explore difficult thoughts and emotions safely, to understand each other’s experiences and views, appreciate each other’s needs, build on strengths and make useful changes in their relationships and their lives. Individuals can find Family Therapy helpful, as an opportunity to reflect on important relationships and find ways forward. http://www.aft.org.uk/consider/view/family-therapy.html 15 | P a g e Referral to Eating Disorder Clinic 2.29 At the same time the Family Therapy sessions were started, the Clinical Psychologist met with Becky and Becky’s Step-mother after a gap of 7 weeks. Becky was noted to have lost a significant amount of weight and was complaining of physical symptoms such as fainting. The Clinical Psychologist organised an immediate psychiatric and medical assessment. Becky was assessed as having anorexia nervosa14 and initially inpatient treatment was considered, but Becky made progress and she was referred to the Eating Disorder clinic within CAMHS. The Clinical Psychologist provided a full summary of the family history (as provided by Becky’s Step-mother and to some extent Becky) and support provided by CAMHS thus far to ensure consistency of approach. 2.30 Becky was provided with an appropriate treatment programme for anorexia, including meeting with the specialist eating disorder nurse, medical support from the GP, and psychiatric support. Becky and Becky’s Step-mother attended 13 sessions over a 13-month period. Father attended one and Mother four. These sessions focussed on getting the family to work together to support Becky and this was successful with a reported improvement in family relationships. The family were encouraged to continue to attend the family therapy sessions as an important part of the treatment approach15 for the anorexia nervosa and they did so for a further two sessions. CAMHS worked hard to engage the whole family and Becky’s health and wellbeing improved. She reported coping better at HES, developing friendships, attending sleepovers and engaging in group activities. This was considerable progress and at the end of the 13-month period Becky was assessed as having recovered from her anorexia nervosa, and her social anxiety was assessed as being much improved. 2.31 The GP who was part of the team offering medical support around the anorexia nervosa was kept updated about progress and the wider CAMHS team were copied into these letters. This was usual practice for the work of CAMHS, but again raises important questions about the impact of different approaches to record keeping and information sharing across the multi-agency group which is discussed in Finding 2. CAMHS work finishes 2.32 HES were informed of the planned case closure because the work of CAMHS had been successful, and it was made clear that HES could make contact with CAMHS in the future if they had any concerns about Becky in recognition that they would need to support the continued complex needs of this family. This was helpful, but the process for doing this was not clear; HES believed that they would need to make a completely new referral through the GP, whereas CAMHS thought they were offering direct advice. It is important that the complexity of the needs of the children being supported by HES is recognised and that the process by which they can access advice and support 14 Anorexia nervosa is a serious mental health condition. It's an eating disorder where a person keeps their body weight as low as possible. 15 http://www.nhs.uk/Conditions/Anorexia-nervosa/Pages/Introduction.aspx 16 | P a g e from CAMHS or other specialist services is made clear and this is discussed in Finding 3. 2.33 HES had concerns almost immediately about Becky’s low mood, poor behaviour and concentration. These issues were discussed in the regular progress reviews, which were now only attended by HES staff. The conclusion was that the probable cause of these difficulties was Becky’s worries about Becky’s Step-mother being very unwell. Before HES could take any action to address these issues Becky returned to mainstream schooling at the end of term, and this was appropriately facilitated. 2.34 After eight weeks at the new school Becky returned to HES because she had not felt able to cope. There were initial issues regarding Becky being bullied which were successfully addressed. The previous concerns about poor concentration (an educational assessment was completed and proved inconclusive), low mood, conflict at home and poor behaviour were immediately evident, and these were viewed again in the context of Becky’s Step-mother’s continued poor health. These concerns were regularly discussed at the student review meetings, but no overall plan of action was formulated to address them or keep track of progress – were things getting better or worse, and what was an appropriate response. A referral was made to the Young Carers16 project, but despite being followed up no progress was made and there was no further formal discussion regarding what might be causing Becky’s difficulties. 2.35 Over the next 10 weeks HES concerns about Becky continued to deepen. She reported that Father had thrown her out of the house over Christmas (she went to stay with friends) and from this point Becky exhibited serious anxiety about being asked to leave home permanently; something she reported that Father threatened her about. This was a serious issue given that she continued to have fears about the outside world and her safety. Becky appeared distracted, was observed to be low in mood, behaving inappropriately and she complained that she was hungry. She was provided with individual support at this time and a referral to Brook Advisory Service was suggested which she declined. She also started attending a group off-site to look at her post 16 options. HES considered Becky’s behaviour was likely to be caused by Step-mother’s illness and the impact on the whole family. HES Referral to First Response 2.36 The staff at HES were increasingly worried about Becky’s low mood, her sense of hopelessness and fears about being “made” to leave home by Father. They understood how serious this was for her because home and Becky’s Step-mother were very important to Becky. In May 2014 HES made a verbal referral to CYPS First Response17 Team. The referral was comprehensive; it included full information about what was known about Becky’s complex past family history, and present concerns were said to be evidence of possible adolescent neglect, Becky being a young carer, a risk of sexual 16 A service offering support to Children and Young People who hold caring responsibilities 17 First Response is the Bristol front door service for referring concerns about children 17 | P a g e exploitation and homelessness. At the conclusion of the referral conversation, it is recorded that HES thought there was a need for youth services support and some family support. This did not represent the level of concern HES felt for Becky, and it is unclear why this mismatch occurred. Current policy is for referrals to be provided in a written format so that these misunderstandings about a child’s needs are avoided. 2.37 First Response accepted the conclusion of HES, despite its mismatch with the information shared. It is the view of the Review Team that given the long history of concerns and the current level of risk, this verbal referral should have been accepted for assessment, but instead the case was quickly passed to the Early Help Services. At this time the First Response Team were newly established, and the existing arrangements did not routinely involve a qualified social work manager in decision making. Since then, changes to the First Response Team have been made including the routine involvement of qualified senior social workers/ managers who are responsible for reviewing referrals, summarizing concerns and clarifying the risks before referring to other services. This would have made a difference to the progress of this referral. This also highlights the critical importance of providing written referral information. This is now an expectation of all agencies. 2.38 HES were informed of the decision of First Response to pass the referral to Early Help, and although they were disappointed with this response, they believed that First Response were the experts and did not think it was appropriate to question or clarify the decision. Early Help Response to Referral 2.39 The subsequent response from the Early Help team was muddled. They made an onward referral to the youth service as had been agreed with HES; they also asked a commissioned voluntary family support service (Action for Children) to undertake “a safeguarding home visit”. It is unclear exactly what this meant; this type of visit is not part of existing policy and procedures18. This visit was agreed because Early Help had no social worker available and the Action for Children Manager was a qualified social worker and there was recognition at this point of the seriousness of the concerns. There was also discussion about Action for Children providing services to the family. Action for Children were commissioned by Bristol City Council to work with children aged 0-19, with a particular focus on children aged 5-13. Following the visit to Becky and her Father, Action for Children determined that Becky’s needs were not such that a service from them was required. 2.40 The manager from Action for Children made one attempt to contact HES but they did not speak to anyone and did not leave a message, so no contact was made with the referrer and the professionals who knew Becky best. Contact was made with the family who said they were going on holiday and it was agreed that contact would be made on 18 http://www.proceduresonline.com/swcpp/bristol 18 | P a g e their return. It is not clear why responsibility for the home visit was not passed back to the Early Help Team, given that the urgency of the situation had dissipated. It appears Action for Children wanted to ensure continuity as they had already contacted the family. 2.41 At this time the Early Help Teams were at the very early stage of development, there was limited capacity and decision making did not routinely involve qualified social work practitioners. Significant changes in capacity have since been made, and decsion making is now overseen by suitably qualified practitioners. 2.42 A week after the referral had been made, Becky shared concerns with staff at HES about a young male peer threatening to publish explicit photographs on the internet and worries about ‘sexting'. HES made verbal contact with Early Help with the intention of linking this information with the recent referral, but this did not happen and this request for help and advice was treated in isolation. HES made it clear that Becky was scared to discuss this issue at home because she was worried about her Father’s reaction and that he might “throw her out”. Advice given was for HES to support Becky to make a complaint directly to the police and for HES to consider a referral to Brook Advisory service and/or Barnardo’s. This was incorrect advice, and the additional information should have been seen as strengthening the previous concerns raised about possible sexual exploitation. The information about sexual exploitation concerns was shared with Action for Children. 2.43 HES talked to Becky who did not want to contact the police because she said she was frightened of repercussions. 2.44 HES were not happy with the advice they had been given but felt that this issue would be addressed through the Early Help response. HES did not seek clarification of next steps, and they were not informed that a home visit had been organised. Again, HES did not feel that they could do anything about the decision made. They also felt uncertain about how much further they could explore the concerns with Becky. They felt constrained by the advice in the child protection procedures which say that when dealing with disclosures “the child must not be pressed for information, led or cross-examined” and did not know how far to explore the concerns. This is discussed in Finding 1. Visit by Action for Children 2.45 Father was telephoned by Action for Children three weeks later and agreed to a home visit. During this visit, Father denied that he had threatened to ask Becky to leave, but said he expected her to attend college or find a job. Becky refused to be seen alone, but the Action for Children Manager spoke to Becky briefly alone outside the house and provided her with leaflets about a local specialist Barnardo’s Child Sexual Exploitation project. They did not have a proper conversation about the concerns regarding the explicit photographs and the attendant professionals’ worries about the risk of sexual exploitation. These should have been regarded as unaddressed and requiring further action. Although the decision taken by Action for Children to undertake the home visit 19 | P a g e was because they recognised that Becky and her family needed to be seen, and they wanted to support their overstretched colleagues in Early Help, this stepping outside of role and task added further confusion to an already muddled response (this has been addressed by Action for Children through actions within their own internal review). The issues raised within the referral were never properly assessed and the issue of family relationships, and particularly the concerns about the relationship between Father and Becky remained unaddressed. 2.46 A referral to Barnardo’s child sexual exploitation project was discussed, but did not happen due to confusion about whose responsibility it was. It appears each of the three agencies involved, HES, Action for Children and the Early Help Team believed the other was going to make the referral, and the continued lack of any coordination of services meant that no one realised it had not been done. This issue is addressed in Finding 2. HES were not made aware of the outcome of their referral, so also did not know that this issue had not been addressed, and at this point school ended and Becky left HES and moved to post 16 education provision. Involvement of Youth Services 2.47 A referral had been made to the youth services by Early Help and an experienced youth worker visited the family home at this time. Becky was reluctant to engage, but the youth worker persevered and a period of individual work started. The focus was on building Becky’s confidence, supporting her to attend post 16 education and to work on her relationship with her Father. The youth worker sensitively discussed the concerns about sexually inappropriate behaviour and Becky dismissed these and reported no concerns. The youth worker was not aware of the issue of explicit photographs and so was not able to explore this. Becky engaged well with the youth worker and used the time to continue to explore her worries about her poor relationship with her Father and her continued worry that he would ask her to leave. After 12 weeks in September 2014 Becky decided she did not want further involvement with the youth service; at this point Becky was attending post 16 education and she reported feeling much happier about home. The case closed, but the youth worker made it clear she could re-engage in the future if she needed to. Becky made contact a month later for some brief support but did not attend a subsequent appointment. Becky continued to attend post 16 education provision but did so erratically until the time when she was murdered. 20 | P a g e 3. The Findings 3.1 The central purpose of a Serious Case Review is to learn lessons about how to improve the safeguarding system for the future. In essence, the review looks back at one case in order to look forward to what would improve the practice in the wider safeguarding system. Although this case was unique to those involved, there are aspects that are familiar to all professionals who work with vulnerable children and their families, and therefore this one case can provide useful organisational learning to underpin improvement more widely. 3.2 The evidence for the findings comes from the case itself, the knowledge and experience of the Review Team and the Case Group, from the records relating to this case and other documentation from agencies, and from relevant research evidence. Findings 1. Services need to be focussed on an evidence based understanding of the needs and circumstance of adolescents; the absence of this can lead to adolescents inappropriately becoming the focus of concern, and being seen as “troublesome” rather than troubled because of their circumstances. 2. The inconsistencies within intra and inter-agency approaches to recording, analysis, planning, coordination and review makes joint working for children and their families less effective. 3. Children in receipt of specialist services from Hospital education services (HES) have complex needs, and some require a multi-agency response to meet these needs. Despite this, HES are often working alone in providing services to children; such lone working does not meet the needs of all children. 4. The propensity for professionals to take parent/carer perspectives at face value without triangulating information from other sources, including observations of how a child or young person appears, can lead to a limited understanding of a child or young person’s needs. 5. Professionals are less challenging of the lack of engagement of Fathers in child welfare practice leaving the risks they may pose unassessed and the contribution they could make to children’s lives unknown. Finding 1: Services need to be focussed on an evidence based understanding of the needs and circumstance of adolescents; the absence of this can lead to adolescents inappropriately becoming the focus of concern, and being seen as “troublesome” rather than troubled because of their circumstances. 3.3 This review builds on the Findings of the recently published Operation Brooke Serious Case Reviewiv that raised important questions about the service response to vulnerable adolescents locally and nationally. There has been concern over the past few years from 21 | P a g e professionals, policy makers and researchers that services across the safeguarding continuum do not recognise the risks that adolescents face and do not adequately meet their needs. This is despite the evidence that many adolescents experience significant abuse and neglect and this abuse and harm has a more global negative impact into adulthood than childhood-limited maltreatment (Radford et al. 2011v). It is, therefore, essential that adolescents are provided with services that they are able to access to meet their needs. 3.4 This review has found that there were three key areas where more understanding of Becky as an adolescent who had a traumatic past and complex family relationships was required. These are: • Ensuring that professionals do not focus entirely on adolescents as the problem and develop a clear formulation or analysis which is family focussed; • Engagement of adolescents; • Enabling adolescents to talk about concerns and worries. Ensuring that professionals do not focus entirely on adolescents as the problem 3.5 Adolescence is a time of considerable biological, psychological and social change and consequently the transition from childhood to adolescence can be difficult vi . Adolescents who have experienced early trauma and abuse and whose family and social circumstances are complex have not always been equipped with the skills and emotional repertoire to manage this transition and can thus find it more difficultvii. These difficulties are not always then perceived as a result of those early experiences or current family difficulties, but as a problem with, and of, the adolescent. Researchviii and SCR’s ix have highlighted that because adolescence is a time of independence, when adolescents become known to services there is a tendency for professionals to evaluate their difficulties in isolation and they can become seen as “troublesome” rather than “troubled by their circumstances”; their behaviours and responses should be understood as a manifestation of trauma, not a manifestation of adolescence. 3.6 Unpicking these issues requires careful assessment and the development of a clear formulation or analysis; in essence in order not to compound an adolescents’ feelings of low self-worth and self-esteem professionals need to understand the causes of adolescent difficulties and carefully locate them in the context of their past trauma, current family relationships, social circumstances and individual needs. This requires professionals to ensure that parents/family members understand this holistic approach and resist attempts to blame the adolescent for their problems. 3.7 Becky came to the attention of service when she was 13. It was known that she had a traumatic past and complex family and social circumstances. The first assessment was an important opportunity to bring all this information together and build a formulation or analysis of her and her family’s needs which should have provided the foundation for appropriate interventions. The assessment offered was an initial assessment and this did not provide the framework for an in-depth assessment. Services were offered and 22 | P a g e located as a response to the potential for family breakdown. However, the work became focussed on Becky and her problems. This was compounded by the referral to CAMHS and HES; both were appropriate to Becky’s individual needs, but because none of the services were joined up this reinforced the view that the focus of attention was on Becky. 3.8 The organising framework should have been the CIN plan, but this was not formulated, and no multiagency meetings were planned. FISS worked with Becky for six months, and although her mood improved, the family problems that caused the initial contact remained, and services offered to address these issues were not engaged with. The lack of a transition arrangement meant that this information was not shared with any other agency and was not really acknowledged by FISS. 3.9 A CAF was initiated, and this was a further opportunity to establish a formulation and analysis of what the issues were that needed addressing and how they were to be addressed. Again, this did not happen, and the focus was on Becky and what was seen at this time as her problematic behaviour. 3.10 The provision of Family Therapy meant that there was some discussion regarding the role of the past and current complex family relationships, but this was disengaged from. The absence of an overarching plan, based on a formulation or analysis, with goals and objectives which were holistic meant that the move back to providing services to Becky as an individual with the problems was not acknowledged or addressed. 3.11 The referral to First Response by HES was a further opportunity to understand Becky’s circumstances in the context of her family. This was addressed in a muddled way, and instead of an assessment one home visit was completed, where Father did not acknowledge any of the concerns and the focus became again on Becky and the provision of support services to her alone. This individual support was appropriate, but it needed to be located in the context of a holistic formulation bringing together the past and present and helping Becky understand her difficulties as not her own, but as a result of the context she lived in. Engagement of adolescents 3.12 The recent evidence scope; That Difficult Age, x has highlighted the importance of working positively with what is known about adolescent development and thinking carefully about the implications for services. This is particularly necessary in considering engagement with services where adolescents can be perceived as difficult to engage, per se. The responsibility is often placed with them, and there can be a perception that they are making a free and informed choice. However, research makes it clear that adolescents’ struggles with services are often connected with their past experiences and they may be cautious about services which they perceive will destabilise their established strategies for coping with their problems. Services which are focussed on problematic behaviour can reinforce feelings of low self-esteem and depression; many vulnerable adolescents will also have had to engage with large numbers of professionals, and there are often issues regarding trust and perceived 23 | P a g e reliability. All of this requires professionals to think carefully about how to enable vulnerable adolescents to engage with services. 3.13 Becky was often described by professionals as not engaging with services and not being motivated to change. This was not sufficiently reflected on. During the time under review she was asked to engage with 17 different professionals and there was often overlap with a number of professionals trying to engage Becky in individual work without there being any discussion of whether this would be too many new people and too much to engage with. 3.14 Finding 5 focuses on services’ failure to engage fathers, yet the contradiction that this was not subject of comment or criticism was not acknowledged. It is not clear the extent to which Becky was aware that professionals considered that she was difficult to engage, or that she was somehow making a free and informed choice not to access services, but this perception is likely to have a negative impact on an adolescent’s sense of self-worth. 3.15 For Becky, it would have been more accurate to say that she was engaging in some services, she formed good relationships with some professionals and there was evidence that she was able to make good use of these services. What was missing was a broader reflection of the meaning of what was termed her non-engagement in the context of wider case coordination and planning. This reflection should have focussed on what services and professionals could do differently to enable her to engage. Enabling adolescents to talk about concerns and worries. 3.16 It is critical that adolescents are enabled to talk to professionals about their concerns and worries, particularly about their safety and potential experiences of abuse. Although there is no evidence that Becky was abused during the time under review she did share worries that lead to concerns regarding possible sexual exploitation, which she found difficult to discuss. This led to a referral to First Response, passed to Early Help and then Action for Children. She was not seen for three weeks, due to a family holiday, and refused to be seen alone. Given that she had not met either of the workers from Action for Children, this is not entirely surprising. This Finding focusses more generally on professionals enabling children and adolescents to be able to talk about any abuse they may have experienced. Local and national guidance makes it clear that children and adolescents must be offered an opportunity to be sensitively enabled to “tell their story” as well as disclose concerns and harm. 3.17 Research by the Office of the Children’s Commissionerxi found that as few as one in eight victims of abuse come to the attention of professionals and many victims wait until adulthood before being able to tell someone about their experiences. Research by the NSPCCxii highlights that this is not because the children do not seek help, but because they are often not heard, not believed, or adults do not notice the behavioural signs that indicate something is going on for them. 3.18 There are significant issues regarding enhancing the skills of all professionals to work in this area and enabling children and young people to seek help safely. Research 24 | P a g e demonstratesxiii that there are significant barriers to children feeling able to talk about abuse and worries for their safety and for professionals to notice that this might be an issue for the children they are working with and asking them about it. 3.19 Children and adolescents sayxiv they need professionals to be able to discuss concerns about abuse openly and without embarrassment and be prepared to ask questions and explore what children’s/adolescents’ concerns are. The current policy and guidance framework, developed because of concerns raised by the Cleveland Inquiryxv, suggests to professionals that they need to exercise great caution when talking to children about sexual abuse. The mismatch between what children say they need and what policy prescribes needs urgent attention locally and nationally. 3.20 Becky talked about her worries about someone she described as a boyfriend having explicit photographs of her and threatening to publish them. The staff at HES were worried about her and gave her time to talk about these concerns, but they felt constrained by guidance which suggests that they could not ask leading questions. They were uncertain about how to enable Becky to talk about what she was worried about. They are not alone in this concern. Recent research from the NSPCC xvi and as highlighted in the Brooke SCR xvii , professionals generally, and social workers specifically, lack confidence in this area. Questions for the Board • Are services appropriately structured in order that evidence-based approaches can be provided for adolescents that agencies find hard to engage? • How can BSCB support professionals to feel equipped and confident to carry out this complex work? • What can BSCB learn from the work of voluntary sector agencies about dealing effectively with disclosures? • How will BSCB be informed of changes achieved through the learning and development in this area? Finding 2: The inconsistencies within intra and inter-agency approaches to recording, analysis, planning, coordination and review makes joint working for children and their families less effective. 3.21 Critical to interagency work is a joint understanding and ownership of assessments and plans, and a shared vision of what constitutes good outcomes for a child. The need for information sharing is well-rehearsed in statutory guidance, and concerns about the nature of this information sharing is the subject of numerous Serious Case Reviews. 25 | P a g e There is less notice given to the disparity of multi-agency information sharing in relation to case recording, planning, and review. 3.22 During this review, the Review Team were struck by the differences in how agencies recorded information about a child and family and how difficult it was to bring this information together to make sense of shared outcomes, assessments and plans. 3.23 There were significantly different approaches (within and across agencies) to case recording and it was clear that different custom and practice had developed across agencies, making multi-agency work more complex. For example, CAMHS approach to sharing information is through the issue of letters. The information contained in these letters is comprehensive, but is addressed to one agency, in this case the GP, and other involved professionals within CAMHS and outside are copied in. This is a very different approach to, for example, Children’s Social Care. Although each agency has its own rationale for recording approaches, there is a danger that these differences can confuse practitioners and undermine multi-agency practice, and leave children without a joined-up approach. There was evidence of this here. 3.24 Each agency undertook its own assessment process, and drew up a plan of action which was single agency in approach. This was exacerbated by the lack of child in need processes, and confused by the CAF arrangements that happened separately from other service provision. There was little connection between what support had been provided, what the implications were of any unfinished work, what that meant for future work and for Becky feeling listened to. Overall, Becky’s needs were split between different services and as a result the provision was fragmented. There was little transfer of care or information between services, and little meaningful dialogue or connections between services leading to duplication and confusion. Multi-agency involvement was marked by a lack of coming together to think about Becky and consider what response she needed, by whom, in what timescale, and for what purpose. Who was best to do the job in the interests of Becky and her family, how could they be supported to do this, and how could agencies and services work together to understand Becky and meet her needs? 3.25 This confusion was particularly highlighted in relation to the role of the Lead Professional. When there was a CAF in place for Becky, the Lead Professional chaired the CAF meetings but took no active role in the coordination of services. 3.26 Since the time under review the arrangements for the delivery of CAF’s has changed and there is now greater clarity about the role of the Lead Professional. The delivery of services to Becky, however, raises questions about the coordination of services when there is no involvement of Children’s Social Care and no CAF. The multiagency network looks to Children’s Social Care to provide a coordinating function, even when it has no role to play in service provision (because the needs of children and young people are being met by other services). However, it is important that the other agencies in this situation are prepared to take a coordinating role to avoid the duplication and fragmentation seen in this case. 26 | P a g e 3.27 The approach to reviewing mechanisms in this case was almost entirely single agency. Although single agency reviews did take place, the quality was variable and it was noticeable that agencies seemed to be focussed on different outcomes. There were few opportunities where agencies got together to review collectively. In the early days of service provision this was because of there were no child in need meetings. This was outside expected practice, and is an issue which is currently being addressed by Children’s Services as part of its transformation programme. When the child in need process was finished there was a CAF in place; this should have been an opportunity to coordinate all services and review progress. This was not achieved, and this appears to have been caused by the arrangements in place at the time for the provision of CAF’s. 3.28 This review found that the points where planning and review were least effective were at points of transition from one period of service provision to another. When the FISS work finished, the closing summary of their work was not shared with those agencies who remained providing a service to Becky, and therefore they did not know what had been effective and what remained outstanding. In fact, the CAF put in place almost identical services. These were not connected to the work of CAMHS, and so when one plan to offer individual support was being very successful, but time limited, another offer of individual work with a different focus was unsuccessful, and Becky was described as ‘unwilling to engage’. Exactly the same issue occurred when the FISS team were involved. The lack of any sort of multi-agency reviewing mechanism meant this duplication of effort and pressure on Becky to engage with several different professionals was not understood. This same dynamic was played out in the support to Becky’s Step-mother and family support more generally. 3.29 In this case, the different systems and structures that are in place and the pressures on agencies to fulfil their own responsibilities appears to have impacted on their ability to work in a multi-agency way. This, paradoxically, caused more work, rather than less by leading to duplication, and a lack of analysis of what needed to happen at points of transition. It became clear through the work of the review team with the case group that locally there is a tendency for all agencies to look to Children’s Social Care to facilitate the multi-agency approach. Questions for the Board • Is the Board confident that record keeping is suitably robust in each agency and the function of record keeping is clearly understood by across all agencies? • What current mechanisms are in place to ensure that complex, multi-factorial risks and needs are effectively assessed and reviewed within non-statutory multi-agency interventions? • How will the Board ensure that new multi-agency and multi-disciplinary developments are informed by this finding? 27 | P a g e Finding 3: Children in receipt of specialist services from Hospital education services (HES) have complex needs, and some require a multi-agency response to meet these needs. Despite this, HES are often working alone in providing services to children; such lone working does not meet the needs of all children. 3.30 Children with complex health, mental and social care needs who are unable to access mainstream education provision are provided with education through a variety of specialist placements, including hospital-based education services. In these circumstances, children are either educated within a hospital or attend specially adapted sites where dedicated teachers provide education. For children to receive this service, a referral must be made by a health consultant. The staff team considers the referral, and a decision is taken about whether the resource can meet the child’s needs. Despite providing highly specialist services to children at what could be considered a Tier 4 level of intervention, and therefore requiring a multi-agency approach, when a child receives hospital education the experience of HES is that other services such as CAMHS or Children’s Social Care often cease their involvement with a child and family. 3.31 Becky was referred to HES by the CAMHS consultant. Becky had a history of significant mental health difficulties, and whilst the extensive services provided by CAMHS had led to some clear improvements in Becky’s mental health, she remained a child with complex needs and so met the criteria for this specialist service and was offered a place at the school. At this point, the FISS Team closed Becky’s case, and some 13 months later, CAMHS also closed their involvement. 3.32 During the following 13 months, Becky continued to have multiple health and social care needs and it was evident that stresses at home were mounting, responding to her needs was a complex multi-layered task. HES took their support of Becky seriously, with many members of the team involved; although they reviewed their work regularly, no member of the team was provided with reflective supervision because this is currently not provided. This meant they had no opportunity to reflect on this complex work. No support was provided by other agencies. 3.33 HES were aware that CAMHS had offered to be available for advice but knew that obtaining such advice would entail a complicated route involving re-referral of Becky to the service and this could not be done by them. They made a formal referral to First Response; this was passed to Early Help and then a commissioned service. As such HES were outside this professional network, with no sense of how their concerns were being understood or what action was being taken. It is clear that the passing on of verbal information, with no written account from the referrer, led to a dissipation of concerns, and the lack of a feedback loop to HES meant that this was not known. What was needed was a multi-agency dialogue between these safeguarding partners to agree on what should happen next to best respond to Becky. 3.34 The Review Team learnt from HES that despite working with children and families who are coping with significant complex needs, they are often the only service who are 28 | P a g e providing support to the child and family. This single agency approach often leaves HES working alone and in isolation, reducing the possibility that the holistic needs of a child will be met. The reason for this is not entirely clear; it was suggested that differences in agency focus, thresholds, the volume of work, historical practice and the internal organisational pressures to confine agency involvement to a limited duration, all impact on this issue. 3.35 Much policy and guidance assumes that children’s needs for health, social or educational services can be separated out and provided by different agencies. However, researchxviii shows that this assumption does not tally with the experiences of children with complex health and social care needs and their families, whose needs are inextricably linked and form part of their everyday lives. Therefore, dividing a child’s needs into separate categories and responding to these needs in isolation is untenable. Children with complex needs require a multi-faceted, integrated, multi-agency response. Questions for the Board • How can the Board facilitate the development of a partnership and accessible pathway between specialist services and other services that improves the coordinated multi-agency, multi-disciplinary response to a specifically vulnerable group of children? • How can the Board support specialist services such as HES in undertaking the role of Lead Professional in cases at this threshold? • How can the Board support the implementation of supervision arrangements for these specialist services? Finding 4: The propensity for professionals to take parent/carer perspectives at face value without triangulating information from other sources, including observations of how a child or young person appears, can lead to a limited understanding of a child or young person’s needs. 3.14 It is essential that all professionals working with children and their families do so in a respectful and open way. This is the cornerstone of partnership practice as embedded in the Children Act 1989 and subsequent guidance and legislation. However, researchxix and Serious Case Reviews emphasise the importance of not taking at face value what parents or carers say when asked about the wellbeing of children. The Munro review commented that adults in this situation have a number of motives for not always providing a full picture of their or their children’s circumstances. The task of professionals is to remain in a position of “respectful uncertainty” and display “healthy scepticism” which in practice means: • checking the validity of information provided by parents/adults by cross referencing/triangulating with other sources 29 | P a g e • testing out the level of parental care and concern for children and the extent to which parents feel a sense of responsibility for their children and their well-being. 3.36 There were a number of examples in the work of involved agencies illustrating this finding. A great deal of information was provided by Becky’s Step-mother, and this self-report often formed the basis on which Becky’s needs were understood. The reliance on self-report and the absence of respectful uncertainty about the information provided led to an assessment of Becky and family life unintentionally dominated by the perspective of one family member. 3.37 Becky’s Step-mother provided information about family history from her perspective, but this information was taken by professionals as a factual account without other perspectives being sought or considered. Little account was taken of the complexities of blended families, where there can be conflict, and different family members will have their own understanding of what happened in the past or what is happening in the present. This meant that the progress made by Becky’s Mother in her personal difficulties was not reflected upon, nor the fact that Maternal Grandmother became abstinent during this whole period and played an emotionally and financially supportive role in Becky’s life. 3.38 There was little reflection on Becky’s perspective and concerns from Becky’s Step-mother about her early adolescent behaviour meant that assessments and reports were often negative about Becky. 3.39 It was the view of case group and review team members that this pattern can be seen in a range of the work across the multi-agency spectrum. Case members commented on their experiences of reading assessments where the perspective of the child or young person was missing. They emphasised the importance of professionals being clear about the source of the information and of attempting to make sense of the information gathered in terms of what it meant for the child or young person; they felt this to be particularly important in circumstances where it has not been possible to speak to the child or young person alone, where there are speech and language difficulties, lack of engagement by young people, where young people have mental health difficuties or in non-verbal or pre-verbal children. 3.40 Evidence for professionals accepting what adults say at face value also comes from several National Serious Case Reviews and the most recent Government initiated Triennial Review of Serious Case Reviewsxx. Questions for the Board • How will the Board ensure that partner agencies provide the tools, reflective supervision and culture which help professionals to remain in a position of “respectful uncertainty” and display “healthy scepticism”? • Is the Board assured that multiple hypotheses are used to explore and better understand complex family dynamics and is evidenced in recordings? 30 | P a g e • Do Board partners have information systems and information sharing arrangements in place which adequately facilitate accurate triangulation of information? • Are professionals encouraged to pose and consider reflective questioning within multi-agency discussion in order to improve assessments and understanding of family functioning over a period of intervention? Finding 5: Professionals are less challenging of the lack of engagement of Fathers in child welfare practice leaving the risks they may pose unassessed and the contribution they could make to children’s lives unknown. 3.41 There is considerable research and public policy evidence that child welfare services have often focused their attentions on working with mothers, and that fathers or father figures are often absent from the work and from the thinking of professionalsxxiiixxi. The reasons for men to be less engaged than women are complex, and include men’s own reluctance to be involved, mothers acting as gatekeepers and a professional culture whereby gendered ways of understanding problems in families and responding to them become taken for granted within organisationsxxii. The marginalisation of fathers or father figures is a significant issue because research shows that they are very important for children’s wellbeing and safety and can also pose significant risks which need to be evaluated. 3.42 When Becky came to the attention of professionals in 2011 one of the key issues was the relationship between Becky and her Father. However, he was not involved in the subsequent assessment and there was no reflection on his absence or what responsibility he needed to take to improve family relationships. The FISS team offered parenting support to improve family relationships. Father was not part of this, and based on the records seen as part of this review it remains unclear why, because it is not commented on in the record of parenting sessions or analysed in the closing summary. Father engaged briefly in the family therapy sessions and the support for Becky’s eating disorder, but was not part of the review process with HES despite there being growing concerns about Becky, including reporting that he was threatening her to leave home. 3.43 He was seen as part of the CAF and when the voluntary organisation visited he was asked directly about the threats to make Becky homeless, which he denied. What is striking throughout the period of review is that Becky highlighted that the poor relationship she had with her Father was an important issue to her, yet there is more analysis of her relationship with Becky’s Step-mother. There was also much professional discussion about Becky’s non–engagement with services (see Finding 1) but Becky’s Father’s non-engagement was not acknowledged or understood. 3.44 During this SCR Becky’s Father’s perspective was sought, it was clear that he was not aware of the range of services involved with his daughter. When he was asked about his 31 | P a g e views regarding what was helpful (and what was not so helpful) about the services that were provided, it was evident that he had little knowledge of the services provided by FISS, CYPS or Action for Children. Becky’s Father acknowledged that he largely left this part of family life to Becky’s Step-mother and that he did not actively pursue involvement. However, he felt that little was done to include him in the work. When he was asked about whether he would like to say anything to the services involved he asked for services to better understand the constraints faced by parents who work full time and asked that a more flexible approach is taken when meetings are arranged/visits are made “so that they do not only happen 9-5”. 3.45 Services need to consider not only how to enable fathers to engage with services, but also how to factor in a professional understanding of their role in causing difficulties that bring children into contact with services or the contribution that they can make to solutions to ensure children’s well-being, even when they are absent. Questions for the Board • Can the Board be assured that the Think Family approach to considering all family members has been fully embedded within frontline practice? 32 | P a g e References iWorking Together to Safeguard Children (DFE 2015) https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 iihttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/575273/DHR-Statutory-Guidance-161206.pdf iiiSCIE Guide 24 (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews: Social Care Institute for Excellence ivhttps://www.bristol.gov.uk/documents/20182/34760/Serious+Case+Review+Operation+Brooke+Overview+Report/3c2008c4-2728-4958-a8ed-8505826551a3 v Radford, L. et al. (2011) Child abuse and neglect in the UK today. London: NSPCC. vi DOH (2000) Framework for the Assessment of Children in Need and their Families http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf vii Raws, P. (2016) Troubled Teens: A study of the links between parenting and adolescent neglect: The Children’s Society https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/troubled-teens viii RIP (2014) That Difficult Age: Developing a more effective response to risks in adolescence: https://www.rip.org.uk/news-and-views/latest-news/evidence-scope-risks-in-adolescence ix NSPCC (2014) Teenagers: learning from case reviews: Summary of risk factors and learning for improved practice around working with adolescents: https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/teenagers/ x RIP (2014) That Difficult Age: Developing a more effective response to risks in adolescence: https://www.rip.org.uk/news-and-views/latest-news/evidence-scope-risks-in-adolescence xi Horvath, M.A.H., Davidson, J.C., Grove-Hills, J., Gekoski, A. and Choak, C. (2014). “It’s a lonely journey” A Rapid Evidence Assessment on intrafamilial child sexual abuse. London: Office of the Children’s Commissioner. xii Alnock, D and Miller, P (2013) No one noticed, no one heard: A study of disclosures of childhood abuse: NSPCC. https://www.nspcc.org.uk/services-and-resources/research-and-resources/2013/no-one-noticed-no-one-heard 33 | P a g e xiii Martin, L., Brady, G., Kwhali, J., Brown, S. J., Crowe, S. Matouskova, G. (2014) Social workers’ knowledge and confidence when working with cases of child sexual abuse: What are the issues and challenges? NSPCC https://www.nspcc.org.uk/globalassets/documents/research-reports/social-workers-knowledge-confidence-child-sexual-abuse.pdf xiv Children’s Commissioner (2015) Protecting children from harm: A critical assessment of child sexual abuse in the family network in England and priorities for action. http://www.childrenscommissioner.gov.uk/sites/default/files/publications/Protecting%20children%20from%20harm%20-%20full%20report.pdf xv Dame Butler Schloss (1987) Inquiry into Child Abuse in Cleveland http://discovery.nationalarchives.gov.uk/details/r/C3001 xvi Alnock, D and Miller, P (2013) No one noticed, no one heard: A study of disclosures of childhood abuse: NSPCC. https://www.nspcc.org.uk/services-and-resources/research-and-resources/2013/no-one-noticed-no-one-heard xviihttps://www.bristol.gov.uk/documents/20182/34760/Serious+Case+Review+Operation+Brooke+Overview+Report/3c2008c4-2728-4958-a8ed-8505826551a3 xviii Knowledge Review 18 (2007) Necessary stuff: The Social Care Needs of Children with complex health needs and their families: SCIE xixxix Burton, S (2009) The oversight and review of cases in the light of changing circumstances and new information: how do people respond to new (and challenging) information? C4EO http://archive.c4eo.org.uk/themes/safeguarding/files/safeguarding_briefing_3.pdf xx Sidebotham, P., Brandon, M., Bailey, S., Belderson, P., Dodsworth, J., Garstang, J., Harrison, E., Retzer, A. and Sorensen, P. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014: final report. [London]: Department for Education. xxixxi Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., et al. (2009). Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews 2005-07. London: Department for Children, Schools and Families. xxii Scourfield, J (2006) The challenge of engaging fathers in the child protection process: Journal of Social Policy May 2006 vol. 26no. 2 440-449 http://csp.sagepub.com/content/26/2/440.abstract xxiii Daniel, B and Taylor, J (2001) Engaging with Fathers: Practice Issues for Health and Social Care: JKP |
NC50546 | Cardiac arrest of 11-month-old child as a result of cocaine ingestion in July 2016. Child L survived the incident and was made subject to care proceedings. Criminal proceedings were brought against both parents in June 2018, and both were found not guilty. Child L was the subject of a Child Protection Plan in Lambeth since before his birth in July 2015. Family had a history of domestic abuse, mental health problems, and alleged self harm. Father had a history of drug misuse. There was a background of cultural tension between the parents, including an allegation of forced marriage. In May 2016 the family moved to Croydon who took over responsibility for his child protection plan. The case review was jointly commissioned by both LSCBs and led by Croydon LSCB. Uses the Welsh model methodology. Key lessons include: keeping the child's lived experience at the centre of safeguarding children practice; knowledge and skills in working with drug using parents; impact of homelessness and temporary accommodation on child protection; cross-borough working; getting the basics right, adherence to procedures and supporting frontline practitioners with guidance and reflective supervision. Recommendations include: ensure that safeguarding practice and supervisory system in place keep the child's lived experience at the core of all safeguarding work; the LSCBs and partner agencies should review practitioner knowledge and skills in understanding, assessing and responding to hidden substance misuse by parents where there is no sign of addiction or problematic lifestyle.
| Title: Serious case review: Child L. LSCB: Croydon and Lambeth Safeguarding Children Boards Author: Malcolm Ward Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Croydon and Lambeth Safeguarding Children Boards Serious Case Review Child L August 2018 Croydon and Lambeth Safeguarding Children Boards 1 Contents 1 Introduction 2 2 Background and reason for the review 2 3 Executive Summary and Key Lessons 3 4 Case History 5 5 L’s Family 13 6 Family Perspectives on the Services offered to them 14 7 Practitioners’ and Managers’ Perspectives 16 8 Discussion and Evaluation 19 9 Lessons 42 10 Recommendations 49 Appendices 52 Croydon and Lambeth Safeguarding Children Boards 2 1. Introduction 1.1 The purpose of a Serious Case Review (SCR), is to seek to understand what happened and why it happened in the context of local safeguarding systems, rather than to view solely the actions of individuals relating to a single case. The case under review is an example of local working arrangements in several areas of London at the time that the work was undertaken. 1.2 The lessons learned should be used to seek to improve the protection of children and multi-agency safeguarding systems. 1.3 Where possible a review should be informed by the experiences, views and perspectives of the family and practitioners at the time, rather than just from agency records in the light of hindsight. Judgements and lessons should follow from what was known to practitioners at the time or which could or should have been known at the time, but not using information which could not have been known. 1.4 The review is to ensure that agencies are held accountable for their services, systems and processes in safeguarding children and how they work together as a multi-disciplinary team. A SCR aims to enable the Local Safeguarding Children Board and its partner Agencies, through the single case, to test the wider effectiveness of local and national safeguarding children procedures, protocols and working arrangements. 1.5 A review should be proportionate and seek to understand, explain and evaluate what happened through a systems framework, but not to blame. 1.6 The Croydon and Lambeth Safeguarding Children Boards each endorsed this report in the Autumn of 2017 and agreed the recommendations within it. The Review could not be published at that time as the criminal investigation into the harm to Child L was not complete. 1.7 Both Parents were charged with causing or allowing serious physical harm to a child, contrary to section 5 of the Domestic Violence, Crime and Victims Act 2004. This was on the basis that they were persons who were members of the same household and had frequent contact with Child L and there being a significant risk of serious physical harm to L from the unlawful act of one of them; and that either (i) caused serious physical harm to L by an unlawful act, or, (ii) as someone who was or ought to have been aware of the risk of serious physical harm to L from the unlawful act of the other, failed to take reasonable steps to protect L from that risk, the unlawful act having occurred in circumstances of the kind that he/she foresaw or ought to have foreseen. 1.8 The case came to trial at the end of May 2018. The Jury found both parents Not Guilty. 1.9 The Review and the lessons from it can now be published as all legal proceedings from this case have been concluded. The Croydon and Lambeth Safeguarding Children Boards have been progressing the actions arising from the agreed recommendations and monitoring their impact; and will continue to do so. Croydon and Lambeth Safeguarding Children Boards 3 2. Background and reason for the review 2.1 In July 2016, L (age 11 months) was taken to Hospital 2 by his parents. He was in cardiac arrest, as a result of ingestion of cocaine, which appeared to have been hidden in his cot. At the time of this review this was under investigation as a crime. L survived the ingestion and was later made subject of Care Proceedings1. 2.2 L had been a subject of Child Protection Plans since before his birth, in July 2015. This level of safeguarding arose from concerns about his Mother’s behaviour, emotional state and possible self-harm (or harm to the foetus) and apparent mental ill-health during and after pregnancy; ongoing domestic abuse, including allegations and counter-allegations of assault between the parents; a background of cultural tension between the Mother’s and Father’s families, including an allegation of forced-marriage; and reluctance by the parents to follow through agreed actions and Child Protection Plans. The case was complicated by homelessness and temporary moves across borough boundaries in London. Previous drug use by Father was known, but not seen to be a safeguarding issue. A later allegation that Father was a drug dealer, was denied by him. 2.3 Information gained from enquiries after the critical incident, but not previously known to practitioners, showed that L had ingested cocaine over several months, from January 2016. The view formed was that on a balance of probability he had ingested it by coming into contact with cocaine powder/residue left lying on surfaces and that he had transferred it to his mouth on his fingers, by accident. Mother also had evidence of cocaine in her system from before the critical event. The SCR Panel considered whether one of the parents may have given L cocaine deliberately, but there was no evidence to support this view. Mother had breastfed L briefly, but there was no evidence of transmission through breast milk, and the traces found in his system were from some months after she ceased breast-feeding. It was alleged that Father snorted cocaine rather than smoked it, there is no evidence, therefore, that ingestion could be through passive inhalation. 2.4 Agencies involved were Midwifery, Acute Hospital Services, Perinatal Mental Health Services, Primary Health Care, Children’s Social Care, Health Visiting Services, Police, Housing, Domestic Violence Services and a Children’s Centre. These were across three London boroughs. 2.5 Lambeth agencies had initially worked with L’s parents as his Mother was temporarily resident in Lambeth, with members of the Father’s family. At the time of the critical incident, L was permanently resident in Croydon and had been transferred to a Child Protection Plan there. Because of the harm and public agencies’ involvement with L since before his birth, the Independent Chairs of Croydon and Lambeth Safeguarding Children Boards jointly agreed that the 1 The meaning of technical terms relating to safeguarding children law or guidance can be searched in the London Child Protection Procedures http://www.londoncp.co.uk/search/search.html Croydon and Lambeth Safeguarding Children Boards 4 case met the criteria for a Serious Case Review (SCR)2. 2.6 It was agreed that Croydon Safeguarding Children Board would lead the SCR. A joint SCR Panel was convened and Terms of Reference for the review and its Scope were agreed. An Independent Chair (the newly appointed Chair of Lambeth Safeguarding Children Board, independent of this case) and an Independent Reviewer were appointed to lead the SCR. The methodology is the Extended Child Practice Review Model. Details of the Panel and Terms of Reference are set out in Appendix 1. 3. Executive Summary and Key Lessons 3.1 The case concerns a young couple in a volatile relationship. There were concerns about domestic violence, possible mental ill-health – including alleged self-harm (with risk to the foetus in pregnancy), homelessness, temporary housing and moves across local authority boundaries. There were also suggestions of drug use and dealing, which were denied. The concerns about the Mother’s alleged self-harm and domestic violence in pregnancy led to a pre-birth assessment which resulted in the unborn Baby, L, being made subject of a Child Protection Plan from birth. 3.2 The Parents agreed to, but did not co-operate with the Child Protection Plan. This prevented essential perinatal assessments being completed. At times, the couple separated making counter-claims against each other. They often retracted the claims and re-united. 3.3 The case originated in Lambeth, where the Mother was living temporarily with Father’s family. Lambeth took the case responsibility and placed L on the Child Protection Plan. However, she was later accepted as homeless by Croydon Council on two occasions. Opportunities to transfer the case to Croydon, and later Camden, were missed, when, first Mother and subsequently Mother and L were resident there. 3.4 The complications of cross-borough co-ordination led by Lambeth, where L never lived, led to difficulties within the work to ensure the completion of the Child Protection Plan, particularly the completion of the mental health assessment for Mother and work on the marital relationship and domestic violence. It also led to problems in establishing an effective Core Group process. There were also difficulties for the Lambeth Social Workers in seeing Mother and L since Mother often did not stay in the Camden accommodation but moved at times to relatives. 3.5 When L was seen by Practitioners he was seen to be developing normally and there were no immediate concerns about his welfare. As a result, consideration of legal proceedings was stepped down, even though there was minimal co-operation, and it was thought that Mother and Father had separated. 3.6 Mother and L were permanently re-housed in Croydon after six months, during which time they had been allocated temporary accommodation in a hostel in north London. Following a delay, 2 Working Together to Safeguard Children 2015, Chapter 4 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf Croydon and Lambeth Safeguarding Children Boards 5 Croydon Children’s Services accepted the case at a Transfer-in Child Protection Conference, at which key professionals were not present. Because of the ongoing concerns L was retained on a Child Protection Plan. However, little work was done with the family from this point and the co-ordination of the Core Group was ineffective. It is understood that Father was regularly present at the accommodation in Croydon. 3.7 L collapsed in cardiac arrest six weeks later, having ingested cocaine. He survived the collapse. Care Proceedings and a criminal investigation were initiated. As a result of these enquiries it came to light that L had been exposed to and ingested cocaine over the preceding six months. 3.8 The Review of the case has highlighted lessons about the operation of the safeguarding systems in Lambeth, Croydon and Camden. They are discussed in the analysis of the work in Section 8. The priority lessons are summarised here, in section 3, and discussed in greater detail in Section 9 of the Report. Section 10 sets out recommendations resulting from those lessons. Key Lessons See section 9 for fuller discussion of these lessons 3.9 Keeping the child’s lived experience at the centre of safeguarding children practice 3.10 Knowledge and Skills in Working with Drug Using Parents 3.11 Homelessness and Temporary Accommodation and their impact on child protection 3.12 Cross-Borough Working 3.13 Getting the basics right, adherence to Procedures, and supporting Frontline Practitioners with guidance and reflective supervision 4. Case History 4.1 Background Mother and Father had known each other as teenagers. They had met at college but had not remained in contact. Father was said to have married and divorced, by Islamic custom. The couple resumed their relationship after a chance encounter in 2013. 4.1.1 They came from different cultural backgrounds (Kurdish-Turkish and Turkish-Cypriot); their families were initially reluctant to accept the relationship and it is alleged that they sought to stop it, with arguments and harassment and threats to kill, to which the Police were sometimes called. 4.1.2 In November 2014 Father was cautioned for possession of cannabis, found in his car, in which Mother was also travelling. It was accepted that the cannabis was for his own use and that Mother was not involved. 4.1.3 In Autumn 2014, Mother became pregnant with L. 4.1.4 The couple married, Mother has said that this was both an Islamic marriage, in November 2014, and a registered marriage, in January 2015. An allegation was made, by Father, that this was a forced marriage to prevent any shame to Mother resulting from the pregnancy, but this was not substantiated, or followed through by him. Croydon and Lambeth Safeguarding Children Boards 6 4.1.5 Their relationship was volatile. Father continued an on-off relationship with his previous wife and at times sought to leave Mother or did leave Mother; Mother was jealous. This led to aggression, allegations and counter-allegations, often involving the Police. The allegations included aggression initiated by Mother and by Father. 4.2 December 2014 – April 2015 4.2.1 Mother was, at times, described or seen to be hysterical or alleged to be threatening self-harm or harm to the foetus. In late December 2014 and January 2015, Mother was seen at Hospital 1 Emergency Department. There were concerns about her emotional state and that she may have mental ill-health (depression and suicidal thoughts) and a suggestion of ‘personality disorder traits.’ Mother did not co-operate with further attempts to assess her mental state and denied that she had mental ill-health. 4.2.2 In March, Mother was conveyed to Hospital 1 by ambulance. It was alleged that she had self-harmed and sought to harm the foetus by punching her abdomen. Father alleged that she was depressed and that Mother had not co-operated with an assessment by the GP. Hospital 1 referred Mother to Lambeth Children’s Services, as she was then resident in Lambeth in the home of Father’s Mother. 4.2.3 A Section 47 Child Protection Enquiry was agreed and multi-agency assessment was started. This resulted in a Pre-Birth Child Protection Conference, in April, where unborn Baby L was made the subject of a Child Protection Plan. 4.2.4 Mother was living with Father’s family in Lambeth but made an application as homeless to Croydon where she had grown up. In April, she was offered temporary accommodation in Croydon but did not fully use this. 4.3 May – July 2015 4.3.1 The volatile relationship between Mother and Father continued. On three further occasions Mother was conveyed to Hospital 1 by ambulance with concerns about her emotional health and risk to the baby. Police were also involved in allegations of domestic abuse between the couple, and allegations of threats involving Father’s previous wife. 4.3.2 Mother did not attend planned mental health assessments with the Perinatal Services or the GP. 4.3.3 As Mother had left the temporary accommodation provided by Croydon Housing she was informed that Croydon Council had discharged its duty to her as a vulnerable homeless person. 4.3.4 A further Pre-Birth Child Protection Conference was held in July, where it was noted that the concerns continued and that there had been little progress in completing assessments, as parents had not co-operated. It was confirmed that unborn Baby L should be subject of a Child Protection Plan for risk of physical abuse. 4.4 End of July – end of August 2015 4.4.1 L was born two weeks later, at Hospital 2, and after a few days discharged with his Mother to her Croydon and Lambeth Safeguarding Children Boards 7 Mother’s home in Croydon, as part of the Discharge Plan agreed by Children’s Services with the Mother, Father and the grandparents. Health visiting responsibility was transferred from Lambeth to Croydon, but the social work case responsibility remained with Lambeth. The outstanding mental health assessment was referred to the Croydon Perinatal Team from the Lambeth Team within the same Mental Health Trust. 4.4.2 Midwifery Services, Health Visiting and Lambeth Children’s Services visited Mother and Baby L appropriately throughout August. Good care and bonding between L and Mother were noted. It was noted that the Parents were back together and were considering renting a private flat in East London. 4.4.3 The Review Child Protection Conference was held at the end of August. Perinatal Services and Croydon Housing were invited to the Review Child Protection Conference but did not attend. Good care of, and good bonding with, Baby L were noted; but as there had been little progress of the Child Protection Plan and Parents had not co-operated with assessments it was agreed that L should remain subject of a Plan, under the changed category of risk of Emotional Abuse. The Plan was revised. Lambeth Children’s Services continued to hold lead case responsibility, although Mother and L were now living in Croydon. 4.5 September – end of November 2015 4.5.1 At the Core Group meeting in early September, it was noted that Mother and Father were planning to separate (he was reported to have returned to his previous wife) and that Mother could not stay longer with her parents, in Croydon. The perinatal mental health assessment was noted as still not done. 4.5.2 Two days later, Police stopped Father in his car. He was in possession of a large quantity of cash which was unaccounted for, but no offence was detected and Police took no further action. As no child was in the car there was no requirement for the Police to notify children’s services. The amount of cash was below the threshold for seizure or other action. 4.5.3 Later in September, the Parents were said to be ‘back together’, though not living together. Care of Baby L was observed to be good. 4.5.4 In the third week of September, Mother alleged to the Police that Father had assaulted her and threatened to bomb her home. A few days later she withdrew the allegation. Police informed Croydon Children’s Services, which passed the information on to Lambeth Children’s Services. 4.5.5 At the end of September, following a Legal Panning Meeting, Lambeth Children’s Services asked Croydon Children’s Services to convene a Transfer-in Child Protection conference to take over the responsibility for safeguarding Baby L, as he was resident in their area. 4.5.6 The following day Croydon Housing accepted Mother and Baby L as homeless and provided temporary accommodation in a hostel in Camden. Lambeth Children’s Services expressed concerns about Mother and Baby L being rehoused so far away from family support. 4.5.7 At the beginning of October, Baby L was registered at and seen for the eight-week development check at a local GP Practice in Croydon. This was the GP Practice for the Mother’s Family, although Mother was no longer registered there herself and continued to be registered with the Lambeth Croydon and Lambeth Safeguarding Children Boards 8 GP. This Practice was unaware that L was subject of a Child Protection Plan until April 2016. From this point, all his immunisations and GP care were at this Practice, even when he was living in Camden. The registration of Mother and L with different GPs and differing levels of awareness by other health workers of Mother’s and L’s moves led to complications in information sharing and key Practitioners being unaware that either L was subject of a Child Protection Plan or was resident in their area. (Adoption of the NHS electronic Child Protection Information Sharing System (CPIS)3 may help mitigate against this.) 4.5.8 In early October, Croydon Children’s Services declined to accept the case on the basis that Mother and Baby L’s residence in Croydon was temporary. They were unaware that Croydon Housing had accepted responsibility to assess Mother as homeless. 4.5.9 Croydon Health Visiting Services transferred the case to the Camden Health Visiting Service. The Lambeth Social Worker had difficulty in visiting Mother in Camden, as at times Mother was staying with a sister in Enfield, or with a friend in Hackney, or she was visiting family in South London. 4.5.10 In early-October, Mother alleged to the Police that Father had assaulted her in Lambeth and dragged her out of his car. She alleged that he had not wanted her to be in his car as he was mentally ill and dealing in drugs. Police informed Lambeth Children’s Services of the assault. A few days later Father was arrested. He denied the allegations and claimed that Mother had a history of self-harm and caused the injuries herself. He was charged with assault and bailed to have no contact with Mother, pending appearance at court. 4.5.11 The Lambeth Social Worker visited Mother and Baby L at her sister’s home in Enfield. Mother was staying there as she felt safer than being alone in the accommodation in Camden. Mother stated that Father had texted her to say he wanted to divorce her. 4.5.12 It was alleged that Father injected steroids. 4.5.13 The Croydon Perinatal Services, in following up the referral for an assessment of Mother’s mental health, learned that she had moved to Camden, and discharged her back to the care of her Lambeth GP. 4.5.14 There was liaison between the Camden Health Visitor and the Lambeth Social Worker; the Health Visitor was concerned about Mother’s emotional state and unrealistic expectations. She was concerned about unsuitable sleeping arrangements for Baby L. The Social Worker visited and found the care of Baby L to be good. Lambeth Children’s Services provided a new mattress for the cot. 4.5.15 The Core Group was cancelled as Mother had moved to Camden. The Social Worker contacted Camden Children’s Services to ask them to convene a Transfer-In Child Protection Conference. The Social Worker also liaised with Croydon Housing, raising the need for housing local to Mother’s family in Croydon. 4.5.16 The day before the court hearing regarding the alleged assault by Father, at the end of October, Mother withdrew her allegation saying that she had lied and that the injury seen by Police was historical, and not previously reported. The charge was withdrawn. 3 https://digital.nhs.uk/child-protection-information-sharing Croydon and Lambeth Safeguarding Children Boards 9 4.5.17 At the end of October, Baby L was seen at the GP Practice in Croydon with diarrhoea. A few days later Mother contacted an Out-of-Hours GP Service saying that L was not breathing. An ambulance took L from the Temporary Housing to a hospital in North London. He had had several days of diarrhoea and vomiting after feeds and one day of running nose and cough. He was alert, had a clear chest, cough, white sputum and had a strong heart rate. There was no evidence from the hospital records that he had been in a state of collapse and breathing was said to be normal. The hospital was unaware that L was subject of a Child Protection Plan but was told by Mother that he had a social worker. The hospital contacted Lambeth Children’s Services later the same day and advised that Baby L had been seen, had been suffering with a stomach bug, had been monitored and was well enough to be discharged. His Mother was described as caring and L appeared well-cared for. 4.5.18 The Croydon GP Practice for Baby L was alerted to the out of hours GP call, by routine notification, stating that L had collapsed and was not breathing, but not to the later hospital assessment. The GP Practice sought to follow this up by ringing Mother, but not the hospital. Mother did not respond to the phone call. When seen in the GP Practice the following week L was well enough for an immunisation. The matter of L's reported collapse was not raised again with Mother. 4.5.19 In early November Mother was staying with a friend in Hackney as she was fearful of being on her own in the homeless accommodation in Camden. The Lambeth Social Worker visited her in Hackney and noted the care of Baby L to be good. 4.5.20 Camden Children’s Services declined to accept responsibility for safeguarding Baby L as he and his Mother were only temporarily resident in Camden. 4.5.21 The Social Worker saw Mother and Baby L at the Maternal Grand Mother’s home in Croydon and noted no concerns about the care of Baby L. Mother was also noted to show understanding of the possible impact of domestic violence on Baby L. A week later in mid-November the Social Worker contacted Croydon Housing and asked for Mother and Baby L to be moved back to Croydon. 4.5.22 At the end of November, the Social Work Supervisor noted variable progress of the Child Protection Plan and that Mother’s mental health appeared more stable, but that Mother was not using the accommodation in Camden and was staying with family or friends in other boroughs. It was agreed that Lambeth would continue to hold the case to prevent Baby L falling through the net and would convene a further Legal Planning Meeting if circumstances did not stabilise. The Social Worker contacted Croydon Housing again, asking for Mother and Baby L to be moved closer to her family; Housing was also asked to attend the planned Core Group Meeting to be held in Camden. 4.6 December 2015 – end of February 2016 4.6.1 The Social Worker saw Mother, Father and Baby L, who was observed to be fine. They had rowed as Mother alleged she had found another woman’s hair in his bed, she had assaulted him and he had slapped her in return. Alternative contact arrangements were agreed for Father with Baby L and Father agreed to have no contact with Mother. The Social Work Supervisor asked for the Public Law Outline process to be reviewed. 4.6.2 The Social Worker had regular contact with Mother to support her in separating from Father and shared up-to-date information with the Camden Health Visitor and Camden Independent Domestic Croydon and Lambeth Safeguarding Children Boards 10 Violence Advisor. There was difficulty visiting Mother and Baby L in Camden as she was not always there. They were seen in the third week of December at the Grandmother’s home in Croydon. No concerns about Baby L’s welfare were noted on that visit; observation was of good physical care and a close emotional bond with Baby L. These observations were reported to the Supervisor in early January. 4.6.3 Baby L had the third immunisation at the GP Practice in early December. 4.6.4 In early January, the Social Worker contacted Mother to arrange to visit in Camden, but Mother was with her sister in Enfield. Mother reported that Father was being supportive. Mother was staying in Enfield as there was reported to be no heating at the homeless persons’ accommodation in Camden. A few days later Mother and Baby L were visited in Enfield and Baby L was fine. As Mother and Baby L were in Enfield a planned Core Group Meeting was cancelled. 4.6.5 In social work supervision, at the end of January, it was noted that Baby L’s care was good, that Mother was engaging with the Child Protection Plan, and there was an improvement in the parents’ relationship. There was no report of significant domestic violence since the end of October. It was thought to be too soon to step the case down from child protection to child in need status. 4.6.6 The Social Worker visited Mother in Camden and noted Baby L was fine; and that at times Father was also staying in the accommodation. 4.6.7 The Child Protection Review Conference planned in Lambeth, at the end of January, was inquorate and had to be reconvened. 4.6.8 In early February and mid-February, Father reported to the Police that he had been trying to end his relationship with Mother, describing her as his ‘ex-girlfriend’. He said that he had rung her to tell her and he alleged that she had reacted badly threatening to report him to the Police as having assaulted her to get him arrested. On the second occasion, he alleged that she was threatening to damage his car. He was worried that it may affect his contact arrangements to see Baby L. 4.6.9 Croydon Housing informed Mother and Lambeth Children’s Services that they had accepted a duty for her long-term housing needs. In mid-February Mother cancelled meetings with the Lambeth Social Worker as she was preparing to move back to Croydon. She was offered a tenancy in Croydon in the third week of February; but it was not deemed suitable. 4.6.10 The reconvened Review Child Protection Conference was held at the end of February, in Lambeth. It was believed that Mother and Baby L had now moved back to Croydon, but that was not the case, as the property she had been offered in mid-February was unsuitable, which was not made known to the Child Protection Conference. Baby L was to remain subject of a Child Protection Plan as the required assessments had not been completed and there were still concerns about domestic violence. Croydon Children’s Services was to be asked to convene a Transfer Child Protection Conference to accept responsibility for the case. The request for transfer was made to Croydon at the end of February. 4.7 March to May 2016 4.7.1 In early March, L was seen at the Croydon GP Practice with diarrhoea and vomiting. The Practice Croydon and Lambeth Safeguarding Children Boards 11 was not yet aware that L had been subject of a Child Protection Plan from birth. 4.7.2 A Women’s Refuge in North London received a referral about Mother and long term domestic violence with Father, from a Camden domestic violence advice agency. The referral also noted that it had been alleged that Father was a drug dealer. The refuge sought to contact Mother on six occasions with no response and referred the case back to the Camden Agency. 4.7.3 The Core Group Meeting (in Lambeth) was cancelled, as it was inquorate. 4.7.4 Mother was offered alternative accommodation in Croydon, as the first tenancy was unsuitable. 4.7.5 Mother cancelled visits from the Lambeth Social Worker because of her planned move back to Croydon. 4.7.6 The Social Worker saw Mother and Baby L at the Mother’s new accommodation in Croydon at the beginning of April. Baby L was happy and well. Mother reported that she and Father ‘were a couple’. 4.7.7 The Social Work Team Manager contacted Croydon Children’s Services to expedite the request for a Transfer-in Child Protection Conference and two days later relevant documents were sent to Croydon. A week later Croydon Children’s Services requested additional information. In the third week of April, Croydon Children’s Services also asked Lambeth Children’s Services to complete a referral form. 4.7.8 In mid-April, the Lambeth Social Worker visited Mother and Father in their new accommodation in Croydon. They saw themselves as a couple again. Parents said they were working on their relationship. 4.7.9 Four days after the visit to Mother and Father in the new accommodation, the Father contacted the Lambeth Social Worker to say that Mother was ‘mad and aggressive’ and that he wanted contact with Baby L, without being threatened by her. A week later, they visited the Lambeth Children’s Services office together to say that their relationship was over and that they would seek support with counselling. Baby L was seen and was fine. 4.7.10 Towards the end of April, L was seen twice at the GP Surgery, once with an ear infection and a week later with fever. The Practice also received information from the Camden Health Visiting Services that they were ceasing their involvement as L and Mother had moved back to Croydon, and that Lambeth Children’s Services was transferring the case to Croydon Children’s services. This was the first time that the Practice knew that L was the subject of a Child Protection Plan. 4.7.11 In early May, in social work supervision it was noted that Mother was not engaging with local services in Croydon, there were concerns about her mental health. A further Legal Planning Meeting was to be sought and the referral to Croydon Children’s Services was to be chased up. The following day Croydon Children’s Services agreed to the Transfer-In Child Protection Conference. 4.7.12 The Lambeth Social Worker referred Mother and Baby L to the Lambeth Children’s Centre, which was located on the borough boundary between Croydon and Lambeth. 4.7.13 In the second week of May, Mother and Baby L were seen at home by the Lambeth Social Worker. Baby L was fine. A Core Group meeting was held the same day. The Parents stated that they would work on their relationship, although they had previously told the Social Worker that the Croydon and Lambeth Safeguarding Children Boards 12 relationship had ended. They agreed to access domestic violence services in Croydon; but there was concern that Mother had no insight into domestic violence and its impact. It was agreed to escalate the concern about delay in arranging the Transfer-In Conference to senior management. 4.7.14 The Transfer-In Child Protection conference was held at the end of May. Baby L was made subject of a Child Protection Plan in Croydon, under the category of risk of emotional abuse. A social worker was to be allocated by Croydon Children’s Services and Lambeth’s responsibility came to an end. The Croydon Health Visiting Services and L’s GP Practice were not invited to the Conference. 4.7.15 At the end of May, a few days after the Conference, there was liaison between Camden Health Visiting Service and the Croydon Health Visiting Service to transfer responsibility back to Croydon. Mother and Baby L had been seen on three occasions in Camden and there had been telephone contacts, but Mother had not engaged with health visiting services in Camden. Mother had reported to the Camden Health Visitor that Father was seeing Baby L every day. The Croydon Health Visitor had been unaware that a Transfer-In Conference had already been held and sought information from the Lambeth Social Worker. 4.7.16 Mother and Father attended a Parenting Course session at the Children’s Centre which they had ‘enjoyed’; but Father said that he would not be able to attend again, because of work. 4.8 June to July 2016 4.8.1 In early June, the Croydon Health Visitor sought to visit Mother and Baby L but Mother did not respond to contact. The Mother visited the new GP with Baby L and shared the information that Baby L was on a Child Protection Plan to Croydon and the history of a turbulent relationship with Father, as well as worries about her mental health and post-natal depression. She stated that she had no current worries about mental health. The GP noted good bonding between Mother and Baby L and that Baby L appeared well. Croydon Children’s Services was not yet aware of who L’s new GP was. 4.8.2 In the second week of June both the GP and the Children’s Centre asked Croydon Children’s Services for information about the identity of the new allocated Social Worker. Mother attended a planned Core Group Meeting, but no professionals were present, not even the new Social Worker, and the meeting did not go ahead. 4.8.3 In the third week of June, the Health Visitor visited Mother and Baby L at home. The home was clean and tidy and positive interaction was noted between Mother and Baby L. Baby L was assessed and was up to developmental milestones. Mother was to continue attending the Children’s Centre. Father was said to be living elsewhere, but visiting regularly. 4.8.4 In the third week of June, the Children’s Centre contacted the Croydon Social Worker to say that Mother had not been attending. The Social Worker agreed to follow this up. 4.8.5 In early July, the Croydon Social Worker contacted the GP to share the history of concern about Mother’s mental health and to ask for mental health support for Mother, now that she was resident in Croydon. 4.8.6 In the second week of July, Baby L was taken to Hospital by his parents in cardiac arrest, as a result of ingestion of cocaine. The investigation into this showed that Father had been resident in the Croydon and Lambeth Safeguarding Children Boards 13 property for a week. 5. L’s Family 5.1 Genogram 5.2 Background Sister in NE London Father’s Ex-wife Mother Grand Mother Croydon Step Grand Father Lambeth Grand Father Croydon Father Grand Mother Lambeth Brothers Grand Father Lambeth Baby L Born July 2015 Croydon and Lambeth Safeguarding Children Boards 14 5.2.1 Both Mother and Father are Muslim. 5.2.2 Mother is of Turkish-Kurdish heritage, born in Istanbul, she came to London as a toddler. Her family lived in Croydon. She had several siblings. She had lived with her mother and father in Croydon but during the initial period of this review was at times resident with Father’s Mother in Lambeth. 5.2.3 Father is of Turkish-Cypriot heritage. His mother and father separated and for a period he lived in his Father’s home in Lambeth with brothers. He alleged a difficult childhood and some use of drugs and alcohol, as an adolescent. Father worked as a security guard in the leisure industry, mainly at night. Father was said to have married his first partner by Islamic custom, Nikah4. There is no evidence that this marriage was formally registered in the UK or any other jurisdiction. He was said to have ‘divorced’ his first ‘wife’ by Islamic tradition. 5.2.4 The couple met when they were teenagers at college. They lost contact with each other for a year, re-met by chance in 2013 and started a relationship, their families were unhappy about this and sought to stop it. There was animosity and some reported aggression between the families, said to arise from cultural differences. 5.2.5 Mother reported that she was very much in love with him after this, and that this clouded her views of him and her emotional reactions when he continued a relationship with his former partner. She said that they married in November 2014, by Nikah, ‘between themselves’ and later in January 2015 they registered their marriage formally. The information about the Muslim marriage in November, was not shared when agencies were working with them and when there were allegations of forced marriage in January 2016. 6. Family Perspectives on the Services offered to them 6.1 Both Mother and Father were informed in writing of this Review and invited to contribute. They were advised that this was to get an understanding of their views about L’s care and what they thought about support or services that were offered; and to know if there was anything else that they thought would have helped, at that time. Parents’ perspectives are important. 6.2 The Independent Author and a Panel Member met with Mother and Father separately to explain the SCR process and to seek and learn from their views about the services provided. Their comments have been summarised. They were given in retrospect, and have not been verified. Mother’s comments were given at the time when Care Proceedings in relation to L were still ongoing and the Police had not completed the investigation into the ingestion of drugs. Mother was hopeful of having L returned to her care. Father’s comments were obtained after the Care 4 Nikah or Nikkah derives from the Quran and refers to the Muslim marriage contract or agreement between a man and woman, in front of at least two witnesses, under Sharia law. It may take a variety of forms in different Islamic cultures. It is not clear whether the marriages referred to in this case were witnessed or contracts signed. Both the man and woman must consent. It can also be used sometimes to refer to the ceremony in which the contract is agreed. In the UK, such an arrangement would be regarded as co-habitation and would not confer the legal rights or responsibilities of marriage; unless it had been conducted in a country where it also met civil law requirements, and was accepted as such by the UK. Croydon and Lambeth Safeguarding Children Boards 15 Proceedings and when both Parents were facing trial. He said he had been ‘traumatised’ by what had happened to L. 6.3 Mother 6.3.1 Mother maintained that the allegations of her threatening her abdomen with a butter knife and hitting herself, while pregnant, were not true. She saw someone at Hospital 1 (in Lambeth) but despite calling back she was never offered a follow up appointment. Mother was clear that she did not have a mental health problem. 6.3.2 Mother said she was very much in love with Father and did not want the relationship to end. She did not want Baby L to be without a dad. Even when people, including professionals, strongly encouraged her to separate from him she did not wish to do so. She continued to hope that they could be reconciled and work it out. Mother now realises that as she loved him she had unrealistic expectations of him; but at the time she hoped that they would be able to resolve the issues. Mother’s views about the services Baby L and the family received 6.3.3 Mother was positive about the services she received from hospitals, antenatally and at the time of L’s birth. The hospital and community Midwives were good. 6.3.4 The Health Visitors were ‘really helpful’. Mother felt able to talk with them. 6.3.5 Mother accepted that the Social Workers were trying to help her. But each time there was a change of social worker it was stressful to have to explain things from the beginning again. Mother was positive about the relationships with the Social Workers in Lambeth (but had not met the Croydon Social Worker before the critical incident). 6.3.6 The Children’s Centre was seen to be good. 6.3.7 Mother had mixed feelings about the Housing Service. She had wanted the best for Baby L. She accepted that she did not properly use the hotel accommodation provided initially in Croydon. She accepted that she had to go to Camden when she could not stay at her Mother’s home for longer after L’s birth. However, the Camden accommodation was not good and Mother was clear that ‘she could not stay there for a year’. She felt that she needed to be closer to family. For this reason, occasionally, she stayed with relatives in north London. She was grateful when Croydon Housing offered a flat in Croydon and then provided a better flat. 6.3.8 Mother felt that she was treated unfairly by the Police who, in her view, did not take her point of view into consideration. She felt that other agencies believed the Police too readily. 6.3.9 Child Protection Conferences and Core Groups Mother said: ‘There were so many meetings’. She understood why they were needed and that professionals had worries and were trying to help and to advise her. She thought that her wanting the relationship with Father to work clouded her response to the Plans and the advice she was given. The advice made sense to her, even though she did not follow it. She was treated fairly in the meetings, and was always able to give her point of view. However, she ‘never’ felt believed, for example when she said that Father was not Croydon and Lambeth Safeguarding Children Boards 16 committed and was cheating on her. When she was in Camden it might have been better if the meetings were held there. 6.4 Father 6.4.1 Father said that he met Mother when he was 18 but they lost contact. When they re-met by accident he was 21 and just coming out of a relationship with his first wife (by Islamic marriage). The relationship with Mother progressed to becoming serious more quickly than he had anticipated. 6.4.2 Father acknowledged that this was a testing time for each of them as they had different expectations of each other. He was used to having his own space and felt that she was jealous and wanted to keep close tabs on him. 6.4.3 When Mother became pregnant he felt pressured by both families to marry, even though he did not feel ready to do so. He saw this as a ‘forced marriage’. He said this made him depressed; but he was happy about the pregnancy and hoped it might bring them closer. 6.4.4 When L was born Father ‘fell in love with him’. He was very pleased to have a son and wanted to take responsibility for him. The family tensions made it uncomfortable for Father to have contact with L. Father said that this depressed him. Later after Mother and L moved to Camden and later back to Croydon he stayed with them most of the time and his clothes were there. Father’s views about the services Baby L and the family received 6.4.5 Father was worried about Mother’s mental health and called ambulances and went with her to hospital when she threatened to harm herself or shouted in the street when was pregnant. He thought the ambulance and hospital responses were helpful. In his view she needed help with her mental health, but she denied that she had a problem and would not accept help. He felt pressured to lie and say that things were ‘okay’ in meetings with professionals. 6.4.6 Father thought that the Police response of arresting him was not helpful and that what was needed was a solution, such as mediation in their relationship. He said that he tried to arrange mediation himself, but Mother refused to attend. One Police Officer had advised him that things would probably not change. 6.4.7 In terms of the social work he felt excluded at times, not all the workers returned his calls, but one was helpful. He didn’t think that they saw how aggressive Mother could be and why he left her on occasions. He said that he told workers that ‘everything was okay’ in order to pacify Mother. 6.4.8 He did not think that he had seen all the reports to meetings. He understood the Child Protection Conferences he attended but thought more help was needed. He had not understood that the incidents which led to the police being called were treated as possible domestic abuse and that Mother was being encouraged to leave him. Croydon and Lambeth Safeguarding Children Boards 17 6.4.9 Father thought that what may have helped was some work, including with the wider families, to help them bond and accept the relationship and also see things from his point of view as well as Mother’s. 7 Practitioners’ and Managers’ Perspectives 7.1 Lessons arising from the Practitioners’ Learning Events As part of this Review the Practitioners who had worked with L and his family were identified and invited to two Practitioners’ Learning Events, led by the Independent Author with members of the SCR Panel. Croydon and Lambeth Safeguarding Children Boards are grateful to the Practitioners and Managers who attended, including those from Camden. In the first Event, the Practitioners were given a summary of the case timeline and a summary of the emerging lessons identified by the SCR Panel. The purpose of the Learning Event was to obtain the Practitioners’ experience of the case and the operation of local systems at the time it was being managed to assist with understanding what happened and why. The value of their comments is that they show more of the emotional content of the direct work with the family than can be recorded in agency databases. In the second Event, the SCR Panel’s final analysis and draft priority lessons were presented. The Practitioners responded in a child-focused, open, reflective and honest way, sharing their insights and experiences. They commented on how helpful it was to be involved in this way in the review process. 7.2 Practitioners noted the following: 7.2.1 Focus on Baby L Despite all the problems practitioners kept a focus on L and his welfare. 7.2.2 Information sharing Initially this was very good between services but later as Mother and Baby L moved around professionals were less aware of which other professionals were involved. The transfers across boroughs meant that information sharing was hampered. At times Practitioners coming new to the case had to rely on the family as the informants. Problems with different client recording systems and databases hampered effective information sharing. 7.2.3 Family engagement It is challenging to engage with parents who do not wish to engage. Mother did engage superficially, but there was a question about her insight and commitment. Mother’s overwhelming wish was to remain in the relationship with Father, when he did not want this. This impacted on her willingness to accept advice. To several Practitioners, Mother seemed immature and to lack understanding. It seemed clear, initially, that Mother had mental health concerns and there were attempts to refer these on for fuller specialist assessment and help. Mother did not engage with these. At times workers found her telephone contacts tiring. Mother could also be Croydon and Lambeth Safeguarding Children Boards 18 quite assertive and able to put her point of view. She could also be controlling of Father, silencing him. 7.2.4 Father appeared to have insight but minimised the concerns. Initially, he was seen as a protective factor. At times, including in Child Protection Conferences, a view was formed of Father, that he often sought to appease Mother. 7.2.5 Both Parents minimised the concerns. Initially they both wished to remain together in the chaotic relationship. 7.2.6 Practitioners wondered if there was ‘disguised compliance’ 7.2.7 Wider family Father’s family was understood as being more ‘liberal’ and open to inter-relationships with other cultures or lifestyles. The Maternal Grandmother was seen as a protective factor and gave strong support after L was born. 7.2.8 The issue of homelessness and case responsibility across boroughs The case should have been allocated in Croydon sooner. The issue should have been escalated through senior management sooner. The cross-borough issues meant that key professional staff were not invited to essential meetings – e.g. the Health Visitor was not invited to the Transfer-In Child Protection Conference in Croydon. The importance of involving Housing fully in the child protection conference process was noted. This also prevented continuity of care within services. 7.2.9 Assessments There were unanswered questions about Mother having emotionally unstable personality traits. 7.2.10 Use of protocols More use should have been made of the agreed local protocols5 relating to drug use, mental ill-health and domestic violence. Domestic violence was being dealt with. There was thought to be little evidence of drug usage, and when it was raised it was denied. 7.2.11 Systems issues Work across borough boundaries hampered effective multi-agency safeguarding. At the Second Practice Learning Event the following points and questions were noted: 7.2.12 With very young children the focus of the work is mostly with the parents. Good reflective supervision can help keep the impact on the child in mind. 7.2.13 The importance of informing and involving the child’s GP, especially where the child is subject of a Child Protection Plan; and the importance of the communication between the child’s Health Visitor, the GP Practice and any liaison Health Visitor who works alongside the GP Practice on safeguarding. 5 LSCB Protocols https://www.lambethscb.org.uk/professionals Croydon and Lambeth Safeguarding Children Boards 19 7.2.14 The challenges where parents choose to have a different GP for the child to the GP for the parent; leading to information being held in different places and more complex communication for Partner Agencies. 7.2.15 Different Practitioners have different levels of awareness and experience of dealing with drug misuse. There is therefore a need for access to specialist advice as well as any generic training. 7.2.16 How can Practitioners learn to discuss possible drug use in an advisory way, such as the way Practitioners can be more confident about advising or querying risks associated with alcohol use or smoking, in a public health way? It was agreed that some drug use, such as cannabis use, may not always be seen as a serious issue; even though cannabis use may make parents unavailable to children and their needs. 7.2.17 Worry about how to manage any adverse reaction from service users if drug usage is raised with them. 7.2.18 Communication is hampered between professionals by a lack of commonality in IT Systems. 7.2.19 It is important to consider other ways of working together through telephony and IT – not just face to face meetings. 7.2.20 The importance of identifying the key professionals around a child, including the GP, and keeping the network, not just the Core Group advised of moves and changes. Some families can be chaotic and so it is important that the Practitioners are supported to work hard to stay connected and prevent gaps. Some Agencies feel that they are not kept informed about what is happening, even when they raise concerns. There was a view that Agencies are not always told in a timely way when children, whom they are working with, are made subject of a Child Protection Plan or there are significant changes. 7.2.21 How is the lack of progress of a Child Protection Plan monitored over time? L was subject of a Plan for over 15 months. What is the role of the Child Protection Conference Chair in escalating lack of progress? 7.2.22 Practitioners experience is that it is not easy to escalate concern when things are not working well. 7.2.23 It was agreed that problems of accessing social housing and temporary housing in London are major systemic issues. This underlined the importance of close liaison between Housing and Social Care in case management. The recent changes in Croydon were seen to be seeking to address this issue. 7.2.24 There was broad agreement by the Practitioners with the analysis and lessons from this case. Practitioners also believed that the findings were not unique to this case. 8 Discussion and Evaluation Croydon and Lambeth Safeguarding Children Boards 20 8.1 What worked well? 8.1.1 Police and midwifery staff appropriately recognised the concerns about the volatility in the parental relationship and Mother’s emotional well-being and referred on to social care for antenatal safeguarding assessments. 8.1.2 When the concern was referred to Lambeth Children’s Services it was appropriately recognised as a safeguarding matter and a section 47 inquiry was initiated. This resulted in a Child Protection Conference, which agreed that L should be subject of a pre-birth Child Protection Plan. 8.1.3 It was appropriate to consider that the case may require legal intervention and to initiate the Pre-Legal processes. 8.1.4 L was born at a hospital where the background of concern was unknown. But immediate enquiries to the hospital, where Mother had been seen for antenatal care and emergency appointments, showed the concern and information was shared quickly and appropriately to confirm the history and the Child Protection Plan. 8.1.5 When Mother and Baby L were transferred to temporary accommodation in Camden there was a timely transfer of responsibility from one Health Visiting Service to the other. 8.1.6 Good attempts were made to counsel Mother on domestic abuse and to refer her to specialist agencies, but she did not follow this up. 8.1.7 Lambeth Children’s Services was clear that the case should remain with Lambeth until secure housing was found, despite the complexities of working across boroughs. However, there were missed opportunities to get the case transferred to where it should have been held. 8.1.8 The Lambeth social work visits followed Mother and L, wherever they were staying in different parts of London, not just the temporary accommodation in Camden. 8.2 Cross-Borough Issues Impacting on the Effectiveness of the Child Protection Plan 8.2.1 The geographical issues in this case gave rise to some of the biggest challenges. Mother was not normally a Lambeth resident. Her residence rights were in Croydon. She was temporarily and inconsistently staying in Lambeth with Father’s family. This was not a permanent arrangement. She made her housing application to Croydon on the grounds that she and her unborn child could not stay at her family home in Croydon and she was accepted, from there, as potentially homeless, twice. 8.2.2 The initial pre-birth child protection concerns arose from a Lambeth address and were appropriately referred by the hospital and Police to Lambeth Children’s Services. Fuller enquiry about Mother’s housing history might have established that her housing ‘rights’ were in Croydon and might have led to earlier co-ordination between social care and housing. Croydon and Lambeth Safeguarding Children Boards 21 8.2.3 The London Child Protection Procedures (section 6: Children and Families moving across Local Authority Boundaries6) are clear about the additional vulnerability ‘as a consequence of homelessness and the dislocation that is likely to occur as a result of moving between local authority areas’. 8.2.4 Lambeth Children’s Services acted appropriately in accepting the section 47 referral. However, more should have been done to liaise with Croydon Housing, or even Lambeth Housing when it became clear that the Father’s Mother’s home was not a viable alternative as accommodation for Mother and the expected baby. This was particularly so when it seemed clear that the parental relationship was turbulent and possibly characterised by frequent arguments and / or domestic violence, leading to a question about the viability of the relationship. 8.2.5 Mother made her first ‘homeless’ application to Croydon from her parental family home address in November 2014 but was not accepted as having proved homelessness at that point. She might already have been staying in Lambeth at the Father’s Mother’s address, at that time. In December 2014, she alleged to the Housing Department that she had been excluded from the family home in Croydon and had been sleeping rough but discontinued the call when asked for evidence of this. In February 2015, the Maternal Grandmother confirmed to Croydon Housing that she had asked Mother to leave the Croydon address; and in March, Housing confirmed through a health agency that Mother had been staying in Lambeth at the Father’s Mother’s house. In the second week of April, Mother denied this and said that she had not been resident in Lambeth for over a month. A few days later she was offered homeless person’s accommodation at a hotel in Croydon. Lambeth Children’s Services was unaware of this. 8.2.6 Housing was not invited to the Pre-Birth Child Protection Conference held in Lambeth, even though Lambeth Children’s Services was aware that Mother had made a housing application; but not that she had been offered the temporary accommodation. 8.2.7 Under the London Child Protection Procedures, the case responsibility should have been transferred to Croydon Children’s Services as the unborn baby was then clearly resident in Croydon, and Croydon Housing had accepted responsibility to assess for homelessness. Section 6.1.14 is clear that responsibility lies with the Local Authority where the child (in this case unborn child) is to be found. No application to transfer the case to Croydon was made and the issue was not considered at the Initial Child Protection Conference held in Lambeth later in April, when unborn Baby L was made the subject of a Child Protection Plan. 8.2.8 Mother later left the homeless accommodation voluntarily. Croydon Housing rightly judged that it had met its responsibilities to Mother and unborn baby. For a period before Baby L’s birth Mother lived with Father at his Father’s home, also in Lambeth. At that point, it was appropriate for Lambeth Children’s Services to continue to hold the case accountability as the unborn baby was again resident in their area. 6 London Child Protection Procedures section 6: Children and Families moving across Local Authority Boundaries 5th Edition 2016 http://www.londoncp.co.uk/chapters/chi_fam_bound.html Croydon and Lambeth Safeguarding Children Boards 22 8.2.9 A further opportunity to transfer the case to Croydon Children’s Services arose when Baby L was born and discharged from hospital to be placed with Mother in her Mother’s home in Croydon. It is puzzling that Lambeth Children’s Services did not then transfer the case to Croydon as Mother and Baby were now fully resident there and had no call on any other housing. Managers and the Review Pre-Birth Child Protection Conference held before Baby L’s birth missed the need to consider and plan for this. Thus, complications arose in the inter-agency management of the case led by Lambeth when no other Lambeth agencies continued to be involved. The key worker had to work with unfamiliar services and colleagues, out of borough. 8.2.10 Lambeth Children’s Services formally notified Croydon Children’s Services that Baby L was a child subject to a CP Plan to Lambeth and was in their area, but received no response. 8.2.11 In the third week of September, Lambeth Children’s Services was given legal advice that Baby L’s case should be transferred to Croydon Children’s Services, as he was resident there. A referral was made to Croydon Children’s Services, which was correct, but overdue, under the London Child Protection Procedures. Croydon did not accept the transfer on the basis that Baby L was not resident in the borough at the time it made the decision even though he had been resident at the time of the referral; and it was Croydon Housing that had transferred him to Camden, thereby another section of the Local Authority was accepting residency – albeit temporarily. This may be a systemic issue of Social Care Departments, under bombardment, seeking to limit the volume of work, which is understandable. However, Croydon Children’s Services did not consider all the facts of the case. 8.2.12 Lambeth did not challenge this decision, which it should have done, using the London Child Protection Procedures and, if necessary, seeking legal assistance or senior management involvement. Baby L was a ‘Croydon resident’, even though Lambeth was holding case responsibility through a Child Protection Plan, which should have transferred to Croydon within 15 days of the formal request. Although court action was being considered as part of the protection plan there was no immediate risk or need to seek an order and so no reason for Croydon to refuse the request. 8.2.13 Mother had made a further application to Croydon Housing, while resident at her Mother’s home in Croydon, on the grounds that she could no longer reside there; and at the end of September 2015 was offered homeless accommodation in a hostel in Camden for herself and Baby L. Baby L’s move to Camden raised a fundamental question about the safeguarding system as relationships had been formed with Mother by local health services which were monitoring Baby L and Mother’s care of him. The Croydon Health Visiting service appropriately transferred the responsibility to Camden Health Visitors after the move. 8.2.14 The responsibility for the overdue perinatal mental health assessment had been transferred within the Mental Health Trust to the Croydon team from the Lambeth team and now had to be transferred to Camden services. 8.2.15 There were questions about the quality and suitability of the accommodation provided in Camden; and it is understood that Camden Children’s Services and Camden health services would not advise use of this accommodation. Croydon Housing subsequently agreed not to use this facility. Croydon and Lambeth Safeguarding Children Boards 23 8.2.16 This is a systemic issue in terms of emergency and short-term homeless accommodation in London, which is wider than any one local authority and beyond the capacity of any social worker to resolve. Had the case been held by Croydon Children’s Services, as it should have been from the time of L’s birth, it may have been possible to use local working arrangements within Croydon to require that Baby L, as a child subject to a Child Protection Plan, was housed within or very close to the borough. In this case although domestic violence was a factor it was not sufficiently risky to warrant a geographical move away from extended family and known local services for Mother and Baby L’s safety. 8.2.17 The placement of Mother and Baby L in Camden led to systemic issues affecting the co-ordination and quality of multi-agency work and the engagement with Mother across London. It was also an additional burden on the Lambeth Social Worker having to travel across London and engage with Mother to ensure the completion of the Child Protection Plan, especially when Mother also opted to stay in different parts of north London to escape the unpleasant temporary accommodation and her sense of isolation. There was also an impact on the functioning of formal Child Protection Conferences and Core Groups (essential mechanisms in safeguarding processes) which will be discussed below. 8.2.18 The Lambeth Social Worker contacted Croydon Housing in early October, a few days after Baby L’s move to express concern about the placement in Camden and was advised that this would be referred to senior management within Housing. 8.2.19 At the end of October, the Lambeth Social Worker made a formal request to Camden Children’s Services to accept case responsibility for Baby L given that he was now resident in their area. Camden refused this request, in early November, because Baby L was only temporarily resident, placed by Croydon. The London Child Protection Procedures are clear on this point, saying that the grounds for refusal are: section 6.2.7 ‘If the child and their family have been placed in temporary accommodation in the receiving authority for a specified period of time, which is less than 4 weeks, after which they will be located elsewhere’. The intention at that time was that Mother and Baby L may be in Camden ‘for up to a year’, therefore, there were grounds to challenge this decision not to accept the case made by Camden. 8.2.20 This type of ‘gatekeeping’ is understandable systemically, when, because of shortage of suitable local temporary housing, local authorities may be resentful of out-of-borough children in need of protection being placed in their area. This is hard territory for a social worker alone to negotiate, when they have busy caseloads; and in this case the worker had now to cross London, arrange practical items for Mother and Baby L’s new accommodation and seek to re-establish a Core Group and re-build the Child Protection Plan, which was already faltering as a result of the parental behaviours. Housing and transferring case responsibility had become imperatives over the issues of incomplete assessments, concerns about the volatile, on-off parental relationship and monitoring Baby L’s welfare. 8.2.21 Two weeks later, the Social Worker contacted Croydon Housing, again, to ask for Baby L to be moved closer to Croydon, nearer to her family, and followed this up in writing a week later. It is not clear why this was not escalated at that time, as the request had originally been made for Baby L to be placed close to family, in early October. Croydon Housing was invited to the next Core Group Meeting but did not attend. At the time, there was no safeguarding protocol for Housing in Croydon and Lambeth Safeguarding Children Boards 24 Croydon. Now there is an agreement that a Housing Manager will attend Child Protection Conferences and Housing Caseworkers will attend Core Groups. Lambeth Housing and Lambeth Children’s Services were reviewing their local arrangements at the time of this review. 8.2.22 At the Core Group Meeting, held at the end of November, it was noted that neither Croydon nor Camden would accept case responsibility and that Lambeth would therefore would retain it. This was laudable in the face of the failure to get the case transferred but was outside the London Child Protection Procedures and should have been escalated to senior management to make representation across Local Authorities. It is the view of this Review Panel that Croydon should have accepted the case responsibility and worked with Croydon Housing to bring Baby L back (closer) to Croydon. 8.2.23 As noted previously, Mother being placed in Camden, but not always residing there impacted negatively on the Child Protection Plan and the working of the Core Group over the next few months. 8.2.24 In the middle of February, Mother was offered accommodation in Croydon. The Lambeth Social Worker asked for a Transfer-In Child Protection Conference at the end of the month. This should normally be convened within 15 days. In early April, the Lambeth Team Manager followed up this request for a transfer conference and ensured that all the documents required were sent as Croydon queried that they had been given all the correct documentation. At the beginning of May, the request was made again; in the middle of May Croydon responded saying that it would provide a date for the Conference, which was held at the end of May, several weeks outside the agreed timescale. Lead case responsibility then transferred to Croydon Children’s Services and the multi-agency arrangements under the Croydon Safeguarding Children Board. The delay in arranging the Transfer-In Conference was poor practice. 8.2.25 The complications arising from the moves across borough boundaries by Mother and Baby L, led to challenges to completing the Child Protection Plan and possible escalation to legal proceedings when this was required. It also contributed to the difficulty of gaining full co-operation by Mother and impeded an effective multi-agency core group. These are discussed further below. 8.2.26 The SCR Panel queried how big a system issue this may be, as families are housed in temporary accommodation across London and outside London, and not always for reasons of protection from domestic violence. The known cases in Croydon and Lambeth where this was an issue were low in number, but significant in management terms. It is a matter that may benefit from discussion by the London Safeguarding Children Board, to establish if this is a London-wide problem. 8.3 Focus on Baby L 8.3.1 The child should be central to the work. In the pre-birth phase, there is no doubt that there was appropriate professional concern about the possible risks to the foetus by police and antenatal services, often as a result about Mother’s own reported behaviour and emotional state. Appropriate referrals were made and at times of crisis antenatal checks and scans were done. 8.3.2 A Midwife noticed that Baby L was not falling asleep after feeds and queried whether he was ‘over-stimulated through maternal substance misuse’. The Social Worker was advised that Baby L was Croydon and Lambeth Safeguarding Children Boards 25 monitored for withdrawal symptoms but there was no further evidence to suggest substance misuse. 8.3.3 After discharge home with Mother to the Maternal Grandparents’ home. Midwifery services, Health Visiting and Social Work services visited appropriately and Baby L was observed and assessed to be developing normally and there was noted to be a good relationship with his Mother. 8.3.4 Later in the work, although Baby L was seen often, there was greater focus on the Mother, the overdue mental health assessment, the relationship problems with Father, and the need to resolve appropriate housing. 8.3.5 Overall the view, despite the original concerns, was that Baby L was developing normally and that his Mother was caring for him well. There was no evidence of impact on Baby L of the original worries resulting from Mother’s mental state or domestic violence. 8.3.6 However, information made available to this Review, from hair strand tests undertaken after the critical incident, show that Baby L had been exposed to cocaine continuously from January 2016, and that it had metabolised in his body. Assessment was that the cocaine levels were too high to have been ingested through breast milk or inhalation. 8.3.7 Direct observation of Baby L – Child protection research and enquiries show that it is important for professionals ‘to see the world through the eyes of the child’. In such young infants, their ‘voice’ is heard through good observations, over time, and attention to their emotional state and their responses to care-giving and attachment seeking behaviour. Concern about Baby L was a focus of the antenatal work. In the eleven months after birth, up to the critical incident, L was seen with his Mother, and occasionally with Father, 36 times by Practitioners; not including occasional attendance with Mother at the Lambeth Children’s Centre on their return to Croydon in March 2016. Midwives in the early post-birth visits assessed Mother mainly and observed but expressed no concerns for L. Health Visitors saw Baby L five times, twice in Croydon before the family move and twice in Camden, with one additional contact where the Health Visitor was unable to see him as Mother was going out; and one contact after their re-housing in Croydon. He was also seen several times by the GP Practice for a development check, immunisations and for what appeared to be minor illnesses. L was taken to hospital once with a stomach bug. Lambeth Social Workers saw him 22 times, with Mother; other attempted visits were prevented, either by Mother staying in different parts of London or Mother postponing visits on the grounds that it was not convenient with her impending move back to Croydon. All the workers noted that the care was good and that there was a close bond between Mother and Baby L, with Mother looking after him well, and there was good mother-child interaction; at times, he was described as ‘happy’. The Health Visitors undertook development checks and noted good development. Workers thought he was thriving. 8.3.8 The Lambeth Social Worker discussed L in supervision on several occasions in November 2015, and January 2016. It was noted that Mother ‘was managing L’s care well’ and ‘L was thriving and well-presented’. There was a ‘close bond’ and ‘good physical care’. 8.3.9 There were no social work visits, observations of Baby L, or Core Groups after the case was accepted by Croydon Children’s Services at the end of May up to the critical incident in July 2016. This did not meet agreed standards for monitoring. Croydon and Lambeth Safeguarding Children Boards 26 8.3.10 The Croydon Health Visitor saw Baby L in mid-June 2016 she noted ‘good mother-child interaction’ and ‘L was developing well’. 8.3.11 Although there are some gaps in observations of Baby L and the move across London prevented health visitor contact at the frequency a child subject to a plan would expect, professionals were observing Baby L for signs of harm, in both planned and unannounced visits. The anticipated harm that had resulted in him being subject of a Child Protection Plan was not being evidenced; there were continuing, but diminishing, concerns about Mother’s instability and the volatile parental relationship. 8.3.12 Parental drug misuse had been raised as a possibility historically, and there had been suggestions and queries during the period, but these had not been substantiated. Practitioners were not, therefore, holding in mind that Baby L might have been or may be being exposed to drugs. This was not part of the Child Protection Plan. Workers tend to be more vigilant when there is known parental drug use. This case raises questions about whether the local safeguarding systems sufficiently equip practitioners to consider the possibility of hidden drug use and its possible impact on children. 8.3.13 There is little research into the impact of cocaine on healthy infants and how it would be manifested, except in neonates where the transmission has been in utero and the baby shows withdrawal symptoms or where it is ingested through breast milk; or inhaled through smoke. Such literature as there is derives from clinicians attending to crises where a child has been adversely affected7 or a 1991 prevalence study in Boston, USA.8 It is not thought that Baby L ingested cocaine in utero, through breast milk or passive smoking. Dinnies, et al describe a very small sample of cases of accidental ingestion or indirect exposure, which would appear to be the case with Baby L. Pagliaro and Pagliaro, 20129 briefly note the possibility of exposure by unintentional childhood poisonings which, unless there is a severe adverse reaction will probably not come to clinical attention. Parents may not seek help, drawing attention to the ingestion unless the effects are serious. Adverse symptoms which may be recognised are seizures, arrhythmias and hypertension. 8.3.14 Clinical advice to the Review Panel is that ingestion of cocaine in a baby may be noted by the following symptoms: Tremors (trembling) Sleep problems High-pitched crying Tight muscle tone Hyperactive reflexes 7 Cocaine Toxicity in Toddlers; J D Dinnies, et al; The Pediatric Forum; American Journal of Diseases of Childhood Vol 144, July 1990 8 Unsuspected Cocaine Exposure in Young Children; SJ Kharasch, et al; American Journal of Diseases of Childhood; Vol 145, pages 204-206, February 1991 9 See also Chapter 5 Exposure to the Drugs and Substances of Abuse From Conception Through Adulthood in Handbook of Child and Adolescent Drug and Substance Abuse: Pharmacological, Development, ad Clinical Considerations; Pagliaro and Pagliaro; John Wiley and Sons; 2012 Croydon and Lambeth Safeguarding Children Boards 27 Seizures Yawning, stuffy nose and sneezing Poor feeding and suck Vomiting Diarrhoea Dehydration Sweating Fever or unstable temperature It should also be noted that the impact on a baby would be short-lived. A Practitioner would have to see a baby who had ingested cocaine soon after the event to note any symptoms. Caution should be taken in considering such a list, as such symptoms are common in babies and are not a clear indicator of cocaine ingestion but may be as a result of other causes, requiring a differential diagnosis, in context and over time. 8.3.15 Father had reported that Baby L was sometimes agitated but that was not witnessed by Practitioners. 8.3.16 The query about whether he was over-stimulated as a neonate, possibly through breast milk and any substances Mother may have used was not substantiated and the hyperactivity was not noted again. 8.3.17 On some of the occasions when L was seen by the GP and at hospital, in October 2015, diarrhoea, vomiting and fever were noted. Those services were unaware of the child protection concerns. 8.3.18 Other Practitioners did not note any such symptoms. It should be noted, however, that most of them would not have had training in what to look for. As there was no active concern about the possibility of drug misuse such symptoms were not being looked for. 8.4 Lessons from research into parental drug use, mental ill-health and domestic violence and the relevance 8.4.1 The impact of these three factors in child maltreatment is well-publicised, particularly from analyses of lessons from Serious Case Reviews, where the phrase ‘toxic trio’10 has been coined to alert workers and managers to the specific risks where one of more of them is present as a dynamic in parenting. All three dynamics were present in this case. Lambeth Safeguarding Children Board had published Protocols for each of the toxic trio in the past. A revised combined Protocol was agreed by the Lambeth Safeguarding Children Board with the Safeguarding Adults Board in March 2014, Lambeth Joint Service Protocol to Safeguard and Support Families where the adults have 10 Working with families where there is domestic violence, parent substance misuse and/or parent mental health problems. A rapid research review: Oxford Brookes University. Institute of Public Care; 2015 http://www.scie-socialcareonline.org.uk/working-with-families-where-there-is-domestic-violence-parent-substance-misuse-andor-parent-mental-health-problems-a-rapid-research-review Croydon and Lambeth Safeguarding Children Boards 28 additional needs Protocol. The Safeguarding Children Board had provided multi-agency briefings on the Protocol. Although other agencies were using this protocol it was unknown to Lambeth Children’s Services Practitioners working with this case; and it was no longer on the Lambeth SCB website, which was being re-designed. 8.4.2 Parental Mental Ill Health Mother’s reported behaviour and emotional responses gave rise in the early phase to a question about Mother’s mental state, which was unresolved throughout the work as no psychiatric assessment was possible, because of a range of systemic issues; including Mother herself, moves across London, and who can commission such assessments. A ‘view’ was given in December 2014, at Hospital 1, without a formal assessment or diagnosis that she may have ‘emotionally unstable personality traits’. This view probably clouded later judgements of her and was never confirmed. 8.4.3 Given Mother’s observed behaviour, it was appropriate that a perinatal mental health assessment should be sought. This was a key but unresolved part of the Child Protection Plan, throughout. At times, Father described her as ‘mad’. She was clear that she did not have a mental health problem and although she agreed to an assessment, both Mother and circumstances prevented it. Sometime after L’s birth, Mother told a worker seeking to understand the previous concern about her mental state that she had had some depression but that it had cleared up. 8.4.4 The Mental Health Trust was commissioned to provide services in both Lambeth and Croydon. There was confusion about who could refer Mother to the Trust for a perinatal assessment. The Social Worker tried to make a referral but was advised that the GP must do this; but this is not the Trust’s policy, a social worker is able to make a referral. Mother did not attend a planned Multi-Agency Perinatal Team Meeting. After unsuccessful attempts, the Lambeth Perinatal Team spoke with Mother and agreed a home visit for the end of June. However, Mother was not at home for the visit and did not respond to phone calls. 8.4.5 In early August, the responsibility for assessment was transferred within the Mental Health Trust to the Croydon Perinatal Team as Mother and Baby L were resident in Croydon. The Perinatal Psychiatrist based at Hospital 1 suggested that a worker from the Croydon Team should visit Mother with a Midwife. This was not arranged. In mid-August, the Social Worker contacted the Perinatal Team for information about the assessment and was asked if the needs were social or mental health; the Social Worker agreed to speak to the Social Work Manager about whether the assessment was still needed. This is puzzling on two levels; the Social Worker could have made clear that the assessment was part of the Child Protection Plan; and the Practitioner who had requested the perinatal assessment was, in fact, the GP. If the Trust needed to have confirmation that an assessment was still required it should have gone back to the referring GP. There is no information that the Trust was advised that an assessment was still required. The Trust took no further action until September. 8.4.6 It is not clear why the Trust was not invited to the next Review Child Protection Conference or Core Groups as this was a key part of the Child Protection Plan. 8.4.7 In late September, the Trust contacted the Social Worker to check whether a (late assessment was still required and was advised that it was. After unsuccessful attempts to contact Mother at her Mother’s home, the Team was told by Grandmother in mid-October that Mother and Baby L had Croydon and Lambeth Safeguarding Children Boards 29 moved to temporary accommodation in Camden. The Trust discharged Mother’s care back to the GP; the Social Worker was not informed. 8.4.8 Mother was later referred to a Camden Mental Health Service but did not attend appointments offered to her. 8.4.9 Workers across the system were aware of the risks from parental mental ill-health and worked to get to the bottom of it. This case shows that the practitioners understood the significance of parental mental ill-health in safeguarding and that on this, the local system was robust. 8.4.10 Psychiatric assessment after the critical incident (and therefore with hindsight) showed that Mother had no major mental illness, at that time, and questioned whether her behaviour arose from the volatile parental relationship, immaturity and possibly from drug use. 8.4.11 Father was not thought to have any mental illness. It was acknowledged that he had anger management problems and in August 2015 he told the Social Worker about adverse childhood experiences and how he thought that these had affected him. He agreed to a referral being made to work on his anger management. Parental Drug Misuse 8.4.12 Drug use by parents is a challenge for all workers in health and child care agencies; especially, where there is denial and there are no apparent signs of its use or negative impact, such as chaotic lifestyle, impaired thinking or behaviours; or signs of addiction and its physical and mental side-effects. For a safeguarding system, this raises questions about how well workers are equipped to assess and work with parents who conceal use of cannabis, cocaine or other drugs and apparently do not display ill-effect. As noted above, it also raises questions about Practitioners’ awareness of the possible secondary effects of parental drug use through smoke or ‘accidental’ ingestion. Would workers know to look for drug residue, with which a mobile infant or child may be able to contaminate / poison himself? 11 8.4.13 In the antenatal phase, there was no evidence of drug use by Mother. There were known concerns about her emotional state and questions about her mental health; but, it is not clear whether thought was given to whether these may have been as a result (or partial result) of any concealed drug use. 8.4.14 Mother told this Review that she was not and never had been a drug user. She accepted that, after the critical incident, tests showed that she had had cocaine in her system. She said that the cocaine metabolites in her and in Baby L were from passive reception. Expert advice refutes this. 8.4.15 Father’s possession of cannabis, in Mother’s presence, was known to the Police. He was charged with possession of cannabis for personal use; he stated that he was a regular smoker of cannabis, 11 See Merton Safeguarding Children Board SCR Child A (2013) on issues relating to parental use of cannabis and its impact on parenting. Croydon and Lambeth Safeguarding Children Boards 30 as it helped him with his anxiety. Mother was present when the drugs were found, but her denial of use was accepted. Father was found on another occasion to be in possession of a large amount of money, which could be suggestive of drug dealing (or another crime); but there was no evidence of drugs at the time, nor supporting intelligence. The possibility of drug use being a factor was discussed at the first Child Protection Conference but there was no evidence to show that it was significant, chaotic or problematic; or that Mother was using. Historic parental substance use was noted; but was not seen as an issue for the Child Protection Plan. 8.4.16 When Mother alleged that Father was a ‘drug dealer’, the allegation was put to Father, but he denied it. In the absence of clear corroborated evidence or other signs or symptoms suggestive of drug use or dealing, it was proportionate to raise the issue with the Parents but there were no grounds to insist on tests or searches. Her allegation was also made in the context of her having made allegations against Father and then later retracting them; she was not a reliable witness. A second allegation to domestic violence services in Camden, that Father was a drug dealer, was not passed to Children’s Services or followed up. 8.4.17 It has been noted above (8.3.6) that there was a question raised about whether new born Baby L was being impacted by possible maternal drug use. The Social Worker was advised that Baby L had been monitored and that there were no signs of withdrawal. 8.4.18 There was also a question about whether Mother’s emotional and mental presentation and mood may have been signs of drug use. 8.4.19 As new allegations of possible drug use or drug dealing were made, there should have been a multi-agency conversation to consider how to assess this and if it met the threshold for higher level action; if not in a Strategy Discussion the allegations should have been discussed in a Core Group. The allegations about Father’s drug use should have been considered as part of the regular and ongoing re-assessments as part of the Child Protection Plan. 8.4.20 Clinical advice to the Panel is that the effects of cocaine ingestion are short lived, unless serious, and that Practitioners would not easily have noticed any ill-effects of small amounts of cocaine ingestion by a child, by simple observation (even if they had been alerted to the risk of it?) 8.4.21 Given that there were possible indicators and that drug use had been raised at the Child Protection Conference the multi-agency network should have had a continuing curiosity about the possibility that drug use was a dynamic in the parenting. The NSPCC Summary of Lessons from SCRs where parental drug and alcohol misuse had been a factor12 shows the need to treat with caution a parent’s account of how much and how often they drink alcohol or take drugs; and remain alert to risks of drug or alcohol use, even if parents seem to be complying. Practitioners must also be 12 Parents who misuse substances: learning from case reviews: Summary of risk factors and learning for improved practice around parents with substance misuse problems https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/parents-misuse-substances/ Croydon and Lambeth Safeguarding Children Boards 31 confident in challenging carers about the risks to which they may be exposing their children.13 There was, however, insufficient evidence to take any further action in this case despite several suggestions of drug use, as there were also retractions and denials. 8.4.22 In the legal discussions, there was no consideration of whether to seek drug-testing as the alleged drug use was not substantiated and was not seen as problematic and so there was no reason to challenge it. Domestic Violence 8.4.23 The volatility of the Parental Relationship was a continuing concern throughout the period of the safeguarding work. There were arguments, shouting, allegations and counter-allegations, jealousy, unrealistic expectations and at times physical encounters which gave rise to worry about domestic violence and its possible future impact on Baby L. The risks were noted early on and with the worry about Mother’s emotional state led to the safeguarding referral which initiated the work. The recognition and referral part of the multi-agency safeguarding system worked well. Ongoing concern about domestic violence was central to Child Protection Plans. 8.4.24 The Child Protection Plans sought to address the parental behaviour and actions were put in place at various times to help the Parents work on the ‘abusive’ aspects of their behaviour. However, this was not a classic case of male violence to a woman. At times, Mother through her possessiveness and perhaps unrealistic expectations of Father also appeared to initiate abusive behaviour. It was also noted by practitioners that she could be assertive and controlling of him. She was offered counselling, specialist work by an Independent Domestic Violence Advisor, and they were both offered training in understanding domestic violence. They were both offered support when they wished to end the relationship. 8.4.25 When there was believed to be evidence of physical violence by Father the Police took this seriously and put conditions in place to protect Mother and charged him, but Mother later retracted, maintaining that she had fabricated the allegation of assault (also retracting at the same time the allegation that he was a drug dealer). Father also later claimed that she had threatened to make false allegations against him on another occasion. 8.4.26 The Police appropriately completed DASH assessments14 when domestic disputes were brought to their attention. It should be noted that the number of times that this volatile behaviour came to Police attention warranted consideration of the need for referral to MARAC15 to review the level of risk and what actions should be considered to prevent harm to adults or child. The reasons why it was not decided to refer to MARAC were not recorded. Other agencies could also have referred the case to MARAC for multi-agency review. A question arises, therefore, as to whether practitioners 13 See BASW Alcohol and Drugs A Pocket Guide, University of Bedfordshire, 2012 https://www.basw.co.uk/pocket-guides/ 14 DASH Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model www.dashriskchecklist.co.uk 15 MARAC Multi-Agency Risk and Assessment Conference Croydon and Lambeth Safeguarding Children Boards 32 were not seeing the parental behaviour as serious enough to warrant a full domestic violence response. Agencies may need to ask if there is sufficient awareness of when to consider MARAC as the ‘trigger of repeat incidents’ had been reached in this case and no evidence has been found that there was active consideration and a proper decision not to refer. The volatile behaviour remained central to the case throughout. 8.4.27 The Police, the Lambeth Community Safety Unit and Camden Safety Net referred the case to Refuge16 on three separate occasions to support Mother with the alleged domestic violence by Father. Mother did not respond to the specialist Domestic Violence Agency’s attempts to engage her. 8.4.28 The Social Worker undertook direct work with Mother and Father, together and separately, on the domestic violence and its impact; and worked with Paternal Grandmother to supervise contact with Baby L when Mother and Father could not safely manage being together. 8.4.29 Practitioners, and Mother, noted the intensity of her emotional feelings towards him and her difficulty in following through plans for separation. At times, he appeared more resolute but then he returned to her; sometimes, his concern was about losing his relationship and contact with Baby L. A question which should perhaps have been asked is whether her having accommodation of her own was perhaps an attraction to him; as he, too, was ostensibly ‘homeless’. 8.4.30 The attempts within Child Protection Plans to work on the abusive aspects of their relationship were appropriate and sought to protect Baby L. Mother and Father lacked insight, about their behaviours and motivation. They agreed to work on this, but did not do so or carry through agreed actions. As there was no evidence of harm to L and he was seen to be developing well there were no grounds to consider Care Proceedings and work on their relationship or alleged domestic violence could not, therefore, be required. 8.5 Engaging the Parents and Working with Them 8.5.1 Mother There were good attempts to work with Mother by a range of Practitioners from across services and to make clear to her what the concerns were arising from her perceived unusual and erratic behaviour and her allegations about Father. Although at times she agreed to work on issues she did not follow these through, and at times also made it clear that she did not agree with them – particularly concerns in relation to her emotional and mental health. Practitioners queried whether there was ‘disguised compliance’17 but there was also clear evidence of avoidance and misleading Practitioners when she made allegations and then later denied or retracted them; e.g. Mother worked with the Lambeth Social Worker and an Independent Domestic Violence Advisor in Camden on how she would manage giving evidence in court against Father knowing that she had already retracted the statement to the Police about the alleged assault with which Father had been charged. 16 Refuge is an agency which supports women affected by domestic violence www.refuge.org.uk 17 Disguised compliance: learning from case reviews , NSPCC, 2014 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/disguised-compliance/ Croydon and Lambeth Safeguarding Children Boards 33 8.5.2 Mother’s priorities were a home for herself and Baby L and maintaining her relationship with Father. At times, she accepted advice and assistance on separating from Father but her strong wish to be with him meant that she did not follow through actions to separate from him. The moves across London meant that it was difficult to create supportive professional relationships with her where her behaviour could be monitored and worked with in a constructive and challenging helping relationship. 8.5.3 Father Research from serious case reviews and other sources shows a long history of challenge in safeguarding work to engage Fathers. The Social Worker spoke with him alone on two occasions, in August and October 2015, about his relationship with Mother and about his anger/behaviour which may contribute to the emotional abuse of Baby L. On the latter occasion, it was suspected that he may have been under the influence of cannabis. In August 2105, Father explained his volatile behaviour stemming from what he saw as adverse childhood experiences and as reactions to Mother’s behaviour. He agreed to a referral to work on anger management; he was not referred for such work. 8.5.4 He was ambivalent about his wish to be with her; declaring on several occasions that he had left her – only ‘to feel sorry’ for her and to return to her. It was not possible to build a clear picture of when they were together in the homeless accommodation. He was not part of the housing application. Housing recognised him as her partner, but was unaware that they were married. It was understood that they were no longer a couple but it is clear that he was a frequent visitor and probably stayed regularly. 8.5.5 Father’s attendance at formal child protection meetings was sporadic. His statements to Police and Social Workers contributed to the understanding that he no longer wished to be with Mother, but that he wished to have contact with Baby L. 8.5.6 In the late February 2016 Child Protection Conference, it was noted that both parents had agreed to access Domestic Abuse Services. In May, both parents again agreed to attend Domestic Violence Services in Croydon, however, nothing was arranged for them. 8.5.7 The Police and Social Worker tried to work with Father on his part of abusive behaviour. It is not clear that he took part in any formal programme to manage his anger or reactions, however. It is not clear how much his behaviour may have been impacted by drug use; but that may be hindsight, as considering him as a possible drug user and the impact of drug use on his behaviour and thinking were not part of the work or its supervision. 8.6 Information sharing, thresholds and referrals 8.6.1 The review has shown that information sharing was mixed in its quality. Initial concerns were appropriately noted by antenatal services and Police and were appropriately shared as a need to consider safeguarding. Hospital 1 advised the GP of the initial concerns when Mother was seen in late December 2014 and recommended that she may need counselling, it was questioned whether she may have a personality disorder. At that time, her behaviour was not seen as reaching the threshold for pre-birth child protection assessment. Croydon and Lambeth Safeguarding Children Boards 34 8.6.2 As concerns increased they were appropriately shared with Lambeth Children’s Services and led to a Strategy Discussion with the Police and the agreement that an assessment should be undertaken. Given the nature of the concerns and Mother’s pregnancy health services (Hospital 1 and GP) should have been involved in the discussion. The assessment led to the Initial Child Protection Conference. 8.6.3 The Lambeth Social Workers regularly shared information with other professionals. However, L’s GP (a different GP to Mother) was not aware that L was subject of a Child Protection Plan from birth. 8.6.4 The Lambeth Social Worker sought information from the local Mental Health Trust on several occasions and was told that Mother was not known to their service, despite information that Trust staff had been involved and that she had been referred. 8.6.5 At the end of September, Baby L and Mother moved to temporary accommodation in Camden, disrupting the Core Group. Her parents had asked her to leave. Croydon Housing did not liaise with Lambeth Children’s Services about this. 8.6.6 When Mother returned to live in Croydon in 2016 the Croydon Health Visiting Service was not advised of her return to the area and was not invited to the Transfer-In Child Protection Conference. This was an oversight. 8.6.7 After Baby L was made subject of a Child Protection Plan in Croydon in May 2016, key agencies requested information about who the allocated Social Worker was, but were not informed in a timely way. 8.7 Pre-birth section 47 assessment 8.7.1 The pre-birth section 47 assessment was thorough and appropriately sought information from relevant agencies. Given that the reported concern had been about domestic violence it was appropriately sceptical of the united front that Mother and Father were displaying and took into account the recent episodes and concerns as well as family history. It noted concerns about Mother’s emotional health, self-reported depression and thoughts of self-harm. It was right that the assessment led to the convening of a Pre-Birth Child Protection Conference. 8.8 Child Protection Conferences, Child Protection Plans and Core Groups 8.8.1 Child Protection Conferences, Plans and Core Groups and their effectiveness are a measure of how well a local safeguarding system is working. Conferences were held appropriately from April 2015 to May 2016 given the concerns which professionals had noted and the lack of progress in being able to properly assess or diminish the assessed risk to Baby L. Croydon and Lambeth Safeguarding Children Boards 35 8.8.2 The Initial/Pre-Birth Conference held at the end of April 2015 before Baby L was born rightly noted the concerns and strengths in the family dynamics and that more information was needed about Mother’s emotional and mental health and the nature the volatile relationship. Both Mother and Father attended this conference which meant that the concerns could be put to them directly. Father was seen as showing more insight into why Practitioners were concerned; Mother showed little insight and was seen not to recognise the concerns or to be minimising them. Police and Health Visiting Services were present. Maternity Services and Mother’s GP were not present in the Meeting. Given the nature of the worries it would have been helpful to have had them, or their views, represented. It was right to make the unborn baby subject of a Child Protection Plan. 8.8.3 The Child Protection Plan was agreed in outline at the Conference and confirmed at the Core Group in early May. It appears that by the time of the May Core Group Mother and Father had separated. Mother agreed to be referred to the Perinatal Service for an assessment. Father agreed to attend with her. The Parents were to agree a safety plan with wider family members regarding the Baby’s welfare. The risk of domestic violence was to be addressed in the Family’s safety plan. The new Social Worker was to collate a fuller family history, including childhood experiences, to provide a better understanding of the Parental behaviours and wider family dynamics. The Parents agreed to attend antenatal classes. A Discharge Plan was to be agreed and in place before the Baby was born, including who would care for the Baby, should Mother become unwell. 8.8.4 It was noted that Mother was placed in temporary accommodation in Croydon but no action was agreed regarding this, which was a missed opportunity to transfer the case to Croydon where support could be more easily offered, given that Mother was resident there and the Baby may be born or live there. 8.8.5 Review Pre-birth Conference July 2015 – held a week before Baby L was born. Mother was no longer living in temporary accommodation in Croydon. Mother had attended antenatal appointments and there were no concerns about the Baby’s development in-utero. Mother had been receptive to the Social Worker’s visits. There had been continued examples of altercations and allegations between the couple, involving Father’s ‘ex-wife’. A report of self-harm by Mother was denied by Mother and Father. Mother had not attended the Perinatal Service for an assessment, as agreed. The plan was for the couple to stay with Mother’s Parents in Croydon after the birth. The Child Protection Plan had not progressed. It was agreed that Unborn Baby L should remain subject of a Child Protection Plan for risk of Physical Abuse. The Conference was robust in noting the unchanged and possibly increased risk. 8.8.6 The Child Protection Plan was revised to include the need for an urgent Legal Planning Meeting, which was seen to be overdue. A parenting assessment was to be completed. A new urgent referral was to be made to Perinatal Service, to which the Parents agreed. A safety plan involving the family was to be in place before the Baby’s, imminent, birth. The work with both parents on domestic violence was not completed and was required. The Plan was to be firmed up at a Core Group meeting at Hospital 1 in early August. The Conference was robust and appropriately addressed the continued concerns and lack of progress. 8.8.7 Baby L was born at the end of July in Hospital 2. Croydon and Lambeth Safeguarding Children Boards 36 8.8.8 The Core Group met shortly after Baby L had been discharged with Mother from Hospital 2 to the Maternal Grandparents’ home. The Maternal Family was unhappy about Father staying overnight. Mother and Father were present in the meeting. A new Social Worker was allocated on the day that Baby L was born, as a result of staff turnover, but meaning that the social worker and Mother were new to each other. The Perinatal Assessment was transferred to the Croydon Perinatal Service and assessed as non-urgent as Mother was showing no sign of urgent need, or mental instability. The Parents and Maternal Family had agreed to and signed a Safeguarding Agreement; Baby L and Mother were resident with them. Parents were denying the previous levels of domestic violence and were optimistic that now that Baby L was born there would be no more incidents. They agreed to work with domestic violence services; an agency was to be identified to work with them. The fuller family history was still to be completed. Parents had attended antenatal classes. A discharge meeting had taken place in Hospital 2 and it was agreed that Mother and Baby L would stay with the Maternal Grand Parents in Croydon until housing was offered. It was noted that housing was an important factor and that the Parents could not stay long-term with the Maternal Grandparents. Housing was to be asked to prioritise this; it was not stated that this was Croydon Housing. There were positive signs that Mother and Father were bonding with Baby L. Mother was encouraged to work with the Croydon Health Visitor. 8.8.9 The case should have been transferred to Croydon at this time as Baby L was resident there and the network of Agencies were Croydon agencies. This is not noted in the revised Child Protection Plan and was a missed opportunity. 8.8.10 A Review Child Protection Conference was held at the end of August. There was a different Chair Person. Mother, but not Father attended; Mother and Father had argued on their way to the meeting and, as a result, he had decided not to attend (He spoke with the Conference Chair the following day). Only the Mother, Lambeth Social Worker and Manager, Croydon health visiting representative (in place of the allocated Health Visitor) and Chair were present. The Perinatal Team and Croydon Housing had been invited but did not attend. 8.8.11 The report to the Conference was positive in that care of Baby L was good and that there were signs of attachment. Mother was said to be following advice. Father was said to be taking an active role in caring. There were also fewer arguments reported between the Parents. It was Father’s view that these were caused by Mother’s instability, but he had also been unfaithful. The Parents had agreed to work with Domestic Violence Services and for Mother to attend the Perinatal Service. It was of concern that the Legal Planning Meeting had not been convened. It was agreed that Baby L should remain subject of a Child Protection Plan under the changed category of Emotional Abuse. This was appropriate. 8.8.12 The Plan was formally revised at the Core Group at the beginning of September and timescales set for the previously agreed bur incomplete actions. Domestic violence services were to be identified in Croydon by the Health Visitor. The case was to be transferred to Croydon now that Mother and Baby L were living there. The Social Worker was to support Mother in expediting housing, and had provided a letter for Mother to take to Croydon Housing. It is right that the case should have been transferred as Baby L was resident in Croydon, but at that point Croydon Housing had discharged its responsibility to Mother as a homeless person. Croydon and Lambeth Safeguarding Children Boards 37 8.8.13 At the end of September, Baby L and Mother moved to temporary accommodation in Camden, disrupting the Core Group. 8.8.14 In late October, the scheduled Core Group was cancelled as Mother had moved to Camden. This was not appropriate. 8.8.15 A Core group planned for early November in Camden was postponed as the Mother was staying in Croydon, as she was unwell. 8.8.16 The next Core Group was held at the end of November, in Camden. Mother, Social Worker and an Independent Domestic Violence Advisor from Camden were present. Croydon Housing had been invited to attend a few days before hand, but was not present. The Perinatal Assessment had not been assessed as urgent by Croydon Mental Health Service and had not been completed. The Legal Planning Meeting had been held at the end of September and had recommended that the case should be transferred to Croydon. Croydon had declined to accept the case. The Camden Health Visitor, in absentia, expressed grave concerns about the temporary accommodation. There had been further incidents of domestic violence. The Health Visitor had agreed to refer Mother to local parenting programme and a Children’s Centre. A new domestic violence service for Mother was to be located in Camden. The Social Worker was waiting to hear from Croydon Housing about the request to move Mother back to Croydon. 8.8.17 The Core Group scheduled for early January was cancelled as Mother was staying with a family member in another part of London. 8.8.18 The Child Protection Conference scheduled for the end of January 2016 was inquorate and had to be reconvened, as no other professionals were present. 8.8.19 The Review Conference was held in the third week of February. Croydon Housing had agreed to transfer Mother back to Croydon, although this had not happened at the time of the review conference. The Social Worker, Line Manager, Mother and Conference Chair were present. The Camden Health Visitor, the Lambeth GP for Mother, Police and Camden Children’s Centre were unable to attend; L’s GP was not invited. The Perinatal Assessment had still not been achieved. The Parental relationship continued to be volatile and there was confusion about whether it had been ended by Mother, or not. There had also been allegations of assault by Father, later retracted by Mother and the allegation that Father was a drug dealer; which he had denied. 8.8.20 Baby L remained subject of a Child Protection Plan for Emotional Abuse. The referral to the Perinatal service was to be referred back to Croydon Mental Health Team as Mother had moved (in fact, she had not yet moved). A new safety Plan was to be devised as Mother had moved to Croydon. The case was to be transferred to Croydon Children’s Services. Mother had done some minimal work in Camden on domestic violence and separating from Father; and was now to be referred to a domestic violence service in Croydon; Father was to work with a project for men and domestic violence. A request was to be made for a Child Protection Conference in Croydon, as Mother was now thought to be living there. A Family Group Conference was to be considered but Mother did not want Father’s family to be involved. The Parenting Assessment had been completed. There had been a change of Social Worker. Croydon and Lambeth Safeguarding Children Boards 38 8.8.21 The Core Group scheduled for early March was cancelled as only the Parents and Social Worker attended. 8.8.22 There were no more Core Groups held before the critical incident. This was not acceptable practice. 8.8.23 The Transfer Child Protection Conference was held in Croydon at the end of May. Key local agencies were not invited. Croydon accepted the case and agreed that Baby L should remain subject of a Child Protection Plan under Emotional Abuse. It was noted that in April, Father had informed Children’s Services that he had ended his relationship with Mother. Several of the actions for the Child Protection Plan agreed in February were incomplete. 8.8.24 In summary, it can be noted that it was right to make and keep Baby L subject of a Child Protection Plan given the parental behaviour and lack of change. Attendances at Conferences and Core groups was seriously impacted by the cross-borough issues and retention of the case responsibility by Lambeth. It is to be noted that there were no formal contingency plans. When there was continued lack of progress on the tasks agreed with parents the case should have been escalated to consider whether there were grounds for legal action. However, it should be noted that, despite repeated domestic disputes and alleged violence, lack of co-operation and parents failing to complete agreed tasks, there was no evidence of the impact of the anticipated harm to Baby L. 8.8.25 Legal Planning There was drift in seeking legal advice and arranging a Pre-Legal Planning Meeting, in two phases. The original decision to seek legal advice was made in mid-May 2015 before Baby L’s birth but had not been achieved by the Second Pre-Birth Conference in late July. A referral was made a week later. At the Review Conference in late August, the legal planning meeting had not happened and the need was escalated to a manager. It was a further three weeks before a meeting was held, with advice that the case should be transferred to Croydon as Baby L was resident there. When Croydon refused to accept the case, it is not clear why further legal advice was not sought about what could be done, including a legal or escalated senior management challenge to Croydon’s decision. 8.8.26 In late November 2015, Lambeth decided to continue to hold the case as neither Croydon nor Camden would accept it, although there were grounds to challenge both decisions as they were outside the London Child Protection Procedures. As there was still no progress, it was agreed to convene a further Legal Planning Meeting, which was held a few days later. The advice was that the threshold for legal proceedings was probably met but that the case should be transferred to Croydon. The Management decision was to continue to hold the case. This was a missed opportunity to consider with legal assistance how the Croydon (or Camden) decision could be challenged. 8.8.27 At the Review Conference in February 2016, it was again recommended that legal advice should be sought with a view to using the Public Law Outline, this was included in the Child Protection Plan. Action to progress this was not taken until early May as effort had been put into transferring the case to Croydon. As the case was transferred at the end of May the Legal Planning Meeting in Lambeth did not go ahead. Croydon and Lambeth Safeguarding Children Boards 39 8.8.28 It has been noted that during the period there were changes in the way that Legal Planning Meetings were requested and arranged in Lambeth, which may have had some small systemic impact. However, the delays were unacceptable. 8.8.29 It is not clear whether Parents were ever advised that Legal Action was being considered as a prompt to helping them realise how serious their non-co-operation was. The use of a Public Law Outline meeting or legal letter and formal recommendation to the Parents to seek legal advice as the Council was considering Family Proceedings may have helped the parents realise the seriousness of non-co-operation. Written Agreements 8.9 There was one written agreement with Mother, Father and L’s Maternal Grandmother. This was completed following a Discharge Planning Meeting at the hospital after L was born and covered arrangements for Mother and L to stay with the Maternal Grandparents; and for Father to visit. Mother, Father, Maternal Grandparents and Paternal Grandmother were present, with an interpreter, plus the Social Worker and Safeguarding Midwife. The concerns about family animosity and the reasons for the Child Protection Plan, resulting from Mother’s and Father’s behaviour, were clearly set out in the meeting and the arrangements for accommodation, support and supervision were agreed. Not all family members were happy with the agreed arrangements. Family Group Conference 8.10 The Initial Child Protection Plan (April 2015) included that there should be a Family Group Conference. This was never arranged. It is not clear why. This would have been an opportunity for Practitioners to put to the wider family what the concerns were and what actions were expected, and to seek family support and solutions to act on the perceived risks. It would have been difficult to bring Mother’s and Father’s Families together given the history of animosity and mistrust between them. Alternative arrangements were not considered, even though this action was part of the Plan. Race and Culture 8.11 The Review has shown that cultural and religious factors were explored in depth by the Lambeth Social Worker; and the Police in relation to the allegation of forced marriage. The cultural differences between the two extended families were seen to be a part of the dynamics; and were discussed with Mother and Father and their families. Interpreters were used, when needed with Grandparents. 8.12 Case Supervision and Management Croydon and Lambeth Safeguarding Children Boards 40 8.12.1 The importance of reflective thinking in child protection work has been recognised for some time. Assessments can be impacted by a range of dynamics, thought processes and biases18. For social work, the safeguarding system has built in case supervision with an experienced line manager, as a way of supporting the social worker and helping them stand back and think critically about the case and the hypotheses being developed through assessments and attempted interventions. Supervision is also the place where the line-manager can support the worker in unsticking complex issues and resources. 8.12.2 The Social Worker discussed the case and its progress with managers in supervision on several occasions. In March 2015, the Social Work Manager noted the case to be of high risk. In July 2015, the Child Protection Conference Chair escalated the drift in the case to the Team Manager, noting that the Legal Planning Meeting which was part of the Child Protection Plan had not been convened. In supervision in late August, it was noted that the case would continue to be managed under a Child Protection Plan as the Legal Planning Meeting had not yet been convened. This was further delay. It is not clear what the Manager did to expedite this. 8.12.3 Staying with the Maternal Grandparents was part of the safety arrangements for L. It is not clear how Managers reviewed this when the Maternal Grandmother stated that Mother and L could not stay longer and would need to leave the home. The actions in the Plan had not been progressed. 8.12.4 In November 2015, the Supervisor noted that progress had been variable. L was said to be thriving and Mother was managing his care, and her mental health was said to be stable, although Mother was ‘low’ when she had to stay in the temporary accommodation in Camden. The Management view was that Lambeth would retain the case, as there was a risk that professional networks may keep changing, with a negative impact on L. A Legal Planning Meeting was to be convened if circumstances did not stabilise. As noted above, by not escalating the case for transfer to Croydon (or Camden) this decision failed to grasp the issues and to ensure that the right network was able to support Mother and L. Within a week it was agreed in Supervision that the Legal Planning process should be reviewed. But this did not happen. 8.12.5 In early January 2016, the Supervisor noted good physical care and that there was a close bond between Mother and baby L. It is not noted what was happening with regard to the Child Protection Plan or the agreement to review legal advice. 8.12.6 In late January, it was stated that Baby L was developing appropriately and that Mother had now engaged with the Child Protection Plan. Consideration was given to stepping down the case to Child in Need – but it was agreed that this would be premature as improvements were too recent. 18 Clinical Judgement and Decision-Making in Children’s Social Work: An Analysis of the ‘front door’ system Research report, Apr 2014; Elspeth Kirkman & Karen Melrose, The Behavioural Insights Team; https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/305516/RR337_-Clinical_Judgement_and_Decision-Making_in_Childrens_Social_Work.pdf Croydon and Lambeth Safeguarding Children Boards 41 8.12.7 In late February, the Supervisor and Social Worker noted Mother’s distressed presentation at the Review Conference and Mother’s unrealistic view of the state of the marriage and her denial that Father was saying that the relationship was over. It was also noted in this discussion that it had been alleged that Father was a drug dealer. No action appears to have been agreed in relation to this allegation, which was a missed opportunity. The Supervisor could have helped the Social Worker to think what could be done to explore the allegation further and whether a strategy discussion or referral for Legal Advice was required. 8.12.8 In early April, the Team Manager contacted Croydon Children’s Services and asked them to accept the case. In early May, it was noted in supervision that Mother was not co-operating or accessing local services. There was a question about Mother’s mental state. The request for transfer to Croydon was to be followed up and a Review Legal Planning Meeting was to be convened. A few days later the case was escalated to a Service Manager in Croydon to progress the transfer of the case. 8.12.9 There is no record that the case was discussed in Supervision after this, in either Lambeth or Croydon, before the critical incident, two months later. This did not meet social work standards. 8.12.10 Management and reflective supervision should have been a place where the case would be kept under review and the worker/s should have been assisted in working with any obstacles, resistance or disguised compliance. The issues of cross-borough dynamics have been noted as part of the cause for delays and drift in the case, but supervision and management should have addressed the drift and considered how to support the workers in challenging Mother and Father to undertake the agreed tasks. Failing that there should have been escalation to legal processes, such as the Public Law Outline, with clear setting out to both Parents and their lawyers of the consequences of not undertaking the agreed actions. Child Protection Conferences and Core Groups should also allow reflective consideration of the changes and reasons for lack of change. The systems issue, in this case, of not having a stable and consistent Core Group, because of working across boroughs, meant that there was not reflective challenge from Partner Agencies to the lack of progress. 8.12.11 There is no available information for this case about how Practitioners in other Agencies were supervised and supported in their thinking. This raises a question about management and supervisory processes in safeguarding in non-social work agencies. 8.13 Systems dynamics outside the case which may have impacted on the multi-agency case work 8.13.1 The second Practitioners’ Learning Event highlighted that at the time of the case there were a number of systemic issues within Lambeth Children’s Services. These included frequent changes in Social Workers and Managers. Croydon and Lambeth Safeguarding Children Boards 42 8.13.2 During the period of the transfer of case responsibility between Lambeth and Croydon from February to the end of May 2016, Croydon Children’s Social Care was subject of a Joint Targeted Area Inspection (JTAI). It has been stated that this may have affected the management and timing of the transfer of this case. 8.13.3 There were systemic issues relating to homelessness and the availability of local temporary accommodation for families being assessed where there are also concerns about the parenting. This is known to be a London-wide and national issue. 8.13.4 The case has also raised a question about how common drug use is in society, how it is hidden or accepted as ‘normal’ if it is not assessed as ‘problematic’, and questions about the possible impact on children of regular use by parents if drugs. This raises a question about whether a public health awareness approach may be needed to warn of the risks of parental drug use; like smoking and alcohol. 8.13.5 It has been noted as part of this review that an added systemic complication was that Mother and Baby L had different GPs, in different GP Practices. This was not understood at the time and assumptions were made that child protection information and invitations given to one of the GPs (Mother’s) also applied to the welfare of L. L’s GP Practice was unaware for several months that L was subject of a Child Protection Plan. This raises questions about the co-ordination of child protection information across the health economy and the role of information sharing between GPs and Health Visitors, as well as Social Workers. Key members of Core groups should be confirmed at each Conference and Core Group to identify any such discrepancy and agree how to manage this. 9 Lessons Only the most important lessons as agreed by the Panel are discussed in this section. Other lessons have been noted in the analysis and discussion above. These lessons were shared and agreed with the Practitioners and Managers at the second Practitioners’ Learning Event. Keeping the child’s lived experience at the centre of safeguarding children practice 9.1 There is a challenge for practitioners in holding the child’s lived experience in mind and at the centre of the work. Professional and Agency Systems should support practitioners in contemplating the ‘child’s journey’ from the child’s point of view, and any possible adverse impact from parenting or the context in which the child is living. Practitioners can be easily diverted from holding the child’s experience in mind by parental behaviours or other complicating or systemic factors. 9.1.1 The problems of housing, domestic violence, and non-co-operation with the perinatal mental health assessment, exacerbated by the cross-borough moves and changes in personnel or responsibility, meant that consideration of L’s own experience of the world appears to have been lost, as Practitioners sought to negotiate with the Parents or with each other. Croydon and Lambeth Safeguarding Children Boards 43 9.1.2 It is not clear to this Review how the Practitioners, their Supervisors or the safeguarding system of Child Protection Conferences and Core Groups assessed L’s needs and development and the impact of parental behaviour, and several changes of home and environments in a short space of time. 9.1.3 An additional challenge was L’s age; for the period under review he was a pre-verbal baby and infant. Physical developmental checks and observations by those practitioners who saw him suggested that all was ‘fine’, that he was thriving, and the expected harm had not transpired. It raises questions about how Practitioners assess pre-verbal children’s experience and what they should look out for. 9.1.4 A question is, therefore, how Practitioners are supported in keeping a focus on the child and the child’s experience, especially through reflective supervision and pro-active consideration as part of the agenda of Core Groups and Conferences. This case suggests a focus on process and that, as in other cases, Core Groups and Conferences may concentrate on challenges in achieving Plans and Tasks and may lose sight of the child’s experience, over time. 9.1.5 The absence of social work visits and case co-ordination from the point of transfer to Croydon at the end of May 2016 meant that there was no focus on L, at all. This was unacceptable practice. 9.1.6 It has come to light that probably there were times that one parent, or possibly both, were unavailable to him emotionally through drug use. While this is hindsight for this case, it needs to be borne in mind for learning in future cases where there is a suggestion of drug use. Knowledge and Skills in Working with Drug Using Parents 9.2 Illicit, and, or denied, parental drug use is a challenging area for safeguarding systems, practitioners and managers. Local safeguarding systems should be confident in the levels of awareness and skills of frontline staff to assess and work with the potential risks of illicit drug use, including possible signs of ingestion in children to look out for. 9.2.1 The Review has raised important questions about the level of knowledge and skills of front-line practitioners and their managers in working with parents who use drugs; particularly where the drug use is not 'problematic' or not fully apparent. This view is supported by Prof Sarah Galvani19: ‘In spite of a growing evidence base, social work has struggled to respond adequately to substance use within its service user groups although evidence shows that some social work educators and local authority workforce and development training departments have attempted to respond with training on substance use topics (Allnock and Hutchinson 2014, Galvani and Allnock 2014). However, this is inconsistent across English social work qualifying programmes and Local Authority employers. The evidence also shows that many social work and social care professionals are not clear what they should be doing in relation to substance use and their role expectations vary according to their specialist area of practice, their knowledge of substance use, and their levels of confidence (Dance 19 Alcohol and other Drug Use: The Roles and Capabilities of Social Workers; Prof Sarah Galvani, Manchester Metropolitan University, March 2015. Research Funded by Public Health England http://cdn.basw.co.uk/upload/basw_25925-3.pdf Croydon and Lambeth Safeguarding Children Boards 44 and Galvani 2014; Galvani et al. 2011, Hutchinson et al. 2013, Loughran et al. 2010). For the profession of social work to engage fully with substance use, it needs clarity over the roles and function its social workers should fulfil along with the capabilities they need to do so effectively. This clarity needs to begin at qualifying training level and extend into continuing professional development.’ The Panel’s view is that this is not just an issue for social work. 9.2.2 Given what is understood to be the widespread prevalence of drug use,20 this is an important finding; as it suggests local safeguarding systems lack assurance in both competence and confidence to tackle hidden parental substance misuse and its potential harmful impact on children. 9.2.3 Tests undertaken after the critical incident, when Baby L (aged 11 months) collapsed after he had ingested cocaine, show that he had, in fact, been exposed to and ingested cocaine continually over, at least, the preceding six months. This is, of course, hindsight not available to the Practitioners at the time. However, during the period of safeguarding under review there were occasions when drugs were found or parental drug misuse was suggested. 9.2.4 The Review Panel's view is that Practitioners are more able to challenge and work with drug use where it is known to be problematic rather than hidden, usually through chaotic lifestyle, conviction or known addiction, or where an adult shows clear signs of the effects of drug misuse. 9.2.5 If practitioners were better educated in understanding hidden drug misuse, denial about it, and the risk of secondary or accidental ingestion by toddlers or children, it could have led to more curiosity and openness to disguised compliance. This in turn would have enabled potential parental drug use to be included in Child Protection Plans, Public Law Outline consideration and direct work with these Parents, including educating them in the possible accidental or secondary risks to children of hidden parental drug use. Working with parental drug use is seen as a specialist skill but needs to be seen as core to all frontline practitioners. 9.2.6 The London Child Protection Procedures Section, Section 29, Parents who use misuse drugs21 sets out the requirement on LSCBs to have a local multi-disciplinary protocol on parental drug misuse. Lambeth Safeguarding Children Board had previously issued such multi-agency guidance in 2010 and revised it in 2014; but, by the time of this case it had fallen into disuse, was no longer available on the LSCB’s website and was not promoted in the multi-agency training on parental drug misuse. Lambeth Children’s Services Practitioners advised this Review that they had been unaware of such 20 Health and Social Care Information Centre, Statistics on Drug Misuse, England 2016, National Statistics, July 2016: 1 in 12 16-59 year olds had used drugs, this increases to 1 in 5 for 16-24 year olds; More men than women were users; cannabis was used more than other drugs 21 London Child Protection Procedures, section 29.4 6: Local Safeguarding Children Boards are responsible for taking full account of the challenges and complexities of work in this area by ensuring that inter-disciplinary / agency protocols and training are in place for the co-ordination of assessment and support and for close collaboration between all local children's and adult's services. Croydon and Lambeth Safeguarding Children Boards 45 guidance, but it was still available to the staff of the Health Trust. Croydon LSCB had such guidance in place. 9.2.7 However, such guidance as is available rarely alerts practitioners to the risk of accidental ingestion. The 2011, Advisory Council on the Misuse of Drugs inquiry: 'Hidden harm'22 reporting impact on the children of drug users briefly mentions risk of accidental ingestion, but not of drugs in powder or residue form. 9.2.8 Literature reviewed for this enquiry rarely covers signs or symptoms of possible drug ingestion in toddlers or children, except when in clinical collapse, through withdrawal from in utero addiction, or the impact of ingestion through breast milk. Non-specialist practitioners are not aware what to look out for, in terms of possible signs and symptoms of ingestion in children. In a case, such as this one, where drug misuse has been suggested on more than one occasion, this was a potential shortcoming. Homelessness and Temporary Accommodation and their impact on child protection 9.3 A systems lesson highlighted by this case is that of the (national and London) shortage of suitable social housing and local temporary accommodation for homeless families, and within that, the prioritising of children subject of Child Protection Plans. 9.3.1 A lack of sufficient suitable social housing stock is a national issue and, in particular, a problem for London authorities. Temporarily housing children who have been identified as being in need (under the Children Act 1989) outside the local authority area causes systemic problems in the co-ordination of multi-agency work, particularly for cases where a child has been assessed as being at risk of significant harm and made subject of a child protection plan. 9.3.2 Croydon Housing placed Mother and Baby L in temporary hostel accommodation in Camden, intending that they may reside there for up to a year, as there was no suitable local provision. At the time of this case Croydon did not give additional priority to families with children subject to Child Protection Plans. It has been stated that as Baby L was a ‘Lambeth child’ no additional priority would have been given. The Lambeth Social Worker asked Croydon Housing twice to give priority and move Mother and Baby L closer to her family in south London. However, there was no action on this request for six months. 9.3.3 The review has raised the question of how well homelessness and housing law is understood by non-housing professionals, particularly social workers, and the strategic relationships between Local Authority Children’s Services Departments and Housing Departments in working together to prioritise the most vulnerable children and families. Are social workers (and others) aware of the rules and powers governing Local Authorities in relation to homelessness, security of tenure and why it may be necessary to place families outside the borough, temporarily? 22 https://www.gov.uk/government/publications/amcd-inquiry-hidden-harm-report-on-children-of-drug-users Croydon and Lambeth Safeguarding Children Boards 46 9.3.4 It also raises the question about how well housing workers understand safeguarding children, and safeguarding children processes, such as Core Groups. As a result of another local SCR, Croydon has introduced a Joint Protocol to deal with this and now provides Single Points of Contact in Housing Sections for safeguarding advice, and tracks cases where children are known to be subject of Child Protection Plans; a Housing Safeguarding Co-ordinator post has also been created. Lambeth Children’s Services and Lambeth Housing are in the process of agreeing a joint protocol on this issue. 9.3.5 Where a family’s housing has a negative impact on a child’s welfare or safety this should be assessed as part of the ongoing re-assessments as part of the Child Protection Plan and relevant Housing Staff should be engaged in the Core Group. 9.3.6 During the review, the use and the effectiveness of the London Councils’ ‘notify2’ System was raised. This is an online notification system for tracking the movement of vulnerable homeless families, across London Boroughs. ‘Notify2 enables London boroughs to continue supporting homeless households moving to a new address. The scheme can help families and vulnerable people access schools, NHS and social care services. With the consent of service-users’ borough Housing Departments provide information about homeless households to notify2, which issues notifications to education, social care and health detailing households placed, moving between or leaving temporary accommodation. Notify2 is provided by London Councils and used by all 33 London Local Authorities.’23 9.3.7 London Councils informed this review (July 2017) that an analysis of the effectiveness of the notify2 arrangements had led to a decision to change the purpose of the database to be for notification of the moves of homeless families to Housing Departments only, and no longer to Social Care, Education or Health, which should, henceforth, use the London Child Protection Procedures for guidance. 9.3.8 In this case, Croydon Children’s Services were not directly advised when Mother (pregnant) and, then later, Mother and Baby L were placed in temporary accommodation by Croydon Housing. It was not common practice for the Multi-Agency Strategic Hub (MASH) to enquire of the notify2 database, if that had happened in this case Croydon would have seen earlier that Mother and Baby L had been accepted as Croydon’s responsibility by Croydon Housing while being assessed for eligibility for permanent housing. It is not clear, however, that this would have altered their view that Baby L was a Lambeth case, until he was permanently re-housed in Croydon. 9.3.9 Camden services had strong reservations about the quality of the temporary accommodation and its suitability for children. This raised a systems issue about how this concern about the suitability of such accommodation is made known across other placing authorities. 23 London Councils’ website: http://www.londoncouncils.gov.uk/services/welcome-notify Croydon and Lambeth Safeguarding Children Boards 47 Cross-Borough Working 9.4 Strong safeguarding systems require local networks of professionals (Core Groups) who can work closely together as a multidisciplinary team with parents to minimise risk, support Child Protection through parental change, and challenge parental non-compliance or drift. When those networks are disrupted by Cross-Borough working, systems must work harder to ensure effective safeguarding. 9.4.1 As noted above, a key systems dynamic impacting on this case was having to work across several boroughs and agencies, as the Mother (and Father) moved several times, as Core Groups had to be re-formed several times; and proved to be ineffective as a result. 9.4.2 Lambeth Children's Services decisions to continue to hold the case, for fear that Baby L may fall through the net when Croydon and Camden declined to take it, exacerbated the problem of securing the right network of people across social care, health, mental health and domestic violence services, when some of those services were based in north London. 9.4.3 The majority of key meetings were held in south London, rather than local to Mother and Baby L in Camden, this resulted in non-attendance of key professionals. Consideration should have been given to both the location of key meetings and to creative and modern ways of involving more geographically remote professionals, such as teleconferencing for Core Groups or Child Protection Conferences. 9.4.4 There was a lack of awareness of, or adherence to, the agreed London child protection procedures24 on this issue see 9.5.1 below. Getting the basics right, adherence to Procedures, and supporting Frontline Practitioners with guidance and reflective supervision 9.5 There were several examples in this case of lack of awareness of, or lack of adherence to, statutory guidance or local protocols. On occasions, timescales were not followed. From this one case, it cannot be assumed that this is common. It raises questions, however, about how Agencies monitor the use of safeguarding guidance, track adherence to requirements, use escalation and support Practitioners in critical and reflective thinking. 24 London Child Protection Procedures section 6: Children and Families moving across Local Authority Boundaries 5th Edition 2016 http://www.londoncp.co.uk/chapters/chi_fam_bound.html Note that a revised draft edition of the London Child Protection Procedures was published in March 2017 for consultation http://www.londoncp.co.uk Croydon and Lambeth Safeguarding Children Boards 48 The effectiveness of Core groups and their management in this is important. 9.5.1 The case history, discussion and evaluation above show that on several occasions the basics of safeguarding were not right. Key agencies did not have the information that they needed. Protocols and procedures were unknown or not followed. Child Protection Conferences were not well attended and at times the right professionals were not invited. Core Groups, an essential tool in safeguarding were ineffective; not just because of the geographical problems. This raises questions about the co-ordination, chairing and quality of Core Groups in implementing Child Protection Plans, ensuring compliance, monitoring drift and ensuring that higher thresholds are considered when there is non-compliance by parents or insufficient change. 9.5.2 From the point of transfer of case responsibility to Croydon child protection standards were not met, in terms of visits to observe Baby L and check on his welfare and there was no systematic co-ordination of the multi-agency child protection work; despite requests from some professionals. This gap was not picked up by a management monitoring system. 9.5.3 Changes in workers, sometimes at key points, impeded the ability to form good working relationships with Mother and Father, as a foundation for bringing about change. 9.5.4 The work was task-focused and did not have sufficient professional curiosity to get behind what were the causes of the parental behaviour, and the reasons for lack of change. When it was thought that there might be ‘disguised compliance’ there was no plan to tackle this. 9.5.5 The Review has not been able to obtain a clear picture of the use of reflective supervision in the case, by all agencies. Agencies confirmed that systems were in place but some could not give a clear account of how supervision or management was used, or how effective it was, in this case. Critical refection and management oversight are important in work with stuck or resistant families; particularly in supporting professional curiosity and hypothesising about causes for behaviour as well as monitoring tasks. This raises a question for the LSCBs about how this is monitored and quality assured across all safeguarding work. 9.5.6 There was a lack of awareness of when and where to escalate concerns about insufficient progress, especially in the cross-borough work. The case should have been escalated to senior managers when frontline practitioners were stuck because of decisions by senior managers in other places e.g. transfer of case responsibility across boroughs. 9.5.7 It is acknowledged that this case was seriously impacted by the cross-borough issues. However, the view of the Panel is, that had the right quality assurance and management oversight been in place the cross-borough issues would have been resolved sooner. Greater attention was also needed to ensure that the right people were advised of the case, as a child protection case, and invited to key meetings and that their attendance or involvement was monitored. 9.5.8 Within this there were particular concerns about the management of transfers of responsibility, for a child subject of a Child Protection Plan, across boroughs and the need to ensure the effective handover of the multiagency responsibility between Core Groups. Such transitions present a risk that the focus and momentum may become lost as practitioners new to the case must catch up Croydon and Lambeth Safeguarding Children Boards 49 and make new relationships with the family. This suggests that more attention needs to be paid to the transfer of such cases between the old Core Group and the new Core Group and the tracking of key tasks; including consideration of the need for a re-assessment in the new and permanent housing and community. 10 Recommendations Croydon and Lambeth Safeguarding Children Boards and their Partner Agencies should consider the following recommendations and, if endorsed, agree an Action Plan to address them. 10.1 Ensuring that the child’s experience is central to the work Croydon and Lambeth Safeguarding Children Boards should satisfy themselves that their Partner Agencies seek to ensure that the safeguarding practice and supervisory systems in place keep the child’s lived experience at the core of all safeguarding work. The purpose of such a review will be to make the needs of children paramount, particularly where the needs or actions of parents may divert from this. 10.2 Knowledge and Skills in Working with Drug Using Parents Croydon and Lambeth Safeguarding Children Boards and their Partner Agencies should review Practitioner Knowledge and Skills in understanding, assessing and responding to hidden substance misuse by parents, such as use of cannabis and other common drugs but where there is no clear sign of addiction or problematic life-style. This should include awareness of the possible clinical signs and impact of (accidental) drug ingestion or exposure by children. As part of this Agencies should review any practice guidance on recognising and working with drug use which is hidden or not deemed ‘problematic’. Consideration should also be given to how front-line practitioners can raise questions about drug use and the risks of drug-taking in a general and more ’universal or public health’ way to ensure that parents are aware of the risks to babies and children. This will ensure a more confident and competent workforce able to enquire about and challenge the use of drugs, which parents may deem to be acceptable or common and non-problematic. 10.3 Cross Borough Working, Homelessness and Temporary Accommodation Croydon and Lambeth Safeguarding Children Boards, with their Children’s Services and Housing Departments, should ensure that suitable arrangements are in place for prioritising the needs of children who are the subject of Child Protection Plans and who are in families placed in temporary accommodation. Such arrangements, including local guidance, should seek to ensure that where a child is transferred in or out, across borough boundaries the transition of multi-agency Croydon and Lambeth Safeguarding Children Boards 50 responsibility is timely. There should be full transfer of information and handover to a new Core Group of essential Practitioners, able to continue the Plan. As part of this, there should be clarity of the respective roles and responsibilities of housing officers and social workers and a sufficient understanding by non-housing practitioners of homelessness rules; with access to specialist advice. Such arrangements will provide the necessary additional knowledge and strong transition arrangements where there is no alternative to moving a child out of the home area. 10.4 Getting the basics right, adherence to Procedures, and supporting Frontline Practitioners with guidance and reflective supervision Croydon and Lambeth Safeguarding Children Boards should review the Agency systems in place for quality assuring the safeguarding processes, including awareness of and use of multi-agency procedures, specialist guidance and reflective supervision or management. This should include how data and tracking are used to monitor cases, timescales and possible drift or non-adherence to Plans. Through this the Boards should have a view of how frontline practice is overseen and an exception reporting system can be put in place to alert the Boards to any systemic issues which require attention. 10.5 Single Agency Recommendations / Actions 10.5.1 The Metropolitan Police, as part of their review of this case, has agreed that the Senior Leadership Teams of the Lambeth and Croydon Borough Operational Command Units (BOCU) carry out a dip-sample of Domestic Abuse cases to establish compliance with the current MARAC referral thresholds. It is recommended as part of this review that the BOCUs report to their home LSCB on the findings and any actions to be taken as a result of those audits. 10.5.2 Croydon and Lambeth Health Services and Children’s Services and the NHS Child Protection Information System (CPIS)25 Croydon and Lambeth CCGs and Croydon and Lambeth Children’s Services should review progress on the adoption of the CPIS and report to their respective LSCBs on this. Adoption of CPIS will not act as a full substitute for information sharing about children subject of Child Protection Plans but it will assist in ensuring that children about whom there are concerns may be identified within the health economy; including any discrepancies in identifying data. 10.5.3 Lambeth Children’s Services and Lambeth Housing – Joint Protocol 25 https://digital.nhs.uk/child-protection-information-sharing Croydon and Lambeth Safeguarding Children Boards 51 Lambeth Children’s Services and Lambeth Housing should agree the Joint Protocol on Child Welfare, Child Protection and Housing (does it have a particular name?) and inform the Lambeth Safeguarding Children Board of the agreed arrangements. The Lambeth SCB should ensure that the Protocol is on the Board’s website. This will assist in ensuring that where temporary housing is a key issue in a child’s welfare and protection that there is effective co-ordination and understanding between Practitioners and that the Child Protection Plan can take this into account. -------------------------------------------------------------------------- Malcolm Ward Independent Reviewer August 2018 Croydon and Lambeth Safeguarding Children Boards 52 Appendices Appendix 1 Terms of Reference Serious Case Review Child L Following discussion with the two Serious Case Review Sub Groups of Croydon and Lambeth Safeguarding Children Boards, in accordance with Working Together to Safeguard Children (2015), we have decided that a Serious Case Review should be undertaken on the above child. 1. CRITERIA FOR SERIOUS CASE REVIEW The case meets the two criteria below set out in Working Together 201526 5(2)(a) Abuse or neglect of a child is known or suspected And 5(2)(b) (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 2. The Purpose of a Serious Case Review The Boards have adopted the principles of the SCIE NSPCC SCR Quality Markers27 which confirm the purpose of the SCR should be organisational learning and improvement and, where relevant, the prevention of the reoccurrence of similar incidents. The framework accepts that errors are inevitable and, where they are identified, they become the starting point of an investigation. Individual and organisational accountability is manifest through being open and transparent about any problems identified in the way the case was handled, and demonstrating a commitment to seek to address the causes LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. 26 HM Government Working together to safeguard children. A guide to inter-agency working to safeguard and promote the welfare of children. March 2015 27 SCIE NSPCC Serious Case Review Quality Markers 2016 Croydon and Lambeth Safeguarding Children Boards 53 SCRs and other case reviews should be conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children (using a systems analysis); seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. SCRs should: be proportionate involve the professionals fully and invite them to contribute their perspectives without fear of being blamed for actions they took in good faith; involve families, including children, where possible. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process; 3. Methodology The methodology being used for this review is the Welsh Model; Extended Child Practice Review a nationally recognised model which ensures that all the core elements of a high quality learning review are in place. The methodology incorporates:- Oversight by a Serious Case Review Panel Agencies to provide: o A short summary report describing agency involvement with the family prior to the period under review. o A detailed chronology for the period under review:1 October 2014 to 31 July 2016 o A brief analysis of relevant context, emerging issues and concerns –this may be in the form of bullet points o A note of any actions already taken or recommendations for future improvements in systems practice as a result of the critical incident. o List of all practitioners and their immediate Line-Managers who were significantly involved in the case Engagement with family members Practitioner Learning Event Child Practice Review Report written by the Independent Author, Malcolm Ward Debrief event to all participants Learning events for all with dissemination of the SCR Croydon and Lambeth Safeguarding Children Boards 54 4. SCR Panel An SCR Panel of senior managers from agencies involved in the provision of services to the family but independent of the management of the case is being appointed to oversee the SCR. Andrew Christie (Chair of Lambeth SCB) will chair the Panel. The Independent Reviewer/Author will be Malcolm Ward. Panel Membership will be drawn from services in Croydon and Lambeth. It will not be proportionate for every agency to be involved directly in the Panel Sarah Baker is the commissioner of the review and Croydon LSCB will take the lead for the review process, and the review will be funded 50:50 by Lambeth and Croydon LSCBs. 5. Practice Learning Event Agencies should identify all Practitioners and their immediate Line-Managers who were significantly involved in the case (i.e. involved in the direct practice, planning or decision-making), including those who may have left the agency; and ensure that they are invited to and supported in attending the Practice Learning Event/s. Both Croydon and Lambeth LSCBs expect these practitioners to be released and to attend the Events as an essential part of the methodology. Dates will be agreed in advance to give as much warning as possible to ensure attendance. The Police and CPS will be consulted about any professional staff who may be required to give statements or have a role as a witness in any possible criminal proceedings. 6. Documentation The SCR will request direct access to some agency documents, for example:- agency reports to child protection conferences minutes of child protection conference, Child Protection Plans any written agreements notes of Core Groups transfer documentation between local authorities any other documents identified by the SCR Panel 7. Scope of This Review As a minimum, the review should cover the period from: 1 October 2014 to 31 July 2016 Croydon and Lambeth Safeguarding Children Boards 55 Agencies are asked to provide information during this period within their chronologies, using the Chronolator Tool and provide a summary of any relevant information that falls outside of this period. 8. Family Involvement The independent chairs of the LSCB will inform the parents about the SCR and invite them to take part should they wish to do so. Family views about the SCR will be sought prior to publication. 9. Consent In order to obtain the best possible understanding of the child’s circumstances we need to consider information about his parents and carers. The parents will be advised that medical information about them, relevant to the care of their son will be shared for the purpose of the SCR. 10. Agencies requested to provide chronology and summary 1. NHS England (GPs) 2. Croydon Health Services (including Croydon University Hospital, Health Visitors and School Nurses and Family Nurse Partnership) 3. Kings College Hospital 4. Guys & St Thomas’ Hospital 5. St George’s Hospital 6. South London and Maudsley NHS Foundation Trust (SLAM), 7. Metropolitan Police, SCR Team 8. LB Croydon Children’s Social Care 9. LB Lambeth Children’s Social Care 10. LB Croydon Housing Dept. 11. LB Lambeth Housing Dept. 12. London Ambulance Service 13. National Probation Service/London CRC 14. Crown Lane Children’s Centre 15. GAIA 11. Terms of Reference for this review The circumstances of this SCR contain a number of issues which we expect to be explored by the SCR Panel and within the summary reports, as follows:- What did the practitioners know or could they have known at the time and what knowledge, skills and values did they base their judgements on? How did agencies and their practitioners take account of any specific cultural or religious needs of the parents or child? Croydon and Lambeth Safeguarding Children Boards 56 How was the allegation of forced marriage assessed? How was the risk of domestic abuse assessed? How was the parent/s’ drug possession and possible use assessed? How were concerns about the mother’s mental health and possible self-harm assessed? Was it considered that the father may have mental health issues? What history was taken from the parents about their own childhoods? And how did they come to meet? How well did the pre-birth assessment work? How effective was the child protection plan and the work of the Core Group? The transfer of case responsibility ad recognition of risk to the child? Was there appropriate information sharing across services and geographical areas? Was there appropriate challenge to the parents? Together and individually? How were policies and procedures used in relation to the work undertaken at the time? What was the good practice? Are there any gaps? If either what led to these? Systems and context In terms of a systemic analysis were there things happening in the wider family which impacted on this case? Were there any processes in the professional teams working on this case at the time which impacted on the case – resources, staffing, professional knowledge and skills, workloads, changes etc. Croydon and Lambeth Safeguarding Children Boards 57 Appendix 2 SCR Panel Membership Andrew Christie Independent Review Chair (Chair Lambeth SCB) Malcolm Ward Independent Review Author / Lead Reviewer Maureen Floyd Croydon Safeguarding Children Board Manager Sian Foley Manager, Croydon Housing Tina Hickson Associate Director of Nursing, Croydon University Hospital NHS Trust Moira Keen Head of Service, Children in Need, Croydon Children’s Services Sally Innis Designated Nurse, Croydon CCG Ann Lorek Designated Doctor, Lambeth CCG / Guys & St Thomas’s NHS Hospital and Community Trust Sabina Malique Lambeth Safeguarding Children Board Manager Chris McCree Safeguarding Lead for Children, South London and Maudsley NHS Mental Health Trust Russell Pearson Metropolitan Police, Specialist Crime Review Group Naeema Sarkar Assistant Director Quality Assurance, Lambeth Children’s Social Care Debbie Saunders Named Nurse for Safeguarding Children, Guys & St Thomas’s NHS Hospital and Community Trust Avis Williams-McKoy Designated Nurse, Lambeth CCG Nia Lewis Croydon Safeguarding Children Board Administrator The Panel is very grateful to Nia Lewis for her careful administration of the review process. October 2017 |
NC51183 | Sexual abuse of a girl between the ages 10-16 years old. Child N disclosed the abuse to a mental health worker in September 2015 at age 19-years-old. Perpetrator convicted of multiple offences against her. Family is white British. Child N lived with her mother and older sister. Maternal history of: foster care; mental health problems; attempted suicides. Child Protection Plan initiated for both siblings for emotional abuse in 2007 due to concerns about multiple men in the home, and Child N being collected from school by different men; stepped down to Child in Need Plan and closed in 2008. Child N known to multiple agencies. Child N's sexual abuse was not identified; several professionals aware of her sexual relationship with an older man. Learning includes: need to reduce thresholds for intervention in complex cases involving neglect; need for professional curiosity and challenge; using historical information, including timelines, can help build a true picture, especially in neglect cases; a multi-disciplinary and/or multi-agency approach is good practice; need to 'think family'; need to consider sexual abuse when very young children self-harm or have injuries to intimate areas; perpetrator confession should be acted on. Uses a hybrid Individual Agency Review and Learning Review methodology. No recommendations. Considerations for the board include ensuring: all practitioners understand the indicators for neglect and are trained to do this effectively; guidance for sexual abuse, including the threshold guidance, is robust and understood; Child Protection Plans are outcome focused; all agencies escalate concerns and use a case resolution protocol appropriately.
| Title: Serious case review: ‘Child N’. LSCB: Devon Safeguarding Children Board Author: Louise Newbury Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review ‘Child N’ November 2018 Report Author Louise Newbury 2 | P a g e Serious Case Review ‘Child N’ Overview Report Contents INTRODUCTION Page Background to this review 5 The review process 5 Scope of this review 6 Methodology 7 CHAPTER 1 Family Background 8 CHAPTER 2 Timeline of key events 8 CHAPTER 3 Analysis 15 CHAPTER 4 Summary and Conclusion 33 Learning Points 34 Considerations for the DCFP 35 GLOSSARY AND APPENDIX Appendix 1 – Glossary of terms 37 Appendix 2 – Participating agencies 38 Appendix 3 – Documents consulted 39 3 | P a g e INTRODUCTION Background to this Serious Case Review 1 This serious care review (SCR) involves a young person who at the age of 19 disclosed to her mental health worker that she had been sexually abused as a child over several years between the ages of 10 and 16, by a man 10 years her senior. This man has since been convicted of multiple offences against her and has received a lengthy custodial sentence. 2 As a child, she was known to multiple agencies including health, mental health, Police and Children’s Social Care and was the subject of both a Child In Need and Child Protection Plan at times including during the time of her sexual abuse, yet her sexual abuse was not identified. 3 As a result of her sexual abuse, this young person has suffered significant mental health problems including several serious self-harm attempts, behavioural issues resulting in very limited school attendance and educational attainment, and ongoing health problems. 4 This young person was living with her parents and older sister. To protect their privacy, names have been changed and the young person will be known as child N, her sister as P and her parents as Mr and Mrs Q. Her assailant will be known as Mr R. The Review Process 5 When a child dies or is seriously hurt and the family are receiving services from child care agencies, the Local Safeguarding Children Board (LSCB)1 has to consider whether a Serious Case Review (SCR) should be carried out. 6 The Devon Safeguarding Children Board, now known as the Devon Children and Families Partnership (DCFP) under the arrangements of Regulation 5 of the Local Safeguarding Children Boards Regulations, 2006, decided that in Child 1 See appendix 1- glossary of terms 4 | P a g e N’s case, the criteria were met for a SCR. The Chair of the DCFP confirmed this and notification of the decision was made to the Department of Education. 7 The purpose of the Review is: To establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children; To identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result; and As a consequence, to improve interagency working and better safeguard and promote the welfare of children. Scope of this review 8 The review covers the period from N’s birth to when she was 18 years old. It follows the government guidance on Serious Case Reviews within Working Together to Safeguard Children (2015, page 75); however given that this review is being carried out a number of years after the abuse took place, it was felt unlikely that professionals involved at the time are still in post. The assumption was also that agencies’ understanding of child sexual abuse and child sexual exploitation and their practice in response to this form of abuse has also improved significantly in that period of time. 9 The Serious Case Review subgroup were therefore keen to understand in what ways practice has improved in Devon and to receive assurances from agencies that opportunities to identify child sexual abuse and appropriately intervene that were missed in relation to N, would not be missed today. They also wanted to understand what support enabled N to disclose the abuse when she was an adult, in order to ensure the right environment is in place to facilitate disclosure. In particular they wanted to find out what promotes early disclosure, and what helps practitioners to hear and recognise disclosure in such cases. 5 | P a g e Methodology 10 A Serious Case Review Group was convened with appropriate independent representation from partner agencies and decided that the case met criteria for a Serious Case Review. Chronologies were obtained from agencies involved and collated into a joint chronology. After collation of chronologies, the Serious Case Review Group devised the following 6 key lines of enquiry: a. There is evidence that practitioners failed to recognise indicators of neglect, physical abuse, sexual abuse and/or sexual exploitation. How are organisations assuring themselves and the DFCP that practitioners are robust in their identification of and assessment of the risk of abuse? b. Are there barriers, individual or organisational – preventing professionals from identifying and acting on these indicators? If so what actions are taken or need to be taken to mitigate against these? c. Is there evidence that Child N disclosed or attempted to disclose abuse as a child and if so, why was this missed by professionals? d. How do professionals facilitate disclosure? What skills are needed by professionals dealing with children at different stages of development to facilitate this? e. To what extent do professionals recognise grooming (of children and professionals) and understand how this inhibits disclosure. f. To what extent do professionals understand the links (including coexistence) between neglect, CSA and CSE? 11 The SCR Group decided to use a hybrid Individual Agency Review and Learning Review methodology, focusing on key points in time where there were missed opportunities for identification and intervention. Agencies were tasked to provide an agency review that addressed these areas and also to compare how (if) services have changed since the time period of the assaults and provide assurance through analysis of their current services that practice has improved. Action plans were requested to address any identified gaps. 12 An Independent Reviewer was appointed. A shared learning event was held in April 2018, with over fifty practitioners representing Police, Education, Health 6 | P a g e and Voluntary agencies, to draw out key points of learning from the agency reports, and to identify any additional current organisational barriers or opportunities leading to improved practice today. 13 In addition, some policy documents from agencies and national research documents of relevance to the issues of the Review were consulted. All the documents consulted are listed in Appendix 3. 14 N and her family were informed that the review was to take place. They were invited to take part in the review, and meet with the Independent Reviewer, but they declined contact. CHAPTER 1 Family background 1.1 N was the second child born to Mr and Mrs Q. Her sister P was four years older. The family are of white British ethnicity and English is their first language. They are not known to have any particular religious identity. 1.2 Mrs Q’s mother died when she was an infant and she was in Foster Care from the age of 5 until 16. She had an ongoing, although reportedly difficult relationship with her Foster Carers. 1.3 Mr and Mrs Q separated when N was age 2. Mrs Q had long standing mental health needs and was under Mental Health services for many years. Several episodes of overdose are found within the clinical record. After separation from Mr Q, Mrs Q had several male partners living in the home, some of whom were a cause for concern regarding inappropriate behaviour towards the children and domestic abuse. 1.4 Mr Q continued to have ongoing contact with the children, visiting them several times a week. The relationship between Mr and Mrs Q appeared amiable. 1.5 From the age of 8 to 12, N’s older sister P became increasingly difficult to manage. Her school attendance fell, she developed mental health concerns and she was the subject of five referrals to Children’s Social Care during this time. In 2007, at the age of 14, P was made the subject of a Child Protection Plan 7 | P a g e under the category of emotional abuse. This plan moved to a Child In Need basis in December 2007 and she remained a Child In Need until July 2008. 1.6 In September 2009, P was pregnant at the age of 16. The father of her baby was age 17. He and his older cousin Mr R (age 22) were found to be living in the attic of the family home in January 2009. They both had a criminal background and were felt by Police to be unsuitable males to be living with N and P. CHAPTER 2 Timeline of key events Date Age Event Agency May 1998 1 year Torn fraenum2, bruised lip and gum Health Visitor (HV) Nov 1999 2 years Child not brought to developmental review despite concerns regarding speech development 6 months previously HV March 2000 2 years Parents separate March 2000 2 years Child referred to Paediatrics at local hospital for Encopresis (faecal soiling). Settles once starts nursery. Noted to have dental caries, poor diet, poor speech and poor growth. HV/ Hospital/ Nursery May 2001 4 years Behavioural change, extreme aggression. Mother later reports she is ‘full of bruises’. GP/ Hospital Feb 2002 4 years Onset of stammering and bedwetting, then recurrent urinary tract infections – later felt to be Hospital 2Fraenum– small piece of joining tissue between upper lip and gum 8 | P a g e cystitis3. Failed to respond to preventative antibiotic therapy. Later found to have duplex kidney4. Unusual symptoms, negative urine tests. May 2004 7 years A and E attendance with bruising to inner thigh and injury to ‘vagina’ having fallen off swivel chair. Hospital Aug 2004 7 years Over familiar behaviour noted with mother’s new partner by child N and her sister. Strategy meeting. Plan for monitoring by school nurse. CSC Children’s Social Care (CSC) / GP /HV Nov 2004 7 years Safe work5 to start (both girls). Felt not to be child protection issue as partner had left home, but still in contact with mother CSC June 2005 8 years CAMHS (Child and Adolescent Mental Health Services) referral for behaviour concerns. CAMHS question Child Sexual Abuse in view of recurrent urinary symptoms. GP/ CAMHS 2007 10 years Assaults commence according to disclosure March 2007 9 years Sister, P, made subject to Child In Need plan due to poor school attendance and absence of CSC 3 Cystitis – a inflammation of the bladder wall, not always caused by infection, may also be caused by irritation or trauma 4 Duplex kidney – kidney with two drainage systems rather than one. Can be associated with infections. 5 Safe Work- a programme of intervention with a child, teaching them about safe relationships with adults. 9 | P a g e boundaries in the home – no plan made for child N. May 2007 10 years Referral to Children’s Social Care as male with risk to children in contact with child N’s mother. Initial assessment and section 476 enquiry results in child protection meeting. CSC/ Police/ Health May 2007 10 years Child Protection meeting: multiple men in home, child N being collected from school by different men. Child Protection Plan initiated for emotional abuse for child P and likely emotional abuse for N. Poor home conditions and mother’s mental health needs including overdose noted by core group. Stepped down to Child In Need in December 2007 and closed July 2008. CSC Dec 2008 11 years Behavioural concerns and distress related to multiple overdoses by mother and older sister P noted by school – referred to CAMHS. N not wanting to leave mother alone. CAMHS referred to CSC. CAMHS closes case after initial meeting with N and her mother independently. N discloses to CAMHS that domestic violence in home by mother’s partner, and that he has assaulted her. CSC and Police assessment of N’s allegation, then case closed without further action. CAMHS/ CSC/ Police Jan 2009 11 years S18 search (a search of the home after any arrest under section 18 of the Police and Criminal Police/ CSC 6 Section 47 enquiry – an investigation that takes place when Children’s Social Care have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. 10 | P a g e Activity Act) – home found to be ‘disgustingly filthy’ + 2 x ‘undesirables’ in home – living in attic. These were child P’s boyfriend and his older cousin who was child N’s abuser. Initial Assessment started by Children’s Social Care then not progressed Feb 2009 11 years Bruise to cheek, referred to Children’s Social Care by school for assessment. Poor attendance at school – 34%. Behavioural problems. Referred back to CAMHS. Police/ Education /CSC Feb 2009 11 years Attended GP surgery with heavy periods – given Norethisterone7 tablets. Attended with mother’s partner who was under influence of alcohol. GP April 2009 11 years Dressing ‘provocatively’, untreated Urinary Tract Infection. Concern she could be sexually active. CAMHS/ CSC April 2009 11 years Mr R tells Probation Officer that he has a 15-year- old girlfriend with whom he has a sexual relationship. Names child N. Probation Officer refers to Children’s Social Care and is told that a Child Protection Conference will be held. CSC/ Probation April 2009 11 years Overdose. Not felt to be suicidal. Noted to be mixing with much older men. CAMHS say they can’t do therapeutic work as home life unstable. CAMHS/ Hospital June 2009 12 years Social Worker tells Probation Officer that the allegation of sexual relationship between X and Mr C is false and was made up by X’s mother and that there is no suggestion of any sexual contact. CSC/ Probation 7 Norethisterone is a hormone treatment given to stop periods 11 | P a g e July 2009 12 years Seen weekly by GP with headaches and urinary symptoms. GP July 2009 12 years Overdose. Felt to be due to situational issues. For CAMHS follow up. CAMHS/ Hospital July 2009 12 years Child protection meeting (ICPC) - onto a Child Protection Plan for emotional harm. Sister P is pregnant at age 16 with one of men previously identified as living in attic in Jan 2009. N not attending school and mixing with people older than her. Going out at night with persons unknown. CSC/ Education /Health March 2010 12 years Child Protection Plan ends, step down to Child In Need Plan (ended December 2010). N told Social Worker that she had had sex with a young man (Jamie) and another young person said that N was seeing an ‘older man’. CSC/ Health/ Education April 2010 13 years Overdose. Anxious regarding counselling sessions ending and not wanting to return to school. Closed to CAMHS May 2010. Hosp/ CAMHS Sept 2010 13 years Chlamydia screening Health Nov 2010 13 years Not attending school. Anxiety in crowds. Self- harm – boyfriend stopped her (age 14). Referred to CAMHS for initial assessment GP/ CAMHS Jan 2011 13 years Anonymous report to Police that P’s boyfriend had sold N to a drug dealer. Intelligence received that N and Mr R have been in a relationship since 1/1/11. Referral to Police and CSC, ABE8 interview – no disclosure of sexual contact. Core Police/ CSC 8 ABE interview – interview under Achieving Best Evidence arrangements (video recorded interview) 12 | P a g e assessment shows a number of other concerns but no further involvement. Feb 2011 13 years Police called to domestic incident at Mr R’s house – evident N in a relationship with Mr R age 23. N’s mother said she was unable to prevent the relationship so took her to see him. Bail conditions for incident include Mr R to have no contact with N. Disclosure by Mr R’s mother that N claims she has had a termination of pregnancy. This is later denied by parents. N says her period was late and she did a pregnancy test which was negative. She later denies sexual contact between herself and Mr R. No further action by Police or Children’s Social Care as information felt to be insufficient for disruption legal activities. Police/ CSC March 2011 13 years Mr R found drinking in a public place with N in breach of bail conditions. Mr R arrested. No further action. Police April 2011 14 years Mr R first investigated for possession of indecent photographs of children. Lengthy process to court –arrested initially July 2011, bailed but failed to attend interview repeatedly and arrested in June 2012. October 2012 (18 months later), CPS made charging decision and court appearance December 2012 where found guilty. Sentenced January 2013 for custodial sentence and given a Sex Offenders notice. Police/ Crown Prosecuti on Service (CPS) May 2011 14 years Mr R again discloses relationship with N to Probation Officer. Enquiry to MASH9 but no onward referral to CSC. Police investigate – N CSC/ 9 MASH – multiagency safeguarding hub 13 | P a g e denies sexual relationship. Probation contact school nurse to arrange contraception for N. Probation /Police/ School Nurse June 2011 14 years Mr R seen with N in public place simulating sex. No further action. Police Aug 2011 14 years Mr R found in N’s bedroom wearing no top by Police seeking him for another matter. Appeared he had spent night with N. On bail for possession of indecent images of children. Referral to CSC and joint visit with Police. Decision for Core Assessment and subsequent Child In Need Plan. Jan 2012 14 years Mr R and N have argument. Police called. Mother admits N has contraceptive implant and items of ‘provocative’ underwear found in N’s bedroom. Mother not protective during argument. Information sent to MASH. No further action by MASH or CSC. Police/ MASH Feb 2012 14 years Food aversion Hosp/CA MHS Sept 2013 15 years Chronic pain referral Hosp 2013- 2015 15-18 years Miscarriage age 17, overdose, mental health concerns, domestic violence, and repeated health concerns with urinary problems. CAMHS, Police, GP Sept 15 18 Discloses abuse to Adult Mental Health worker in April and then Police in Sept 2015 Adult Mental Health services/ Police 14 | P a g e CHAPTER 3 Analysis 3.1 Each agency produced an Individual Agency Report, looking at the key time points and identifying strengths and weaknesses in relation to N’s management. They were then tasked to provide evidence of current practice and whether the same strengths and weaknesses apply to practice today. 3.2 Identified strengths in relation to N’s management included: The consistent and extensive support provided by N’s adult mental health worker, which included attending Police interviews with her. The sensitive and victim centred approach taken by the Police after N’s disclosure, again with consistency of worker. 3.3 Identified weaknesses in N’s management included: Failure to recognise multiple indicators of neglect. Failure to recognise indicators or physical abuse, sexual abuse and sexual exploitation. A lack of appreciation of the co-existence of forms of harm. A lack of including family associates and regular visitors to the home in a ‘think family’ approach. Failure to truly appreciate adolescent risk in the context of neglect Organisational barriers to disclosure including multiple changes of staff and a lack of staff ‘hearing’ disclosure Poor supervision of individual workers. A lack of escalation when interagency difficulties were identified. Procedure based rather than outcome-based planning within child protection procedures. Poor information sharing and working together in the context of complex and multiple risks. 3.4 In view of the length of time since many of the events occurred in this review, agencies were asked to provide evidence of where they are now in relation to 15 | P a g e the key lines of enquiry, both within their written reports and through the practitioner event. 3.5 This analysis is presented here with reference to the key lines of enquiry. a. There is evidence that practitioners failed to recognise indicators of neglect, physical abuse, sexual abuse and/or sexual exploitation. How are organisations assuring themselves and the DFCP that practitioners are robust in their identification of and assessment of the risk of abuse? 3.6 Agencies identified multiple opportunities to recognised indicators of all these forms of abuse in this case. Key points included: 3.7 Missed indicators of neglect including dental decay at a very young age, a requirement for behavioural modification under a year of age and delayed development including speech and social delay. She also had failed health appointments, poor linear growth, and rapid toilet training once at nursery, yet inability to achieve continence whilst still at home. She had behavioural problems and school refusal. Poor home conditions were identified by several agencies. Multiple men were known to be visiting the home and picking N up from school. Mother was seen to be taking N to her abuser’s home and she failing to intervene during an altercation between N and her abuser. 3.8 Missed indicators of physical abuse including torn fraenum and facial injuries at a young age, allegation of assault by mother’s partner and facial bruising at the age of 11. 3.9 Missed indicators of sexual abuse including recurrent urinary infections from a young age with a lack of response to treatment, sexualised behaviour with her mother’s partner, a disclosure that she had a sexual relationship at the age of 12 and taking a Chlamydia screen and a pregnancy test at the age of 13. 3.10 In addition, further indicators of sexual abuse and exploitation included an anonymous disclosure of her being ’sold’ to a drug dealer at age 13 and her long-known association with her abuser including his living in her home from age 10. She was also found to have ‘provocative’ underwear found in her bedroom and a disclosure she had a contraceptive implant at age 14. In 16 | P a g e addition, a disclosure was made by her abuser to his probation officer that he was in a sexual relationship with her, made when N was only age 12. 3.11 Agencies were clear that there have been significant improvements in education and processes. All agencies have shown evidence that they have in place policies and procedures for safeguarding children, which are in line with the DCFP Procedures. All information in these procedures is based on ‘Working Together’ principles. 3.12 There has been a particular focus on neglect in Devon over the past year. In December 2017, the DCFP held its annual conference, on neglect. At the conference, they launched the new neglect strategy and toolkit. There was good representation from all agencies, including those involved in this review. Further training is expected across agencies on the use of the toolkit and the Graded Care Profile 2. Health services have additional guidance on some specific indicators of neglect, such as children not brought for appointments. 3.13 This is all very recent however, and it is possible that practice is not yet embedded. It will be important to ensure that all agencies have an understanding of this work and how it applies to their practice. There is optimism amongst agency representatives that the lack of recognition and triangulation of neglect plus other possible forms of abuse would not happen now. 3.14 Since the publication of the independent enquiry into Child Sexual Exploitation (CSE) in Rotherham in 2014, the focus amongst many agencies and safeguarding boards nationally has been the detection and management of CSE. This has led to considerable improvements since the time when N suffered her abuse - in both knowledge about CSE and how to disrupt the perpetrator’s activities in order to protect the victim. The same rigor however does not seem The DCFP should consider assuring themselves that practitioners from all agencies understand the indicators for neglect. They may wish to assure themselves that practitioners are confident in the use of the neglect strategy and toolkit. 17 | P a g e to have been applied to Child Sexual Abuse (CSA) as a whole. DCFP however appear to be ahead of many other regions. In 2016 they set up a Child Sexual Abuse Task and Finish Group following publication of the Serious Case Review CN11 in January 2016, and in light of the Children’s Commissioners’ report on Child Sexual Abuse. 3.15 The DCFP have a well-established CSE subgroup, and partners have made significant changes to practice over the last 2 years. The Devon and Cornwall Police PEEL report of 2016 highlighted that Police had made improvements in its response to and management of child sexual exploitation, rolled out training across the force, introduced CSE champions and their awareness of CSE was high. Since then, the Police have trained most of their frontline practitioners in CSE in 2017 and CSE training including advice on disruption powers is now incorporated into generic safeguarding training. 3.16 The 2013 Ofsted inspection of Devon Children’s Social Care found ‘the current arrangements to respond to the needs of children and young people who are at risk of child sexual exploitation (CSE)... are not sufficiently robust. Inspectors identified a number of cases where the risks of CSE had not been considered or identified: consequently, children and young people are not adequately protected’. The subsequent Ofsted 2015 inspection reported notable progress, including risk assessment, management oversight and the extent to which the individual experiences of children are identified and considered. Policies, procedures and training are informed by the Rotheram enquiry of 2014, the Oxford Serious Case Review10 in 2015 and the Bristol Serious Case Review11 report of 2016. 3.17 Health services staff attend DCFP generic level 3 safeguarding training in which CSE is included. 10 The Oxford Serious Case Review 2015 into CSE in Oxfordshire– OSCB.org.uk/wp- content/uploads/SCR-into-CSE-in-Oxfordshire-FINAL-FOR-WEBSITE.pdf 11 The Operation Brooke Serious Case Review Bristol 2016 - bristolsafeguarding.org/media/1213/brooke-overview.pdf 18 | P a g e 3.18 For all agencies, there is a CSE risk tool providing guidance on defining, assessing and managing CSE. There are also a number of independent organisations providing support and advice including: • The REACH service (Reducing Exploitation and Absence from Care or Home) includes one to one support for young people to help them recognise exploitation and to build on existing strengths to develop coping and keeping safe strategies. They also work with professionals offering support for cases and perform Return Home Interviews for missing children and young people. • CHECKPOINT (the equivalent service to REACH for Torbay), who also work with young people who have been sexually exploited in a similar way with one to one support. • There are MACSE (Missing and Child Sexual Exploitation) forums in Devon. These are multiagency meetings which share information regarding children and young people who are particularly vulnerable to being sexually exploited or trafficked. The aim is the prevention, protection and disruption of CSE and to ensure these children and young people are safeguarded. • JACAT (Journey after Child Abuse) is a child centred service which provides in depth psychological support to children and young people who have been abused. They provide consultation, co-working, training, group work, direct and indirect work. • The SARC (Sexual Advice Referral Centre) in Exeter provides crisis worker support, forensic examinations, sexual health information and referral and follow up emotional support to both children and young people who have been the victims of sexual abuse and assault. For children they also provide a clinic service for historical abuse. 3.19 The DCFP Child Sexual Abuse Task and Finish Group was set up in 2016 as a formal sub-group of the safeguarding board. Many other Safeguarding Boards still have no specific CSA subgroup. They have reviewed internal agency and DCFP training on CSA, they have conducted a benchmarking exercise of staff awareness and confidence in the recognition of CSA, and developed a toolkit 19 | P a g e including the use of one minute guides and the use of the Brook tool12 for recognition of Child Sexual Abuse. They also determined several key performance indicators (KPIs) to monitor the impact of their plan. Unfortunately, whilst professionals indicated that they felt confident in recognising CSA, analysis of the KPIs last year showed little impact, and the number of children subject to a child protection plan for Child Sexual Abuse remains low in Devon. The CSA subgroup remains active and is now under new leadership with a new focus. 3.20 In the MASH, all staff have undergone CSA training, and managers from REACH offer regular consultations and workshops in relation to CSE. When practitioners working in Children’s Social Care (in the Initial Response team) were asked about CSA, a culture of empowerment was evident for staff, with managers supporting ground staff in confidence around dealing with possible CSA in families. 3.21 North Devon Healthcare Trust, who run the self-testing services for Chlamydia screening, have changed their policies since N took her test in order to better pick up cases of CSA and CSE. It is now their policy for any child under the age of 16 to be phoned with the result of their test, regardless of the result. Fraser competency is assessed, and a risk assessment carried out depending on age. This includes talking about emergency contraception, offering an opportunity to attend a setting, and if age 13-14 then contact is made with the safeguarding team and a safeguarding assessment takes place. 3.22 As part of this Serious Case Review, the social work team performed a dip sample audit of current cases under Children’s Social Care where children are subject to Child Protection Plans for Child Sexual Abuse (CSA). They found good examples of manager oversight and assessment in these cases. Of course, these are cases where CSA has been identified, we do not know about cases such as this one where there are indicators of CSA but no formal identification has been made. 12 The Brook Sexual Behaviours Traffic Light Tool – www.brook.org.uk 20 | P a g e b. Are there barriers – individual or organisational – preventing professionals from identifying and acting on these indicators? If so what actions are taken or need to be taken to mitigate against these? 3.23 Concerns still remain regarding identification of child sexual abuse, as a very low number of children are subject to Child Protection Plans for Child Sexual Abuse in Devon (in 2017, 2.8% of all children were subject to CP plans). This compares to a national average in 2017 of 4.4% of children on a Child Protection Plan and 6.4 % of children on a Child In Need Plan. 3.24 The current barriers to recognition of sexual abuse and exploitation appear still to be a lack of knowledge regarding symptoms and signs, and a reliance upon verbal disclosure - as was seen in this case. Although there has been considerable investment in resources and guidance for Child Sexual Exploitation over the last few years, a comparable investment has not been made in resources and guidance for Child Sexual Abuse. 3.25 It is important to ensure practitioners have up to date knowledge and good quality, easily accessible guidance relating to Child Sexual Abuse. 3.26 In this case, further identified barriers to identifying and acting upon indicators of abuse, appear to be a lack of information sharing and joint working in such complex cases as this. Examples of gaps in information sharing include: a) Although Probation shared information by telephone with Children’s Social Care, they were not aware from this conversation of N’s true age. b) As there was no written communication, the significance of Mr R disclosing to a professional that their relationship was sexual may have been missed. The DCFP should ensure that guidance relating to Child Sexual Abuse, including that within Threshold Guidance, is robust and easily understood. They should consider assuring themselves that practitioners in all agencies are adequately trained and able to recognise and manage cases of Child Sexual Abuse in Devon. They may wish to consider developing a Child Sexual Abuse strategy as part of this. 21 | P a g e c) The early health information from hospital and Health Visitor does not seem to have been taken into account when N was assessed in 2007 for emotional abuse. d) The hospital did not seem to have appreciated the full background of Mrs Q’s antenatal problems with mental health and other risk factors for neglect. e) The GP notification of the sexualised behaviour in the waiting room which was appropriately shared with Children’s Social Care, does not seem to have been taken into account when CAMHS queried CSA in view of her urinary infections. f) The possibility of CSA, raised by CAMHS to the GP, does not seem to have been shared with the hospital or Children’s Social Care. g) The Police do not appear to have been informed about Mr R having disclosed that his relationship with N was sexual – this may have informed their subsequent management when faced with the pair being together in various settings. h) The risks of Mr R being investigated for possession of indecent images of children does not appear to have been shared with health, CAMHS, or Children’s Social Care until he was found in N’s bedroom in August 2011. 3.27 It is possible that if N had remained on an early help pathway between periods of Child Protection Planning, that the channels of communication between agencies would have been easier, as regular face to face meetings (team around the child or TAC meetings) would have occurred between the family and all professionals looking after N. Face to face meetings such as strategy meetings or team around the child meetings with all those involved with the child (even in a satellite manner such as the Probation) is by far the best way of ensuring information is adequately shared and risk assessed by all agencies, with multiagency engagement in planning. If this had happened in this case, it is possible that identification and termination of the abuse could have happened much earlier. 22 | P a g e 3.28 In addition, the use of the Early Help and TAC electronic recording process (meeting minutes and an Early Help Plan) can help clarify the information which is shared, and ensure all information is held in a place that all professionals can access. 3.29 It is important that methods of recording safeguarding information about children and young people are secure, yet available to other professionals if needed. The CP-IS (NHS Child protection information sharing system) system of information sharing has been adopted in Devon, currently involving the hospital and Children’s Social Care, though there are problems with its roll-out and it is not yet functional. 3.30 A highlighted problem has been retention of safeguarding records within schools. Both schools had destroyed or lost their safeguarding records regarding N. This has been a highlighted area recently within education, and most schools are now using online safeguarding data storage such as CPOMS13. There is now clear guidance regarding record keeping and the secure transfer of files between schools in a secure way, and this was highlighted in one of the recent Education ‘one-minute guides’ used by schools. 3.31 Training in record keeping is planned for health staff working in Community Paediatrics and Child and Adolescent Mental Health (CAMHS) in May and June 2018. 3.32 The use of the MASH as a means of sharing information between agencies at the point of contact has had positive outcomes for children. In January 2018, over 70 strategy meetings took place via the MASH, with 100% of cases having feedback to practitioners. 3.33 In N’s case, information gathered in previous assessments was not carried forwards. There was little consideration of historical factors and information became lost within the record. The use of chronologies and timelines is helpful 13 CPOMS – safeguarding and child protection software for schools – an online system to record and monitor child protection concerns in pupils. 23 | P a g e in such complex cases and is recommended within the new practice standards for Children’s Social Care. 3.34 Children assessed by Children’s Social Care now have their assessment recorded on a Single Assessment template. The template contains embedded guidance which highlights that the assessment, conclusions and plan should be considered within a strengths based perspective and give close consideration to the personal, family and community resource available to the family and the need to target strengths and develop resilience. 3.35 The need for plans to become more outcome focused to drive purposeful interventions and improve outcomes for children has been highlighted as one of the top 10 areas for improvement in the Social Care Improvement plan for 2017/18 and has been made a priority for improvement in the forthcoming year. c. Is there evidence that Child N disclosed or attempted to disclose abuse as a child and if so, why was this missed by professionals? 3.36 N had numerous interactions with practitioners in health, CAMHS, Children’s Social Care, education and Police but did not disclose verbally and directly her sexual abuse until she was an adult. She said herself that she lied about her relationship with Mr R to practitioners as she loved him and also feared she would not be believed if she told the truth. 3.37 N’s fear about not being believed was likely to be related to the fact that she had previous experience of disclosure leading to no action: The DCFP may wish to assure themselves that Child Protection Plans are outcome focused and drive purposeful interventions and improve outcomes for children and their families. The DCFP may wish to assure themselves that there are standards within organisations regarding safeguarding record keeping and that such standards include guidance on retention of records, clarity of record keeping, and accessibility. 24 | P a g e • She disclosed in 2008 that her mother’s partner had assaulted her. • She disclosed that she was having sex at the age of 12 to a social worker. • She disclosed at the age of 12 to another young person that she was ‘seeing an older man’. • She said to her GP at the age of 13 that she self-harmed but was stopped by her ‘boyfriend’. • She disclosed that her overdose in 2010 was due to her worries about CAMHS input stopping, yet it still ceased. • She said in 2011 that she had taken a pregnancy test yet when she said their relationship was non-sexual this was not challenged. 3.38 We also know that at times she was told to lie to cover up abuse – such as when she disclosed about Mum’s partner assaulting her and later retracted her allegation. 3.39 Mr R was well known to the Police and his dealings with them may have coloured her interaction with the Police. He appears to have exhibited considerable control over her, evidenced by the fact that N’s relationship with Mr R had ended, and he had moved out of area, by the time she finally disclosed her abuse to her mental health worker in 2015. We know that victims of abuse in childhood often disclose only when they feel safe, and often only as adults. Mr R having moved out of the area may have allowed N to feel safe enough to disclose. 3.40 The appointment where N disclosed, was her first appointment with an adult mental health services worker – the change in approach from professionals working with children and those working with adults may have encouraged her to disclose. Her mental health worker also saw her at her home at this appointment, rather than in hospital. The change in venue may have added to her feeling safe enough to disclose her abuse. 3.41 Frequent changes of professional may have impacted on N’s ability to disclose. N had multiple changes of mental health worker when under CAMHS. She frequently had short action intervention and then was discharged again, sometimes after only one appointment. In total she went in and out of CAMHS services six times. She did have one long period of 9 sessions with one worker however and still made no disclosure. Her eventual disclosure was at her first 25 | P a g e appointment with her adult mental health worker; however, this time the same worker then worked with her for over a year, until she herself felt ready to disengage with the service. 3.42 Medical appointments and hospital admissions focussed on N’s medical needs. She was rarely seen on her own without her mother. This may have been a barrier to disclosure. 3.43 Services often provided very separate care packages to N. Little face to face liaison took place between professionals, except for the episodes of statutory intervention within a child protection plan. When N did finally disclose to her Mental Health Worker, this individual travelled with N to see the Police and enabled her to forge a trusting relationship with the investigating officer, leading to further disclosure of her abuse. 3.44 Good quality supervision and interagency planning at the Early Help level can help facilitate disclosure even when changes of practitioner are necessary in services with a high turnover of staff, or patients are moved in and out of services. 3.45 Good planning is needed for transfer from one professional to another. Children’s Social Care are about to launch a case transfer policy, which includes principles of case transfer including that children and young people should experience the least number of transitions during their contact with Children’s Social Care. d. How do professionals facilitate disclosure? What skills are needed by professionals dealing with children at different stages of development to facilitate this? 3.46 Agencies were asked specifically how they facilitate disclosure today, both in the Independent Agency Reviews and in the practitioner learning event. Devon The DCFP may wish to assure themselves that all agencies facilitate disclosure through consistent involvement of practitioners and good interagency sharing of information in all cases but particularly in those identified as high risk of abuse. 26 | P a g e and Cornwall Police now have specific workers within the Police Force and good links with third sector agencies who can work over a long period with children and young people at risk. They are of the opinion that should N have presented today, the Youth Intervention Officer for her area would have become involved. The links with agencies such as SPACE14, Checkpoint and REACH enable workers to form trusted bonds with such young people. 3.47 In all agencies there is an increased awareness of the need to hear the voice of the child, both individually and in planning services. 3.48 Disclosure may happen at any age, to any professional. It is important that all staff know how to handle disclosure when it is made. Agencies identified that skills such as child focussed interviewing, the use of age appropriate references and language, and the importance of acting upon disclosure were vital to facilitate disclosure. Accurate recording of disclosure was also highlighted as an important skill. e. To what extent do professionals recognise grooming (of children and professionals) and understand how this inhibits disclosure? 3.49 All agencies identified a risk of grooming of both children and professionals in complex cases such as this. Grooming of children was felt to be a particular problem for adolescents. 3.50 In this case, both N and her family showed signs of being groomed by Mr R and his cousin Mr S, including the men living in the family home, and N’s mother taking her to visit Mr R at his mother’s house. 14 SPACE (formerly the Devon Youth Service) has 8 youth centres within Devon, offering a range of services for Young People. The DCFP may wish to assure themselves that all agencies train staff to facilitate disclosure at all ages from young children to adolescents. 27 | P a g e 3.51 There is also evidence of grooming of professionals in this case. When Mr R disclosed a sexual relationship with a 15-year-old to his probation worker (N was actually only 12 at the time), although there was a referral made to Children’s Social Care, no referral was made to the Police at the time. Although health and social care professionals found considerable evidence of neglect, there was frequently a lack of challenge made to the family. When N showed signs of mental ill health and distress at a young age, attribution was made to her difficult home life and the abuse she was suffering was not discovered. N was made subject to a Child Protection Plan twice with multiagency involvement, however both times the plan was ended with it recorded that there were no ongoing concerns and changes had been sustained. Between both plans however and after the second plan, N continued to have significant problems and her abuse was ongoing throughout this period. 3.52 It is recognised by professionals that N’s grooming by Mr R, together with possible grooming by Mr R and the family of professionals inhibited N’s disclosure. It is understood that to prevent this happening in future, grooming must be recognised and actively disrupted. To facilitate this, it is recognised that a culture of professional challenge and scrutiny is necessary. Where these were missing in this case, this led to drift and a delay in disclosure and resolution for N. 3.53 Since this case, a formal escalation, or case resolution policy has been instituted within Devon. The policy is clear and concise and user friendly. If it had been in force at the time, the problems escalating concern regarding N’s care could have been resolved, leading to her abuse being recognised much sooner. 3.54 Audits within Children’s Social Care have continued to show a need for improvement in management and supervision. In order to tackle this, both practice standards and the supervision policy have been updated in 2017. Within this new policy, each child open to the supervisee should be the subject of supervision at least every 4 weeks, and the template for recording supervision includes prompts to ensure elements such as the child’s voice and experience are regularly considered. 28 | P a g e 3.55 Within the Police, there has been an increase in scrutiny and supervision of cases for safeguarding issues. With the development of the MASH and the central safeguarding team, all new Police cases involving children are now scrutinised daily. Internal reflective learning panels are timetabled throughout the year to critically examine the investigation of safeguarding offences. Multiagency case audits also take place and identify areas for development and facilitate the sharing of good practice. Direct supervision of cases takes place by the first line supervisor and complex cases are reviewed weekly by the Senior Management Team. 3.56 Within Health, all referrals to MASH are now quality assured both by community and hospital-based services. There are supervision policies within all health agencies and audit details of supervision by the community trust shows a clear understanding of concerning factors in both the child and their adults and carers. Within the hospital, safeguarding supervision has been embedded within the working culture, particularly of high risk areas such as Midwifery, Paediatrics and the Emergency Department. Peer Review also takes place for clinicians involved directly with safeguarding cases. 3.57 Probation are midway through a major organisational re-structure, resulting in increased recruitment of operational staff and increased capacity of front line workers and managers. Management spans of control are being reduced, enabling more frequent supervision of staff and performance data reports are being produced as a further check to ensure the right cases including child safeguarding cases are discussed and monitored. In addition, staff supervision templates are being revised to ensure safeguarding cases are identified as a standing agenda item in supervision. 3.58 Within the voluntary agencies involved in this case, there is an excellent supervision structure, including weekly case meetings as well as individual supervision. 3.59 Within Education, there is more difficulty. SWDA, the provider of out of school education provision, where the most vulnerable children often receive help, identify that they have an ongoing need for supervision. This is not provided currently due to limited resources. Within one school, internal supervision is performed informally, and they also have some external supervision from the 29 | P a g e early help for mental health team. There appears to be no formal supervision however in either school contacted. This is an ongoing gap. 3.60 There are in addition several initiatives taking place in Devon where possible perpetrators of grooming may be identified. In particular, the ‘think family’ approach, which has been adopted by most of the partner agencies may aid identification. The acute hospital board have been particularly helpful in ensuring their staff use this approach. Devon and Cornwall Police use their ViST (vulnerability screening tool) to record all contacts where children are present. They are all reviewed by the central safeguarding team, who decide which cases need further information to be shared with partner agencies, or a child protection referral. 3.61 The MACSE forum considers perpetrators as well as victims of exploitation and today it is likely that Mr R would have come to their attention, further enhancing the response provided to N. 3.62 Community Health services also operate a ‘think family’ approach. In this case, N’s father received little attention or focus in investigation or planning. The increased use of genograms and considering the wider family and associates is vital in such cases. 3.63 The co-location of services in the MASH enhances the ‘think family’ approach. The close working relationships with Police, Health and Children’s Social Care allows for the consideration of the wider family and associates. The DCFP may wish to assure themselves that all agencies escalate concerns when needed and are aware of and use the DCFP case resolution protocol appropriately. The DCFP may wish to assure themselves that all agencies have appropriate policies and practice with regards to safeguarding supervision. They may wish to consider holding a themed audit of supervision. 30 | P a g e 3.64 Audit themes continue however to highlight the need to work with fathers and men in families. f. To what extent do professionals understand the links (including coexistence) between neglect, CSA and CSE? 3.65 Several agencies identified a possible lack of understanding by professionals of the links between neglect, CSA and CSE. There appears to be a lack of research in this area, particularly in adolescents. 3.66 All adolescents may exhibit risky behaviour. In a safe and supportive environment, this leads to exploration of boundaries and is an essential part of development. In the context of neglect, or other abusive environments, then normal risk-taking behaviour can rapidly escalate and become damaging. In the case of N, she had suffered long standing neglect, and therefore was very vulnerable to all forms of exploitation and dangerous behaviour. 3.67 N was already exhibiting this by the age of 12, when she was known to be going out at night with persons unknown, associating with people older than her and possibly taking part in sexual activity. In addition, it is possible that N suffered sexual abuse at a young age, so this further impacted on her knowledge of healthy relationships. She was not in school so was removed from her peer norms and their experiences at the same age. Her role models in her sister and mother were not ideal and so she was at further risk of mental health problems and risk-taking behaviour in the form of overdose. 3.68 N’s vulnerabilities and particular risks as an adolescent appear to have been lost in the attempts to safeguard her. They should have led to an up-regulation of the early concerns regarding her relationships and lifestyle. Any relationship with Mr R, be it sexual or non-sexual should have been very concerning in view of his age difference and criminal behaviours in addition to her other The DCFP may wish to assure themselves that practitioners consider the whole family and associates in the assessment and management of child protection cases. They may wish to assure themselves that there are effective ways of working between children’s, young peoples and adult services in the families most at risk. 31 | P a g e vulnerabilities and a focus on changing the underlying risk factors should have taken priority. 3.69 A reflection of the lack of understanding of co-existence of risk is that there was an assumption that mother could protect N, despite evidence to the contrary. At times, agencies withdrew intervention citing these risk factors as a barrier (such as CAMHS withdrawing care due to an unstable home environment). 3.70 The risks associated with neglect can become compounded further as in this case. N’s out of school provision relied on her remaining under mental health services, as it was provided on a health basis. When her CAMHS care was withdrawn as it was felt her home life was too turbulent, her out of school provision was also withdrawn, leaving her extremely isolated and vulnerable in the community. She cited withdrawal of services as the reason for one of her episodes of self-harm. Her vulnerability factors which were cited as her reasons for not receiving care should have led to increased support not a reduction in care for such a vulnerable adolescent. 3.71 Many of N’s long-term problems are likely to be not only due to her sexual abuse, but also due to her neglect. This has had a definite impact on her development and educational attainment. Her mental health problems are likely to be due to a mixture of her longstanding abuse and her lack of emotional development secondary to neglect. These are pervasive and lifelong conditions brought about by a combination of her neglect and sexual abuse. 3.72 The additional risks conferred from long standing neglect should be taken into account, and this is included in both the CSE and Neglect toolkits. There is evidence of excellent partnership working with a focus on adolescent risk within the MASH, within Multiagency Risk Conferences (MARACs) and within the MACSE forums. There are also a number of excellent providers of support to adolescents within Devon such as Young Devon, who have around 140 staff operating in more than two dozen locations across the county. 3.73 The provision for management of adolescent risk today appears very different from that present at the time that N suffered her abuse; however, some of the risks now are different too. It may be that agencies wish to broaden the remit 32 | P a g e of their sexual exploitation forums to include other forms of adolescent risk such as other types of exploitation. CHAPTER 4 Summary and conclusions 4.1 N was 19 years old when she disclosed that between the ages of 10 and 14, she was sexually abused by a man 10 years her senior. 4.2 N was known to many agencies both before and during her abuse, and she had two periods of being subject to a Child Protection Plan. 4.3 N did not disclose her abuse until she was out of contact with her abuser and had a stable therapeutic relationship with a mental health worker. 4.4 N suffered longstanding neglect; opportunities to pick this up at a young age were missed by several agencies. 4.5 N had multiple symptoms and indicators of possible sexual abuse, there were missed opportunities to recognise this by several agencies. 4.6 When sexual abuse was considered, the lack of a disclosure meant that concerns were dismissed. The DCFP should assure themselves that partners are moving from a sole focus on CSE to a wider remit of all forms of exploitation faced by young people. They may wish to assure themselves that organisations providing support to adolescents are appropriately funded and that pathways for access and collaboration are secure. The DCFP may wish to assure themselves that practitioners receive specific training on the co-existence and indeed increased risk of other forms of abuse such as such as sexual abuse and exploitation when neglect is identified. They may wish to ensure that these risks are identified and assessed appropriately within the neglect and CSE toolkits. 33 | P a g e 4.7 A confession of sexual contact by the abuser to his Probation worker was dismissed when information by N and her family was given that no sexual contact had taken place. 4.8 N tried to call for help, by self-harming including taking overdoses, seeing her GP frequently with low grade concerns, and giving clues regarding sexual activity even whilst denying it during dealings with professionals. She claimed she was sexually active to professionals (but with a child of her own age). 4.9 Professional curiosity was absent from many of N’s interactions with professionals. 4.10 N has suffered long term complications with her emotional and physical health due to her neglect and sexual abuse 4.11 In most of these areas, agencies within Devon have shown considerable improvements in practice, especially with regards to Child Sexual Exploitation. Learning Points 4.11 In complex cases where multiple classes of risk occur, the presence of neglect should reduce thresholds for intervention in other areas. 4.12 In order to disclose, children and young people need consistent contact with trusted professionals but may still not disclose until they are certain they are safe from their abuser. 4.13 Children and young people who are the victims of childhood sexual abuse and exploitation may not recognise themselves as victims and may actively mislead professionals investigating the case. This is because sometimes they feel that they are to blame for the abuse, and also because children often do not want to see harm or punishment coming to the perpetrator, especially if a care giver, or if they perceive themselves as being in a relationship with the abuser. Abusers are also often good at silencing their child victims. Professional curiosity and challenge needs to be applied in these situations. The DCFP should consider the best way of disseminating the learning from this SCR, so that it reaches as many practitioners as possible. 34 | P a g e 4.14 In some child protection cases, particularly in neglect cases, it is important to use historical information to build up the true picture and fully assess for progress long term against goals. 4.15 Children who fail to attend school need a multiagency approach to investigation and management of their non-attendance. 4.16 Children who self-harm at a very young age, need a multidisciplinary approach to investigation and management of their self-harm. The possibility of sexual or other child abuse should be considered. 4.17 Children with injuries to intimate areas should be assessed for the possibility of sexual abuse. 4.18 Poor quality of supervision leads to drift and poor outcomes for children. 4.19 Adolescents with risky behaviour benefit from a multiagency approach to management of their problems. 4.20 Perpetrator confession, especially to trusted professionals, should be held as the highest level of evidence for child protection investigations, in line with disclosure by the child. 4.21 Interagency working within the MASH facilitates high quality investigation and positive outcomes for children. Considerations for the board The DCFP should consider assuring themselves that practitioners from all agencies understand the indicators for neglect. They may wish to assure themselves that practitioners are confident in the use of the neglect strategy and toolkit. The DCFP should ensure that guidance relating to Child Sexual Abuse, including that within Threshold Guidance, is robust and easily understood. They should consider assuring themselves that practitioners in all agencies are adequately trained and able to recognise and manage cases of child sexual abuse in Devon. They may wish to consider developing a child sexual abuse strategy as part of this. The DCFP may wish to assure themselves that there are standards within organisations regarding safeguarding record keeping and that such standards include guidance on retention of records, clarity of record keeping, and accessibility. 35 | P a g e The DCFP may wish to assure themselves that Child Protection Plans are outcome focussed and drive purposeful interventions and improve outcomes for children and their families. The DCFP may wish to assure themselves that all agencies facilitate disclosure through appropriate training, consistent involvement of practitioners and good interagency sharing of information in all cases but particularly in those identified as high risk of abuse. The DCFP may wish to assure themselves that all agencies have appropriate policies and practice with regards to safeguarding supervision. They may wish to consider holding a themed audit of supervision. The DCFP may wish to assure themselves that all agencies escalate concerns when needed and are aware of and use the DCFP case resolution protocol appropriately. The DCFP may wish assure themselves that practitioners are aware of the whole family and associates in assessments and management of child protection cases. They may wish to assure themselves that there are effective ways of working between children’s, young peoples and adult services in the families most at risk. The DCFP should assure themselves that partners are moving from a sole focus on CSE to a wider remit of all forms of exploitation faced by Young People. They may wish to assure themselves that organisations providing support to adolescents are appropriately funded and that pathways for access and collaboration are secure. The DCFP may wish to assure themselves that practitioners receive specific training on the co-existence and indeed increased risk of other forms of abuse such as such as sexual abuse and exploitation when neglect is identified. They may wish to ensure that these risks are identified and assessed appropriately within the Neglect and CSE toolkits. The DCFP should consider the best way of disseminating the learning from this SCR, so that it reaches as many practitioners as possible. 36 | P a g e APPENDIX 1 – Glossary of terms LSCB (DCFP) The LSCB is the Local Safeguarding Children Board, known in Devon as the Devon Children’s and Family Partnership (DCFP). This is a board made up of senior representatives of the organisations who have contact with children including Children’s Social Care, Police, health and education. It was a recommendation of section 13 of the Children Act 2004, that such a board should be established in each area. Serious Case Review Group This is a group of senior managers from across all agencies, whose role is to oversee the SCR process, advise the Independent Reviewer on local issues and ensure the quality of the report. Some members of the Group will ensure any recommendations from the Review are followed up with an action plan. Child Protection Case Conference A meeting of professionals such as teachers or social workers and a family to discuss a case and determine how best to safeguard a child and promote their welfare. This may be held following an investigation under section 47 of the Children Act 1989 (a child protection investigation). Child Protection Plan An outcome from conference, which assesses the likelihood of the child suffering harm and looks at ways that the child can be protected. Professionals decide upon short and long term aims to reduce the likelihood of harm and clarify people’s responsibilities and actions to be taken, together with outlining ways of monitoring and evaluating progress. Child In Need Plan When it is decided that a child is unlikely to achieve or maintain a reasonable standard of health or development without the provision of services from the Local Authority, then the child is registered as a Child in Need. This may be as step-down from a Child Protection Plan, or may be the outcome from a child protection investigation and a Case Conference. This is under section 17 of the Children Act 1989. A Child in Need plan sets out what works well, what support is required and why and which agencies will provide the required services. It also outlines what the expected outcomes are and what the timeframe of the plan is. 37 | P a g e APPENDIX 2 – Participating agencies Devon and Cornwall Police Devon Children’s Social Care Devon Multiagency Safeguarding Hub (MASH) National Probation Service Virgin Care Ltd – CAMHS, Health Visiting, School Nursing1 South West Ambulance Services NHS Trust North Devon Healthcare Trust Torbay and South Devon NHS Foundation Trust Devon Doctors (out of hours GP services) GP Surgery Devon Partnership NHS trust (adult mental health services) Teignbridge Housing (Young Devon) Education (including education other than at school service) 1 Virgin Care Limited were involved in the review but were not the provider of childrens community health services during the period under review. 38 | P a g e APPENDIX 4 Documents consulted Devon Neglect Strategy Devon Case Resolution Protocol UK Government official statistics – characteristics of children in need 2016-2017 https://www.gov.uk/government/statistics/characteristics-of-children-in-need-2016- to-2017 NSPCC child sexual abuse facts and statistics 2017: https://www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/child-sexual- abuse/sexual-abuse-facts-statistics/ Working Together to Safeguard Children 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach ment_da/file722305/Working_Together_To_Safeguard_Children_-_Guide.pdf DCFP Annual Report 2016-2017 https://www.devonchildrenandfamiliespartnership.org.uk/uncategorized/annual- report-2016-2017/ NSPCC – How safe are our children? 2018 |
NC043758 | Death of a 3-year-old girl in August 2012, from internal bruising to the abdomen as a result of blunt force trauma. Post mortem revealed evidence of older injuries. Father pleaded guilty to manslaughter and mother was convicted on a charge of child cruelty. Paternal history of: childhood trauma; time spent looked after by the local authority; frequent use of cannabis; controlling behaviour, especially towards females; and having his first child placed for adoption following an assessment that he was incapable of caring for a child. Father was known to criminal justice agencies and had spent time in prison for burglary and an offence of having sex with a girl under the age of legal consent. Mother had experienced a chaotic childhood, was identified as compliant and passive by professionals and was working long hours in two jobs prior to Child K's death. Sets out key findings using a systems model based typology developed by Social Care Institute for Excellence (SCIE) and raises issues for consideration in regards to the identified themes for learning. Key themes include: importance of enquiring into parents' history and how this might impact on parenting capacity; addressing professional optimism and lack of professional curiosity; addressing the needs of children who have a parent in prison; and increased and more consistent use of risk assessment tools and frameworks.
| Title: A serious case review: ‘Child K’: the overview report LSCB: Lancashire Safeguarding Children Board Author: Peter Maddocks Date of publication: November 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 69 Lancashire Safeguarding Children Board A Serious Case Review ‘Child K’ The Overview Report July 2013 Page 2 of 69 Index 1 Introduction and context of the review ..................................................... 4 1.1 Rationale for conducting a serious case review .................................... 5 1.2 The methodology of the serious case review ....................................... 5 1.3 Reasons for the review and terms of reference .................................... 7 1.4 The scope of the serious case review .................................................. 8 1.5 The terms of reference in national guidance ...................................... 10 1.6 Particular issues identified by the SCR panel for further investigation by the individual management reviews: ............................................................... 10 1.7 Membership of the case review panel and access to expert advice ........ 12 1.8 Independent author of the overview report and independent chair of the serious case review panel ......................................................................... 12 1.9 Parental and family contribution to the serious case review ................. 13 1.10 Timescale for completing the serious case review ............................... 14 1.11 Status and ownership of the overview report ..................................... 14 1.12 Previous serious case reviews ......................................................... 15 1.13 Inspections of services for children in Lancashire ................................ 15 1.14 Summary conclusion of the review panel .......................................... 16 1.15 The family and other significant people ............................................ 19 1.16 Cultural, ethnic, linguistic and religious identity of the family ................ 21 2 Synopsis of agency involvement ............................................................. 23 3 The critical reflection and analysis from the individual management reviews. . 31 3.1 Summary .................................................................................... 31 3.2 Significant themes for learning that emerge from examining the IMRs ... 31 TOR1 Historical information...................................................................... 33 TOR2 Child and her experiences at the centre of assessments ......................... 35 TOR 3 Consideration of diversity, social background and integration ................ 39 TOR 4 Information sharing and communication ............................................ 41 TOR 5 Examination of how relevant historical information was examined in assessment and taken into account for providing services .............................. 45 TOR 6 Extent to which services understood the significance of father’s personal and family history ................................................................................... 49 TOR 7 How child protection and safeguarding issues were identified and managed ........................................................................................................... 51 TOR 8 Resources and capacity ................................................................... 52 4 Analysis of key themes for learning from the case and recommendations ...... 55 4.1 Learning from previous serious case reviews ..................................... 56 4.2 Innate human biases (cognitive and emotional) .................................. 56 4.3 Responses to incidents or information .............................................. 60 4.4 Longer term work ......................................................................... 62 4.5 Tools .......................................................................................... 64 4.6 Issues for national policy ................................................................ 65 5 APPENDICES ........................................................................................... Appendix 1 - Procedures and guidance relevant to this serious case review ....... 67 Legislation ............................................................................................. 67 Page 3 of 69 The Children Act 1989 .......................................................................... 67 The Children Act 2004 .......................................................................... 67 Safeguarding Procedures ......................................................................... 68 The local safeguarding children procedures .............................................. 68 Other local procedures relevant to this serious case review ........................ 68 National guidance ................................................................................... 68 Working Together to Safeguard Children (2013) ........................................ 68 Common Assessment Framework (CAF)................................................... 69 Page 4 of 69 1 Introduction and context of the review 1. In late August 2012 the regional ambulance service received an emergency telephone request to attend at the family home of a three year old child; the call had been made by the father aged 22 and the mother aged 20. Upon their arrival the paramedics found Child K to be in cardiac arrest. Child K was taken immediately by ambulance to the local hospital where the child was formally certified dead within 20 minutes of arrival; it was noted that there was already evidence of rigor mortis which can set in between one and eight hours after death. 2. The parents had told the paramedics that Child K had been unwell with sickness and diarrhoea on waking up; Child K had not been eating or drinking. The parents said that their child had collapsed after being taken to the toilet. 3. A post mortem examination identified internal bruising to Child K’s abdomen; this was judged to be consistent with blunt force trauma of the type that can be the result of a punch or being kicked. Damage to several internal organs was identified including the spleen and bowel. Older injuries were also diagnosed. 4. It was noted that the house had some animal waste inside (rodent) and outside the home (dog). Father had been using cannabis. Arrangements were made for Child K’s sibling to initially stay with her maternal grandmother. 5. Mother and father were both arrested. No admission was made by either to causing injury to Child K. They stated to the police (as well as to the media) that their child’s injuries were the result of falling off a swing. Therefore a second post mortem was undertaken which provided the same result as the first; Child K had died as a result of a blunt edge trauma and internal bruising to the abdomen likely to be caused by a kick or punch. 6. Father was charged with murder and remanded into custody. Mother was subsequently charged with causing or allowing the death of a child and was also remanded into custody. The surviving sibling is subject of separate legal care proceedings. 7. During their trial, father changed his plea to being guilty of manslaughter; as a result of that change of plea, the judge directed the jury to discharge mother for the original charge of causing or allowing the death of a child and instead to consider whether she was guilty of a charge of child cruelty. She was convicted on that charge. 8. Both of the parents were criticised for their attempts to misdirect the investigation. The police had to balance whether their initial statements were true and believe that they were grieving parents or, as in fact proved to be the case the parents had relevant knowledge about the circumstances of the Page 5 of 69 death of Child K. There were only a small number of adults who had been in contact with Child K in the days leading to her death; some of these were not family members. A public appeal in the local media had been made for information to assist the police with their inquiries. 9. Child K was the eldest of two siblings and was living with both of her parents when she sustained her injury. Father had been looked after by the local authority for several years when he was an adolescent. He was known to criminal justice services and this had included terms of imprisonment in regard to burglary and for an offence of having sex with a girl under the age of legal consent. 10. Child K’s mother was not known to any services other than the usual universal services associated with being educated and receiving health care for herself and her children. 11. Although there had been referrals to children’s social care services (CSC) in relation to the family with the last occurring about two weeks before Child K died children’s social care services were not involved when Child K died. The children had never been the subject of a multi agency child protection conference. Further information and analysis is provided in later sections of this report. 1.1 Rationale for conducting a serious case review 12. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 8 of Working Together to Safeguard Children (2010). 13. The LSCB should always undertake a serious case review when a child dies and abuse or neglect is either known or is suspected to be a factor in their death. 1.2 The methodology of the serious case review 14. A serious case review panel was convened of senior and specialist agency representatives to oversee the conduct and outcomes of the review. The panel was chaired by an independent and suitably experienced person. 15. Work began on compiling a chronology in October 2012, which coincided with the appointment of the independent chair of the serious case review panel and of the independent author of this overview report. Neither the chair nor the overview author has worked for any of the services contributing to this serious case review. Further information about their relevant experience and knowledge is provided in section 1.8. Page 6 of 69 16. This serious case review was completed using the methodology and requirements set out in the government national guidance that applied at the time of the review being commissioned and completed. That guidance has been extensively revised in the latest edition of Working Together 2013 following the publication of the Munro Review’s final report and recommendations in 2011. 17. The government revised national guidance for assessment, multi-agency child protection and the conduct of serious case reviews in April 2013 as the review was nearing completion1. 18. The LSCB in Lancashire was already working on how future serious case reviews in the county could be developed in order to provide a more productive window into the local systems for safeguarding and protecting children2 and have participated in regional and national pilot work on using system learning within serious case reviews developed by SCIE (Social Care Institute for Excellence). 19. The SCR panel decided to build on the learning that had been developed from two previous SCRs in the county; one of those had been wholly conducted using the SCIE framework and another SCR had used the framework to present the findings from the review. 20. For this SCR the panel wanted to have greater level of practitioner involvement in compilation of information and in the development of analysis. A seminar style session was held in October 2012 that involved the panel members meeting with practitioners who were directly involved with the family. This session was used to help identify the key episodes of practice and outline some of the contributory factors influencing key events and decision making. 21. This material was incorporated into the individual discussions and the drafting of the agency individual management reviews (IMRs). A further session was held involving the panel and practitioners at the point that draft overview reports were being developed to contribute to the key findings and analysis. 1 Working Together to Safeguard Children. A guide to interagency working to safeguard and promote the welfare of children March 2013. which also incorporates the revised arrangements for assessment of children that will be based on locally determined single assessment. 2 Analysis of clinical incidents; providing a window on the system not a search for root causes. CA Vincent; Quality and Safety in Health Care, 2004; The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to serious case reviews in England. Page 7 of 69 22. The analysis in the final chapter of this report uses some of the framework developed by SCIE to present the key learning within the context of the local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have limited impact and value in complex work such as safeguarding children3. The final chapter of the review for example explores the influence of family and professional interactions, the responses to incidents and the tools that are used by professionals to help inform their judgments and decisions. 23. It is important to state that although the SCR panel has sought to place the learning from the review into a framework of systems learning this is not a SCIE review that has entirely used systems methodology to collect and analyse information from the people directly involved with the family. The evidence explores how the local systems both promote and in some circumstances inhibit professional practice and decision making. 24. The panel agreed case specific terms of reference that provided the key lines of enquiry for the review and were additional to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review (and are listed in section 1.4). These reports were completed by senior people who had no direct involvement or responsibility for the services provided to the children and their parents. 25. An overview of the health agencies was provided in a health overview report (HOR). This was provided by the Associate Director for Safeguarding, Assurance and Governance (incorporating designated nurse for safeguarding children) for the NHS in a specific part of Lancashire. The HOR was written in compliance with the expectations of Working Together to Safeguard Children (DCSF 2010) and combines information from health services commissioned by the NHS in Lancashire. This included three separate GP practices, health visiting services, maternity services, emergency care services and the historical information held by the child and adolescent mental health services (CAMHS) in relation to father. 1.3 Reasons for the review and terms of reference 26. The reason for undertaking this review is that Child K may have died as a result of non-accidental injuries. The death was reported to the Lancashire 3 A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al, Department of Education, September 2011 The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans Page 8 of 69 Safeguarding Children Board (LSCB) on 3rd September 2012 and was considered by the serious case review (SCR) group who recommended to the independent chair of the LSCB that the circumstances of Child K’s death met the criteria for a mandatory serious case review. 27. The review was commissioned by Nigel Burke, the independent chair of the Lancashire Local Safeguarding Children Board (LSCB) on the 14th September 2012. A serious case review panel was convened and was independent of all the services involved. 28. The serious case review panel at their first meeting on the 2nd October 2012 confirmed the scope and terms of reference for the SCR. The scope and terms of reference of the review was routinely discussed and updated at subsequent panel meetings to take account of any new or emerging information and reflection. 29. The purpose of the review is to establish what lessons are learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and better safeguard and promote the welfare of children in Lancashire. 1.4 The scope of the serious case review 30. The time period covers the lifetime of Child K, including the time her mother was pregnant with her. The period under review is from the beginning of 2009 until the end of August 2012. 31. There is significant earlier involvement by universal or specialist agencies in the lives of the parents. Therefore organisations were asked to include any earlier information about both parents, especially where it had a bearing on understanding their capacity as parents, including any evidence of violent or sexual behaviour, mental ill health or substance misuse. 32. All information known to a service providing an IMR was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the IMR and the health overview report. 33. All agency chronologies included detailed information about when the child was seen or observations were made about them. 34. Agencies that identified significant background histories on family members pre-dating the scope of the review provided a brief summary account of that significant history. 35. Reviews of all records and materials were considered including; Page 9 of 69 Electronic records Paper records and files Patient or family held records. 36. Individual management reviews were completed using the template provided by the Lancashire Local Safeguarding Children Board (LSCB), and were quality assured and approved by the most senior officer of the reviewing agency. 37. The following agencies have provided an individual management review that was to be completed in accordance with Working Together to Safeguard Children (2010), Chapter 8 and the associated LSCB guidance and relevant procedures. Health services in Lancashire that include: o A Hospital Trust (provided maternity and paediatric services) o Lancashire Care Foundation NHS Trust (provided health visiting services) o NHS for a specific part of Lancashire (general practitioner services) Lancashire County Council Children’s Social Care (historical involvement with father when he was looked after and provided after care services in addition to completing assessments more recently) Lancashire Sure Start Early Years (mother attended groups) Lancashire Constabulary (in relation to father’s criminal behaviour and investigation of Child K’s death) Lancashire Probation Trust (in relation to father’s criminal prosecutions) Lancashire County Council Young People’s Services4 (mother was a very regular attendee at a local youth centre and participated in activities although there was less contact after father joined the household) Cafcass (the children and family court advisory support service who provided reports in regard to the adoption proceeding for father’s first child) Independent nursery (mother worked as an apprentice until Child K’s death; the children had attended another nursery until a few weeks before Child K died; the parents had withdrawn the children because they were falling behind in paying fees) 4 Both parents in this case would have been included in vulnerable group categories for different reasons. Father as a former looked after child (LAC), having had a criminal background and links to the YOT; mother solely due to status as teenage pregnancy and a young parent. As such, both would have received more regular contact in the post 16 years period and father during his involvement with the YOT. This would have been delivered through the service obligations/responsibilities in delivering Connexions Services and through the voluntary attendance by both parents at youth centre activities including the young mums group. Page 10 of 69 38. Information was sought from other services although these agencies were not required to provide an IMR. North West Ambulance Service (responded to the initial emergency call) Youth Offending Team (worked previously with father) The Prison Service (father had served terms of imprisonment at two establishments for one offence; he was recalled under licence) 39. Information was also sought from members of the families and is described in section 1.9. 1.5 The terms of reference in national guidance a) Keep under consideration if further information becomes available as work is undertaken that indicates other agencies should carry out individual management reviews. b) To establish a factual chronology of the action taken by each agency; c) Assess whether decisions and action taken in the case comply with the policy and procedures of the Lancashire Safeguarding Children Board; d) To determine whether appropriate services were provided in relation to the decisions and actions in the case; e) To recommend appropriate inter-agency action in light of the findings; f) To assess whether other action is needed in any agency; g) To examine inter-agency working and service provision for the children; h) To establish whether interagency and single agency policies adequately supported the management of this case; i) Consider how and what contribution is sought from the family members; j) To develop a clear multi agency action plan from the overview report. 1.6 Particular issues identified by the SCR panel for further investigation by the individual management reviews5: 40. In addition to analysing individual and organisational practice, the individual management reviews should focus on: 5 These are the detailed issues that are analysed by the IMRs and in the detailed analysis. Page 11 of 69 a) The SCR should be focused on Child K and the safeguarding of her and her welfare. However, where historical factors have relevance, they should be included, with explanations as to their relevance to Child K. The Review will consider key episodes in the history of agency involvement with the child and her family in order to understand what factors may have influenced practice at the time. b) Examine whether all agencies kept the child and her experiences at the centre of their assessments of and interventions with the family. The Review will consider interactions between professionals and the family in order to understand the aspects of the family which influenced practitioners’ thinking. c) Examine whether all agencies and professionals gave due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration. d) Examine whether information sharing and communication systems within and between agencies were effective in safeguarding Child K. The Review will consider communication and collaboration in multi agency working in order to understand the influence of any significant factors on practice. e) Examine whether historical information was given appropriate emphasis within assessments and interventions. This relates to mother and father's histories, extending to others where this is relevant to the period under review and thus the care of Child K. Any relevant historical information prior to the timescale for the Review should therefore be summarised and included in IMRs. f) Examine whether agencies fully understood any issues about the father’s care history, offending history and mental ill health and the impact this may have had on Child K and took appropriate actions. g) Examine whether any safeguarding and child protection issues were identified and dealt with appropriately by agencies. Consider whether agency responses were correct and timely and whether safeguarding procedures were followed appropriately. The Review will consider the tools available to practitioners and the effect of management systems on practice in order to understand how these supported practice h) Consider whether agencies had the necessary resources and capacity. Consider also whether professionals working with the family were suitably skilled and adequately supervised and whether there is evidence of management accountability and support. The Review will consider the effects of human judgement and reasoning and any strategies used to combat biases in this case in order to understand how these impacted on work with the family. Page 12 of 69 1.7 Membership of the case review panel and access to expert advice 41. The case review panel that oversaw this review comprised the following people and organisations; Position Organisation Annie Dodd Independent Chair Directorate Safeguarding Manager Safeguarding, Inspection and Audit Services (LCC) Early Years Lead Quality and Continuous Improvement Service (LCC) Temporary Deputy Head of Children's Social Care Children’s Social Care Services (LCC) Strategic Safeguarding Lead Nurse Lancashire Care Foundation Trust Detective Chief Inspector Lancashire Constabulary Senior Probation Officer Lancashire Probation Trust Designated Doctor Primary Care Trust for a specific part of Lancashire (PCT) Assistant Head Lancashire Young People’s Service (LCC) Designated Nurse Primary Care Trust for a specific part of Lancashire (PCT) Safeguarding Lead Hospital Trust Panel Observers/Support Peter Maddocks Independent Author Business Manager Lancashire Safeguarding Children Board (LSCB) 42. The independent author of the overview report attended every meeting of the panel. 43. The panel had access to legal advice from a solicitor in the council’s legal service. 44. Written minutes of the panel meeting discussions and decisions were recorded by a member of the LSCB staff team in Lancashire. 1.8 Independent author of the overview report and independent chair of the serious case review panel 45. The independent chair of the serious case review panel was Annie Dodd. Ms Dodd was previously employed as an assistant director with a local authority children’s social care service and has over 30 years experience as a qualified social worker. Ms Dodd is now self employed as a consultant. She has previously chaired a serious case review for Lancashire SCB but has no other connection with Lancashire Safeguarding Children Board and has not been involved in any aspect of the management of the case. Page 13 of 69 46. Peter Maddocks was commissioned in September 2012 as the independent author for this overview report. He has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales as well as work on domestic homicide reviews. He has undertaken work as an overview author on two previous serious case reviews in Lancashire. Apart from this, he has not worked for any of the services contributing to this serious case review. 1.9 Parental and family contribution to the serious case review 47. The parents and other members of the extended family were made aware of this serious case review when it was commissioned. A letter was initially sent by the independent chair of the panel, who in consultation with the police ensured that the relevant national guidance was complied with6. 48. Father wrote a letter to the chair of the panel prior to the trial. Mother met with the chair of the panel. Information from both was considered by the panel and is incorporated where appropriate and relevant in the report. 49. The information that mother provided to the panel included her ambitions to get qualifications and to earn enough money through work to provide for her children. This impression of a motivated parent was consistent with the evidence from the IMRs. It contrasted with the difficulties that father had in finding work and holding down a job. Inevitably it meant that he gradually took on more daily responsibility for looking after the children while mother was working very long hours. 50. Mother had been aware of some of father’s history; this included knowledge of his first child and about his offences. She commented that although she was prevented from taking the children to visit father when he was in prison there was little contact in respect of risk assessment and management when he was released and became part of the household. 6 A Guide for the Police and the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 serious case reviews and criminal proceedings; April 2011 Page 14 of 69 51. Father wrote a letter to the chair of the panel. He commented on the amount of information that was provided when he consulted the NHS Direct website and had used the symptom checklist before calling the ambulance on the day Child K died. He reported that the website had provided many possible causes for the symptoms that he reported as having inputted into the website. He felt that there the information was not specific enough and asserted that it did not suggest that Child K’s life was at risk. The symptom checklist did not include a blunt trauma injury which both parents had denied any knowledge of until father changed his plea to guilty. 52. The letter was sent prior to the trial and before he admitted his responsibility for the fatal injury that killed Child K. In the letter he made clear statements that he intended to prove that both parents were innocent of any allegation that they were responsible for Child K’s death. He asserted in the letter that they did not know that Child K was so poorly. He stated that a two year old relative had similar symptoms and had to undergo a surgical procedure. 1.10 Timescale for completing the serious case review 53. The case review panel met on seven occasions between October 2012 and June 2013. The initial chronology of services involvement was completed by October 2012. The first draft agency reviews were completed in late November 2012. The first draft of the health overview report was completed in December 2012. The independent chair of the LSCB agreed to an extension for completing the review to allow the panel an opportunity to consider any additional information to emerge from the criminal trial of the parents. This overview report was presented to an extraordinary meeting of the LSCB in July 2013. 1.11 Status and ownership of the overview report 54. The overview report is the property of the Lancashire Safeguarding Children Board (LSCB) as the commissioning board. 55. Since June 2010, all overview reports provided to LSCBs in England have to be published in full7. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Child K and her family. 7 The coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children requires that both the executive summary and the overview report with suitable redaction to provide confidentiality are published. This arrangement has been confirmed in the revised national guidance issued in April 2013 and referred to in earlier paragraphs. The coalition government had ended the formal evaluation of SCRs from the 5th July 2012. Page 15 of 69 56. The report has to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible level of learning. 57. In reading this report, it is important to remain clear about the purpose of the overall review and of this overview report in particular. The review examines with the benefit of hindsight, if it is possible to identify whether alternative judgments and decisions could or should have been taken, and whether different outcomes might have been achieved for Child K. The review does not investigate the circumstances of Child K’s death. That is a matter for the coroner and for the police. 58. The review aims to be very challenging of all services for the purpose of building on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK. In doing this work, the panel are mindful about how complex or unclear some of the information and events may have looked to practitioners at the time of events. 59. An executive summary was provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The LSCB will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the overview report and executive summary to the Department of Education. 1.12 Previous serious case reviews 60. The LSCB in Lancashire had undertaken eight previous serious case reviews between 2008 and 2013. 61. Reference is made by several IMR authors to some of these and other previous serious case reviews completed in other parts of the country and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that action already recommended is not unnecessarily repeated. 62. Subsequent chapters of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this serious case review and include comments on how learning from previous reviews has been used. 1.13 Inspections of services for children in Lancashire Page 16 of 69 63. All children’s services in England are subject to inspections8. In December 2011 the comprehensive area assessment (CAA) annual rating given to children’s services in Lancashire was performing well9. This meant that services were above minimum national standards. 64. The CAA letter highlighted that although many aspects of contact, referral and assessment arrangements for children in need and children who may be in need of protection were satisfactory, a number of areas required attention. These included the uneven distribution of experienced and newly qualified staff within social work teams and the under-developed use of the common assessment framework (CAF) across the partnership. However, focused action was being taken by the local authority and plans were in place to address immediate deficiencies. These factors are identified as being contributory factors in how aspects of this case were managed. 65. In early 2012 there was a statutory inspection of safeguarding and looked after arrangements in Lancashire10. This evaluated safeguarding arrangements as being good in Lancashire with a well managed child protection service; Child K was never subject of any child protection plan. The inspectors commented that the local authority contact, referral and assessment arrangements had been comprehensively redesigned and had already had a positive impact. The quality of referrals made by partner agencies seen was good. Child protection enquiries were prioritised and responded to effectively to ensure children are safe. The CART (contact, referral and assessment team) had already led to improvements in the management of contacts and referrals but there were a small number of examples where referrers had not been satisfied with the CART and not all aspects of the service were subject to rigorous audit. 1.14 Summary conclusion of the review panel 66. The purpose of conducting a serious case review is to undertake a detailed examination of the events within the context of understanding how the judgements, decisions and actions were taken by the various professionals involved with Child K and her family for the purpose of drawing out learning to inform future policy, service development and individual practice. 8 The coalition government may change aspects of the inspection arrangements. 9 This profile includes findings from across Ofsted’s inspection and regulation of services and settings for which the council has strategic or operational responsibilities, either alone or in partnership with others, together with data from the relevant Every Child Matters indicators in the new National Indicator Set (NIS). 10 The inspection was carried out under section 138 of the Education and Inspections Act 2006. It contributes to Ofsted’s annual review of the performance of the authority’s children’s services, for which Ofsted will award a rating later in the year, subject to any changes that the coalition government may introduce. The inspections are part of a national programme of enhanced inspection of children’s services introduced in 2009 following the death of Peter Connolly (Baby P) and the two subsequent serious case reviews in Haringey. Page 17 of 69 67. The Munro Review commissioned by the coalition government in 2010 has emphasised the importance for learning and improving services and practice by looking at information within the context of people’s professional and organisational arrangements and the information they knew at the time of events. Hindsight can distort and mislead and cause the focus to fall on how individuals behave and act rather than understanding how they are influenced by a range of contributory factors. 68. The influences on practitioners doing their work effectively include the stability of the organisation they work in, their personal workload and more generally of their services, the quality of their training and knowledge, the clarity of working arrangements in matters such as recording and sharing essential information as well as their cognitive functioning (how they are processing and analysing information). These were all important in understanding this case. 69. The review panel are agreed that no opportunities were missed to prevent Child K’s tragic death. Until Child K had been injured and died she had been seen by several different professionals who consistently recorded that the children’s physical care was appropriate. The house was generally clean as were the children, who were also kept warm and were fed appropriately. Before Child K’s death, it is possible there had been a deterioration given the description of the house on the day that Child K died during a period when no professionals had been to the home and was when mother was working much longer hours including evenings and father was increasingly responsible for the care of the children. This changing pattern of care was not known by any professional. 70. The children were taken to health clinics and had their immunisations and other routine treatments. Professionals were never prevented from going into the house. The parents displayed a high level of co-operation and apparent compliance in their dealings with services that included health, social care as well as the police. 71. The review panel concluded that greater attention to other sources of historical and other information would have given improved context to what was seen during routine or other visits to the home or when the children were in clinics or at nursery. The information and analysis provided in later sections of the report explores the circumstances and factors that influenced the processing of information. The children’s father was in prison during the first pregnancy and his history should have been explored much more thoroughly. This complex history was largely stored in archived and historical records that were not accessible through the electronic system and was not available in an easily accessible chronology. This was a significant factor for practitioners; the CSC IMR author spent two days collating information for this review. Page 18 of 69 72. CSC had the most information about father because of his longstanding problems as an adolescent and young care leaver. Maternity services were not aware of this information as they were reliant on what was told them by mother. Yet there were indicators, by virtue of mother’s age and family circumstances that should have indicated a higher level of vulnerability. 73. It is apparent that the parents were keen to present themselves in a positive way. They acknowledged that they had both had difficult childhoods although the detail was not made explicit through the enquiries and assessments by health and social care in particular. Professionals generally relied on the parents following through their good intentions and did not receive any significant information to contradict this for much of the time. 74. There were reports about cannabis being in the house and objects that included screwdrivers and domestic knives being hidden as potential weapons that were reported by the police. Thus information was noted although was not regarded as a significant risk to the children. 75. Father in particular has had a difficult and at times traumatic history and was allowed to minimise aspects of his behaviour including his sexual offence. There are many factors in that history that resonate with research evidence in relation to a heightened concern about whether children are more likely to be maltreated. This does not mean that it predicts that child abuse or a child death will occur but it does provide important context for deciding on the type and style of assessment that is appropriate. 76. If practitioners, especially in CSC had been in a position to understand the history and significance more clearly, it would have created better opportunities for a more rigorous and searching assessment and ongoing contact. It would have challenged people to look beyond the behaviour being displayed in the contacts between the parents and various professionals. 77. The reasons that intervention was not better focussed included a reliance on unqualified or inexperienced practitioners, complex information systems that did not contain chronologies that could have shown up history and patterns as well as overstretched supervisors. These were the conditions in which misplaced optimism prevailed. 78. It is significant that father’s first child born to a previous partner had been placed for adoption following an assessment that had very clearly identified that he was incapable of caring for a child. Hindsight reinforces that this should have been explored far more carefully as part of the work with Child K and her sibling to establish what had changed. The adoption proceedings were still in progress when Child K’s mother had become pregnant. Page 19 of 69 79. There are themes for learning in regard to how the children of prisoners are supported and information is exchanged. There was some evidence that confidence in how sensitive information is shared and managed between statutory and independent providers might require further development. The invisibility of men is a recurring theme in reviews and is an issue in this case where there was probably an overreliance on what mother was able to offer the children that mitigated the deficits in regard to father. 80. Information and support was never properly coordinated through either a CAF or other framework. If the risks had been properly identified, it is likely that either a CIN (child in need) or child protection plan would have been developed; this would have meant that a more experienced lead professional would have been allocated responsibility for the case. There was no CSC involvement at the time that Child K died and the health visiting service had also stepped down their level of contact in the absence of any concerns. 1.15 The family and other significant people 81. Mother was aged 21 years old when Child K died and Father was 22 years old. Although CSC was not involved with Child K at the time of the death, there had been historical and more limited recent involvement. 82. Father had been looked after by the local authority in several different placements from the age of 12 years old until he was 16 and then continued to receive support as a care leaver until he was 21 during which time he had lived in seventeen different addresses that were mainly bed and breakfast. His mother had died when he was seven years old following an overdose of paracetemol. These traumatic events in his childhood in relation to attachment difficulties, abuse and transience were not mentioned or analysed within any assessments on Child K and his ability to meet her needs or consider any potential risk that he might pose. He had an unhappy education that was apparently compounded by the unrealistic expectations he felt his father had for him. He was assessed as having special education needs in regard to social, emotional and behavioural problems and was eventually permanently excluded from school and had attended a pupil referral unit (PRU). 83. He has 16 convictions from ten court appearances the first of which occurred when he 13; the majority have been for financial gain (he has had a chaotic lifestyle throughout much of his adolescence and been a long term user of cannabis; he had a series of disrupted placements and being homeless); his first custodial sentence was for criminal damage, burglary and arson (setting fire to a van at a car sales premises) when he was 16 and he served a sentence of five months at a youth offender institution (YOI). By this stage he was habitually using drugs and alcohol and was presenting with problematic sexualised and violent behaviour to carers and to other young people. Page 20 of 69 84. He was violent in his relationship with a previous girlfriend who became pregnant during that relationship in 2007. Care proceedings were taken in regard to that child and he had no further contact with that child after April 2008. By November 2008 mother had become pregnant with Child K. In August 2008 he was convicted of three sexual offences as a 17 year old involving a 13 year old girl and a separate offence of criminal damage for which he received a suspended sentence and a requirement to complete 100 hours of unpaid community work; he returned to court for further offences of burglary for which he received a suspended sentence of 12 months. Father maintained that he believed the girl had been 16 and on the day of his court appearance he overslept and was convicted in his absence. 85. Father participated well in the community work and complied with supervision requirements. Father was living with his brother at this time but ended in January 2009 due to domestic violence between the brother and his partner. In April 2009 he was arrested for burglary and was sentenced to 29 months at a YOI. He did not receive visits from mother until he moved from the first YOI in August 2009. Child K was born in July 2009. 86. During his time in prison father showed effort and motivation to participate in vocational and educational programmes and acquired several certificates including parenting, ICT, health and safety, food and catering, social and life skills as well as numeracy and literacy. Although he has been a long term user of cannabis and experimented with other drugs he was not apparently considered eligible for any specialist drug intervention programmes. 87. Other information from his time in prison indicates that father had a degree of vulnerability that reflected the very difficult childhood and later life experiences. There are reports of immature behaviour and he was involved in bullying incidents as a victim as well as perpetrator. He did try to circumvent restrictions placed upon him especially during his prison term in 2009 through to 2010 when he had restricted contact with mother and no contact with his daughters. His relationship with mother and the birth of his two daughters appear to be important sources of resilience for him and a motivating factor in addressing issues such as his impulsive behaviour and offending. 88. Mother had been reprimanded for criminal damage in 2005 but was otherwise unknown to the police. The police had executed search warrants of the family home in July 2012 when a small amount of cannabis was discovered along with a significant amount of money which was confiscated. 89. In 2009 mother and Child K were referred to the children’s centre to offer support and help encourage use of local services. There were 15 contacts between September 2009 and April 2010 when involvement by the early year’s services finished. Child K attended a nursery one day a week in the Page 21 of 69 autumn term of 2009 whilst mother completed a young parent’s course provided by the county young person’s service. 90. In February 2011 Child K had begun attending the same nursery again for two and a half days a week while mother was at college. In September 2011 the sibling also had begun attending for one day a week. Mother began working as an apprentice at another nursery operated by the same owner. Mother was working full time and both children also attended nursery fulltime. By December 2011 Child K was attending only four days a week although the sibling continued to be at nursery full time. Mother continued to work at the nursery until the death of Child K. The children had been withdrawn from their nursery placements in early August 2012 at which point their parents’ owed £1200 in nursery fees. 91. The synopsis in chapter two of involvement by services from 2009 onwards provides further information. 1.16 Cultural, ethnic, linguistic and religious identity of the family 92. Child K’s maternal and paternal families are white British. Their first and only language is English and there is no record of a physical or learning disability. Child K was living with her parents in rented accommodation at the time of her death. Her father was unemployed. 93. Lancashire has a population of 1.16 million, which is projected to grow by almost eight per cent to 1.23 million by 2028. The county comprises a mixture of urban, rural and coastal communities and covers twelve district councils four of which (Burnley, Hyndburn, Pendle and Preston) rank in the top 30 most deprived districts in the country (Index of Multiple Deprivation 2007). 94. Five per cent of the population are from minority ethnic backgrounds, predominantly Pakistani and Indian, clustered mainly in parts of the east of the county and in Preston. The particular area that Child K and the family lived is one of the most densely populated in the county and reflected the general ethnic profile of the county. More recently, small but growing numbers of people from Eastern Europe have begun to settle across the county, with concentrations in Lancaster and Preston. 95. A total of 20 per cent of children across the county are income deprived according to the Index of Multiple Deprivation 2007. Six areas (three in Burnley, two in Preston and one in West Lancashire) are ranked in the two per cent of the most deprived in England for child poverty and 9.5 per cent of children in Lancashire live in super output areas ranked among the 10 per cent worst nationally for income deprivation. Page 22 of 69 96. The particular area where the family were living in Lancashire in the region has almost 23 per cent of children living in poverty. This is just above the national average of 21.3 per cent and higher than the county average of 18.6 per cent. Of the adult population living in the area, just over 75 per cent are classified as being economically active. Page 23 of 69 2 Synopsis of agency involvement 97. This narrative summary of professional contact with Child K provides an account of the most significant events and decisions from the different services involved with Child K during the timeframe established for the review. 98. This summary, and indeed the whole overview report, has to strike a balance between protecting the confidentiality of the children, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later chapters. The summary does not therefore contain every contact with the children and their family; for example, the children attended a nursery at different times on a regular basis until they were withdrawn in early August 2012. 99. Mother’s pregnancy with Child K came soon after the termination of contact between father and his first child as a result of the care proceedings that resulted in that first child being placed for adoption (although this had not been completed). The parents were not living with each other during the pregnancy and by the time that Child K was born her father had been sentenced to 29 months at a YOI that began in the summer of 2009 following his conviction for burglary. Mother was living with the maternal grandparent before and after the birth of Child K. 100. Before and after the birth of Child K there was routine contact and follow up by primary health care services in relation to GP, midwifery and health visiting services. In September the health visitor in consultation with mother made a referral to the local children’s centre. Mother accepted a place on a young parent’s course run by the county young people’s service during the autumn term of 2009 and Child K attended a nursery one day week while mother was on the course between September and December 2009. 101. The maternal grandmother had been pregnant at the same time and there was a referral to the vulnerable family’s panel in late September 2009 in regard to the maternal grandmother’s pregnancy that noted that maternal grandmother had declined to engage with any offers of support made earlier in the year. This contrasted with the more positive engagement that Child K’s mother had with services. 102. A joint visit was made by two heath visitors following that panel discussion and a decision was made to continue follow up at level 2; this is an enhanced level of contact over and above the core universal provision for all new parents. The significance is that the additional need for support was recognised by health professionals but the family were reluctant to take up offers of help and contact. In the absence of more specific concerns, Page 24 of 69 professionals were reliant on continuing to work on a voluntary basis with the family. 103. In October 2009 mother responded to a suggestion by the teenage pregnancy support worker to join a parent and child group. In October it became apparent that father was writing letters to mother despite restrictions in contact that had been imposed by the prison’s governor. The leaving care worker wrote to the prison supporting contact between father and mother. 104. A home visit in October 2009 by the children’s centre worker provided an opportunity for the maternal grandmother to speak about the difficulties she was having with one of her other teenage daughters who was refusing to go to school. 105. In late October 2009 mother was offered the tenancy of a house and she had moved to the property by November 2009. Child K had a recurring upper respiratory tract infection for which mother sought advice and treatment from the GP and discussed with the health visitor. In late November mother took Child K to the local hospital A&E service with a particularly chesty cough. 106. Mother continued to receive support from the children’s centre and also attended groups such as a weaning group. 107. In January 2010 the offender manager contacted CSC to request an initial assessment to be completed to assess father’s request for contact with mother and Child K and it was clear that his sentence plan was being updated to reflect planning for discharge from prison under licence. The initial assessment was completed by a student social worker as an office based ‘paper exercise’ according to the CSC IMR author. Further analysis and comment is offered in later sections that include the IMR’s commentary about the acute staffing problems at the time and the consequences it had on aspects of case management and assessment. 108. There was a telephone discussion between mother and the student social worker during which mother stated that father had been convicted of the sexual offence because he had not attended court and that the offence occurred because the girl had not told him that she was only 13 years old. Mother also indicated that it was her intention to marry father on his release from prison and thereby signifying this was to be a long term relationship. 109. The referral was the subject of a discussion between the assistant team manager (ATM) and the after care worker in late February when the ATM indicated that father’s sexual offence was a source of risk that would require a specialist risk assessment of a type not undertaken by CSC and that a strategy meeting would be required as and when father was due to be Page 25 of 69 released and intended to live with mother. This never happened and is analysed in later sections of the report. 110. A couple of days later during a visit by the children’s centre worker she was told that the social worker had visited and had told mother that it would be inappropriate for her to visit father with Child K; there is no record of that visit by CSC. 111. A letter from the offender manager to father in mid March 2010 informed him that the issue of father’s risk to children was a matter for CSC to assess and make decisions but advised father to undertake a parenting course whilst he was still at the YOI; he completed this course. 112. In April 2010 mother had some concerns about weaning Child K that she discussed with the health visitor. Maternal mood was described as good. No concerns were identified in regard to mother’s parenting and care of Child K. 113. A telephone discussion between the offender manager and the leaving care worker in May 2010 confirmed that mother and father had no direct contact with each other due to the prison governor’s prohibition and acknowledging that if father was planning to live with mother upon release an assessment of risk would be required. 114. In late June 2010 a core assessment was opened because a strategy meeting was to be convened to discuss father’s release from prison. The assessment was completed by early July 2010 and states that father did not pose a risk on the basis that his conviction occurred because he did not attend court when convicted to explain that he had not known the girl was 13 with whom he had sexual relation on at least two occasions (he had been convicted of other offences at the same hearing that included burglary). The assessment commented on how father had engaged positively with his offender manager. The IMR provides further detail and analysis that is reflected in later sections of this report. 115. A meeting took place on the 8th July 2010 which was referred to as a strategy meeting (which has a specific purpose and function in national and local safeguarding guidance); it was referred to as a multi agency meeting by services such as probation confirming some lack of clarity about the status of the meeting; the record of decisions was written up by the after care worker who was about to transfer to a another job who also appeared to chair the meeting. As the CSC IMR comments this was inappropriate given she was not a qualified social worker and it was not compliant with local and national Page 26 of 69 standards and therefore could not be regarded as a strategy meeting11. The meeting agreed that father could move in with mother and Child K and that CSC would close their involvement. Further analysis is provided in later sections. 116. For the purpose of clarity, the IMR and this author do not place responsibility for the decision making on the leaving care worker; this was a multi agency meeting and therefore there was a shared responsibility for all services to have been satisfied about the rigour and robustness of arrangements. 117. Father was released from YOI under licence at the beginning of August 2010 having served just less than 14 months of his custodial sentence; the conditions of his licence included continuing supervision by an offender manager employed by the local probation service. Coincidentally, two days after this Child K was taken to the local hospital A&E with a rash; there were no other concerns were identified. 118. Father complied with the terms of his supervision and this included attendance at a job club. He was receiving medication for depression. 119. In September 2010 father talked with his offender manager about his problems with attending CAMHS; he felt that he did not have the same problems of anger management that his paternal grandfather and his brother have had and questioned why he needed involvement by that service; he said that he was not finding it helpful. 120. In November 2010 father’s benefits were stopped and later the same month the police interviewed him about a number of local burglaries. He denied involvement. Father secured a temporary employment working as a painter and decorator. 121. In January 2011 the police executed a search warrant of the family home and of other family member’s homes and located a small amount of drugs and a significant cache of money. Members of the extended family were charged with money laundering offences. 11 Readers of this report who are not professionally involved in safeguarding work will suspect that the author is indulging in irrelevant semantics about what a meeting is called; the significance of being clear about the status and purpose of the meeting is that a strategy meeting is supported by clear multi agency protocols that should ensure all relevant services give priority to the meeting, will bring all relevant information to the discussion and will understand that the meeting is focussed on assessing whether a child might be at risk and considering what actions need to be taken. It will also ensure that only a suitably qualified and experienced person is responsible for chairing the meeting and making sure there is a clear record of key information and actions agreed. Little of this was achieved in this case. Page 27 of 69 122. In February 2011 mother had begun attending a local college for two and half days a week. To enable her to study Child K began attending nursery again, this time for two and half days per week. After Child K’s sibling was born the sibling began attending the same nursery from September for one day per week. 123. In March 2011 father told his offender manager that mother was pregnant. At the beginning of April 2011 father was questioned and bailed in relation to charges of burglary. He was subsequently charged with the offences that triggered the revocation of father’s licence and he was remanded to appear before magistrates in Lancashire. He was in prison for almost six weeks during which time he had visits from mother and child. He was convicted of the offences and sentenced to a 12 month community order and 80 hours unpaid work. He failed to attend an initial supervision session but then attended subsequent appointments and work sessions. He completed the sentence in October 2011. 124. The second child had been born in July 2011. There developed a pattern of no access visits for primary health care workers such as the health visiting service. This prevented any routine assessment of mother’s emotional and mental well being. Child K was taken to the GP and the A&E with a chesty cough on different occasions in late 2011. 125. In early September 2011 the family moved to their second property. 126. On the 7th October 2011, the Health Visitor took a telephone call from a social worker. The purpose of the phone call as documented in the health visiting records was to share information regarding father’s criminal activity including being convicted of a sexual assault on a minor when he was 17 years of age. It was also documented that children’s social care had completed a core assessment in July 2010; the health visitor was informed that the assessment had concluded that father was not a risk to children 127. Following this phone call the health visitor increased the dependency tool12 to level 2 indicating the need for additional contact above that of the core programme. Two attempts were made to see the family and although these were appointed visits the outcome was ‘no access’. Around this time Child K was due for a two year development review but the planned visit again resulted in a ‘no access’ visit. However during the course of these ‘no access’ visits the sibling attended the GP surgery for a routine immunisation appointment and both Child K and sibling were seen in the well baby clinic. 12 This is the tool used to help determine workload allocation across a caseload based on the level of need; it is not a risk assessment tool and is an area for analysis by the HOR that is commented upon in later sections of the report. Page 28 of 69 128. In November 2011 mother began work as an apprentice at a nursery operated by the same proprietor as the nursery that Child K and sibling attended. In late 2011 and in 2012 Child K was looked after by her father for some of the days that she had been attending nursery; it is unclear if this was to help reduce the cost of nursery care. 129. In April 2012 Child K was seen for a routine health development review and a two year review of Child K in June 2012 found her to be developing appropriately and to be suitably dressed. Health visiting contact was stepped down to the level of a universal pattern of contact. There had been few contacts within the home which both the LCFT and HOR comment was unusual for a case where the children are subject of targeted support although acknowledge that there had been a good level of contact at the clinics. 130. In July 2012 there was a further search of the family home by the police looking for drugs. Father was found to be smoking cannabis and was looking after both of the children on his own. A small cannabis plant was seized along with two knives and a screwdriver that had been hidden and apparently intended for protection if required. The police officers confirmed that the children were dressed appropriately and were clean and that the house was warm and there was food in the kitchen. They had no concerns about the immediate safety of the children but made a report to the police public protection unit (PPU) given the circumstances of the search and their knowledge of father’s history. Information was shared with the health visitor and a referral was made to CSC. 131. The CART who received the police referral made telephone checks with the health visitor and the nursery; mother was an employee and therefore arrangements were made to speak with the owner. The case was allocated for an initial assessment by the IAS (integrated assessment and support team). Telephone checks took place with the nursery about whether they had any concerns regarding either child; they confirmed they did not. The proprietor did not deal with the enquiry but was told by the nursery manager and asked the manager to contact CSC to check whether there were any concerns that the nursery needed to know about to ensure the children were kept safe as well as anything that might compromise mother’s suitability working in another nursery. This check was done and CSC confirmed that mother had not been at the house when the police search had taken place and did not appear to be involved in the issues raised by the police. 132. In the absence of any specific information suggesting concern about mother, the nursery management did not feel that that a referral to LADO Page 29 of 69 was necessary13. As part of the review process, the panel have been made aware of revised regulations that have extended the scope of disqualification to apply to the partners of early year’s staff working in a registered day care setting. Father was disqualified by virtue of his conviction in regard to sex with an under age girl and therefore according to the panel’s understanding of the interpretation of the regulations by Ofsted14, this would probably have disqualified mother from working in a registered child care setting. Further comment and analysis is provided in later sections of the report about this and how communication was managed with the nursery about issues such as the children’s attendance at the nursery. 133. Neither mother or either child attended at nursery on the day of the telephone check was done and father came to the nursery to say that mother had been having an affair with the father of another child which she denied although had exchanged messages on a social networking site. When mother did not come into work and both children were not at their nursery on a second day a member of nursery staff made a home visit and saw mother at home. Mother returned to work but was warned about breaching the nursery code of conduct. During a discussion about the referrals to CSC the issue of over £1000 in unpaid nursery fees was raised; both children were removed from the nursery by their parents. 134. A developmental assessment of Child K in early August was routine. On the 10th August 2012 father texted the social worker to express his dismay that CSC were involved because of ‘a plant’ and referred to how he was a different person from when he was younger. The case was closed to CSC four days later on the 14th August 2012. The IMR for CSC highlights a number of issues for analysis in later sections; these include for example a lack of contact with services such as probation or the leaving care service and the 13 This is a reference to the Local authority designated officer (LADO) works within the local authority and should be alerted to all cases in which it is alleged that a person who works with children has behaved in a way that has harmed, or may have harmed, a child possibly committed a criminal offence against children, or related to a child or behaved towards a child or children in a way that indicates s/he might be unsuitable to work with children. The LADO has the role, knowledge and responsibility to be consulted in regard to any allegations or concerns in relation to people who have responsibility for the care and supervision of children. The LADO gives advice to employers and others regarding action they should take and provided an important co-ordinating role of information within a local area. 14 Disqualification from working in children’s social care No 080157 published October 2011 and Early Years Foundation Stage (EYFS) “3.14 In the event of the disqualification of a registered provider, a person living in the same household as the registered provider, or a person employed in that household, the provider must not continue as an early years provider – nor be directly concerned in the management of such provision. Where an employer becomes aware of relevant information which may lead to disqualification of an employee, the provider must take appropriate action to ensure the safety of children. In the event of disqualification of a person employed in early year’s provision, the provider must not continue to employ that person.” Page 30 of 69 information about mother working as a dancer in a local resort was not explored. 135. In late August 2012 the ambulance service were summoned by an emergency phone call made by the parents in regard to Child K. Those details have been summarised at the start of this report. 136. The ambulance control alerted the police to the incident and police responded. They alerted the PPU who in turn contacted CSC. A strategy meeting involving the relevant services took place at 19.00 on the 30th August 2012. The meeting was told of police concerns about some of the conditions within the home; descriptions of rabbit droppings in the house, no bedding for the children and dog mess in the rear yard. There was evidence of cannabis having been smoked in the house. There had been delay in seeking medical attention for Child K and the medical opinion was concerned about the injuries although the bruising that was visible was a possible consequence of falling from the swing as father had described; the post mortem and skeletal survey subsequently identified further injuries. 137. A visit was made to the family and consent was secured for mother and Child K’s sibling to stay overnight with a relative. Further analysis and comment is made in later sections of the report along with comments about the manner in which the safeguarding and the unexpected death in childhood (SUDC) protocols were used. 138. Mother did not return to work at the nursery although the outstanding balance of nursery fees was paid off. Page 31 of 69 3 The critical reflection and analysis from the individual management reviews. 3.1 Summary 139. All of the individual management reviews were completed using Working Together to Safeguard Children (2010) which was also supported with additional local guidance provided on behalf of the LSCB. The IMRs include action plans for implementing recommendations. All the IMRs are countersigned by the senior manager for the individual commissioning agency. 140. Many of the services have already taken action or initiated action in response to improvements or areas of development identified through their individual review. 141. For some of the authors, they were simultaneously working on other IMRs for other serious case reviews and were also undertaking their usual range of professional roles and responsibilities. All of the IMRs provided to the review were of a standard necessary for a serious case review and more than one were of particularly good quality and detail. 3.2 Significant themes for learning that emerge from examining the IMRs 142. The agency reviews identify themes that have implications for policy development and staff training that applies to all services working with children. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the findings from national evaluation and research. The HOR identifies the following learning themes; a) The importance of identifying early whether parents and mother’s in particular are vulnerable and likely to require additional support; in this case, the factors of vulnerability were most acute in regard to father (but were hidden) although mother was a teenager when she became pregnant and at the time was living in a chaotic and crowded home; b) The invisibility of men in SCRs generally and in this case when father was in prison he was out of sight in respect of assessment and planning; he did not feature sufficiently in the collation of ante natal information; c) The poor recognition of risk factors and associated information that should have been indicators of vulnerability; Page 32 of 69 143. The HOR also discusses the confusion that occurred following the death of Child K in regard to how the SUDC (sudden unexplained death in childhood) process was invoked and managed. This led to misunderstanding about what information had been taken and which professionals had completed respective tasks. The events of that day have been the subject of a learning event involving police and health. Processes have since been put in place which aim to ensure consistency in action, robust information sharing and have reinforced the importance of all professionals having sufficient confidence to seek clarification and to challenge each other if there is cause for concern about the robustness of the process or actions of others. 144. Other important messages for learning from this review include: a) The unintended consequences that can arise when the leadership of planning is taken by staff who are not sufficiently experienced or qualified or do not have the appropriate emotional and psychological aptitude (are more focussed on supporting a vulnerable adult rather than seeing more clearly the consequent needs and risk to a child); b) Not using opportunities such as CAF/TAC systems (team around the child) to help co-ordinate earlier help; c) Information systems that are cumbersome and difficult to navigate will discourage proper checking of historical information and inhibit meaningful and contemporaneous recording; d) Understanding the importance of getting a good enough history about parents and families and being aware of the factors that can indicate increased risk of harm (although not predict it) and to understanding current events and circumstances. e) The dangers of relying only on observing behaviour or conversations with parents and not triangulating with other sources such as history and third party information; f) The influence of mindset and language and how it can lead to misdirected conclusions or inference; parents stating good intentions and evoking emotional responses in workers who want to give parents ‘a chance’; g) Impact of organisational stress on workload; this has implications for supervision and quality assurance as well as face to face contact; h) Ensuring there are no cultural barriers in regard to information sharing for example in treating independent or third sector services as less robust in managing sensitive or confidential inquiries and information; i) The invisibility of prisoners and the vulnerability their children in regard to their overall wellbeing; in this case Child K’s father was managed as an invisible part of the family although clearly had an ongoing contact and influence through the mother; upon his release and in spite of efforts to have a risk assessment done, his return was accepted without enough attention to the implications or his history or the risk assessment that had been completed while father was in prison; Page 33 of 69 j) Co-ordination between prison and other services working with the families of prisoners. 145. It is important that constructive feedback and reflection continues to be provided to all the practitioners involved in this case and who have helped provide the learning from the review and to give them the appropriate positive encouragement for their continued professional development and retention in the workforce. 146. The remainder of this chapter summarises key evidence relating to the terms of reference established for the IMRs. TOR1 Historical information The SCR should be focused on Child K and the safeguarding of her and her welfare. However, where historical factors have relevance, they should be included, with explanations as to their relevance to Child K. The Review will consider key episodes in the history of agency involvement with the child and her family in order to understand what factors may have influenced practice at the time. 147. The history of agency involvement with the families of both parents was not known to the midwifery service when Child K’s pregnancy was initially booked and managed. Father’s childhood includes the traumatic loss of his mother, a difficult relationship with his father and being looked after in several different placements during his adolescence. He had displayed significant emotional and behavioral needs that represented considerable challenge in various care and educational settings and many of which had ended in disruption. These problems had been exacerbated by his use of cannabis and possibly other substances and he has continued to use cannabis on a very regular basis although this had never been quantified in assessments. 148. His sexually coercive behaviour to peers and female staff and his persistent criminal behaviour had required the intervention of criminal justice and specialist services over several years and he was in prison for much of the pregnancy with Child K who was born before his release from prison. 149. Father’s first child with a previous partner had been placed for adoption due to concerns about the child’s safety and the ability of the child’s needs being met. He had been found guilty of sexual offences with a thirteen year old girl although denied his responsibility and culpability. 150. Mother lived with the maternal grandmother until after the birth of Child K. There had been involvement with maternal grandmother in regard to the care of the younger siblings and mother had been used to provide care for her siblings. Page 34 of 69 151. The childhood experiences of both parents were significant in terms of their capacity to meet the needs of their two children. Although the majority of people who were in contact with the family during the timeline for this serious case review were aware of some of this history none had a complete understanding of the narrative or apparently the implications of it. 152. This lack of historical context meant that everybody relied on the information they got from direct observation and conversation with the parents in particular. This had consequences for how the family were viewed by the different people in contact with Child K and her family. Both of the parents were positive and outgoing in their attitude and behaviour with the various professionals and services that came into contact with them and their children; they were polite and did not obstruct for example when the police searched the house. The house was seen to be clean and the children were appropriately dressed and fed. 153. Although the house was described as being ‘a little basic’ reflecting a family living with a limited income from mother’s work and casual work by father there was no concern about the children’s physical care and safety. Both parents had been regarded as managing well in spite of the difficult childhoods they had both experienced; one of the IMR author’s comments on how neither of the parents had been provided with a positive role model upon which to base their own parenting. 154. Father declared on more than one occasion his intent to give his children a different experience to the one he had as a child. He received good encouragement in this from professionals but there were not enough enquiries into his personal and family history or analytical discussion about the barriers and deficits he would have as a result of his own experience of childhood trauma his chaotic lifestyle and vulnerability. 155. Both parents had a strong bond with each other but there is little knowledge or understanding about the circumstances of their meeting, the dynamics of their relationship or the different vulnerabilities each of them brought to the relationship. Given father had only recently been assessed as unsuitable to parent a child, the assessment needed to address explicitly what the relationship with mother had achieved in counteracting that risk. Such enquiries require more purposeful empathy and sensitivity than just listening to statements of good intent. 156. Although professionals working with adults who have experienced trauma and difficulty in their lives will want to be positive and encouraging to a young parent for example, the consistent lesson from this and other reviews is that care needs to be taken in not relying on optimism alone; human behaviour and interaction is shaped by personal history and circumstances and denying history is unhelpful for example when assessing parenting capacity or the quality of emotional care and stimulation. Later sections of Page 35 of 69 this report highlight particular aspects of history that had a direct relevance to this case. TOR2 Child and her experiences at the centre of assessments Examine whether all agencies kept the child and her experiences at the centre of their assessments of and interventions with the family. The Review will consider interactions between professionals and the family in order to understand the aspects of the family which influenced practitioners’ thinking. 157. Knowing what life is like for a child growing up in their family is a recurring theme in reviews, inspection and research. All too often the focus of any recorded information is on the physical standards such clothing and cleanliness of the house with much less information that describes the emotional and psychological well being of children. A preoccupation with physical standards and the positive inferences that were drawn from that information is a factor in this case. 158. Frequently in reviews, the needs and problems of adults dominate the interaction and narrative. It is especially problematic in cases where children have not yet developed very much language. It is for this reason that work with the parents of very young children has to explore with the parents what their child means to them and whether their behaviour reflects what they say. In this case for example, both parents expressed a wish to provide a better childhood than they had experienced for Child K and her sibling although their behaviour often provided some contradictory or perplexing evidence. 159. The prevailing mindset that influenced the interaction with the family was focussed on helping and supporting two parents who appeared to be motivated and wanted to overcome their difficulties. A common theme for all the services providing IMRs for the review is that professionals generally felt very positive and optimistic about the parents’ ability and motivation to look after their children. 160. The children were seen by several different services and conditions in the home were described as clean if basic and the children were appropriately dressed, fed and clothed. It was noted that conditions in the home on the day that Child K died were not as clean as had been observed on previous visits and may be attributable to the fact that mother was going out to work and leaving father in sole charge of the children and that he had been found on more than one occasion smoking cannabis. 161. Ensuring that children are at the centre of assessments especially when the children are very young and language is not yet developed requires more than relying only on observation of physical standards and the interaction between professionals and the family. The fact that the parents were friendly influenced how practitioners generally viewed the needs of this family. This Page 36 of 69 had an impact on how inquisitive and curious people were about information about father in particular. There was a great deal of empathy with the parents but not enough sceptical curiosity and challenge. 162. There is research evidence that validates the value and importance of health and social care practitioners talking with new parents about their experience of becoming parents, the significance of the child to each of them and the implications for their relationship. Mother and father began their relationship while father was still opposing the adoption plan in regard to his first child. Mother became pregnant very quickly in the relationship with father. Both parents were in flight from difficult circumstances. 163. Having a well informed knowledge about families requires time to develop appropriate relationships; the CSC author refers to the work of Harry Ferguson15 who describes the complexity of cognitive influences, systems and processes and understanding the significance of the factors that are linked to increased harm; recognising the families who through their history as well as immediate circumstances, are likely to have less resilient to face events that can derail them; how this relies on professionals having the capacity and aptitude to develop appropriate relationships with the family that goes beyond relying on empathetic support. 164. In this case there is evidence that a series of events were occurring over the summer; this included the strains in the relationship between the parents that was doubtless exacerbated by mother working very long hours in two jobs; the evidence of potential crimes combined with father’s continued use of drugs. It was unclear how secure their tenancy was at the house and there were financial problems. In looking at this information there is little sense of understanding what the implications were for the children and how they were feeling. 165. Purposeful enquiries do not predict that a child might be harmed but it will provide the improved opportunity to identify sources of particular stress or difficulty and explore the parent’s capacity and motivation to use help and advice meaningfully. Issues such as child neglect are a reflection of parents for example having little empathy for each other or for their baby or being overwhelmed by their own needs and problems. 166. The CSC IMR is critical of the quality of assessments and provides a good deal of information about the various factors that contributed to the inadequacies in practice. This included an organisational preoccupation with meeting timescales reflected in national frameworks at the time that was not sufficiently focussed on quality and the problems of complex systems for managing information. 15 Child Protection Practice; Palgrave Macmillan; 2011. Page 37 of 69 167. Another factor explored in that IMR was the degree to which the needs of the parents came to dominate; this is an area of practice recognised frequently in other serious case reviews. In this case there was some understanding about the difficult childhood that father in particular had and professionals had a great deal of empathy for him and the rest of the family; they wanted the family to overcome the history. 168. Although this motivation by professionals to encourage the apparent determination of the parents is understandable, it did require a far more informed and rigorous approach that kept the needs of the child at the focus of the help provided and to counteract misplaced optimism. This is a difficult balance to achieve and requires access to professional supervision that can provide appropriate levels of challenge that provokes more analytical reflection rather than just checking on compliance or reciting narrative detail. 169. Unqualified or inexperienced practitioners could not be expected to have the degree of knowledge for complex work. The recruitment and retention of experienced practitioners is a regional and national issue. Matters were compounded by the categorisation of the case as being a child in need case that may have inferred that it had a lower level of complexity in comparison to a more explicit child protection case. The CSC IMR concluded that this was influential in the mindset and overall approach to the case. 170. Problems in securing a clear enough focus on the children and the history of the parents was a factor that was common across the health and social care support. 171. For some like the midwifery service it reflected an absence of information certainly at the time of the first pregnancy about father and with the benefit of hindsight a degree of misplaced confidence in the extent and quality of support that could be available from the extended maternal family. Other services had different levels of detail that in general was confined to the separate agency silos that generally contributed to people believing that they were doing well enough in spite of the difficulties each of them had experienced. 172. Although the history of both parents was not completely known or understood, for services such as leaving care, health visiting and early years there was a clear motivation to help the family overcome the difficulties that were known about. The extent to which their childhood experiences had the potential to be a negative influence in spite of any positive intentions and impact on their parenting capacity was less well attuned to. 173. This reflects a common difficulty in assessment practice where there is a pre-occupation with recording observation of current behaviour and interaction without dealing with the underlying influences and factors. Page 38 of 69 Although there was a recognition that both parents appeared to be motivated to do the right thing for their children and that they had the disadvantage of not having had positive roles models, the emotional damage was not recognised or enquired into. 174. The notification of Child K’s birth to the 0-19 health visiting team provided no advance advice and information about a young mother having her first baby whilst the father was in prison and she was living with her mother who was reluctant to accept help from services. The midwives did not regard Child K as a pregnancy that merited significant additional support. Some of this was attributable to a mistaken understanding about the quality of support that would be forthcoming from the maternal grandmother. 175. The 0-19 service made their first home three weeks after the initial notification and completed an assessment; the assessment acknowledged that although mother was young and living in very crowded and chaotic conditions she was providing appropriate care to Child K. She was assessed at level 2 which reflected an additional level of contact and visits by health visitors but not intensive support. A referral was made to the local children’s centre with the purpose of reducing mother’s social isolation and encouraging her to use the services. 176. The LCFT IMR author comments that although mother’s needs are acknowledged there is no reference or analysis in the records of the potential impact of her early experiences or her young age is sufficiently acknowledged in relation to Child K. In order to meet the needs of the child the parental needs cannot be ignored, and must be skilfully addressed, balancing risk and resilience factors; in this case the IMR found documentary evidence as well as the reflections of the practitioners that focused on resilience but without the balancing knowledge in regard to history. This contributed to the degree of optimism exhibited and is referenced to national studies and research. 177. There was further evidence of professional optimism when father returned to the family home and the health practitioner reminded mother to prioritise the needs of herself and Child K. It was presumed that mother would be able to do this as father joined the household for the first time when he was released from prison. This did not apparently take account of mother’s high degree of compliancy that had characterised her relationship with her own mother and was present in the relationship with father who had a history of abusive behaviour with other women. 178. The potential impact on Child K of his father’s return to the home was not sufficiently analysed or documented by any of the services in spite of the team manager’s practice direction in 2006 (which predated the timeline for the review and was before the birth of Child K). It was apparently overlooked and therefore was not carried forward into the subsequent work. No information was known about father at the time by the health visiting service Page 39 of 69 and the contact by CSC apparently took little account of his history and its significance. 179. Local SCRs for Child S (2010) and Child M (2010) and national reviews have included analysis of the inclusion of fathers in assessments. It has been found that practitioners sometimes ‘forget’ about fathers when they carry out assessments and interventions with families. Recurrent problems have been identified amongst many different professional groups in taking sufficient account and notice of men in households where young children are living. TOR 3 Consideration of diversity, social background and integration Examine whether all agencies and professionals gave due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration. 180. National research and inspection evidence highlights the considerable variability in how information about the overall environment of a child is collated and analysed. For example, the degree to which parents may have undiagnosed learning or cognitive difficulties is a common theme in serious case reviews and there is some evidence of this occurring in this case. Father had been assessed as having special education needs as a child but the detail was not sought in any assessment associated with Child K. 181. Very little is known about either of Child K’s parent’s educational history or whether mother had ever been identified with any additional need. Certainly the impact of father’s much disrupted care and education history was not explored meaningfully in this case. Mother’s difficulties in processing information and advice were noticed during the pregnancy and she presented as being very passive and compliant. 182. In contrast to the worrying history that largely remained hidden and unknown to many people in contact with the family, there were more positive indicators suggesting that the family were reasonably integrated with their local community. The fact that mother was taking up opportunities to go to college was a sign of an adult keen to improve her parenting and work related skills, She was successful in securing an apprenticeship and was working well in that role. 183. The extent to which individual families as well as communities can be deeply suspicious about statutory services having contact with them and their families can have an impact on how they interact with significant services such as health, police and social workers. 184. The family are white British and speak English as their only language. There is no information regarding any religious affiliation; this is commonly not explored and yet research studies highlight that religious or cultural affiliation is an important source of resilience. The area in which the family rented their Page 40 of 69 home was not particularly deprived and was popular with a broad range of people including students. There is no indication as to how far the family felt they were part of their local community and were integrated. Simply by living in a better neighbourhood does not mean a family feel part of it or participate in the daily life and activity of the area. 185. Specific reference is made to mother’s social background and integration. Some health practitioners recognised her vulnerabilities including her age, her own poor experience of parenting and as she moved into her own home her isolation. Appropriate steps were taken by the health visiting team to address this, through referrals to services and additional visiting over and above the core programme. 186. Poor social integration and chaotic family background are significant risk factors for children that are commented upon by the LCFT IMR and also can influence the way in which parents work with agencies (Brandon et al 2009, NSPCC 2010). The 0-19 Team were sympathetic to mother’s background and aimed to understand and support her need for parenting support as a result. It appears that the extended family were reported by mother to be supportive but the extent of the support they actually offered was not known. 187. There was no evidence to suggest that mother was not being honest and open in her communication with health professionals. She disclosed some information regarding her background and regarding Father of Child K, but this was not explored further by professionals and therefore did not feature in assessments. There was for example a remarkable lack of curiosity on the part of some people in why father was in prison. 188. The historical information now known concerning father’s mental health, self-harm, experience of physical abuse, history of disrupted care and offending behaviour are important predictor’s of his ability to parent Child K appropriately. Research suggests that parents who have been in the care system and have experienced abuse and chaotic parenting are less likely to display positive parenting approaches and are more at risk becoming abusers of their own children (Brandon et al 2009, NSPCC 2010). None of this information was taken into account. 189. This is not intended to suggest that parents who grew up in public care cannot be good and effective parents for their children; it is an acknowledgement about the importance of understanding the childhood experience of parents and the implications for their capacity to parent and the help that they might require. 190. The CSC IMR describes how the overall presentation of this family had an influence on how the family were viewed. The family lived in an area where CSC does not often receive referrals. The property was well maintained and Page 41 of 69 the street they lived on was quiet. The house was also quiet whilst the social worker visited in the summer of 2012 and there were no visitors to the property on her first visit. The mother worked in a nursery which was unusual in families referred for CSC support and there did not appear to be any financial issues. 191. The children were attending nursery four times a week, albeit at a discounted rate which would still have been quite expensive in a household with limited income. The social worker did not know and neither was she informed by any of the agencies that were contacted, that the children had stopped going to nursery due to the debts the family had incurred. The observations about the family's property and apparent circumstances influenced the conduct of the assessment and view of risk which would realistically only have been recognised with closer regard to the significant historical information. 192. A considerable range of research describes how professionals can be trapped into ignoring or dismissing the contribution, positive or negative, of fathers or loading responsibility onto the children’s mother for keeping the children safe16. 193. It was mother who appeared to provide the best level of reassurance. Mother (but not father) participated well in groups at the children’s centre and the health visiting service found her to be a good clinic attendee who enjoyed being a mother. She sought advice from the GP appropriately. These are all important and relevant indicators about the quality of care that Child K and her sibling received but took little account of father’s role and contribution or the relationship between the parents. TOR 4 Information sharing and communication Examine whether information sharing and communication systems within and between agencies were effective in safeguarding Child K. The Review will consider communication and collaboration in multi agency working in order to understand the influence of any significant factors on practice. 194. The quality of information sharing and communication are frequently an area of particular difficulty identified in serious case reviews. Successive child death inquiries or serious case reviews have shown that failure in communication and information sharing between professionals played a pivotal role in the way parent behaviours or life style was understood. 195. The features that are identified frequently in reviews include an absence of chronologies that could have helped reveal the underlying themes or issues not obvious by the current observation of parent and child behaviour. Other 16 Scourfield, Gender and Child Protection, Palgrave MacMillan 2003. Page 42 of 69 similarities include no single professional having a sufficient overview of the case (which does not mean that it always has to be the task of a social worker if for example CAF/TAC had been used at an early stage); and different pieces of information held by individuals and services that appear insignificant (the jigsaw pieces that make no sense until assembled). 196. The importance of information sharing has been a cornerstone of national and local guidance. The response to this area of practice has led to an increasing array of protocols and form’s exemplified by the recently abolished national assessment framework. The framework which was amended by the publication of the latest Working Together guidance in April 2013 had created burdensome bureaucracy that had inhibited professionals in working with families. 197. In considering the quality of information sharing the focus needs to be on the extent to which information sharing and communication reflected a proportionate understanding and intelligence about the circumstances of Child K and her sibling. 198. Effective information sharing is a balancing act of collecting sufficient data in order to reveal any underlying patterns that are not obvious in isolated episodes. Simply collecting information can overwhelm individual professionals and result in not seeing ‘the wood for the trees’. 199. There was not enough discussion between professionals at the point at which referrals were made or formal enquiries were completed. Although mother was a teenage parent she was not regarded as requiring any specialist or enhanced support by the midwife service and therefore a verbal handover to health visiting services was not deemed necessary. 200. When the health visiting service became involved they considered that mother required social and practical support and a referral was accordingly made to the local children’s centre. This did not involve any direct discussion between the health visitor and the early year’s worker who worked directly with mother. 201. The involvement of the children’s centre provided access to individual support as well as participation in group sessions with other parents. There was no direct communication between these activity leaders. 202. Although the referrals to CSC did result in routine telephone contact with the health visiting service the discussions were limited to checks regarding any current concerns. The reasons for the phone checks were not fully explained or discussed. 203. The ‘strategy meeting’ (which was not properly constituted) called to discuss the planned release of father from prison did not result in a Page 43 of 69 sufficiently planned discussion and participants did not bring historical information; the CSC IMR author includes comments from a worker who attended the meeting recalling that the meeting did not resemble a strategy meeting in the way they understood them to be as it was not clearly structured and organised. 204. Child K's social worker's core assessment or risk assessment was not referred to at this meeting. The social worker who had been involved with Child K’s father's previous child was not invited or present. Neither the leaving care worker for father's previous partner nor the social worker for the mother to the child being placed for adoption was invited or present. Agencies working with Child K were not present or invited, for example the health visitor and early years workers. 205. Health services sought insufficient information about father in particular; the true vulnerability of both parents’ histories was insufficiently understood. Staff shortages and the changes to corporate working in the health visiting service created barriers in regard to different health visitors having contact with the family. CSC undertook superficial consultation with other services when assessments were required. 206. The CAF was never considered by any service. The CAF could have been used to co-ordinate information. The LCFT IMR comments that CAF and TAC meetings would have supported a more consistent approach to information sharing with other agencies. Lack of integrated working is often criticised when a review takes place (Laming 2003, Laming 2009, Brandon et al 2009, Brandon et al 2012) and this has also been acknowledged in local reviews (Child Z 2009, Child C 2009, Child S 2010, Child M 2010). Certainly with hindsight more cooperative working and regular multi-agency reviewing of all relevant information would have enabled consideration of the risk and protective factors by all agencies for Child K. 207. There were opportunities for multiagency information sharing but these were not utilised well enough to inform the assessment and to re-evaluate evidence from different sources. On two occasions health practitioners received a call from CSC to determine if they had any concerns and advised there were none evident. The health visiting service did not adopt a sufficiently inquisitive approach and did not question why the phone inquiry was being made. Some of this might have reflected a lack of professional self confidence as well as knowledge about what information can be asked for. 208. Simple accumulation of information does not lead to more analytical assessments and safer practice and these episodes should have resulted in further assessment of risk. It is important that when agencies are requesting information a reason for the request should routinely be given or asked for. This would promote shared discussions that are more meaningful and purposeful and support better informed decision making. Page 44 of 69 209. The LCFT IMR points to examples of where information sharing and communication was managed more proactively. There is evidence of an appropriate response to information sharing, when thorough information is shared. When the HV received a call from CSC informing of information regarding father, records are detailed and this contributed to an assessment of dependency level and increased contact to the family. 210. This appeared to be a turning point as there seemed to be evidence that some health professionals became more curious and started to adopt more of an ‘assessment mind-set’ and take opportunities to ask questions and re-evaluate their work in light of new information and changes in family circumstances; an example of this is the opportunity taken by the community nursery nurse to question mother about the police visit to the family home. Such responses need to happen consistently to manage risk. The gaps in information that was exchanged with the nursery in August 2012 have been highlighted in previous sections. 211. Hindsight often makes people feel they would have done something differently if they had been given all of the relevant information at the time. For example, the nursery had tried to find out more about why CSC had made telephone inquiries in August 2012 to establish if the nursery had any concerns about Child K or the sibling. The nursery asked if there were any concerns and were advised there were none. The issue of unpaid fees might have been seen differently if all the information about the family’s history had been known to the nursery. 212. The nursery had very little information about the background of the children and when for example in early August 2012 the nursery attempted to get further information they faced limits in what CSC felt they could legitimately say. 213. The lack of confidence about how far to share information had some implications for other conversations for example in mid August about removal of the children from the nursery. The social worker assumed that the children were attending the nursery when following up the referral from the police. 214. The nursery IMR authors acknowledge the importance of routine contacts between different services and people being used to create more complete information through a reciprocal and sufficiently curious exchange in such discussions. In this case for example, CSC did not know the children had been withdrawn from the nursery. Nothing in this commentary implies that any of this would have changed decisions or outcomes in this particular and tragic case. Page 45 of 69 215. The CSC IMR describes the complexity of different sources of information storage and archiving and the restrictions of electronic recording systems and how this influences important professional activity by being confusing, time consuming and hard to navigate. Additional issues are highlighted regarding weaknesses in systems being able to support practitioners in elementary task such as identifying associations and relationships for example. The CSC IMR explains that a new and hopefully improved system is being procured. TOR 5 Examination of how relevant historical information was examined in assessment and taken into account for providing services Examine whether historical information was given appropriate emphasis within assessments and interventions. This relates to mother and father's histories, extending to others where this is relevant to the period under review and thus the care of Child K. Any relevant historical information prior to the timescale for the Review should therefore be summarised and included in IMRs. 216. Although there are clear and validated reasons about why early years, health and social care professionals need to know about relevant historical information about families where pregnancy and young children are concerned, this continues to be an area of practice that is highlighted frequently in child deaths and serious case reviews as requiring further development. 217. Although the serious injury and killing of children is rarely a predictable event, there are factors that have their origins in personal and family history that can indicate a child might be more vulnerable to neglect or significant harm. This does not mean that where such factors are recognised should lead to parents being suspected or accused of harming their children but rather should alert and provoke a higher level of informed and skeptical curiosity that is proportionate, respectful and persistent. The HOR author along with several of the IMR authors comment on the general lack of professional curiosity displayed. 218. The factors that are identified in research as being likely to be found in the maltreatment of children include the following; a) Isolated parents who have little or no extended family capable of providing good emotional and practical support or have other forms of support available for example from a community or faith based group for example; in this case father had very limited family support available and some professionals may have been over optimistic about the quality of family support that mother had; b) A history of being abused or rejected as children or had multiple changes of carers; father’s history is especially Page 46 of 69 relevant and there are gaps and mistaken assumptions in regard to mother; c) Mental illness, personality disorder and/or a learning disability/difficulties; these are often not recognised or diagnosed and in this case father declined to participate in assessments when younger and both parents may have unrecognised needs; the education history in respect of both despite being young parents was not sought to establish if there was any evidence of special educational needs as school students and it is known that father was subject of an SEN statement; d) Particular vulnerability if there is no other parent or extended family member is available to share parenting (that becomes exacerbated if a child is hard to parent which does not appear to been the case for Child K); father was in prison and mother was clearly being expected to look after her younger siblings whilst she lived with the MGM; latterly father was caring for both children whilst mother was working; there is evidence that professionals noted that the parents appeared to be providing appropriate care although is was often couched as admiring the extent to which both parents were overcoming the legacy of their own upbringing; for example there was a tolerance of father using cannabis whilst in sole charge of the children; e) The parents have different children by different partners often involving abusive relationships; father had his first child placed for adoption and had a history of being abusive, had minimised the offence with the 13 year old girl for which he had been imprisoned; there is no information about mother’s previous relationships or the circumstances under which she met Child K’s father and the pregnancies; f) There is reliance on alcohol or drugs and do not accept they need to control it; father had a historical and problematic use of alcohol and drugs and continued to use cannabis even when he was the sole carer for two young children; there is no evidence of enquiry about his use of substances and similarly no enquiry regarding mother; this is an area of practice that is frequently not managed well by any professional group outside of specialist services and was a theme in a recent serious case review; g) There is a history of aggressive outbursts and a record of violence including intimate partner violence; father’s record of Page 47 of 69 violence was known to CSC, CAMHS and to YOT although not so well understood by early years the other health professionals in contact with the family; no inquiries were made during any of the assessments about the circumstances of the adoption and the relationship between father and the child’s mother; h) There is a history of obsession/very controlling personalities often associated with low self esteem; father’s history included episodes of very controlling behaviour especially to females and his history of being bullied and his childhood trauma of maternal death were all factors that were not looked at and the implications for his sense of identity and self worth; i) A history of being in care and having multiple placements; father’s care history was very problematic and had involved him living in a succession of placements and at times being in unsupported arrangements such as bed and breakfast outside his home environment; j) There is fear of stigma or suspicion about statutory services; this is a frequent and unrecognised factor in interaction between professionals and families and in this case there was clear evidence for example at the children’s centre about concerns of involving services such as CSC; it has implications for how parents will seek to present themselves and manage information that minimises the motivation and reasons for key professionals to become curious and further involved when it is not welcomed. 219. It is apparent that many of these factors were present in this case but either went unrecognised or that individual practitioners were misdirected by a false sense of reassurance largely from what father and mother said. In addition to these factors that are indicators for enhanced historical curiosity there are specific areas that a sufficiently competent parenting assessment would give attention to and requires historical inquiry; this includes the style of attachment experience that parents had as a child and bring to their own parenting for example. 220. At the time of mother booking the pregnancy with Child K the midwifery service were unaware of father’s history although because of the MGM’s pregnancies felt they had good enough understanding about mother’s background. Arguably, this apparent knowledge about mother was insufficiently informed and was unduly optimistic about the extent of support and therefore resilience that Child K’s mother had to draw on as a pregnant teenager. This assessment of mother’s background persisted even when the Page 48 of 69 information about involvement of the vulnerable families team with maternal grandmother became known during the second pregnancy. 221. Mother did volunteer information that father was in prison but this did not provoke any further inquiry by the midwives or by subsequent health professionals and was largely minimised in CSC assessment; it became part of the environmental background to the case that did not attract curiosity or interest. 222. It is not clear if the lack of interest in this and other information reflected a lack of knowledge about the potential significance of information to help inform observation of current circumstances or was the behaviour of professionals who were clearly experiencing considerable change to their organisation and working arrangements that are described elsewhere in this review. Similar issue in terms of not identifying historical information are identified by the early years IMR and from CSC. 223. The consequence is not that any professional could have predicted that Child K would be killed by one of the parents but rather all of the observations, judgments and decisions about the needs of Child K and the sibling were not sufficiently informed by historical understanding that could inform and balance the optimistic information that both parents wanted to present to services. 224. The only agency that realistically could have known about most of the information was CSC although this should not have prevented other people from becoming more curious about aspects of information and family circumstances. 225. The police made appropriate referrals to CSC following their search of the family home; they did not have any immediate concerns about the safety of either children but they were correct to see that evidence of involvement in using drugs and threats of potential violence were factors of potential interest to other services. 226. There were opportunities for CSC to have undertaken an assessment on more than one occasion that could have revealed both the history and its relevance; the CSC IMR provides a detailed critique of how those opportunities were not taken and the significance for the management of the case and for multi-agency working. A significant contributing factor discussed in the IMR was a pre-occupation with meeting performance targets on issues such as timescales during periods of high demand and staffing shortfalls and insufficient attention on the purpose and quality of key activities such as collating chronologies and history for the purpose of assessing a vulnerable child and their family. The same IMR acknowledges the considerable work by managers and practitioners to address the shortcomings identified. Page 49 of 69 227. Although there is reference to some aspects of father’s history principally in regard to having been looked after it is used as a narrative background that describes a difficult and harsh childhood; little information or understanding about the implications for him as a parent is explored. 228. In 2008 as part of the adoption process involving father’s first child the assessing social worker had found that father was barely able to meet his own needs and was very immature. The assessing worker had concluded that father was likeable but was not thought to have the requisite parenting ability required. The assessments that were completed in regard to Child K were all regarded as being unsatisfactory by the CSC IMR. The superficial approach to the assessment extended to not seeking information in regard to the adoption or the assessments that were undertaken at that time. TOR 6 Extent to which services understood the significance of father’s personal and family history Examine whether agencies fully understood any issues about the father’s care history, offending history and mental ill health and the impact this may have had on Child K and took appropriate actions. 229. The extent, significance and relevance of father’s history and the potential impact it would have upon his role as a parent has been referenced in other and earlier sections of this report. The role and significance of father’s and the extent to which they are often invisible to the various professionals supporting very young children in particular has also been described. 230. CSC had longstanding and historical involvement with father and other members of his family from 1997. Latterly and before the birth of Child K the contact had been through the leaving care service. The account from the CSC IMR is comprehensive in describing the extent to which the history was not sufficiently accessed when referrals were made and assessments undertaken after the birth of Child K. An account of the reasons and the contributing factors are dealt with in detail in the agency report and are referred to in other parts of this report. Of particular note is the fact that it took the IMR author two days to collate the history for the IMR. 231. This first assessment of father in relation to his risk to his children was completed by a student social worker that concluded that a prison visit was not in the interest of Child K and further made clear to the leaving care worker that as and when father was released from prison and intended to move into the household, an expert and forensic assessment of risk was required; this was never undertaken. The student social worker had concerns that mother was minimising father’s offence and history and was concerned about her vulnerability; the nature of that vulnerability does not appear to have been developed in that or the subsequent assessments. Page 50 of 69 232. In June 2010 the leaving care worker was made aware that father was due to be released from prison and a further referral to undertake a risk assessment was made; this was allocated to a temporary although qualified agency social worker. 233. A subsequent core assessment relied on information that had originally been collated by the student social worker and still lacked any evidence or analysis about Child K’s developmental or other needs or analysis. 234. According to the CSC IMR some individual workers saw their role as primarily being an advocate on behalf of father and determined to see that because of his poor life opportunity he was to be ‘given every chance’. 235. The work of the leaving care service was primarily focussed on trying to help father and was the overriding focus of their involvement. The focus of the relevant regulations for providing leaving care support is upon the support given to a young person gaining independence. 236. Although there was information stored in various health records it was not available or accessed to be considered in regard to the impact on Child K and her sibling. The LCFT had historical records relating to CAMHS involvement that the 0-19 team were not aware of and did not have any reason to access at the time. This information was therefore not known to the midwifery service. No detailed information was apparently sought in regard to father as part of the ante natal care and planning to trigger any further curiosity. The importance of seeking information about fathers is now given much clearer focus. 237. When father arrived at HMP/YOI in August 2009 with a history of arson, self harm, violence and a risk to children a detailed risk assessment was carried out in September 2009 and level 1 child restrictions were applied. This meant that he was not allowed contact with any person under the age of 18. However it must be noted that mother at times tried to visit father possibly utilising false ID. In addition this restriction authorised the monitoring of all calls and correspondence that father may have made. 238. A copy of that report was sent to the GP who acknowledged that it was a very thorough letter with lots of information within it and if there had been any mention of father leaving prison soon it would have been vital to try and identify the mother and Child K and thus share information. However as father was still in prison the letter was simply filed and was not accessed until this serious case review. If the CSC assessments had been more rigorous and had asked for information from the GP along with other relevant services, it would have possibly caused the information to be retrieved from the patient record. Page 51 of 69 239. There were a number of reports of father trying to circumvent the level 1 restrictions placed upon him, by attempting to contact mother. These attempts took the form of written communication, telephone conversations and attempting to arrange a visiting order for her. 240. There were also reports of father being the victim of bullying and at times he was involved in fights with other prisoners. One report of concern came from a cellmate who feared for his own safety as father had on more than one occasion attempted to set fire to his mattress; he had been convicted of arson as a teenager. TOR 7 How child protection and safeguarding issues were identified and managed Examine whether any safeguarding and child protection issues were identified and dealt with appropriately by agencies. Consider whether agency responses were correct and timely and whether safeguarding procedures were followed appropriately. The Review will consider the tools available to practitioners and the effect of management systems on practice in order to understand how these supported practice 241. The assessment in regard to father’s first child was recent and unequivocal; he was not suitable to parent a child. This was the opinion of the social workers completing assessments and providing reports to court and also reflected the view of the child’s mother. These assessments were not accessed when enquiries and assessments were completed in regard to Child K and her sibling. 242. The prison service was otherwise the only service to make a clear assessment that father was a risk to children and had controlled prison contact and visits accordingly. This assessment was completed after father had been convicted and placed in custody for having a sexual relationship with a 13 year old girl. The prison service do not appear to have had information about other aspects of father’s adolescence that were also risk factors although there had been assessments of father’s mental and emotional health. 243. It is notable that father minimised the significance of the offence and maintained that he would not have been convicted if he had appeared in court to defend himself against the charge before he was convicted and sentenced. He also relied on claiming that the girl had misled him about her age. The offence had occurred following a significant history of sexually abusive behaviour displayed to other females. It seems clear that father’s minimisation was accepted by several professionals working with him; when the prison governor made the decision that he was to have no contact with Child K the leaving care worker advocated on his behalf and the core assessment of risk by CSC also relied on father’s account about the offence to judge that he represented a low risk to his children. Page 52 of 69 244. Although there were referrals made to CSC on three occasions, the concerns did not arouse explicit safeguarding concerns and this was significantly influenced by how the parents behaved with different professionals who took reassurance from their demeanour and apparent openness. 245. The way in which the opportunity to refer information to the LADO in August 2012 reflected an approach focussed on offering help and support rather than taking a more rigorous and questioning approach. If the LADO had been consulted, it would have prompted more searching queries in regard to aspects of lifestyle and how it related to the care and supervision of very young children. TOR 8 Resources and capacity Consider whether agencies had the necessary resources and capacity. Consider also whether professionals working with the family were suitably skilled and adequately supervised and whether there is evidence of management accountability and support. The Review will consider the effects of human judgement and reasoning and any strategies used to combat biases in this case in order to understand how these impacted on work with the family. 246. The importance of organisational context was highlighted by Professor Munro’s review commissioned by the coalition government in 2010 and completed in May 2011. The review explored how the effective safeguarding of vulnerable children depends upon the ability of organisations to create the working conditions and arrangements that place a value on the development and retention of professional expertise. 247. The evidence and information provided in this and other serious case reviews illustrate the complexity of information that professionals deal with and the extent to which they have to have the capacity, motivation and support to develop appropriate skills and knowledge that help them make balanced and effective judgements in relation to vulnerable children and their parents. 248. The limitations of trying to redress shortcoming in knowledge and expertise through over prescriptive procedures and protocols were a central aspect of the Munro review and a reasons for embarking upon wide ranging change at national and local levels. 249. There is a degree of irony that according to the IMR, the best of the assessments undertaken by CSC was completed by a student social worker in response to the first referral in February 2010 requesting a risk assessment of father, although the IMR comments that this assessment was not satisfactory. This is not personal criticism of the student social worker but of the supervision and oversight provided at the time. It invites further reflection in regard to the quality of learning and development being offered Page 53 of 69 to a trainee social worker who will be using their experience to inform their future practice. 250. The empathy and ability to build relationships with vulnerable adults whilst at the same time achieving and maintaining an appropriate level of professional detachment and sceptical rigour is not to be underestimated and it requires all professionals to have access to appropriate advice, supervision and mentoring. 251. What is clear in regard to this specific aspect of the case is that the organisational capacity of CSC was impaired in regard to the quality of referral management, assessment and multi-agency communication. No manager was involved in the decision making that took place in regard to the strategy meeting. 252. The CSC IMR also discusses the importance of a service such as CSC having the capacity to support social workers to be a source of ‘good authority17’ and the extent to which this was not achieved in this case. The IMR describes the extent of difficulties in the district social work service at the time and the impact it had on the standards of practice and oversight. 253. The referral in July 2012 from the police to CSC did not identify concerns about the safety of the children. In the absence of any immediate a concern regarding the safety of the children, the response was to make routine checks with other services which focussed on whether any body else had current worries or concerns; none were identified as a result of the enquiries which in turn did not attract any request for further information from the other services. 254. The referral from the police had included information that father had been using cannabis whilst supervising the children on his own; there was reference to the cannabis plant, the hidden ‘weapons’ and the fact that mother was working as a dancer in a club. It was also not disclosed during the assessment that the children were no longer attending nursery due the parents withdrawing them because they were in significant arrears with the fees. The parents provided a reassuring response when the social worker followed up the information. 255. The IMR process has identified that during the timeframe of the SCR there were also difficulties with staff shortages within the health visiting team. This was reported to senior management appropriately at the time and action plans were established. However this resulted in a number of different health visitors visiting the family and workload was becoming ‘task orientated’. 17 The IMR author attributes Harry Ferguson and his book Child Protection Practice which was also referenced in the professional capabilities framework developed by the Social Work Reform Board 2011. Page 54 of 69 256. The individual practitioners fulfilled core aspects of their roles and responsibilities, but there was at times a narrow focus dealing too much with current observation and not always considering more historical and longer term perspectives; this was an issue identified in CSC as well. Sickness levels have now improved within the health visitor team and according to the IMR the difficulties in capacity will also be resolved with initiatives such as the health visitor implementation plan. 257. Under corporate working arrangements the named health visitor maintains overall responsibility for assessment and planning of the health related interventions with children and families. However certain targeted and routine interventions are delegated to staff nurses and nursery nurses in the team with expectation that they will report back to the relevant health visitor. There is evidence of this practice within the records and community nursery nurses confirmed this was the case with this family. They felt supported by the named health visitor and felt there was sufficient opportunity for discussions and ad hoc supervision. 258. The CSC author describes and analyses the impediments that confronted practitioners from using cumbersome systems for the retrieval and collation of information which are being addressed through a plan to procure new systems. This implies there will be some further risk to be managed during any transfer to new systems as and when this occurs. Page 55 of 69 4 Analysis of key themes for learning from the case and recommendations 259. This report begins with an acknowledgment of the imminent changes that will take place over the forthcoming months in the conduct of serious case reviews throughout England. These changes are driven by the recognition that for any meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable families has to understand why things happen and the extent to which the local systems (people, processes, organisations) help or hinder effective work within ‘the tunnel’18. 260. In this chapter the panel set out key findings that are designed to offer challenge and reflection for the LSCB and partners. The emphasis is not on the more traditional articulation of SMART recommendations. The key findings are framed using a systems based typology developed by SCIE. Although this serious case review has not used systems learning to collate evidence there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice in Lancashire whilst accepting there are some limitations and mismatch between how the evidence has been collated and this form of presenting the key findings. a) Innate human biases (cognitive and emotional) b) Family-professional interaction c) Responses to incidents d) Longer term work e) Tools f) Management (and agency to agency) systems 261. The remainder of this report aims to use this particular case, and to reflect on what this reveals about gaps or areas for further development in the local child protection system and use it as a limited window into the local systems. 262. In providing the reflections and challenges to the LSCB there is an expectation that the Board will provide a response to each of the key findings as well as to the recommendations and action plans that are described in the IMRs. As far as the key finding described in the remainder of this chapter it is anticipated that the Board will take the following action. LSCB response a) Does the Board accept the finding? 18 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight. Page 56 of 69 b) How is the Board to take this forward? If not, please explain why. c) Who is best placed to do this? d) What are the timescales for response? e) How and when will it be reported? 263. The LSCB will determine how this information is managed and communicated to relevant stakeholders. This report recommends that the LSCB discuss the key findings and make a formal response that is also published. 4.1 Learning from previous serious case reviews 264. The LSCB in Lancashire had undertaken eight previous serious case reviews between 2008 and 2010. 265. Reference to the evidence from serious case reviews has been made throughout the IMRs, the health overview report (HOR) and this overview report. 4.2 Innate human biases (cognitive and emotional) Thinking, fast and slow; busy professionals rely on intuitive and impressionistic data and information and clear visible signs of abuse including what parents disclose. Sceptical and inquiring curiosity about family history and parental motivation and lifestyle requires more deliberate, purposeful effort to identify the underlying patterns of history and vulnerability. 266. The influence of human bias in how information is processed and analysed in complex processes such as children’s safeguarding enquiries and assessment is an area that a learning based review attempts to explore in order to understand how people make their judgments and decisions. The title of Daniel Kahneman’s book, Thinking, fast and slow19, refers to two systems of the human mind used to process information. 267. System 1, or fast thinking, operates automatically and quickly with little or no effort and no sense of voluntary control; it is the ‘secret author of many of the choices and judgments you make’. Most System 1 skills such as detecting the relative distances of objects, orienting to a sudden sound, or detecting hostility in a voice are innate. Some fast and automatic System 1 skills can be 19 Penguin Books Ltd, November 2011 Page 57 of 69 acquired through prolonged practice, such as reading and understanding the nuances of social situations. Experts in a particular field or discipline can use System 1 to quickly retrieve stored experience to make complex judgments that would be more challenging for others. These are the sorts of skills that workers in emergency services will use along with other practitioners who work with volatile and unpredictable situations such as alcohol, drug, mental health and social care settings. 268. System 2, or slow thinking, allocates attention to the mental activities that demand effort, such as complex computations and conscious, reasoned choices about what to think and what to do. System 2 requires most of us to pay attention when doing things such as drive on an unfamiliar road in poor weather, complete a crossword, or understand a complex ethical argument. 269. Kahneman focuses much of his book on the interactions of System 1 and System 2 and the problems inherent in those interactions. Both systems are “on” when we are awake. System 1 runs automatically and effortlessly but System 2 idles, because using it requires conscious effort and is tiring. 270. It is System 1 that generates impressions and feelings, which then become the source of System 2’s explicit beliefs and more deliberate choices. System 1, when it encounters something it cannot quickly understand and did not expect (in other words, a surprise!), enlists System 2 to make sense of the anomaly. The alerted System 2 takes charge, overriding System 1’s automatic reactions. System 2 always has the last word when it chooses to assert it although is fallible. It can for example, allow the rule of optimism to operate20. 271. The systems operate to minimise effort and maximise performance and are the result of hundreds of thousands of years of human evolution in our environment. They usually work extremely well. System 1 performs well at making accurate models and predictions in familiar environments. System 1 has two significant weaknesses: it is prone to make systemic errors in specified situations; these are “biases” and it cannot be turned off. System 2 can, with effort, overrule these biases if it recognises them. Unfortunately, 20 In 1983, Dingwall, Eekelaar Dingwall and Murray, (The Protection of Children: State Intervention and Family Life, Blackwell, Oxford) investigated professional decision making in an English child protection system. They developed the 'rule of optimism' to explain how health and social workers were screening or filtering out many of the cases with which they were involved. These researchers asserted that under the 'rule of optimism' workers applied a heuristic or routine method of practice which was used to reduce, minimise, or remove the concerns for the child's welfare or safety. This was done via the workers applying overly positive interpretations to the cases that they were assessing. The same research suggested that the 'rule of optimism' was only discounted when parents refused to cooperate with workers and rejected help (a 'failure to cooperate'), or when there was a 'failure of containment' where a number of workers became involved with the case and the pressure for protective action became too great. Child death inquiries and serious case reviews have continued to comment on the phenomenon and Lord Laming has also referred to the same rule of optimism. Page 58 of 69 System 2 is demonstrably very poor at recognising one’s own biased thinking. Trying to engage System 2 at all times to prevent System 1 errors is impractical and exhausting. 272. Within this model for example there are a number of phenomena that have relevance to complex work such as safeguarding. It is System 1 that will initially make an active effort to assign meaning to events and phenomenon, and to make judgments about people and events. Because System 1 is tasked with doing this very quickly, and as in this case, often in very busy and stressful circumstances, it must rely on short-cuts and educated guesses. 273. In addition to making sense out of the events unfolding before it, System 1 is also involved in judging and evaluating the people and behaviours it experiences. Here again, System 1 must resort to shortcuts and educated guesses to render its impressions as quickly as possible. Essentially, what System 1 does is that it jumps to conclusions based on what limited information it has access to; information, which given that it lives very much ‘in the moment’, is confined to what is directly in front of it, and/or most readily comes to mind. 274. System 1’s tendency to consider only the information that is directly at hand is so pervasive and Kahneman refers to it so often, that he uses a cumbersome abbreviation to represent it: WYSIATI: what you see is all there is. In this case, what people saw was two young people who had not had the greatest of starts in their lives saying they wanted to do the best by their children and presented themselves as being motivated, friendly and kind. 275. In addition to WYSIATI, System 1 also jumps to judgments and evaluations in several other ways. For example, when we are presented with a question that we do not know the answer to, System 1 will simply get to work and answer a related but much easier question, and then offer up this answer to System 2 as the solution to the more difficult question. In a case such as this, a question might be whether a parent has changed or is able to care effectively for their child and will be much more difficult than the question is the parent likeable? 276. System 1 is also very susceptible to first impressions. System 1 also takes a third short-cut in evaluating people, and this short-cut is known as the ‘halo effect’. As Kahneman explains, the halo effect is “the tendency to like (or dislike) everything about a person including things you have not observed”. Essentially, System 1 tends to evaluate someone on one or a handful of traits, and then simply extends this evaluation to other traits. For example, “you meet a woman named Joan at a party and find her personable and easy to talk to. Now her name comes up as someone who could be asked to contribute to a charity. What do you know about Joan’s generosity? The correct answer is that you know virtually nothing… But you like Joan and you will retrieve the feeling of liking her when you think of her. You also like Page 59 of 69 generosity and generous people. By association, you are now predisposed to believe that Joan is generous. And now that you believe she is generous, you probably like Joan even better than you did earlier, because you have added generosity to her pleasant attributes” 277. Thinking, Fast and Slow provides an accessible vocabulary to discuss the processes of human cognition which are the interactions between System 1 and System 2 thinking. It does not, however, provide solutions or reliable approaches to bias mitigation. According to Kahneman, the best we can hope to do is learn to recognise the situations in which mistakes are likely, and try harder to avoid specific errors when the stakes are high; for example when making enquiries and completing assessments where there is evidence of vulnerability. 278. A significant theme in this and a previous serious case review is the influence that was exerted on professional mindsets arising from how the adults presented themselves combined with an absence of historical perspective and knowledge and it implications and an optimistic tendency to treat information for example about cannabis use without much concern. 279. All of the IMRs confirmed the views that were expressed during the initial practitioners learning event at the outset of the review that both parents were polite and not obstructive in their interaction with professionals. This included the contact they had with health professionals, social care as well the police. 280. Initially, when the first pregnancy was booked, father was in custody and the main point of contact was with mother. From the outset, both parents were keen to minimise the sexual offence for which father had been convicted in regard to a 13 year old girl. There was a lack of challenge from the outset about how father in particular wanted to have it regarded as an injustice done to him in his absence from the court as a result of him oversleeping. 281. The couple expressed on more than one occasion a desire to provide better childhoods for their children compared to their own and the observations recorded by the different services visiting the house confirmed that the children were clean, fed and kept warm and were dressed in appropriate clothing. 282. All of the services were influenced to some extent and was a product of a lack of knowledge about the history of either parent. The police and probation service knew of father’s criminal history and the police were continuing to keep an active interest in father’s activities. The police made a referral following a search of the family home which found father smoking cannabis and in possession of a plant along with a substantial cache of money and a collection of hidden weapons. Page 60 of 69 283. In making the referral the police acknowledged that the children were apparently well cared for. The disclosure that father made about mother working as a dancer was subsequently dismissed by father as an effort to wind up the police. 284. There was additional susceptibility that arose from the relative inexperience and lack of training for some of the professionals who were allocated responsibility to take a lead at various times; a student social worker completed the initial assessment following the referral regarding the risk of father and the role of the leaving care worker when father was released from prison and joined the family. 285. A significant learning point to come from this and other serious case reviews is the requirement for professionals to have had the opportunity to cultivate the appropriate emotional and mental skills through which to process information and observation. This was unlikely to have been achieved for workers who were unqualified or had not completed their training or were still at a relatively early stage in their career let alone whether they had an understanding of constructs such as Kahneman’s ‘Thinking, Fast and Slow’. 286. Another dimension examined in the IMR from CSC explores the requirement for key professionals in social care (and by implication primary health and early year’s settings) to have the motivation and capacity to develop relationships with parents who have additional needs or vulnerability. 287. These relationships have to create the conditions within which there can be a level of knowledge and confidence to challenge and understand the underlying patterns. In this case, there was significant history in both parents that if it had been known and explored would have created an improved context within which the parents behaviour and interaction was better understood. Issue for consideration by the LSCB 1. How can practitioners develop and improve their cognitive framework upon which to evaluate their experiences and improve the manner in which they process and analyse information about children? 4.3 Responses to incidents or information Enquiries have to be a reciprocal exchange of relevant information and intelligence that requires both parties to have confidence in the local information sharing protocols and develops common trust and confidence in how sensitive information is managed Page 61 of 69 288. A central theme of the serious case review is the extent to which the opportunities for making sufficient enquiries and sharing of information were not sufficiently exploited. The considerable history of father in particular remained undiscovered for many of the services. 289. The enquiries and assessments that were completed were hampered by the complications of several different people handling individual incidents or reports such as in the exchanges between the police and CSC as well as health. The focus tended to be on what adults were saying or doing with insufficient attention to the implications for children. The manner in which father joined the household in spite of the offence and concerns expressed from within the prison service, the information sent from the police in regard to the presence of drugs and weapons and evidence of offending. 290. A significant episode in respect of responding to information was the way in which the police referral was followed up in August 2012. The referral highlighted lifestyle issues in relation to the use and presence of cannabis in the house, evidence of involvement in crime and mother working as a dancer. 291. A telephone conversation between CSC and the nursery did not achieve a full exchange and disclosure of relevant information. It appears that there was a reluctance to share much information about the referral with the nursery for reason of maintaining confidentiality and managing third party information. 292. A degree of misplaced reassurance was taken from the social worker having an understanding that both children were attending the nursery and the nursery had no concerns to report. The narrow focus of the enquiry did not encourage a wider discussion and the social worker did not for example have an understanding that the pattern of attendance had reduced and the parents had already incurred debts in regard to fees that were also not disclosed. 293. The panel spent time discussing the biases that might be operating in regard to the confidence and trust that services such as CSC have in for example sharing sensitive information with independent operators of services. 294. There was no reason for a referral to have been made to the LADO because there was no information that suggested that parents were committing an offence against a child. What was not known at the time or to the panel at the outset of the review was that under the statutory framework for the early year’s foundation that is referenced in footnote 14 earlier in this report, Ofsted have applied the scope of disqualification to apply to partners or other people living in the same household under section 75 of the Children Act 2006. If this had been known, a referral to the LADO would have been Page 62 of 69 made. The panel were otherwise not persuaded that the information in regard to drugs which had not suggested involvement by mother would have merited consideration as to whether it had implications for her employment as a trusted adult. The CSC IMR makes the point that the relative inexperience of the social work team might have been counterbalanced with the input from a more experienced professional designated as the LADO. 295. Information about the use of cannabis was generally not regarded as a significant threat to the well being of the children. Father’s long term use including during his adolescence had implications for his emotional and mental well being and should have been explored within any parenting assessment. 296. There was also information held by the GP from risk assessments conducted in the prison that was not shared or accessed at any stage. When the GP received the information, father was not living with the family and therefore the GP judged there was not a duty to disclose. The GP was not then made aware when father was released and had moved in with the family. The GP along with other services was not asked to provide information for any of the enquiries or assessments which would have been the opportunity to share the information. Issue for consideration by the LSCB 1) Is the LSCB sufficiently confident that information sharing protocols are operating effectively enough in respect of enquiries with all providers of early years services? 2) Is the LSCB satisfied that the management of enquiries made during statutory enquiries and assessment are able to identify relevant information held by services such as early year’s services and GPs? 3) What are the factors that discourage practitioners from regarding information about cannabis use as meriting more rigorous enquiries within children’s assessment? 4.4 Longer term work Longstanding contact or knowledge with a family can be a source of misdirection and assumption leading to misplaced belief in parental resilience and capacity 297. The fact that both families had some significant contact with services over several years has been an important area for analysis and reflection. It is a paradox that knowledge about father’s particular history was insufficiently understood particularly by the social workers who had responsibility for assessing whether there was evidence of need or risk. 298. The first assessment that was completed was a desk based activity although does not appear to have secured any substantial information in regard to the Page 63 of 69 childhood history of father. It failed to enquire into the circumstances under which father’s first child had been removed and placed for adoption and it also failed to uncover the compelling evidence from a previous partner in regard to father’s potential for coercion. 299. It is not apparent that archived information was examined and might reflect an over reliance on what the electronic record system is able to deliver. It is also probable that for a practitioner still undergoing training, they would have a less developed insight and understanding about the significance of childhood and family history although this is an area of practice that is often identified in assessment practice and serious case reviews. It is also a fact of life that in services that are under significant workload pressure, there is less capacity and motivation to be looking for evidence and information in regard to referrals that are not presenting evidence of immediate risk and concern. 300. Assumptions were also made by services such as midwifery that the geographical proximity and involvement of maternal grandmother in domestic arrangements was a source of greater support and resilience than was in fact the case. 301. The police and probation service along with the leaving care service had considerable knowledge of father and his offending although did not appear to have concerns about him being a risk to his children. There may have been some assumption made that the sexually coercive behaviour he displayed to previous partners as well as carers was historical. Parents who are in prison continue to exert influence and have significance for the partners and children and have implications for assessment and the planning of appropriate intervention 302. It is apparent that father and mother were determined to keep their relationship intact when father was imprisoned. The request by the prison service for a risk assessment to be completed as part of the sentence planning process was postponed until the imminent release of father. 303. In the spirit of identifying learning that applies more widely than a single case, Child K provides an opportunity to reflect upon the needs of children who are frequently hidden from view. An estimated 160,000-200,000 children in the UK have a parent in prison. This is about twice the number of children looked after (91,000) and over three times the number of children who are subject of a child protection plan (50,500). 304. Children who have a parent in prison are more likely than others to experience poverty, mental ill health, poor housing and other negative outcomes, but are much less likely to receive any help or assistance. Although government policies refer to them as one of the groups of disadvantaged Page 64 of 69 children who should receive attention it is a minority of local areas that make any reference to this group in their children’s plan. 305. The history of father combined with his record of being a prisoner had implications for his children in the immediate and longer term. 306. It is not infrequent for a father to be absent from the family home as in this case; the particular issues that arise from managing relationships for example between men in prison and their children is a significant issue. Professional vigilance by all relevant services is essential to ensure as much information is collated about fathers especially as they can exert considerable influence even when they are not living in the household for example as a result of returning to prison. It is essential that consideration and assessment of such factors is built into assessments that are routinely completed by early years, health or social care services. Issue for consideration by the LSCB 1. To what extent are the needs of children who have a parent in prison included in local strategic plans and professional development and training? 4.5 Tools The use of recognisable tools or frameworks can enhance the collation and analysis of information in regard to risk from offenders who may pose a source of harm to children 307. The review has highlighted gaps in how assessments were sufficiently focussed on risk. The removal of the first child should have been considered; understanding access to confidential and archived adoption records was a factor. If the records had been examined along with evidence from a previous partner the assessment in relation to Child K and sibling would have been much more focussed. 308. The fact that father appeared able to minimise his sexual offence and the manner in which the practice direction for a forensic assessment was not followed through might have been a product of not having enough confidence in handling this specific aspect of work. 309. The information that was provided in regard to father’s use of drugs does not appear to have been assessed meaningfully. It is possible that some of this might reflect a misplaced tolerance of what appeared low level substance use. It is an example of some of the areas of practice where there has to robust supervision to deal with ethical dilemmas that some individual practitioners are dealing with. Page 65 of 69 310. In the absence of any tools, scales or other frameworks, the practitioners were even more reliant on observation and inferring and interpreting significance without recourse to more objective measures to help inform their judgments. Issue for consideration by the LSCB 1. How will the LSCB promote the increased and more consistent use of relevant risk assessment tools and frameworks that include the use of cannabis? 4.6 Issues for national policy 311. The issues raised in the CSC report for this review in regard to social work training that underpins a concept of investigative social work and the use of good authority versus anti oppressive practice, partnership working and support in social work practice. 312. The Ofsted guidance (No. 080157) issued in November 2011 on disqualification from working in children’s social care states that a person is disqualified from working in specified settings including registered child care setting ‘if they live in the same household as person who is disqualified’. Child K’s father was disqualified by virtue of the sexual offence he was imprisoned for. According to the panel’s understanding of the Ofsted guidance, Child K’s mother should have been disqualified from working in a nursery despite the fact that she had not at that stage committed any offences and was not undertaking and registered child care in premises shared with Child K’s father. 313. The Ofsted guidance on this specific detail is not widely known in Lancashire and has implications for the recruitment policy and practice of registered services. Early year’s providers in other parts of England may be similarly unaware of the interpretation. 314. In the opinion of the panel, there are significant policy implications of the interpretation for the initial checks at recruitment and selection stages and for ongoing disclosure in early year’s settings. Peter Maddocks, CQSW, MA. Independent author July 2013 Page 67 of 69 Appendix 1 - Procedures and guidance relevant to this serious case review Legislation The Children Act 1989 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act21 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need. Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm. These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a person has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998. Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. The Children Act 2004 Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate. The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes. This section is the legislative basis for children’s trusts arrangements. 21 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Page 68 of 69 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act22 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Safeguarding Procedures The local safeguarding children procedures The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review. Other local procedures relevant to this serious case review National guidance23 Working Together to Safeguard Children (2013) The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable. The guidance in respect of the Framework for the Assessment of Children in Need and their Families was replaced by the Working Together 2013. 22 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. 23 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government. Page 69 of 69 Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review. Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008. |
NC52756 | Death of two children as a result of a house fire, believed to have been started by their mother, in March 2021. Learning includes: practitioners should think more holistically about families and consider all the presenting needs; recognition of practitioners' role and responsibilities for parents caring for children with disabilities and how legislation and guidance can support their work; assessment of the impact of domestic abuse and its emotional effects on family members; practitioners to be cognisant of the impact of intrusive thoughts and for those to be risk assessed at an early stage; understand children's day to day lived experiences; and the support that families receive from their faith and from their church should be assessed as a vital part of their support network. Recommendations include: ensure awareness of revisions to existing protocol with front-line practitioner events and audits of practice; ensure that carer's needs are sufficiently considered and assessed in line with the expectations of parent carers assessments; review training strategy to ensure that all partners equip their practitioners to be confident when dealing with families where domestic abuse is (or has been) a factor; ensure assessments and ongoing work includes the child's experience and emotional impact of these experiences as well as the child's voice; and professionals should be equipped with cultural competency together with an understanding of intersectionality to properly identify and consider these factors when assessing and managing the risk to children.
| Title: Children C and D: LCSPR report. LSCB: Greenwich Safeguarding Children Partnership Author: Jane Doherty Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Children C and D LCSPR Report Author: Jane Doherty December 2022 Greenwich Safeguarding Children Partnership 1 Introduction 1.1 This Child Safeguarding Practice Review (CSPR) is being conducted in response to the death of two children Child C and Child D who died as a result of a house fire in March 2021. The fire is believed to have been started by their mother who also died. Children C and D were known to several services in Greenwich - Child C had an Education Health and Care Plan (EHCP) due to his additional needs. Child D was being assessed for an EHCP at the time of his death. 1.2 The deaths were notified to the Greenwich Safeguarding Children Partnership (GSCP) and a Rapid Review meeting took place a few days later. Members felt that there was learning for the Partnership from the circumstances of this family and recommended a Child Safeguarding Practice Review. They notified the National Panel who agreed with the recommendation. 1.3 At the time of writing, police enquiries had concluded (having established the cause of the fire) and the coroner’s inquest into all three deaths was in train. This had been substantially delayed due to issues caused by the global C-19 pandemic. 2 Terms of Reference 2.1 The Terms of Reference were agreed by the panel. Agencies involved with the family were asked to analyse their involvement via a brief written submission. To ensure that the review was proportionate, the period covered is the preceding year i.e., from March 2020 up to the date of the incident in March 2021. However, agencies first became aware of the family in 2009 and, with help from the family, the panel used this early history to help build a picture of them. The review period coincides with the first and subsequent national lockdowns imposed by the government as the impact of the Covid-19 pandemic hit. Agencies were therefore asked to comment on how this had disrupted services. 2.2 The report is based on the agencies’ submissions and a practitioner event with key staff that had worked with the family and knew them. Meetings were held with members of the family and their contribution is summarised at Section 6. 2.3 The broad areas included in the Terms of Reference that the panel agreed were the most important to look at were: • The quality of information sharing across agencies about the needs of the children and their mother • Exploration of family relationships including Mother’s extended family and the children’s father • Were needs identified swiftly, thresholds applied correctly, and services provided in a timely manner. If not, what were the barriers to this? Were opportunities missed to identify risk at any stage? • How were issues arising from diversity addressed e.g., were ethnicity, culture and background of the family considered during assessments? If so, were any issues or barriers identified? • What impact did Covid-19 have on how professionals worked with this family and on the family stressors? • The support for the family to try and minimise the impact of the challenges presented by the children and their additional needs • What was understood, assessed, and shared by agencies about Mother’s mental health and physical health (i.e., Mother’s diagnosis of MS) and how these impacted on her capacity to parent? • How much priority was given to understanding the lived experiences of the children? • Examples of strong multi agency practice as well as lessons to learn across the Partnership. 3 The children 3.1 Before detailing the contact professionals had with this family it is important to pause and reflect on both children who are subjects of the review. It has been evident throughout the process that the children were popular, engaging and loved by those around them. These profiles have been collated from family members and from practitioners who knew the children well. Child C 3.2 Child C was a unique funny, kind, and sweet young man who brightened up everyone’s day. He smiled a lot and would put on funny voices, acting out different characters and being a comedian. He was a cheeky individual and everyone who knew him loved him. He loved all things ‘tech’ and was a great older brother. He would cook every day and was planning to take food tech as a subject in GCSE. Child C’s family described him as clever, witty, energetic, and very helpful. In the time he spent with them he made jokes and was mischievous but always made time to help. He liked to play with his phone and watch television and liked to look after his little brother. He enjoyed working with his grandmother and was happy chatting to the people he met there. In short, he was a total joy to have around, and he is very sadly missed by everyone. Child D 3.3 Child D was a well-loved member of the school, he always made his friends and adults smile. He was a quiet member of class, but he was always included in the children’s chatter. He quite often sang to himself throughout the day, and he loved listening to stories and being read to. He could also be mischievous and one time he hid some maths resources from his teacher because he didn’t want to do the activity! Each day he helped to collect a group of children together to lead them around a sensory circuit and this was one of his favourite things. In doing that he showed that he cared for others. Child D’s family described him as a ‘wonderful’ boy. He had little speech but often would speak when he decided to. MGM has fond memories of him reading words such as ‘swimming’, ‘dad’, ‘mum’. He loved home made food and wanted to help in the kitchen and taste everything. He was great at shopping enjoyed bus journeys. His family said he was ‘just lovely’. When he saw his uncle and brother playing, he wanted to join in and sometimes complained that they were not including him. Child D enjoyed watching his IPAD and laughing at what was going on. He is also very sorely missed. 4 Agencies contact with the family 4.1 The agencies’ submissions as part of the review process have been co-ordinated into a combined chronology and briefly summarised here. Further information is provided in subsequent sections to add context where relevant. This is not intended to be an exhaustive list of day-to-day contacts but highlights the main interactions. Background information 4.2 The family (Mother and the two children) lived and received services in Greenwich. Mother was separated from the Children’s father, and he lived in another borough with his new family. There was a history of domestic abuse from father towards mother, dating back to 2009, and he received a community order for assaults against her. The children’s contact with him was sporadic, particularly once he had other children. The parents’ relationship remained difficult. Mother had another relationship which professionals were aware of, but she kept this very private, and he was not part of the children’s lives. 4.3 Both children had additional needs and their behaviour could be very challenging. Child C had an Education Health and Care Plan (EHCP) due to his diagnosis of autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). He received a high level of support in school. Child D was in the process of being assessed for an EHCP which was submitted in January 2021. He also received support in school. Of particular concern for him (aged 5) was that he had very limited speech. 4.4 Prior to and throughout the period under review there was a high level of contact with the ASD Outreach Team to support the family and this continued as much as possible through the national lockdowns. The children received other services such as Speech and Language Therapy (SALT) and music therapy, to try and support them with their associated communication difficulties. Agencies worked closely together throughout this period via a series of Team Around the Child (TAC) meetings, particularly around the boys’ education and offering the family support during the lockdowns. Mother and other members of the family such as Maternal Grandmother (MGM) engaged in the meetings. Events in 2020 4.5 At the beginning of the first national lockdown (due to the C-19 pandemic) in March and April of 2020, schools were closed to try to contain the virus. Mother became overwhelmed with the demands of looking after both children at home. In addition, Mother reported the impact of the children’s father telling her that if she couldn’t cope, she ‘should kill herself’. This was very upsetting and on top of everything else, this had got her down. 4.6 To try and support her, Child D’s Music Therapist made a referral to Children’s Social Care in Greenwich. It was agreed that the school would assist her further and a plan for daily contact with them was made. Mother found the contact helpful and although many services had to be delivered online, rather than in person, the children received a package of support. 4.7 In the autumn of 2020, Mother received a diagnosis of Multiple Sclerosis (MS). She had been experiencing symptoms for some time, but the diagnosis came as a shock. Mother reported that she had balance issues, found walking difficult and was suffering with fatigue. There were additional symptoms she struggled with, including loss of sense in the fingers, and being unable to grip. This caused challenges to simple day to day activities e.g., buttoning her or the boys’ clothes, cooking, writing etc. In addition, she also told her family that she had started suffering from memory loss. 4.8 She undertook treatment in the following months and reported some improvement in her symptoms, but she understood that this was a long-term condition. She was understandably worried about the future and the impact of this on her ability to care for her children. 4.9 The primary school made a further referral to Children’s Social Care in Greenwich. The family were allocated to the Early Help Service to assist with co-ordinating services. A referral was made almost immediately for assistance from Health and Adult Services in Greenwich, but no services were offered as they assessed that Mother was not eligible. She was reluctant in any case to receive any practical help at that stage. 4.10 In the autumn of 2020, Mother’s brother and MGM were babysitting the children but Mother did not return at the agreed time. A family member reported her missing to the police and they commenced an investigation into her whereabouts. She returned the following day, saying that she had needed some respite and space to process everything that was happening. 4.11 The referral to Health and Adult Services (HAS) was revisited when Mother was feeling more positive about accepting services. They were unable to contact Mother to explore what services would be helpful and referred back to Children’s Services. 4.12 Mother took up the offer of counselling from Greenwich Time to Talk1 and had several sessions. She engaged well with these and when the allotted amount came to an end, the counsellor recommended that the sessions continue. 4.13 At the beginning of 2021, the UK again experienced a national lockdown to try and contain the spread of C-19 virus. Both children were allocated places in school and attended as normal. The Team around the Child meetings continued as a school-based plan, as the family were closed to Early Help services in early February. Early Help had put a sustainability plan in place in case the family needed help and they were also able to link in with the school. Week leading to the tragedy 4.14 In the first week of March 2021 there were several contacts with the professional network. Mother had a counselling session with ‘Time to Talk’ where she disclosed that Child C had unwittingly seen her, and her partner in bed. The exact details of this are not known but Mother disclosed that she had spent money on Child C to try and appease him. Mother was tearful and low in this session and sought advice about how to deal with the situation. NB Mother’s partner did not live in the family home and was not well known to the children. 1 Greenwich Time to Talk is part of a national programme of Improving Access to Psychological Therapies (IAPT). It is for people with mild problems of anxiety or depression who are motivated to work to change the problem. 4.15 There was a Team Around the Child meeting in the same week where Mother initially presented as being very subdued and tearful. She was reported to be more positive at the end of the meeting. After this, MGM contacted the Early Help team as she was worried that her daughter’s mental health was deteriorating and wanted to see what other support could be offered. MGM was unaware that this team were no longer involved. Mother contacted Early Help services later to apologise for her mother’s contact with them saying that she would use QWELL2 as per the sustainability plan. 4.16 On the same day Mother reported to her MS consultant that there had been an overall improvement in her condition after her treatment, but she still had walking and balance issues. This was recorded by the service as a positive interaction. 4.17 The primary school also referred to the Multi Agency Safeguarding Hub (MASH) concerned that mother was becoming overwhelmed. Her mental health was deteriorating, and the referral noted she was very tearful in the recent TAC meeting. MASH and Early Help services communicated about this and MGM’s contact to services. 4.18 On Friday (the day before the fire), Child C arrived at school saying that his bag had been stolen on the way to school. Police and MASH were informed, and school staff contacted Mother. This was being dealt with by MASH but had not yet been uploaded to the system. Mother did not seem concerned about this and was happy to see Child C when she collected him. NB this turned out to be untrue and he had left his bag at home. 4.19 The following day the events leading to this CSPR unfolded. Mother and both children died as a result of the house fire. 5 Findings The Team around the Child/Think Family 5.1 The Team around the Child for this family was well established, having been started in both the children’s schools and then brought together by the Early Help team during the review period. Strong plans were established to help the children with their communication difficulties and to try and support Mother in caring for them. Mother was very engaged with the process and professionals had good relationships with her. Professionals noted that Mother’s anxiety presented itself by talking at length to them about her issues and she seemed ‘lighter’ at the end of these sessions. 5.2 The review has highlighted however that some services could have adopted a stronger ‘think family’ approach. The children’s needs were the focus of the Team around the Child and support to Mother in relation to their needs was evident. However, Mother had needs in her own right which also impacted on her ability to care for the children. Not least, these were around her physical deterioration due to her MS, coupled with the worries and anxiety this had understandably provoked in her. 5.3 It was evident through the review that Mother was troubled about a number of things in 2 QWELL is a free anonymous, online counselling and emotional wellbeing service for adults her life E.g. being a victim of domestic abuse from the children’s father, the ongoing difficulties in that relationship, and her disappointment and possibly shame in her current relationship that she conveyed to practitioners. Very little is known about him and was worthy of further exploration. Whilst there is no suggestion that their association was anything other than consensual it seems that this also contributed to her anxiety and having low self-esteem. 5.4 In addition to these factors, it is not unusual for parents of disabled children to feel grief and depression at the loss of the type of life they had imagined their children living and the achievements they wished for them. The family also noted Mother’s struggles with the demands of her children, and more is said about this in Section 6. In relation to her own life changing condition, Mother was extremely fatigued and day to day life was becoming more difficult in terms of managing routine tasks. Mother’s family noticed that these all became more pronounced during the C-19 pandemic as the restrictions meant that access to her coping mechanisms such as exercising at the gym were not available. 5.5 There was some liaison between children’s services and adults’ services, but these were limited. Adult focused practitioners such as the MS nurse did not attend the Team around the Child meetings. She was invited to at least one but was unable to attend. The information gleaned through this process states that she was able to feed in information to the meetings through the EH practitioners, but it lacked continuity. Attendance at the meetings would have given her a more holistic view of the family and what Mother needed in terms of her own care. 5.6 In consultation with practitioners, they reflected on the reasons for this. They were clear that Mother’s emphasis in these meetings was the children and there was some resistance from her to mix the two sets of services. Whilst this was understandable from Mother’s perspective, the lack of co-ordination meant that there was a mismatch between the needs of the children, Mother’s needs in terms of being able to care for the children and Mother’s needs in her own right. The hospital based MS service (Queen Elizabeth Hospital), Health and Adult Services (HAS) and Greenwich Time to Talk all had information to contribute. This would have given a more rounded picture of Mother’s difficulties and would have informed the assessment of need. Instead, the assessment of Mother and her needs was piecemeal. 5.7 Whilst it would not have been appropriate for Mother’s counsellor to join meetings as such, the information from Oxleas during the review makes the point that there is merit in counsellors contacting other services e.g., children’s services, to exchange information. This would have been especially beneficial around Mother’s mental health and mood which fluctuated between sessions. Opening this channel of communication would also have been advantageous when dealing with the issue of Child C and the complexities of those dynamics. There was a missed opportunity for the practitioner and the organisation to seek safeguarding advice and supervision outside of their own organisation. Had Children’s Services been made aware of this issue, statutory intervention may have been offered at an earlier stage. 5.8 In families such as this one, where there are complex needs for both the adults and the children, services need to work in partnership with each other as well as in partnership with the family, to ensure that all members of the family’s needs are met effectively. Adult health services and the family GP who were providing support to Mother in relation to her MS, had very limited knowledge of the family as a whole. 5.9 An avenue that could have gone some way to bridging this gap may have been a formal Parent Carers Assessment under the Children and Families Act 20143. It was not utilised and there is a question about whether the pathway in Greenwich is clear to practitioners about when this can and should be used. Mother’s physical deterioration and fluctuating mental health was a major factor in finding the demands of caring for her children overwhelming. This is unsurprising given their additional needs and the fact that she was a single parent. Meeting her needs under the auspices of this legislation may have opened up more resources to be help her. Mother never requested this, but it was unlikely that she was aware of her right to ask for such an assessment. Recommendations are made at 8.2 and 8.3 to ensure practitioners are aware of this legislation and obligation to assess carers and that carers are aware of their rights. 5.10 Although no formal assessment of her caring needs was completed, good practice was demonstrated by offers of respite care, child minding and after school clubs for Child C. It seemed however, that there were multiple barriers for Mother as to why these were not utilised and opportunity for a more detailed exploration of what these barriers were, may have been more evident through this formal assessment. Information from Early Help services usefully identified that a possible barrier for Mother was the sheer number of services offered, which may have felt overwhelming. 5.11 Professionals were aware of the children’s extended family on Mother’s side and knew that they were supportive and close as a family unit. An organised pattern of respite through a Family Group Conference would have been an avenue to explore this further. It is not clear if Mother would have followed through with any such plans given information gleaned from family and professionals alike which acknowledged that when services were offered, they were rarely taken up. 5.12 Health and Adult Services (HAS) also offered services which Mother declined on the first occasion. A further referral was made, and this was not followed up by them when they were unable to contact her. Learning identified is again about the need for adult focused services and child focused services to better comprehend each other’s worlds. There was no doubt that Mother did have eligible needs under the Care Act 2014, but the information was shared between agencies in a fragmented way resulting in limited understanding of Mother’s needs. 5.13 Since this review and because of learning from it, Greenwich have updated their existing joint protocol between the Greenwich Safeguarding Children Partnership and Safeguarding Adult’s Board. This is due to be launched in spring 2022 to help practitioners identify and respond to concerns about a vulnerable child or adult at risk. The protocol will help to ensure effective and timely referrals between all adult’s and children’s services and promote good practice in multi-agency working. This guidance for staff will be invaluable to Greenwich in how to provide better joined up services between adults and children. A recommendation is made at 8.1 to ensure that this is 3 The Children and Families Act 2014 amended some sections of the Children Act 1989. Under this legislation local authorities must assess parent carers if it appears that the parent carer may have support needs, or they receive a request from the parent carer to assess their support needs. embedded into practice Responding to fluctuating mental health needs 5.14 It was well known to the network that Mother struggled with her mental well-being. To this end services were in place to try and support her with trying to improve her mood. Mother was given a choice of services and opted for counselling provided by Greenwich Time to Talk. This was her main mental health support. Mother also confided in other professionals and many of them reported lengthy sessions with her where she would talk freely and often feel more positive after these. Family members also offered their ongoing support both in terms of helping her and the children. As the outcome in this instance was so tragic, it is necessary to examine some of the practices and factors that led to her mental health crisis going unrecognised. Significantly during the period under review, Mother was never assessed formally under the Mental Health Act, nor did she seek mental health support from her GP. i.e., she was never considered to be high risk of harming herself or others. 5.15 Prior to Mother being supported by Greenwich Time to Talk, Early Help Services recognised that Mother’s mental health was an issue. What this looked like for her and how it impacted on her day-to-day functioning was not explored sufficiently. In terms of initial safety planning i.e., whilst waiting for counselling, Mother was advised to seek alternative support such as the Samaritans or present herself to A&E. The reasons that these suggestions were made is not explored with her (or at least not recorded). The information gleaned during the review identified learning for Early Help practitioners in being equipped to identify mental health struggles on a person’s ability to parent and to ensure that the reasons for referral are re-visited. Since this incident, the Early Help Service in Greenwich are developing practice guidance for their staff specifically about how to approach assessing risk thoroughly where parents are experiencing intrusive thoughts. 5.16 A referral was made to Greenwich Time to Talk, and they provided a service to Mother between December 2020 and March 2021. The sessions were led by Mother as per their practice model and the therapist worked with what she brought to each session. Much of the work was focused on her personal issues but Greenwich Time to Talk used screening tools to assess risk as per their usual practice. Learning was identified in relation to how risk is assessed using their standard patient questionnaire. The questionnaire is based on a series of questions answered by the client in relation to their day to day lives and how they are feeling. In this instance, the overall scores in terms of Mother’s well-being were getting better but this does not tell the whole story. There were times when Mother’s response to the specific question about intrusive thoughts should have triggered more in-depth assessment of risk. 5.17 Practitioners expressed (and was confirmed by managers) that there was limited time to check individual scores. Custom and practice in that service was that counsellors only looked at the individual scores more closely if there is a reason to e.g., serious concerns expressed in the sessions. OXLEAS acknowledged this learning and made a recommendation to alter their practice. This is a systemic issue that needs to be addressed and new practice has been embedded whereby practitioners are asked to check the individual scores and not just the overall score. Quality assurance mechanisms to ensure compliance with this are in train. 5.18 Due to COVID, the sessions were also delivered via the internet or the telephone and in these circumstances, subtle nuances of body language and other cues may have been missed. There is a view from Mother’s family that this approach was not helpful to her, and this is expended on by them in Section 6. This is a systemic issue as practitioners were directed by their employers to work online, in line with government instruction and were not permitted to meet clients in person. It is nevertheless an important point. Now that agencies have experienced service delivery through a pandemic, how services are offered and how risk is managed for individuals will be an important feature for major disruption to services in the future. A recommendation is made at 8.7 to put in place contingency plans for any future interruption to services 5.19 A challenge for practitioners working with the family was not just Mother’s poor mental health but also the fluctuating nature of it. It is likely that this was, at least in part, connected to her physical health also being up and down. As we have seen, Mother responded well to agencies and really appreciated the support. She was very verbal about this and often wrote to agencies to thank them for their help. In her darker moments she would express how down she felt but practitioners observed that she was frequently visibly more positive at the end of an interaction. As outlined, there are lessons to learn but this may go some way to explaining how this was missed. Mother was able to mask her true feelings and intentions, perhaps as a coping mechanism. The day before the fire, despite being ‘down’ earlier in the week, school staff had a conversation with Mother (ostensibly about Child C’s bag being stolen) where outwardly she appeared to be fine. She was supportive to Child C, pleased to see him and did not show any signs of distress. Individual agencies recognised this issue in their submissions to the review. They have plans in place to address these practice shortfalls so although this is identified learning, there is no recommendation for the Partnership. The legacy of domestic abuse 5.20 It was very positive that services (Early Help in particular), tried very hard to engage the children’s father with their work. He was resistant to being directly involved but did agree that the practitioners would keep him up to date as he did not want to attend Team around the Child meetings. His contact with the children was sporadic and became more so when he had a new family in the autumn of 2020. The relationship between the parents was complex and mother found the legacy of the domestic abuse difficult to deal with. Little is said by agencies about the impact of this on the children. It is not therefore known how the children viewed their father and how keenly they felt his absence in favour of his other children. 5.21 An important lesson from this review is about domestic abuse between partners who have separated but where there is ongoing contact with children. This is a complex dynamic; the power imbalance is likely to be still present and practitioners need to consider how this should be assessed. Research tells us that parental separation does not guarantee an end to domestic abuse and that for many women who separate from violent partners, the domestic abuse continues beyond this. The Domestic Abuse Act 2021 recognises that separated women are at particularly high risk and so therefore are their children.4 The new legislation extends the controlling and coercive behaviour offence to cover post separation abuse. 5.22 For many families, contact between fathers and their children provides a context for domestic abuse to continue.5 Notably in this instance, Mother had reported that Father made her feel uncomfortable. She found him controlling and verbally abusive and if he did come to the house to collect the children, she stayed upstairs. It is likely that this added to Mother’s poor self-esteem and her feelings of shame. Although by no means the only issue Mother faced, it was an important one to assess. A recommendation is made at 8.4 to try and address this. Understanding the Family’s lived experience Children C and D 5.23 Understanding of the children’s needs and lived experiences in this family was mixed. From the information provided it is evident that many services were geared towards the children. These were both in terms of maximising their education opportunities but also improving their emotional well-being. Both schools (primary and secondary) had a good relationship with the children and provided them with a huge amount of support. Unfortunately, there was a long lead in time to submitting the EHCP application for Child D, due largely to the amount of evidence needed for this and it was inevitably delayed further due to COVID. This was not however outside of usual waiting times and the school followed the process of gathering the substantial evidence needed to progress the application. School funded support was made available to Child D prior to the EHCP being in place. Consultations with Mother were child focused and she contributed to developing plans for both children in and out of school. 5.24 During the lockdowns, schools were under an immense amount of pressure, and it would be reasonable to assume that services faltered whilst they got to grips with the demands that lockdown brought. That said, as soon as they were able to provide more services, they did so as Mother was finding it very difficult to manage the two children at home. During the first lockdown the children were not allocated school places as they did not meet the very specific criteria. In any event, Child D would have struggled to cope with the daily staff changes that were a feature of how the school managed their timetable in that period. With Mother’s agreement, extra support was put in at home, and this was a mixture of face to face and virtual contact. During subsequent lockdowns when schools were able to exercise their discretion and allocate places according to need, both children attended as normal. 5.25 From the information provided, no agency had an in depth understanding of what day to day life was like for these children when they were at home. Their voices are not strong in the information submitted by agencies. Mother’s physical deterioration would have 4 The Domestic Abuse Act 2021 came into effect in 2022. 5 Children Experiencing Domestic Violence: A Research Review (Stanley 2011). Children’s health and well-being, and service responses. www.rip.org.uk/publications meant changes for the children in how they were cared for and there are reports of Child C stepping in to help Child D get ready for school. Those who knew him well felt that this would be a great expectation on him which he would have found difficult. It is understandable in this context, how Mother might have come to rely on his help, but it is by no means clear to what extent Child C was providing support to his mother. 5.26 Assessments and subsequent work with children will always be unique to the individual features of that family. Multi agency services are aware of the impact of specific factors such as race, religion, and family background. It is disappointing therefore that there was insufficient exploration of the children and their identity, e.g., their relationships and extended family. A genogram would have enabled further exploration of the nuances of the family. Whilst it is unlikely that this would not have impacted on the outcome, it would have provided a more complete picture and enable further understanding of the children and their lived experience. This resonates with other reviews that have been carried out in Greenwich. A recommendation is made at 8.5 to ensure that practitioners are equipped to be able to carry out this work competently. 5.27 It is likely that the contacts and referrals to MASH in the days just prior to the incident would have led to a more formal statutory assessment, and more information (such as the extent of Child C’s help) may have been captured then through a safeguarding lens. The lack of emphasis on Mother’s deteriorating parenting capacity in the Team around the Child is an area for practice development within that structure. This was exacerbated by adult services not being involved in meetings and a holistic understanding, shared by all the professionals involved with the family, would have been valuable. The Early Help service identified that the practice was more focused towards supporting parenting. Where this is the case, there are now quality assurance mechanisms in place to ensure the impact on the children in the family is also sufficiently considered. Mother 5.28 Throughout the review, Mother’s circumstances have been highlighted. As in all families, circumstances in relation to their day to day lived experiences were unique. Viewing this family through the lens of intersectionality6 would have been a helpful framework to aid practitioners’ understanding of their uniqueness and therefore their needs. Mother encountered multiple disadvantages, the combination of which meant that she faced multiple barriers to accessing services. Mother was a Black African single mother to two children with additional needs. She struggled with her mental health, was a victim of domestic abuse, and she had a debilitating, life limiting condition. Whilst all of this was identified and acknowledged, assessment of the cumulative effects of these factors was not evident across the multi-agency network. 5.29 One vital aspect of Mother’s life that was missing from assessments was the support she got from church members. It is significant to note that Mother’s faith did not feature in any of the information provided to the review and it was the extended family who brought this to the panel’s attention. 6 Intersectionality is the interconnected nature of social categorisations such as ethnicity, race, religion, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage 5.30 Mother had a rich spiritual life and a strong faith. The church had been a very important feature of her life since childhood and she had known some church members since then. She had always drawn spiritual guidance from the church and in times of need she was supported by different members. She attended services and various other activities both in person (prior to lockdowns) and online. 5.31 During the many lockdowns during this period, she had at least weekly contact with a mentor who encouraged her and prayed with her. Mother was able to confide in the people from the church that she trusted, and they formed a huge part of her support network. Much of this was done online as the situation allowed, but feedback from members of the church was that she gained great comfort from their contact. Whilst the focus of the support was Mother, the children also had a relationship with the church, particularly Child C who was able to communicate more ably through the internet. 5.32 The bringing of all the information together in assessments, plans and direct service delivery would have been beneficial. Its absence is a stark reminder that issues of practitioners being culturally competent and addressing the discrimination experienced by some communities, is still some way to being fully embedded in practice. Mother’s spiritual life and her faith were central to her being and very important to the rest of her family, yet it was not known about throughout the work being done. It is not clear if the question about the family and religion was specifically explored but the conclusion reached here is that this, and other multiple factors were not sufficiently assessed or understood. A recommendation is made at 8.6 to try and address this within the Partnership 6 Family Contribution 6.1 The author had the privilege of meeting and liaising with family members during the review. It is to the family’s credit that they were able to contribute as thoughtfully as they did, considering the devastation they felt at the loss of their family members. The report is a richer piece of work for this, and the author and panel are grateful to the family for taking the time to do this at such a painful time. 6.2 The family spoke freely about what they considered the strengths and weaknesses of services offered to them. Where these were triangulated with other material from the review, these are referenced in the body of the report. Otherwise, the following is a summary of what was discussed and reflects how the family viewed things at the time. 6.3 In essence, the family wanted to emphasise that they feel that services for Mother did the bare minimum. Throughout the last few months of her life, the lack of face-to-face interactions with her and particularly throughout Covid, contributed to Mother’s deterioration and perhaps even the actions that followed. The family think there was a lack of contingency planning for when clients could not be seen, and that services did not talk to each other. To them it feels like Covid will be used as a “reason” rather than an excuse as to the level of service that was received. They did not want this to detract from how let down they feel as a family, regarding Mother’s care from the services she was involved with. More aspects of why the family thought this are detailed in the next few paragraphs. 6.4 The family had a good understanding of the process of this review and appreciated that it was focused on learning lessons to improve practice, but they were frustrated by how long everything was taking, especially the inquest. At the time of speaking to them, there was no date for the inquest and several of Mother’s personal effects had not been returned to them. Although they understood that everything had been delayed by the C-19 pandemic, this was causing them some distress knowing that the inquest was still outstanding and would be a difficult thing to go through. The Police Family Liaison Office was keeping in touch as much as they could but frequently there was no update to give. To date the police still have not contacted the family. 6.5 The family did not understand or realise the extent of how low Mother was feeling and wondered why this was not picked up by professionals who knew her. As family members they felt that they were not trained to do this but that professionals who were should have explored this more. They reported that Mother found the children’s needs very overwhelming, and they helped as much as they could. They offered much support – e.g., for the children to spend the day with them - MGM even offered for Child C to go and live with her. Mother would always agree but then often this would not happen. They felt that this was because she did not want to be a burden and reflected that the reason for this may have been that she had already planned the deaths. Mother was always very good at covering up how she really felt, and this had always been the case. 6.6 The situation deteriorated as Mother’s MS symptoms became worse and her ability to perform practical tasks lessened. MGM noted how much more difficult Mother found it to do housework and this was very upsetting for her as she was very house proud. Issues such as being able to claim benefits such as Personal Independence Payment (PIP) became important to her, but this was turned down, nor was she entitled to Mobility Allowance to enable her to travel more easily. 6.7 As it got worse – particularly in those final days before the fire, MGM had contacted Early Help Services to see if they could provide more assistance as she could see that Mother’s mental health was deteriorating. In discussion about this, the family agreed that a conversation with Mother about contacting her GP or more formal mental health services may have been beneficial to see if they could provide further support. MGM thought that Mother had a good relationship with her GP so this may have been an avenue to explore. They believed that the GP had prescribed sleeping pills, but there is no record of this. 6.8 The family could see that COVID had influenced how services were being delivered, particularly when face to face services were replaced by online services. They felt that this was not good for Mother or the children and that in future if circumstances such as a pandemic should reoccur, consideration should be given to keeping some face-to-face appointments open. Mother used her sessions to the full but also found them distressing as she talked about deep and painful experiences. She was then left in her own space, in her own home and was isolated with her ‘heavy’ thoughts with just the children to look after. They felt this ‘blanket approach’ to delivering services virtually was not helpful to her. In addition, Mother had lost access to all her coping mechanisms such as the gym, spa days and being able to swim. These things were always important to her but especially so in these circumstances. 6.9 The family explored the notion of help from adult services and wondered why this had not been pursued more vigorously. They understood that Mother was reluctant to accept help but were unsure about at what point services should be obligatory when it was clear that someone was really struggling. The question of mental capacity came up for them and although they knew that Mother always had capacity, they questioned why it was that services could be refused so easily. 6.10 All in all, the family felt that Mother’s mind and character had changed immensely since her diagnosis of MS. She felt that life had treated her very unfairly and she was angry and upset. She struggled with her children’s challenges and would sometimes say she wanted them to be ‘more like other children’. She was able to see that Child D had some profound needs and that these would get more difficult to manage for her and him, as he got older. MGM said that the schools had offered a lot of support and that they and Mother were very grateful for that. MGM did question however the length of time that the EHCP for Child D was taking when it was so obvious that his needs were very great. Child D had no speech and was very delayed compared to his peers. 7 Conclusion 7.1 There is learning from this tragedy for the partnership which may require some strengthening of practice for agencies. The learning is captured in the body of the report but can be summarised by the following points. • The need for practitioners to think more holistically about families and consider all the presenting needs, including those of the adults in the family. • A recognition of practitioners’ role and responsibilities for parents caring for children with disabilities and how legislation and guidance can support their work • Assessment of the impact of domestic abuse whether current or historic and the emotional effects of that on family members. • The need for practitioners to be cognisant of the impact of intrusive thoughts and for those to be risk assessed at an early stage. • The importance of grasping children’s day to day lived experiences and how their history, identity, and individual struggles shape this. • The support that families receive from their faith and from their church should be assessed as a vital part of their support network. • Issues of intersectionality and the impact of multiple oppressions experienced by this family needed to be explored and understood. • The disruption to services caused by COVID meant that Mother’s needs in relation to her own support were not adequately met. 7.2 The review has also identified good practice. E.g., despite the restrictions imposed by COVID the children were well supported in their schools and a variety of services were offered to support Mother’s care of the children. There was a co-ordinated Team around the Child in place and strong plans in place that were reviewed regularly. 8 Recommendations 8.1 The Safeguarding Families Joint Protocol which requires practitioners to ‘think family’ to be launched in Spring 2022. This should include awareness raising of the revisions to the existing protocol with front-line practitioner events, audits of practice, visual aids etc. The Greenwich Safeguarding Children Partnership should ensure that this continues to remain a primary focus for safeguarding partners as a result of the learning from this review. 8.2 Greenwich Safeguarding Children Partnership should ensure that the learning from this review i.e., the need to assess parents as carers when caring for children with additional needs, is embedded in practice. This is to ensure that carer’s needs are sufficiently considered and assessed in line with the expectations of Parent Carers Assessments in the Children and Families Act 2014. 8.3 In addition to the recommendation above, the provision of information available in Greenwich about Parent Carers Assessments needs to be reviewed so that it is clearer to carers what their entitlement is, how to request it, who can access it and what to expect as a result of such an assessment. 8.4 Greenwich Safeguarding Children Partnership to review their training strategy to ensure that all partners equip their practitioners to be confident when dealing with families where domestic abuse is (or has been) a factor. This should include the importance of professional curiosity about all relationships, exploring potential ongoing risks, when parents separate and the need for ongoing contact arrangements to be kept under review. 8.5 Greenwich Safeguarding Children Partnership should ensure through its learning and development programme, that all agencies have arrangements in place to ensure assessments and ongoing work includes the child’s experience and emotional impact of these experiences as well as the child's voice. 8.6 In line with the above and in light of the findings in this review about families who experience multiple oppressions and disadvantage, professionals in the Partnership should also be equipped with cultural competency together with an understanding of intersectionality to properly identify and consider these factors when assessing and managing the risk to children. 8.7 Greenwich Safeguarding Children Partnership should oversee partner agencies have sufficient contingency plans to provide nuanced, child centred services in the event of a major disruption to services such as experienced during the C-19 pandemic services. 8.8 The learning from this review should be shared with the Greenwich Adult Safeguarding Board. Jane Doherty Independent Social Work Consultant December 2022 |
NC046632 | Serious brain injury to a 3-month-old girl in May 2013. Mother was convicted of child neglect and Mr A, mother's new partner, was given a custodial sentence for causing the injuries. Prior to Child G's birth her half-sibling had been subject to a child protection plan for neglect. In the months before and after Child G's birth, mother had attended hospital a number of times due to injuries to half-sibling. Mother had diagnosed learning difficulties, a history of difficult family relationships and mental health issues. Mother's partner was known to probation and other local authorities due to a history of violence towards women and children. Issues identified include: the challenge of sharing information about vulnerable families across GP's, midwives and health visitors; the need to focus on the role of fathers/partners through pregnancy and early years; the need for offender managers to report any safeguarding concerns when an offender starts a new relationship; and the need to understand the impact of parental learning difficulties. Recommendations include the development of a system to allow tracking of violent offenders against children.
| Title: Serious case review: Child G: overview report. LSCB: Essex Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Essex Safeguarding Children Board Serious Case Review Child G Report Author Jane Wonnacott BA MSc MPhil CQSW AASW Director In-Trac Training and Consultancy Page 2 of 31 CONTENTS 1. THE REASON FOR THIS SERIOUS CASE REVIEW ................................................................ 3 2. THE REVIEW PROCESS ........................................................................................................... 3 3. AGENCIES INVOLVED WITH THE FAMILY .............................................................................. 5 4. EVENTS PRIOR TO TIMEFRAME FOR THIS REVIEW ............................................................. 6 5. EVALUATION OF PRACTICE FROM 1ST AUGUST 2012 ........................................................ 10 6. THEMATIC ANALYSIS OF PRACTICE .................................................................................... 17 7. CONCLUSIONS ....................................................................................................................... 23 8. FINDINGS AND RECOMMENDATIONS .................................................................................. 24 APPENDIX ONE - THE REVIEW PROCES…………...……………………………………………….27 Page 3 of 31 1. THE REASON FOR THIS SERIOUS CASE REVIEW 1.1 At the age of three months, Child G was taken to hospital and found to have serious inflicted injuries which occurred whilst in the care of her mother (known in this report as “Mother”) and her mother’s partner (known in this report as Mr A). These injuries were considered to have enduring life changing consequences for Child G. A serious case review referral was made to Essex Safeguarding Children Board. 1.2 Initial information gathering revealed that at the time of the injury Mother lived alone but was in a relationship with Mr A. This relationship had started after the birth of Child G. Mother had another child, age three (known in this report as Half Sibling) who had been subject of a child protection plan in Essex in 2010. 1.3 Mr A was known to Essex Probation as a result of a number of offences and had been known to other Local Authorities due to concerns about domestic violence and risk to children. 1.4 As Child G had sustained serious injuries and there was evidence to suggest that there were weaknesses in the way that information regarding Mother and Mr A was shared and acted upon between agencies, the Essex Safeguarding Children Board serious case review referral panel agreed that the criteria for a serious case review had been met. On 3rd September 2013 the panel recommended to the chair of Essex Safeguarding Children Board that a serious case review should be carried out. The Board Chair agreed with the recommendation and commissioned this review. 1.5 Mother was subsequently charged with offences and received a custodial sentence. Mr A was convicted of two offences and received a significant custodial sentence in respect of one offence, and a concurrent custodial sentence for the other. 2. THE REVIEW PROCESS 2.1 The review has been undertaken in line with the principles set out in statutory guidance1 at the time and has been overseen by a panel of senior professionals from the local partnership. Independence has been assured through the involvement of two independent lead reviewers, Kevin Harrington (panel chair) and Jane Wonnacott (report author). Full details of the review process including the terms of reference and the credentials of the lead reviewers are set out in Appendix One. 2.2 The original intention had been to use a review methodology which took a multi-agency perspective from the start, collaborated with professionals who had worked with the family and did not rely heavily on individual management review reports. However, this was not possible due to complications associated with the criminal process (see para 2.3 below) and as a result agencies provided individual management review reports with associated recommendations for their own organisations. This has resulted in a lengthy set of recommendations in addition to those resulting from this overview report which will need to be monitored by the Essex Safeguarding Children Board. 1 HM Government (2013) Working Together to Safeguard Children Page 4 of 31 2.3 The main reason for the delay in the process and completion of this review has been the concurrent criminal proceedings which were completed in July 2014. The position of Essex Police, following discussion with the Crown Prosecution Service (CPS), was that they were unable to participate in any aspects of the review (including panel meetings) whilst the criminal process was taking place. At the second panel meeting they recommended that the review should be suspended. This is an unusual stance as, although it is not uncommon to delay speaking to key witnesses and family members prior to a trial, in many areas in line with current guidance2 the review still proceeds with police involvement in the process. The decision of Essex Police meant that although individual organisations did complete individual management review reports and therefore reviewed their own practice, a full multi-agency review of practice was not possible until the completion of the criminal proceedings. This has been a problem in another serious case review in Essex and there is a recommendation at the end of this report addressing this issue. 2.4 A further issue hampering the smooth running of this review has been the ability to locate and access health records in respect of Mr A. The panel were originally informed that his records could not be located as they are within the prison system, although subsequent information from NHS England is that “when someone goes into prison their community health records do not follow them. Prison GPs will contact GPs, hospitals or mental health providers for relevant information if appropriate”. In the light of this information a further attempt was made to locate the full GP records but this was unsuccessful, although some information has been obtained from the GP responsible for Mr A at the time of the injuries to Child G. 2.5 In addition, despite several attempts by the GP individual management review author to gain further insight from GPs involved in the care of Mother, the practice has not responded to requests for further information in relation to why domestic violence incidents were not recorded in Mother’s notes and previous child protection concerns were not noted on the ante natal booking. It cannot therefore be said with confidence that this review has fully explored the role of GPs in the information sharing process, particularly in respect of historical information. 2.6 In spite of the challenges presented by the review process, the author is satisfied that sufficient information has been obtained in order to understand what happened and the various factors that affected the way in which professionals responded to the family. Consequently it has been possible to identify lessons learned areas for service improvement. Family Involvement 2.7 Following conclusion of the criminal process Mother and Maternal Grandmother were offered an opportunity to contribute to the review. Maternal grandmother, accompanied by an aunt of Child G, met with the report author and the manager of Essex Safeguarding Children Board and we are very grateful for their contribution to this review. The information they gave has given a better understanding of the family circumstances during the period under review. 2 ACPO/CPS (May 2014) Liaison and information exchange when criminal proceedings coincide with chapter four serious case reviews or welsh child practice reviews. (first published 2011) http://www.cps.gov.uk/publications/docs/liaison_and_information_exchange.pdf Page 5 of 31 2.8 Mother expressed a willingness to contribute but at the time of writing felt that she was too upset to do so. Since the report had already been significantly delayed it was agreed by Essex Safeguarding Children Board that her views should be sought by the Board at a later date, reported to the Safeguarding Children Board, any necessary amendments made to the report and an amended version placed on the board website. 2.9 In addition Mother gave permission for the release of two reports ordered by the Court prior to sentencing. The pre-sentence report and psychological assessment contain information gained directly from Mother and have been used to inform this review. 3. AGENCIES INVOLVED WITH THE FAMILY 3.1 The following agencies had been involved with either Mother and her children, or Mr A, and provided information to this review either via an individual management review report with associated recommendations for their agency, or via a written report for information. In respect of Mother 3.2 The Local Provider Health Service provided health visiting services to Mother and was responsible for the management of the local minor injuries unit. The service completed an individual management review report for this review. 3.3 The local Clinical Commissioning Group commission extended GP services and completed an individual management review report for this review. Two GP practices were involved as Mother had moved areas within Essex in January 2012. 3.4 The local hospital Foundation Trust provided maternity care, accident and emergency services and specialist paediatric services. The hospital completed an individual management review report for this review. 3.5 Essex Children's Social Care had been involved with Mother during the period that Child G’s Half Sibling had been subject of child protection and child in need plans. 3.6 Essex Police had some historical involvement with Mother and the father of Half Sibling and provided a report for information. In respect of Partner - Mr A 3.7 A London Borough Council area provided an information report for this review. They had involvement with Mr A in 2001-2002 when his child was on the child protection register under the category of physical abuse. There were concerns about domestic violence perpetrated by Mr A. His child’s name was removed from the child protection register when he moved away from the area. We understand that Mr A had no further contact with his first child apart from making contact via letter when in prison in 2013. 3.8 Another local authority area Police Force had considerable contact with Mr A as he lived sporadically in the other Local Authority area since 2005. They have provided an individual management review report. 3.9 The other Local Authority children's social care had contact with Mr A in relation to a child abuse incident with another family. They have provided a report for information. Page 6 of 31 3.10 Essex Police had knowledge of Mr A from approximately 2009 onwards in relation to a wide range of offences. They have provided an information report for this review. 3.11 Essex Probation was involved with Mr A in 2010 when he was released from prison on license following a conviction for assault. He was subject to a further period of probation in 2012 when he received a community order and Essex Probation were responsible for providing supervised unpaid work. In 2014 the responsibilities of Essex Probation were divided between the National Probation Service and Essex Community Rehabilitation Company and a combined individual management review report has been provided to this review. 3.12 NHS England commissioned the core GP services to Mr A via the national contract and the Clinical Commissioning Group provided the named GP3. 4. EVENTS PRIOR TO TIMEFRAME FOR THIS REVIEW 4.1 The timeframe for detailed consideration during this review was agreed as 1st August 2012 – 10th August 2013; the rationale for this being that early August was at the beginning of Mother’s pregnancy with Child G. However, any relevant background information within case records prior to this date was to be included in the chronology and agency reports. Since this background information has proved to be useful in understanding the context for later events, a summary is included in this section of the report. 4.2 Both Mother and Mr A had significant involvement with statutory agencies and the extent to which this information was taken into account in work with Child G pre and post birth is a focus for further discussion later in this report. Events relating to Mother 4.3 The first contact between children's social care and the family was during Mother’s adolescence when she made an allegation of sexual abuse by a family member. Child protection enquiries were carried out, Mother withdrew the complaint and after putting her in touch with other adolescent support services the case was closed to children's social care. Maternal Grandmother told the review that after this Mother began running away, self-harming and eventually became pregnant whilst living away from home in another part of Essex. Maternal Grandmother feels strongly that more help should have been offered to Mother at an earlier stage and that the lack of help for Mother with her mental health problems and support at a critical stage affected her for the rest of her life. 4.4 When Mother was pregnant, Maternal Grandmother referred her to children's social care expressing a number of concerns relating to Mother’s unsettled lifestyle, difficult family relationships, domestic abuse from the baby’s father, mental health issues (including self-harm and mention by the GP of a possible personality disorder) and her emotional vulnerabilities. 4.5 This referral led to a pre-birth child protection conference. The social work report to this conference stated that Mother had learning needs and attended a special school at primary phase, although she then attended a mainstream secondary school. The report 3 A named GP is a GP with specific responsibility for supporting good practice in safeguarding children Page 7 of 31 recommended that further information should be gathered to understand if this impacted on her and her child. Mother’s own account confirms that she had diagnosed learning difficulties as a young child and psychological testing for the criminal proceedings confirms a full scale IQ within the “extremely low” descriptive classification of overall intellectual functioning. 4.6 The initial child protection conference agreed that the baby (known throughout this report as Half Sibling) should be subject of a multi-agency child protection plan under the category of neglect. It should be noted that Mother’s own account of this period of her life is that the issues in relation to the father of Half Sibling related to drug use, he was never violent and that she left him and returned to live with her mother when children's social care became involved. Maternal Grandmother also recalls Mother returning to live with her for three to four months after Half Sibling’s birth, before Mother and Half Sibling moving into a mother and baby home nearby. 4.7 A child protection plan remained in place at the first review conference but at the second review conference in January 2011 it was agreed that the child protection plan should be discontinued and replaced by a robust child in need plan. The reason for this was that although Mother had not completed recommended work in relation to managing risks with violent partners, her care of the baby was good. 4.8 The problem at this point was that the child in need plan was not developed into an effective multi-agency tool which provided a framework for evaluating whether Mother was able to sustain the changes needed to provide safe care for her baby. It had also not addressed all the issues highlighted in the social work report, with no further investigation taking place in respect of Mother’s learning difficulties. This is significant in relation to whether the plan was tailored to her needs, and expectations set out in the most appropriate format. The case was closed to children's social care two and half months later; there is little evidence of effective supervision and management oversight resulting in a clear rationale for case closure. Health visiting input continued with Mother attending the baby clinic eleven times during 2011. No concerns were noted. 4.9 The review panel discussed the significance of the failure to progress the child in need plan. Although it cannot be said with any certainty that this would have made a difference to later events, it would have ensured that Mother’s capacity to maintain the changes needed was properly assessed and that the most appropriate family support services were in place. 4.10 Mother moved area in January 2012 and registered with a new GP practice. Notes were reviewed according to expected procedure and the previous child protection concerns were recorded as being primarily due to domestic violence and that Mother had now taken steps to distance herself from her abusive partner. Around this time, Maternal Grandmother recalls Mother moving to another area of Essex (initially staying with her aunt) in order to distance herself from further harassment from Half Sibling’s father. Maternal Grandmother felt that following case closure by children's social care the family was relied upon to support Mother, but this was not always easy due to her reluctance to listen to advice from her relations. 4.11 Just prior to confirmation of Mother’s pregnancy with Child G, Half Sibling was taken by Mother to Accident and Emergency after a possible ingestion of washing up liquid. The health visitor received a report a week later and made a note that Mother had not mentioned this at a contact the previous day. This did not prompt any follow up visit and the panel were informed that this would not have met specific commissioned criteria to Page 8 of 31 do so. Events relating to Mr A 4.12 Records indicate that Mr A had a troubled childhood and spent most of his teenage years in the care of the local authority. He has a significant criminal history dating back to 1999 involving theft, fraud, violence, public order and firearms offences. 4.13 He is known to have had a child whilst living in the London Borough Council area and this child was placed on the child protection register as a result of concerns about physical abuse. Before this child’s name was removed from the register Mr A had moved away from the area. 4.14 Whilst living in the other Local Authority area there were two allegations of abuse of his new partner’s child. The first allegation was investigated by police and children's social care but not substantiated and at this point neither agency were aware of the previous concerns in the London Borough. Following evidence of a second serious incident he was charged with assaulting his ex-partner and her daughter. He was convicted of these assaults and received a prison sentence. He was also convicted of driving whilst disqualified and sentenced to a further period in prison. In total he completed a nine month prison sentence. 4.15 This short period of custody did not attract a period of post release supervision. However whilst in prison he received a further prison sentence for an assault on an adult male that had taken place in the community prior to his imprisonment. During his time in custody, prison staff intercepted letters to an underage girl. This information was passed to Essex Probation as following this second offence he was released on licence in 2010 with various conditions. These conditions restricted his employment or residence with children under 18, and included a requirement to disclose any developing relationships with women, as well as attend a domestic violence course. He was allocated to an offender manager, was referred to MAPPA4 and remained subject to these arrangements for four months when he was considered to no longer need multi-agency risk management. He successfully completed his period of license in February 2011 and no further concerns were raised about his relationships with women or children. 4.16 During this period there is no evidence of any information sharing or communication between the other Local Authority area and Essex police forces. However, the MAPPA referral from Essex probation to Essex police contained information that raised clear concerns about Mr A’s risk to children as well as women. 4.17 The information regarding Mr A’s previous abuse of a child was therefore clearly known within the Essex multi-agency arena through MAPPA arrangements which included police, probation and children's social care. 4.18 The other Local Authority area Police report refers to allegations in 2011 that a 15 year old was being influenced, controlled and directed by older men to commit crime. Two of these older men were Mr A and his uncle, a known burglar in the other Local Authority area. There was a professionals’ meeting and an action plan set up to share intelligence with local CID regarding the grooming of children to commit crime. At this stage it is not 4 MAPPA is the name given to the multi-agency public protection arrangements are in place to ensure the successful management of violent and sexual offenders https://www.gov.uk/government/publications/multi-agency-public-protection-arrangements-mappa--2 . Page 9 of 31 clear whether Mr A was known to be living in Essex but intelligence reports in relation to other crimes suggested that Mr A was using addresses in both the other Local Authority area and Essex. 4.19 There is nothing in the Essex or other Local Authority area police reports to indicate that information regarding grooming young girls to commit crime was shared across police forces. Had this been known to Essex police this may have been a reason to consider reconvening the MAPPA in respect of Mr A, although the intelligence did not relate to any crime relating to sexual abuse or violence. 4.20 In 2012, Mr A received a community order for an offence not related to violence to women or children. This sentence included a supervision requirement which meant that he was allocated an offender manager and also carried out unpaid work which was managed by the unpaid work team. One month into his licence period the offender manager had concerns about him living in the grounds of a family home and made a referral to Essex children's social care initial response team. When the offender manager followed up this referral they were told by children's social care that a social worker had spoken to the family concerned and safeguarding measures were in place. As far as the review is aware, this family had no connection with Mother and Half Sibling. The offender manager also made a referral to MAPPA but there is no record within the MAPPA system of this referral being received and there was no follow up by the offender manager. Summary of learning: events prior to timeframe for this review Although these events were outside the initial scope of this review it has become clear that actions during this period had a significant impact on the case during the review period. Most crucially Mr A had a significant history of violence towards women and children, resulting in one child being placed on the child protection register and Mr A serving a prison sentence for violence against a woman and child. There was a lack of systems in place for ensuring that all relevant information was tracked across local authority borders as well as limitations to the MAPPA arrangements which are in place to manage current risk of violence. However, despite some limitations in the process, evidence shows that the most significant information regarding the assault in the other Local Authority area was known to Essex Probation and was available to inform any future contacts. In addition, Mother had been known to have a level of vulnerability and the potential to be targeted by perpetrators of domestic violence. Although there was evidence to suggest that she had made progress, the assessment had not fully addressed the possible implications of any learning difficulty for service provision, and the work carried out had not addressed all the requirements of the child protection plan. The capacity of Mother to sustain change was therefore insufficiently assessed and did not provide an adequate foundation for decision making by any professional in the future. The child in need plan was not specific enough, nor focused on outcomes for the child and the case was closed to children's social care without sufficient scrutiny by managers. Key lessons from this period are therefore: the need to develop effective systems for tracking men who are known to be violent. This needs to include proactive information sharing of any intelligence about related activities where they are known to have moved across local Page 10 of 31 authority boundaries the importance of robust, fully documented, outcome focused child in need plans the need to work with parents to understand the implications of any learning difficulty and mental health problems for service provision. This should, where appropriate, include liaison with colleagues in Education. 5. EVALUATION OF PRACTICE FROM 1ST AUGUST 2012 5.1 It was in September 2012 that Mother’s pregnancy with Child G was confirmed. The father of Child G is not Half Sibling’s father or Mr A, who started the relationship with Mother when Child G was approximately six weeks old. This narrative is therefore split into two parts, the first part focusing on Mother’s pregnancy and the second, events following Child G’s birth and the relationship between Mother and Mr A. Mother’s pregnancy with Child G 5.2 One key feature of this period is the challenge of taking a whole family approach within health services where a woman is pregnant. The focus of midwifery services is on the mother and her developing child; serious case reviews in other areas5 have found that indicators of vulnerability or previous concerns in relation to siblings may not be easily accessible to midwifery services. Similarly without effective systems for information sharing, health visitors may not be aware of any concerns known to GPs or midwives. The following section of this report should be read with this in mind. 5.3 In August 2012, two months prior to the confirmation of Mother’s pregnancy, Half Sibling was taken to the minor injuries unit by Mother. He had burns to his foot sustained some days before due to treading on hair straighteners. Due to the delayed presentation the liaison health visitor sent notification to health visitor team. This was reviewed by a student health visitor but since the wording suggested that follow up would be at the minor injuries unit and the document did not concentrate on issues related to delayed presentation, there was no follow up by a health visitor. At this point Mother was living with Child G’s father. 5.4 The The Local Provider Health Service6 and GP individual management reviews note that, in September 2012 police were called following an alleged assault by Mother on her sister. According to the police report, Mother was initially arrested and taken to a police station but there was no further action due to insufficient evidence. Both the health visitor and children's social care received a police notification of this event and it was reviewed by the senior practitioner in the initial response team who considered the family history and noted: This incident was not witnessed by [Half Sibling] and the adults involved in this incident do not reside within the same home. NFA recommended at this time. This referral does however raise concern regarding coping mechanisms and should further DV incidents be received consideration will need to be given to further assessment. This was a reasonable professional judgement at that time. 5 For example the deeper analysis in relation to Daniel Pelka (Coventry LSCB 2013) found that concerns relating to Daniel were not taken into account during a subsequent pregnancy. The importance of effective information sharing across health agencies was a key feature of that case. 6The health organisation responsible for health visiting services. Page 11 of 31 5.5 Eight days after the domestic abuse incident, Half Sibling (age 25 months) was again seen in the minor injuries unit on a Sunday with swelling in the underarm area. According to Mother he had fallen from his bed. Again the health visitor was notified and reviewed the case three weeks later; at this point Half Sibling had been taken to hospital three times in four months.7 Eight days after the case was reviewed, the health visitor attempted to contact Mother and found her telephone was disconnected. This health visitor would not have been aware that a nursery nurse had seen Half Sibling in clinic earlier that day. As it was not possible to contact Mother on the telephone, a letter was sent out to offer a two year check at home; this took place in November several weeks after Mother had been seen by a midwife in respect of her pregnancy. At this check no concerns were noted, her sister was present throughout and family relationships had settled. Mother would have known she was pregnant at this point but did not tell the health visitor and she was returned to a universal health visiting service. 5.6 It had been in mid-October 2012 that Mother had been “booked” by a midwife in respect of her pregnancy with Child G. Despite the previous child protection plan for Half Sibling, there were no risk indicators for child protection noted at this stage and Mother was booked for midwifery-led care. The midwifery individual management review clarifies that when women book with a midwife the booking form is usually completed over the telephone, although in the area where Mother lives the individual management review does note that “women also drop into maternity”. A week later there is evidence of a face to face consultation with a midwife in clinic during which a full ante natal history was taken. Although medical factors changed the assessment to high risk, the form noted “No social circumstances affecting the family. Previous/current support involvement from a social worker in 2010 - as previous partner a drug user. The summary noted no social care issues. Information given by Mother during her psychological assessment explained that Child G’s father moved out during her pregnancy as he did not want any more children. Mother described him as “gentle not controlling” and she was extremely upset when their relationship ended. 5.7 There was no further exploration by the midwife of the previous involvement by social care and midwifery care continued in apparent isolation from more detailed information about the previous child protection concerns. The midwifery individual management review explores a number of possible reasons for this including: The midwife concerned was new to community midwifery Staff shortages within the midwifery service No single named midwife responsible for each mother and therefore no single midwife overseeing actions including safeguarding. All history taking was in a paper format and information/alerts were easily overlooked Community midwives did not have access to the Mother’s main health records until later in the pregnancy and therefore they were not routinely reviewed. 5.8 There was an opportunity at this point to consider all the information available across health agencies. This did not happen and information about Mother’s potential vulnerability and indicators (from accidents and delayed presentations) that she may be struggling to care for Half Sibling whilst pregnant with Child G were not bought together in one place and used to explore mother’s situation with her in more detail. 7 One occasion was prior to the start of this review period: (presenting problem diarrhoea and vomiting) Page 12 of 31 5.9 Knowledge about previous safeguarding concerns would have been available within the GP records but the lack of routine information sharing between GPs and midwives contributed to the fragmented approach across health organisations. At the point that previous concerns became known the midwife should have completed information sharing form and sent it to the GP and cannot explain why this was not done. There were therefore no discussions between GPs and midwives regarding potential vulnerabilities. Up until the birth of Child G, midwifery involvement consisted of seeing Mother at regular ante natal appointments, two brief hospital admissions, and one attendance at clinic due to abdominal pain. 5.10 The fragmented approach within health precluded any reasoned assessment of whether a referral to children's social care for a pre-birth assessment was needed. The review was told that an additional factor that may have influenced practice was that although pre-birth procedures did not prevent a referral early in pregnancy, custom and practice within children's social care was to ask referrers to call back when the pregnancy was more advanced. A myth had therefore built up that no referral could be made until after 15 weeks and therefore even if a professional had a concern it is unlikely that a referral would have been made at the point. 5.11 There is some evidence that Mother was in contact with her own Mother (Maternal Grandmother). In December 2012 Maternal Grandmother contacted the health out of hour’s service as Half Sibling was unwell and complaining of pain on the forehead, cold symptoms, and not eating for two days. He was asked to attend the out of hours centre and he was sent home with advice on fluid intake and paracetamol. It is not recorded who took him to be seen and there is no reference to this event in the GP report. 5.12 Apart from routine ante natal care and three attendances at hospital with abdominal pain, there are no further records of contact with Mother and Half Sibling until the birth of Child G and Mr A was not in a relationship with Mother during her pregnancy. Mr A was in contact with Essex Probation. His Community Order had started in April 2012, the supervision requirement finished in April 2013 although the unpaid work requirement continued beyond this as, due to Mr A’s sickness, the required hours had not been completed. From this time onwards, although he remained allocated to an offender manager, he was not seen by them and was supervised on a day to day basis by the unpaid work supervisor. Summary of learning: Mother’s pregnancy with Child G During Mother’s pregnancy with Child G the main issue is the challenge of effective information sharing across a fragmented health system. During this period there was an accumulation of events that, put together, could have been seen as indicative of increased vulnerabilities for children within the family. These events were: two attendances by Half Sibling at the minor injuries unit. evidence of family tensions resulting in Mother being arrested for an alleged assault on her sister, Mother’s second pregnancy little evidence of Mother accessing support outside the family. If these events had been considered in the light of previous knowledge of the family, health professionals could have considered referring to children's social care with a request for an assessment of Mother’s needs and any potential concerns relating to her Page 13 of 31 capacity to care for both her children. However, information was known to different health professionals at different times and communication pathways between GPs, health visitors and midwives at time of booking were not used. There were no practice meetings within GP surgeries where vulnerable patients could be discussed and although the review has been informed that this is now happening in some areas, the surgery concerned still reports lack of effective communication with health visitors and midwives. In addition, midwives recorded Mother’s self-disclosed history regarding previous child protection concerns but did not explore this further or ask searching questions about the father of Mother’s child. Although the father was not Mr A, lack of a practice culture which does not focus on fathers/partners is significant when Mr A later joins the household. Key lessons from this period are: the need to consider whether it is possible to track the whereabouts and activities of individuals with a history of violence involving children the importance of developing and using effective information sharing regarding vulnerable families across GP’s midwives and health visitors the importance of systems which enable midwives to access a full history from medical records at the point of booking the need to mitigate the risks associated with no overall lead midwife for each mother the need to ensure a focus on the role of fathers/partners throughout pregnancy and during the early years of a child’s life. Most importantly practitioners need to develop respectful curiosity about the circumstances of people they are working with and ask questions which will help them to develop a picture of the whole person and follow up any queries which may indicate a cause for concern. The birth of Child G until the serious injury 5.13 Child G was born in hospital in late May 2013 and maternal grandmother and maternal aunt are noted in the records as Mother’s birthing partners. Following the birth there were no concerns about the care of Child G and Mother and baby were discharged. The community midwife was informed of transfer of care by telephone and the GP informed by letter. The information on the midwifery records was contained in a series of tick boxes (as described in the individual management review) “complex social factors/safeguarding ‘yes’” and “social services involvement with previous partner” does not seem to have reached the GP as the GP individual management review notes that there was nothing on the GP records to indicate that Child G was part of a vulnerable family, and there did not seem to be any discharge planning in place despite the previous history. 5.14 The health visitor received discharge information that did note previous social care involvement in 2010 but stated that there were no indicators of any additional needs at that time. Due to pressure of work, the health visitor did not access Half Sibling’s records and explore the previous concerns any further and Mother and Child G were therefore seen as requiring universal health visiting services only. The local Provider Health Service individual management review gives a helpful explanation as to why accessing Page 14 of 31 Half Sibling’s records would have been a challenge at that time in a health visitor team under pressure. Trigger factors would have been necessary to alert the staff member to review records and one disadvantage of electronic records is that there is not the trigger of bulky paper files that automatically indicate a high level of previous contact with the family. The individual management review goes on to explain: In this case the health visitor seeing the baby at the new birth visit did not have these clear information/triggers to indicate past concerns either by the physical presence of the paper record, or ante natal triggers from the midwife ... Although the siblings are linked in groups and relationships making for rapid retrieval, it is reliant on practitioner expertise to think to access and review prior to visits. The electronic system at this time did not have a process where significant information can be recorded and then accessed to provide a succinct overview of events. In addition if the electronic record for the sibling had been reviewed it then required the HVC to access and read the paper record for the detailed information. This would have been time consuming when under pressure and under resourced. This is a three step process to gain vital information. 5.15 The importance of accessing sibling records and face to face handovers between practitioners is understood by the Trust but it is recognised at the time of the events in this review, the Standard Operating Policies (SOP) did not cover this aspect of the work. This is now being rectified. 5.16 A new birth visit by the health visitor took place two days after Mother was discharged from midwifery care but this was rescheduled as mother was going out. 5.17 The next day Mother called the out of hour’s service at 20.15 saying Half Sibling had fallen from high chair the previous day and hit his head. He was described as quiet and cold, with his tummy and head hurting. When seen at 21.27 Mother’s focus was on urinary symptoms and there was no recording of any investigations relating to the head injury. A recommendation was made to see the GP but there is no record of this taking place. This was the third delayed presentation of Half Sibling to an out of hour’s service but nowhere within the health system was this pattern identified. The attendance was summarised in the GP record but not reviewed or linked with previous attendances and there was no formal notification to the health visitor team with the result that when the health visitor carried out the new birth visit, they were unaware of all the details of the consultation with out of hours as Mother only informed her of the urine symptoms. Mother explicitly stated that the father of Child G was unknown. There was no expectation at that time of a full family needs assessment and the notes recorded that mother was coping well and there was good handling between mother and children. The next health visitor appointment at the family home was set for one month later. In addition, Mother attended the baby clinic, each time being seen by a different member of staff. She was not at home as agreed for the next home visit, but had attended clinic earlier that afternoon. 5.18 According to Mother, she met Mr A when Child G was about six weeks old. She had known of him previously as he had attended the same school as her sister and after briefly communicating via BBM8 they began a relationship and he quickly began to live with her on a part time basis. Maternal Grandmother felt uneasy about him from the start and local people made various comments about him not being a nice man. They were reluctant to say more, seemed to be afraid of his family and Maternal Grandmother was similarly reluctant to contact children's social care. 8 Blackberry messaging Page 15 of 31 5.19 If Maternal Grandmother had contacted children's social care at this point with worries about Mr A it is possible that this would not have led to any action as social work practitioners told this review that the practice then (and now) is they could not undertake any checks on Mr A without his permission. This concern about data protection does not take account of the very clear information sharing guidance both at that time and currently which states that where there are concerns that a child is suffering or likely to suffer significant harm practitioners do not need to seek consent9. Today, under the Domestic Violence Disclosure Scheme (Clare’s Law) maternal grandmother would have had the “right to ask” Essex Police to check whether Mr A had a history of domestic violence but this did not come into force until March 2014. 5.20 None of the health records indicate that any health practitioner was aware of Mother’s relationship with Mr A. Mr A’s allocated offender manager had left the organisation in June 2013 and the case transferred to offender manager 2. The transfer papers did contain alert flags for domestic violence, schedule 1 offences10 and the fact that he had been subject to MAPPA arrangements, although the verbal handover did not specifically explore third party information that may have indicated specific additional risks to children. Mr A talked about his new partner (Mother) to his unpaid work supervisor but there did not seem to be a need to tell anyone about them. The unpaid work supervisor would not have been aware of the details of Mr A’s offending history as such information is held by their manager, (the community payback coordinator), and the offender manager. 5.21 In late July 2013 Child G was referred by the GP to the paediatric department at the hospital with a fever and poor feeding. She was admitted and discharged two days later after a course of IV antibiotics. Maternal Grandmother recalls going to the hospital but Mr A would not let her near Child G. She also remembers Half Sibling having a bruise around that time and saying that Mr A had “done it”. 5.22 On the same day, Mr A had left his unpaid work site early telling his unpaid work supervisor that he needed to go to hospital with his partner and her baby. The supervisor told the unpaid work requirement organiser and due to the known history of safeguarding concerns, offender manager 2 was alerted. There is no record that this was discussed with the offender manager’s supervisor although they were aware that they needed to gather further information and then make a referral to children's social care. However, since they were not aware at this stage of all the confidential information on the files, they did not assess that an urgent referral was required. 5.23 An alternative course of action at this point would have been for the offender manager to visit Mr A, ascertain the name of his partner and refer to children's social care, specifying the risks posed by Mr A to women and children. 5.24 Eight days later, the health visitor carried out a home visit. Due to concerns about significant weight loss Child G was seen the same day by a locum GP and since the loss was felt to be as a result of her recent illness a review was planned for two weeks’ time. Although by now Mr A was living part time in the home the health visitor was unaware of 9 HM Government (2015) Information Sharing: advice for practitioners providing safeguarding services to children and young people, parents and carers. Page 13. 10 Offences against a young person under the age of 18 as set out in in the Children and Young Persons Act 1993 Page 16 of 31 Mother’s relationship with him. 5.25 Four days later, Child G was taken to the minor injuries unit at 18.18 hrs. Mother informed staff that she had laid Child G on the sofa the previous evening, and her three year old brother had picked her up and dropped her onto her head. She had been grizzling since and vomited once. Subsequent reports given by Mother as part of the criminal proceedings vary in detail and it is beyond the scope of this report to comment on the accuracy or otherwise of the varying accounts. However, it is now known that the original account given by Mother was false and Mr A has now been convicted of causing the injuries to Child G, and Mother pleaded guilty to child neglect. Information to the court identified a gap of one and half days between the injury and Mother’s presentation at the minor injuries unit, a delay explained by Mother as linked to her fear of Mr A. 5.26 On arrival at the minor injuries unit Child G was examined by a nurse, was alert and looking around but in view of history of a fall Mother was advised to take Child G to the accident and emergency department at the hospital to be reviewed by a doctor. 5.27 The local Provider Health Service individual management review makes the point that there was an insufficiently robust assessment of Child G’s injuries by the nurse practitioner within the minor injuries unit. Child G was not undressed and Mother’s explanation was taken at face value. The symptoms in a non-mobile baby should have been taken as signs of a more serious injury and the possibility that they were non accidental could not be ruled out. The most appropriate course of action would have been to arrange for an ambulance transfer to hospital rather than relying on Mother providing the transport. There should also have been a formal referral to the hospital by the minor injuries unit. 5.28 The individual management review report discusses in detail the factors that contributed to the practice decisions within the minor injuries unit and highlights the challenges of responding to young children presenting with a head injury when this is an unusual presentation within that setting. 5.29 On arrival at hospital Child G was examined and found to have sustained a fracture to one of the bones in her skull with an associated brain injury and suspicious bruising elsewhere. Due to concerns about the nature of the injuries, a safeguarding referral was raised. Summary of learning: the birth of Child G until the serious injury A number of issues emerge from this period, particularly in relation to the importance of taking a whole family approach to understanding the needs of parents and children. Health services continued to be fragmented, with the health visitor being unaware of the details of the out of hours medical consultation and not having a full picture of previous concerns regarding Half Sibling. Neither the GP nor the health visitor had a sufficient grasp of the whole picture to reflect on the number of times that Half Sibling presented to health services and there is no indication that any practitioner identified the level of Mother’s vulnerability. Within the probation service there was a similar pattern of insufficient consideration of the meaning of historical information combined with current events. One reason for this was the transfer of the case between offender manager 1 and offender manager 2 and an overreliance on verbal information at handover that did not include all the information Page 17 of 31 contained within the records. Key lessons from this period are: the importance of a holistic approach to families including family needs assessment within health visiting practice the need for effective information sharing and review of vulnerable families between GPs and health visitors the need for thorough review of all records when a case transfers between offender managers the need to consider whether the system for alerting unpaid work supervisors to potential risks offenders may pose to children is sufficiently clear and understood the need for offender managers to consult immediately with their supervisors where information comes to light that a person with a history of safeguarding concerns has formed a new relationship with a partner who has children. This discussion should consider what further information they should obtain immediately from the offender and whether a referral should be made to children's social care. The rationale for the decision made should be recorded. the need for clarity that consent to share information may be dispensed with where a child is suffering or is likely to suffer significant harm the importance of developing skills and confidence of staff working in settings, such as the minor injuries unit, where they may not be regularly exposed to severe injuries indicative of child abuse. 6. THEMATIC ANALYSIS OF PRACTICE Managing mobile individuals who may pose a risk to children 6.1 This is a significant concern which highlights the challenges in managing situations where individuals known to be a risk to children move between partners. Police reports indicate that Mother met Mr A via Blackberry messaging and professionals were totally unaware of his presence in the family. Essex children's social care were made aware of risks posed by Mr A in relation to another family but when a visit reassured social workers that the family had appropriate safeguards in place the case was closed. 6.2 One issue that has emerged is the sharing of information across police force and local authority areas. Mr A was operating across both the other Local Authority area and Essex and was known to pose a risk to children and young people either through direct violence or grooming to commit crime and exploitation. Much of the information was known by Essex probation and shared within the MAPPA process but other activities, not linked directly to physical violence, including the grooming of young people to commit crime, were not. The professional meeting in the other Local Authority Police area which considered intelligence related to this grooming activity was not shared with Essex police or children's social care; although in the current context it is not clear how this might have affected the final outcome. The other Local Authority Police investigation did not lead to any criminal charges and since the crimes were nonviolent, may not have reached the criteria for a reinstatement of the MAPPA arrangements and hence informed other agencies such as probation of the additional concerns. 6.3 The individual management review from the probation service helpfully highlights the Page 18 of 31 difference between monitoring arrangements for men with violent or sexual offences, noting that had Mr A been convicted of a sexual offence ... he would have been subject to Sex Offender registration and police monitoring. The police would have been an ongoing presence in his life. The current conviction for violence against a child will not trigger police monitoring in the community. Potentially an additional licence condition could be imposed that requires [him] to cooperate with police monitoring officers, however ongoing statutory obligations will not apply. 6.4 A serious case review in Southampton (Child G, April 2012) had a number of features similar to this case and makes the point that where violent offences have been committed against children, risk assessments do not address risk of future harm, and no system exists for the same level of monitoring that is in place for sexual offences. It made two national recommendations. The first recommendation identified the need for a system whereby offenders who have committed certain offences against children are required to register their details of their address with the Police and to be subject to monitoring arrangements for specified period of time. A second recommendation to the Home Office emphasised the need to have in place systems for monitoring and working with individuals who have offences against children, and ensuring that these not only address current risk but … ensure that their assessed high risk to children in the future can also be adequately addressed. Southampton Local Safeguarding Children Board have informed this review that no progress has been made with these recommendations. 6.5 Had the systems outlined in the above recommendations been in place, the assessment of potential future risk may have resulted in multi-agency risk management arrangements being more effective. However, since Mr A apparently did not move in with Mother the requirement regarding registration of address would not have made a difference in this case. Safeguarding practice within the probation service 6.6 Issues relating to safeguarding practice within the probation service will in part be influenced by the issues discussed in the section above. In this case the significance of an offender with a previous conviction for violence against a child, describing a relationship with a new partner was not given sufficient weight and urgency. Confidential information within the file should have increased concerns but this was not adequately reviewed or communicated verbally between offender managers. However, even without this information there was sufficient knowledge about Mr A’s criminal history to indicate that he could pose a risk to a family with a child. Consequently immediate action should have been taken by the offender manager once it was clear that Mr A was in a relationship with a woman with a child. This action by the offender manager should have included seeing Mr A and making an immediate referral to children's social care. This is the subject of a recommendation in the probation individual management review. 6.7 The panel has considered why there was a lack of recognition by the offender manager of the serious implications of Mr A forming a relationship with a woman and her child. One hypothesis is that the offence for which he was carrying out unpaid work did not relate to violence against women and children and did not involve this current partner. The focus of probation activity is on preventing reoffending (in relation to the offence) and as far as this was concerned Mr A was compliant with his order. Page 19 of 31 6.8 There is the additional issue of the role of unpaid work supervisors needing good safeguarding knowledge and ability to recognise when they should raise a concern. Although they do not receive details of offences, they do have access to codes which in this case would have indicated that Mr A was a risk to others (including children). The individual supervisor in this case had not familiarised themselves with the codes and the lack of an individual code relating to children also contributed to the likelihood that risks would not be recognised. Training for unpaid work supervisor and the provision of a separate code are subjects of recommendations in the individual management review. Information sharing across health organisations 6.9 With the various aspects of health provision to families being provided by different health organisations, information sharing across health disciplines is a common theme from serious case reviews. In this case, integrating the previous information regarding child protection involvement with Half Sibling did not always work well and when Child G was born, the possibility that Mother may have additional needs was therefore not adequately assessed. This was for a variety of reasons but the overriding message from reports to this review is that although there were known and used processes for liaison, at the time the pressure of work overwhelmed practice. Between midwives/health visitors and GPs 6.10 GP records could be the hub of all information sharing since they bring together all aspects of health care, received by an individual, in one place. However, within current contracting arrangements, relying on this is not possible as the central GP contract does not include specific requirements in relation to safeguarding. In this case there appears to have been both a lack of formal and informal processes where information could be shared, particularly between the midwives and GPs. In addition, the health visitor did not have time to access all the historical records regarding the sibling. As a result of the health individual management review a formal “link post” within the health visiting teams has now been established which aims to ensure communication flow to and from the GPs and that health visitors are invited to and attend practice meetings. 6.11 As it has not been possible to access Mr A’s GP records, it is not possible to assess how far his own GP was aware of his relationship with a woman with a child and whether or not proper consideration was given to finding out more about this relationship and sharing information regarding possible risks. Between midwives and health visitors 6.12 The impression from the reports is that communication was via written reports of variable quality. There was (and is) no expectation of face to face meetings although the Standard Operating Policies currently being developed do prompt a review of information at handover and require verbal communication (at least) if there are any indicators that are out of the ordinary. Generally Page 20 of 31 6.13 The panel has been informed that Essex, as part of the eastern region, will be early adopters of the Child Protection Information Sharing Project11 and that this may address some of the issues within this review. However, this will not be the case since the project focuses only on: children with a child protection plan children with looked after status pregnant women whose unborn Child Gas a pre-birth child protection plan. 6.14 Children who do not fall within these categories will continue to need practitioners to think carefully about how they record information, who they need to share information with, and the most appropriate method for doing so. Understanding parental learning difficulties 6.15 Impaired intellectual ability does not in itself mean that a parent cannot successfully care for their child. However, when low intellectual ability combines with other stressors relevant to all parents, such as adverse childhood experiences and other social problems, extra support is likely to be needed. The vulnerability of mothers to abusive males in these circumstances also needs to be addressed.12 6.16 It is only with the benefit of hindsight that it has been possible to understand precise nature of Mother’s vulnerabilities, although she was known to have had a statement of special educational needs and the social worker who wrote the report for the initial child protection conference made the very appropriate recommendation that there should be further exploration of the nature and impact of any learning difficulty. This would have been important to make sure that services were appropriately tailored for both Mother’s needs and those of her unborn child. However, this recommendation became lost and did not find its way into the child protection plan. It is hard to know why this key aspect of Mother’s life did not receive further attention. Reports prepared as part of the criminal proceedings have confirmed that Mother’s intellectual ability falls within the “extremely low” range and her verbal ability exceeds her cognitive ability. The psychological report notes that “she may experience few, if any, difficulties in keeping up with her peers in situations that require verbal skills”. This may well have lulled professionals into a false sense of security. 6.17 How far there were unique features in this case that should have informed the support offered to Mother as a parent, or whether there is the need to improve knowledge, skill and access to specialist assessment services, will need further scrutiny by both children's social care and Essex Safeguarding Children Board. The importance of child in need plans 11 This is an NHS England sponsored work programme which is developing an information sharing solution that will connect local authorities’ child protection social care IT systems with the healthcare systems of the NHS. 12 Cleaver, H., Unell, I. and Aldgate, J (2011) Childrens Needs Parenting Capacity 2nd Edition London: TSO Page 35 Page 21 of 31 6.18 This review has confirmed the importance of effective child in need planning13 arrangements when children are stepped down from child protection plans. 6.19 It is clear from the reports received for this review that at the time that Half Sibling was removed from a child protection plan, significant parts of the child protection plan had not been progressed. Mother had not completed group work in relation to managing risks from violent men and the parenting assessment had not been completed. These issues could have been picked up during the child in need planning phase but this plan was never actively implemented. From reports received for this review it seems that although there are a number of family support services in the area where Mother lives, she was not using these and relied heavily on the support of her own mother. The case was closed to children's social care without a proper review within supervision of outcomes achieved. 6.20 The significance of this in relation to later events with Child G can only be speculated upon and it is important to remember that there were no concerns about mother’s parenting identified by any professional until after her pregnancy with Child G. It is not unreasonable to assume that had there been active multi-agency involvement at that stage, and a clearer assessment of Mother’s parenting capacity on file within health records, this would have provided a more effective foundation for understanding any vulnerabilities in the future. Responsibility does not only lie with children's social care, as there was no evidence of any challenge from other agencies when the child in need plan did not progress. It is possible that at that time expectations were low and consequently there was a lack of challenge from other professionals. 6.21 The children's social care report identifies that in 2010 social care services were on a trajectory of improvement but still recovering from a history of staffing shortages, high levels of agency staff, high caseloads and a backlog of assessment work. The CQC inspection report14 published in April 2014 noted problems with child in need meetings including lack of minutes, clarity about the support being offered and roles and responsibilities of the services involved. In contrast, the Ofsted inspection (January/February 2014)15 confirmed that children with additional needs are benefiting from “good coordinated multi-agency help and support”. 6.22 Given the disparity between the two inspection findings it is likely that the quality of child in need planning was patchy in 2010-11 and the significant improvements described to this review had yet to bed in. The panel heard that, from February 2014, Essex children's social care have made significant improvements in their child in need services which are set out in more detail in the response to this review. This includes a dedicated child in need reviewing service staffed by child in need reviewing officers who chair complex child in need review meetings. Although this currently only constitutes 18-20% of the child in need reviews there is a positive move towards a greater degree of consistency, challenge and oversight within the system. 13 S17 of Children Act 1989 defines a child in need as a child whose health or development is likely to be impaired without the provision of services by the local authority. Child in Need Plans set out how those services are to be coordinated and delivered. 14 CQC (April 2014) Review of Health Services for Children Looked After and Safeguarding in Essex (Communities served by Mid Essex, North East and West Essex Clinical Commissioning Groups) Para 2.8 15 Ofsted (February 2014) Inspection of services for children in need of help and protection, children looked after and care leavers. Para i Page 22 of 31 Pre birth assessments 6.23 In this case there was the opportunity to consider whether a pre-birth assessment should have been undertaken at the point mother was pregnant with Child G. Given the previous child protection plan it would have been reasonable for health professionals to have looked carefully at all current and past information and explored with mother the extent to which she was coping with Half Sibling whilst pregnant with Child G. However, due to the lack of a holistic approach, and fragmentation in information sharing identified above, this did not happen. 6.24 It is important to consider whether additional reasons relate to more general problems with the pre-birth processes within Essex, and paragraph 5.10 identifies the myths that had built up regarding at what stage in pregnancy a referral could be made to children's social care. There is no evidence that this was a problem with procedures or general practice in relation to pre-birth assessments. The most recent CQC report16 identified that generally the process for pre-birth assessments works well with children's social care responding promptly to concerns. It does, however, note that there is no formally agreed pre-birth protocol in place to ensure a clearly identifiable pathway and a recently published serious case review17 has recommended that current guidance on the interface between pre-birth/ante natal child protection processes and discharge planning should be reviewed. The guidance is currently in the process of development and it will be helpful if the pathway gives clear guidance relating to factors to consider when there has been a previous child protection plan in place. Supervision within Health organisations 6.25 There is evidence of supervision structures being in place and it is positive that safeguarding supervision is provided within acute settings as many areas struggle with this. The area where regular safeguarding supervision was not in place is within the minor injuries unit (MIU); this is significant as the nurse practitioner has identified that within that setting there may be a lack of confidence in dealing with babies with injuries. There is relevant recommendation within the Local Provider Health Service individual management review which is in the process of being implemented. 6.26 Another gap is safeguarding supervision arrangements for GPs and this is an area for development. However, in the area of Essex where this family lived it has not proved possible to recruit to the post of named GP and move this aspect of practice forward. 6.27 Even though supervision structures were in place for midwives and health visitors, there is little evidence that this was promoting a critically reflective approach to the work which identified potential gaps in information and reduced the likelihood of taking parental explanations at face value. Where there are significant workload pressures it would not be unusual for supervision to concentrate on those children subject of a child protection plan, resulting in little reflection time for children such as Child G. The panel have been told that supervision has been improved and discussions about the child are recorded in the notes. This is basic good practice and the new “lead nurse” role that is tasked with leading peer review and reflection will be key in ensuring the development of an approach to supervision which enables sufficient attention being paid to both recording, 16 CQC (April 2014) Review of Health Services for Children Looked After and Safeguarding in Essex (Communities served by Mid Essex, North East and West Essex Clinical Commissioning Groups) Para 3.8 17 Child J Page 23 of 31 and the critical reflection, that informs an effective analysis of the meaning of the information being presented. Organisational risk and the role of the LSCB 6.28 The Local Provider Health Service individual management review sets out in some detail the extreme pressures on the health visitor during the period under review. The health visiting team is described as being understaffed and there were no suitable candidates for any vacant positions. In an establishment of 4.5 whole time equivalent (WTE) posts, 1.14 were vacant, and within the team 1.36 health visitors were new to the area and two were both newly qualified and new to the area. The health visiting team were therefore in “survival mode” but did escalate their concerns, and there is evidence that managers attempted to support their staff within available resources. However, commissioned resources at the time are described as insufficient to provide any sustainable support in the long term. 6.29 It is clear from the Local Provider Health Service individual management review that managers were attempting to find ways to manage the service and prioritise safeguarding, and they did alert the Clinical Commissioning Group via three different quarterly meetings (contracts, quality and monitoring). The 2013 section 11 audit did not include any standards in relation to workforce capacity of non-safeguarding specialist roles and the Safeguarding Children Board would not have been alerted to any concerns via this route. There is no evidence that the risks associated with the stresses on the service were escalated to the Essex Safeguarding Children Board in any other forum. One function of Safeguarding Children Boards is to monitor and evaluate the effectiveness of what is done by partner organisations to safeguard and promote the welfare of children18 and while LSCBs do not have the power to direct other organisations they do have a role in making clear where improvement is needed.19 6.30 In this case it seems that the questions were not asked via audits, or other mechanisms, about capacity to deliver effective safeguarding, nor was information volunteered. This inhibited the effectiveness of the LSCB in holding organisations to account for the effectiveness of their safeguarding practice. 7. CONCLUSIONS 7.1 The injuries to Child G were caused by a man who had a history of violence towards women and children and to this extent it was predictable that women and children with whom he formed an intimate relationship were at risk of harm. Prevention of harm must include knowledge about the perpetrator’s whereabouts, activities and relationships. This case highlights gaps in the systems that are in place to track perpetrators and identify risk of future harm where the identified concern is physical rather than sexual violence. 7.2 One of the challenges in this case was that the relationship with Mother was relatively new and Mr A was not living with her on a full time basis. Mother’s only contact with professionals at this time was with health practitioners, and within health organisations there was a general lack of curiosity about fathers/men in the family. This was 18 Regulation 5, Local Safeguarding Children Boards Regulations 2006 19 HM Government (2015) Working Together to Safeguard Children Page 67 Page 24 of 31 exacerbated by a workforce which was under extreme pressure, lack of a joined up approach across GP services, midwifery and health visiting and supervision which did not provide sufficient opportunities for critical reflection. Members of the family did have concerns about Mr A’s relationship with Mother but were unclear who to talk to about this. In fact, a great deal of information was held within the extended family, who provided Mother with a significant level of support but this was not known to those professionals who may have been able to intervene to protect Child G from harm. 7.3 The safeguarding risks associated with workload pressures within health visiting were not brought the attention of the Essex Safeguarding Children Board and quality assurance systems within the Board did not bring these to light. 7.4 At the time of the injuries, Mr A was still in contact with the probation service and there was insufficient recognition of risk when Mr A spoke during unpaid work activity about his relationship with Mother and her children. Information systems did not give sufficiently precise information to unpaid work supervisors regarding potential risks to children, and not all supervisors were familiar enough with the meaning of the coding system used. In addition, lack of attention to the detail in the file at the point of transfer from offender manager 1 to offender manager 2 meant that when his relationship with Mother came to the attention of the offender manager, they did not see the risks as immediate. Although they planned to contact children's social care this did not happen before the injuries to Child G took place. 7.5 The other side of the prevention coin is recognising when mothers may be vulnerable to being targeted by violent men. In this case Mother’s learning difficulties, combined with her problematic social history and lack of social support outside the family, made her particularly vulnerable. These factors had not been sufficiently assessed and the child in need plan in relation to Mother’s first child was therefore insufficiently tailored to Mother’s needs. The lack of focus within the plan on outcomes for the children and insufficient management oversight contributed to case closure within children's social care without sufficient scrutiny or challenge. This in turn may have contributed to health professionals subsequently paying insufficient attention to Mother’s vulnerability, over-relying on family support and not recognising a pattern of events that indicated that she may be struggling to cope. Improvements have been made to child in need planning processes in Essex but there is varying evidence as to the impact of these changes. This will be explored further in the Safeguarding Children Board response to this review. 7.6 Throughout the various stages of work with Mother and her children there was a need for practitioners to stop and think about the information that they held, what additional information they needed and who might hold that information. 8. FINDINGS AND RECOMMENDATIONS 8.1 The following findings and recommendations focus on areas for attention by the Safeguarding Children Board and are in addition to a large number of specific recommendations made by the individual management reviews. 8.2 Although Mr A had a history of violence against women and children there were no systems in place enabling effective tracking of his movements and relationships. This finding was also made by a serious case review in Southampton in 2012. Page 25 of 31 Recommendation One Essex Safeguarding Children Board should ask the Home Office and Ministry of Justice to develop: arrangements at a national level to ensure that offenders who have been convicted of violent offences against children are required to register their details of their address with the Police and to be subject to monitoring arrangements for specified period of time systems for monitoring and working with individuals who have offences against children, to ensure that their assessed high risk to children in the future can also be adequately addressed. 8.3 Information sharing systems between health agencies did not facilitate the development of a full understanding of Mother’s vulnerability by any one practitioner. Recommendation Two Essex Safeguarding Children Board should ask Commissioners of health services to report via the Health Executive Forum how compliance is measured and monitored in relation to the information sharing issues identified within the review. Namely Between health visitors, midwives and GP’s Between midwives and health visitors 8.4 Practitioners did not consistently stop and think about the information that they held, what additional information they needed and who might hold that information. Recommendation Three Essex Safeguarding Children Board should ask partner agencies to report to the Board on the criteria they use to determine how reflection and critical thinking is embedded within their organisation in order to enable practitioners to consider the information they hold, what additional information they need and who would hold this information why they are content that this is working well any steps that need to be taken to improve this aspect of safeguarding practice. 8.5 There is a lack of clarity within children's social care regarding when enquiries can be made of other agencies about a person who may cause harm to a child without their consent. If a referral had been made by family members expressing concerns about Mr A this may not have led to any further action due to a belief that his consent was needed to seek further information. Recommendation Four Essex Safeguarding Children Board should ask children's social care to use the information sharing guidance (HM Government 2015) to clarify with all staff good practice in seeking and sharing information where a child is suffering or likely to suffer significant harm. 8.6 The child in need plan for Half Sibling was not sufficiently outcome focused, was Page 26 of 31 discontinued and the case closed without effective management discussion, oversight or challenge from any other agency. Children's social care has reported that there has been significant improvement in practice since events in this review took place. Recommendation Five Essex Safeguarding Children Board should ask children's social care to coordinate a multi-agency audit of child in need planning arrangements and report to the LSCB on the effectiveness of management oversight and plans for provision of services at the point of case closure. 8.7 The nature, extent and impact of Mother’s learning difficulties were not fully understood and taken account of in service provision within any agency and did not inform an assessment of parenting capacity. Recommendation Six Essex Safeguarding Children Board should: ask children's social care and health commissioners to consider whether there are adequate accessible arrangements in place for providing any necessary psychological assessments to help the development of effective plans and service provision review learning and development needs in relation to the impact of learning difficulties/learning disability on parenting capacity ask for evidence that the implementation of PAM assessments in family centres is having a positive influence on child in need and child protection plans. 8.8 The quality of health visiting service to vulnerable families was compromised by capacity within the service. This was not brought to the attention of Essex Safeguarding Children Board and Board mechanisms did not provide active scrutiny of this aspect of safeguarding practice. Recommendation Seven Essex Safeguarding Children Board should: require agencies to inform them of any untoward “risk” their organisation acknowledges which has implications for safeguarding children in any of the services they commission or provide reflect on the effectiveness of s.11 audits 8.9 The quality of GP information available to this review was compromised by problems in accessing records once someone has entered the prison system. Recommendation Eight Essex Safeguarding Children Board should ask NHS England to review the mechanism for making the GP records of prisoners and ex prisoners available to serious case reviews and inform all Safeguarding Children Board chairs of the correct process. Page 27 of 31 8.10 The review process was delayed by the inability of Essex police to fully participate due to the criminal proceedings. Recommendation Nine Essex Safeguarding Children Board should work with Essex police to implement ACPO/CPS (May 2014) Liaison and information exchange when criminal proceedings coincide with chapter four serious case reviews or welsh child practice reviews (first published 2011). Appendix One The Review Process Introduction Statutory guidance at the start of this review was set out in Working Together to Safeguard Children (2013). The approach of all serious case reviews should be governed by the principles set out in the guidance although the specific methods used may vary. These principles are: 1. There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works to promote good practice. 2. The approach taken to reviews should be proportionate according to the scale and complexity of the issues being examined. 3. Reviews should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed. 4. Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. 5. Families including surviving children should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring the child is at the centre of the process. 6. The final report must be published, including the LSCB’s response to the review findings. 7. Improvement must be sustained through regular monitoring and follow up. Following the decision to undertake this serious case review, a panel of local senior professionals was appointed to oversee the review process. Independence was assured Page 28 of 31 by the appointment of two lead reviewers, one acting as an independent panel chair and the second as an independent report author. The Panel Chair Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has worked on more than 40 Serious Case Reviews in respect of children and vulnerable adults. He has recently been engaged by the Department for Education to re-draft high profile Serious Case Review reports so that they can be more effectively published. Mr Harrington has been involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council, and has undertaken investigations commissioned by the Local Government Ombudsman. He has served as a magistrate in the criminal courts in East London for 15 years. The Report Author Jane also trained in social work and social administration at the London School of Economics and qualified as a social worker in 1979. She has an MSc in social work practice, the Advanced Award in Social Work and an MPhil as a result of researching the impact of supervision on child protection practice. She has published two books on supervision and co-wrote, with Tony Morrison, the national training programme for social work supervisors. Since 1994 she has been the author or chair of many serious case reviews and in 2010 completed the accredited Tavistock Clinic and Government Office London nine day training programme for panel chairs and authors. She has also attended the 2012 Department for Education serious case review training programme. The Panel The panel comprised: Executive Director for People Operations, Essex County Council Director for Safeguarding, Children’s Social Care Deputy Chief Executive, Essex Community Rehabilitation Company Professional Lead Designated Nurse SCCN Designated Doctor for Child Death Review, NHS Mid Essex Chief Inspector & District Commander, Essex Police Head of Commissioning Education of Children Looked After, Essex County Council Lay member, Essex Safeguarding Children Board. Also in attendance at each meeting were: Lead for Safeguarding, Family Operations, Essex County Council Business Manager, Essex Safeguarding Children Board Page 29 of 31 Serious Case Reviews and Child Death Review Manager, Essex Safeguarding Children Board Project Officer, Essex Safeguarding Children Board Review Method The initial aim had been to use an approach to this review which moved away from individual agency reports and collaborated directly with practitioner from the start. It was agreed at the first panel meeting that the process should start with the compilation of a detailed chronology which would be reviewed by the panel. The next stage would be to meet with key practitioners to explore the detail of events and why actions and decision were taken at key points in time. The timeframe for the detailed chronology was agreed as starting from August 2012 through to the date that Child G was taken to accident and emergency in August 2013. Since this was a relatively short time frame, it was agreed that all organisations should review previous records in order to ensure that all information relevant to the terms of reference was available to the review. The specific questions to be answered by this review were: Were practitioners knowledgeable about potential indicators of abuse or neglect and what to do if they had concerns about a child’s welfare? Did they identify any causes for concern? If not, why was this? Were assessments, including pre-birth assessments, carried out and followed up appropriately? How did the adults present to the agencies they were in contact with? Was domestic abuse adequately taken into account? What factors affected the quality of assessments? Where relevant, were formal planning arrangements in place and implemented appropriately? Were MAPPA20 arrangements used appropriately? How effective are the multi-agency systems/ processes for flagging adults who are considered to be a Risk To Children (RTC), and how do we link adults who are RTC when they become involved with other families? Did agencies have reliable and efficient arrangements for storing, accessing and sharing information? Were they used to best effect in this case? What factors affected this? Were communications, within and between agencies, effective and what factors affected the quality of communication? Was practice sensitive to racial, cultural, linguistic and religious identity and any issues of disability? Were managers appropriately involved in this case? What role did supervision play in managing the emotional impact of the work and professional relationships in order to aid decision making and practice interventions? 20 MAPPA is the name given to the multi-agency public protection arrangements are in place to ensure the successful management of violent and sexual offenders https://www.gov.uk/government/publications/multi-agency-public-protection-arrangements-mappa--2 Page 30 of 31 The area where this family lived is relatively well resourced with services that could have supported them. If referrals to these services were not made, or were not effective, why not? Did any resourcing issues affect the way this case was dealt with? Is there evidence of good practice in the way this case was handled? At the second panel meeting in December 2013 Essex Police asked for the review to be deferred due to unspecified complexities within the criminal proceedings. Their position was that they would be unable to continue to contribute to the review at this point. A compromise position was reached whereby agencies would complete a paper based review without talking to any practitioners. The usual position of only a small number of practitioners who may be witnesses being “out of bounds” was not possible since Essex police were unable at this stage to specify which information might compromise the proceedings. Once the criminal proceedings were over, practitioners would be spoken to, agency reports would be finalised and Essex police would resume their involvement in the process. Following the conviction and sentencing of both Mother and Mr A in October 2014 agency reports were finalised and presented to a full day meeting of the panel, following which a draft overview report was produced and discussed at panel meetings in January and April 2015. Family Involvement Following production of a first draft overview report in April 2015 arrangements were made to see Mother and Maternal Grandmother, but due problems in finalising these meetings they did not take place at this stage, causing some further delay in the process. The Mother of Child G decided that she did not feel able to contribute to the review and the offer has been left open for her to make her views known to a member of the Safeguarding Children Board should she wish to do so at a later date. Maternal Grandmother and an aunt of Child G did meet with the lead reviewer and the Essex Safeguarding Children Board Business Manager and their comments have informed the final report. Involvement of practitioners The original intention to work closely with practitioners from the start of the review was not possible in this case. A meeting was held with practitioner to share a final draft of the report and this was attended by 17 people representing all the agencies involved in this case. This provided an opportunity to check accuracy and develop further the findings and recommendations. Page 31 of 31 Quality Assurance This report was presented to the Essex serious case review subcommittee on 19th August and minor amendments were made to the wording of the recommendations. The report was then presented to the Essex Safeguarding Children Board in October 2015. |
NC044925 | Deaths of a 2-year-old boy, Child M, in January 2011 and his 4-year-old half-brother, Child I, in April 2011. An open verdict was recorded for both deaths but subsequent care proceedings found that both boys had experienced neglect. Mother was arrested on suspicion of murder but charges were later dropped. Child I and Child M were subject to child protection plans at the time of Child M's death. Mother was well known to adult and children's social care and received a wide-range of support services. Mother was diagnosed with a learning disability as a child and had a congenital health problem requiring her to take regular medication. Mother experienced trauma as a child and was accommodated by the local authority from the age of 15-17. Mother expressed worries about coping to agencies on a number of occasions and admitted not feeding and hitting Child I. Identifies 11 significant areas of practice in which professionals' actions to protect Child I and Child M were compromised, including: working across adult's and children's social care; understanding the impact of learning disability on parenting capacity; assessment of family carers and confusion regarding the legal status of Child I; and working with early years providers to assess risk.
| Title: Serious case review: Child I and Child M. LSCB: Southampton Local Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Serious Case Review Child I & Child M Report Author Jane Wonnacott Director In-Trac Training & Consultancy BA MSc MPhil CQSW AASW Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 2 of 58 TABLE OF CONTENTS Section Page 1. INTRODUCTION........................................................................... 3 2. REVIEW PROCESS.................................................................... 4 3. SUMMARY CHRONOLOGY........................................................ 8 4. CASE HISTORY AND EVALUATION OF THE WAY IN WHICH AGENCIES WORKED WITH THE FAMILY.................................. 10 Agencies’ response to Mother’s pregnancy with Child I 11 Agencies’ response to emerging concerns about Child I (age 7 -12 months) 14 Agencies’ response to further concerns about the care of Child I and Mother’s pregnancy with Child M. 15 Agency response to emerging concerns about the care of Child M (birth to 12 months) 21 Child protection planning for Child M (age 14 - 20 months) and Mother’s pregnancy with Sibling 1. 22 Child protection planning for Child M until his death, and action taken in respect of Sibling 1 26 Events following the death of Child M and until the death of Child I 31 5. THEMATIC ANALYSIS OF PRACTICE ISSUES........................ 36 Working effectively across children’s and adults’ services: understanding the impact of Mother’s learning disability on her parenting capacity. 36 Quality of assessments 38 Assessments of family carers and confusion regarding the legal status of Child I 41 Working together with early years providers to assess risk of significant harm 41 The use of strategy meetings 42 Using child protection conferences, core groups and child protection plans effectively 43 Assessing risk at point of hospital discharge 44 The role of the emergency duty team 45 Working with fathers 45 The effectiveness of child death rapid response processes 46 Staff supervision and management oversight 48 6. CONCLUSIONS.......................................................................... 49 7. RECOMMENDATIONS................................................................. 51 Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 3 of 58 1 HM Government (2010) Working Together to Safeguard Children. London: TSO Paragraphs 8.9 & 8.12 1. INTRODUCTION 1.1 This is the serious case review report in respect of two children known in this review as Child I and Child M. Child M died aged 2½ in January 2011 and along with his sibling was subject of a child protection plan at the time of his death. Child M’s half-brother, Child I, died three months later in April 2011 at the age of 4½. He was understood to live with Maternal Grandmother but was in the sole care of Mother at Maternal Grandmother’s house at the time of his death. 1.2 No charges have been brought in relation to either death, although a finding of fact in subsequent care proceedings did find that both boys had experienced neglect. The inquest into the deaths of Child I and M heavily relied on the finding of fact and resulted in an open verdict for both children. Decision to undertake a serious case review 1.3 Child M’s death on 6th January 2011 was considered by the Southampton Local Safeguarding Children Board serious case review sub-committee. It is the role of this committee to review serious cases and recommend to the Board chair whether the criteria for a serious case review have been met. On this occasion, it was agreed that there should be no serious case review but the case would be reconsidered after the post mortem results were obtained. 1.4 When further information was obtained, it was agreed that there was no indication that Child M’s death was linked to the reason for his child protection plan and therefore the criteria for a serious case review had not been met. It was the view of the sub-committee that this was in line with the guidance in place at the time1 which stated that a serious case review should be carried out when a child dies and abuse or neglect is known or suspected to be a factor in the death. This was a finely-balanced decision and did not involve consideration of additional criteria suggested within the guidance. These criteria included considering a review where the child was subject of a child protection plan and where the case indicated that there may be failings in one or more aspect of the formal safeguarding procedures. It could be argued that both of these criteria were present at that time. 1.5 Following the death of Child I on April 2011 the serious case review subcommittee noted that the case had met the criteria for a serious case review but the review should not start until further results from the post mortem and toxicology tests were available in order that the scope of the review could be determined. 1.6 The case of Child I was kept under review. The serious case review subcommittee agreed that as well as waiting for the toxicology results, a review should not be agreed until after a Finding of Fact in care proceedings relating to the surviving siblings. An initial Finding of Fact in July 2012 found that there was evidence of neglect, but no evidence that this had led to either child’s death. It was therefore agreed that the criteria for a serious case review had not been met but a review of practice would take place. The way that this would be carried out was to be determined once the outcome of the decision of the Crown Prosecution Service Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 4 of 58 (CPS) as to whether to charge Mother was known. 1.7 In May 2013 the CPS decided not to charge Mother with any offence and the serious case review subcommittee agreed that a review would be undertaken below the level of a serious case review. 1.8 Following a change of senior managers within children's social care and the departure of the Southampton Local Safeguarding Children Board Chair, the case was reviewed by the interim chair of the Board and it was agreed on 9th July 2013 that a serious case review should take place. This review is one of five reviews being conducted concurrently within Southampton. 1.9 This decision to conduct the review two years and three months after the death of Child I has inevitably hampered the process, with many staff within children's social care who had known the family no longer working for the organisation, and not being willing or able to contribute. The recall of others had been adversely affected by the passage of time. It has therefore not always been possible to understand with any degree of certainty why practice decisions were taken at the time. 1.10 This review has focused on events that occurred between three and seven years ago and since that time there have been many changes in practice and personnel within the agencies involved and efforts have been focused on improving many of the practice problems identified in this review. It is beyond the scope of this particular report to set out these changes in detail. The aim of this document is to identify as clearly as possible what the practice problems in this case were from 2007- 2011 and as far as it possible why they occurred as well as recommendations for practice change. The Southampton Local Safeguarding Children Board will set out in its response what specific action has been taken to address any of these issues. 2. REVIEW PROCESS 2.1 The review was carried out in line with the principles set out in statutory guidance (Working Together 2013). These are: ● there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; ● the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; ● reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; ● professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; ● families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 5 of 58 ● final reports of SCRs must be published, including the LSCB’s response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections. 2.2 Jane Wonnacott and Kevin Harrington, experienced independent consultants, were appointed independent reviewers and a panel of senior managers formed to support the process. The panel was chaired by Kevin Harrington, and Jane Wonnacott wrote this report. Further information about the reviewers and the panel is set out in appendix A. 2.3 The terms of reference for the review were agreed and are appended to this report in appendix B. Following consideration of the most appropriate method for carrying out the review it was decided that organisations who had contact with the family should be asked to submit individual management reviews of their involvement for consideration by the independent reviewers and the panel. This method was chosen mainly due to the fact that the time frame for the review was 2006-11 and since that time many of the staff involved, particularly within children's social care, were no longer working for the organisation. Where involvement was limited, a short report for information was submitted. 2.4 In order to ensure that the review fully involved professionals who had worked with the family, individual management review authors were asked to ensure that any professional who had significant involvement should be invited to contribute, even if they had left the organisation. 2.5 All individual management review reports were accepted within the individual organisation and action taken to address any outstanding practice issues, whether at an individual or organisational level, that may be adversely affecting child protection practice currently. 2.6 Individual management review reports were received from: ● CAFCASS who had brief involvement as a result of Maternal Grandmother’s application for a Residence Order in respect of Child I. ● Hampshire Constabulary who had various contacts with both Mother and the father of Child M and Sibling 1. ● NHS England for Southampton GPs. Mother, Father and all Mother’s children were registered with GPs in the Southampton area. ● Southampton City Council Legal Services who were responsible for providing legal advice to social work teams involved in this case. ● Solent NHS Trust who provided health visiting and speech and language therapy services. ● South Central Ambulance Service who conveyed various members of the family, but most significantly the children, to hospital on several occasions. It should be noted that despite the best attempts of the panel to obtain Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 6 of 58 information about the involvement of the ambulance service, this report was surprisingly brief considering the level of contact with the family and did not assist the review a great deal in understanding the role the service played in this case. The panel made several attempts to obtain a fuller report but this was not forthcoming and at the time of writing the matter is being taken up with the ambulance service by the Chair of Southampton Local Safeguarding Children Board. ● Southampton City Council Adult Social Care who provided services to Mother via their learning disability team. These services included social work assessment and support, residential provision and domiciliary family support. ● Southampton City Council Children's Social Care who had extensive involvement with Mother during her childhood. The pathways (leaving care) team were involved with Mother at the time of her pregnancy with Child I and from that point onwards the intake and long term children’s social work teams were involved with a focus on supporting Mother to care for her children. There was also involvement by the hospital social work team and emergency duty teams. ● Southampton City Council Children’s Services Prevention and Inclusion who were responsible for early years provision including children’s centre services, playgroups and childminding. ● Southampton City Council Housing who provided housing to Mother following her move from supported accommodation. ● Southern Health who provided mental health services to Mother and Father and health learning disability nursing services to Mother. ● Supported Housing Project who provided supported housing to Mother when she was pregnant with Child I and immediately post birth. They then provided supported outreach at the point that Mother moved into independent accommodation. ● University Hospital Southampton NHS Foundation Trust who were responsible for accident and emergency, midwifery and paediatric health services. 2.7 In addition, a report for information was requested and received from the Crown Prosecution Service. This was received and provided a full explanation for the decision not to proceed with a prosecution following the death of Child I. 2.8 All individual management review authors were invited to attend two meetings of the panel in order to discuss their reports and hear from other individual management review authors. 2.9 Since this review has been one of five reviews taking place concurrently and covering similar time frames, the independent reviewers have met on three occasions the Chair of Southampton Local Safeguarding Children Board in order to Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 7 of 58 identify emerging themes that are relevant to all reviews and indicate deep-rooted issues within the safeguarding system. In addition, two of the independent reviewers were commissioned to undertake an analysis of the context within which practice was taking place since this was relevant to all reviews and did not need to be repeated within five separate reports. 2.10 In the light of the number of concurrent serious case reviews individual management review recommendations are not appended to this report as work is being done to identify common issues across all reports and develop a composite set of recommendations for each organisation. This will help in the speedy and efficient response to the issues identified and also enable the Safeguarding Children Board to more easily hold organisations to account for required changes in practice. Family Involvement 2.11 Mother and Maternal Grandmother were invited to contribute to this review and considered whether they wished to take part. Maternal Grandmother did not wish to contribute but Mother agreed to meet the report author and the Southampton Local Safeguarding Children Board manager. Discussing events leading up to the deaths of two children is clearly an extremely sensitive and potentially distressing matter and arrangements were made for Mother to be accompanied by support of her choosing. 2.12 We are very grateful to Mother for her willingness to contribute to this review and her views regarding specific issues are included at relevant points in the narrative. The general points made by Mother were that: ● She asked for help when she could not cope with Child I but did not receive an adequate response from children's social care. ● The support she received did not always meet her needs. She frequently felt judged and criticised and felt that she was being told what to do but not why. There was no one there for her who was not going to judge her. ● It was hard to build up relationships with social workers as staff were always “chopping and changing”. ● Services were very confusing and she did not know what to expect from people and what thy expected from her. 2.13 The father of Child M and Sibling 1 (known as Father in this report) was informed via the medical team responsible for his care that the review was taking place. The panel took advice from the mental health services as to the best way of involving him and contact was made via a member of staff who knew him well. Father was given further information about the review process but decided that he did not wish to contribute. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 8 of 58 3. SUMMARY CHRONOLOGY Feb 2006 Agencies were aware of Mother’s first pregnancy (aged 20). Mother was known to have a learning disability and significant level of involvement with children's social care as a young person. At this time Mother had an allocated social worker in the adult learning disability team and was living in residential accommodation. Once the pregnancy was confirmed Mother moved to a supported housing project. The case was opened to children's social care. Sept 2006 Child I born. Nov 2006 Case closed to children's social care. April 2007 Mother expressed worries about coping with Child I and this, combined with concerns at the supported housing project, resulted in the case being re- opened to children's social care. June 2007 Mother and Child I moved to independent accommodation with floating support from supported housing. Aug 2007 Case closed by adult social care learning disability team although agency support worker input continued. Sept 2007 Case closed to children's social care. Oct 2007 Evidence that Mother not coping and she was admitted to the Department of Psychiatry and the case was re-opened by children's social care and adult social care. Child I moved in with Maternal Grandmother. Jan 2008 Mother pregnant. She had met Father whilst an inpatient at the Department of Psychiatry. Mother living at this time with adult placement carers. Child I remained with Maternal Grandmother who was encouraged to apply for a Residence Order. June 2008 Court hearing regarding Residence Order, and all parties assumed order had been made although no evidence of the order has been found. Aug 2008 Child M born. Mother stayed briefly with Maternal Grandmother and then moved back into independent accommodation. June 2009 Child M taken to hospital by Mother and Father concerned he had ingested cleaning fluid. Subsequent visits to the home by social worker and health visitor identified hazards in the home. Aug 2009 Case closed to children's social care. Sept 2009 Mother pregnant with Sibling 1. Oct 2009 Child M taken to hospital by Mother and her support worker concerned that he had ingested Sudocreme. Nov 2009 Initial child protection conference in respect of Child M and unborn baby. This conference was as a result of an allegation made by Mother against Father and police concerns about care of Child M when they visited the home. Child Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 9 of 58 M and unborn baby were made subjects of a child protection plan. Feb 2010 Review child protection conference in respect of Child M and unborn baby. Child protection planning continued. Community child minding arranged for Child M. April 2010 Sibling 1 born and admitted to hospital. May 2010 Sibling 1 admitted to hospital twice: firstly at the age of two weeks with vomiting and low weight and subsequently with a rash, diarrhoea and vomiting. June 2010 Legal planning meeting in Children’s Services. July 2010 Review child protection conference in respect of Child M and Sibling 1. This conference was not aware that the legal planning meeting had been held. Aug 2010 Newly qualified social worker had taken over the case and identified concerns about neglect of the children. These concerns were not seen as requiring action by the senior practitioner managing the case. Sept 2010 Change of health visitor. Child M started nursery. Nov 2010 Sibling 1 taken to hospital with vomiting and diarrhoea and episodes of unresponsiveness. Concerns about state of the home expressed by the support worker. Mother found to be drunk in charge of Child M and Sibling 1 and children stayed temporarily with Maternal Grandmother. Dec 2010 Mother asked social worker to remove Child M and Sibling 1. Jan 2011 Death of Child M. Investigations did not identify any evidence that the death was suspicious. A strategy meeting was held following the death which agreed there was no need for section 47 enquiries. A review child protection conference was held in respect of Sibling 1 who remained subject of a child protection plan. March 2011 Sibling 1 taken to hospital three times; on the first occasion with shortness of breath and on the second occasion unwell and vomiting. Ambulance staff commented to hospital staff on the second occasion that they were concerned about the home environment. Sibling 1 was noted to be unkempt. On the third occasion Sibling 1 was found to have low blood sugar and was noted to be hungry and thirsty. April 2011 Child I died whilst in sole care of Mother. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 10 of 58 4. CASE HISTORY AND EVALUATION OF THE WAY IN WHICH AGENCIES WORKED WITH THE FAMILY 4.1 This section of the report sets out a narrative of the contact that Mother, Child I and Child M had with both statutory and non statutory organisations. It seeks both to describe the help that was offered to the family and to comment on the effectiveness of this help in relation to identifying risk to the children and preventing significant harm. The nature of the contact with the family was at times intensive and the narrative seeks to explore the most significant aspects of involvement insofar as these were pertinent to protecting the children. Since this report will be publicly available, personal family details have been kept to a minimum. 4.2 The mother of Child I and Child M had a significant history of involvement with Southampton children's social care primarily as a result of concerns about the care she was receiving within her own family. This resulted in periods of accommodation by the local authority from the age15 to 17. The GP individual management review records issues which indicate a number of social and emotional needs relating to the care she had received as a child. In addition, Mother had been assessed as having a learning disability and from the age of 13 to 15 had regular contact with the NHS learning disability team. She was also diagnosed with a congenital health problem which requires regular medication throughout her life. Not taking this medication could result in an exacerbation of any learning disability, tiredness and low mood. Therefore, at the time of Mother’s first pregnancy with Child I at age 20 she was known to have a number of vulnerabilities alongside a complex family history. 4.3 At the time of her first pregnancy Mother was in contact with: 1. Children’s Services Pathways (leaving care) team who, under the Care Leavers Act 2000 was responsible for offering assistance and support until age 21. This support was offered via a ‘duty’ system. A specialist teenage pregnancy worker was also available but Mother did not take up this offer of support. 2. The Southampton City Council learning disability team who held and managed a care plan to support Mother. A risk assessment carried out by a social worker in this team concluded that Mother was unable to manage independently. As a result of this assessment, at the time of her pregnancy, she was living in a residential placement organised by adult social care. 4.4 From this point onwards Mother and her children were in contact with a number of different agencies who were charged with providing support either to: ● Mother as a vulnerable adult ● Mother in her role as parent ● The children; particularly in relation to ensuring that they were kept safe from harm. 4.5 The father of Child I played no significant part in his life during the time frame for this review. However, the father of Child M was involved with Mother and Child M post birth and known to health organisations (including mental health), police and children's social care. Like Mother he also experienced difficulties in his own Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 11 of 58 childhood and had a history of significant mental health issues from a young age. These at times resulted in violent behaviour. 4.6 It is a feature of this case that at times roles became confused and there were many different professionals involved with one or more aspects of Mother’s life. It has been hard to unravel the full, accurate, picture of the work that was happening at any one time, with records, particularly within children's social care, being poorly kept and organised during the early stages of the period under review. Mother’s input to the review has therefore been invaluable in clarifying the sequence of events. The picture that has emerged is a complex one and in order to be as clear as possible about the quality of services delivered at various points in time, the rest of this narrative is divided into seven specific timeframes: 1. Mother’s pregnancy with Child I. 2. Emerging concerns about Child I (age 7-12 months). 3. Further concerns about the care of Child I and Mother’s pregnancy with Child M. 4. Emerging concerns about the care of Child M (birth – 12 months). 5. Child protection planning for Child M (age 14-20 months) and Mother’s pregnancy with Sibling 1. 6. Child protection planning for Child M until his death and action taken in respect of Sibling 1. 7. Events following the death of Child M until the death of Child I. Agencies’ response to Mother’s pregnancy with Child I 4.7 Mother’s pregnancy first came to the attention of the social care learning disability team who alerted the children's social care intake team who were the team responsible for taking referrals and the initial stages of work with children and their families. This was an appropriate course of action but Mother was already an open case to a children’s services team (Pathways). Although Pathways did subsequently share information with the safeguarding team the recording within the pathways team made little reference to safeguarding issues in respect of the unborn and their responsibility in this aspect of the work. There was no protocol or procedure for managing and supporting pregnant care leavers who require a range of services or for managing situations where there might be a conflict of interests between the capability of the mother and the needs of the baby. 4.8 The social care learning disability team also wrote to the learning disability nurse who had previously had significant involvement with Mother between the ages of 18 and 20. The records of the learning disability nurse note that the pregnancy had implications for the residential placement as it was not registered for mothers and babies and that they advised the adult social care social worker that they should contact the GP and midwife to support Mother in relation to her health needs. There was good awareness of the need for information sharing by the learning disability Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 12 of 58 nurse at this point and she stated in a letter to adult social care that she felt it was important that she shared all her information as early as possible to contribute to future plans. It is unfortunate that she was not subsequently involved in any pre-birth meetings and the case remained closed at that point to the NHS learning disability team. 4.9 Once the GP became aware of the pregnancy they referred to the midwife. The GP records would have contained significant information about Mother’s vulnerabilities and safeguarding history but according to the GP individual management review author “there is no evidence that the mother or father’s health issues, their socioeconomic circumstances were shared at this point.” The midwife, at booking, appropriately arranged obstetric-led care but there is no record of questions being asked about the presence of domestic violence or substance misuse as was expected good practice at that time. 4.10 It was the expectation of the adult social care learning disability team that a pre-birth assessment would be carried out by the children's social care team and information about Mother’s significant history and care episodes was shared by the learning disability team with the intake team in order to facilitate this. Information sharing at this point was clearly crucial and it should have been possible for adults’ and children’s social workers to access each other’s records since they did share the same database, although in line with data protection requirements access to each other’s records was not automatic. A protocol was in existence that meant that a request could be made for access to records but this was not widely known about or used. However, despite this, it is clear from the records that the intake team had available to them all the information that should have alerted them to the need for a thorough pre-birth assessment. 4.11 Within the intake team there was delay in allocating the assessment to a social worker and the individual management review notes that this assessment was never properly completed. The reason for this is not clear, although the most likely explanation is pressure of work and a lack of effective management oversight. The liaison that might have been expected between children's social care and health colleagues did not take place and health records note that the first contact between the midwife and social worker was some seven months after Mother’s pregnancy had been confirmed. This contact was instigated by the midwife. In addition, there is no evidence that the health visitor was invited to any planning meetings that took place prior to Child I’s birth. 4.12 The opportunity to work effectively with health colleagues was further hampered by the lack of effective liaison between the GP, midwife and health visitor during Mother’s pregnancy. The GP records would have contained significant information about Mother’s own experience of being parented and her mental health history but this information does not seem to have been available to the rest of the health network. Had this been known it may have promoted a more proactive approach by health professionals in challenging the approach of children's social care. 4.13 Meanwhile, the adult social care learning disability team referred Mother to a supported housing project whose resources included a mother and baby unit and Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 13 of 58 2 Floating support is support within the community deigned to maintain the capacity of the parent to live independently in their own accommodation. floating support2. Mother moved into a room in the project four months before Child I’s birth and met with a support worker two to three times a week. All records point to very good practice by the supported housing unit throughout their contact with mother. A high level of support was offered and any concerns about Mother’s parenting were recorded and passed onto children’s social care. 4.14 It is a feature of social work practice at this time that responsibility for case management was devolved to a senior practitioner and there is little evidence throughout the records of any discussions at key decision points with the team manager. The post-birth plan which was for Mother to stay with her own Mother (Maternal Grandmother) immediately post birth and then return to supported housing was therefore agreed by a senior practitioner in the intake team. The midwifery plan set out by the safeguarding midwife included more frequent home visits than usual and good liaison with the health visitor. 4.15 Child I was born in September 2006 and after spending time with Maternal Grandmother, Mother and Child I moved back to the supported housing project. There were no concerns about Child I’s care or development post-birth and this may have contributed to the fact the community midwives did not adhere to the advice of the safeguarding midwife to undertake frequent home visits. 4.16 No concerns about Child I were identified at a Child In Need planning meeting which took place without any health input, and the case was closed to children's social care when Child I was less than two months old. It is unclear whether adult social care were aware that the case was closed as their individual management review notes that they believed that children’s services were monitoring Child I. The risk assessment completed by adult social care prior to mother’s pregnancy which concluded that she was unable to manage independently was not at this point influencing the thinking of children's social care, possibly due to a lack of understanding by children’s social workers of the significance of this assessment and no one “event” that had identified a cause for concern. 4.17 Summary – agencies’ response to Mother’s pregnancy with Child I There was a failure at this point to carry out a pre-birth assessment that integrated all known information about Mother’s experience as a child and analyse this in terms of the support she was likely to need as a parent. This resulted in an inadequate understanding of risk and premature closure of the case to children’s social care. Information that should have informed an assessment was known to professionals within the network, yet it was either not shared (as in the case of the GP’s liaison with the midwife and health visitor) or its significance was not recognised (as in the case of children’s social care). The expertise within adult social care and health teams in assessing Mother’s capacity and vulnerability was not used by children’s social workers despite it being known that a high level of support was being (or had been) offered by these services. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 14 of 58 3 Safeguarding supervision is a type of supervision used within health organisations, delivered by a safeguarding specialist and provides a forum for discussion and oversight of work with children where there are safeguarding concerns. Agencies’ response to emerging concerns about Child I (age 7 -12 months) 4.18 When Child I was six and half months old (April 2007) children's social care received a referral from the supported housing project as Mother was low in mood and was saying that she could not cope with him. This coincided with Mother receiving an adult caution from the police for an offence which took place in the presence of Child I, followed by concerns about Mother’s mental health. At this point information was passed to the health visitor by the community health nurse that Mother was not taking her medication. The significance of this information exchange was that failure to take the medication could result in low mood, fatigue, difficulty with memory and concentration and could have exacerbated the effects of Mother’s learning disability. At no time throughout the period under review did any professional assess the impact of failure to take medication on Mother’s capacity to parent. Indeed, at the point of Child M’s death, there was a prevailing view that health visitors and social care did not know that Mother had not been taking this on a regular basis. 4.19 The case was inappropriately allocated to a student social worker and the only feasible explanation for this is that there were workload pressures within the team at that time. However, there is no documentary evidence that the team manager alerted senior managers to the fact that work could not be allocated to qualified social workers and instead a student was inappropriately used to plug gaps in the service. This would have been an overwhelming case for an inexperienced worker as there were wide ranging concerns about Mother, both in her role as a parent and in her own right. 4.20 It is therefore perhaps unsurprising that assessments and plans at this point were inadequate, with little analysis of the potential risk to Child I, despite the supported housing project alerting the social worker on several occasions to concerns about Mother’s mental health and ability to care for her baby. Even when the student social worker visited with a qualified worker and witnessed Child I becoming ill after ingesting cigarette butts and there was further first hand evidence of rough handling and poor parenting, no protective action was taken. The only recorded action at this time by children's social care was a referral to “stay and play” sessions at the family centre. 4.21 It was, however, recognised by the intake team that Mother needed longer term support and two months after the referral from supported housing Child I was transferred to the long term social work team. 4.22 The absence of effective multi agency working is noticeable during this period with the health visitor noting concerns about the delay in starting the core assessment by children's social care, but not challenging this, despite this being an agreed action in a safeguarding supervision session3. The individual management review author believes that failure to challenge at this time may have been a result of Mother subsequently moving address and a change in health visitor. 4.23 The other negative impact on information sharing across professionals was Child I’s Child in Need status and Mother’s refusal to give social workers permission to share Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 15 of 58 information with others. This appears to have been accepted rather than being considered as part of a wider assessment of Mother’s capacity to work together with professionals to improve her care of Child I. 4.24 At the end of June 2007, Mother and Child I moved out of supported housing into independent accommodation with floating support provided by the supported housing project. It is unclear why this decision was made although Mother recalls asking to move out as she found the accommodation noisy. Prior to the birth of Child I, a previous risk assessment by adult social care had identified that Mother should not live alone, yet she was deemed to be safe to live alone with a small baby. 4.25 Mother’s case was closed by adult social care in August 2007 although they continued to fund an agency family support worker. Following a Child in Need meeting attended by the long term social worker, senior social worker, the health visitor and Mother a decision was made also to close the case to children's social care in September 2007. It is likely that this decision was based on the fact that a number of support services were available to Mother, including a family support worker, a play worker (as Mother had moved to a Sure Start area) and floating support from the housing project. The opportunity to understand the accumulating signs of risk to Child I despite the presence of support from a number of agencies was lost at this point. 4.26 Mother remembers being unhappy at the closure of her case by children's social care and going to the office to ask for social work help. She recalls the response as being that she should be able to manage on her own. 4.27 Summary - agencies’ response to emerging concerns about Child I (age 7 - 12 months) Despite evidence that Mother was not coping, was not providing Child I with appropriate safe care, and the best efforts of the supported housing worker in bringing this to the attention of the student social worker, the focus on work within children's social care remained firmly on this as a case of a child in need. Mother was seen as a parent needing support and the interaction between her learning disability and significant trauma as a child/young person, as well as accumulating evidence about her struggles to cope with parenting, were not understood in terms of potential risk to Child I. Although significant support was provided, this was un-coordinated and it seems that others in the network felt powerless to challenge children's social care’s lack of decisive action in response to any concerns that were expressed. A low standard of parenting became accepted as the norm. Agencies’ response to further concerns about the care of Child I and Mother’s pregnancy with Child M. 4.28 Within a month of case closure, Mother approached children's social care to say that she could not cope. This is not recorded in the children's social care records but Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 16 of 58 4 An EPO is an Emergency Protection Order issued by a Court under section 44 of Children Act 1989 in order to ensure the short term safety of a child. 5 Where a child is suspected to be suffering or likely to suffer significant harm, the Local Authority is required by s47 of the Children Act 1989 to make enquiries to enable it to decide whether it should take any action to safeguard and promote the welfare of the child. 6 According to guidance in place at that time a strategy discussion should take place whenever a child was suspected of suffering significant hare, This discussion should ‘involve LA social care, the police and other bodies as appropriate (eg. Children’s centre, school and health). (Working Together to Safeguard Children 2006, para 5.54) Mother clearly recalls asking for help and the GP chronology notes her telling the GP that she had “approached social services to have child taken away.” Mother asked for admission to a psychiatric unit but the GP advised a referral to the community health team. Whilst the GP was arranging this referral to mental health services, Mother abandoned Child I at the supported housing project. Mother remembers that at this point she was clearly asking for help and records show that she admitted not feeding Child I, hitting him, feeling low and not taking her medication. 4.29 A decision was made by children's social care to ask Maternal Grandmother to care for Child I. She agreed but was clear that she did not want to care for him long term. There was no consideration at this point of Mother’s own experience as a child, her relationship with her mother or Maternal Grandmother’s capacity to care for Child I. This uncritical acceptance of Maternal Grandmother as an alternative carer set the tone for all future work with the family. The children's social care individual management review notes that: The threshold to remove and safeguard Child I has been met. The alternative family option is not a safe and secure one for Child I and Maternal Grandmother’s motivations and capacity have yet to be properly assessed. An EPO4 should have been sought for Child I and he should have been placed with an experienced foster carer to ensure his needs were fully met. 4.30 The next day Mother was admitted to the Department of Psychiatry via Accident and Emergency after presenting at hospital with symptoms of mental illness. It is notable that she spoke at this time of being happy and supported at the mother and baby unit but unsafe, lonely and suicidal when alone in the flat. Further disclosures made by Mother of maltreatment of Child I, including hitting him on several occasions and denying him food and fluids, were shared with all appropriate professionals by the Accident and Emergency staff prior to Mother’s admission to the Department of Psychiatry. 4.31 The Police did not receive notification by children's social care of the disclosures of maltreatment until a week later. This was far too late as any possibility of gathering evidence that may have helped a police enquiry would have been lost. The police were informed that children's social care had begun child protection enquiries5 and police records note that a joint decision was made with children's social care that a single agency response by children's social care was most appropriate. The reason for this within the police individual management review is that the information given to the police relating to the treatment of Child M was vague, there was no context and the concerns were historic in nature. The police refer to this telephone conversation as a formal strategy discussion6 as required by child protection procedures but there is no indication that the social worker viewed it in this light, there are no minutes within the children's social care records and other people who Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 17 of 58 7 A detailed assessment of the child’s developmental needs and parents capacity to meet those needs in line with statutory guidance set out in Framework for the Assessment of Children in Need 2000. 8 Multi Agency Public Protection Arrangements which task ‘responsible authorities’ with the management of registered sex offenders, violent and other types of sexual offenders, and offenders who pose a serious risk of harm to the public. should have been included in the discussion, such as the health visitor, were not spoken to. There is no indication that this situation was challenged by the police who seem to have accepted poor practice. 4.32 The exact reason for the failure to use child protection procedures properly at this point is not clear, although at this time it is known that there were significant service delivery problems within children's social care, with a senior management consultant being brought in during the next year to identify weaknesses. 4.33 An assessment was completed by the social worker whilst Mother was an inpatient in the Department of Psychiatry. According to the children's social care individual management review, this assessment did not meet the requirements of a core assessment7. There is no evidence that Child I was seen, or of any input from health professionals into this assessment, which concluded that Child I was thriving in the care of Maternal Grandmother and that Mother did not have the capacity to improve her parenting skills. 4.34 However, the decision of the children’s social care senior practitioner was at variance with the findings of the assessment. Their decision was that Child I should return to the care of his mother and that Maternal Grandmother would support this through a “shared care” arrangement. At this time the supported housing outreach worker was withdrawing support as Mother was deemed “too dependent” and spending many hours at the supported housing office. Support from an agency funded by adult social care was arranged instead. The impact of returning Child I to his mother following an inpatient episode at the same time that there was a change in the nature of support does not seem to have been considered by the senior practitioner. There is no evidence that this was discussed with the team manager or that there was any opportunity for the social worker (who had concluded that Mother did not have the capacity to improve her parenting) to challenge the decision. 4.35 In fact, despite the decision by the senior practitioner, there appears to be a lack of clarity within children's social care regarding Mother’s living arrangements. Prior to Mother’s discharge from the Department of Psychiatry there was information that Mother was associating with a sex offender managed under MAPPA8. This resulted in an adult safeguarding strategy meeting. Prior to the strategy meeting Mother was discharged from the Department of Psychiatry to an adult placement carer, with the adult social care learning disability team assessing the possibility of moving her and Child I to another adult placement carer on a permanent basis. This did not happen as Mother became pregnant and wanted to return to her flat. She told this review that this was because she wanted to prepare for the baby and prove that she was able to manage. There is no evidence of a continuing association with the registered sex offender. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 18 of 58 9 A Residence Order is a court order settling the arrangements as to the person with whom a child is to live. The person to whom the order is made shares parental responsibility with the parent(s). 4.36 It is concerning that around this time Child I slipped, almost by default, into a long term living arrangement with Maternal Grandmother who had previously said that she did not wish to care for him long term. A decision was made within children's social care to encourage Maternal Grandmother to apply for a Residence Order9 without any proper consideration being given to Maternal Grandmother’s capacity to parent her grandchild. This is a particularly significant omission, given the information that was available about Mother’s own experience as a child. 4.37 The permanent move to Maternal Grandmother resulted in a change of health visitor for Child I. However, Maternal Grandmother was reluctant to engage with health visiting services, a pattern that continued until his death. Child I’s notes were not forwarded to the new health visiting team, which would have hampered their focus on his history and needs. 4.38 From January 2008 the focus of work by the health services was on Mother’s second pregnancy and it is clear from medical records that Mother was ambivalent about this pregnancy from an early stage. The father of Mother’s second child (known in this report as “Father”) was someone whom Mother had met in the Department of Psychiatry and who had a significant history of mental health problems, including failing to take medication, and a number of hospital admissions. From this point on there was a disconnection between services to Father as a mental health patient and Father as the parent of a child. Father’s GP was unaware that he was about to become a parent and there is no record of this being considered as part of his care plan. 4.39 The GP individual management review comments that again there was minimal background information and that there is no evidence that Mother’s involvement with children's social care was shared. However, at booking, the midwife ascertained that there were a number of safeguarding concerns including Father’s history of mental health problems, and raised a safeguarding concern form which was forwarded to the safeguarding midwife, children’s social care and the liaison health visitor. 4.40 An issue has emerged in the University Hospital Southampton individual management review regarding the positive benefits associated with midwives checking the Mother’s accident and emergency records at the point of booking. At this point and again with Mother’s later pregnancies information regarding her mental and physical health could have enhanced the midwifery assessment. The legal advice is that a review of Mother’s previous care within the Trust would not breach the data protection Act 1998 and a recommendation is therefore made within the hospital individual management review to develop this practice. 4.41 An additional issue is the need to consider the background of the Father at this point as there was an opportunity, following the booking appointment with the midwife, to join up what was known about Mother and Father through liaison with Father’s GP. Father’s GP was not aware of the pregnancy and at no point were they involved in any subsequent assessments which could have understood more fully the impact of the parental relationship on the unborn child. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 19 of 58 10 Meetings designed to plan care for adults in receipt of services. 4.42 There was evidence at this point of the potential impact of Mother’s learning disability on her ability to take proper care of herself, with a consultant noting that she was not taking her medication and was also having difficulties understanding her clinical/medical issues. The midwife and GP were aware of this information and the Southern Health individual management review notes that this was discussed at a Care Programme Approach (CPA) meeting10 which would have been attended by adults and children's social care. 4.43 Social work continued to be inappropriately led by adult services, with CPA meetings being used to discuss Mother’s ability to care for her unborn child. These meetings did result in appropriate action being taken to understand the support Mother required with, for example, a speech and language assessment identifying that the most useful way to assist Mother in understanding complex information was to “use short clear sentences and easy words and give extra time to process and understand what is being said”. The learning disability nurse was also providing additional support to Mother at this time and there had been an occupational therapy assessment which recommended that her care manager needed to find ways to develop mother’s confidence in meeting new people. 4.44 Despite work being undertaken to understand Mother’s needs there is no evidence that this was used effectively to develop a joined-up approach with children's social care which maintained a focus on the needs of Child I and the unborn baby. Although it was known to all professionals that Mother should not have unsupervised contact with Child I there were indications that this was happening, with Mother taking him to at least one care planning approach meeting. The health visitor was also aware that Child I was cared for by Mother from time to time, yet the whole network seems to have failed to challenge Mother, or each other, about the fact that this was known and allowed to continue. During this period there were staffing problems within children's social care and the case was again inappropriately allocated to a student social worker. 4.45 The issue regarding Child I’s legal status whilst placed with Maternal Grandmother from this point became confused. In May 2008, the court granted leave for Maternal Grandmother to apply for a Residence Order and the case was adjourned for a month. The Cafcass individual management review report notes that in June 2008 both parties and the Cafcass duty family court adviser were in court and a Residence Order to Maternal Grandmother in respect of Child I was agreed. However, the court has confirmed that only a draft order was prepared as Magistrates required written confirmation that the application was supported by children's social care and the allocated social worker was on holiday. They therefore wrote to the social worker asking for confirmation that children's social care supported the Order and a final hearing date was set for 23rd July 2008. Maternal Grandmother and Cafcass were told that they were excused from attending on that day unless issues were bought to the attention of the court by children's social care. No reply was received from the social worker and due to this failure to reply and an oversight within the court system the case file was not put before the court on the July date. The Residence Order was therefore not made and the court cannot provide any explanation as to why the file was then not reviewed until after the death of Child I. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 20 of 58 4.46 From this point, professionals and Maternal Grandmother believed that she had Parental Responsibility for Child I whereas no order had in fact been made and Parental Responsibility remained with Mother. It is clearly highly unsatisfactory that the legal status of a child can be so misunderstood but it should be noted that this situation is unlikely to happen today. Due to changes in court processes in April 2010, Cafcass would have been required to prepare a letter outlining any safeguarding concerns and in this case this would have alerted the court to the background to the application and ensured a greater degree of scrutiny by the court. 4.47 As Mother’s pregnancy with Child M progressed, she was admitted to hospital and during the admission there were significant concerns relating to her continuing ambivalence towards this pregnancy and her potential to provide safe care for the unborn baby. At this point she received appropriate psychiatric assessment; the adult social care learning disability social worker noted the need for Mother’s support package to be increased and liaised with the social worker from children's social care. It is notable that the health visitor recalls finding the planning for discharge confusing, with a lack of clarity regarding the relative roles of a planning meeting convened by the learning disability team and a professionals’ meeting to plan for the birth of the unborn child. 4.48 Mother was discharged from hospital on a Saturday and the hospital notes record that this was agreed by the children’s emergency duty team. The team had no authority to make this decision and it seems likely there was a misunderstanding/lack of clarity in the verbal communication between the two teams resulting in the hospital gaining false reassurance about the plan for discharge. 4.49 A professionals’ meeting agreed that when the baby was born, Mother and baby should stay with Maternal Grandmother for three months post-birth and the learning disability health services agreed to close the case as Mother’s needs were being met by other professionals. There were discussions with the safeguarding midwife who advised community midwives to undertake more frequent post natal visiting as well as liaise with the health visitor. It is, however, important to note that safeguarding midwives can only advise and have no direct line management responsibility for the actions of others. 4.50 Child M was born in August 2008 and as agreed Mother and Child M were discharged to the home of Maternal Grandmother. 4.51 Summary – agencies’ response to further concerns about the care of Child I and Mother’s pregnancy with Child M. This period is characterised by muddle and confusion on a number of levels: Poor recording within children's social care which resulted in a lack of a clear understanding of Mother’s living arrangements. Inappropriate allocation to a student social worker. Adult social care processes inappropriately driving a children’s case. Child I moving permanently to live with Maternal Grandmother without a proper assessment of whether this was safe or appropriate. There was an assumption that a Residence Order had been made but this Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 21 of 58 was not the case due to the social worker failing to reply to a query from the court and an oversight within the court system. Information known to the GP and midwife about Mother’s failure to take medication was not understood as significant information in relation to her parenting capacity. Police and social care were not working effectively together, with a failure to use strategy discussions to plan section 47 enquiries in line with procedure. A result of this confusion was that the focus on the individual needs of the children was lost. Agency response to emerging concerns about the care of Child M (birth to 12 months) 4.52 Within a month, it was clear that Mother was staying most of the time with Child M in her own flat. Significant concerns soon emerged about her ability to provide appropriate care for Child M who was observed to be prop fed and in soaking nappies. Additionally, the support worker supplied by adult services was withdrawn due to Mother threatening them when they challenged her about her care of Child M. A note in the file by children's social care senior practitioner commented that they were happy for the case to be overseen by adult services but there is no indication from the adult social care files that this was a joint decision. Since Mother had returned to her own accommodation, a new health visitor was allocated to the family. 4.53 An allegation by Mother of sexually inappropriate behaviour between Father and Child M was discussed between Police and children's social care, and a single agency response by children's social care agreed. This is recognised within the police individual management review as an inappropriate response. The inadequacy of decision making was compounded by an inadequate section 47 enquiry which assumed that because Mother and Father were no longer in a relationship, Child I was safe. This assessment was not revisited when it became known that Father was once more living in Mother’s flat. 4.54 Meanwhile, the health visitor became aware that Child I was often in the sole care of his mother and that Maternal Grandmother was refusing all contact with the health visitor in her area. In fact, it was the health visitor for Child M who referred Child I for speech and language therapy after an assessment in Mother’s home and Mother who was noted to take him to the first appointment. The significance of Child I’s presence was not adequately understood, particularly within the context of increasing concerns about the physical care of Child M. These concerns were noted by both the health visitor and the social worker who carried out a number of joint visits together to the home. 4.55 Mother took Child M to hospital in June 2009 (aged 10 months) concerned that he had tipped cleaning fluid over his legs and hands. Hospital staff were concerned about possible ingestion, although tests did not identify any external signs of either ingestion or contact with a harmful substance. Hospital systems at this point worked well with Accident and Emergency staff accessing previous records, filling in a concern form and alerting the social worker and health visitor. Despite this the social worker did not discuss with their manager or visit for a further two weeks. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 22 of 58 4.56 When the social worker and health visitor visited the home, both Child I and M were there along with Maternal Grandmother, and the health visitor records note that Child I had been staying with Mother for the past month. Hygiene and safety concerns were identified, including batteries and cables lying around and a bottle of bleach propping open a door. The social worker said these would be discussed with their manager although there is no evidence that this happened and equally the health visitor did not follow up to find out the outcome of this discussion. The health visitor did, however, take action to provide additional support regarding home safety through a referral to the community nursery nurse. 4.57 A month later in August 2009 the case was closed to children's social care as part of a “closure project”. These projects are described by children's social care as historical features within Southampton and were used to review ‘Children in Need’ cases to identify those that could be safely passed onto other professionals delivering more preventative services. 4.58 Mother’s case had been closed to the adult social care learning disability team a month previously and there were therefore greatly reduced support services available to Mother, who was living on her own with a 12 month old child. The fact that she had previously been assessed as needing consistent support as a vulnerable adult (without a child) appears to have been overlooked. 4.59 Child I’s case had also been closed two months previously as he was understood to be safe in the care of Maternal Grandmother. Little attention seems to have been paid to the evidence that he was frequently in the care of Mother. Since there was no further children's social care involvement with Child I, when he started at nursery they were unaware of any safeguarding issues, and the fact that he was usually taken to nursery by Mother did not cause any concern. 4.60 Agency response to emerging concerns about the care of Child M (birth to 12 months) This was a period where there was a failure to recognise the experience of Child M, increasing evidence of neglect within the home and indications that Mother was aware that she was not coping. The health visitor was aware that Child I was spending significant amounts of time cared for by Mother but the significance of this information was lost. There was a lack of management oversight within children's social care at key points as well as poor management decisions regarding allowing the case to be led by adult social care and then eventually closed. The fact that closure was part of a “closure project” indicates that practice in this case was influenced by wider stresses within the social care system. Child protection planning for Child M (age 14 - 20 months) and Mother’s pregnancy with Sibling 1. 4.61 Within a month of Child M’s case being closed by children's social care Mother was Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 23 of 58 11 The form used by Hampshire Police to alert other professionals when a child has come to their notice. pregnant. By this time there was not only information about Mother’s history available to the GP but also accumulating evidence about the difficulties she had in parenting Child I and M. This had not been coded correctly within the GP records and was not included in the referral to the midwife. The fact that Father was registered with a different GP practice resulted in no consideration by primary care of the potential relevance of his mental health history to Mother’s pregnancy with his child. Midwives did note Mother and Father’s mental health history at time of booking and alerted the safeguarding midwife, but there is no evidence of proactive liaison with children's social care. 4.62 Whereas failure to engage with antenatal care is known to be a significant risk factor in child abuse cases, this was not an issue in this case. Mother regularly attended antenatal appointments, with 22 contacts being recorded with maternity and obstetric services from the point of booking with third child. 4.63 Mother again took Child M to hospital concerned about ingestion of a toxic substance as he had been found in the cot with Sudocrem on his hands and mouth. Although he was found to be medically well, ward staff were concerned that Child M was unkempt as well as this being the third Accident and Emergency visit within six months. A referral was made to the duty social worker within the hospital who also spoke to the health visitor and a plan was agreed for section 47 enquiries and for children's social care to have daily contact. Planning at this stage appears muddled since there was no strategy meeting, despite mention of section 47 enquiries; the role of the hospital social worker in making plans for discharge without discussion with the manager of the allocated social worker (the allocated worker was on leave) is not appropriate. It is unclear whether the plan for daily visiting was relayed to the allocated social worker. 4.64 In November 2009 Mother made an allegation that she had been assaulted by Father, which resulted in his arrest and return to the Department of Psychiatry. 4.65 At the point that Mother made the allegation Police arranged for Child M to be placed with a neighbour overnight. They were, however, very worried about the state of the home and the condition of Child M. They contacted children's social care emergency duty team at 10.20 pm who agreed that Child M should stay with the neighbour overnight and that the situation would be reviewed in the morning. The emergency duty team worker informed the police officer that children's social care were aware of the situation and were planning to remove Child M. It was the view of police officers at this time that there should be no delay in removing Child M from the home and a comprehensive CYPR11 form was completed and shared with children's social care and relevant health professionals. Despite this effective sharing of information, the police individual management review identified a number of areas where police practice could have been improved, including the fact that no domestic risk assessment took place at this point. 4.66 Following this event Child M spent two weeks with Maternal Grandmother until a “planning meeting” (as recorded in the children's social care and Solent Health records) agreed that he should return home to Mother and there should be a child protection conference. It is unclear what the status of this meeting was as there had Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 24 of 58 12 HM Government (2006) Working Together to Safeguard Children. London: TSO Paras 5.110 & 5.112 still been no formal strategy meeting between police, children's social care and health as would be expected as part of the child protection process. Had such a meeting taken place there could have been a fuller sharing of all available information in order to inform the social work assessment prior to conference. 4.67 A child protection conference was held in November 2009 at which both Child M and the unborn baby were made subjects of child protection plans. There was no midwifery, GP or adult social care attendance at the conference and no evidence that reports were received from these key agencies. Despite Mother not having an allocated social worker within adult social care at this point, the team held important information which should have informed the conference, including their original assessment that Mother was too vulnerable to live independently. The minutes do not show any analysis of the current situation in the light of all known facts including Mother’s history with Child I, her medical condition, and capacity and motivation to change. The health visitor noted that the “only” concern was safety within the home and there seems to be a focus on Father as a main risk factor and an optimism that if this relationship ended risks would be significantly reduced. Whilst this may have been the case, the resulting plan was insufficiently robust in identifying what needed to change to keep the children safe, the timescale within which change should take place, how this change would be measured and the consequences of no change occurring. The social worker, the midwife and the health visitor had tasks which included “monitoring” aspects of care with no clarity about what “good” would look like. 4.68 Child I was not considered at this conference as it was assumed that he was safely placed with Maternal Grandmother. Questions about the time Child I spent with Mother and the quality of his overall care (including failed speech and language appointments resulting in the case being closed by that service) were at no point effectively considered. Failed speech and language appointments should have been a cause for concern, but in this case worries about attendance were not passed on by the speech and language therapist as they were unaware of Child I’s history. This was because there is no place on the referral form to highlight any safeguarding concerns. Child I was noted to live with Grandmother most of the time but the significance of the fact that he was taken to appointments by Mother was lost, as was the fact that he spent time in front of the TV with Mother. 4.69 After the child protection conference it seems that Mother became reluctant to engage with social workers and during December 2009 and January 2010 most social work visits were failed visits. One visit by a health visitor is referred to in the individual management review and there are no visits recorded in the chronology at the regularity agreed in the child protection plan. 4.70 A core group meeting took place two months after the child protection conference rather than within the ten days which was expected practice. The role of the core group set out in guidance at that time was to work as a multi agency group to develop and implement the child protection plan, and monitor actions and outcomes against the plan making any alterations as circumstances changed12. Since the core group meeting was only two days before the review child protection conference it Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 25 of 58 13 Community childminders are commissioned by Children’s Services to provide short term targeted support for vulnerable children. would not have been possible for the group to fulfil its function effectively in making sure that the plan was reducing the risk of harm to Child M and the unborn baby. The meeting that did take place did note a number of concerns about the care of Child M and that Mother was not taking her regular medication, but it did not address failed visits and professionals’ inability to progress the plan. 4.71 Although the review child protection conference agreed that Child M and the unborn child should remain on a child protection plan there is no evidence that the conference chair challenged the lack of progress with the original plan, including the parenting assessment and the implications of this for the safety of Child M and the unborn baby. It is questionable whether the chair should have agreed to the conference going ahead as the social worker was sick and no substitute sent and the only attendees were the health visitor, the agency support worker, a police officer and Mother. The tone of discussion was overwhelmingly positive, based on Mother’s self- reporting and the fact that she was noted to be in a relationship with Father no longer. 4.72 One change to the plan was the addition of community childminding13 for Child M five days a week from 9.00 am – 13.00 pm. (in June 2010 this was extended to 9.00 - 14.30) The child minder was given minimal information about the family and no information at all about the care arrangements for Child I. This is significant as Child I was at times seen by the childminder being cared for by Mother when she dropped Child M off at home. The childminder was unaware of the discussions at the core group meeting (which had taken place the day after child minding started) which had noted that Maternal Grandmother was expecting Mother to look after Child I every day, and that the social worker was to visit and ask for this arrangement to stop. 4.73 The childminder was aware that Child M was subject of a child protection plan and she was diligent in recognising and recording concerns about Mother’s parenting. Concerns identified by the childminder between March and August 2010 included Mother frequently not being there when Child M was returned home, a bump and a bruise on Child M’s forehead, extremely bad nappy rash and rough handling. The childminder alerted the social worker but did not appear to have any structured support systems or pathways for escalating her concerns when she disagreed with the social worker’s comment that Mother would not harm Child M. 4.74 An additional problem with the childminding arrangements was that the procedure for appointing community childminders was that only one month at a time could be contracted. In the case of Child M this meant that there were occasions where the contract was not renewed in time to keep continuity of care. There was a gap of nine days in April 2010 and another of over three weeks in May/June 2010. 4.75 Meanwhile, Mother’s third child was due in April 2010. There appears to have been a lack of proper multi agency pre-birth planning with no documented liaison between the health visitor and midwife, no pre-birth assessment being completed and records showing that Mother was not cooperating with parenting assessments at the family centre. In addition, there was an over-reliance on Mother’s self-assessment, with the social work file noting that Mother had “assessed herself as being capable” to care Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 26 of 58 for Child M and the newborn baby.” 4.76 Summary - child protection planning for Child M (age 14 - 20 months) and Mother’s pregnancy with Sibling 1. During this period the risk of significant harm to Child M was recognised, with the case being managed under child protection procedures. However, there was a failure to use these procedures properly with no strategy discussion being used to plan enquiries at the start of the process and confusion about the role of hospital social workers in making plans. There was a failure to use the core group effectively to implement the child protection plan and assess the effectiveness of the plan in keeping Child M safe. In particular, there was no assessment of Mother’s motivation to change and the implications of her non-engagement with the social worker. Even though Mother was known to care for Child I he remained peripheral in professionals’ minds. He was not considered at the child protection conference and information about him not being taken to speech and language sessions was not considered in terms of impact on his wellbeing. In fact, speech and language professionals were not appropriately involved in the planning process. There is a noticeable failure to work effectively with the childminder and value the important information that she was able to provide. In addition, it is clear that the childminder lacked supervision and support systems that would have enabled her to challenge children's social care. Planning for the unborn baby (who was subject of a child protection plan) lacked focus with lack of communication both within health and across the professional network. Child protection planning for Child M until his death, and action taken in respect of Sibling 1 4.77 When the baby was born (referred to in this report as Sibling 1) a planning meeting at the hospital agreed an extended inpatient stay and when Mother was discharged home the plan was for Maternal Grandmother to stay with Mother along with Child I and M. 4.78 Sibling 1 was admitted to hospital via Accident and Emergency at the age of two weeks for clinical investigation of vomiting and low weight. She remained in hospital for three days and during this time a discharge plan was agreed, which included children's social care visiting three times a week, the health visitor once a week and the agency support worker organised via adult social care visiting daily Mondays to Fridays. 4.79 Following discharge there are records of increasing concerns expressed by the community midwife. These concerns were relayed to the GP whose notes record that the midwife had difficulty accessing the social worker and felt both children should be taken into care. There is record of a conversation between the midwife and the social worker during which the midwife described the environment as a “picture of neglect”. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 27 of 58 The next day Mother took Sibling 1 to the GP with medical concerns, and the GP referred to the hospital who checked the electronic records and noted the presence of a child protection plan. The safeguarding team in the hospital was alerted and the admission discussed with the social worker. Sibling 1 was discharged, well, the next day. 4.80 Subsequent social worker visits observed and noted highly critical parenting in respect of Child M; also adult social care noted that Mother was frequently not in when the support worker visited. 4.81 Eleven days after being discharged from hospital, Sibling 1 was taken to Accident and Emergency by Mother with a rash and diarrhoea and vomiting but was discharged home, well. Subsequent gastro-enterology outpatients’ appointments in June/July/August did not identify any concerns. She was described as ‘well and happy baby, smiling, bright, interactive and handles well’. 4.82 In June 2010 a meeting was held between a senior social worker in children's social care and a locum pupil barrister in the childcare legal team. The legal advice given was that the threshold for commencing legal proceedings had been met and that “a very clear contract of expectations should be drawn up, setting out clear parameters for Mother to meet and ensuring that SCC was not setting mother up to fail” (Legal Services individual management review para 5.2.11). 4.83 The reason for using a pupil barrister at this point was that resources were stretched within the legal team. It is recognised by the individual management review author that it was not appropriate for advice to be given by an unqualified member of staff, although the advice given at the time was sound. 4.84 In July 2010, Mother reported to her social worker that Father had allegedly been sexually abusing Child M. There is no evidence that the social worker discussed this with their line manager or referred to police for a strategy discussion. It appears that Mother was told to contact police herself and did not do so. It is not clear why something so significant was not discussed by the social worker with a manager. The most compelling explanation is that at this time there were severe staffing pressures within the service with a major recruitment drive underway to recruit qualified social workers from America. Information given to this review describes a service in crisis and within this context, the availability of managers (both physically and emotionally) is likely to be limited. 4.85 A review child protection conference took place at the end of July and it was significant that: The social worker reported Child I had been left in the care of Mother most days by Maternal Grandmother. Mother’s allegation about Father earlier that month was not included in the social worker’s report. A verbal report of the results of the parenting assessment stated that Mother was unlikely to be able to care for her children in the long term even with support. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 28 of 58 14 The Public Law Outline refers to the statutory guidance underpinning care applications which came into force in April 2008. It was designed to ensure that cases were better assessed prior to an application being made and through better preparation speed up the court process. The conference was not informed that legal advice had been given about the need to initiate the Public Law Outline (PLO)14 process and in fact the chair’s summary refers to it being “highly likely that legal advice will need to be sought”, clearly indicating that the conference had no knowledge of the previous discussions. 4.86 The same day as the child protection conference, Father and his community psychiatric nurse attended a meeting with the children’s social worker to discuss supervised access with Child M and Sibling 1. Father was noted to be polite throughout the interview and refuted the previous allegation about sexually inappropriate behaviour with Child M (as described in paragraph 4.53). Father and the community psychiatric nurse left the meeting under the impression that supervised access would be arranged and the child protection conference minutes record that the social worker had asked Mother to agree to contact at the contact centre. 4.87 Following the child protection conference a newly qualified social worker was allocated to the case and immediately identified issues of neglect. However, when the contract of expectations was reviewed during social work supervision in August 2010 the manager concluded that since Mother had signed the contract she was cooperating. Twelve days later Mother told the social worker that she would no longer abide by the contract of expectations. This, combined with continuing serious concerns which were noted during social work visits, did not result in a reassessment within children's social care. It is possible that the newly qualified social worker did not feel able to challenge a manager who appeared to have formed a fixed view about this particular case. There continued to be a discrepancy between supervision notes which focused on supporting Mother to care for the children and social work recordings which document significant concerns about the care that the children were receiving. 4.88 The health visitor did not attend the core group at the beginning of September 2010 but they did do a home visit on same day. The reason for this appears to be that they were fitting in a last visit prior to moving to work in new area. A new health visitor was allocated and within two weeks undertook a joint home visit with the social worker. There had been a verbal handover with the previous health visitor and at the time of the visit they were aware of the child protection plan but they had no time to review notes in detail. 4.89 Meanwhile, Child M had investigations by the ear nose and throat surgeon due to concerns that he had a sweet up his nose. The allocated social worker, health visitor and GP were all kept informed appropriately by the hospital. 4.90 At the end of September 2010 Child M, age two, started nursery. The early years coordinator informed the nursery of parental learning difficulties, domestic violence, and the fact that he was on a child protection plan. The nursery was subsequently invited to and attended core group meetings. No concerns were identified by the nursery who described Child M as a ‘normal two year old’. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 29 of 58 4.91 At the same time there was a change of community childminder for Child M. Mother recalls a good relationship with this childminder who cared for Child M until his death. However, despite extensive searching of the records it has not been possible to trace the name and address of this childminder and they have not been able to contribute to this review. It is concerning that there are not adequate records of a resource that was being paid for by the local authority. 4.92 In November 2010 there is evidence from the support worker that home conditions were deteriorating and Sibling, 1 aged seven months, was taken to Accident and Emergency by ambulance at 01.09 hrs on a Friday morning, with a history of vomiting and diarrhoea and episodes of unresponsiveness/floppiness. Hospital notes record that ambulance staff advised Accident and Emergency that the home was clean and tidy. Sibling 1 recovered well and the unresponsiveness/floppiness was thought to be secondary to dehydration from vomiting. Accident and Emergency staff checked the child protection plan and ward staff accessed old records regarding Mother’s learning disability. No new safeguarding concerns were identified and Sibling 1 was discharged home later on Friday afternoon. The hospital social worker, health visitor and GP were advised of the admission and there is also a record of telephone liaison with the health visitor. There is no reference to whether any discussion took place about arrangements to provide support over the weekend. 4.93 The health visitor visited the home the following Thursday but there is no record of a visit by a social worker until the emergency duty team visited the next Sunday, apparently as a result of a telephone call from the agency support worker who had visited on Saturday and was reporting that Mother was not attending to the children’s basic needs and that the house looked like “Armageddon”. The emergency duty team social worker did not visit immediately and the children's social care individual management review author has been unable to ascertain why this was the case. By the time they visited the next day they noted that the house was untidy but not dangerous raising the possibility that the support worker had helped Mother to tidy up. From the information based on the file it was a reasonable decision not to take any further action at this time. However, it is not clear what prior information the emergency duty team social worker had about the family when they visited the house and whether they communicated information about their visit to the allocated social worker. 4.94 The allocated social worker did not visit until the next day, which was over a week after the hospital admission, and this sequence of events raises a possibility that there was ineffective liaison between the hospital social worker and the allocated social worker or that the allocated social worker did not see the hospital admission as a significant event requiring a visit. The social worker noted that no “new” concerns were noted. 4.95 The agency support worker was clearly concerned about the family and having called the emergency duty team on Saturday also called adult social care learning disability team on the following Tuesday reporting that Mother’s engagement was erratic and that Mother did not know or understand that she needed the support to enable her to look after her children. There is no record that this was shared with the allocated social worker in children's social care. 4.96 The following Saturday there was an anonymous call to the Police alleging that Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 30 of 58 Mother was drunk in charge of Child M and Sibling 1. When the Police visited, the children were asleep and noted to be “safe and well” although being looked after by a 14 year old. Police contacted children's social care emergency duty team who found an emergency foster placement, however, this was not needed as Maternal Grandmother agreed to have the children for the night. Despite these being children subject of a child protection plan and a record of concerns the previous weekend, no one from the emergency duty team consulted with the duty manager or visited the family in order to make a proper assessment of the potential risks to the children. Police notification forms in respect of a vulnerable adult were completed and sent to relevant organisations. 4.97 There was follow up by children's social care at a statutory visit on the Monday during which Sibling 1 is described as “ashen” and cold with blue fingers. There was no visit by the health visitor following the police report; the only contact was a telephone conversation between the health visitor and Mother on the Wednesday. 4.98 During December 2010, there are clear indications from Mother that she was feeling unable to cope. She told the social worker that she wanted Child M and Sibling 1 removed and on a separate occasion told the health visitor that she found Child M difficult as he reminded her of his father. There is no record of any liaison between the health visitor and social worker regarding these contacts but records show that the social worker visited and persuaded Mother to keep the children. There is no file note indicating that this approach was discussed with a manager. 4.99 The minutes of the core group meeting held just before Christmas 2010 do mention that Mother was struggling with Child M’s behaviour, the episode where she had been drunk and that she had asked for the children to be removed. However, the information from the health visitor and nursery was generally positive and the focus of the meeting was on organising a support plan over Christmas and New Year. 4.100 On the evening of New Year’s Day 2011(a Saturday) Child M was taken to hospital by ambulance with a possible febrile convulsion. Accident and Emergency staff had noted Child M was on a child protection plan and “slightly unkempt and dirty” and there was little interaction between Child M and his mother. A “concern form” was raised for the allocated social worker, and copied to liaison health visitor for action next working day (Tuesday). Ward staff had no concerns but documented their intention to speak to children's social care emergency duty team on the Sunday. There is no evidence that this call was made. 4.101 The diagnosis made by the paediatrician was possible febrile convulsion or meningococcal meningitis and Child M was admitted, treated and discharged home, well, the next evening (a Sunday). Hospital policy is that in general children are better off in their home environment when well, rather than in hospital where they may be exposed to other illnesses, but in this case a child on a child protection plan was discharged on a winter’s evening with no discussion with anyone from children's social care. 4.102 The day after discharge, Child M was again admitted to Accident and Emergency with another possible febrile convulsion. Hospital notes record that both Mother and Maternal Grandmother were present and it is not clear who was caring for either Child I or Sibling 1 at this point. Child M recovered quickly and chicken pox was diagnosed. He was discharged home fit and well with Mother’s agreement at 02.35 Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 31 of 58 15 A rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child. Working Together to Safeguard Children (2010) Para 7.1 am. Accident and Emergency staff again raised a “concern form” for children's social care and for the liaison health visitor, since it was a second attendance in three days. Again, there is no evidence of any direct liaison between hospital staff and social workers from the emergency duty team before discharge. 4.103 In the early hours of 6th January 2011 Child M was taken to Accident and Emergency by ambulance in cardiac arrest and was declared dead at 04.00. He was two years four months old. At this point the Child Death Rapid Response Protocol15 was activated in order to plan next steps. 4.104 Child I and Sibling 1 were both admitted to hospital at the instigation of hospital staff for paediatric sibling medical assessments. Sibling 1 remained in hospital because of bronchiolitic cough and plateaued weight and discharged the next day. 4.105 Summary - child protection planning for Child M until his death and action taken in respect of Sibling 1 During the nine months leading up to his death Child M was subject of a child protection plan yet there is little evidence of any coordinated action to reduce the risk of continuing neglect. This was also a feature of work with Sibling 1. The main practice issues during this period were: A failure to act on the legal advice that the threshold for intervention had been met and to advise members of the child protection conference that this was the case. An inexperienced social worker identifying concerns and not discussing these with her manager, possibly due to unavailability of the manager or because she felt she would not be heard due to the manager’s overly optimistic view of the case. A newly allocated health visitor without full knowledge of the background due to not having had time to read all the records. A pattern of significant events at the weekend which either resulted in insufficient action by the social care emergency duty team or children being discharged from hospital at a weekend without adequate consideration of the potential impact on Mother’s capacity to care for them. Events following the death of Child M until the death of Child I 4.106 At the point of Child M’s death, in accordance with the rapid response protocol, a Detective Inspector from the Child Abuse Investigation Team took charge of the police response and in conjunction with the doctor who had been looking after Child M, examined his body and requested other appropriate examinations to be completed. Both Mother and Maternal Grandmother were interviewed and the children's social care emergency duty team contacted. An initial assessment of the home was carried out that night by a detective sergeant and detective constable in Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 32 of 58 line with the 4lscb rapid response protocol which states that: When a person under 18 dies unexpectedly in a non hospital setting, the police SIO will consider an immediate visit to the scene of the death by a police investigator to assess the scene and to gather information from the scene to enable an early decision to be made as to whether the death is suspicious or not. 4.107 At 8.40 am the detective inspector examined the home; no obviously suspicious circumstances were identified. It is arguable whether at this point it would have been more appropriate to wait for a joint visit with a health professional who would have been available from 9am. This is explored further in paragraphs 5.50-5.56 below 4.108 On 7th January 2011, the day after Child M’s death, in line with child protection procedures, a strategy meeting was convened in order to consider potential risk to other children in the family. This was chaired by a senior practitioner from children's social care who had neither previous experience of chairing such meetings nor previous involvement with the case. It seems that the team manager delegated this task to the senior practitioner without proper consideration being given to the seriousness of the situation or the level of expertise required. The meeting did not have a full picture of the family history since no one attended from children's social care who had worked with Mother or her children. The health visitor did attend the meeting but had not had a chance to fully review the historical records and was only able to contribute information that had been gathered over time from contacts with the family and attending multi agency meetings. She was unaware of the history of problematic relationships between Mother and Maternal Grandmother. The safeguarding nurse from the hospital had gathered information from the GP regarding Mother’s failure to collect prescribed medication since 2009. Since it is known that failure to take this medication can exacerbate symptoms of a learning disability and cause tiredness and low mood it is surprising that the minutes note the consultant paediatrician saying that there was no evidence that failing to take the medication affected Mother’s ability to care for the children. 4.109 The meeting was informed by the police sergeant of recent allegations that Child M had been left outside the home by a busy road and Mother had been seen to kick his backside and slap his bottom. However, the lack of relevant contextual knowledge within the meeting meant that when the police officer told the meeting that these allegations were not pertinent to Child M’s death this was accepted by others without question. 4.110 The decision of the meeting was that the section 47 investigation which had started the previous day could be discontinued as there were no child protection concerns regarding Child M’s death. 4.111 Five days after the death of Child M, a review child protection conference was held in respect of Sibling 1. Child I was not considered at conference and the health visitor report was not used as the chair did not feel it appropriate to do so because information about Child M was included in the report. The plan from the conference was to continue with daily visiting from the agency support worker, bi-weekly social worker visits, regular health visitor visits, childminding and a package of support from adult social care. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 33 of 58 4.112 On 26th January 2011 a phase two child death rapid response meeting was held. Procedures suggest that this meeting should take place within 5 to 7 days of death; this meeting was therefore considerably out of time and there is no reason given for this in the minutes. The meeting noted that no specific cause of death had been identified. The meeting notes also record that both the health visitor and senior practitioner from children's social care commented that Mother “struggled with Child M’s behaviour”. This gives the impression that Child M was somehow to blame for Mother’s poor parenting and is at odds with descriptions from the nursery which noted no behaviour concerns whilst he was in their care. Although it is recorded that children's social care were looking at long term planning with the legal team there is no information in the minutes which accurately describes the level of maltreatment described in the records. Again, it is recorded that Mother had not collected her medication from the GP surgery for over a year and both social worker and the health visitor were unaware of this. This is at odds with other evidence as failure to take medication was referred to in core group minutes in August 2008 and was also commented on within the parenting assessment which concluded in 2010. 4.113 Following Child M’s death attempts were made by the health visiting service to see Child I. Maternal Grandmother, however, did not wish to avail herself of health visitor support saying that she only needed help with housing matters. There is evidence that little consideration was given to the impact of the death on Child I, with the pre school reporting that they were simply told by Mother one morning that “Child I may be out of sorts his brother died”. It would have been more appropriate if professionals had given immediate consideration to the impact on Child I and liaised with the pre school at that point. 4.114 Support was offered at this time to Mother from the learning disability nurse who saw Mother at Maternal Grandmother’s, undertook a comprehensive assessment and put Mother on a waiting list for work to help her understand her medical condition. 4.115 Sibling 1 was taken to Accident and Emergency on 3rd March 2011 with a shortness of breath and discharged home with antibiotics. She was again taken to Accident and Emergency 5 days later unwell and vomiting, having been seen earlier in the day by the GP. The ambulance crew are recorded as expressing concerns about the home (it is unclear which address this was) and there is no further information about the exact concerns as ambulance records are not kept of conversations with hospital staff and no safeguarding referral was made. Sibling 1 was admitted overnight and Accident and Emergency staff left a message with the safeguarding team in the hospital at 00.26 hrs. 4.116 The next morning the ward staff nurse discussed with the social work senior practitioner on site the hospital staff concerns about the appearance of Sibling 1 and the ambulance crew’s concerns about the home. The health safeguarding team further discussed with onsite children's social care, as Sibling 1 was ready for discharge and the allocated social worker off duty. The hospital records note that the onsite hospital social worker and senior practitioner agreed discharge, with allocated social worker follow up. This repeats earlier confusion within hospital records regarding the role that hospital social workers or emergency duty team workers can play in “agreeing discharge”. The hospital social worker is clear that this would not have been her remit and she did not “agree”, yet a conversation between ward staff Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 34 of 58 16 HM Government (2010) Working Together to Safeguard Children 7.29 17 4lscb (2010) Rapid Response Procedures 7.20 and the social worker has been interpreted as such. 4.117 The evening of the next day, Sibling 1 was taken to taken to the Paediatric Assessment Unit as an emergency by Mother on the advice of the community asthma nurse. She was found to have low blood sugar and recovered well. Ward staff were, however, concerned as she was hungry and thirsty on admission and was in dirty clothing. Mother also seemed low in mood. The ward staff alerted children's social care emergency duty team. It is not clear what the emergency duty team did with this information. 4.118 The next day ward staff alerted the hospital safeguarding team who discussed concerns with the senior practitioner in the Children in Need team and agreed to keep Sibling 1 on the ward for a further day to support mother. This meant that Sibling 1 would be discharged home on a Saturday. 4.119 Sibling 1 was duly discharged into the care of her mother the next day, a Saturday. On the Monday the hospital safeguarding nurse contacted the health visitor to inform her of the discharge and that there were concerns that Mother was not coping. The health family support worker called Mother who said she was low in mood but was going to the GP. 4.120 Following the death of Child M, Mother requested a housing move which was eventually agreed. Support was offered by adult social care but Mother was not present when support workers visited, with Maternal Grandmother requesting that only regular support staff should visit and no replacements sent if the usual staff member was on holiday. There is no evidence of regular children's social care visits as would be expected for a child on a child protection plan where there are significant stressors within the family. 4.121 It is unclear how much regular contact Mother was having with Child I but subsequent Police statements are clear that he was in the sole care of Mother when he was rushed to hospital on 1st April 2011 in cardiac arrest. He died on 4th April 2011. 4.122 Summary - events following the death of Child M until the death of Child I There are three relevant issues during this period: firstly the response to Child M’s death, secondly the adequacy of the help aimed at reducing risk of harm to Sibling 1, who was still on a child protection plan and thirdly consideration of the impact of the death on Child I. The child death response was limited by the fact that in within Southampton in January 2011 there was no designated paediatrician for child deaths as required by national16 and local17 guidance. This meant that there was no one in post with the responsibility for coordinating the multi agency response, including out of hours. The implications of this are explored further in section 5 of this report. The plan at this time relied on adult social care to provide support and there is Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 35 of 58 evidence of an appropriate package of help and support being offered. However, there was no evidence of a joined up approach which focused both on the needs of Mother and the care of Sibling 1. The impression from the records is that children's social care “backed off”, probably wishing to be sensitive to Mother’s feelings at this time. The potential for Mother to care safely for Sibling 1 after Child M’s death appears not to have been given adequate consideration at this time. Even though the death was not thought to have been suspicious, at the very least the impact of her child’s death on her mental health and capacity to parent should have been more fully assessed. Practice following Sibling 1’s admission to hospital repeated the previous pattern of discharge home at a weekend as well as lack of clarity regarding the role of hospital social work staff in making decisions about plans for discharge. Child I’s needs remained tangential and there is no evidence that proper consideration was given to the impact of his brother’s death on him or the implications of Mother having unsupervised contact. 4.123 Following the death of Child I there was a further Police investigation into the deaths of both children. Mother was arrested on suspicion of murder and a file submitted to the Crown Prosecution Service who recommended “no further action”. This decision was challenged by Hampshire Constabulary and the case was therefore reviewed by an experienced senior crown prosecutor. They took into account the finding-of-fact in the concurrent care proceedings which had decided that on the balance of probabilities the Local Authority had failed to establish that Mother had deliberately suffocated Child I and Child M although she was responsible for significant acts of neglect. In the light of this, as well as thorough review of all the evidence and consideration of existing case law, the decision was made that the prosecution would be unable to prove a criminal case beyond reasonable doubt and there was therefore not a realistic chance of prosecution. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 36 of 58 5. THEMATIC ANALYSIS OF PRACTICE ISSUES 5.1 This section of the report focuses on areas of professional practice that have emerged from the case history as being in need of improvement. The analysis aims to explore the link between the practice issues and outcomes in this case as well as why this was the practice at the time. Understanding why events occurred has, however, been hampered in this review by the historic nature of the case and the fact that many staff at all levels of seniority (particularly in children's social care) are no longer in post. 5.2 An analysis of the case history shows that professional actions to protect Child I and Child M from harm were compromised in 11 significant areas of practice: Working effectively across children’s and adults services to assess the impact of Mother’s learning disability on her parenting capacity. Quality of assessments. Assessments of family carers and confusion regarding the legal status of Child I. Working together with early years providers to assess risk of significant harm. The use of strategy meetings. Using child protection conferences, core groups and child protection plans effectively. Assessing risk at point of hospital discharge. Working with fathers The role of the emergency duty team. The effectiveness of child death rapid response processes. Staff supervision and management oversight. Working effectively across children’s and adults’ services: understanding the impact of Mother’s learning disability on her parenting capacity. 5.3 Mother was known to have a learning disability and congenital health issues as well as experiencing significant trauma as a child; a combination of factors which led to an assessment by the Southampton City Council learning disability team that she was at risk living alone. At this point, prior to her pregnancy, there was good joint working across adult and children’s services and a residential placement was joint-funded by adult social care and the children’s services team responsible fr care leavers. 5.4 Once Mother became pregnant with Child I, it is positive that there was continued involvement by learning disability services provided by both the NHS and Southampton City Council. A wide range of services was provided, including a short term adult family placement for Mother after she had spent a period as an inpatient in the Department of Psychiatry, art therapy and provision of agency support workers. However, roles and responsibilities became confused and children's social care relied on adult services to take overall responsibility for managing the case, rather than the two services planning how to work together. Working effectively together should have led to a clear plan for making sure that there was a focus on Mother’s Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 37 of 58 18 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J., Black, J. (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can we Learn. London DCSF Research report DCSF-RR023. needs, Mother’s capacity to parent and the developmental needs of each child. The fact that this did not happen meant that neither Mother’s nor the children’s needs were met. 5.5 Knowledge held by one set of professionals should have informed the work of others but too often either the information was not shared or its significance not understood. The information known to the GP, adult social care and the learning disability nurse was not used effectively to plan children’s social work and health visiting responses. For example, the GP notes identify that Mother’s verbal IQ had been assessed as 12 points lower than her performance IQ, information that is not seen anywhere else in the records and should have informed the way in which information was conveyed to her. The speech and language therapist did note the need to take care in verbal communication but there is no reference to this within child protection plans. Mother told the review that she often felt that she was being told what she had to do and did not understand why she had to do it, possibly a result of lack of consideration being given to the most appropriate ways of communicating with her. 5.6 Within the local authority, information sharing should have been possible through adults’ and children’s social workers accessing each other’s case records. However, although there is a protocol in place to allow this to happen when one worker specifically requests access, current staff interviewed for this review were not aware of the protocol’s existence and it is likely that this was also the case during the period of work with this family. Whilst access to records would not have solved all the problems, the fact that sharing is not automatic suggests a culture where a joined-up approach is not the norm. In other local authorities access to records is automatic and consideration of improving information sharing forms the basis of a recommendation within the adult social care individual management review. 5.7 The issue of Mother’s failure to take her regular medication is noted at various points in the chronology and was discussed at care programme approach meetings which were attended by adults’ and children’s health and social care staff. However, this information became lost in the system and was not understood to be significant in relation to her emotional and mental health. Perhaps the GP was the professional best placed to track her use of medication and understand the implications of her failure to take it but they apparently did not understand the significance of information that they held. Not taking the medication would have exacerbated the challenges Mother faced in parenting safety, yet the GP did not raise this as a concern with other professionals, including the health visitor and social worker. 5.8 The lack of effective joint working was most telling in respect of the overall understanding of Mother’s capacity to parent. Once Mother became pregnant with Child I, there is evidence of “interacting risk factors” [Brandon et al (2008)]18 that should have worried professionals. This is where the specialist knowledge held within adults’ and children’s services should have been brought together and understood in terms of risks to the children. Learning disability itself is not indicative of an inability to parent but in Mother’s case this was combined with significant trauma as a child, Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 38 of 58 19 Tymchuk, AJ. (1992) ;Predicting adequacy of parenting by people with mental retardation’ Child Abuse and Neglect 16 165-178 20 Cleaver, H. and Nicholson, D. (2007) Parental Learning Disability and Children’s Needs: Family Experiences and Effective Practice. London JKP 21 Department of Health (2000) Framework for the Assessment of Children in Need and their Families. London: The Stationary Office mental health problems and lack of social support. Research indicates that where learning disabled parents have been abused themselves, have spent time institutionalised or in special education and there is evidence of maternal, emotional or medical disorders, there is a strong likelihood that parenting ability will be diminished (Tymchuk 1992)19. There is no evidence in any agency that this knowledge was used to inform thinking at any planning meeting including child protection conferences. Mother’s own psychological and emotional needs were not adequately addressed once she became a parent and she told the review that there was no one there just for her who would not judge her. 5.9 Additionally, research shows that where there have been concerns about the capacity of a parent with learning disabilities to care for their child, one of the features that distinguishes children who remained safely with their parent from those who do not is the day-to-day presence of another caring adult such as a partner or relative (Cleaver and Nicholson 2007)20 . In this case there was an over-reliance on Maternal Grandmother as a day to day support without adequate consideration of the problematic relationship with Mother going back many years. 5.10 Understanding the reasons for the disconnect between the good understanding that adult social care originally had in relation to Mother’s vulnerability and the failure to recognise risk in children's social care has been hampered by the fact that some workers involved with the family are no longer working within Southampton. However, the following appear to be relevant and are subject of recommendations. 1. Lack of knowledge by professionals in relation to the combined effect of a learning disability, long term medical condition and trauma in childhood on parenting capacity. 2. Lack of understanding of each other’s roles and responsibilities and how to work together where there is a need for a whole family assessment which adequately addresses the potential risks to vulnerable adults and their children. Quality of assessments 5.11 During the period covered by this review, once a child had been identified as a child in need, it would have been a requirement that an assessment was completed using the national assessment framework21. This should have included considering the needs of any unborn children. The importance of this framework was that it prompted a focus on the developmental needs of each child, the parents’ capacity to meet the child’s needs and the potential influences of family history, current relationships and the current environment on their capacity to provide safe appropriate care for the child. The findings from this assessment should have been regularly updated and used to inform plans for each child. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 39 of 58 22 HM Government (2006) Working Together to Safeguard Children London: The Stationery Office Para 5.14 23 McGaw, S and Newman, T. (2005) What Works for Parents with Learning Disabilities London_ Barnardos 24 For example the Parenting Assessment Manual developed by Sue McGaw, See McGaw, S. and Sturmey, P. (1994) ‘Assessing Parents with Learning Disabilities: The Parental Skills Model’ Child Abuse Review 3 36-51 25 DOH (2000) Framework for Assessment of Children in Need. London: The Stationary Office 5.12 Assessments should have utilised information from the multi agency network and completed by a qualified social worker. In this case, there is no evidence that there was sufficient information shared between relevant professionals and the social workers involved with the family did not coordinate an effective multi agency approach to understanding the whole family. This was likely to be partly driven by the case being allocated to either unqualified or inexperienced staff who could not have been expected to have sufficient knowledge and expertise to manage such a complex case. 5.13 There was no assessment before the birth of Child I and if this had been done properly there would have been an understanding of Mother’s vulnerabilities right from the start. This assessment would have considered the information that was known to the GP, involved the midwife and thought about the implications of Mother’s own childhood relationships on her capacity to care alone for a child. The fact that her history and experience as a child was not considered in any meaningful way meant that the implications of Child I being cared for by Maternal Grandmother were never properly considered. 5.14 Government guidance regarding specific issues to be addressed in relation to pre-birth assessments simply stated that the same procedures and time scales should be followed when there are concerns about the welfare of an unborn child22. There was little detailed guidance and in this case nothing appeared to prompt a pre-birth assessment in relation to any of the children. It would have been from this point that the children’s fathers could have been considered and where appropriate contributed to the overall understanding of the situation. 5.15 One parenting assessment was commissioned from the family centre; although thorough it did not use a framework specifically designed for learning disabled parents. The literature suggests that successful work with learning disabled parents involves the use of specialist toolkits that match the parents’ level of understanding (McGaw and Newman 2005)23 and a parenting assessment tailored for learning disabled parents should have been used to inform an overall assessment of risk24. 5.16 The parenting assessment was significant in that it concluded that Mother would not have the capacity to look after her children in the long term. There is no indication that this conclusion informed the overall assessment or plan of work, and from an examination of child protection conference and core group records it seems that its findings were largely ignored. 5.17 The parenting assessment focused on the “parenting capacity” elements of the assessment framework25 but the findings were not integrated into an overall assessment of both need and risk to each child. Where a separate parenting capacity assessment is commissioned in this way, it should be the job of the social worker to integrate the information with other knowledge of the family from others in Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 40 of 58 26 Tymchuk, AJ. & Andron, L. (1990 ‘Mothers with Retardation who do or do not Abuse or Neglect their Children. Child Abuse and Neglect 14 313-323 27 Gabinet, L (1983) ‘Child Abuse Failures Reveal Need for Definition of the Problem’ Child Abuse and Neglect 7 395-402 and Jones, D. (1987) ‘The Untreatable Family’ Child Abuse and Neglect 11 409-420 the network and use this to inform their overall judgement. This did not happen and there is no indication that other professionals challenged the absence of an assessment. It is hard to understand why this was, unless the whole network had developed very low expectations or did not understand exactly what good practice looked like. 5.18 One feature that should have influenced assessments was the clarity with which Mother was saying by her words and actions that she could not cope. On more than one occasion she asked for her child(ren) to be removed and she took Child M to hospital when she had failed to protect him from ingesting harmful substances. There was evidence of deliberate abuse from an early stage and this could have been understood within the context of research available at the time, which indicated that deliberate abuse by parents with learning disabilities is rare but where it does occur it is a very strong predictor of the occurrence of future abuse in the absence of parenting education or support (Tymchuk et al 1990)26. Even where supports are in place the chance of recurrence may be high (Gabinet 1983; Jones 1987)27. 5.19 The child protection conference should have been one place where assessments could be scrutinised and discussed with the family, and gaps challenged. Neither of the two conference chairs was strong enough in identifying this as a significant omission or in questioning the implications of the findings of the parenting assessment. Again it seems that a low standard of practice was accepted as the norm. 5.20 The lack of challenge in relation to the assessment process was most striking within children's social care where no manager ensured that assessments took place and were used to inform decisions. Problems with overall management and supervision were very significant and are specifically addressed elsewhere in the report. 5.21 Due to the passage of time it has been hard to understand the detail of why assessment practice was so poor and why poor practice was not recognised and challenged. In summary, the most likely reasons seem to be: ● Social work staff with insufficient knowledge and experience to carry out the task. ● Lack of understanding across social care, general practice and midwifery regarding the importance of a thorough multi agency pre-birth assessment in situations where a Mother has a high level of vulnerability. ● A tolerance of poor assessment practice within children's social care which extended to a lack of effective challenge by the chairs of the child protection conferences and members of the core group meetings. ● Lack of training and availability of assessment tools specifically designed for parents with a learning disability. The Southampton Local Safeguarding Children Board will wish to be reassured that these factors are no longer affecting practice. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 41 of 58 Assessments of family carers and confusion regarding the legal status of Child I 5.22 The lack of a proper assessment of Maternal Grandmother meant that Child I was placed without any consideration of her parenting capacity or the fact that she had said she did not wish to care for him long term. When it became known that Child I was spending increasing amounts of time with Mother, Maternal Grandmother’s capacity and commitment to keeping him safe was not sufficiently questioned. In addition, Maternal Grandmother’s lack of engagement with health services, including not taking him to speech and language appointments, was not assessed in relation to the impact on his development. 5.23 One factor that contributed significantly to the lack of scrutiny of Maternal Grandmother‘s care was the prevailing assumption that a Residence Order had been granted and Child I was therefore safe with her. The failure to make the Order was a result of a Court process at the time that did not require information from Cafcass about any safeguarding issues, although Cafcass were aware that the local authority supported this application. The lack of formal information regarding safeguarding, the failure of the social worker to respond to the letter from the court and administrative failures within the court system resulted in the failure of the Court to make the final Order. The Southampton Local Safeguarding Children Board will need to be reassured that all these factors have now been addressed and in particular that social workers understand the importance of ensuring that the court has all relevant information when a Residence Order application is made. Working together with early years providers to assess risk of significant harm 5.24 Those providing day to day care for the children in both pre-school and childminding services were those who arguably had the best information about the children. It is noticeable that there is no evidence that they were included as equal partners in the child protection planning process, were given appropriate information that would have helped to understand the whole experience of the child or, most crucially, that they were listened to when they had concerns. This was particularly significant in respect of the first community childminder who told the social worker about serious concerns, but these were not acted upon. 5.25 There is no evidence of effective support systems for the childminder to assist her in escalating her concerns about the children when she remained worried about their safety following lack of action by children's social care. The childminder’s link with NCMA (National Childminding Association) did not apparently include active support and intervention with the local authority in situations such as this. There is no evidence of any role within the local authority such as an early years safeguarding advisor, which could have focused on the safety of children in an early years setting. 5.26 The practice of short term contracting for community childminders may have been in place to ensure that this provision was used appropriately in the short term to target specific needs in vulnerable families. However, in this case the inefficient administration of the scheme resulted in gaps in provision that were not planned and Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 42 of 58 28 HM Government (1991) Working Together under the Children Act 1989 London: HMSO 5.13 and left a vulnerable child without a vital element of the plan that was designed to protect them. Inefficiencies have been further identified in relation to the failure to find any records identifying the childminder who cared for Child M at the time of his death. 5.27 In respect of Child I, the pre school knew nothing of his background, vulnerability and the potential significance of Mother’s involvement with his life. The lack of contact with the pre school was most notable at the lack of information that they were given at the point of Child M’s death. 5.28 The focus on the importance of early help for vulnerable families and the role that early years providers could play in providing this was not well developed during the period of this review. This, combined with inefficient systems within the local authority, resulted in a lack of continuity and marginalisation of a key service. The use of strategy meetings 5.29 Strategy meetings or discussions have been an important part of the child protection process since 199128. Their purpose is to plan next steps where there is cause to suspect that a child is suffering significant harm, and there is an expectation that those involved in the discussions include police, children's social care and relevant others including health professionals. Procedures allow for either a face to face meeting or a telephone discussion depending upon the complexity of the case. However, due to time pressures they may be an understandable tendency to avoid face to face meetings but unless there are effective conference calling facilities this may exclude some key professionals. This is an issue that is not confined to Southampton. 5.30 In this case, there are several occasions where expected procedures were not used in relation to strategy discussions/meetings. There were two ways in which this came about: 1. Police officers thought discussions with social workers were strategy discussions and they were not recorded as such within children's social care. 2. Social workers did not initiate discussions at points where there was clear risk of harm. In addition, there was no recognition that health professionals should be asked to contribute to the discussions that did take place. 5.31 Lack of, or ineffective, strategy meetings resulted in a lost opportunity to bring together the information known to the police, health professionals and social care, assess the level of risk and plan an appropriate response. They would also have provided another forum where there would have been the opportunity for professionals to challenge each other and recognise the lack of any previous competent assessment of risk. 5.32 It is possible that this came about due to the inexperience of the social workers involved and the lack of effective management oversight which underpins so much of Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 43 of 58 the poor practice in this case. Equally, police officers did not challenge the fact that they would not have received any minutes for strategy discussions, or consider the need to ensure that other appropriate professionals were included in the discussion. Again this seems to be a case of low expectations of each other and, in the case of children's social care, a focus on de-escalating concerns. Using child protection conferences, core groups and child protection plans effectively 5.33 Child protection conferences should be the place where all relevant information can be shared and discussed in order to identify whether a child is at risk of harm and what needs to be done to reduce any identified risk. Core groups are the place where professionals and family come together to develop and monitor the effectiveness of the plan that has been developed to protect the child. When this case eventually entered the child protection conference arena there is little evidence that this had a positive impact on the work being carried out to reduce the risk of harm. 5.34 Conference discussions were not always based on the best possible information. The lack of social work assessment has been commented on above and one conference went ahead with no social worker present. Minutes do not note who submitted reports but indicate that although there was generally information from the health visitor and police officers, there was patchy information from other professionals. Midwives attended core group meetings but were not at either of the conferences where there was a focus on the unborn child. Information from the GP was entirely absent from all meetings and this gap was very significant due to Mother’s complex health history. Neither was there specialist input from adult learning disability services until the conference that took place after the death of Child M. Community childminder input was also absent from both conferences and core groups. 5.35 It has been established good practice for many years for parents to be included in child protection conference discussions. Since most children remain with their parents it is important that there is an open and honest discussion about risks and what can be done to reduce the likelihood of harm but this approach is only successful if there is a degree of clarity and honesty about what the concerns are and what needs to change. The conference minutes suggest that in an attempt to be sensitive to Mother’s feelings there was an over-emphasis on positives and little clarity about the concerns. No account was taken of the best way to explain the concerns to Mother; who told this review that this did not understand the reasons behind the tasks she was being asked to undertake. 5.36 There were two different conference chairs involved within the timeframe of this review. Neither chair challenged the significant gaps in information or the lack of progress with important aspects of the child protection plan, such as asking for legal advice. The chair of the initial second and third review conferences was an experienced chair who told this review that conferences at that time were hampered by a lack of good information from social workers, and that chairs could only manage and consider the information that was shared at the conference. It is the view of the children's social care individual management review author that there was probably a reluctance to be too demanding of social workers due to the pressure they were Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 44 of 58 under. In addition, at that time this chair was the only permanent child protection conference chair and was therefore under significant pressure. 5.37 The structure that was being used for child protection plans at that time did not help in focusing on what a safe environment would look like for the child(ren), how this could be achieved and on reviewing progress against expected outcomes. Plans generally focused on tasks to be achieved and included vague references to “monitoring” by health professionals. 5.38 The LSCB will need to be reassured that conference chairs proactively review the information at child protection conferences, challenge and follow up any gaps and focus carefully on whether the child protection plan is making a difference to the safety of the child. In addition, the responsibility of key professionals such as GPs needs to be re-emphasised and their contribution to the conference process evaluated. This is the focus of a recommendation. Assessing risk at point of hospital discharge 5.39 Although hospital staff were conscientious in recognising and recording concerns about Child M and/or Sibling 1, there was little evidence of a systematic assessment of risk involving hospital and community staff when either Child M or Sibling 1 were discharged from hospital. 5.40 Handwritten concern forms were placed in a tray in the emergency department for collection (Monday to Friday) and action by the onsite social work team and liaison health visitor. They were then distributed to all the appropriate professionals in the community. This system inevitably led to some delay in communicating important information. 5.41 The use of concern forms was backed up by conversations between hospital staff and out-of-hours or hospital based social workers. However, at this point there were misunderstandings about the status of this discussion, with hospital staff believing that social work colleagues had “agreed” the discharge arrangements. Neither of the social work teams involved believes that this was the case and that instead; they had merely been informed that the child was being discharged home. This belief is based on an appropriate view that it is not the role of social workers to agree discharge in this way. 5.42 There were instances where the discharge home took place at night or at weekends. One discharge was on Friday afternoon, one on a Saturday, one on a Sunday, one at 00.26hrs and another at 2.35am. Hospital procedures aim to discharge children home as soon as it is safe to do in order to avoid any hospital based infections and promote recovery. However, in this case, the advisability of discharging a child subject of a child protection plan outside working hours and particularly during the night needs to be questioned. Mother told the review that she recalls getting a taxi home during the night and finding this very stressful. There appears to have been no assessment of the stress that may be placed on a mother who was known to be vulnerable and finding it hard to cope, or the delay in social worker and health visitor visits following weekend discharge. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 45 of 58 5.43 The issue of hospital discharge is not subject of a recommendation within the hospital individual management review and there is, therefore, a recommendation within this overview report. The role of emergency duty team 5.44 Children's social care emergency duty team received specific referrals on two occasions. There is no evidence that they checked the extensive children's social care records in order to help in deciding how to respond and, in fact, failed to take their own record of a visit one weekend into account when there was further referral the following weekend. The children's social care individual management review author has been unable to explain why this was, other than this was custom and practice at the time. 5.45 Custom and practice was also that emergency duty team social workers saw themselves as autonomous workers and have said that they were encouraged not to contact duty managers unless there was an issue on which they were unable to make a judgement. As noted by the children's social care individual management review author: This meant that decisions that would have routinely received management oversight during office hours did not receive the same level of consideration out of hours (individual management review addendum report). This is subject of a recommendation within the children's social care individual management review and the Safeguarding Children Board will need to be reassured that emergency duty team services are able to adequately safeguard vulnerable children from harm. Working with Fathers 5.46 The issue of involving Fathers in assessments and plans has been a feature of a number of serious case reviews across England in recent years. In this case, the father of Child I had no involvement with Mother or his child at any point during the period of this review. However, the father of Child M and Sibling 1 was known to professionals and from time to time was living with Mother. Midwives did note the potential risks associated with Father’s mental health problems, but beyond this there was little attempt made to understand the effect of his history, and circumstances on his capacity to parent or the nature of his relationship with Mother. 5.47 The mental health team working with Father only attended the initial child protection conference, sent apologies for the next two conferences and were not invited to the conference held after Child I’s death. There is no evidence that information was sought from them in order to inform any ongoing assessments by children's social care. The professionals working with Mother viewed Father as an additional risk, although the exact nature of the risk was not adequately understood due to the lack of proper child protection investigations when allegations were made about his behaviour. He was, from time to time, known to be living with the family (he was for example present when Child M was taken to hospital in June 2009) and there was a focus on encouraging Mother to end any contact with Father. However, the lack of Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 46 of 58 29 4lscb Rapid Response Procedures September 2010 para 1.2 engagement with Father as the father of the children would have made it difficult to work in any explicit way with Mother to explain the exact nature of the concerns. 5.48 One reason for the marginalisation of Father in this case was that he did not describe himself as part of the family. For example, the Southern Health individual management review noted that: The Assertive Outreach team working with Father did not view Father to be part of the family and they never viewed Mother and Father as a couple with joint caring responsibilities. This was the clear message that Father gave the team during any discussion about Mother or the children. 5.49 Father’s GP surgery also did not understand him to be part of a family unit and the significant information that was known to the GP about Father’s mental health history was not shared with professionals who had responsibility for the children. Equally, this was not sought by others and, had it been asked for as part of child protection enquiries, the GP would have been alerted to Father’s status as a parent. The effectiveness of child death rapid response processes 5.50 The role of child death response procedures is relevant to this review in relation to the response to the death of Child M since this was an opportunity to make sure that adequate steps were taken to protect the remaining siblings. 5.51 The 4lscb rapid response procedures are designed to ensure an appropriate balance between: • The bereaved family’s need for sensitive, empathetic care • The need to identify and preserve anything which might explain why the child has died • The need to conclude investigations expeditiously so that the child’s funeral is not delayed unnecessarily29 5.52 Effective implementation of these procedures is particularly vital where there are surviving siblings whose safety may be compromised if there is a slow or insufficiently robust response and in this case there are indications of problems with the way in which rapid response processes were working within the Southampton area. There were immediate discussions in hospital where a medical management overview meeting was held within a few hours of Child M’s death, police officers were appropriately involved at this point and made an immediate visit to the home. The further visit to the home the next morning by the Detective Inspector at 8.40 am did not include a health professional, as suggested by the rapid response procedures, which state: the purpose of such a visit is to: ....gather information which may provide immediate insight into the cause of death, information which may later prove significant to the coroner/investigation and to provide support and reassurance to the family in their bereavement process. The SIO will be accompanied by the DP[Designated Paediatrician]/senior health care Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 47 of 58 professional or by an assigned healthcare team who will talk with the parents/carers and assess the scene (paragraph 7.30) The procedures go on to say: Should the joint visit be considered inappropriate or professionally not possible in the circumstances, separate visits will be made with the [designated paediatrician] and {senior investigating officer] conferring later to identify all possible factors, from both as medical and police perspective which could have contributed to the child’s death. (paragraph 7.31) There are indications in subsequent meeting minutes that the joint visit did not take place as the police officer did not wish to wait for health staff to be available after nine am and there was no specific provision for a response out of hours. Although there was no designated paediatrician, additional safeguarding nurse specialists had been trained to contribute to the rapid response process during working hours and after nine am there would therefore have been an opportunity for a separate visit to the home by a health professional to take place. There is a need for Southampton Local Safeguarding Children Board to consider adequacy of out of hour’s responses in such situations and this is reflected in recommendations made by this review. 5.53 The strategy meeting the next day, which took place under child protection procedures, provided an opportunity to ensure that effective measures were in place to protect the remaining siblings, but this was not chaired at a senior enough level, it did not consider and analyse all known information about the family and failed to consider the needs of Child I. 5.54 Although, the rapid response process requires a second meeting to take place within five to seven days, this review was informed that this is frequently impossible due to the variability in the timing of post mortems, the release of findings and the availability of relevant staff at short notice. A third meeting within the eight to-twelve week timeframe suggested by the procedures was equally impossible in this case since the final post mortem results were not signed until December 2011. 5.55 An additional factor during early 2011 that also affected the application of procedures was the lack of designated paediatrician for child deaths. This role was originally described in Working Together 2006 and was further refined in Working Together 2010 and has an important role to play in both the commissioning and organisation of services as well as coordinating responses in individual cases where a child has died unexpectedly. Within Southampton until June 2013 where a rapid response was required specialist nurses from the safeguarding team in Solent NHS contributed to enquiries and undertook home visits. 5.56 Since a good response to the unexpected death of a child potentially affects the safety of other siblings, the effectiveness of rapid response processes is an issue for the Safeguarding Children Board. Although this case is unusual due to two linked deaths being treated as suspicious, it is unsatisfactory to have a set of procedures that may, in many cases, be impossible to apply and the need for these to be reviewed is the subject of a recommendation within this report. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 48 of 58 Staff supervision and management oversight 5.57 One aspect of this case that cuts across all the themes discussed above is the lack of effective management oversight and the fact that no one in a senior position challenged the poor practice and drift in this case. 5.58 Several of the reports submitted for this review identify that within individual agencies staff supervision took place regularly (e.g. health visiting service, adult social care and the supported housing project), or that managers at an appropriate level were involved in decision making (e.g. within the hospital and police). Within children's social care the situation is less acceptable, with evidence of social workers being supervised but an absence of consistent management oversight above the level of senior practitioner. As explored above, in relation to the emergency duty team there is evidence that managers were not consulted even though they were available to the staff on duty. 5.59 The quality of supervision that did take place is commented on within the individual management reviews. Whilst much was found to be positive there are indications that in some areas it could have been improved with more emphasis on a detailed analysis of the safeguarding concerns (for example within children's social care and the health visiting service). Within children's social care, the chronology shows that although supervision took place, social workers did not always take their worries about this family to the meeting possibly because of previous experiences where, when they did so, the senior practitioner response was to downplay the concerns. At one point this may have been an unintended consequence of attempts by senior managers to manage workflow through “closure projects”. This is likely to have influenced social workers’ thinking regarding the likely response from managers should they suggest escalating the case to one requiring child protection intervention. There are comments in the chronology about social workers telling the health visitor that they would discuss the case with their manager and then failing to do so; possibly because they predicted that the response would be focused on case closure. 5.60 The fact that this case was allocated at various times either to unqualified or newly qualified social workers did not prompt a style of supervision which allowed for an exploration of the potentially confusing and overwhelming nature of the case and a focus on potential risks to the children. One factor possibly contributing to this situation was the absence of any effective supervision for the senior practitioners themselves, a lack of involvement of team managers in practice decisions and a culture within the department which encouraged senior practitioners to reduce demands on the service. 5.61 In respect of early years providers, the absence of supervision and support for the childminder is commented on above. There is no specific evidence within the prevention and inclusion individual management review that others involved in providing early years services had the opportunity to reflect on any unanswered Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 49 of 58 30 Department for Education (2012) Statutory Framework for the Early years Foundation Stage London : Department for Education questions about the children as well as their own role within this case. It should however be noted that although the need for adequate supervision opportunities in the early years sector became a requirement30, this was not the case during the period of this review. 5.62 The picture that emerges is of a situation where although there was evidence of staff supervision, managers across all organisations were not proactive in recognising poor practice and challenging fellow professionals. This was also the case within the child protection conference where, as discussed above, the lack of proper risk assessment and failure to progress the plan was not challenged. 5.63 Reasons for this lack of challenge are not clear but the most likely explanations are: 1. Lack of knowledge on the part of managers about what good practice looked like. 2. Lack of scrutiny of the decision making of front line managers. 3. Accommodating lower standards in recognition of the demands on the child protection services. It is known that children's social care was going through a very difficult period with high staff turnover including at senior management level. There were also significant capacity issues within the health visiting service in 2010. In such situations there can be reluctance to make yet more demands of over-stretched colleagues. 5.64 The LSCB has in place escalation procedures designed to ensure that where there are concerns that a child is not being protected this is brought to the attention of colleagues in the relevant agency. However, in this case the issue was not whether procedures existed, but rather the ability of managers to recognise poor practice outside their own environment, recognition of their responsibility to bring this to the attention of others and a multi agency culture within which constructive challenge is understood to be a fundamental aspect of effective safeguarding. Southampton Local Safeguarding Children Board will need to be assured that this is now the case. 6. CONCLUSIONS 6.1 This was not a case where the potential for the children to be harmed was hidden. Mother was open about the problems she experienced in coping as a parent and on more than one occasion asked for the children to be removed. The physical abuse of Child I and the neglect experienced by Child M and Sibling 1 were obvious, yet did not prompt the necessary action to protect them from further harm. 6.2 It was assumed that Child I was protected through living with Maternal Grandmother, despite no assessment of the advisability of this arrangement and he slipped from the sight of all professionals. The fact that Maternal Grandmother refused health visiting services, the failure of Maternal Grandmother to take him to speech and language appointments and the time he spent in the sole care of Mother was not questioned. Of particular significance is the issue of the Residence Order which all professionals assumed had been made but we now know was never issued by the Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 50 of 58 Court. Child I was therefore residing with an adult who did not have Parental Responsibility for him and without the safeguards that were assumed to be in place. The inexperience of the social worker and their failure to reply to the Court’s request for confirmation that the Residence Order was supported by children's social care contributed to this situation, as did inefficiencies within the Court system. 6.3 Both children's social care and community health professionals failed to adequately assess the combined impact of a learning disability, trauma as a child and failure to take medication on Mother’s ability to parent. No multi agency pre birth assessments were carried out and the significance of information contained within GP records was not recognised as being relevant to raise with others including children's social care. There was a lost opportunity for midwives to understand the whole picture at the time of all the antenatal bookings as they did not routinely access Mother’s other hospital records. Where there was a change of health visitor it is clear that they did not have the time to review all the notes and were unaware of the complexity of the case history. At no point was all relevant information brought together in order to inform assessments and plans. 6.4 Meeting the needs of vulnerable adults and their children is a challenge and can only be achieved through effective joint working across children’s and adults services. It requires clear roles and responsibilities and the ability to maintain a focus on the family as whole whilst never losing sight of risks involved to individual family members. In this case this balance was rarely achieved. The case was either being inappropriately driven by adult services or their information was not utilised effectively when planning for the children within the child protection arena. The end result was that the assessments carried out in relation to Mother and/or Father failed to inform an understanding of risk to the children. 6.5 Where a parenting assessment did raise concerns about Mother’s ability to parent, this was not taken into account in decision making within children's social care mainly because where social workers did raise concerns with their supervisors, the management message was to minimise the significance of the risks to the children. This seems to have resulted in social workers failing to continue to inform supervisors of all the risks that they were noticing in their day to day work. 6.6 Southampton Children’s Services were in some disarray during the period covered by this review with staff shortages, problems with retaining experienced staff and recognition within the senior management team that there were significant challenges in delivering a safe service. Mother experienced this in terms of a lack of opportunity to form a trusting relationship with a social worker and the staffing problems contributed to the case being allocated to staff lacking in the necessary experience and skills. This combined with ineffective supervision and management oversight at all levels of the organisation led to a situation where there was a lack of clear decisive action to protect the children from harm. 6.7 The problems within Children’s Services were well known across the City and the evidence points to low expectations about the standard of practice by children's social care and a failure across all agencies to challenge both Children’s Services and each other. Where supervision systems were inadequate, such as within child minding services, there was no mechanism to use the support of more senior staff to escalate concerns. Even where individuals had identified risks within their own Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 51 of 58 safeguarding supervision systems these were not escalated via management systems. Low standards therefore prevailed in relation to a number of areas of practice that were not questioned by anyone within the network. Of particular significance were: Strategy meetings that were not always held at key points in time. Where they did occur they did not include all relevant people particularly from health and were not recorded appropriately. Planning meetings in relation to the children being led by adult services under procedures designed to focus on the adult’s needs Child protection conferences that were not always attended by all relevant professionals and did not have all the information needed to make a sound judgement. A failure to complete actions required within child protection plans including taking legal advice. Failure by children's social care to take action where there was a clear risk of harm. 6.8 Whilst there has been insufficient evidence to prosecute anyone and there was an open verdict at the inquest for both children, it has been determined that both children experienced neglect. It is clear from this review that this experience of neglect would have been preventable had all professionals worked more efficiently and effectively together. Children's social care as lead agency did not fulfil their responsibilities and this was undoubtedly influenced by an organisational context where leadership and management was weak, there were staffing shortages and staff were insufficiently equipped with the knowledge and skills to work with complex cases. However equally, they were not challenged by other professionals who appear to have had low expectations and accommodated to a poor standard of practice. 7. RECOMMENDATIONS 7.1 No pre birth assessments were carried out and there was therefore a lost opportunity to analyse all the information known across the professional network and consider Mother’s capacity to parent. Recommendation 1 Southampton Local Safeguarding Children Board should review the use of the 4lscb “maternity services and children’s social care joint working protocol to safeguard unborn babies 2011” and ensure that it is being implemented across Southampton. 7.2 Work with the family as a whole and particularly Mother as a learning disabled parent with complex needs, failed to keep a focus on risk to the children at the same time as providing services to meet the adult’s needs. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 52 of 58 Recommendation 2 Southampton Local Safeguarding Children Board should review the approach across the partnership to “Think Family” and ensure: There is a holistic approach across adults and children’s services to assessment and service provision where a parent has a learning disability and/or mental health problem. It promotes an approach which includes fathers. The effectiveness of the protocol on working with adults with a learning disability. Adequate knowledge and skills in assessing the parenting capacity of adults with a learning disability. Adequate access to records across adults and children’s social care services. 7.3 Although there were concerns in a number of organisations about the failure to adequately address risks to the children, the escalation processes were not used to bring these concerns to the attention of senior managers in children's social care. Recommendation 3 Southampton Local Safeguarding Children Board should promote the use of the escalation procedures as part of the development of a culture where constructive challenge across agency boundaries is understood to be an essential and positive element of safeguarding practice. 7.4 Strategy meetings were not used in line with procedures Recommendation 4 Southampton Local Safeguarding Children Board should evaluate the effectiveness of strategy meetings with particular reference to whether: Face to face meetings (rather than telephone discussions) are taking place when required All relevant staff are included Meetings and/or discussions are recorded in line with procedures. 7.5 The post of Designated Doctor for child deaths is relatively new within Southampton and in addition, there are indications that some aspects the rapid response procedures cannot be consistently implemented. Recommendation 5 Southampton Local Safeguarding Children Board should review the effectiveness of rapid response arrangements in delivering services as set out in the 4lscb protocol particularly where these affect the safety of surviving siblings. The Board should work with the Child Death Overview Panel to develop this service. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 53 of 58 7.6 The child protection conference system did not work well in gathering all relevant information, analysing the level of risk and ensuring that effective plans were implemented. Recommendation 6 Southampton Local Safeguarding Children Board should evaluate the current approach to child protection conferences and ensure that conferences include all those who had relevant contact with the family and the provision of reports from all key professionals. 7.7 Supervision was either absent or ineffective in supporting an analysis of risk. Recommendation 7 Southampton Local Safeguarding Children Board should establish a core standard for safeguarding children supervision and seek evidence regarding its implementation. This standard should: take account of differing governance arrangements, supervision cultures and organisational structures for the delivery of supervision; promote reflection, critical analysis and evidence informed practice ensure that all staff have the psychological and emotional support required for effective decision making in safeguarding children require regular evaluation of the quality of supervision being provided. 7.8 The support available to the child minder in escalating concerns was not effective. Recommendation 8 Southampton Local Safeguarding Children Board should ask Children’s Services to identify a strategic lead for safeguarding for early years services and be assured that there are robust arrangements in place for supporting childminders to escalate concerns if they are dissatisfied with the response they receive from Children's Social Care. 7.9 There was a lack of clarity regarding the role of emergency duty team or hospital social workers in “agreeing discharge” and there was insufficient consideration given to the implications of discharging a child on a child protection plan from hospital outside normal working hours. Recommendation 9 Southampton Local Safeguarding Children Board should seek assurance that Southampton Hospital has adequate systems in place to review discharge plans in the light of all known information and adequately safeguard vulnerable children Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 54 of 58 discharged outside working hours. 7.10 There was a misunderstanding regarding the legal status of Child I due to the failure to finalise the draft Residence Order and lack of information before the court regarding the involvement of children's social care. This led to an inappropriate reliance on Maternal Grandmother to exercise Parental Responsibility and keep Child I safe. Recommendation 10 Southampton Local Safeguarding Children Board should review current practice in relation to Residence Order applications in order to seek assurance that: Any safeguarding concerns are known to the Court Social workers are aware of the importance of responding to requests for information from the Court. Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 55 of 58 APPENDIX A: THE LEAD REVIEWERS AND PANEL MEMBERS Kevin Harrington chaired the Panel of agency representatives which oversaw and challenged the process of this review. He trained in social work and social administration at the London School of Economics and worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has worked on more than 40 Serious Case Reviews in respect of children and vulnerable adults. He has recently been engaged by the Department for Education to re-draft high profile Serious Case Review reports so that they can be more effectively published. Mr Harrington has been involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council, and has undertaken investigations commissioned by the Local Government Ombudsman. He has served as a magistrate in the criminal courts in East London for 15 years Jane Wonnacott was the author of this report. She also trained in social work and social administration at the London School of Economics and qualified as a social worker in 1979. She has an MSc in social work practice, the Advanced Award in Social Work and an MPhil as a result of researching the impact of supervision on supervision practice. She has published two books on supervision and co-wrote with Tony Morrison the national training programme for social work supervisors. Since 1994 she has been the author or chair of many serious case reviews and in 2010 completed the accredited Tavistock Clinic and Government Office London nine day training programme for panel chairs and authors. She has also attended the 2012 Department for Education serious case review training programme. The Panel Designated Doctor NHS Southampton City CCG Designated Nurse NHS Southampton City CCG Detective Chief Inspector, Hampshire Constabulary Team Manager, NSPCC Housing Services Manager, Southampton City Council Service Manager (Intermediate Care), Southampton City Council Named Professional for Safeguarding Adults, Southampton City Council Interim Head of Service, Southampton City Council Children’s Services Manager Southampton Local Safeguarding Children Board (in attendance) Assistant Head of Legal Services Hampshire County Council (in attendance) Kevin Harrington Lead Reviewer and Panel Chair Jane Wonnacott Lead reviewer and report author (in attendance) Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 56 of 58 APPENDIX B TERMS OF REFERENCE Child I and Child M REASON FOR SERIOUS CASE REVIEW This serious case review report is commissioned by Southampton LSCB in respect of two children known in this review as Child I and Child M. Child M died aged 2½ in January 2011 and along with his sibling was subject of a child protection plan at the time of his death. Child M’s half-brother, Child I, died three months later in April 2011 at the age of 4½. He was understood to live with Maternal Grandmother but was in the sole care of Mother at Maternal Grandmother’s house at the time of his death. No charges have been brought in relation to either death, although a finding of fact in subsequent care proceedings did find that both boys had experienced neglect. The inquest into the deaths of Child I and M heavily relied on the finding of fact and resulted in an open verdict for both children. SCOPE Period under review The timescale of the review for individual management review authors is from the date that mother was known to be pregnant with her first child (Child I) i.e January 2006 to the date of Child I’s death on 4th April 2011. Contextual information Agencies are also asked to summarise relevant background/contextual information/key factors/significant events about family that was known or knowable by the agency at the start of the review period. This will include any relevant agency knowledge of : The family background and childhood of the parents and carers of Child I and M and their siblings AGENCIES INVOLVED Hampshire Constabulary Southampton City Council Children’s Social Care Southampton City Council Prevention & Inclusion (including involvement of Children’s Centres and child minders) University Hospitals Foundation Trust Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 57 of 58 Solent NHS Trust Southampton City Council Adult Social Care ( learning disability and mental health services) Southampton City Clinical Commissioning Group / GP Southampton City Council Housing Services CAFCASS South Central Ambulance Service ANALYSIS ISSUES Each IMR author is asked to explore not only what happened but why professionals took the actions they did. Factors that might have influenced practice should be considered including: The nature of the family circumstances including level of complexity, the nature of the issues presented, the way family members interacted with professionals. Individual staff factors including knowledge skills and expertise, previous experiences of similar situations, assumptions that may have driven responses, levels of stress and any relevant personal circumstances. Influences on the effectiveness of inter professional communication and practice including the nature of relationships between professionals (within and across agency boundaries), systems and processes in place to support communication and the impact of status and hierarchy on decision making. Organisational and strategic factors including priorities, resources and quality of guidance Quality of management and team support including the effectiveness of supervision in promoting reflective practice, team relationships, learning and development opportunities. The following should be covered within the report but authors should not feel constrained by these topics and should actively explore any issues that emerge as important influences on practice. a) Was practice child focused e.g. were the children’s wishes and feelings ascertained and given appropriate priority? Was consideration given to what it was like to be a child living in the family? b) Were assessments and investigations carried out and followed up appropriately? This includes the use or not of CAF, initial and core assessments, medical and health assessments, strategy discussions and criminal investigations and any other assessments that should be provided by each agency Jane Wonnacott Independent Reviewer Child I & M Final Report 29.4.14 Page 58 of 58 c) Where formal plans were in place in relation to adults or children in the family were they appropriately focused on outcomes for the children clear in relation to professional roles and responsibilities and revised in the light of new information? d) Following the death of Child M how effective was the professional network in reviewing the implications of this event for work with Child I and his sister? e) Did practitioners have and use appropriate knowledge and professional expertise in relation to safeguarding the children in the family? f) Were communications, within and between agencies, effective in: ensuring that all relevant information was available to support professionals in their respective roles with the family Providing an opportunity for professionals to challenge each other as appropriate? g) Was practice sensitive to racial, cultural, linguistic and religious identity and any issues of disability?: include here also cultural issues relating to the family such as the where the family lived, their lifestyle, environmental and social factors h) Were managers and supervisors appropriately involved in this case and how did their involvement affect the quality of work being undertaken with the family? i) Did any resourcing issues affect the way this case was dealt with? If so in what way and why was this? j) Is there evidence of good practice in the way this case was handled? If so what was this and what factors contributed to enabling such good practice? INVOLVEMENT OF STAFF IMR authors should identify and interview any staff that they feel can add value to the review. This should include staff who have left the organisation whose practice may be referred to in the review and who wish to contribute. It may also be appropriate for the lead reviewers to interview staff but this will be subject of discussion and agreement of the serious case review panel. INVOLVEMENT OF FAMILY Child I and M’s adult family members have been notified that the review is happening. The lead reviewers will be responsible for meeting with family members who wish to contribute to the review. |
NC51236 | Review of the practice and care of several children between 2002 and 2011 in the Isle of Man. Report focuses on learning and does not include details of facts or a chronology of events. Ethnicity or nationality not stated. Good practice identified includes: eventual conviction of the father/foster carers due to the dedication of the police officers involved; prompt safeguarding action when children first disclosed physical abuse which led to their removal from foster care. Learning includes: need for staff to fully understand the behaviours and presentation that is indicative of sexual abuse; need for staff to understand the factors that have an impact on disclosure; importance of multi-agency engagement in all aspects of the child protection process; need for staff to feel confident in working with challenging families; need for professionals and sectors to enhance their confidence and build opportunities to hear the voice of children and young people; importance of professional curiosity and for professionals to respectfully challenge each other. Recommendations to the Safeguarding Board include: review single agency training on child sexual abuse to ensure sufficient focus on the key indicators and disclosure process; provide clarity on the use of professional meetings as a tool in dealing with difficult and complex cases, highlighting the opportunity they provide for multi-agency reflection.
| Title: The learning from a serious case management review. LSCB: Isle of Man Safeguarding Board Author: Lesley Walker Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 The Learning from a Serious Case Management Review Independent Author: Lesley Walker June 2019 2 Introduction In accordance with the Isle of Man Safeguarding Act 2018, which places a duty on the Safeguarding Board to review practice, identify lessons to be learnt and apply these lessons in future safeguarding work in the Isle of Man, this Serious Case Management Review was commissioned by the Independent Chair of the Safeguarding Board, Glenys Johnston OBE, to review the practice in relation to the care and support of several children between 2002 and 2011. The review was led by Lesley Walker an Independent Social Work Consultant with no previous involvement with the Isle of Man or the cases which were the subject of the review. A Review Panel, made up of managers who were not involved in the case, provided oversight and support to the Review, professionals who were not involved with the case provided chronological information and a report of the practice of their agency. Very few practitioners or managers who were involved in the case or practice at the time remain the Isle of Man but in accordance with best practice, meetings were held with practitioners and managers to explore what happens now and what if anything needs to be improved. The reflective and thoughtful contributions of everyone involved in the review, including family members is appreciated by the Safeguarding Board The Review Panel has borne in mind the significant passage of time since agencies were involved with this case and has listened carefully to the views of professionals and available family members. It has examined case records and independent agency reports, has factored in the prevailing cultures and pressures within respective organisations at the time the incidents that led to the review took place and has endeavoured to produce recommendations which are pertinent to safeguarding practice in 2019. . A number of agencies contributed to the Review including the: - • Isle of Man Constabulary • Children and Families Service 3 • Health Service • Department of Education, Sport and Culture Analysis and Learning. The following areas were highlighted by the review as examples of good practice: - • The eventual conviction of the father/foster carer, due to the dedication of the police officers involved. • The referral by the school when the children first made allegations of physical abuse. • The prompt safeguarding action taken to protect the children when they first disclosed physical abuse which led to their removal to foster care. • The initial identification that the father/foster carer’s job brought him into contact with children. The Review concluded that there are a considerable number of lessons to be learnt from the analysis of practice in this case. The following themes emerged and assisted in identifying the key learning: - Recognition of sexual abuse and staff’s understanding of the disclosure process. This Review highlighted that throughout the involvement with these children, there appeared to be a lack of understanding about indicators of sexual abuse. There were lots of concerns about the children’s presentation and behaviours, that even without the disclosures they made, warranted an in-depth look at their family situation. Incidents were seen in isolation and there was a failure to put the information together, to develop a comprehensive picture of the children and their family. Even when direct disclosures were made by the children no longer living in the family, there was sometimes little or no follow up in relation to the allegations and no protective action taken in respect of the children who remained at home. These failures were compounded by the fact that the early physical abuse allegations were so poorly dealt with, including returning the children home, that it left the children with no confidence about the ability of statutory agencies to protect them. 4 There was also a lack of understanding of thresholds for intervention. The view was taken, that if a criminal case threshold was not met, then there was insufficient evidence to take any further action. Children and Families should have been assessing risk on the balance of probabilities and acted to protect the children, which is distinct from the police’s consideration to charge and prosecute an offence. In addition, there appeared to be no knowledge that disclosure is not a simple or straightforward process and does not usually occur as a one off but that for many it is a journey. Assumptions were made that because some of the children had not disclosed directly, that abuse could not have occurred. The NSPCC commissioned research of disclosures of childhood abuse “No one noticed, no one heard” published in 2013, highlighted that on average it takes seven years for a young person to disclose sexual abuse. The young people in the NSPCC study desperately wanted someone to notice something was wrong. They wanted to be asked direct questions and wanted professionals to investigate sensitively but thoroughly-this finding was supported by the Review. Key Learning A. The need for staff to fully understand the behaviours and presentation that is indicative of sexual abuse. B. The need for staff to be aware of the factors that have an impact on disclosure and how best to support and facilitate this. Multi-agency engagement in the protection and planning for children and young people in need of safeguarding. This historic Review identified very poor engagement on a multi-agency basis in both identifying and assessing the issues and risks to the children in this family. Very significant improvements have been made to practice in the Isle of Man over the last number of years and the Review Team and professionals, gave significant reassurance in relation to the robustness of current practice. However, this Review provided all the agencies with an opportunity to challenge themselves and each other about whether any improvements can be made in respect of multi-agency engagement that would keep children safer. Those involved identified that attendance at and information provided to Core 5 Groups could be improved. Also, greater clarity about the use of professional meetings was needed. It was also recognised that there is an excellent opportunity to reinforce the key changes brought about by the Safeguarding Act 2018, as the regulations have now been approved. The Act confers duties to co-operate with the Safeguarding Board and safeguarding bodies and imposes a duty on relevant safeguarding bodies to safeguard children and vulnerable adults. These duties provide an opportunity for a renewed focus on how the agencies work together, understand each other’s roles and build enhanced trust and engagement in their day to day work. The Board needs to use data and audit to provide assurance that multi-agency safeguarding practice is effective and in line with policies and procedures. Key Learning C. The importance of multi-agency engagement in all aspects of the child protection process, particularly core groups and Section 46 Investigations. D. The necessity of using professionals’ meetings, where necessary, to allow open and honest discussion in complex cases. Working with challenging families. There is no doubt that the staff working with the parents in this case faced significant challenges. There are numerous references and very significant evidence of the difficulties, including aggression, continual challenge, refusal to co-operate and clear blocking of attempts to engage or speak to the children. Unfortunately, as in other cases there is clear evidence the staff became caught up in this and lost focus on the children. The Care Plan presented to the court that recommended a non-continuation of the Care Proceedings and stated that; “due to a lack of engagement by the parents it has not been possible to gain any insight into family life or family functioning and not possible to complete the core assessment because of this”. Despite this, no further action was taken, and the case was closed. This missed opportunity set the tone for all the other engagement with the family, where 6 the blocking, withdrawal and challenge kept agencies at arm’s length and ultimately allowed the abuse to continue. During this Review, it was generally felt that the context and training currently offered in the Isle of Man, did provide a strong base for staff but it was helpfully identified that, “the tool box to deal with the issue of work with challenging families, is not complete.” Whilst, the work recommended earlier to improve the effectiveness of core groups, which develop and deliver the child protection plan, would provide an opportunity for a more supportive multi-agency structure, that would assist joint working and challenge in difficult cases, more specific guidance for staff in dealing with uncooperative and hostile families was felt to be required. This would need to be backed up by appropriate training. Key Learning E. That opportunities exist to challenge fixed mind sets through reflective supervision or other supportive conversations particularly when dealing with challenging families. F. The need for staff to feel confident in working with challenging families and that current policies, procedures and guidance exist to guide and support their work. Evidence of the voice of children and young people in all work. Sadly, there was little evidence of the children’s voices being heard or proactively sought in this case. There was little evidence, of any professional trying to build a meaningful relationship with the children, that could have led to disclosure or a clear view about the realities of their life at home. This was despite many issues and indicators of abuse being recorded by professionals, which raised serious concerns about their welfare. The failure of social workers to speak to the children was a missed opportunity to gain information about the realities of their lives. Culturally in the Isle of Man, the child’s voice is now embedded in all work currently carried out by social workers and significant input and resources have been put into direct work with children. The police also reflected the importance of this and feel it is fully embedded and reflected in all their work. It was felt that other professionals and sectors may not feel as confident in 7 eliciting the views and feelings of children and young people and this could be built into the work required from the learning identified in relation to children’s disclosure. Key Learning G. The need for all professionals and sectors to enhance their confidence and build in opportunities to hear the voice of children and young people in all aspects of their work and record this accurately. Professional curiosity and challenge across agencies There was also a lack of “professional curiosity” in significant aspects of this case and very limited challenge both within and across agencies. Again, agencies were very open in reflecting on the culture in their own organisations at the time, they recognised there was generally little challenge of officers or senior managers and this also applied to the lack of action or direction of travel in the case. All agencies described a very different position within their organisations today, with clear whistleblowing policies in place. Moreover, they highlighted the improvements including the Safeguarding Board’s Multi-Agency Escalation of Concerns Policy and the Resolving Professional Differences in Safeguarding Policy - Multi Agency Reflection Discussion process that has given them permission and confidence to escalate cases and providing them with formal routes to challenge each other. The lack of clarity in relation to the use of professional’s meetings as a useful tool to discuss complex cases, has been highlighted earlier and merits further exploration by the Safeguarding Board on a multi-agency basis. Key Learning H. The importance of “professional curiosity” and the role of all professionals to respectfully challenge each other, when concerns are evident. Robustness and awareness of the Safeguarding Board’s Managing Allegations Strategy Meeting and Complex Abuse Procedures. 8 In 2011 it was recognised that the father/foster carer, had access to children and young people within his job role and the potential risks relating to this were highlighted. However, due process was not followed and a Managing Allegations Strategy Meeting for a person working with children was not held, therefore his employers were simply informed of the allegations and the matter was left for them to deal with. Equally, further allegations that ultimately led to the father/foster carer’s conviction, did not trigger a referral for a Managing Allegations Strategy Meeting nor the Complex Abuse Procedure. Police in another jurisdiction did complete follow up enquiries in relation to his fostering status but this did not lead to any other convictions. It is important to highlight that this failure did not, according to any information held by any agency lead to any abuse of children or young people, with whom he had contact outside of the family home. However, the importance of using the safeguarding Board’s Managing Allegations Strategy Meeting and the Complex Abuse procedures and having the relevant meetings to consider potential risks and actions is clearly critical in such cases. The Review has highlighted that there is a lack of joined up understanding and agreement in relation to the operation of these procedures; therefore, these need to be reviewed on a multi-agency basis. Key Learning I. All staff need to have a clear understanding of the policies and processes, that relate to allegations against people working with children and where that abuse is “complex”, to ensure tight multi-agency investigation. Conclusions The agencies involved in this case were extremely reflective of practice and what has and needs to improve. It is to the credit of agencies in the Isle of Man, that the Safeguarding Board commissioned this Review of this historic case and used it to reflect in depth, on their current practice and use the learning as an opportunity to challenge themselves, in relation to how they can further improve current systems and practice. 9 The fact a Safeguarding Board now exists, with an Independent Chair who is directly responsible to the Council of Ministers and that its operation, is embedded in legislation and regulation, demonstrates the commitment of the Government to oversee and improve safeguarding on the Isle of Man. Its role; to co-ordinate work to protect and safeguard children and to ensure the effectiveness of that work and the Chair’s role to constructively challenge the agencies ensures oversight of necessary improvements. Due to the historic nature of the case, it needs to be recognised that very significant improvements have already been made to safeguarding legislation, structures, culture, procedures, processes and practice. This has been also been backed up by single and multi-agency training and more robust governance and assurance systems across all agencies. It was not the role of this Review to provide assurance that the changes are robustly embedded on a multi-agency basis and the Safeguarding Board should consider how it wishes to seek assurance in relation to this. Recommendations The following recommendations were agreed as the best way to address the key learning from this review. The Safeguarding Board should :- 1. Review its training strategy, to ensure that there is sufficient focus on multi- agency training that engenders effective practice between agencies particularly focussing on professional curiosity, effective professional challenge and reflective supervision. 1a. All agency representatives on the Safeguarding Board should review their single agency training on Child Sexual Abuse, particularly to ensure sufficient focus on the key indicators and the disclosure process. 2. Review their current training on recognising and responding to child sexual abuse and ensure there is clear understanding about the process and conditions for disclosure. 10 2a. In respect of the Isle of Man Constabulary and the Children and Families’ Department they should develop a joint working protocol for child protection inquiries. 3. Provide clarity on the use of professional meetings as a tool in dealing with difficult and complex cases, highlighting the opportunity they provide for multi-agency reflection. 4. The Board should consider how to seek assurance, that multi-agency practice is of a high standard, through enhanced audit and data, provided directly to the Board. In particular, the robustness of Sec 46 investigations and attendance and information sharing at Child Protection Conferences and Core Groups. 5. Consider developing a protocol for working with challenging and hard to engage families, that ensures staff remained focussed on the child. 6. Review the Managing Allegations Strategy Meeting (MASM) and Complex Abuse Procedures in conjunction with the Office of Human Resources and relaunch and promote how and when to apply them. End of report |
NC049096 | Circumstances around Child N becoming a looked after child at the age of 7. Child N was the fourth child within a sibling group of six children born to the mother (MN) and father (FN). Aged 3 Child N was removed from nursery in an intimidating and threatening manner by FN when he felt that the Early Years Lead was interfering with his family. Health visitors felt that FN was aggressive on a visit to the family home and left under threat. Three years later MN contacted the police when FN physically assaulted an older sibling of Child N. Following this all children were placed in foster care and disclosed physical, sexual, emotional and psychological abuse. FN and MN are both under public law investigations for the abuse against the children. The family was known to Trafford Council, Pennine Care and Greater Manchester Police. Identifies learning lessons in relation to multi agency working maintaining the child as the focus. Recommendations included: focused outcomes and plans for children, the value of multi-agency working, undertaking a thematic audit on working with violence and aggression and developing a strategy to hear the voice of a child for children subject to multi agency procedures.
| Title: Serious case review report: Child N. LSCB: Trafford Safeguarding Children Board Author: Trafford Safeguarding Children Board Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. TLSCB SCR ‘N’ (MAY 2016) 1 Serious Case Review Report Child N This report will be published in line with statutory guidance. In order to preserve the anonymity for the children in this family, the author has: • used initials to represent people • made no reference to the gender of children • avoided the use of exact dates • not used any details about local services which could lead to recognition of the children and family TLSCB SCR ‘N’ (MAY 2016) 2 Contents 1. The circumstances which led to a Serious Case Review 2. Methodology, Scope and Terms of Reference 3. Parallel Proceedings 4. Overview of what was known to Agencies 5. The Family Perspective 6. Context in which professionals were working 7. Analysis 8. Learning Outcomes 9. Recommendations TLSCB SCR ‘N’ (MAY 2016) 3 1 Introduction 1.1 This Serious Case Review (SCR) concerns Child N who became Looked After by the Local Authority at the age of 7 years. Child N was the fourth child within a sibling group of six children born to the mother (MN) and father (FN) over a period of nine years. 1.2 Aged 3 years, Child N commenced a nursery school which was part of a primary school attended by Child N’s older siblings. Child N was considered to be a timid and somewhat withdrawn child and the Early Years Lead staff member quickly identified Child N as vulnerable. In order to support Child N, and, noting that MN was pregnant with a sixth child, the nursery offered a full time place rather than the more usual part time hours. By the end of the first term, the Early Years Lead had concerns about Child N’s development and had observed a lack of warmth towards Child N by MN. Shortly into the second term, Child N was removed from the nursery by FN in an act that was intimidating and threatening to those present because he considered that the Early Years Lead was interfering within his family. 1.3 Shortly after this incident, a visit to the family home was made by a Health Visitor and Nursery Nurse from the Health Visiting service. This visit was made outside of the core heath visiting programme in order to follow up on the primary visit for Child N’s youngest sibling and to discuss Child N’s needs. During this visit, and with children present, the Health Visitor and Nursery Nurse experienced FN as extremely angry and aggressive when Child N was discussed and the professionals had to leave the house under threat. The incident was reported to the Police and to Children’s Social Care. 1.4 A Strategy Meeting was convened and following an Initial Assessment, it was agreed that a period of social work intervention was required as the children were identified as Children in Need. Over the following six months, a Core Assessment was completed and four social work visits were made before the case was closed to Children’s Social Care. The Trust providing Health Visiting services communicated to FN and MN that no further health care professional would be visiting the family home and that MN could attend clinics for child health services whilst FN was not permitted to attend any Trust premises. 1.5 A three year period elapsed with the children accessing universal education and health services. Child N was 7 years old when MN contacted the Police and stated that FN had TLSCB SCR ‘N’ (MAY 2016) 4 physically assaulted an older child of the family. When Police attended the property, MN further disclosed that she had also been subject of a sexual assault by FN and he was taken into police custody. The Police Officer attending the property noted that all the children were up late at night and that the house was unkempt and untidy. The Officer applied a vulnerability coding to the recording of the visit so that the Public Protection Investigation Unit (PPIU) would be made aware of the circumstances. 1.6 Initially, the children remained in the care of MN, but over the course of the following week, evidence emerged through a range of sources that MN also had culpability for the harm that the Child N and the siblings had suffered. All of the children were removed from her care and public law proceedings were initiated. 1.7 Once placed in foster care, Child N and siblings made many disclosures about their life with MN and FN, and it became evident that they experienced physical, sexual, emotional and psychological abuse throughout their childhoods. The extent and forms of abuse are shocking and the children lived through highly damaging experiences in a family where fear and control was used to isolate the children from opportunities to connect with, or confide in people outside of the family unit. 1.8 The case was referred to Trafford Local Safeguarding Children Board (TLSCB) for consideration as to whether a SCR or a Learning Review should be undertaken. From information known at that time, it was considered that Child N had been seriously harmed by an adult and there was cause for concern about the way in which local professionals and services had worked to together to safeguard and promote the child’s welfare. The crux of the determination was the fact that a period of multi-agency working had occurred following an incident from which the family home was considered to be too unsafe for health professionals, but had been determined as safe for the children. 1.9 There was no dissent to the decision to recommend to the TSCB Chair that a serious case review was appropriate. TLSCB SCR ‘N’ (MAY 2016) 5 2 Methodology 2.1 Working Together 2013 requires that Serious Case Reviews are conducted in a manner which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what, and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way that data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. 2.2 The TLSCB appointed an Independent Reviewer to facilitate the Review, and a Review Panel of senior officers representing the agencies that had been involved with the family was established. This included: • Director, Safeguarding and Professional Development, Trafford Council • Head of Service, Pennine Care • Safeguarding Development Manager, TSCB • Designated Nurse Safeguarding for Children and Children in Care • Designated Doctor Safeguarding for Children and Children in Care • Detective Sergeant SCR Team, Greater Manchester Police • Early Years Foundation Stage Consultant, Trafford Council • Senior Tutor, Trafford College 2.3 The Review Panel did not set rigid Terms of Reference from the outset, instead, the Review identified the key issues as they unfolded through scrutiny of professional practice. Each agency submitted a timeline of interventions at the start of the Review and this was chronoIated to illustrate the multi-agency activity, who knew what and when. In addition, each agency completed a brief agency report which addressed the key issues emerging from the single agency timeline of interventions. The general timeline for the Review covered from 2011 to 2015, the period of time from Child N commencing nursery to becoming Looked After TLSCB SCR ‘N’ (MAY 2016) 6 in the care of the Local Authority. Agencies were asked to provide any pertinent information in relation to Child N and the siblings prior to this period. 2.4 In line with statutory guidance, the Review Panel wanted to adopt an approach that involved practitioners directly and at the heart of the Review, to understand this case and the general practice issues that emerged from the practitioners perspective, but also to maximise the opportunities for reflection and learning. A multi-agency practitioner’s event was planned to review this case, however, shortly before the planned date, new information emerged through the police investigation that meant bringing practitioners together could have been detrimental to a new line of criminal enquiry. For this reason, practitioners were seen individually to talk through their recollections and reflections of the case. This information was considered by the Review Panel and from this, the following lines of enquiry remerged: 1. To what extent was the significance of family history identified and appreciated; 2. To what extent was the approach to Child In Need robust and complaint with expected standards of practice; 3. To what extent was Child N and siblings the focus of multi-agency work; 4. To what extent was multi-agency working characterised by trust and/or challenge; 5. What contributed to the circumstances by which MN and FN could disguise a degree of compliance that satisfied agencies that the children were safe in their care? 2.5 Given that this Review was examining practice that took place some four years ago, the Review Panel considered it important to build in the opportunity to establish across agencies the extent to which the findings in relation to practice and the systems that supported it were reflective of current experience. To this end, the Independent Reviewer held two seminars to discuss the issues that emerged from this case, one with a multi-agency group of practitioners and one with a multi-agency group of senior managers. This proved to a very useful exercise in contextualising what can be learnt from this SCR in order to enhance current practice. TLSCB SCR ‘N’ (MAY 2016) 7 3. Parallel Proceedings 3.1 The Review was mindful throughout of two concomitant processes. Firstly, Child N and siblings were subject to pubic law proceedings within which the children’s ongoing therapeutic needs were identified in line with plans for permanence. The Review Panel understood this to be an anxious time for the children, and therefore considered any plans to consult the children as part of the Review would need to take place once they felt secure about their future. 3.2 Secondly, a complex police investigation was ongoing. Whilst FN was charged with serious offences against Child N and sibling children early into the process, during the Review significant new information emerged about MN which led to her becoming a suspect of investigation, with the possibility of co-charges with FN. This created additional complexity in the timing of criminal proceedings which are incomplete at the time of this report. 4. Overview of what was known to Agencies 4.1 In 2010, aged 3 years, Child N began attending a Nursery School which was integrated with the Primary School attended by Child N’s three older siblings. The Early Years Lead was keen that Child N accessed maximum support as Child N was identified as needing additional support to aid social development and speech and language. For this reason, and knowing MH to be pregnant with a sixth child the Early Years Lead extended the core offer of a part time place to a full time place. Through observations during the first term, the Early Years Lead developed a concern that the relationship between MN and Child N lacked warmth and noted an occasion at the end of the first term when MN was asked to collect Child N because of illness, MN was angry and stated there was nothing wrong with the child. 4.2 Child N was removed from Nursery shortly into the second term. The Early Years Lead had invited a representative from the local Sure Start programme into Nursery to talk about what support was available locally. On this day, because MN was in hospital with the recently born sixth child, it was FN that attended the Nursery with Child N. FN was described as having dragged Child N away from the Nursery setting once he was made aware that a Sure Start representative was present to speak with parents. FN stated that he would not have people TLSCB SCR ‘N’ (MAY 2016) 8 interfering with his family and would not allow Child N to attend the Nursery again. The Early Years Lead was alarmed and somewhat surprised by FN’s reaction, and informed both the Primary School Head teacher (also the Designated Safeguarding Lead) and the Health Visitor of what had occurred. The Early Years Lead was particularly concerned that Child N needed the support of Nursery and although Child N never returned to Nursery, the Early Years Lead recalled occasions when she would see MN in the school playground and try to encourage Child N’s return. 4.3 S5, the sixth sibling was born with a blockage to the bowel that required surgery at a regional children’s hospital. This necessitated a lengthy period in hospital whereby MN remained at the hospital leaving FN to care for the five children at home. 4.4 After receiving the information from the Early Years Lead, the Health Visitor made a home visit accompanied by a Health Care Assistant. This was a primary visit following the birth of S5, but the Health Visitor also wished to discuss the health and development of Child N. During the visit, Child N was said to be asleep upstairs and therefore was not seen and FN remained upstairs throughout the visit. MN told the Health Visitor that Child N had attended a speech and language walk-in clinic as well as a hearing and eye appointment with no concerns. It was noted that the health needs of S5 placed additional pressure on the family. 4.5 The Health Visitor returned to the family home approximately three weeks later accompanied by a Nursery Nurse to give advice about S5 and to discuss Child N further. The Health Visitor had checked records between visits and found that Child N had attended audiology, attended an initial appointment with an orthoptist but did not attend the follow up appointment, but no record could be found of Child N attending a speech and language assessment. This visit was unannounced and initially only MN was in the home with the children; FN returned to the home part way through the visit. When the Health Visitor said she needed to discuss Child N, FN suddenly became verbally aggressive, shouting and swearing and was extremely upset that the Health Visitor was suggesting there was anything wrong with Child N. FN said he was sick of the Early Years Lead contacting the Health Visitor about Child N’s development and there was nothing wrong. The Health Visitor attempted to speak to both parents; however, FN continued to shout, initially with the baby in his arms before passing it over to MN. FN’s manner became quite erratic, darting in and out of the room and behaving in an intimidating TLSCB SCR ‘N’ (MAY 2016) 9 manner. The Health Visitor tried to talk to FN and asked him not to shout, reassuring him that her interest was the children’s health. FN responded by saying that the Health Visitor was there to see the baby and not Child N. When FN walked out of the room, the Health Visitor took the opportunity to ask MN if she wanted any further appointments for Child N which MN declined. FN said that they had finished with everyone and would not be taking the children to further appointments. At this point, the Health Visitor and Nursery Nurse considered it safest for all concerned if they left the premises. As they were leaving the Nursery Nurse heard FN say if you come back here I will ‘blade’ you. 4.6 The Health Visitor and Nursery Nurse returned to the office shaken by the incident and were concerned that in trying to end the incident safely the children remained in the house. They had noticed that although Child N and two younger siblings were present, none of the children flinched at the incident and appeared to react as though this was a common occurrence. With support from a Line Manager, a referral was made to the Police and to Children’s Social Care first response MARAT Team. As decision was taken to initiate an investigation under Section 47 Children Act 1989. 4.7 The Police took statements from the Health Visitor and Nursery Nurse and established that FN had a criminal record which included dishonesty, offences against the person and public order. The Police spoke with FN who stated that the Health professionals had misheard him and denied that he had made any threats; FN said that he had said that if they returned be would ‘blame’ them. The Police established that no physical violence was used and there was no charge from this incident as Public Order offences are only relevant if committed outside of the house, therefore FN had not committed any offence and was not liable for arrest. FN was warned about his behaviour. The attending Police Officer recorded the incident and applied a vulnerability coding to his written report. The Officer noted concern that children had been present during this incident, that FN had five children already in care and that from his observations all of the children appeared under nourished and sad. The vulnerability coding meant that the incident was picked up the PPIU, the Sergeant of which was co-located in the MARAT team with Children’s Social Care. TLSCB SCR ‘N’ (MAY 2016) 10 4.8 A home visit was undertaken by two social workers from the MARAT Team three days after the referral was made. FN, MN and the children were at the family home. FN repeated that the health professionals had misheard what he said but agreed that he did shout but not swear because he believed the Health Visitor was too intrusive. FN stated that he had also removed Child N from Nursery School because he was unhappy that Sure Start were becoming involved. FN told the Social Worker that he had five older children from two separate relationships, that one child was adopted and one child in a residential home from his first relationship and two children adopted from the second relationship. The Social Worker looked around the house including the children’s bedrooms and spoke with the children in the presence of FN and MN. FN was advised to follow up health appointments for Child N and locate alternative Nursery provision if he was not agreeable to a return to the current Nursery. 4.9 Within ten days a Strategy Meeting was held. Fulsome minutes of this meeting indicate that: • FN had previously had an aggressive outburst in the Nursery in front of all the children. For this reason two health professionals visited the home together • FN had said that he had already had children taken away from him and it wasn't going to happen again. FN was described as shaking and shouting • During the incident in the home, the children were present but very quiet even when FN became very angry and loud they did not flinch, move, or look at him. Although S4 was woken up by FN shouting the child did not react • A similar referral was investigated four years earlier of FN shouting and making threats to the children • Police records indicate one previous referral of domestic abuse and also that FN was convicted on an assault to a neighbour’s child seven years previous • That FN had agreed he was angry during the incident but denied swearing or making threats • FN agreed with the Social Worker that Child N could return to the same Nursery. The Description of Child N by the Early Years Lead raised concerns about health and development. Although Child N attended Nursery School for one term, the child did not speak TLSCB SCR ‘N’ (MAY 2016) 11 at all for the first half term and speech and language was described as very limited. Child N was described as very subdued and withdrawn spending most time alone. The Early Years Lead recalled the incident in school when as soon as she mentioned Sure Start, FN started to swear and shout and became very intimidating pacing in and out of the room and into the personal space of staff. The Early Years Lead said that the speed with which FN switched from being a reasonable adult to being a threatening and aggressive individual without any apparent trigger was shocking. It was noted that all of the children in Primary School had good school attendance and were well presented, they were described as polite and engaged in conversations. From a health perspective the following issues were noted: • S5 had been re-admitted to hospital which placed additional pressure on the family. There are concerns about slow weight gain • S4 was referred to the GP but was not taken because growth and weight were below 0.4 – 2nd centile at the 32 week check. The Health Visitor made a further assessment with minor improvement noted but S4 was not taken to child health clinics for monitoring and assessment as was advised and was overdue immunisations • Child N was referred to the paediatrician at the 32 week check for a small head circumference. Child N saw a Paediatrician at hospital but did not attend 2 appointments for a Griffiths development assessment with the community paediatrician. A 2 year assessment was completed with height and weight stable on 0.4 and 2nd centile. The health Visitor identified concerns at a 3 year speech and language assessment and referred for speech therapy, orthoptist and audiology. There was no evidence of attending speech therapy or follow up to an initial orthoptist appointment. • S3 failed an orthoptist test in 2010, and when the orthoptist rang the family home, MN shouted at the orthoptist and refused to re-attend the clinic. S3 did attend a later appointment for spectacles • S2 height and weight on 25th centile. No outstanding health issues • S1 height and weight below 2nd centile. No outstanding health issues TLSCB SCR ‘N’ (MAY 2016) 12 4.10 The Strategy Meeting concluded that FN’s anger issues appeared to have increased since the birth of S5, and that MN presented as low and depressed. It was agreed that MN and FN would be encouraged to work with a multi-agency plan at Child In Need however, if the parents refused to do this, than an Initial Child Protection Conference would be convened. 4.11 Within Children’s Social Care, the case then transferred from MARAT to a locality based Area Team. There was a significant gap from transfer to allocation and several failed attempts to visit the family which meant it was ten weeks before a further social work visit was made to the family home. The case was allocated to Social Worker 2 (SW2) who wrote to FN and MN to make introductions. FN contacted the office irate and a third social worker (SW3) made the first home visit on the day of receiving the telephone call. In the intervening period, S5 had been discharged and re-admitted to hospital with dehydration, and FN had been sent a letter by Pennine Care NHS Foundation Trust advising that he was not permitted to enter any Primary Care Trust premises and that the Health Visiting service would continue to be offered at a clinic base or children’s centre with the children accompanied by MN alone. S4 did not attend for a scheduled 2 year developmental assessment. 4.12 The first of four social work contacts at the family home was made by SW3 who responded to the phone call by FN. During the visit it was established that S5 was in hospital with MN and that FN was finding it difficult to cope with the five children at home. FN said he had been offered support from neighbours and an after school club but did not want to be seen as not coping for fear of losing the children. FN told SW3 that he had lost two sets of children and was fearful the same thing would happen again. SW3 discussed the incident with the Health Visitor and FN repeated that he had not sworn or threatened anyone but did not like what the Health Visitor was saying. FN said that MN would be really angry that he had met with SW3 and initially asked that SW3 did not tell MN. SW3 advised that this was not appropriate and both spoke with MN by telephone. The children were seen playing around the house and garden, they were recorded as chatty and interactive with SW3 and well presented. The meeting concluded with SW3 encouraging FN to accept the available offers of support and to contact SW3 if he wished for further discussions about help. S5 was discharged approximately two weeks later with support from the Community Nursing Team. TLSCB SCR ‘N’ (MAY 2016) 13 4.13 A Core Assessment is recorded as completed by SW2 three weeks after the first home visit. The Core Assessment is mainly generic in respect of all six children, but does state that MN and FN will take Child N to speech therapy even though they do not agree it is necessary and will ‘in all likelihood’ permit Child N to return to the Nursery School. The Core Assessment places a lot of emphasis on the impact of S5 being hospitalised, and also on the limited observations of Child N from one visit presenting as happy and growing in confidence. This somewhat dismissed the concerns of the Early Years Lead gathered over the course of a term. The assessment outlines that FN has parented five previous children some of whom have been adopted, all of the information on this matter was self-reported by FN. The assessment concluded that MN and FN were meeting the needs of all of their children but would benefit from ongoing support through Child in Need procedures. 4.14 A second, unannounced visit was made to the family home by SW2 and SW3 five weeks later however the social workers were not permitted access to the family home. FN was in bed and shouted at the social workers through the window to go away. FN said that he was going to move to the family to Wales to get away from them. 4.15 The first Child in Need Meeting was held three weeks later, five months after the precipitating incident. This meeting was attended by SW2, Health Visitor, Primary School Head Teacher and the Community Nursing Team. In the intervening period, S5 had been discharged from hospital with a nasogastric tube for additional feeding but missed a subsequent appointment with the Paediatrician. Child N did not recommence Nursery or access speech therapy and S4 had not had a 3 year developmental assessment. FN and MN were invited but did not attend the meeting. The minutes of this meeting record the following issues: • That the older children were attending school and were well presented • There is little co-operation from FN despite stated intentions • That MN was disputing the frequency that S5 required weighing according to the hospital discharge plan • That Child N is due to start reception class after the summer break • That whilst in hospital with S5, MN had made allegations to ward staff of domestic abuse by FN TLSCB SCR ‘N’ (MAY 2016) 14 • The Health Visitor expressed a view that the children were like ‘frightened rabbits’, the Head Teacher disagreed with this, describing the children as quiet but not withdrawn. The meeting concluded that FN would be asked to meet with SW2 and the Team Manager to outline the necessity of working together. 4.16 The next record made by Children’s Social Care is of supervision between SW2 and the Team Manager. Contrary to the minutes of the Child in Need meeting only three days earlier, the record indicates that FN was engaging and agreeable to fortnightly visits for three months and that the children are presenting well. 4.17 A third planned home visit was made by SW2 one week later. During this visit, FN agreed that his aggression gets him into trouble and stated that he had previously attended an anger management course. It was agreed that FN would provide the Social Worker with names of professionals that he had been involved with in relation to his previous children. The children were seen during this visit playing about the house and MN and FN were described as attentive to their needs. The Social Worker discussed the possibility of entering into a restorative justice process with the health professionals, FN said although this would be difficult he was prepared to try. The Social Worker advised that further visits would take place over the following two months. Three weeks later, and with no additional inputs the case was discussed in supervision between SW2 and the Team Manager and it was recorded that a further Child in Need Meeting should take place to plan the closure of the case. 4.18 The second and final Child in Need Meeting was held two weeks later, seven weeks after the first. In the intervening period, as well as the second social work visit to the home, S5 had the nasogastric tube removed but was not taken to the one year developmental assessment. The second meeting was attended by SW3, Head Teacher Primary School and MN. The minutes of the meeting stated that Children’s Social Care had offered the family a schedule of fortnightly visits to monitor and support and that during these home visits concerns were discussed with both parents and all of the children were seen. It was documented that MN and FN had engaged with services, were meeting the needs of the children and that the children were thriving. On this basis it was agreed that the case would be closed to Children’s Social Care after two further visits. TLSCB SCR ‘N’ (MAY 2016) 15 4.19 Four days after this meeting, a fourth home visit was made by SW3. FN advised SW3 that he had been given medication by his GP to help him relax which would be reviewed after one month. The GP had no knowledge that the children were identified as Children in Need. FN was advised that the Primary School Head Teacher was happy to make himself available to FN when he needed to talk. S4 and S5 were both at home and seen by SW3 whilst the other children were in school. SW3 advised one further visit would be made before the case was closed. A date was scheduled for this visit but it did not happen. Two weeks later, the Health Visitor was advised during a telephone discussion with a Social Worker that the case was being closed, the Health Visitor reminded the Social Worker about the outstanding developmental assessments and immunisations which the Social worker agreed would be communicated to FN and MN in writing. Two weeks later a letter of closure was sent to FN and MN by Children’s Social Care. 4.20 The Health Visitor subsequently left a telephone message reminding the parents of S4’s developmental check. MN returned the call and stated that they would not be attending for the developmental check for S4 and that S5 was being followed up by the hospital so they would not be attending appointments for S5 either. MN was described as rude on the telephone, hanging up when the Health Visitor tried to explain why the checks were important. Following this, the School Nurse tried to engage the parents in follow up audiology appointments for Child N but they were non co-operative. 4.21 Five months after the case was closed to Children’s Social Care the School Nurse discussed concerns about Child N with the Primary School Head Teacher. The School Nurse believed that a Paediatric overview of Child N was necessary and the Head Teacher agreed to speak with FN alone, concerned that he would not react well to this suggestion from a health professional or within a meeting. FN stated that he was told by a Paediatrician that there was nothing wrong with Child N, and that the child would catch up over time because of being born prematurely. 4.22 Over the following years, children’s health service made continued attempts to engage MN and FN in a preschool health programme without success. S4 did not attend Nursery but went straight into reception class. The children did continue to attend the Primary School and the Head Techer worked carefully with MN and FN to ensure the children were able to access the TLSCB SCR ‘N’ (MAY 2016) 16 opportunities and extra-curricular activities. On one occasion S5 was taken to accident and emergency with an arm injury, the parental explanation was that a fall from a chair onto a carpet had taken place. One another occasion the School contacted MN and requested that the children be treated for persistent head lice. When arriving at school, MN banged on the office door and upon seeing S4 poured the lotion over the child’s head stating ‘there it’s done now’. 4.23 No further episodes of multi-agency interventions or significant single agency interventions occurred until MN contacted the police when Child N was 7 years old. 4.24 Through subsequent disclosures it is now believed that Child N was exposed to sexual abuse during the period that the multi-agency professionals were working with the family. 5 The Family Perspective 5.1 The Review Panel was keen to involve family members in the Review, firstly to explore the day the day lives of Child N and siblings, but secondly to seek information from FN and MN about how they experienced working with agencies and individual professionals. Their perspective is seen as particularly important to understanding the circumstances within which the professionals around the children accepted the family was functioning well when the opposite is now known to be true. 5.2 Due to the continuation of the criminal investigation, the Police, following consultation with the Crown Prosecution Service advised that speaking with FN, MN or any of the children should be scheduled only after a criminal trial had taken place. The Review Panel intends to seek consultation with FN and MN once the criminal trial is completed. 5.3 The Review Panel gave careful consideration to the possibility of involving Child N or siblings in the Review either directly or by consultation through professionals working closely with the children. The Panel was however mindful that that children are experiencing a period of change and adjustment and refocussing on past events was not considered to be in their best interests at this moment in time. Once the criminal trial is completed, consultation will take TLSCB SCR ‘N’ (MAY 2016) 17 place with professionals and carers around the children to consider how best to advise them of the Review. 5.4 To the best knowledge of this Review, there are no other family members who were involved with the children during the period of Review. 6. Context within which Professionals were working 6.1 The social work service was structured in such a way as that referrals were made to a front door service MARAT (multi-agency risk assessment team). This team undertook Initial Assessments and cases would be passed onto area social work teams if a threshold was met for continued intervention. This meant that the plan for intervention would be determined within the MARAT team prior to allocation within the area social work team. The area social work team that received this case was a fully staffed patch based team that held cases under both Child Protection and Child in Need categories. The social workers generally held a mixed caseload of both thresholds. Child N was allocated to a newly appointed Social Worker, a Social Worker with substantial post qualification experience but with a differing client group of young people. The Social Worker had never previously undertaken a Core Assessment and working with younger children and assessing risk within a familial setting was a new area of work. The team had a culture of co-working, and this case was co-worked between the allocated Social Worker and the Team Senior Social Work practitioner although this is not reflected in records. 6.2 In 2011, the Health Visiting and School Nursing teams were located within Bridgewater Community Healthcare NHS Foundation Trust in co-located teams. The practitioners worked within the policies and procedures of that Trust, this included Lone Working, Violence and Aggression and Health and Safety. From April 2013 the functions moved to Pennine Care NHS Foundation Trust. 6.3 A Serious Case Review was completed by Trafford in 2012 (Child MLK). This Review considered the approach to working with Children in Need during the same period of time at this current review and made the following recommendation: Trafford Safeguarding Children’s Board must take immediate steps [1] to implement its Children in Need policy fully and [2] consider what continuing organisational support is necessary to ensure that implementation is and remains TLSCB SCR ‘N’ (MAY 2016) 18 effective. This Review has drawn some similar conclusions about the effectiveness of Child in Need arrangements and drew together current practitioners and managers to establish the extent to which changes as a result of the precious SCR have been effective and maintained. 6.4 The school attended by Child N and siblings has a catchment area that incorporates a relatively high level of need. The school takes a highly nurturing approach to the children and regularly works with a range of children’s agencies as part of multi-agency plans around children. 7. Analysis The examination of single and multi-agency working leading up to the precipitating incident of this Serious Case Review has identified several aspects of single and multi-agency learning alongside some significant reflections about how judgements were applied at key points of interventions. The analysis is structured around the key lines of enquiry and endeavours to use the findings about practice of four years previous as a mechanism to review aspects of current single and multi-agency practice. 7.1 To what extent was the significance of family history identified and appreciated 7.1.1 Good quality assessment is the underpinning foundations of successful interventions with families and children in need. Effective targeting of interventions can only be achieved by understanding the complexity of current family functioning which is acutely influenced by past family experiences. Shortcomings deriving from the absence of key information, and the impact this has on the reliability of the analysis of strengths and risk in families can lead to compromised decision making for children and leave children exposed to risk and danger. 7.1.2 When Child N commenced Nursery school, the family was known to the school as the older siblings attended primary education at the same site. The Early Years Lead quickly identified that Child N was a vulnerable child, the observations being that Child N was somewhat isolated from peers, was shy to the extent of being withdrawn and tended to play alone. The Nursery was keen to support Child N, and as an expression of this offered a full time Nursery placement to support Child N’s development. The Nursery Head was therefore taking a measured and methodical approach to getting to know the family in order to best support the child. This TLSCB SCR ‘N’ (MAY 2016) 19 approach was thwarted when FN refused to let Child N return to Nursery when he concluded that the Nursery were ‘prying’ into his family life. At this time the Early Years Lead was suspicious about the reasons for FN’s behaviour and contacted the Health Visitor as the only other professional with access into Child N’s life at that time. The Health Visitor diligently followed up the work of the Nursery with FN and MN and this led to the aggressive exchange which ultimately led to the referral to Children’s Social Care. 7.1.3 From the first Strategy meeting it was documented that FN had children from two previous relationships that he had no contact with, some of whom had been adopted. In terms of assessment and family functioning this was highly significant information, firstly because adoption is the highest form of intervention in family life and in general occurs only when birth parents are assessed as unable to safely parent, and secondly because it meant that FN had a substantial history of working with professionals which led to the loss of his older children. Records indicate that FN was open about his history with professionals and cited this as a reason why he reacted aggressively for fear of losing his third family of children. 7.1.4 A DFE Research Brief in 2011 Social Work Assessments of Children in Need: Messages from Research, identified five areas that were found to be repeatedly problematic at that time; differential thresholds, failure to engage the child, inadequacies in information gathering, short comings in critical analysis and shortcomings in inter-professional working. This Review illustrates how all of these factors were a feature of the work around this family. 7.1.5 All professionals from Children’s Social Care, Health, Education and Police were aware that FN had children previously adopted, and this Review has found it quite remarkable that despite this, the facts were never established with the Local Authorities who initiated the interventions and therefore any information that was known was accepted at face value when self-reported by FN. This issue was discussed with all professionals as part of this Review. The Chair of the Strategy Meeting and SW2 both readily acknowledged the significance of this information and reflected that a firm line of enquiry should have been to follow up this information with the Local Authorities concerned. SW2 considered that the reason this did not happen may have been because of her inexperience in child care matters at that time and a lack of understanding TLSCB SCR ‘N’ (MAY 2016) 20 of the significance of adoption in the life of a father as much as a mother. The Chair of the Strategy meeting is an experienced manager who agreed that this information became lost. The passage of almost five years between the meeting and the Review means that any real memory of the meeting is limited, but the Review Panel, taking into account the reflections of practitioners, considered that a number of factors may have influenced the decisions of the Strategy Meetings to conclude the enquiries without establishing all relevant history. These included the fact that relatively speaking FN did not have an extensive criminal history (although he did have an offence against a neighbours child), that FN’s older children were significantly older and would have been adults, that that Primary School gave positive reports of the older children in school and potentially a belief that a Health Visitor is less seasoned and able to cope with an aggressive incident than a Social Worker would be. 7.1.6 The Head Teacher and School Nurse both recalled that there was a gap in establishing the family history because the social workers had not made contact with the Local Authorities who were previously involved with FN, and the Police Officer agreed this should have raised questions that required concrete answers. It is apparent that the absence of this information is perceived as an oversight by Children’s Social Care, but this also raises the fundamental principle that every agency must take responsibility for safeguarding and offer constructive challenge to key agencies were there is discontent or dissent. 7.1.7 In contrast to the reflections of other professionals, SW3 told the Review that it would not be expected that historical information was pursued with another Local Authority in a case that had a Child in Need status. The view of this social worker suggested that children were receiving a two tier service, and that a case with a Child in Need status would not have the same safeguarding standards applied as a case that had met the threshold for a Child Protection Plan. Whilst the practitioners meeting spoke about the constant pressure of time to dedicate to individual cases, they were also clear that cases that fell within the Child in Need category could potentially have greater risk than those managed under a Child Protection Plan because the risks may well be less exposed and articulated. In general terms, the practitioners were extremely clear that safeguarding standards applied to all cases consistently and that it TLSCB SCR ‘N’ (MAY 2016) 21 was a function of their role with a family to access all available sources of information to triangulate the evidence in analysis. 7.1.8 The views of SW3 are particularly significant as SW2, a then inexperienced worker, was looking to SW3 to provide mentorship and guidance. The Core Assessment was completed after the first home visit to FN and before any work had taken place with the family. The Core Assessment followed the Assessment Framework but was superficial and generalised. In the case of Child N, the assessment was not informed by a clear articulation of child development or by the information available from an experienced Early Years practitioner. To this end the assessment concluded that Child N’s needs were being met when the child’s developmental and socialisation needs had been severely compromised by being removed from an Early Years education setting with no alternatives considered. The management oversight of this case did not identify the deficiencies of the Core Assessment or that SW2 needed additional support to complete such an assessment for the first time. There is a sense that the assessment was little more than a document that needed to be completed rather than the key to working with a family in need. 7.1.9 The Review has been keen to establish what practitioners understood of the reason why this case met the threshold for a Child in Need allocation. SW2 recalled that the brief was to achieve FN’s ability to work with other agencies and this would account for the reason the home visits seemed to focus on establishing and seeking to understand FN’s vulnerabilities rather than those of the children. An Ofsted thematic inspection, In the Child’s Time: Professional Responses to Neglect (2014) found that nearly half of the assessments in the cases considered did not take sufficient account of the family history and did not adequately convey or consider the impact of neglect on the child. Some assessments were found to focus almost exclusively on the parent’s needs rather than analysing the impact of parental behaviour on children. In this instance, the lack of clarity about the reason for intervention was compounded by an acceptance of self-reported information by FN and MN. This approach paved the way for the parents to maintain a position of non-compliance, they received no challenge about the missed health appointments or the impact of Child N not attending Nursery school. TLSCB SCR ‘N’ (MAY 2016) 22 7.1.10 The Review would go as far as to say that FN manipulated the professionals around the family, he directed professionals away from his family through a range of behaviours: - by being aggressive, by being charming, by being avoidant and by paying lip service to what he knew professionals wanted to hear. It was apparent that during the period of intervention led by SW3 several professionals empathised with FN as a man with a wife and poorly baby in hospital struggling to look after the five remaining children in the family alone. It may be in this context that another piece of significant information was missed by professionals, that being that MN had disclosed to nursing staff that she experienced domestic abuse perpetrated by FN. Despite this being reported in the first Core Group meeting, the issue of domestic abuse was never discussed with either FN or MN, meaning that any potential impact on the children was never assessed. During the conversations with practitioners, several described MN as having limited intellectual capacity, it was also known that the relationship formed when MN was an older teenager and FN was twenty years her senior. 7.1.11 Examination of the issues in the case show several aspects of family history that required deeper exploration within a Core Assessment. These included: • A history of substandard parenting by FN when he reported that his children were placed for adoption against his wishes • A history of poor engagement with child health services • FN’s history of aggressive behaviour evidenced by a conviction for the assault of a child. Behaviour towards two sets of professionals in different settings, and a police attendance at an incident of domestic abuse • MN disclosing the presence of domestic abuse within the relationship Specifically historical and current issues that gave rise to safeguarding concerns were identified within the multi-agency working processes, but there was a significant deficit in the appreciation why the issues were so significant in understanding the family functioning and the impact this had upon the individual children of the family. These issues were not subject to rigorous assessment because there was an absence of clarity about why the case met the threshold of Child in Need and this impacted greatly upon a lack or purpose or desired outcomes to be achieved. TLSCB SCR ‘N’ (MAY 2016) 23 7.1.12 The practitioners meeting advised that since the period covered by this Review, two key changes have occurred; the introduction of a single assessment which replaced the Initial and Core Assessment, and the introduction of a transfer meeting between the key professionals in the case when it moves from MARAT to an area team. This professional’s only meeting allows dedicated time to think and reflect on the issues of the case so that the reasons and focus of intervention are clearly articulated. Currently, it is a requirement that a single assessment is completed prior to transfer of a case from MARAT although it was recognised that this could become problematic if the receiving team did not revisit and update the assessment during the longer term interventions. The MARAT is a busy intake team with a need to process work in an efficient manner in order to respond to the incoming referrals. This means that in reality, the completed assessments are more likely to address the issues of crisis rather than provide the depth of exploration one would expect in longer term work with a family. The locality social work teams are also under pressure of competing demands for time, so it is important that the social workers and managers ensure that assessment is not simply seen as one off activity completed prior to transfer, but as part of a dynamic process of engaging and working with a child and family. 7.2 To what extent was the approach to Child In Need robust 7.2.1 Trafford LSCB had a comprehensive Child in Need policy and procedure which is underpinned by a commitment to placing the child at the heart of a multi-agency plan around the child. This has been strengthened and developed since the multi-agency practice examined within this Review. Without doubt, the approach to managing this case as Child in Need was weak and compromised by the lack of clarity about the purpose of intervention as well as poor adherence to multi agency processes and a lack of challenge between agencies. 7.2.2 It is expected that every child subject to a Child in Need process would have a Plan that is bespoke to their needs. Within this family of six children, the Child In Need Plans were not appropriately individualised, and this was significant as to how the particular needs of Child N became overlooked. Child N was the fourth child of the sibling group, and whilst reports of TLSCB SCR ‘N’ (MAY 2016) 24 school attendance, presentation and attainment were generally positive for the older three children, the same was not true for Child N. Child N was described by the Nursery teacher as timid and withdrawn and observations suggested a lack of warmth from MN. The Core Assessment and Child in Need Plans addressed the needs of the children collectively and this approach resulted in the specific needs of Child N being overlooked because the older children were reported as having no difficulties in the primary school setting. 7.2.3 During the period of multi-agency planning, two Child In Need Meetings were held. As this case was not formally co-worked by SW2 and SW3, their respective roles in the case were not clarified. The two meetings were chaired by different social workers and overall it is difficult to get a sense of continuity. The first meeting was attended by representatives from health, school and SW2 with no parent present and the second was attended by the school, SW3 and MN. The first meeting identified significant concerns about the level of parental engagement in the plan and the impact of this on the children, yet only seven weeks later with only one visit to the family in between, the second meeting recommended that the case was near ready for closure to Children’s Social Care. This was on the assertion that following a schedule of fortnightly visits to the family home, MN and FN had engaged with services, were meeting the needs of the children and that the children were thriving. In reality, four visits had been made to the family home over a seven month period, one of which FN refused entry to the social workers, attendance at medical appointments remained an issue of concern and Child N had missed six months of early years education. 7.2.4 The limitations of the Core Assessment and Child in Need Plans impacted upon the purposefulness of the Child in Need meetings, there are minutes of both meetings which indicate a lack of focus on the plans for the children and what the professionals were seeking to achieve for Child N. This contributed to the two meetings drawing very different conclusions without any additional progress other than Child N starting statutory education. 7.2.5 The meeting with practitioners discussed in some detail the current approach to multi-agency meetings for Children in Need. It was agreed that the convention of multi-agency meetings around the child are a common occurrence, however, it was also suggested that the purpose TLSCB SCR ‘N’ (MAY 2016) 25 of the meetings and desired outcomes were clearer for children subject to a Child Protection Plan. The sharing of Child in Need Plans as a common approach to working towards change with families was described as inconsistent and this may be because there is a perception that child in need is predicated on voluntary engagement whereas Child Protection is referred to as the statutory element of the work. The Children Act 1989 placed a statutory responsibility on Local Authorities to provide services to children in need, with the need for protection being a part of that continuum. In recent years, diminishing resources and pressures on workloads has resulted in a tendency to raise thresholds for intervention as a means of rationing resources and this means that it is children and families with substantial problems that become known to Children’s Social Care. The difference between Child Protection Plans and Child in Need Plans is often as simplistic as the parent’s willingness to engage in the plan and work towards change and the presence of additional resilience factors for children. What may be perceived differently by professionals is the level of independent scrutiny and oversight through the Independent Conference and Reviewing service that is more commonly associated with Child Protection Plans. In 2013, following the SCR of Child MLK, Trafford Children’s Social Care introduced an Independent Reviewing Officer for Child In Need Plans. In the reflective session held with senior managers, they identified that this post had led to improvements in the quality of planning and review for the cases that attracted this level of accountability, however, it was recognised that the impact is limited because there is only one post which restricts the scope of what can be achieved by this quality assurance role. Senior managers agreed there was a need to tackle any culture which suggested that Child in Need work was less significant than work completed under Child Protection procedures. 7.2.6 The strength of the progress that can be made within Child in Need processes will be highly influenced by the parental response to the identified need for a multi-agency plan around their children. SW3 commented during the Review that consent is necessary progress a Child in Need Plan, and whilst this is true, it must be recognised that it also the role of professionals to assess whether consent and co-operation is genuinely present or whether a parent is paying lip service to appease professionals and detract them from identifying serious dysfunction in families that presents risk to children. For children subject to multi-agency plans because of concerns about their welfare, there will be a need for change in parental TLSCB SCR ‘N’ (MAY 2016) 26 behaviour at some level and assessing parental capacity for such change, alongside determining the impact of continued substandard parenting upon children, is the core business of multi-agency working in safeguarding. In common with a culture that places Child in Need as lower priority, there is a danger that if co-operation is not achieved without appropriate escalation, then a fatalistic sense of hopelessness follows. It is for this reason that robust assessments and clearly articulated plans subject to stringent review are crucial to achieving positive outcomes for children. It is already stated that FN manipulated professionals, systematically removing them from his family life through various strategies. The Review Panel considered whether this case demonstrated typical features of disguised compliance, but ultimately considered there was non-compliance in part because no particular expectations were placed on the parents to attend all medical appointments or address Child N’s needs for early education and support. Brandon et al (2008) in the biennial analysis of Serious Case Reviews noted that disguised or partial compliance can often wrong foot professionals, and lead to prevention or delayed understanding of the severity of harm to the child. A common pitfall when working with openly hostile parents, is the ease at which professionals can be lulled into a false sense of security when parents appear to be welcoming to certain professionals only. Taking this at face value paves the way to professional manipulation and parental control of the perception of compliance. 7.2.7 The Core Assessment was not an assessment completed with the parents, indeed there is no evidence that the need for, or presence of, a written assessment was discussed with FN or MN. Neither parent was asked to take part in the assessment, their own history of being parented, their attitudes to parenting and their responses to the individuality of each of their children was not discussed with them. In essence, the assessment did not have enough information to inform any measured analysis of strengths and vulnerabilities and was not used as a tool to engage with the parents or children. Given FN’s propensity to aggression, it is surprising that no contact was made with the GP either at the point of the Core Assessment or when FN reported that he had been prescribed medication for his mood. GP’s are important safeguarding partners, yet infrequently are they advised a Child in Need Plan or asked to contribute to assessments. GP’s often hold the most readily accessible records as to TLSCB SCR ‘N’ (MAY 2016) 27 where a person has lived and if previous safeguarding concerns have been apparent as GP records travel with the patient throughout their lives. 7.2.8 The Child in Need arrangements achieved little for Child N but the limitations on expectations and challenge of the parents would have served to develop FN’s feeling of omnipotence and distorted thinking about how he could control his family. Ultimately, the unlocking of the key to understanding the depth of abuse suffered by Child N and the siblings came from within the family itself, from the contact by MN to alert to the risk of physical harm and then once feeling in a safe place, from the children telling their experiences of sustained physical, emotional, psychological and sexual abuse. 7.3 To what extent was Child N and siblings the focus of multi-agency work 7.3.1 The referral to Children’s Social Care from Health Visiting services stressed that three of the children were present in the family home when FN became aggressive. The Heath Visitor spoke of the need to think quickly on her feet about how to best diffuse the situation, in particular as the children were present. The Health Visitor said she felt very concerned about leaving the children in the house, but as she was the focus of MN’s anger, made a judgement that he would be calmer if she left and she could get help without inflaming him further. Despite feeling the ‘most threatened I have every felt’, the Health Visitor did remain focussed on the children and was particularly concerned to note that the children did not register or flinch at their fathers irrational behaviour and aggressive shouting. The Early Years Lead at the first Strategy Meeting gave an account of having witnessed FN behave irrationally and aggressively with Child N present and also shared that over the period of a term she had observed Child N and was worried the child’s demeanour and development. 7.3.2 From the first Strategy meeting a picture was emerging of specific concerns about Child N that were not present in the older children. The Early Years Lead spoke of feeling frustrated by being told that the Social Worker had seen Child N yet had no concerns when she had gotten to know the child over a four month period and became increasingly concerned. The Early Years Lead said she was anxious to extend a welcome so that Child N could return to Nursery TLSCB SCR ‘N’ (MAY 2016) 28 and was disappointed that this never happened. The Children Act 2004 places a duty on Local Authorities to ascertain the child’s wishes and feelings and take them into consideration when making decisions that affect them, as far as is reasonable, practicable and consistent with child’s welfare. The contacts and observations of the children made by SW2 and SW3 were limited to short visits to the home and none of the children were purposefully engaged in any direct work to ascertain how they experienced day to day life or to establish whether they wished to discuss any worries or concerns. The comments on the strength of attachment between the children and their parents were similarly superficial but carried weight in the decision to close the case. 7.3.3 Each child had an individual Child In Need Plan but they did not address the issues of concern and this had a particular impact for Child N. A great deal of emphasis was placed on the view of the school who identified no issues of concern for the older children, they were reported to be well presented, engaged in school life and appropriately social with adults. None of the children were ever however specifically asked about their life. The Munro Report (2011) consulted with young people who had experience of the child protection systems and they stressed the importance of children being heard separately from their parents and being listened to. A report by Action for Children, Child Neglect: The Scandal that Never Breaks (2014) includes some poignant comments by young people who have experienced neglect: • ‘I think it’s the adults that need to approach children if they think something is not right, it’s not up to the children to approach them. It can be a big burden for a child to ask for help’ • ‘some kids don’t know they are being neglected until they go to school because it has just been their life, so teachers need to ask’ • ‘If you see an unhappy kid, you should ask them what is wrong’. Simple and straight forward messages from children reminding professionals not to be afraid of talking to children, asking questions, and enabling children to confide their worries. The approach and the method of consulting and communicating with children needs to be a feature of every child’s plan. TLSCB SCR ‘N’ (MAY 2016) 29 7.3.4 The Review Panel has discussed in depth the decision made by Pennine Care NHS Foundation Trust to cease all home visiting by staff and prevent FN from attending any Trust premises. Taken at its simplest level, one has to question if a parent is not seen as safe for professionals to be in contact with, what this means for any child in the home. The decision to cease working with FN was taken by the Trust as a protective measure as an employer, however, this also had implications for the welfare of children and wider aspects of multi-agency working. It could be argued that the decision gave FN what he set out to achieve, to be rid of health care professionals asking questions about his children and having a presence in his family home. Successive enquiry reports have highlighted the dangers to children when professionals do not engage with abusive men and that by taking this approach, professional are colluding with men who wish to avoid services and refuse to face up to problems that stem from their behaviour. It is somewhat ironic that the very reason to be concerned about the children’s welfare also became the reason not to work with the source of that threat. Whilst appreciating that organisations need to put in place risk assessments and control measures for staff facing aggression and violence, there also needs to be an appreciation that working with aggression and violent men needs to be a core function of safeguarding agencies and multi-agency working. In a multi-agency partnership, the operational decisions of one agency will have an impact upon another agency and it is necessary therefore to think beyond the immediacy of the response to an incident to reflect of the bigger picture from the perspective of staff and vulnerable service users. 7.3.5 The focus of the multi-agency work in this case was not structured around the needs of Child N and the sibling children. The focus was on FN, and achieving a degree of compliance that would satisfy agencies into accepting that there was no need for further intervention. 7.4 To what extent was multi-agency working characterised by trust and/or challenge 7.5.1 The early interventions and communications between the Nursery and Health visitor demonstrated a trusting and co-operative working style. The Nursery was able to share the concerns about Child N which the Health Visitor endeavoured to follow up when the Nursery was no longer in a position to do so. TLSCB SCR ‘N’ (MAY 2016) 30 7.5.2 The Review Panel were keen to explore the perception of cultures across agencies, and one practitioner was brave enough to admit that the seriousness of how FN behaved towards the Heath Visitor may well have been diminished by a prevailing view that Health Visitors and teachers do the nice, safe parts of multi-agency working and wouldn’t cope with the more gritty issues commonly experienced by social workers and police. The reality is somewhat different from the rhetoric, and this is particularly evidenced in this case where it the teacher and Health Visitor that are challenging of aspects of FN and MN’s parenting yet when the social workers were allocated there is little evidence of challenge to the parents, and in turn FN took up a position of seeming co-operation. 7.5.3 A particular feature of this case that undoubtedly had an impact on the continuity of approach and the strength of multi-agency working was the co-working arrangements between the two social worker that lacked clarity about who was acting as Lead Professional, why a co-working arrangement was in place and how the family and other professionals understood this. Although SW2 was the nominated case holder and completed the Core Assessment, in reality it was SW3 who made the majority of visits to the home and implemented the decision about case closure. SW2 was reliant on SW3 to provide mentorship through this period of intervention, and in the conversations with the Reviewer it was clear that SW2 was a reflective practitioner who showed considerable distress about the limitations in practice whereas SW3 was not so reflective and could ostensibly fall into the same pitfalls of practice. 7.5.4 A particular feature of the case was the absence of challenge from all agencies despite the obvious limitations in approach to developing and reviewing the Child in Need Plan. The school have been stunned and shaken by what is now known about the children’s experiences and questioned hard whether and how they could have identified anything that would indicate the abuse they experienced. The school reflected that there was a risk of being falsely reassured about children’s welfare by overly focusing on issues such as physical presentation and how they needed to ensure they remained equally attuned to children’s emotional presentation. The school prides itself in having a culture of high control alongside high TLSCB SCR ‘N’ (MAY 2016) 31 warmth, and of creating an environment that supports and takes ownership of the pupil’s welfare. The Review was however advised that one member of staff had made an anonymous referral to Children’s Social Care, and that this was not shared with the Head Teacher as designated lead for safeguarding. It must be stated that no such referral has been identified as received by Children’s Social Care however, the information does beg questions as to why a professional would resort to making an anonymous referral. The motivation to undertake such a course of action can only be speculative as the identity of the person is unknown to the Review despite efforts to establish this but it does suggest a mistrust of using professional processes to raise concerns about a child. 7.5.5 The conversations with practitioners suggested a passivity of approach to the Child in Need process, and the absence of any challenge about process, suitability and accessibility of a Child in Need Plan is suggestive of a culture that overly defers to Children’s Social Care. This issue was discussed in the Practitioners meeting, and Practitioners demonstrated a general feeling of confidence in multi-agency working but recognised some of the limitations from this case in current practice, specifically the limited development of the Child in Need Plan as a tool to action and review progress and a tendency to passively accept that it is the sole responsibility of Children’s Social Care to convene and facilitate multi-agency meetings. 7.5.6 Perhaps the most significant issue in respect of trust was the poor appreciation of what the Nursery and Health Visitor observed in respect of Child N. The Early Years Lead was clear and gave precise information from a basis of early year’s knowledge and experience of the concerns she had about Child N’s demeanour and development. The Health Visitor has clearly articulated concern about Child N’s lack of emotional response to the witnessing the father’s erratic, loud and intimidating behaviour. Through my work with multi-agency professionals in case reviews I see a pattern of responses that I describe as an ‘invisible filter’ that diminishes concern, to describe the process of what happens very often when one agency expresses concern about a safeguarding matter to another in contrast to how a professional may react if the same piece of information was shared by a direct colleague. This is suggestive of an inbuilt level of professional mistrust and a need to test out the issue for oneself. So when FN allowed the social workers into the house without challenge or troublesome behaviour this TLSCB SCR ‘N’ (MAY 2016) 32 almost negated the testimony of Nursery and health professionals and similarly when Child N responded socially to the social worker this overshadowed the testimony of the Nursery. 7.5.7 The practitioners group indicated a reasonable level of confidence in multi-agency working, they also acknowledged the need to sharpen aspects of practice for cases within Child in Need arranges and replicate the more developed planning and review processes embedded into multi-agency child protection work. 7.6 What contributed to the circumstances by which MN and FN could disguise a degree of compliance that satisfied agencies that the children were safe in their care 7.6.1 Disguised compliance has become commonly understood term in multi-agency working to describe what happens when a parent doesn’t admit to their lack of commitment to a process and subversively works to undermine it. Professionals are continually encouraged to maintain a ‘healthy scepticism’ and triangulate additional sources of evidence to support analysis in assessment. In this case much of the information relied upon was self- reported by the parents or based on relatively superficial observations of the children in the home environment. 7.6.2 The multi-agency process lacked any real sense of engagement with either parent or the children themselves. The assessment and Child in need plans appeared as documents to be completed as a bureaucratic exercise as opposed to a tool to working with the family to address the issues of concern. SW2 stated that the assessment was rushed in order to meet timescales, in particular because there had been a gap in allocation since the Initial Assessment was completed. This occurred at the same month as the publication of the Munro Review of Child Protection which concluded that ‘complying with prescription and keeping records to demonstrate compliance has become too dominant. The centrality of forming relationships with children and families to understand and help them has become too obscure’ TLSCB SCR ‘N’ (MAY 2016) 33 7.6.3 The approach of the locality social workers was to seek satisfaction that FN’s behaviour was not a cause for concern in a parenting context, and I would suggest that from the first contacts a mind-set was adopted that meant that the social workers sought out information to support this and too readily dismissed the factors that challenged this. The multi-agency working reflected this position, the school appeared comfortable because they did not have concerns about the older children and were anxious not to become alienated from the parents in order to get their support in pursuing a Statement of Educational Needs for Child N, health professionals were however much less comfortable and through strategic decisions and case work practice they effectively came adrift from multi-agency working. The decision to close the cases to Children’s Social Care was made in the second multi-agency meeting with just Children’s Social Care and School represented. 7.6.4 The tendency to dismiss information that does not support a working hypothesis is emphasised by the way in which FN’s behaviour was too readily dismissed when both social workers attended the home unannounced (see para 4.14), they were refused and entry and FN threatened to move the children away from the vision of services. Although the multi-agency meeting following this incident discussed this visit as a matter of concern, this did not appear to translate into challenge of FN and it would appear that no further unannounced visits were attempted. As already stated, FN used a variety of methods to keep professional at bay or see them only on his terms. 7.6.5 There were a number of indicators that FN was a controlling man who could quickly rise to aggression. The hospital reported in the first multi-agency meeting that MN had disclosed domestic abuse but no opportunity was created to speak with MN alone and FN was never held to account with regard to this allegation. This was a poor response to the information about domestic abuse, especially as MN was perceived to be vulnerable herself. During the period of work with the family, the following significant factors were known but not addressed: • that FN had a long history of involvement with child welfare agencies and had been unable to parent five older children • that FN had a conviction for a physical assault to a child in the neighbourhood TLSCB SCR ‘N’ (MAY 2016) 34 • that FN had shown aggression to all professionals around the children, health visitor, school, Nursery and social workers • that Child N was removed from much needed early years support • that there was a history of patchy co-operation with health appointments for the children • that MN was perceived as vulnerable and had disclosed domestic abuse whilst staying away from the family home in the hospital all of these factors if analysed rigorously should have led to a more questioning approach to how FN’s behaviour impacted upon family life. Child N experienced multiple forms of abuse, including sexual abuse during this period. A recent report published by the Children’s Commissioner, Protecting Children from Harm: A Critical Assessment of Child Sexual Abuse in the Family Network in England and Priorities for Action (November 2015) notes that there is an over-reliance on children disclosing abuse to statutory services and that a refocus is needed so that professionals are attuned to changes in behaviour of children, their emotional responses and to enable them to talk about their experiences. In 2015, the national average of the percentage children subject to Child Protection Plans under category of sexual abuse is 4.5% and in Trafford this is 3.4%. This Review is a an important reminder to professionals to think beyond what is obvious and be particularly alert to the many forms by which power is abused within a family setting and that professionals should always make the connection between the difficulties they experience when trying to see or work with a child and the likelihood that the child is experiencing stressful and abusive behaviour. 8 Learning Outcomes 8.1 Optimum and safer outcomes in multi-agency working with children will be achieved through systems which maintain the child as the focus which are underpinned by comprehensive assessment and understanding of family functioning, considered planning to meet children’s needs with robust and objective review systems in place. There was a fundamental weakness in how this case was approached which stemmed from the limitations of the assessment and adherence to Child in Need procedures which resulted TLSCB SCR ‘N’ (MAY 2016) 35 in sub-standard Children’s Plan. This limited implementation of formal Child in Need processes was identified by the previous SCR which considered multi-agency practice in 2011. There is confidence amongst practitioners and managers that positive developments in relation to Child in Need have taken place since then partly as a consequence of actions taken following the Child MLK SCR which strengthened structures and raised the safeguarding profile of Children in Need. The introduction of oversight and scrutiny from a designated IRO was identified as a particularly important mechanism to provide feedback and support to multi-agency systems around children. Extending this role across Child In Need cases open to Children’s Social Care was identified by practitioners and managers as a favoured position but also recognised as something a utopian desire within a climate of rationalisation. There is however a recognition of a need to further develop and standardise multi-agency practice for Children in Need incorporating the principles of improvement as Plan, Act, Review and Adjust. In taking a lean approach to strengthening this area of work, maximum impact can be achieved through targeting the Plan and Review stages and the following recommendations are made to support this. Recommendation: 1. That the activity of the Board promotes the pathway to, and practice of, achieving personalised, SMART and outcomes focussed Plan for children across all spectrums of need. Children’s PLANS – what training/development have staff received 2. That the within the existing Child in Need processes, consideration is given as to how to strengthen the independence and objectivity that needs to be available when reviewing Plans 8.2 The most effective multi-agency working will be achieved through dismantling the barriers and myths that exist between agencies and to continually build up trust and respect for the specific knowledge , skills and experience that multi-agency partners bring to case assessment, planning and review. TLSCB SCR ‘N’ (MAY 2016) 36 Achieving and maintaining a multi-agency culture of ownership and challenge must be a constant objective delivered through LSCB training, development and reflective practice opportunities. The establishment of effective multi-agency working relationships depends on four key areas: clarification of roles and responsibilities in a manner which values diversity and ensures parity, securing commitment at all levels, engendering trust and mutual respect and fostering understanding between agencies through joint training and sharing of expertise. This case is illustrative of commonly found issues across multi-agency partnerships, that being that when Children’s Social Care become involved, all too often other agencies relax their approach in the belief that the ‘experts’ are taking responsibility. This tendency, coupled with Children’s Social Care at times also seeing themselves as the real professionals in safeguarding mitigates against the key area outlined above. Multi-agency working can be time consuming, it can lead to conflict, and for this reason it can be tempting to take a silo approach. However, irrespective of individual professional perceptions of value, procedures and policies, guidance and legislation is driven by extensive research on what it is that best protects and support the welfare of children. Real cases such as this demonstrate locally to professionals the pitfalls of agencies working to poorly defined common goals, and remind of the need to continually nurture and develop strong multi-agency partnerships. Recommendation: 3. That the Board promote the value of multi-agency partnerships though all of its activity, taking opportunities to bring multi-agency professionals together to think, reflect and learn through a practitioner led approach to audits or reviews. 4. That Board partners review their internal policies and procedures with regard to Violence and Aggression to reflect that critical decisions that impact on responsibilities to children are taken in consultation with multi-agency partners and place the safety of children as the paramount consideration. TLSCB SCR ‘N’ (MAY 2016) 37 8.3 Working with male figures in family life, especially when their behaviour is the source of concern is critical to exposing and addressing abusive behaviours and utilising this knowledge to robustly assess risk to children The tendency to either consciously or unconsciously avoid focus on men, particularly men with problematic behaviours needs to be ever present in the minds of practitioners, managers and quality assurance officers. Whilst not wishing to move from the specific to the general on the strength of one case, the contacts with professional would indicate a need to give further consideration to this issue to develop current practice. To this end, it would be useful to undertake a thematic audit on working with known violence and aggression to learn from practice to what extent multi-agency partner’s work together to achieve a non-collusive approach whilst protecting the needs of all vulnerable clients. Recommendation: 5. The Board to undertake a thematic audit on working with violence and aggression with the purpose of sharing good practice and identifying problematic practice that makes poorer outcomes more likely 8.4 Working directly with children of all ages when undertaking assessments of risk and plans to enhance their welfare and safety should be a feature of every multi-agency plan around a child. Successive Case Reviews, research and academic studies have shown that both children and professionals believe that better decisions will be made for children if they are actively involved in assessment and decision making processes. The LSCB needs to be assured that practitioners have the skills, resources and commitment to achieve this. To this end, every child’s plan should include when, how and who will work with the child as an integral part of intervention, and how any resistance to achieving this would be addressed. Recommendation: 6. For the LSCB to undertake a consultation with multi-agency partners to establish what is needed to support practitioners to develop skills, confidence and resources to work with TLSCB SCR ‘N’ (MAY 2016) 38 children. This information to support a strategy to develop the voice of the child for children subject to multi-agency procedures, 8.5 The national statistics for children subject to Plans for sexual abuse support the view that practitioners may be less attuned to the risk of familial sexual abuse than perhaps was the case in previous decades. The statistics in Trafford are lower than the national average and this would suggest a need to develop an understanding of why this is so. Recommendation: 7. For the Board to dedicate time to debate the issue of sexual abuse, using recent studies and performance data to consider the position in Trafford and whether further Board directed work is indicated. SCR Child N Trafford Safeguarding Children Board SCR Child N Action Plan September 2017 It should be noted that since the SCR Report was written in May 2016, there have been a number of significant organisational changes in Trafford. A Section 75 agreement was signed between Trafford Council and Pennine Care NHS Foundation Trust in April 2016 – a strategic partnership agreement for the delivery of integrated all age community health and social care services. The last 18 months have seen the establishment and continued development of Trafford’s integrated health and social care neighbourhood model. Trafford is also in the process of securing transformation funding from GM which includes ambitious plans to reshape our children and families services. This project aims to promote more appropriate, cost-effective and family & community based services that promote family resilience. This work will be underpinned by a new theory of practice and operating model, based on restorative principles, to stem the increase of demand on social care and to ensure families & young people receive the support they need at the correct level of intervention. Regardless of funding, we have already begun to make changes which directly impact on a number of the recommendations made below. Recommendation Action to be taken Lead Timescale Outcome/Evidence/RAG 1. That the activity of the Board promotes the pathway to, and practice of, achieving personalised, SMART and outcomes focussed Plan for children across all spectrums of need. Upgrade LCS system so that format of plans is smarter and more outcomes-focussed CA July 2015 Format of CIN/CP plans and EH plans has been amended Audit of CP & CIN plans to be completed CRe July 2015 71% of plans found to be Good or better Appoint Review and Improvement Team to identify multi agency model of practice to enhance assessment and planning CRo September 2017 Team appointed Promote role of IROs in making formal and informal challenges to care plans CRe March 2016 IRO Annual Report 2015/16 demonstrates significant increase in challenges Review all CP cases of children subject to a plan over 18 CRe/GW Feb 2017 Completed February 2017 SCR Child N months Introduce recording structure to ensure health visiting and school nursing records are outcome focused and provide a plan of care. LW Oct 2015 Completed Currently in the process of being further updated. 2. That within the existing Child in Need processes, consideration is given as to how to strengthen the independence and objectivity that needs to be available when reviewing Plans Continue to develop the role of the Child In Need Independent Reviewing Officer CRe April 2017 Refocus of CIN IRO role agreed April 2017 Management review of CIN cases open over 2 years KM July 2015 Completed TSCB Child in Need policy and guidance to be updated CF Nov 2015 Completed 3. That the Board promote the value of multi-agency partnerships though all of its activity, taking opportunities to bring multi-agency professionals together to think, reflect and learn Multi agency neglect audit completed CF Feb 2016 Completed – presented to TSCB June 2016 Further multi agency neglect audit to be completed CRe/SW Oct 2017 Audit completed – report to be finalised. Multi agency neglect conference/learning event held CF/JA Feb 2016 Completed SCR Child N through a practitioner led approach to audits or reviews. Enhance our Early Help training offer JP Mar 2017 TSCB now offer 6 Early Help training courses per year, increased from 2 per year TSCB Learning & Improvement Committee “Framework in Practice” presentation to multi agency staff CF/JA Oct 2016 Completed Thematic review of cases referred to the LIC undertaken, and findings to be shared with the workforce and will inform the development of improvement strategies SW Dec 17 To be included in learning events on 5th and 6th December Learning and Improvement committee receive referrals from frontline practitioners for review of cases that they believe could have been managed more appropriately. Cases are reviewed by partners, and improvement strategies are developed to address practice issues SW Ongoing Completed SCR Child N Professional thinking time (PTT) has been embedded into practice so that complex and difficult cases can be discussed so that core groups are clear about thresholds and plans. Use of PTT Will be reiterated in Child N Learning event SW Ongoing Completed SCR learning event to be held following publication JP/SW/CRe December 2017 Learning events booked for 5th and 6th December 2017 4. That Board partners review their internal policies and procedures with regard to Violence and Aggression to reflect that critical decisions that impact on responsibilities to children are taken in consultation with multi-agency partners and place the safety of children as the paramount consideration. Health visitors/school nurses to change criteria for supervision to include compulsory discussion about any parents that have displayed aggression to staff SW Aug 16 Completed Chair of Safeguarding Children’s Board to seek assurance from partners that they have appropriate policies and procedures that staff are familiar with MN October 2017 Chair to write to partner agencies to seek assurance. 5. The Board to undertake a thematic audit on working with Establish a Complex Safeguarding Group reporting to the Safeguarding Board Executive Group December 2017 We do not feel that an audit is necessary but the establishment of the complex safeguarding group will include work on SCR Child N violence and aggression with the purpose of sharing good practice and identifying problematic practice that makes poorer outcomes more likely which will develop a work programme relating to improving practice in working with violence and aggression violence and aggression and an action will be included from this SCR. Trafford already has an established multi agency Domestic Abuse Strategic Forum. 6. For the LSCB to undertake a consultation with multi-agency partners to establish what is needed to support practitioners to develop skills, confidence and resources to work with children. This information to support a strategy to develop the voice of the child for children subject to multi-agency procedures Practitioners to continue to be supported through training, professional supervision and support to ensure that the voice of the child is embedded into practice All Board partners Ongoing Develop a Neglect toolkit which indicates level of assessment required within each threshold of need CF/JA April 2016 Completed Use of the neglect toolkit will be reiterated at the planned SCR learning event Update child protection consultation booklets for young people CL Feb 2017 Completed Commit to funding annual subscription to Research in Practice CRo March 2017 Completed SCR Child N 7. For the Board to dedicate time to debate the issue of sexual abuse, using recent studies and performance data to consider the position in Trafford and whether further Board directed work is indicated TSCB partners to write a self-assessment in preparation for a potential JTAI inspection which would include a themed inspection around intra-familial sexual abuse. CRo Dec 2017 This Self-Assessment will allow us to benchmark existing practice, identify areas for improvement and create an action plan to implement changes required. Leads CA Cathy Atherton CRe Chris Reilly CRo Cathy Rooney KM Katherine Mackay CF Catherine Fleming SW Steph Whitelaw JA Julie Adesanya JP Jed Pidd MN Maureen Noble LW Lauren Whyte |
NC52205 | Death of a 15-year-old child in 2019. Child R became unresponsive at home and died after being taken to hospital. Child R was found to be emaciated but otherwise well cared for. Concerns from school about poor attendance. Child R had been removed from school and commenced Elective Home Education (EHE) in 2018. Initially planned to be short-term with a place at grammar school which subsequently fell through. Several GP appointments were attended for chest pain from eating fatty food. Contacted NHS 111 and eating disorder charity counselling services days before death. Coroner's inquest returned a narrative verdict which indicated that Child R died of natural causes with Anorexia Nervosa as a causative factor. No criminal charges made by police. Family is White British/Russian. Learning includes: parents and professionals should remain curious about what their children are thinking, feeling and accessing on mobile devices; social isolation can have a negative impact on emotional and psychological health; school staff should act on healthcare concerns by offering referral to appropriate services; GPs should use tools to recognise faltering growth and eating disorders are part of the differential diagnosis for this. Recommendations include: review material available to parents to help them recognise the signs of Anorexia Nervosa and the importance of early diagnosis in children; consider requesting a National Review on EHE to change non-statutory guidance to improve opportunity to promote the welfare of children receiving EHE; raise awareness across the partnership of early recognition of children with eating disorders and professional curiosity and how to promote this within systems.
| Title: Local child safeguarding practice review: Child RN19. LSCB: Nottinghamshire Safeguarding Children Partnership Author: Kathy Webster Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Nottinghamshire Safeguarding Children Partnership Local Child Safeguarding Practice Review Child RN19 29/09/20 Author: Kathy Webster – Independent Safeguarding Consultant 2 Content Item Page Introduction 3 Methodology 3 Family Composition and Context 5 Circumstances and significant events (25/08/17 till 25/08/19) 6 Analysis of practice and organisational learning 9 Eating disorders in adolescence. 9 Engaging adolescents in their own healthcare. 15 Promoting child welfare in School and Elective Home Education setting. 21 Good Practice 26 Practice Issues 27 Conclusion 27 Recommendations 28 References 29 Acknowledgements 30 Statement of Reviewer Independence 30 3 Introduction This Local Child Safeguarding Practice Review (LCSPR) was commissioned by the Nottinghamshire Safeguarding Children Partnership (NSCP) on 16th September 2019. The decision to conduct a LCSPR was made following a rapid review of the circumstances of the case and advice from the National Child Safeguarding Practice Review Panel that the criteria had been met for a LCPR to be commissioned in line with Working Together 2018. The catalyst for this review was that a 15-year-old child, who will be known as Child R, had become unresponsive at home and tragically died soon after being taken to the hospital. The child was found to be emaciated but otherwise appeared well cared for. A coroner’s inquest took place on 24th and 25th September 2020 with a narrative verdict. The review author attended the inquest, gave evidence and was present throughout, and any additional relevant information gathered as a result has been added to the report for completeness. At the time that Child R sadly died she was being electively home educated (EHE). The child had enjoyed ice skating as a hobby and loved the family pet dogs. Following the death of the child a police investigation into possible neglect issues was commenced. The police report that after a full and thorough investigation, no evidence of neglect has emerged and with no criminal charge being made. The key learning themes identified in this review include; eating disorders in adolescence; engaging adolescents in their own health care and promoting child welfare in the school and elective home education settings; Methodology This review was carried out using the systems model approach to learning as outlined in the Child Practice Review process provided by “Protecting Children in Wales Guidance for Arranging Multiagency Practice Reviews” (Welsh Government 2012). The overall purpose of the LCSPR model was to enable consideration of what happened in this case and explore why services were delivered as they were. Also, to consider how practice can be improved through changes to the system to improve outcomes for children. The process involved a review panel of representatives made up of senior managers and safeguarding leads who were from the organisations involved in providing services for the child and family. The role of the review panel was to provide relevant information and analysis of their organisation’s involvement in order to capture service/practice issues and to agree the key learning themes and actions required for multiagency practice improvement. Local Child Safeguarding Practice Review - local authorities are required, under a statutory duty, to conduct an independent review of serious case where they know or suspect that a child has been abused or neglected and a child has died or been seriously harmed. Safeguarding Children Partnership - provides the safeguarding arrangements under which the safeguarding partners and relevant agencies work together to coordinate their safeguarding services. National Child Safeguarding Practice Review Panel - Are an independent panel commissioning reviews of serious child safeguarding cases. 4 There was appropriate representation at the panel meetings and participants were knowledgeable about their own area and safeguarding arrangements. They were keen to submit and consider learning issues. A composite timeline which included all agency interactions between 25/08/17 and 25/08/19 was scrutinised by the Independent Reviewer and together with the review panel to identify the key themes of learning. The key lines of enquiry for the review included: 1) The review should explore the way that professionals assessed and responded to the child’s emotional and physical health and well-being and safeguarding during the following key practice episodes. a. Presentations to health professionals b. Relationships and behaviours in school c. Transfer from school to EHE d. Support offered to the young person and family by agencies during the period of EHE. 2) Examine the impact of language, ethnicity and culture on the way services responded to the needs of the child and family. 3) Was there evidence of child focus and the “voice of the child” influencing services? 4) Were there any gaps in service that may have led to a different outcome? Family involvement Family involvement in the reviewing process was key to understanding the nature of services provided to the individual family. This provided an understanding of how helpful practitioners / services were perceived by the family members on a day to day basis. The Independent Reviewer and NSCP Development Manager visited Child R’s mother at home but Child R’s father was not available at the visit and was therefore, seen separately. The home environment was seen to be conducive to home education and everyday family life. Mother demonstrated how well home education had been progressing in terms of meeting Child R’s education needs and examples of the child’s academic work was seen by the Independent Reviewer and NSCP Development Manager. The Independent Reviewer was of the view that Child R had produced some beautifully well-presented academic work which was well detailed. Following a period of reflection with Child R’s Mother she was of the view that: • More direct contact is needed between professionals, children and the families they are working with. • More direct contact was needed from school to parents when children were moving into EHE or if they have concerns about a child’s appearance in school. • GPs should follow up when children do not attend for planned tests and provide an opportunity for adolescents to be seen alone. 5 Child R’s father was invited to meet the Independent Reviewer and NSCP Development Manager separately. Father was very reflective and emotional about what he felt had been the issues. Home education had been left to Child R’s mother who had a very close relationship with their child. He was self-employed and often away from home on business so often left mother and child to make decisions for themselves. During discussions about agency involvement he expressed that had been very grateful for the support of the Ambulance Service, Police and Emergency Department who had received his daughter and done everything they could. Father’s messages to other parents were that: • Parents cannot always see what is happening before their own eyes • Parents cannot do everything alone. Further views and reflections of both parents will be used throughout the narrative of the report. The Reviewer had access to a number of documents as follows: • Rapid review information gathering po-formas • Individual agency individual management reports (IMRs) • Joined multiagency timeline of significant events/analysis • Policy for Elective Home Education (Sept 2013) • Elective Home Education dashboard – data • Child R’s – Progress Report – Year 9 Research evidence and national statutory guidance was considered and used throughout this review. Family composition and context at the time of the child’s death. Child R Age 15 years. White British. An only child. Described as happy, friendly, sensitive and loved animals. Child R had a fascination for ice and snow which built into the love of ice skating. Child R was an accomplished student who was expected to achieved good things in adult life. Mother Age 50 years. White Russian. Professional dog walker who had previously been employed as a Scientific Chemical Engineer. Enjoyed being a stay at home mother. Took the lead for educating Child R at home and for addressing health care concerns. Mother speaks good English with a strong Russian accent. It was not clear if mother always fully understood all the nuances of a lengthy conversation. Father Age 62 years. White British. Self-employed contractor. His work involved travel and evening work and he was in and out of the home during the day/evening. 6 Circumstances and significant events (25/08/17 till 25/08/19) Information outside the timeframe Child R left Primary School in 2015 and was described by the school as having exemplary behaviour, was hard working and making good progress when leaving the school. Child R had a good group of friends who were supportive. Primary school held two notes of concern. In May 2012 mother had written to school complaining about bullying and during the child’s final year at school their attendance had been 313 out of 353 (89%) which was less than expected and should have been referred to the secondary school in transfer record. Child R moved to the local secondary school in September 2015 transferring with close friends where the child made very good academic progress. The only concern at school was around the child’s school attendance levels which was at 91% for the first year. All absences had been authorised by the parents contacting school. This level of attendance triggered a standard letter being sent to parents about the importance of good attendance. Father responded by email to confirm the child’s illness and challenged the school welfare manager about their competence to question the child’s medical fitness to attend school. In Year 8 school attendance improved to 96.3%. The child was weighed as part of the National Child Measurement Programme (Gov.UK 2013) and was found to be within the normal range. Year 9 at secondary school - (September 2017 till February 2018) In Year 9 commencing September 2017 school attendance became a concern at 87.2%. The absences were all authorised by the parents for medical reasons. In January 2017 the school First Aid and Wellbeing Co-ordinator wrote an email to colleagues highlighting concerns that the child had requested mother to pick up Child R from school early. The email stated that “this is getting more and more regular and got a feeling there’s more to it than illness”. The following day Child R’s joint form tutor shared their views which resulted in an entry being made on the schools “my concerns” computer system referring to Child R “extreme difference in appearance. Gaunt/pale. Keeps feeling sick”. The form teacher phoned home to share concerns and mother said that the child’s appearance was due to illness and anxiety about sitting grammar school exams. Following this conversation Child R only attended school for two more days after which the child was recorded as authorised absent from school for a further 6 days. On the following day school were notified by email from the Local Authority - Elective Home Education service that Child R had left school to commence EHE. The student welfare manager was unable to reach the parents by telephone and asked by email the reason for their decision. Mother replied that Child R was not happy at school and 7 had passed the grammar school entry test (February 2018) and would be home educated while waiting for a grammar school place. Child R was seen by the GP on five occasions during this period and there was one significantly delayed presentation to the local hospital Emergency Department following advice from the Out of Hours (OOH) service. Presenting concerns were primarily reported to be for a chest infection and then mainly for chest pains reportedly brought on by eating fatty food and stress. Medication for gastric acid reflux was appropriately prescribed by the GP. Treatment for anaemia was also commenced which was attributed to Child R being unwell and having heavy periods. There were two episodes of not attending GP follow-up appointments. There were also two episodes of blood tests not being undertaken, where there was a reliance on the child’s family making the necessary arrangements for the tests to take place. Transition into Elective Home Education (EHE) (February 2018 till March 2018) The EHE administration team received an email from mother informing them of her wish to EHE her child and to remove the child from the school roll. School were informed the same day by the Local Authority EHE service. The school were asked to complete the standard pro-forma giving information about Child R. The student welfare manager at the school did not complete all the sections of the proforma and edited it to remove sections intended to pass on additional information. The completed form stated “There are no safeguarding concerns about this pupil being removed from school roll to be electively home educated”. On receipt of the pro-forma the EHE Programme Manager approached one of the EHE advisors to offer advice to the family. This was agreed and the family was informed of future contact arrangements. EHE administration emailed school to inform them they could remove the child from roll and requested that they send the child’s school file. This file was never sent and was not requested a further time. Application to grammar school (February 2018 till August 2019) Confirmation of Child R’s success on reaching the appropriate standard in the grammar school advanced entry tests was received in February 2018. Following this mother emailed the grammar school for assurance that Child R would be able to start school in September 2018. A return response was received explaining that there were currently no places available. The following day an email from Child R’s personal account replied “please I’m begging you” to which the school replied there were no vacancies at present. Elective Home Education (March 2018 till August 2019) In March 2018 the first EHE advisor visit took place. Mother explained her concerns at secondary school and hoped for a place at grammar school. The expectation was that the EHE would be a short-term provision and the need to avoid social isolation and the importance of maintaining friendships were discussed. 8 Mid-March 2018 mother made a call to the OOH GP services (02.30hrs) and voiced concern about Child R having chest pain and upper back pain and the child was refusing to take Paracetamol offered by mother. OOH advised that the child should attend the local Emergency Department within 6 hours, but the child was not presented until 13 days later. Investigations at the hospital did not find anything abnormal. A further three appointments took place in April 2018 with a GP within a three-week period. All appointments were concerned with chest pain made worse with eating fatty food. On the third visit the GP checked the child’s height and weight and requested a blood test. However, the blood test did not take place and a follow appointment was not arranged. Child R did not see the GP again. The EHE advisor made a second visit in July 2018. It was normal to re-visit EHE pupils three months after the initial visit. The home education plan was judged to be good and a discussion around post 16 education took place. Again, the need to avoid social isolation was raised. In line with local practice the next visit by the EHE advisor was planned to take place one year later. Between July 2018 and August 2019 (13 months) there was no agency involvement with the child and family. One week before Child R died. The child texted a friend to say that they (Child R) thought they had an eating disorder. The friend who was not previously aware of this, texted back and advised getting support. 5 days before Child R died. Child R’s mother made a GP appointment for the child but the mother attended the appointment alone. Mother was reported to have discussed her daughter’s poor eating. She reported Child R was eating healthily, but eating less than before. She was advised to encourage Child R to attend the practice for a review. 4 days before Child R died. The child telephoned Beat (support charity for eating disorders) helpline. There was a 24-minute-long anonymous call. Child R was worried about having to go out to a family meal and wanted to know what to eat without putting on weight. Advice about seeing a GP was given. Following this, Child R made an extremely short call to NHS 111. The child requested to speak to someone anonymously and hung up after only providing a date of birth and confirming age (15). 3 days before Child R died. The EHE advisor visited the home to review the child’s education programme. There was good evidence that this had been progressing well. There was talk about post-16 and post-18 education and Child R had been keen to hear all the options available. Following the death of the child the EHE advisor has reflected that at the final visit Child R was seated on the sofa throughout the visit and was wearing layers of thick clothing despite the hot weather. The child’s long hair was worn down and covered most of the face. 2 days before Child R died. The child contacted an Eating Disorder Charity helpline to find out what they could eat without gaining weight. Child R told the call handler that they were worried that they would have to eat a family meal and did not want to put weight on. Child 9 R was advised to speak to their GP. Shortly after this call the child contacted 111 service but ended the call after only providing their date of birth, age and postcode. Incident – (August 2019) The local ambulance service received a call at 12.52. The child had been sleeping all morning but was now unconscious and not responding. The caller confirmed the child was breathing and that they had worries about the child not eating properly for some time. The caller confirmed that the breathing had become very shallow. Advice was given around maintaining an airway after which the caller stated there was no breathing and instruction on CPR was given. As soon as the ambulance crew arrived, they commenced advanced life support until handover to hospital staff. The crew described the child as looking “skeletal”. Mother was very distressed and said she had been trying to get her child to see a GP that week. Hospital staff continued with resuscitation for a further 45 minutes to no avail. A Police investigation was commenced as part of the Rapid Response Procedure and the conclusion was that the case did not meet the evidential threshold for the case to proceed to criminal charges. It was concluded that the adolescent child had clearly been hiding their condition from the parents. Analysis of practice and organisational learning There were three main learning themes which emerged during the reviewing process as follows: • Eating disorders in adolescence. • Engaging adolescents in their own healthcare. • Promoting child welfare in school and elective home education settings. Eating disorders in adolescence. As previously stated, a Coronal Inquest has taken place with a narrative verdict which indicated that the child died of natural causes and that undiagnosed and untreated Anorexia Nervosa had been the causative factor. Anorexia Nervosa is a type of eating disorder. Eating disorders have increased nationally by 37% in two years. NHS Digital data for England shows there were 19,040 hospital admissions among all age groups in 2018/19, up from 13,885 in 2016/17. The figure includes 4,471 admissions for young people aged 18 and under with an eating disorder which is up 8% in a year. More than half of those requiring admission to hospital were due to anorexia nervosa. Rapid Response Procedure - relates to unexpected deaths of children up until the age of 18 and sets out the roles and responsibilities for those agencies who are involved with responding to unexpected deaths as part of the child death process (police, health professionals and children's social care) and reflects roles and responsibilities set out in Working Together to Safeguard Children. 10 Anorexia Nervosa is a type of restrictive eating disorder where individuals consume very restrictive quantities of food which leads to starvation. Eventually they become dangerously thin and malnourished, yet they still perceive themselves as being overweight. (NHS website). It has the highest mortality rates of all the psychiatric disorders with reported mortality rates in adolescents and young people of up to 20%. (Jon Arcelus, Alex J Mitchell et al. (2011). In addition to food restriction, some people with anorexia may also make themselves sick, do an extreme amount of exercise, or use medicine (laxatives) to help speed up the digestion process to stop themselves gaining weight from any food they do eat. The complexity around extreme exercising is that exercising is seen as a virtue and is often seen as providing significant health and mental health benefits. However, for those with eating disorders, excessive exercise is a common symptom and can play a role in the development and maintenance of the disorder. (Muhlheim.L. 2020) Although eating disorders can occur at any age there is a higher risk for young people (both boys and girls) between 13 and 17 years of age. Those with an eating disorder may find it difficult or distressing to discuss their eating disorder with a healthcare professional and others. Poor insight into eating problems, lack of motivation to tackle the eating problem, resistance to changes required to gain weight are all features recognised in anorexia nervosa. (NICE 2018) Triggers for the onset of eating disorders vary from person to person. Triggers have been known to include the internalisation of the thin ideal, healthy eating education, sports performance motivations, weight-related teasing and wanting to exert control in particular circumstances. Non-specific factors included general preoccupations about weight, shape, and healthiness (Chen. A & Couturier. J, 2019). The illness can affect people’s relationship with family and friends, causing them to withdraw; it can also have an impact on education. As with other eating disorders, anorexia nervosa can be associated with depression, low self-esteem, alcohol misuse and self-harm. The seriousness of the physical and emotional consequences of the condition is often not acknowledged or recognised, and sufferers often do not seek help. They may go to great lengths to hide their behaviour from family and friends, and sometimes might not realise that they’re ill. Getting help is often reliant on friends, professionals and family members. Early identification by GPs and referral to specialist treatment services are recommended. A recent study by the charity Beat demonstrated that, on average, there was an 18-month period before those under 19 years recognised themselves as having an eating disorder, with a further 9 months delay before seeking help. Boys were found to take longer than girls for attending a first visit with a GP or specialist service. Following a first visit it can then take another 4 months until the sufferer receives a specialist assessment. In other words, it takes approximately 2.5 years from the onset of the eating disorder to receiving specialist therapy to address the individual child or adolescent needs. (Beat - published 2017) 11 Beat have suggested that Clinical Commissioning Groups should extend their focus on early intervention to include earlier stages of the illness, ensuring attention and resource are applied to reduce the delay between the onset of an eating disorder and the individual seeking help. Also, increasing measures around awareness for GP’s and other relevant healthcare professionals. Information heard at the Coroner’s Inquest revealed that the parents became aware of their child’s interest in healthy eating from the Christmas of 2017. Father recognised that Child R was checking food packaging for the food values to ensure low carbohydrates and calories. By Christmas 2018 Child R would only eat the turkey at the Christmas meal. Mother was worried that Child R was not eating enough but respected the child’s wishes to eat healthily. There was evidence that mother was trying to get Child R to eat more and to see the GP. One week before the child died mother purchased a book on Anorexia Nervosa and this appears to be the catalyst for mother attending the GP on the final visit. The Reviewer, supported by the NSCP Development Manager has met with both of the child’s parents in this case, to gain insight into the homelife. The first observation was that Child R appeared to be a very much loved and treasured child. Mother and child were said to have a very close bond and went on many adventures (outings) together. The child’s bedroom and study room were still intact and was seen as being warm and possessing all the resources that a child would need for a comfortable life and home study. Mother was the lead parent in Child R’s education and care. Father who was in and out of the house most days appeared to have little influence over their activities. There were a number of dogs at the house which reflected mother and child’s love of animals. Child R’s much-loved Golden Retriever dog died in May 2019 and the child was said to be very upset about this. We now know following the Coroners Inquest that the impact of this loss on Child R and mother was profound and both mother and child lost weight during this period of grieving. Mother purchased another Golden Retriever to take the previous dog’s place. The parents explained that Child R would have been home alone for various parts of the day when mother and father were out working. The reviewer was told that Child R prepared all of their own meals and that Child R liked chicken, vegetables and insisted on having a very healthy diet. Prior to leaving school Child R was seen eating normally (usually Panini and Coke) at lunchtime and no one in the friendship group had noticed any weight loss. The termination of Child R’s school placement came out of the blue for Child R’s school friends. Changing schools had never been discussed with them. Clinical Commissioning Groups - are NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England. 12 Once Child R left school the child gradually started to lose contact with friends and as a result would have become socially isolated, although the child did continue with weekly ice-skating lessons until June 2019. Child R also, experienced a range of visits with mother including visits to museums, art galleries and had a family stay at a holiday leisure park. Child R was taken to see the GP on several occasions during the first few months of EHE and the child’s healthcare issues and treatment will be discussed later in this report. One of the GPs was aware that the child had an EHE status but did not recognise the significance of this in terms of the child not being regularly monitored by other professionals. The Child Safeguarding Practice Review Panel (CSPRP) have identified that there is a consensus that attending school is a protective factor for children. This is because children are seen regularly by many different professionals and by peers and other families. This enables any early indicators of concern to be identified and for decisive action to take place. In understanding what happened in this case and as part of the police investigation, the child’s electronic devices have been interrogated and it is the police opinion that this material provides an insight into the voice of the child. Child R used the notes section of the mobile phone as a diary and noted eating habits and extensive workouts. Child R may have been confident in not being found out by their parents because mother had been firmly of the view that a personal mobile phone was private and not to be seen by others. Mother told the reviewer that she had a very controlled up bringing herself and she did not want this for her child. The mobile phone extracts below are taken from April to August 2019. • Pretend eggs breakfast have one egg white only basically and say it’s a “meal” Go to Sherwood pines walk have the jelly maybe sometimes then 2 egg yolk and yogurt and a bit of cucumber or salad dinner • Toast and something one day for breakfast maybe and say egg thing low calorie • Don’t eat a lot out maybe bring a clementine or something - when back don’t eat a lot only cucumber or something like that small not anything else • I love how I look and feel right now💕💗 Finally I feel confident, I can wear clothes I have always wanted to, look how I’ve always wanted to, feel amazing and do all the things I’ve wanted to do. My habits and my workout is perfect and I couldn’t feel happier. So why does she hate it. Don’t change for anyone do what you love and enjoy and don’t do anything for anyone ✨💕✨💕✨ • Drink tea then just eat cucumber and yogurt ONLY FOR DINNER • Center Parcs don’t eat lunch Bring big tub of yogurt and a few small and say it’s for snack 13 • Work out as much as possible without eating / collapsing then have breakfast then workout again Love handle Ab workout X4Thigh workouts Sanne vander vs and thigh Molly dolke ab Chloe ting ab and alexis ren ab Through the day try a few arm ones quick • Before mum goes do thigh ab and sanne vander • Only one small meal maybe one orange (Names mentioned are all models on YouTube offering workout and wellbeing advice) The mobile phone extracts suggest that the child was significantly restricting their diet intake and using extreme workouts to burn off calories in order to reduce their weight. This appears to have been done in secret when the parents were out of the house. Within the same device, in addition to the written notes there were a number of selfies showing images of the child’s “progress”. It was evident that in April 2019 the child appeared as slim. However, following on from this date there was a rapid deterioration in appearance and weight. Police report that these images were distressing to view. This period of deterioration coincided with the loss of the Child R’s dog and this may have been a trigger for the rapid weight loss. The device also disclosed that during this period there was limited contact in respect of socialisation. Child R’s main contacts were with parents and with grandparents who lived in Russia. This would appear to support the view around social isolation and its negative impact. Child R did reach out for support in the last days of life. Child R texted a school friend saying they thought they had an eating disorder and the friend texted back advising that the child should get support. At some point Child R visited a different GP practice to possibly enquire about a Teenage Clinic which was held there. Child R told mother that she had been to the Practice but had only spoken to the receptionist. What was said is not known. It is possible that Child R had been looking for help. Child R made a call to an Eating Disorder Helpline requesting advice about what food they could eat without gaining any weight. Child R was worried about a family meal that was being planned and didn’t want to gain weight. The call handler managed to keep the child on line for several minutes and tried to convince the child into seeing their GP. Following this call Child R contacted 111 and asked to speak with someone anonymously although the child did confirm their date of birth, age and postcode. The call handler asked 14 for the child’s address at which point the child ended the call. This should have resulted in a call back to the patient but due to worker failure this did not happen. This has been addressed by 111 internally. There is no evidence to suggest that the child would have responded to a return call. Child R did not have the checks and support of professionals that children have when they are routinely attending school. Neither did Child R have a friendship or peer group for support and feedback. Child R appears to have been aware that they needed support but did not want to gain weight and was therefore reticent about allowing any help available. According to the data found on the child’s mobile devices, it is clear that Child R was hiding the full extent of their illness from their parents. It may be that the child was not aware of the danger they were in at the time. Despite both parents loving their child wholeheartedly neither parent appears to have fully recognised or been able, for whatever reason, to adequately deal with the situation around their child’s eating disorder. Practice learning for parents and professionals • Eating disorders are becoming more prevalent in England. • Anorexia nervosa is very complex and has significant effects on physical, psychological and emotional growth and development. • Parents do not always see what is happening in front of them – it is a well-recognised symptom of eating disorders to cause the sufferer to be secretive and the potential for the disorder to deceive and manipulate can be extensive. This extends to the sufferer themselves who often lack insight. • Parents and professionals need to remain “curious” about what their children are thinking, feeling and accessing on mobile devices. • Parents need to be aware of the positive aspects of technology and internet use for their children as well as the risks and follow guidance to help them keep their children safe on line. • Parents need to understand the signs of an eating disorder and get support early for children demonstrating these whether or not the child accepts they may need help. • Social isolation can have a negative impact on emotional and psychological health • Know what to do to help parents when children refuse to attend GP appointments. This can sometimes be complex where children have capacity to make their own decisions and do not consent to comply with medical care. • Beat (Eating Disorder Charity) Youthline is available to local young people Tel: 0808 801 7110 email: [email protected] 15 The local picture relating to eating disorders The Nottinghamshire Child Death Overview Panel (CDOP) Co-ordinator has confirmed that this is the first case of the death of a child (normally resident in the Nottinghamshire Local Authority area) due to an eating disorder since CDOP records began in line with statutory guidance in April 2008. Learning from this review will be shared with CDOP to support future practice improvements for children and young people across the county. The county where the child lived has a well-established Child and Adolescent Mental Health Service (CAMHS) Eating Disorder Team. This service has a role to assess and provide treatment for children and young people up to 18 years with significant eating disorders. There are a number of CAMHS bases across the county for easy access and a helpful web-page with contact numbers and email addresses for those who need help. Referrals from professionals and self-referral is accepted either on line and by telephone. This service, given the opportunity would have been available to help the child which makes this child death all the more tragic. Engaging adolescents in their own local healthcare. The World Health Organisation (WHO) recognised that adolescents have significant needs for health services. They pose different challenges for the health-care system than children and adults, this is due to their rapidly evolving physical, intellectual and emotional development. WHO recognises that school health services bring health care closer to adolescents and they may have advantages in terms of access, equity and responsiveness to help meet their unique health care needs. Local school health services form part of the local 0-19 years health services and are commissioned by the Local Authority Public Health service. The 0-19 service is provided by a local Community Health Trust provider. The 0-19 service have local involvement with schools and a Healthy Child Programme for 5 -19-year olds. School nurses are part of the school health service and are trained to identify and support children with additional health needs. There may have been an opportunity for the school to consider making a referral for Child R to the school nurse when they had concerns about the child’s change in appearance and behaviours around contacting mother to leave school early. Involving a school nurse at an early stage of concern may have provided an opportunity to engage the child in early healthcare. The school nurse would have had easy access to the child’s weight taken as part of the National Screen Programme should this have been relevant at the time. However, there has been nothing to suggest that the child was underweight at this point in time. World Health Organisation - primary role is to direct international health within the United Nations' system and to lead partners in global health responses 16 Practice learning – school staff should act on healthcare concerns by engagement with parents and offering referral to appropriate services for example the school health service who are well placed to assess healthcare needs of children. Spotting the signs of an eating disorder is essential for early treatment and better outcomes for children. At the time when Child R was receiving EHE, the school health service was not being routinely informed about children who were being EHE and this was due to local concerns about parental consent. The school health services were therefore, not aware that Child R was receiving EHE. This situation was resolved prior to the death of Child R and a new information sharing process was already established prior to this review being completed. The school health service and EHE programme manager had established the improved process by working together to develop an information sharing agreement. Further to this, in August/ September 2019 the EHE service wrote out to all parents registered as receiving EHE for consent to share information with the 0-19 service giving them an opportunity to opt out of the service offer as is their right to do so. From the end of October 2019, the school health service started to receive a list of all children and young people registered with EHE which goes to a secure NHS email address for the information of the local school health service. The local school health service will be contacting all families who have chosen to EHE their children to ensure they are aware that their child is still able to access a universal healthcare services which are readily available to all children and young people who attend school. This will be done via the EHE advisors who are in contact with the families concerned. Practice learning – it is important that EHE and school health services work together and share relevant information with one another about issues and concerns relating to EHE children in their area. As previously stated, eating disorders have the highest mortality rates of any of the psychiatric disorders. This, along with the potentially irreversible effects of eating disorders on physical, psychological and emotional growth and development, require early recognition and intervention of these young people. It is important that primary care providers, such as GPs, along with other health professionals who may come into contact with young people, recognise their important role in the early identification of an eating disorder, and that they recognise that anorexia nervosa is a serious disorder with life threatening physical and psychological complications. Child R was seen by the GP on five occasions between July 2017 and April 2018; this was primarily for a chest infection followed by complaints about chest pains linked to eating fatty foods and stress. Medication for gastric acid reflux was appropriately prescribed for two weeks with a request to see the GP again to monitor progress. 17 The cause of the stress was not explored by the GP although the mother did explain that stress was related to school attendance. She informed the GP that Child R was now receiving EHE which could have suggested that the child’s stress would now be alleviated. The relevance of the child being EHE was not explored further by the GP and there was no flagging system in place to record the child’s educational status. Child R was reported as appearing pale at the majority of appointments and treatment for anaemia was commenced and was attributed to being unwell. Practice Learning – The flagging of EHE status on the GP record keeping system may give rise to alerting the GP that the child is not in regular contact with other professionals and this information can be factored into any clinical or psychosocial assessment required. There were two missed GP follow-up appointments, two missed blood tests and one delayed presentation following advice from OOHs that the child should attend the local Emergency Department. It took thirteen days for the child to attend the Emergency Department, where investigations for chest pain were explored with no concerns being found, the discharge letter from this attendance was sent to the GP. The reasons why Child R did not attend the emergency department, as advised, was never explored. There was no professional curiosity by the GPs in terms of questioning around non-attendance and given mothers Russian accent no professional curiosity to check that mother fully understood the importance of the blood tests and follow up appointments. The 3 in 1 routine vaccination was offered by the school age immunisation service however, consent was refused with no reason for this being specified. Previous vaccinations had been up to date with no issue. There was no professional curiosity around why consent had been withheld given the importance of the vaccination programme. The child’s final appointment with the GP took place in April 2018 which was sixteen months prior to the child’s death. At this appointment the child was weighed and measured and a blood test requested. Child R was weighed as part of the GP assessment at 45kg with a height of 1.67m which gave a BMI of 16.14 kg/m. At the time the GP weighed the child the GP was unaware that the child had previously been weighed by school health service in 2015, three years earlier, 45.4kg. This information was available as part of the wider record available to the GP, but they were unaware of this at the time of the consultation. Reports of Child R having problems with heavy periods, may have distracted clinicians from considering an eating disorder, as periods often stop in those who are severely underweight. Centile Chart - Centile charts are used in child growth assessment and show the position of a measured parameter within a statistical distribution. They do not show if that parameter is normal or abnormal. They merely show how it compares with that measurement in other individuals and over time. Faltering growth - Faltering growth (also known as failure to thrive or under-nutrition) is a term used to describe a lower weight, or rate of weight gain, than expected for age and sex in childhood. BMI – Body Mass Index is a value derived from the mass and height of a person. The BMI is defined as the body mass divided by the square of the body height, and is universally expressed in units of kg/m², resulting from mass in kilograms and height in metres. 18 It is recommended that when height, weight and BMI is taken in a child or young person it is plotted on the relevant centile chart. This allows the professional to review the child’s metrics in the context of any other previous measurements and in comparison, with their peers. If the chart had been reviewed and both weights plotted by the GP, this would have provided valuable information about the child’s growth which had plateaued. The blood test never took place. It is difficult to extrapolate what actions may have been taken if these blood tests had been obtained. Had these blood tests been reviewed in the context of a young person with faltering growth then, even if they were normal, they may have prompted exploration of other causes for faltering growth, including an eating disorder. The simple fact that a family who were presenting as worried, but had not attended for the recommended blood tests, should be a highlight that further assessment was warranted. Mother told the Independent Reviewer that blood tests did not take place because the child refused to attend hospital due to the child developing a needle phobia, although this was never discussed with a healthcare professional at the time. If needle phobia had been recognised then the GP could have referred the child to the Community Children Nursing service for support around vaccinations and blood tests and engaging the child in healthcare. The issue of missed investigations such as blood tests being a warning sign to professionals was an issue raised by father who felt that children who miss out on investigations should be reviewed to ensure they are not missing out on vital healthcare. It was apparent that the GPs who saw Child R were not given an history of an eating disorder and had not detected any physical signs that the child may have an eating disorder, apart from the faltering weight which was not recognised on the one occasion that the GP weighed the child. Five days before Child R died, mother attended alone to a GP appointment which she had made for the child. Mother voiced concern that she thought her child had eating problems and was worried about this, but went on to describe a healthy diet. The GP advised mother to bring the child to see a GP at the practice. Given the situation that mother had already attended the appointment without the child it may have been helpful for the GP to check with mother if she would be able to get the child to attend an appointment. Being professionally curious about why the child had not attended with mother and how the mother was going to get the child to attend an appointment if the child refused to attend were not addressed. Consideration of use of the Community Children Nursing Service and School Health Service would have been useful should the GP have required clinical support. Professional learning –Professional curiosity is the capacity and communication skill to explore and understand what is happening within a family rather than making assumptions or accepting things at face value. This is an important skill which would have helped in the early identification of an eating disorder or other clinical diagnosis. 19 Following the death of the child the GP practice have worked with the local Named and Designated Professionals to consider learning from the child in this case and there have been a number of practice issues identified and implemented which will improve clinical practice and outcomes for children in the future. The practice areas identified and progressed are relevant to all GP Practices and should be considered by all GP’s in the area as set out below: “Was not brought” (previously known as “did not attended”). Child R was not brought for follow up to the GP despite the GP requesting an appointment. Also, relevant blood tests were not taken up as requested. At the time the GPs were reliant on parents’ ability to bring the child as requested. Reasons why there had been a failure to attend follow up appointments and blood tests were not addressed following the non-attendance, or at subsequent appointments. There are multiple reasons why children and young people may not be brought to attend medical care. One reason may be that young people do not wish to attend. It is important that healthcare professionals including GP’s understand issues of consent and capacity in relation to young people so that they can work with parents to support a young person to engage. There was a local policy which indicated that if a child “was not brought” for an appointment for three times in twelve months then the GP would chase up reasons and issues for none attendance. This set criteria did not apply to Child R because only two appointments were missed. Progress – The “was not brought” GP policy has been reviewed and appointments will be considered for non-attendance every time and followed up as necessary. Blood test requests for children will be monitored through scheduled tasks on the practice web-based system to ensure children are followed up when any referral and investigation requests are made. This will promote GP professional curiosity around why children miss their GP appointment and any request for medical investigation. Continuity of care. Child R was seen by seven different GPs. This lack of continuity of care has been attributed to the requests for GP appointments being made at short notice and the practice efforts for children to seen as soon as possible. Appointments with the same GP may have led to a stronger relationship between the adolescent child and GP being formed and may have helped assessment over the eight months that the five appointments took place. Child R did have a usual GP but because the child did not attend for follow up appointments the child did not see their usual GP. Progress – The GP practice are formalising a process in order that patients are seen by the same GP at consultations where possible. This will promote and improve opportunities for continuity of care. 20 Faltering weight in children. It is recommended that height, weight and BMI are plotted on an appropriate centile chart to allow comparison with peer group and subsequent or past measurements. If this had been done the GP would have seen a worrying trend that the child had crossed from 91st to 25th centile over three years. This may have alerted the GP to the fact that the child was not gaining weight at a time when the child should have been as part of the child’s natural development and may have resulted in an assessment for faltering growth including a referral to specialist paediatric services. Sadly, the child did not attend for a GP appointment again and the child died sixteen months later. There was a clinical tool available on the GP record system which plots height and weight on growth charts for children. These had not been routinely used by GPs in the practice at the time. Progress - The GP practice is developing an electronic record template to document weight, height and BMI in children (up to eighteen years) and will use growth charts to guide their plans and follow up children where these charts identify concerns. Furthermore, local guidance is being developed to highlight faltering weight by making use of existing software which is based on NICE guidance on eating disorders (2017). This will be shared with the wider GP community and will promote and improve the early detection of faltering weights in children. Importance of providing opportunity to see adolescent children alone. Offering to speak to adolescent children alone is an important factor in healthcare. Child R attended all appointments with mother, and it was recorded in the GP record that mother had reported that Child R had been stressed at school and was being home educated until a place at grammar school became available. Offering the adolescent child, the opportunity to be seen alone without mother would have given an opportunity to explore the adolescents’ perspective but also to ask psychosocial questions which may not be answered truthfully in front of parents. This can often give an insight into the young person’s medical presentation. Children receiving EHE may have no other time to speak in private with a professional without their parent being present. EHE children having lost daily contact with school staff and potentially with friends can become isolated and may not feel able to tell their parents what is worrying them. We know that some children and young people will disclose to friends or a trusted professional rather than parents, often to avoid upsetting them. As previously mentioned, Child R did disclose to a friend by text the week before the child’s death. Progress – The GP practice recognise there was a potential gap in the way they engage with adolescents and will be mindful in future about additional risks for those who do not attend school and the need to offer an opportunity for the child to be seen alone. It is hoped this 21 will promote professional curiosity and provide an opportunity for the adolescent to speak in private about any concerns. Practice learning – It is important that GP’s use tools available to recognise faltering growth and that eating disorders are part of the differential diagnosis for this. It is important that once recognised appropriate referrals are made to secondary care services. Young people should routinely be offered appointments alone, and practices should provide clear communication about this in public areas. They should be asked screening questions as part of a brief psychosocial assessment such as HEADSSS. • HEADSSS is an interview prompt or psychosocial assessment tool to use with young people to understand their situation and concerns around Home / Education / Employment / Activities / Drugs / Sex (& relationships) / Self harm (& depression) / Safety (&abuse). Royal College of Paediatrics and Child Health, 2003. Promoting child welfare in school and elective home education settings National guidance in 2017 made clear that parents had a right to decide to home educate their child at any stage up to the end of compulsory school age (5 – 16 years). This right applies equally to parents of children with special educational needs. Home education may also be used to meet the requirement to participate in education or training up to the age of 18 years. In England, education is compulsory but schooling is not. Under section 7 of the Education Act 1996, the responsibility for a child’s education rests with their parents. Parents who home educate their children have the ultimate responsibility for ensuring that the education provided is efficient, full time and suitable to the child’s age, ability aptitude and any special educational needs that they may have. Parents are not required to provide a broad and balanced curriculum and do not have to follow the national curriculum. Local authorities have no duty in relation to the monitoring of the quality of home education on a routine basis. However, they do have duties to make arrangements to identify those children not receiving suitable education and to intervene if it appears that they are not. Intervention could take the form of issuing a School Attendance Order via the magistrate’s court. Local authorities also have a duty to make arrangements to ensure that their education functions are exercised with a view to safeguarding and promoting the welfare of children. (Education Act 2002, Section 175(1)). This section does not extend existing powers to make home visits for the purpose of seeing and questioning children about the suitability of their education. As part of their safeguarding duties, local authorities have powers to insist on seeing a child to enquire about their welfare but this is separate from the purposes of establishing whether they are receiving a suitable education. 22 Updated elective home education guidance (2019) para (7.2) clarifies the EHE service role to share relevant information about individual children and para (7.4) clarifies local authorities es approach to considering “suitable education” and states that local authorises should be ready, if a lack of suitable education appears likely to impair a child’s development, to fully exercise their safeguarding powers and duties to protect the child’s wellbeing. The structure of the local EHE service since 2016 had been that there was an EHE Officer sitting within the School Place Planning Team. Home visits were made by a group of associates who were self-employed professionals with a teaching or other education background. Their work was administrated by two members of the business support team. At the time this structure was consulted upon EHE numbers were significantly lower than they are at present. The structure was designed to provide parental guidance about their responsibilities and to monitor the appropriateness of the education plans. As previously stated, the EHE service had no information sharing links with the school health service and this area has since been addressed. In relation to Child R there are a number of school/EHE practice learning areas identified as follows: Transition from school to EHE. Prior to being home educated Child R attended a local secondary school where the child was seen as being quiet, hard-working and making good academic progress. The child had one particular close friend and a number of other friends in the child’s school year. There had been some concern around less than optimal school attendance in Year 7 and 9 and this was appropriately managed by the school by contacting the parents. Immediately prior to Child R leaving school staff had raised some concerns about Child R which were recorded on the schools “my concerns” IT system. This system was used in school for sharing concerns about pupils with other members of staff. Concerns related to the child phoning home to be collected early and appearing “gaunt and pale”. It was agreed that school staff would monitor the situation in school. However, Child R only attended a further two days and the opportunity for school to monitor the situation over time was lost. The concerns identified were shared with mother who reported that Child R had been ill and was anxious about sitting the exams for Grammar school. This was the first time that school were aware of the parent’s intention to change schools. Following Child R’s death, the teaching staff have reflected and report that there had been no signs that the child had lost weight and there were no concerns about anorexia. Apparently, the school has a number of pupils with eating disorders in school and feel confident in recognising early physical signs and behaviours. Around a week following mothers’ conversation with school about concerns relating to Child R, mother notified school via email that Child R would be home educated pending a place at Grammar school. This came as a complete surprise to school who had not been approached about any parental concern or issues around the level of education and support offered to 23 the child. Child R had been making good progress and had received a very promising Year 9 report outlining good academic progress. The reviewer has seen Child R’s progress report for Year 9. It is clear that the child was making good progress and there were a number of positive comments from teachers including, Child R is a lovely child with a good attitude; polite, considerate and growing in confidence; shown amazing skills so far; putting 100% effort into their work; making above expected levels in some subjects. Child R was advised to engage a little more in class discussions which was a theme which ran throughout the report. Given the circumstances, there was no professional curiosity about why Child R was being abruptly removed from school roll and no face to face resolution meeting with the parents to allow the school to address any concerns. As a result, there was no opportunity to respond to concerns about school and to work with the child and parents to alleviate any problems. Practice learning – The importance of professional curiosity - Schools need to make efforts to understand the reasons why parents choose to remove children from their school roll to home educate in order to address any issues concerning individual children and to identify any school wide issues which need attention. Mother was asked by the Independent Reviewer the reason why the child left school and how she knew about home education. Mother shared that Child R was unhappy in school with the suggestion that the child had concerns about the standard of education they were receiving. According to mother the child had experienced some level of bullying and had become unsure about her friendship group. Mother was aware of home education from a local friend who was successfully home educating their own children. School were asked to reflect on whether they had been aware of any bullying or any dissatisfaction with the standards of teaching at the time. The school was not aware of either issue and were surprised that bullying had been suggested as this had not been recognised or indicated. The school in question has a robust anti bullying policy and procedure in place. Once the child had left school, the child was registered with the EHE service who requested transfer forms to be completed. The school returned an older version of the form rather than the form that they had been sent. This older form collected less detail than the revised form, and although the response received did state that there were no safeguarding concerns in relation to this pupil, there is no evidence that the school were contacted to complete the full form they were originally sent, as requested. Therefore, recent concerns identified in school were not shared with EHE which was below the level of expected practice. The programme manager for EHE at the time has reflected that had EHE been aware of the concerns identified in school he would have allocated a tutor with specialist experience in working with children and young people with mental health issues. The programme 24 manager would also have requested an “intervention meeting” to get to the bottom of the situation and seek a suitable resolution. Practice learning- Schools have a duty of care for children on their roll. Parents have a right to remove their child from school and educate them at home. Nevertheless, although it is not a legal requirement, it would be best practice for schools to consider what is in the child’s best interest prior to removing children from school roll. Schools should work with parents and the local authority to make sure that all issues are understood and addressed prior to removal from school roll. Practice learning – Schools and EHE services must share information about any concerns, even if they appear low-level and should ensure these matters have the opportunity to be addressed and to be continually monitored. Delivering EHE services At the time of this review the EHE service was experiencing an increase in the number of EHE students to be monitored while at the same time experiencing pressures to reduce expenditure. Numbers of students requiring EHE services was as follows: • April 2017 = 591 / advisor refusal = 29 • April 2018 = 674 / advisor refusal = 21 • April 2019 = 834 / advisor refusal = 199 There was also in increase in parents who refused the services of the EHE advisor which is of concern because it may be leaving children even more vulnerable. This area of service concern should consider a review for this aspect of the service to better understand the context of this issue if not already known. In this case, the child and parents were allocated an experienced EHE advisor who made an initial visit to the home and then provided annual reviews. The EHE made a total of three visits and found the education programme being provided to the child was of good quality. The reviewer has seen some beautifully well-presented work which was produced by Child R during home education. During the EHE visits the advisor saw and spoke to Child R at length. Their impression was that mother and child had a good relationship and that home education was well planned. There were no concerns raised in relation to Child R’s welfare and the advisor had no concerns. The advisor knew how to report any welfare concerns to the EHE manager and had done so in the past in other cases. Following Child R’s death, the EHE advisor reflected on the child’s appearance at the last annual visit. He observed that the child was seated of the sofa throughout the visit and the child was wearing several layers of clothes in hot weather. The child wore their hair down which covered most of the child’s face. The child had sounded optimistic about the future 25 and was looking forward to post 16 and post 18 education. In hindsight, there may have been some physical clues of the child’s weight loss but the advisor had no reason for concern at the time. Practice learning – Importance of professional curiosity for EHE advisors when working with parents and children at times when children are presenting differently from previous visits. Change may present in many forms including physical, emotional, behavioural or educational. What we now know from the police investigation of Child Rs mobile phone is that the child was spending a lot of time working out and exploring how to lose weight on YouTube when parents were out of the home working. It is not uncommon for sufferers of anorexia nervosa to cover their body with several layers of clothing to prevent others from noticing their weight loss and too conceal their condition as previously stated. Also, wearing hair over of the face can be a sign of trying to hide away. Practice learning - EHE advisors need to develop a focus on contextual safeguarding and to think more broadly about the home educated children and young person in the context of the environment and circumstance they are in. This should include wider questioning and use of professional curiosity beyond educational planning. Selective Grammar School Parents want the best for their children in terms of their education and happiness. A place at a selective Grammar school is an option that many parents wish to pursue in the belief that this is in their child’s best interest. When Child R became unhappy at school mother tried to secure a place at a Grammar school with an excellent reputation, which was approximately thirteen miles away. Mother was willing to take the child to school every day and as long as the child could pass the entrance exam there did not appear to be a problem. The child passed the entrance exam and was placed on a “reserve” list to attend the Grammar school if and when a place became available. “Congratulations on what, I am sure you must regard as good news”. “Please note, however, that reaching the standard in the tests does not in itself guarantee your child admission to the schools Year 9 is currently full. Your child will now be placed on the reserve list, and we will contact you should a place become available”. Mother and possibly the child initially sent begging emails for a place at the school but the school had no place for the child and a brief response was provided. What the parents and child did not understand and were not told, was that it was highly likely that Child R had zero chance of ever getting a place at the school because of the school’s admission criteria. The child was left in limbo whilst waiting for a school place which was never going to materialise and the opportunity was then lost for other school options to be explored. 26 Practice learning- When popular schools have children on waiting lists parents and other relevant agencies should be provided with realistic advice on the likelihood of a place coming available. In this way parents or services such as EHE can discuss an alternative school placement if appropriate. Initially, EHE was seen as an interim arrangement whilst awaiting a place at Grammar school. This position was left to drift without being reconsidered in terms of whether EHE was still the best course of action for the child. A system for more radical review of EHE placements would have been helpful. For example, the decision of where and when the child would sit GCSE’s was never fully addressed. What was needed was a broader review around the appropriateness of her home education not simply a review of whether or not home education was being adequately provided. Practice learning – EHE should develop a system to ensure that interim and short-term home education arrangements do not drift without appropriate review of a return to school as a viable option. EHE Progress Since September 2019 the safeguarding training of EHE advisors has been monitored by the EHE administration team. Further training on contextual safeguarding and learning from this case has been provided. In September 2019, the responsibility for monitoring EHE transferred to the leadership of the Team Manager for Fair Access who is the responsible person for children missing education in the area. A new full-time officer post has been appointed to co-ordinate the work of three of the most experienced EHE associates available, these associates are now employed on a higher rate to act as programme managers to improve co-ordination of the service. The team of associates and the two business support staff continue to fulfil their original roles, and additional associates have been engaged to meet the growing need for home visits. Practice learning – All public services working with children should regularly review the level of service and quality of service provision in order to keep pace with the changing requirements of children and young people. Good Practice There was a number of good practice examples recognised across the time period of this review as follows: • “My concerns” IT system in school for monitoring and sharing low level concerns for individual children appeared to work well and was used appropriately. 27 • GP same day availability for children – the practice worked hard to ensure that children are seen as soon as possible All agencies have worked hard to follow up on any practice issues which needed resolving as addressed in this review. in particular, the GP Practice has highlighted practice areas where progress has been made. These practice areas may have relevance for all other GP Practices in the area. Practice Issues There were a number of practice learning issues identified by the individual agencies and these have already been addressed to reduce the chances of this situation ever happening again. A lack of professional curiosity is a golden thread which was a feature in all agency reports. The barriers to professional curiosity and how systems are used to support professional curiosity need to be considered across the partnership. The reviewer got the impression from the reports that agencies were presented with what could be called a “normal, average family” and were too willing to take everything which happened at face value. This resulted in a lack of understanding about the needs of the child and family and may have allowed opportunities for recognising the signs of social isolation and eating disorder to go by undetected. Conclusion This CSPR outlines the tragic death of a child who was receiving EHE. The child and family did not pose any particular “problem” to any of the agencies involved and professionals did not seek to fully check out what was happening in the life of the child. There was a thirteen-month period when the child did not see any professional at all and this raises the question about what more can be done to identify those children who may be at risk of harm and are effectively lost from the view of professionals. National EHE guidance (2018) reflects on areas of safeguarding and the role of social care but it does not provide any robust focus on promoting the child’s welfare. With more children than ever before becoming EHE, there should be a national consideration for future amendment of the EHE guidance. This CSPR provides insight and reflection for the Nottinghamshire Safeguarding Children Partnership. The majority of required improvements have already taken place as identified in this CSPR. Perhaps the key learning theme throughout this CSPR was one of professional curiosity and the importance of asking questions to better understand children and families even when on the surface there are no apparent concerns. This review should be shared to promote learning across the safeguarding partnership. 28 Recommendations The following recommendations are for the consideration of NSCP as follows: Recommendation 1 NSCP should review the material available to parents to help them recognise the signs of Anorexia Nervosa and the importance of early diagnosis in children. Intended outcome – To improve parental awareness of Anorexia Nervosa and importance of early intervention. Recommendation 2 NSCP should progress work to raise awareness across the partnership in the following areas: • Early recognition of children with eating disorders. • Professional curiosity and how to promote this within systems. • Increased vulnerabilities such as social isolation of children and young people who are EHE and the role of the EHE service. Intended outcome – To increase the awareness of the frontline workforce across the partnership. Recommendation 3 NSCP should request quality audit evidence from the local authority that the recently reconfigured EHE service has the capacity to function appropriately and that EHE advisors have increased their role to consider individual child welfare as part of their routine visits. Intended outcome – For NSCP to be assured that the EHE is functioning appropriately and individual EHE children are having their welfare promoted. Recommendation 4 NSCP should request quality assurance evidence from the local authority that all schools in their area are taking steps to identify and support children and parents during decision making about moving from school into EHE. Intended outcome – For NSCP to be assured that schools are considering the best interests of children prior to moving into EHE. Recommendation 5 NSCP should explore the possibility of agencies flagging their children records to identify those who are receiving EHE on their systems. Intended outcome –. To ensure professionals can quickly ascertain the educational status of the child and factor this into their clinical assessment. Recommendation 6 NSCP through its links with the National Child Safeguarding Practice Review Panel, should consider requesting a National Review on EHE to change non-statutory guidance to improve opportunity to promote the welfare of children receiving EHE. Intended outcome: To better promote the welfare of all children receiving EHE. 29 References Protecting Children in Wales – Guidance for Arrangements for Multiagency Child Practice Reviews (Welsh Government 2012) https://gweddill.gov.wales/docs/dhss/publications/121221guidanceen.pdf Working Together to Safeguard Children (Gov. UK 2018) https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 Elective home education – guidance for local authorities (DfE 2019) https://www.gov.uk/government/publications/elective-home-education Beat eating Disorders Delaying for years, denied for months. The health, emotional and financial impact on sufferers, families and the NHS of delaying treatment for eating disorders in England (2017) https://www.beateatingdisorders.org.uk/uploads/documents/2017/11/delaying-for-years-denied-for-months.pdf The Child Safeguarding Practice Review Panel Annual Report 2018 - 2019 https://www.gov.uk/government/publications/child-safeguarding-practice-review-panel-annual-report-2018-to-2019 Mortality Rates in Patient with Anorexia Nervosa and other Eating Disorders. Jon Arcelus, Alex J Mitchell et al. (2011) https://jamanetwork.com/journals/jamapsychiatry/article-abstract/1107207 National Child Measurement Programme (Gov.UK 2013) https://www.gov.uk/government/collections/national-child-measurement-programme Triggers for Children and Adolescents with Anorexia Nervosa: A Retrospective Chart Review (J Can Academic Child Adolescent Psychiatry. 2019 Nov; 28(3): 134–140) Published online 2019 Nov 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6863573 Eating disorders: recognition and treatment – NICE 2017 https://www.nice.org.uk/guidance/ng69 Eating Disorders – NHS 2018 https://www.nhs.uk/conditions/Eating-disorders HEADSSS Assessment - TeachMePaediatrics https://teachmepaediatrics.com/community/holistic-care/headsss-assessment Education Act 2002 (Gov.UK) www.legislation.gov.uk/ukpga/2002/32/contents 30 Excessive Exercise as an Eating Disorder Symptom When Does Excessive Exercise Become Problematic? Lauren. Muhlheim. Publication. 1987. Updated 2020. https://www.verywellmind.com/excessive-exercise-eating-disorder-symptom-4062773 Acknowledgement The Independent reviewer would like to especially thank…. Dr Rebecca Sands – Consultant Paediatrician with special interest in child eating disorders for her expert contribution throughout this review in relation to helping the panel to understand the complexities of adolescent eating disorders. Also, Bob Ross – NSCP Development Manager for his organisational expertise and for his support when visiting the parents. Statement of Reviewer Independence The reviewer, Kathy Webster is independent of the case and of Nottinghamshire Safeguarding Children Partnership and its partner agencies. Prior to my involvement with this Local Child Safeguarding Practice Review; • I have not been directly concerned with the child or any of the family members or professions involved with the child, or have I given any professionals advice on this case at any time. • I have no immediate line management of the practitioners involved. • I have appropriate recognised qualifications, knowledge and experience and training to undertake this review. • The review has been conducted appropriately and with rigours analysis and evaluation of the issues as set out in the Terms of Reference. Signature: Name: Kathy Webster – Independent Reviewer Date: 29th September 20 |
NC049218 | Circumstances leading to a 15-year-old girl being placed in a secure setting in summer 2015. Rachel and her family had been known to services since she was very young due to concerns of neglect and sexualised behaviour in primary school. She had been subject to two Child Protection Plans and one Child in Need plan, and had been diagnosed with ADHD. There were continuing concerns about her safety and wellbeing, and sexual exploitation, which resulted in Rachel being accommodated by the local authority and made subject to a Secure Accommodation Order in summer 2015. Learning focuses on: better understanding by professionals and practitioners of the interplay between adolescent choice and risk, especially in relation to sexual behaviour and sexual exploitation; importance of multi-agency assessments which focus on the child's care and experiences; child sexual abuse in the family will often come to the attention of services as a result of a secondary presenting factor; the range and nature of adolescent risks are different to those facing younger children and the traditional response to such risks does not necessarily fit with young people's lived experience. Recommendations to the Local Safeguarding Children Board include: strengthen skills and knowledge base of the children's workforce so that professionals are better equipped to recognise and respond to sexual abuse within the wider family; ensure that services to young children with harmful sexual behaviour are proportionate and timely; improve the effectiveness of multi-agency practice with adolescents who are at risk due to substance misuse and other risk taking behaviours and/or abuse and exploitation.
| Title: Serious case review: Young Person Rachel. LSCB: Sunderland Safeguarding Children Board Author: Sunderland Safeguarding Children Board Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final 8th November 2017 Serious Case Review Young Person Rachel1 1 Not her real name Final 8th November 2017 2 Contents Section Page Number 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 3 2. The circumstances which led to this Review 3 3. Family Involvement 5 4. The context in which this SCR took place 5 5. The approach used 6 6. Analysis of Practice and Findings 7 Understanding complex behaviour in children and pre- adolescence 8 Risk Assessment and Planning 14 Multi-Agency working and collaboration 17 Mental health services 19 An adolescent-centred approach 20 Engaging Adolescents 24 7. The situation now 25 8. Conclusion 26 Appendices Appendix 1: Summary of Findings and Recommendations 27 Appendix 2a: SSCB Impact Statement 29 Appendix 2b: Sunderland CCG Impact statement 33 Appendix 2c: Education and School Impact Statement 35 Appendix 2d: General Practitioner (GPS) Impact Statement 36 Appendix 2e: South Tyneside NHS Foundation Trust Impact Statement 37 Appendix 2f: Northumbria Police Impact Statement 38 Appendix 2g: Together for Children (CSC) Impact Statement 39 Appendix 2h: City Hospitals Sunderland Impact Statement 42 Appendix 2i: Youth Offending Service 43 Final 8th November 2017 3 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 1.1. The main responsibilities of Local Safeguarding Children Boards (LSCBs)2 are to co-ordinate and quality assure the work of member agencies to safeguard children. The statutory guidance3, which accompanies legislation and underpins the work of LSCBs, sets out its expectation that LSCBs should maintain a local learning and improvement framework so good practice can be identified and shared. 1.2. In situations where abuse or neglect of the child is known or suspected, and children die or are harmed, LSCBs are required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce the risk of future harm to children. There is an expectation that these processes, known as Serious Case Reviews (SCRs), should be transparent with the findings shared publicly. 2. The circumstances which led to this review 2.1. Rachel and her family had been known to agencies since she was a very young child. As she grew older, concerns about her safety and well-being continued amid fears she was being sexually exploited. In summer 2015, at the age of 15, Rachel was accommodated by the local authority and made subject to a Secure Accommodation Order4 following concerns about her vulnerability, safety, and well-being. 2.2. The Youth Offender Service (YOS) referred their concerns to SSCB, suggesting that the absence of co-ordinated agency involvement and the circumstances leading to her being placed in a secure setting amounted to significant harm. They requested that a SCR be considered by Sunderland Safeguarding Children Board (SSCB). A decision was taken by the retiring SSCB chair in September 2015 to undertake a SCR in respect of Rachel, but this decision was challenged by Children’s Social Care (CSC), and the SCR did not immediately commence. The decision to commission a SCR was later reviewed in May 2016 by the incoming interim Chair of SSCB who confirmed that the 2 Children Act 2004, s14 3 Working Together to Safeguard Children 2015. HMSO 4 A Secure Accommodation Order (section 27 of the Children and Young Persons Act 2001) authorises a local authority to restrict the liberty of a Looked After child and place them in secure accommodation Final 8th November 2017 4 circumstances which led to Rachel being made subject to a Secure Accommodation Order, together with concerns about multi-agency working, met the criteria for a SCR. 2.3. At the same time as the SCR for Rachel began in September 2016, another SCR which related to a 15 year old male who had been sectioned under the 1983 Mental Health Act also began. The Safeguarding Board partners agreed that both SCRs should have due regard to any common areas of learning and should also relate these to previous recent findings from other reviews concerning adolescents. The Review Team were also asked to take into account the changes already being embedded in Sunderland, especially given that the SCRs related to roughly the same period. The Terms of Reference were agreed as: • To explore how well the system worked together in identifying, responding and meeting the needs of both young people. • To determine what collective understanding there was in terms of the young people’s vulnerabilities and the risks to which they were exposed. • Building on learning from previous [and not dissimilar] SCRs to examine the barriers and system challenges for agencies and professionals in working effectively with young people with complex and challenging behaviours. • How well were staff supported and supervised when working with these young people, and were they able to use evidence, research and good practice to exercise professional judgement in a safe and appropriate way? • Identify required system changes to enable and support practitioners to work more effectively with older children like Mark and Rachel. • Identify opportunities to learn from and improve frontline practice when working with vulnerable adolescents. 2.4. The Review Team were asked to consider the period between March 2013 when concerns were raised about Rachel and September 2015 when she was made subject to a Secure Accommodation Order. Final 8th November 2017 5 3. Family Involvement 3.1. The Review Team took advice on three occasions to determine whether Rachel could contribute to this SCR but was informed by social workers and health professionals that Rachel’s mental health was not good and she was, at the time of writing this report, extremely vulnerable. The Review Team therefore agreed not to contact Rachel directly and left open the possibility that Rachel may at some in the future want to know more about the SCR and its findings. 3.2. Attempts were made by the SSCB to involve Young Person Rachel’s Mum in the process but she declined to be involved. Further attempts will be made to share the overview report with her and if she would want to add anything to the report regarding her views on the work undertaken with Young Person Rachel and her family an addendum to this report will be published. 4. The context in which this SCR took place 4.1. In 2012 Ofsted found children’s services in Sunderland to be good but by 2015, children’s services were placed into special measures when they were deemed by Ofsted to be inadequate. As a result of that rating, many changes to single and multi- agency systems were introduced, and other longer-term improvements are currently under way. Recent monitoring visits by Ofsted in 2017 have confirmed that steady progress is being made and there is clear evidence of significant and steady improvement. 4.2. To date, nine SCR reports have been published in Sunderland and 4 more are moving towards completion. Given that all these SCRs have reviewed practice up to and including 2015, it is not surprising that some of the findings also reflect those identified in the Ofsted report. The challenge therefore for this SCR was to ensure that any findings were viewed against a landscape of significant change within and across the authority which continues to emerge and develop. A Thematic SSCB report commissioned after the tragic deaths of two adolescents had also led to some significant changes in processes and systems in Sunderland, some of which have already been introduced and some of which, at the time of writing this report, are still in progress. There is an acknowledgment by SSCB that there is still much to be done in Final 8th November 2017 6 relation to work with adolescents but it is encouraging to see this work has been identified as a priority in the 2017 – 2019 SSCB Business Plan. 4.3. In light of this context and in relation to the findings in this SCR, the Review Team has sought to identify where changes have taken place, where changes are in progress and where further work is still required. It must also be reiterated that this SCR is reviewing practice 2 to 3 years old, and whilst other SSCB reviews and the Ofsted monitoring visits suggest that the improvement journey is still on-going, there is evidence of steady progress being made to achieve better outcomes for children and young people in Sunderland. 4.4. The Review Team was grateful to the practitioners involved in this review who willingly engaged in this process and volunteered their reflections and professional insights, which have helpfully contributed to this report. 5. The Approach Used 5.1. A Review Team was established which included senior managers from all agencies which had worked with or knew Rachel and her family. The Agencies represented were: • Independent Lead Reviewer • SSCB Business Manager SSCB • Detective Inspector Northumbria Police • Lead Policy Officer Sunderland City Council • Head of Educational Attainment & Sunderland City Council Lifelong Learning • Operations Manager Youth Offending Service • Chief Social Worker Sunderland City Council • Deputy Head of Safeguarding & Public Northumberland, Tyne & Wear NHS Trust Protection • Lead Nurse Safeguarding STFT • Community Safety & Safeguarding Gentoo • Named Professional for Safeguarding North East Ambulance Service • Safeguarding Children Lead Nurse & Sunderland Clinical Commissioning Group Designated Nurse for Looked After Children Final 8th November 2017 7 5.2. Senior managers from the above agencies identified practitioners from their own agencies who knew or had worked with Rachel during the period under review. These practitioners were known as the ‘Practitioner’s Group’ and were invited to an initial introductory session so they could be briefed on the SCR process and offered an opportunity to discuss lessons from previous SCRs and how and where these had relevance for their work with Rachel. 5.3. The practitioners were extremely forthcoming about the issues they faced in their day to day work and their reflections of the challenges of working with Rachel and other adolescents were particularly illuminating. The Practitioners’ Group later came together for a full day with the Review Team and other practitioners who worked with adolescents, to discuss and to explore whether single and multi-agency systems and processes were changing to better support existing work with adolescents. 6. Analysis of Practice and Findings 6.1. The purpose of Serious Case Reviews is to support improvements in safeguarding practice. This means it is not sufficient just to describe professional activity in a case or to identify elements of practice that were problematic, without explaining why they occurred. The analysis needs to provide an explanation of what influenced professional activity and decision-making at key points in the management of the case. The Review Team were aware of how hindsight can distort judgment but wanted to understand why certain actions and decisions would have made sense at the time and importantly, what systemic factors in place then, were still impacting upon practice in 2017. As the Review Team were asked by the interim SSCB Chair not to request Agency Learning Reports 5 , the integrated chronology and the views and experiences of front line practitioners were key to understanding why some professionals acted as they did or why they did not act at all. 6.2. This SCR has not identified a significant contravention or action by any professional that was a critical factor in what happened to Rachel. Indeed there was evidence that many professionals with whom Rachel came into contact were concerned about her welfare and safety and sought to engage her or seek access to other services. The learning 5 This request was made as the agencies had only recently participated in two other SCRs and a Thematic Report relating to adolescents and concerns were expressed about duplication of effort and of learning. Final 8th November 2017 8 from the SCR does, however, invite and require a better understanding by managers and practitioners in education, health and social care of the interplay between adolescent choice and risk, especially in terms of sexual behaviour and sexual exploitation; the importance of shared assessment processes for children showing indicators of need or vulnerability; and the management of concerns and referrals when dealing with young adolescents whose life style, circumstances and mental capacity may be factors that require a more assertive and inquiring approach. 6.3. The Review Team was concerned to note that although a probation officer on secondment to YOS was the lead worker for this young person during her involvement with the YOS service, on return to her agency, she was not given permission to contribute to this review. Although concerns were escalated through to senior management in the Probation Service, the SCR was left without the benefit of contributions from that practitioner. Assurance has been provided by the National Probation Service that the learning from the work undertaken has been addressed in the agency. Understanding complex behaviour in children and pre-adolescence 6.4. Concerns about parental neglect in the family are first recorded when Rachel was a very young child. The term ‘neglect’ is used to describe a variety of behaviours with varying impacts on children and young people but at its heart, ‘neglect is essentially parental failure to meet the needs of the child’.6 The harm resulting from neglect can be wide-ranging and life-lasting and the longer a child is exposed to neglect, the greater the harm is likely to be. Neglect is also thought to be the most likely form of maltreatment to recur multiple times; its effects are cumulative. 6.5. As Rachel grew older, concerns about the physical and emotional care within the family continued and there were frequent reports about her parent’s lifestyle and that children in the family were often left in the care of a slightly older family member. As a result of a concern about Rachel’s sexualised behaviour when at primary school, a social worker undertook an initial assessment, but following discussions with family members no further action was taken. However, concerns about the behaviour of the children in the family continued to emerge. 6 Howarth J Neglect Planning and Intervention (2013) Final 8th November 2017 9 6.6. Pre-adolescent children with particular types of behavior problems (such as sexualised behavior) are a diverse group with differing levels of need who display a wide range of problematic behaviours that are beyond what might be considered ‘normal’ for their developmental stage. Such behaviours may emerge as a direct consequence of children’s own experiences of abuse, or may represent a more complex and indirect response to trauma and neglect. Rachel’s worrying behaviour at such a young age should have alerted professionals to the need for further more detailed assessments, if not under child protection procedures then certainly under child in need arrangements. 6.7. Rachel was diagnosed with ADHD when she was young and the naming of her ‘condition’ seems to have distracted professional’s attention from thinking more deeply about what may have been happening in her life. The Review Team found that the frequent references in agency records to Rachel’s ADHD in relation to her risk-taking and self-harming behaviours indicated that professionals accepted ADHD as a purely objective medical diagnosis. The risks for children with ‘labelled conditions’ are that their basic needs, which have nothing to do with their condition, can be disregarded, as the focus is more on the perceived problems arising from ‘the condition’. In addition, very often, their parents are seen as deserving of extra support and sympathy rather than an assessment as to whether they are adequately meeting their children’s needs. Reading through case notes, the Review Team found evidence that this was the case with Rachel and practitioners acknowledged that medical labels like ADHD could sometimes throw professionals off track. 6.8. If neglect is not routinely considered as a factor affecting young people with complex problems and behavioural difficulties, thorough assessments of the adequacy and quality of their parenting will not be made and this can leave them vulnerable. There is little evidence to suggest consideration of how the ADHD diagnosis came about and whether the experience and impact of adverse childhood experiences could have better explained Rachel’s behaviours. These issues should have been explored in far greater detail then and in the many assessments to which Rachel was later subjected. Finding 1: Without robust multi-agency assessments, which focus on the child’s care and experiences within the family, the needs of children who have been diagnosed with a ‘condition’ may be overlooked Final 8th November 2017 10Findings previously identified in SCRs/Thematic Report: Multi-agency assessments/Use of Assessment tools to aid professional judgment 6.9. In 2014, the Office of the Children’s Commissioner Concerns published the results of an inquiry into child sexual exploitation in gangs and groups. The inquiry found that ’...so many young people told…of their early histories of being sexually abused within the family home and of their experiences never being acknowledged’7. Research suggests that children and young people are often identified as victims of sexual abuse following the provision of support for other presenting problems, such as challenging behaviour, substance or alcohol abuse or missing from health and education. Some of these are problems which may already have been present in the child or young person’s life or environment; however, many of the factors which bring the child or young person to the attention of professionals may also result from the impact of the sexual abuse. Upon reading and listening to details of Rachel’s background, it appears highly likely that Rachel was subject at an early age to some form of sexual activity/abuse and yet this and its impact on Rachel as a young child, and as she became an adolescent, appears at best to have gone unrecognised and at worst was disregarded. 6.10. The Children’s Commissioner Inquiry suggests that while society now better recognises the existence of the sexual abuse of children by family members or people close to their family, and child protection practice has improved over the last two decades, the outcomes for children do not appear to have improved. The numbers of children made the subject of a Child Protection Plan for sexual abuse has fallen steadily over the last decade and it could be suggested that this decline, which is not commensurate with what we know about the overall prevalence of CSA8, has resulted in, or has been the result of, declining levels of professional understanding and awareness in relation to the issue of CSA. 6.11. It is important that professionals can spot the signs and symptoms of sexual abuse. This is not a straightforward task – the signs and symptoms are not always clear cut, and there are few signs which very clearly and conclusively point to sexual abuse. However, Rachel’s behaviour from such a young age and the nature of that behaviour towards other children was a very clear indicator that she had been subjected to or had 7. The Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation In Gangs and Groups 2014 8 See How Safe are our Children. NSPCC 2016, Final 8th November 2017 11witnessed some form of sexual activity and was acting out this behaviour with other children at school. 6.12. Overall, as with any type of abuse, there is an overreliance on children to come to statutory services to disclose abuse happening to them, but the focus must always be on professionals being attuned to changes in behaviour of children, their emotional responses and other indicators that those things are not going well in their lives. However, before any careful and sensitive outreach towards a child can take place, professionals must first consider a number of hypotheses to explain a child’s behaviour and sexual abuse should always be considered even though it may be discounted then or later. In Rachel’s situation, this appears not to have happened and the family’s self-reporting to social workers undertaking the Initial Assessment that nothing was amiss in their family was accepted at the time and during conversations which took place in the following years. 6.13. The younger the person when problematic behaviours first appear, the more likely they have experienced adversities, such as being victims of child sexual abuse. If their trauma is never validated or addressed, or they were never supported towards recovery, research shows that as a consequence they can enter adolescence highly vulnerable to subsequent exploitation.9 New Finding 2: Child Sexual Abuse in the family environment will often come to the attention of statutory and non-statutory agencies as a result of a secondary presenting factor, which then becomes the focus of intervention. If professionals are not skilled or confident in their ability to identify child sexual abuse, children may be left at risk Understanding of risk in adolescence 6.14. The risks adolescents face are distinct. They differ from those facing young children and older groups, as do the impacts of those risks. Research10 suggests it is not that the risks are greater or lesser than young children, it is that they are qualitatively different; for example sexual abuse at a young age is more likely to lead to sexualised behaviour, anxiety and hyper-arousal whereas sexual abuse or sexual exploitation in adolescence is associated with high rates of post-traumatic stress disorder (PTSD) and lower 9 ‘Children’s Commissioner: Inquiry into Child Sexual Abuse in the Family Environment (2014) 10 Child Sexual Abuse: Consequences and Implications Gail Hornor, RNC, MS, PNP DISCLOSURESJ Pediatr Health Care. 2010; Final 8th November 2017 12psychological functioning. Certainly, Rachel’s past and present self-destructive behaviors appear indicative of some sort of childhood trauma, and there is strong evidence of PTSD which appears to have gone unrecognised. 6.15. The Review Team could find no clear rationale as to why protective action was not taken earlier for Rachel, i.e. before 2015; she was associating with known sex offenders, misusing substances and openly talking about risky sexual behaviours. Practitioners suggested that at the time sexual exploitation of children was not well understood locally or nationally despite statutory guidance being in place since 2009.11 They added that volume of work, poor leadership and a lack of joined up working by agencies meant that work with Rachel just ‘kept on going’, and without any good assessments or effective multi-agency planning, work was not as effective as it might have been. In times of competing priorities it is often work with adolescents that is deprioritised, especially if there is an organisational or sometimes a professional mind-set which holds the view that because of their age, adolescents are more ‘resilient’ and can ‘walk away’ from harm, unlike a young child. 6.16. Underpinning this view is an assumption that some of the risks encountered by adolescents are a result of choices that are ‘freely made, informed and adult-equivalent’. The Review Team was interested to note evidence of this assumption implicit even in agency records where Rachel’s behaviours were described as: ‘placing herself at risk’, ‘associating with known sex offenders’, ‘acting impulsively’, and ‘choosing to self-harm’. It is important that professionals and managers are supported to think carefully about the terminology used to describe the risks faced by adolescents. Language provides a medium for describing perceptual experiences and views and therefore has an extraordinary capacity to influence the way we think.12 Professionals can compound misconceptions through their attitudes and inappropriate language and euphemisms – for example, by describing a 12-year-old girl as ‘sexually active’ or describing a 35 year old male as a 14-year-old’s ‘boyfriend’ as opposed to an abuser or perpetrator. 13 Additionally, the response of practitioners may reflect faulty assumptions 11 Safeguarding children and young people from sexual exploitation. DCSF (2009) 12 This is sometimes called the Sapir-Whorf hypothesis. ‘ Language may indeed influence thought’ Jordan Slatev and Johann Blomberg. Phil Papers October 2015 13 Dr Helen Beckett: ‘Not a World Away’ (2011) Barnardo’s Final 8th November 2017 13that young people or adolescents are more resilient than younger children by virtue of their age, despite having experienced more cumulative harm.14 6.17. The view that Rachel was ‘placing herself at risk’ should have been challenged in supervision and professionals supported to be more curious about the reasons why Rachel was behaving in this way. Research 15 suggests that where choice and behaviour are playing a part in the lives of children with complex needs, this is typically because one or more of the following factors or processing are at work or are interacting; • Normal adolescent developmental processes (risk taking, peer influence, the desire for high status with friendship groups) • Adaptive behaviour in response to previous maltreatment and adversity • Societal attitudes and policies which increase risk or harm in response to adolescent choices and behaviour i.e. responding to youth offending which inadvertently reinforces criminal identity. 6.18. A challenge for professionals however was in determining which of the above factors better explained Rachel’s self-harming behaviours. There is evidence that views of professionals were influenced initially by a perception that this was ‘stroppy teenager wanting attention’. Police records clearly indicate this view. The Review Team concluded that it was this perception, without analytical assessments, multi-agency collaboration, and challenge and quality supervision, which prevented earlier intervention. 6.19. It would have been helpful had these workers, supported and guided by their managers, been more curious about why Rachel was behaving as she did rather than try to manage or stop her destructive behaviour. Simple though this may sound, the Review Team did recognise this as a challenge in itself requiring, as it does, a definite paradigm shift in how services to adolescents are delivered. It seemed on reading through the integrated chronology for Rachel that social workers and other professionals were often drawn into a cyclical and constant pattern in which her behaviour determined what 14 Nicky Stanley (2011) Children experiencing domestic violence A Research Review 15 Research in Practice, Developing a more effective response to risks in adolescence (2015) Final 8th November 2017 14services were offered to the family, and when. Consequently, interventions were far too frequently crisis driven and appear to have focused solely on her presenting behaviours. 6.20. There is a growing awareness across the UK about child sexual exploitation (CSE), and since 2009 there have been an array of public documents aimed at local authorities to advise about how to recognise and respond to concerns about CSE. Even so, as late as 2014 professionals in Sunderland were slow to respond to the vulnerabilities of Rachel as a child whose behaviours indicated she was not just at risk of CSE, she was actually being significantly harmed through sexually exploitation. Practitioners suggested that even at that time the systems for reporting and responding to CSE were not well embedded in any agency and certainly not within a multi-agency framework. Ofsted reported in 2015 that the Sexual Exploitation and Missing (SEAM) processes for responding to and working with children at risk of CSE were not working and they were subsequently strengthened and replaced with Missing, Sexually Exploitation and Trafficked (MSET) arrangements. The SSCB has this area work identified as another priority in its 2017 – 2019 Business Plan. Risk Assessments and Planning 6.21. Rachel was subject to numerous assessments during 2013 and 2015 but the Review Team could find no evidence of any quality risk assessments which sought to identify her needs or which captured views and information from Rachel herself or from other agencies such as YOS, CAMHS or education. It is these assessments which are so essential to the development of carefully designed and purposefully maintained child in need, child protection plans and safety plans. Although the focus of risk for Rachel centred on sexual exploitation, she was also at risk as a result of her childhood experiences, her disengagement with education and the fact she was misusing substances and alcohol. 6.22. A child or young person is considered to be at risk of significant harm if the circumstances that are causing concern for the safety, welfare or wellbeing of the child or young person are present to a significant extent. Rachel was clearly not just at risk of significant harm, the harm was evident. Agency records highlight that whilst some risks to Rachel were well understood, they were not well managed. The purpose of risk management is to either identify potential problems before they occur, allowing professionals to make choices to avoid, minimise, or mitigate potential harm. By pre-Final 8th November 2017 15empting and managing risks, practitioners and managers make strategic choices about which types of risks to accept and which to avoid. 6.23. It is clear that until decisions were taken in September 2015 to seek a Secure Accommodation Order, professionals were of the view that risks to Rachel could be managed and the harm to her minimised, but without a robust multi-agency safety or child protection plan, Rachel remained at significant risk and highly vulnerable. 6.24. There is considerable research16 which suggests that without the use of tools to assess risk, professional judgment is too often found to be flawed. The Review Team found no evidence that any risk assessment tools were used to aid professional judgment in terms of risks to Rachel. Practitioners told the Review Team that they were unaware of any multi-agency risk assessment tool they could have used with Rachel to inform their practice or decision-making and without this, agencies inevitably resorted to their own systems when undertaking risk assessments and opportunities to share information with other agencies were lost. 6.25. There is little to evidence that assessments took into account parenting lifestyle, and the family dynamics do not appear to have heightened concerns or led to any assessment process. Rachel was made subject to a child protection plan in 2013 and although this was stepped down to child in need status, it is difficult to identify what improvements or changes had been made in the family. Concerns that mother could not keep her daughter safe were even then apparent and remained so until Rachel was again placed on a child protection plan two years later. The ‘rule of optimism’ that can affect assessment and decision-making in child welfare and child protection work is well documented.17 Rachel’s’ mother at times appeared to be working with professionals and this, professionals acknowledged, gave the impression of collaboration. However, a seemingly co-operative parent such as Rachel’s mum also has considerable power to disarm and distract professionals from what is or might be happening in their family. There is evidence that suggests that Rachel was seen within her family as the ‘problem’ and professionals mirrored this view in the way in which they intervened. 16 www.rip.uk 17 Humphreys C. and Stanley N. (eds) 2006. Domestic violence and child protection. Ofsted 2011b. Ages of concern: learning lessons from serious case reviews: A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 Final 8th November 2017 166.26. The dilemma of how to work to a strengths-based approach, whilst also maintaining a critically evaluative focus on whether parental avoidance is happening is well documented.18 It suggests that professionals often place too much reliance on what parents say and fail to consider that families can be resistant to contact from professionals and are able to develop skillful strategies for keeping them at arm’s length. The possibility that this could be the case with Rachel was not explored. Finding 3: Without a purposefully designed multi-agency risk assessment tool, embedded within all organisations and accessed through a single point of access, professional judgments about risk are more likely to be flawed and this will reduce the likelihood of effective interventions leaving some young people vulnerable. Findings previously identified in SCRs/Thematic Report: Use of Assessment tools including risk assessments to aid professional judgment 6.27. The Review Team discussed with practitioners the single and multi-agency systems in place to support the production and maintenance of quality records and in particular why chronologies, an essential and invaluable assessment tool, were not used to better effect. The Review Team were of the view that practitioners were not being negligent in not ensuring that chronologies were maintained but that inadequate and failing ICT systems, pressure of work and not having enough time combined to make the production and upkeep of useful and effective chronologies less likely. Inevitably, this leads to criticisms when chronologies are either missing from reports or full of inaccuracies. Whilst professionals acknowledged that the time has yet to come when single agency IT systems communicate with each other, they also pointed out that there is currently no system or agreed process in place to support the production of shared chronologies within a multi-agency framework. They suggested this would be a welcome development and one which would have a significant impact on shared decision-making. 6.28. This issue has been raised repeatedly in SCRs, both locally and nationally. It will always be practitioners who must determine the key events in a case and the degree of impact on the child, and learning what should be transferred into a chronology is an important skill which managers must help all professionals to develop. Without functioning IT systems it will remain a challenging task. Creating integrated 18 Ofsted, 2008, Evaluation of 50 SCRs Final 8th November 2017 17chronologies for SCRs for example is time consuming and costly but unless there are more simplified systems and clearer expectations that these must be produced when opening, reviewing or closing a case, practitioners will struggle to see the child’s history and the significant events and transition in their lives. To do justice to chronologies,, practitioners need to spend time with families and the Review Team was told that very often that time is simply not made available to establish good working relationship with adolescents and their families. Finding 4: When concerns are raised about a child, a clear chronology of events can show agencies where risks lie, but unless practitioners understand how to build and maintain purposeful chronologies, and without clear systems to gather, record and share this information, the use of chronologies to inform good assessments and decision making is less likely to happen. Findings previously identified in SCRs/Thematic Report: Use of Chronologies as multi-agency tool Multi-Agency Working and Collaboration 6.29. Rachel was made subject to two child protection plans and one child in need plan, but all three plans were of very poor quality. They did not clearly identify defined goals, expected outcomes, or the measures by which progress could be measured. In effect the plans were not SMART 19 and consequently they did not drive forward any sustainable improvements in Rachel’s life. Despite the information available, the plans did not pull together how Rachel’s emotional, physical educational and safety needs would be addressed by key practitioners. The plans that were used in Sunderland to protect and safeguard children at that time appeared cumbersome, complicated and were not child/parent friendly, making them difficult to follow and largely ineffective. Significantly, the Review Team shared that although the plans in current use were significantly improved, they had not been designed from a multi-agency perspective. 6.30. The importance of an integrated professional group being accountable for safeguarding children rather than confining the responsibility to children’s social care was stressed in Munro’s20 first two reports on the child protection system (2010, 2011). Research21 19 Specific, Measurable, Achievable, Realistic and Timely 20 The Munro Review of Child Protection: Part 1: A Systems Analysis, 2010; Part 2:The Child’s Journey 2011 Final 8th November 2017 18suggests that the value of such inter-agency collaboration is widely accepted by professionals, including those working in adult services, who now are more likely to regard themselves as part of the child well-being system. However, ensuring that practice reflects these principles is not always easy, despite the support of national policy and guidance. 6.31. The Thematic Report commissioned by SSCB and published in September 2016, concluded that in Sunderland there was ‘a safeguarding partnership seemingly operating at a basic and pragmatic level only, and working in parallel rather than in an integrated, cohesive manner 22’. Whilst this is clearly evident in reviewing practitioner involvement with Rachel between 2013 and 2015, there are also examples of some good practice and sound information sharing between professionals. Core groups took place regularly but the Review Team did not have a sense that professionals were working to an agreed plan and there is no evidence of any therapeutic work taking place with Rachel. 6.32. Practitioners intimated that within their own agencies there is still considerable reliance on their own agency procedures and recourse to multi-agency working is not always a first consideration. Other issues include barriers to specialist intervention and multi- placements, differing thresholds within each agency or differing interpretation of the thresholds. The threshold document within social care, practitioners suggested, is not user friendly and given that agencies have differing protocols the threshold document needs to be simplified in order to facilitate better multi-agency working. The Review Team found evidence that Rachel was referred back and forth between early intervention and CSC, and until the intervention of the YOS worker, Rachel’s education needs were largely ignored for almost a year. 6.33. Practitioners acknowledged the benefits of multi-agency working but suggested that actually collaborating across agencies is not always easy, given time and other workload pressures. Research carried out by ADCS23 suggests that many areas in the 21 Children’s needs – Parenting capacity Child abuse: Parental mental illness, learning disability, substance misuse and domestic violence DFE 2011 22 Children’s needs – Parenting capacity Child abuse: Parental mental illness, learning disability, substance misuse and domestic violence DFE 2011 23 ADCS is a membership organisation. Its members hold leadership roles in children’s services departments in local authorities in England. They specialise in developing, commissioning and leading the delivery of services to children, young people and their families, including education, health, youth, early years and social care services. Final 8th November 2017 19UK are seeing an increase in adolescents such as Rachel coming to the attention of formal Child Protection services and without sound and effective multi-agency working, interventions are likely to be less than effective. 6.34. Practitioners stated that they knew the value of multi-agency working but suggested there was and still is a need for greater clarity as to when professionals should have recourse to multi-agency meetings outside CIN and CP processes, and what the status of those meetings should be. Agencies confirmed there remains a tendency to give greater priority to meetings called by CSC than by other agencies and this led the Review Team to conclude that more could be done to ensure that systems and processes better support multi-agency working. Finding 5: Multi Agency assessments and planning are key to supporting better outcomes for children and young people but this requires close collaboration between agencies and inevitably raises the question of who takes responsibility for coordinating this work. Multi-Agency collaboration did not work as well as it should have done with Rachel and this left her vulnerable. Finding previously identified in SCRs/Thematic Report: Multi-agency information sharing and collaboration Mental Health Services 6.35. The work with Rachel as an adolescent was certainly constrained by an issue not specific to her but related to the legislative and professional framework within which professionals were working, namely the lack of placement options which could offer care and security to children with complex and demanding needs. As Rachel’s behaviour became more concerning and her self-harming behaviours even more serious, professionals sought mental health assessments but were continually advised that Rachel was suffering from a conduct disorder and not a mental illness. This meant that professionals were unable to access a bed on mental health grounds to keep her safe. 6.36. The question of diagnosis of mental illness in young people is a vexed one. Adult mental health disorders such as schizophrenia or bipolar affective disorder occurring in adolescents are clearly psychiatric disorders, which affect the behaviour of the Final 8th November 2017 20adolescent and are treatable conditions. Young people who have suffered considerable emotional damage can present with behaviours of an antisocial nature and/or self-harm, and like Rachel, can sometimes too easily acquire the diagnoses of conduct disorder (and later in life, borderline personality disorder). These disorders very often respond poorly to mental health interventions in adolescence, and the lack of treatment for these conditions often leads to considerable frustration for parent and professionals. 6.37. Professionals face particular challenges when seeking placements which would meet all the needs of troubled young people. Such resources have always been expensive, and providers are selective regarding whom they will accept. This places an immense burden on responsible professionals in securing a suitable placement. This was certainly the case with Rachel as daily attempts to find an appropriate placement were unsuccessful; the case records suggest approximately 170 providers were contacted nationwide between July and September 2015 and only one offer of accommodation was made, but the timescales did not coincide with what was needed for Rachel. Faced with finding such resources in situations of extreme concern or pressure, it is not surprising that placements of marginal benefit are sometimes made, and occasionally decisions that are wrong in absolute terms are made. Even without hindsight, professionals knew that placing Rachel in a supported house, albeit with a bespoke package of care, was not ideal and had the potential to place her in even greater danger, but at the time options were limited and this was seen very much as the least worst option. 6.38. Although a decision had been made to obtain a Secure Accommodation Order for Rachel on welfare grounds, the fact that no accommodation was available offers a rationale as to why social workers pursued the possibility of obtaining a bed via mental health provision, but as Rachel was not and could not be diagnosed with a mental health disorder this in effect was not an option. An adolescent –centred approach 6.39. The Review Team could find no evidence of any shared values and principles to govern specific work with adolescents in Sunderland. Reading through records and the integrated chronology for Rachel, the Review Team did find evidence of child centred work and the considerable efforts made by professionals who tried to engage with Rachel through various means. The Review Team and the practitioners considered that Final 8th November 2017 21even the term ‘child-centred’, while laudable in work with young children was not a particularly useful or appropriate approach when working with adolescents. These discussions highlighted the need for a different way of working and perhaps a different language when working with young people. 6.40. Practitioners suggested that for the most part the existing child protection/child in need systems do not adequately fit in with young people’s lives and experiences but in the absence of any different service designs they have to make the most of existing processes. It was also suggested that risks to young children are too often seen as more of a priority for services/intervention because adolescents are thought to be able to ask for help or ‘choose’ to remove themselves from risk situations. 6.41. The pathways leading to a number of harms that adolescents experience are however complex and do not easily fit with accepted child protection categories. Maltreatment in adolescence is no less harmful than maltreatment at an earlier age, indeed it could be argued that the opposite is true given what we know about the cumulative impact of harms over a given period and that adolescents are more likely to be subject to ‘polyvictimisation’ i.e. being victim to multiple forms of harm because of the external world/environment they also inhabit. 6.42. Harnessing and working with the risks of adolescent choices and behaviours is an essential aspect to them keeping safe, but existing child protection processes, public opinion and media coverage make this a particular challenge for practitioners trying to work with rather than for adolescents. 6.43. Whilst the Thematic Report urges a wide-ranging review of services to those adolescents who are known to be vulnerable, the Review Team would argue that there is an equal and perhaps more pressing need to examine how well risks in adolescence are understood in Sunderland and whether the right framework and services are in place to meet their needs. Research in Practice argues that a child protection system that is conceptualised primarily around preventing harm and maltreatment in younger children, who may be at risk within their own family, may not be well placed to serve the needs of adolescents and an adolescent- centred approach as opposed to a child-centred approach requires a different set of underpinning principles. Final 8th November 2017 226.44. The Thematic Report states that ‘without a clear statement of values guiding and underpinning the actions of those with responsibilities for safeguarding [young people] with often complex needs and at considerable potential risk, there lies an opportunity for inconsistency and outcomes for [these young people] will fall short of what good parents would accept as ‘good enough’. 6.45. The Review Team was struck by the similarities between the experiences of the four young people who were each the subject of SCRs during 2015 and 2016. Although there were different circumstances, each young person had, to varying degrees, experience of the following: • Complex and difficult families • Domestic abuse and/or family breakdown and family disruption • Subject to child protection plans • Appeared unable to make and sustain good relationships or develop strong attachments • Self-harming, going missing, struggling to stay in education, and using substances, and ‘legal highs’ • Emotionally vulnerable, distressed and depressed and at times in need of specialist mental health interventions • Experiencing difficulties at school and using or being bullied through social media • Associating with older men, and sexually active from a young age • Professionals were unable to effectively engage with family members 6.46. Professionals acknowledged that many of the adolescents with whom they worked, or who were referred to CSC, also had these factors in common and they expressed some frustration in a system which was predominantly focused on younger children. Examples were given of having to record the ‘voice of the child’ but not having enough time to build a relationship with the adolescent in order to ascertain their ‘wishes and feelings’. 6.47. Research studies 24 suggest that adolescents are not simply young adults or old children. The risks they experience, and the impact those risks have, are often very 24 https://www.nap.edu/read/10209/chapter/2 Final 8th November 2017 23different to those affecting other age groups, and as such, work with adolescents requires an identified set of specific principles upon which to build a distinctive and adolescent-centre approach. Despite the considerable efforts of professionals to engage with Rachel, it remains the case that overall, the interventions did not bring about the necessary changes within a timeframe which met Rachel’s needs. 6.48. Research in Practice states that ‘all too often services do not recognise or respond to underlying causes of crises, do not adequately ‘work with the grain’ of adolescent development, do not draw on the strengths of young people, their families and peers, and do not support practitioners sufficiently to manage the complexity involved with adolescent risk.’ The Review Team found evidence of significant amounts of professional activity and some good practice but little to suggest activity was in response to well thought out plans or clearly defined expected outcomes. The challenges and stresses of working with these young people require strong leadership; resources and levels of expertise which hitherto had not been evident in Sunderland. 6.49. Training and workforce development, including quality supervision, must ensure practitioners and managers have the skills to work with adolescent choice and complex behaviours and have opportunities to develop their understanding of the adolescent world, including access to technologies and social media. The issue of professional supervision was explored with practitioners, and the very clear message that emerged from this discussion was that practitioners in all agencies needed and wanted access to regular and quality supervision by managers well skilled to deliver reflective supervision. 6.50. Whilst some practitioners said they were satisfied with their supervision sessions others were far less so and cited sessions that were too often cancelled, reduced to ‘catch up’ conversations or even left to email exchanges. Practitioners were acutely aware of the demands placed on their managers but many felt that vacant, interim, or merged managerial positions significantly weakened managerial oversight of their work and supervision was not always given a high priority. Finding 6: The range and nature of adolescent risks are different to those facing younger children and the traditional response to such risks does not necessarily fit with young people’s lived experience and research. The identification a multi- agency framework with clearly defined underpinning principles would support better practice for those professionals working with adolescents at risk of harm. Final 8th November 2017 24Engaging Adolescents 6.51. Research25 highlights clear evidence of the powerful and central role that relationships play in adolescent’s well-being. The Review Team found evidence of some good practice through the efforts of committed workers from a range of agencies as they strove to engage, support and motivate Rachel. Listening to the experiences and concerns of frontline practitioners and their managers, the Review Team was struck by how difficult and frustrating it must have been at times to work consistently and constructively to help Rachel and her family. There is evidence that some workers tried hard to find solutions to Rachel’s distress and negative core beliefs and were sincere in their efforts to offer support to her during times of what were daily crises. 6.52. However without a multi-agency understanding of how best to work with adolescents with complex and harmful behaviours, individual work was compromised. In addition, many practitioners spoke of not having the time or not having a managerial/organisation mandate, to prioritise the building of a relationship with young people, despite the volumes of research and young people’s voices which say this is what they need before they can feel confident to engage with workers. 6.53. Practitioners involved in this Review said that the need to develop authentic and sufficiently intensive long-term relationships with young people is not fully recognised and has certainly not been part of the service response in Sunderland to date. The use of non-engagement as a coping strategy is known to be a common feature in adolescents. Professionals trying to help can sometimes interpret such behaviour as sabotaging attempts to help the young person and can too easily rationalise non-engagement as adolescent ‘resilience’, within a ‘self-determining and young person’s rights’ perspective. This can lead to a negative cycle of mutual rejection and result in a lack of effective help for the young person, leading to them becoming even more vulnerable. References in agency records to Rachel’s banter and amusement when being interviewed by police or spoken to about the dangers of sexual exploitation may well have unwittingly led practitioners to feel reassured about Rachel’s ability to keep herself safe. 6.54. Frequent changes of social worker or other key professionals are a constant complaint from young people. For adolescents who have strained or fragmented relationships with 25 World Health Organisation (2014) Health and wellbeing of young people Final 8th November 2017 25their family, and particularly for those who have experienced abuse or neglect and have poor attachments to their parents, these changes in key professionals can be unhelpful or even devastating and militate against attempts to engage or support them in a meaningful way. Changes of social worker can also undermine care planning and contribute to placement difficulties. Rachel seems to have been passed back and forth between services, and the Review Team were unable to identify a professional who managed to establish a long term or meaningful working relationship with Rachel. 6.55. The evidence suggests that professionals struggled to engage Rachel to the point where she felt able to participate meaningfully in activities or with services. One of the key negative outcomes for Rachel, common to many adolescents who require services26, may have been a lack of trust in adults, including those professionals who had attempted to intervene in her life. Rachel’s pattern of seeking help and then withdrawing from help offered is also evidence of a lack of trust in the professional system which sought to protect her. This can so easily lead to a professional perception of a ‘hard to reach’ adolescent who ‘does not engage’ with services. New Finding 7: If authentic and sufficiently intensive long term relationships are not part of the service response to young people, and professionals are not actively supported to invest time in establishing these relationships, then interventions to reduce risk and promote resilience in young people is likely to be ineffective. 7. The Situation now 7.1. The Thematic Review identified six overarching issues in relation to work with adolescents in Sunderland which also have a bearing on this SCR: • Importance of values and principles to underpin multi-agency work with young people • Need for specific services to vulnerable adolescents • Recognition and response to Child Sexual Exploitation • Assessment, Interventions and Planning • Multi-Agency working 26 Brandon / NSPCC / University of East Anglia, 2013 Final 8th November 2017 267.2. The response of SSCB to the findings from previous SCRs are captured in Appendix 1 and if these actions are implemented as stated, they will undoubtedly lead to improved practice across the Children’s Workforce and will drive forward improvement in outcomes for children and young people. Care does however need to be taken to ensure that action plans, improvement plans, indeed plans of any sort, identify intended outcomes or impacts rather than just state what actions have been or are to be implemented. Equally important is that the processes through which changes or the desired results are measured are identified. 7.3. The Review Team asked practitioners for feedback about what if anything is different now. Responses indicated that were beginning to sense changes in their organisations and especially within Children’s Services but they also indicated that developments were not involving practitioners in a way which was inspiring and importantly the changes were not happening fast enough and this left young people vulnerable. 8. Conclusion 8.1. The risks that adolescents face are particularly complex and wide-ranging but there is no reason to believe that they are any less harmful than those experienced by younger children. It is important to acknowledge that there are some young people in Sunderland who may not be having their needs met effectively by services, and this review and other more recent reviews relating to adolescents suggest more needs to be done as a matter of some urgency to work with young people to avoid, reduce and recover from risks they face. 8.2. There is however, a wealth of talent and knowledge across partner agencies, which needs to be galvanised through multi-agency working, strong leadership, and appropriate adolescent-centred policies, to create a more sophisticated model of risk prevention and protection for adolescents in Sunderland. Final 8th November 2017 27Appendix 1 Summary of Findings and Recommendations New Finding 2: Child Sexual Abuse in the family environment will often come to the attention of statutory and non-statutory agencies as a result of a secondary presenting factor, which then becomes the focus of intervention. If professionals are not skilled and confident in their ability to identify child sexual abuse, children may be left at risk Recommendation 1: SSCB should a) Strengthen skills and knowledge base of the children’s’ workforce so that professionals are better equipped to recognise and respond to sexual abuse within the family network by March 2018. b) Ensure whether services to young children with harmful sexual behaviour are proportionate and timely and are delivered in such a way as to reduce the risk of this behaviour continuing into adolescence and adulthood by July 2018. Finding 1: Without robust multi-agency assessment, which focus on the child’s care and experiences within the family, the needs of children who have been diagnosed with a ‘condition’ may be overlooked Finding 3: Without a purposefully designed multi-agency risk assessment tool, embedded within all organisations and accessed through a single point of access, professional judgments about risk are more likely to be flawed, and this will reduce the likelihood of effective interventions leaving some young people vulnerable. Finding 4: When concerns are raised about a child, a clear chronology of events can show agencies where risks lie but unless practitioners understand how to build and maintain purposeful chronologies, and without clear systems to gather, record and share this information, the use of chronologies to inform good assessments and decision making is less likely to happen Finding 5: Multi Agency assessments and planning are key to supporting better outcomes for children and young people but this requires close collaboration between agencies and inevitably raises the question of who takes responsibility of coordinating this work. Multi-Agency collaboration did not work as well as it should have done with Rachel and this left her vulnerable. New Finding 6: The range and nature of adolescent risks are different to those facing younger children and the traditional response to such risks does not necessarily fit with young people’s lived experience and research. The identification of a multi- agency framework with clearly defined underpinning principles would support better practice for those professionals working with adolescents at risk of harm. Final 8th November 2017 28New Finding 7: If authentic and sufficiently intensive long term relationships are not part of the service response to young people, and professionals are not actively supported to invest time in establishing these relationships, then interventions to reduce risk and promote resilience in young people is likely to be ineffective. Recommendation 2 (finding 1, 3, 4, 5, 6 and 7) In order to improve the effectiveness of multi-agency practice with adolescents who are at risk due to substance misuse and other forms of risk taking behaviour and/or abuse/exploitation, SSCB should: a) Work with the Children’s Strategic Partnership, the Safer Sunderland Partnership, and the Sunderland Safeguarding Adult Board to develop a multi-agency framework to support the development of resilience and improve outcomes for vulnerable adolescents. This framework should include: - A strategy, robust systems, protocols, and tools for working with vulnerable adolescents - Workforce Development opportunities to support staff to engage effectively with young people, better assess and understand issues of risk such as CSE, substance misuse, and transition. This will be in place by June 2018. Final 8th November 2017 29Appendix 2a Sunderland Safeguarding Children Board (SSCB) impact statement What have we done, what are we going to do and what difference has it made/will it make? A new Board structure was implemented from April 2017 with a new permanent Chair in place from May 2017. The new arrangements have strengthened governance arrangements to ensure high support and high challenge across the system, with clearer functions, a new structure, and newly developed and robust approaches to performance management, quality assurance, practice development, and the application of learning from research, evidence and review, as well as evaluating compliance with required standards of practice. The Board has been more effectively supporting (and challenging) the improvement programme for Children’s Services and continually evaluating the improvements taking place, the investments being made and the differences these are making to children, young people and vulnerable families as well as supporting and challenging each partner agency’s own improvement and development plans. The SSCB has strengthened its MSET Sub Committee arrangements and this was confirmed by an independent review in 2016 which identified that the Board’s MSET Subcommittee showed clear evidence of coordination, scrutiny, and challenge, including of the work of the MSET Operational Group, challenged partners to provide updates on their activities to address the risks to children, and raised issues about the attendance of key partners. The Reviewer concluded that the outcome of this work has been to deliver a focussed discussion of current, local safeguarding risks to children with clear leadership. The Ofsted Monitoring Visit Letter published December 2016 also found improvements concluding that “Sunderland’s multi-agency arrangements to respond to children at risk of going missing and being sexually exploited and trafficked have been strengthened. The quality of information recorded and collated in the risk management tool ensures a well-coordinated multi-agency response. The child sexual exploitation referral tool is a comprehensive assessment document that has a strong focus on the views of the child. Arrangements for return interviews for children missing have been strengthened through the commissioning of a voluntary agency to undertake this work. Analysis of information and intelligence is informing preventative work for individuals and more widely. Examples seen were detailed and focused on risk, and were used well within the missing, sexually exploited and trafficked children meetings to inform practice on individual cases and also in relation to wider disruption activities. Work undertaken by MSET Sub Committee includes: • Multi-agency detailed audits undertaken in respect of 5 CSE cases and a sample of 20 CSE Risk Assessment Tools led to a review of the toolkit to strengthen practitioners’ skills in respect of CSE cases. Both SSCB audits identified positive aspects of practice since the adoption of the revised tool and Final 8th November 2017 30the inclusion of professional judgement and the voice of the child have informed the continued learning and reflective practice. This gives a demonstrable influence of frontline practice on strategic direction. This was confirmed by practitioners who were part of this SCR and the Young Person Mark SCR. • The toolkit is currently under consultation and implementation of the new tool aims to lead to more robust identification, assessment and intervention for young people who are being sexually exploited/at risk of CSE. • In September 2016 the SSCB undertook a multi-agency Self-Assessment against the Joint Targeted Inspection Framework for children at risk of CSE or who go missing from home. The response included only 10 completed responses with a variety of approaches but demonstrated high levels of confidence in the awareness of CSE and the MSET arrangements across agencies, leadership and the SSCB and the overall effectiveness of the multi-agency arrangements were deemed Good by 80% of respondents. Gaps were identified in the ability to capture the preventative work undertaken and any work with adult offenders. These areas of work will be taken forward as part of the work of the Board and included in the development of a vulnerable adolescent framework. • Challenged the commissioner and provider of the contract for the return home interviews for children who go missing from home and care. This has resulted in improved commissioning arrangements and improved provision for vulnerable adolescents. Performance data demonstrates an improved completion rate but further analysis of quality is required as outlined below. • The Strategic CSE Co-Ordinator funded by Children’s Services to work across the partnership delivered MSET (Missing Sexually Exploited and Trafficked) briefings to multi-agency practitioners and the voluntary sector, that is, 780 practitioners, 30 foster carers/adoptive parents, 220 taxi drivers, 15 licences, and 30 elected members received this training which also included changes to the Trafficking legislation brought in by the Modern Day Slavery Act • Robust scrutiny and analysis of performance data relating to vulnerable adolescents to better understand the vulnerable adolescent population, their needs and how these can be addressed. The outcomes of this analysis has to date identified issues with the return home interview provider as mentioned above, a potential gender bias in respect of application of the missing vs. absence category by the Police. This relates to similar gender bias issues identified in this SCR with males being seen to be better able to protect themselves. The Board is developing a strengthened performance monitoring and assurance framework for the MSET Operational Group to more effectively focus on these areas. • In recognition of the wider issues related to CSE the Board has ended the MSET Sub Committee and established a Vulnerable Adolescent Strategic Project Group (VASPG) which has a wider focus on the risks to vulnerable adolescents. The MSET subcommittee was sufficiently robust to support this shift and this is in keeping with the updated definition of CSE in Working Together 2015 (amended February 2017). The anticipated outcome is that there will be a more comprehensive and robust approach to addressing the Final 8th November 2017 31needs of vulnerable adolescents in Sunderland. This was originally for a 12 month period and as a result of this and the Young Person Mark SCR, the Group has been extended until September 2018 • Learning from this SCR and the SCR for Young Person Mark the Group has commissioned focussed reports from the commissioner and provider of the Return home interview contract November 2017, the Youth Drug and Alcohol Project (YDAP) in October 2017, the CAMHS Transformation work and the Transition Board. These reports are intended to provide an understanding of how effective these services are and what difference they making to children and young people, including when an adolescent is transitioning into adult hood. • Met with the CSE National Working Group (NWG) regarding transitions and the learning that has been identified from this and the Young Person Mark SCR. The learning from the SCRs was shared with the NWG as part of research they were producing. The Board has agreed to undertake a benchmarking exercise in 2018 led by the NWG to have an evaluation of the arrangements for CSE etc. in Sunderland. This will provide the Board with a progress check; identify what difference we have made and where we can improve to better meet the needs of our vulnerable adolescent population. The SSCB worked with the NSPCC to launch the PANTS campaign across Sunderland which is part of the SSCB preventative approach to addressing sexual abuse as it can be delivered by professionals and family members without any specific training. It aims to teach children to know how to protect themselves and raise concerns with family members etc. It has been very positively received across the partnership. A joint conference on sexual abuse including links between sexual abuse and neglect and sexual abuse and sexual exploitation was delivered by the SSCB with the NSPCC. The learning from the conference is to be used to inform future work for the SSCB with the NSPCC around these areas of work. The SSCB Strategic Plan 2017-2019 and the SSCB Business Plan 2017-2019 has been developed based on learning from these SCRs. The Board has 3 Service Priorities in these plans which are neglect, vulnerable adolescents and compromised parenting. In conjunction with the Children’s Strategic Partnership the Board is developing a framework for vulnerable adolescents which will address the key learning identified from this and the Young Person Mark Review. Working with the other partnerships across the City to deliver a campaign highlighting where young people and adults can seek help if they are struggling to cope due to issues such as emotional or mental health issues. The aim of this campaign is to highlight that there are services available for our young people and their parents/carers and to reduce the incidence of self-harm and suicide. Final 8th November 2017 32A further SSCB audit of neglect practice is planned for 2018 to understand and asses if practice is improved around identifying and dealing with child neglect. The Board will continue to audit has effectively learning from services is being embedded access the partnership. An audit undertaken in early 2017 around the Learning from 6 Serious Case Reviews published in September 2016 identified some evidence that learning has been embedded. It has identified further work is needed to embed the learning. A second audit is planned for November 2017. Final 8th November 2017 33Individual Agency Impact Statements Appendix 2b Sunderland Clinical Commissioning Group The CCG Safeguarding Team will take a key strategic and operational lead role in sharing the learning from this review with all GPs and Practice staff across Sunderland to support individuals to meet their learning and competency needs in accordance with the Intercollegiate Guidance 2014 and their role and responsibilities. Young people will be seen by a highly skilled workforce who understand the importance of liaising and sharing information with professionals involved with young people, and make appropriate referrals in a timely manner therefore ensuring the needs of young people are met. The aim of the Team’s work specifically in Primary Care (GP) is to: • Provide telephone advice and support to individual practitioners who have identified a possible concern about a child or young person – this can be measured by the number of calls to the team and evidenced on a tracker tool held by the team. Work is evolving with Together for Children – Sunderland to ensure that their Liquid Logic system can identify the separate agencies representing “health” and ensure feedback to relevant health leads on referrals which may be inappropriate or contain insufficient information. Should concerns be identified from TfC the Team will work with individual GPs/practitioners to improve safeguarding practice. There have been no quality assurance issues highlighted by TfC to the CCG regarding referrals from Primary Care since April 2017. In addition the annual primary care safeguarding audit cycle includes an audit into the quality of referrals submitted from GPs/practice staff. This will be undertaken November/December 2017. • Support individual Practices in developing their internal systems and processes to monitor outcomes of referrals. This can be evidenced by the Practice visits undertaken by the Named GP (either planned or in response to queries, incidents or significant events) and the CQC inspection framework. • Provide peer support and supervision to GP Safeguarding GP leads. Evidence - there is an annual programme of quarterly peer support sessions. • Plan, deliver and evaluate bespoke training packages to those staff requiring Level 3 Safeguarding Children Training – Evidence - an annual training programme is in place and numbers of attendees and evaluation reports are compiled by the CCG Safeguarding Team – copies available on request. Final 8th November 2017 34Regular updates are also provided via Time in Time out sessions – a calendar of events is available. • Disseminate immediate learning from reviews via a Primary Care briefing – this can be evidenced within the CCG files. Evidence - copies available on request. • Disseminate safeguarding updates by a quarterly safeguarding newsletter – this can be evidenced within the CCG files – copies available on request. • Seek assurance that the GPs in Sunderland understand their statutory responsibilities and respond to learning identified in reviews. Evidence – annual SSCB S11 audit, SSCB mystery shopper audit and the SSCB multi-agency audit programme. In addition to the multi-agency audits a range of single agency audits are undertaken with GPs – reports available on request. Final 8th November 2017 35Appendix 2c Education and Schools The learning has been focused on ensuring that safeguarding procedures and protocols are more robust and properly followed, particularly in relation to record keeping, information etc: • Handover arrangements between the Link School and the excluding or dual registered school are conducted face to face with all relevant information shared and files handed over; • All safeguarding information now recorded electronically at Link School on Child Protection Online Monitoring System (C-POMS) which is regarded as best practice system; • C-POMS which is a referral system for any concerns records information in real time, requires receipted response and note of any further actions. Also produces electronic chronologies; • No concern considered too small or insignificant to be recorded; • Paper files no longer used (nb: Rachel’s safeguarding file could not be found at the time the chronologies were being pulled together and has still not been found despite best efforts); • As a result of the above procedures for archiving have also been tightened up for historic and paper files; • Stronger professional curiosity and challenge to other agencies encouraged – and followed up in school safeguarding meetings The timescales for above learning started at around the time that Rachel was at the Link School. Link School referred appropriately and were involved in strategy meetings with agencies and with Ferndean etc. Final 8th November 2017 36 Appendix 2d General Practitioners 1) All GPs in Sunderland to receive information in training and briefing papers regarding the learning and recommendations from this review. • On publication of the SCR a briefing document will be circulated to all GP practices. • Learning from the SCR will be highlighted in the GP Safeguarding Newsletter • Learning from the SCR will be discussed at the quarterly Safeguarding leads meeting; the Safeguarding Leads will disseminate the learning to practice staff. • Learning will be shared at future TITO events • There will be a coordinated approach to the dissemination of the learning to ensure all staff across primary care have knowledge of the issues identified. • The dissemination of the learning from this review will reinforce lessons learned from previously published SCRS in Sunderland in relation to young people with complex problems 2) When ‘fathers’ attend surgery with a child or make contact about a child the legal status of the relationship to be established to determine who has parental responsibility • When a child/young person attends surgery with a male reporting to be the father the GP will clarify the status of the relationship at each consultation and record in the child’s records, ensuring that records contain correct and up to date information. • When ‘fathers’ attend the surgery requesting referrals to services GP/Practice will clarify the fathers information to ensure he is the biological father or has parental responsibility to ensure there is no breach regarding confidential information. • Young people to understand that their health records contain correct information about their legal status • The issue of taking a social history when fathers are registered with the practice has been identified and actioned in previous SCRs Final 8th November 2017 37Appendix 2e South Tyneside NHS Foundation Trust During the timeframe for this SCR Young Person Rachel accessed STNHSFT health services provided by the Young Person nurse, School Nursing Service, Looked After Children Nurse and STNHSFT safeguarding team. STNHSFT author identified a number of areas of good practice, namely prompt information sharing, and timely attendance at Multi-agency meetings as requested. There was also evidence of challenge and escalation evident within the health records reviewed when concerns were expressed with regard to decisions made for Young Person Rachel. The learning identified within the agency reflective learning report highlighted the need for the Young Person Nurse Health documentation to be amended to include advice and support with regard to sexual health. Action Outcome Impact The health assessment completed by the Young Person Nurse needs to reflect the sexual advice given. The Young Person Nurse health assessment documentation has been amended and incorporates as standard practice advice and support with regard to Sexual health. YP have a risk assessment completed which demonstrates advice and support either given or sign posted. The assessment form will be audited 2018. Young person Nurse to be more visible across health and partner agencies. The Young person Nurse is to be moved into the Sunderland School Nursing team. The YP Nurse works with YDAP who are now part of TfC. The school nursing team will be able to access the YP as part of early intervention. This will take place in October 2017. Final 8th November 2017 38 Appendix 2f Northumbria Police Rachel was interviewed in presence of mother following rape allegation. Police could have handled this more supportively and considered other options: All staff understand the importance of listening to children and young people and have access to the policy at all times. In order to provide evidence of this: All staff receive training within their role on how to communicate with children. Specialist child protection officers have SCAIDP training and are subject to continuous professional development this includes ABE training where Officers and staff learn not to overpromise and not to lie to children in order to gain trust or persuade them to co-operate. During all contact with the Police during an investigation Officers agree a contract with the victim in line with their needs to ensure that the victims are listened to. Dedicated rape teams and pilot schemes of dedicated Sexual Offences Liaison Officers (SOLO’s) being deployed solely for initial contact for victims are now well established and have positively impacted on the service provided to children and young persons. Young Person Rachel’s drug taking, alcohol misuse, sexualised behaviour were indicators of sexual abuse and CSE. In June 2015, Young Person Rachel’s behaviour was escalating. Missing from home episodes, drug taking, being given alcohol, this should have been flagged as a higher risk: Northumbria Police have invested in a bespoke training package with Safeguarding Associates For Excellence (SAFE) for a targeted audience within the force which will be mandatory for all staff involved. This training incorporates all aspects of CSE including recognising the signs. Northumbria Police now have two dedicated Missing from Home Coordinators. Their role includes the flagging of missing children and young persons to MSET. This dedicated ‘spoc’ has resulted in improved liaison between partners in relation to flagging and escalating identified risks to children and young persons. The SSCB MSET Operational Group was focussing on victims and not using disruption tactics as robustly as they could. More disruption work should have been done around father. There were 3 allegations of rape made against father: The MSET Operational Group is now more established and robust providing improved safeguarding to children and young persons.Final 8th November 2017 39Appendix 2g Together for Children – Children's Social Care Project/Action Activity (how much) Outcomes (how well) Impact (what difference your action has made/will make) 1. To make sure the Together for Children (TFC) children’s social care workforce is fully aware of lessons learned from previous serious case reviews involving adolescents A series of workshops have been delivered to all frontline staff through team meetings (x11) covering the recommendations set out on the single agency action plans Young Person(s) K&I Worked collaboratively with partners to design an adolescent risk management panel (proposed implementation April 2017) The TFC workforce will be aware of the risk factors associated with vulnerable adolescents and will have the knowledge and skills to assess, respond, and reduce the risk/s More streamlined multi-agency response to adolescents who are assessed as at risk Young people receive an appropriate and timely and co-ordinated response from all agencies that reduces risk and creates the opportunity for maximising positive change. This will be evidenced in the outcome of audits, quality of assessments, evidence of timely access to services in children’s plans (child protection, child in need, looked after and pathway plans) The impact of the new arrangements will be monitored by the group and shared with the SSCB Final 8th November 2017 40Project/Action Activity (how much) Outcomes (how well) Impact (what difference your action has made/will make) Reviewed MSET procedures and risk assessment tool Planned e safety training for staff for October and November 2017 This has to be put in place – planned for October and November 2017 2. Child Protection (and Child in Need) Plans for adolescents are appropriate and fit for purpose • The reasons for child protection plan should be carefully considered and categorisations appropriate • Access to appropriate services in a The IRO service to receive training in respect of Child Protection and Adolescents – training plan being developed for implementation 2017/8 Collaborative working with partners to design More appropriate categorisation of Child Protection issues eliciting more appropriate services Coordinated and timely response from all agencies Improving the quality of plans leading to improved responses and access to services resulting in improved outcomes for young people. This will be evidenced through audit, feedback from young people, quality of commission information Panel to commence in Spring 2017 – evaluation built in to the pilot Final 8th November 2017 41Project/Action Activity (how much) Outcomes (how well) Impact (what difference your action has made/will make) timely way is paramount in keeping young people safe an adolescent risk management panel (proposed implementation April 2017) Final 8th November 2017 42Appendix 2h City Hospitals Sunderland Within the set timeframe for the SCR Rachael accessed the services via the adult emergency department (ED) when she self-harmed and alleged rape. During these times she was either subject to a child protection plan or a looked after child, where she would be seen for her LAC review health assessments. Although action was taken on all ED attendances there was a general attitude from staff that she was a regular attender with a mental health problem which would be the responsibility of the CYPS team to assess. The learning CHS is in respect of her attendance into Adult ED with lack of professional curiosity, lack of awareness to vulnerability when looked after child and understanding adolescents behaviour. Action Outcome Impact Within patient records children and young people who are known to be LAC in Sunderland will have an alert which will alert staff with information on what they need to do. The paediatric liaison nurse has oversight of all children and young people less than 18 years attending ED and paediatric and alerts make this clear. Children who present into ED and are known to be LAC the paediatric liaison nurse shares this information with the LAC Named Nurse and Social worker. The audit is 100% For under 18 years ED documentation to include an adolescent risk assessment tool. HEADSSS - Home, Education, Activities Drugs/alcohol, Sexual relationship, Social history and Suicide risk assessment HEADSSS assessment is within ED records and training has been delivered to staff and is within safeguarding children level 3 training. Level 3 training is 90% compliant. HEADSSS compliance audit to be completed as part of audit cycle 2018. Improve mental health service access when children/ young people present into ED with mental health issue. Introduction of a 24/7 CYPS service within CHS which can see children at the point of need. NTW now see children within 1 hour of presenting into ED with mental health issues. This is part of the wider Mental Health National Project to have a psychiatric liaison within all major acute providers by 2020. Set up a CSE task and finish group within CHS to include ED staff, sexual health and safeguarding. CSE task and finish group set up and implementation of HEADSS progressed, sexual health referral pathway from ED to sexual health/GUM in place. CSE task and finish group now monitoring group, who meet 6 monthly to address gaps in service. Increased activity from ED to sexual health services noted on their performance data in past 3 months. Level 3 training to LAC update and reflect learning form SCR. Part of safeguarding children mandatory training. Increased awareness of what LAC through training with compliance at 90% Final 8th November 2017 43 Appendix 2i Youth Offending Service The Youth Offending Service worked with Rachel for a significant period of time as well as other family members. During that time Rachel and her family were compliant with the expectations of her Court Order and it was also believed that further additional support had been offered successfully to her family following a referral to the Family Intervention project. What has become apparent is that staff did not question whether the family’s engagement was disguised compliance. Since then a workshop has been held for all staff in March 2017 which uncovered topics such as disguised compliance, we have also revisited in supervisions with staff practice guidance on signs of neglect in teenagers. The impact of this is that staff should be better able to identify neglectful parenting etc. and refer parents for appropriate support including specific parenting programmes now in place through Early Help. We will review how referrals can be monitored. Staff were aware that Rachel was vulnerable and therefore potentially at risk of exploitation. At the time MSET procedures were not fully developed but staff were engaged and knowledgeable about the issue including existing processes within the local authority. There was no identification of on-going abuse or exploitation in this young person’s case but YOS staff continues to contribute to and attend MSET meetings regularly. |
NC050349 | Death of a 15-week-old boy after feeding from a propped-up bottle sitting in a car seat in October 2015. Cause of death was unascertained. Mother (Child MF) was 15 years old when Child F was born. There was uncertainty as to who the father was. Child MF suffered from back pain, dizziness and lethargy when the baby was about 3 months old; she was struggling to cope with Child F and relied on her family for support. An adult was caring for Child F when he died. A post mortem discovered fractures to both legs which were non-accidental and occurred between 3 and 6 days before death. No person was identified as responsible for the injuries as it was impossible to conclude who was the carer at the time of the injuries. Key learning includes: recognition of underage sex; where the mother is a child, both her and the baby need to be treated as such; the quality of the Child in Need procedure and meetings needs improvement; professional curiosity was lacking and over optimism took place. Recommendations include: to ensure that the LSCB's Child in Need process is operating effectively; to ensure that all agencies working with a child or family record full details of all adults within the household; carry out and complete appropriate and relevant CSE risk assessments; highlight the importance of record keeping; professionals need to be able to recognise disguised compliance and dis-engagements; professional curiosity and healthy scepticism should be included in all levels of safeguarding.
| Title: Serious case review concerning Child F. LSCB: Lincolnshire Safeguarding Children Board Author: Russell Wate Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 | P a g e Serious Case Review concerning Child F Independent Author: Dr Russell Wate QPM March 2018 v 2.0 2 | P a g e 1.0 Introduction 1.1 The key subject of this Serious Case Review is a baby boy (15 weeks at time of death) who will be referred to as Child F. Child F is of a white British background. At the time of his death Child F was living with his mother, who for the purpose of this review is called CHILD MF (also a key subject of this review). CHILD MF was 15 years old when Child F was born. 1.3 There was past involvement from Children's Services with CHILD MF. 1.4 On 3rd October 2015 Child F died. Adult E who is described as Child F’s godmother and a family friend was caring for Child F overnight on the 2nd October 2015 and she stated that he had woken up at about 8 am on the 3rd October 2015 and Adult E gave him a bottle of milk which was propped up to his mouth with a rolled-up blanket. He was in a car seat at the time. She then fell asleep. Adult E further reported that she woke up later (it is not recorded how much later) and she found Child F to be unresponsive to anything she did to try and wake him. An ambulance was called. Child F was not breathing. 1.5 Child F arrived at hospital in cardiac arrest and died, he was pronounced dead at 10:57 am. The appropriate rapid response liaison processes were then followed. Early investigations centred on whether Child F had choked and a post mortem initially stated that there was no specific cause of death and so further tests were commenced. A referral containing the information around the death of Child F was made to Lincolnshire Children's Services on 3rd October 2015. This was closed as a referral, as is normal practice on the 5th October 2015. The case for CHILD MF was then re-opened to CSC. 1.6 A Police investigation commenced and as the circumstances of the death were suspicious Adult E was arrested. 1.7 A Post Mortem was carried out by a Forensic Pathologist and the cause of Child F’s death was deemed as unascertained. Injuries were found to his legs which were investigated the conclusions were, that there were fractures to both legs and that these injuries had occurred between 3 and 6 days prior to Child F’s death and were indicative of non-accidental injury. The Forensic Pathologist further concluded that though the fractures would have been very concerning for Child F’s well-being whilst alive and needed investigating, they were not the cause of his death. It must be noted here that Children’s Services were not told about these fractures until April 2016. The reason provided to the review author why this delay took place, is because the police needed clarification from the pathologist as to how the fractures could have occurred and this wasn’t received until March 2016. 1.8 The initial police investigation then became an assault (GBH) investigation and this was concluded with no person identified as being responsible for the injuries to Child F. As there was a large pool of carers it was impossible to conclude who could have been the carer at the time of the injuries. 1.9 As the family were residing in Lincolnshire during Child F’s life Lincolnshire Safeguarding Children Board (LSCB) have completed this Serious Case review. 1.10 The period under review was agreed as around the date of July 2014 (As it was at this time that it was first discovered CHILD MF was having under age sex) to the date of Child F’s death on 3rd October 2015. Other information outside of the defined period was to be considered and included if identified as relevant or significant to any learning. The review centres on the following family members. Child F. Referred to only by this name in this review. 3 | P a g e Relationship to Child F Name Age at time of the death Mother of Child F CHILD MF 15yrs Assumed father of Child F and previous partner of CHILD MF Young Person A 18yrs Mother of CHILD MF and maternal grandmother to Child F Adult B 34yrs Partner of Adult B making him step father of CHILD MF and step grandfather of Child F Adult C 38yrs Friend of family and son of Adult F and possible father of Child F Adult D 20yrs Family friend and carer of Child F when he died Adult E 39yrs Family friend and mother of Adult D Adult F 49yrs 2.0 Terms of Reference, Contributions and Methodology 2.1 The purpose of this review is to: Identify improvements which are needed and to consolidate good practice Translate the findings into a programme of action which leads to sustainable improvements and the prevention of death, serious injury or harm to children. Agencies were asked to consider the events that occurred, the decisions made and the actions that were taken or not taken. Where judgements were made or actions taken which indicate that practice or management could be improved, the analysis should aim to provide an understanding of what happened and why. 2.2 The review author and panel asked some specific questions of the agency authors to focus on. These are the key issues that form the specific Terms of Reference for the review. Was there a Pre-Birth assessment undertaken and was the Pre-Birth protocol followed. Did all agencies contribute effectively and was the information collated and analysed to identify risk and need? Was there an effective Pre-birth Plan and was it delivered? Did the CIN process recognise the separate and individual risk and needs for both children, CHILD MF and Child F? Did the CIN process collate and analyse risk and needs and review them appropriately? Did agencies have a clear picture of who was supporting and caring for CHILD MF and Child F? 4 | P a g e How did agencies support CHILD MF in managing her physical health needs whilst she was caring for Child F and meeting his needs? On the information available to Agencies at the time of closure of the case(s) did agencies have a clear knowledge of the family's vulnerabilities and was the decision to close appropriate? Contributors to the review 2.3 A number of agencies have contributed to this review as follows: Lincolnshire Partnership NHS Foundation Trust (LPFT) United Lincolnshire Hospital NHS Trust (ULHT) Lincolnshire Community Health Services (LCHS) Lincolnshire Youth Offending Team (YOT) GP Surgery Lincolnshire Lincolnshire County Council Children’s Services (CSC) Schools – Lincolnshire East Midlands Ambulance Service(EMAS) Lincolnshire Police Independent author 2.4 Lincolnshire Safeguarding Children Board commissioned an independent author to carry out the review. The review is supplied by RJW Associates and the lead reviewer is Dr Russell Wate QPM. He is independent of any agency within Lincolnshire. 2.5 The review panel was of great assistance to the review process and the review author in the compiling of this report. The panel was chaired by an independent chair that has had no involvement with this case. Methodology 2.6 Agencies with any relevant information were asked to provide an Agency Narrative Report (ANR) using a suggested template and including a chronology of significant events. Analysis then took place of the findings and after requests for further information following an ANR presentation day; the report was completed for sharing and presenting to the Lincolnshire Safeguarding Children Board. 3.0 Summary of the case 3.1 This section aims to provide a picture of the lives of Child F and his mother CHILD MF as seen through their interactions with services and professionals from the various agencies. Significant Background information 3.2 CHILD MF was known to the Local Authority and other agencies throughout her early years. CHILD MF went missing from home on occasions and was displaying vulnerabilities that raised her risk and was believed to be having underage sex. 3.3 Young Person A spent a number of years as a Looked after Child, with foster parents and went missing on occasions. At the time of Child F’s death, he was in a Youth Offender Institute serving a sentence for an unprovoked knife attack on an innocent person. He played no part in the care of Child F. 5 | P a g e Pre-pregnancy information 3.4 On 29th June 2014 Lincolnshire Police were informed anonymously that Young Person A had two young girls in his room. One of the girls was named as CHILD MF. The Police attended the location which was Young Person A’s lodgings but there was no evidence found of the girls having been there. This unconfirmed information was the first connection between Young Person A and CHILD MF. 3.5 On this date it was discovered that CHILD MF had been taken to hospital by her mother Adult B with stomach pains. CHILD MF thought she was pregnant as she had had unprotected sex. due to inconsistencies in the information provided, the Nurse became concerned and made a referral to the customer service centre in CS and informed her school. This information was also shared by the school nurse with CS on 17th July 2014. Child MF had an allocated targeted youth worker due to concerns about her risk-taking behaviour and there was put in place a multi-agency TAC (team around the child) process. 3.6 On 15th July 2014 CHILD MF and her mother Adult B met with a Targeted Youth Worker to discuss problems at home and school. 3.7 On 16th July 2014 CHILD MF attended the Out of Hours Department which is part of Lincolnshire Community Health Services (LCHS) with abdominal pain, thinking she may be pregnant. No questions were asked about the identity or age of CHILD MF’s partner which would have further informed their risk assessment. The School Nursing team were advised and a Nurse from this team followed this up but identified no further action was required. The case was open at this time to Children’s Services. 3.8 On 12th August 2014 a joint home visit was completed by the Family Worker (FWT) and the Targeted Youth Worker (TYW) from Children’s Services and CHILD MF was seen with her mother Adult B. They discussed the behaviour of Adult C and his alleged assaults on CHILD MF. 3.9 CHILD MF attended the Out of Hours Department on 31st August 2014 as she was vomiting and a further pregnancy test carried out, which was negative. The School Nurse was again informed and planned to see CHILD MF at school to offer support and sexual health advice. 3.11 In supervision on 1st September 2014 the Children’s Services Targeted Youth Worker requested an escalation in the level of intervention/service offered to the family due to the increasing risks for CHILD MF. The worker’s supervisor advised that there needed to be a review of the concerns, strengths and what gaps there may be before escalating to Social Care, this occurred on the 8th September using signs of safety mapping. 3.12 On 8th September 2014 CHILD MF disclosed at school, that during an argument, Adult C had put his hands around her throat and shaken her causing her to hit her head against a door frame. This information was then reported to the Police central referral unit (CRU) and a decision was made for a CSC single agency enquiry and the circumstances assessed by an allocated Social Worker. The Police were informed by the Social Worker that an assault had taken place but CHILD MF would not engage with them or make any complaint. There were no visible injuries. A common assault investigation was commenced but was filed with NFA. 3.13 Also on the 8th September 2014 a school visit was completed by a School Nurse following CHILD MF’s recent visits to the Out of Hours Department. CHILD MF stated that she had a 16-year-old boyfriend (Young Person A), he lived in Nottingham and that she saw him at weekends. She went on the train which he paid for and that they did have a sexual relationship which was consensual and they did not use contraception as Young Person A 6 | P a g e did not like to use condoms. She was referred to the Community Sexual Health Advisor and her GP. 3.14 On 9th September 2014 a Social Worker made a home visit and CHILD MF was not at school and was in bed unwell. The discussion was about the allegation she had made against her step father Adult C. She said she wasn’t in fear of him nor did she want to take it any further but that he had assaulted her as she didn’t want to go to school. The case was allocated for a full Social Care Assessment. 3.15 On 10th September 2014 the School Nurse followed up the school visit with a home visit. The family were seen and no concerns were raised in relation to them. At this visit the School Nurse was not aware of CHILD MF’s disclosure that Adult C had assaulted her so it led to in the view of the LCHS ANR author a missed opportunity for her to have a safeguarding discussion, with Children Service’s. A further visit was arranged and Children’s Services were already doing a section 47 enquiry. 3.16 It was confirmed that CHILD MF and her family had moved home and a new Social Worker was allocated and a transfer summary completed. This highlighted that further work needed completing around school attendance, potential sexual exploitation and relationship building with her mother, also work around her drug use and CHILD MF’s vulnerabilities. This work was carried out by her early help worker. 3.17 On 6th October 2014 the school that CHILD MF was expected to attend in her new area was contacted by LCHS and were told that CHILD MF had not yet enrolled. CHILD MF was no longer at her previous school so had not been in education for a number of weeks. Ante natal period 3.18 On 7th October 2014 Children’s Services received information that CHILD MF (14yrs) had had a positive pregnancy test and the father was said to be Young Person A. A CIN meeting was already scheduled. 3.19 Children’s Services completed a home visit on 9th October 2014 and saw CHILD MF with Adults B and C. The pregnancy was discussed and Adult C became aggressive claiming he was going to “kick off” and he was blaming professionals for the situation. He stated he did not want to bring up someone else’s baby. A Family Plan was completed. 3.20 The same day, on 9th October 2014 East Midlands Ambulance Service (EMAS) received an emergency 999 call from CHILD MF reporting that she was 14 weeks pregnant and had been kicked in the stomach. Adult B took over the call and voiced that she was fearful that if the police were called she “would lose all her children”. EMAS dispatched a solo responder to the address who arrived at 9.41 pm. The EMAS control room notified the police due to the concerns around the alleged assault of a child. 3.21 CHILD MF advised the crew that she was pregnant but that she was unsure for how long. Adult B was present and said that she was aware of the pregnancy and the alleged assault. CHILD MF said that she had been pushed in the stomach by her step father which unbalanced her but didn’t cause her to fall. A full clinical assessment was carried out and no injuries were noted. CHILD MF reported that she didn’t have any pain and all tests were normal. 7 | P a g e 3.22 As mentioned the Police were informed via EMAS that CHILD MF had been assaulted by her step father Adult C and that tensions were high at home. Officers attended and it was revealed that CHILD MF was pregnant after completing a positive home test. The attending police officers believed that Children Services were aware and dealing with the family and so did nothing further. (This was an error of judgement and the attending officers have since been interviewed and accept their mistake and learned from it via managerial advice and correct awareness of compliance with policies). 3.23 On 13th October 2014 CHILD MF was seen by a midwife. CHILD MF was still not at school. Her pregnancy was confirmed on 17th October 2014. On the same day a School Nurse recorded a notification of the 9th October incident. The School Nurse demonstrated persistence in following up concerns by contacting CSC to establish what the outcome of this referral made by EMAS was. The CSC Customer Service Centre are not authorised to share this information, the process is that it would be the SW who would do it, and so contact was made directly with EMAS who communicated the outcome to the School Nurse. 3.24 On 30th October 2014 the respective Social Worker’s for CHILD MF and Young Person A met, and it was revealed that it was not known that Young Person A had visited CHILD MF’s home. 3.25 On 3rd November 2014 it is recorded by Children’s Services that the Social Care Assessment was nearly finished and there was already a plan to move from Team Around the Child (TAC) to CIN. The CIN meeting was set for 13th November 2014. 3.26 On 12th November 2014 CHILD MF told her Social Worker in a meeting regarding the CIN that her relationship with Young Person A was over. She was worried about attending a new school and agreed to a Young Expectant Parents (YEP) group. The Social Care assessment was completed, it included looking at the vulnerabilities listed earlier in this report and concluded that CHILD MF had a difficult relationship with her mother and stepfather. 3.27 On 13th November 2014 the CIN meeting was held. The outcome was that a School Nurse would complete a health assessment of CHILD MF. CHILD MF was due to start her new school on 24th November 2014. A further CIN was set for 2nd December 2014 for a handover to the new Children’s Social Care team. 3.28 On 19th November 2014 a health assessment was completed with CHILD MF by a School Nurse at the school attended by her siblings. CHILD MF was worried about starting at her new school and feared what people would say when they found out she was pregnant. She discussed her new boyfriend who apparently lived across the road but no details of him were obtained. She was assessed as well and healthy. Her home life was more settled. 3.29 On 28th November 2014 CHILD MF attended her first (booking) appointment at the antenatal clinic and was thought to be approximately 14 weeks pregnant. CHILD MF stated there were two potential fathers but the names are not recorded. Child MF was identified as being involved with Social Care at this point. 3.30 On 2nd December 2014 a CIN meeting took place, which was well attended by all agencies. CHILD MF had not been attending school and she was encouraged to do so and also attend the YEP class. 8 | P a g e 3.31 On 5th December 2014 Children’s Services record the information about CHILD MF’s confirmed gestation time and that a family friend who is 19 years old must be the father. It does not state why this is known. 3.32 On 11th December 2014 a Families Working Together (FWT) worker saw CHILD MF and her family at home, as did a Social Worker. All was recorded as well and a note on the file is made that “it has been proven / agreed that Young Person A is not the father of the baby “. 3.33 On 17th December 2014 Children’s Services record that CHILD MF is attending school and making friends. A later note says the opposite as she is seen at home the same day and is off school and feeling down about school. 3.34 On 12th January 2015 a CIN meeting was held. CHILD MF attended and said she was ill and not at school. It was established that her school attendance was only 44% which gave concern. It was felt that CHILD MF was using her pregnancy as an illness to avoid school. 3.35 On 21st January 2015 in supervision the Social Worker was tasked to complete a pre-birth assessment as part of the pre-birth protocol and developing the CIN plan. A Social Worker saw CHILD MF and took her to the YEP class where she completed the second stage of the process. CHILD MF now stated that she wanted home education and she discussed her relationship with this unknown man which was going well. 3.36 On 23rd January 2015 CHILD MF attended hospital with Adult B and an unknown friend for an Ultrasound Scan (USS). The unknown friend is also recorded as an unnamed partner. He was not asked his name. 3.37 On 9th February 2015 a CIN meeting took place and it focussed on CHILD MF not attending school and what was now in place for her education. As she could not develop routines it was of concern that she may not cope when the baby was born and had little comprehension of what life will be like when this happens. 3.38 In mid-February 2015 CHILD MF attended the antenatal assessment centre three times due to abdominal pain and reduced foetal movements. Concerns were raised to the Community Midwifery Manager regarding the Community Midwife’s not referring to Children’s Services at 20 weeks gestation. No clarification could be found that an early help assessment had been undertaken or a referral made for the unborn (it was known that CHILD MF was already involved with Social Care, so rather than an EHA the information should have been passed to Child MF’s SW). (It appeared to have not occurred due to a combination of sick leave and annual leave.) A safeguarding alert was requested to be added to CHILD MF’s patient’s electronic admission system. Also, in mid-February 2015 it was established that CHILD MF was not attending her Young Expectant Parents (YEP) groups and that she was not committed to it. 3.39 On 11th March 2015 a CIN meeting took place. No Health Visitor was present and there were no apologies sent for this. The Midwife attempted to contact the SW to clarify the date of next CIN meeting (as the MW had been informed by the School Nurse that meeting was scheduled for 11/3/15.) The MW received no direct communication from the Social Worker. A Pre-Birth plan WAS to be drawn up with Children’s Services, Health and Midwifery by 24th March 2015. 3.40 On 24th March 2015 Children’s Services completed a pre-birth assessment visit where CHILD MF was present with Adults A and B. A further CIN meeting was planned for 5th May 2015. 9 | P a g e 3.41 On 9th April 2015 the Pre-Birth assessment was completed and it did not identify any safeguarding issues of sufficient concern to move the unborn Child F into Child Protection planning, so it led to a CIN plan 3.42 On 5th May 2015 a CIN meeting was abandoned as the Social Worker failed to attend with no reason given. This was being held at CHILD MF’s school and CHILD MF was seen by the community midwife and was now 34 weeks pregnant. The Midwife was still, at this point, awaiting contact from the SW in relation to the previous CIN meeting, and also confirmation of date for next meeting. On 14th May 2015 a new Social Worker completed a home visit and CHILD MF was reported as tired and fed up and wanted her baby to be born. 3.43 The CIN meeting was reconvened on 18th May 2015. The meeting attendees had received no updates from the previously held meeting and so were not able to provide any updates to the plan at this meeting. It was agreed that the case would remain at CIN for CHILD MF and Child F (when born) and be reviewed at the next meeting in July. 3.44 On 6th June 2015 Children’s Services were informed that CHILD MF was in labour. The birth plan or written agreement stating Young Person A was not allowed on the ward could not be located by ward staff. CHILD MF was at the maternity ward and was accompanied by her mother Adult B and friend Adult F and Adult F’s son Adult D. CHILD MF was told she could only have two visitors and Adult D stayed rather than Adult B. It was documented that it appeared that Adult D was in a relationship with CHILD MF but this was denied by Adult D and CHILD MF, both saying they were just good friends. Adult D was recorded as being 20 years old. CHILD MF gave birth in June 2015. Social Care was informed. Post-natal period 3.45 On 8th June 2015 CHILD MF was transferred to the postnatal ward and she then informed staff on the ward that Adult D was her partner and CS was informed of this disclosure. There was some confusion in relation to written agreements. Adult B also told the midwife that the Social Worker had said CHILD MF could be discharged without a written agreement being in place. Due to this conflicting information clarification was sought. A member of CS when contacted agreed that CHILD MF and her baby could be discharged without the written agreement (It is disputed by CS that this advice was given and is discussed further in this review). CHILD MF and Child F were discharged. The plan didn’t include a discharge planning meeting so one didn’t take place. (The ULHT ANR author however believes it would have been helpful for one to have taken place, due to the conflicting information. The review author supports that consideration for this should have happened, to ensure all agencies were aware of the CIN plan). 3.46 A CIN meeting was held on 10th June 2015 and it was decided that no further support was required for CHILD MF and the case could be closed but not for another month. It was discussed whether a TAC was needed and the decision was that it wasn’t required, and the family did not want this either, and as in CIN cases, it also needs to be voluntary. 3.47 A postnatal visit was completed by the Community Midwife on 11th June 2015 and CHILD MF and Child F were seen. Child F was feeding and a significant tongue tie was recorded. (There appeared to be no suggestion that the tongue tie was having an adverse impact upon Child F as he was gaining weight appropriately). Although the midwife undertook a post-natal home visit on the morning of the 11th, she was not made aware of the CIN 10 | P a g e meeting being held on the afternoon of the 11th (according to their records) and therefore was not in attendance at the meeting. CHILD MF and Child F were seen again on 12th June 2015 by the Community Midwife and no concerns were identified. 3.48 A CIN home visit was completed on 15th June 2015 by a social worker. The SW describes the interaction CHILD MF has with CHILD F as being very positive. 3.49 On 16th June 2015 a further postnatal visit was completed by the Community Midwife and no concerns were identified. CHILD MF was discharged from Midwifery care. 3.50 On 17th June 2015 a Health Visitor made a home visit and CHILD MF and Child F were seen. Contraception was discussed and her emotional well-being showed no concerns. Support was being provided by CHILD MF’s parents. 3.51 CHILD MF attended a Health Visitor appointment with Child F on 22nd June 2015 and he was recorded as progressing appropriately. CHILD MF was accompanied by Adult D whom she described as her partner. Adult D is 20 years old. The Health Visitor did not inform the social worker of this development. 3.52 Child F was taken to the GP surgery on 25th June 2015 and seen by a Nurse Practitioner. He was accompanied by as referred to in the notes mum and nana. The GP Practice document the relationship of the attending adults but not the names (the review author questions how they actually know who is present or able to carry out further checks without the names of people.) It was a normal examination after Child F had recently been unsettled and was vomiting after feeds. 3.53 A planned closure visit by a Family Support Worker took place on 1st July 2015 and the analysis was that all was really positive and they appeared to be a family unit. CHILD MF was thankful for the support she had received and now wanted to do it on her own. Her siblings however mentioned that CHILD MF and Child F did not live at home but stayed with Adult F across the road. 3.54 There were some continued ongoing issues with Child F’s feeding which involved visits to the GP surgery and on 9th July 2015 Child F was taken there by a male recorded as being Child F’s dad. No detail of him are asked or known. (The review author questions this practice and the assumptions made that this male person had parental responsibility.) 3.55 A CIN meeting took place on 13th July 2015. It was reported that there had been no contact with Young Person A and he had not tried to make any contact with CHILD MF. His name was not on Child F’s birth certificate as father. CHILD MF stated that she wanted to resume her education and Adult B would look after Child F when she went to school. CHILD MF was now taking the pill and she denied that Adult D was her boyfriend. She claimed they were just good friends and Adult B stated she had no concerns about Adult D. It was agreed that Children’s Services would undertake an assessment of Adult D to see if he posed any risk to CHILD MF. If no concerns were raised then the case was to be closed. 3.56 On 29th July 2015 a social worker completed a home visit and recorded all was well with CHILD MF and Child F. CHILD MF again denied that Adult D was her boyfriend. The following day Children’s Services looked to close all of their services to CHILD MF and her family. Universal services were of course still in place. 11 | P a g e 3.57 On 4th August 2015 CHILD MF failed to attend her 8-week post-natal appointment and did not take Child F for his first vaccinations. A further appointment was made. It is not known why she did not attend or whether it was ever questioned with her. 3.58 Children’s Services closed the case on 14th August 2015. It was considered that CHILD MF was positive and caring for Child F and did not need support. CHILD MF however was still a 15-year-old mother who could be seen as vulnerable; accepting the fact that age alone may not be a sole reason for her being vulnerable no assessment had taken place of her new boyfriend which had been an agreed action at the last CIN meeting. 3.59 On 3rd September 2015 CHILD MF failed to attend her post-natal appointment. She attended the GP surgery the following day feeling dizzy and lethargic. 3.60 Throughout September and early October 2015 CHILD MF attended her GP surgery a number of times suffering with back pains, dizziness and feeling lethargic. She was prescribed medication and a course of physiotherapy. Due to the pain she was in she was now finding it difficult to look after Child F and various family members were now looking after him. This information was not known at the time to agencies. Period at death 3.61 CHILD MF was struggling to cope with Child F and feeling that she had relied on her family too much for support (it is fully accepted by the review author that agencies were not made aware of this struggling to cope by CHILD MF) on 2nd October 2015 she asked Adult E to look after Child F through to 7th October 2015. Child F was taken to Adult E’s address and left in her care with his car seat/travel system combo. Adult E put Child F to sleep in the reclined car seat and woke in the night to feed him. She propped a bottle of milk up with a blanket so that she did not need to hold it whilst he fed. She then fell back to sleep and woke up, now 3rd October 2015 to find that Child F wasn’t breathing. An ambulance was called. On its arrival, the crew found Child F was not breathing and had no respirations, nor pulse. Cardiac monitoring was applied which read asystole (the absence of any heartbeat). CPR was taken over by the paramedics and Child F left in the ambulance and was taken to Lincoln County Hospital who had been pre-alerted. 3.62 Child F arrived at hospital in cardiac arrest. Further resuscitation was attempted; however, the decision was taken to discontinue resuscitation and he was pronounced dead at 10.57 am. The appropriate liaison processes were then followed. Early investigations centred on whether Child F had choked and a post mortem initially said there was no specific cause of death and so further tests were commenced. Adult E was arrested for the murder of Child F. 3.63 A post Mortem was carried out by a Forensic Pathologist and Child F’s death was still deemed as unascertained. Injuries were found to his legs, with the conclusion that there were fractures to both femoral condyles, and that these injuries had occurred between 3 and 6 days prior to Child F’s death. They were also indicative of being caused by non-accidental injury. The Forensic Pathologist further concluded that though the fractures were concerning for Child F’s well-being whilst he was alive and needed investigating as to who caused the injuries, they were not the cause of his death. 3.64 A referral containing the information around the death of Child F was made to Lincolnshire Children's Services on 3rd October 2015. This was noted to have been closed as a referral on 5th October 2015 (In line with policy). The case for CHILD MF was then re-opened to Children Services. 12 | P a g e 3.65 As already mentioned earlier the police investigation moved from a murder investigation to one of serious assault after the results of the post mortem, and as a result Adult E was not investigated further for blame around Child F’s death. It was eventually concluded with no person identified (due to a wide pool of possible carers) as being responsible for the injuries to Child F’s legs and the case has been filed pending any fresh information. Period post death 3.66 Information that has transpired now is that CHILD MF and Adult D had lived together during her pregnancy with Child F and Adult D was claiming to be the father of Child F. Adult D states that he, CHILD MF and Child F moved into his mother's home straight from hospital after Child F's birth and so he was clearly involved more than professionals knew. Both CHILD MF and Adult B misled the Social Worker and Early Help Worker regarding where CHILD MF and Child F were living at the time of the closure in August 15. 4.0 Analysis of significant safeguarding events This analysis includes where possible the response to the challenges and questions that the SCR panel and review author set for the ANR authors. Pre-pregnancy information 4.1 There was no recognised assessment in relation to CHILD MF having underage sex. The first information existed in June 2014 when the police were notified that Child MF was one of the girls visiting Young Person A, and then through health visits later that summer. A later opportunity is where intelligence was received by the Police Divisional Intelligence Unit (DIU) on the 4th February 2015 about CHILD MF who was 15 years old, being pregnant and this was passed through to the CRU, who correctly forwards it on to CS. Unfortunately, it was not picked up that this was information which may have resulted in a crime. It appears that both the staff members in the DIU and the CRU thought the other was assessing the information. It has been accepted that this information was missed and so a crime report was never raised. A dip sample of submissions and referrals has taken place and Lincolnshire Police are confident that the CRU team are now more proficient and accurate in this area of assessment and that this was a one off. 4.2 There is record of consideration by professionals that CHILD MF maybe vulnerable to, or at risk, of child sexual exploitation (CSE). On the 22nd September 2014 in planned Supervision between Deputy Named Nurse and School Nurse, the School Nurse was advised to complete work regarding the risks of child sexual exploitation and ensure this was handed over to the new school nurse team. So, consideration was given but not executed. (This reflects the recommendation from the LCHS ANR for follow up of all staff to have completed the LSCB CSE training). The Signs of Safety mapping identified vulnerabilities and risks. The LSCB CSE risk assessment was completed by a Children’s Services worker in November 2014, this scored as medium risk. 4.3 A TAC meeting was arranged for early September 2014 by the school due to mounting concerns that they had and invites were made to the appropriate professionals. CHILD MF had moved schools after difficulties at her previous school. She failed to attend on a number of occasions and Adult B would contact the school to inform them, the school felt that CHILD MF’s truancy was a result of unclear boundaries and Adult B’s inability to apply appropriate sanctions. A date of 24th September was eventually agreed upon but this never occurred as the family had moved and CHILD MF would no longer be attending that 13 | P a g e school. This information was sent to the TAC administration team and it would appear that no TAC meeting ever took place as CHILD MF started at her new school on 24th November 2014 (CHILD MF had been seen by the School Nurse at the school attended by her siblings on 19th November 2014 for a health assessment) and they had no record that she was at TAC status. This information should have been shared by the schools. 4.4 The communication of the discussion (which took place by LCHS’s Deputy Named Nurse for safeguarding (DNN) following CHILD MF’s disclosure of an assault by Adult C) was not seen by the School Nurse until after a home visit had been made on 10th September 2014. After a review of the records it shows that the DNN sent a task to the School Nurse informing her of the incident and the decision to proceed with a Section 47 investigation. Due to the School Nurse not seeing this task until completing the records after the home visit to the family on 10th September 2014, the School Nurse was not able to discuss any concerns with the family or liaise with the Social Worker prior to contact. Due to this above information not being known, it is clear to the review author that the School Nurse had a missed opportunity to discuss with CHILD MF and Adult B the risk posed by Adult C at the time of the home visit. The review author has been made aware that actions have since been adopted by the LCHS to send all such tasks to the LCHS 0 -19 Team task message box with an urgent red flag attached. It has been agreed that the Team task boxes are checked daily to ensure urgent tasks are responded to in a timely manner and named professionals notified. This will ensure that this doesn’t happen in the future. 4.5 During CHILD MF’s two attendances to the Accident and Emergency Department it is noted that there was a lack of documentation to suggest further exploration of the reason(s) for presenting. It is expected that there would be documentation pertaining to this within the attendance records and that safeguarding of CHILD MF should have been considered. There is no documented evidence of any liaison with Social Care following either attendance or any enquiries relating to whether CHILD MF was known to Social Care at that time. Ante natal period 4.6 There were concerns highlighted about possible contact from Young Person A, the possible father of Child F. The family were aware that he was not to be in contact, Young Person A made limited contact prior to the birth. He was at the family home on one occasion during the Social Care Assessment of CHILD MF’s pregnancy. CHILD MF initially said that Young Person A was the father, but when the pregnancy was properly dated she said that these dates confirmed that he could not be the father. 4.7 CHILD MF’s pregnancy and her vulnerability further came to light on 9th October 2014 when Lincolnshire Police attended the incident after a notification by EMAS. It has been recognised by the Lincolnshire Police that they did not address issues relating to CHILD MF’s pregnancy and situation and this was a missed opportunity. (In 2014 a system called Stop Abuse was introduced within Lincolnshire Police which allows any officer or staff member who, for whatever reason, has any concerns or doubts about children or adult safeguarding or domestic abuse to press a button and activate a simple form. This form once completed is automatically sent to the Central Referral Unit for assessment and onward referral. This has given staff more confidence in referring incidents which they otherwise may not have. On 9th October 2014, the system was not fully embedded and there was still a need for professional judgement to be made at the time by the officers attending and not all of them used the Stop Abuse system. Now it is wholly embedded and 14 | P a g e used as a natural process of the officer’s assessments at relevant incidents. This is a system that Lincolnshire police have adopted to try and prevent any missed opportunities in relation to safeguarding.) 4.8 CHILD MF was supported in education by her school when she did attend. Families Working Together and Early Help worked closely with CHILD MF and her family. CHILD MF attended the Young Expectant Parents Group (attendance though was very variable) and the issues of unassessed risk from Young Person A were noted. CHILD MF and the wider family appeared to accept and work with these workers generally well, and at the closure expressed particular appreciation to the Families Working Together and Early Help worker. The review author feels the actions taken are a demonstration of good practice. CHILD MF did not attend all the Young Expectant Parents Group on all occasions but was assisted to work through the material in different ways, to the point where it is described as completed by the point of closure by Early Help. CHILD MF, it was hoped, would return to education in September 2015 and Adult B made it clear that she would care for Child F whilst this happened. 4.9 The rest of the Pre-birth protocol was not used as it was felt by CS that it was not needed from the indications from the Social Care Assessment. There were however, many vulnerabilities that would indicate consideration for pre-birth protocol to be followed by professionals from the different agencies (young age of CHILD MF, her poor childhood experiences, long history of CS involvement, CHILD MF vulnerable to CSA, chaotic household: domestic abuse, criminality, mental health concerns etc). There was never a suggestion that CHILD MF would not care for her own son and needed some support for her and the family over the next few months as the pregnancy came to an end and her baby was born. This assessment though was not complete as there was no information from CHILD MF’s GP surgery in this assessment, as no request for information had been made (it is accepted that CS do not always seek information from GP’s in relation to Social Care Assessments but might have been useful in this case). Neither was any information recorded from other health agencies or education so a complete account was not obtained. There was no assessment of Adult B and whether she would be able to cope with another child in the household. Bearing in mind her own children were at this time being supported by CS. 4.10 CHILD MF attended her routine antenatal care appointments as expected and only failed to attend one appointment with the Community Midwife, claiming that she had forgotten. This was rearranged and CHILD MF subsequently attended. There were some inconsistencies noted from the documentation in CHILD MF’s maternity records with regard to who accompanied CHILD MF to her appointments. At some appointments, the names of who accompanied CHILD MF was documented, however, at other appointments it was documented that CHILD MF was accompanied by a ‘family friend’, ‘cousin’ or ‘partner’ and there is no evidence that the Midwife used professional curiosity to ascertain the identity of these people. Local learning implemented from reviews recently undertaken, requires midwifery staff to document the identities of adults accompanying children and young people to their health appointments. CHILD MF’s attendances occurred at the time that this new process was being implemented and therefore would not have been fully embedded; however, should CHILD MF attend in similar circumstances today, one would expect the documentation to more fully reflect those in attendance. 4.11 CHILD MF sought appropriate care from the Antenatal Assessment Unit on several occasions during February 2015. There is documented evidence of effective liaison 15 | P a g e between hospital-based Midwives, Community Midwives and Social Care at this time. Although the majority of the documentation does evidence effective liaison, challenges relating to communication were noted on one occasion due to a change in CHILD MF’s Social Worker and the allocated Community Midwife being on long term sick leave. This resulted in a lack of clarity regarding whether a referral for CHILD MF’s unborn child had been made to Children’s Services at 20 weeks’ gestation as would have been expected. Appropriate escalation to the Community Midwifery Manager was noted in order to address these challenges. The review author has been told that such information is now held centrally within a Safeguarding Database, which is accessible to all Midwifery and Neonatal staff. 4.12 At the booking appointment it was documented CHILD MF had disclosed that there were two potential fathers to her unborn child, however, no details were recorded in respect of this in CHILD MF’s maternity records. It would be expected that the midwife would use professional curiosity to ascertain details regarding both males which would include their name, age and their history, including any potential substance misuse, criminal history and Social Care history and communicate this information to the relevant agencies. 4.13 CHILD MF failed to attend a number of appointments at the GP surgery and these are referred to as DNAs (did not attend). The practice “did not attend” policy states, “Where a child repeatedly DNAs this should be considered under child protection procedures as it may be a sign of neglect”. CHILD MF did have several DNA’s recorded on her notes however the GP felt that as CHILD MF was almost 16 she was aware of the consequences of her actions and so they took action to address this directly with her. (Child F only missed one appointment, for his 8-week check and this was followed up). At no time did any clinicians at the surgery feel there were any safeguarding concerns regarding Child F or CHILD MF. The review author fully accepts that CHILD MF was from the information he has been given, Gillick competent and the surgery carried out the Fraser guidelines1 in relation to her sexual health, however he does feel that CHILD MF was still a child and at times extremely vulnerable. 4.14 When a child transfers to another service or area, all safeguarding concerns including plans should be discussed and relevant information shared appropriately. There is some evidence of this with the schools. There was also a handover in Children Services and the social worker in the previous team kept the case for a while after the family had moved. 4.15 The contacts made to some of the agencies did not identify who some of CHILD MF’s male partners were. The Biennial Analysis Report of Serious Case Reviews (Brandon et al 2009) highlighted this as a theme: “The failure to know about or take account of men in the household was a theme in a number of serious case reviews. Assessments and support plans tended to focus on the mother’s problems in caring for her children and paid little attention to the men in the household and the risks of harm they might pose to the children given histories of domestic violence or allegations of or convictions for sexual abuse.2” (Brandon et al, 2009). This is clearly relevant in CHILD F & MF’s case. Various professionals never asked or enquired who 1 Gillick competency and Fraser guidelines refer to a legal case which looked specifically at whether doctors should be able to give contraceptive advice or treatment to under 16-year-olds without parental consent. But since then, they have been more widely used to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions. 2 Brandon M et al (2009), ‘Analysing serious case reviews and their impact’. A biennial analysis of serious case reviews 2005-2007’. Nottingham, DCSF publications. 16 | P a g e the male partners were and assumptions were made that they were the father or other person with care responsibility. 4.16 As already highlighted a recommendation from other Serious Case Reviews in the area, is that the names and relationships of all adults attending medical appointments with children should be sought and documented. This did not occur on various occasions. Emergency Departments and GP and Health systems should require these details to be inputted as a mandatory field. It is recognised as vital and particular good practice for Health Visitors to obtain the name and date of birth of any new partners who play a significant role in a child’s life. There is already a section within the Emergency Department record system that is involved in this SCR that highlights for staff to identify who a patient is accompanied by. The requirement to add names of those in attendance is also written into this Trusts policy. The use of this facility is audited on a quarterly basis. Consideration should be made for this audit at times being shared with the LSCB. 4.17 During the time that CHILD MF attended hospital for the induction of labour, it was documented that CHILD MF was accompanied by her Mother, a family friend (Adult F) and Adult D. Adult D supported CHILD MF throughout her labour and the nature of their relationship was questioned by Midwives in view of him being 20 years of age. Any intimate relationship was denied between CHILD MF and Adult D which has transpired to be untrue. Again, there should have been further professional curiosity as to why CHILD MF chose Adult D to accompany her through her labour. Post-natal period 4.18 Initially, Social Care were requesting that CHILD MF and Child F remained in hospital overnight to allow for Written Agreements to be created with CHILD MF and her family, however the nature of the Written Agreements is not clarified in any documentation. A decision was made for CHILD MF to be discharged home without any Written Agreements in place or a discharge planning meeting being held. Discharge planning meetings would not routinely be convened for cases managed at Child in Need unless there were any identified complicating factors, but in view of the information known regarding CHILD MF’s relationship with Adult D, the Midwife should have given consideration to discussing with Social Care whether a discharge planning meeting would be justified in this instance. 4.19 CHILD MF and Child F have been allocated the same Social Worker which is believed not to be common practice when both children are open to Social Care. This can impact on safeguarding each child as individuals, with the needs in particular of the mother outweighing the looking at their child’s individual safeguarding needs. However, there is no evidence that there were any conflicts with only having one social worker in this case actually having a detrimental impact. 4.20 At a Child in Need meeting on 13th July 2015 the attendees heard that CHILD MF was doing well in caring for Child F and there was agreement that the Child in Need Plans were no longer needed. There is however, no evidence in either CHILD MF’s or in fact Child F’s GP record that any members of the GP practice team were notified about CIN meetings or any CIN plan. As a result, there was never any GP information at the CIN meetings. The family declined a TAC. The attendees at this meeting are recorded as the family with only two professionals, being an Advanced Practitioner for Social Care on behalf of the Social Worker and a Health Visitor, who was not Child F’s Health Visitor. The Social Worker for the case was not present. These two professionals had limited knowledge of the case yet still made the decision to close it down. The review author questions whether this was an 17 | P a g e appropriate action, although does accept that there was further supervision between the social worker and their supervisor on the 30th July that reinforced that the closure was appropriate. 4.21 At the point of the closure CHILD MF was reporting that she is at home with her family, that she is managing well and enjoying being a mum, that her mother was available for support (albeit that CHILD MF said she did not need this support from her mother). The stepfather Adult C had been witnessed as interacting well with Child F and no longer said that CHILD MF and her baby would need to leave. As such, Children’s Services believed that they did have a clear picture of who was supporting and caring for CHILD MF and Child F but the review process has revealed a different picture as the information they had was not accurate. Given the information available to Children's Services at the time of closure, it can be seen as safe practice, but it is arguable that there were no outstanding identified needs for either CHILD MF or her baby. However, the quality of this decision could be open to question given the family history and CHILD MF's young age as a new parent, leaving the case open for a longer period of time and supporting CHILD MF to access community resources may have been better practice, and also ensuring that an assessment of the new partner was completed. The review author would like to stress that this view is purely specific to this case. The closure of cases in general is a lot more sophisticated than taking this case as an indication of what should happen in all cases. This must be left to the judgement of the social worker in the case, their supervisor and their partners working on the case. 4.22 The information regarding CHILD MF and Child F having moved across the road to Adult D and F’s house was mentioned to the Families Working Together (FWT) worker by CHILD MF's siblings at their closure visit on 1st July 2015, CS were also aware by the information passed to them from the midwife that CHILD MF was in a relationship with Adult D. It is recorded that this information was emailed to the Social Worker. There is no corresponding record in CHILD MF or Child F's CS records. The Social Worker has reported that this information was followed up during a further visit by the advanced practitioner (not Child F or CHILD MF’s SW) and was denied by Adult B and CHILD MF but there is no record made of the visit. The question also wasn’t asked of why Adult D was present at the birth of Child F. The siblings were never spoken to further about this information which may have been beneficial to do so, notwithstanding that CHILD MF and Adult B denied this information and this was accepted on face value. It is now clear this was CHILD MF and Adult B showing disguised compliance. This action by CHILD MF and Adult B fit what Brandon (2008) describes in her research as “Apparent or disguised cooperation from parents often prevented or delayed understanding of the severity of harm to the child and cases drifted. Where parents ...engineered the focus away from allegations of harm, children went unseen and unheard.” (Brandon et al, 2008)3. If it had been confirmed, the new situation would have been considered and may have led to the case remaining open for longer. Analysis of this therefore is that whilst not recorded, the SW did follow up this information and as it was denied it went no further. The SW has retrospectively reported to the review that the matter was followed up appropriately. Although the review author fully understands the thoughts of the SW, it is definitely poor record keeping and showed an apparent lack of professional curiosity as it would appear that the information provided by the children was correct, as was discovered later. It was an opportunity missed by CS to 3 Brandon, M. et al. (2008a) Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005. Research Brief DCSF-RB023 London: Department for Education and Skills (DfES). 18 | P a g e look at the implications of the move and assess why CHILD MF and the adults were covering it up. This shows a lack of professional curiosity to this disguised compliance. Lord Laming (2003) suggested social workers needed to practice “respectful uncertainty”, applying critical evaluation to any information they receive and maintaining an open mind.4 4.23 At a closure visit on 29th July 2015 CHILD MF is recorded as saying to the Social Worker that she has no boyfriend at present. The Social Worker asked who "the male" was that attended CHILD MF's health appointment and if she was involved with him. CHILD MF stated that he was a friend and that was all. Professional curiosity should have taken place and this would probably have established that he was Adult D (who was 20yrs old), and whom we now know CHILD MF was living with. 4.24 Looking at the Child in Need (CIN) plans that were in place for CHILD MF and Child F. There were gaps in the timely running of Child in Need meetings and the recording of these and poor distribution of the minutes. Meetings did not take place when they should have done and there were breakdowns in communication such as the Community Midwife not being aware of nor invited to certain meetings. One such meeting had to be abandoned because of non-attendance of the social worker. It is not right to say on the strength of looking at this one case that improvement in the CIN process is required, however it is important that LSCB seek assurance that it is working effectively via for example an audit. 4.25 Health Visitors completed the primary birth and 6-week assessment within the timescales expected. The 3 to 4-month Health Visitor contact did not take place and no additional contacts made which would be expected for a family with these identified vulnerabilities. However, the HV responsibilities though were not fully completed or multi-agency working not fully carried out for example by attendance at meetings and liaison with other health and/or outside agencies. It is believed by the ANR author and the review author that an enhanced level of contact was not provided to an identified vulnerable mother (a child herself) with a young baby in order to enable her to make the required assessments and analyse and act upon concerns identified. Records do not reflect an assimilation of the history of concerns regarding CHILD MF, to inform the risk assessment following any visits for either the primary birth contact or 6-week assessment. 4.26 The Health Visitor team leader did not allocate CHILD MF and her unborn baby a named Health Visitor and complete their part of the pre-birth assessments however the review author has been informed that this has been addressed. All referrals for antenatal care requiring an appointment by the Health Visitor are recorded within the patient’s electronic record following midwifery referral via Child Health. All referrals are screened by the Team Manager to ensure even where staffing capacity issues are present pregnant women with identified vulnerabilities received antenatal assessment from a named Health Visitor. This ensures the required responsibilities to LSCB Pre-Birth protocol are identified and completed. Whilst acknowledgement in this case is that the LSCB Pre-Birth protocol was not followed as a result of the incomplete pre-birth assessment by the SW, LCHS has ensured that this is embedded in practice within the organisation and would be able to demonstrate this via internal audit. This demonstrates really good and prompt learning from this SCR process. Period at death 4 Laming, Lord, (2003) The Victoria Climbie inquiry: report of an inquiry by Lord Laming (PDF). Norwich: TSO P205. 19 | P a g e 4.27 With regard to the carer at the time of Child F’s death, Adult E, there is nothing in the records to suggest that she was actively involved in caring for Child F until a description of this arrangement is provided at the time of his death. At such there was no opportunity to analyse if there were risks inherent in such arrangements. 5.0 Family perspective. 5.1 Neither CHILD MF nor her mother Adult B have taken up the review authors offer during the writing of the review to speak to them and hear their views. There are other parallel processes taking place that make this understandable. At the inquest they did speak to him. They had seen the draft SCR and had a chance to read it extensively. They were pleased that the review highlighted the risk factors with bottle prop feeding and being put to sleep in a car seat. They also wanted included the risk factor of sleeping with a baby on a sofa (This was information given by Adult E when giving evidence at the inquest but was unknown to the review) in particular whilst under the influence of drink or drugs that included prescription drugs. They felt that fact the Child F could have had his own SW and separate CIN plan wasn’t explained and in hindsight may have wanted this but still didn’t want it for CHILD MF. The review author has contacted CHILD MF further but no further information has been forthcoming. 6.0 Conclusion 6.1 The above commentary and analysis shows what happened during the period set for the review and at previous significant times. Conclusions have been made and there are some lessons to be learned in relation to the way safeguarding and promoting the welfare of children could improve. Instances of good practice have been highlighted in the report. 6.2 The review has recognised a number of themes for learning that have arisen from the analysis, and where possible answering the questions posed to the ANR authors. These were: following the Pre-Birth assessment being undertaken was the Pre-Birth protocol followed? Did all agencies contribute effectively and was the information collated and analysed to identify risk and need? Was there an effective Pre-birth Plan and was it delivered? Did the CIN process recognise the separate and individual risk and needs for both children, CHILD MF and Child F? Did the CIN process collate and analyse risk and needs and review them appropriately? Did agencies have a clear picture of who was supporting and caring for CHILD MF and Child F? How did agencies support CHILD MF in managing her physical Health needs whilst she was caring for Child F and meeting his needs? 6.3 Looking at the above questions and taking account of the analysis the following themes for learning are as follows: Key Learning Themes Recognition of underage sex; Where the mother is a child both her and the baby need to be treated as such; The Pre-birth assessment was not to the appropriate depth required; The quality of the CIN procedure and meetings in this case needs improvement; Professional curiosity was lacking and over optimism took place; The lack of assessments of known males; Poor record keeping at times was revealed. 20 | P a g e 6.4 During the summer of 2014, when CHILD MF was 14yrs old, it was clear that she was engaging in underage sex. There was no real exploration provided to the review of who this was with, and whether CHILD MF maybe subject to child sexual abuse or sexual exploitation. It is fully accepted by the review author that the FWT and targeted youth worker did as is mentioned earlier some good work with CHILD MF and believe some of this would have taken place during this time. The Family Education Trust have published a book ‘Unprotected’ by Norman Wells (20175) which strongly suggests that agencies and professionals are normalising underage sex and undermining the age of consent. The learning from this publication is in particular important learning for this review and should be acted on by all agencies. 6.5 There are a number of examples when CHILD MF was not treated as a child; an example of this is the sexual activity as described in this review. There was no real examination of her as a vulnerable 15yrs old, the Social work assessment which closed at the beginning of April does however look at how she will cope as a mother. There was also some work done with her relating to risks and impact. It was not known by most if not all agencies at the time of how she was really struggling as a child mother, in the months after birth and in particular the period before Child F dies. During this period family members and friends were looking after Child F as CHILD MF was struggling so much, this though was not shared with agencies that had made it clear to CHILD MF that they were there to support her. This seems to demonstrate how life was like for this child at this time, albeit agency records portray a different picture to what reality was really like. The GP records do show how much in pain she was and as a result struggling to cope. 6.6 CHILD MF had become more vulnerable during the period from leaving the home family unit to living with Adult D and Child F at a separate address (which the siblings had already told a worker, and we now know in hindsight both CHILD MF and Adult B agree this happened). It was clearly during that period that she found it so difficult to cope she asked Adult E, for her help. It was agreed that Adult E would take care of Child F for that five-day period to give CHILD MF a break and it was during that time that Child F tragically died. This highlights how difficult CHILD MF was finding coping as a mother. There appeared to be a lack of consideration of the fact she was likely to be struggling given the quality of her own parenting and her environment and no attempt to analyse reality as opposed to what was being said by CHILD MF and her mother, who clearly were showing disguised compliance. 6.7 As already stated in the review, the author’s view is that Child F should have stayed on a CIN plan. The review author has also already stated that this is his view specific to this case and not CIN plan closure in general. There is little separation from activity with his mother to treating him as an individual child. Both having the same SW is an indication of this. What was life like for Child F during this period; although not a causation of his death he suffered broken legs which due to his age were highly likely to be non-accidental injury. The moving around all of these friends and family members could not be settling for him, hence him not sleeping at night. The bottle prop feeding and sleeping in a car seat (albeit reclining) is not recommended by research. 6.8 A Pre-Birth assessment took place and was completed on 9th April 2015. This covered the period from 5th February 2015 to 2nd April 2015. The review author considers this assessment to be incomplete. There was information available about risks and vulnerabilities retained in other agencies in particular education, health agencies and for example the GP, which had not been sought or included. There is no assessment of Adult B 5 Wells N (2017) ‘Unprotected’ ‘How the normalisation of underage sex is exposing children and young people to the risk of sexual exploitation’ Family Education Trust, Middlesex. 21 | P a g e and the fact that all of her children had been subject to CIN and CPP plans in the past. No assessment of the males involved. The LSCB pre-birth protocol wasn’t followed to the depth required as further information seeking in particular from health agencies should have taken place. 6.9 When CHILD MF was pregnant with Child F the agencies mainly knew where she was and that her mother was the support for her. After Child F’s birth some agencies, such as the police, attended no further incidents (Child F’s death aside) and thus had no cause to monitor their whereabouts. However, what came to light through the subsequent investigations (albeit looking back in hindsight) was that the family was anything but supported and CHILD MF and Adult D were finding it very difficult to understand and deal with their roles as parents. The review author feels the multi-agency partnership lost close contact with CHILD MF, Adult B and Child F and did not identify the risks at the very time when they were at their most vulnerable. The CIN plan is what could have done this. Agencies at the time of Child F’s death did not have a clear picture and possession of all the information some which was available to some agencies and some information that was concealed by the family. 6.10 During the CIN process, there were five different Social Workers identified to have been allocated and present at the meetings. Once the family moved, there was a lack of continuity of care by the School Nursing team with two different nurses being involved, neither of whom received the transfer information from the previous team. This information was present in Child MF’s record and could have been reviewed by the new area SN team. 6.11 There was also a lack of professional curiosity demonstrated by professionals across the agencies, on numerous occasions, whether it was finding out who the males were that were in contact and close to the family or earlier on who CHILD MF was having underage sex with. There was a shortfall in this professional curiosity around this family when the Social Worker did not record the visit where the information was checked regarding whether CHILD MF and Child F had moved to a neighbour’s house across the road. They did not further check with the siblings who had given the information in the first place or pursue the matter further. Another example is following the receipt of the Child in Need documentation at the GP’s practice which gave a different surname and date of birth for CHILD MF, should have prompted the GP practice to follow up with the issuing agency to clarify the information is correct. 6.12 This review has highlighted numerous occasions when recording of information or the sharing of information was not completed correctly: for example, the visit as mentioned by the SW in the previous paragraph or the information not passed to the School Nurse when she has done her home visit about the assault on CHILD MF. (As already mentioned earlier in the review action has already been taken that has resolved this as an issue). Information should also have been shared when the radiologist and pathologist first suspected (October 2015) there was a possibility of fractures to Child F’s legs rather than when confirmed in March/April 2016. 6.13 The review has found nothing to suggest that any agency or professional could have predicted the death of Child F. 6.14 An inquest was held into the death of Child F and on the 9th of February the Coroner made the following judgement. He concluded that: "On the 3rd October 2015 Child F, age 4 months, was being cared for at the home of Adult E. At around 8.00am Child F was placed in a car seat at the property and bottle feed some milk. 22 | P a g e His bottle was propped on a blanket. At some time between 8.00am and 10.00am he died from choking on that milk." 7.0 Recommendations Each individual agency has identified its own learning and made recommendations to improve services and outcomes for children. The Lincolnshire LSCB will monitor these to ensure that the recommendations are fully implemented. This Serious Case Review has also identified learning and made some recommendations as detailed below and the implementation of these will assist the partnership to deal more effectively with similar circumstances in the future resulting in the improved safety and welfare of children. Recommendation 1 It is recommended that assurance is provided by the Local Authority and their partners that the Lincolnshire LSCB’s Child in Need process is operating effectively. Recommendation 2 The LSCB should make it a requirement that all agencies working with a child or family, record the full details of all adults within the household as well as those who have significant contact with the child. (It is accepted by the review author that some agencies already have this mechanism in place). They should also ensure that is incorporated in all relevant multi-agency training. (This requirement is already in some agencies policies and should be monitored through audits.) Recommendation 3 The LSCB should seek assurance from its partners that the quality of assessment for the pre-birth protocol is of the right standard on all occasions where vulnerable mothers who are children themselves are pregnant. This is a multi-agency requirement. Recommendation 4 I) Assurance to be provided by all partner agencies to the LSCB that the application of the 'Sexually Active Young People Policy' and 'Harmful Sexual Behaviour Policy' is happening. ii) The LSCB should continue to seek assurance from all in their partnership that they are carrying out and completing appropriate and relevant CSE risk assessments, and appropriate staff have completed the LSCB CSE training. Recommendation 5 The LSCB’s should issue a practice note to all agencies using this case to highlight the importance of recording information and sharing this where and when appropriate. Recommendation 6 The LSCB should review its training to ensure: a) That professionals are able to recognise disguised compliance and dis-engagements and know what to do in order to able to work these circumstances. 23 | P a g e b) That professional curiosity and healthy scepticism is included in all levels of safeguarding training to give staff confidence and skills to challenge and check service user’s information (this requirement is already in some agencies policies and checked happening through audit.) The understanding of ‘what life would be like for the child’ in that family will assist this process. Recommendation 7 The LSCB should ask its Child Death Overview panel to consider i) Research and producing information in relation to the dangers of bottle prop feeding and babies sleeping in car seats. ii) Re-issue guidance on safer sleeping in particular guidance about the high risk to a baby of sleeping on a sofa or in an armchair, which is an even further risk if drink or drugs are being used (this includes drugs that may make a person drowsy). Recommendation 8 Review the information sharing meetings (in particular the one after post mortem to ensure all information is being shared). Recommendation 9 I) The LSCB should seek assurance from children's services as part of the social care assessment process, that all agencies are contacted for information. ii) The LSCB should seek assurance that all universal services can do this, and will respond in 10 working days, unless it is an urgent safeguarding under section 47. |
NC50863 | Life-threatening head injuries and other serious injury to 20-month-old boy in April 2016. Child T was born in Scotland in August 2014, and was named on a child protection register from birth. He was placed with foster carers before moving to the north of England in December 2015 to live with his maternal aunt who was approved as a kinship carer by Highland Council who continued to manage the case. Following Child T's admission to hospital his aunt and her partner were arrested and investigated in relation to his physical abuse. Findings include: the focus on processes in kinship care system to collect information rather than a full analysis of information gathered led to undue optimism about a potential kinship placement at the expense of critical thinking; the decision that Highland Council would retain management responsibilities when Child T moved to England was unrealistic and it was optimistic to expect that supervision could be maintained at this distance. Uses the Social Care Institute of Excellence (SCIE) learning together model. Recommendations include: ensuring that guidance supports staff to lead and contribute to risk assessment generally and specifically in relation to kinship care; discussion at national level with chairs of child protection committees (CPCs)and Social Work Scotland about disclosure/ vetting systems between Scotland and England; the need to value foster carers contributions in the assessment and planning of children moving to kinship care.
| Title: Report of the significant case review carried out by Highland Child Protection Committee in association with Local Safeguarding Children Board: Child T: executive summary. LSCB: Highland Child Protection Committee and North Tyneside Safeguarding Children Board Author: Jacquelyn Jennett and Donna Munro Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Report of the Significant Case Review carried out by Highland Child Protection Committee in association with Local Safeguarding Children Board – Child T Executive Summary: March 2018 Reviewers: Jacquelyn Jennett and Donna Munro 2 Executive Summary Reason for Case Review In April 2016 Child T was admitted to hospital with serious injuries, including a life threatening head injury. He required urgent specialist medical intervention including surgery. At the time he was living in a kinship placement in England with his maternal aunt (F) who had been approved as a kinship carer by the Kinship Panel in Highland in October 2015. He was subject to statutory measures of supervision following a Children’s Hearing in December 2015. T’s mother (M) had been known to services throughout her childhood with this contact continuing into adulthood and to date. As a child she and her siblings spent periods looked after and accommodated by the local authority. Departmental records suggest her parents had a tense and on occasion violent relationship. There were issues relating to substance misuse and this impacted on their ability to successfully care for their four girls. M’s mother died when M was a teenager and she has continued over the years to have fractious relationships with her three sisters and her father. M’s first child had successfully been placed with another maternal aunt from birth. T was born in August 2014. He was accommodated with foster carers on release from hospital and his name placed on the child protection register. Due to M’s lifestyle, poor choices and lack of consistent contact there was no opportunity to return him to his mother’s care. In January 2015 it was agreed that alternative permanent arrangements should be sought for Child T. In February 2015, F presented requesting to be assessed as a kinship carer. Following assessment and approval by the Kinship Panel in Highland, T moved to the North of England in December 2015 to live with F. Highland Council maintained all case management responsibility. The receiving authority were notified of his presence but were advised that no contact or assistance was required to be taken on Highland Council’s behalf. Following T’s admission to hospital F and her partner were arrested and investigated in relation to physical abuse of the child. Their children were both accommodated immediately by the local authority in England. Methodology It was decided that the child’s circumstances met the criteria for a significant case review (SCR) as set out in:’ Criteria for establishing if a case is significant’, National Guidance for Child Protection Committees Conducting a Significant Case Review (2015) (National Guidance). Given that the injuries had occurred in their Local Authority, the English Safeguarding Children Board met to consider the need for a significant case review 3 (SCR). As Highland held case responsibility at the time of the injuries, and full knowledge of the history of the case, it was agreed that Highland Child Protection Committee (HCPC) would conduct the SCR with input from local professionals. Any learning would be shared between HCPC and the local Safeguarding Board. The mandated sub-group considered that there was likely to be multi-agency learning in relation to the assessment and approval of kinship carers and in relation to cross border placements and communication. The timeframe for the review was agreed by the CPC to be from T’s birth in August 2014 until April 2016 when he was admitted to hospital. It was agreed that the SCR would be undertaken using the Social Care Institute of Excellence Learning Together Model. Learning Together reviews take their focus from what a CPC wants to learn more about, using a review of the case as the vehicle. Whatever the CPC agrees is then framed as a research question(s), which underpins the investigative work carried out by the review. The use of research questions in a Learning Together systems review is equivalent to Terms of Reference. The research questions identify the key lines of enquiry that the CPC wants the review to pursue and are framed in such a way that make them applicable to casework more generally, as is the nature of systems Findings. Further information about the SCIE Model can be found at: http://www.scie.org.uk/children/learningtogether/ Research questions and appraisal of practice examined in the review The Child Protection Committee identified that this review held the potential to shed light on particular areas of practice and agreed the following research questions: 1. What can we learn about the effectiveness of our approach to risk assessment, with particular reference to: a. The assessment of kinship carers, and b. The use we make of historical information to inform our work in the present 2. What helps or hinders the operation of effective Panels in the context of family placements? 3. What are the issues about working across borders in planning for children? 4 Findings of Review and CPC Response The review team prioritised 6 findings for the CPC to consider. Finding 1 Are the various checks and balances within the kinship care system working well enough to routinely pick up when there is undue optimism about a potential kinship placement at the expense of critical thinking? The checks and balances that existed to assure the safety and wellbeing of the child placed with a family member in this case failed to do so. This Finding raises the need to test the functioning of the same mechanisms for other children in a cautionary way, in order to reinforce the requirement to be constantly vigilant. Although this case was extreme in its outcome, if it is that easy for optimism to outweigh the actual evidence presented to support it, then it places children at risk. Questions for the CPC to consider: How does CPC ensure that practitioners and their managers are competent and confident in both assessing and challenging information presented to them? Are CPC confident that members of Kinship Panel are adequately trained and supported to fulfil the functions of their role? Are CPC confident that the Children’s Hearing System is clear about expectations for managing cross border Kinship Placements where the Local Authority retains case management responsibility? Finding 2 The focus on process in existing guidance is not helping staff to think in a child centred way about kinship placements and risks a default adherence to what should happen when at the expense of critical and sometimes creative thinking. Assessment is often used to collect and collate information about children and families. However, a good analysis of the information available is often lacking. Professionals need to use their professional knowledge and judgement to conduct a full assessment and analysis of the situation rather than relying on a Practice Guide to provide a step-by-step instruction, but if guidance exists it should be as helpful as possible towards facilitating the critical analysis of information gathered, not just the gathering of information. It is important to recognise that a ‘one size fits all’ approach is not effective in assessing children or carers and that tools will usually focus on the commonest denominator rather than how to assess each situation. Questions for the CPC to consider What value does the Committee place on practice guidance to support the assessment of kinship carers? If there is specific guidance, how different should it be to the kind of guidance that supports any risk assessment work? 5 Is the Committee assured that the right kind of guidance exists in Highland to support all staff to lead and contribute to risk assessment, both generally and specific to kinship care? What kind of action does the CPC consider that it may be necessary to take to better support the professionals undertaking assessment work? FINDING 3 Are supervisory arrangements working well enough to support professionals to think through the complexities of assessment work, specifically in relation to the placement of children with kinship carers and more generally? This Finding shows how easily supervision can move from being a mechanism of assurance to being complicit in, or even encouraging, non-critical thinking. There will be no quick solution to this, but in the first instance, raising awareness of the fact of the problem and its likely pervasiveness is a vital first step. The assessment sets the direction of travel for casework thereafter, notwithstanding the fact that it should be regularly reviewed. If the quality of an assessment is poor or overly optimistic then it is also likely that plans for children will be less robust, as in this case, where contact arrangements were minimal. Questions for CPC: Is the CPC aware that this is a common issue in child protection work? What kind of supervisory arrangements exist to support critical thinking in non-social work agencies? What value do organisations place upon reflective practice and to what degree does supervision demonstrate this? Is there the right balance between quality of work and timescales for completion in assessment of kinship carers? What kind of support do practice supervisors receive and is this sufficient? Are the professionals who contribute information towards a kinship assessment sent a copy of that assessment when it is complete? If not, what avenues for challenge and/or escalation are there? Finding 4 Is there too much emphasis in Highland on retention of case responsibility for children placed at distance out with the authority, at the expense of on-going dialogue with an authority where a kinship carer is resident, where necessary negotiating proxy responsibilities on Highland’s behalf? This Finding shows how quickly responsibility for a young child can turn into irresponsibility, just because of professional choices that are made about ‘ownership’ of that child. Negotiating proxy responsibilities with another area does not equate to a loss of control, but it makes it more likely that the viability of a placement will be well tested and therefore that children will thrive. 6 Questions for the CPC to consider How can the CPC ensure practitioners from all agencies are clear about their roles, responsibilities and limitations when working with cases that cross borders How do CPCs and LSCBs ensure that authorities work together effectively in cross border cases? Finding 5 There are problems with the Disclosure/Vetting systems between England and Scotland to make criminal records and intelligence checks easily available on potential kinship carers who are not resident in Scotland, risking key information not being available to support assessment and decision making. The delay in the vetting process was a crucial matter in this case and could be in others. No actual written criminal conviction statement was ever received. Decisions not to move the child were made in the kinship panel then overruled with the absence of the information being well known – a separate issue around governance, but it was as if folk got ‘fed up’ waiting for it and decided to take the risk. The information that is now known and could have been known at the time illustrates all of the concerns that existed but that practitioners did not act on, that F, like her sister, M, bore the consequences of a traumatic childhood. She clearly had issues around aggression and anger which culminated in assaults against others and undoubtedly facilitated either by action or inaction the assault and injury of T. Questions for the CPC to consider This is undoubtedly an issue wider than Highland. Can this be represented and discussed at a national level with the Chairs of CPC’s and Social Work Scotland? Are staff in CPCs/Safeguarding Children Boards clear about the processes for Criminal Records checks in England and what these might mean for children coming into their area? How can HCPC and the Safeguarding Children Board help practitioners understand the processes for carrying out Criminal Records checks in cross border cases? FINDING 6 There is a tendency for professionals in a child’s network not to consider a foster carer to be part of that network, which not only makes it more difficult for foster carers to escalate any concerns that they have pre and post placement but also more likely that they will not be taken seriously as other professionals if they do. 7 The foster carer in this case knew T better than anyone and yet her suggestions as to how best he might transition between her care and the care of F were dismissed at the time. The degree to which this is indicative of a deeper dismissal of foster carers as being less significant than others within a ‘professional’ network is for the CPC to determine by hearing the views of all parties. Certainly, in a case which highlights the lack of child-centred assessment work in other Findings, there is a need to better value the importance of foster carer contributions in this context. Questions for CPC: What is the considered status of foster carers relative to other professionals contributing to the assessment and planning of children moving to kinship care? Have the experiences of foster carers in Highland ever been canvassed relative to this Finding and if not, is this something the CPC would find of value? Has there ever been any study in Highland or more widely of the impact of kinship placements on children in later life? Might this be something that the CPC considers of interest? |
NC52643 | Neglect and abuse over several years of seven siblings aged between 16-years-old and 1-year-old. The siblings' circumstances were discussed at a rapid review meeting in early September 2021 after suspected sunburn injuries which were the subject of a police criminal investigation. Learning includes: importance and workload implications of focussing on individual children within larger sibling groups; behavioural and emotional symptoms of persistent neglect and how they are reflected in risk statements such as the signs of safety scaling; the importance of considering children's lived experiences when the cumulative effect of neglect and the impact on children's development and well-being is a factor; the importance of chronology and holistic assessments; need for GP practices to be involved in enquiries and assessments; procedures for escalating concerns about children through internal systems and how they can be linked with local partnership escalation pathways; importance of a clear strategy for responding to neglect that is owned by all respective organisations; the importance of providing trauma-informed early intensive help for parents who have experienced trauma in their own childhood; and aligning legal and child-based risk discussions. Recommendations include: the Director of Children's Services (DCS) should satisfy themselves with the effectiveness of signs of safety in supporting effective assessment and management of risk for children; DCS should ensure that advocates for children can be appointed and are routinely considered in complex and/or longstanding cases involving neglect; DCS and Director of Legal Services should ensure appropriate arrangements are in place for social workers to seek emergency protection for children when necessary.
| Title: A local child safeguarding practice review (LCSPR): ‘W’ Siblings: overview report. LSCB: North East Lincolnshire Safeguarding Children Partnership Author: Peter Maddocks Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 30 A local child safeguarding practice review (LCSPR) commissioned under The Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018 ‘W’ siblings Overview Report Page 2 of 30 Index 1 Context and circumstances of the review ................................................. 3 2 Overview of information ......................................................................... 5 3 Research and national learning relevant to the review .............................. 8 4 Summary of learning ............................................................................ 13 5 Assessment of systemic or underlying influences .................................... 22 6 Recommendations to safeguard and promote the welfare of children ...... 26 The methodology and terms of reference .................................................. 27 Agencies who provided information to the serious case review ................ 27 Action from the rapid review ................................................................. 28 Details of the independent author ............................................................. 30 Page 3 of 30 1 Context and circumstances of the review 1. This review is about seven siblings aged between sixteen and one year old born to different fathers. Two older siblings who are now young adults were previously removed from the mother’s care. 2. The case is complex with a long history. The focus of the review is on events between December 2019 when a strategy meeting agreed on a joint s47 investigation leading to a child protection plan (CPP) and one of the older children became looked after and goes through until July 2021 when three other children sustained injuries as a result of suspected sunburn. 3. For clarity, the use of acronyms is kept to a minimum. To help preserve the privacy of the children in particular and of the adult stepsiblings none are referred to by gender. Schools are not identified by name. Birth family members are referred to by their relationship with the children. Professionals are referred to by their job titles or role such as family support worker (FSW) GP, health visitor, police officer, social worker or teacher. Some of those roles had multiple people such as police officers or social workers; there were for example three social workers between January 2020 and July 2021. 4. The circumstances of the siblings were discussed at a rapid review meeting in early September 2021 after the suspected sunburn injuries which were the subject of a police criminal investigation. All the siblings have suffered longer-term neglect and abuse over several years. One of the children was sexually abused by adult males and another child was at risk of child criminal exploitation. Evidence of neglect discussed at the rapid review included delayed and impaired development, poor attachment and severe dental decay resulting in extractions. 5. All of the school-age children suffered disruption to their education which compounded with parental neglect had contributed to significant developmental delays. The children have been presented to health services with an array of ailments at different times as well as with physical injuries many of which were not adequately explained. One of the children has cystic fibrosis and another has an autism spectrum disorder. 6. The children lived in an area that is amongst the nine per cent most deprived in England. The local authority as a whole is ranked among the 20 per cent most deprived in England. All of the siblings’ fathers and the mother are white British and English-speaking. There is no record of any faith-based affiliation. 7. The mother is thought to have learning difficulties although this has not been formally assessed and diagnosed. Her childhood history was of poor parenting and sexual abuse by a close relative; there was extensive involvement by CSC; she has described it as being ‘difficult’; she does not have a family or friendship network capable of giving consistent and positive Page 4 of 30 support. Domestic abuse has been a feature of her intimate relationships although little detail has been collated in assessments. Little information has been collated about the identity or background history of men who have been part of the household at different times although one was deemed a significant safeguarding risk and contact was prohibited without a court order. The identity of the fathers of some of the children is not known. Although convicted of assaulting a previous partner the mother is also described as a woman who has had little power in some of her relationships. 8. Statutory involvement with the children began in 2008 with a child in need (CIN) plan until 2010. This was followed by two further CIN plans as well as child protection plans and short periods for some of the children being looked after. The public law outline (PLO) was used on four occasions although no proceedings were issued until after the suspected sunburn injuries in July 2021. A legal gateway meeting had agreed that the PLO should be opened in January 2021; this involved further parenting work being done with the mother. 9. Multi-agency working was extensive with high levels of communication between different professionals and core groups and statutory meetings were generally well attended and continued through the Covid lockdowns. Although intensive work produced some improvement in school attendance it was not satisfactory and not sustained without a great deal of effort from different professionals. The children’s circumstances and cumulative experiences changed little as a result of the multi-agency working or achieved sustained changes; the mother struggled to sustain changes and improvement in her care and parenting. The escalation of concerns about the children preceding the suspected sunburn injuries did not generate an appreciable change in how the local authority worked with the family. 10. The local authority relied on working with the consent of the mother. On more than one occasion children have needed to be looked after. These and other arrangements have been made on the reliance of the mother giving her consent although the children were subject to interim care orders and ongoing Family Court proceedings during the review and are being cared for in five different placements. 11. Some services struggled to recruit and retain appropriate staff, and all are working in an area that has some of the highest levels of child poverty and deprivation in the country. In particular children's social care appeared to have a succession of different social workers and managers involved with the case. Ten different social workers were involved with the family over three years; there were three social workers between January 2020 and July 2021. 12. The rapid review found that no individual or service had an effective chronological oversight. It was agreed that the serious harm criteria were met in that all seven children had experienced neglect and other abuse over several years. A recommendation was made to the NEL Safeguarding Page 5 of 30 Children Partnership's Executive by the NEL SCP Safeguarding Review Group on the 13th of September 2021 that a serious notification was submitted to the National Panel. The National Panel confirmed that there would not be a national review; that there was learning to be drawn from the case and agreed with the local decision to commission this LSCPR in early October 2021. 13. The rapid review acknowledged that there are examples of good individual practice to be found, and people had tried to work together. Professionals had tried to respond empathetically to a mother, who had multiple difficulties with a history of childhood abuse, social isolation and domestic abuse. Any changes that were made were only achieved with intensive agency support but were not sustained. 14. The rapid review was only able to give a limited picture of the lives of the children and the impact of their long-term neglect; agencies had limited information about why the history of the mother and the various males who were part of the household at different times does not appear to have been part of any enquiry or assessment. The review has to establish why despite some assessments and professionals being so negative about the safety and well-being of the children nothing substantially changed until three children were injured in July 2021. 15. The rapid review acknowledged that the case had highlighted that urgent improvements were needed in a series of recommendations being made to address significant learning. This LCSPR takes account of those recommendations and any outcomes. 16. The review identified key practice episodes (KPE) of professional practice and decision-making to be examined by the review. Details about the organisations that provided information and participated in the review are included in an appendix. 17. The siblings have not been asked to participate in any aspect of the review. This decision took into account the trauma and distress they had experienced before becoming looked after and the progress that the children are making and their differing levels of age and understanding. 2 Overview of information 18. Statutory involvement with the children began in 2008 with a child in need (CIN) plan that lasted until 2010. There was a second CIN plan from June 2016 until February 2017 when it was stepped down to early help. 19. A graded care profile (GCP) was completed in July 2017 and again in February 2018 which was “wholly negative on all domains”. These were not completed by CSC. Although the children presented with behaviour symptomatic of poor or disordered attachment no assessment of this was completed. Significantly one of the children who presented with anxiety and Page 6 of 30 did not speak at school started to talk after becoming looked after in 2020. Levels of aggression and other behaviour presented by one of the other children also improved after becoming looked after. Although there was a recommendation to complete a psychological assessment of the mother as part of a CPP this was reversed by a senior manager in the local authority and was not completed. There is no baseline of the mother’s functioning and her ability to make sustainable changes. 20. A third CIN plan from July 2017 until January 2018 was stepped up to a child protection plan (CPP) for neglect until March 2019. The decision to end the CPP in March 2019 did not have an updated assessment; the health visiting service which was not represented at the CPC raised a formal objection to the decision afterwards; the health visitor had been on a training course which had prevented her attendance. 21. In December 2019 one of the children reported to their school not being fed regularly because mum had no money; the social worker was informed. Another school raised several concerns with the social worker by email in early December 2019. A child was regularly staying at an older sibling’s home where there were concerns about the household and there was no bed for the child to sleep in and who was arriving late every day and their behaviour at school had deteriorated and was often “spaced out”. The school reported seeing bruises on the child with unconvincing explanations. The mother was asking the school to let an 8-year-old child walk home from school; one of the siblings had been assaulted by another. Staff had found one of the children at school just after 08.00 having walked to school. Other concerns included seeing bruises on the child with unconvincing explanations, the mother asking the school to let an 8-year-old child walk home from school and a child being assaulted by a sibling. No action was recorded by CSC. The information was not considered at a strategy meeting almost a month later when the police had found the same child with bruising at the same older sibling’s home. 22. In late December 2019, the police responded to a domestic abuse incident at the home of one of the adult siblings where the same child was present and found to have a bruised eye. The child told the responding officers that mum had assaulted the child. During the subsequent investigation, the child said that the injury had been caused by an older sibling rather than their mum. The police used their police powers of protection (PPOP) to make arrangements for the children to be cared for and the mother was arrested. Some of the children were in an unkempt condition with severe head lice infections. Several had bruises when examined. A younger child had a nappy rash. Some of the children had skin lesions. The children’s history of being neglected was well known to all the agencies at this stage. The mother was 19 weeks pregnant with her seventh child, had been late making her booking appointment and had missed two other appointments. The NLaG concealed pregnancy guideline was followed at the time and social care was made aware of the pregnancy. Page 7 of 30 23. The children gave different accounts for the injury to the child none of which alleged that the mother had assaulted the child. The children had returned home before a strategy meeting in early January 2020. It discussed the information that included the history of missed health appointments for the children, poor school attendance, poor and neglected physical condition of the children and poor home conditions. The initial child protection conference (ICPC) agreed to the CPP for neglect that was still in place when the suspected sunburn injuries occurred in July 2021. 24. In early March 2020, an older sibling told a YMM practitioner that they had a secret but did not want to talk about it because the police would be told about it. The YMM were trying to complete one-to-one work with the child at the time although this was being disrupted by Covid restrictions. 25. The youngest child’s birth at full-term in late March 2020 coincided with the first Covid 19 lockdown. Before the birth, the mother had intended to give up her child but now decided she wanted to keep the baby who was included in the CPP along with the six older siblings. In early April 2020, the midwife noted the baby’s right eye was bloodshot; no further outcome was recorded. In late April 2020, the baby was admitted to the hospital via A&E; the baby had breathing problems and lost weight since birth. There was no contact with social workers or the MASH. On presentation the child protection information sharing system (CP-IS) was utilised appropriately by NLaG; however, a call should have been made to children’s social care by A&E staff or the ward. 26. The day after the baby had been admitted to A&E the first review CPC agreed to continue with the CPP. Like all the other meetings it was a virtual meeting because of Covid restrictions; the mother did not log in to participate. The CPC was not aware of the presentation at A&E or the baby’s bloodshot eye; the health visitor was concerned that the mother had not sought medical advice when the baby had been observed with blue feet. 27. In late July 2020, an older child reported that mum was assaulting the siblings and throwing objects in their home. The police and social workers visited. The house was observed to be chaotic; the baby was being prop fed and had a soiled nappy1; another child was running around naked and another was sitting in a chair ignored and neglected. 28. The second review CPC in late September 2020 coincided with the case transferring to a new social worker. Although limited progress was reported by the participants there was optimism that the mother might be engaging with the help and support being provided. 29. In mid-November 2020 a strategy meeting attended by 16 professionals discussed several concerns; the further deterioration of one of the children’s 1 Bottle propping exposes the baby to the risk of choking, ear infection, development of tooth decay and interrupts the bonding process. Page 8 of 30 behaviour; increasing aggression; a younger child’s personality was changing adversely; another had a developmental delay and was not attending the nursery and was often naked as was another child; the baby was being left strapped in a pushchair; child immunisations were not up to date. There was discussion about seeking CSC management approval for an older sibling to be looked after and whether to go to the legal gateway panel; school 2 was becoming very concerned and escalated with the CSC team manager over three days; the school was very concerned about the deterioration in the older sibling and the impact on the other children; the school had to remove some of them from home temporarily because they were so concerned for their safety from the behaviour of siblings; nobody requested to reconvene the CPC and there was no consultation with the CPC chair. 30. A legal gateway meeting in late January 2021 agreed to the PLO process being started. 31. The day after the legal gateway meeting the baby was presented to the GP with an injury. There was no referral to CSC even though the CPP was still in place. 32. In late March 2021, the PLO was reviewed. The meeting was told that parenting work was ‘nearing completion’ and recommended that the mother needed time to have her parenting monitored with less dependence on professional support. 33. The third CPC review conference in late April 2021 discussed the CPP which had been in place for 15 months. 34. In June 2021 members of the core group escalated their concerns about the children with senior CSC management. 35. In late July 2021, three of the younger siblings were treated for severe suspected sunburn injuries. The children became looked after with the agreement of their mum and the legal gateway panel agreed that care proceedings should be opened in the Family Court. Interim care orders were made in September 2021. 3 Research and national learning relevant to the review 36. This summary includes the different types of neglect and the importance of understanding child and parent behaviour in that context, health care markers of neglect, adverse childhood experiences (ACE) and criminal child exploitation with a summary of contextual safeguarding when the risk to children comes from outside their immediate home environment (in this case it was in addition to the risk at home). 37. The neglect of children is the most prevalent form of abuse (and the largest category of risk for CPP nationally); it also presents the greatest challenge Page 9 of 30 for assessment, intervention and presenting evidence to courts. This is a contributory factor in the slow progress through legal pathways in this case. Children can experience neglect in very different ways and including the failure to: a) Meet basic physical needs (in this case home conditions were often described as unsuitable although was an area of temporary improvement with sustained support from the FSW in particular). b) Access to appropriate health care (poor starting in prenatal care). c) Meet emotional needs (little detailed recording about the emotional care of the children whose feelings and lived experiences were not explored in assessments or CPC discussion; there was no structured work on issues such as the attachment of the respective children). d) Ensure adequate supervision (evidence that it was largely absent in the home with a lax parental approach to allowing very young children to make journeys alone in the community). e) Provide appropriate cognitive stimulation (little recorded evidence but all the children had delayed speech and some of the children had significant cognitive difficulties) 2. 38. Horwath3 describes different types of neglect related to parental behaviour (that a parenting assessment should be exploring): a) Disorganised neglect is when parents are driven predominantly by emotion and often experienced an unstable childhood; they have learnt to not depend on others but to focus on meeting their needs4. b) Emotional neglect is when parents may display a good standard of physical care and might be meeting the child’s cognitive needs but are unable to provide a warm caregiving environment; it’s a form of behaviour that can give a false positive where professionals are relying on physical standards and can be seen in this case. c) Depressed, passive and physical neglect is when parents are unavailable to their children in terms of providing emotional warmth and meeting other developmental needs. 39. Children not being taken to health appointments is a tangible indicator of neglect relating to the behaviour of the parent and the impact and consequences for the child. Children are more likely to be from deprived backgrounds and to be the subject of child protection alerts in their patient records which are reflected in these siblings’ circumstances5. For some 2 https://www.safernel.co.uk/wp-content/uploads/2021/10/WORKING-WITH-CHILD-NEGLECT-DURING-THE-COVID19-PANDEMIC.pdf 3 Horwath, J., 2013. Child neglect: Planning and intervention. Macmillan International Higher Education. 4 Howe, D., 2005. Child abuse and neglect: Attachment, development and intervention. 5 French LRM, Turner KM, Morley H, et al. Characteristics of children who do not attend their hospital appointments, and GPs’ response: a mixed methods study in primary and secondary care. Br J Gen Pract 2017; DOI: https://doi.org/10.3399/bjgp17X691373 Page 10 of 30 time, the term did not attend (DNA) has been discouraged when describing a non-attendance at a health appointment although was evident in some of the recordings for these children. A parent/caregiver is responsible for taking children to appointments and it is, therefore, more appropriate to describe a child as not brought to the appointment. This was proposed in 20126 and evidence from serious case reviews and further research has reinforced the value of accurate coding of information in primary and other healthcare settings7. 40. An abused child has been estimated as being up to eight times more likely to have untreated, decayed permanent teeth than a non-abused child8. Dental decay is a marker of a potentially wider neglect of children9. It is unlikely as an isolated issue to lead on its own to a child protection referral but is an example of being part of a cumulative experience for children that is harmful. It should be considered as part of a mosaic of issues associated with a neglected child. 41. It is generally recognised that there is no magic intervention that can address the different dimensions of neglect. Early help can assist in stopping difficulties from becoming entrenched and strengthening protective factors and resilience10. That did not apply to the circumstances of the W siblings. Research in the USA has shown that some long-term neglect cases can make progress but can take up to two years of sustained and intensive involvement and support11. Account has to be taken for what happens to children over such an extended timeline. 42. Adverse childhood experiences (ACE) cause harm during childhood and into adulthood. It encompasses abuse including neglect, domestic abuse in the household, mental illness and problematic substance misuse of a parent or carer. Experiencing ACEs along with hate crime, community violence or not having supportive adults exacerbate longer-lasting damage and is sometimes referred to as “toxic stress”12. 6 Powell C, Appleton JV. Children and young people’s missed health care appointments: reconceptualising ‘Did Not Attend’ to ‘Was Not Brought’ — a review of the evidence for practice. J Res Nurs 2012; 17(2):181–192. 7 Safeguarding Nottingham. Rethinking ‘Did Not Attend’. 2017. Rethinking ‘Did Not Attend’ - YouTube (accessed 22nd December 2021). 8 Greene, P.E., Chisick, M.C. and Aaron, G.R., 1994. A comparison of oral health status and need for dental care between abused/neglected children and nonabused/non-neglected children. WALTER REED ARMY INST OF RESEARCH FORT GEORGE G MEADE MD. 9 Bradbury-Jones, C., Innes, N., Evans, D. et al. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health 13, 370 (2013). https://doi.org/10.1186/1471-2458-13-370 10 Allen, G. (2011) Early Intervention: The Next Steps. London: HMSO. 11 Turney, D., & Tanner, K. (2005). Research and Practice Briefing: Understanding and Working with Neglect. Research in Practice. 12 https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/ Page 11 of 30 43. Parents who experience significant ACEs in their childhoods are more likely to present with a range of needs and difficulties such as poor learning and employment history, illness and substance abuse and will influence how they meet the needs of their children which can bring them into contact and conflict with people and services focussed on safeguarding children. 44. The co-existence of poor physical and mental health, poverty, learning difficulties and domestic abuse are factors that contribute to inconsistent parenting and disorganised lifestyles that are harmful to children such as these siblings. It can leave a parent with difficulty in controlling their emotions and providing adequate emotional care for their children and can be further complicated if there are cognitive or other issues to consider. It is why taking a good history is important as part of completing an assessment which is not evident in this case. 45. Interventions by health and social care services, in particular, have to develop responses that can help adults address the impact of an adverse childhood experience as part of strategies to prevent children from suffering harm. This has implications for how assessments of parents and children are completed and for encouraging greater curiosity and routine enquiry by people such as primary health care professionals and for providing access to appropriate help which can include trauma-informed care. 46. Poverty, as experienced by children such as the W siblings, alters the course of a child’s life and sets in motion a disadvantaged path of social, economic and health outcomes (The Children’s Society, 201713; Ayer, 201614). Adverse childhood experiences and becoming a looked-after child are considered factors of vulnerability to criminal exploitation (Children’s Society, 201915; Longfield, 201916). 47. Children and vulnerable adults are often targeted by criminals because they are easy to manipulate and control, less likely to be detected and cheap to employ17. Children with special educational needs (SEND) have a generally 13 Children’s Society (2017), Understanding childhoods: growing up in hard times [report], London, The Children’s Society. 14 Ayre, D. (2016), Poor Mental Health: The Links between Child Poverty and Mental Health Problems [Report], London, Children’s Society 15 Children’s Society (2019), “Counting lives: responding to children who have been criminally exploited”, available at: www.childrenssociety.org.uk/information/professionals/resources/counting-lives accessed on 20th December 2021 16 Longfield, A. (2019), “Keeping kids safe: improving safeguarding responses to gang violence and criminal exploitation”, London, Office of the Children’s Commissioner for England, available at: www.childrenscommissioner.gov.uk/report/keeping-kids-safe accessed 21st December 2021 17 Williams, A.G. and Finlay, F. (2018), “County lines: how gang crime is affecting our young people”, Archives of Disease in Childhood, Vol. 104 No. 8, pp. 730-732, http://dx.doi.org/10.1136/archdischild-2018-315909 Page 12 of 30 reduced capacity to process facts and other information to make ‘informed decisions. They are most likely to be children with undiagnosed learning needs. There is well-documented evidence about the link between absence from school and safeguarding concerns; Covid has represented an unprecedented additional risk factor for these children. 48. The emergence of these ‘cross over’18 child protection involved children being especially vulnerable to criminal exploitation such as one of the older siblings is a major challenge for safeguarding partnerships across the country. Contextual safeguarding extends the locus of child protection thinking from the “home” to include the “environment”. The effect of this strategy is to draw crime prevention and community safety approaches into safeguarding thinking and practice. 49. Public health is rooted in the philosophy of providing the maximum benefit for most people. A public health approach to reducing levels of criminal exploitation requires developing insights into the “causes of the causes” of criminality, offending and victimisation. This goes beyond situating the problem with the child and their family, to investigating the opportunities that allow for such criminality and identifying where organised abuse is occurring. 50. CCE, therefore, needs a comprehensive strategic safeguarding response rooted in a public health ethos of early intervention and prevention and is not just targeted at children such as the W siblings who have been subject to CPP and CIN over many years. The fact that their vulnerability was already known and caused the CPP and CIN, there should have been an additional element of assessment and intervention. Contextual safeguarding that does not just focus on the child’s immediate home setting but also the wider setting has to be addressed. This applies in terms of strategic public health and policing prevention strategies as well as to child-specific decision-making. Barlow19 describes ‘the intersection of a motivated perpetrator, suitable target and absence of capable guardians (e.g., police, parents, neighbours, park wardens)’ within a theoretical systemic framework of child criminal exploitation. 51. In addition to contextual safeguarding, other promising emerging approaches identified in the south-east England study include harm reduction approaches, trauma-informed practice and the value of relationship-based practice20. 18 Baidawi S & Sheehan R 2019. 'Crossover kids': Offending by child protection-involved youth. Trends & issues in crime and criminal justice no. 582. Canberra: Australian Institute of Criminology. https://www.aic.gov.au/publications/tandi/tandi582 accessed 6th January 2022 19 Barlow, C et al 2021 Circles of analysis: a systemic model of child criminal exploitation Journal of Children’s Services p7 20 Lefevre, M. et al 2020 [Report] Child Criminal Exploitation in the South East of England: family experiences and professional responses University of Sussex https://yjresourcehub.uk/images/Childexploitation1/Child%20criminal%20exploitation%20along%20the.pdf accessed on 20th December 2021 Page 13 of 30 4 Summary of learning 52. The family had a good level of contact with different services with regular communication between the different professionals. Meetings such as core groups were well attended and there are examples of highly dedicated support to individual children by several people. The FSW developed a good supportive relationship with the mum who managed to improve some aspects of her care for the children using the graded care profile and Triple Plus Parenting programme and improved attendance at school although absences still occurred21. There were several occasions when people such as teaching staff and out of hour’s workers visiting the home intervened to keep children safe from a sibling often going far beyond what would be expected. The school where the older siblings attended had for a long time been providing a great deal of support to the family which included intervening when the behaviour of one of the older children in particular, became dangerous, helping to clear up the house after episodes of damage and help to get the children to various appointments. 53. National studies describe the importance of good quality relationships with families as the primary requirement for effective safeguarding practice. The triennial review in 201622 outlined the importance of moving from episodic incident-based interventions to more extended models of support that are rooted in a cumulative perspective on safeguarding needs and are informed by a historical understanding of family patterns including how services are used. 54. This is a case where CSC struggled to provide the right level of leadership and coordination and did not appear to understand how to recognise and respond to neglect in a large sibling group. Some of the people who saw the children most often were not listened to carefully enough. CPC discussion was too focussed on action planning at the expense of developing a deeper understanding of the children’s circumstances and independent chairs were not in a position to offer the level of reflection and challenge the case deserved. There was a palpable sense of drift including the use of legal measures to protect the children. Legal discussion involved people who generally knew least about the children or understood potential evidence to put before a court. Although professionals became very concerned about the children the concerns were raised outside of the statutory partnership’s escalation process. It provided no significant impetus for senior managers to act differently or more effectively. 21 NSPCC had previously used the graded care profile when working with the mother and the older siblings although only two sessions were completed due to the home circumstances being impossible to complete any planned work 22 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final Report 2016 Page 14 of 30 55. The chaotic behaviour in families being mirrored in professional thinking and action and becoming overwhelmed by too many problems to deal with and with too much to achieve was described in 2009.23 Practitioners who are overwhelmed not just by the volume of work that they are expected to do but also by the nature of the work are less likely to achieve good enough outcomes for children. 56. The family and its multiple difficulties were complex and overwhelming. The impact of being overwhelmed included: a) The inability to analyse or understand the family promoted a lack of confidence in the overall strategy and approach contributing to a reactive approach relying on the mother's cooperation and hesitancy in using the law better; the mother asserted several times that she saw nothing wrong with her parenting. b) Social workers and their supervisors, in particular, did not recognise indicators of neglect, the inability of the family to meet the diverse and complex needs of the children and complicated further by the family living in an area of generally high deprivation; social workers are less well equipped to understand the significance of data from education and health. c) Lack of a sustained professional challenge with a preoccupation with thresholds; the risk matrix against generalised danger statements or whether PLO was met for example. d) The temptation of starting again is exacerbated by an absence of consistency in key services such as CSC, an absence of good enough chronology and insufficient good quality assessment. 57. Some professionals such as health visitors and teachers were very worried about the children. The level of worry was less in CSC which had less direct contact and where there were problems of high workloads, high staff turnover and difficulties in recruiting and retaining social workers. This contributed to drift and less sense of urgency particularly when attempts were made to escalate concerns with more senior people. The reviewing service was also under pressure and could not provide the level of challenge and reflection the case needed. 58. Strong management support was not available to help social workers and conference chairs, in particular, manage, monitor and think more systematically about a case where long-term complex neglect had been an issue for many years. The focus was more on avoiding the children being on a CPP for too long rather than inverting the thinking into why these 23 Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C., and Black, J., (2009) Understanding Serious Case Reviews and their Impact: A biennial analysis of serious case reviews 2005-7, Department for Children Schools and Families, Research Report DCSF-RR129. Page 15 of 30 children had so many episodes of being on CIN and CPP and with such little improvement. 59. Although neglect is less likely to be fatal compared to other abuse it nonetheless has serious long-term adverse consequences for children of all ages and especially during infancy when critical development needs to happen. The level of risk facing the baby when the mother changed her mind about relinquishing was poorly understood particularly when it was known that face-to-face contact was going to become very problematic due to Covid. 60. The neglect of the children was manifest in multiple issues; none of the children had a good attendance record at school or nursery despite the efforts of the schools which included visiting the home physically helping to get children to school; several of the children presented with slower development in language and social skills compared to their peers; one of the children had multiple dental extractions; all of the children were exposed to violence from the behaviour of older siblings as well as from various adults who visited or spent time in the home. The children individually displayed behavioural and emotional symptoms of the persistent neglect they experienced in the care of their mother although were not reflected in risk statements such as the signs of safety (SoS) scaling. 61. Neglect is the result of a complex interplay between risk factors in children and the care they receive from their primary caregivers and is appropriate to their age and stage of development. Appropriately structured assessments that explore parental risk factors such as poor experiences in childhood, and mental and physical health and take account of other issues that can include domestic abuse and misuse of substances. Neglect is cumulative in terms of the child’s lived experience and the impact on their development and well-being and was a factor for all the siblings. Assessment has to be from the perspective of the child. What is the child feeling? Are they feeling stressed? What makes them happy? Do they feel loved and valued? The quality and style of the respective children’s attachment were not explored (despite behaviour and what some of the children were saying). 62. The baby needed regular changing and washing; a calm and nurturing environment with attention and stimulation to develop basic skills and to feel safe and secure. Records of visits to the home do not describe this level of care but rather the chaos and risk from the behaviour of siblings. The younger children needed stimulation and opportunities to experiment and interact with others through play; sensitive and supportive conditions to promote abilities and encouragement, praise and security. Attendance at the nursery was not prioritised by the mother. Neglectful care might result in a significant event such as an injury such as occurred in December 2019. Cumulative child neglect will be manifested in other evidence that includes Page 16 of 30 the behaviour of the children as can be seen in this case along with their impaired social, linguistic and educational development. Their intellectual and social functioning was below average and although linked to learning difficulties for some of the children was an issue for others who were not diagnosed with a learning difficulty. Language delay, difficulty in using expressive and receptive language, unable to articulate feelings was an issue for two of the children. All of the children had a poor vocabulary. Assessment has to be focused on what is happening to a child not what an adult says or expresses as their intention or wish. 63. The recording and consideration of the children’s lived experiences, wishes and feelings were not given enough attention. Given the size and range of complexity of the sibling group and the absence of information being provided by CSC, an advocate could have been considered but was not. Children’s behaviour is an important indicator of their lived experiences. Talking with children and encouraging them to speak about their day-to-day lives was given limited attention in CPC meetings. There was a reliance in the minutes of the CPC discussion that the social worker would be doing this work although is not included in reports or records of discussion. Another CPC met after the children became looked after and delegated the task to the LAC review process. 64. Except for the substance misuse service was in contact with two of the sibling's respective fathers no other service was working with the siblings and their mother had much-recorded information about the different men who were known to visit and sometimes stayed in the house. 65. The strategy meeting in December 2019 was the culmination of concerns about the children although the focus was on the allegation that the mother had assaulted the children which had been withdrawn and different accounts were given by different children for the injury to one of the children’s eyes. The strategy meeting involved CSC, the midwifery service and the police as well as the schools that had daily contact with the children. The injury was not seen enough as a symptom of likely neglect when the responsibility was shifted from the mother to one of the children. Physical abuse rather than neglect was the preoccupation. The police highlighted during this review that the recording of decisions needed to be improved. None of the children was spoken to as part of enquiries. 66. The initial CPC in January 2020 was the second time a CPP was made and as before it was for neglect. The extent of concerns discussed included the specific needs of one child associated with autism and sensory overload of a chaotic household, the level of another child’s aggression, emotional and behaviour difficulties, the sexual assault on another, their mother’s pregnancy and her difficulty in meeting the needs of her children, the absence of a supportive family network as well as the general neglect of the children. The recent history of interventions through CIN and CPP should have provoked a discussion about whether the children were safe in the household without emergency measures being used or invoking the PLO Page 17 of 30 process. Such a large sibling group with complex needs represented a challenge in terms of possible placement options and may have been a further deterrent to a more assertive approach. Some of the ICPC attendees had concerns that it was mum and her needs that dominated the discussion rather than giving enough focus on the individual children. 67. The absence of a chronology being developed at this stage meant that until the rapid review and this LCSPR, none of the people who were trying to address the complexity of this family had the benefit of a complete picture of the cumulative harmful experiences to the children. 68. The signs of safety (SoS) framework is used in NEL (and many other local areas) to help professionals develop a shared understanding of the risk to children discussed at child protection conferences. The SoS draws heavily on elements of solution focussed brief therapy, working with the family’s strengths and resources, goal setting and scaling. The SoS assessment or mapping is set out in a matrix of danger statements supported by separate columns detailing what is worried about, the reason, what is working well and what needs to happen. 69. The safety scale aims to judge the severity of risk by taking into account what mitigates risk alongside other factors that exacerbate it. It provides limited analysis and by its nature is a barometer of where people estimate the risk to be at a given moment. It is inherently flawed if there is not a robust enough assessment underpinning the discussions, particularly when working with cumulative harm from neglect. A short-term improvement in parental behaviour or physical standards can result in misjudging or becoming mistakenly optimistic. Disguised compliance may have been a factor in this case given the mother’s repeated assertion that she saw little wrong with her parenting and access to the home became especially problematic during the Covid lockdowns when the mother reported more than once having symptoms and therefore preventing scheduled visits from taking place. Some of the professionals who participated in a consultation event as part of the review described their repeated efforts to make contact with the children at home and how this was not sufficiently flagged as a concern. This included the SAL practitioner who was not included in the core group or invited to child protection conferences. 70. A difficulty facing the SoS process was not having danger statements that reflected need and risk as they related to each of the children. For example, a danger statement that reads “that conference is worried that all children have suffered neglect” is not as compelling as making statements about how neglect had harmed each particular child; one child was sexually abused by an adult allowed into the home; another child’s multiple and complex problems were not a condition of a learning difficulty or disability; a third child’s constant state of distress to the physical and sensory chaos around the home. These are harms that had been happening to the children for a long while and continued. The complexity of actions that resulted along with how progress was then managed resulted in professionals becoming persuaded that progress was being made when for example there was an Page 18 of 30 improvement in some aspect of physical care. There was a disconnect between harm and what was then being assessed as an improved outcome for the children. 71. The long and complicated actions that flowed from the SoS process constrained and encouraged the CPC to be a discussion and activity planning session rather than a forum able to address the quality or effectiveness of various actions in improving the circumstances of individual children. 72. One of the children’s levels of aggression was a dominating concern and after becoming looked after in 2020 a review CPC queried whether PLO proceedings were still required suggesting that there was not clear enough attention on the harm to other children irrespective of one of the sibling’s particularly violent behaviour in the home. The Young Minds Matter (YMM) service worked with the child. It was this service that recognised that the child had multiple risks in terms of themself and others. The child was being careless with personal hygiene as well as displaying increasingly risky behaviour towards other people and had access to large amounts of money. This was reported to the initial CPC in January 2020. The YMM were focussing on therapeutic work to help the child self-regulate their anger and emotions. The Covid lockdown brought an end to the involvement of YMM. 73. The ICPC agreed that the children needed a “safe and happy place to live for their basic needs to be met by their mother who was expected to ensure there were no unsafe adults in the family home”. The midwifery service was not a party to the ICPC and there was no discussion with the midwifery service about the impact on the baby from the already chaotic and risky home environment. The ICPC resulted in 25 tasks being agreed upon. The mother was pregnant with the baby and throughout the pregnancy was planning to relinquish the child at birth. 74. The quality of assessments overall was not good enough and the absence of a chronology and changes to social workers contributed to the cycle of starting again which frustrated other professionals. No psychological or cognitive assessment was completed with mum to establish a baseline about mum’s understanding of her individual children’s needs; it was not supported by managers in CSC. Mum disputed that there was anything wrong with how she was parenting her children. The absence of a positive and supportive family or friends was given little attention. A parenting assessment could have created the opportunity for a clearer understanding of how some very complicated history and need was interacting and influencing the parenting of the children as well as where and from whom mum would get support other than professionals. 75. The minutes of the first review CPC provided an update against actions agreed at the previous CPC as well as describing new or refreshed actions. The CPC was not aware that the baby had been presented at the A&E the Page 19 of 30 day before the CPC. However, the CP-IS that notifies children's social care of their attendance at A&E was utilised. 76. The baby’s birth was full term and occurred before the first review CPC. There was no strategy for responding to mum’s change of plan to take the baby home just as the Covid 19 lockdown was being implemented. In a core group discussion just after the birth was told this was a last-minute decision. The health visitor expressed concern that no preparations had been made. There was no consultation by the social worker or any other core group member with the chair of the CPC or request to convene an early CPC and no discussion about the potential use of emergency legal measures. It is an example of where there was little confidence and challenge. Following the birth, the midwifery team informed the social worker of the delivery and that mother did not wish for the baby to go into foster care. A social worker contacted midwifery and confirmed that the mother and the baby could go home when fit for discharge and CSC would visit the family home. There was not a discharge planning meeting due to Covid -19. 77. The lockdown prevented the routine birth home visit by the health visitor who tried unsuccessfully to call mum on the phone. When the health visitor managed to speak to mum in early April 2020 the health visitor was concerned about the slow weight gain. The baby was not taken for the new-born hearing test and was presented at the A&E the day before the first review CPC which was not made aware of the contact. The attendance was routinely notified to the GP who would have known about the CPP but did not follow up on the information either with the health visitor or the social worker. Also due to restrictions of the Covid-19 pandemic, the new-born hearing test was not able to be completed on the ward at birth and not at home either due to shielding with another sibling with complex health problems and Covid restrictions. This was later picked up and health professionals were aware this was required at a later date. 78. The social worker’s email to the core group confirming that mum had decided to keep the baby informed the core group that a legal meeting had been held. There is no reference to an outcome and there is no record of a legal meeting taking place since the birth. The social worker reported waiting for senior management advice on how to proceed and confirmed that core groups would meet virtually. The email stated that CSC was “reviewing how best to support the family” and acknowledged that there would be a reduction in the visits to the home. It also acknowledged that there were “significant concerns for all the children” and the need for “oversight” and would do its “best to have the support in place for the family”. It was effectively hoping for the best. The email is indicative of a significant systemic weakness in critical oversight and decision-making for children. The social worker had no mandate or clear direction and did not appear to have the necessary support and direction from a manager. 79. There was little knowledge and discussion about the legal pathway outside of CSC which meant that evidence about neglect held by most of the Page 20 of 30 services was not included. The safeguarding nurse for Children’s Health Provision (CHP) is now part of the gateway panel. 80. The schools continued to have almost daily contact. Some of this was to help with practical arrangements for organising remote learning but it was an opportunity to talk with mum about what was happening and how she was coping. It was evident she was struggling physically and part of that was letting the older siblings do their own thing such as sleeping in to avoid arguments. It was the schools that had the most regular contact and escalated concerns later in the year. The schools were not made aware of other significant contacts such as the joint visit by CSC and the police in late July 2020 or the contacts with the GP. 81. The GP had little involvement or knowledge about the significant events that occurred during the scope of the timeline. The record of the mother’s adverse childhood and abuse was contained in the GP records. The GP was also aware of a pattern of the children not being brought to health appointments and there were also presentations at the A&E service. These were all potential alerts. The GP practice did not receive invitations to CPCs or receive minutes or the CPP. The GP had no information recorded about the baby’s presentation at the A&E in April 2020 because the baby was not registered until mid-May 2020. The consultation in January 2021 when the baby had sustained a bruise does not refer to the CPP; the recording is only focused on physical symptoms and giving reassurance. There is no discussion at an MDT safeguarding meeting. 82. NAVIGO mental health services were not invited to any multi-agency meetings although were working with two of the sibling fathers who had regular home visits from substance misuse practitioners. 83. The school’s escalation of concerns in mid-November 2020 followed several email exchanges within the core group and with CSC which included the school, social worker and out-of-hours service as well as the police having to intervene in a series of incidents where the mother was struggling to manage very challenging and destructive behaviour from some of the children. Significant damage was caused to the fabric of the house and various possessions on different occasions. The school like other services did not contribute information directly to the legal gateway discussions. Members of the core group had wanted the siblings' circumstances to be discussed at a legal gateway meeting during 2020 although this was not supported by senior managers in CSC. It was at that point that the core group escalated their concerns although this was not done through the safeguarding partnership’s procedure. 84. The criminal exploitation of children is a threat to the safety of children who are already likely to be experiencing an adverse childhood that includes multifaceted abuse within their homes. The older child’s needs were already complex and made them vulnerable to criminal exploitation. This was a significant additional and different threat to the child’s safety from outside Page 21 of 30 the family. It required an assessment and analysis of the community risk factors alongside family functioning and coordinated professional intervention that included criminal justice as well as other services. 85. Contextual safeguarding is a model that recognises children and young people are influenced by a wide range of people and environments outside their immediate family. Children such as the W siblings are confronted with multiple risks associated with their family as well as from outside through criminal exploitation for example. This means that at an individual level for a child, the risk assessment needs to take into account where the risk is coming from and identify strategies for addressing it. 86. It also requires individual risk assessment and safety planning to be part of a broader public health strategy that targets the context and conditions in which criminal exploitation is taking place and develop effective partnerships focused on systems-based interventions such as those advocated by Public Health England24 and the contextual safeguarding network25. The PHE report includes the following infographic summarising the risk factors for offending behaviour for children and young people. 24 Public Health England (2019) Collaborative approaches to preventing offending and re-offending in children (CAPRICORN) A resource for local health & justice system leaders to support collaborative working for children and young people with complex needs PHE Available from https://www.gov.uk/government/publications/preventing-offending-and-re-offending-by-children [accessed 31st December 2021] 25 https://contextualsafeguarding.org.uk/wp-content/uploads/2020/10/CS-Legal-Briefing-2020-FINAL-1-1.pdf Page 22 of 30 87. The W sibling had few sources of resilience the risk of becoming criminally exploited was always high. 5 Assessment of systemic or underlying influences 88. This part of the report includes information and reflections from the consultation event with people who worked with the children or for example chaired child protection conferences. 89. Significant influences and learning from the review include: a) Keeping a focus on individual children within larger sibling groups in collating direct testimony about their lived experiences, feelings and wishes as well as measuring their development, health, safety and wellbeing has workload implications; having a baseline from which to make reliable judgments about the evidence and impact of neglect; the value of a child’s advocate in complex and longstanding cases to ensure children’s voices and lived experiences are sought, considered and given status in assessment and plans despite the information being reported by schools in particular; this includes giving clearer attention to behaviour as indicators of emotional distress; Insufficient direct work with children included within reports and CPC discussions; reliance on the social worker representing the children's view despite having less contact and knowledge than other professionals such Page 23 of 30 as schools; during the consultation event the social worker currently working with the children since the summer of 2021 described how each of the children’s needs were now being assessed. b) Lived experience of children and understanding communication; several people at the consultation event talked about how the way the children behaved was not understood well enough by non-specialist staff including social workers; some talked in detail about how a non-verbal child’s behaviour had profound implications for understanding the importance of their care environment and routine that was absent at home and the acute distress displayed by the child at home compared to other places; another health professional talked about the evidence of head flattening (Positional Plagiocephaly) for the baby not being picked up as evidence of a child being left unattended. c) The importance of chronology and holistic assessments; no single assessment model is a substitute for thorough assessments that provide sophisticated analysis that takes account of the development needs of individual children, family and environmental factors; sufficiently comprehensive assessments that consider the history and are informed by an analytical understanding of cognitive, developmental and psychological factors; at the consultation event there was a consensus that there had not been enough knowledge about the history and that frequent changes of social workers had diluted knowledge. d) People with the most contact with children and who are best informed about their needs and their daily lived experience are vital sources of information and professional partners; school and health professionals are clearer about evidence of developmental harm; people who have the least day-to-day contact with children can have a superficial understanding. e) Good participation in meetings and regular communication is not a substitute for well-co-ordinated and purposeful work and analytical reflection; respecting the validity and specialist insight that people like education and health professionals can provide in understanding signs and consequences of neglect; the SALT was not invited to the child protection conferences or involved in the core group. f) GP practices need to be involved in enquiries, assessments and shared information about children subject to CPC and CPP; the role of other health services such as dentistry as potentially important partners in identifying concerns about children. g) People working with children subject to CPP need access to effective systems of consultation that are linked to Page 24 of 30 procedures for escalating concerns about children through internal systems and these are linked with local statutory partnership escalation pathways. h) The importance of having a clear strategy for responding to neglect that is owned and understood by all the respective organisations; this also needs to be supported by having assessments that can meaningfully explore the nature and impact of neglect. i) Having enough social workers with the appropriate knowledge and experience to work with complex families and have the time and support appropriate to the task; means having the right people with the time and aptitude who are well supervised and supported being able to develop effective relationships with parents whose lives are complicated and complex; many factors combined as cumulative harm such as ill-health, substance misuse, poverty, criminality, and domestic abuse create the latent conditions for inconsistent and ineffective parenting. j) Relationship-based practice and working with parents who have experienced trauma or instability or abuse in their childhood are likely to display difficulties in how they can respond to and understand the needs of their children; this can manifest itself in many ways including disorganised parenting, putting their own needs before that of their children, emotional unavailability; providing timely trauma-informed early intensive help. k) The chairs of the CPC have the remit and capacity to ensure effective risk assessment and good quality reviewing is more than discussion and activity planning sessions and can challenge including the use of legal measures; distinguishing between the CPC overseeing the effectiveness of intervention and the core group being responsible for detailed activity and planning; the importance of professionals bringing clear information and concerns to a CPC and recognising that the CPC is an integral part of escalating action to protect children; the chair of some of the CPCs described how the SoS scaling did not reflect the level of concerns that had become evident through the review; several people who attended the CPC and core groups described it as an exhausting and very frustrating process. l) Quality assurance and supervisory oversight of social work practice including oversight of information being provided by CSC to the CPC; in this case reports were unsigned; no use of child advocates despite a large sibling group where children have distinct and individual needs and some have become voiceless; poor understanding about the importance of observing recording and understanding behaviour within developmental frameworks. Page 25 of 30 m) Escalation processes that are effective and that all professionals understand and confidently know how to use to raise concerns and deliver outcomes for children; although concerns about the slow response of CSC, in particular, were raised, this was done outside of the escalation framework and protocol; a contributory factor was agencies not having a designated lead to ensure the process is used and there is no oversight or auditing; three separate occasions were described at the consultation event when different professionals tried to raise concerns that did not lead to change happening; on one of those occasions the core group wrote to the Director of Children’s Services (DCS) who acknowledged it was an escalation of concerns but did not result in different outcomes; some people were surprised that they had not been aware of all the times an escalation had been attempted; the escalations had been with line management in children’s services rather than to the safeguarding board (now a partnership) and there was discussion about how the process is now routed to the chair of the safeguarding partnership; more than one person at the consultation event reported that the challenge of identifying suitable placements as well as cost was a factor in not removing the children more promptly. n) Managers in children’s services did not take timely action which led to the informed advice and judgment of professionals working with the children being disregarded; they contributed to the episodic start-again cycle and retained undue influence as key decision-makers such as the legal gateway panel meetings. o) Legal and child-based risk discussions being aligned and delegation of decision making; agendas for strategy meetings and child protection conferences considering whether legal advice including emergency action is likely and have access to legal advice; several participants at the consultation event described their frustration when there were repeated requests for new or additional evidence and their exclusion from conversations about legal action; one person referred to “changing the goalposts”. p) Understanding of contextual safeguarding concerns and the axis of family and individual factors with the environment; children at risk of harms from outside of their family; different approaches and interventions are required for children at risk from criminal exploitation; it requires a focus on crime prevention and community safety strategies that are part of child protection, child welfare and safeguarding and built on partnerships. Page 26 of 30 6 Recommendations to safeguard and promote the welfare of children 1. A copy of the report should be given to the commissioner appointed by the Secretary of State for Education to inform the improvement plan and development of professional practice in response to neglect. 2. The Director of Children’s Services (DCS) should provide information and evidence about how issues of social worker and manager recruitment and the capacity of the service to respond to complex child protection highlighted by this case will be addressed. This includes management oversight/supervision to prevent drift and to improve social work practice and IRO capacity and effectiveness. 3. The Director of Children’s Services (DCS) should satisfy themselves with the effectiveness of Signs of Safety (SoS) as implemented in NEL in supporting effective assessment and management of risk for children. 4. The Director of Children’s Services (DCS) should ensure that a review of arrangements for the chairing of child protection conferences and reviewing of child protection plans is completed and action is taken to ensure the CPC provides appropriate reflection and challenge and is linked to the processes for escalating concerns about children. 5. The Director of Children’s Services (DCS) should ensure that the IRO service has an effective system of escalating concerns about individual children that are also linked to the safeguarding partnership’s escalation procedures for local services. 6. The Director of Children’s Services (DCS) should ensure that advocates for children can be appointed and are routinely considered in complex and/or longstanding cases involving neglect. 7. The Director of Children’s Services (DCS) and Director of Legal Services should ensure that appropriate arrangements are in place for social workers to seek emergency protection for children when necessary and that strategy meetings, child protection conferences and core groups have access to appropriate legal advice when necessary. 8. The Director of Children’s Services (DCS) and Director of Legal Services should review the constitution, membership and functioning of the legal gateway to ensure appropriate evidence from professional core groups and child protection conference participants is considered. 9. The Director of Public Health should consider what further work is necessary to raise awareness among public health professionals including dental services about their role in identifying and responding to potential child neglect. 10. The CCG should consider what further advice and support should be given to primary health care services about having effective policies and protocols in place for responding to child Page 27 of 30 neglect. This includes the use of relevant codes to flag patient records and the value of multi-disciplinary team meetings. 11. The NEL safeguarding children partnership should ensure that a strategy for understanding and responding to neglect in NEL is agreed upon and is supported by multi-agency and assessment frameworks. 12. The NEL safeguarding children partnership should review and if necessary, change the escalation procedures to ensure that all relevant organisations and their workforce can raise concerns about a child. This includes making sure that the chair of the partnership has a clear role and oversight of the arrangements, and that organisations have appropriate arrangements to promote awareness and use of escalation when necessary. 13. The NEL safeguarding children partnership should review existing policy and practice guidance for responding to children not brought to appointments and for this to encompass SALT along with other health care professionals. 14. The NEL safeguarding children partnership should consider what further developments may be indicated in respect of early help and intervention with younger children at risk of community-based harm and the use of local contextual safeguarding arrangements. 15. The quality assurance sub-group of the NEL safeguarding children partnership should ensure that arrangements for inviting primary care health professionals including GPs to child protection conferences and sharing minutes and child protection plans are effective. The methodology and terms of reference Agencies who provided information to the serious case review 90. The following services provided information although for some such as Cafcass26 and the local contact service this was not until the children became looked after as a result of the Family Court proceedings: a) Humberside Police have responded to multiple incidents which included domestic abuse and child behaviour. b) Lincolnshire Partnership Foundation NHS Trust provided the Young Minds Matter service (YMM) working with one of the older children from October 2019 until May 2020. c) NAVIGO substance misuse services had regular contact with two of the siblings' fathers. 26 Children and family court advisory and support service Page 28 of 30 d) North East Lincolnshire Children’s Health Provision is responsible for health visiting, school nursing and a team of specialist safeguarding nurses. e) North East Lincolnshire Residential Care Services; one of the children was provided with respite care from December 2019 beginning with an emergency placement. f) North East Lincolnshire Council Children’s Safeguarding and Review Service; independently chaired the child protection conferences and statutory looked after child (LAC) reviews after the children became looked after by the local authority. g) North East Lincolnshire Council Inclusion Service; service was involved with one of the children for behaviour support to prevent permanent exclusion from mainstream education; their reintroduction to the mainstream was delayed by several incidents of Covid related shielding and isolation; the service advised that a PAMS assessment might be helpful but mum declined. h) Northern Lincolnshire and Goole NHS Foundation Trust hospital-based outpatient emergency care centre (ECC) had contact with six of the children, four at ECC and two on an outpatient basis i) NSPCC knew the family that predates the scope of the review and concerned the mother’s two eldest children; during their contact, they attempted to complete a graded care profile although only two sessions were completed despite the efforts of social workers who were concerned about the level of neglect both children suffered. NSPCC did not have involvement with the family during the scoped timeline for the review but participated in the review and contributed to learning. The service has introduced a case management and supervision planning tool to better capture case progress and actions when significant personnel such as social workers or managers move to different roles. j) School 1 was attended by one of the children from 2018. k) School 2 was attended by four children until they became looked after in 2021. Action from the rapid review The rapid review identified the following action to be taken: i. A Performance Report of children who have been open/closed for neglect for significant periods across CIN/CP/EH is to be built and run within two weeks. Cases are to be reviewed and reported to SCP within six weeks. This will identify any children in the system who may have similar characteristics in terms of length of involvement across thresholds. ii. Children on CIN / CP plan for neglect for more than 15 months to be audited by auditors skilled in neglect to eliminate drift any drift and delay. Page 29 of 30 iii. The SCP Executive to consider how a greater understanding of the reasons why the local escalation process over time has not been effective. iv. An inter-agency task and finish group is to be established to develop Standards for multi-agency meetings, (Early Help CIN/Core groups) to include children not seen by any member of a core group within a time frame, child development and key milestones) the lived experience of the child and using Signs of Safety scaling to demonstrate progress. v. Where a child who is open to Children's Services has an identified therapeutic service provision i.e., SALT, Occupational Therapy and discharge are being considered due to the child not being seen, this should be reviewed in supervision with the safeguarding lead for the agency and decision recorded. vi. Children receiving short breaks are to be subject to children’s social care performance reporting meetings monthly to ensure compliance with legislation in that no short break should exceed 17 days of continuous care and total provision should not exceed 75 days. If accommodation is needed which exceeds this, then it should be provided under the specific duty of S.20 (CA 1989) and is not classed as a short break. vii. Work to be undertaken with local dentists to raise awareness, highlight safeguarding issues related to safeguarding issues and local referral pathways. viii. Strategy discussion to be held within 24 hours of Police Protection being issued and a decision regarding whether any other legal order is required to be made. ix. The SCP to make a decision/ recommendation in respect of the use of multi-agency chronologies on neglect cases at key decision points x. Multi-agency chronology technological solution to be explored. xi. Any children subject to initiation of 2 Public Law Outline episodes for the same concerns are to be reviewed at the Head of Service level and consider whether all appropriate assessments have been completed. xii. Multi-agency family history to be considered as an indicator of risk within single assessments and reassessments. xiii. Clear practice guidance on when reassessments or specific assessments should be undertaken (for example but not exhaustive) new pregnancy, concern re neglect (GCP2), parenting assessment, PAMS, psychological, AIMS, mental capacity, video interaction guidance VIG). xiv. The SCP Executive facilitates partners to produce, and agree on the local approach and /or response to neglect, to ensure consistency of application of thresholds. xv. Children's Social Care to review the scheme of delegations and determine management decision points including but not exhaustive: escalation, and children subject to more than one period of Public Law Outline. xvi. The effective use application and impact of the local Escalation process to be added to the SCP audit programme Page 30 of 30 xvii. NLaG is developing Guidance for the Management of Bloodshot Eyes in babies. xviii. A&E to ensure that a pathway is followed for Children and young people who attend without a GP and who would be notified. This is followed up by the safeguarding liaison nurse and children's health providers are notified. Details of the independent author Peter Maddocks was the independent reviewer. He has not worked for any of the organisations that have contributed to this review and has not held any elected position in North East Lincolnshire (NEL). He is not related to any individual who either works or holds an elected office in NEL. |
NC046638 | Death of a 6-week-3-day-old baby boy and neglect of his older half-siblings (13 and 15-years-old). Ambulance service was called by parents on 29 November 2015. Baby V was not breathing and was judged to have been dead for some time. Parents had been drinking heavily. Coroner returned a verdict on the cause of death as "unascertained". Both parents pleaded guilty to child neglect and received a custodial sentence. All three children were subject at that time to child protection plans for neglect and physical abuse. The parents of Baby V and father of U and B, who was still involved with the children, all had histories of alcohol misuse, mental health problems and domestic abuse. U and B had poor school attendance and B had disclosed her struggles with self-harm and suicide-ideation. Issues identified include: the overwhelming needs of the adults dominated the work undertaken; increasing concerns about the children's wellbeing failed to trigger intervention via the Common Assessment Framework (CAF); and adults' accounts were accepted without reference to other available information. Lessons learned include: the need for better use of early help; the importance of good reflective supervision and management scrutiny; and the need for all agencies to consider information on fathers and other significant males during assessments. Recommendations include the local safeguarding children board to review and report on the effectiveness of early intervention; and to ensure commissioning arrangements for assessing substance misusing parents/carers are in place and there is a clear pathway to accessing services for families.
| Serious Case Review No: 2016-C5807 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Children U,B and V Overview Report ANONYMISED OVERVIEW REPORT Child U Child B and Baby V 2 TABLE OF CONTENTS Page FOREWARD 3 1 INTRODUCTION 4 2 ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 5 3 FAMILY INVOLVEMENT 7 4 METHODOLOGY USED TO DRAW UP THIS REPORT 8 5 FACTUAL NARRATIVE CHRONOLOGY 9 6 KEY THEMES IDENTIFIED BY THE REVIEW PROCES 25 7 ANALYSIS FROM IMRS 36 8 CONTRIBUTION FROM THE FAMILY 44 9 LESSONS LEARNED 47 10 RECOMMENDATIONS 49 APPENDIX 1: RECOMMENDATIONS FROM IMRS 50 APPENDIX 2: ACRONYMS REFERENCES 55 3 FOREWARD A Local Safeguarding Children Board (LSCB) commissioned this Serious Case Review (SCR) in December 2014 and the final version was presented to the LSCB In September 2015. Many of the themes arising from the review had been identified elsewhere in work undertaken by the Board and in other areas of Children’s Services, including previous SCRs. In short many of the lessons and related recommendations were already subject to scrutiny by the Board and monitored closely by the Independent Chair via the sub groups. At the time this review was underway LSCB commissioned two separate pieces of work. One was a multi-agency audit, the subject of which was safeguarding pre-birth cases and children under one year old. This was conducted by an Independent Safeguarding Consultant on behalf of the LSCB. The focus of the audit was domestic abuse, parental mental health and substance misuse – themes which are replicated in this report. The second piece of work was a review of the Multi Agency Safeguarding Hub (MASH) also undertaken by an external consultant. The findings from these separate pieces of work largely echoed those in this report and so it is important to note that the LSCB were already aware of many of the practice issues and had included them in their business planning priorities in 2014-15. Since 2013 the government’s publication Working Together to Safeguard Children has placed an increasing emphasis on recognising the complex and difficult circumstances in which safeguarding professionals work and that these should be reflected in the lessons identified by SCRs. This local authority has been facing some obstacles which have been acknowledged by the LSCB over recent years. Of significance, it has been noted that the child population is predicted to continue to increase. Also, the prevalence of poverty, domestic abuse, substance misuse and parental mental health - factors that compromise safe parenting - are expected to rise. This coupled with the difficulties in the recruitment and retention of permanent staff across key areas adds to the overall picture of a service with significant challenges to overcome. These factors should be taken into account whilst reading this report. 4 1 INTRODUCTION 1.1 This is the overview report from a Serious Case Review (SCR) conducted by Local Authority 1(LA1) Safeguarding Children Board (LSCB). The matter under review is the death of a baby aged 6 weeks and 3 days in November 2014. The exact date and cause of the baby’s death are uncertain and the coroner returned a verdict of ‘unascertained’. At the time of writing this report both parents had pleaded guilty to Child Neglect and had received a short custodial sentence. 1.2 The case pertains to and highlights the following issues: The sad and untimely death of Baby V aged 6 weeks and 3 days old due to abuse and neglect Neglect of his two older half siblings born to a different father aged 13 and 15 at the time of the incident The extreme vulnerability of the three adults involved in the children’s care including chronic alcohol misuse, associated mental health difficulties and domestic abuse The father of Baby V having been deemed unsuitable by a neighbouring LA (LA2) to care for a son from a previous relationship The middle child experiencing mental health difficulties in the form of hearing voices and suffering from anxiety Chronic poor school attendance for the older two children The difficulties that arise when families span a number of boroughs and different Clinical Commissioning Groups (CCGs) over a number of years. 1.3 The following is a summary of the basic circumstances leading up to Baby V’s death. 1.4 The three children of this LA1 family were made subject to Child Protection Plans (CPP) for Neglect and Physical Abuse on 11 November 2014. 1.5 On 27 October 2014, the mother, Ms X and the three children were moved to temporary accommodation in LA3 following eviction from their LA1 property. 1.6 Ms X left the family home with Baby V on Thursday 27 November 2014 to go to his father’s (Mr W’s) home in another borough (LA4) leaving the older two children alone overnight. On Saturday 29 November the parents called the Ambulance Service (AS) and they attended Mr W’s address. The baby was not breathing and was judged to have been dead for some time. Both parents admitted that they had been drinking heavily. There was confusion at the scene which was further exacerbated by the adults’ differing accounts of events over the previous 48 hours. 5 2 ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 2.1 After the death of Baby V LSCB took the view that the criteria for an SCR had been met which is entirely consistent with the guidance in ‘Working Together’1 (WT) 2013. 2.2 The case meets the two criteria below set out in Working Together, 5(2)(a) Abuse or neglect of a child is known or suspected and 5(2)(b) (ii)The child has died. 2.3 Working Together (2013) Chapter 4 Para 10 states a Serious Case Review should be conducted in a way which; recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. The purpose of the review is to; Look at what happened in the case and why and what action will be taken to learn from the review findings; Identify actions that result in lasting improvements to those services working to safeguard and promote the welfare of children; Provide a useful insight into the way organisations are working together to safeguard and protect the welfare of children. 2.4 Arrangements were made to appoint the independent people who are required to contribute to the conduct of SCRs. An independent professional was appointed as the Chair of the SCR panel. This person has had a lengthy career in local authority social work, in adult mental health and children and families services. As an independent consultant, the person acts as both Chair and author of Serious Case Reviews, and is accredited as a reviewer using the Social Care Institute of Excellence (SCIE) Learning Together model. A second independent professional was appointed to produce this overview report. This person is an Independent Social Work Consultant with a considerable background in child protection and quality assurance. As an independent consultant the person specialises in multi-agency learning reviews including partnership reviews and SCRs. 1Working Together to Safeguard Children (Working Together) is the government’s overarching guidance on safeguarding. It has recently been revised but the terms of reference for this review were in place before the publication of Working Together 2015 6 2.5 LSCB arranged a Review Panel to manage and oversee the review. The membership of the panel is set out below; Name/Designation Organisation Role Independent N/A Chair of the panel Independent N/A Overview author Designated Doctor NHS Trust and CCG Panel member Designated Nurse CCG Panel member Head of Housing Need and Assessment Housing Panel member Head of School Standards Education Panel member Acting Assistant Director of Nursing Trust, Named Nurse Safeguarding Mental Health Service 1 (MHS1) Panel member Associate Director for Safeguarding Children Mental Health Service 3 (MHS3) Panel member Head of Service Children’s Social Care Panel member Review Officer Specialist Crime Review Group Police Service Panel member Board Manager LSCB Panel member 2.6 It was determined through the emerging facts of the case that the following agencies had had contact with the family and should therefore contribute to the review: Agency Nature of contribution Children’s Social Care, Local Authority 1 Chronology and IMR Education (covering School, educational psychologists and education welfare) Chronology and IMR Local Health Services (Covering Health Visiting, Hospital 6 and School Nurses) Chronology and IMR MHS1 Chronology and IMR MHS3 Chronology and IMR Hospital 2 NHS Trust (including the Health Visiting service) Chronology and IMR Police Service Chronology and IMR NHS England (including GPs) Chronology and IMR Community Drug and Alcohol Service 1 (CDAS1) Chronology and Background Summary Report Hospital 1 Chronology and Background Summary Report Housing Service 1 Chronology and Background Summary Report LA2 Chronology only Ambulance Service Chronology only 7 2.7 The Terms of Reference (ToR) agreed by the Panel were that the period under detailed review would be from 1st January 2014 to the 1st December 2014, with the proviso that agencies would summarise any other relevant information to add context and background to their report. In line with this some background information about events prior to January 2014 and the current position of the siblings is also included in the report. 2.8 The methodology used by the LSCB in this review is a hybrid model, in that each agency was asked to complete a chronology, and undertake an Independent Management Review (IMR). Those agencies who have had minimal contact were asked to complete an Agency Summary report (see table at 2.5) 2.9 The LSCB held a series of SCR Panel meetings, chaired by the Independent Chair, where all the agencies and the overview author contributed to the process. 2.10 A consultation and learning event was held in April 2015 to enable those practitioners who worked with the family to contribute to the overall findings and lessons from the review. Where relevant their views have been incorporated throughout the report. 2.11 LSCB plan to hold further learning events at the conclusion of the review both for practitioners and other staff from Children’s Services and Adults Services as well as other board partners. 3 FAMILY INVOLVEMENT 3.1 Consideration was given to involving the family in the review process and family members were advised early on that the review was underway. The maternal grandparents and both Baby V’s parents accepted the invitation to contribute and their views are included in the body of the report 3.2 Child U and Child B were encouraged by their grandparents to contribute their views but they felt too overwhelmed by the events of recent months. During the course of the care proceedings they had spoken to many different professionals and, understandably, declined the offer to speak yet more. 3.3 Mr R was contacted and invited to contribute his views but also declined as he wanted himself and his family to be left alone and did not consent to his personal records being used to inform the review. 3.4 The panel discussed the issue of consent carefully and at length, giving due consideration to the views of the family members involved, current guidance and legislation and the proportionality of the information used in the review. 8 3.5 The LSCB notified each parent that the SCR was taking place and asked whether they would be willing to participate in the process. They were advised that their relevant medical records would be accessed for the purpose of the review and were additionally asked if they gave their specific consent. 3.6 Contact with Mr W and Ms X was via their legal representatives as they were in custody at the time and direct contact was made with Mr R. 3.7 Mr R advised that he was not the carer of his children during the review time period and as such felt that his records were irrelevant. The SCR Review Panel took legal advice and made the decision that information from Mr R’s mental health records was needed in order to understand the family context and the decision-making undertaken by professionals. Mr R was informed accordingly. 3.8 In recognition of his explicit denial the only medical records of Mr R’s that were considered were those at MHS1 and only matters which were relevant, proportionate and necessary to the SCR were commented upon by the report authors. Those records were not accessed by anyone outside of the MH Trust. 4 METHODOLOGY USED TO DRAW UP THIS REPORT 4.1 This report is informed by The agency chronologies, IMRs and summary reports Background information from agencies involved in the review Panel discussions and analysis Dialogue with IMR authors Input from family members Input from practitioners via the consultation and learning event held on the 15th April 2015 Research findings. 4.2 The report consists of A factual context Analysis of how the agencies worked together from the information provided in their IMRs Commentary on the family situation and their input into the SCR Analysis of the specific issues identified in the ToR Findings and lessons learned Recommendations 4.3 The review has been conducted and written with the benefit of hindsight which often distorts the reader’s view of the predictability of events which may not have been evident at the time. It is important to 9 be aware as Munro (2011)2 states just how much hindsight distorts our judgement about the predictability of an adverse outcome. Once an outcome is known we can look back and believe we can see where practice, actions or assessments were critical in leading to that outcome. This is not necessarily the case, and information often becomes much clearer after an event has occurred. The review is therefore sensitive to this ‘bias’. 4.4 The review is also sensitive to pressures on agencies and the demands of the work which are sometimes overwhelming for even the most capable of workers. The pressures are felt more keenly in the face of a tragedy such as the death of a baby; therefore it is important to disseminate the learning and reflect on how the lessons can help change practice rather than apportion blame to agencies or individuals. 5 FACTUAL NARRATIVE CHRONOLOGY The Family Structure Name Relationship Age at time of incident Ethnicity Baby V Subject 6 weeks and 3 days White British Ms X Mother 40 White British Mr W Father to Baby V 47 White British Child U Subject (half sibling to Baby V - same mother) 15 years and 7 months White British Child B Subject (half sibling to Baby V - same mother) 13 years and 8 months White British Mr P Half sibling to Baby V (same mother) 20 years and 10 months White British Mr N Half sibling to Baby V (same mother) 22 years and 7 months White British Child S Half sibling to Baby V (same father) 8 years and 1 week White British Ms J Mother to Child S N/K White British Mr R Father to Children U and B 58 White British Grandfather Maternal grandfather to 62 White British 2 Munro review of child protection: final report - a child-centred system. Department of Education, May 2011 10 Children U and B Grandmother Maternal grandmother to Children U and B 63 White British 5.1. Introduction 5.1.1 Each of the agencies involved in this review submitted a detailed chronology of their involvement with the family members in the period under review. Those submissions have been co-ordinated into an integrated chronology which is summarised here. Further factual information is provided in some subsequent sections where relevant. The Family background 5.1.2 The family in question consists of Ms X who is mother to all three children, Mr W (father to Baby V), child U (aged 15 years and 7 months at the time of Baby V’s death), Child B (aged 13 years and 8 months at the time) and Mr R who is the ex-partner of Ms X and father to children U and B. Ms X has two adult sons from her first marriage, the eldest of whom does not reside in the family home. The other son stays in the family home during visits and holidays from university. Mr W also has a son from a previous relationship who resides in another area. 5.1.3. The members of the family are all White British and their first language is English. Little information is provided in the IMRs about their socio-economic background and there was no knowledge of either of the adult men’s current employment status. Ms X was said to run her own business. There was no evidence that any member of the family followed any established religion and there was minimal information provided about their cultural identity. 5.1.4. It would appear from the records that Ms X met her first husband in 1990 when she was 16 years old. She described this relationship as controlling and her husband drank alcohol to excess. They separated in 1997 having had two children. 5.1.5. Ms X met Mr R in the same year and they were together until 2012. Child U and Child B are the result of this relationship. The two adults along with Children U and B lived together until January 2012 when there was a serious episode of DV. This led to an assessment by CSC and Mr. R pleaded guilty to, and was convicted of, Common Assault on Ms X. Ms X was encouraged to take an injunction out against him, which she did and he left the family home. CSC was notified by Probation that Mr R had returned to the family home in August 2012. It is not clear when he obtained his most recent address but what is now known is that he continued to have frequent contact with Ms X and their two children despite the agreement with CSC that he would not. 11 5.1.6. There are two accounts of how Ms X met Mr W. According to Ms X whilst being interviewed for this review they met in 2013 through a family friend and this version of events was corroborated by the MGF. However, according to CSC records Ms X disclosed to the SW that they had met through a counselling group for recovering alcoholics. 5.1.7. The family friend in question had met Mr W through this route (Alcoholics Anonymous) so it is possible that this was misunderstood or misinterpreted by the SW. In any event Ms X does not dispute that the relationship began in 2013 and she became pregnant with Baby V in early 2014. 5.1.8. At the time covered by the review period Ms X, Child U and Child B lived in privately rented accommodation, her older two children having left home by this time (one was at university). It would seem that although both Mr R and Mr W had their own accommodation they were frequent visitors and lived in the family home on and off throughout the period under review. In October 2013 the family were notified that they were to be evicted although this was did not take place until the end of October 2014 and as a result were provided with emergency accommodation in LA3. 5.1.9. At the time of the review Mr W was living in LA4 having lived in a series of hostels for the homeless. He has a son from a previous relationship who lives in another local authority and more detailed information from the LA2 is contained in section 5.2. 5.1.10. Information to this review suggests that Mr W had a formal diagnosis of Asperger’s Syndrome (a form of autism). Asperger’s Syndrome is a lifelong disability that affects how a person makes sense of the world, processes information and relates to other people. This is likely to have added to his vulnerability especially in combination with his other significant problems - e.g. problematic alcohol misuse and associated physical and mental health difficulties. 5.1.11. The relationship between all three adults is complex and not completely understood at this stage but it is known that they spent time in each other’s company and their contact was characterised by their mutual long standing abuse of alcohol. 5.2. Agencies’ Involvement with family Members – LA2 5.2.1. As part of the review information obtained from the LA2, Children’s Social Care (CSC), confirmed that Mr W’s son (Child S) was subject to involvement from them between 2006 and 2010. The involvement started in 2006 when soon after he was born Child S’s mother (Ms J) - rang her local hospital stating that she was unable to cope with her son. 12 5.2.2. Over a period spanning approximately four years CSC’s involvement consisted of conducting Initial and Core assessments and later in 2007 s47 (CP) enquiries were undertaken. The concerns were due to domestic violence between the parents and excessive alcohol misuse. 13 5.2.3. In June 2007 Mr W received a police caution for Common Assault against Ms J following heavy drinking sessions by both parties. In August 2007 he was found ‘not guilty’ of an offence of Common Assault again against Ms J. 5.2.4. In the same year due to a growing number of incidents Child S was made subject to a Child Protection Plan (CPP) under the category of neglect. Child S was also taken into Police Protection, again in 2007, due to Ms J and Mr W breaking a written agreement that Mr W would not have sole care of his son. Child S was accommodated in foster care under s20 of the Children Act 1989 for a short period. 5.2.5. Child S was subsequently moved to the care of his maternal grandparents and the couple were required to live at Ms J’s parents’ house with the baby. It is not clear if Mr W joined them there but in any event it would appear from the information provided that the relationship with Ms J ended around 2008. The CPP ended in September 2008 and Mr W was having no contact at that time. 5.2.6. It is significant to this review that the couple’s relationship was categorised by incidents of domestic violence, which appeared to be fuelled by Mr W’s excessive alcohol misuse and associated mental health difficulties. During this period LA2 reported that Mr W was admitted to hospital on at least four occasions due to mental ill health including having taken overdoses of various medications and feeling suicidal. He was also an in-patient in at least two detox units but relapsed on both occasions. Mr W is also reported to have made threats to CSC staff stating that he would ‘bomb’ anybody he felt was working against him. 5.2.7. The case was closed to LA2 in September 2010 with no contact offered between Child S and Mr W. 5.3. Agencies’ Involvement with family members – LA1 Relevant events prior to 2014 5.3.1. In July 2011 Ms X reported to her GP that she was suffering from insomnia and excessive alcohol intake which she stated was as much as 75 units per week. 5.3.2. In 2012 Children’s Social Care in LA1 conducted an assessment of the family due to concerns around domestic violence – Mr R was said to have held a Samurai sword to Ms X’s neck and threatened to kill her. The assessment concluded that Mr R was not to have contact with Ms X or the children. This was agreed by Ms X and as a consequence of this Mr R left the family home 14 5.3.3. The outcome of this was No Further Action (NFA) to CSC as Ms X co-operated with the assessment and sought an injunction against Mr R. Mr R pleaded guilty to Common Assault in relation to the incident. 5.3.4. In November 2013 Ms X made an appointment with a Housing Needs Officer (HNO) saying that she had been threatened with eviction due to the landlord wanting the property back. Mr W attended the appointment but was not included in the application. Mr R was listed as a tenant on the privately rented property and Ms X was open about the fact that there had been DV between them, which led to CSC involvement. She cited the DV for the reason Mr R no longer lived in the family home. Her application was followed up in February 2014 when she provided written documentation from her landlord that he intended to evict her. At this point Ms X also requested that Mr W be added to her housing application. Events from January 2014 onwards 5.3.5. In January 2014 Child B disclosed to a school teacher that she had been hearing voices and could describe the characters that were speaking to her in detail. Child B said that she had not attended the GP as she feared she would be seen as ‘mad’. The school staff were concerned about this and as a result the teacher spoke to Ms X who said that she was aware of Child B’s disclosure re voices. Ms X was advised by the school to take Child B to the GP which she did, and the GP made the referral to Mental Health Service 2 (MHS2) for Child B to be assessed. The referral was accepted by MHS2 and after the information had been assessed in line with their usual process Child B was placed on their standard waiting list.3 5.3.6. It is significant also to note during this period that the children’s school attendance was very poor and between January to July of 2014 it was as low as 50%. February 2014 5.3.7. In February 2014 Mr W presented to A&E in the LA5 and was assessed by a psychiatrist which led to a hospital admission for approximately one week. Mr W presented as very distressed and said that he felt suicidal and would ‘jump into the river’ if discharged from A&E. He reported that this was as a result of his girlfriend who had ‘kicked him out of her house’ the day before as he did not get on with her children. He further informed the doctor that the previous day he had taken an overdose of 25-30 painkillers. Mr W also disclosed that after abstaining from alcohol for a period of three years he had started drinking again in January. He disclosed the reason for his relapse was due to his girlfriend drinking with him and that they consumed 3 - 5 cans of cider (7.5%) a day. 3 The national standard waiting time for MHS2 is currently 18 weeks 15 5.3.8. The staff at A&E took a detailed history from Mr W and his previous presentation in terms of hospital admissions, previous diagnoses (including Asperger’s Syndrome and alcohol dependence) and self-reported overdoses. Mr W was assessed as being depressed and suicidal in the context of alcohol misuse further complicated by the fact that he had spontaneously stopped his medication for depression about 6 months previously making his depression worse. The doctor assessed that he had active suicidal thoughts and intent and plans to commit suicide were present. 5.3.9. A risk assessment concluded that at that time he was moderate/ high risk to self and low risk to others. By the time he was discharged seven days later the risk to himself was said to have reduced and he and Ms X were reported to have agreed to work ‘as a team’ in regards to the children. He was discharged and informed members of staff that he was going to an address in LA1 to stay with his girlfriend but no discharge address was elicited. March 2014 5.3.10. Less than three weeks later in early March Mr W was again admitted to hospital under similar circumstances. He had reportedly taken an overdose of medication and had drunk heavily. Mr W complained about his girlfriend’s children (Children B and U) and said that they were trying to sabotage his attempts to get himself organised. He was worried about housing and said that he had wanted to commit suicide for a long time, claiming that it was always in the back of his mind. He also disclosed that he believed his girlfriend was pregnant. 5.3.11. Mr W was discharged six days later and Hospital 5 offered an outpatient appointment and encouraged him to register with a GP in LA4 so that his mental health care could be transferred over to them. A Mental Health Project (Rehab2) was to assist him in receiving counselling for his alcohol use, help with housing and registering with a GP in LA4. 5.3.12. It would appear he was discharged to accommodation in LA4 who were assessing Mr W’s housing situation to see if they would accept responsibility for this as he had spent some time there in a hostel for homeless people. 5.3.13. Mr W received some aftercare services from GP Practice 1 (based in LA4) and he eventually registered with a regular GP practice later in the year. He was however reluctant to engage further and declined most services offered to him. Within the paperwork transferred by Hospital 5 there was a mention of his girlfriend’s pregnancy but this was not picked up. 16 5.3.14. After several attempts to make contact with him after his discharge from hospital, Rehab2 closed Mr W’s case in June 2014. It is not clear what MH services he received (if any) between March and September as he was not registered with the GP in LA4 until September 2014. 5.3.15. Around a similar time to Mr W’s hospital admissions Mr R also presented to an A&E on the 18/03/2014. He presented as drunk and was experiencing chest pains. It is documented that he reported that this was following an alcohol binge with his ex-wife (believed to be Ms X). NB Ms X would have been 8/9 weeks pregnant at the time. 5.3.16. Mr R presented a further four times to A&Es and had several contacts with mental health services during the review period. On each occasion this was due to excessive alcohol use (or complications associated with alcohol use), depression and suicidal thoughts. Notably one of these was the 14th October, which was the day Baby V was born. Mr R had fallen over and had cuts over his face and body. April 2014 5.3.17. There are two significant events that happened in relation to members of the family in April 2014. On the 12th April an ambulance was called regarding Ms X. On arrival of the ambulance staff it was explained that Ms X believed she was having twins as she could feel two babies. She described having contractions every minute or so. 5.3.18. On examination in hospital all clinical observations were within expected parameters and it is documented by the ambulance crew that Ms X had no apparent bump but claimed she was 22 weeks pregnant. In the hospital the pregnancy was confirmed, as was the normal development of a single foetus. 5.3.19. As a result of this seemingly bizarre episode the Ambulance Service made a referral to MHS1 querying Ms X’s mental health. 5.3.20. The referral was discussed at the Multi-Disciplinary Team meeting on the 22nd April and a decision was made to request further information from Ms X’s GP. A telephone call to the GP was made on the 30th April and a written request was sent as advised on the same day. Information from the surgery was faxed from the GP confirming that Ms X was pregnant and was prescribed fluoxetine4 and thiamine5. Further attempts were made to contact the surgery for more information about Ms X’s mental health but no contact was made. The outcome was that Ms X was not offered a service by LA1 mental health services in relation to the referral. 4 A prescribed medication taken to treat depression 5 Thiamine is also known as vitamin B, essential for the metabolism of carbohydrates in order to release energy for growth, nerve function and muscle tone 17 5.3.21. Ms X had registered her pregnancy and her first ante natal appointment took place three days after the ambulance was called on the 15th April, by which time Ms X was in fact 14 weeks pregnant not 22. Mr W attended the antenatal appointment with Ms X and they were asked routine questions about mental health and drug and alcohol use. It is recorded that Ms X admitted to smoking 12 cigarettes a day and drinking 3-4 units of alcohol a day. She also stated that she was being treated for depression as was her partner (Mr W). She did not disclose past or present domestic violence although there is some ambiguity in the Health Service IMR about whether or not a direct question in relation to this was asked. 5.3.22 When asked the mental health questions she answered ‘yes’ to past and present mental illness, previous treatment, family history of mental health issues and also answered yes to the question ‘does your partner have any history of mental health illness’? She also answered positively (i.e. yes) to being asked if she felt low, depressed or hopeless, having little interest or pleasure in doing things, worrying or feeling anxious about things and was it something she needed help with. 5.3.23 As a result of the above booking appointment the midwife became concerned for two reasons. One was concern for the unborn baby and the amount of alcohol and cigarettes that had been disclosed as being consumed, and the other was in relation to Ms X’s mental health 5.3.24 On the 24th April the midwife made a referral to LA1 CSC asking for support for Ms X and her partner in relation to their alcohol use, smoking during the pregnancy and depression. The referral mentions the impending issue about being evicted and Mr W’s severe anxiety issues. 5.3.25 The referral was considered by CSC but not accepted as a referral that would progress to assessment. Instead the recommendation was that, as Ms X was willing to engage in support, a health-led Common Assessment Framework (CAF) should be put in place. In a letter dated 6th May CSC informed the midwife that there would be NFA from CSC and that they recommended she complete a CAF. There is no record of this letter on the files held by the Health Service and no CAF was completed. 5.3.26 The midwifery service received a copy of the reply from the MASH which was addressed to Ms X, confirming that no further action was to be taken at this time. It advised her to engage with her GP and midwifery services and ensure that her mental health needs were adequately met. 5.3.27 In relation to the second issue of Ms X’s mental health the midwife also made a referral to the Perinatal Mental Health Team (PMHT). However PMHT did not assess Ms X’s mental health or offer any 18 support at that time because she was already under the care of the GP who had prescribed medication. The GP was informed and a prescribing guideline was dispatched, advising the GP to re-refer if they had any concerns. 5.3.28 Of further significance in April was the continuing issue with Child B and her mental health. The school became increasingly concerned about the deterioration in her mood and presentation. As a result the school contacted MHS2 and expressed their continued concern about Child B’s low mood and high anxiety. They reported that she was experiencing suicidal thoughts and had self-harmed through superficial cutting. As a result of this intervention by school, Child B was placed on the semi-urgent waiting list a day later. The initial assessment of Child B eventually took place on the 05/08/2014 (approximately 7 months after the original referral) when a comprehensive history about Child B and the family was obtained and a mental state examination of Child B was conducted. 5.3.29 Child B remained under the care of MHS2 throughout the rest of the review period and attended a number of appointments in August and September. There were no appointments attended in October despite several contacts from MHS2 to arrange one. Ms X was reluctant to take Child B due to the impending birth of Baby V and the fact that they were about to be evicted. At an appointment on 21st November Child B was prescribed fluoxetine for anxiety and depression. May 2014 5.3.30 On May 14th 2014 Ms X attended a routine antenatal appointment. There were no noted concerns about the pregnancy and Ms X told the midwife that she had given up smoking and drinking. This was the only other record of the question of smoking and alcohol consumption being addressed in the midwifery appointments. 5.3.31 From that point on there were no major concerns noted about her or the unborn baby and she attended antenatal appointments as requested. In all she attended 11 appointments shared between the consultant clinic and community midwives. 5.3.32 July 2014 saw the start of some considerable contact between Mr R and various Adult Mental Health Services and it would appear that Mr R’s mental health was deteriorating during this time. Over the next three month period he was assessed and treated for depression, suicidal ideation and attempts. This was on top of several presentations to A&E against a similar background of chronic alcohol dependence and past history of suicide attempts. 5.3.33 On 9th July Mr R was assessed at MHS4 for depression and suicidal ideation; he was accompanied by Ms X on this occasion. As a result of this assessment he was admitted to the Hospital 8 for alcohol detox 19 and discharged on the 12th July. After this he had various contacts including the following: One further contact with MHS4 (21st July) Two contacts with Hospital 3 Psychiatric Liaison Team (30th July and 7th September) Four Community Psychiatric Reviews (31/07/14, 01/08/14, 18/08/14, 02/09/14) Two further admissions to hospital; Hospital 10 triage ward (8-10th September) and Hospital 7 (10th September to 13th October) 5.3.34. It was understood by these services that at times Mr R was living in the family home with Ms X, Child U and Child B and also that Child B was receiving a service from MHS2 for depression and anxiety. The children also visited him in hospital with Ms X and Mr W. MHS2 were however unaware of Mr R’s contact with services. 5.3.35. It is documented in the IMR provided by MHS1 that risk assessments took place, which included information about Mr R's family and were completed on numerous occasions. These related to the risks Mr R posed to others, including his children and to himself across different domains including self harm, neglect, violence, and suicide. This was an internal process and no other agency was contacted to inform the risk assessment. It would be normal practice to share these with the person’s GP but as Mr R was not registered with a GP this did not happen. 5.3.36. Mr R did not respond to attempts to organise follow-up appointments after his discharge from the Hospital 7 so much of the intervention was centered around crisis management. August 2014 5.3.37. In August 2014 Child B had her first appointment with MHS2. She was accompanied by Ms X. A comprehensive history was taken from Child B and Ms X and among other things Ms X was asked about her use of drugs and alcohol during her pregnancy with Child B and she denied use. Information about other members of the family and Ms X’s partner, Mr W, was also obtained. Child B’s father, Mr R, was identified as having alcohol-related problems and concerns about Mr W’s behaviour were raised by Child B. These included violent behaviour towards her (twisting her arm) and the inappropriate behaviour of kissing the cuts on her arms which she had made whilst self harming. Child B also disclosed that she believed (and it was not disputed by Ms X), that Mr W was not allowed contact with his son from a previous relationship but she did not know the detail of why this was the case. 20 5.3.38. An assessment was completed and Child B was discussed in a MDT meeting on the 7th August where a decision was made to make a child protection referral to CSC in view of the disclosures made by Child B. 5.3.39. The referral was delayed due to attempting to gain consent from Ms X which was eventually obtained on the 14th August. It was further delayed by IT problems in completing the on line referral form for CSC. The referral was eventually made on the 27th August three weeks and one day after Child B’s original disclosures. 5.3.40. The referral to CSC progressed to a detailed single assessment, planned to take 45 days and a social worker was allocated to complete the assessment under s17 Children Act 1989. 5.3.41. Further issues emerged in relation to the health of Mr W when at the end of August (28th) an ambulance was called for him and he was taken to Hospital 1. It was reported that he was experiencing chest pain, pain in between his shoulders and pins and needles in his legs, arms and hands. He was diagnosed with a respiratory infection and discharged. September 2014 5.3.42. On the 10th September Mr R was admitted to Hospital 10 Triage Ward for assessment of his suicide risk and depression. He was transferred to Hospital 7 for treatment where he remained in hospital until 13th October, an admission of just over one month. 5.3.43. The following day a further incident similar to the one on the 28th August occurred (described in 5.3.41) when an ambulance was again called for Mr W who was experiencing chest pain. Following the crew’s examination, Mr W was conveyed to Hospital 1. He complained of pain similar to that described in the previous section and it is significant to note that he reported having had 20 units of alcohol that day. Mr W left A&E before being seen. 5.3.44. The same day on the 11th September CSC received a referral from an anonymous source concerned about Child U, Child B and the unborn baby. The referrer was worried about the following issues; Mother and father of unborn drinking all day Mother admitting to drinking Mother supplying the children with cigarettes Father of unborn walking round with a knife and a hammer Ex-husband also living in the property. She (Ms X) says he was taken into an ‘institute’ as he was found lying on a train track recently Father of unborn held Child U up by his neck when he was drunk Children have not been going to school 21 Caller says mother was home at attempted last visit but didn’t come to the door to see Social Services (CSC have recorded that a visit was made on the 3rd September but it was reported by her older son that no one was home except him) 5.3.45. It is not clear what action was taken by CSC as a response to the referral but the SW undertook a visit on the 12th September (but no notes were recorded). There are however references to the information as part of the later s47 enquiries conducted in October after the birth of Baby V. The issues from the referral were also raised at the ICPC held on 11th November and were assessed on balance to be accurate. 5.3.46. Throughout September Child B continued to have various appointments (four in total) with MHS2 for psychological interventions. These sessions were designed to target her low mood and anxiety and one of the appointments was with the team’s doctor who was a Specialist Trainee Child and Adolescent Psychiatrist. October 2014 5.3.47. A number of significant events occurred in October 2014. 5.3.48. LA4 had accepted housing responsibility for Mr W, he had been allocated accommodation and he had registered with a GP (September 2014). 5.3.49. On the 8th October Mr W presented to his GP and gave a history of feeling suicidal. He disclosed a past history of deliberate overdose and self harm. The GP also elicited that Mr W had alcohol dependency syndrome and he admitted drinking more than 9 units daily. The GP made appropriate referrals to alcohol services and the Mental Health Team. Mr W declined mental health service input despite the recommendation from his GP, who was concerned about Mr W’s suicidal ideation and alcohol abuse. The impending birth of Baby V was not discussed; the GP practice was unaware of the birth and Mr W did not mention it. 5.3.50. Six days later on the 14th October Baby V was born in hospital. The birth was normal with no complications. Ms X however remained in hospital for a further three days due to a request from CSC that there be a discharge planning meeting before mother and baby were discharged home. 5.3.51. The next day two members of staff from the school conducted a visit to the family home to check on the older two children who had not been in school. After visiting the grandparents first (as that was the 22 address they had) they then went to the family home and were met by a man (later confirmed as Mr R) who was drunk and had lacerations and bruises all over his face and body. Mr R stated that the children were not present and it was later established that they were with their mother in the hospital at the time. They did however stay with their father in their own home whilst their mother was in hospital. The school did not pursue any other lines of enquiry as they felt unsafe with Mr R. On their return to the school a referral to CSC was made. 5.3.52. As a result of this referral a strategy discussion between the police and CSC took place the same day and a decision made that single agency s47 enquiries should be commenced in relation to all three children. 5.3.53. Amid the growing concerns for the children (including Baby V) a discharge planning meeting was held in the hospital prior to the baby being discharged home. Representatives from the school, the midwives and CSC attended the meeting. A full exchange of information took place in relation to the background of the original referral from MHS2 and the two more recent ones. Mr W confirmed that what Child B had disclosed to MHS2 was correct which was that he had been prevented from having contact with his son from a previous relationship. He was open about the fact that this was to do with issues around excessive alcohol use but stated that this was not an on-going problem. 5.3.54. A Written Agreement (WA) was put in place prior to Ms X and Baby V’s discharge home which included that there was to be no contact between any of the children and Mr R. Ms X and Mr W however refused to sign this version of the agreement and from information gleaned it would appear that the agreement was changed in favour of Mr R being allowed contact with the children with conditions applied. The lack of clarity around the agreement, and its exact content at this stage, is due to being unable to locate the final version signed by Ms X and Mr W. However the Child Protection Plan made on November 11th clarified that Mr R was not to visit the home address and that the core group should put plans in place to ensure that any contact between Child U, Child B and Mr R was safe. 5.3.55. The document also stated that Ms X was not to leave Baby V, Child U or Child B in the sole care of Mr W. Mr W was further asked not to have any unsupervised contact with them until the result of initial alcohol screening and the outcome of a risk assessment. 5.3.56. The WA had made a stipulation that the baby’s parents needed to be tested for alcohol use. On the 20th October Ms X and Mr W attended 23 CDAS1 of their own volition explaining that they needed to be assessed to demonstrate to CSC that they did not have problematic alcohol use. 5.3.57. Both adults (Ms X and Mr W) were offered an assessment to determine their needs around how they used alcohol. Both denied there were any concerns with their alcohol use and suggested they had presented to CDAS1 on the advice of CSC and not because it was something that they were worried about. The worker explained that support could be given in terms of an assessment, care plan, alcometer test and support from a key worker. Both declined the offer of any of these services. 5.3.58. After a formal referral from the SW Ms X then presented to CDAS1 on 25th November and was screened to determine risk prior to being given a full assessment appointment. Again, Ms X denied her use of alcohol was problematic, hazardous or high risk. 5.3.59. A further appointment for the full assessment was offered but was not attended as this was after the death of Baby V. 5.3.60. On the 21st October Mr W attended his GP surgery and became aggressive and intimidating as he was demanding painkillers for his shoulder, which the GP would not prescribe due to not having his previous medical records. 5.3.61. On 24th October the HV completed a new birth visit at the home address. Both parents were present and Ms X denied any history of mental illness and denied drinking 3-4 units of alcohol a day stating that the midwives had recorded it incorrectly and it was 3-4 units per week. She said that she had stopped drinking and smoking cigarettes altogether in September. The HV discussed issues around DV and Ms X disclosed DV between her and ex-husband but stated that she did not see him now. This was at odds with her subsequent admission that he looked after the dogs and the children while she was in hospital. 5.3.62. The HV completed a thorough assessment of Baby V, who was healthy and good bonding was observed between Baby V and Ms X. Various routine health promotion leaflets were given. No concerns were noted about the care of the baby. Ms X had opted to breastfeed, which was going well and the decision of the HV was to offer a Universal Plus Service to mother and family due to the impending eviction. 24 5.3.63. The family were evicted from their home on the 27th October and placed in emergency accommodation in a neighbouring area. It would appear that only Ms X, Baby V and the two older children moved to this accommodation. November 2014 5.3.64. On the 1st November a Social Worker in the LA4 contacted the police concerned about the welfare of Baby V because he was being transported in the street in a pram that was unsuitable for a newborn baby and the parents appeared to have been drinking. Police were sent to conduct a welfare check on the child. 5.3.65. Ms X was assessed as being able to care for Baby V who was warm and sleeping. She was drinking a can of pre mixed alcohol but was judged not to be drunk and therefore police assessed that she was capable of caring for the baby. The police took No Further Action (NFA) except to send a MERLIN to LA4 Children’s Social Care (CSC) which was then forwarded to LA1 CSC. Baby V was two weeks old when this incident occurred. 5.3.66. On the 7th November a newly allocated Health visitor based in LA3 completed a ‘Transfer in’ home visit. Baby V was seen with both parents and there were no major concerns noted at the visit. Ms X informed the HV about the impending CPC which was due to take place on the 11th November. The allocated HV was unable to attend the ICPC and her manager went in her place. 5.3.67. Amid the growing concerns as referred to above an ICPC took place on the 11th November in LA1. All three children were made subject to CPPs under the category of Neglect and Physical Abuse. Concerns were expressed in relation to the parents’ excessive alcohol use and past violence in all the relationships. The conference was attended by Ms X and Mr W, but not Mr R. Ms X’s mother also attended. 5.3.68. After the conference the case transferred to the locality team and an introductory visit was conducted by the new workers on the 17th November. They discussed the issues raised at the ICPC. 5.3.69. On Thursday 27 November 2014 Ms X left the temporary accommodation in LA3 and went to Mr W’s home in LA4 taking Baby V with her and leaving Child U and Child B alone overnight. She left her mobile phone with them so that she could be contacted (via Mr W). On Saturday 29 November the Ambulance Service were called by the parents and they attended father’s address. The baby was not breathing and was judged to have been dead for some considerable time. 25 5.3.70. On the morning of the 28th November the Health Visitor called to see Ms. X and the intercom was answered by Child U who said that his mother was not in and that he had not seen her since the day before. The HV left a message with Child U for his mother to call her. 5.3.71. When the school realised that the children were not in they rang Ms X’s mobile phone. It was answered by Child U and the teacher asked him to come into school with Child B which they did. On arriving at school they became distressed and disclosed that Ms X had been drinking and had left the previous evening with Baby V because she was worried about Mr W. She had said that she would be back in order to take them to school but she had not returned. 5.3.72. The police and CSC were contacted later that afternoon by the school who responded straight away in trying to locate the baby and his parents. The parents were not located on the 28th November due to an incorrect address for Mr W being held by both the Maternal Grandfather (MGF) and CSC. The police arrived at the scene on the morning of the 29th November. 5.3.73. Exact events in relation to the death of Baby V between 27th November and 29th November have not been established for this review and the cause of Baby V’s death has been officially recorded as ‘unascertained’. What is known is that both parents admitted to drinking heavily and failed to respond appropriately when they discovered Baby V not breathing. The parents did eventually contact emergency services on the morning of the 29th November and the Ambulance Service was dispatched to Mr W’s home address immediately. The parents were arrested at the scene and taken to hospital to be medically examined due to their disclosures that they had taken overdoses of Phenergan (anti-histamine) 5.3.74. On 29 Nov Ms X and Mr W were arrested and remanded in custody facing charges in relation to Baby V’s death. Child U and Child B were removed to the care of relatives and remain in their care. 5.3.75. On April 2015 Ms X and Mr W both pleaded Guilty to the charge of Child Neglect in respect of baby V. Additional charges of Child Neglect against Ms X were withdrawn. Mr W and Ms X each received a custodial sentence of two months and fifteen days, which had been served whilst they were on remand; they were released with immediate effect. 26 6 KEY THEMES IDENTIFIED BY THE REVIEW PROCESS 6.1. The impact of alcohol abuse in families. 6.1.1. A feature of the work with this family is that presentations to agencies were dominated by the needs of the adults Ms X, Mr W and Mr R. Between them their contacts with agencies number in excess of 70 during the period under review (just under a year) with a significant proportion of these contacts being in relation to the alcohol abuse of one or other of the adults. This compared with Children U and B which, save for the time they spent in school (which was also patchy), number approximately 10. Between August and November MHS2 saw Child B seven times and the SW who conducted the assessment and subsequent s47 enquiries saw Child B twice and Child U once. 6.1.2. We know from extensive research that children are particularly affected by parental alcohol use and that parents become physically and emotionally unavailable often to the detriment of parental responsibilities. Increasing amounts of time are spent drinking or recovering from drinking which is associated with increased risk for children. Parental alcohol problems are associated with negative outcomes in children, e.g. poorer physical and psychological health (and therefore higher hospital admission rates), poor educational achievement, eating disorders and addiction problems (West & Prinz, 1987;6 Girling et al., 2006)7, many of which persist into adulthood (Balsa et al., 2009)8. 6.1.3. In this family much of the adults’ contacts were with a range of services such as GP appointments and A&E departments which then led to other services such as psychiatric assessments, hospital admissions and the offer of on-going treatment plans and support. The latter was rarely taken up by any of the adults. 6.1.4. It has become clear throughout the process of this review that these services were in possession of information which provided a worrying perspective on the adults involved in the lives of the children. Examples of these contacts include dates going back to 2011 when Ms X disclosed to her GP that she had been drinking more than 75 units per week at a time when Child U and Child B would have been 12 and 10 respectively. Later on in January 2014 she also admits 6 West, M.O., and Prinz, R.J Parental alcoholism and childhood psychopathology. Psychological Bulletins 102:204–218, 1987. 7 Girling, M., Huakau, J., Casswell, S. and Conway, K. (2006). Families and heavy drinking: Impacts on children's wellbeing. Wellington, New Zealand: Families Commission 8 Balsa, A.I., Homer, J.F. and French, M.T. (2009). The health effects of parental problem drinking on adult children. The Journal of Mental Health Policy and Economics, , 55-66. 27 again to the GP that she has been ‘drinking heavily’ for the past year. This is with the backdrop of Mr R and Mr W (the children’s other two caregivers) also having significant problems with alcohol misuse. 6.1.5. More examples of these are Mr W’s two admissions to hospital in February and March 2014 when he disclosed information about his background, his mental health history and his history of alcohol abuse. He talked openly about his difficult relationship with his girlfriend’s children and cites them at one point as part of the reason he wants to kill himself describing Child B as ‘spiteful’. 6.1.6. Similarly Mr R presented many times to health services requiring treatment for excessive alcohol use, depression and suicide ideation. Much was known to these services about his family life as he was accompanied by his ex-wife Ms X on at least one occasion and the whole family (including Mr W) visited him whilst he was in hospital. Risk assessments were regularly conducted which included the risk to himself and considered risk to his immediate family. These were however internal processes and did not involve exchanging information with other agencies. 6.1.7. Ms X disclosed to the SW conducting the assessment that Mr R had been admitted to hospital due to excessive alcohol use and associated mental health difficulties but this was not followed up. 6.1.8. The reasons why practitioners did not assess this information as significant in terms of the impact on the children are very complex. No doubt the issue about Mr W in particular choosing to present to services outside of the LA1 area is a particular challenge. He accessed health services in LA4 and LA5 with similar issues (excessive alcohol use, depression and suicidal ideation) and although he talked about his girlfriend’s children he ostensibly presented as a single man with either his own address or as itinerant. The extent of his contact with the children was not considered. 6.1.9. The impact of the relationship between Ms X and Mr W which was one largely borne out of their mutual alcohol misuse was not understood by any agency. Furthermore attempts to understand the impact of this relationship on the children were few and far between. 6.1.10. There is a significant gap in information about the level of alcohol used on a regular basis by Ms X. As mentioned above in her history there are references to as much as an excess of 75 units of alcohol per week and at other times she describes ‘drinking heavily’. These descriptions are probably Ms X at her most candid (and may also be conservative) as when the referral to CSC by the midwife was made in April 2014 she did not disclose problematic drinking and claimed 28 that she had ‘given up’ both cigarettes and alcohol. She was not however consistent as to the date that she had given up but due to the number of different professionals involved this went unnoticed and therefore unchallenged by agencies. NB - The government’s current proposed safe limit of daily alcohol consumption is 2-3 units for women and 3-4 units for men. Smoking and drinking any amount in pregnancy is actively discouraged. 6.1.11. In April 2014 at her booking appointment Ms X disclosed to the midwife that she was drinking 3-4 units of alcohol per day. In November after CSC became involved and began to conduct their assessment she stated to the Health visitor that the original midwife recorded this amount incorrectly and that it was 3-4 units per week. 6.1.12. Along with these factors it is noteworthy that no service or agency had an accurate assessment of the actual level of alcohol each adult was consuming on a daily basis. The levels of alcohol allegedly consumed were entirely self-reported and different amounts were reported to different professionals. 6.1.13. Whilst Mr W disclosed harmful amounts of alcohol to mental health professionals and his GP, his stance with CSC was that his alcohol use was no longer a problem. As these services were not connected up professionals were not able to establish a holistic picture and therefore make a more educated assessment of the impact that this was likely to be having on the children. 6.1.14. The CSC IMR’s analysis of this issue makes much of the fact that alcohol is a socially acceptable drug and argues that this may have been a factor in the failure to explore the issue further. Whilst there is no doubt this is true the answer is much more complex than that. It perhaps lies in the myriad of misinformation provided by the adults coupled with the lack of cogent information-sharing between agencies which happened largely because they were unaware of each other’s contact with the family. A combination of factors were at play here and some are summarised below: Ms X never appeared under the influence of alcohol when she met with professionals. Ms X in particular appeared to professionals to function effectively in her day to day life e.g. she was on top of her housing crisis; she appeared to hold down a job and attended all her antenatal appointments. Although it is not clear if the children were asked directly about their parents’ alcohol use they did not disclose any concerns about their parents’ use of alcohol. 29 The midwives did not revisit the issue of cigarette and alcohol use in ante natal appointments and it is likely that if they had Ms X would have stuck to her script of having ‘given up’. The GP in Practice 1 who held information about Mr W and his history was not present at the CP conference and did not provide a report. CSC and other children’s agencies were unaware of Mr W’s presentations to hospitals. Mr R was not assessed by a multi agency network in relation to his children and the impact of his presentation on them. CDAS1 did not identify any concerns with problematic alcohol use when the parents presented there. Historical information was not treated with due weight and consideration (see next section). 6.1.15. At critical points when all of the information should have come together such as the discharge planning meeting after Baby V was born, the ICPC and the subsequent core groups, large chunks of information about the adults were missing - e.g. those professionals were unaware of Mr W’s hospital admissions earlier in the year. Information about Mr R’s admissions to hospital was not followed up. 6.1.16. Furthermore information that was available was not considered robustly enough. For example the meaning behind the crucial piece of information from LA2 CSC that Mr W was not allowed contact with his own son (not a decision that is ever taken lightly) was lost in favour of Mr W’s assertion that this was ‘no longer an issue’. This was despite information to the contrary which is discussed in more detail in section 6.3. 6.2 Early Intervention as a tool for safeguarding 6.1.17. One feature of work with this family was that throughout the period under review agencies involved with the children were concerned about them for a variety of reasons. 6.1.18. In August 2014 MHS2 made the referral that led to CSC intervention but prior to that the school had ongoing worries about their attendance and Child B’s presentation. They were also aware of Ms X’s drinking and had concerns about nutrition and hygiene. The midwife was concerned about the unborn baby in relation to Ms X’s and Mr W’s alcohol use and mental health issues, resulting in her making a referral to CSC. 30 6.1.19. These were all early indications that the needs of the children were not being fully met. Early Intervention (EI) through universal services or more targeted provision is the nationally identified mechanism by which families can be encouraged to accept help from a range of agencies. The Common Assessment Framework (CAF) is the most commonly used conduit to providing services to families whose needs fall below the threshold for intervention from CSC. 6.1.20. School did provide some services that could be described as Early Intervention in that the children were provided with extra help and support and were often in special classes where they could be more easily nurtured and supported. There was also good communication between school and MHS2 particularly when Child B’s mental health deteriorated. 6.1.21. No agency however conducted a formal CAF assessment despite at least one recommendation by CSC that one should be undertaken. It has transpired during the process of this review that the midwifery service have no record of a letter that CSC sent following the referral in April 2014 recommending that they complete a CAF. It has not been established how this went astray but it meant that agencies failed to identify one of the key benefits of EI which is that it engages the parent in a positive partnership on behalf of the child/ren. It is clear that there were increasing concerns about the children’s well-being throughout this year but there was no evidence that Ms X (or Mr R for that matter) was engaged in a purposeful dialogue about them. 6.1.22. Eileen Munro in her review in 2011 identified the challenge for professionals working with families. ‘There is a tension in providing support to parents. For most, the right approach is to offer services with families making a voluntary choice to receive them. There are families whose level of parenting raises some concern and the relevant services make more strenuous efforts to make them aware of the help available and to gain their co-operation. A complicating factor is that parents who voluntarily engage with support services tend to make more progress while a more coercive approach can deteriorate into an adversarial relationship which blocks progress.’ 9 6.1.23. The benefits of a CAF can be assessed as it being the opportunity for agencies to gather information and have a more structured multi-agency response to the presenting issues. This in turn may have uncovered further evidence of harmful behaviour traits associated with the adults. It may also have elicited more information from the children themselves about their lived experience. The absence of this process meant that the signs of neglect already evident were not shared. As Eileen Munro goes on to comment in her later document 9 Page 21, The Munro Review of Child Protection Interim Report: The Child’s Journey Professor Eileen Munro Crown Copyright 2011 31 there is a risk that ‘parents who are neglectful may become more harmful’10. 6.1.24. It is possible that Ms X would have refused such an intervention and as can be seen, particularly in the latter stages of her involvement with CSC, she not only begins to withdraw her minimal acceptance of services, she becomes unco-operative. E.g. Ms X fails to let the SW know her new address and Housing provided this. She did however at least on the surface engage (in so much as she generally attended meetings and appointments) with other agencies despite the fact that she was sometimes less than truthful about her lifestyle. She attended many meetings with school who attempted to assist her in improving the children’s attendance. 6.1.25. The agency that Ms X had the strongest relationship with was school and they rightly analyse this issue in their IMR and see it as a missed opportunity to work with the family in a more structured way. 6.2. Lack of dynamic assessment 6.2.1. When undertaking a serious case review it is important not only to understand what professionals did but also why they took the actions they did. A factor in this case is the way in which childcare professionals accepted the word of the adults without cross referencing this with other information available. 6.2.2. Ms X and Mr W were dishonest about their alcohol intake. Ms X was not truthful about her relationship with Mr R, telling professionals (Housing and Midwifery) that due to an incident of DV she no longer had any contact with him. This is in direct contrast to what Child B said in September who described her mother as having a strong relationship with Mr R. More conflicting information became particularly apparent from the end of August when separate pieces of information began to emerge. Examples include the anonymous referral in September which stated that the adults were ‘drinking all day’ and Ms X had ‘admitted to drinking’, and the police referral at the beginning of November where although not described as drunk Ms X was drinking alcohol in the street with Baby V aged two weeks. Further concerning information was received from LA2 CSC in relation to Mr W’s extensive history. 6.2.3. Adult services in turn had a more accurate picture of the extent of the adults’ alcohol use but for perhaps for some of the reasons stated in section 6.1 did not share the information with children’s services colleagues. 10 Page 25, The Munro Review of Child Protection Part One: A Systems Analysis Professor Eileen Munro Crown Copyright 2010 32 6.2.4. One of the most persistent and problematic tendencies in human cognition is a reluctance to revise an initial assessment of a situation. Once people have formed a view on what they believe is an accurate picture of a given situation, there is a tendency to dismiss later evidence to the contrary. As Eileen Munro has described it, ‘Becoming fixated on one assessment despite an emerging picture that conflicts with it becomes a significant source of cognitive error.’11 6.2.5. Opportunities to identify and assess the conflicting information were not used effectively. The CSC assessment stemming from the referral from MHS2 at the end of August lacked analysis and the report presented to the ICPC is a factual narrative of the presenting concerns with limited analysis included. Working Together 2015 (p.22) states that the aim of the Child Protection investigation is to “reach a judgement about the nature and level of needs and/or risks that the child may be facing within their family”. It would appear that no such meaningful judgement was made with the information available. The CSC IMR rightly concludes “professionals appeared optimistic about the mother’s abilities and intentions, misguided by her presentation and the fact that she had seemingly carried out her care of Baby V without any incident or notable concerns”. The optimism in my view is not just with regard to Ms X but also about all the adults responsible for the care of the children. 6.2.6. Many of the agencies that had had significant contact with the family throughout this review period did not attend the ICPC: The Housing Needs Officer, the Midwifery Service, the Health Visitor, MHS2, Ms X’s GP, Mr W’s GP, CDAS1 and most importantly the children, all had information to contribute but were not present. Ms X’s GP gave a verbal update to the SW prior to the conference and did not report any safeguarding concerns. A document was faxed to Mr W’s GP surgery but there was some confusion at the surgery as to what the document was and through the review it has been established that it was believed to be a set of incomplete conference minutes and as such they did not respond. It is not clear why this was not followed up with CSC to try to clarify the information. 6.2.7. In 2013 LA1 LSCB endorsed the model of ‘Strengthening Families’ for Child Protection Conferences. This is a strengths based model based on the work of Andrew Turnell who developed the risk assessment tools known as ‘Signs of Safety’. This model allows all those present to contribute to what they perceive the risks, strengths and protective factors are and these are openly discussed and displayed on whiteboard (or equivalent) during the meeting. Complicating factors and grey areas are also discussed and it is significant to note that the amount of alcohol the adults consumed 11 Page 53, A review of safety management literature, Eileen Munro, London School of Economics. SCIE 2008 33 was not listed as a grey area, nor was the question of how much time the respective fathers spent with the children and what the quality of that contact was. A more thorough assessment prior to the ICPC may have answered some of those questions but equally they were not posed by any of the professionals present. 6.2.8. It is possible that the professionals attached more significance than was warranted to positive information such as Ms X’s interaction with Baby V to the detriment of attaching more meaning to the worrying information. This is again a common flaw in human thinking and can be explained because “early cues strongly suggest [plausible but] incorrect answers, and later, usually weaker cues suggest answers that are correct’12 This coupled with the fact that significant information was missing from the complete picture led to insufficiently robust action by the multi-agency network. 6.2.9. Reflective Supervision is crucial when addressing cognitive issues. These types of erroneous thinking and decision making are unlikely to be recognised by the individuals themselves. The role of the manager is to provide an opportunity for reflective thinking and to challenge the worker to consider whether the assessment process has been sufficiently broad and robust. This is a challenge faced by health, social care and other professionals working in the field of safeguarding. (More is said on the subject of supervision in 6.6.) 6.3. The Voice of the Child 6.3.1. An important theme that arises from many SCRs is how well professionals ensured that children were at the centre of the service delivered. The child’s voice within any assessment or ongoing contact is important as it ensures that professionals understand the impact of issues on each individual child. The ultimate aim of the assessment is to improve outcomes and life chances for children. 6.3.2. The three children in the family came into contact with a range of services throughout the period under review and all had differing needs. In relation to Child U and Child B agencies’ contact was limited and as been said elsewhere the number of contacts for the children was considerably less than that of the adults. As the children presented with such differing needs there is a separate section for each one in turn. Child U 6.3.3. At the time of the death of Baby V Child U would have been 15 years and 6 months old. He was a year 11 student preparing to undertake his GCSEs. The education IMR prepared for this review 12 Page 53, A review of safety management literature, Eileen Munro, London School of Economics. SCIE 2008 34 details how he presented in school and it seems that the school and particular teachers had a positive relationship with him. The IMR also does however describe Child U as a child with low self esteem and little motivation with an unusual sleeping pattern which did not appear to have any explanation (i.e. he slept from 5pm and was awake from midnight onwards). The school provided him with an alternative provision which consisted of a small group of students and teachers. Within the unit he was supported in catching up with school work that he had missed, in a more nurturing environment. 6.3.4. A major feature covered by the education IMR was the chronic poor school attendance of both children which at times during the period covered was as low as 50%. No statutory action was taken in relation to the poor school attendance and although the school worked hard to maintain relationships with the children and Ms X this was to the detriment of the children’s need and right to education. Specifically in relation to Child U, there was a period of prolonged absence between May and June 2014, when due to an administrative error about how the absence had been recorded, he was not seen in school for a period of 28 days. This had implications regarding increased risk for both children. The education IMR is right to be concerned about this putting Child U ‘in an increasingly vulnerable position, which subsequently may have also minimised the perceived level of risk placed on Child B’s absence when she was absent during some of the same period of time’. 6.3.5. During the review period Child U was also seen by the family GP who made an hour long appointment to see the family to assess them prior to the ICPC. This was very good practice on behalf of the GP in terms of making the appointment and seeing the family altogether and she did offer the children the chance to be seen on their own but they declined. During the interview neither child disclosed anything remarkable but they were unlikely to do so given that mother was present. The information provided by the GP to the ICPC did not highlight any concerns and it would seem that Ms X was not challenged in relation to historical information about her past alcohol use or the children’s relationship with Mr W. It is however unlikely that this would have elicited more accurate information. 6.3.6. Child U was seen once by the SW from CSC during an assessment period that lasted from the beginning of September to the start of November. This is unacceptable as it would appear that when the case status changed from s17 to s47 enquiries in October Child U was not consulted separately about the particular concerns raised by the s47. In the interview the SW conducted with him it would appear that specific questions were not directly asked. This may have been due to the SW trying to get to know him first and from information contained in the CSC IMR he appeared reluctant to give any information about his life. Further opportunities to build a more 35 meaningful rapport did not present themselves and Child U was clear with the SW that he would prefer not to have further contact. 6.3.7. It is not clear if Child U was invited to the ICPC in his own right or if it was discussed whether, and if so how, he would like to participate but he was not present. His views were discussed at the conference and were based on his conversation with the SW. The views shared were around Child U’s worries about their financial situation and the fact that he was worried about housing and where they would live. Appropriate significance was attached to these concerns being beyond what a fifteen year old boy should be concerned about but the truth of his lived experience was largely unknown at that stage. Child U was seen twice by the new SW after the ICPC but there was little time before the death of Baby V to attempt to build a relationship. This has been rectified since and the children’s grandparents reported that the children enjoyed a positive relationship with their social workers through the care proceedings. 6.3.8. In the period under review save the time he spent in school Child U was seen only four times by other professionals and only one of these was on his own. As has been discussed elsewhere in the report earlier opportunities to assess Child U’s needs in a more structured way via Early Help were missed and therefore the extent of the neglect he suffered went undetected. Child B 6.3.9. Child B was 13 years and 8 months old at the time of the incident. She had more contact with professionals largely due to her mental health difficulties and subsequent involvement with MHS2. She was also more open about her feelings than Child U. Although the referral took several months to come to fruition, once established regular appointments were offered. Sadly not all of these were taken up for various reasons but there was some targeted intervention to try and assist Child B with her anxieties. 6.3.10. At the first appointment with MHS2 Child B’s description of her experience with Mr W resulted in them making the referral, which led to the CSC involvement. The referral was delayed but it did indicate that the service had taken her statements seriously and that they had listened to her concerns appropriately linking her distress with his arrival in the family home. The service continued to attempt to work with her but there was an inconsistent pattern of attendance and apart from four appointments that were attended in September attendance was sporadic. It is significant to note that no further appointments were attended in August after the referral was made to CSC and there was a gap of at least 7 weeks between September and the last appointment before the death of Baby V on the 21st November. It is not clear if or how the lack of attendance was communicated to CSC who by mid October were conducting s47 36 enquiries and by mid November had made the children subject to CPPs. 6.3.11. As with Child U the school had a positive relationship with Child B and facilitated the referral to MHS2 when she made her disclosures about hearing voices. School made every effort to support Child B whilst the referral to MHS2 was in the offing and made a further referral when her mental health appeared to deteriorate. Again as with Child U, Child B was able to make use of the special unit (alternative provision) and there is no doubt that she benefitted from the extra support they were able to offer. The lessons to be learned in terms of her poor attendance are echoed from the previous section concerning Child U. 6.3.12. Child B was seen twice by the SW who completed the C&F assessment but again was not consulted separately about the concerns raised via the s47 enquiries. The SW engaged her in some Direct Work and the information gathered was shared at the ICPC but Child B and Child U were anxious about the conference and would have benefitted from greater preparation for the meeting and being able to participate more fully. Baby V 6.3.13. Ensuring that the voice of the child is assessed and analysed becomes trickier when the child is preverbal as was the case with Baby V. As has been discussed opportunities to assess Baby V prior to his birth were not taken and opportunities after he was born were few and far between. In situations where children are not verbal professionals rely on other cues such as observations, eye contact and physical contact between parent and baby. Further in the case of a newborn baby professionals may also consider whether or not they were planned and what preparations had been made for their birth. Parents’ lifestyles may also be assessed and as we have seen there were such gaps in the information known that these did not have as much bearing as they might have done. Two health visitors made encouraging observations of Ms X and Baby V, and no concerns were noted by hospital midwifery staff in the days following his birth, further reinforcing the positive aspects of Ms X’s parenting. 6.3.14. Assessments were completed by CSC, Midwifery, Health Visiting Services and police (on one occasion) but were cursory in terms of the impact of the parents’ lifestyle on the needs of a new born baby. 6.4.15 The child’s voice is missing from the referral from the Midwife in April as it details the need for support for Ms X and Mr W but does not specifically mention the needs or risk of harm to Baby V as an unborn child. 37 6.4.16 Other adults may also try and speak on behalf of the child or children by expressing concerns – this can be said of the anonymous referral received by CSC at the beginning of September but the concerns were not specifically addressed with any of the children prior to the ICPC. 6.4.17 The ICPC itself was mostly silent in relation to Baby V and his lived experience and there was further scope within the conference to be much more specific about the incompatibility of parents who are heavily reliant on alcohol and being able to meet the emotional and physical needs of an infant. More focused outcomes in relation to the baby may have been beneficial for him and indeed for the older two children. 7. ANALYSIS FROM THE IMRs Introduction The IMRs reviewed by the panel in relation to this review were all accepted by the panel and were generally of good quality. A training event was held at the beginning of the SCR process where the authors were given guidance on what information to include in their reports. The authors were invited to complete a first draft on a specific template which was reviewed by the panel. This was followed by a presentation by each author at an extraordinary panel where authors were given feedback and asked to amend their reports. The IMRs contain relevant details about the particular issues to be addressed from the ToR and these have been commented on where necessary either drawing on them directly or the author drawing conclusions obtained in the process of pulling the review together. These are mainly points where the author particularly agrees or disagrees with the conclusions reached by the various agencies. Other points have been made where issues were particularly significant. Where these have already been commented on at length the section refers the reader to the relevant section. 7.1. Were established policies and procedures well understood and followed? 7.1.1. All agencies referred to appropriate policies and procedures being in place and generally followed and where they were not followed agencies have endeavoured to correct these well before the publication of this review. For example Housing have changed their policy on attending Child Protection Conferences and will now always try to keep families who are subject to CP procedures remaining in their home borough. Education note that their Missing from Education policy was not adhered to in the first half of 2014 but this has been rectified by the latter half of the year. 38 7.1.2. There are a few exceptions regarding procedures that had implications for the way in which the case was dealt with. The MHS2 referral in relation to Child B at the end of August was delayed by some three weeks. The reason for this was due first of all to waiting for consent from Ms X. Whilst it is good practice to inform the parent of a referral it is not necessary to gain consent for a CP referral and this caused an unnecessary delay as Ms X proved difficult to get hold of. It has become clearer through the process of the review that she became more avoidant of MHS2 after Child B’s disclosures particularly in August. 7.1.3. The second reason was due to difficulties in accessing LA1’s on line referral form which was experiencing technical problems. Although it is recorded by the worker that the system was down, and they had attempted on several occasions to make the referral it is not clear why an alternative method (phone, email, letter) was not considered sooner. The London Child Protection Procedures are clear that once a concern has been identified the referral should be made ‘not longer than within one working day’ (1.5.7 p22). This practice falls short of acceptable standards due to the serious nature of the concerns that were disclosed by Child B. This was then exacerbated by the tardiness of CSC in establishing the reasons behind Mr W’s non-contact with his son, which were not confirmed until the beginning of November. 7.1.4. It is also worthy of note that the MHS2 referral took 8 months to come to fruition and for Child B to be seen. The author understands that the referral passed through the appropriate channels and that this length of time from referral to assessment was not unusual. NB Separate to this process a review of MHS2 has been undertaken and a plan is in now in place, which will be managed through the local relevant Partnership covering children and their families. As part of this plan, a significant uplift in resources is being made available to MHS2 over two years to improve access times for children and young people within LA1, with the impact of this work starting in 2015-16. 7.1.5. Local Health Services failed to keep the issue of Ms X and her alcohol use under review throughout her pregnancy. Although it is unlikely that this line of questioning would have elicited a different response other than she had given up it would have kept the issue on the agenda. This was important as she had not accessed help or support for it and this could have been routinely offered through the services of the CDAS2. Hospital 3’s IMR rightly points out that ‘this was not done and therefore, a robust approach to monitoring Ms X's alcohol consumption was missing throughout the pregnancy’ 39 7.1.6. It is unfortunate that on the day of the crisis (28th November) following Ms X’s disappearance with Baby V a series of misinformation and other events prevented more urgent action from being taken. 7.1.7. The HV called to see the family for a pre-arranged appointment but was told by Child U that his mother had left for LA4 the evening before and had not returned. The HV was not concerned about Child U being on his own as rightly he was at an age where this would not be a problem. However it overlooked the safeguarding concern that two children under the age of 16 who were the subject of CP plans due to neglect, had been left alone overnight. No action was taken and on reflection there has been an acknowledgement that it would have been good practice to have made contact with the social worker to inform her of this. Further exploration of the children’s circumstances by the HV and more professional curiosity about the whereabouts of Ms X and why she had not returned may have alerted other agencies sooner that something was amiss. 7.1.8. Child U and Child B were then contacted by the school and made their way there. They arrived at school at about midday and according to school records Child U became distraught and disclosed that their mother had been drinking heavily and had left with Baby V the evening before and had not returned. The children were extremely upset and the school’s attitude and approach to ensuring they were looked after including feeding them was exemplary. The school made several attempts to contact Ms X via Mr W’s mobile phone but to no avail (they had the wrong number for Mr W) and it was not until 3.30 that the first call was made to the police. The immediacy of needing to ensure the safety of the baby was overlooked. A further call was made to the SW at 4pm. School had also attempted to contact the children’s grandfather who was also not contactable straight away. He did however respond as soon as he was able and acted appropriately. 7.1.9. When the police became aware of the situation they responded straight away but were dispatched to the wrong address because of an error in the information held by both the MGF and CSC. The police did not arrive at the address until the following morning after the ambulance had been called. This matter is subject to an investigation by the Police’s Professional Standards Unit so what can be said in this review is limited by that. 40 7.2. Were appropriate and robust assessments, including risk assessments carried out in view of the parents’ historic involvement with agencies, and ongoing issues with alcohol and substance misuse, and Baby V’s father’s previous involvement with social care? 7.2.1. Much of this subject has been covered in section in 6.1 and 6.3 but other analysis is also worthy of note in this section. 7.2.2. Many of the agencies conducted assessments throughout this period and with the exception of CSC all were carried out in isolation without consultation with other agencies. This meant that none of the agencies had a holistic picture of the family and their day to day lives. The CSC assessment was lacking information from adult services for the reasons discussed in section 6.1. 7.2.3. As discussed in section 6.2 there were missed opportunities to initiate the CAF process which would have brought together at least some of this information much earlier in the year leading up to the death of Baby V. 7.2.4. School missed an opportunity to formally assess Child U and Child B’s lack of school attendance under statutory regulations despite their attendance being well below the threshold (the threshold being 85% and their attendance for significant periods was as low as 50%) where statutory intervention would apply. Although much support was offered to the family by the school the rationale for not considering referring to the LA was to try and maintain a relationship with Ms X and not further alienate her. 7.2.5. Unfortunately the support offered did not improve the children’s attendance to a satisfactory level and as current guidance indicates should have been considered more robustly as per the Education (Pupil Registration) Regulations 2006, therefore triggering a Criminal Investigation by the Local Authority. The IMR provided by Education makes this point well, stating that ‘Prosecution is only one of a variety of outcomes of an investigation, and will not be considered if it is evident where a family has unmet needs that would benefit from further support from professionals’. Further support may have then been offered in the form of an Early Intervention Support Plan. The added benefit of an investigation of this nature would have been in the gathering of information from a range of other sources as well as more targeted help with getting the children to school. The school nurse would have been one such professional to have contributed to a more multi-agency approach to consider any health problems the children may have had. 41 7.2.6. In their IMRs mental health services (children and adults) refer to risk assessments carried out in their agencies. These are internal assessments and were not shared with, or completed with, information from other agencies. There may well be fundamental cultural and organisational differences in the term ‘Risk Assessment’ with its meaning between agencies at considerable variance in terms of the types of information that make up an assessment of this kind. In a review of effective approaches to risk assessment Dr. Monica Barry states that “differing organisational cultures, differing definitions of risk and a hierarchy of professional expertise may deter the development of a common understanding and language of risk”13 7.2.7. As discussed elsewhere in the report a fundamental difficulty with many of the assessments was either the lack of knowledge of the history of the adults or the failure to place it in the context of an overall assessment. A further example of this is the assessment made by GP Practice 2 who concluded after an hour appointment with Ms X, child U and Child B prior to the ICPC that there were no safeguarding concerns. Although this thoroughness was very commendable and more proactive than most GPs are usually able to be, it failed to take into consideration the history held on record by the surgery re Ms X and added weight to the notion that alcohol was not a current problem for her. 7.2.8. Mr W’s GP failed to make the connection between the unborn baby and Mr W by not exploring this issue further when the information presented itself in March 2014. This was further compounded by confusion over the receipt of information about the ICPC. The result of this was that no risk assessment was made on receipt of this information and no contact re Mr W and the children was made between the practice and CSC to inform the ICPC. 7.2.9. The drug and alcohol agency CDAS1 took over the services previously provided by another provider from the 1st October 2014. On advice from the SW and to demonstrate compliance with the Written Agreement Ms X and Mr W presented themselves to that agency on the 20th October but were not fully assessed. This was due to the fact that there had not been a formal referral at that point from the social worker. The parents presented denying any misuse or abuse of alcohol and the referral from the social worker with supporting information was made the following day. Ms X was then 13 Page iv Effective Approaches to risk assessment in social work: An International Literature Review: Dr. Monica Barry Social Work Research Centre University of Stirling (2007) 42 offered a triage appointment which took place towards the end of November (3 days prior to the death of Baby V). Again Ms X denied any problematic alcohol use and nothing in the appointment alerted the worker to think otherwise, perhaps compounding the view further that Ms X’s alcohol use was under control. 7.2.10. A common feature of all the assessments examined as part of this review is that they lacked the professional curiosity described by Lord Laming (2009)14. The importance of ‘respectful challenge’ of parents, colleagues and professional in other agencies, needs to be an integral part of professional practice. Pertinent issues were identified in all of them and this is to be commended but there was limited on-going challenge of the presenting vs. the emerging picture. Much has been said already in this review about the use of supervision which is also integral (see section 7.6) 7.3. Did professionals have sufficient understanding of how cases of alcohol misuse may present? How was this addressed and the possible impact on the parents and children considered? 7.3.1. This subject is covered extensively in section 6.1 7.4. Did professionals have sufficient understanding of how cases of neglect may present? How was this addressed and the possible impact on the parents and children considered? 7.4.1. Much of this has been covered in section 6.2 when considering issues about Early Intervention but other issues should be noted in this section. 7.4.2. The Health Overview Report (HOR) rightly makes the point about the needs of Baby V as an unborn child. There is no evidence to suggest that there was consideration of the impact of Ms X’s alcohol consumption on foetal development or the risks associated with safe care and breastfeeding. 7.4.3. The midwife who booked the ante-natal care did make the referral to CSC in April 2014 but the issues were not explicitly stated and the referral requested ‘support’ for Ms X in her alcohol consumption and mental health. There was no follow up communication between the midwife and CSC which would have further verified the concern and helped clarify the way forward. According to CSC workers who were consulted as part of this review the volume of referrals received simply does not permit follow up for this type of (as perceived) low 14 The Victoria Climbie Inquiry, 2009 43 level referral. The issue of alcohol and smoking cigarettes was not addressed again through the pregnancy. 7.4.4. There was no challenge to CSC’s decision not to pursue an assessment but the issues identified did not disappear. This serves as a reminder that referring concerns to another agency does not discharge agencies’ safeguarding responsibilities. The referral would have benefitted from being discussed between agencies and if no resolution at that stage could be reached about the best way forward escalated to senior managers to resolve. 7.4.5. The review also highlights the challenges of working with teenagers suffering neglect and it is surprising in many ways that Child U and Child B did not come to the attention of statutory services sooner. As mentioned previously the CAF process may have assisted in this case but it would appear that when the children were spoken to they (unsurprisingly) remained loyal to their mother and father. 7.4.6. The difficulties of assessing neglected children are well documented (Reder and Duncan (2004). They may be silent, have no expectations that their needs will be met and, despite their suffering will remain loyal to their parents. Child B’s disclosures to MHS2 were entirely in relation to Mr W – an adult she felt no loyalty to and resented the presence of, but there were no such disclosures regarding either of her parents despite their turbulent and neglectful behaviour. Child U similarly does not disclose problems at home other than worrying about their housing and financial situation. 7.4.7. There are indications that despite the difficulties there were aspects of good parenting and both children are described as polite and respectful. This is perhaps another reason professionals did not realise the extent of the problems within the home. Children displaying more problematic behaviour are more likely to come to the attention of statutory services sooner. 7.5. To what extent was the relationship between any of the parents explored by professionals. 7.5.1 A feature of this case was the uncertain nature of the relationship between all of the adults. Some of the history is known through the information collected by the social worker for the assessment and s47 enquiries but information about the current situation from the family was sketchy and not always completely accurate. Information shared between professionals about the extent of the contact between all three adults was also sketchy and was underlined by a 44 lack of curiosity about the relationships. The result was that no one agency had a complete picture. 7.5.2 Information and therefore assessment about the men in particular was weakened by the fact that neither of them lived permanently in the family home. Their extensive contact and influence was overlooked. 7.5.3. This reflects a previously considered topic in SCRs (including a recent LA1 one) about practitioners failing to assess the impact of men who have significant involvement in children’s lives. Much has already been said about how little was known about the two men. Turney et al (2011) says it succinctly: ‘Professional vigilance is necessary to ensure that information about fathers is available whenever possible, especially as fathers may exert a considerable influence even when they are not living with their children’15 7.5.4. Furthermore in this family the impact of all three adults’ lives being heavily dominated by alcohol, associated mental health problems and domestic abuse was underestimated. The dynamics of having all three of them together in the household (referred to on at least one occasion by Child B) was not considered. 7.6. Management oversight and supervision 7.6.1. Many of the IMRs are silent on the issue of supervision as they do not generally describe the supervision process and its impact on how the case developed and how decisions were made. 7.6.2. There are also discrepancies in agencies about the expectations of supervision in a safeguarding context. For example in some agencies such as the Health Service, health visiting and midwifery the volume of cases means that not every case is discussed in supervision and it is the responsibility of the practitioner to flag up those that need specialist attention. There is an expectation that cases where children are subject to CP plans would always be presented but this does not preclude practitioners discussing other cases of concern. This did not happen in either of these services despite the referral to CSC having been made in April 2014 and their subsequent involvement from August 2014. 15 Social work assessment of Children in need: what do we know? Messages from research: Turney et al DFE 2011 45 7.6.3. The HV in LA3 did take the case to supervision as the case had been presented to ICPC (albeit in another borough). Not much detail is given about the content of that other than to say that the HV plan (which was appropriate) was to visit fortnightly. It was also fortuitous that the supervisor in this case was familiar with the family as she had attended the ICPC on behalf of the HV. 7.6.4. The review also highlights the lack of safeguarding supervision for schools and GPs who deal with children at risk on a regular basis. 7.6.5. The CSC IMR analyses this issue effectively by asserting that the supervision conducted about this case summarised the concerns clearly but did not act as a catalyst to move the case on and revise current thinking. The author goes on to describe the likely organisational context in which this happened such as the high pressured environment in which practitioners work, high caseloads and raised thresholds. The extent of this has not been confirmed for this review but it was noted in the SCR panel that a recent audit of LA1’s MASH arrangements found that thresholds were in line with the London Continuum of Need Threshold document. 7.6.6. The review has found that not enough attention was given to the supervision process in any agency given the complexities of this family situation. 8. CONTRIBUTION FROM THE FAMILY Maternal Grandparents 8.1. The maternal grandparents (MGP) were interviewed as part of the review and were open and honest about the events leading up to the death of Baby V. They were informative and considered in the information they gave and were happy to contribute. 8.2. The MGPs felt that there had been a big build up to Ms X becoming very stressed and very low which as far as they could tell began in late 2013 when she was threatened with eviction. They said that some of the information about this is incorrectly stated in reports and that the impending eviction was not due to rent arrears (as depicted in some agencies records) but because the landlord wanted the property back. Ms X did not have the money for a deposit for a new property hence her seeking assistance from Housing in LA1. 46 8.3. In terms of services offered to the family they felt very strongly that Housing should have offered the family accommodation which would have enabled them to remain in the LA1 area. They felt the move to LA3 had contributed to Ms X feeling low as the accommodation was so far away the family lost their support network. The move made life very difficult as the children now had a long journey to school, Child U was very upset about the fact that he could not take the family dogs and Ms X was isolated from her family. They all missed the familiarity of their previous surroundings. 8.4. The MGPs also felt that it was difficult to liaise with professionals such as CSC Emergency Duty Services (EDS) and the police on the night that their daughter was missing (28th November). They stated that they had expected a visit from the police that evening but they didn’t visit and they rang EDS and were told that someone would ring them back which they did not. They were naturally very worried about their daughter and grandson and were unable to glean information from agencies about the progress of any enquiries to determine their whereabouts. They did however also comment that services had been ‘brilliant’ since the death of their grandson, particularly school, CSC and the police. 8.5. The MGPs commented that their daughter had a very loving relationship with all her children but treated them more like friends. They thought that this might be one of the reasons why she struggled to get Child U and Child B to school as sometimes when they refused to go she found it hard to display the necessary firmness to get them up out of bed and to school. The MGPs appreciated everything that school had done for them and were continuing to do so whilst the children were with them. Ms X and Mr W 8.6. Ms X and Mr W were interviewed together by the overview author together with the LSCB Manager and at the time of writing the report they had lived together in rented accommodation virtually since the time of their release from prison. 8.7. Their overwhelming sense of sadness at the loss of their baby was very evident and it is to their credit that they offered their views to the review at such a difficult time. 8.8. Both Ms X and Mr W felt that they needed to raise the fact that they felt services had made them out to be much worse than they were 47 and also felt that they had been maligned in a way that was neither accurate nor fair, particularly during the care proceedings initiated by CSC. For example they disputed the fact that the children ever went to school looking unkempt and stated that Ms X always made every effort to get them to school. Ms X acknowledged that she sometimes treated Child U and Child B more like her siblings than her children and despite her best efforts she could not get them to school if they did not wish to go. She recounted the various meetings that had been held with school to try to improve their attendance but nothing worked and she could not suggest anything different that could have been done at the time to assist further. 8.9. School and MHS2 had tried to help with Child B’s behavioural difficulties but this was also to no avail – again she could not think of any other services that could have been offered or that services could have done more to help her or the children in this respect. They both acknowledged the difficult relationship between Mr W and the children, especially Child B. They felt this was caused by jealousy and that when Mr W had twisted her arm behind her back this was in self defence as they advised that Child B had jumped on Mr W to assault him. Ms X advised that she had told Mr W that it was inappropriate to kiss the Child B’s self-harm scars and they both dismissed the account of having held Child U up by the neck as untrue and malicious. 8.10. In terms of their housing situation at the end of October when the family were evicted they both felt (as did the MGPs) that placing them outside the borough put undue pressure on the household and that life became very burdensome after this move. The children would not go to school unless Ms X drove them in the car, which with a tiny baby and a car that was parked some distance away from the accommodation (due to parking restrictions), proved almost impossible. 8.11. In relation to their drinking Mr W acknowledged that his drinking at one time was problematic and that he had spent considerable time in rehabilitation centres. He did however gain control of his drinking and prior to meeting Ms X in 2013 he had been abstinent for 3 years. He became an AA sponsor and was part of AA’s management team using his experience to help other problem drinkers turn their lives around. One person he sponsored was a family friend of Ms X and the couple met through her. He turned to drink again due to the stress of his living situation but claimed that it was under control during pregnancy with Baby V. 48 8.12. Ms X said that her drinking was never problematic and that she never drank or smoked in front of the children, and therefore she did not require any help to curtail it. However, she did advise of having an addictive personality. 8.13. On the night in question before Ms X realised that Baby V had died she had every intention of going back to the accommodation in the morning to take the older children to school. She did not think it was a problem to leave them on their own due to their ages and the fact that Child U in particular was very sensible. She acknowledged that she had been drinking (two drinks) before she left but was still able to care for the baby. When she realised that Baby V had passed away she was too distressed to leave him and could not return to the flat. The parents feel very strongly that it was nobody’s fault that Baby V died and there were no services that could have prevented it. 9. LESSONS LEARNED FROM THE REVIEW Better use of early help and intervention 9.1. Children are much more likely to have a positive outcome if their difficulties are recognised at an early stage and they receive help. The importance of early intervention processes that are understood and owned by all agencies are crucial. Early signs of neglect were not shared between professionals because no use was made of the current mechanism for doing so e.g. a CAF assessment. Individual agencies offered a range of support to the children but the extent of their neglect went unchecked. As has been said teenagers who are neglected can be particularly difficult to engage but a multi-agency approach would have had the advantage of considering the forms of help available and who was best placed to provide this. The role of supervision for all agencies 9.2. The review highlights the necessity of good reflective supervision and management scrutiny in all agencies to minimise the effect of common cognitive errors which practitioners need assistance with. The role of managers to stand back and help practitioners unpick and fully appreciate the complexities of a situation was missing. This is particularly prevalent in families such as this where the issues are multi-faceted and complex. 49 Assessment and impact of males in families 9.3. Fathers and other significant males can be very influential in families and as such there is need for all agencies to ensure that relevant information about them is collected during the assessment process and kept under review. Very little information was known or considered about either of the fathers in this family particularly in relation to their role as carers, how their difficulties with alcohol and its associated problems impacted on the children and how the dynamic between all the adults influenced the day to day lives of the children. Professionals should take time in establishing the role of fathers and other significant males who have frequent contact with children, to assess the meaning of their presence in children’s lives. Mr R was not engaged as part of the s47 enquiries, did not attend the CPC and the information about his hospital admissions was not followed up. Follow up about Mr W and his lack of contact with his other son was not treated as a priority. Exchange of information between agencies 9.4. In an assessment process the exchange of information between agencies is crucial. Poor exchange of information is likely to result in a flawed assessment and in this case the exchange of information between Adult Services and Children’s Services was distinctly lacking. The needs of the adults in this family were overwhelming and their needs dominated contacts with agencies. The review has highlighted the need for Adult Services to ‘think family’. This problem was exacerbated by the myriad of services accessed by the adults that crossed several other areas, hospital trusts and GP practices. Assessing neglect and the impact of alcohol misuse 9.5. Children suffering neglect are likely to remain loyal to their parents and as such in the light of a lack of clear disclosures professionals should be alert to other signs of neglect and assess accordingly. There was insufficient exploration or appreciation of the day to day experiences of Child U and Child B and the likely impact on development and life chances. There was uncertainty among professionals about the level of alcohol use by each of the adults, the extent to which each of them prioritised alcohol and what amount of alcohol would be problematic in parenting adequately. The net effect of this was no shared assessment of risk about these issues was completed. 50 10. RECOMMENDATIONS FROM THIS OVERVIEW REPORT These should be read in conjunction with the recommendations from IMRs detailed in Appendix 1. LSCB 10.1. LSCB to review and report on the effectiveness of Early Intervention in enabling front-line professionals to provide early help to vulnerable families. 10.2. LSCB to review its learning programme to ensure it includes multi agency training on children living with parents who have complex needs including substance or alcohol misuse, DV and mental health difficulties 10.3. The LSCB via the Section 11 process should require all agencies to report on the effectiveness of their supervision and management processes in ensuring that the work of front-line professionals is scrutinised and challenged. 10.4. In disseminating the learning from this review LSCB should remind all agencies of their safeguarding responsibilities and the need to be child focused when dealing with adults with complex difficulties. 10.5. LSCB to ensure, and review if necessary, that the current method of conducting Child Protection Conferences is sufficiently robust i.e. child centred, outcome focused and well understood by all agencies. 10.6. That all partner agencies should satisfy LSCB that assessment processes and ongoing work with families ensures the effective consideration of significant males in children’s lives. This should not be limited to males who live within households but should include fathers, stepfathers, partners and family friends even where they do not reside with children. 10.7. LSCB to ensure that the commissioning arrangements for assessing parents and carers who have problematic drug and alcohol use are in place and that there is a clear pathway to accessing services for families. 10.8. Relevant learning from this review should be shared with the appropriate LSCBs from the various LAs involved in this review. Independent Social Work Consultant July 2015 51 Appendix 1 Recommendations from IMRs These recommendations have been taken from the agencies IMRs and have been accepted by the panel Children’s Social Care CSC to take steps to understand the barriers to implementing learning from serious case reviews and develop a strategy to address any barriers identified Review the current links and work with maternity services to develop a pre-birth referral pathway Review the management oversight of No Further Action contacts within the MASH CSC should ensure that practitioners receive effective supervision which enables them to reflect critically on factors that may be impacting on their practice, including workload concerns, personal biases and intuitive responses CSC should review the current caseloads of Social Workers in the assessment service to ensure Social Workers have manageable caseloads, so they can spend more time with children, young people and families CSC to review staff development programmes and ensure that they include support for practitioners in developing and sustaining skills for working with avoidant families Training and assessment tools on the effects of alcohol abuse on parenting to be available to practitioners, to enable them to understand how they can address this issue without reliance on specialist agencies Consideration to be given to how to work most effectively with fathers and improve their engagement in the assessment process CSC should ensure processes are in place for monitoring the effectiveness of supervision. These should evaluate the appropriateness of case allocation, the quality and impact of supervision on case planning, and management oversight in individual cases. Education The school to access training and support from their Early Help Advisor and the Early Help Co-ordinator. The focus of the training should be around the use of the Early Help Assessment, The London Continuum of Need, and conversations with parents around the Early Help Assessment and how to undertake EHA’s. There should also be an increased understanding of the Team around the Family. There is an expectation that Heads of Year, the Student Support Team and the Deputy Head teacher attend this training. 52 The school to access training and support from their Education Safeguarding and Investigations Officer in relation to the staged approach to poor school attendance. This should lead to the school making requests for statutory intervention from the Local Authority in relation to children whose attendance hits the threshold for intervention. The threshold for intervention is any child whose attendance is below 80% and has recorded 20 or more unauthorised absences in the last 12 school weeks. The school to review its policy and procedures around record keeping to ensure all records of contacts made with children and their parent/carer(s) around issues such as child protection, safeguarding and poor attendance meet local and national guidance. The school to discuss children with high levels of absence due to illness with their allocated School Nurse. Discussions to be recorded in line with Recommendation 3, including agreed actions. (Joint Action with the School Health Service). GP Practice – Practice 1 The authors to contact the Safeguarding Lead at NHS England to share the report, and request a review of GP patient medical record systems. Moving to an electronic/web based system for all GP practices, to facilitate electronic transfer of records to avoid delay. Practice 2 should introduce a system for receipt of child protection conference paperwork to ensure it is reviewed by the Safeguarding lead for the practice and alerts added to the parent’s records. GP Practice – Practice 2 The aims of these recommendations are firstly; to improve the systems of communicating with other safeguarding agencies and secondly, to ensure that all practices in the local areas have the opportunity to learn the lessons from cases. Nearly all GP practices would be well served from developing systems and knowledge as a collective team. 1. NHS England Local Area Team should write to the GP2GP electronic notes transfer team, explaining the benefit of allowing all patients notes to be transferred electronically. This communication should include a brief summary of this case and ask for a risk assessment to be completed around the issue. 2. Local CCGs and NHS England should advise GP Practices to develop their policies and procedures to include compliance against the 2014 RCGP Safeguarding Toolkit self assessment audits (Chapter 5). 53 3. Professionals communication systems which relate to safeguarding children should be reviewed, specifically looking to ensure that: GPs are proactive in gathering relevant detailed information when completing a safeguarding report. Safeguarding information that is communicated by GPs to children’s social care should be confirmed in writing. GP practices should be advised to develop robust systems for processing child protection/child in need requests and reports in order to ensure that these are completed within timeframes and that there is satisfactory documentation within records. Police Service The actions taken by police between 28 and 29 November 2014 to identify the whereabouts of Ms X and Baby V for the purposes of a welfare check are subject to an ongoing internal DPS inquiry. It is expected that the pathologist will, in his post mortem report, provide comment on the length of time Baby V was assessed to have been dead prior to the attendance of the LAS. This may be of significance to the DPS inquiry. The DPS inquiry may identify recommendations that would have impacted on this IMR. However, the enquiry is not expected to conclude for many months. There are no recommendations to be made in respect of all other police contact with the subjects and family at the time of submission of this IMR to the SCR Review Panel. PS will ensure that any relevant information or actions from the current DPS enquiry will be reported to the LSCB on its conclusion. Housing The Housing Department will ensure that they attend all Child Protection Conferences where families have a housing need. Housing will change their policy in relation to families where there are child protection concerns and wherever possible place them in borough (except in cases where it is deemed beneficial for the family to be placed out of borough.) MHS MHS2 to conduct a Clinical Audit of case notes to determine if letters to GPs following the initial assessment are sent in a timely fashion and include adequate information about the family composition and family history of mental illness and substance misuse. 54 Teaching session for staff responsible for the initial assessment of children on the importance of family history of mental illness and family composition to be organised in MHS2. MHS1 NHS Foundation Trust Named Nurse for Safeguarding Children to review Level 3 training in MAP and design training session to highlight the importance of communication of AMHS with MHS2 and Social Care when safeguarding issues are identified in adult service users. Health Service The new process within Health Services is that on completion of the IMR, the author will visit the services involved and discuss the findings pertinent to their agency and ask for suggestions on how they will redress the issues highlighted. Hospital 2’s NHS Foundation Trust LA3 Health Visiting team to review the way in which they deal with and record communications from other agencies/teams. More robust and timely communication from agencies where there are child protection and safeguarding concerns when transferring care to another borough. Review the process of families of concern being housed in another borough, particularly where child protection concerns exist. MHS3 It is recommended that the Psychiatric Liaison Team at A&E and the Psychiatric Inpatient Services, with support from the Safeguarding Children Team, review their documentation and arrangements to prompt staff to gather information about children in contact with adult service users, to discuss concerns with managers / psychiatrists and to consider when to seek or share information about children with other agencies. Health Overview Report Recommendation 1 Consideration must be given to improving communication links between GPs and health visitors. This will need to take into account the capacity of the relevant professionals and require a creative approach to finding a suitable solution. (This will be discussed with commissioners in light of the 2015-16 NHS HV Core Service Specification requirements for an HV to be linked to each GP). 55 Recommendation 2 The quality and standard of referrals into MASH should be included in the multiagency audit programme. If findings identify that there are issues of concern, consideration must be given as to how this can be addressed across the health economy and the partnership if required. Recommendation 3 All local health agencies must ensure that practitioners are aware of alternative referral process into MASH when the on line referral fails. Recommendation 4 Consideration must be given to how health professionals can develop their understanding of the complex nature of alcohol abuse and the consequential impact on parenting capacity. This may be through a learning and development programme but should also include the development of relationships with expert practitioners working in alcohol misuse services in order to seek advice and support. Recommendation 5 Health service providers should review their systems for transferring information particularly across borders in order to ensure that there are no gaps in communication and the sharing of identified risks. (GP authors have made their own recommendations re transfer of GP records). Recommendation 6 The multi-agency partnership should consider how information is shared or requested by children’s social care in order to promote a culture of collaborative working and shared responsibility, providing timely opportunity for all professionals working with families to contribute to child protection and safeguarding processes. Recommendation 7 All GP practices should be reminded of the need to link patients who are family members and to ensure that cases of concern are identified through the appropriate use of read codes. 56 Appendix 2 ACRONYM MEANING A&E Accident and Emergency AA Alcoholics Anonymous AS Ambulance Service CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Service CCG Clinical Commissioning Group CP Child Protection CPP Child Protection Plan CSC Children’s Social Care DV Domestic Violence EI Early Intervention GP General Practitioner HNO Housing Needs Officer HOR Health Overview Report HV Health Visitor ICPC Initial Child Protection Conference IMR Independent Management Review LA Local Authority LSCB Local Safeguarding Children Board MASH Multi Agency Safeguarding Hub MDT Multi Disciplinary Team MGPs Maternal Grandparents MH Mental Health NFA No Further Action PMHT Perinatal Mental Health Team SCR Serious Case Review SW Social Worker WA Written Agreement WT Working Together to Safeguard Children |
NC52550 | In May 2020, police were alerted to female aged 13-years-old, sitting on the 'fall side' of a multi-story car park; it was established that she had been experiencing mental health problems for some months that escalated into suicidal thoughts and expressed intent. Recommendations include: safeguarding children partnerships should clarify its expectations of agency reports and chronologies for a CSPR and take steps to meet any need that emerge from its deliberations, for enhanced briefing or training; seek confirmation from local agencies that there exists sufficient clarity, agreement and confidence to discern apparent/suspected professional malpractice; the respective functions within and content and the inter-relationship of all records maintained, by the child & adolescent mental health service; evaluate the extent to which the care plan and its implementation, complied/complies with requirements and expectations of the Children Act 1989 and statutory and non-statutory guidance; ensure that in what is understood to be a current transition to a new information technology/service user database, that policies and procedure for 'locking down' material in prescribed circumstances do not have the unintended consequence of denying access to key information to subsequent operational staff, or those seeking to review service delivery; should review the extent to which pre-existing information and/or supervision records offered the possibility of earlier detection of questionable conduct; and schools should develop and introduce guidance with respect to the nature and quantity of pastoral records that are maintained by local schools.
| Title: Child safeguarding practice review (CSPR): ‘C85’. LSCB: Torbay Safeguarding Children Partnership Author: Fergus Smith Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CAE 1 TORBAY SAFEGUARDING CHILDREN PARTNERSHIP CHILD SAFEGUARDING PRACTICE REVIEW (CSPR) ‘C85’ FERGUS SMITH 31.08.21. CAE 2 1 INTRODUCTION 1.1 TRIGGER FOR CASE REVIEW 1.1.1 In late May 2020, Police were alerted to ‘C85’, a White British female aged 13, sitting on the ‘fall side’ of a multi-story car park. It was established that C85 had been experiencing mental health problems for some months. These had initially been described as an eating disorder though later escalated into suicidal thoughts and expressed intent. Attending officers exercised ‘Powers of Protection’ (s.46 Children Act 1989) and C85 was returned home. In June 2020, as a result of her parents reporting that they were unable to keep her safe and worry about the impact of her behaviours on their younger child, C85 was voluntarily accommodated under s.20 Children Act 1989. 1.1.2 Subsequently, as a result of C85’s allegations of abuse by her father, coupled with reported parental opposition to her remaining in voluntary care, Care Proceedings were launched and C85 made subject of an interim Care Order. Since becoming a ‘looked after’ child, C85 has made further allegations of sexual abuse by several individuals and there have been more self-harm or potentially fatal incidents. To date, joint s.47 Children Act 1989 investigations by Police and Children’s Social Care have not yielded evidence to progress any prosecutions. 1.1.3 In accordance with national statutory guidance within Working Together to Safeguard Children 2018, a ‘Rapid Review Meeting’ was convened on 22.09.20. Rooted in concerns about how involved agencies had provided and/or co-ordinated services, Torbay’s Safeguarding Children Partnership was informed and on 28.09.20 notified the national ‘Child Safeguarding Practice Review Panel’ that a safeguarding practice review was considered necessary and would be completed. 1.2 SCOPE & PURPOSE OF PRACTICE REVIEW 1.2.1 The review period was determined to be from May 2019 to September 2020 focusing on the following lines of enquiry: • C85’s Background and Experiences: reviewing multi-agency case recording to identify pre-existing information and relevant learning, seeking examples of good practice and analysing how escalating risks were understood, responded to and shared across the Partnership • Supervision & Oversight: evaluating nature and quality of supervision and management oversight provided to / by all involved professionals • Safeguarding Practice: establishing how safeguarding concerns were identified, recorded and responded to, how effectively practitioners are supported by their line manager when working with a young person who has made multiple allegations, timeliness and effectiveness of information sharing and review this against local and national guidance regarding self-harm and Adolescent Mental Health CAE 3 1.2.2 A detailed report was developed from written material supplied by involved agencies, records of a multi-agency practitioners’ event and interviews with members of C85’s family. The author also was advised and supported at panel meetings with representatives of: • NHS Devon Clinical Commissioning Group & Primary Care (GP Service, Child & Adolescent Mental Health Service (CAMHS) and local hospital) • Torbay Children’s Social Care (Looked After Children (LAC), Local Authority Designated Officer (LADO) and Independent Reviewing Officer (IRO) Services) • Devon and Cornwall Police (attending self-harming incidents & investigating alleged sexual offences) 1.2.3 The review was conducted between March and June 2020 and its recommendations accepted by Torbay’s Safeguarding Children Partnership in September 2021. 1.3 FAMILY STRUCTURE & INVOLVEMENT Ages at time of trigger event 1.3.1 The parents of C85 were informed of this CSPR and, in acknowledgement of their ongoing shared responsibility for C85, invited to contribute. Given C85’s reported ongoing mental health difficulties, advice was sought from the currently involved CAMHS / Residential Provider team. C85 was subsequently invited by an advocate with whom she has a positive relationship to respond to a number of agreed subject areas. Regrettably, at the time of writing, the continuing fragility of C85’s emotional condition has, after careful consideration, been determined to preclude that planned involvement. Father (43) Mother (42) Sister (10) C85 (13) CAE 4 2 SERVICE DELIVERY 2.1 INITIAL DIFFICULTIES NOTED 2.1.1 During her time at Primary School, C85 had shown no indications of vulnerability or additional needs. From late September 2019 onwards, school records refer to concerns that C85 was not eating enough. Following consultation with her mother, the advice of the GP was sought and referrals made to Child and Adolescent Mental Health Services (CAMHS). CAMHS declined the first referral and mother was advised to access an eating disorder charity. Enquiries pursued during this CSPR confirmed that a specialist ‘eating disorder function’ / team - Torbay & South Managing Eating Pathway Service (TASME) within CAMHS, did respond positively to a 2nd referral and remained involved even after it was concluded that C85 did not have an eating disorder. Self-injury episodes 1 & 2 2.1.2 In late October 2019, school pastoral staff were shown the result of C85’s superficial cutting of her wrist and her reluctance / refusal to eat at school lunch-time continued. Parents were fully informed and appropriately involved. In mid-November, C85 reported a second example of self-injury. During the remainder of the Autumn term, C85 was incentivised to eat by the promise of being allowed back into school (which she enjoyed) and/or access to her mobile phone. By early December, C85 had returned to school and teaching staff were closely monitoring her consumption of lunch. A subsequent refusal to eat at all resulted in a further withdrawal from school and the possibility of admission to hospital if her weight reached a critical point. 2.2 FIRST HOSPITALISATION / SAFEGUARDING CONCERNS 2.2.1 A week later C85 was admitted to hospital and remained there, subject to tube-feeding, for over 2 weeks. She re-stated her intention to cease eating once she was discharged. C85 was re-admitted at the end of December and on that occasion, for the first time, indicated that she did not feel safe at home. C85 referred in a consultation with a psychiatrist to suicidal thinking. C85 returned home in mid-January 2020. School pastoral records of a conversation with a TASME worker reveal that C85 was no longer regarded as having an eating disorder and that the challenge was more about managing emotions and rigidity of thought i.e. less focus by staff or pupils on observing food intake was required. Self-harm episode 1 – with stated suicidal intent 2.2.2 In mid-January 2020, C85 was presented to the local hospital having overdosed on painkillers and other ‘over-the counter’ medication. She reported that her intention had been suicide. Self-injury marks over her arms, abdomen and neck were noted. Both parents attended and were distressed. C85 was admitted and remained for 3 days. 2.2.3 Upon discharge, mother took her for a consultation with the CAMHS consultant psychiatrist. C85 returned to school in late January and within days was reporting hearing voices in her head. In mid-February, Police were made aware by the relevant charity that C85 had been CAE 5 messaging an online support service and expressing suicidal thoughts. Following a home visit, an amber ViST (a vulnerability screening tool graded as red, amber or green) was submitted by officers. It noted that parents were aware of the threat and were supportive. The incident was appropriately relayed to GP and Children’s Social Care. A week later, father brought C85 to hospital following a fainting episode and she was admitted for 1 night. A letter from CAMHS reporting an ‘undiagnosed restrictive eating disorder, not anorexia’, was noted to upset C85, who was at that time refusing to take prescribed anti-depressants (‘voices told her not to’) and refusing to have her weight recorded. Loss of schooling associated with pandemic 2.2.4 In the context of Covid 19, the possibility of C85 being allowed to return to school in accordance with a ‘vulnerable child’ criterion was delayed by an assumption that to satisfy that criterion, s/he must be subject of a ‘child protection plan’. In fact ‘vulnerability’ in Government guidance allowed for professional discretion. The school did anyway maintain contact and encouraged home–schooling. It also helpfully passed on information about an online support source - www.kooth.com. 2nd stated suicidal intent 2.2.5 In late April, C85 called the Samaritans who in turn alerted Police to her report that she was suicidal. Attending officers located her on a footbridge over a railway. She was persuaded to come off, was assessed by attending paramedics and deemed sufficiently fit and healthy to go home to her parents who said that they would call CAMHS for advice. Ambulance records also indicate C85 claimed an intention of jumping out in front of a car to ‘kill herself’ but had then sat on a footbridge. She was very open about her desire to commit suicide. Her father had attended the scene and was noted to be ‘caring’. Having taken advice from the CAMHS Crisis team, and Psychiatric Liaison, hospitalisation was agreed. A safeguarding referral was completed and sent to Children’s Social Care, named nurse and her GP. 2.2.6 Hospital records confirm that father attended during his daughter’s assessment and seemed very caring, though poor eye contact between them was observed. C85 admitted not taking prescribed medication, though spoke of future plans and becoming a nurse. The CAMHS Crisis Team was consulted and a discharge with an agreed safety plan was agreed. Further exchanges between home and school had clarified that C85 could, in compliance with Covid precautions, be accepted back. During early May, C85 was offered the chance to resume part-time attendance at school and the mentor role transferred from a teacher who was leaving, to an alternative. Based upon inter-agency checks, and discussions with family members, it was determined (justifiably) that there existed no need for Children’s Social Care involvement. 2.2.7 Messages sent to Pastoral Care include a cryptic reference by C85 to father ‘having done something’. When this was shared with mother, she surmised it might refer to his worried and angry comments when they attended hospital earlier that month. CAE 6 3rd & 4th stated suicidal intention 2.2.8 On a date in late May 2020, Police were alerted during the late evening by ChildLine, to an online conversation C85 had had with them in which she had stated that she was feeling suicidal. Officers attended at 02.00 and when her mother answered the door, she correctly anticipated it would be due to a message C85 (by then asleep in bed) had sent. Officers were told that C85 was not engaging with CAMHS anymore, possibly linked to what the parents report as an unhelpfully extended period of involvement by the TASME Service, even after her difficulties had been concluded to be other than an eating disorder (this has been reported during the CSPR to have been a consequence of repeated self-harming events). 2.2.9 Only 2 days later, C85 was found by a member of public on the 9th floor of a car park reportedly trying to end her life. Police officers used their ‘Powers of Protection’ to detain her. Whilst at the Police station C85 pleaded to be let her out so she could find somewhere high to jump off. She was taken to hospital and after liaising with the paediatrician and the Crisis Team, transferred under s.136 of the Mental Health Act to Plym Bridge1 for assessment. She persisted in saying she wished to end her life as soon as possible and alleged her father had hit her when her mother was not present. A strategy meeting was subsequently held and the case immediately allocated to social worker SW1. 2.3 FIRST ALLEGATIONS OF ABUSE BY FATHER 2.3.1 Having been returned home C85 ran away and was subsequently found by Police. Following admission to the Paediatric ward, staff noted scarring from earlier deliberate self-harming as well as a bruise on her right upper arm. C85 threatened to leave and jump from a car park. She began to talk about physical abuse from father and said that there was ‘more to tell’ but that she ‘wasn’t ready yet’. The consultant was made aware and messages were left for the social worker. 2 days later, discussions were held with SW1 about discharge planning. C85 was refusing to complete an ABE interview. Hospital and SW1’s records note that in the context of agencies formulating their responses to the allegations of physical abuse, father was resisting a move out of the home. 2.3.2 By early June, C85 had changed her mind and a date was agreed for an interview. C85 disclosed (unspecified) sexual abuse which triggered a strategy meeting convened next day. Arrangements were agreed with mother for father to have supervised contact with his younger daughter. Nurses supported C85 in follow -up discussions with Police and she was made aware of an intention to arrest her father. CAMHS continued to provide support and C85 went on to allege to ward staff, what she said that she had ‘not’ to that point in time, reported to Police i.e. that she had been raped on more than one occasion by her father. 1 Plym Bridge is 12 bed purpose-built psychiatric unit in Plymouth for teenagers with severe mental health problems or mental illness. CAE 7 2.3.3 C85 completed an Achieving Best Evidence (ABE) interview and her father was arrested next day. A Sexual Assault Referral Centre (SARC) consultant proposed that a further ABE be completed. In anticipation of C85’s discharge from hospital, SW1 began to explore extended family options though could identify none. C85 completed a further ABE, disclosed 3 more rapes and referred to numerous attempts plus daily touching of her breasts and that her father had made repeated threats to stab her. 2.4 ENTRY TO CARE SYSTEM & 1ST FOSTER PLACEMENT 2.4.1 Though not apparent from records submitted, C85 was discharged to a foster carer FC1 in mid-June. Nominally anyway, she remained there for about 2 weeks before being re-hospitalised for a further 3 weeks. In mid-June an initial child protection conference (ICPC) was scheduled but replaced, after C85 entered the Care system, by a plan to convene a s.26 Children Act 1989 review (i.e. a routine case review required by regulation at regular intervals for all children ‘looked after’ by Children’s Social Care). 5th statement of suicidal intent 2.4.2 Within 2 days of her placement with FC1, Police received reports of a female on level 7 of a car park wanting to jump. C85 disclosed to officers attending that her reason for this apparent suicide attempt was because her father sexually abused her. She refused to return to her foster home because of ‘the other children’ and not liking the carer. If returned, she threatened to leave and kill herself. Officers spoke to her CAMHS worker who arranged a mental health assessment at Torbay Hospital. Though not in Police records, Children’s Social Care records refer to C85 later describing a scenario preceding the above events, when, feeling suicidal, she had gone to pick up some drugs. She reported that having no money, the dealer told her she could pay via sexual intercourse. She sought to reverse her initial agreement but he persisted. C85 (who had no record of substance misuse) declined an ABE interview about her account. Next day, she went missing and was traced to a friend’s house. She said she was still having suicidal thoughts and was subsequently taken by SW1 to the local Sexual Abuse Referral Centre (SARC). She co-operated with the planned examination only to the extent of providing a urine sample. A strategy meeting next day discussed her reports of sexual assaults in the community, ‘missing episodes’ and escalating behaviours exposing her to risk of sexual exploitation. 6th reported suicidal intent / detention under Mental Health Act 2.4.3 On a date in late June, C85 again attended a multi-storey carpark threatening to jump. She was reported to have a suicide note (content unknown) and a razor blade. She was detained under s.136 Mental Health Act 1983. The carer described a history of allegations of assault and rape by males e.g. she had been reporting romantic relationships with male police officers. The potential for unfounded allegations was recognised and officers were (sensibly) alerted and advised when possible, to be ‘double crewed’ and use Body Worn Video (BWV). CAE 8 Confusion in inter-agency discharge planning 2.4.4 It seems that after her detention at Plym Bridge Psychiatric Unit, C85 was admitted once again to the Paediatric ward at the local hospital. Its records are difficult to follow but appear to indicate: • A strategy meeting involving paediatrician, CAMHS, Children’s Social Care and Police at which the need for a new placement was acknowledged • A request from C85’s parents for further medical opinion and investigations • A possible overdose whilst on ward, along with a suicide note, leading to removal of medication and sharp implements • In response to her claim that she had illegal drugs in her possession, an unsuccessful search (this may not have been shared with SW1) • Scheduling a professionals’ meeting • Further concerns about deliberate self-harm and vomiting 2.4.5 At the professionals’ meeting the failure to identify a placement was debated and parental frustration noted. Further medical investigations revealed nothing abnormal. By 17.06.20 a multi-agency meeting was told that no placement had yet been identified and that C85 had made an additional allegation of an incident (no detail provided) 5 years previously. Though the parents were and remain anxious to know if there might be a medical explanation for observed symptoms, correspondence (copied to the parents at the time) of comprehensive medical tests all pointed toward psychological rather than physiological origins. Though not included in the minimal hospital records provided to this case review, the parents remain resentful that a visiting neurologist who examined C85, failed to speak with them. 2.4.6 The ward confirmed C85’s readiness for discharge by late June but, Children’s Social Care was still unable to find a placement and it was agreed that C85 remain until a suitable one was available. Enquiries have revealed that the acting Head of Service in Children’s Social Care submitted an extremely comprehensive and constructive response to the hospital’s concerns about the potential impact of an indefinite stay. It noted the need for updated psychiatric input and progression of a plan agreed earlier at a completed DICES2 assessment. The practical implication of the message was the (wholly justified) need for a multi-agency pre-discharge meeting so that the efforts of all involved agencies could be combined. 2.4.7 On 06.07.20 an independently chaired s.26 Children Act 1989 Review was completed and at a (remote) pre-discharge meeting on 10.07.20 attended by the lead nurse, it was confirmed that C85 was medically fit to be discharged. The ward confirmed that C85 was continuing to self-harm and ‘becoming attached’ to nurses. 2 DICES = a risk assessment tool developed by the Association of Psychological Therapies CAE 9 2.5 CARE PROCEEDINGS & 2ND FOSTER PLACEMENT 2.5.1 A week later, the parents are reported to have indicated they no longer supported the use of voluntary accommodation for C85. Apparently in response, an application for an interim Care Order was made at the Family Proceedings Court (and subsequently issued on 28.07.20). C85’s younger sister remained at home subject to a child protection plan. The parental account of this period is that they wished that C85 remain on the ward pending a diagnosis. 2.5.2 Torbay’s Fostering Service identified a possible replacement carer FC2. It was left for SW2 to liaise with FC2 for a ‘Matching Discussion’. In spite of parental opposition, C85 was subsequently placed though went missing the next day. An ‘Initial Matching Meeting’ convened following placement was not attended by the allocated social worker and lacked management input. IRO1 is recorded as supporting the placement and the apparently ambivalent carer left to define for herself what support she might need to sustain the placement which it was hoped would begin again on 18.08.20. Meanwhile C85 (by then subject of an interim Care Order) remained with a friend. Given the intrinsic complexity of C85’s needs and significant delay, the placement required a good deal more thought and management support. No record has been supplied of steps taken to authorise or regulate C85’s placement in what is presumed to have been a ‘connected person’ placement. Poor quality of records renders it difficult to be sure of events or their sequence. Further self-injury 2.5.3 In the first week of August, C85 inflicted superficial cutting of her arm and was taken by a male social worker SW3 (to whom she was subsequently allocated and about whom she would later make allegations) to the hospital to clean and dress her wounds. C85 was later introduced to her proposed new placement. C85 liked FC2 and her home, but insisted on staying with a friend pending a move there. Following transfer, daily CAMHS visits to C85 began. No records of a ‘Placement Planning Meeting’ or other routine functions have been traced. At a poorly recorded announced visit, FC2 spelled out her support needs and concerns about the risk of further self-harming. She made it clear her that her ability to manage was constrained by other personal priorities. A ‘Placement Stability Meeting’ was scheduled. 7th stated intent to commit suicide & confusion in responses 2.5.4 Within days of moving to FC2, Police attended C85 on the top floor of a car park and again heard allegations of sexual assaults by her father. C85 also said she was hearing voices and felt worthless. She appeared excited to meet officers not seen before (reinforcing the wisdom of the precautionary arrangements put in place by the Police). She was taken to hospital where SW3 attended and spoke to her. After initial consideration of detention under s.136, CAMHS confirmed she could be taken directly to the Paediatric ward. Whilst awaiting a bed, C85 disclosed that she had been raped by a male (forename given) whom she ‘had met on-line’ as well as by some of his friends. CAE 10 2.5.5 Though no formal minutes were kept and uncertainty as to date and attenders remains, a ‘Placement Stability Meeting 1’ was convened. Its summary reiterated FC2’s lack of confidence. Records of internal exchanges between Fostering and Community teams do not provide clarity though the net result is certain i.e. contrary to instruction initially given to SW3 by his head of service and later ‘justified’ by the support or acquiescence of an alternative manager, SW3 provided direct care (‘babysitting’) on the evening of C85’s return to placement whilst FC2 attended a pre-arranged family event. It remains uncertain whether SW3 was alone with C85 at any time or always accompanied by the carer’s elderly mother who was present though might be considered limited in her protective / supervisory value. 8th & 9th stated intent to commit suicide 2.5.6 Within a week of the Stability Meeting, C85 again ran to a car park with the stated intention of ending her life. She did not resist intervention by attending police officers and was willingly returned to placement by SW3. Though not formally minuted, ‘Placement Stability Meeting 2’ was then convened. It listed outstanding actions including the need to log episodes of running away and self-harm and organise respite for FC2 who was finding the placement very demanding. The consensus was though, (surprisingly) that the placement was a ‘good match’. 2.5.7 In late August, a 2nd review chaired by IRO1 was convened involving the Sexual Exploitation Team, SW3, parents and FC2. A ‘Safe Care Agreement’ was formulated and identified the need for caution amongst males in contact with C85. Given his direct participation in formulation and agreement to the plan, SW3’s subsequent conduct was all the more questionable. 3 days following the 2nd review, Police and SW3 attended a train station when C85 had been observed at the edge of the platform. Her response to officers were comparable to earlier episodes. SW3, who eventually took her back to her placement, attributed some of her distress to his imminent departure, reporting that he was something of a ‘father figure’ to her. C85 was introduced to newly allocated SW4. Having later spoken with her CAMHS worker, C85 ran away again and, evaluated as a high risk missing person, was traced by Police to local woods. C85 was again sectioned under s.136 and, following a mental health assessment, returned to her placement. 2.5.8 In partial response to C85’s expressed concerns about his behaviour toward her (which she said she did not want followed up because she ‘liked’ SW3) a ‘local authority designated officer’ (LADO) meeting was held on 25.08.20 to consider what was a clear blurring of professional lines, in particular the amount of time that SW3 had been spending with C85 which included calling her while he was off duty and late into the evenings. He was also giving her his own personal money. C85 subsequently recognised (in a conversation with ChildLine) the possibility that SW3 had been grooming her. She confirmed receipt of money from him though was equally clear in her refusal to complete a video interview or support any prosecution. An email is reported by Children’s Social Care to have been subsequently received from SW3 (by then an ex-employee) admitting to the above behaviours, including giving her money, which he asserted he had been going to reclaim. CAE 11 2.5.9 The multi-agency chronology provided for this CSPR refers to a ‘Risk Management Plan’ implemented by SW3 on 26.08.20 and covering self-harm, going missing, social media and school attendance. The plan (not seen) is said to exclude reference to the promised support package, or expectations of allocated support workers. A further record dated 27.08.20 offers an account of the day before, in which SW3 had failed to call to say goodbye to C85 who was reported (having planned to give him a thank you card) to be distressed. It seems likely that any plans SW3 may have had for his final days of employment were not implemented as a result of Management’s responses to his suspected professional misconduct. Strategy meeting & consequent enquiries 2.5.10 By this time, the previous report of sexual offences by her father was due to be filed with ‘no further action’ but it was noted that C85 had not yet been told, whilst thought was given to informing her without exacerbating her emotional difficulties. A strategy meeting was held on 01.09.20 in response to a new claim made to a community care worker that C85 had been involved in intercourse days earlier with a ‘year 11’ (estimated 15 year old) male. It was agreed that C85 was at risk of significant harm and the threshold for joint s.47 enquiries was satisfied. 2.5.11 On 02.09.20 a police officer, SW4 and a CAMHS worker visited C85. She agreed to tests for pregnancy and sexually transmitted infection (STI), but declined to offer any further detail or confirm that the event had been non-consensual. She shared with SW4 how close and dependent she had become on her CAMHS worker. In what may be a reference to the same visit, the Children’s Social Care chronology also confirms a visit by a social worker and CAMHS worker that day, the aim of which was ‘to gain information about her relationship with the social worker SW3’. C85 subsequently called ChildLine stating she had been assaulted sexually by SW3 i.e. he had touched her breasts under her tee-shirt whilst she was in his car. ChildLine informed Police and a visit next morning by a female and male officer to seek evidence may in turn, have triggered the incident described below. Self-harm incident & 10th suicidal intent statement 2.5.12 In early September 2020 the CAMHS Crisis Team placed a 999 call because C85 was reporting that she had taken an overdose. She told Ambulance control that she was overdosing as they spoke. An ambulance was dispatched and she explained that she had made some superficial cuts to both forearms and made her way to the train station where she took 36 Paracetamol tablets. C85 refused to report any other medication taken and denied any alcohol. A Police Community Support Officer travelled to hospital with C85 and all standard notifications were completed. C85 was discharged to her placement 2 days later and her stated intention, was to resume school the next week. Hospital records capture her account of ingesting 36 Paracetamol and some Sertaline ‘obtained from a 21 year old male’ with the intention of ending her life. She also referred to ‘something happening with a boy’ prompting a call to ChildLine. CAE 12 ‘Risk management meeting’ 2.5.13 Some days later, a conversation between SSW1 and FC2 was described as a ‘Risk Management Meeting’ (elsewhere a ‘Placement Stability Meeting’). The carer informed SSW1 of the planned strategy meeting and expressed concerns lest allegations be made about her or her son (no age recorded). The need to terminate the placement and the notice period required was discussed. Agreement was reached that the carer would continue until late October. C85 was to be told once a new placement had been identified. The discussion lacked any contributions from the placing social worker SW4 and others and it is unclear why alerting SSW1 to the strategy meeting was left to FC2. 2.5.14 During the second week of September, C85 inflicted further razor cuts on her arm whilst at school. These were managed by the school nurse. She later claimed that CAMHS had agreed with her carrying a blade though CAMHS assured the school that this was not so. This event highlighted that, notwithstanding the enormous care and commitment shown by her school, it remained challenging and potentially risky to reconcile the additional needs of a vulnerable individual against the legitimate needs of the majority of pupils and staff. 11th statement of suicidal intent 2.5.15 On a date in mid-September Police were alerted by a local Charity to a claim C85 made via text messages that she had something around her neck and wanted to kill herself. When Police arrived at the house she said she had done it for attention though did want to kill herself. C85 refused to co-operate with a planned ‘Initial Health Assessment’ (a regulatory requirement under Children Act 1989 Regulations). An incident report completed by the foster carer noted daily self-harming and also referred to a new ‘boyfriend’ (a named year 9 pupil). 2.5.16 A partially completed Care Plan dated 22.09.20 was considered at the 3rd LAC review on 24.09.20 chaired by IRO1. Records indicate that the required ‘Permanency Plan’ was either long-term foster care or reconciliation with family. CAE 13 3 FINDINGS & RECOMMENDATIONS 3.1 CONSTRAINTS 3.1.1 The potential for evaluating professional service delivery in compliance with the terms of reference has been constrained by: • A dependence upon a merged chronology that was disproportionately dominated by school-based welfare-related records and insufficiently informed by records of the thoughts, assessments and actions of (in particular) CAMHS and hospital practitioners, or (with the exception of the school) agencies’ supervision and management of practice • A probably connected difficulty, of missing or incomplete and inadequate recording of activities across case accountable v family placement provider functions within Children’s Social Care 3.1.2 Though additional records supplied in early July have provided some reassurance, the following findings still reflect the uncertainty that follows from the observations in para.3.1.1. Attempts have been made by means of the practitioners’ event, meetings with parents and C85’s contribution to compensate for these limitations. The recommendations below, if effectively introduced, should improve the Partnership’s capacity to derive systemic learning from case analyses. 3.2 RESPONSES TO TERMS OF REFERENCE C85’S BACKGROUND & EXPERIENCES 3.2.1 It seems clear that C85, prior to the concerns about her eating emerging in September 2019 had experienced no known adverse experiences or displayed any needs or difficulties that would have distinguished her from her peers. She appeared to be a bright child from a caring 2 parent family, who was enjoying her attendance at a well-respected and (according to regulator Ofsted) ‘outstanding’ school. SUPERVISION & OVERSIGHT 3.2.2 In the material supplied to this CSPR, limited evidence has been supplied of professional supervision or oversight. It remains uncertain on what basis (the first GP-initiated referral to it having been declined) that CAMHS eating disorder team first became involved. It seems probable that involvement was triggered by the aggregated information supplied by a very attentive parent and school and/or the initial thinking and influence of the hospital’s consultant paediatrician when presented with a potentially anorexic C85. 3.2.3 Whilst the volume and detail of educational records may have been excessive, they do highlight clearly, a commendable level of compassion, sensitivity and debate between class / subject teachers and those with additional pastoral responsibilities. CAE 14 3.2.4 An example of positive management practice emerges in June 2020 when Children’s Social Care’s senior manager submitted a comprehensive response to the hospital which, wholly understandably, was keen to discharge C85. 3.2.5 Supervision and management are not apparent at the time of an immediate need to build-in additional support for FC2 (though this may have reflected deceit on the part of SW3). Further comment is provided under the sub-heading of Safeguarding Practice below. 3.2.6 There was a welcome injection of objectivity from IRO1 in late August when she raised concerns about over-involvement of SW3 with C85. The CSPR panel has been reassured to learn that (pending completion of an investigation by regulator Social Work England) SW3 has been suspended and is currently unable to practice as a social worker. 3.2.7 No evidence has been provided to suggest a pre-allocation debate about what gender, experience or skill-set might have been needed to respond to the complex needs of a very vulnerable girl; nor has evidence been seen of the source or frequency of SW3’s case supervision. SAFEGUARDING PRACTICE Introduction 3.2.8 The following paragraphs offer a brief agency-specific evaluation of the safeguarding practices so far emerging from material made available. It is followed by a more general observation of the net result of those efforts and the untapped potential for a more co-ordinated approach. School 3.2.9 Whilst school staff clearly made great efforts to sustain their relationship with C85 and through their unwavering efforts, to support her capacity to learn, they were arguably over-involved. It may be that pastoral staff derived more meaning and value from the voluminous records (which included page-shots of numerous communications from C85) than the author has been able to do. Unsurprisingly, some staff did appear at times to feel that they were ‘out of their depth’. CAMHS 3.2.10 Without sight of CAMHS records (community or hospital-based Crisis Team), the rationale for initial rejection of a GP referral, subsequent re-consideration or provisional diagnosis may have been, is uncertain. An absence of formal reports and instead numerous phone calls, added to the volume and some confusion within the school’s records shared for this CSPR. 3.2.11 CAMHS’ Eating Disorder Team (TASME) introduced a useful distinction in December 2019 when the possibility of a compulsive ‘eating disorder’ was replaced with the idea of a ‘disorder of eating’ i.e. C85 deploying eating or non-eating as means of effecting control. Beyond that thought, little progress was made with respect to a diagnosis. CAE 15 Children’s Social Care: Fostering Service 3.2.12 Only after further research by panel members, was it possible to confirm that C85 had been placed with a FC1 prior to her (also disrupted) placement with a FC2. There was insufficient clarity or consensus about processes or widely understood terms and limited evidence of a collaborative approach between case accountable social workers and foster carer providers. Assurances have been provided, though no evidence seen, of supervising social workers for carers, themselves receiving supervision. Children’s Social Care: Case Accountable Service 3.2.13 No written confirmation has been seen to confirm that SW3 received case supervision. Completion of a Social Work England investigation might reveal that he elected to circumvent what did not suit him. The CSPR panel is satisfied that the responses to the concerns about SW3’s conduct, first identified by IRO1 were prompt and well-informed. It remains unknown whether, during his earlier employment, unprofessional conduct had been identified. Organisational responses in September 2020 were appropriate viz: alerting the director, informing Police and issuing a notification to professional regulator ‘Social Work England’ so that the latter organisation could take appropriate action. Children’s Social Care: Partnership Working 3.2.14 In addition to the failures to keep C85’s school updated about changes of social worker and other events, there was scope for a more collaborative and sensitive approach to her family. In spite of the lack of evidence to support numerous allegations and resulting need for ‘respectful uncertainty’, there was an insufficiently inclusive approach that accepted that the professional network was (and remains) unable to explain C85’s ‘inner world’ and triggers for her distress. Parental feedback suggested that this remained so and prompted the author to contact the principal social worker / director. The agency’s positive response indicates a renewed and welcome attempt to forge an effective partnership with parents. Police 3.2.15 The responses by officers in attendance at C85’s 11+ incidents were (setting aside some minor recording issues) sensitive and professional. Case Co-ordination 3.2.16 The limited record of CAMHS involvement prior to C85’s allegations against her father make it impractical to evaluate what scope may have existed for its efforts and the school being more formally co-ordinated e.g. was the reluctance at the hospital on New Year’s Eve 2019 to go home debated between the involved agencies? It was 5 more months before C85 offered (to her school) a more concrete reference to why she might be anxious about home. CAE 16 3.3 RECOMMENDATIONS Torbay Safeguarding Children Partnership 3.3.1 The Partnership should: • Clarify its expectations of agency reports and chronologies for a CSPR and take steps to meet any need that emerge from its deliberations, for enhanced briefing or training • Seek confirmation from local agencies that there exists sufficient clarity, agreement and above all, confidence to discern apparent / suspected professional malpractice, distinguishing between the need for internal management action, reporting to relevant Regulatory Bodies and/or reporting of suspected crime Torbay & South Devon NHS Foundation Trust 3.3.2 The Trust should review expectations and clarify for its staff and colleagues in other agencies, the respective functions within and content and the inter-relationship of all records maintained, by the ‘Child & Adolescent Mental Health Service’ (CAMHS). Torbay Children’s Social Care 3.3.3 Children’s Social Care should: • Evaluate the extent to which the ‘Care Plan’ and its implementation (in particular with respect to parental contact and involvement), complied / complies with requirements and expectations of the Children Act 1989 (as amended) and statutory and non-statutory guidance [confirmation in July 2021 from the head of regulated services of a proposed Care Planning Review should serve to meet this need] • Complete a limited case audit to determine the extent to which the interface apparent in this case between case accountable staff and those responsible for family placements is typical 3.3.4 The agency should also ensure that in what is understood to be a current transition to a new Information Technology / Service User Database, that policies and procedure for ‘locking down’ material in prescribed circumstances do not have the un-intended consequence (seen to an uncertain degree in this case) of denying access to key information to subsequent operational staff, or those seeking to review service delivery. 3.3.5 Whilst recognising that responses to reports and allegations in August 2020 were prompt and proper, the agency should review the extent to which pre-existing information and/or supervision records offered the possibility of earlier detection of SW3’s questionable conduct. CAE 17 Torbay & South Devon NHS Foundation Trust 3.3.6 The Trust should address and act to ensure that when requested for information to inform a ‘Rapid Review’ and/or any other form of evaluation of service delivery, that CAMHS and Torbay Hospital have the capacity to do so within agreed time limits. Torbay Education Safeguarding Service (TESS) 3.3.7 TESS should: • Seek comments from the very supportive school about its views of un-tapped potential for support by partner agencies and, informed by the results of that exercise • Develop and introduce guidance with respect to the nature and quantity of pastoral records that are maintained by local schools ‘C85’ Publication Version 31.08.21 |
NC044033 | Death of six sibling children in May 2012, as the result of a fire at their home where they lived with their father and mother (mother (a)). Father and mother (a) and another adult were convicted of the manslaughter of all six children. Father lived simultaneously with his wife (mother (a)) and their six children and another partner (mother (b)) and their five children until February 2012. Family had appeared on television and had, at times, a high profile in the media. History of: paternal conviction for attempted murder and wounding with intent in 1978; domestic abuse in mother (a)'s previous relationship; and father and mother (a)'s suicide attempts within 2-weeks of each other in February 2012. Key themes include: overcrowding, with periods where up to 15 people were living in the household at the same time; the adults' relationships; father's history of violence; father's controlling and manipulative manner and his hostile and aggressive behaviour toward social workers; and the impact of media coverage on the family. Makes recommendations covering: children's services, police, education, health, fire and rescue services and housing services.
| Title: Serious case review overview report: ED12 LSCB: Derby Safeguarding Children Board Author: Glenys Johnston Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Derby Safeguarding Children Board Serious Case Review Overview Report ED12 Date: 15 January 2014 Independent Overview Report Author Glenys Johnston OBE 2 Contents Page 1 Introduction 3 2 The format of the Overview Report 4 3 The Decision to hold a Serious Case Review 4 4 Key Issues to be addressed by the SCR 7 5 The circumstances that led to this Serious Case Review 9 6 The Facts 9 7 Family History 10 8 Summary of Significant Events and Agency Involvement Prior to 2006 11 9 Consideration of the key themes 12 10 Conclusion 24 11 Recommendations 27 Appendix 1: The Review Process: Terms of Reference 29 Appendix 2 Agency Action Plans 33 3 1.0 Introduction 1.1 This Serious Case Review (SCR) overview report brings together, in a thematic format, the overall conclusions from information and analysis contained in the Independent Management Reviews (IMR), the Health Overview Report and supplementary information from the criminal prosecution of the parents. It does not seek to repeat the detailed contents of the IMRs or the recommendations they made. 1.2 The report has been written to comply with a Reporting Restriction Order and balances what can be published with information that cannot be disclosed, to avoid breaching the human rights of family members. 1.3 The delay in publishing the report is due to ensuring that all learning was obtained in respect of the large number of children and relevant family members involved. Delays were also incurred due to the necessity to obtain specialist legal advice and complying with above. 1.4 The father and mother(a) and their six children, and the same father and female partner (mother (b)) and five children lived at a house together in Derby. In February 2012 the relationship between the father and mother(b) broke down and she and her five children left the family home. 1.5 On 11th May 2012 a fire occurred at the home address where the father and mother(a) continued to live with their six children. All six children died, five on the night of the fire, and the oldest, later in hospital. 1.6 On 2nd April 2013 the father and mother(a) and another adult (adult (c)) were convicted of the manslaughter of the six children. 1.7 This has been a comprehensive review with full co-operation from all agencies the outcome is that despite the horrific deaths of these children there are few areas for learning for professionals. 4 2.0 The format of the Overview Report 2.1 As previously stated, the Overview Report will be published in a way that complies with the Reporting Restriction Order, upholds the human rights of the surviving siblings and ensures that their welfare is not adversely affected by publication. 2.2 To achieve this, the Overview Report sets out the narrative of the events thematically. This includes a brief overview of the circumstances, prior to a robust analysis of lessons learned in seeking to answer questions about multi-agency practice. 2.3 This thematic approach recognises the complex circumstances in which professionals work together to safeguard children and seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight. Relevant research and case evidence has been used to inform the findings. 2.4 The thematic approach of the Overview Report includes analysis of the key issues set out in section 4 below. It summarises the relevant information that was known at the time to the agencies and professionals involved, about the parents/carers, any perpetrator and the home circumstances of the children. 2.5 The Overview Report seeks to analyse how and why events occurred, decisions were made and actions taken or not taken. The report considers whether different decisions or actions may have led to an alternative course of events. 3.0 The Decision to hold a Serious Case Review 3.1 At an extraordinary SCR Panel meeting on the 15th May 2012 the tragic deaths of the six children was discussed and it was noted that there were ongoing police investigations being carried out into the cause and person(s) responsible for the fire. There was no evidence at that time that the case should be considered as meeting the criteria set out in Working Together 2010 for a SCR. 3.2 Following the decision that the mother and father had been charged with killing their six children; notification was made to Ofsted of a serious childcare incident on 31st May 2012. 3.3 The SCR Panel considered the details known about the case on 11th June 2012. The Panel recommended that, from the evidence available at the time, 5 a SCR should be conducted. The rationale for this decision was that evidence indicated that the fire had been started deliberately and that the parents had been charged with murder. 3.4 The Panel noted however, that there would be difficulties in carrying out a SCR at this stage given the continuing and complex police investigation and the complexities around identifying and safeguarding other associated children and vulnerable adults, and recommended a pause in the process. Ms Christine Cassell, the Independent Chair of Derby City Local Safeguarding Children Board (DSCB) endorsed the recommendation of the Panel to review this incident, with the proviso that the timing of the review should take account of the ongoing investigation and related judicial processes, as well as the immediate safeguarding needs of the wider family. 3.5 On 26th June 2012 Ms Cassell wrote to the Department for Education (DfE) advising them of the complexities of the case and that as a result, a multi agency Gold Group had been convened. This group was responsible for co-ordinating the investigation and work with the family and were sufficiently concerned to have set up two specialist Silver Groups – one to ensure that the children within the family were identified and safeguarded and the second with a similar remit in relation to any vulnerable adults within the family. 3.6 It was noted that although the parents had been charged with murder, the evidence gathering was continuing and the DSCB was concerned not to prejudice the outcome of any criminal proceedings by commencing the SCR process at that stage. 3.7 There was a shared concern amongst all agencies that the information available at the time was not sufficient to enable a meaningful SCR to be commenced in relation to such complex circumstances. The DSCB wished to ensure the potential for identifying any learning was maximised and it was noted that this was not possible when new information continued to emerge on a daily basis. 3.8 The DfE wrote to the Ms Cassell on 13th July 2012 acknowledging the complexities of the case and accepting the reasons for delay. 3.9 At the SCR Panel on 3rd September 2012 it was agreed that the SCR review could proceed without potential adverse impact on the police investigation or the court case. It was also established that the immediate safeguarding of family members had been achieved and their future needs understood. 6 3.10 It was confirmed on the 12th October 2012 that: Ian Johnson, Assistant Director, Safeguarding and Specialist Services, Derbyshire County Council would be the Independent Chair. Glenys Johnston OBE would be the Independent Overview Author. Ray McMorrow, Designated Nurse, would be the Health Overview Author 3.11 It was agreed that the question of whether the deaths of the children could have been predicted and prevented would remain key to the learning arising from the review. 3.12 The SCR focuses on the deceased children known for the purposes of this report as: CH1 CH2 CH3 CH4 CH5 CH6 3.13 It was agreed that consideration would be given to any relevant information in relation to other family members who had lived at the address and, to a more limited extent, extended family members. 3.14 Following the conclusion of the Criminal Trial, a Reporting Restriction Order was made in respect of other family members who had lived at the address. In order to comply with this order the Overview Report was reviewed and appropriate redaction undertaken, following the advice of legal counsel. Mr Wise, QC, reviewed the draft report and consideration was given to the human rights and future short, medium and long term welfare interests of the surviving siblings and family members and the requirements of Working Together for LSCB’s to publish as much detail as possible. 3.15 In order to comply with the terms of the Reporting Restriction Order and also respect the ongoing human rights and welfare needs of the children it is appropriate to acknowledge that five other children were part of the household prior to the fire occurring. Their welfare and safeguarding interests are of paramount concern to the DSCB. 3.16 In order to ensure that the human rights of these children are upheld and prevent any potential adverse consequences of publishing details of their lives in the public domain, the Terms of Reference were subsequently amended to 7 reflect these circumstances and the SCR does not include additional information in relation to them. 4.0 Key Issues to be addressed by the SCR 4.1 What specific issues or questions does this case raise? Discussion at the SCR Panel on 3rd September 2012 and subsequently on 12th October 2012 and 3rd December 2012 identified the following key issues. 1. Overcrowding: It appears that there had been overcrowding issues at the home of the deceased children, but not at the time of their deaths. It needs to be determined whether or not the overcrowding constituted an issue that should have raised a safeguarding concern and how the impact of overcrowding on all the 11, and at times 12, children was understood. It needs to be determined whether or not at the time of re-housing requests from the father, safeguarding concerns should have been raised, and/or whether there were systems or processes in place for this to take place. 2. Adult relationships: What was known by agencies about the adult relationships at the home address? It needs to be determined whether there was any consideration of the impact of this on the emotional and psychological well being of the children living in the home. 3. Previous convictions and domestic abuse: What was known about the conviction of a domestic violence offence by the father in 1978 and any other subsequent concerns about domestic abuse or violence in relation to adult family members? It needs to be determined whether complaints about domestic abuse arising from the mother, or father's partner during the period they were all living together in the family home, or elsewhere, were acted upon appropriately and whether the safety of the children was considered in line with the safeguarding policies relevant and in place at the time. 4. Adult behaviour and manner: It needs to be determined whether or not the manner, presentation or behaviour of the father or adult members in the household impacted on the services provided by practitioners. 5. The impact of media coverage: The family had appeared on television and at times had a high profile in the media. It needs to be determined whether the agencies were aware of this and whether or not this had an impact on their assessment or the assumptions staff 8 may have had about their own roles, and that of their and other agencies. 4.2 Footage in respect of family involvement in TV programmes has been collated by the Police as part of their ongoing investigation. This has been made available to me, as part of the review. 4.3 Are there any unusual factors in this case and if so what are they? The father lived simultaneously with his wife (mother(a)) and their six children and another partner(mother(b)) and five children until February 2012. This is not a frequently occurring family arrangement and it needs to be determined whether there is any indication that these arrangements were having a detrimental effect on the welfare of the children and whether appropriate consideration was given to their needs? 4.4 Are there similarities with previous IMRs or SCRs, if so, what are they? The Overview Author and Independent Chair both have experience of a SCR in which children died as a result of fire caused by a parent. Learning arising from this review and any other similar reviews has been considered. 4.5 Were there any failings or gaps in multi agency working? Early analysis by the SCR Panel does not identify obvious failings or gaps in multi -agency working but this has been considered by the review and action taken as required. 4.6 Are there any issues which relate to ethnicity, disability or faith which may have a bearing on this review? The initial scoping of the SCR did not identify specific issues relating to ethnicity, disability or faith that presented a significant dimension to the involvement of agencies with the family. 4.7 It needs to be determined whether or not the background and culture of the family were issues about which professionals and agencies could and should have been aware and whether or not this had an impact in respect of the safety of the deceased children. 4.8 Further details of the review process are attached at Appendix 1 9 5.0 The circumstances that led to this Serious Case Review 5.1 This SCR concerns the deaths of six sibling children caused by a deliberately set house fire. The children lived at the property with their father and mother(a). The fire was reported at 03.46hrs on Friday 11th May 2012. Five of the children died on the night of the fire. The eldest child was taken to Birmingham Children’s Hospital and placed on a life support machine. It was turned off on 13th May 2012. 5.2 On 2nd April 2013, the father, the mother and their associate adult(c) were all convicted at Nottingham Crown Court of the manslaughter of the six children. 5.3 The father was later sentenced to life imprisonment with a minimum of 15 years. The mother(a) and adult(c) were each sentenced to 17 years imprisonment. 6.0 The Facts 6.1 At the time of the children’s deaths there were eight people living in the household, the father, mother(a) and their six children. The house was a three bed roomed semi –detached property with a large kitchen and a living room. The children all slept in two bedrooms, on bunk beds. The property was extended by a conservatory and additional sleeping accommodation was provided by a caravan parked at the front of the house. Before the fire, there were up to 13 children living in the household with their parents at different times. 6.2 Prior to the fire the number of people living in the household had increased over time. 6.3 The family structure was effectively polygamous, with two concurrent female partners living together with a male partner in one household. This type of arrangement is unorthodox and not one that professionals often come across. 6.4 The children were all of white British origin. There are some indications of connections with the travelling community but no evidence that these were strong links, or significant to the family's identity. They were geographically stable: these children were born and grew up in Derby and the three adults mostly live in Derby. The parent’s religion is Roman Catholic though not all the children have been baptized in this faith. Although the family did not follow their faith’s religious requirements in many respects, they did have connections with the church and the children attended faith schools. 10 6.5 They lived in an area of traditional social housing where levels of deprivation are relatively high, although mixed with traditional working class households and some where incomes can be significant. 6.6 Housing Departments often deal with applications from large families including, different families living in one property together. However, it is unusual for a housing application to include a husband, wife, partner and all of their children together. 6.7 Although other communities in Derby, especially amongst new migrants, often include large families and multiple or extended family households, this is less common in this family's community and they did attract local attention. This was something that the father seemed to enjoy and he courted media attention on the TV and in the local press. There were no reports of the children being subjected to bullying or teasing as a result of the way their family lived. 6.8 There has been no information that suggests that any parent has a disability. 7.0 Family History Mother (a) 7.1 There is little known about mother(a)’s history other than that she is believed, by some professionals, to be of Irish gypsy/traveller origin and has two sisters. The relationship with her family is unknown, apart from one comment in one of the IMRs that at one point she had stopped speaking to her mother. Father 7.2 See para 9.42 Extended Family 7.3 The IMRs contain no information about other family members. 11 8.0 Summary of Significant Events and Agency Involvement Prior to 2006 8.1 The SCR Panel agreed that events prior to the first period, from 6th February 2006 to the events that caused the deaths of the children on 11th May 2012, would only be considered if appropriate. Information from the detailed IMRs has led me to conclude that some of the information gathered through the review, about issues before the 6th February 2006, are worthy of inclusion by way of background information, they are included here in summary. 8.2 On the 19th December 1978 the father was convicted at Nottingham Crown Court for the offences of attempted murder and wounding with intent. He received a sentence of seven years imprisonment and five years imprisonment, to run concurrently. Records show that the circumstances were that he visited the house of a recent girlfriend and that during an argument he repeatedly stabbed her and her mother, causing permanent damage. 8.3 The earliest contact with health agencies is in connection with the birth of CH1 on 30th December 1998. Mother(a) was 17 years, 9 months at the time of his conception. The child was of a previous relationship and domestic violence within this relationship was evident, as she was living in a refuge in the county. 8.4 On the 28th May 2000 police officers spoke to former partner(d) who reported a difficult split with the father. She stated that they had been together since she was 15 years old. There was mention of two children at the time of this separation and a three year custody battle followed the separation. 8.5 CH2 was born on 26th August 2001 to the father and mother(a), it is documented by the Health Visitor that two of the father’s older children by former partner(d) had been living with them but that he had lost a custody settlement. 8.6 In May 2003 the father and mother(a) were married. 8.7 On the 1st March 2005 the father reported to the police that he had argued with his former partner(f) over child access. She was pregnant and was offered advice by the police. Later the same year (in December) she reported that she was receiving abusive text messages from the father during the time she was in a hostel. Police officers visited the hostel however, former partner(f) had left without leaving any contact details. 12 8.8 Throughout the period between 1998 and 2007 12 children were born to the father and the number of people in the household increased, this was particularly so in 2006, when mother(b) and her children joined the family of the father and mother(a). 9.0 Consideration of the key themes This section is linked to the terms of reference which identified the key issues that would best inform any learning in relation to what was understood about the family and circumstances relevant to the review. 9.1 Overcrowding Background 9.2 It was well known to professionals and the public, over several years, that a considerable number of children lived with the father, mother(a) and mother(b) and that the number of children had increased over time. a. In January 2006, Derby Homes (Housing) received an application from the father and mother(a) requesting re-housing, due to overcrowding. At the time of their application, the father and mother(a) occupied the property with five children, and the father advised that he had access to five other children who did not routinely live with him. He also stated that another partner(mother(b)) wished to move into the property with her three children and that she was expecting a baby. Shortly afterwards mother(b) ended her own tenancy and, against advice from Housing, she and her children moved in with the father, mother(a) and their children. b. In March 2006 Royal Derby Hospital contacted Derby City Council Children’s Social Care (CSC) at the request of mother(b) and mother(a) for assistance with housing in respect of Child 10. c. In May 2006 the Health Visitors described the home circumstances as housing nine children with the boys sharing one bedroom and the girls another. d. In 2006/7 there was considerable media attention paid to the father. The Derby Evening Telegraph interviewed him in 2006, and subsequently produced articles relating to the size of his house, and the size of the family. These were quickly followed up by national press articles in the Daily Express, Daily Star the Sun newspapers and others. The father was seen as using the media to put pressure on Housing for a larger property. The articles and the television 13 programmes all described the living arrangements of the family, and their frustrations with the Council for not providing a bigger house. e. On 26 March 2007 an overcrowding assessment was carried out by the Housing Department. This assessment determined that the property could cater for seven people, and was overcrowded by half a person. Increased priority was awarded to the household, in recognition of this. f. In April 2007 two further children were added to the household. g. In June 2007 the father applied to buy the property under the ‘Right to Buy’ scheme, which indicates that he thought the property was suitable for his family. h. In December 2007 the father requested permission from Derby Homes to erect a conservatory at the rear of the property. i. In June 2008 the father withdrew his ‘Right to Buy’ application. j. There were two further contacts with CSC by the father in March 2011 regarding overcrowding and he was again advised to contact Housing. k. In September 2011 the father discussed with his GP, the over-crowding at home, as there were now 15 people in the household. The GP was already aware of the over-crowding but as there were no other indicators of distress amongst the children in the family, no concerns were raised with other professionals. Analysis 9.3 Currently in Derby, demand for housing outstrips supply. There are approximately 4,000 people on the housing register, who are in some form of housing need, and are requesting housing. Housing let approximately 1200 properties each year, through the Council’s housing stock and housing association partners. These include all types of accommodation ranging from single person properties, to family homes and age restricted living accommodation such as retirement living. 9.4 The type of arrangement in this family is unorthodox and not one that housing professionals often come across. Housing often deal with applications from large families including, different families living in one property together. However, it is an unusual occurrence for a housing application to include a husband, wife, partner and all of their children, and for them to request housing together. 14 9.5 The limited supply of affordable housing and lack of larger housing units in the city is a major factor when considering overcrowding cases. Derby City Council’s Allocations Policy recognises overcrowding/cramped conditions as a reason for some priority to be awarded to applicants requesting housing through the joint housing register. However, this level of priority is no greater than is awarded, for example, to applicants who have a medical or welfare need to move. The Housing Health and Safety Rating System (HHSRS) guidance issued in April 2009 advised local authorities, as a first step to assessing the health and safety implications of overcrowding to enforce part 1 of the Housing Act 2004 as to continue to use part 10 of the Housing Act 1985 would maintain the use of an outdated legislative system which does not reflect modern day standards. Health and safety were therefore considered and assessed not to be a factor in this family. 9.6 Housing Options and Derby Homes staff have received training in relation to safeguarding of vulnerable adults and children. They have also received training on the Common Assessment Framework (CAF). There are policies in place on how to make a safeguarding referral should staff have concerns. 9.7 There was no evidence that at any time there were health and safety issues that related to the children in the household and should have triggered a referral to CSC by Housing. 9.8 Following the fire the fire investigation carried out by Derbyshire Fire and Rescue Service identified that no concerns had ever been reported about fire safety in the home and the property was fitted with working smoke alarms at the time of the fire. 9.9 Although other agencies did not formally consider the information that emerged in the press, in terms of the impact on the children of overcrowding, there was no indication that the situation included safeguarding issues caused by the housing situation. Agencies that visited the house described it as having adequate amenities (given the use of a caravan that provided sleeping accommodation for the father and his partners and a large conservatory) and that the atmosphere during their visits was observed to be consistently warm, comfortable and loving. Learning 9.10 The information reviewed evidences that the way the overcrowding was dealt with by Housing professionals, using the legislation followed at the time, was correct however, this review has also identified that, although it was not required practice at the time covered by this review, it would be good practice for senior managers to undertake periodic reviews of overcrowded situations, 15 whether there is or is not a trigger to consider this and that this will improve practice. However, in relation to this case it is unlikely that this would have changed the decisions made, which were appropriate. 9.11 Adult relationships 9.12 The relationships between the adult members of the household were not kept secret and were known to a number of agencies including Housing, CSC, Health Visitors and the family GP and to the public through the press and media including the television appearance of all three. 9.13 The records reviewed and interviews undertaken as part of this review include several references to the relationships but none indicate any concerns, even when considered: a. There were several difficulties between the father and his previous partners but these related to custody and access. b. In 2005 and 2006 Sure Start staff commented positively on the family atmosphere and the father’s engagement with his children. c. The CSC assessment of 2006 noted that the relationships looked positive. d. There was a contact by school in September 2011 relating to one child who said she had been slapped at home that may, but not necessarily, have been indicative of some tensions within familiar relationships. There were no visible marks or injuries when the concern was raised and when it was discussed with CSC by the school head, it was concluded that what was described was within normal styles of parenting and was not felt to be a significant concern. It was agreed however, that the school would discuss the reported incident with the parents and report back to CSC if there were ongoing concerns. The child concerned and all the other children in the family continued to appear well adjusted and happy. e. In January 2012 a Social Worker visited the family with the Police and a Student Social Worker, following a referral from the Police to Derby Social Care ‘Out of Hours’ Team, in connection with a related family member. The Social Worker recalls observing mother(b) and mother(a) chatting cheerfully and the children seen in the home being well behaved. 9.14 Relationships in the UK are predominantly monogamous and the arrangements in the family under review are unusual, the father was only married to mother(a) and therefore he had not committed bigamy which is illegal. Whilst professionals may have had personal views about the nature of the relationships they acted in a professionally non-judgemental manner; the 16 records reviewed and the interviews conducted as part of this review indicate that although professional recognised the arrangements as unusual, they did not appear to affect the children and there was no evidence of difficulties between the adults. 9.15 Information that has emerged after the deaths of the children have described some tensions between the father and the women who lived in the house, due to his controlling manner but this was not apparent at the time. The relationship between the two mothers was always viewed as supportive and caring with neither of them having any difficulty with the partnership arrangements or any jealousy. Indeed mother(a) described mother(b) as her “sister”. 9.16 There is no information that indicates that the arrangements had a detrimental impact on the children and between 2006 and July 2011, no agency expressed concerns about any of the children to CSC, other than the incident covered in 9.13(d) above. 9.17 Previous convictions and domestic abuse: 9.18 The father has a history of violence which preceded his relationship with mother(a): a. On the 19th December 1978 he was convicted at Nottingham Crown Court for the offences of attempted murder and wounding with intent. He received a custodial sentence of seven years and five years to run concurrently. Records show that the circumstances were that he visited the house of a recent girlfriend, and, during an argument he repeatedly stabbed her and her mother. b. There are indications that the father has frequently found separation from partners and his children particularly difficult: I. The stabbing of his girlfriend in 1978 was prompted by his inability to cope with her leaving him. II. In May 2000 another former partner(d) reported a difficult split with him. She stated that they had been together since she was 15 years old. Their two children were involved at the time of the separation and a three year custody battle had followed the separation. III. In March 2005 the father reported that he had argued with another former partner(f) over child access. At the time she was pregnant. Later on the same year she reported that she was receiving abusive text messages from him during the time she was staying in a women’s refuge. 17 9.19 During the period that the father, mother(a) and mother(b) lived together there were few reports of domestic abuse, those that were made included the following: a. In 2006, following the father’s appearance in the media, a Midwife queried with the GP whether domestic violence may have occurred, after she noted a bruise on mother(a). The GP was reported to have stated that mother(a) had attended with bruising in the past, but there is no date for this and it may have pre-dated her relationship with the father. The Midwife passed this information and that she had seen in the newspaper that the father had a previous conviction for murder, to CSC. This concern was appropriately followed up by CSC who contacted Probation and the Police Domestic Violence Unit. Probation reported that they had no information about the incident and the Police said they only had a record of one incident relating to a previous partner, amounting to unwanted text messages. A written Police check was requested, but there is no copy on file and no recorded consideration of the result. b. In May 2009 mother(b) reported to the Police, by telephone, that during an argument with the father he had thrown a cup of coffee over her. The operator checked whether she was injured or whether the children were in danger, she replied “No” to both questions. Police officers attended the home address later the same day and found that mother(b) and the father had resolved their differences. Mother(b) had not sustained any injuries and declined to make a formal complaint. c. A record was completed with reference made to the children but as there was no evidence that any of the children witnessed the incident, it was assessed as being of standard risk i.e. a minor incident with no evidence that any of the children were a witness to this incident. As a result, no referral was made to CSC. d. In March 2010 a report was received by the Police from the father who expressed concern about his wife mother(a). He stated he had hit her and that she had left the house and not returned. He stated that she had been drinking. e. Police officers attended and found mother(a) had returned home and was in bed with the father. She had sustained a minor injury and refused to give an account of what had happened and declined to make a complaint. Nevertheless, the father was arrested and later cautioned for committing a common assault on mother(a). 18 f. In November 2011 Nottinghamshire CSC shared an assessment that includes a reference to the father’s historical violence against a previous partner. g. In February 2012 a non emergency call was received by the Police, from the father reporting that mother(b) was at his house trying to kick the door in. By this time mother(b) had separated from the father and had left the house together with her children. Police officers attended the address where no offences were disclosed but it was recorded that the dispute was about child access and the financial issues. h. The father took an over-dose on 12th February, 2012 and attended AED and was noted to have family problems, but no additional information was available. i. On 21st February mother(a) attended AED following an overdose A clear intention to die was evidenced in three suicide letters in which she noted that the children wanted mother(b) to return, that she (mother(a)) has mistreated the children and that she wanted mother(b) and the father to be happy together. j. The hospital referred the incident to CSC regarding the children remaining at the family home. It is noted under the section of the assessment entitled ‘parenting capacity’ that “Mother of children took intentional overdose with a view to end her life, tablets taken whilst some of the children in the house”. k. In March 2012 a number of calls were made to the Police reporting a disturbance in the street between mother(b) and the father in relation to access to the children and financial matters. l. On the 1st May 2012 a Multi Agency Risk Assessment Conference (MARAC), which brings together a range of agencies to consider the potential risk to victims of domestic abuse, was held in respect of mother(b) who was concerned that she was at risk from the father. The request for the MARAC meeting was made by Derwent Living and the names of all the children were contained in the agenda. The meeting was well attended by a wide range of appropriate agencies. 19 Analysis 9.20 In 1978 the methods for recording convictions were very different from today. A paper system was used to record the detail, with a brief record kept on the Police National Computer. As a consequence, historic cases were stored on a microfiche, and the papers were destroyed. This made searching for previous information very time consuming and difficult; it created challenges in sharing the information when it was requested. 9.21 Furthermore, at the time of the offence and his discharge from prison, the father did not have any children and did not join a household with children. His offence was not against a child (formerly known as a Schedule 1 Offence). Thus on neither count would there have been a requirement for the Probation or Prison Service to notify the Local Authority (which at this time was Nottinghamshire). From 2005 his offence would have met the criteria1 for notification to the Local Authority as a potential risk to children, but the Government of the day did not apply this retrospectively. 9.22 When CSC sought information from the Police, following the information being received in 2006, no information was therefore provided. In addition, due to concerns at the time about Data Protection compliance in relation to adults it was practice not to keep a copy of any Police check and not to record any information on CSC’s adult files. A file alert could have been created on the father’s file but practice was that this would only be done where there was corroboration in writing of a conviction of an offence against a child which was not received. 9.23 There is some evidence that a previous partner of the father was aware of the convictions and circumstances of the 1978 offences, but it is unclear whether mother(a) and mother(b) had the same degree of knowledge. 9.24 During the 2006 assessment, concerns were raised about domestic violence against mother(a), but were explained away as insignificant by the family. Because it was a minor incident, caused during an assault on the street, by a previous partner who was known to be violent, the GP, Health Visitor and Midwife were consulted by the Social Worker but as they had no records of other incidents and the incident was minor it was understandable why the Social Worker asked the Health Visitor, who knew the family, to speak to mother(a) and mother(b) and refer back to CSC, if there were concerns. There was no further contact from the Health Visitor and the case was closed by CSC. However, if Health Staff had been aware at the time of o 1 PC32/2005 Identification of individuals who present a Risk to Children interim guidance 20 the father’s earlier conviction, it is likely that this incident would have been cause for greater concern and investigation. Verbal reports from the Police did not reveal all the instances of domestic abuse which it subsequently emerged were known, and there is no indication that the CAFCASS report, which would have been on the half-siblings' case files at the time, was referred to, although this too makes no reference to the father’s conviction. There is no record of a written Police check being received or considered by CSC. 9.25 CSC practice at this point here could and should have been more thorough , with checks being made on all the children’s files, the Police being contacted again for any information and further contact made with the Health Visitor to ask whether she had seen the two mothers. It would however, have been difficult to review all the sibling’s files as records were kept on paper and would have had to have been manually retrieved. It is not known why this did not happen but there were pressures to maintain the throughput of work and as information had been obtained verbally before, it may have been considered that the Social Worker should move on to other more urgent cases. 9.26 Best practice would also have been for the Social Worker to have seen mother(a) and mother(b) alone. However, there was no confirmed report of a domestic violence incident and mother(a) was not making an allegation or complaint about the father’s abuse of her and there was no corroborating evidence. The lack of a clearly recorded consideration of risk of domestic abuse is an omission, but given the information which appeared to be available at the time to the Social Worker and his manager, any assessment would likely have been one of ‘low risk’. However this judgement is made with the benefit of what information subsequently became known but was not known to everyone at the time. 9.27 The domestic abuse incident of 2009 was appropriately managed by the Police. 9.28 The Police acted appropriately by responding to the incident of March 2010 although some aspects were missed. Records of the incident note that the children were asleep in the house at the time the incident took place however, officers did not ascertain their names and dates of birth, nor add their details to their records. They were therefore not aware that the youngest child was three years old which would have resulted in an automatic referral to CSC. 9.29 The management of the non-emergency incident in February 2012 was partly acceptable in that officers attended and information was taken about 21 the children who no longer lived in the father’s household, but not about mother(a)’s children who continued to live there. As a result the incident was not referred to CSC which should have happened. 9.30 The outcome of the hospital referral to CSC, in respect of the suicide attempts of February 2012, is unknown to the hospital but it appears that the Social Worker did not see mother(a), as it was considered that when she had been seen by a mental health worker, following her overdose, she had not disclosed any violence or abuse towards herself. It is therefore unlikely mother(a) would have disclosed anything to a Social Worker. Any agency checks would also have revealed happy, well-adjusted children. Available information at that time would certainly have confirmed that the father was manipulative and controlling, but there was little known at this point about recent violence, and there were no grounds for statutory intervention. 9.31 On 19th March 2012, the GP Practice received a domestic violence alert from Nottinghamshire Police about the father sending abusive texts and a copy was forwarded to the School Nursing records. The GP Practice placed an alert on the father’s record – however, there is no record of any conversation with other Health Professionals, in particular Health Visitors and School Nursing. 9.32 Information gathered for the MARAC meeting of May 2012 did identify the father’s previous conviction for attempt murder in 1978, but not that it was linked to domestic violence. The information researched for the MARAC had been completed before information had been received from Nottinghamshire about other matters involving the father and a previous partner. This subsequent information did include the domestic abuse related conviction. It is possible that if the inclusion of the domestic abuse element of the historic attempted murder had been discussed at the MARAC, it would have changed the final risk assessment and agreed actions. 9.33 The MARAC concluded that there were no incidents, intelligence or information to suggest that any of the children they were ‘at risk’. The children were described as well nourished, clean, well presented and happy. During those discussions the suicide attempts by the father and mother(a) were also revealed, although there is no record of the Police being made aware of these incidents at the time that they occurred. Analysis 9.34 The MARAC meeting of 1st May 2012 could have been convened a little earlier, following the difficulties caused by the father’s behaviour after mother(b) and the children left the father and mother(a) in February 2012. CSC had had the historical information about the father’s violent past since 22 2011 and could have contributed this to a consideration of any potential risks to mother(a) and her children who continued to live with the father. 9.35 There was insufficient consideration of the risks to the children who remained with the father and mother(a), the focus was on potential risks to the victim mother(b) and her children. 9.36 The incident of March 2012 shortly before the fire was responded to appropriately; however, although no offences had been committed, there was no referral to CSC, which would have been appropriate action in the circumstances. 9.37 The information that has emerged during this review evidences that the father is a man with a violent past. He also has a history of finding challenges to his authority difficult, particularly where this involved the ending of relationships with former partners and access to their children. However, this was not known or observed, over time as a pattern, by professionals during the period covered by this review. 9.38 There were relatively few incidents of domestic abuse that were reported or became known, during the period covered by the review. The significantly violent offence of 1978 was not known until 2011 due to the way records were previously held and because the incident did not involve a child. Learning 9.39 There were however a small number of incidents, albeit minor in nature that should have resulted in referrals being made to relevant partner agencies by the Police. However, the failure to make these referrals is unlikely to have influenced a change in how the family were managed by other agencies. 9.40 There could have been more consideration by MARAC of the risks to the children who remained living with the father and mother(a), given the information shared at the meeting. 9.41 Adult behaviour and manner 9.42 The father is a very confident, arrogant, manipulative man and there is evidence from information gathered during this review that professionals were aware of this and at times experienced it: a. He made sexual advances towards a Midwife, and hugged her in the presence of her husband. b. There are examples where he appears to attempt to take the initiative and report incidents to the Police where he has committed a criminal offence for example his assault of mother(a). 23 c. He had a reputation for being hostile and verbally aggressive which did act as a deterrent to some staff, although in fact it appears that it was only Social Workers who directly experienced his aggressive and controlling manner. 9.43 However, he is described by school as co-operative and reliable. When he became angry about the disciplining of one of his children, he apologised the following day. 9.44 There is no evidence that his manner affected the services provided by practitioners and agencies took appropriate steps to ensure this by supporting and protecting their staff, for example by ensuring that senior practitioners or managers either accompanied more junior staff or dealt directly with him. Learning 9.45 However, whilst he was known to be challenging to some professionals and in the media, there does not appear to have been any reflection or professional curiosity as to what he might be like at home and the impact of this on his family. There is also no information on the father’s history or any exploration of his experience of childhood. Several agencies did not know of his violent past; had they, they may have considered their assessment of him differently at the time of their involvement. 9.46 The impact of media coverage: 9.47 The father and his family appeared in the press and media on a number of occasions: a. In March 2006 the Daily Mail published an article headlined Dad of 14 - “I want a bigger house”. The article describes how the father was living in a house with his wife and his “mistress” along with several of his 14 children. The father claimed that at the time that he was living in a tent because the house was too small. Comment was made that the father had applied for a larger house but none was available. The article stated that he was expecting a fifteenth child. b. In August 2006 the Sun newspaper published an article headlined “Dad of 14, sick of Britain”. This article features the family and how their application for a larger house had been turned down by Derby City Council. c. In November 2006 The Daily Telegraph published an article headlined “Shameless (naming father)”. This article was very similar in content to the Daily Mail and The Sun newspaper articles and it described the family and how they were seeking a larger house. It also stated that both his partners were pregnant. The article quotes an unnamed 24 Council spokesman who stated that the house was large enough to accommodate sixteen people. d. In 2007 the father, along with mother(a) and mother(b), appeared on the Jeremy Kyle show. The father described how he slept in a caravan adjacent to the house and his two partners alternated sleeping with him on a nightly basis. Though unprovoked, the father became aggressive with the show host without justification, resulting in a member of the security staff being called to stand on the stage. The father appeared to be very defensive of his children and challenged any criticism despite none being made of them during the show. e. In 2007 the father featured on a programme entitled “Ann Widdecombe Versus the Benefit Culture”. The theme was to challenge the benefit culture and engaged a number of individuals who were unemployed and claiming benefit and get them into employment. The father was one such individual, the programme found him a job but he failed to turn up, claiming that he had an injured wrist. Analysis 9.48 Most agencies were aware of the father’s notoriety, the media appearances and the hostility to him by neighbours and the public but there is no evidence that this had a detrimental impact on the way they dealt with the family. However, there is also no evidence that his media appearances, what he reported and the way he appeared was reflected on in relation to what sort of father he was by individual agencies or through a multi-agency meeting when there was particular involvement with the family in 2006 and 2012. 10.0 Conclusion 10.1 The death of any child is a profound tragedy and creates distress for the family, the community and the professionals involved. This Serious Case Review concerns the deaths of six children and has created national concern and a wish to understand why the events that took place occurred. There is, quite naturally, some interest in the fact that the children lived in the circumstances in which they did, the extent to which this was challenged by agencies and that they remained with parents who were capable of such atrocious behaviour. 10.2 The aim of this Serious Case Review is not to investigate the incidents that occurred on 11th May 2012, as this has been concluded by legal process, but it is to examine closely the work of individual agencies and their inter-agency practice, to identify any learning and to answer the key question ‘Could the deaths of the children have been predicted and/or prevented?’ 25 10.3 There are a number of factors that I have born in mind when reaching a conclusion: a. The parents have been convicted of manslaughter, not murder which would indicate deliberate intent. b. The living arrangements of the children were well known to agencies and the public, indeed the father boasted about them on television in 2006. This was not a secret arrangement and though morally unpalatable to some, it was not bigamous and therefore not illegal. c. Agencies took the view that the arrangement, though unusual, was not apparently harmful to the children. d. No member of the family, immediate or extended, the community or any agency raised concerns about the care of the children, during their lives before the fire. e. Before the fire, the children were not hidden from or invisible to universal services. Their voices were well heard: o They were well known to their school teachers who described them as happy, well adjusted, caring children who had good relationships with each other and with children from other families. They did not appear cowed, malnourished or uncared for and attended school regularly. Although they did not join in school outings, this is not uncommon in large families where resources can be stretched. o The children’s contact with health services was unremarkable. Their contacts with the Primary Care Health Team were appropriate and would not have alerted the team to any safe guarding issues. The illnesses that the children presented with at the surgery did not indicate that these were related to overcrowding issues. The parents did not make any excessive or inappropriate demands from the health professionals. The frequency of attendance at the GP practice was not excessive. There is no evidence of persistent ill-health. The children did not have any excessive or inappropriate contacts with the out-of-hours health services and they were not taken to different hospitals, in an attempt to avoid detection of abuse. o None of the children were involved in criminal behaviour. 10.4 The parents of the children, particularly the father, engaged well with the children’s schools. He also made contact with Children’s Social Care, Health professionals and Housing, to support him with his request for a larger house. 10.5 There were some challenging aspects for all professionals which are identified in this report. 10.6 When reviewing practice over several years it is important to consider what was expected of professionals at the time and what research and professional knowledge guided their practice. As could be expected, when 26 reviewing the practice of a number of agencies who had contact with the family, the quality of practice has been found to be variable with some good professional practice and some that could have been better. However, in the months before the deaths of the children it is apparent that, with hindsight and the wealth of information provided by the IMRs, the situation within the household was increasingly difficult, particularly after mother(b) left with her children and as the father began to be less able to exert control, there were also increasing difficulties without information being gathered together about the whole family and a lack of consideration about the father and his adult relationships. This would have ensured that the father’s violent history was made known to all agencies and it may have resulted in closer involvement in the family and some additional support however, given the reluctance of the mothers to describe what life in the family was really like, indeed a former partner has said she would not have confided in anyone, due to her fear of the father, it is unlikely that a true picture would have been obtained; it is also unlikely that the family would have accepted any intrusion into their family and given the lack of any verbal or behavioural concerns from the children there were no grounds for statutory intervention, or the removal of the children. 10.7 There is no evidence whatsoever that the intention to start the fire that killed the children was known to any agency and I am of the view that the intention could not have become known prior to the event. 10.8 Given the notoriety of the father, the incidents of domestic abuse and visibility of the children there were some opportunities to get to know the family better. However, this would not have led to professionals becoming aware that there were plans to deliberately set fire to the house when the children were sleeping. 10.9 I am therefore of the opinion that the tragic deaths of the children could not have been predicted or prevented. 27 11.0 Recommendations 11.1 The agencies involved in this SCR have made a number of recommendations, which are attached below, some of these have already been implemented and the DSCB will monitor the implementation of the remainder. Overview Recommendation 1 Ensure Multi Agency Risk Assessment Conferences (MARACS) consider not just the victim, but all children who possibly remain at risk from the perpetrator. Agency Recommendations Recommendations: Children’s Social Care 1 For all referrals, explicit consideration should be given to any needs which may arise for siblings or half-siblings. The decision whether to include other children in a referral, and the rationale for this, should be clearly recorded on the case file. Recommendations: Derbyshire Police 2 All front line police officers will be reminded of the necessity to document the details all children at an address when attending incidents of domestic violence and to fully consider their welfare, making physical checks whilst they are asleep in bed where necessary. Recommendations: Education Service 3 Improve security of use of E1 Database and text messaging by schools, particularly in relation to safeguarding and domestic violence. 4 All head teachers aware of potential for breaches of confidentiality that E1 Database and texting poses, particularly with regard to schools with a Women’s Refuge in their catchment area. Recommendations: Derbyshire Healthcare Foundation Trust 5 Consider through a review of this case if toxicology reports should be considered as a more significant element of risk assessment where there is contradictory information to the reported overdose. Recommendations: Derby Hospitals NHS Foundation Trust 6 That the impact of parental mental ill health on children should be identified when adults attend emergency departments with overdose/self-harming behaviour. Recommendations: Derbyshire Fire and Rescue Service (DFRS) 7 To firmly connect and communicate the National Fire Safety messages of having fitted, working tested smoke alarms on each level of a domestic property with the recommendation for a practised, familiar escape plan that is 28 familiar to anyone in the property (family, friends and visitors) and that smoke detectors are additionally located in bedrooms and that they are easily heard throughout the property. 8 DFRS will continue to work in partnership with developers, the residents of Derbyshire and social housing landlords to encourage the installation of sprinklers in new builds and homes occupied by the most vulnerable people. 9 Local and national attention continues to be drawn to the publication of the current and future research into the effectiveness of domestic smoke alarms in waking children under the age of 13 years. Recommendations: Derby Homes 10 Completion of overcrowding assessment to be reviewed and countersigned by senior manager. 29 Appendix 1 The Review Process: Terms of Reference 1.0 Expert Opinion 1.1 The need for expert opinion was reviewed during the SCR and was obtained about the publication of the report and compliance with both the Reporting Restriction Order and the human rights of surviving relatives. 2.0 The period over which it was agreed events should be reviewed and the framework for the Independent Management Reports (IMR) 2.1 The period of time which has been focussed on has been February 2006 until May 2012 but this period has been flexible and extended to cover any additional key issues that emerged during the SCR. An outline of key events during the above period was provided for IMR authors and their chronologies have concentrated on these key events. Additional events may subsequently have been included if relevant, as judged by the IMR Authors, the SCR Panel, Overview Author, Health Overview Author and/or Independent Chair. ‘Key events’ mean those events where agencies had opportunities or duties to assess the needs of the children and those events over the preceding year that appear to be linked to the tragic outcome for the children. Routine events have not been included. 3.0 Chronologies 3.1 One chronology has been completed by each agency and covers all the six children who died, providing a short and succinct illustration of relevant events for each child. An explanation of the significance of the events has been highlighted. The chronologies cover the period from February 2006 until May 2012. The IMR authors have exercised judgement about what is relevant and significant and whether additional information should be included that predates the timeframe. Specific IMRs address issues outside this timeframe and the details are set out below. 4.0 The key issues addressed by all IMRs 4.1 The following questions were considered by each agency in reviewing their practice for this SCR: a. Were practitioners aware of and sensitive to the needs of the children in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? Had they appropriate training and supervision? 30 b. When, and in what way, were the individual child’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded? c. What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Did actions accord with assessments and decisions made? Were appropriate services offered/provided or relevant enquiries made, in the light of assessments? d. Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? e. Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with? f. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded? g. Were senior managers or other organisations and professionals involved at points in the case where they should have been? h. Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? Was the work in this case consistent with each organisation’s and the DSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? I. Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff being absent on sick leave or subject to disciplinary procedures have an impact on the case? Was there sufficient management oversight and accountability for decision making? 5.0 Organisations involved in this SCR 5.1 Individual Management Reviews have been provided by: 31 a. Derby City Council Children and Young People’s Department (covering Children Social Care and Early Intervention Services) b. Derbyshire Constabulary c. Derbyshire Healthcare Foundation Trust (Universal Services and Mental Health Services) d. Derby Hospitals NHS Foundation Trust (Midwifery and Royal Derby Hospital) e. NHS Derby City (CCG) (GP services) f. Derby City Council Learning and Inclusion Service (covering schools’ involvement) g. Derby City Council Housing Services h. CAFCASS i. Derbyshire Probation 5.2 Summary Reports have been provided by: a. Derbyshire Fire and Rescue Service b. East Midlands Ambulance Service 6.00 The Involvement of Family Members 6.1 The principle of involving family members has underpinned this SCR. 6.2 The father and mother were invited to participate in the review and to share their views with the Overview Author. Both declined to have any involvement. 6.3 Father's former partner has participated in the review and her invaluable contribution is included in a way that is consistent with the Reporting Restriction Order. 7.0 Other Parallel reviews (e.g. PPO/ homicide or suicide reviews) 7.1 There were no parallel reviews. 8.0 Involvement of organisations in other LSCB areas 8.1 LSCBs, where children lived in the area, were notified of the SCR 9.0 Coroner’s Inquiries/Criminal Investigations 9.1 The conclusion of the criminal trial and conviction of manslaughter of the father, mother and third adult means that a Coroner’s Inquiry will not be required 32 10.0 SCR Review Timescales The commencement of the SCR was delayed, due to the complexities set out above and therefore it has been completed outside the expected six month timescale. 11.0 Independent Overview Author 11.1 Glenys Johnston OBE has been commissioned as the Independent Overview Author. She has previously been the Independent Author of a SCR in which children died as a result of a fire caused by their parent and several other SCRs. She has extensive safeguarding experience as an Assistant Director for Children and Families Services; she is the former Independent Chair of a tri-partite LSCB and the current Independent Chair of an LSCB and SAB. She has undertaken a considerable number of inspections and reviews and a domestic homicide review. 11.2 Mrs Johnston has never been employed by any of the organisations involved in the SCR and has no personal connection with any of the professionals involved in the case. She is therefore considered to be independent Derby City Council. 33 Appendix 2 Agency Action Plans Derby Safeguarding Children Board Action Plan Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Ensure Multi Agency Risk Assessment Conferences (MARACS) consider not just the victim, but all children who possibly remain at risk from the perpetrator. Issue guidance to attendees at MARAC to require consideration on all relevant children Risks to all children in contact with the perpetrator have been assessed and action taken to ensure the children are safe Chair of MARAC Jan 14 MARAC minutes record confirmation of the consideration of all relevant children An audit report will be provided to the Board to demonstrate compliance in March 2014 Children’s Social Care Action Plan Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 For all referrals, explicit consideration should be given to any needs which may arise for siblings or half-siblings. The decision whether to include other children in a referral, and the rationale for this, should be clearly Review protocol for file alerts and ensure any individual who is assessed as posing a risk to child is tagged in future Staff can readily identify any adult who may present a risk to children Service Director – Specialist services March2014 Robust alert process is in place enabling individuals who present a risk to be identified Data cleansing process of current records to take place before migration to new recording system (April 2015) In the commissioning of a new CYPD recording system, address how to provide easy access to Staff can readily identify related or linked children to check their As above As above Staff guidance has been re-issued for use of current recording system Current procurement process for new recording system 34 recorded on the case file historical and sibling records records, and will easily see relevant historical info will ensure this requirement is an integral part of system. New system to be in place for April 2015. Issue guidance to explicitly consider related children, to all current Social Workers and managers, with particular focus on Reception. Include in assessment checklist. Ensure this is addressed in training Related children are considered with all referrals accepted by social care Service Director EISS Jan 2014 Revised flow chart developed for First Contact Team- staff briefed week commencing 13/1/14 Assessment check list developed for Reception workers- currently in draft for consultation- staff briefed on draft week commencing 13/1/14 To ensure action is reflected in guidance for new Single Assessment Guidance (joint with Derbyshire County Council). Implementation of new assessment scheduled for April 14 Baseline audit of files of sibling groups completed Nov/Dec 2013 Further audit of files of sibling groups completed Nov/Dec 2014 Clarify use of linked referrals for related children and how Guidance in place and staff are clear Service Director – March 2014 Current system specification allows File auditing tool and monthly 35 the required response or management action can be assured. Specialist services for the linking of referrals of related children. Staff memo to be issued January 2014 reminding staff of process. Also an integral part of training and induction on the system process provides opportunity for regular monitoring including at first contact point Clarify practice with regard to "sign-off" function on referrals, assessments, etc on sibling records to ensure decisions are recorded on all siblings Guidance in place and staff are clear Service Director – Specialist services March 2014 Required practice has been confirmed with managers and staff and streamlined process will be built into new recording system Audit of files of sibling groups completed Nov/Dec 2013 36 Derbyshire Police Action Plan Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 All front line police officers will be reminded of the necessity to document the details all children at an address when attending incidents of domestic violence and to fully consider their welfare, making physical checks whilst they are asleep in bed where necessary As part of the ongoing awareness raising in Safeguarding issues across the Force, a message will be sent out to all officers and staff utilising ‘Chief’s Orders’ and there will be a periodic reminder in one of the Public Protection bulletins highlighting SCR lessons Action has been completed Head of Public Protection Sept 2013 July 2013 Bulletin has been circulated There will be a periodic reminder in one of the Public Protection bulletins highlighting SCR lessons Dec 2013 37 Education Service Action Plan Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Improve security of use of E1 Database and text messaging by schools, particularly in relation to safeguarding and domestic violence. Review E1 Database current custom and practice so that safeguarding practice is improved Estranged parents who no longer have access to children do not learn of children’s new school via text message circulars from new school using out of date contact details. Information Manager Information and Performance Analyst Head of Inclusion and Intervention Sept 2013 Guidance forms part of routine safeguarding training for school heads and schools’ data protection officers Guidance delivered to all schools Summer 2013 and will be repeated Spring 2014 2 All head teachers aware of potential for breaches of confidentiality that E1 Database and texting poses, particularly with regard to schools with a Women’s Refuge in their catchment area Head teacher’s to be made aware through briefing meeting and through School Circular. Head teachers and school staff aware that contact details of children transferring to a new school following parents move to a Women’s Refuge do not include contact details for estranged partner. Records from previous schools should not be copied into the receiving schools records. Head of Inclusion and Intervention July Term 2013 LSCB provided with copy of agenda and briefing Guidance forms part of routine safeguarding training for school heads and schools’ data protection officers Dec 13 38 Derby City Health Providers Action Plan Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken On-going monitoring Date signed off by LSCB Derbyshire Healthcare Foundation Trust 1 Consider through a review of this case if toxicology reports should be considered as a more significant element of risk assessment where there is contradictory information to the reported overdose Trust to adopt this recommendation with toxicology report forming part of all deliberate self-harm assessment. Adoption of recommendation by September 2013. Deputy Chief Nurse/ Head of Effectiveness Sept 2013 Emergency Dept. Liaison Services compliant with recommendation Subject to random audits March 2014 and reported when completed to the Health Quality Assurance hub Derby Hospitals NHS Foundation Trust 2 That the impact of parental mental ill health on children should be identified when adults attend emergency departments with overdose/self-harming behaviour That all staff are reminded of the importance of asking all adults about their care of children and the necessity of referral That staff “Think Family” when adults attend emergency departments with self-harming behaviour and refer relevant children to Children’s Social Care for assessment Trust Lead for Safeguarding Completed E-mail and training notes Audit of referrals to be started by June 2014 and reported when completed to the Health Quality Assurance hub 39 Derbyshire Fire and Rescue Service (DFRS) Action Plan Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 To firmly connect and communicate the National Fire Safety messages of having fitted, working tested smoke alarms on each level of a domestic property with the recommendation for a practised, familiar escape plan that is familiar to anyone in the property (family, friends and visitors) and that smoke detectors are additionally located in bedrooms and that they are easily heard throughout the property. All press releases and media communication to contain these messages. Communication of this across the Service via its internal Organisational Assurance Bulletin. Increased number of fitted smoke alarms in domestic properties Corporate Communications Officer Immediate effect Press releases and corporate communication. Entry on DFRS website This to be monitored by the Service’s Corporate Communications Department Dec 2013 2 DFRS will continue to work in partnership with developers, the residents of Derbyshire and social housing landlords to encourage the installation of sprinklers in new builds and homes occupied by Where appropriate produce memoranda of understanding with partners to encourage the installation of domestic sprinkler systems MoUs produced and signed off between partner agencies. Installation of domestic sprinkler systems in homes occupied Chief Fire Officer Continuing MoUs signed off between partner agencies Prevention & Inclusion Department to monitor progress and report to Service via its Strategic Leadership Team Dec 2013 40 the most vulnerable people. by vulnerable people. 3 Local and national attention continues to be drawn to the publication of the current and future research into the effectiveness of domestic smoke alarms in waking children under the age of 13 years. On completion, the research should be published as soon as possible. That the research be disseminated as widely as possible and the results used to encourage smoke alarm manufacturers to develop systems to address this problem. Corporate Communications to disseminate the message Research completed June 2013 Press release produced and disseminated June 2013 Continuing close liaison with manufacturers to ensure this is achieved Dec 2013 Derby Homes Action Plan Recommendation Actions required Outcome required Responsible person Timescale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Completion of overcrowding assessment to be reviewed and countersigned by senior manager. Discussions for Service Level Agreement with Housing Standards for completion of overcrowding assessments. Independent review and countersignature by senior manager Overcrowding Assessments with be independently assessed to ensure decisions are quality assured Head of Housing Management. Head of Housing Options Oct 13 New standard forms produced for overcrowding assessment and counter signature by a senior officer. Audit of compliance with procedures as part of wider housing management audits reported to Board at the end of March 14 |
NC050516 | Death of a 7-week-old baby girl in September 2020. Isla was found unresponsive in the arms of her sleeping mother. Learning themes include: risks around past and present substance misuse and parenting; family and environmental factors contributing to neglect; risk of sudden unexpected death in infancy (SUDI) and safe sleeping advice; and effectiveness of agency assessments, risk management, decision making and rigour. Recommendations for the local safeguarding children's partnership (LSCP) include: promote collaborative assessment, information sharing and clear pathways between both systems and services to ensure families experiencing drug or alcohol problems receive holistic, child and whole family approaches; disseminate information on the risks associated with cannabis use during pregnancy, challenging any complacency in practice due to common use of the drug; support practitioners with the skills to enable confident conversations with parents on difficult topics such as neglect, SUDI risk and safe sleeping; explore ways of improving practitioner understanding of cumulative neglect, identification and impact of poverty, and possible desensitisation to the warning signs of neglect; informal space for practitioners to think reflectively on practice themes; and ensure the red, amber, green (RAG) risk rating process is effective and clearly communicated to all lead practitioners.
| Title: Local child safeguarding practice review: Baby Isla. LSCB: Plymouth Safeguarding Children Partnership Author: Andrew Bickley Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. OFFICIAL:SENSITIVE Plymouth Safeguarding Children Partnership Local Child Safeguarding Practice Review Baby Isla Authored by: Andrew Bickley, Independent Safeguarding Consultant Published: June 2022 1 OFFICIAL:SENSITIVE Contents 1.0 ISLA – A PEN PORTRAIT .................................................................................................................................................. 2 2.0 THE CRITICAL INCIDENT THAT LED TO REVIEW ............................................................................................................... 2 3.0 COMMISSIONING AND PURPOSE OF LOCAL CHILD SAFEGUARDING PRACTICE REVIEW ................................................. 3 4.0 THE REVIEW PROCESS .................................................................................................................................................... 4 5.0 FAMILY ENGAGEMENT IN THE REVIEW .......................................................................................................................... 5 6.0 FAMILY COMPOSITION .................................................................................................................................................. 6 7.0 BACKGROUND HISTORY ................................................................................................................................................. 7 8.0 CONTEXTUAL INFORMATION AND SUMMARY ............................................................................................................... 7 9.0 ANALYSIS BY THEME .................................................................................................................................................... 10 9.1 IDENTIFYING RISKS AROUND PAST AND PRESENT SUBSTANCE MISUSE AND PARENTING ........................................................................ 10 9.2 IDENTIFICATION OF FAMILY AND ENVIRONMENTAL FACTORS WHICH MAY CONTRIBUTE TO NEGLECT ....................................................... 12 9.3 RISK OF SUDI AND SAFE SLEEPING ADVICE ................................................................................................................................. 16 9.4 EFFECTIVENESS OF AGENCY ASSESSMENTS, RISK MANAGEMENT, DECISION MAKING, RIGOUR ................................................................ 18 10.0 IMPACT OF COVID-19 AND ORGANISATIONAL DEMANDS ............................................................................................ 19 11.0 IDENTIFIED GOOD PRACTICE ........................................................................................................................................ 22 12. LESSONS FOR THE PARTNERSHIP ................................................................................................................................. 22 13. CONCLUSIONS .............................................................................................................................................................. 24 14. LEARNING INTO PRACTICE CONSIDERATIONS .............................................................................................................. 26 15. ACKNOWLEDGEMENT .................................................................................................................................................. 27 Note: The names of those involved in this case have been changed to ensure their anonymity and the privacy of individuals and wider family members. 2 OFFICIAL:SENSITIVE 1.0 ISLA – A PEN PORTRAIT 1.1 This review focuses on a seven-week-old baby girl who died in September 2020. For the purposes of this review, she is referred to as Isla. Isla is of British white ethnicity and at the time of her death lived with and in the care of her mother and father, who within this review will be referred to as Karen and Colin, respectively. Isla had three older siblings who also live at the family home. Isla’s eldest sibling is an 8-year-old boy who will be named throughout this review as Daniel. Daniel has complex needs, including autism and severe learning difficulties. Daniel and his family are supported by children’s social care (Children’s Disability Team) and the hospital Children Development Centre in respect of these complex needs. Daniel attends a school with specialism in meeting the needs of children and young adults with complex needs. Isla also had two older sisters, aged under 6, who are named in this review as Elizabeth and Susan, respectively. Elizabeth has some additional needs but neither Elizabeth or Susan were, at the time of Isla’s death, open to children’s social care as children in need. Susan is described by her general practitioner as fit and well and has no additional needs. 1.2 Karen and Colin describe Isla as perfect in every respect, a baby that completed their world and meant everything to them. To give birth to Isla represented a blessing to them both as Karen carried age and significant medical related anxiety throughout her pregnancy, often believing that she would miscarry. Both parents speak with affection about Isla’s beautiful red hair, dark eyes, and dainty presence. A corner of the dining room holds photographic and other memories of Isla, as a visible representation of the daughter they cherished. Part of the rear garden of their home has also been set aside as a ‘fairy garden,’ a place for her family to reflect on the happiness Isla brought to them. 2.0 THE CRITICAL INCIDENT THAT LED TO REVIEW 2.1 On the morning of 18 September 2020, Isla was discovered by her father, at their home address, unresponsive in the arms of her sleeping mother. Colin called the ambulance service using the 999 system. Both Colin and Karen remained on an open line to the ambulance control room whilst Karen attempted cardiopulmonary resuscitation (CPR). When Karen gave the first breath into Isla, she described that there was “an eruption of blood from Isla’s mouth.” An ambulance subsequently attended the home and CPR was then undertaken by clinicians. Isla was taken to the Emergency Department by ambulance and CPR continued, but Isla was declared dead on arrival. During CPR provided by clinicians, blood had been found around Isla’s mouth. 2.2 In the early hours of 18 September, the family report that Isla had been given a feed by Colin and was initially placed in the cot. She would not settle in the cot and slept resting in the right arm of her mother, Karen, supported by a ‘V’ shape pillow. Isla was swaddled and face up which was reported to be her normal sleeping position. Karen slept in the dining room of the property, in a single leather square seat in the corner of the room next to Isla’s travel cot. It was in this seat that Isla was discovered by Colin to be unresponsive in Karen’s arms around 8am that morning. 2.3 Following police and ambulance clinicians’ attendance at the family home on the date of Isla’s death, significant concerns were raised in relation to the sleeping arrangements of Isla and her mother. The family report that Colin slept in the lounge of the property with Daniel, so he could provide for Daniel’s care and support needs, manage Daniel’s limited sleeping pattern (sometimes sleeping as little as 20 minutes within 24-hour periods) and to promote Karen’s and Isla’s opportunity to sleep. Following attendance at the home on the morning of this critical incident, it was seen by the police that Isla’s travel cot was cluttered and showed no signs of her having been able to sleep in it. Colin and Karen challenge this assertion, and they report that Isla had slept in the cot the previous night, and during the night of her death she had also been placed in the cot to sleep as she was described by her parents as restless and grisly. The family report that the cot only contained soft toys and blankets, covered by a 3 OFFICIAL:SENSITIVE changing mat. Colin and Karen believe the ‘clutter’ described when the police arrived is likely to have been because of frantic attempts to revive Isla and the panic that arose when she was found to be unresponsive. However, the police reported feeling that the scene they encountered was not about one morning of panic, but many weeks and months of a neglectful home environment. 2.4 As well as the general unease with the sleeping arrangements agencies were also concerned about the condition of the family home, mother’s complex needs, medical history, and substance misuse. 2.5 A full post-mortem was carried out with ancillary tests. Following post-mortem toxicology1, it was established that neither alcohol nor drugs played a part in Isla’s death and the cause of her death is unascertained. There is no information which suggests Isla’s death was caused by a non-accidental injury. Due to the possible sleeping circumstances, the forensic pathologist has stated that Isla’s death would not fulfil the criteria of a ‘sudden infant death syndrome or SIDS2.’ Following investigation by the police, criminal proceedings have not been instigated against the parents or any other individual. An inquest is still awaited at the time of concluding this report (May 2022). 3.0 COMMISSIONING AND PURPOSE OF LOCAL CHILD SAFEGUARDING PRACTICE REVIEW 3.1 This review was commissioned by the Plymouth Safeguarding Children Partnership (PSCP) in accordance with the Working Together to Safeguard Children (2018) statutory guidance.3 Following discussions between Devon and Cornwall Police and Plymouth City Council it was agreed that Isla’s death met the criteria of a serious incident notification in that: Abuse or neglect of Isla was known or suspected and Isla had died. 3.2 A Serious Incident Notification was submitted by the local authority to the National Safeguarding Practice Review Panel (“the Panel”). As a consequence of this notification the Plymouth Safeguarding Children Partnership (“the partnership”) undertook a rapid review which identified key learning points and findings for the partnership. These are set out in paragraph 4.4 below. The rapid review concluded in October 2020 and recommended that a local child safeguarding practice review should be undertaken under the Working Together to Safeguard Children (2018) guidance. Findings and recommendations contained within the rapid review were welcomed by the Panel with immediate learning being identified, which included: The need to improve multi-agency awareness of safe sleeping and to work with families to have sight of sleeping arrangements within the family home. A review of the criterion and guidance used for the ‘Red, Amber Green’ rating system which informed the green risk assessment for this family by the Children’s Disability Team, meaning virtual home visits as opposed to physical visits could be facilitated during the Covid-19 pandemic. 1 Conducted in accordance with child death review (Working Together to Safeguard Children (2018), Chapter 5) 2 This refers to the sudden and unexpected death of an infant under 12 months of age, with onset of the lethal episode apparently occurring during normal sleep, which remains unexplained after a thorough investigation including performance of a complete post- mortem examination and review of the circumstances of death and the clinical history. (The Royal College of Pathologists, Sudden unexpected death in infancy and childhood. Multi-agency guidelines for care and investigation 2nd edition, November 2016). 3 Chapter 4 4 OFFICIAL:SENSITIVE These issues were addressed through multi-agency training and awareness raising, and a full review of the RAG rating system within the Children’s Disability Team by the local authority service manager for safeguarding and quality assurance. 4.0 THE REVIEW PROCESS 4.1 The local learning review process was postponed by the partnership in January 2021 due to the Covid-19 pandemic lockdown restrictions and the associated challenges in both responding to the demands of the pandemic and managing the impacts within the workforce. Detailed scoping and planning arrangements were undertaken between March and April 2021 with the aim of delivering an Appreciative Inquiry model of review involving partnership practitioners and managers. Two Appreciative Inquiry Learning Events were scoped, referenced, and put in place with supporting materials to promote strength-based facilitation and learning. Following challenge from key practitioners as to the independence of this process and pressures of meeting timescales, these events were withdrawn by the partnership. However, Appreciative Inquiry information gathering forms aligned to the key lines of inquiry identified within the rapid review (paragraph 4.4), were sent to all involved agencies for completion. 4.2 Additional operational pressures on the partnership further delayed the completion of the review. In October 2021, the three statutory safeguarding partners on the partnership’s Child Safeguarding Practice Review Group concluded that a detailed and analytical desktop review of the material available should be undertaken by the independent quality assurance lead for the partnership. This decision was ratified by the partnership’s strategic lead partner. It is acknowledged that despite these deferments, learning on issues identified in this case were still being addressed through wider partnership work on the drivers of neglect and sudden unexplained deaths in infants (SUDI)4. This work was undertaken through the partnership’s quality assurance arrangements, single and multi-agency training, and the embedding of the partnership’s ICON package and Dad Pad5 to support safe sleeping. 4.3 The agencies involved in this review are: Plymouth City Council Livewell Southwest Devon and Cornwall Police University Hospitals Plymouth NHS Trust Southwest Ambulance Service Trust Schools attended by Daniel, Elizabeth, and Susan Family General Practitioner. 4.4 Several documents and submissions completed for and after the rapid review process were considered as part of this report: Agency Initial Scoping and Information Sharing Forms Integrated Multi-Agency Chronologies Appreciative Inquiry information gathering forms received from Plymouth City Council – Children’s Disability Team, Devon & Cornwall Police and Livewell Southwest. Returns were not received from 4 This is the preferred term for use in cases in which there is no clear cause of death and there are no features to suggest unnatural death or inflicted injury, but in which the circumstances do not fit the criteria for SIDS (for example, deaths in which the history, scene or circumstances suggest a high likelihood of asphyxia but in which positive evidence of accidental asphyxia is lacking). (The Royal College of Pathologists, Sudden unexpected death in infancy and childhood, Multi-agency guidelines for care and investigation 2nd edition, November 2016). 5 ICON : Babies Cry, You Can Cope! - Plymouth Safeguarding Children Partnership (plymouthscb.co.uk) 5 OFFICIAL:SENSITIVE University Hospitals Plymouth NHS Trust, Southwest Ambulance Service Trust, the School, and Family General Practitioner National literature, research papers and related evidence. 4.5 Initial draft reports and conclusions based on the desktop review, rapid review and consideration of national literature and learning reviews were submitted to the partnership between December 2021 and March 2022. 4.6 Whilst valid, these reports highlighted several gaps in the information and knowledge of the partnership that could only be meaningfully addressed directly with practitioners and managers involved with providing a range of services to the family during the review period. Consequently, the partnership arranged for a reflective learning workshop to be held with practitioners and managers in April 2022 facilitated by an independent consultant with a professional background in social work. Seven professionals attended the in-person workshop, representing the following agencies: Devon and Cornwall Police University Hospitals Plymouth NHS Trust Schools attended by Daniel, Elizabeth, and Susan Plymouth City Council - Children’s Disability Team Livewell Southwest. The review author also attended as did members of the PSCP Business Unit. 4.7 In preparation for the event, thematic lines of inquiry were identified, which the attendees were asked to reflect upon during the workshop. Questionnaires were also circulated to attendees prior to the workshop which sought specific information in the areas of supervisory support arrangements for practitioners, the specific nature of agency involvement with Isla and her family, definitions of home visits and policies that influenced the need to undertake virtual or physical home visits during the response to Covid-19. The event was run as a plenary session and included agencies being asked to reflect on the risk factors associated with issues of neglect which may have impacted on family members and the home environment. These risks were documented on pro-forma questionnaires by the attendees and subsequently shared with the report author. 4.8 The review covers the period between September 2019 and September 2020 and focuses on the themes identified within the rapid review, which form the scope of this review: Identifying risks around past and present substance misuse and parenting. Identification of family and environmental factors which may contribute to neglect. Risk of SUDI and provision of safe sleeping advice. Effectiveness of agency assessments, risk management, decision making and professional rigour. 5.0 FAMILY ENGAGEMENT IN THE REVIEW 5.1 Karen and Colin were keen to contribute to the review and did so through a meeting with the review author. This meeting offered an opportunity for both parents to ask questions on the review process, including the purpose of the review and outcomes arising from it. The issues of review publication and the anonymisation of the review were also discussed. The meeting started with Karen and Colin giving the pen portrait of Isla, captured at paragraph 1.2 above. They offered, on more than one occasion, self-reflections on what they could have potentially done differently which may have prevented their tragic loss. The following paragraphs present their feedback and considerations which they wish to be included and recognised as part of this review. 6 OFFICIAL:SENSITIVE 5.2 Karen shared her deep anxieties and concerns with her pregnancy given her complex and long-standing health conditions (including heart conditions, emphysema), sustained use of medication and use of drugs (past and present). Karen’s age was also a worry for her. The family report that these uncertainties led to Karen having several scans throughout the pregnancy at times once every 7 to 10 days. These scans were undertaken in a private facility at the parents’ expense, prioritised within the family budget. Karen carried a pervading sense that she would miscarry as the odds were stacked against a healthy baby being born. 5.3 The restrictions in place because of the Covid-19 pandemic created what Karen describes as a surreal pregnancy for her. She advised that most of her clinical appointments were undertaken alone, without the support of Colin or via Zoom or telephone calls. When discharged from hospital, Karen felt very unsure of how to manage the transition to her home environment with Isla. Karen feels an unfounded and unrealistic confidence was placed on her abilities to be a good mum by healthcare workers when she returned home. Karen felt that she had been left and was isolated. To illustrate this Karen highlighted the fact that Isla’s index finger on her left hand was red, swollen and contained pus but, according to Karen, no medical interest was shown in this. 5.4 During the reflective learning workshop, health professionals believed that there was a close working relationship with Karen during and after her pregnancy. Midwifery and health visiting services visited the home. They recognised the extremely complex nature of Karen’s health conditions and vulnerabilities that arose from this and felt they invested a prominent level of care in this regard. They stated that Karen was engaged and communicated well with the multi -disciplinary team supporting her. 5.5 In terms of Isla’s swollen finger, health professionals were confident this had been picked up in hospital and identified as ‘paronychia’, a bacterial infection of the nail bed that is common in babies as result of a break in the skin around the nail. However, health professionals were unable to confirm this as Isla’s medical notes were not available to them at the time of the workshop. 5.6 Colin recognised he had a key role in co-parenting and supporting the family, a role which he undertook willingly. Despite the complex family background and context, he reports that he was offered no specific parenting support, guidance, or advice. 5.7 At the reflective learning workshop, midwifery services advised how they were encouraged by the way Colin attended a number of Karen’s appointments and indicated that Colin was present when safe sleeping advice was offered and discussed. They also noted that Colin visited the maternity unit and discussions were also held with him there. 6.0 FAMILY COMPOSITION The names of those involved in this case have been changed to ensure their anonymity and the privacy of individuals and wider family members. Family Member Relationship Ethnicity Baby Isla Baby the focus of this review White British Daniel Brother White British Elizabeth Sister White British Susan Sister White British Karen Mother White British Colin Father White British 7 OFFICIAL:SENSITIVE 7.0 BACKGROUND HISTORY 7.1 Isla was born in July 2020 and was of a low birth weight, remaining in hospital for a period of days for neonatal abstinence syndrome observations (symptoms of opiate withdrawal) due to Karen’s prescribed medication history. Fortunately Isla did not require any treatment for neonatal abstinence syndrome. Isla is the fourth child of the family. 7.2 Karen has a complex physical and mental health medical history, which has included historic drug use. Karen was prescribed opiate-based medication, for pain relief and anxiety, respectively. Karen also reported that she smoked 1 to 3 joints of cannabis a day to aid pain relief, as well as smoking tobacco. 7.3 During a search of the home address on the morning of Isla’s death, police officers located a quantity of cannabis within the property. The quantity was assessed by the police as commensurate with personal use. 7.4 Colin’s medical records indicate one historic episode of him experiencing mental ill- health. There is nothing of significance in other agency records. 7.5 Daniel was Isla’s eldest sibling. Daniel himself has complex needs, including autism and severe learning difficulties. Daniel attends a local school which specialises in meeting the needs of children with such complex needs and is under the care of the local hospital’s Child Development Centre and children’s social care, Children’s Disability Team. 7.6 One of the sisters has developmental delay and complex needs. 7.7 The family lived in an area which scores 35.8 on the overall IMD2010 deprivation6 scale. 34.9% of the private sector housing stock was classed as non-decent homes in 2010, above the city averages of 33.3%.7 7.8 Prior to Isla’s birth the family had arranged for support from paternal grandmother and paternal sister and adult nephew. At the point of Isla’s birth, the paternal grandmother was ill in hospital, but the paternal sister and adult nephew stayed in the family home, for a brief period, to offer support. Neither the paternal sister nor adult nephew was staying at the family home at the date of Isla’s death. The adult nephew continues to offer day to day support for the family. 8.0 CONTEXTUAL INFORMATION AND SUMMARY 8.1 This section provides a summary of the family’s engagement with services from the perspective of the agencies involved in providing those services, as set out below: Hospital Child Development Centre Elizabeth’s and Susan’s School Daniel’s School General Practitioner Public Health Nursing Health Visitor Hospital Midwifery Children Social Care 6 Deprivation measures attempt to identify communities where the need for healthcare is greater, material resources are less and as such the capacity to cope with the consequences of ill-health are less. Areas are therefore deprived if there is inadequate education, inadequate housing, unemployment, insufficient incomes, poor health and low opportunities for enjoyment. A deprived area is conventionally understood to be a place in which the residents tend to be relatively poor and are likely to suffer from misfortunes such as ill-health. 7 Neighbourhood Profile; Public Health, Plymouth City Council (January 2020) 8 OFFICIAL:SENSITIVE Devon & Cornwall Police Southwest Ambulance Service Trust 8.2 The family were known to children’s social care (Children’s Disability Team) in respect of a child in need plan to provide family support for the complex needs of Daniel. In 2017 and 2018 respectively single assessments were carried out. The former following concerns for Daniels’s development delay, Karen’s use of cannabis, Daniel’s dental decay and lack of nursery attendance; resulting in a common assessment framework and no further intervention from children’s social care. The latter followed an episode of a lack of parental supervision, resulting in a strategy meeting and single assessment. This led to early help interventions for the family, but no further intervention from children’s social care. 8.3 A further referral was received by children’s social care in 2019 from ALHELP8 following parental requests for support for Daniel. Concerns had also been raised by Daniel’s school and Children and Adolescent Mental Health Services (Severe Learning Disability) team about Daniel’s behaviour which included hitting his sisters to wake them up. A single assessment was carried out for Daniel regarding his specific needs in December 2019 and he was held on a child in need plan, as agreed with the family, with a review every 12 weeks. 8.4 From December 2019 onwards none of Daniel’s siblings were supported under a child in need plan. Social workers did consider and approach the parents to undertake single assessments for both Elizabeth and Susan, but the parents did not consent to this process. 8.5 The last child in need home visit, prior to Covid-19 lockdown restrictions, took place on 26 February 2020, and the social worker engaged carefully and fully with Daniel, Karen, and Colin to provide further support for them all. At this point the family home is described as, ‘Home remains at good enough level. There is some clutter at the front door of the house. Home is adequately furnished and general cleanliness good enough standard. The home is tired in places.’ 8.6 The family shielded at the point of Covid-19 lockdown in March 2020, due to Karen’s vulnerability arising from her physical health conditions. 8.7 Due to Covid-19 the visiting of the family was ‘RAG’ (red, amber, green) rated green by children’s social care. Virtual visits took place during the period of March to September 2020 in lieu of scheduled face-to-face visits as the family were self-isolating. There was a doorstep visit in June 2020 to deliver a laptop, but the children were only seen briefly by their social worker. The issue of RAG ratings and their application in this review are further analysed in the next section of the report under the heading– Impact of Covid-19 and organisational demands. 8.8 In addition to telephone contacts, the health visitor visited the family on three occasions, in July and August 2020, and there are five midwifery home visits following Isla’s discharge from hospital. Susan’s school did offer her a place at the school, but this was declined by the family due to Karen’s physical health. Both Daniel’s, Elizabeth’s and Susan’s schools made regular telephone welfare calls. Any school concerns regarding Daniel, e.g., behaviour and Karen’s drug misuse, mental health, and anxieties, were appropriately notified to Daniel’s social worker. There were no school concerns indicated about Elizabeth or Susan resulting from the welfare calls. 8 Aiming High Enhanced Lead Professional: Early Help level support for children with special educational needs who do not meet the threshold for statutory assessment. Introduced via the Family and Children Act 2014 9 OFFICIAL:SENSITIVE 8.9 During March 2020 the family advised the hospital’s Child Development Centre that Daniel is having some difficulties, including sleeping, and could be awake 4 to 5 hours per night, being very loud and waking the family. 8.10 At the end of March 2020 agencies became aware that Karen was pregnant. Karen had a specialist midwife who communicated effectively with the health visitor who recorded risk factors including the previous history of drug misuse, prescribed medication, and use of cannabis for pain management. The review did not identify, through written records or in discussions with practitioners, any wider communications between agencies at this point or any escalation of risks based on the family context or the history of any individual family member. 8.11 During June 2020, Karen reports to Daniel’s school her concerns as to Daniel’s behaviour (acting out like a baby), and her concern that Daniel may unintentionally hurt the new baby if she were to fall asleep. These concerns were raised by the school with children’s social care. The documents reviewed do not offer explicit information on any response by children’s social care to these concerns, but there is evidence that the school undertook to create a social story for Daniel on babies crying and keeping babies safe. 8.12 Between June and September 2020 several virtual and face to face (socially distanced) visits occurred either to the family home, or at an agency venue. The last visit by children’s social care took place, virtually, in early September 2020, and Daniel is seen on video. The midwife and health visitor visit the family home to see Karen in July and August 2020, and the health visitor further contacted the parents by phone in September when a home visit is arranged to take place two days later, which was the date of Isla’s death. Records indicate that the practitioners had no safeguarding concerns during this visit with no professional referrals or concerns being logged with children’s social care. The subject of home visits and in particular the kind of activity undertaken during a home visit are pertinent to this review and are further analysed in the next section of this report under the heading- Identification of family and environmental factors which may contribute to neglect. 8.13 In July 2020 a child in need meeting for Daniel is convened and the safeguarding midwife shared information regarding delivery planning and known risks regarding Karen’s health relating to the delivery and impact of medication. Karen and Colin were considered to be seen to be working well with services such as the safeguarding midwife, health visitor, and the school. Practitioners reflected that Colin and Karen engaged well with services throughout her pregnancy, appearing attentive and keen to support the best care for both Karen and Isla. A referral had been made for support from a children’s centre, together with a plan for family support. This was not progressed due to the restrictions of Covid -19. A pre-birth assessment was not considered by any agency at this stage. 8.14 Following attendance at the property, in September 2020, as an emergency response to Isla’s condition, both the police and the Ambulance Trust commented on the poor condition of the home. It is recognised that the paramedics who attended the property were focused on resuscitation attempts, but two clinicians commented on the house being cluttered and unclean, whilst the police hypothesised that the house had been in a neglectful condition for a period of time stating that there were inadequate sleeping arrangements, a very cluttered household with unusable parental bedroom and family bathroom, as well as a garden without space in which children could play. The police shared this hypothesis with children’s social care. 8.15 A multi-agency strategy discussion followed, and a section 47 enquiry (Children Act 1989) was opened in response to the concerns raised around potential neglect within the home. The family were visited by the social worker that day and immediate advice was given to address the condition of the family home. 10 OFFICIAL:SENSITIVE A further visit was undertaken on the 22 September to consider the family support needs and review the condition of the home again. Single assessments commenced for all the children and children in need visits were undertaken. The home conditions are then reported as improving with an ongoing plan in place for this. 9.0 ANALYSIS BY THEME The rapid review submitted to the Panel on 26 October 2020, highlighted four themes as lines of enquiry. Following a desktop review of the information provided by the agencies, the review author concludes that these lines of enquiry remained appropriate, with no additional lines to be added. As such the following themes are identified and subsequently analysed: Identifying risks around past and present substance misuse and parenting. Identification of family and environmental factors which may contribute to neglect. Risk of SUDI and provision of safe sleeping advice. Effectiveness of agency assessments, risk management, decision making and professional rigour. 9.1 Identifying risks around past and present substance misuse and parenting 9.1.1 Case reviews highlight professionals often focus on the issues faced by parents who abuse substances without considering the impact on their children. Substance misuse by a parent or carer is widely recognised as one of the factors that puts children at greater risk of harm. The biggest risk posed to children is that parents, when under the influence of drugs or alcohol, are unable to keep their child safe (including overlay through co-sleeping, and accidents caused through lack of supervision).9 From a review of the information available, there is evidence of a multi-agency focus upon Karen’s and Daniel’s needs. This specific focus potentially impacted agency understanding of the level of parental care and protection afforded to all the children resulting from maternal drug use (illicit and prescribed), and the sufficiency of subsequent planning and assessment. 9.1.2 On 18 December 2019 a single assessment commenced to consider Daniel’s needs following a parental request for support for his challenging behaviour and potential respite from this. This single assessment does provide a clear picture of Karen’s self-reported drug consumption and usage, and noted parents’ statement to children’s social care that: Karen does not parent alone and Colin is present to ensure basic care. Colin is not using substances. Family and safe friends provide support when Colin needs to go out. There is no information available on professional exploration of this statement, or consideration as to whether this parental assertion was realistic, how it occurred in practice, or its effectiveness as a safety plan. Neither is there any assessment of Colin’s parenting capacity because Karen was not parenting alone. There is a need for active multi-agency curiosity including with substance misuse treatment agencies, to identify, intervene and provide a child centred response to parenting needs where there is known drug consumption and usage. 9.1.3 The single assessment concluded on 29 January 2020. Between the period December 2019 and 29 January 2020 Karen advises the Children Disability Team that she is pregnant. 9 NSPCC (2013), Parents who misuse substances: learning from case reviews. Available at Learning from case reviews briefing: parents who misuse substances (nspcc.org.uk) (Accessed: 22 November 2021) 11 OFFICIAL:SENSITIVE 9.1.4 The reviewer has noted that Karen’s GP did discuss with Karen a potential referral to Harbour10, (at a date unknown) but this does not appear to have been followed up or further discussed with Karen, or any other agency, during her pregnancy with Isla. It cannot be seen that it translated into the child in need plan already in place for Daniel. 9.1.5 During pregnancy, care was provided by a specialist midwife for women with substance misuse and Karen was seen regularly and monitored closely. There was recognition across midwifery, health visiting and children’s social care, that this was a high-risk pregnancy due to the prescribed medication, cannabis use and long-term health conditions. This recognition was highlighted during the child in need meeting of 20 July 2020. A personalised antenatal and postnatal plan was devised by midwifery, and this included a plan for an early help assessment antenatally, but this does not appear to have gone ahead. The recognition of a high-risk pregnancy did not translate into a pre-birth assessment and a referral was not made by any agency into children’s social care. 9.1.6 There is the possibility that the agency professionals working with Isla’s family trusted the parents’ self-reporting of drug (both prescribed and illicit) use, and thus this use was not seen as excessive or problematic. There is no evidence of inter-agency challenge, discussion, or escalation on this point. This optimism or acceptance may have impacted agency decision making as well as their understanding of parenting capacity at the point that Karen’s pregnancy became known. Such optimism can impact on professional’s ability to fully identify and assess concerns, so that interventions are not effective in minimising risk of harm to children. 9.1.7 All agencies need to work together in tackling any problems caused by substance misuse in families to safeguard the children and promote their wellbeing. Parents who misuse drugs may be good enough parents who do not abuse or neglect their children, and it is important not to generalise or make assumptions about the impact on a child of parental/carer drug and or alcohol use. It is, however, equally important that the implications for children are assessed having full regard to the parents’ ability to maintain consistent and adequate care in the environment and changing circumstances in which they live. Regard should be given to each child’s level of dependence, vulnerability, and any special needs. 9.1.8 Karen’s complex medical history meant that she was prescribed oral morphine for pain relief, and diazepam for anxiety. Clinical advice about the impact of these prescription drugs, and their use with cannabis was not directly sought. Indeed, during the reflective learning event Karen’s use of cannabis did not feature prominently as a risk consideration with agencies, despite its reference within the child in need meeting in July 2020. At the reflective learning event, health professionals suggested that there was a high prevalence of cannabis use in the community together with limited research into the harms caused to an unborn baby by smoking cannabis during pregnancy or smoking it in combination with medication. However, the review author notes many NHS trusts publish information about the risks of cannabis use when pregnant and Plymouth Hospital’s own antenatal website says, “Illegal drugs (street drugs), such as cannabis, ecstasy, cocaine, and heroin can harm your baby. If you use any of these drugs, it is important to talk to your maternity team straight away so they can give you advice and support to help you stop.” 9.1.9 Further sources on this matter include: www.babycentre.co.uk/x25014277/is-it-safe-to-smoke-weed-during-pregnancy 10 Plymouth based charity providing drug and alcohol services to people with complex lives 12 OFFICIAL:SENSITIVE www.mja.com.au/journal/2020/212/11/deleterious-effects-cannabis-during-pregnancy-neonatal-outcomes www.medway.nhs.uk/services/maternity/Maternity%20Patient%20Leaflets/Cannabis%20and%20Pregnancy.pdf https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-020-0880-9 9.1.10 It is noted by children’s social care that the family general practitioner (GP) was not present at the child in need meeting of 08 July 2020. They note the benefit of having the GP present in the multi-disciplinary discussions to consider the risks associated with the medication and cannabis use. As part of this review no records can be found to evidence whether the GP was invited, if they were invited but could not attend and submitted apologies, or in their absence submitted a written report. 9.1.11 Considering the above, and with knowledge that Karen was pregnant, a single assessment of all the children could have been undertaken to understand their needs and the potential for harm and captured a holistic perspective on the maternal drug use. This would have provided greater information for triangulation and assessment, so that the analysis of the presenting situation could have better supported a multi-agency response/intervention. Assessments must be dynamic rather than static and must be reviewed considering emerging evidence or a change in family circumstances. Except for children’s social care (Children’s Disability Team), as set out below, it is noted that no agency from within the multi-agency network made a referral for, or otherwise actively sought such assessments. 9.1.12 It is noted that the parents were approached by children’s social care (Children’s Disability Team) in January 2020, to seek consent to undertake such single assessments. However, the parents declined, and this appears to have been accepted without further discussion with the parents or the other agencies involved in family care. No record has been provided to the reviewer to suggest the contrary. Where a parent refuses to give permission for an assessment further advice should be sought from a manager to consider what, if any, further action should be taken, including consideration of a strategy discussion. Any outcome should be recorded along with the rationale for that decision. This action is not seen within the records provided to the reviewer. It is noted that the Children’s Disability Team, within their Appreciative Inquiry return, have acknowledged that because of the parent’s lack of consent, a single updated assessment for Daniel should have been undertaken due to the change in circumstances identified. Information gathered from this assessment could have further informed the subsequent child in need meetings in January, April, and July 2020, to assist with an up-to-date analysis of family vulnerabilities and strengths, as well as aiding effective multi-agency decision making. 9.2 Identification of family and environmental factors which may contribute to neglect 9.2.1 The rapid review which led to the commissioning of this local child safeguarding practice review identifies several predisposing factors regarding cumulative neglect. These include, poor parental mental and physical health, parent substance misuse, poor supervision of children, Daniel’s previous dental decay and low attendance at school, inadequate housing and a cluttered disorganised home with rooms that could not be effectively used for their purpose. Some of these factors date back to 2017/2018 and in response an Early Help Plan was put in place and the Child Development Centre continued to assess and support Daniel’s needs. The assessment concluded that there was no ongoing role for children’s social care. The subsequent single assessment (Dec 19 to Jan 20) following the referral from ALHELP for family respite, considered Daniel’s needs in detail, as well as family dynamics and functioning, basic care, capacity to meet Daniel’s needs, home conditions and housing to evaluate risk. Children’s social care state that this assessment did not identify concerns of neglect from the information gathered at the time. 13 OFFICIAL:SENSITIVE 9.2.2 HM Government statutory guidance, Working Together to Safeguard Children (2018) provides a statutory definition of neglect, “The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of a child’s health or development. Neglect may occur during pregnancy as a result of maternal substance misuse.11Once a child is born, neglect may involve a parent or carer failing to: a. provide adequate food, clothing and shelter (including exclusion from home or abandonment) b. protect a child from physical and emotional harm or danger c. ensure adequate supervision (including the use of inadequate caregivers) d. ensure access to appropriate medical care or treatment It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs”. 9.2.3 At the point the agencies became aware of Karen’s pregnancy there was no clear co-ordinated multi-agency response to assessing the potential risk of neglect arising from maternal substance use during pregnancy; nor any apparent respectful and professional challenge with the medical profession, or Karen herself, on the continued cannabis use combined with the prescribed medication. A pre-birth multi-agency assessment was neither discussed nor commissioned by any agency involved with the family. 9.2.4 Isla’s family lived in a socially deprived area of the city, wherein there are social and environmental risk factors, including poverty, social isolation, and housing difficulties. 24.7% of the children (aged under 16 years) in the area are in low-income families. Neither Colin nor Karen was in paid employment. They were in receipt of benefits including Universal Credit, Disability Living Allowances, and Child Benefit. The family live in a privately rented three bedroomed property, which the health visitor describes as “poor housing.” The housing costs are covered by housing benefits. Children’s social care supported the family with an application to housing for a four-bed need, and the family were given a Band C priority. In August 2020, Daniel floods the family bathroom, and in September the parents discussed with their health visitor the application for a grant for replacement flooring and furniture damaged during the flood. 9.2.5 Whilst it is recognised that poverty is not the same thing as having a low income12, it is recognised that this family lived in an area of Plymouth with a higher rate of child poverty, higher rates of universal credit claimants, increased numbers of non-decent homes, and shorter life expectancy13 than the average for Plymouth. Further, there was knowledge of the parent’s mental and physical health, previous trauma, and Karen’s use of drugs. These indicators and signs can be causes of poverty. 9.2.6 Whilst the presence, or perceived presence of poverty, does not necessarily equate to the presence of neglect, the increased stress associated with poverty can make coping with the psychological as well as the physical and material demands of parenting much harder.14 In this respect poverty can add to the likelihood of poor parenting and neglect and be one of the many cumulative adversities a child can experience. 9.2.7 Research has found that professionals who work with children and families sometimes normalise and become ‘blind’ to poverty in their assessment of risk and need for support. Poverty is often seen as an outcome or co-existing factor rather than a potential cause of a family’s difficulties. Poverty blindness may occur where professionals are working in areas of high deprivation and so poverty becomes the 11 Reviewers’ emphasis 12 Poverty in the UK: a guide to the facts and figures - Full Fact (Accessed 17 February 2022) 13 Neighbourhood: area profiles | PLYMOUTH.GOV.UK 14 Brandon M. (2015) In What Ways Might Poverty Contribute to Maltreatment? In: Fernandez E., Zeira A., Vecchiato T., Canali C. (eds) Theoretical and Empirical Insights into Child and Family Poverty. Children’s Well-Being: Indicators and Research, vol 10. Springer, Cham. https://doi.org/10.1007/978-3-319-17506-5_16 14 OFFICIAL:SENSITIVE norm and an associated desensitisation to warning signs of poor hygiene, dirty clothes, and poor dental hygiene.15 This is further highlighted within learning from previous serious case reviews.16 9.2.8 Children’s social care contacts with the family were virtual during the period March 2020 to September 2020 (except for a doorstep visit in June). It is seen that the health visitor visits the family on two occasions, in July and August, and there are five midwifery home visits following Isla’s discharge from hospital. No concerns were raised regarding the home conditions following these visits although the health visitor reported that she was supporting the parents to obtain grants to replace damaged items. This is explored in the paragraphs below to establish if there was either a degree of normalisation and/or a lack of curiosity and sighting of home conditions by health practitioners who had access to the home. 9.2.9 The reflective learning event offered insight, and in terms of the Children’s Disability Team who were supporting Daniel, a RAG rating of amber or red would have necessitated a physical home visit. The green rating applied to Daniel led to virtual visits during the lockdown restrictions which were more difficult to conduct on a room-by-room basis. 9.2.10 Midwifery and health visiting services maintained some face to face visits for some families during the Covid-19 pandemic unless there was a positive Covid-19 test in the home. 9.2.11 When the conduct and practice issues of home visits were explored at the learning event it became clear that health professionals would not generally look around a home unless previous safeguarding concerns had been raised (which was not the case in this review), or the parents invited them into other rooms. In this case, Karen and Isla were always seen by midwifery and health visiting services in the downstairs living room of the home. The impression given to professionals was that Isla was sleeping in a cot in an upstairs bedroom. On the day of Isla’s death in the parents’ upstairs bedroom, neither the parent’s bed nor the cot appeared to have been used. 9.2.12 Police photographs taken on the day of Isla’s death were shared with practitioners at the learning event. The ground floor kitchen/dining room where Karen had been sleeping in a chair, beside Isla’s travel cot, and upstairs bedrooms were shown as significantly cluttered and chaotic and at best only partially fit for their respective purposes. Some attendees reflected that the conditions of other rooms in the house did not represent the rooms they had been in. However, based on what was seen in the photographs of other rooms in the house, there was a recognition from a health professional that if they had previously seen this on their home visits, they would have made a safeguarding referral which would have generated multi-agency responses and additional considerations. 9.2.13 It has not been possible to establish over what period the home environment deteriorated to the condition it was found on the day of Isla’s death. What is clear is that the home environment was not coherently assessed by multi-agency partners in terms of condition, cleanliness, or appropriateness to safely support this family with multiple and complex needs. 9.2.14 In addition to the condition of the home environment, the reflective learning workshop also provided an opportunity for professionals to consider the nature of other risk factors for neglect potentially being experienced by the family. They were asked to complete a pro forma questionnaire of these factors that applied to the family, that they were aware of. A considerable number of predisposing factors regarding cumulative neglect were collectively identified by professionals including: Parental depression and other mental health problems including anxiety 15 SCR analysis 2020 for the education sector: Neglect | SCIE 16 Poverty a key factor in a third of serious case reviews | CYP Now 15 OFFICIAL:SENSITIVE Living in poverty Parental misuse of drugs Developmental delays with two of the children Behavioural difficulties with Daniel Inconsistent school attendance often linked to health issues Home being described as poor and worn -but tidy in some rooms. 9.2.15 It is considered in light of the above, that the risk factors for and indicators of neglect within this family of complex needs experiencing cumulative adversity, a further child being born into the family, and loss of familial and community support due to the Covid-19 pandemic should have been further explored by the multi-disciplinary teams engaged with the family. The reviewer has also identified other opportunities where the family’s socio-economic circumstances and the potential for neglect could have been identified: A neonatal team meeting to discuss ‘social issues’ – it’s not clear that all factors were considered when there was a decision taken that “no input” was required; and the medical discharge summary for Isla provided little information about the family’s social circumstances, or specific concerns about Karen’s ability to safely care for Isla alone. 9.2.16 The Department for Education’s research report ‘Missed Opportunities: indicators of neglect – what is ignored, why and what can be done’ (2014), notes there are some characteristics of young children which put them at an elevated risk of neglect. This is especially the case for babies born before term, with low birth weight, or with complex health needs.17 Isla had a low birth weight and neonatal abstinence syndrome observations (symptoms of opiate withdrawal) due to Karen’s prescribed medical history, although she did not require treatment for opiate withdrawal. This information was shared between the midwife and the health visitor, but the reviewer cannot see that the information was shared with children’s social care. A single assessment for Isla, at this point, was not considered. Additionally, the report explores that a particularly vulnerable group of young children is those with disabilities like Daniel. Disabled children are more likely to be maltreated than their non-disabled peers and neglect is the most common form of maltreatment they experienced.18 Practitioners who are cognisant of this learning and risk, and who are supported with effective multi-agency tools and strategies, can apply the same during assessments and multi-agency discussions such as child in need meetings and core group meetings. 9.2.17 In this case practitioners focused on and worked hard to ensure practical support for Daniel and his parents, but this focus meant that the wider multi-agency network was not sufficiently alert to what may be contributing to neglect within the declining family environment, and the children’s lived experiences. 9.2.18 The fact that a single assessment was not completed for Daniel’s siblings (as discussed in paragraph 8.19) represents a missed opportunity to gain insight to experiences of neglect for Daniel, his siblings and the risk presented for Isla both unborn and as a new-born. This assessment could have considered the impact upon the family, the family history, the wider family network, and the effect that current environmental and Covid-19 factors were having on the parents’ capacity to respond to all the children’s needs and parental concerns as described in paragraph 7.11, where Daniel is expressed to be a potential risk to a new-born sibling. 17 (Strathearn et al., 2001). 18 (Stalker and McArthur, 2012). 16 OFFICIAL:SENSITIVE 9.2.19 To prevent desensitisation to potential signs of neglect, the Plymouth partnership can implement multi-agency group and peer reflective practice models to enable practitioners to identify poverty and work proactively with each other and with families to address its causes and consequences; to improve children’s wellbeing and outcomes. The use of such group/peer reflective practice can support practitioners to feel safe and identify and address feelings of desensitisation or poverty blindness when working with neglect. Mutual reflection and group discussion can support individual practice and lead to service improvement. It also differentiates from supervision, which can be vulnerable to tension between practitioner support and performance management.19 9.2.20 In terms of supervision, the pre-learning event questionnaires asked several questions on this aspect of practitioner’s experience. The health visitor did not take this family for discussion in supervision as she did not identify any safeguarding concerns or any other issues of concern. Health visiting only discuss, in supervision, those families that the practitioner identifies as needing a discussion. Midwifery were able to offer extensive details on the supervision for those working with the family. This identified regular and consistent supervisory discussions with the lead midwife for safeguarding. These discussions were held in a safe space for clinical and relationship-based conversations. This supervision mirrored relationship-based practices with families. The police highlighted consistent but not protected spaces for supervision citing the vagaries of operational demands as limiting their ability to protect these discussions. The Children’s Disability Team questionnaire highlighted that the head of service, team manager and social worker involved with the family for most of the review period, no longer worked for the local authority. It was noted that although there was continuity of supervision and meetings (supervision and management observation) were held during the review period the social work records offer no information on the issues discussed, nor the quality and nature of the supervisory arrangements. 9.3 Risk of SUDI and safe sleeping advice 9.3.1 This review formally notes the coroner’s findings that due to the possible sleeping circumstances Isla’s death would not fulfil the criteria for ‘sudden infant death syndrome’ or ‘SIDS’. The cause of Isla’s death is unascertained. As this report forms part of a wider learning opportunity, the awareness of such SUDI or SIDs risk is included. 9.3.2 Agency records demonstrate the following: Midwifery There is clear documentation of discussions about the dangers of co-sleeping in the medical records with specific reference to maternal medication and the infant’s prematurity. It is documented that Karen said that there is a separate cot at home. In the midwifery records there were 3 entries stating that aspects of safe sleeping had been discussed and on the day of discharge it is documented that “travel safety and SIDS were discussed, and a cot-death leaflet given.” Following discharge midwifery home visits were undertaken on five occasions, although Karen and Colin only recall two visits. There was documentation from four visits that safe sleeping was discussed. There was specific documentation on day twenty about co-sleeping issues being discussed and SIDS. The reviewer is unable to locate any documentary evidence of whether safe sleeping discussions included both Karen and Colin, particularly in light of Colin being the prime carer. Public Health Nursing 19 How reflective practice can help social workers feel 'safe' - Community Care 17 OFFICIAL:SENSITIVE Antenatal visit in July 2020 and telephone contact by a health visitor to complete new birth assessment in August 2020. The health visitor discussed infant feeding, all relevant health promotion topics and recorded that Karen was fully aware of safe sleeping advice. Seven days’ later a home visit is undertaken by the lead health visitor. Whilst there was good engagement with the family including Isla’s siblings, there is no record or commentary on sight of the sleeping arrangements, or that safe sleeping advice was given in the environment or context of the family’s sleeping arrangements. As above, the reviewer is unable to locate any documentary evidence of whether safe sleeping discussions included both Karen and Colin, particularly in light of Colin being the prime carer. Children’s Disability Team In July 2020, a child in need meeting was convened, attended by safeguarding midwifery. Information was shared to the multi-agency attendees regarding delivery planning and the known risks for Karen’s health relating to the delivery and the impact of medication. However, there was no multi-agency conversation as to the risk of SUDI and the embedding of safe sleep advice with Karen and Colin; particularly as the latter was undertaking prime carer duties. 9.3.3 In conclusion, there is some good single agency advice, and a wealth of information given, but a fundamental absence of a comprehensive multi-agency identification and response to SUDI and safe sleeping assessments. There is no practitioner assurance as to the understanding of both Karen and Colin of the dangers of co-sleeping, and their ability to apply the safe sleeping advice they had been given. Safe sleep advice and risk assessments were not joined up with wider considerations of the safeguarding risks and plans to work with Isla’s family to address safeguarding concerns. It cannot be seen that any agency had sight of the family sleeping arrangements either antenatally or postnatally. It is imperative that all agencies, not just midwives and health visitors, are able to see where a baby is sleeping to undertake a safe sleep assessment and give appropriate safe sleeping advice in context. This requires a culture of curiosity and the application of inquisitive practices to be assured that the arrangements are appropriate and safe and are regularly reviewed in this regard, challenging parents where necessary when their good enough is simply not good enough. This underscores the provision of safe sleeping advice and guidance. It is also critical that physical home visits form an integral and rigorous part of the single assessment process. 9.3.4 In consideration of the above, the review author turns to the findings from The Child Safeguarding Practice Review Panel’s report ‘Out of Routine’11. The report asks, “In families with children considered to be at high risk of significant harm through child abuse or neglect, how can professionals best support the parents to ensure that safer sleeping advice can be heard and embedded into parenting practice so as to reduce the risk of SUDI?” 9.3.5 The Panel’s report’s conclusion reflects the themes identified within the rapid review, and the learning arising from this review. The report’s conclusions are replicated below: A better understanding of parental perspectives by all professionals enables local areas to adopt a more flexible and responsive partnership with parents, develop supportive yet challenging relationships that facilitate more effective safer sleep conversations, and co-produce appropriate information and support for parents and carers to aid their decision making about the sleep environment. There needs to be better links between the work in local areas to reduce the risk of SUDI and wider strategies for responding to neglect, issues related to social and economic deprivation, domestic violence, parental mental health concerns and substance misuse. This work needs to be embedded in multi-agency working and not just seen as the responsibility of health professionals. 18 OFFICIAL:SENSITIVE The use of behavioural insights and models of behaviour change should be investigated to explore whether these can support interventions to promote safer sleeping, specifically with this group of families with children at risk of significant harm. Approaches such as motivational interviewing hold out promise, particularly when combined with other strategies for family support and risk reduction. Such an approach could include the use of marketing and social media to influence behaviour change and could be linked to ongoing national work to provide consistent and evidence-based safer sleep messages as part of good infant care and safety. 9.3.6 It is recognised that the Plymouth partnership is putting in place the key recommendations outlined above. It is therefore prudent to ensure that the recommended prevent and protect practice model highlighted by the Panel for reducing the risk of SUDI is expedited to fully transfer the learning into multi-agency practice. 9.4 Effectiveness of agency assessments, risk management, decision making, rigour 9.4.1 The review has identified missed opportunities for effective multi-agency assessments and support, which could have better informed subsequent risk management and decision making. As previously recognised, in the July 2020 child in need meeting, the safeguarding midwife shared information regarding the delivery plan, and the known risks regarding Karen’s health relating to the delivery, and the impact of medication and drug misuse. However, this did not result in a pre-birth multi-agency assessment being undertaken which would have provided an opportunity to evaluate and respond to potential risks and impact upon the then unborn Isla and her siblings. This specialist assessment could have enlightened professionals around the family in respect of: The increased demands for the family of caring for new-born Isla together with 3 other children, one of whom had complex needs and another with learning needs Family housing Karen’s dependency on high dose prescribed morphine medication and diazepam Karen’s regular use of cannabis Karen’s poor physical and mental health Colin’s prime carer responsibilities and parenting capacity (as Karen was not to parent alone) Availability of support from family and community network Access to resources and services during Covid-19 pandemic The multiple risk factors for SUDI Successfully embedding safe sleeping advice. 9.4.2 Understanding what a child sees, hears, thinks, and experiences daily, and the way these factors impact on their development and welfare, is central to protective safeguarding work. The complexity of situations in vulnerable families can lead to a particular focus on parental needs, which can get in the way of professionals understanding risks faced by the children. It is essential to explore the child’s experience of living with neglect, and substance misusing parents and to understand how these harms impact on their safety, health, and overall development. The child’s views should inform analysis and assessment so that intervention is appropriate to address key concerns and needs.20 In reviewing the documentation presented, the reviewer is unable to form a picture of the children’s daily lived experience, and their voices are not explicitly sighted within agency documentation/submissions. 9.4.3 Single assessments were not completed for Daniel’s siblings, and this has limited the consideration of information regarding their lived experience which may have provided additional insight to cumulative neglect and their lived experience of maternal substance misuse. There was significant work by agencies 20 Child Safeguarding Practice Review Panel Annual Report 2020: Patterns in Practice, key messages and 2021 work programme 19 OFFICIAL:SENSITIVE to support the family with Daniels’ complex needs, but this potentially led to the lived experiences of the siblings and Isla’s needs being overlooked as they were not adequately seen. 9.4.4 There is no evidence that the agencies sought to assess and understand Daniel’s changing needs in light of Karen’s pregnancy, and the impact upon him of having a new baby within the family home. At the point of Karen’s pregnancy, and knowledge of her concerns that Daniel may unintentionally harm the baby whilst she was asleep, the assessment for Daniel could have been updated. Daniel’s single assessment was not sufficiently dynamic in noting and responding to this change in the family’s circumstances and the support Daniel may have needed within this context. 9.4.5 Taking a ‘think family’ approach to assessment which considered the environment, housing, Colin as prime carer, family history, the birth of Isla, availability of familial support, and the wider social construct, particularly during the Covid-19 period, could have provided a better understanding of links and relationship between risk of poor outcomes, resilience, and the changing patterns within the family parenting over time. 9.4.6 From a partnership perspective, multi-agency access to a shared risk assessment tool for neglect may provide an opportunity to improve the partnership’s coordination of risks associated with neglect. The learning event highlighted that there is no single approach for this in Plymouth. There would be merit in researching approaches being utilised in other areas to address this issue. A multi- agency risk assessment tool for neglect, like the NSPCC’s strengths-based approach in the Graded Care Profile 221 is a useful point of reference. A common assessment tool, shared across partners and regularly updated offers a way of better managing neglect and its cumulative effects, and can help bring about positive changes for families. 10.0 IMPACT OF COVID-19 AND ORGANISATIONAL DEMANDS 10.1 Clearly Covid-19 and the first national lockdown which came into effect on 23 March 2020 are contextually significant. Lockdown and associated measures taken to delay the spread of the coronavirus posed substantial and previously unrecognised challenges for child protection, health and welfare, education, and police. Universal and targeted support services were either closed or their services severely restricted and social distancing meant that social workers and other frontline professionals could not see some children and families face to face. The context of Covid-19 was a significant factor for those attending the learning workshop in terms of the ways it detrimentally affected their normal practices and services. The Covid-19 concerns professionals held in respect of risks to their own and their family’s health during this time on an individual basis should not be underestimated. 10.2 With certain caveats, health services continued to undertake some home visits during lockdowns. However, children known to local authority services and schools were re-evaluated (using separate methodologies) because of the Covid-19 restrictions and RAG-rated to inform approaches and methods of working related to visits, contacts, and the frequency of these access points. For the local authority, those marked red were prioritised for face-to-face visits and more frequent contact and those rated amber experienced alternate face to face and virtual visits. The local authority guidance on RAG-rated assessments stipulated that the assessments should be regularly reviewed in light of information from social workers and other agencies. 10.3 As noted above, Daniel was RAG-rated green by children’s social care throughout the Covid-19 pandemic and until Isla’s death. This meant that face to face visits were not deemed essential and 21 NSPCC GCP2 20 OFFICIAL:SENSITIVE consequently only virtual visits took place, with one doorstep visit on 24 June when the children were briefly seen. 10.4 The review author has considered the RAG guidance document used by Plymouth City Council for social work teams, including the Children’s Disability Team (V1.2 2020 04 23). The guidance was designed to support social work managers using the RAG system when considering the urgency for visiting children and young people under Covid-19 conditions. The guidance states, “Risk assessment is dynamic, and it will be important for social worker to flag up any new information relating to cases that might indicate a higher or lower risk rating. Risk could be reduced in several ways, for example, if the child is attending school regularly throughout this period this might offer a level of protection.” Further, the guidance sets out that, “every case must be given a RAG rating and that the status and rationale must be recorded on the child’s file as a management observation. Discussions about RAG ratings will take place in supervision. Red ratings must be reviewed weekly and all other cases at least once a month and immediately if information is received that indicates the risk may have changed.” 10.5 Social work case notes within the Children’s Disability Team do not identify if any actual risk assessment process was undertaken in respect of the family or Daniel, or the rationale for the appropriateness of a green rating. Between the start of the first lockdown and the time of Isla’s death, any discussions or review of the RAG rating were not recorded on the three occasions of supervision (two in April, one in August) or the one occasion of management observation in April. It appears that any concerns raised during this time (by schools or health professionals) did not trigger a review of the social work RAG rating. Similarly, it does not appear that Isla’s birth triggered a review of this rating. The RAG rating process and its application, in this instance, did not provide an outcome which proportionately addressed systemic and complex risks arising from the family. It was not subject to continuous assessment, as it should have been, in line with the children’s social care policy at the time. 10.6 The reflective learning workshop also highlighted that health professionals were unaware that social workers were not undertaking physical visits to the family’s home during this period. This is a significant oversight in communication and risk management during a time of heightened vulnerability for the family. 10.7 Daniels school, using a different RAG rating framework, assessed social care risks to the family as amber and health risks as red. It is instructive to note that in some other local authority areas all school RAG ratings were shared with children’s social care, with discrepancies discussed and a rationale identified for the discrepancy if the discussion did not lead to a shared view on risk. According to those that attended the learning workshop, this process in Plymouth was not quite as defined as this and there were times, as in this case, where agencies have different ratings and were not aware that each other had assessed the risk differently. If the RAG rating policy had been followed by the children’s disability team; then the rating would have been regularly reviewed, taking into account the information shared by other agencies. 10.8 The necessity to provide a prioritised operational response to service delivery during the pandemic was a national consideration by several agencies and not solely reflected in local practices by local agencies. However, this review highlights the need to ensure a consistent application of any such policy, regularly reviewed in light of changing circumstances and crucially shared and communicated across the partnership. On this occasion, the RAG rating for home visits was based on a single agency assessment and lacked rigour and coherency from a partnership perspective. It is not clear from the guidance or those that have contributed to this review, if the RAG ratings across agencies were consistently based on family needs, parenting capacity, children’s needs, or wider risks. 21 OFFICIAL:SENSITIVE 10.9 Whilst acknowledging the restrictive environment and changes to working practices during the Covid-19 response, it is difficult to reconcile why individual agency approaches to home visits were not widely promoted across partner agencies particularly where services are being provided to vulnerable families with complex needs. Further, there is also an opportunity to consider a single, multi-agency approach to such policies or at the very least a process which enables the outcomes of the single agency RAG assessments to be challenged, communicated, and shared with other agencies. Processes should also be established to ensure future adherence to any single or multi agency policy guidance related to home visiting for vulnerable families. 10.10 During the Covid-19 pandemic, schools provided consistent support and Susan’s School offered her a place where she could have been professionally sighted. Due to Karen’s health circumstances and the risk of Covid-19 transmission to her health, this was declined by the family. From the commencement of the Covid-19 lockdown in March 2020 and until September 2020, the family’s children did not attend school. Daniel’s school made welfare calls two to three times a week, for the period 23 March until 24 July 2020, with information shared with children’s social care. The school periodically dropped schoolwork and other essential items to the family home, but it does not appear from the records that they had sight of Daniel and his presentation/appearance, nor sight of the home conditions. No referrals or concerns were made by either school to children’s social care for potential neglect. 10.11 The birth of Isla, a baby of low birth weight, into a family with complex needs and support did not trigger a review of the Children’s Disability Team RAG rating, and the family were not prioritised for face-to-face visits and more frequent contact. The missed opportunity of either an updated single assessment for Daniel, or single assessments for Daniel, Susan, and Elizabeth and/or a pre-birth assessment for Isla, also meant that this RAG rating was unable to be reviewed with fully triangulated information and family history. The RAG rating policy in place, at the time, suggests that a review of the risk assessment should have taken place. Further, the six home visits conducted by the health professionals following Isla’s birth did not evidence any concerns or trigger a referral into children’s social care, which may have led to the RAG rating being reviewed. 10.12 As children’s social care contact with the family occurred virtually, the social worker’s ability to identify neglect, and visually identify the declining home conditions was limited. This could have been partially overcome by creative engagement with the family and the children to include virtual tours of the house, and in particular sleeping arrangements. The use of a multi-agency protocol or practice guidance for video call/contact and virtual, online home visits, such as that provided in April 2020 by the Principal Children and Families Social Worker Network22 can help, to an extent, negate any such future limitations. That said, nothing can replicate the full benefit a physical visit can offer to a potentially neglectful home. 10.13 During the period of this review, the Children’s Disability Team had also been through a change in team management. A long standing and experienced manager had moved onto a new role. Attempts to recruit to a permanent post had been unsuccessful. Therefore, a secondment was agreed to provide management cover in the interim. The team manager came from adult social care and provided an important contribution through skills and knowledge to the team, with reference to the complex assessment and care planning for young people with learning disabilities and autism, knowledge of the mental capacity act, knowledge of deprivation of liberty. This made a positive impact on the work of the team. However, the incumbent was not experienced in statutory children’s social care. The Children’s Disability Team have commented as part of this review, that they have considered whether potentially the seconded manager not having an experienced statutory children’s social work background impacted 22 PSW best practice guide for video call and virtual home visit (skillsforcare.org.uk) 22 OFFICIAL:SENSITIVE on the professional oversight of the case open to Children’s Disability Team. The honest answer is they do not know whether this was a factor, or not. This consideration is recognised by the report author. The report author also acknowledges that the family had the support of an advanced social work practitioner, who had access to a full range of child protection measures and the wider children’s social work team. 11.0 IDENTIFIED GOOD PRACTICE 11.1 The value of reviews of this nature are widely recognised as an opportunity to learn and signpost improvement to services where necessary whilst also building and enhancing strengths that exist in agency responses. The following aspects of partnership working were presented as strengths in written records and at the reflective learning event. 11.2 The advanced social work practitioner in this case worked actively to build a relationship with Isla’s family and engaged with the wider multi-agency network to support Daniel’s needs. Karen and Colin would both call the social worker with any concerns, questions, or updates. 11.3 There was specialist midwifery involvement within the Jasmine Clinic (a clinic run for women who have problems with drug use, currently or historically). 11.4 Good and timely information sharing between the midwife and health visitor. Karen and Isla were doing well following the birth. 11.5 Within the hospital midwifery service, the importance of Colin’s role in caring for Isla was recognised and enhanced visiting was facilitated postnatally despite the Covid-19 restrictions. There was also a personalised plan of care produced antenatally that detailed medical considerations for Karen and Isla, including the need for monitoring signs of opiate withdrawal. 11.6 Support was being provided to secure new flooring at the home, to try to get the family re-housed and to seek respite care for Daniel. 11.7 The children’s schools kept good safeguarding records and provided welfare calls to the family and timely shared information with the social worker, which was followed up, as necessary. There was effective liaison between the siblings’ different schools. The school’s engagement and levels of support offered to the family were extensive throughout the pandemic, often going beyond what one could reasonably expect. 11.8 The social story provided to Daniel by the school following Isla’s birth had a positive impact. 11.9 The initial sharing and information forms, and subsequent Appreciative Inquiry returns for this review, from the hospital and the Children’s Disability Team evidence thoroughness and high-quality reflective practice as part of the child safeguarding review process. 12. LESSONS FOR THE PARTNERSHIP 12.1 As with all reviews, there are lessons to be taken from this review by both the wider safeguarding partnership and individual agencies. Significant factors in this case are the effectiveness of agency’s assessment, risk management and decision making. 12.2 The undertaking of a multi-agency pre-birth assessment could have been a critical opportunity to enable the multi-agency network of professionals to identify and respond to the potential risks, including substance misuse, cumulative neglect, SUDI, and co-sleeping, for Isla. 23 OFFICIAL:SENSITIVE 12.3 Given the complex family situation and the impact of Covid-19 restrictions on a family already under pressure, there may have been benefit of single assessments being undertaken for all the children. Whilst the parents declined the offer of the single assessment, a strength based, restorative conversation with them could have potentially better informed their decision on consent. 12.4 As identified paragraph 11 there is evidence of good practice to build a relationship with Isla’s family and with the multi-agency network work with the family to support them with Daniel’s needs. However, this potentially led to the lived experiences of the siblings and Isla’s needs being overlooked. Developing a strategic approach to ‘think family’ is essential in embedding family and significant others into the day-to-day work of agencies across the partnership to ensure family work is sustained and developed. Such an approach can mitigate any tendency to lose balance and focus on parental needs meaning that the child or children are not effectively seen and heard, and their voices not captured. 12.5 Practitioners were aware of the need to improve and consistently maintain such improvement of the home conditions. All practitioners were aware of the complex needs and additional support required for Daniel. When parents and family are this complex, this can be mirrored in professional’s thinking as they become overwhelmed by the complexity, nature and often the volume of work, becoming ‘stuck’ and unable to be proactive about protecting the children.23 12.6 It is well recognised that practitioners can become desensitised to levels of neglect particularly when working in areas with high levels of deprivation and this can cause inertia. The chronic and fluctuating nature of neglect can also cause difficulties in deciding at which point to act. Despite the family history, there appears to be a lack of reflective sighting of the home conditions and the sleeping arrangements by agencies who had access to the family home. 12.7 The partnership has published and disseminated its multi-agency neglect strategy alongside a framework and guidance. Whilst referenced and recognised by the Children’s Disability Team, it does not appear to be widely known or effectively implemented across the wider multi-agency network. This lack of knowledge and effective implementation affected multi-agency assessment and decision making; their responses to neglect were not made in the children’s time. This review welcomes the ongoing activity by the partnership to quality assure its response to child neglect and evaluate alternative potential multi-agency tools to support recognition of child neglect, e.g., Graded Care Profile 224 or Signs of Safety.25 12.8 Home visiting in the arena of child protection is the accepted norm. Professional and respectful curiosity to family home environments, their community and day to day living informs knowledge of family welfare and support needs. A good home visit supports dynamic risk assessment. Building relationships with a family can support any multi-agency colleague to be able to ask to see the home environment and to see a child’s sleeping arrangements. The focus of seeing the child alone, can also be placed on seeing the home environment within multi-agency home visiting practice and culture. 12.9 The partnership has published and rolled out ICON: Babies Cry, You Can Cope programme to help parents and carers manage crying babies. This programme aligns itself to the Lullaby Trust’s safe sleeping campaign and initiatives, together with Dad Pad, a free app which provides essential guides for new dads. All these initiatives seek to ensure that parents can support themselves and each other so that babies get the best possible start in life. It remains unclear from this review as to the multi-agency 23 Brandon M et al Understanding Serious Case Reviews and their impact DCSF Research Report June 2009 24 NSPCC GCP2 25 Signs of Safety 24 OFFICIAL:SENSITIVE awareness of these programmes and initiatives or if they were provided to Colin, as prime carer, or the wider family as a part of parental support. 12.10 Assessments of fathers’, including their parenting capacity, protective as well as risk factors, and their resultant needs, should be carried out as robustly as they are for mothers, and services can do more to have fathers within their focus when considering interventions and support. 12.11 With regard to the risk of SUDI and safe sleep advice, it is recognised that the partnership has already undertaken work to put in place the prevent and practice model for reducing the risk of SUDI, recommended by the Panel.26 The partnership should note that all agencies reflected that a multi-agency system, process and response to this issue is welcomed. Focus should be given to ensuring that the recognition of unsafe sleeping arrangements, and risk of SUDI, are incorporated across multi-agency safeguarding procedures tools for responding to neglect, domestic violence (although not a feature in this case), children of alcohol and substance misusing parents and children at risk where a parent has a mental health problem. The partnership must further assure itself as to the effectiveness of its work to promote safer sleeping and reduce the risk of SUDI. This includes the learning and dissemination of reviews undertaken within the child death review process overseen by the Child Death Overview Panel (CDOP).27 12.12 With regard to the key themes of maternal substance misuse, neglect, safe sleeping, and SUDI risks, for many agencies, the use of effective supervision is a means of improving decision making, accountability, and supporting professional development among practitioners. Supervision is also an opportunity to question and explore an understanding of a case. Group supervision and peer reflective practice groups can be even more effective in promoting curiosity and safe uncertainty, as practitioners can use these spaces to think about their own judgments and observations, particularly regarding social deprivation, potential for poverty blindness, and cumulative neglect. It also allows multi-agency teams and disciplines to learn from one another’s experiences, with the issues considered in one case relevant to others. 12.13 Karen’s cannabis use was not considered a prominent safeguarding risk for some agencies in attendance at the reflective learning event. Whilst there is some empirical research on cannabis use in pregnancy, literature reviews have indicated that there is no known safe level of cannabis use during pregnancy and women should be counselled as to the risk of in utero exposure.28 Changing cultural acceptance of cannabis, its tendency to be publicly viewed as a safe drug, and increased use of cannabis amongst pregnant women29 may have lent itself to decreasing agency perception of risk. The Southwest Child Protection Procedures highlight drug misuse as a risk factor for unborn babies, and its use in pregnancy as an indicator of neglect. 13. CONCLUSIONS 13.1 The purpose of this review is to identify improvements to be made to safeguarding and promoting the welfare of children. Understanding whether there are systemic issues, and whether and how policy and practice needs to change, is critical to the system within the local area being dynamic and self-improving. It is not surprising to find that the learning from this review echoes, in many respects, the findings of national reviews and other reports that have considered safeguarding practice. 26 Child Safeguarding Practice Review Panel, (2020) Out of Routine: A review of sudden unexpected death in infancy (SUDI) where the children are considered at risk of significant harm; Figure 6. 27 Working Together to Safeguard Children (2018) Chapter 5 28 Badowski S, Smith G. Cannabis use during pregnancy and postpartum. Can Fam Physician. 2020;66(2):98-103. 29 Gabrhelík R, Mahic M, Lund IO, et al. Cannabis Use during Pregnancy and Risk of Adverse Birth Outcomes: A Longitudinal Cohort Study. Eur Addict Res. 2021;27(2):131-141. doi:10.1159/000510821 25 OFFICIAL:SENSITIVE 13.2 Practitioners from agencies who have contributed to this review demonstrated their wish to offer the best possible service and protection for children. However, the intention of individual workers and agencies were not sufficient to counter some of the barriers which inhibited practitioners’ ability to effectively safeguard Isla. 13.3 Whilst practice within children’s social care is for child in need single assessments to include all children living within the household, the single assessment conducted in December 2019/January 2020 by the Children’s Disability Team focused on Daniel’s complex needs. It did not include Elizabeth or Susan or their needs and was not reviewed and updated when Karen’s pregnancy with Isla first became known. The reviewer is aware that this matter has been addressed as immediate learning and qualitative audit activity was undertaken to provide reassurance. There was an absence of curious and inquisitive conversations with health clinicians and drug misuse professionals to understand the impact of the cannabis misuse with high levels of prescribed medication and whilst it was recognised that Karen was not to parent alone, there was no clear assessment of Colin’s parenting capacity and his role within the family. 13.4 No agency sought a referral for or recommended a pre-birth assessment. This is despite the following known circumstances which can increase risk to an unborn child/new-born child: Karen’s pregnancy with Isla was understood by all agencies to be high risk due to the prescribed medication, cannabis misuse and chronic health conditions. There was already a child within the family on a child in need plan Daniels’ child in need plan required Colin to be always present to provide basic care to the children. Working Together 2018 contains the statutory description of neglect, which includes the statement that ‘neglect may occur during pregnancy because of maternal substance misuse’. Karen’s concerns that Daniel may unintentionally hurt the baby whilst she is asleep. 13.5 The findings of the rapid review regarding the impact of Covid-19 upon families, and what was in effect socially distanced child protection are repeated here. Covid-19 meant that the family were shielding, due to Karen’s health conditions, for a considerable period, resulting in limited access by professionals for face-to-face visits. It is considered that the home conditions had declined since those visibly seen and noted by the social worker in February 2020. Improvements to, and sustained maintenance of home conditions were not adequately evaluated and addressed. Visiting for Daniel was ‘RAG’ rated green by the Children’s Disability Team, meaning only virtual visits took place, with one doorstep visit on 24 June when the children were briefly seen. Health visiting and midwifery undertook home visits, but there does not appear to be a recognition of the condition of the home environment or sight of the family sleeping arrangements. Health professionals were unaware that children’s social work was not visiting the house. 13.6 Practitioners can ask for physical and virtual tours around homes, to see fridges and cupboards, bedrooms and sleeping arrangements. With planning practitioners can be directive about which parts of the home they need to see physically or virtually, and which children. Engagement with children, via play, can be adapted to the online world, via short quizzes or games. 13.7 Lastly, there should have been a review of the Children’s Disability Team green risk rating following notification of Karen’s pregnancy and the birth of Isla, as well as when Karen and Colin expressed concerns to the school, social worker, and health practitioners that they were finding it difficult to cope, and the family presence for support had ended. The RAG rating process should have been co-joined between agencies and clearly communicated to all lead practitioners. 26 OFFICIAL:SENSITIVE 13.8 In summary, there are several shortcomings and much learning that has arisen in areas of both practice and strategy from this tragic incident. The learning points were reflected on at the learning workshop, and in the written submissions from agencies that formed part of this review. However, what is now clear is that deficiencies in several areas combined to inhibit positive safeguarding activity and outcomes, including: The ineffectiveness of holistic assessment and planning to fully understand the children’s lived experience and potential risk to Isla as both unborn and new-born. No formal assessment of Colin’s parenting capacity and his role within the family nor of availability and capacity for support from parents’ wider familial network. A lack of a ‘think family’ approach and response when supporting families with a child or children with complex needs. A poor response to the factors that contribute to the effects of neglect be they cumulative or otherwise. Potential challenges with professionals’ alertness to desensitisation when working in areas of high levels of deprivation and increased levels of need or at least an absence of curiosity in this regard. A lack of a multi-agency strategic approach and practice to risk of SUDI and provision and assuring the application of safe sleeping advice. A lack of awareness, understanding and application of the partnership’s current neglect strategy. The absence of a coherent, clearly communicated multi-agency risk assessment strategy for home visits to safeguard children and promote their welfare during occasions of restrictive lockdowns in response to Covid-19. A perceived tacit acceptance of the use of cannabis in pregnancy and reticence to reinforcing the dangers of cannabis use pre and post birth, challenging parents with medical, evidence-based research where appropriate. A benign culture and practice for agency home visits which detracts from developing a shared understanding across agencies on the condition and appropriateness of individual rooms, wider neglect factors as well as sleeping arrangements for children. 14. LEARNING INTO PRACTICE CONSIDERATIONS 14.1 The Plymouth Safeguarding Children Partnership (PSCP) to be assured that its work is addressing the following identified core practice and strategic issues. Drug misuse and parenting a. The PSCP promotes collaborative assessment, information sharing and clear pathways between both systems and services to ensure families experiencing drug (or alcohol) problems receive holistic, child and whole family approaches.30 b. The consequences and risks associated with using cannabis during pregnancy and post birth are widely promulgated within the PSCP, challenging any potential complacency in practice due to common use of this drug. Risks of SUDI and safe sleeping advice 30 Public Health England Guidance: Parents with alcohol and drug problems: adult treatment and children and family services (May 2021): https://www.gov.uk/government/publications/parents-with-alcohol-and-drug-problems-support-resources/parents-with-alcohol-and-drug-problems-guidance-for-adult-treatment-and-children-and-family-services#system-and-service-level-requirements: Accessed 25 March 2022 27 OFFICIAL:SENSITIVE c. The PSCP supports multi-agency practitioners with skills and tools to enable confident and courageous conversations with parents on difficult topics such as neglect, SUDI risk and safe sleeping. d. The PSCP ensures that the findings and learnings of its current evaluation of the multi-agency strategic response to the risk of SUDI and provision of effective and embedded safe sleeping advice is fully considered in the context of the findings documented in this report. Family and environmental factors of neglect e. The PSCP ensures its multi-agency practice tools are well understood and used effectively so that they actively support practitioners to identify and respond to child neglect. Options such as the NSPCC Graded Care Profile 2 should be considered in this respect. f. The PSCP embeds in practice demonstrable engagement of children and their understanding and experience of living with or at risk of being affected by neglect; thereby strengthening a think family approach to child safeguarding. g. The PSCP explores ways of improving leadership and practitioner understanding of cumulative neglect, identification and impact of poverty, and possible desensitisation to the warning signs of neglect. h. The PSCP supports its multi-agency work force to undertake both effective child centred virtual and physical visits to family homes using processes and guidance such as that provided by the Principal Children and Families’ Social Worker Network. i. The PSCP considers opportunities for practitioners to have informal multi-agency space to think reflectively on practice themes, such as neglect, fathers in safeguarding, and think family approaches. Agency assessments, risk management and decision making j. The PSCP identifies options to improve the quality of multi-agency assessments (including specialist) where children and unborn children are experiencing neglect or are at risk of neglect. k. The PSCP works collaboratively with other partnerships to address the recommendations of the CSPR Panel Report “The Myth of Invisible Men.” The reviewer acknowledges that the premise of the report considers safeguarding children under 1 from non-accidental injury caused by male carers, but its recommendations on service design apply equally to the context of this case and the findings of this review.31 l. The PSCP seeks assurance on the RAG Rating system of all statutory agencies, to ensure that they are effective and provide an appropriate, timely and joined up response to changing safeguarding needs and risks experienced by families. The outcomes from this process should be widely communicated across the partnership organisations. 15. ACKNOWLEDGEMENT 15.1 The sudden and unexpected death of an infant is one of the most devastating tragedies that could happen to any family. It is also recognised that the impact of a child death, and resultant inquires, on safeguarding professionals can have a negative psychological and emotional impacts. The independent review author would like to take this opportunity to express his thanks to the Plymouth Safeguarding Children Partnership, safeguarding professionals and practitioners in supporting this local learning review. He would particularly like to put on record his appreciation for the contributions of Karen and 31 The Child Safeguarding Practice Review Panel. (September 2021) “The Myth of Invisible Men”, Ch18, pp57-59 28 OFFICIAL:SENSITIVE Colin who made this review ‘real’ by the compelling way they shared their lived experiences and that of Isla’s profound legacy. |
NC046080 | Death of a 2-year-old boy by choking. Child C1 had been left alone with his older sibling when he swallowed and choked on a small item. He later died in hospital. Following his death some unexplained bruising was identified and Child C1's sibling was made subject to an interim care order. No charges were made against either parent. Mother had a history of depression and suicide attempts. Father had a history of domestic abuse and substance misuse. Mother and children had spent some time in a homeless family unit following disclosure of domestic abuse by the father. Social workers had conducted two initial assessments of the family, but did not identify any concerns. Issues identified include: parents were interviewed together during social work assessments despite allegations of domestic abuse; the overwhelming focus on Child C1's medical care distracted attention from potential safeguarding concerns and police reluctance to share information from the criminal investigation with social services to help with care proceedings for Child C1's sibling. Recommendations include: the common assessment framework should be actively pursued for homeless families with no formal social work intervention; the safeguarding children board should discuss with the crown prosecution service the possibility of children's services providing advice on complex child protection cases and NHS trusts should review first aid education for parents.
| Title: Child C1: serious case review [overview]. LSCB: Manchester Safeguarding Children Board Author: Sian Griffiths and David Hunter Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD C1 SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 15th December 2014. INDEPENDENT LEAD REVIEWERS: Sian Griffiths David Hunter August 2014Page 1 of 36 Child C1 SCR Published Report 151214.doc CONTENTS 1. Introduction: 1.1. The circumstances leading to this Serious Case Review Page 2 1.2. Family Composition Page 3 1.3. Brief summary of the case Page 3 2. Methodology Page 4 3. Key Dates Table Page 7 4. How professionals understood the case Page 11 5. Appraisal of Practice and Analysis 5.1. Introduction Page 15 5.2. The referrals to Children’s Services in early 2012 Page 16 5.3. Accommodation with Homeless Families 2012-2013 Page 19 5.4. Emergency Presentation at Children’s Hospital 2013 Page 21 5.5. Actions taken consequent to Child C1’s death Page 25 5.6. Concluding comments Page 26 6. Findings and Recommendations for the Board Page 27 Bibliography Page 29 Appendix A: Individual Agency Actions Page 30 Appendix B: Multi Agency Actions Page 32 Appendix C: Acronyms Page 36 Page 2 of 36 Child C1 SCR Published Report 151214.doc 1. INTRODUCTION 1.1 The circumstances that led to undertaking this Review 1.1.1 In the summer of 2013 Child C1, who was aged under 2 years old, died after choking on a small item at his home in Manchester, whilst in the care of one of his parents. The Post Mortem examinations subsequently identified unexplained injuries. 1.1.2 The Manchester Safeguarding Children Board’s Serious Case Review (SCR) Sub Group concluded that the case had met the criteria for a Serious Case Review as identified in Working Together to Safeguard Children 20131, in that there was information that: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. At the time of this decision, the cause of injuries, including that which led to Child C1’s death had not yet been resolved, however the SCR Sub-Group concluded there were signs of suspected neglect, including: parental supervision; dangerous home circumstances; the children having been left with an adult about whom the extended family had previous concerns; historical information regarding drug and alcohol use by the parents. 1.1.3 A full Home Office Post Mortem was undertaken and an Inquest took place during the course of this Review. The Inquest verdict was Accidental Death and the Coroner referred to Child C1’s death as a ‘tragic accident’. 1.1.4 A Police investigation also took place and a file was sent to the Crown Prosecution Service seeking consideration of offences of neglect. However the CPS advice was that there was insufficient evidence to charge either parent with any offences. 1.1.5 Care proceedings were initiated in relation to Child C1’s older sibling who is now subject to a Care Order. 1 Working Together: HM Govt 2013 Page 3 of 36 Child C1 SCR Published Report 151214.doc 1.2 Family Composition The family members referred to in this review have been anonymised as follows: Family member Anonymisation Age at Summer 2013 (date of ChildC1’s death) Mother MC1 Father FC1 Subject’s older sibling Sibling C1 Under 4 years SUBJECT Child C1 Under two years Maternal grandmother MGM Maternal grandfather MGF Paternal grandmother PGM Paternal grandfather PGF 1.3 Brief Summary of the case 1.3.1. Child C1 lived with his2 mother, MC1 and older sibling, Sibling C1. The mother and children had recently moved into a Housing Association tenancy having previously been living in Homeless Families accommodation for over a year following allegations of domestic abuse involving the father, FC1. At the time of Child C1’s death the parents were reconciled and FC1 was caring for the children whilst MC1 was out for the evening. 1.3.2. During the course of the evening the two children were left in a downstairs room while FC1 went upstairs to iron some of his clothes. The period of time FC1 was upstairs cannot be accurately established. FC1 has stated that it was only a few minutes, although MC1 questions whether he would have been that quick and a longer period appears to have been likely. FC1 described being aware that the children had become quiet and went downstairs to find Child C1 apparently choking on a small item and unable to breathe. FC1 attempted to remove the item but could not do so and ran with the child to his grandparents’ home a few doors away. As it was a very short distance from the hospital, FC1’s grandparents drove him and Child C1 to the A&E department and FC1 carried him inside. 1.3.3. Child C1 was given Cardio Pulmonary Resuscitation. Removal of the small item was extremely difficult but was eventually successful and Child C1 was transferred to the Paediatric Intensive Care Unit (PICU), where he was placed on a ventilator. The parents were informed that it was likely that Child C1 would not survive. Of particular significance to this Review is that there was no safeguarding referral made by hospital staff on admittance. Three days later, with the agreement of his parents, Child C1’s life support was discontinued and he died shortly afterwards. 2 To protect children’s anonymity they are both referred to using the male pronoun. Page 4 of 36 Child C1 SCR Published Report 151214.doc 1.3.4. Prior to Child C1’s death there had been involvement with a number of services. The parents had met in 2010, but had periods of separation. There was evidence of domestic abuse including an allegation of physical assault by FC1 on MC1 during her pregnancy with Sibling C1. This led to a referral to Children’s Services and an Initial Assessment (IA) being undertaken in June 2011. The IA concluded that no further action was required as the parents were reconciled and living with paternal grandparents who were considered to be protective. After a short period of reconciliation MC1 disclosed further domestic abuse to health professionals and moved with Sibling C1 to live in Homeless Families accommodation. At the time MC1 believed that she could manage the domestic abuse, which she says was more verbal than it was physical. 1.3.5. Historically the mother was known to have had periods of depression and suicide attempts. The maternal grandmother had serious health issues and there were difficulties in family relationships. In early 2011 the police had been called to a disturbance at the maternal grandmother’s house after an allegation that the Mother, who was pregnant with Sibling C1, had taken her own mother’s prescribed morphine and threatened to kill herself. 1.3.6. The children are of dual heritage. FC1 is dual heritage, Black Caribbean and White British. MC1 has identified as White Northern Irish/English. Both parents have well established connections with their local area. FC1’s grandparents, with whom he lived as a child, lived in the same street as MC1 and the children. The family lived in a long established, racially diverse area of the city. No other information regarding issues of diversity has been provided to the Review. 2. METHODOLOGY 2.1.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows: Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together, 2013:66) 2.1.2. The statutory guidance requires reviews to consider: “what happened in a case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; Page 5 of 36 Child C1 SCR Published Report 151214.doc • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. 2.1.3. In order to meet these requirements the model adopted in undertaking this review uses a ‘systems approach’ which draws significantly on the work undertaken by Professor Munro3 and SCIE [Social Care Institute for Excellence]. A ‘systems approach’ to learning recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it is designed to identify which factors in the wider work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. The purpose therefore is to move beyond the individual case to a greater understanding of safeguarding practice more widely. 2.1.4. The process was led by two Independent Reviewers working with a Review team and included: • Consideration of chronologies and learning summaries produced by 6 key agencies. • 6 meetings of the Review team. • 2 meetings with the ‘Case Group’ – key practitioners involved in the case. • Conversations with 12 of the key practitioners. • Specialist advice from the Consultant Paediatrician and SUDC4 Lead for Greater Manchester. 2.1.5. Two Independent Lead Reviewers, Sian Griffiths and David Hunter, were commissioned to lead the review. The Review was authored by Sian Griffiths, an independent consultant who has significant experience in undertaking Serious Case Reviews and is an Accredited SCIE Learning Together Reviewer5. David Hunter is an independent practitioner and author and chair of child Serious Case Reviews, Domestic Homicide Reviews and kindred matters. Both the Lead Reviewers were independent of the case and of all the agencies involved. 2.1.6. The Review Team was comprised of the Independent Lead Reviewers, and the following senior managers/senior professional leads who were independent of the case: 3 See Munro, 2011 Chapter 4 4 Sudden Unexplained Death in Childhood 5 Whilst this Review has used many of the principles of the SCIE model, it has not been undertake as a SCIE Learning Together Review Page 6 of 36 Child C1 SCR Published Report 151214.doc Modern Matron for Safeguarding/Child Protection- Saint Mary's Hospital Central Manchester University Hospitals NHS Foundation Trust Detective Sergeant Serious Case Review Team Specialist Protective Services Greater Manchester Police Consultant Paediatrician Community Child Health Designated Dr Safeguarding Children Manchester NHS Citywide Clinical Commissioning Group Designated Nurse Manchester NHS Citywide Clinical Commissioning Group Team Leader Homelessness Division Children & Families Directorate Manchester City Council Central Locality Manager (Children’s Services) Children & Families Directorate Manchester City Council 2.1.7. A Team Manager from the NSPCC took part in the panel in order to offer further independent challenge. This manager left the NSPCC during the process, but continued her involvement with the panel. The MSCB Business and Performance Manager, Policy and Performance Officer and Business Support Officer also contributed to Review Team meetings. 2.1.8. The Case Group consisted of front line practitioners and first line managers who had worked with the family in various capacities. Individual conversations took place with 12 of these practitioners in order to obtain a detailed picture of what happened in this case, with a particular focus on establishing what the practitioners knew at the time the events unfolded in order to minimise hindsight. The members of the Case Group were also invited to a briefing meeting at the outset of the Review and to a Learning event at which the emerging analysis was discussed with the Review team. 2.1.9. As well as the individual agency chronologies and learning summaries, the Review requested and had access to a range of other documentation, including Pathology reports and Children’s Services Initial Assessments. 2.1.10. The timeframe under consideration for this Review was: 1st December 2011 – 31st December 2013. The starting point was chosen as this was shortly after MC1 and Sibling C1 moved into Homeless Families accommodation, and also the time when a referral was made to Children’s Services. The end point was chosen to allow consideration of actions taken to protect Sibling C1 following the death of Child C1. Page 7 of 36 Child C1 SCR Published Report 151214.doc 2.1.11. In order to minimise the risk of pre-judging any learning, the Review did not set out specific terms of Reference, but did identify four issues that were of particular interest to the Board. The Board were particularly keen to identify whether learning had been embedded in practice following a previous Serious Case Review (Child V) in which Sudden Unexpected Death in Childhood (SUDC) procedures also were a key feature: 1 To consider the effectiveness of the interface between the police, health professionals and HM Coroner in undertaking the child death investigation. 2 To consider to what degree the agencies, individually and collectively, identified any safeguarding implications in relation to surviving or future siblings. 3 To consider what actions were taken as a result of any identified safeguarding concerns arising out of the child death investigation. 4 To consider the role of family members in identifying and responding to child safeguarding concerns. 2.1.12. Family involvement. The involvement of key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services. Both the mother and the father agreed to speak to one of the Lead Reviewers during the course of the Review. Their comments, where relevant to the purpose of this Review are woven in to the report. 3. Key dates table Dec 2011 MC1 and Sibling C1 move into Homeless Families accommodation following allegations of Domestic Abuse (DA). Mother reports she is 10 weeks pregnant and it is unplanned. 07.12.11 Pre-assessment MCAF6 checklist completed by HV [health visitor]. January 2012 MC1 fails to attend two antenatal booking appointments. 17.01.12 FC1 attempts to see MC1 at Homeless Families Unit, police called. 29.01.12 FC1 issued with a harassment warning following an incident when he followed MC1 around a supermarket. Police make referral to Children’s Services who conclude no further action. 31.01.12 Referral received by Children’s Services from hospital midwives due to Domestic Abuse. No further action taken as concluded that Mother was effectively safeguarding the children. 31.02.12 MC1 attends antenatal booking appointment. 6 MCAF Manchester Common Assessment Framework Page 8 of 36 Child C1 SCR Published Report 151214.doc MAY 2012 CHILD C1 BORN May/June 2012 HV has difficulty contacting and seeing MC1 and the children. HV contacts staff to follow up Over the following months there were several health referrals made for both children and appointments were generally missed or there was a delay attending. August 2012 HV visit. Sibling C1 referred to Paediatrician due to difficulty walking – feet turning inwards and to the orthoptist because of a squint. Referred Child C1 to Ear Nose and Throat [ENT] for tongue tie. Immunisations overdue for both C1 and Sib C1. September 2012 MC1 and FC1 seen arguing at door of Homeless Families accommodation. September 2012 HV refers Child C1 to hospital as poor feeder and faltering growth. MCAF completed by HV due to homelessness and health concerns re both children. October 2012 Police called to incident. FC1 at his grandfather’s address, abusive, refusing to leave. C1 given first immunisations 10 weeks late and had 8 week baby check, also 10 weeks overdue. Nov 2012 Two appointments for Child C1 failed with Paediatric ENT. GP informed, would require re-referral. Dec 2012 Child C1 brought for immunisations. March 2013 MC1 informs Homeless Families accommodation staff that she will be staying out overnight with FC1. Agreed that FC1 be allowed to visit as a day visitor. 18 April 2013 MC1 asks for FC1 to be allowed as overnight guest. 22 April 2013 Phone call to Homeless Families accommodation from MC1’s mother. Wanting her keys back from MC1, describing her as abusive and stealing her morphine. Stated concerns about FC1’s violence and therefore concerns about the children. 22 April 2013 Permission given by Homeless Families for FC1 to stay as overnight guest. May 2013 MC1 moves into own tenancy with Child C1 and Sibling C1. Day 1, (Sunday) Summer 2013 21.10hrs Child C1 brought into Paediatric Emergency Department by FC1. Explained he had found Child C1 choking on a small object, was unable to remove it. Ran to his grandparents nearby who brought them into the hospital. Object removed with difficulty in A&E and C1 transferred to Paediatric Intensive Care Unit [PICU]. Child C1 critical recognised he might not survive. Day 2 (Monday) Scan identifies brain damage. PICU Consultant prepares parents for possibility Child C1 may not survive. Day 3 (Tuesday) Further review, PICU Consultant explains that life support cannot continue indefinitely. Staff Nurse contacts Central Manchester University Hospitals NHS Foundation Trust [CMFT] Safeguarding Children’s Nurses informing of admission. Safeguarding Nurse contacts Named Doctor who advises no Page 9 of 36 Child C1 SCR Published Report 151214.doc child protection concerns about the way C1 was transported to hospital. Day 4 (Wednesday) 10.40 hrs Parents give consent to life support being removed. 13:00hrs Staff Nurse records concerns just raised by maternal grandmother about care provided by FC1 and an incident when Child C1 allegedly fell down stairs. MGM asking for Sibling C1 to be scanned. Information shared with PICU Consultant who attempted contact with Consultant Paediatrician for Safeguarding who was not available and the GP. PICU took further advice from duty Paediatrician and then contacted SUDC doctor and Police. 13.10 hrs Police informed by hospital of Child C1 admission and plan to remove life support that afternoon. Police SIO identified and SUDC Paediatrician informed. Children’s Services informed. 15:30hrs Child C1 pronounced dead. 2 Strategy meetings take place – SUDC Paediatrician, Police, Children’s Services. Early view that this was tragic accident, but possible issue with FC1’s supervision of children. Information shared about allegations made by maternal family to hospital staff regarding FC1’s care of Child C1. Allegations of occasional unexplained bruising/accidents in the past. Agreed S47 assessment, Sibling C1 staying with family. Police and SUDC Paediatrician undertake initial investigation; meet with PICU Staff nurse and family 18:30hrs Child C1 examined by SUDC paediatrician in the presence of Det Inspector1. Some bruising noted, difficult to determine significance. 19:00 hrs Police and SUDC team request notes from ward. They were told that the request would have to go to Clinical Governance the next day. 19:30 hrs Police and SUDC Paediatrician undertake visit to home. Day 5 (Thursday) 12.18 hrs Children’s Services Team Manager contacted by Coroner’s Officer. Informed that Post Mortem had been stopped and a Home Office Post Mortem was to be completed. Unexplained bruising had been found on Child C1. Hospital also had the information. Strategy meeting arranged with police. 14.24 hrs Post mortem skeletal survey takes place. 15.30 hrs Strategy meeting takes place with Social Worker, SW Team manager, DI and DC. Police inform of possible fracture to arm. Agreed Police Protection for Sibling C1, to be placed in foster care. Child Protection medical for Sibling C1 booked for later that day. Further strategy meeting booked. Video interviews undertaken with parents Police and C/S working closely together. 16.50 hrs Hospital Cashier contacts Named Nurse/Matron for Safeguarding Children re concerns shared with her by MGM. Page 10 of 36 Child C1 SCR Published Report 151214.doc 20.10hrs Sibling C1 taken to foster placement under police powers of protection7. Day 6 (Friday) Child Protection Medical undertaken; Sibling C1. No non accidental injuries or concerns identified. 09:00 Home Office Post Mortem takes place. Joint briefing undertaken by DI. Possibility of other injuries, further tests required. 15:15hrs Strategy meeting held at the Hospital. SUDC Paediatrician, SW, DC, HV and DI. Section 20 [Children Act 1989] Accommodation agreed with parents, but Emergency Protection Order/Interim Care Order would be sought if parental consent withdrawn. Day 9 Domestic Abuse referral sent to Women’s Aid by police requesting support for MC1. Day 12 Strategy Meeting - Police and C/S. Agreed that Skeletal survey will take place for Sibling C1. C/S will be initiating Care Proceedings. Disagreement between Police and C/S regarding what information Police willing to disclose for use in Care Proceedings due to consequent need to disclose to parents C/S find an alternative source, unbeknown to police. Rapid Response8 Report provided by SUDC Paediatrician to Coroner. Day 18 Sibling C1 – skeletal survey undertaken. No evidence of injuries. Following month Looked After Children Review Following month Police called by family member following argument between Mother and Father in the street. Forwarded to PPIU. Domestic Abuse Stalking and Harassment [DASH] risk assessment undertaken. Risk Medium. Officer in case informed. Following month Multi-agency planning meeting. Police, C/S and Local Authority Legal. Continued dispute about disclosure of information by police to C/S. November 2013 Sibling C1 made subject to Interim Care Order. December 2013 Police submit pre-charge decision form to CPS. CPS advice- insufficient evidence to charge either parent. December 2013 Police inform C/S that no charges against the parents following advice from CPS. 7 Police Protection: When a police officer has reasonable cause to believe that a child would be at risk of significant harm unless action is taken immediately they may: [Section 46 Children Act 1989] • remove the child from the situation and take them to a place of safety • Take action to prevent the child's removal from a place of safety. 8 Rapid Response is the process that is followed by agencies as detailed within the Greater Manchester Procedure for The Management Of Sudden Unexpected Death In Childhood Page 11 of 36 Child C1 SCR Published Report 151214.doc 4. How professionals understood the case at the time The following section is a summary reconstructing how professionals understood the children’s experience and their situation at the time. It is produced in the present tense in order to ensure focus on what was known at the time, rather than what we know with hindsight. This enables us to gain a better understanding of the context in which professionals worked and therefore what either helped them or got in the way of their safeguarding practice. 4.1. The Review period begins soon after Mother moves into the Homeless Families Unit following disclosures of domestic abuse against Father. At this point the professionals who have routine contact with the family are the staff at the Unit and the Homeless Team Health Visitor. All the practitioners experience Mother as a private person who is ‘compliant’, but they do not feel they know her or the children particularly well. In the Health Visitor’s description “there was something intangible about her”. The Mother spends most of the daytime out of the accommodation, reportedly caring for her own mother who is terminally ill with cancer. The Mother informs staff that she is no longer having contact with the Father and the relationship is over. Staff are aware of the Father’s grandparents visiting but there is no direct recording of their relationship with Mother C1 and Sibling C1 or what the arrangements are for contact between father and child. 4.2. The role of the staff at the Unit is to provide general housing related support for families who have been referred to this accommodation as a result of their vulnerability. Staff refer to specialists when they identify a particular need, which does not appear to them to be necessary in this case. There are some concerns about Mother’s health, but Sibling C1’s development and the care he receives do not give cause for concern. 4.3. In early 2012 the Police are involved on a couple of occasions as a result of Father harassing the Mother. On both occasions the officers identify that these are domestic incidents and refer to the PPIU9. The father is issued with a harassment warning. On the second occasion the PPIU make a referral to Children’s Services. At the end of January the Mother is booked in to the Ante-natal clinic and tells staff that she has experienced Domestic Violence and has a court order preventing the Father from contacting her, but not from having contact with Sibling C1. The information is not recorded on the Neonatal Record, the reasons for which are not known, however, a referral is made to Children’s Services. It is not known if Mother had such a court order. 4.4. Both Referrals are dealt with by the same Social Worker in the First Response Team. The Social Worker accesses the 2 Initial Assessments prepared the previous year both of which had judged there were no concerns. She experiences the mother as ‘very accommodating’ and assesses she is able to protect the children, as evidenced by her leaving the Father and promptly 9 The PPIU is the Public Protection Investigation Unit of the police which is staffed by specialist officers responding to cases involving Child Protection, Domestic Abuse and safeguarding Vulnerable Adults. Page 12 of 36 Child C1 SCR Published Report 151214.doc reporting his behaviour. The Social Worker notes there are no concerns about the care of Sibling C1 from the Health Visitor. The Social Worker therefore concludes that there is no need for further action. 4.5. The Health Visitor refers the Mother to the Community Nursery Nurse for extra support as well as to the GP as she is worried that the Mother is very underweight. On several occasions the Health Visitor reminds the Mother to ensure that Sibling C1’s immunisations are undertaken. The Health Visitor and Unit staff have regular communication, all are aware that the Father should not be allowed access to the building and there are no pressing concerns. 4.6. Child C1 is born in May 2012 and discharged home with his Mother to the Homeless Families Unit. Whilst hospital staff speak to the Mother at different times both about her mental health and domestic abuse, the Hospital records contain limited information about these issues and again, the reasons for this are not known. 4.7. Both the Health Visitor and the Midwife record a number of missed appointments with the Mother and Child C1, but this does not cause excessive concern and they are reassured by the fact that she is being seen regularly by staff in the Unit. She is felt to be “disorganised with appointments and routines”. When the Health Visitor does see the Mother and children, she has no significant concerns about Child C1, but does again remind the Mother about ensuring Sibling C1’s immunisations are completed. Overall the Health Visitor and Community Nursery Nurse are happy with Child C1’s progress. He is described as “alert and sociable”. Other appointments with health specialists for the children are missed over the next few months. The Health Visitor tries to encourage the Mother to take the children to the crèche/playgroup, but she does not do so. 4.8. In March 2013 the Mother tells Unit staff that she is seeing the Father again. She asks if he can now visit the accommodation. Initially the ban on him visiting is upheld. But as she openly continues to see him, often returning very late with the children, a decision is made by the team leader that he can be a day visitor, on the basis that at least this provides some level of monitoring. It is unclear what consideration, if any, is given to whether Father might present a risk to the children, staff presuming the mother will be able to protect them. There does not appear to be any discussion of this decision with the Health Visitor or Children’s Services. 4.9. In April 2013 the Mother is informed she will be allocated her own tenancy. At this point she asks staff in the Unit if the Father can be allowed to stay as an overnight guest “to support her ahead of the move”. The same month one of the Support Workers at the Unit takes a phone call from maternal grandmother, who alleges that Mother has been stealing her morphine, can be verbally abusive and will not return her house keys. She also says that the Father is violent and she is worried about the children’s safety. The Support Worker who takes this call describes being told by a more senior member of staff that this is not their concern, although this is firmly denied by the Page 13 of 36 Child C1 SCR Published Report 151214.doc individual concerned. The Support Worker documents the conversation with maternal grandmother in the running record, but does not take any other action. The Support Worker believes that based on previous history there is little point in doing so as she feels from previous experience her concerns would not be taken seriously. On the same day it is agreed at an operational level that Father can stay as an overnight guest. 4.10. By late spring 2013 Mother and the two children are living in their new property, which is in the same street as the paternal grandparents. A local Health Visitor is now allocated to the family and meets them for the first time shortly afterwards. She describes Sibling C1 as being active and appearing well and that Child C1 is now walking unaided (which had previously been slow in development). The Health Visitor finds Mother to be friendly. 4.11. At 9.10 in the evening on a Sunday in summer 2013 Child C1 is brought into the A&E department of the Children’s Hospital by his Father. The father explains that he was caring for the children and had gone upstairs for 5 minutes. When he returned he saw that Child C1 was choking on a small item. He was not able to remove it so ran with Child C1 to his grandparents’ house down the street and they drove Father and Child C1 to the hospital. Child C1 is unresponsive and in cardiac arrest. It proves difficult for A&E staff to remove the item which is eventually achieved by the surgical registrar. Child C1 is transferred to the PICU but it is clear that he is critically ill and may not survive. His parents are informed of the seriousness of the situation. 4.12. A significant amount of highly skilled work is required to treat Child C1 and ensure he has the best care. He remains on a ventilator in Paediatric Intensive Care and is regularly reviewed during Monday and Tuesday. Following the review on Tuesday afternoon, it is explained to the parents that Child C1 has irreversible brain damage and that ventilation will need to be ceased. It is agreed with the parents that they will have 24 hours to think about what they have been told. 4.13. During the afternoon of Tuesday (Day 3), a Paediatric Nurse on the PICU, is surprised on checking Child C1’s notes that no-one has spoken to the Safeguarding Team at the hospital. She feels that the presentation of a young child with a cardiac arrest outside of hospital and the delay in his presentation at hospital should have led to a safeguarding referral. The nurse therefore contacts the Hospital Safeguarding Children’s Nurses and informs them. They in turn speak to the Named Doctor for Child Protection who advises that there are no child protection concerns at this time regarding the way Child C1 was brought into hospital. A member of the hospital Safeguarding Unit also telephones the Health Visitor and leaves a message in her absence. A message is then left for the PICU nurse quoting the Named Doctor’s response that there are ‘no concerns’ although the context is not detailed in the message that the nurse receives. 4.14. The following day, Wednesday, the parents agree to withdrawal of life support for Child C1. The maternal grandmother then speaks to the same Nurse and tells her that there is a history of domestic violence from Father; that Child C1 Page 14 of 36 Child C1 SCR Published Report 151214.doc had previously fallen down the stairs and had unexplained bruising whilst in the care of his father who also became aggressive after smoking cannabis. The Nurse ‘feels sick’ when she hears these allegations and immediately shares the information with the Consultant Paediatrician. The Consultant Paediatrician is unable to contact either of the Named Doctors for Safeguarding, but does speak to the duty Paediatrician who advises him to contact the SUDC team and the police, which he does. He has great difficulty in finding the right police officer to speak with. 4.15. The police immediately contact Children’s Services and the SUDC Paediatrician and Rapid Response/Strategy Meetings take place. The Children’s Services Team Manager is surprised that they have not previously been told about Child C1 by the hospital. The initial view of professionals is that this is a tragic accident, although there is some concern about the Father’s supervision of the children. It is therefore agreed that there should be a Section 47 assessment10, and that Sibling C1 should be cared for by the maternal family. The Police and Children’s Services work well together in managing the decision making and working with the family. The Children’s Service Team manager maintains an open mind throughout but is satisfied at this point that there is no evidence to justify any other course of action. 4.16. Child C1’s life support is withdrawn that afternoon. This marks a particularly distressing outcome not only for the family but for practitioners who have been providing Child C1’s care. 4.17. The Police and SUDC paediatrician undertake the expected inquiries in line with the protocol, including visiting the home. 4.18. The following day, Thursday, the Children’s Services Team Manager receives a call from the Coroner’s Officer who informs her that the post mortem has been halted as unexplained bruising has been found. The Team Manager identifies immediately that this raises the possibility that Sibling C1 may be currently at risk. A Strategy Meeting is put in place that day and all necessary actions to protect Sibling C1 and video interview the parents are initiated and completed. By the end of the day Sibling C1 is placed with foster carers. 4.19. The same afternoon, a Hospital Cashier contacts the Named Nurse to tell her that maternal grandmother had spoken to her about concerns regarding the Father. The cashier’s personality and the nature of her work environment allow her to engage with the grandmother and respond to her distress without distraction. The cashier feels strongly about the importance of everyone taking responsibility for safeguarding children and has never forgotten the image of Jamie Bulger being walked out of a busy shopping centre with no-one intervening. 10 Section 47 of the Children Act 1989 places a duty on LAs to investigate and make inquiries into the circumstances of children considered to be at risk of ‘significant harm’ and, to decide what action, if any, it may need to take to safeguard and promote the child’s welfare. This is also referred to as a Core Assessment. Page 15 of 36 Child C1 SCR Published Report 151214.doc 4.20. From this point onwards Police, Health and Children’s Services all work together to fully assess any risk to Sibling C1 and investigate the circumstances around Child C1’s death. 4.21. The only difficulty that arises in relation to the multi-agency approach is that some time later there is disagreement between the Police and Children’s Services regarding what information should be shared by the Police in order to inform the Care Proceedings underway in relation to Sibling C1. The Police do not feel able to provide information about some aspects of their investigation as they are aware that this would become disclosable within the Care Proceedings and therefore known to the parents who had not yet been interviewed under caution because the specialist medical opinion on the cause of the injuries was not ready. However, the police do provide a written disclosure document to Children’s Services. The outcome is that Children’s Services Legal Department access the information themselves through another route. The fact that the Senior Investigating Officer was not a part of the Strategy meetings and also that the Police have had some previous negative experience of Children’s Services in other similar circumstances appears to contribute to the inability to resolve this jointly. 5. Appraisal of practice and analysis 5.1 Introduction. 5.1.1. This section of the Review assesses the quality of multi-agency practice at those key points which were considered to provide the most significant learning. In doing so, it takes into account both the contemporary required standards and also the information that was known, or could have been known at the time of the events. Where there is information about why practice may not have met required standards these are explained. By understanding why things happened in the way that they did, rather than simply what happened, the Review is seeking to achieve a greater depth of learning about safeguarding systems within Manchester beyond this individual case. Where learning in relation to individual agencies’ practice has been identified within the agency learning summaries it is not repeated here. The recommendations for individual agencies which were produced at the outset of this Review are included in Appendix A. 5.1.2. It is important to note that no legal judgement has been made as to whether either parent caused any harm to Child C1, either by the inquest, which has no role in identifying individual responsibility for a death, or arising out of criminal proceedings. Nevertheless, as a result of the circumstances around Child C1’s death, Children’s Services concluded that there was evidence that Sibling C1 could be at risk of significant harm and therefore reached the threshold for statutory intervention. Sibling C1 was subsequently made subject to an Interim Care Order by the Family Court. The long term plans are for Sibling C1 to be returned to his mother’s care. Page 16 of 36 Child C1 SCR Published Report 151214.doc 5.1.3. The Review has reached the clear conclusion that no causative link could reasonably be made between the responses of agencies at the time and the outcome for Child C1. Nothing in the information available to this Review suggests that agencies could have anticipated Child C1’s death within his family in these, or other, circumstances. Nevertheless in analysing agency actions it is possible to identify potential strengths and weaknesses in safeguarding practice as part of overall learning. 5.2 The referrals to Children’s Services in early 2012 5.2.1. In January 2012 two referrals were made by the police to Children’s Services regarding domestic violence. At the end of the month a hospital midwife also made a referral to Children’s Services due to the history of domestic violence and the fact that the mother and Sibling C1 were living in homeless accommodation. The referrals, which were all appropriately made, went to the First Response team. The team which is staffed by Social Workers responds to all new contacts coming in to Children’s Services; undertakes initial enquiries and where the case requires a statutory social work response forwards it to a locality social work team for further assessment. The required standard is that each contact will be considered and responded to within 24 hours. 5.2.2. In this case the Social Worker assessed that there was no need for further action. The Social Worker had access to two previous assessments undertaken in the preceding 6 months which had also concluded that no further action was required. The Social Worker in reflecting on her response felt that she had adequate information to make this judgement and that the previous assessments were of a good quality. She did not question the previous Initial Assessments, which included some unresolved information that could reasonably have triggered concern about the Mother’s history. She gave significant weight to the mother’s separation from the father and her ability to protect her children. The manager who signed off the Initial Assessment accepted this assessment. 5.2.3. It is the conclusion of this Review that there was enough information to indicate the need either for a MCAF or for a fuller social work assessment of both Sibling C1 and unborn Child C1’s needs. The Review Team identified a number of aspects of the two previous Initial Assessments which were of concern. Despite the allegations of Domestic Abuse the parents had been interviewed together and there is no evidence of MC1 being seen on her own. There had by this point been 7 referrals to Children’s Services and this was clearly a vulnerable family, although not a family that was displaying evidence of high or increasing risk. The Social Worker was explicit during her conversation with Review team members that she did not feel that she was working under unreasonable pressures at this particular time and she did not identify any other work factors that had an impact on her decision making. This suggests that her response to this case was not untypical. It cannot be discounted that the approach and assessment skills of a particular individual may have been a significant factor. However, focussing on this alone will not provide adequate insight into the factors that impact on work Page 17 of 36 Child C1 SCR Published Report 151214.doc within the First Response team and in what way practice might be strengthened and risks minimised. 5.2.4. In reflecting on this episode of practice it is possible to identify a number of common ‘error traps’ which are increasingly recognised as familiar factors in child protection practice. The individual referrals relating to this family largely repeated similar concerns from different agencies at different times. There was no explicit information suggesting an increase in the level of concern over time. This is a familiar pattern from practice experience both locally and nationally. Because the referrals appear to be repeating the same information, there is a tendency to assume that the previous assessment of the situation remains unchanged. As a result, the potential cumulative impact for a child of living in what may be a damaging environment may not be recognised. 5.2.5. A second common error trap when working in complex environments11 is a failure to revise assessments or reconsider initial judgements. This was demonstrated in this case by the absence of challenge about the previous Initial Assessments, despite further information and changing circumstances, such as further evidence of domestic abuse and the impending birth of another child. The Social Worker was explicit that as the team manager had signed off these previous assessments there was no reason for them to be revisited or questioned. This approach points towards the need for greater willingness to challenge and be challenged on decision making throughout the organisation. Lastly, the weight given in the assessment to the mother’s capacity to separate from the father and protect her child post separation was not balanced adequately against concrete evidence or tested out over time. 5.2.6. Practitioners should not be judged as if they are working in a vacuum when reaching such decisions, as their work context will have a fundamental impact on how they respond to individual cases. There is a body of knowledge about the particular difficulties of ensuring that teams at the ‘Front Door’ of Children’s Services are able to effectively manage the inevitable risks within this setting.12 Safeguards, such as time for reflection and comprehensive individual case supervision, are considerably harder to embed in this setting and therefore best practice which requires practitioners to routinely achieve a ‘constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events”13 is particularly difficult. Practitioners working at the ‘front door’ of Children’s Services are required to reach quick judgements with limited information and as such there is a particular level of vulnerability built in to the practice. Research also suggests that such teams may be inclined to ‘filter out’ referrals, particularly where there is no information of immediate significant harm to a child.14 11 Munro (2008: 137) 12 Broadhurst et al (2009) 13 Reder and Duncan, cited in Burton, S (2009 :7) 14 Broadhurst et al (2009) Page 18 of 36 Child C1 SCR Published Report 151214.doc 5.2.7. The First Response team is responsible for assessing all the first contacts for the whole of Manchester. It manages a very high throughput of work and by its nature is an intense work environment. It will therefore not be possible to achieve absolute certainty that every decision made will stand the test of a subsequent detailed examination. “Child protection inevitably involves working with uncertainties and making difficult decisions and complex judgements on the basis of incomplete information in rapidly evolving, often hostile and highly stressful contexts.” 15 Nevertheless the expectations of good, defensible, decision making are rightly high and practitioners need good quality support and assessment so that the organisation can be confident in the standards that are achieved. This Review recognises that ensuring best practice at this early point is a continuing area of priority for Children’s Services and the Board. It has been subject to critique within OFSTED inspections, audits, a peer review and reports to the Council’s Scrutiny Committee. Planning is in place to develop a Multi Agency Safeguarding Hub [MASH] as the first point of contact by 2015. The recommendation to the Board regarding this aspect of practice is therefore made clearly within this context and framed to ensure that focus on the particular vulnerabilities of assessment practice within this setting is given priority in both current and future developments. (Recommendation 1) 5.2.8. It is also of note that despite the concerns of agencies and the repeat referrals, the option of undertaking a MCAF was not pursued by the referring agencies or recommended by Children’s Services. Standards and practice at the time were intended to ensure that contacts not requiring statutory social work intervention were followed up with appropriate community resources for immediate support to the child and family, which would often entail a MCAF. The Social Worker stated that she had informed the Homeless Families Unit that they should make a further referral if the mother restarted her relationship with the father. However, there is no evidence of this advice in the records of either agency and no reference to a MCAF. 5.2.9. The experience of this case again underlines the continuing work required to ensure the appropriate use of MCAFs when working with families with additional needs who are below the threshold for Children’s Services’ intervention. The experience of this Review provides further case evidence as to the comparatively low use of MCAFs at that time, something which was already recognised by Children’s Services and the Board following an unannounced OFSTED inspection in 2009. It has further raised the question as to the effectiveness of the Pre-CAF questionnaire, intended to identify whether a MCAF is needed. In this case, it is unclear why the Pre-CAF which was undertaken did not lead to a MCAF, something which the practitioner concerned has clearly recognised themselves. Good practice would be to include an explanation as to why the Pre-CAF did not result in 15 Burton (2009:4) Page 19 of 36 Child C1 SCR Published Report 151214.doc the initiation of a MCAF. Responding to this concern within the Early Help programme has been identified as a continuing priority for the Board, and therefore this Review does not consider there is significant value to producing a general recommendation in relation to MCAFs. However, what has been recognised as a result of this review is that the normal expectation for homeless families where there is no formal social work intervention would be that a MCAF is actively pursued with the family. (Recommendation 2) 5.3 Mother, Child C1 and Sibling C1’s accommodation in Homeless Families Accommodation 2012-2013 5.3.1. The Mother and Sibling C1 lived in the Homeless Families Unit for approximately 18 months with Child C1 being born during this period. Mother was experienced by staff as ‘a private person, who took control of her own affairs’. She was considered to be co-operative but did not actively seek or take up professionals’ time in the way that was more typical of residents in this setting. MC1 describes herself as someone who ‘likes to get on with things’ and did not present problems to the staff. The children were mainly seen by staff when the mother was arriving or leaving and there was nothing of concern about their presentation. It would appear that the fact that the Mother presented as quite able and self-contained had the impact of dampening professional curiosity or concern. There was no evidence during their time in the Unit that the children were suffering harm. Nevertheless, the story of this family has been recognised by Homeless Families as providing some important learning about the way in which families who do not present as chaotic or high risk may remain fundamentally unknown to professionals, or their problems underestimated. 5.3.2. One of the factors that have been identified as having impacted on the way in which the service was provided to the families living within the unit was the staff grading system in place at this time. Support workers were appointed at two different pay grades without clarity as to the different roles or skills required to fill those roles. There was direct evidence provided to the review of the negative impact it had had on some practitioner’s perception of their worth and their responsibility. This system has since been redesigned in recognition that it was counterproductive. To some extent, a culture developed whereby those staff at the lower grade may not have felt they were able to, or should engage with the residents other than at the most practical level, which was not the intention of the service. 5.3.3. A particular concern was the response to maternal grandmother’s allegations regarding MC1’s drug use, FC1’s aggressive behaviour and her fears for the children. The Support Worker (Support Worker A) who received the call stated that she had informed a Support Worker at the higher grade (Support Worker B) about what had been said, but was told that this was not their business. Support Worker B denies absolutely that this conversation took place and there is nothing in Support Worker A’s contemporaneous record to confirm that it did. Support Worker A did note the conversation with maternal grandmother in the running records, but she took no further action, as in her view, there was little point escalating concerns, because she believed Page 20 of 36 Child C1 SCR Published Report 151214.doc nothing would be done. Clearly this represents unacceptable safeguarding practice. Support Worker A described personal disputes between some workers, linked in part to the grading system, as well as a sense of disaffection with senior management. An investigation into this incident has taken place, but the only conclusive evidence is that Support Worker A did not escalate her concerns and that if any other staff members read the record they did not consider taking action either. Support Worker A no longer works in this setting and relevant staff in the Unit have been made aware of the agency expectations regarding safeguarding. The Service has identified no evidence to consider that this episode was typical of practice. 5.3.4. The most significant area of learning which is judged to have wider relevance to practice in the Homeless Families Unit is the response to the risks of domestic abuse to the mother and children. The mother, and any risk to her, had been assessed prior to moving to the Unit and she had contact with an IDVA (Independent Domestic Violence Advisor). The reason for her move into the unit was specifically because she had been made homeless following allegations of domestic abuse and this was known to staff. 5.3.5. The Father was not allowed in the unit and on a couple of occasions when he attempted to gain access, appropriate action, including calling the police, was taken. However, until the spring of 2013 Mother stated that she was not in contact with FC1. 5.3.6. Then, in early 2013 it became apparent that MC1 was meeting with FC1 and a pragmatic decision was made by a team leader in the unit to allow him to visit and subsequently stay overnight. There was, and is, no evidence that either the mother or children were subject to abuse as a result of this decision. However the Review team were concerned about the decision in principle and as a result it was further investigated by a senior manager within the Homeless Families Division. It has been judged that whilst the thinking behind this decision was well intentioned, it was nevertheless flawed. It was based initially on the fact that as the unit could not prevent MC1 from seeing FC1, it was safer that she did so where there might be some oversight. 5.3.7. On reflection it becomes apparent that taking this approach could place children at risk and may send an unintended message to victims and perpetrators about the seriousness of domestic abuse. Staff noted they had followed the policy that children should always be accompanied by a parent, but had not taken into account the possibility that the parent might not be in a position to protect. Given the Unit’s specific role in housing families as a result of Domestic Abuse this is of some concern. In attempting to understand why this was the case the Review has considered four significant issues for the unit: • The professional perception of MC1 as not presenting any concerns for herself or her children. Page 21 of 36 Child C1 SCR Published Report 151214.doc • The degree to which adherence to policies may provide a false sense of security that the correct actions have been taken. • The degree to which staff understand the dynamics of domestic abuse and its relationship to safeguarding children. • The risk of focussing on the adult perspective of risk, rather than the child’s experience. 5.3.8. The Homeless Families Service has made procedural changes as a result of this Review, but has also made a commitment to work with staff to develop their reflective skills, through supervision and training. This is subject to a recommendation. In particular this Review has highlighted a potential skills deficit, which the Review team felt had relevance across agencies more generally. Practitioners who contributed to this review were able to articulate the principles of safeguarding. However, this left an unanswered question about practitioners’ confidence or skills in engaging parents in difficult discussions about issues such as domestic violence. This was also reflected in some of the records from health workers. From their wider experience Review Team members felt that skills, as opposed to knowledge, in working with adults, were often an area of vulnerability across services. For example, although protocols or procedures in some situations require questions about domestic abuse to be asked, there was a concern that due to varied staff confidence or experience, this was not infrequently done in a formulaic manner and was therefore limited in its effectiveness. (Recommendation 3) 5.4 Emergency Presentation of Child C1 at the Children’s Hospital, summer 2013 5.4.1. The medical care provided to Child C1 when he was taken into A&E at the Children’s Hospital met the high standards expected. Considerable difficulties were met in removing the object from his throat and this will have been both professionally and personally demanding for the medical staff concerned. Similarly the care that Child C1 received on the Paediatric Intensive Care Unit, and the response to the family, has been assessed as being of a high quality. Again, the professional and personal demands on staff of working with children in this setting should not be underestimated. “Few of us can imagine a greater nightmare than facing the death of a child. The professionals who work with families through such a tragedy – doctors, nurses, policemen and social workers – deal with the rawest of emotions”16 What has however been identified in relation to Child C1 is that safeguarding concerns had not been recognised at the earliest possible stage following his admission to hospital. The potential implications of this are twofold: 16 Foreword by Baroness Helena Kennedy QC in Sidebotham & Fleming, (2008) Page 22 of 36 Child C1 SCR Published Report 151214.doc • Sibling C1’s safety could have been compromised, although there is no evidence that he did experience any harm as a result. • Access to evidence that would have contributed towards the police investigation was compromised. The learning arising out of this episode of practice therefore reflects one of the issues of interest identified at the outset of this Review and requires priority consideration by the Board. 5.4.2. Child C1 had experienced an unusual, serious medical trauma, which should have triggered concern from a much earlier point of admission. Whilst this is understandable in the early hours, during which time significant medical input was required to attempt to stabilise him, the Review Team were concerned that there was no consideration of a referral to the Safeguarding team in the hospital until Day 3 when a new member of staff came on to the unit. The Consultant Paediatrician in discussion with the Review Team identified that the focus in the PICU was very much on the end of life care in relation to Child C1. He recognised that whilst safeguarding should be considered automatically, in reality this was dependant on the medical presentation of the child, which in Child C1’s case did not trigger any concerns. Whilst in complex work environments, it can be difficult to identify signs of concern, this mirrors the comment by Lord Laming in the Victoria Climbie enquiry that: “Child protection does not come labelled as such”17. The result of the overwhelming focus on the child’s medical care had the effect of distracting attention from other information which might have led to consideration that there were safeguarding concerns. 5.4.3. That a staff nurse who arrived on shift on Day 3 was immediately concerned that the safeguarding team had not been consulted for advice about Child C1, illustrates that there were indicators of potential concern present. The nurse was surprised that given: the method by which the Father had brought Child C1 into hospital; the confusion as to whether or not the parents were separated; recognition of the mother’s previous address as being a hostel; and that this was a cardiac arrest of a child which in itself is unusual, she believed that advice should have been sought from the safeguarding team in the hospital. The apparent reasons for this difference in approach include: • The nurse concerned had a particular interest in safeguarding and was studying a Safeguarding module in a Masters Degree. • The nurse was able to bring a fresh perspective after the point of crisis management when staff would have been under particular pressure. • The safeguarding team would not have been available for consultation at the weekend. 17 Laming (2003: p60) Page 23 of 36 Child C1 SCR Published Report 151214.doc 5.4.4. The absence of the safeguarding team at the weekend has been raised by hospital staff as a potential weakness in the system. However, in this case there is no evidence from those involved that consideration was explicitly given to seeking safeguarding advice over the weekend and therefore this would not appear to have been a critical factor. The alternative route for advice would be through the on call Consultant Paediatrician in any event. Whilst the principle of the availability of working hours has been accepted by the Trust, nevertheless, it is the conclusion of this Review that the underpinning focus on safeguarding within the PICU setting needs further development. The evidence provided to this Review would suggest that safeguarding is not firmly ingrained in thinking within this setting, something which has been commented on by other paediatricians who have safeguarding explicitly as part of their role. Whilst there may be benefits to identifying a named member of staff with a safeguarding remit for all children in the unit, if this were to be considered it should be additional to, not instead of, a strong commitment to developing a mindset that ‘safeguarding is everyone’s business’ being developed in specialist paediatric settings. (Recommendation 4) 5.4.5. It is also the case that the possibility of seeking safeguarding advice could have been considered whilst Child C1 was in Accident and Emergency. Information provided by the Named Doctor for Safeguarding was that typically systems at A&E for contact Safeguarding were well followed. Two possible factors may have influenced why this did not take place on this occasion. Firstly, that the child was transferred from A&E into the PICU and therefore A&E staff may have assumed that once the child was stabilised any safeguarding concerns would be managed within that unit. Secondly, the fact that Child C1 was carried into A&E by a parent, rather than brought in by ambulance meant that the more typical response, i.e. that paramedics or accompanying police officers would have raised a safeguarding concern, was not available. Given that this is an unusual set of circumstances, it would not appear proportionate to suggest significant changes in policy or procedure at A& E as a result, however, a recommendation is made that the learning from this review is shared with key staff at A&E. (Recommendation 5). The response of the cashier in sharing her concerns is a potent reminder that safeguarding is very significantly an attitude of mind, rather than a function of a particular role. 5.4.6. The day after the Staff Nurse contacted the safeguarding team for advice she was also told by the maternal grandmother of concerns about domestic violence and that Child C1 had previously suffered accidents in FC1’s care. This disclosure was immediately passed to the Consultant Paediatrician who attempted to speak to a member of the Safeguarding team, but was not able to do so. The Consultant Paediatrician gave a powerful description of the frustration of having to make a number of phone calls before finding the right person to speak to and this procedural gap will require attention by the Trust. (Recommendation 4) The Consultant Paediatrician’s response at this point then led to the SUDC procedures being initiated. Page 24 of 36 Child C1 SCR Published Report 151214.doc 5.4.7. Clear procedures have been developed over recent years to respond to sudden unexpected deaths in childhood. The Greater Manchester Procedure18 has been revised and updated since its introduction in 2009, most recently including specific learning from a Serious Case Review (Child V, 2013). This Review was specifically asked to consider whether the processes which were undertaken following Child C1’s death were in keeping with the expected procedures and particularly whether there was evidence from Child C1’s experience that learning from Child V had been embedded. 5.4.8. Child V’s case had identified that there were gaps in the SUDC procedures at the time. In particular it had revealed that if a child died from natural causes, yet the post mortem examinations identified unexplained injuries which did not relate to the cause of death, there was no requirement or trigger to ensure that safeguarding services were informed, potentially leaving other children at risk now, or in the future. In Child C1’s case, when information was received by the Coroner’s office that he had unexplained injuries, not related to the cause of death, the Police and Children’s Services were informed immediately by the Coroner’s Officer. The Social Work manager concerned was particularly impressed at this response, which was her first experience of such information being shared by the Coroner’s office and clearly demonstrates learning from Child V. 5.4.9. The actions taken by those involved in the SUDC procedures, health, Police, Coroner’s Office, were timely and met the required standards both in the letter and the spirit of the procedures. All steps were taken in order to ensure that the safety of the remaining sibling was secured, the family were supported appropriately and necessary investigations were initiated. Professionals from different disciplines worked together co-operatively, for example police and social work staff spoke to each other most days. 5.4.10. The effectiveness of this period of practice was to a significant degree a consequence of the professionals concerned having a good mix of relevant experience. There was an experienced police Senior Investigating Officer, who had very recently completed SUDC training and another experienced DI was appointed to focus on the safeguarding role. The Social Worker and her manager were both experienced and confident in their roles. Although neither had previously had experience of the SUDC procedures they had a very clear view about their role and were very focussed on the safeguarding of Sibling C1. The SUDC paediatrician was also very experienced, with a strong commitment to multi-agency approach to safeguarding. The Social Work team manager was highly self-critical about her assessment that there was no reason to consider immediate protective actions for Sibling C1 on Day 3 and that she had accepted the view that the injury was the result of a ‘tragic accident’. She was then ‘devastated’ when she was informed of both the allegations about the father and the unexplained post mortem injuries. 18 Greater Manchester Procedure For The Management Of Sudden Unexpected Death In Childhood (Rapid Response) Version 4 ()1.07.13) Page 25 of 36 Child C1 SCR Published Report 151214.doc However until Day 4 there was no evidence that could reasonably have led to Children’s Services intervening to protect Sibling C1 and no reason to criticise the practice of the Social Worker or her manager. 5.4.11. The sequence of events in Child C1’s case has however exposed an anomaly in the SUDC procedure which requires considered, but urgent resolution. It was recognised within hours of Child C1’s admission to hospital that he would not be able to survive independently without continued life support and therefore that his life would end within the foreseeable future. As such the need for the SUDC procedures was predictable. However, because the child’s death followed a planned process within the hospital, there was in effect a built in delay. This raises the question as to why there is not a clear trigger or professional mindset that initiates such a procedure when the death of a child in such circumstances is recognised as inevitable. 5.4.12. The SUDC lead for Greater Manchester has been working with a group of colleagues for some time in an attempt to develop a protocol to respond to children who present following an Acute Life Threatening Event linking this with the SUDC procedures. As a result of this Review, which again has highlighted potential vulnerabilities in safeguarding practice for this group of children, a further meeting has been arranged to try to progress this work. It is therefore the recommendation of this Review that this work is completed urgently. (Recommendation 6) 5.5 Actions taken consequent to Child C1’s death 5.5.1. Joint working between the Police and Children’s Services in investigating Child C1’s death and safeguarding Sibling C1 was predominantly of a high standard. However there was one aspect which did cause difficulty. During the course of the Police investigation there was a dispute between the Police and the Local Authority as to what information about that investigation could be shared. A decision was made by the Police not to share information about some details of the investigation which the Local Authority legal advisors considered were crucial as part of their application to the Family Court for an Interim Care Order. This was not resolved, leading to the Local Authority obtaining the information from another source, which was evidently not good practice from either agency’s perspective. 5.5.2. That there was an impasse between these two services was not acceptable. Such difficulties in managing information are not unusual in these cases and require a constructive problem solving approach on both sides, with escalation to more senior levels if necessary. It is therefore the Recommendation of this Review that the experience identified in this case is shared with the multi-agency Child Protection Investigation Steering Group for further consideration. (Recommendation 7) 5.5.3. A detailed analysis of decisions made by the police and CPS as whether to bring criminal charges in an individual case is outside the remit of this Review. Information provided to the Review was that consideration was Page 26 of 36 Child C1 SCR Published Report 151214.doc given by the police both as to whether there were grounds for a criminal charge relating to the cause of Child C1’s death, either due to a deliberate action, or a failure to act, by either of his parents. Based on the file of evidence prepared by the Police the CPS subsequently concluded that they could not authorise charges on the evidence available. 5.5.4. This Review is not challenging either the Police or CPS decision in this case. However, the Review team were in wide agreement that in some cases involving questions of possible neglect, the involvement of other key professionals in an advisory role, particularly those from Children’s Services, might provide extremely helpful to the CPS in weighing up the evidence. The CPS has recently identified the need for a change in its approach in other circumstances where there are questions about abusive behaviour by adults, particularly cases of Child Sexual Exploitation. The Review team felt strongly that in complex child protection cases, there was merit in exploring this further with the CPS. (Recommendation 8) 5.5.5. The physical vulnerability of young children and the degree to which parental knowledge about the actions that should be taken when a child experiences some critical accident has been given consideration within this Review. It is important to note that Child C1’s mother believes that had the father had better knowledge of First Aid there was a possibility that the outcome for Child C1 might have been different. Similarly the importance of calling 999, and therefore receiving immediate medical advice, even when the distance to a hospital is a very short one, has also been highlighted. In these circumstances this Review recommends that a proportionate piece of work is undertaken to consider whether there is the means to provide First Aid advice or training for new parents. (Recommendation 9) 5.6 Concluding comments 5.6.1. At the outset of this Review four issues were identified as of particular interest, however, these were not intended to define or constrict the learning for this Review (see page 7). Each of these has been considered within this report, however it is of significance that a number of other issues have emerged as having been of particular importance for safeguarding within Manchester and these have led to three key recommendations. 5.6.2. Issue 1: The interface between police, health professionals and HM Coroner in undertaking the child death investigation. The Review has reached a clear conclusion the practice following the initiation of the SUDC procedures was of a good standard and demonstrated learning from previous incidents. 5.6.3. Issue 2: Agency response to safeguarding implications for surviving or future children. The Review has undertaken a detailed analysis of the response of agencies in recognising the potential safeguarding issues for future children and where this has identified weaknesses in safeguarding practice, recommendations have been made. Page 27 of 36 Child C1 SCR Published Report 151214.doc 5.6.4. Issue 3: Actions taken as a result of any identified safeguarding concerns arising out of the child death investigation. The review has reached the conclusion that actions taken when safeguarding issues were identified were timely and appropriate. 5.6.5. Issue 4: The role of family members in identifying and responding to safeguarding concerns. Given the information provided by family members about their concerns following Child C1’s admission to hospital, and the particular circumstances of his being brought into hospital, the Review was keen to consider whether there was any wider learning from the family’s perspective. This has led to a recommendation regarding the provision of First Aid information to new parents. 6 Findings for the Board and Recommendations This section brings together the recommendations arising out of the learning from Child C1’s experience which will require further consideration and prioritisation by the Board. The recommendations are not framed primarily to meet the SMART19 criteria as whilst some have comparatively straightforward solutions, others may trigger a range of responses at a multi and individual agency level and may also benefit from being linked to and incorporated with other ongoing work-streams. Similarly Action Plans are not incorporated within this report in recognition of the growing awareness of the importance of ownership by the Board of the learning arising out of Serious Case Reviews and the often limited effectiveness of SCR Recommendations where this ownership has not been clearly established20. 1. The Board to consider how the role of Reflective Supervision in strengthening assessment practice can be developed and enhanced as a key tool in safeguarding children, both in relation to Children’s Services and to other partners. 2. Learning from this Review to be incorporated into the development of the role of MCAF within Early Help. This to include: • Where families placed in homeless families’ accommodation are not subject to formal intervention from Children’s Services, there should be a normal expectation that a MCAF is actively considered with the family. 19 SMART criteria for setting goals , are (with occasional variations in the words used) Specific, Measurable, Achievable, Realistic, Timely 20 See Brandon et al (Sept 2011) Page 28 of 36 Child C1 SCR Published Report 151214.doc • Where a pre-CAF does not lead to a MCAF, the reasons for this should be identified. 3. The Board to consider what support or multi-agency training could be provided to enable partner agencies to assess and/or develop staff skills in working effectively with adults, particularly, but not exclusively with regard to experiences of domestic abuse. 4. CMFT to evaluate the degree to which awareness of safeguarding is evidenced in practice within the Paediatric Intensive Care Unit and identify any supportive processes or other steps which need to be taken as a result, including clear routes for contacting other agencies. 5. Information from this Review to be shared with A&E staff and consideration to be given to any changes in safeguarding practice as a result. 6. The Board to ensure that a safeguarding protocol for responding to children presenting with an Acute Life Threatening Event is completed and implemented as a matter of urgency. 7. At the earliest opportunity, the Board to share this report with the Child Protection Investigation Steering Group. That group to review the practice relating to information sharing between the police and Local Authority as this impacts on criminal and family court processes. 8. The Board to seek discussions with the CPS regarding the possibility in some complex child protection cases of the involvement of Children’s Services in an advisory capacity. 9. The Board to request a focussed and time limited review by the relevant NHS Trusts regarding First Aid information provided to new parents and for any achievable improvements to current provisions to be identified. Page 29 of 36 Child C1 SCR Published Report 151214.doc BIBLIOGRAPHY Brandon et al (Sept 2011) A study of recommendations arising from serious case reviews 2009-2010 Broadhurst et al (Nov 2010) Ten Pitfalls and How to avoid them. NSPCC Burton, S (2009) C4EOSafeguarding Briefing: The oversight and review of cases in the light of changing circumstances and new information HM Government (2013) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London Lord Laming, The Victoria Climbié Inquiry, London: The Stationery Office, 2003 Munro, E Effective Child Protection. 2008 Sidebotham, P and Fleming, P (2008) Unexpected Death in Childhood: A Handbook for practitioners Page 30 of 36 Child C1 SCR Published Report 151214.doc APPENDIX A: Individual Agency Actions The following actions were identified by individual agencies at the outset of the Review based on their initial analysis of the practice. Central Manchester NHS Foundation Trust 1. Health Visitors should demonstrate that a process is in place to ensure that medical referrals are not delayed, and that the responsibility for making a referral is clearly documented. 2. Vulnerable Babies team should provide regular bespoke training to Health Visitors and Midwives to ensure that the referral process for MCAF and Vulnerable Babies is commenced at the earliest possible opportunity. 3. Health Visitors and Midwives should clearly document within the child’s records why an MCAF has been rejected by them when faced with obvious concerns. 4. Rotational Midwives to antenatal clinic continue to have their booking history taking “peer reviewed” to ensure that local guidance is being adhered to and that errors have not been made. However, core staff should be regularly reminded of referral process and guidance in order to ensure that the peer review process is fit for purpose. 5. All midwives receive documentation appraisal at their annual Supervisor of midwives review. This should include documentation for the neonate. 6. An audit should be undertaken by the Safeguarding Midwifery Team in order to identify the percentage of information which is appropriately shared by the Neonatal record, which should be commenced at booking. 7. Midwives, Doctors and Health Visitors need to regularly review case notes and correspondence to ensure that all social concerns are regularly addressed, as circumstances could deteriorate throughout the pregnancy and following delivery of the baby. 8. Antenatal care and post natal care guidelines for midwives and medical staff and health visitor guidance should direct all staff to readdress social care issues regularly, especially where there has been an increased risk of concern identified earlier. 9. Provision for documentation should be made for any attendance into the hospital with regard to who is caring for the other children. 10. Provision for documentation to be made with regard to who is present in labour and at delivery. 11. Provision for documentation to be made when estranged partners visit or attend the post natal ward or are present during community home visits. Page 31 of 36 Child C1 SCR Published Report 151214.doc Manchester City Council - Homelessness 1. Safeguarding children training refresher to be provided for staff. GP Services 1. Review the process of patient record transfer and consider ways to minimise the journey time and optimise communication of patient care issues between practices as a patient changes registration, particularly in the case of a safeguarding concern. Children and Families - Children’s Services 1. Summary of learning from this case in relation to the need for good quality assessments that include gathering information from all agencies involved, to be presented to all Social Work teams. 2. All Social Workers to attend training on domestic abuse within 6 months. Page 32 of 36 Child C1 SCR Published Report 151214.doc APPENDIX B: Multi Agency Actions The finding identified by the SCR Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? 1. The Board to consider how the role of Reflective Supervision in strengthening assessment practice can be developed and enhanced as a key tool in safeguarding children, both in relation to Children’s Services and to other partners. Yes 1. MSCB will take this forward by tasking the Quality & Performance Improvement Sub-Group to assess & evaluate the impact of the Multi-Agency Supervision Policy implemented and published following the Child U SCR. 1. Quality & Performance Improvement Sub-Group by the end of February 2015. (Chair SPIG RW) 1. Via a report to MSCB by the end of February 2015. 2. Learning from this Review to be incorporated into the development of the role of MCAF within Early Help. This to include: • Where families placed in homeless families’ accommodation are not subject to formal intervention from Children’s Services, there should be a normal expectation that a MCAF is actively considered with the family. • Where a pre-CAF does not lead to a MCAF, the reasons for this should be identified. Yes 2. MSCB will take this forward by requiring the Early Help Strategy Group to produce a plan of action. 2. Early Help Strategy Group.(Lead EM) 2.1 Initial plan of action by the end of November 2014. 2.2 Report on completed plan of action by the end of February 2015 Via report to MSCB in two phases: 2.1 End of November 2014. 2.2 End of February 2015. Page 33 of 36 Child C1 SCR Published Report 151214.doc APPENDIX B: Multi Agency Actions The finding identified by the SCR Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? 3. The Board to consider what support or multi-agency training could be provided to enable partner agencies to assess and/or develop staff skills in working effectively with adults, particularly, but not exclusively with regard to experiences of domestic abuse. Yes 3.1 MSCB will take this forward by linking with recommendation 1.1 from the Child B1 SCR requiring the CSP to provide assurances to MSCB that the ‘Delivering Differently’ response to domestic abuse will incorporate strengthened arrangements for safeguarding children; including the monitoring of the new arrangements by the Safeguarding Children Practice Development Sub-Group. 3.2 The Learning & Development Sub-Group will ensure that the outcomes from this activity are integrated into relevant Multi-Agency training. AS SCR B1: 3.1.1 Letter to CSP end Sept 2014. (Business Manager AMc) 3.1.2 SCPD SG monitoring by end Jan 2015 (Chair tbc) 3.2 Learning & Development Sub-Group. By the end of February 2015. (Chair AMc tbc) 3.1 By report to MSCB by the end of January 2015. 3.2 By report to MSCB by the end of February 2015. 4. CMFT to evaluate the degree to which awareness of safeguarding is evidenced in practice within the Paediatric Intensive Care Unit and identify any supportive processes or other steps which need to be taken as a result, including clear routes for Yes 4. MSCB will take this forward by requiring a report from the Head of Safeguarding CMFT. 4. Head of Safeguarding CMFT (KK) by the end of December 2014 4. Report to MSCB by the end of December 2014. Page 34 of 36 Child C1 SCR Published Report 151214.doc APPENDIX B: Multi Agency Actions The finding identified by the SCR Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? contacting other agencies. 5. Information from this Review to be shared with A&E staff and consideration to be given to any changes in safeguarding practice as a result. Yes 5. MSCB will take this forward by requiring a report from the Head of Safeguarding CMFT. 5. Head of Safeguarding CMFT (KK) by the end of December 2014 5. Report to MSCB by the end of December 2014. 6. The Board to ensure that a safeguarding protocol for responding to children presenting with an Acute Life Threatening Event is completed and implemented as a matter of urgency. Yes 6. MSCB will take this forward by requiring a report from the Head of Safeguarding CMFT. 6. Head of Safeguarding CMFT (KK) by the end of November 2014. 6. Report and protocol presented to MSCB by the end of November 2014. 7. At the earliest opportunity, the Board to share this report with the Child Protection Investigation Steering Group. That group to review the practice relating to information sharing between the police and Local Authority as these impacts on criminal Yes 7. MSCB will take this forward by tasking the Child Protection Investigation Steering Group to review existing joint/Multi-Agency Practice with a view to producing a protocol, which addresses the issues indentified in this review and promotes effective child protection investigations. 7. Child Protection Investigation Steering Group by the end of January 2014 (Chair HJ) 7. Protocol presented to MSCB by end of January 2015. Page 35 of 36 Child C1 SCR Published Report 151214.doc APPENDIX B: Multi Agency Actions The finding identified by the SCR Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? and family court processes. 8. The Board to seek discussions with the CPS regarding the possibility in some complex child protection cases of the involvement of Children’s Services in an advisory capacity. Yes 8. MSCB will take this forward by tasking the Superintendent, South Manchester Division, GMP and Strategic Lead Children’s, CSC to convene a meeting with CPS with a view to involving an independent Child Care expert in CPS’s review of complex child protection cases. 8. Superintendent South Manchester Division, GMP (WC) & Strategic Lead Children’s, CSC (RP) by the end of December 2014. 8. Via report to MSCB by the end of December 2014. 9. The Board to request a focussed and time limited review by the relevant NHS Trusts regarding First Aid information provided to new parents and for any achievable improvements to current provisions to be identified. Yes 9. MSCB will take this forward by requesting a review facilitated by Head of Safeguarding, Pennine Acute Hospitals Trust; Divisional Head of Nursing, University Hospitals South Manchester NHS Foundation Trust and Head Of Safeguarding Central Manchester Foundation Trust. 9. Head of PAHT (LM for SS), Head of Nursing UHSM (HT) and Head of Safeguarding CMFT (KK) by the end of January 2015. 9. Report to MSCB by end of January 2015. Page 36 of 36 Child C1 SCR Published Report 151214.doc APPENDIX C: Acronyms A & E Accident and Emergency ALTE Acute Life Threatening Event CMFT Central Manchester University Hospitals NHS Foundation Trust CPS Crown Prosecution Service C/S Children’s Services DASH Domestic Abuse Stalking and Harassment DC Detective Constable DI Detective Inspector GP General Practitioner HV Health Visitor IA Initial Assessment IDVA Independent Domestic Violence Advisor LSCB Local Safeguarding Children’s Board MASH Multi Agency Safeguarding Hub MCAF Manchester Common Assessment Framework PCT Primary Care Trust PICU Paediatric Intensive Care Unit PPIU Public Protection Investigation Unit SCR Serious Case Review SCRP Serious Case Review Panel SIO Senior Investigating Officer SUDC Sudden Unexplained Death in Childhood |
NC043755 | Death of a 2 1/2-year-old boy in January 2013. Mother admitted to killing Child A; she was convicted of manslaughter and received a hospital order. Mother was detained under the Mental Health Act 1983 for a period in 2011. Child A spent some time in the care of the Local Authority during this period before being returned to the care of his adult half siblings. History of domestic abuse and a Restraining Order against the father was in place at the time of the incident. Uses the Social Care Institute for Excellence (SCIE) systems methodology to identify findings, including: arrangements for parents with mental health issues disproportionately favouring adult's rights over children's; insufficient professional understanding of other's roles and responsibilities leading to assumptions over levels of knowledge and inhibiting professionals' confidence to challenge other agencies/professionals; systemic concerns over assessment processes and inconsistent application of thresholds within the Multi-Agency Safeguarding Hub (MASH); and lack of robust assessment of risk to children at Multi-Agency Risk Assessment Conferences (MARACs). Raises questions for consideration by Devon Safeguarding Children Board and makes various interagency and single agency recommendations.
| Title: Serious case review CN08. LSCB: Devon Safeguarding Children Board Author: Maria Kasprzyk, Helen Hyland, Beverley Dubash, Sophie Creed and David Taylor Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review CN08 April 2014 2 Foreword In 2011 the DSCB was among a number of Safeguarding Children’s Boards across the country who undertook a pilot in using the Learning Together (Fish, Munro & Bairstow 2008) systems methodology developed by the Social Care Institute for Excellence (SCIE). The DSCB went on to use the systems methodology for two case reviews and then in 2012 the Board was given special dispensation from the Department of Education (DfE) to conduct a Serious Case Review (SCR) using the Learning together systems methodology. This was to be the first review nationally (using this methodology) to be conducted concurrently with the criminal investigation. In February 2013, when the case for this review was first considered, it was decided that the same process would be used and approval from the Department of Education was given. In March 2013 the new version of Working Together to Safeguard Children was published. In relation to conducting SCRs it states: ‘SCRs and other case reviews should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight Is transparent about the way in which data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings. LSCB (Local Safeguarding Children’s Board)’s may use any learning model which is consistent with the principles in this guidance, including the systems methodology recommended by Professor Munro.’ The new Working Together to Safeguard Children sets out a number of principles which should be applied by LSCBs and their partner organisations to all reviews. Whilst the new guidance was not published at the time this particular review was instigated and planned due consideration has been given throughout to those principles and the guidance about reviews as a whole. Two of the key principles in the guidance are that: ‘there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; 3 Improvement must be sustained through regular monitoring and follow up so that the findings from these reviews make a real impact on improving outcomes for children.’ The Learning Together methodology is designed to get professionals thinking about the systems that they work within and to challenge those systems and identify where weaknesses exist. The involvement of front line professionals, and family members, is the key to drawing out clear understanding of how things seemed at that time and why decisions were made. Those who have taken part in this SCR are clear that the learning begins as the review unfolds which is quite different to the historical method of conducting SCRs. It is intended that the energy, enthusiasm and reflective understanding which was a common theme throughout this review is adopted by the DSCB and its partner organisation in taking the findings forward and put in place lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm. Translating the findings from reviews into programmes of action which lead to sustainable improvements has always been a challenge for LSCBs and their partner organisations but there is a clear expectation that the LSCBs takes on this challenge proactively, has ownership of review findings and acts positively in response to them. David Taylor Chair Devon Safeguarding Children Board 4 Contents Page No. 1 Introduction to the Case Why was this case chosen to be reviewed 6 Succinct summary of the case Nature of findings 6 7 2 Introduction to the Review Sources of Data Parallel criminal investigation considerations 7 9 3 The Review Introduction Timeline Key Practice Episodes (KPE’s) 10 10 12 4 A summary judgement of how professionals responded to this family Synopsis 14 In what ways does this case provide a useful window on Devon’s safeguarding systems? 16 What light has this case review shed on the reliability of our systems to keep children safe? 17 5 Findings in Detail Finding 1 18 Finding 2 22 Finding 3 25 Finding 4 28 Tools 30 Ownership and action – DSCB and member agencies responsibilities 31 6 Glossary Appendices 1. SCIE methodology and special dispensation/conditions adopted by the DSCB 2. The review Team for CN08 3. Documentation 4. Introduction to the Review 34 5 o Methodology o Learning Together systems methodology o Review Team o Governance o Structure of the review process o Sources of Data o Methodological comment o Structure & publication of the report 6 1. Introduction to the case Why this case was chosen to be reviewed 1.1 On 19 January 2013, following a concern for the mother of the child and her admission that she had killed her child, the body of the male child was discovered at the home address. The child was just over 2 ½ years of age. 1.2 An immediate police investigation began and the mother was placed under arrest on suspicion of murder. The mother was subject of a mental health assessment when she was arrested and was considered fit to detain and interview. She was charged with murder on 20 January 2013 and later convicted of manslaughter and received a hospital order. 1.3 This case was considered by the DSCB SCR sub group on 11 February 2012. The sub group concluded that the criteria for a SCR had been met in that a ‘child has died and abuse or neglect is known or suspected to be a factor in the death’ (based on the guidance within Working Together to Safeguard Children 2010 Chapter 8, 8.9). The recommendation was confirmed by the Chair of the DSCB and notification was made to the Department of Education of the decision. Succinct summary of case 1.4 Child A lived with his mother; the mother also had two adult children from previous relationships who were not living at the family home at the time of child A’s death. She was estranged from the child’s father, who lived nearby, with whom she had had an on-off relationship since 1996. Throughout the child’s life there were incidents of domestic abuse involving the father which were reported to the police by the mother. A Restraining Order against the father preventing contact with the mother was issued on 8 April 2011 to last until 7 April 2013. 1.5 The mother had a mental health episode in March 2011 when she was detained under Section 2 of the Mental Health Act 1983. As a result, the child was initially accommodated by the Local Authority but then returned to the care of his half siblings who had returned to the family home. The case was closed to children’s social work on 27 April 2011. Child A was not open to children’s social work or any other specialist service at the time of death. 7 1.6 The mother was discharged from hospital in early April 2011 and received further contact from the Crisis Resolution Home Treatment Team (CRHT) until being discharged after two weeks. 1.7 In early November 2011 Adult A’s mental health deteriorated and her GP made a referral to CRHT who completed a mental health assessment. As a result, the mother was placed on medication. She was assessed under the Mental Health Act 1983 but not found to be detainable. CRHT continued phone contact with the mother for a short time after the assessment and then there was no further involvement of mental health services with the mother. Nature of findings 1.8 The Review has identified three main findings which will be explained in detail in section 5. The first finding is in relation to the lack of a system for monitoring the potential risk to a child when adult mental health services are no longer engaging with the parent, (page 17 & 18, 5.1 to 5.6). The second finding is about the standard and depth of assessments and decision making when considering the safety of a child, (page 20-22, 5.7 to 5.12). The third finding is also around assessments, specifically risk assessment processes within MASH (Multi-Agency Safeguarding Hub), (page 24 & 25, 5.13 to 5.16). There is a fourth finding, which is classified under longer term work, regarding MARAC (Multi Agency Risk Assessment Conference) processes (page 27, 5.17 to 5.21). In particular how to ensure that the safeguarding of children is robustly assessed at MARAC and also the challenges for MARACs in cross ‘border’ areas. 2. Introduction to the Review Sources of data Data from practitioners 2.1 The mentored Lead Reviewers conducted structured conversations with professionals in the following roles, who together formed the Case Group: Medical General Practitioner for the child and the mother Public Nursing Health Service 8 Health Visitor for the child Police Local Neighbourhood Beat Manager 121a (police notification form) evaluator within MASH (Multi-Agency Safeguarding Hub) Children’s Social Work Operations Manager MASH (formerly Practice Manager in MASH) Devon Partnership Trust (Crisis Resolution Home Treatment Team (CRHT) Clinical Team Leader Senior Mental Health Practitioner The conversations, with the permission of the professionals involved, were digitally recorded in order to assist the Lead Reviewers in data collection. In addition to the structured conversations a discussion was also held with the social worker who had briefly been involved with the child and the mother in March to April 2011. Data from documentation 2.2 Information was sought from each agency which had involvement with the child, the mother and the father, and was compiled into a multi-agency chronology which was jointly reviewed by the Lead Reviewers and the Review Team. In addition some policy documentation from agencies and national research documents of relevance to the nature of the Review were consulted. The records used and documents consulted are listed in full at Appendix 3. Data from family, friends and the community 2.3 The Lead Reviewers wanted to give the family the opportunity to contribute to the SCR. The Independent Chair of the DSCB wrote to the child’s half siblings, and the father, to advise them about the SCR and the process. The letters also included an invitation for the family members to meet with the Lead Reviewers to talk about the family’s view and in particular their thoughts about ways in which Services can be helped to improve the safeguarding of children. Similar letters were later sent to the maternal and 9 paternal grandparents. The allocated police Family Liaison Officer was advised about the letters and was available to explain the process and provide support to the family if required. Contact was also made with the victim support homicide service case worker, who is working with the child’s half siblings, in order to help facilitate any future meetings with the family. 2.4 It was decided by Devon’s Safeguarding Children’s Board (DSCB), in consultation with the police investigation team, that whilst a conversation about the process would take place with family members, any deeper discussion about the family’s experience should not take place until after the criminal process had concluded. This was due to the fact that some of the family members may be required as witnesses for any future court proceedings. At the time of writing this report there have been two responses from family members, the maternal grandmother and the child’s half-sister, both have been contacted by telephone by one of the accredited lead reviewers. The maternal grandmother has declined further involvement in the Review and the child’s half-sister has stated she will make contact if she feels able to in the future. Parallel criminal investigation considerations 2.5 It was recognised by the DSCB and the Lead Reviewers that there are some inherent risks in undergoing two processes simultaneously. However it was recognised that to delay the SCR would not be in line with the priority of the DSCB that early learning should be gained and disseminated to ensure any failings in the safeguarding system are identified and rectified rapidly. To achieve the DSCB priority, whilst ensuring the integrity of the investigation was maintained, a liaison Detective Chief Inspector was appointed to work with the Lead Reviewers throughout the SCR process. 2.6 The Detective Chief Inspector (DCI) attended the initial meeting and spoke to both the Review Team and the Case Group about his role and in particular how any potential disclosure issues should be handled. The CPS (Crown Prosecution Service) was aware of the SCR and was content from the outset that, with the oversight of the DCI, it would not adversely affect the criminal process. 2.7 It was decided that the involvement of family members, as previously discussed at 2.27, should be delayed until the conclusion of the criminal justice process. This was directly as a result of the family members being key 10 prosecution witnesses for the criminal case. As discussed at 2.21 there are plans to visit the family members who have responded. 3. The Review Introduction 3.1 Once the SCR was instigated in March 2013 an early meeting was arranged between the Lead Reviewers (both accredited and mentored), the DSCB Chair at that time and the Children’s Social Care senior manager assigned to assist the DSCB Chair in quality assurance, to discuss the SCR process. There was a decision made at this point that the time period the SCR should cover would be from the birth of the child until the date of death. This decision was reached primarily as an initial scoping of information held by agencies did not indicate any significant involvement with the mother, the half-brother or the half-sister before the birth of the child. In addition it was known that the SCIE systems methodology was generally more effective when considering more recent professional involvement. 3.2 The Lead Reviewers then considered the multi-agency chronology and, where appropriate, documentation (agency records and case files). The Lead Reviewers identified significant time periods of agency involvement with the child and their family from which provisional KPE’s (key practice episodes) were drafted. 3.3 The provisional KPE’s were shared with the Review Team at the first meeting and they were asked to review the multi-agency chronology themselves and encouraged to consider and challenge the appropriateness of the provisional KPE’s and also to identify any further KPE’s. As a result of the Review Team’s involvement and input the KPE’s were adjusted. Timeline The timeline presented in the table below provides a summary of key events, actions and decisions. It is not comprehensive but intended to provide sufficient detail of how the case developed, to provide the broader context for the illustrations used in the findings. 17 October 2010 Birth of the child. 11 30 January 2011 The father commits criminal damage outside the mother’s home address. 19 February 2011 to 15 March 2011 Repeated reports by the mother to the police concerned about the father coming into the garden and trying to break into the house. 18 March 2011 The mother is arrested by the police and detained for assessment under the mental health act. The child is accommodated. 19 March 2011 The mother is detained under the mental health act and taken to hospital for treatment. 31 March 2011 The child is returned to the care of the half-sister and half-brother. 5 April 2011 The mother is discharged from hospital and returns home. 8 April 2011 The father is convicted of criminal damage. Restraining Order issued for 2 years. He also receives a supervision order and attends meetings with the Probation Trust over the next 12 months. 19 April 2011 The mother is discharged from CRHT. 27 April 2011 Case closed to children’s social work. 18 May 2011 Case discussed at MARAC. 5 November 2011 to 16 November 2011 Concerns raised by police, family and GP about mother’s mental health. Crisis Resolution Home Treatment Team (CRHT) involved from 09/11/11. The mother is assessed under the mental health act on 16/11/11 after several failed attempts in preceding days, she is not detainable. 21 December 2011 Final contact between CRHT and the mother. She stated she wanted no further contact from adult mental health services. 10 April 2012 Last contact between the father and the Probation Trust. 16 July 2012 The father breaches the Restraining Order by attending 12 the mother’s address, banging on the door and then using a knife he had brought with him to cut his wrists (superficial injuries). The father is arrested. 18 July 2012 Child’s father pleads guilty and is convicted on 13/08/12 and sentenced to a suspended prison sentence and unpaid work. 7 September 2012 The child starts pre-school. November to December 2012 The child was seen at the GP practice, diagnosed with viral upper respiratory tract infection. The child was absent from pre-school as result of virus until early December. December 2012 to January 2013 The GP practice initially contacted the child’s mother in late November to arrange a mental health review. On 07/12/12 she failed to attend mental health review. Appointment rearranged for 11/01/13 but was cancelled by her at the last minute. 18 January 2013 The child is collected from pre-school by mother. 19 January 2013 The mother is found by a member of the public and taken to local police station. The child was located deceased at the home address. Key Practice Episodes (KPEs) 1. The first indication to any agency of a repeat of mother’s mental health deterioration and the subsequent agency response (November 2011). Mother’s mental health declined in March 2011 resulting in a mental health assessment with her being detained under the Mental Health Act 1983, Section 21. She remained in hospital for a short time (approximately 2 weeks) before returning home. The child was accommodated briefly by the Local Authority and then placed in the care of half-brother and half-sister prior to their mother’s 1 Section 2 (s2) allows a person to be admitted to hospital for an assessment of their mental health and receive any necessary treatment. 13 discharge. However it was the repeat of the mother’s mental health deterioration in November 2011 which the Lead Reviewers and Review Team considered to be significant. It was felt that a second episode in a relatively short space of time represented a potentially higher level of risk for the child and therefore it was the agency response at this point which was of specific interest. The KPE was drafted as a starting point, as the SCR progressed it became increasingly more evident that the actions by organisations in March 2011 were crucial in understanding future decisions about the mother and child. The period of time from March 2011 to January 2012, when the mother disengaged with the Crisis Resolution Home Treatment Team (CRHT), was the most intensive period of professional interaction with the family and as a result has been a focus for much of this SCR. 2. The re-emergence of the domestic abuse towards the mother and the impact on her mental health, by her ex-partner, the father, and the breach of the Restraining Order in July 2012. A review of the entire multi-agency chronology indicated that the deterioration in the mother’s mental health was potentially linked with an increase in the occurrence of domestic abuse incidents. Between January 2012 and July 2012 there was a relatively inactive period of professional interaction with the mother. The breach of the Restraining Order was seen by the Lead Reviewers and Review Team as a very significant event for the mother and represented a clear opportunity for organisations to become re-involved with her and any risk to the child to be re-assessed. It was known that, due to an administrative error, the breach did not result in specialist domestic abuse officers (police) attempting to engage with the mother or a referral to MARAC (Multi Agency Risk Assessment Conference) or an IDVA (Independent Domestic Abuse Advisor), so it was essential to examine in detail this period. 3. The MASH (Multi Agency Safeguarding Hub) response and decision making process related to the subsequent 121A and the response from universal agencies (July 2012 onwards). The Lead Reviewers and Review Team considered that, particularly in the context of a link between mental health and domestic abuse, there was a requirement to fully understand the rationale behind the decision making in the MASH. It was clear from the multi-agency chronology that there was only limited universal agency interaction with the mother and child from July 2012 to the child’s death. There was a sense with the Review Team that the child became increasingly ‘unseen’ in the family 14 situation as time progressed and as such any risk to the child that might exist could not be properly assessed. 4. A summary judgement of how professionals responded to this family This section aims to judge how appropriate the way professionals handled the case was, given what was known and knowable at the time. This appraisal is made with reference to the available evidence base, professional standards and practice wisdom. Using a systems approach to learn from professional practice does not excuse poor practice. Where errors have been made, or professionals have failed to follow appropriate and expected processes it is important these are identified in a straightforward way. There is always the possibility that these may indicate disciplinary or capability issues related to the professionals concerned. These are not dealt with through the SCR process. The SCR focuses on understanding why people acted as they did. Adequate explanations are necessary to prevent similar types of poor practice reoccurring. The subsequent ‘findings’ section of the report focuses on explaining why people made the decisions they did. 4.1. This case illustrates the very real difficulties experienced by a multi-agency system when faced with a vulnerable adult, with the care of a child, deemed to have the capacity to make decisions about her treatment, including withdrawing from it. Throughout this period the majority of the agencies involved in this case focussed their attention on the child’s mother, and her needs, and were not sufficiently thinking about the potential risk to the child, should mother’s mental health deteriorate again after the first episode of mental illness. The reasons behind this are explored in Finding One. 4.2 This case also embodies the complexities of adult and children’s services working together in circumstances where there is a parent with mental health difficulties. Mental health difficulties affect a significant proportion of the adult population; it is estimated that as many as 9 million adults – 1 in 6 15 of the population – experience mental ill health at some time in their lives. Around 630,000 adults are estimated to be in contact with specialised mental health services. Data is not collected nationally about how many of the adults receiving specialised mental health services are parents or carers, but it is estimated that 30% of adults with mental ill health have dependent children.2 4.3 Nationally there is evidence that some parents with mental illness place their children at potential risk of harm. What is striking about this case is that, despite the number of agencies involved with the family, there was little communication between them which would have allowed for joint assessments of the risks to the child, either from the father or the mother. 4.4 There were some good examples of agencies working together initially, for example, the Neighbourhood Beat Manager and the Health Visitor both attended the ward round at the Glenbourne Unit when the mother was detained under the Mental Health Act, in March 2011. However, this led to the staff at the Crisis Resolution Home Treatment Team (CRHT) believing erroneously that they would be actively monitoring the mother’s behaviour and would refer any concerns. Following the arrangement made by Children’s Social Care for the mother’s adult children to care for the child, the lack of joint working meant that no consideration was given as to what action should be taken were these protective factors to be removed in the event that the adult children left the home and the protection they provided was no longer available. 4.5 The Review Team felt that there were at least two occasions in which concerns were raised and action could have been taken to reassess whether the child was at risk. On neither occasion did this happen. In the absence of any of the agencies taking the Professional Lead in this case there was no obvious point of contact or conduit for concerns to be raised, logged and action taken. The reasons behind this form Finding Two. 4.6 Throughout this case the Review Team found evidence of ‘silo working’ with professionals making assessments based on very little information and knowledge other than that immediately being presented to them. Individuals did make some basic administrative errors in this case which did have some impact on the direction the case subsequently took, but this was within the 2 Families affected by parental mental health difficulties, Family Action; www.family-2 D Meltzer, Inequalities in mental health: a systematic review action.org.uk/section.aspx?id=9054. 16 context of being both short-staffed and with high workloads. Staff under pressure are highly likely to make basic administrative mistakes and the Review Team has not given undue weight to these errors. Of far more significance are the wider operating systems which do not offer any opportunities for professionals working within their own ‘silos’ to routinely discuss vulnerable adults where they have concerns. The reasons behind this form Finding Three. 4.7 The significance of the breach of the Restraining Order and the effect of father’s actions on mother and child was underestimated by all the agencies. The reasons behind this form Finding Four. In what ways does this case provide a useful window on Devon’s safeguarding systems? 4.8 Cases involving mothers who are vulnerable to the ebbs and flows of a mental health condition, together with other significant stress factors in their lives, such as domestic violence, need timely and effective help in order to avoid the ‘sudden and unpredictable outburst’ described by Lord Laming in his 2009 report ‘The Protection of Children in England’. This case presented the agencies involved with the family with a dilemma as currently there is no system for routinely monitoring adults with a history of mental illness when they care for a child, so how would the warning signs of deteriorating mental health be picked up? 4.9 Whilst this case has features which are unique to the individuals concerned and their particular circumstances, there are many other families which have similar characteristics and so this is a useful case to test how reliably our systems respond in such scenarios. 4.10 The case has provided a useful window on systems operating within multi- agency safeguarding teams such as the MASH and other multi-agency processes such as the MARAC. It is a useful test of whether the systems Devon has in place are sufficiently robust in their application to be safe. 17 What light has this case review shed on the reliability of our systems to keep children safe? 4.11 The Review Team identified four findings for the DSCB to consider. 4.12 In order to allow common themes to be readily identified across multiple case reviews, the Learning Together methodology expects underlining issues and findings from case reviews to fall under six broad themes : 1. Response to incidents and crises 2. Longer term work 3. Cognitive and emotional crises 4. Family – Professional interaction 5. Tools 6. Management systems 4.13 The Review Team are expected to present a clear account of: how the issue manifests itself in the particular case in what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case any information they have gleaned about how general a problem this is perceived to be locally, or data about its prevalence nationally how the issue is framed for the DSCB to consider the risk and reliability of multi-agency systems and the relevance of this to the DSCB’s overall aims and responsibilities. 4.14 The four findings from this case review are as follows: RESPONSES TO INCIDENTS AND CRISES 1. Where adult mental health services withdraw services to a parent because they are not engaging, given they have mental capacity, there is currently no system in place in Devon to assess current or future risks to any children in the family and create an appropriate safety plan, leaving it to chance whether professionals are alerted to any deterioration or change that adversely affects the children’s safety and welfare. (Response to incidents and crises) 18 2. Professionals are making assessments based largely on presenting information only and are not considering the wider implications for child safety. (Response to incidents and crises) 3. The system used to triage cases in the MASH does not adopt a clear risk assessment based process and is therefore susceptible to inconsistent application of thresholds. (Response to incidents and crises) LONGER TERM WORK 4. The MARAC process focuses on adult, rather than child protection and this is reinforced by the agencies invited to attend the meetings. (Longer term work) 5. FINDINGS IN DETAIL FINDING 1. Where adult mental health services withdraw services to a parent because they are not engaging, given they have mental capacity, there is currently no system in place in Devon to assess current or future risks to any children in the family and create an appropriate safety plan, leaving it to chance whether professionals are alerted to any deterioration or change that adversely affects the children’s safety and welfare. Illustration from the case On 19th April 2011 the mother’s case was closed to the Crisis Resolution Home Treatment Team and just over a week later, on 27 April 2011, the case was closed to Children’s Social Care without any discussion between the two services. Whilst Social Care staff are normally invited to discharge meetings this is not always the case and there is no system in place to ensure it happens. The prevailing belief appears to be that if the parent is not ‘sectionable’ then they are not a risk and the CRHT do not inform the MASH when they are called out to make an assessment. Joint assessments between adult mental health services and Children’s Social Care do take place sometimes but this is based on professional’s view of the seriousness of the 19 case. In this case it meant that there was no system in place to ensure that the mother’s mental health was being monitored and any escalation of risk addressed. 5.1. During the period between March 2011 and November 2011 there was significant agency involvement. The CRHT, Community Mental Health Team, Children’s Social Care, Police, GP, Health Visitor and Devon & Cornwall Probation Trust were all involved but largely working independently of each other. Any possibility of agencies liaising with each other ended in May 2011 by which time the CRHT, Children’s Social Care and the MARAC had all closed the case and therefore their involvement had ceased. Members of the Review Team confirmed that agencies do close cases independently of each other, without consulting on the possible impact of this, but expressed concern that this should be the case when dealing with vulnerable adults who have the care of children. 5.2 This tendency to work in isolation was highlighted in the recent Ofsted report ‘What about the children? Joint working between adult and children’s services when parents or carers have mental ill health and/or drug and alcohol problems’ March 2013. In that report they found that ‘in assessments where there were issues of parent or carer mental ill health, professionals did not routinely approach the assessment as a shared activity between children’s social workers and adult mental health practitioners, in which each professional drew on the other’s expertise. As a result, the majority of assessments did not provide a comprehensive and reflective analysis of the impact on the child of living with a parent or carer with mental health difficulties.’ The Ofsted Report noted that in most cases they reviewed when parents had been admitted to hospital, joint working was poor in ensuring that plans for discharge took the children’s needs into account 5.3 It might be regarded as good practice that the Neighbourhood Beat Manager and the Health Visitor attended a ward round when the mother was an in-patient at the local mental health Unit (this is very unusual). However, this led to an assumption by the CRHT that the mother would be receiving ongoing support and monitoring when discharged and that any deterioration in her mental health would be observed and action taken. This was particularly important because, following the mother’s discharge from the local mental health unit, she was receiving no further support from adult mental health services. 5.4 Following the discharge of mother from the mental health unit GPs received a discharge summary but health visitors were not copied into 20 this. Health Visitors are further marginalised by not routinely being involved in decision making around potential foster placements and are not informed about Police Powers of Protection or other notification routes when children are taken into care. 5.5 From our conversations it became evident that individual professionals do not fully understand each other’s roles and responsibilities and some assumptions are made, including the level of knowledge and training about mental illness. Because professionals don’t fully understand each other’s roles they lack the confidence to challenge other agencies/professionals and their decisions. For example, in this case the GP expressed surprise that the child’s mother did not receive support following discharge from hospital, feeling that a Community Psychiatric Nurse should have been allocated, but he did not challenge this decision. 5.6 Even when concerns were expressed, firstly by the multi- disciplinary meeting held on 14th November 2011, and then by the Neighbourhood Beat Manager on 4 January 2012, there was no system for systematically logging these concerns and making a fresh risk assessment. The Review Team discussed the possibility of setting up local practitioner groups to discuss such cases but, with agencies stretched, it is unlikely that membership of all the agencies likely to be involved in individual cases could be sustained. In addition, it was felt that if the current systems worked better there should be no need for another process. FINDING 1. Where adult mental health services withdraw services to a parent because they are not engaging, given they have mental capacity, there is currently no system in place in Devon to assess current or future risks to any children in the family and create an appropriate safety plan, leaving it to chance whether professionals are alerted to any deterioration or change that adversely affects the children’s safety and welfare. (Response to incidents and crises) Child protection and mental health services tread a difficult and sensitive line between being proactive to safeguard children and not unnecessarily infringing on the rights of parents, to privacy amongst other rights. This case has drawn attention to the way in which current arrangements in relation to parents with mental health issues disproportionately favour the adult’s rights over those of their children. Where adult mental health services withdraw services to a parent because they are not engaging, there are currently no systems in place in Devon that create safeguards for the children in the future. There is no risk assessment or safety and contingency planning at the point of withdrawal. From the child’s perspective, it is left to chance whether the professional network is alerted to deteriorations in the parent’s mental 21 health or other changes that increase the risk of harm to children even though such recurrences are often more rather than less likely to happen. There are some professionals who would be well placed to monitor, assess and respond to early indicators of potential mental ill health and the attendant risk to children but these professionals may not have sufficient information, knowledge or training to undertake this role. Mental health services work within a framework in which adults who are deemed to have the capacity to make decisions cannot be forced to undergo treatment or receive support. This is the case whether or not they have the care of children. If, at the time of discharge from in-patient care an assessment is made that the adult does not pose a risk to children there is no system in place to ensure that this is a joint or multi-agency assessment, with a system of review built in. In the absence of a system to continually assess the risk to children, universal services are best placed to raise concerns. This case has illustrated that in order to perform a child protection role effectively universal services need to be fully informed of the family ‘history’. However, data protection legislation and concerns about information sharing is leading to anxiety and confusion about when information can be shared, and with whom, with or without consent. The culture of patient confidentiality in some organisations, such as those working within ’health’, means that the focus tends to be on protecting this right rather than on the safety of children. ISSUES FOR CONSIDERATION BY THE DSCB Do DSCB members think that the current arrangements for information sharing are appropriate for children of parents with mental health problems? Is there consensus on how agencies should respond in cases of vulnerable parents with children refusing treatment and/or support? For example, should guidance be issued to adult mental health practitioners and Children’s Social Care stressing the need to work together to agree effective discharge/action plans and the closure of cases? What are the cost-benefits of different options? What are the real and imagined barriers to a more pro-active response by professionals? 22 FINDING 2. Professionals are making assessments based on presenting information only and are not considering the wider implications for child safety. Illustration from the case On Monday 16th July 2012 the child’s mother called the police to state that her ex-partner was outside shouting through the letterbox. Police attended and he was found nearby in possession of a kitchen knife which he had used to self harm by cutting his wrists. He was arrested and later charged with possession of a knife in a public place and breach of the Restraining Order. He was convicted at court on 13th August 2012 and the Probation Service completed a Fast Delivery report for the Court with a recommendation that the ex-partner complete an Unpaid Work Order. Fast Delivery Reports have a three hour time allowance which covers an interview with the offender and writing the report. This only allows for limited further enquiries and in this case there is no indication that the report writer requested any information from Children’s Services. 5.7 A key episode in this case was the re-emergence of the domestic abuse towards the child’s mother by her ex-partner and the breach of the Restraining Order which was dealt with by the Court in July 2012, and the possible impact this had on the mother’s mental health. Information from the CRHT who looked after her when she was first sectioned in March 2011 was that issues around the Restraining Order had a significant impact on her stress levels. This information does not appear to have been shared with other professionals. The apparent lack of information sharing meant that none of the other agencies understood the possible link between the Restraining Order being in place and the mother’s mental health. Discussions with the case group uncovered the fact that none of them properly understood what a Restraining Order is and the implications or significance of the breach. There is also no system in place for supporting domestic abuse victims when Restraining Orders are reaching their end. 5.8 The Probation Service undertook a Fast Delivery Report in July 2012, based on the fact that they did not regard this to be a serious offence (only high risk, complex cases are dealt with by the preparation of Standard Delivery Pre-Sentence Reports). They had previously assessed the father as posing a medium risk of harm to the mother, through their attendance at the MARAC and previous supervision of him. The Senior Probation Officer on the Review Team explained that staff are under pressure by the courts and the Probation Service to complete as many reports as they can as quickly as 23 possible, so Oral Reports and Fast Delivery Reports are now used widely for all but the most serious offences. Fast Delivery Reports have a time allowance of three hours leaving the Probation Officer little time for making enquiries with other agencies (such as Children’s Services) and without making a full risk assessment. However, in this case, a full risk assessment had been completed within the previous four months and information was available from the police domestic violence unit. 5.9 The Probation Service systems and processes means that, as in this case, it is not unusual for an officer from one team to be in court and deal with a case up to adjournment for reports and then an officer from a different team be allocated to prepare the report. This non-alignment with the courts is a structural issue which impacts not only upon the system of allocating and preparing reports but also the communication chain across and between agencies. 5.10 In this case the report in July 2012 was based largely upon the presenting facts and information in the case and the potential risk to the child appears not to have been addressed. As the offender was not living at the home address of the adult victim he was assessed as low risk of harm and the previous spousal risk assessment suggested that his participation in the ‘Building Better Relationships’ Programme was not warranted. His non-compliance with the Restraining Order and bail conditions appear to have gone unremarked. Despite the mother’s wish that the Restraining Order be extended, it is not clear who would be responsible for ensuring that her wishes were acted upon and there is no system in place to deal with issues arising from Restraining Orders coming to an end. 5.11 Both the GP and the Health Visitor had contact with the mother around the time of the Court proceedings. Neither appreciated the impact of the domestic abuse and instead made assessments based on the presenting issues. GPs do not receive 121As so would have been unaware of the notification and the Health Visitor appears not to have recognised the potential significance of the information contained within it. Ironically, her focus was almost exclusively on the child’s physical wellbeing and emotional presentation rather than on considering any wider implications of the domestic abuse on the mother’s mental health and assessing risk. 5.12 Cases assessed as high risk should be referred to the MARAC and actions agreed with relevant agencies. When the breach of the Restraining Order was input by the Central Data Input Bureau (CDIB) a domestic violence code should have been included in the electronic record but this was 24 omitted. This code is used by the Domestic Abuse Unit (DAU) to search for incidents in their area. There was consequently no involvement by DAU and no referral to MARAC or IDVA. In Devon there is no ‘back-up’ system in place to ensure that the DAU is alerted to incidents so is totally reliant upon an administrative process being followed in every case. The absence of a MARAC referral meant that the child’s mother was not offered support by the IDVA and a potential means of monitoring any deterioration in her mental health was lost. Furthermore, police involvement and support was not reinstated. FINDING 2. Professionals are making assessments based on presenting information only and are not considering the wider implications for child safety. Research cited in this report clearly shows that adult mental health services and children’s services must work together to be able to meet the needs of families. The SCIE Guide entitled ‘Think Child, think parent, think family: a guide to parental mental health and child welfare’(1) describes how the current organisational context and separate legal frameworks leading to separate guidance on policy and practice has led to a specialisation of knowledge and management structures in different departments. This has led to agencies being accused of ‘silo’ working and not communicating with each other sufficiently. Services who work exclusively with adults are at risk of losing sight of the child and failing to take into account the impact of the adult’s behaviour on children. Increasingly, time and other organisational constraints are placed on frontline staff and this can lead to assessments and decisions being made on limited information or understanding. The tendency is for adult services to consider the needs and well-being of adults rather than undertake full assessments of risk to children, including any protective factors which might mitigate the risks. This is why a system of joint working with Children’s Services is vital if children are to be adequately protected. During a time of significant budgetary pressures services are almost bound to enter a period of retrenchment. Combine this with a lack of recognition of the impact of adult mental ill health on children and there is then a serious risk of practitioners not engaging with other services in order to understand the wider child protection concerns. Although adult mental health services are expected to consider child protection there are no national requirements to gather information and report on children whose parents or carers have serious mental health difficulties. This lack of accountability increases the likelihood that these services give insufficient attention to the risk of harm to children. 25 ISSUES FOR CONSIDERATION BY THE DSCB How can communication and joint ownership of risk assessments between adult services and children’s services be improved? How can the meaning/ implication of Orders, such as Restraining Orders, be disseminated across a wide and complex workforce? How can the DSCB ensure that financial constraints do not compromise children’s safety? FINDING 3. The system used to triage cases in the MASH does not adopt a clear risk assessment based process and is therefore susceptible to inconsistent application of thresholds. Devon’s Multi Agency Safeguarding Hub (MASH) is a partnership between Devon County Council Children’s Social Care, Education and Youth services; Devon and Cornwall Police, Health and the Probation Service, Youth Offending Team (YOT), Early Years Childcare Services (EYCS) and Domestic Violence Services (DVS). Information can be received into the MASH through enquiries from both professionals and the public; following such enquiries relevant information will be sought from partner agencies within the MASH which will then inform decisions about whether the child is at risk of significant harm or may benefit from support from other services. All referrals are subject of triage at point of receipt and not all will be passed into the MASH process. Illustration from the case In this case the breach of the Restraining Order on 16th July 2012 was dealt with by the police who completed a 121A (police notification form of contact with a child) on 17th July 2012. This form was evaluated by one of the police evaluators who work alongside MASH on 19th July. The form was sent (electronically) to MASH for triage 26 where it was first seen by the triage social worker who provided initial MASH analysis and then the Practice Manager. The decision by the social worker and signed off by the Practice Manager, was that it would not go into MASH with a request for information from all other agencies and was therefore classed as information only. Whilst there are published thresholds, this decision was not based on all the available information and, given the history of mental illness and domestic violence, should have triggered a different response. The 121A was sent to Health (not the GP) and the Education Welfare Service (who do not deal with children below compulsory school age). 5.13 The process by which this 121A form, following the Breach of the Restraining Order, was RAG rated and then sent to the MASH with the words ‘For Information Only’ was a cut and paste error by the police evaluator. At the time the team of police evaluators were not at full strength so were behind with the work. During such periods reduced background research is undertaken in order to keep on top of the workload. The information on the police form passed to MASH did not include the DASH (Domestic Abuse Stalking Harassment) risk assessment or MARAC information. The decision to take no further action (made by a Social Worker and signed off by the Practice Manager) was made on just police historical information and previous children’s services information. The rationale for the decision was based on an inaccurate interpretation of the information provided and the reassurance that the father was not living in his child’s home. This 121A was then sent to health and education, with the potentially misleading message still attached to it. This system of marking 121As ‘for information only’ ceased at the end of 2012. 5.14 The decision to take no further action did not adequately take into account the presence of the ‘toxic trio’ of domestic abuse, adult mental illness and alleged drug taking. At the time the MASH were running a pilot with adult mental health services (from June-September 2012) in which a worker was based in the MASH, contributing to the information gathering and providing advice. Prior to the decision to take no further action this worker was not asked to either gather further information, or provide advice to guide the assessment. The success or otherwise of this pilot has not been formally reviewed. 5.15 The assessment by the Social Worker who triaged the referral was fundamentally flawed as it simply focussed on the potential risk posed by the father. It was based on limited information and therefore did not 27 consider the possibility that mother’s mental health may in itself be a risk to her child. The Review Team were concerned that there is too much scope in the MASH operating system for variable and inconsistent decision making based purely on a social worker’s professional judgement with no consistently applied risk analysis or threshold. 5.16 The workers from adult mental health services expressed the view in the case group discussion that referrals made to the MASH by them are not given sufficient weight and this perception was echoed by other case group members. Given that referrals from adult mental health services are relatively infrequent it seems surprising that this should be the case. The Ofsted Report on joint working between adult and children’s services, referred to earlier in this review, found that in some cases adult practitioners had to make repeated referrals before Children’s Social Care took any action and that adult services practitioners did not challenge Children’s Social Care when they were not satisfied with the response to a referral. This reflects a culture of giving concerns from adult services practitioners insufficient weight (although it may be the case that the level of concern is not always clearly expressed and evidenced). The Review Team felt that the current MASH system has a bias towards Children’s Social Care which takes insufficient account of the knowledge and understanding of other agencies who may bring a different perspective to the decision making process. FINDING 3. The system used to triage cases in the MASH does not adopt a clear risk assessment based process and is therefore susceptible to inconsistent application of thresholds. Almost all Local Authorities have now adopted some form of Multi-Agency Safeguarding Hub. In Devon the decision was taken to get the MASH up and running and then resolve all the issues that would inevitably arise, including those around governance, over time. This approach is not without its risks. The Ofsted Inspection of Devon’s arrangements for the protection of children in April 2013 highlighted serious weaknesses in the MASH system, stating that ‘professional judgements made by social care managers are of variable quality and are not subject to effective quality assurance arrangements’. Inspectors found inconsistent decision-making in the application of child protection thresholds. The report states that ’in some cases, risks are not being sufficiently identified resulting in decisions which failed to provide timely and appropriate 28 protection to children’. This case confirms the weaknesses identified by Ofsted. Whilst the Review Team felt that in this case the outcome would still have been ‘no further action’, it raises systemic concerns. These need to be addressed in order for all the partner agencies to be reassured that children are being caught by the safety net created by the MASH process. ISSUES FOR CONSIDERATION BY THE DSCB What actions do DSCB consider necessary to ensure that MASH is a robust safeguarding hub? - Should professionals from other agencies be part of the risk assessment and decision making processes in the MASH? - What are the cost-benefits of different options? Longer Term Work FINDING 4. The MARAC process focuses on adult, rather than child, protection and this is reinforced by the agencies invited to attend the meetings. 5.17 The Review Team found that once both adult mental health services and children’s services had closed the case the one remaining opportunity to put in place safeguards for the child was the MARAC, which met on 18 May 2011. The focus of the MARAC is not on protecting children but on the perpetrator of domestic abuse and the principal victim (usually the ex-partner). Any risk to children is discussed within the context of the risk posed by the perpetrator and not the potential risk posed by the victim. Reviews by Ofsted of SCRs from April 2007 to March 2011 highlighted repeated examples of the risks resulting from the parents’ own needs being underestimated – including when parents had mental health difficulties and/or drug and alcohol problems. 29 5.18 As far as could be ascertained from the brief Minutes of the MARAC meeting, there were no actions specifically aimed at supporting the child. 5.19 These meetings generally include representatives from both adult and children’s services but, in the absence of clear indications of significant harm to children, the process does not facilitate the protection of children being given top priority. The Review Team felt that risks to children should be given at least as much consideration in the MARAC process given that it is a multi-agency meeting and therefore an ideal opportunity for professionals from adult and children’s services to share information and concerns. 5.20 Whilst it was not a particular issue in this case, the Review Team were aware that attendance at MARAC meetings can be compromised when families live close to the borders between different Local Authorities and may be receiving services from both. Individual agency representatives are not inclined to attend more than one MARAC and this can compromise effective information sharing. 5.21 In this case an administrative error by the police meant that the case was not referred back to the MARAC following the breach of the Restraining Order. This oversight meant that the opportunity was lost to put in place an action plan in the months leading up to the child’s death. It also meant that the mother was not supported during a period when it is very likely that she was becoming increasingly anxious about the Restraining Order coming to an end. FINDING 4. The MARAC process focuses on adult, rather than child, protection and this is reinforced by the agencies invited to attend the meetings. The number of domestic homicides has been a national issue for some time. In response to this a number of police forces, including Devon & Cornwall, alongside ADVA (Against Domestic Violence and Abuse), introduced a system of holding MARACs in high risk domestic abuse cases. This was originally conceived by the police as a way of identifying high risk (adult) victims and supporting them in order to reduce the number of domestic homicides. The MARAC process is therefore led 30 by the police and this has had the unintended consequence of the referrals into the MARAC being made overwhelmingly by the police with the process continuing to have the adult victim as the principal focus. Given that research shows that children are present in at least 30% of domestic violence incidents and approximately half of all child protection cases contain an element of domestic abuse, placing children at the heart of the system would empower professionals from all agencies to consider the particular impact and risks to children living with either perpetrators or victims of domestic abuse. This case demonstrates the inadequacies in a system which defines one adult as the perpetrator and one as the victim, with insufficient attention focussed on the risk to children posed by either adult. If all agencies were better engaged with domestic abuse risk assessments and referral to MARAC the system would not be almost totally reliant upon the police making the referrals. This would help to shift the culture away from it being an adult perpetrator/victim focussed process towards becoming more holistic in approach, considering the impact of domestic abuse on all family members. ISSUES FOR CONSIDERATION BY THE DSCB How could the MARAC process be used more effectively to protect children from harm? Is there a need for a review of the MARAC system and processes? How can we encourage professionals with concerns to refer these to the MARAC? TOOLS What has been learnt about the tools and their use by professionals? 5.22 In conducting this review the Review Team found that front-line practitioners are not always best served by the systems they use, often on a daily basis. 5.23 GP practices now use electronic patient records, often with a flag system to alert GPs to specific conditions or issues. However, these flags (denoting 31 child protection or domestic violence for example), in the words of the GP in the case group, don’t always ‘scream at you’. In a system where patients may be seen by a variety of GPs within the practice this is a system risk. Having an electronic patient records system means that although important information, such as discharge letters from the CRHT, are sent to GP practices and may be scanned into the patient’s records, they are not necessarily easily accessible to other healthcare professionals such as the health visitor. 5.24 Both the GP practice for this case and another GP practice for a different case, (previous local SCR) have, as a result of what happened, recognised the importance of sharing concerns about patients with each other and are taking greater ownership for the receipt of letters and test results. Similar systems may not be in place across other GP practices in Devon. 5.25 A number of services and teams continue to use paper based recording systems which cannot be integrated with other records. A previous SCR in Devon highlighted the shortcomings of using a paper based system in terms of the out of hours GP services. It also means that there is a barrier to sharing information even within GP practices. 5.26 The Single Point of Access (SPOC) system for the distribution of 121As, introduced in 2009, needs urgent review. The Probation Service and GPs do not receive 121As so neither are aware of incidents/concerns involving children. The Review Team heard that even those services which do receive the 121As do not always have effective systems for their onward transmission, leading to delays for all those who would benefit from knowing the information contained within them. Ownership and action – DSCB and member agencies responsibilities During the process of completing this SCR the Review Team and Case Group identified a number of practice improvements which have already been implemented. Listed below are some of these improvements: 5.27 The GP practice is now holding weekly meetings to discuss vulnerable patients and the ownership of letters and test results is much clearer. (GP Practice) 5.28 The Mental Health unit are planning to produce leaflets for carers, including the signs and symptoms of mental illness. It will include details of 32 how to contact them in an emergency. (Crisis Resolution Home Assessment Team) 5.29 The practice of putting ‘For Information Only’ on 121As has been stopped. The police are considering which other agencies might benefit from receiving these notifications. (121A Evaluators) Conclusion Whilst this review has identified a number of issues for agencies to resolve and so improve the safeguarding of vulnerable children in Devon, the opinion of the reviewers is that the tragic death of this child, was unexpected and could not have been predicted and so prevented. Recommendations 1. All services engaged primarily with adults to develop practice tools that will assist staff to identify the risks that adults may pose to their children. All agencies working with adults must make their own assessment of risk to children and should not rely on whether or not the child is known to Children’s Social Care as the basis for this assessment. 2. Where there is a risk of further illness in the parent that is likely to have an effect on the child/children, a multi-agency meeting should be called. The purpose of this meeting is to jointly assess the potential impact on the child/children and agree a contingency plan should protective factors be removed. The plan must be communicated to other agencies that may have contact with the family. 3. GP practices need to find ways to receive and respond to indicators of risk to children, including incidents of domestic violence. A nominated Senior person within every GP practice is to ensure that there is a recognised and effective system within their practice to flag up incidents (including domestic violence) and fulfil their safeguarding responsibilities. 4. A process should be commissioned to enable GP practices to receive police 121A’s. 33 5. The findings from this Serious Case Review relating to the MASH should be referred to the current MASH review/MASH Board. 6. An appropriate representative from all agencies who are signed up to the MARAC operating protocol should ensure regular and effective attendance at all MARAC meetings. Alongside the assessment of risk to the adult victim, the risk to children should be specifically considered in every case. The chair of the MARAC is responsible for ensuring that risks to children are thoroughly considered. 7. The DSCB will receive an annual report from MARAC with specific reference to the identification of risk to children and the appropriate referral of children to the MASH in incidents where the risk meet the threshold for social care intervention. 34 6. Glossary Case Group: Staff directly involved in the case from all agencies Findings: What has been learnt from the particular case about the general functioning of the local multi-agency child protection system First follow-on meeting: Discussion meetings held where staff directly involved in the case are asked to check, correct and amplify the analysis of the Review Team to-date KPEs (Key Practice Episodes): Episodes in the case that have been highlighted for detailed analysis Lead Reviewers: The pair who lead the case review process Review Team: Group of senior representatives from the involved agencies who conduct the case review. Generally the expectation is that they should have had no direct decision making role in relation to the case SCIE (Social Care Institute for Excellence): SCIE is an independent charity and, working with Professor Munro, has been developing the Learning Together systems methodology for case reviews and SCRs since 2006. Second follow-on meeting: Discussion meetings held where staff directly involved in the case are asked to compare their handling of the particular case with their ways of working in other cases and more generally Window on the system: The phrase has been coined by a health academic called Charles Vincent to capture the goal of a case review 35 Appendix 1 SCIE methodology and special dispensations/conditions adopted by the DSCB 1. SCIE methodology 1.1 The focus of a SCR using a systems approach is on the multi-agency professional practice. The methodology allows the reviewers to go beyond the case specifics, and explore what happened and why, identifying underlying issues influencing practice more widely. This ‘deeper’ exploration identifies generic patterns that constitute ‘findings’ or ‘lessons’ about the system which move it from the case specific to a systems wide analysis. 1.2 The key advantage of the SCIE methodology is the emphasis on the ‘learning together’ principle which runs through the entire process. It is the active engagement of professionals that provides real understanding of how things are in practice and therefore what can be improved in the ‘systems’ to help professional consistently achieve good practice. It is also a way of providing professionals emotionally affected by the case to start to come to terms with what happened and why and allows them to see that positives outcomes from such a tragic case can be achieved. Another key observation is the creativity of thinking, often directly from the involvement of frontline professionals, that is captured which directly leads to the development of potential solutions to the findings from the review. There is also evidence that simply the involvement in the process leads to more immediate changes in practice to improve safeguarding. 1.3 The analytic heart of the Learning Together model involves three essential aspects. 36 The ‘systems’ model helps identify which factors in the work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. It supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative model for case reviews – those directly involved in the case are centrally and actively involved in the analysis and development of recommendations. This is a key difference from the historical SCR method of using Agency’s Individual Management Reviews (IMRs) to inform the Overview report. 1.4 For further information about the SCIE Learning Together systems approach for case reviews the full report by authors Dr Sheila Fish, Dr Eileen Munro and Sue Baristow can be seen by following the link below. http://www.scie.org.uk/publications/reports/report19.pdf Alternatively the key messages from the full report can be viewed by following this next link. http://www.scie.org.uk/publications/reports/report19.asp 2. Dispensations and conditions 2.1 These were: Conditions: 37 o All members of the DSCB must support the use of the SCIE model for this SCR. o The DSCB will confirm that the Chief Executive and Lead Member of Devon County Council support the DSCB’s plan to use the SCIE methodology for the SCR. o The SCR will be conducted by reviewers who are fully accredited to use the SCIE model. o The DSCB will provide the DfE with updates when required on the progress of the SCR which should include the projected timescale for completion; nature of the learning achieved and how this is being disseminated; feedback from agencies and practitioners on the process followed; the extent to which transparency is achieved in the process; family involvement; and, how issues of accountability are being tackled. o The DSCB will aim to complete the SCR by September 2013 o The DSCB will put in place arrangements for evaluating the learning outcomes from the SCR. o The DSCB will agree to share the learning about the process used in relation to the SCR with the DfE, professionals and relevant organisations including those outside its own areas. o The DSCB must publish a full report of the findings of the SCR. o The DSCB will use its best endeavours to involve relevant family members in the review in order to ascertain their views and wishes. 38 Dispensations: o When conducting a review using the SCIE model, the DSCB will not be able to meet all the requirements of the statutory guidance for SCR set out in Chapter 8 of Working Together, in particular the guidance contained in: o Paragraph 8.20 on determining the scope and terms of reference of the review; o Paragraphs 8.29 – 8.31 and 8.34 – 8.39 on individual management reviews and health overview reports; o Paragraphs 8.27, 8.32 8.33 and 8.40 on the overview report (but bearing in mind the need for the pilot to result in a report which is suitable for publication); o Paragraph 8.41 on the SCR panel’s responsibilities for the overview report; o Paragraph 8.42 on the executive summary; and o Paragraphs 8.43 – 8.46 about action to be taken on completion of the review, including evaluation by Ofsted. The DSCB will be expected to follow statutory guidance in all other respects. 39 Appendix 2 The Review Team for CN08 Accredited Lead Reviewers – Maria Kasprzyk (Professional Lead for Social Work Devon County Council), Helen Hyland (Designated Nurse for Child Protection NHS Devon). Mentored Lead Reviewers – Beverley Dubash (Portfolio Lead for Learner Support & Safeguarding Lead for Education, Babcock LDP), Sophie Creed (Serious Case Review officer for Devon and Cornwall Police). Nicola Jones – Commissioning Lead for Primary and Community Care (Clinical Commissioning Group (CCG) for NEW Devon). Neil Welock – Senior Probation Officer (Devon and Cornwall Probation Trust). Karen Hayes – Operations Manager, Children and Young People Services (Devon County Council). Deborah Wardknott – Child Protection Lead Eastern Area (Integrated Children’s Services (ICS) Virgin Care). Nigel Wheaton – Team Leader Devon Partnership Trust (Adult mental health services). Julia Slingsbury – Public Health Nurse Lead /Service Manager Southern Area (Virgin Care). Chloe Webber – Domestic Abuse Strategic Officer (Devon and Cornwall Police). Rachel Martin – ADVA (Against Domestic Violence and Abuse) Manager (Devon County Council). 40 Appendix 3 Documentation Agency records reviewed o Public Health Nursing Records (Health Visiting) o GP records for mother and child o Social work electronic record o Multi-Agency Safeguarding Hub (MASH) “referral information gathering form” o Police records and description of contact (including MARAC (Multi-Agency Risk Assessment Conference) involvement) o The Probation Trust records of involvement with the father of the child o Devon Partnership Trust records o South West Ambulance patient clinical records o Community Health Care (CRHT) o Pre-school records o Children centre records Additional data sources considered o The Probation Trust pre-sentence report o Restraining Order o MARAC minutes o 121a records o 121a evaluation working practice o MASH referral document o CRHT discharge summary o The Probation Trust supervision order contact records o Children’s social work initial assessment and Emergency Duty Team record National documents o ‘What about the children?’ Ofsted and the Care Quality Commission thematic inspection report March 2013. o ‘Think child, think parent, think family’ SCIE final evaluation report March 2012. 41 Appendix 4 Structure & publication of the report The main section of the report contains the findings of the SCR but it will not detail all of the ‘workings out’ of the Lead Reviewers and the Review Team in reaching the findings and as a result detailed documents such as the chronology are not included with the final report. However, as a result of learning from the SCR conducted in 2012, a précis of the chronology and decision making process in identifying the key practice episodes will be included to assure DSCB members that the methodology has been robust. This report is laid out using the SCIE report template and SCIE terminology. The report, in accordance with CPS advice, will not be published before the conclusion of any possible prosecution. In the meantime, DSCB are working on improvements that draw on the findings of this SCR and will report on these actions and resulting improvements at the time of publication of this SCR. Methodology The DSCB had previously participated in the SCIE ‘Learning Together to Safeguard Children’ pilot, trialling the systems methodology for SCRs and had completed a pilot review of a case in Devon in 2011. In 2012 the DSCB was one of three LSCBs nationally to use the systems methodology for a SCR. As the new Working Together to Safeguard Children had not been published at this time the 2010 Working Together was used to decide if the case reached the criteria for a SCR. The DfE, whilst not expressly giving special dispensation to use the systems methodology were content that the DSCB had sufficient experience from recent reviews to make an informed decision and therefore did not object to the use of the SCIE methodology. On the 18 February 2013 the DSCB advised the DfE that a SCR had formally been instigated and that the learning together SCIE systems approach would be used. 42 Although there was no official special dispensation given by the DfE the DSCB decided that it would be prudent to adopt similar conditions and dispensations that had been used for the previous SCR in 2012. These are described in detail in Appendix 1 with this report. Learning Together systems methodology The key points of a systems approach are listed below; however Appendix 1 with this report provides a more detailed description of the process. The analysis is not only confined to the specific case but the case is used as a means to assess how multi agency systems are functioning. The ‘systems’ model helps identify which factors in the work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. It is a collaborative model for case reviews – front line practitioners directly involved in the case are centrally and actively involved in the analysis and development of recommendations. The Review Team The DSCB appointed two Lead Reviewers who had previously participated in the SCIE pilot and had then led the SCR in 2012. The Lead Reviewers had also been accredited through the SCIE accreditation process since the 2012 review. However in a change from the previous SCR the DSCB felt it would be prudent to have two additional unaccredited but carefully selected Lead Reviewers who could be mentored through the process. The intention being that the availability of additional, trained and accredited Lead Reviewers from different professional backgrounds would provide resilience to the DSCB for future case reviews, audits and SCRs. The Review team and the Lead Reviewers have collectively undertaken the role of data collection and analysis, the Lead Reviewers have been the authors of the final report but consultation and reflection with the Review Team has been made during the report writing stage. Ownership of the final report lies with the DSCB as commissioner of the SCR. The Review Team was made up of senior representatives from different agencies, for full details of the Review Team members please see Appendix 2. 43 Governance There was an expectation from the DfE that the DSCB would seek peer review for the SCR to provide a form of quality assurance and challenge throughout the review process. Whilst attempts were made to engage neighbouring LSCBs this was difficult to achieve so the previous chair of the DSCB agreed to act as the independent SCR chair to provide quality assurance, with the support of an experienced children’s social work senior manager who had extensive experience in SCRs and had no involvement in the case. The Lead Reviewers were also able to access SCIE for advice and support and through this SCIE were considered to have provided methodological oversight and quality assurance for the process. Structure of the review process The Learning Together review model developed by SCIE has a clearly staged process but as a result of the experience of the DSCB in conducting reviews using this methodology a slight deviation from the process has been developed which has been found to be extremely successful. In the DSCB method the multi-agency chronology and the formal records and case files from each agency are initially scrutinised by the Lead Reviewers to identify, at an earlier stage in the process than the pure SCIE model dictates, key time periods and therefore provisional key practice episodes. A key practice episode (KPE) is identified through its significance in the time period in terms of the role it plays in the overall history and the opportunity it may have presented for professional involvement. The first introductory meeting for the Review Team was a combination of explaining the SCIE systems methodology and an opportunity for the Review Team to come together to consider the multi-agency chronology and review the proposed time periods of specific interest. The Case Group joined the Review Team in the afternoon of the first meeting to be both introduced to the SCIE systems methodology, with a detailed explanation of the conversation process3, and also provide an initial opportunity to share some first thoughts about their involvement with the 3 Term used to describe the individual meetings held with front line practitioners 44 family. The Case Group was also invited to comment on the provisional KPE’s identified. The final meeting to present the report and its findings to both the Review Team and the Case Group is scheduled for October 2013. The table below shows the schedule of meetings held for this SCR: Dates of Meetings: 25 February Scoping meeting with Lead Reviewers, Chair of the DSCB and senior manager from children’s social work. 5 March Document reading – Lead Reviewers 26 March Document (chronology) reading– Lead Reviewers 2, 5 and 22 April Planning meetings – Lead Reviewers 25 April Introduction meeting to Review Team and Case Group 30 April Individual conversations with Case Group members – Lead Reviewers 2 May Individual conversations with Case Group members – Lead Reviewers 14 May 1st Analysis and Follow-On meeting Review Team and Case Group 23 July Consideration of draft report with Review Team 4 October Final meeting - Review Team and Case Group In between these meetings the Lead Reviewers evaluated the information from both the Review Team and the Case Group and began to draft the final report. The mentored Lead Reviewers received supervision, support and guidance from the accredited Lead Reviewers throughout the process to ensure the robustness of the review and compliance with the SCIE systems methodology. 45 Engagement of professionals The Lead Reviewers found that both the Review Team and the Case Group members were committed to the process throughout and were very supportive of the SCIE systems methodology. Only one member of the Review Team had a previous understanding of the SCIE systems methodology having completed the SCIE Learning Together foundation course. The open and reflective discussions by both the Review Team and Case Group members has led to a greater understanding of agency and professional practice in a multi-agency context. Structure & publication of the report The main section of the report contains the findings of the SCR but it will not detail all of the ‘workings out’ of the Lead Reviewers and the Review Team in reaching the findings and as a result detailed documents such as the chronology are not included with the final report. However, as a result of learning from the SCR conducted in 2012, a précis of the chronology and decision making process in identifying the key practice episodes will be included to assure DSCB members that the methodology has been robust. This will be described in the introduction within the Findings section at 3.1. This report is laid out using the SCIE report template and SCIE terminology. The report, in accordance with CPS advice, will not be published before the conclusion of any possible prosecution. In the meantime, DSCB are working on improvements that draw on the findings of this SCR and will report on these actions and resulting improvements at the time of publication of this SCR. Improvements already implemented as a direct result of the review process are included in Section 5. A glossary of terms used in the Learning Together methodology is included in Section 6. |
NC52210 | Review relating to Child A, following concerns about suspected fabricated or induced illness including the prescription of opioids for pain management, covering the period from birth to the age of 11-years-old. Child A was born by emergency caesarean section at 27- weeks-old and was diagnosed with a condition found in premature babies. Child A underwent a wide range of medical and surgical investigations, suffering from an increasing number of conditions leading to more health professional involvement. Evidence of mother declining heath visiting support and cancelling and postponing appointments. Child A attended a school for children with physical disabilities and additional sensory needs, before parents opted for home tutoring. Poor health and authorised absences requested by mother impacted on educational progress. Findings: practitioners did not listen to the voice of child; acceptance of what mother said, and responding without any objective assessment led to unnecessary and inappropriate medical intervention; lack of professional challenge and curiosity culminated in the ongoing medicalisation; an insufficient response in meeting educational needs. Recommendations: embedding the voice of the child in procedures and training and ensuring that children are involved at each stage of their care; review practice guidance on fabricated and induced illness to ensure it takes account of children who are coming to harm through excessive medical intervention; training should include the potential safeguarding impact on children not being brought for health appointments; ensure escalation policy incorporates supporting professionals being able to challenge colleagues.
| Title: Serious case review: Child A. LSCB: City and Hackney Safeguarding Children Partnership Author: Sarah Baker Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Child A January 2021 Sarah Baker, Independent Reviewer 1 Contents 1 Executive Summary .................................................................................................. 2 2 Introduction ............................................................................................................... 4 3 Overview ..................................................................................................................... 5 4 Child A’s Voice in the Review................................................................................ 20 5 The Voice of Child A’s Parents in the Review ..................................................... 21 6 Analysis, Findings and Recommendations ......................................................... 23 6.2 The Voice of Child A........................................................................................... 23 6.13 Assessment, Intervention and Treatment .......................................................... 26 6.37 The Management of Pain ................................................................................... 33 6.51 Non- Attendance, Cancelled & Postponed Appointments ................................ 36 6.59 Professional Coordination .................................................................................. 38 6.75 Education and Home Schooling......................................................................... 41 6.85 The Escalation of Safeguarding Concerns ........................................................ 43 2 1 Executive Summary 1.1 As part of an internal review of a paediatric gastroenterology department, Child A was identified as one of several children about whom concerns had been raised in respect of Fabricated or Induced Illness (FII). The hospital (1)1 Gastro-enterology team commissioned its review to understand team functioning and governance issues contributing to children having received inappropriate diagnoses, uncritical long-term treatment and a sub-optimal level of care. 1.2 This complex case was subsequently escalated to the City & Hackney Safeguarding Children Board and a Serious Case Review (SCR) initiated. The SCR report sets out a range of findings and key messages about what practitioners and agencies need to do differently. A number of recommendations for improvement are also made. In summary, the SCR found the following: • Practitioners did not consistently listen to the voice of Child A so as to understand Child A’s perspective, concerns and feelings in order to undertake a meaningful assessment. This was a feature across agencies. Child A’s voice was strikingly absent from records. • Some of Child A’s reported symptoms were responded to without any objective assessment by health professionals. This led to unnecessary and inappropriate medical intervention. FII was investigated as part of a child protection enquiry when Child A was ten years old, but unsubstantiated. The SCR sets out a basis for reframing existing guidance concerning the management of suspected FII and “perplexing presentations’. • There was an absence of a lead professional to co-ordinate and communicate the input of different agencies. This risked diagnosis and treatment being based on inadequate information and inappropriately left Child 1 Hospital 1 = Provides Secondary and Tertiary Care. Secondary care describes services a child can be referred to if they need to be seen by someone with more specialist knowledge. A referral from a primary care practitioner is required to access secondary care. ./Tertiary care describes the specialist end of the NHS that provide services for very complex or rare conditions. A referral from a secondary practitioner is generally required to access tertiary care. Child A received Tertiary services at Hospital 1 3 A’s parents with the responsibility to pass communications and information between practitioners. • The absence of a local chronic pain team contributed to the inadequate monitoring and supervision of Child A’s long-term medication. Following a period of hospitalisation, Child A was discharged on the analgesic Fentanyl. Over a period of six years, no professional was overseeing Child A’s pain management or the impact of long-term opioid use. • There were weaknesses in practice to monitor the repeated postponement or cancellation of Child A’s health appointments by the parents. Despite practitioners identifying concerns in this respect, there is little evidence that these were raised in supervision, effectively responded to or that local policy was followed. • There was an insufficient response in meeting Child A’s educational needs. Child A became ‘lost’ in the system and there were no reviews held on Child A’s educational progress for four years. • Practitioners insufficiently challenged and escalated their concerns about Child A. The review identified many examples when practitioners should have escalated their concerns and been more critically challenging of decisions made by others that impacted on Child A’s safety and wellbeing. It was not until Child A was ten years old that a referral was made to Children’s Social Care. 4 2 Introduction 2.1 The Serious Case Review (SCR) involving Child A was initiated by the City & Hackney Safeguarding Children Board (CHSCB)2 in December 2017. Concerns escalated to the CHSCB at the time related to: • The amount of Fentanyl (an opioid) prescribed to Child A for pain management since the age of five. Fentanyl was initially prescribed to cover a brief surgical procedure at hospital (1)3. It was still being prescribed to Child A following discharge home. • Suspected Fabricated or Induced Illnesses (FII), which had been investigated as part of a section 47 enquiry and concluded by Children’s Social Care as being unsubstantiated. • The known details of the case highlighting concerns about inter-agency working and the care provided to Child A. 2.2 Child A had also been identified as part of a cohort of children in a review of the gastroenterology services at hospital (1) 2.3 The SCR covers the period from Child A’s birth to the age of 11, although the ante-natal period leading up to Child A’s birth was also considered. 2.4 To reinforce both the context and the importance of the identified themes and to hold Child A at the centre, the SCR has adopted a child’s rights approach. Findings and recommendations are presented with reference to relevant articles of the United Nations Convention on the Rights of the Child (UNCRC).4 2 The CHSCB was abolished in September 2019 and replaced by the City & Hackney Safeguarding Children Partnership (CHSCP). 3 Hospital 2 -. Tertiary care describes the specialist end of the NHS that provide services for very complex or rare conditions. A referral from a secondary practitioner is generally required to access tertiary care. 4https://downloads.unicef.org.uk/wp-content/uploads/2010/05/UNCRC_united_nations_convention_on_the_rights_of_the_child.pdf 5 3 Overview 3.1 Child A was born by emergency caesarean section at 27 weeks gestation and transferred to the neonatal unit for intubation and ventilation. During this time, Child A was diagnosed with Necrotising Enterocolitis, a condition of premature babies where a portion of the bowel becomes inflamed. The health visitor initially saw Child A whilst in hospital (3)5. Child A was discharged home aged eight weeks and the health visiting team undertook a new birth review. Child A was reported to be breast feeding on demand and passing both stools and urine satisfactorily. Appraisal of Professional Practice The health visitor undertook a visit to meet Child A and the parents on the neonatal unit. This is an example of good practice where developing an early professional relationship with a family can help support effective service delivery in the future. 3.2 During the first year of Child A’s life, there were increasing concerns raised by both mother and professionals about feeding, weight gain, constipation, excessive crying and developmental progress. Child A was being monitored by the neonatal team at home and by the neurodevelopmental clinic. The neurodevelopmental clinic referred Child A to a paediatric gastroenterologist, a dietician and an occupational therapist. 3.3 Child A underwent a series of tests and was prescribed medication and nutritional supplements. Mother declined health visiting support, although the neonatal team continued twice monthly home visits to weigh Child A. In late 2007, Child A’s mother reported to the neonatal team and dietician that Child A had measles. Appraisal of Professional Practice The neonatal service visited twice monthly for the first three years to weigh Child A. It is unclear why. Prior to the publication of the Neonatal Toolkit in 2009 there was no local service specification to guide practice. The neonatal service reported 5 Hospital 3 = Secondary Care Hospital 6 to the independent reviewer that there was no-one else available to weigh Child A. Given that Child A’s weight gain was so poor, the neonatal service should have escalated this issue. There was a lack of oversight of professional roles and boundaries, no evidence of supervision and no effective engagement with the wider multi-disciplinary team or health visiting service. This pattern of working by the neonatal service meant that Child A did not receive a health visiting service and the full Healthy Child Programme. This would have provided Child A with health development and health promotion support. Another possible consequence of the neonatal service visiting so often and for so long is that mother might have felt overwhelmed by the number of involved professionals, influencing her decisions not to see the health visitor and subsequently refusing support through the local children’s centre. Child A underwent a wide range of medical and surgical investigations in the first year of life. Many of these were invasive and illustrate the beginnings of the over-medicalisation of Child A. Child A was reported to be suffering from ever increasing conditions, leading to more and more health professionals being involved. It would appear that when one problem was resolved (often with intrusive medical intervention) another issue would occur. These interventions appear to have taken place potentially due to over reliance on mother’s reporting. The review found no evidence that professionals had directly observed Child A to witness symptoms. Given Child A was reported not to be feeding well and was not gaining weight (despite nutritional supplements), a period of observation in hospital (3) would have provided assurance that there were organic reasons for the symptoms. With limited communication between any of the services, Child A seems to have been lost in a medical intervention model. 3.4 In Child A’s second year of life, Child A’s weight remained below the 0.4th Centile, and tube feeding via the nose6 was commenced. A PEG7was later inserted. Child 6 Nasogastric tube feeding 7 A Percutaneous Endoscopic Gastrostomy (PEG) is a procedure involving a flexible feeding tube being placed through the abdominal wall and into the stomach. This allows nutrition, fluids and/or medications to be put directly into the stomach. 7 A was supported by the community children’s nursing team (CCNT) and was referred to the community neurodevelopmental team and speech and language therapy (SaLT). Following SaLT assessment there is limited evidence of Child A being taken for SaLT appointments and Child A was ultimately discharged from the service in 2010. 3.5 Mother continued to decline health visiting support, although the health visitor continued to liaise with other professionals to ensure communication was maintained and access to health visiting remained open. The health visitor had supervision regarding the family declining support and undertook a safeguarding risk assessment. This focused on Child A’s non-compliant immunisation status. Appraisal of Professional Practice Despite extensive nutritional supplements, Child A was not gaining weight, although a hypothesis is that because Child A had been born prematurely with gastroenterology problems, there was an established expectation from professionals that Child A would be slow to gain weight. The review identified very limited records as to what SaLT services were provided. Where they did exist, they were often scant and process led. There was no evidence of any robust action to either plan or review Child A’s care in this context. This allowed for the case to drift. Child A appears to have been discharged from the SaLT service without challenge or consideration that Child A’s needs were likely to impact on future speech and language development. The SaLT Safeguarding Children Policy at the time was clear about what to do when a child missed an appointment. However, the policy was framed to take action for children about whom there were identified safeguarding concerns. SaLT staff did not see Child A in this context and hence no action was taken. Discharging children who are not bought to appointments has been identified as a safeguarding risk in many SCRs. Children who are not brought to an appointment have an identified need that is then not addressed. Discharging 8 such children without a requirement to reassess the need is potentially neglectful and can contribute to ongoing harm. The health visitor appropriately accessed clinical supervision, although it is not clear what her safeguarding concerns were and whether therefore there was an escalation to safeguarding supervision. The safeguarding risk assessment undertaken was narrow in focus (Child A’s had not received primary immunisations). This could have been used to further explore wider issues regarding why the family were not engaging with some health services. This brings into question the effectiveness and delivery of the supervision model. 3.6 In Child A’s third year, Child A had a colostomy and was referred for an endocrine review. It was reported by mother that Child A had developed oral aversion; an avoidance or fear of eating, drinking, or accepting sensation in or around the mouth. There is no evidence this was observed by any health practitioner. 3.7 Child A continued to gain no weight. Increasingly, Child A was not being taken to hospital appointments by the parents. Referrals were made for joint adult and child occupational therapy and Child A was referred for educational assessments. Appraisal of Professional Practice Despite supplementing Child A’s feeds with different nutritional supplements, weight gain did not improve. A pattern of behaviour continued whereby professionals did not take a step back to question the underlying cause for the poor weight gain culminating in a drift in clinical care. The dietician reported to the independent reviewer that now they would admit a child for a two week observation period and any parental resistance would result in a child protection referral. The Paediatric consultants report that there are now protocols in place to enable children who are small for gestational age to be eligible to receive growth hormone. Despite Child A’s mother cancelling multiple physiotherapy and occupational therapy appointments, this did not trigger any safeguarding response. Cancelled and postponed appointments went unchallenged, with no consideration to the 9 adverse effect on Child A’s mobility and whether this constituted a potential safeguarding concern. The review identified that at the time, the policy regarding children who were not taken to occupational therapy appointments was not so stringent and as the reasons for appointments being postponed seemed legitimate, the family were never challenged. The review heard that in the context of practice today, the therapist would ring the primary therapist to get a 360 degree picture and undertake a deeper risk analysis. Whilst acknowledging this position, the review covers a period of time from 2006, when the safeguarding needs of children with significant health needs and disabilities were well established across the health sector. This can be seen from the publications and professional health guidance in 2004 and 2009.8 9 3.8 In Child A’s fourth year, weight fluctuated and ultimately, Child A only gained 0.5kg. Mother reported that Child A was now experiencing urinary retention. Further tests were undertaken, including a genetic assessment, chromosome assessment and skeletal survey. Following endocrine testing Child A commenced treatment with growth hormone. Child A’s mobility decreased, and a wheelchair was prescribed. 3.9 Child A was also referred for a statutory educational assessment and it was agreed that Child A’s educational placement would commence in September 2011. The identified school was for pupils with physical disabilities and additional sensory needs. In February 2011 however, Child A’s parents began to express a view that home tuition (as distinct from Elective Home Education10) would be better able to meet Child A’s particular needs. In April 2011, Child A’s parents made a formal complaint to the Local Authority’s education services concerning poor communication with the family and delays in agreeing an appropriate 8 https://www.cqc.org.uk/sites/default/files/documents/safeguarding_children_review.pdf 9 The National Service Framework for Children (2004) states that: Children or young people failing to attend clinic appointments “may trigger concern, given that they are reliant on their parent or carer to take them to the appointment. Failure to attend can be indicator of a family’s vulnerability, potentially placing the child’s welfare in jeopardy.” 10 Home tuition is an alternative to education in school provided by the Local Authority 10 placement for Child A. The response acknowledged some shortcomings, although the parents chose to escalate their complaint further, citing the response to be insufficient. On further investigation, this again acknowledged that communication could have been improved. Appraisal of Professional Practice Wheelchair services are a secondary service and support the work of therapy services. Given reported professionals concerns regarding the impact on Child A’s mobility should a wheelchair be prescribed, this would suggest that the assessment and approving its provision was not as comprehensive as it should have been. Both occupational therapy and the wheelchair service should have taken a broader, more holistic approach in order to ensure that Child A’s mobility was not compromised. The wheelchair service believed they were prescribing the wheelchair to aid Child A’s independence and to assist mother in coping given her health issues. 3.10 In Child A’s fifth year, due to poor weight gain, Child A was admitted to hospital (1) for a Hickman line insertion11. This would allow Child A to commence Parental Nutrition12. Child A underwent surgical intervention in respect of reported urinary problems (Clean Intermittent Catherization13 (CIC) which culminated in the formation of a Mitrofanoff14). Due to complications with Child A’s PEG Jejunostomy, the hospital stay was extended. Child A was ultimately discharged home after a five-month admission. It should be noted that the prolonged hospital stay should have triggered a referral to Children’s Social Care under Section 85 of the Children Act. 3.11 Whilst in hospital (1), Child A was prescribed an opioid (Fentanyl) for pain relief. Child A continued to be prescribed Fentanyl following discharge home, although there was no documented plan for following up on pain management. At the time, 11 A Hickman line is a long, thin, hollow tube that goes into a vein in the chest. 12 Parental Nutrition is the feeding of specialist nutritional products to a person intravenously, bypassing the usual process of eating and digestion 13 Clean intermittent catheterisation is a way of emptying the bladder of urine if passing urine is difficult or impossible. It involves passing a catheter (thin, plastic tube) through the urethra into the bladder 14 The Mitrofanoff procedure is a surgical procedure in which the appendix is used to create a conduit between the skin surface and the urinary bladder 11 the parents were asked if they would like a referral to Children’s Social Care for ongoing support. This was declined and no referral was made. 3.12 On discharge, the CCNT was asked by the hospital (1) to take blood from Child A on a weekly basis and to monitor blood pressure three times weekly. Due to the prolonged hospital admission, Child A missed the first two terms of planned education and commenced school in April 2012. Appraisal of Professional Practice Child A was discharged home with a continuing prescription of Fentanyl. There was no plan for follow up or how Child A would be weaned off this opioid. Child A had eight further admissions whilst on Fentanyl, but no concerns were raised regarding its use. Child A was not referred back to the hospital pain team by the paediatric gastroenterologist who preferred to manage his own patients, thus isolating them from a wider professional perspective. If Child A had been referred to a pain team, they may have been able to raise concerns regarding the prescribing. During a hospital (1) admission, despite nurses identifying concerns regarding how much Fentanyl Child A was taking, they did not escalate their concerns. Furthermore, the review found no evidence of professionals discussing mother’s own use of opioids for pain management and the impact that this might have had on her parenting capacity of Child A or the family’s views about their use. An open dialogue with Child A’s parents by their GP could have been beneficial to explore this issue. The CCNT is an expensive resource and yet the financial impact of acting as ‘couriers’ to transport blood and blood pressure readings was not questioned by themselves or others. The impact of this is likely to have been unnecessary pressure on the system and availability of the CCNT resource to other families. 12 3.13 In Child A’s sixth year, mother continued to report that Child A was experiencing symptoms of abdominal bloating, pain, retching and vomiting. It is unclear how many of these symptoms were ever witnessed by health professionals. During interaction with the gastroenterology clinic, Child A’s mother reported further medical problems (including Left Ventricular Hypertrophy15). 3.14 The clinic did not know who had made these apparent diagnoses. Mother also reported that Child A required increasing doses of Fentanyl. Referrals were made to the renal team and ophthalmologist. Appraisal of Professional Practice The CCNT raised concerns with a consultant regarding the amount of Fentanyl that Child A was taking, although failed to follow these up. Similarly, Child A’s GP continued to prescribe Fentanyl despite their own professional concerns and escalation to the same consultant. There was no escalation through safeguarding channels. In turn, the community pharmacist did not question the repeated prescriptions for Fentanyl for a child. There was an opportunity for discussion between the community pharmacists and GP, although there is no evidence these discussions occurred. Child A’s mother was noted to interpret and identify when Child A was in pain. Professionals were not convinced Child A was in pain, but did not challenge or raise concerns regarding this. 3.15 In Child A’s seventh year, health practitioners reported continuing cancellation of appointments. Child A was said by mother to be suffering from increased pain and Fentanyl use increased. Child A always attended school sitting with mother, which limited Child A’s ability to engage in educational activities. School attendance continued to be poor and the family had concerns regarding how Child A’s medical needs were being met at school. Ultimately home tuition was agreed. 15 Left ventricular hypertrophy is enlargement and thickening (hypertrophy) of the walls of the heart's main pumping chamber (left ventricle). 13 3.16 Between May 2013 and July 2017, the alternative educational provider was commissioned by the Local Authority’s Special Educational Needs (SEN) department to deliver one hour of education per day to Child A at home. The alternative education provider employed an unqualified teacher to provide Child A’s education. 3.17 During this time Child A was not on the Alternative Providers roll. Child A was taking medication to manage pain, which reduced engagement in educational activities due to the sedation effect. Because of this, Child A’s academic progress varied and whilst some progress was made, this was below expectations due to frequent absences for poor health. 3.18 Mother was managing all of Child A’s care, including medication and intravenous feeds. Child A was transferred to another consultant. He noted that Child A was presenting with joint pain and swelling and suggested Child A may have a syndrome affecting connective tissues, Ehlers Danlos Syndrome Type 3. However, this was never confirmed by a rheumatologist which would be usual practice. Appraisal of Professional Practice In view of Child A’s significant health needs, one hour of education was provided per day. The assumption, following discussion with Child A’s parents, was that Child A wouldn’t cope with more than this. In practice, Child A often did not even have an hour a day, as at times Child A was said to be in pain, or was asleep for part of that hour when the tutor was present. There was very little external monitoring of the regularity of the input or reviews of the amount of tuition that could be put in place. There was a lack of professional challenge to the parents wanting Child A to have home tuition, which culminated in Child A having a minimal number of hours of education allocated and isolating Child A from their peer group. 14 Furthermore, despite Child A’s significant health needs, it was deemed acceptable for an inexperienced and unqualified teacher to support Child A’s education at home. The SEND 2015 code of practice16 states that ‘In line with local authorities’ duty to arrange suitable education as set out above, children and young people who are in hospital or placed in other forms of alternative provision because of their health needs should have access to education that is on a par with that of mainstream provision, including appropriate support to meet the needs of those with SEN. The education they receive should be good quality and prevent them from slipping behind their peers. It should involve suitably qualified staff who can help pupils progress and enable them to successfully reintegrate back into school as soon as possible.’ Child A was given a potential diagnosis of Ehlers Danlos 3 which was not confirmed by rheumatology assessment and potentially hindered professional assessment and recognition that Child A’s immobility and joint pain was due to prolonged disuse. The parents did not take Child A for the rheumatology assessment to have the diagnosis of Ehlers Danlos confirmed. Professionals neither questioned why they had not brought Child A, nor considered the impact because of this. An unreliable diagnosis and associated ‘label’ can have a detrimental impact on future decision-making regarding care. 3.19 In Child A’s eighth year, the CCNT continued to undertake blood pressure monitoring at home. Mother made repeated requests for prescriptions for Fentanyl. 3.20 Following concerns raised by the CCNT and GP about Child A’s Fentanyl use, a multi-agency meeting was held which culminated in an assessment being undertaken by the hospital (3) safeguarding team. No specific safeguarding concerns were identified, rather there was concern regarding a lack of education and home medication. At the same time there was dialogue between one of Child 16 SEND Code of Practice 2015 15 A’s consultants and the GP as to how much Fentanyl Child A should be prescribed. The consultant reassured the GP that, whilst Child A’s pain was ‘problematic’, the prescription was needed. 3.21 The CCNT’s concerns were followed up separately by another consultant who telephoned Child A’s mother. Mother was reported to have said that Child A had complex needs, but was well monitored, seeing lots of consultants, and would call if she needed anything (as Child A was reported as being too unwell to see the consultant at the time). 3.22 A plan was made to see Child A in a few months. Following the consultant’s telephone call, an e-mail was sent by this consultant to her counterpart expressing concerns for Child A’s management and safeguarding concerns. It is not clear what the outcome was as there is no documented update. Appraisal of Professional Practice Despite the GP and CCNT having concerns regarding the use of opiates, Child A remained on this medication for another three years. The GPs were under the belief that Child A would be assessed by a chronic pain team and so continued prescribing the opiates and any concerns they held were downgraded. However, these were false reassurances as Child A was never seen by the pain team. In the opinion of the review, the GPs were influenced by the hierarchy of medical professionals and felt bound to prescribe a medication prescribed by a specialist paediatrician (The serious impact of withholding or stopping this prescription, such as acute opiate withdrawal, pain and suffering, is also likely to have contributed to the reasons this was continued). The GPs identified concerns for Child A became secondary in their decision making. They failed to follow safeguarding procedures, placed an over-reliance on the safeguarding practice at the hospital (3), and despite their continued anxiety about the Fentanyl prescriptions, did not follow these through. 16 Given the increasing number of appointments either cancelled, postponed or missed, neglect should also have been considered. There was a failure to apply policies, failure to see the child’s perspective, failure to communicate and to work together. No one took ownership and acted on behalf of Child A. Record keeping was also poor and further hindered evidence of concern for Child A’s wellbeing. It appears that there was reluctance or lack of confidence to make a social care referral. The review identified a number of examples where practitioners did discuss Child A in safeguarding supervision, but subsequent actions were insufficient in their focus. There was a lack of connection between clinical and safeguarding supervision and supervision did not appear to promote and ensure safe practice. 3.23 Between the ages of eight and nine, Child A was referred to hospital (2) for a pain assessment, although was not taken to the appointment. Child A had increasing lack of mobility and was now totally reliant on a wheelchair. Mother was seeking home adaptations for hoisting. In November 2016 attempts were made to carry out a joint visit with adult occupational therapist services to support mother in caring for Child A and the consideration of home adaptations. There were challenges in arranging this. 3.24 Mother declined consent for the occupational therapist to contact the GP and it was not until the occupational therapist informed mother that Child A would be discharged from the service that an appointment was agreed. However, when this took place, Child A was reported as being unwell shortly after the occupational therapist’s arrival. Specialist hoisting was eventually put in place in May 2017, though this was removed later in the year. Appraisal of Professional Practice The concerns of healthcare professionals regarding Child A’s response to treatment and not being brought to appointments should have been escalated as possible indicators of neglect. 17 The family’s repeated failure to take Child A for review by the pain team between 08/06/2016 & 27/06/2017 is seen as significant in this context due to the many side effects Child A was presenting with. These missed appointments also contributed to the delay in Child A being weaned off the opiates. Mother declined consent for occupational therapy to contact the GP regarding adaptations to the home and this appears also to have gone unchallenged without discussion as to why mother would not want the GP to be able to contribute to the assessment. Good practice requires that health services communicate with each other. 3.25 From the ages of nine to ten, Child A continued to take Fentanyl for pain management via patches and lozenge. Child A was now reported to be totally reliant on mother for all aspects of physical care. 3.26 The impact of opioid dependency was discussed with mother and Child A was referred for assessment with the chronic pain team at hospital (2). Mother did not take Child A for this appointment. Throughout the year, mother either cancelled or failed to take Child A to any outpatient appointments. 3.27 A discussion took place between the occupational therapy team and the hospital (3) safeguarding team who suggested further assessment of the package of care and a referral to the Children’s Social Care disability team if the package of care required review. A referral was never made and neither was there escalation of safeguarding concerns given the number of appointments Child A was not taken to. Appraisal of Professional Practice The occupational therapist raised concerns with the safeguarding team at the hospital (3) who advised further assessment, rather than using the information already presented to make a referral to children’s social care. At this point there is enough concern to prompt the safeguarding team to consider developing a chronology and holding a professionals meeting. Professionals did not appear 18 confident in the safeguarding policy and procedures and consequently there is a loss of sight of Child A. Despite concerns about Child As opioid dependency no decision is made with regard to how to wean Child A off the Fentanyl. This is a significant safeguarding risk which is not addressed and another example of Child A being neglected. 3.28 In Child A’s 11th year, occupational therapy offered a referral to psychology due to a few turbulent months with multiple bereavements. Mother declined these as she felt the family were supporting each other. 3.29 There were increasing concerns regarding Child A’s use of Fentanyl and following a pain clinic review and a multi-disciplinary meeting of health practitioners, Child A was admitted to hospital (1) in July 2017. The admission was co-ordinated to wean Child A off Fentanyl, to provide intensive physiotherapy (to help Child A begin walking again) and to engage Child A with occupational therapy to focus on oral aversion. 3.30 At the same time, a referral to Children’s Social Care was made regarding concerns about possible Fabricated or Induced Illness (FII). Following a child protection investigation, FII was not substantiated. Child A was, however, placed on a Child In Need Plan. In late 2017, Child A had successfully weaned off the Fentanyl and was discharged home with a comprehensive multi-disciplinary plan. 3.31 It is important to document that despite significant health needs, Child A wasn’t prioritised for an Educational Health and Care Plan (EHCP) under the 2014 SEND reforms and wasn’t transferred onto an EHCP until November 2017 following admission to hospital (1). Appraisal of Professional Practice The plan to admit Child A to hospital(1) in July 2017 is the first real indication of practitioners understanding and proactively responding to Child A’s over medicalisation. Hypothesis about possible FII were rightly considered based on 19 Child A’s presentations and that of the family, recognising that FII can exist alongside established medical conditions. A referral was made to Children’s Social Care in line with expected procedure. This was good practice. A child protection enquiry under Section 47 of The Children Act 1989 was appropriately triggered given the nature of the concerns. Whilst the overall outcome was that FII was not substantiated (in that FII could neither be proved nor disproved), the SCR identified a number of weaknesses in this intervention. For example, Children’s Social Care did not contact key health professionals involved with Child A for a view of their involvement. It is significant to note the context of the complex and fragmented health network, however in November 2017 joint health leads were appointed. Of significance to the referral itself, when the request was made for a medical opinion in relation to FII, this was neither provided nor subsequently escalated. Child A was also not seen on their own as part of the child protection enquiry. Social workers were persuaded by the parents that due to Child A’s complex healthcare needs they needed to be present. This was accepted with no challenge to the parents or discussion with healthcare professionals. Not to see a child alone is poor practice and compromises a comprehensive assessment where the child is at the centre. The London Child Protection procedures set out that ‘The children, who are the focus of concern, must be seen alone, subject to their age and willingness, preferably with parental permission.’ Child A became lost in the education system due to a lack of capacity to monitor the database of children. At the time of the review, the Local Authority’s Education Service reported that it was not assured that all children were receiving annual reviews. The review identified contradictory evidence as to when Child A was taken off roll from school prior to commending alternative home tuition. This lack of clarity further emphasised the absence of robust systems and processes in place at the time. 20 4 Child A’s Voice in the Review 4.1 Child A was seen alone by the independent reviewer and chair of the review panel. The parents were in another room, although all doors were open so they could hear the conversation and respond to any requests from Child A. • Child A was very chatty and discussed a variety of topics including favourite books, games and politics. Child A was keen to show us some plants on the balcony, although mother was not happy for Child A to go outside, so instead Child A pointed to various plants. Child A said they wanted to be a blood pressure nurse when older. • At one point, Child A wanted to show their ability to walk. Child A wrapped their arms around mother for support, rising to a standing position and walking around the room. Child A was excited to show they could take sips of water from a glass. This was a very recent development. • It was evident as the conversation progressed that if it strayed anywhere near a discussion about healthcare, Child A would say immediately ‘I don’t know, you need to ask my mother’. • Child A’s mother was very attentive during our visit, checking if Child A was happy for her to leave, checking Child A did not feel too tired and suggesting Child A might only want to talk for about 20 minutes. We ended up talking with Child A for at least an hour. 21 5 The Voice of Child A’s Parents in the Review 5.1 The independent reviewer and chair of the review panel met with Child A’s parents on four occasions. Both expressed a hope that the SCR will allow professionals to think ‘could we have done it differently?’ They believe there is scope for ‘huge learning across the board’. They identified the following as the most pertinent issues for them in respect of the care afforded to their child: • Child A’s prematurity and ongoing health needs. • A shifting diagnosis and the parents never really being clear what it was. • Child A not feeding well, not gaining weight and periods where Child A was tiring very quickly. • They felt psychologically dependent on the Fentanyl as it meant they could do something to stop the pain. • Too many professionals involved and poor communication with the family and between professionals. • They felt caught in the middle with each professional thinking their view carried more weight and not listening to what the family said. • The biggest issue was that of communication between hospital and community and the impact this had on the family in terms of the care for Child A i.e. the prescribing of Fentanyl. • They needed an advocate who would not be swayed by a particular professional background and referenced a similar service in Manchester. • Mother said she felt she had no choice but to co-ordinate care from the outset. She was managing and co-ordinating appointments from different hospitals, all the equipment and stock (which was observed to be extensive around the home). • Child A’s parents emphasised that whilst ‘mother’ was ordinarily noted as either attending, cancelling or postponing appointments, these were joint decisions made by both parents. 22 • Child A’s parents also said they knew other families who are going through safeguarding intervention similar to that with Child A. They expressed a view that child protection investigations undertaken in these contexts ‘should identify systemic failures and not FII and that professionals have to reflect on their own actions’. • They continue to feel vulnerable as Child A is still receiving services, professionals are still practising and that they are ‘protecting themselves’. They believe they are a ‘red flag with Children’s Social Care’. 23 6 Analysis, Findings and Recommendations 6.1 The following sections of the report provide an analysis of the professional practice based on a range of identified themes. Where relevant, this includes a focus on why relevant decisions were taken by practitioners, a critique of how agencies worked together and any shortcomings in this context. At the end of each section, the SCR identifies what professionals and/or their organisations need to do differently and what needs to happen to ensure that agencies learn from this case. 6.2 The Voice of Child A Article 12 UNCRC: every child has the right to express their views, feelings and wishes in all matters affecting them, and to have their views considered and taken seriously. 6.3 Throughout the professional intervention with Child A, there has been insufficient consideration of the child’s individual voice. The review identified that Child A did not have the opportunity to express their own views and opinions. In all aspects of Child A’s life and care, mother spoke for her child. In some instances, professionals reported that when Child A was younger, mother would ordinarily answer any questions and once older, Child A would defer to mother, rather than answering for themselves. 6.4 In other circumstances professionals did not seek to see Child A alone, which would have provided the opportunity for Child A to express themselves. Child A’s ‘lack of voice’ to say how they were feeling may have had a significant impact on treatment, especially pain management. 6.5 Of equal importance is that Child A’s mother is reported by some professionals as being reluctant for Child A to be seen alone and when Child A was, she was in an accompanying room. Child A’s mother was able to hear all that was asked and what was talked about. 24 6.6 The review identified that very few professionals actually saw Child A on their own. The exception to this was the consultant clinical psychologist, although this was under the conditions described above. The rationale provided by Child A’s mother was that she needed to be present to manage Child A’s healthcare needs. This position has been insufficiently challenged. 6.7 During the child protection enquiry, mother would not let Child A be seen alone. The rationale provided by Child A’s mother was the same as that provided to other practitioners. The social workers accepted this explanation, despite this not meeting the expected standards of practice as set out in the London Child Protection Procedures17. 6.8 Both of the involved GPs told the review that it was difficult to interact with Child A and that they found mother a barrier to this. As an example, during the first home visit, mother said Child A was asleep, although the GP thought that Child A only had their eyes closed and was ‘obviously’ awake’. On the second home visit, mother kept putting headphones on Child A if the discussion involved hospitals or medical conditions. This made it very difficult for the GPs to get to know Child A and ensure they understood their needs and feelings. 6.9 Hearing the voice of the child has been a recurrent theme in many SCRs and was the subject of an Ofsted thematic review18, published in 2011 and a CQC report19 in 2016. It is part of safeguarding training and established good practice. However, the absence of Child A’s voice neither raised concerns in a safeguarding context nor prompted further professional curiosity. Practitioners were too ready to accept what Child A’s mother said on behalf of her child. 6.10 Within the context of a child protection investigation, managerial oversight within Children’s Social Care should always ensure that there is clear evidence about 17 3.7.1 The children, who are the focus of concern, must be seen alone, subject to their age and willingness, preferably with parental permission. London CP Procedures 5th Edition 2017 18 The voice of the child: learning lessons from serious case reviews, Ofsted, April 2011 19 Not Seen, Not Heard, A review of the arrangements for child safeguarding and health care for looked after children in England, CQC, July 2016 25 how a child’s views, wishes and feelings have been adequately and appropriately secured during this process. 6.11 Finding 1: Practitioners did not consistently listen to the voice of Child A so as to understand Child A’s perspective, concerns and feelings in order to undertake a meaningful assessment. 6.12 What Needs To Be Done Differently • All practitioners should caution against relying solely on information provided by a parent and ensure that the child’s views are sought directly. • Practitioners from all disciplines should highlight as a matter of concern if a parent is obstructive when seeking to hear the voice of a child. Supervision should be used as one of the mechanisms through which practitioners can escalate their concerns and determine the next steps in this respect. • All children should be fully engaged by health practitioners in their care and treatment and supported to gain an age appropriate understanding of the treatment they are receiving. Recommendation 1: The CHSCP should promote the voice of the child and ensure that the importance of communicating with all children and young people, including non-verbal communication, so that an understanding of their lived day to day experiences can be gained, is embedded in all procedures and training provided. Recommendation 2: The CHSCP should request that health providers undertake an audit of paediatric community and inpatient records to ensure that children have been involved in an age appropriate way at each stage of their care planning, and had their views listened to and considered. The report and associated learning should be presented to the CHSCP. 26 Recommendation 3: The CHSCP should review existing multi-agency guidance to ensure this is sufficient in defining the circumstances when children should be seen alone. Recommendation 4: The CHSCP should establish assurance from safeguarding partners and relevant agencies that there are sufficient mechanisms in place to identify when a child’s voice is not being sufficiently heard as part of professional intervention. 6.13 Assessment, Intervention and Treatment 6.14 The Lack of Objective Assessment and the Over-Medicalisation of Child A Article 3 UNCRC: the best interests of the child must be a top priority in all decisions and actions that affect children. Article 24 UNCRC: every child has the right to the enjoyment of the highest attainable standard of health. 6.15 In the context of the significant involvement with Child A by a range of health practitioners, there was a lack of objective assessment when deciding on proposed treatment. Child A presented with (and mother presented her child with) complex medical problems, which different professionals understood from their own particular disciplines. The review has seen no evidence of a holistic medical overview. Individual medical practitioners appear to have treated Child A’s symptoms as they saw fit. 6.16 The SCR identified that mother began reporting her concerns regarding Child A’s health from a very early stage. The response by medical professionals was to unreservedly accept what Child A’s mother was saying and to respond by investigating and treating the reported symptoms, rather than considering and testing alternative possibilities. Treatment included significant medical interventions for poor feeding, lack of weight gain, bowel problems and later urinary retention and pain. 27 6.17 However, as symptoms persisted there is little evidence that healthcare professionals sought to witness these or examine Child A’s response to treatment directly. When healthcare professionals did attempt to assess Child A, mother was reported to resist engagement on account that Child A was in too much pain. 6.18 For example, despite extensive reviews and changes to the nutritional regime, Child A’s weight gain failed to improve, and at no point was it suggested that Child A should be admitted in order to observe feeding. Furthermore, after mother reported that Child A was not passing urine for up to 16hrs, clean intermittent catherization (CIC) was commenced. Soon afterwards, mother reported she could not continue to undertake the CIC due to bladder spasms. In response, a Mitrofanoff was made. Child A now has a Hickman line, Mitrofanoff stoma20 and jejunostomy stoma 21. 6.19 This approach to healthcare has been well documented; ‘Reliance on carer reports of history and diagnoses, and accepting the carer as a conduit of medical information is based on paediatricians’ default assumptions regarding parents’ truthfulness and reliability - ‘mother knows best’, This leads to repeated investigations and treatments’22. 6.20 The lack of professional challenge and curiosity in this respect culminated in the ongoing medicalisation of Child A. Child A has been the subject of significant medical labelling, with interventions from birth recognised as having a substantial impact on Child A’s life. There remain questions as to whether all of these interventions were needed. 6.21 The SCR identifies a number of issues influencing the professional response in this context, including a possible fear of challenge to an assertive parent (seen as ‘challenging’), a fear of having difficult conversations and a fear of hierarchy (and challenging the decisions / actions of senior health staff). Ultimately, it may also have been easier for health practitioners to medicalise Child A as this was known 20 A stoma is an opening on the abdomen that can be connected to the digestive or urinary system to allow to be diverted out of the body. 21 A jejunostomy is an extension of the gastrostomy feeding tube through the stomach into the small bowel. 22 40 years of fabricated or induced illness (FII): where next for paediatricians? Paper 1: epidemiology and definition of FII. Davis P et al Arch Dis Child Feb 2019 Vol 104 No 2 http://dx.doi.org/10.1136/archdischild-2017-314319 28 territory for them. This approach is unhelpful and potentially harmful for both the child and the parent/carer. 6.22 As part of the internal review of the paediatric gastroenterology department, a number of other children were identified who were also given an unsubstantiated diagnosis, experienced a lack of regular review and were receiving ongoing medical interventions and treatment. 6.23 The review learnt that the complex health needs of some children present some gastroenterologists with challenging problems in identifying the causes of a range of symptoms and pain. Sometimes this can lead to an overly medicalised approach of diagnosis, without sufficient attention to emotional components to the experience of pain for both child and carers. 6.24 In respect of Child A, one of the consultants made a potential diagnosis of Ehlers Danlos 3 (without proper assessment). This served to explain Child A’s increasing immobility. However, when 11 years old, Child A was assessed by a paediatric rheumatologist at another hospital (2). At this point, it was clarified that Child A did not have Ehlers Danlos 3 and therefore had the potential to improve. The news that Child A could do more was reportedly met with shock by the parents, who had believed Child A had reached their limit of capability. 6.25 Child Abuse and Neglect in a Medical Context Article 19 UNCRC: all children have the right to protection from all forms of violence, abuse, neglect and mistreatment by their parents or anyone else who looks after them. 6.26 The referral of Child A to Children’s Social Care for concerns about suspected Fabricated or Induced Illness (FII) was justified on the basis that many of the identified features of FII were evident. It is pertinent to note that many of Child A’s presentations are identified in the work by Glaser et al.23 23 For debate: Forty years of fabricated or induced illness (FII): where next for paediatricians? Paper 2: Management of perplexing presentations including FII Danya Glaser,1 Paul Davis2 29 • Symptoms not observed independently in their reported context. • Symptoms not corroborated by the child. • Reported symptoms or observed signs not explained by child’s known medical condition. • Inexplicably poor response to medication or procedures. • Repeated reporting of new symptoms. • Frequent presentations, seeking opinions from multiple doctors but often with paradoxically poor compliance with medical advice and multiple failed appointments. • Carer(s) insistent on more, clinically unwarranted, investigations, referrals, continuation of or new treatments. • Restriction of child’s daily life and activities that is not justified by any known disorder, possibly including the use of wheelchairs and other aids. 6.27 There has been a debate for many years regarding the terminology of FII, previously termed Munchhausen by Proxy. Fabricated illness is defined as occurring when ‘the child receives unnecessary or harmful medical care at the instigation of a caretaker’.24 This is unhelpful in two ways: • Firstly, investigation focus on establishing the culpability of the parents, rather than on the well-being of the child. • Secondly, the label suggests to all practitioners that the illness is fabricated and distracts from the profound biological effects of this form of maltreatment. The child we see is genuinely and extremely unwell. 6.28 In the USA the term ‘Medical Child Abuse’ (or ‘Child Abuse in a Medical Context’) is now accepted. This provides for an improved focus on the child in that the identity or motivation of the responsible adult is secondary to the fact of abuse. 24 Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians. Royal College of Paediatrics and Child Health (RCPCH) 2009 30 6.29 Many health practitioners feel deep unease about the term ‘Medical Child Abuse’. This is understandable, but there is a clear need to acknowledge that in seeking to do what is best for children, medics can also unintentionally cause serious harm to them. The acknowledgment and recognition of this fact by health professionals is a required first step in effectively managing such cases. 6.30 The term ‘perplexing presentations’ is also considered by the SCR as similarly unhelpful. Whilst accurately describing features of the child’s illness and challenging parental behaviours, asking practitioners to be perplexed is not a recipe for diagnostic clarity or timely intervention. 6.31 Where the problem is ‘over-medicalisation’ (including both over-diagnosis’ and ‘over-treatment’), this should be stated clearly by medical practitioners. In the opinion of the SCR, “over-medicalisation” should replace the term ‘perplexing presentation’. It more appropriately refers to the state of the child’s health as opposed to the state of mind of the doctor. 6.32 Despite the context of the referral to Children’s Social Care, the review identified that practitioners did not actually believe that FII was evident, but rather that Child A was subject to child abuse in a medical context. FII was the ‘best fit’. However, the referral itself potentially distracted professionals from trying to better understand the underlying issues and root cause of Child A’s ‘perplexing presentations’.25 It diverted them from looking more closely at the possibility that Child A may have been subject to medical harm as a consequence of invasive investigations and treatments. 6.33 From a medical perspective, accepting that treatment may not have been necessary may be difficult for professionals to come to terms with. There is an underlying question about how easy it would be for professionals to say, ‘I don’t know’ and not provide treatment. How would the medical world and society view and accept this position? There is also a genuine question about the costs of 25 Glaser D, Davis P. ADC Online First, published on April 4, 2018 as 10.1136/archdischild-2016-311326 31 overdiagnosis26 and the need to develop further guidance on the de-medicalisation of care. 27 28 6.34 There has also been professional resistance to recognising the clustering of such cases around particular paediatric units (Child A was one of twelve children identified by the hospital (1)) and particular new diagnostic labels (Child A was misdiagnosed with Ehlers-Danlos Syndrome hypermobility type)29. There is a need for health services to have in place clear systems where such clusters or routine / frequent misdiagnoses can be promptly identified. Children in these contexts can potentially be at risk from extra-familial harm as a consequence of the treatment they are receiving. 6.35 Finding 2: Child A’s reported symptoms were responded to without objective assessment. This led to unnecessary or inappropriate medical intervention being undertaken. 6.36 What Needs To Be Done Differently • All healthcare practitioners should ensure their practice is proportionately based on fact and that reported symptoms presented by a parent are triangulated through observation and investigation. Practitioners need to consider when standard interventions are failing. • All practitioners need to maintain ‘respectful uncertainty’ and professional curiosity where concerns for the child emerge over a period of time. • If a parent obstructs assessment of their child in the pursuit of medical assessment and diagnosis, professionals should seek safeguarding consultation. 26 £130,000 were spent on Fentanyl prescriptions for Child A, and ongoing costs of intravenous nutrition and other interventions were very significant.. 27 The Royal College of Paediatricians and Child Health is currently consulting on revised guidance which focusses on Perplexing Presentations / FII. And it would be helpful for this SCR to be considered as part of the consultation. 28 Guidelines for the diagnosis and treatment of growth hormone deficiency state that great care should be taken to prevent confusion with psychsocial stress and consequent overdiagnosis and treatment, but there is no published guidance on how to proceed if concerns are raised about a child who is already being treated. 29 The overdiagnosis of Ehlers Danlos Syndrome hypermobility type has been such a serious problem in UK paediatric practice that the RCPCH has produced a position statement https://www.rcpch.ac.uk/resources/establishing-correct-diagnosis-ehlers-danlos-syndrome-hypermobility-type-heds-children 32 • Psychological stress to the child and the profound accompanying biological effects should be recognised when considering children who have been over-medicalised and considered as part of the clinical pathway. • Practitioners should ensure they seek safeguarding supervision where they have concern for ‘cases that don’t make sense’. Recommendation 5: The CHSCP should be sighted on and seek assurance that the recommendations of the internal review undertaken within one of hospitals involved with Child A have been implemented. This should cover reassurance that practice includes direct observation by clinicians has been built into clinical pathways. Recommendation 6: The London Safeguarding Children Partnership should review its practice guidance on Fabricated and Induced illness to ensure it appropriately takes account of children who are coming to harm through excessive medical intervention and references the revised policy of the RCPCH on perplexing presentations. Recommendation 7: The CHSCP should ask the RCPCH to review their pathway for children who are over-medicalised (‘perplexing presentations’) to ensure it includes the impact of psychological stress. Recommendation 8: The responsible commissioner for the wheelchair service should assure the City & Hackney CCG that there is sufficient practice guidance for children who are confined to a wheelchair in the absence of an accepted medical diagnosis. Recommendation 9: The City & Hackney CCG should seek assurance that protocols for nutritional rehabilitation where there is no demonstrated gastrointestinal disease have been developed and are used in clinical practice. 33 Recommendation 10: The City & Hackney CCG should seek assurance that where it is agreed that a rehabilitation program is required because of over medicalisation, clinical leadership is provided by a general paediatrician with safeguarding expertise as part of a multi-disciplinary team. Recommendation 11: The City & Hackney CCG should ensure there is better collaboration and communication between secondary and tertiary care with local processes in place to identify when overmedicalisation / misdiagnoses of children is clustered within a single paediatric department. 6.37 The Management of Pain Article 24 UNCRC: every child has the right to the enjoyment of the highest attainable standard of health. 6.38 Following a long and difficult hospital (1) admission when Child A was five years old, pain was managed through the prescription of an opioid, Fentanyl. At the point of discharge, Child A was still perceived to be experiencing significant pain and it was decided that Child A should be discharged on this analgesic. Over the next six years, no professional was overseeing Child A’s pain management or the impact of long-term opioid use on the child’s health and activities of daily living. 6.39 The SCR identified that once Child A was discharged, the team responsible for acute pain management at hospital (1) no longer held responsibility in the community. There was (and still is) no provision for monitoring and supporting children in the community with chronic pain. 6.40 The SCR further identified that the limited communication between the GP and Child A’s consultant (alongside mother’s reporting that she was in contact with the consultant) meant that the GP was falsely reassured that it was acceptable to continue prescribing the Fentanyl. This reassurance was maintained even with mother asking for increasing amounts. 34 6.41 Child A experienced the significant side effects of Fentanyl which were compounded by further prescribing. When Child A was 11 years old, a multi-disciplinary meeting was held and it was determined that Child A should be admitted to hospital (1) to be weaned off the opiates. This was successfully achieved. 6.42 The initiation of the Fentanyl prescribing for Child A, without clearly addressing the cause of pain, was compounded by the lack of overview of opiate prescribing after discharge. A discharge letter from Child A’s first admission had a very clear plan for follow up of all of Child A’s medical problems, with the single exception of the opiate prescribing. 6.43 Multiple clinicians have recorded that Child A was on long term Fentanyl, although from the documentation, it is unclear if everyone was aware that this included continuous patches as well as lozenges. There was a lack of clarity in the records as to who was overseeing the opiate prescription. 6.44 Some clinicians documented that Child A was under the care of the pain team, but there is no evidence that this was the case in the outpatient setting. During any admissions, whilst Child A was always actively reviewed by the hospital’s (1) inpatient paediatric pain service, this service did not (and still does not) provide an outpatient chronic paediatric pain service. 6.45 Child A’s GP and the CCNT questioned the on-going amount of Fentanyl that was being prescribed and requested a consultant review of the on-going need for such a large amount of pain relief. This was later discussed in a paediatric gastroenterology psychosocial meeting and it was acknowledged that a referral to a chronic pain team may be needed. However, no referral or other action was taken. 6.46 The GPs were under the impression that Child A was being assessed by a chronic pain team and so continued prescribing the opiates, downgrading their own concerns. However, these were false reassurances as Child A was never seen by 35 the pain team. The GPs were influenced by the hierarchy of medical professionals and felt bound to prescribe a medication prescribed by a specialist. 6.47 The need for a dedicated chronic pain team to be involved should have been identified at the time Child A was discharged home on regular opiates. There is no evidence this was considered at this time. 6.48 Child A’s parents reported that ‘They felt psychologically dependent on the Fentanyl as it meant they could do something about the pain. As a parent you don’t question you just do it’. They reported they had no idea that the Fentanyl was making Child A’s pain worse. They did not appreciate that Child A’s wider symptoms of sickness, headaches, abdominal pain could have been caused by the Fentanyl. They were concerned that they were not told that children are no longer discharged home on Fentanyl. 6.49 Finding 3: The lack of provision of a local chronic pain team contributed to the inadequate monitoring and supervision of Child A’s long-term medication. 6.50 What Needs to be Done Differently • Children should not be discharged home on long term opioids except for palliative care. • There is a need for long term pain management pathway for children following discharge from hospital. Recommendation 12: The City & Hackney CCG should review the availability and accessibility of chronic pain services for children in order that effective care pathways can be developed and implemented. Recommendation 13: The CCG / NHSE should seek assurance that General Practice and community pharmacists have protected learning time regarding the prescribing and dispensing of opioids for children. 36 Recommendation 14: The City & Hackney CCG should review competency framework and support for GP safeguarding leads and impact of GP local incentive scheme to ensure that GP safeguarding leads are confident in their roles as set out in Working Together 2018 and by the Royal College of General Practitioners. 6.51 Non- Attendance, Cancelled & Postponed Appointments Article 19 UNCRC: all children have the right to protection from all forms of violence, abuse, neglect and mistreatment by their parents or anyone else who looks after them. 6.52 The SCR identified that Child A was not taken to a significant number of healthcare appointments because these were either cancelled by the hospital (1,2,3) or mother or postponed by mother on the basis that Child A or herself were not well enough to attend. 6.53 Child A is a vulnerable disabled child who relied on their parents to get them to appointments or accept home appointments. Cancelling these appointments arguably made Child A more vulnerable. Whilst practitioners had concerns about the number of appointments not being attended, there is little evidence that these were escalated through supervision or that local policy was followed. 6.54 Given there was no lead professional for the family, different professional groups were not fully aware of the extent of the cancellation or postponing of appointments. The lack of shared healthcare records compounded this matter. 6.55 It was not until 2017 that a multi-disciplinary meeting convened by health services identified the extent to which medical appointments had been cancelled or postponed by Child A’s mother. There is no evidence that professionals working with Child A considered that this might constitute neglect. There also appears to have been little consideration given to the impact of mother’s health issues and her ability to facilitate Child A’s attendance at all the appointments. 37 6.56 The fact that mother cancelled, or postponed appointments, as opposed to Child A ‘not being brought’, might have meant that health practitioners viewed these circumstances as being subtly different. This is likely to have influenced their view of potential risk and may account for the lack of proactive action in response to these events. Regardless of the reasons, the consequences can be the same and involved professionals should have been more robust in their challenge of this issue. 6.57 Finding 4: There were weaknesses in the processes to monitor the repeated postponed or parental cancellation of Child A’s appointments. 6.58 What Needs to be Done Differently • All children who are not brought to appointments should be followed up, for whatever reason, initially through the family and family GP to ensure there are no safeguarding concerns. • All health providers must ensure there is an up to date ‘Was Not Brought’ policy and that all paediatric staff are familiar with the associated guidance. Recommendation 15: The CHSCP should request safeguarding partners and relevant agencies review their systems and policies regarding children not brought for appointments to ensure these extend to include children not brought to appointments through cancellation or postponement. Recommendation 16: Multi-agency and single agency safeguarding training should include the potential safeguarding impact on children not being brought for health appointments. 38 6.59 Professional Coordination Article 24 UNCRC: every child has the right to the enjoyment of the highest attainable standard of health. 6.60 The family had an increasing number of health professionals working with them from the time of Child A’s birth. This was due to Child A’s prematurity, presentation of symptoms and a shifting diagnosis. Child A was referred to and seen by consultants at three hospitals and in the community by the neonatal nurse, health visitor, community children’s nursing team, portage, physiotherapy, occupational therapy, wheelchair services and dietetics. The serious case review identified that over the course of 11 years, Child A was seen by over 150 health care professionals. 6.61 The Francis Inquiry (2013) identified failings over co-ordination of care and made recommendations to address this, identifying that GP’s have a responsibility for monitoring delivery of standards and quality. 6.62 The review identifies that no one professional had oversight of the services and investigations being undertaken. Child A was being seen by a significant number of professionals without evidence of a clinical pathway to follow. This led to a lack of co-ordination by any professional and mother understandably felt she had no choice but to take on this role herself. Child A’s mother felt she was co-ordinating care from the outset, telling the review that there were no discharge planning meetings. 6.63 Practitioners spoke of mother being very strong minded and determined in her relationship with them to the extent that professionals did not feel or were not able to challenge her actions or decisions. This was particularly evident when mother continually cancelled appointments and meetings. When Child A was in hospital (1) and on patient-controlled analgesia (PCA), there were also concerns that mother was managing the PCA herself. 39 6.64 During the review, practitioners spoke of father’s professional background and mother’s reported nurse training, influencing their perceived expectations of the parents. Practitioners believed that the parents would have known what services were available and would have been able to ask for these if required. The consequence was that Child A did not receive all the care they were entitled to. 6.65 When interviewed as part of this review, Child A’s parents said that ‘things went seriously wrong when Child A was discharged home on Fentanyl’. They reported a ‘complete lack of co-ordination and lack of medical management with no support’. 6.66 The role of the GP is a primary record holder for medical notes and the provision of community medical services (alongside the Child Health record held by parents). It is clearly useful for children with complex care needs and their parents to know their GPs and to have good access to primary care. Given the quantity of medication prescribed, it would have been good practice for the GPs to review Child A in line with GMC guidance30. During one consultation, the GP held a long discussion with mother about Fentanyl use, although there were no actions that the GP proposed to take. 6.67 The consultation was viewed as positive with the GP writing ‘the situation is difficult but well managed by mother’. The GPs appeared to accept that mother was managing well without consideration for professional oversight. With children who have complex medical needs, it is not unusual for the majority of their medical care to occur within secondary care settings. However, it is especially noticeable that primary care had minimal interaction with Child A and this is unusual. 6.68 Child A’s mother was put in a powerful position as being the main communicator between primary and secondary care, as Child A was often seen by a consultant outside clinic times and she had access to his mobile number. 30 https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices/reviewing-medicines 40 6.69 It was identified through the review that this was not unusual, and that the consultant had given his mobile number to other families. This resulted in clinic letters not being written and the wider healthcare team (both in the hospital (1) and in the community) being unaware of what was being discussed and what the plan was. 6.70 This was further exacerbated by telephone calls between the consultant and mother which were not recorded. This unusual system carried with it the possibility of misunderstanding / manipulation. Information was not being shared from clinician to clinician, but between one clinician and the parent and then from the parent to other involved clinicians. 6.71 Child A was being seen by a number of different consultants and specialist consultants at three different hospitals which, in the absence of a lead professional, prevented a comprehensive overview of Child A’s medical conditions and treatment. 6.72 It appears that no single health care provider had a full picture of Child A’s medical needs, treatment or of the family functioning. There was a disproportionate reliance being placed on mother’s perception of the diagnoses and treatments of other professionals in the network. This impacted on decision making about Child A’s health and care needs. 6.73 Finding 5: The absence of a lead professional to co-ordinate and communicate the input of different professionals supporting Child A risked diagnosis and treatment being based on inadequate information. This inappropriately left Child A’s parents with the responsibility to pass communications and information between practitioners. 6.74 What Needs To Be Done Differently • There is a need for a lead professional for children who have complex needs and who are over-medicalised (perplexing presentations). 41 • Over-medicalised children who are receiving healthcare services from a wide range of professionals should be allocated a professional healthcare worker who can be impartial and have a complete overview and understanding of the presenting healthcare needs and medical conditions to take the lead • There should be Team around the Child meetings for all children with complex perplexing presentations. Recommendation 17: The CHSCP should seek assurance that partners have agreed processes for agreeing a lead professional, a care co-ordinator and a system of multi-agency team around the child meetings for children who are being over-medicalised. 6.75 Education and Home Schooling Article 28: of the UNCRC states that every child has the right to an education. 6.76 Child A was appropriately referred for a Statement of Education under the 2002 SEN framework. What followed was a complex decision-making process involving the local authority’s education services and Child A’s parents in an attempt to ensure Child A was placed in the right educational environment. 6.77 The education services attempted to assess and determine the right establishment which would provide the right level of educational support and at the same time have the ability to support Child A’s complex healthcare needs. Child A’s parents told the review they felt that Child A’s medical needs and pain management meant their child could not cope in mainstream school and Child A initially went to a school for children with physical disabilities and additional sensory needs. 6.78 Child A’s poor health meant that attendance at school was significantly impacted due, in the main, to authorised absences requested by mother. The parents 42 decided they would like home tutoring, although the rationale for this decision and other possible options weren’t further explored by education professionals. 6.79 However, the pattern of Child A’s health inhibiting education continued. On occasions, when being home tutored, Child A’s mother would ask for the sessions to end reporting that Child A was too unwell to continue. 6.80 The change in provision of education from school to home tutoring occurred at the same time as the 2014 SEND reforms which culminated in a reorganisation of the educational services in the area. Child A ultimately got ‘lost’ in the system and no one received any reviews about educational progress for a number of years. Child A was formally recorded as still being a pupil at their former school, and as a consequence the school was assumed to be responsible for Child A’s annual reviews. These did not take place for four years. 6.81 Education services did not monitor Child A’s education provision in any sense during this time. Child A continued to only receive five hours educational input per week until summer 2017. This change followed the raising of wider concerns about Child A’s welfare, after which there was an annual review and home tuition provision increased to 12.5 hours a week. 6.82 Education staff spoken to in this SCR acknowledged that it was an extremely difficult period at the time and that systems have subsequently improved. Review processes have been strengthened to ensure all children have termly reviews. There is also reported to be much improved working with health professionals and the designated medical officer in order that children with complex medical needs can be discussed. 6.83 Finding 6: There was an insufficient response in meeting Child A’s educational needs. 43 6.84 What Needs to be Done Differently • The review process for all children on an EHCP should ensure that all assessments and reviews take place on time. • All EHCP plan reviews should have impact statements to demonstrate that children are progressing. • There is a need for increased medical involvement by the designated Medical Officer for those children on an EHCP with complex perplexing presentations. • Children should be involved at all stages of the development of the EHCP and their review. • Education providers must ensure that children have the space and freedom to learn outside the family unit. Recommendation 18: The CHSCP should reassure itself that the quality and monitoring of alternative education provision is sufficient. Recommendation 19: The CHSCP should reassure itself that processes for the assessment, provision and review of education for children with SEND are sufficiently robust. 6.85 The Escalation of Safeguarding Concerns Article 19 of the UNCRC states that governments must do all they can to ensure that children are protected from all forms of violence, abuse, neglect and bad treatment by their parents or anyone else who looks after them, including health care workers. 6.86 Escalation of concerns for a child is paramount to support decision making and ensuring a child is safe. It is central to established safeguarding practice and procedure. The review identified many examples when practitioners should have 44 escalated their safeguarding concerns, including when mother declined services (Health Visiting and Portage) or cancelled or postponed appointments (referral to the Pain Team). It was not until Child A was ten years old that a referral was made to Children’s Social Care. A lack of escalation was similarly highlighted in the RCPCH report 2018, commenting that there was ‘uncritical challenge’ by other team members. 6.87 When exploring the reasons why concerns for Child A weren’t escalated further, the review identified a range of reasons: 6.88 Professional Hierarchy • Whilst the RCPCH review 2018 identifies there is a more open culture now, junior professionals can be reluctant to escalate their concerns about senior colleagues. Overall, a theme was heard from a number of practitioners about their inability to challenge the expertise of hospital specialists. This appears to be a widespread cultural phenomenon. 6.89 Family Dynamics – Impact on the Recognition of Need & Risk • Some professionals believed that because of the professional background of the parents, that the family knew what services were available to them and hence, these would not need to be explained. Others spoke of being very conscious of father’s professional experience and that this caused a nervousness, inhibiting escalation to Children’s Social Care. Some said that because of his background, they found it difficult to believe there could be any child safeguarding concerns. • Mother was perceived by practitioners as an articulate and assertive woman with firm views and thoughts about her child’s health and treatment. Professionals reported that this impacted on their ability to respond to Child A, properly establish views, focus on needs and challenge parental accounts. The impact of parental assertiveness on professionals has been noted in 45 previous SCRs (Kingston Family A 2015)31 and in the work of Bernard 201732 who identified that ‘Some practitioners reported being put under a lot of pressure to respond to the demands of the parents which made it difficult to maintain a child-focus approach’. • In many aspects of Child A’s care, professionals appear to have avoided ‘difficult conversations’ with the parents. This may have been influenced by professionals not wanting to ‘make matters worse’ for the family, particularly given mother’s health issues and the clear challenges she was facing both personally and as a parent. 6.90 Accessing Supervision • For some professionals, there was a lack of confidence and understanding about appropriate access to safeguarding supervision. Supervision should have led to escalation of concerns but did not. 6.91 Thresholds • For some professionals, there was a lack of understanding about the threshold for referring to Children’s Social Care. 6.92 Complaints • For some professionals, there was a concern about complaints being made. Some did not feel they could ‘raise their head above the parapet’ and refer to Children’s Social Care for fear of being parental complaint. 31 Serious Case Review Family A; Kingston LSCB 2015 https://kingstonandrichmondsafeguardingchildrenpartnership.org.uk/media/upload/fck/file/SCR/Family%20A%20Serious%20Case%20Review%20Report%20November%202015.pdf 32 An Exploration of How Social Workers Engage Neglectful Parents from Affluent Backgrounds in the Child Protection System; Bernard 2017 https://www.gold.ac.uk/media/documents-by-section/departments/social-therapeutic-and-comms-studies/Report---Neglect-in-Affluent-Families-1-December-2017.pdf 46 6.93 Social Media • There was a concern raised by some professionals regarding the use of social media by some parents, who have used this to attack individual practitioners. 6.94 Finding 7: Practitioners insufficiently challenged and failed to escalate their concerns about Child A. 6.95 What Needs to be Done Differently • Practitioners should not delay in making a referral to Children’s Social Care through potential false assumptions about a parent’s knowledge or experience of services or for fear of reprisal through social media. • Parental behaviours and needs, such as assertiveness and their health issues, should not divert practitioners from their focus on the needs of a child and any required action based on those needs. • NHS Trusts should ensure when addressing a complaint against staff, that the potential inappropriate use of the process by parents and or carers to avoid the detection of abuse and neglect is recognised. • All professionals working in paediatric services must have access to and utilise safeguarding supervision. • Children’s Social Care and health partners to recognise each other’s roles and expectations in respect of decision making. • Any practitioner who has safeguarding concerns about a child should, at an early stage, consult their Safeguarding Lead, e.g. Named GP, Named Doctors and Designated Professionals. • Considerable experience, practice wisdom and knowledge of neglect are essential in relation to working with highly resistant parents who challenge professional’s decision-making. • Different health trusts safeguarding teams would benefit from working collaboratively when children known to both their services are escalated to them. This would result in a more effective risk assessment, a more effective 47 safeguarding plan for the child and clearer communication with parents and professionals on what needs to change. Recommendation 20: The CHSCP should review its escalation policy to ensure it incorporates supporting professionals being able to challenge colleagues within and outside their own organisation. Recommendation 21: The CHSCP should include in its multi-agency training programme the theme of over medicalisation, its management and the importance of escalation in this context. Recommendation 22: The City & Hackney CCG should review and reinforce GP safeguarding training to emphasise the importance of early recognition of a child at risk and escalation to children’s social care. Recommendation 23: The City & Hackney CCG should seek assurance that when there are safeguarding concerns and children are under more than one health provider, there are processes to ensure the relevant health safeguarding teams work collaboratively to ensure their safety and there is guidance on how to manage difference of opinions. |
NC043731 | Executive summary of a review into the death of a 4-year-old girl in 2011, from multiple stab wounds. Suicide notes indicated that Child D was killed by her mother who then attempted to kill herself. Mother had recently been dismissed from her job and was due to attend court in relation to offences in contravention of the Data Protection Act. Following her dismissal, mother maintained the pretence that she was employed to family, friends and Child D's nursery. Identifies additional stress factors that likely contributed to mother's actions, including her failure to gain employment because of unsatisfactory references and the breakup of her relationship. Issues identified include: lack of agency knowledge of father or mother's partner's role in Child D's life; and history of violence and convictions of adults related to the case. Makes recommendations for police, probation, health, children's and childcare services including improved provision of child protection training to child minders and nursery staff.
| Title: Serious case review: Child D (Case Arlene 11): executive summary LSCB: Bury Safeguarding Children Board Author: Dennis Charlton Date of publication: 2012 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Bury Safeguarding Children Board Serious Case Review Child D (Case Arlene 11) SERIOUS CASE REVIEW EXECUTIVE SUMMARY Report Author: Dennis Charlton Date: 12 September 2011 Signed: Date: 12/09/11 Commissioned by: Bury Safeguarding Children Board 2 I can confirm that the Serious Case Review on Child D (Case Arlene 11) was submitted to the Extraordinary Bury Safeguarding Children Board (BSCB) meeting on Monday 12 September 2011. BSCB members agreed to accept the health overview report, Serious Case Review Overview Report, Serious Case Review Executive Summary and multi-agency action plan for submission. I can confirm that BSCB endorse the recommendations made in the overview report and that the BSCB Executive Group will monitor their implementation. The Overview Report and Executive Summary, suitably redacted and anonymised, will be published on the BSCB website at the conclusion of the Ofsted evaluation and any criminal and coronial enquiries. Gill Rigg Independent Chair of BSCB On 10 June 2010, the Parliamentary Under Secretary of State for Children and Families, Tim Loughton, Member of Parliament wrote to Local Safeguarding Children Board (LSCB) Chairs and to Directors of Children’s Services, and advised them of a change to the Working Together guidance. He advised that LSCBs should publish all Serious Case Review (SCR) overview reports on cases initiated after 10 June 2010, suitably anonymised and redacted. This is in addition to the publication of the executive summary. This overview report is published in accordance with that direction and has been redacted and anonymised by Bury Safeguarding Children Board. The sentences which have been redacted or amended are shown in blue. Signed: Date: 12 September 2011 3 Introduction 1.1 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. A 4 year old girl, Child D, was found dead in bed at the family home. From suicide notes it appeared that the child’s mother, Adult MD had killed her daughter and intended to take her own life. 1.2 A post mortem confirmed that Child D died from multiple stab wounds. The mother had ingested a bleach-based solution, apparently in an attempt to kill herself. At the conclusion of the Serious Case Review, the mother remains in hospital, in a serious medical condition. Because of health issues, the Police were unable to interview mother until very recently. At the completion of this Serious Case Review, Police enquiries were still ongoing. 1.3 Bury Serious Case Review Panel met on 16 March 2011. The initial recommendation from the Serious Case Review Panel was that the case did not meet the criteria for a Serious Case Review. 1.4 The Chair of Bury Safeguarding Children Board made a decision on 18 March 2011 that the criteria for undertaking a Serious Case Review were met. 1.5 Ofsted were informed on 18 March 2011 that a Serious Case Review was to be undertaken. 2. Terms of reference and the SCR process 2.1 The following key lines of enquiry were agreed for the Serious Case Review: • Did each agency have in place policies and procedures to safeguard the welfare of children and vulnerable adults to whom they had responsibilities; • Did agencies have the opportunity to work together and communicate effectively to promote the welfare of Child D; • To what extent were relevant intra and inter agency policies and procedures followed in this case and were there any barriers to effective working practices; • Were practitioners knowledgeable about the indicators of abuse and neglect including the impact of domestic abuse and how did this inform agency responses to any issues of concern; • Establish to what extent there was an opportunity to consider the impact of mother’s ex-partner upon the functioning of the 4 family and whether the issue was given appropriate emphasis within agency assessments and interventions; • To what extent did services have an understanding of Child D, her experiences and views, and how did this inform the service; • To what extent did services take account of diversity issues such as race and culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery; • Was the management oversight and supervision in the case adequate; • In relation to any similar themes arising from this case, are these issues from previous SCRs, which agencies have previously acted upon. 2.2 In addition to the Individual management Reports (IMRs), the Overview Report author attended a number of Serious Case Review Panel meetings, as an observer, in order to clarify any issues in relation to the IMRs. 2.3 The following agencies contributed to the Serious Case Review process: Agency Contribution Greater Manchester Police Submitted Individual Management Report Bury Council Children’s Services Social Care Submitted Individual Management Review Bury Council Childcare and Extended Services Submitted Individual Management Review Bury Council Children’s Services Learning Division, (School & Nursery) Submitted Individual Management Review Pennine Care Foundation NHS Trust (Community Services, Bury)- including Health Visiting and GP services Submitted Individual Management Review Pennine Acute Hospitals NHS Trust Submitted Individual Management Review Greater Manchester Probation Trust Submitted Individual Management Review Information was also requested from: Pennine Care Foundation NHS Trust (Adult Services) A Health Overview Report was also commissioned. 5 The Serious Case Review Panel was:- Colleen Murphy Chair of The Serious Case Review Panel Detective Inspector, Child Death Review Team, Greater Manchester Police Service Manager – Safeguarding Unit, Bury Council Children’s Services Social Care Designated Nurse for Safeguarding, NHS Bury Head of Service, Bury Child Care and Extended Services, Bury Council Child Safeguarding Lead, Pennine Care Foundation NHS Trust Lead Officer-Safeguarding, Learning Division, Children’s Services, Bury Council Consultant Paediatrician, Pennine Acute Hospitals NHS Trust Assistant Chief Executive, Greater Manchester Probation Trust The Overview Author attended a number of SCR Panel meetings as an observer. The Overview author also had a conversation with the Information Commission in order to clarify some issues. The Independent Chair of Bury Safeguarding Children Board is Gill Rigg. 3 Independence within the SCR Process 3.1 The Chair of the SCR Panel was Colleen Murphy. Ms Murphy is an Independent Consultant Social Worker. She has considerable experience of child protection and child welfare and had contributed to a number of SCRs both as a Chair of SCR Panels and also as an Overview author. 3.2 The Overview Report author was Dennis Charlton. Mr Charlton is a former Assistant Director of a local authority Children’s Service and is now an Independent Consultant in Child Protection. He has considerable experience of child protection and child welfare and had contributed to a number of SCRs both as a Chair of SCR Panels and also as an Overview author. 6 3.3 All of the Individual Management Reports were undertaken by managers who had no direct involvement with the case. 4. Parallel Processes 4.1 A criminal investigation remains in progress at the conclusion of this SCR. The Police Investigation had not been completed, largely because mother’s medical condition, following her suicide attempt, meant that Police interviews with mother had only just commenced and further Police enquiries were required. Ongoing discussions will continue, as necessary, between the Crown Prosecution Service, the Police and the SCR Panel. A Coroners Inquiry has not as yet concluded. Bury Safeguarding Children Board will ensure that the Coroner and the Child Death Overview Panel are updated about the SCR process. 5. Involvement of the Family 5.1 The father (FD) of Child D was informed about the Serious Case Review and invited to contribute to the process. The former partner of MD (XP) was also contacted and asked if he wished to make a contribution to the SCR. The maternal grandparents of Child D were contacted and asked if they wished to contribute. None of the individuals contacted indicated that they wish to make a contribution although they will be contacted again to seek any contribution they may wish to make. The mother (MD) has also been informed about the Serious Case Review but her contribution will depend upon her physical recovery and also be influenced by any criminal investigation or proceedings. 6. Case Summary 6.1 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. In 2006 Child D was born following a caesarian delivery. Mother and baby were discharged from hospital four days later. Initially the household comprised of Mother (MD), Father (FD) and Child D. 6.2 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. Routine community midwife home visits recorded that Child D was developing well and was of a good weight. 6.3 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. In June 2007 a domestic incident was reported to the Police. MD took Child D and herself to maternal Grandmother’s home. 7 6.4 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. A joint visit was made by a Social Worker and Police Officer in June 2007. MD was seen at the home of maternal Grand Mother. Further support, which MD declined, was offered from both Children’s Social Care and the Police. NHS Bury, Safeguarding Team, were also advised by letter about the incident and action taken. 6.5 Following this incident MD and her partner separated. MD and Child D continued to live at the family home. 6.6 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. In October 2007, MD reported an incident where FD arrived at the family home for contact with Child D and was perceived to be under the influence of alcohol. MD refused to allow contact to take place and this led to an argument, with some threats from FD. MD reported this incident to the Police. Children’s Social Care was informed of this incident by the Police four days later. A letter was sent from Children’s Social Care offering support should MD wish for it. The incident was also reported to NHS Bury Safeguarding Unit by Children’s Social Care. 6.7 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. From the available information, contact between FD and Child D ceased when mother started a relationship with XP. 6.8 In April 2008 Child D also started being in the care of a registered child minder, initially for two days per week. 6.9 This paragraph has been redacted as it contains sensitive personal information, which may potentially be identifiable. 6.10 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. MD and XP started a relationship in July 2009. 6.11 This paragraph has been redacted as it contains sensitive personal information, which may potentially be identifiable. 6.12 This paragraph has been redacted as it contains sensitive personal information, which may potentially be identifiable. 6.13 Mother, who is a trained and qualified health professional, changed her employment in September 2009. Her new role gave her access to information about patients who had suffered injuries because of accidents. 6.14 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be 8 identifiable. Mother had known XP since childhood. Police information suggests that she was aware of XP’s background. XP moved into the family home in December 2009. XP had at this stage started working as a salesman for a firm specialising in claims for personal injuries. 6.15 Mother and XP reached an agreement that she would use her role as a health professional, to supply him with detailed information about patients who had suffered injuries because of accidents. This information would enable XP to solicit their custom and increase his commission for attracting new customers. 6.16 In February 2010 a complaint was made to the NHS Trust, responsible for the service where mother was employed, that personal data had been given out in contravention of the Data Protection Act. An investigation by the NHS Trust took place. 6.17 Investigations led to MD being identified as the person who had seemingly inappropriately accessed patient files on numerous occasions. MD was presented with this information at a formal meeting and suspended by the agency employing her in May 2010. 6.18 Ongoing investigations led to a disciplinary hearing and MD was dismissed by her employer, in August 2010. 6.19 MD had not informed either family or friends that she had been dismissed from her post and there is evidence from the Police IMR that she continued to dress in her NHS uniform on a daily basis, in a pretence that she was still working. Mother also continued to use her child minder for Child D. 6.20 Child D started attending the nursery attached to the local Primary School in September 2010. 6.21 In January 2011 XP finished his relationship with MD and left the family home. Evidence from the Police IMR suggests that he repeatedly declined MD’s requests to continue their relationship. 6.22 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. In February 2011 MD failed in her attempt to gain employment because references were unsatisfactory (they revealed her dismissal for breaching confidential patient information). 6.23 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. On the same day MD had taken Child D to the child minders and was picked up by MD, as usual, in the afternoon. The child minder then received two text messages from MD to say that she (MD) intended to take Child D to nursery the following day. A further text message from MD said that Child D was unwell and that MD intended to keep her off school. 9 6.24 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. During those two days mother sent a number of text messages to XP blaming him for her present problems. MD also sent a further text to the child minder saying that Child D was still ill. 6.25 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. Two days later Maternal Grandmother (MG), who had been increasingly worried about being unable to contact MD, visited the family home and asked a neighbour to force an entry. Child D was discovered dead in an upstairs bedroom with MD beside her. MD was believed to have ingested a toxic substance. 7. Key Issues and Lessons from the Serious Case Review 7.1 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. Although not directly related to the death of Child D there were themes identified in this case of domestic violence and alcohol misuse. 7.2 All of the key agencies involved in the case have comprehensive domestic violence policies and procedures that are actively monitored. The interventions, in response to domestic violence incidents, particularly from the Police and Children’s Social Care were appropriate and timely. There was evidence of a very good working relationship between the Police, Children’s Social Care and Community Health Services in relation to domestic violence. 7.3 Even though there was evidence of effective joint working in cases of domestic violence, this Serious Case Review has identified a need for a more strategic approach to domestic violence that involves information sharing with General Practitioners and a more proactive role for Community Health practitioners. A specific recommendation is made in the Overview Report that addresses this. 7.4 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. There were some issues about information sharing between agencies and there were a number of occasions when the Probation Service should have shared information with Children’s Social Care. The Probation Individual Management Review addresses these issues in some detail and makes appropriate recommendations for future involvement of the service with domestic violence cases. 7.5 There were weaknesses identified, across all agencies, in how information about race, religion, language, and other forms of diversity were collected and recorded. Although this did not have a 10 negative impact on this particular case, a recommendation is made to address this. 7.6 There was also a failure within the nursery to internally report a low level concern. Whilst this was unlikely to alert agencies to any concerns, it does indicate a need to be vigilant about even small pieces of information. 7.7 There were some issues identified about the importance of supervision for professionals and in particular the need for reflective supervision. This Serious Case Review identifies the need for findings from this SCR to be woven into any new guidance in relation to the recently published Munro Review. 7.8 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. There is evidence of a tendency of some agencies to limit their thinking to immediate problems and not focus on wider issues. This is relevant for example when an adult related to the case attended the hospital Accident and Emergency Department on one occasion. Although the adult gave a history of extensive alcohol and some drug misuse, there was no attempt to seek information as to whether the adult had any caring responsibilities. This “silo” mentality has been described in research on child protection and is a feature of some elements of this case. 7.9 A further key issue lies with the potential for agencies identifying that MD had reached such a level of desperation. There had been a number of significant and extremely negative events that had occurred to mother in a relatively short space of time. She had been suspended and dismissed from her employment because of a misuse of patient information. The relationship between her and XP had terminated and there are suggestions that this caused her considerable distress. She had recently failed to be employed because references (following her dismissal) were unsatisfactory. 7.10 These events took place in a context where MD was still pretending to friends and family that she was in employment. 7.11 It seems a reasonable hypothesis, in this case, that MD felt overwhelmed by the cumulative impact of these events and the very tragic outcome may well have been an altruistic attempt to “save” Child D from the cruelties of the world. Certainly this would be consistent with the available research on maternal filicide. 7.12 This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. There was, in fact, very little agency involvement with the family leading up to Child D’s death. The only agencies with any real involvement were the childminder and the nursery. The NHS Trust were only involved because of the disciplinary issues and the misuse of patient information. 11 7.13 There were also no reported concerns about Child D and no incidents that would have raised agency concerns about the potential for harm to Child D. There have, however, been a number of cases on a national basis of both maternal and paternal filicide linked to the adult carer attempting suicide and all agencies working with children and families need to be aware of the research findings on this issue. A specific recommendation is made in the Overview Report covering this. 7.14 In these circumstances the very tragic death of Child D was neither predictable nor preventable. There are however some lessons that can be learned from this SCR and these are reflected in the Individual Management Review recommendations and the Overview Report recommendations. 7.15 One particular area of concern is that there were clearly some significant differences between some agencies about whether the threshold had been met, in this case, for a Serious Case Review. This suggests that there is a need for Bury Safeguarding Children Board to clarify both the thresholds and also the process for undertaking Serious Case Reviews. 8. Recommendations Overview Report Recommendations All of the recommendations (both Overview Report and Individual Agency recommendations) will be actively monitored by Bury Safeguarding Children Board in line with the Action Plan. 1. Bury Safeguarding Children Board should ensure that the findings from this Serious Case Review are made available to practitioners and that the issue of filicide is given prominence in training and awareness programmes for staff. 2. Bury Safeguarding Children Board should take the strategic lead in setting standards for information that is recorded on race, ethnicity, religion, disability and other forms of diversity. There should be a regular audit of this information and the findings reported to BSCB. 3. Bury Safeguarding Children Board should review their processes for determining when Serious Case Reviews should be undertaken and in particular ensure that there is a shared understanding of the criteria for undertaking Serious Case Reviews. 4. Bury Safeguarding Children Board should request Pennine Acute Hospitals NHS Trust to introduce audit and monitoring systems to ensure that documentation about adult patient “caring responsibilities” is properly considered and recorded. 12 5. Bury Safeguarding Children Board should, in considering any implementation of new guidance on supervision, ensure that the findings from this SCR are woven into that new guidance. 6. Bury Safeguarding Children Board should take a strategic lead in a multi agency review of domestic violence working arrangements. Individual Agency Recommendations POLICE 1. That the Operational Communications Branch Commander issues a reminder to operational control room staff, via branch orders, of the critical reasons for the correct application of Force Wide Incident Number (FWIN) closure codes when finalising incidents of domestic violence and abuse. CHILDREN’S SOCIAL CARE 1. Ensure that referrals are dated at the time of contact, rather than at the time they are confirmed in writing. 2. Continue to ensure that Initial Assessments are undertaken if a visit is made or if parents are invited into the office. 3. Explore whether and how schools may be informed of Domestic Abuse notifications where the decision has been made not to undertake an Initial Assessment. 4. A copy of agreed action for all cases screened with the Police is retained by Social Care, not just those where action has been agreed. 5. Review practice of sending letters to parents when no further action is agreed. 6. Provide improved guidance to assist judgment about the severity of incidents and ensure practice adherence. GREATER MANCHESTER PROBATION TRUST 1. The service should ensure greater understanding of offenders’ relationships and contacts with children from the outset of any Probation Order. 2. All cases, which have a domestic violence focus, should be allocated to a Probation Officer. 3. The Offender Manager should ensure that all information from partner agencies informs assessments and any difficulty in 13 accessing information is escalated through line management structures in a timely manner. 4. Re-affirm that home visits should be undertaken by offenders managers when offender circumstances change in any case that involve children or domestic violence. PENNINE ACUTE HOSPITALS NHS TRUST There are no recommendations from this IMR. BURY COUNCIL CHILDCARE AND EXTENDED SERVICES (CES) 1. CES to ensure that childminders are able to access training that is available in the BSCB training booklet with consideration given to providing discrete courses for childminders. 2. CES to communicate to all childminders the importance of written records of all information passed between home, childminder and any other settings attended by children in their care. 3. CES and children’s centre staff to develop a centralised record of involvement with childminders. 4. CES to develop with childminders a written recording system for all information passed on including at key transitions. 5. Childminder to record the ethnicity and religion of all children in her care: CES will also raise awareness amongst all childminders in Bury that this information should be recorded and inform their practice. BURY COUNCIL CHILDREN’S SERVICES LEARNING DIVISION (SCHOOL & NURSERY) 1. Further training to be given to school staff in relation to identification of Domestic Abuse, recording and the use of incident forms. 2. Ensure safeguarding supervision is provided on a formal and regular basis to nursery and school staff. 3. Ensure information is routinely gathered at admission about family dynamics, who holds Parental Responsibility and relationship of the carers to the child. PENNINE CARE NHS FOUNDATION TRUST- COMMUNITY SERVICES 1. Ensure that the process for reviewing and actioning domestic abuse notifications is effectively embedded into practice. 14 2. Devise a process whereby GPs have access to domestic abuse notifications. HEALTH OVERVIEW REPORT 1. NHS Bury reviews its process of information sharing with employing organisation at the earliest opportunity where the NHS Bury are aware of Information Governance Serious Untoward Incidents. 2. This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. IMD’s employer (a private health provider) develop a programme of training to ensure all staff receive the appropriate level of training in line with the Intercollegiate document and Working Together. 3. NHS Bury ensure that identification and assessment of domestic abuse is embedded within the new service specification development for health visiting. 4. Pennine Acute Hospitals NHS Trust undertake a focused audit of records to ensure that admission records reflect the policy to request information about caring responsibilities. 4. NHS Bury to write directly to the General Medical Council in addition to responding on line to the consultation around the new guidance. 5. NHS Bury will consider the risk of the lack of continuity due to corporate caseloads as part of the review into health visiting. |
NC52781 | Child sexual abuse of a 16-year-old adolescent by their male foster carer. Between 2016-2020 Child C made several disclosures concerning an older child in their foster family, the female foster carer, and the male foster carer. Child C had experienced early trauma through neglect and abuse by their birth family. Learning considers: listening to the child, hearing their voice and seeing their true experience; not placing judgments on the accuracy of child allegations; enabling early disclosure of concerns by children; explaining to children what is appropriate treatment in the foster placement and how to raise concerns confidentially; acknowledging that terrible things can happen to children in care; and providing a consistent trusted professional for children in care, aside from those who have caring responsibilities. Recommendations include: the local authority to lead on talking to children about healthy relationships so children in care understand appropriate treatment in their foster placement; professionals to ensure the role of the trusted professional or adult is explicit within the children in care planning process and never seen as being undertaken solely by a foster carer; to review all single agency training so the voice of the child is present and for agencies to provide evidence of impact on practice; practitioners to be confident in always being alert to the potential for, identifying and responding to signs of child sexual abuse; and the local authority to undertake a review of its allegations management processes to address concerns relating to an adult focus within statutory functions.
| Title: Local child safeguarding practice review (LCSPR): the lived experience of a child in our care [Child C]. LSCB: Gloucestershire Safeguarding Children Partnership Author: Gloucestershire Safeguarding Children Partnership Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Local Child Safeguarding Practice Review (LCSPR) THE LIVED EXPERIENCE OF A CHILD IN OUR CARE 2023 "A child's voice, however honest and true, is meaningless to those who've forgotten how to listen." JK Rowling Voice of the Child: Children need to be more clearly heard in decisions about their future. ... Although they are often at the centre of proceedings, the views of children and how they feel are often not heard, with other people making vital decisions for them. This not only refers to what children say directly, but to many other aspects of their presentation. It means seeing their experiences from their point of view. This LCSPR was undertaken and written via a multi-Agency working group set up under the governance of the GSCP Quality and Improvement in Practice Subgroup of the Gloucestershire Safeguarding Children Partnership. GSCP CHILD C LCSPR0220 P a g e | 1 Table of Contents 1. THE LIVED EXPERIENCE OF A CHILD IN OUR CARE .................................................................... 2 1.1 The Voice of Child C ............................................................................................................ 2 1.2 Introduction ........................................................................................................................ 3 1.2 What Happened to Child C? ................................................................................................ 3 1.3 Publication Note: ................................................................................................................ 4 2. LCSPR Report and Recommendations ...................................................................................... 4 2.1 Providing a Consistent Trusted Adult.................................................................................. 4 2.1.1 Activity ............................................................................................................................ 6 2.1.2 Recommendation/s:........................................................................................................ 7 Recommendation One: ................................................................................................................... 7 Recommendation Two: ................................................................................................................... 7 Recommendation Three: ................................................................................................................ 7 Recommendation Four: .................................................................................................................. 7 2.2 Adult Focus .......................................................................................................................... 8 2.2.1 Activity............................................................................................................................ 9 2.2.2 Recommendation/s ......................................................................................................... 9 Recommendation Five: ................................................................................................................... 9 2.3 Adherence to Statutory Process ......................................................................................... 9 2.3.1 Recommendation/s ....................................................................................................... 10 Recommendation Six .................................................................................................................... 10 Recommendation Seven: .............................................................................................................. 10 3. Update on Parallel Processes .................................................................................................. 11 4. Summary ................................................................................................................................. 11 GSCP CHILD C LCSPR0220 P a g e | 2 1. THE LIVED EXPERIENCE OF A CHILD IN OUR CARE 1.1 The Voice of Child C Child C has given the GSCP permission to use this statement as part of this review. Please take time to read and digest what Child C has to say before continuing with the rest of the report. I am a victim of child sexual abuse and rape. I am still discovering all the ways that this abuse has affected me, hurt me, destroyed my childhood, teenage years that every person deserves. My foster father started abusing me when I was 16 years old. He used what I now know are common ways in which abusers get their victims ready for abuse and keep them silent: he told me that I was special, different, that he loved me and that we had our own “special connection”. Since he was a trusted person that I had lived with from a young age, my mother, father, and family didn’t suspect anything whilst I was in his care. At first, he would send me messages saying he was going to come into my bedroom at night and say goodnight to me and then things started from there. I remember he tried to give me oral sex at first and that was very confusing. I remember when he tried to have sex with me for the first time and that hurt even more and was terrifying knowing his wife and my social worker were just downstairs. I remember telling him it hurt. I remember many times that he would take me to the shops to buy underwear to wear for him or he would buy it for me and lay it out under my pillow so I could feel it as I got into bed so I could be ready for him that night or the next morning. After the abuse he would comfort me and tell me how much he loved me and how he was so in love with me. Even now when I may get into a relationship and hear the words of comfort and love it gives me strong feelings of panic, guilt, and humiliation. It’s like I can never get away from what happened to me. At the time I was confused and knew it was wrong and that it didn’t feel comfortable but at the same time it also felt wrong telling someone about my foster father who lived in the same house as me who was telling me he loved me and that I was in a relationship with him. He told me we had to take what was going on “to the grave” and that if I ever repeated anything to my friends or family it would be my fault and his relationship with his family and relatives would fail because of me. There is a lot which is hard to remember but I still can’t forget the feeling of what he did to me as it was at such an early stage of my life. For a long time, I tried to take the terrible memories out of my mind. Thinking about it now is still really painful. Sometimes I am doing everyday things such as watching tv or am in a shop but small things such as smells, and tastes will cause me to be reminded and taken back to that time in my life. When I first spoke up about the abuse and what my foster father was doing, I went to therapy and thought I was getting over it. I was very wrong. My full understanding of what has happened to me has only gotten clearer as I have grown older. My life and feelings are worse now and it hurts knowing my innocence as a child and young person and how it was taken away from me by someone who was in a position of trust and power. GSCP CHILD C LCSPR0220 P a g e | 3 1.2 Introduction In October 2020, a young person shared with their friend about being abused by their foster parent. As the young person was still living in the foster household, along with other young people it is essential to emphasise the courage demonstrated by this young person in disclosing the abuse. Although it is incredibly difficult to comprehend that any Child in Care placement would provide a venue to perpetrate further abuse of children and young people, sadly we know that this can and did happen even within the expected systems of monitoring, oversight and management of both foster carers and children living in Care Placements. We need to understand more about how agencies advocate for children and young people so that their voice is heard, and opportunities to openly share their experiences are placed uppermost in all professionals’ practice. In undertaking a Rapid Review of learning, Gloucestershire Safeguarding Children Partnership seeks to understand what happened and what needs to change. This LCSPR looks to specifically understand and learn from the lived experience of Children in Care in Gloucestershire using the following key questions: • Are we ready to see beyond formal or perfunctory processes so that we listen and hear their voice and see their true experiences? • How are we responding to concerns whilst being entirely child focussed – listening to them and not placing judgements on the veracity of allegations. • Are we consistently believing children and enabling early disclosure of concerns by them? • At the start of any foster placement, how do we explain to the child what is appropriate treatment in the foster placement and how they raise any concerns they have confidentiality? This is particularly important for children from a background of interfamilial sexual abuse. • Do we consider foster carers as safeguarding professionals, parents, trusted adult? And how does that impact on our ability to respond appropriately when situations such as these occur? • As professionals working with Children in Care in Gloucestershire, do we acknowledge and consider that ‘terrible things can happen’ to Children in Care? • How are we ensuring that we provide a consistent trusted professional, aside from those who have caring responsibilities? The Child Safeguarding Practice Review Panel, National Annual Report 2020 (DfE), highlights key practice areas. Theme 1: ‘Understanding what the child’s daily life is like’ that resonates here and has directed the partnership to consider how we could have listened more. What could professional have done better to improve the child’s lived experience and have their voice heard? 1.2 What Happened to Child C? Child C experienced early trauma and harm through Neglect, Physical, Emotional and Sexual abuse by their birth family. Following the conclusion of care proceedings, whereby a full Care Order was granted, Child C was placed with carers whom they had spent some respite time with previously. Gloucestershire Fostering Panel considered and approved this as a long-term match, and this was confirmed as the plan at a Child in Care (CIC) review in October 2016, Child C was 13 years at this time and had lived with the foster family since August 2016. GSCP CHILD C LCSPR0220 P a g e | 4 At age 14 years, Child C was accessing social media material. There were some professional concerns about online grooming, but also what was described at the time as a relationship between Child C and an older child of the foster family; Child C had disclosed information but then retracted it. At aged 16 years Child C then made a call to the Emergency Duty Team talking about being ‘emotionally manipulated’ by the female foster carer and stating that the allegation made previously aged 14 had been true. One year later Child C called ChildLine asking about the legal age of consent, telling them they were in a sexual relationship with their male foster carer; Child C went on to deny this call was made. Within a few months of Child C’s call to ChildLine, further separate allegations were raised by two different young people about two different members of the foster family; one was of alleged sexual assault, and another was about use of physical force Child C’s storyline was drawn together and explored thoroughly within the Rapid Review. This LCSPR has sought to build on what was known and as such has evidenced how Child C’s story presented differently to different people and professionals. Child C’s behaviour and what they said varied, meaning that no one professional or agency had the full picture of the child’s daily life and how things were for them, as a child living in Care, coming from a background of harm and neglect, and continuing to endure abuse. This report can say that disconnection in communication meant interdisciplinary and multi-agency discussions did not join up effectively if at all around Child C. 1.3 Publication Note: The GSCP accept that this LCSPR is being published outside of the six-month timeframe set out in the Working Together 2018 Guidance. The partnership considered that a sensitive and balanced approach was needed and to capture learning from the two parallel processes underway. It was considered by the working group to be vital to ensure that a full picture of what happened to this child could be understood to identify the learning from all the circumstances surrounding the child. In addition, the desire to engage with and involve the child required the partnership to fully understand and mitigate against any potential conflicts with the child’s testimony within the current and ongoing criminal proceedings and most importantly to capture the child’s voice without re-traumatising them. 2. LCSPR Report and Recommendations It is pertinent to remind readers that the review is in place to determine what the multi-agency partnership and hence individual agencies could have done better to understand the lived experience of a child in the county. This review is focused on what we can learn and how we work to change practice. 2.1 Providing a Consistent Trusted Adult The report ‘Your Life Beyond Care,’ which captures the views of care leavers in Gloucestershire on their well-being & what makes life good (June 2020) sets out the voice of the child in care and leaving care and clearly communicates those children in Gloucestershire value consistent and trusted workers “as a very important quality in relationships….” GSCP CHILD C LCSPR0220 P a g e | 5 Baker, 2017 “…care leavers were clear about the qualities they valued in workers such as, someone who was responsive, consistent, and reliable…” As set out in the ‘Child Safeguarding Practice Review Panel, National Annual Report 2020; “It is important for practitioners to build a trusting and respectful relationship with the child”. For Children in Care, the foundation and framework for a trusted support network must surely begin with those social care professionals surrounding them. The day-to-day care and permanence plan for a Child in Care is overseen by the locality children’s social care team (including the permanence teams), the fostering team, the participation team, and Independent Reviewing Officers (IRO). Additionally, other principal agencies and professionals involved in providing care were Primary Care, the Child in Care Nursing Team, Child Adolescent Mental Health Services (CAMHS) and the School Nurse service. Also, two Secondary schools and engagement with the Virtual School provided education services. From entering Local Authority Care Child C experienced changes of social worker which included 10 to 16 different professionals who were a mix of permanent and agency staff. Child C had several professionals working around them and an Independent Reviewing Officer was allocated from October 2016 to August 2019. This would suggest constancy of a professional; however, the records indicate the involvement of several other Independent Reviewing Officers during this time, making it hard to be confident that there was consistency in the oversight and monitoring of Child C’s care planning. At no point was Child C expressing that there was anyone in their view as an identified and trusted individual. Throughout 2016 to 2020, a period indicated by Child C as the time in which the abuse was occurring, the frequent turnover of professionals from within the partnership meant building a trusting relationship would have been difficult for any child. The system assumed that the trusted professional was the Foster Care family, a family who latterly were under some scrutiny for a range of issues relating to their suitability to care for children to an acceptable standard. It is positive that the allocated social worker at the point of disclosure had been in place since 1st February 2019, but this worker has since moved on. Following the disclosure and as part of this review the social worker met with the child and asked for their view on why they felt unable to disclose sooner, this is what the child relayed. (Names have been changed for confidentiality). “Child C said they felt there were times they wanted to talk to me (social worker) and call me, even though they had my number but was worried that the (carer) would hear the conversation. Child C said they were not ready to tell people what was happening sooner, they said they wanted to get evidence and was worried they would not be believed. ….and said they were so worried that the (carer) would find things on their (Child C’s) phone and delete them so there would be no evidence.” “Child C said they didn't feel ready to tell people before they did. Child C said they wanted to tell me (Social worker) before I left and me telling her I was leaving the service triggered her to wanting to tell people sooner as she wanted to tell someone she had known for a long time rather than someone new” GSCP CHILD C LCSPR0220 P a g e | 6 Child C would have been aware that they would shortly get another worker but was still not confident or trusting enough to tell the social worker because from their own experience they did not feel they would be believed. The service had a long-standing relationship with Child C’s foster carers. These foster carers were considered by the service as ‘good carers’ and labelled as designated ‘champions’ for other foster carers. Historically their standing and reputation within the service and community of carers quite likely led a potential for ‘absolute unquestioning trust,’ discounting and misinterpreting Child C’s actions and behaviours. Prior to the final disclosure from Child C, in July 2020 concerns had been raised by another child in the care of the foster carer’s which led to the agency questioning one of the carers’ standards of care and suitability as a foster carer. However, these concerns were in their infancy and not related to the sexual abuse allegation by Child C. The service response to these concerns will have contributed to Child C having less confidence to share the abuse they were experiencing, feeling they may not be listened to and in the absence of a single trusted professional Child C was on their own. In this case Child C’s abuser was seen by professionals as part of the team around the child. However, Child C has stated that they did not have a trusted professional to turn to that would believe them. This leads us to ask how the Partnership can be assured that a child is able to identify and build a trusting relationship with a professional. In many cases children may not wish to challenge who others feel that trusted person is thought to be, and whether they really feel they have a professional who is focused on them. This indicates a need for clearer guidance and understanding of professional roles and accountabilities linked to how being a ‘trusted professional’ is articulated and developed in line with the findings of GCC’s Fostering Service Review. It would appear the expectation is that Children in Care are required to repeatedly renew and develop trusting and respectful relationships with different professionals, not just with Social Care. Other agencies were involved to review, support and advise on the child’s physical, developmental and mental health needs. Child C was talking about their relationships, feelings, and sexual activity but in diverse ways and to different degrees within these contacts. The reality of life for Child C and other Children in Care is challenging and potentially exhausting, with no one external professional who will attune to their needs, to hear and see beyond the surface presentation. In addition, the situation for Child C shows the lack of a collaborative or shared approach to sharing information despite the Child in Care plan and review system. Parts of Child C’s story known to health were missing in the bigger picture. The partnership must also consider how professionals include foster carers as part of the team around the child, whilst ensuring they remain entirely cognisant of the possibility for abuse and neglect perpetrated within families and foster placements. There must be assurance that every child has a key professional who is truly their advocate. 2.1.1 Activity The Gloucestershire Childrens’ Social Care Improvement Board is overseeing and monitoring activity and approaches to improve worker stability and the role of the trusted professional. Representation GSCP CHILD C LCSPR0220 P a g e | 7 from Gloucestershire’s Ambassadors will include the voice of young people and a commitment to improve has been pledged. Completing Life Story work will inform assessment, analysis, and planning with children, thus directly informing risk assessment and better supporting the needs of each child. GCC Children Social Care (CSC) has employed a Life story coordinator to further develop and ensure consistency in relation to life story work for all Children in Care. A pilot project was undertaken with a cross section of children within children’s teams focusing on embedding life story practice. This is in the form of a guide and toolkit now available for all social workers, meaning they can undertake Life Story work with children. This supports close collaboration and dialogue between practitioners, teams, carers, and families to encourage awareness and understanding of key aspects of each child’s life and their experiences, promoting identity, promoting their self-esteem and stronger relationships into adulthood. This Review understands that Life Story work has now been rolled out across all localities, with an expectation that all social workers will have the skills and knowledge to undertake life story work with all Children in Care. Also, Participation Champions in all teams meet regularly with the Principal Social Worker and Gloucestershire’s Ambassadors to update on the progress of life story and direct work and to share examples of effective practice for wider development in teams. GCC Childrens’ Social Care should share their completed report on Life Story work formally with the partnership, with their commitment to report on its impact and outcomes for Children in Care. This is further linked to additional relational practice focused activity, social graces training and emphasis on ‘language that cares’ that continue to be highlighted across the service. 2.1.2 Recommendation/s: Recommendation One: Whilst the identification and reporting of abuse of any kind should not be left to children to undertake there must be confidence that our Children in Care have a voice and are empowered to use it. At the appropriate time the Local Authority must lead on talking to children about healthy relationships, conversations that are age and developmental stage appropriate to support Children in Care to understand appropriate treatment and behaviours in their foster placement. Recommendation Two: Where there is little or no evidence that a child feels they have a trusted professional all efforts to understand and improve that situation must be considered and acted on. Therefore, professionals should ensure that the role of the trusted professional or adult is explicit within the Children in Care planning process and should never be seen as being undertaken solely by a Foster Carer. Recommendation Three: To avoid duplication with activity already being undertaken and reported on: Activity within the Gloucestershire Children Social Care Improvement Board should be shared with the GSCP with regards to improving worker stability and the role of the trusted professional /adult Recommendation Four: To reinforce the importance of the voice of the child the Partnership should consider working with young people and Gloucestershire’s Ambassadors to: Create a short film for professionals about continuity of engagement, the importance of listening to the child’s voice and GSCP CHILD C LCSPR0220 P a g e | 8 enabling the child and professionals to develop trusted relationships. This to be cascaded across the partnership. 2.2 Adult Focus Child C lived in the care of foster carers known by professionals to be trusted and experienced, working with the authority over many years and revered as supportive ‘champions’ for other foster carers. Up to the final disclosure the trusted status and circumstances of the foster carers surrounding Child C remained unchallenged; and yet throughout this time the child was being abused in their care. At so many points the professional focus was demonstrably on the views of adults, not listening to the child’s voice or understanding their help seeking behaviour. Any attempts for Child C to express themselves and reach out for help were either disbelieved, dismissed, not followed up or involved the carers, causing the child to retract statements and say they had lied. Decisions for the foster carer themselves to discuss concerns with Child C following indications of online grooming and suspected sexual contact with the foster carers eldest child in 2017 was flawed and lacked professional curiosity. Likewise, there was a lack of response in June 2019 when Child C, in a call to the Emergency Duty Team, stated they wanted to move placement and that their allegations previously made in 2017 about the foster carers child’s behaviours towards them, were true and that the female carer “emotionally manipulated them”. There was no consideration of a conflict of interest or inappropriateness in them self-investigating the situation with Child C. This was symptomatic of the adult focused approach undertaken throughout. A further allegation from another child outside of the care of the foster carers in June 2020 against the (same) child of the foster carers was reviewed through an Allegations Management Meeting (AMM) process, given as they at that time were a young person employed to give their views on issues and themes affecting young people in this county. This allegation did not consider the previous concerns raised by Child C regarding the foster carer’s child in 2017, as information regards the Strategy Discussion that took place at that time, was not shared and the LADO was unaware of this information. The ongoing determination by professionals that both the concern in 2017 and the allegation (by a second child) in June 2020 were consensual relationships did not display the appropriate level of professional curiosity or rigor. Further, following the information from Child C’s call to ChildLine, Child C should not have been considered as a consensual relationship with the foster carer. This activity would be considered an abuse of trust; the foster carer would be behaving in a way that had harmed a child leading professional to question their suitability to work with children, regardless of the child’s later withdrawal of that allegation. The decision that threshold was not met in February 2020 from the ChildLine disclosure, regardless of Child C’s decision to deny this call, was incorrect. The child’s mobile number could be verified against that call, leading the review panel to conclude that the context and understanding of Child C’s withdrawal of the allegation was not explored. On the balance of probability, the option for a Strategy Discussion and an Allegations Management Process was missed. At the very least a Strategy Discussion should have been instigated to consider all possibilities. Instead, the view was taken that “we do not have enough evidence for a strategy discussion at this time” which was also the position taken with regards to an AMM. GSCP CHILD C LCSPR0220 P a g e | 9 All professionals working with children, young people and their families and carers must be alert to the possibility of child abuse being perpetrated by any adult. We must question how we are responding to concerns whilst being entirely child focussed, and not placing judgements on the veracity of allegations or concerns, or a child’s decision to withdraw or deny making allegations. Are we consistently hearing the voice of children, sustaining paramountcy for the needs of children, listening to children, believing what they say in their language and in the way they are behaving and presenting to us? All professionals must be attuned to the child’s voice and experience in this way to enable early exposure of risk to harm faced by children. 2.2.1 Activity The GSCP Quality and Improvement in Practice Subgroup have oversight of all Multi Agency training via its Quality Assurance group. All Multi agency training has been reviewed regarding the inclusion of the Voice of the Child and the Childs Lived Experience. This work will be cascaded through to all Single Agency training as delivered by the partners and within Education Whole School Training. The GSCP Standard four as set out in the Section 11 audit assesses agencies arrangement with regards to the Voice of the Child which is reported on by the Independent Scrutineer from 2020 and on an annual basis. A copy of this report will be shared with the I.S. for consideration in 2021 S11 audit panel day. As a result of this review and report the partnership is reviewing their approach and expectations of strategy discussions. This work has been underpinned with a revised protocol for Strategy Discussions with follow-on activity and monitoring through the GSCP Quality and Improvement in Practice Subgroup Scrutiny of the GCC Allegations management process with regards to the Voice of the Child and Lived Experience of the Child is being considered within recommendation 7. 2.2.2 Recommendation/s Recommendation Five: To reinforce the importance of the voice of the child: Agencies should review all Single Agency Training to provide assurance to the GSCP that the voice of the child is present and for them to provide evidence of impact on practice. 2.3 Adherence to Statutory Process Abuse by carers is not unthinkable, as evidence locally and nationally shows. Compliance with statutory duty alone does not keep children safe from harm. At no point in this child’s daily life did any professional question whether multiple disclosures, retractions, and incident reports, across different systems and processes consider Child C was making cries for help. What must that have felt like for the child? The serious allegation made in June by a second child against the foster carer’s child was managed through the Allegations Management process; a process designed to focus on “adults in a position of trust.” While there was a Strategy Discussion, there remains little evidence of a proactive or robust safeguarding response. What response there was merely stated there was a lack of evidence to instigate criminal proceedings or even HR Disciplinary Proceedings. The Fact that processes sought GSCP CHILD C LCSPR0220 P a g e | 10 and followed advice that was focused on Employment Law threshold again demonstrates a focus on the rights of the adult and not the welfare of the child. Although there is information to show in Child C’s situation that process was inconsistently followed, there remains a pervasive attitude that compliance with process is a barometer for successfully meeting Children’s needs. That compliance saw a child being coerced and sexually abused whilst partners were being compliant with duty. We must surely turn this around to promote professional curiosity and a true understanding of the lived experience of the child. Processes to manage allegations against professionals require careful thinking and aligning with safeguarding practice. The partnership must place the needs of the child as paramount, whilst fully utilising statutory processes to manage criminal and professional allegations appropriately. Strategy Discussions should have taken place in 2019 and 2020. This information sharing opportunity with the key professionals supporting Child C would have focussed on the child’s perspective, bringing greater analysis and challenge to their circumstances regarding understanding and managing risk and thus afford Child C greater protection. The decision to not undertake Strategy Discussion’s has been seen in Gloucestershire from other Rapid Reviews. Under a backdrop of an existing high rate of strategy discussions in Gloucestershire there clearly remains confusion over the remit and threshold of combined or dual processes even where information is available. The evidence in this case and other SCR’s, LCSPR’s and Rapid Reviews suggests that where criminal threshold is not met there is a propensity for partners to consider safeguarding threshold to be dispensed. More worrying, the default position seems to be where criminal threshold is not met or where a decision on criminal threshold is “no further action.” Disclosures, allegations, and other clear messages from children are neither believed nor acted upon under safeguarding duties. This is concerning as the ability to hear the child’s voice and understand the lived experience of children is the first casualty. Gloucestershire Safeguarding Children Partnership must fully understand local decision making when there are concerns about Child Sexual Abuse (CSA). In this case CSA was not ever considered until the video footage was disclosed by the child. Why is that? The review feels that the absolute and unwavering trust in the carers blinded all professional curiosity and the complete deafness to the voice of the child. 2.3.1 Recommendation/s Recommendation Six: SCR’s and Rapid Reviews undertaken in Gloucestershire identifying the need for practitioners to be confident and competent in being always alert to the potential for, identifying and responding to signs and symptoms of Child Sexual Abuse: The QiiP should revisit the findings of safeguarding reviews to seek assurances from partners about actions to address them. Recommendation Seven: Concerns relating to an adult focus within statutory functions needs to be explored and addressed: The Local Authority should undertake a review of its Allegations Management Processes and report back to the GSCP on its findings and actions to improve identified areas for improvement. GSCP CHILD C LCSPR0220 P a g e | 11 3. Update on Parallel Processes • An immediate joint Complex Abuse Investigation was undertaken, within GSCP policies and procedures. During that investigation agencies came together and worked quickly with all the children, including Child C, so that their needs were at the centre of the decision making. This LCSPR has been informed of the findings of the Complex Abuse Investigation, indicating there were no other criminal prosecutions to be undertaken. The findings have been shared with GCC’s relevant service. • The local authority undertook an independent review of their Fostering Service. The report was made available to the GSCP and this LCSPR. • Criminal proceedings have concluded. • Now criminal proceedings into the Foster Carers have concluded, GCC Fostering Service will undertake their own investigation into their suitability under the Fostering Regulations 2011. 4. Summary We must act robustly in response to indicators of abuse whether children are living with their families or in the care of the local authority and proactively seek to protect children, rather than waiting for abuse to occur and relying on children’s disclosures to take protective action. At the same time as instilling a culture where indicators of abuse are effectively understood and assessed, we must create the safe spaces in relationships with trusted professionals that provide the best conditions to support children feeling able to tell professionals if they are being abused or suffering harm. Practitioners must be open to considering that abuse by professionals and trusted carers is possible and respond accordingly when indications of professional abuse become apparent; think the thinkable. GSCP should not consider this to be an incident suffered by a Child in Care but should consider this to be an incident suffered by a child. As such, and as Corporate Parents, the support and response to these circumstances must be robustly challenged as they would be for any one of our own children, niece, nephew, or grandchildren. |
NC050523 | Local learning review conducted following a serious incident of youth violence. Learning points include: agencies would like clearly defined thresholds in relation to contextual safeguarding; agencies do not always feel confident on what information they should be sharing, with who, and how to escalate concerns of poor information sharing; it is difficult to evidence change where there appears to be positive engagement and possible disguised compliance; the benefits of extensive mapping, including the collection of data on gang related violence, hotspots, presentations at local hospitals, and local police intelligence data; the value of child criminal exploitation leads in agencies including children's social care. Recommendations include: the completion of a review into information sharing between local police, children's social care and youth offending services; ensure information relating to the transfer of care of vulnerable children and their families from 'out of area' is shared with relevant local health agencies; information about hospital attendances by young people related to serious youth violence, especially in hospitals outside the young person's local area, is shared with relevant agencies; ensure the inclusion of health representatives in multi-agency forums related to children who are at high risk of youth violence; develop a clear threshold and pathways document on contextual safeguarding; consider the development of a transitional safeguarding approach with the Safeguarding Adult Board.
| Title: Local learning review of serious youth violence and gang related activity. LSCB: Thurrock Local Safeguarding Children Partnership Author: Russell Wate and Jay Brown Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page | 1 Local Learning Review of Serious Youth Violence and Gang Related Activity Independent Authors: Dr Russell Wate QPM and Jay Brown Page | 2 1. Introduction Following a serious incident of youth violence Thurrock Local Safeguarding Children Partnership (TLSCP) made a decision to carry out a focused review of serious youth violence, along with a deep dive case audit. The focused review was supported by a review panel, which was made up of extremely knowledgeable, passionate, and case specific members, for which the review author is very grateful. The lead reviewer was Dr Russell Wate QPM. He is independent of any agency within Thurrock. He was one of the reviewers for the National Child Safeguarding Practice Review Panel report ‘It was hard to escape - Safeguarding children at risk from criminal exploitation’ (March 2020). The deep dive case audit has been undertaken with involvement from the local Independent Quality Assurance Service and support from the Thurrock Safeguarding Children Partnership. A lead reviewer, Jay Brown, who is an NHS Trust Named Nurse for Safeguarding Children for Southend, Essex and Thurrock (SET), was identified by the partnership to scope and host a learning event for the deep dive and to write the report. 2. Overview of Strengths and Recommendations There is no doubt that in Thurrock there is a strong commitment from all agencies and individuals to tackle serious youth violence. This review can say with confidence that the structures, processes, and procedures that are currently in place, and those proposed actions, are addressing, where possible, serious youth violence. This case was unique in that the child had received extensive support from a multitude of agencies. Although there were concerns of information sharing being insufficient, there was a strong desire from professionals to work together. There was good attendance at multi-agency meetings and frequent communication between professionals. Despite significant engagement with services, it was unclear what motivated the child to carry a knife on the day of the incident. The learning event for the deep dive and the panel engagement for the focussed review had strong and full engagement across all areas of the partnership. The learning event highlighted many areas of good multi-agency practice. There has been clear evidence of individual practitioners going above and beyond their roles, this tenacity, for example, was evident in the work undertaken by the Youth Offending Service (YOS). No practice or system failings were identified, and it is acknowledged that this incident was unforeseen. This deep dive has promoted shared learning, which together with the focused Page | 3 review of serious youth violence, will lead to actions to improve safeguarding practices across Thurrock. There has been learning developed by both review processes, some of it understandably makes the same points, but also, pleasingly, additional learning has been developed by use of both processes. Several points of learning arose from discussions within the five multi-agency breakout groups in the deep dive, and these are summarised as follows: • Agencies would like clearly defined thresholds in relation to contextual safeguarding as they all view risks differently. • Agencies do not always feel confident on what information they should be sharing, with who, and how to escalate concerns of poor information sharing. • Agencies acknowledged it is difficult to evidence change where there appears to be positive engagement and possible disguised compliance. The focused review has found areas of strength, as outlined below, and areas for further development that Thurrock LSCP should consider as actions for further work to tackle serious youth violence: Strengths • The Violence and Vulnerability Unit (Thurrock specific), Youth Crime Justice Board (YCJB) and the Violence and Vulnerability Board (Essex wide). • The comprehensive Annual Public Health Report with an action plan with recommendations to address Youth Violence and Vulnerabilities. • The joint commitment of the Local Youth Crime Justice Board (LYCJB), Community Safety Partnership (CSP), Local Authority Scrutiny Committees, Local Safeguarding Children Partnership (LSCP), Health and Wellbeing Board and Brighter Futures Children Partnership. • Extensive mapping, including the collection of data on gang related violence, hotspots, presentations at local hospitals, Essex police intelligence data. • Child Criminal Exploitation (CCE) leads in agencies including Childrens Social Care (CSC). • Essex Police have created a number of teams across the force area to work and support their established policing teams and partner agencies, enhancing the ability to prevent offending, reduce involvement in criminality and protect those affected by Serious Youth Violence and Gang Related Crime. • A good understanding within Thurrock of the concept of ‘Place’ and how to tackle it. They have identified hot spots for offending, information and access to crime trends, and intelligence to focus resources to anticipate and respond to incidents of this nature. • The Gangs Matrix and the Gangs Related Violence report. • The Child Exploitation (CE) tracker panel. Page | 4 • The members of the YOS team have been consistent for a number of years, with extensive experience of youth justice, gangs/CCE and serious youth violence. • The very active Youth Justice Out of Court Disposal Panel (OOCD). • The YOS and CSC support for the Contextual Safeguarding approach across children’s services. • Several Thurrock agencies provide a ‘Reachable Moment’ offer, for example, YOS and CSC. This includes hospital-based youth workers who work with young people when they present at A&E with an injury/stab wound. • Good relationship based, and trauma informed practice demonstrated in Thurrock. • Thurrock have put together an extremely good leaflet for parents titled ‘Gangs and Exploitation’ ‘Support and information for parents and carers across Thurrock.’ • A good understanding and balance between a child being an offender, but also a child in need of safeguarding • Good use of National Referral Mechanism (NRM) referrals. • There are a number of scrutiny and audit processes in place, some of them internal to individual services but most are multi-agency. Areas for consideration for further development • Consideration within the partnership for overarching governance of serious youth violence strategy and which board leads. • There is a hospital data set collection that helps in this area, but this only applies to the Mid-South and Essex Hospital Group. There is a sizeable gap for Thurrock children that attend other Essex hospitals, and in particular London hospitals in the first instance, as no data is shared. • Support required from London Boroughs and the Met Police with closing intelligence gaps as there is a considerable flow and interaction of youths between Thurrock and the London Boroughs. This has led to recent cases of serious violent and gang related offences committed by youths from London Boroughs within Thurrock. • An early understanding of Thurrock children committing offences of serious youth violence in other areas, in particular London Boroughs. • The priority implementation of the findings of the review in relation to information sharing between Essex Police and the YOS and Children Social Care. • Engagement with secondary schools in relation to permanent exclusions. Including the continuing development of the project with the Alternative Provision in Thurrock. Engagement with primary schools may be a positive move in order to identify children at risk earlier. • Continuing the improvements in the quality of ‘Return Home interviews.’ Page | 5 • Further work to be identified to look at how Thurrock can be more creative in engaging and educating young people and families who do not either recognise identified risk, or are resistant to social care involvement. This will involve identifying different models, skills, services, and ways of working. • Think Family and a trauma informed approach training does take place in some agencies. Have other professionals also had training in trauma informed approach? e.g., health visitors, school nurses and teachers? • The multi-agency partnership to improve the arrangements for support and engagement with children at risk of extra familial harm (as outlined by the Ofsted focused visit, June 2021). • The importance of transitions for children from 14 years old needs to be considered (Ofsted focused visit, June 2021). The development of a Transitional Safeguarding 0-25 approach should be considered jointly with the Safeguarding Adult Board. • Although accepting there is in place a national agreement between probation and YOS for transition, earlier transition planning for children in care and care leavers who are exposed to risk of child exploitation, gangs and extra-familial harm is needed in Thurrock. • Implementation of the findings of the report of vulnerable families moving into the borough. • Work is required to alleviate the major concern for agencies locally in Thurrock regarding those vulnerable families who are moved into the area that they are not aware of, and therefore may not be housed in an appropriate area and not given the support required. • Housing services to consider not using temporary accommodation for those children subject to, or likely to be involved in serious youth violence. • It is suggested that Thurrock considers the need for improvement in regard to communication and information sharing to, and between, health agencies in a number of areas: a) the transfer of care from vulnerable Children and Young People and their families from Out of Area into Thurrock; the communication of Hospital attendances of Thurrock Children and Young People to Hospitals Out of Area (especially when those relate to Youth Serious or Gang related violence); b) the inclusion of health representatives in relevant multiagency forums where Children and Young People who are known to be at high risk are discussed; and the information sharing pathways from agencies (such as Police and YOS) to health services. Page | 6 3. Recommendations A number of the key areas of learning (identified above) could be addressed by implementing the following priority recommendations: Recommendation 1 Improvements are needed in relation to Information Sharing by the Thurrock safeguarding children partnership and the other relevant Thurrock statutory partnerships. i) Ensure the completion of the current review and to then monitor the implementation of actions to improve information sharing between Essex Police to the Thurrock YOS and CSC. ii) Explore ways to gain the support required from London Boroughs and the Met Police to share information in relation to the flow and interaction of youths between Thurrock and the London Boroughs. iii) Improvements are required in the communication and information sharing to, and between, health agencies in a number of areas a) Ensuring information relating to the transfer of care from vulnerable children and their families from ‘Out of Area’ into Thurrock is shared with relevant health agencies. This could be widened to all agencies and the Thurrock LSCP audit group could undertake an audit of information sharing for children transferring into Thurrock from outside the local authority, b) The communication of hospital attendances of Thurrock children to hospitals Out of Area (especially when those relate to serious youth violence) is shared with relevant agencies in Thurrock, c) Ensure the inclusion of health representatives in relevant multiagency forums where children who are known to be at high risk of youth violence are discussed. iv) Thurrock LSCP to consider hosting multi-agency information sharing workshops to develop professionals’ knowledge on serious youth violence in the context of safeguarding. Recommendation 2 Thurrock LSCP to develop a clear threshold and pathways document in relation to contextual safeguarding. Following the completion of this document an extensive practitioner awareness raising campaign should take place across the partnership. Recommendation 3 The development of a transitional safeguarding approach should be considered jointly with the Safeguarding Adult Board. Page | 7 Recommendation 4 i) The Partnership needs to ensure that further work takes place to look at how Thurrock can be more creative in engaging and educating young people and families, who do not either recognise identified risk, or are resistant to social care involvement. This will involve identifying different models, skills, services, and ways of working. ii) Agencies working with children and young people at risk of youth violence need to clearly ascertain in their assessments the views of the child, but also their parents and carers views of risk. Recommendation 5 i) Housing services in Thurrock to exercise managed housing reciprocal and only use temporary accommodation in an emergency, for those children subject to, or likely to be involved in serious youth violence. ii) Work is required with housing providers in Thurrock to alleviate the major concern for agencies locally regarding those vulnerable families that are moved into Thurrock that they are not aware of, and therefore may be housed in an inappropriate area and not given the support required. Recommendation 6 i) Engagement is required with secondary schools in relation to permanent exclusions. This includes Thurrock SCP receiving reports in relation to the continuing development of the ongoing project with the PRU in Thurrock. ii) Engagement with primary schools will also be a positive move by the partnership in order to identify children at risk earlier, this should include an awareness programme to these children highlighting the risk of carrying knives. |
NC50572 | Concerns about a 10-month-old girl having ingested methadone and her two siblings aged 4- and 10-years-old being exposed to drugs in January 2014. Children lived with mother and father and had regular contact with maternal grandmother. Family was known to both adult's and children's services, including children's social care. The older girls were the subject of child protection plans from May 2012. When Emily was born they were subject to child in need plans which were discontinued in September 2013. Father had abused alcohol and drugs from the age of 15. Mother had suffered post natal depression, children were often late or had sporadic attendance at school. The family are of White British heritage. The review used the Significant Incident Learning Process (SILP) model. Learning includes: professionals must assess the impact on parenting of mental health or drug and alcohol misuse; It is important to work directly with children ensuring their voices are heard; professionals should consider the possibility that parents in a drug treatment programme may be tempted to use their medication on their children. Recommendations include: social workers should consider the risk of drug using parents actively giving drugs to their children; training for social workers in order to gain confidence in working with parents who show disguised compliance and manipulative behaviour; extended family who are relied upon should be included in key child protection meetings.
| Title: Serious case review: Jenny, Molly and Emily: overview report. LSCB: Middlesbrough Safeguarding Children Board Author: Nicki Pettitt Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Jenny, Molly and Emily OVERVIEW REPORT Lead reviewer: Nicki Pettitt Date presented to the MSCB: 18 May 2015 Publication has been delayed due to on-going criminal processes 2 Contents 1. Introduction to the case Page 2 2. Summary of the learning Page 3 3. Methodology Page 3 4. Family Structure Page 4 5. Background prior to the scoped period Page 4 6. Key episodes Page 6 7. Analysis by theme and lessons learned Page 15 8. Conclusions Page 30 9. Recommendations Page 31 1 Introduction to the Case 1.1 The subjects of this review are 3 children. They were aged 6 years old, 4 years old and 10 months old at the time that serious concerns emerged which led to the decision to undertake a serious case review. On 8 January 2014 Emily was taken to Accident and Emergency (A&E) by ambulance, she was unconscious. She was later diagnosed with methadone intoxication, through ingestion. At 10 months old it is highly unlikely Emily’s ingestion was accidental. The consultant paediatrician who treated her stated ‘I feel lucky that she is still alive.’ Emily required treatment in the paediatric intensive care unit, but has since made a full recovery. 1.2 The police investigation which commenced later confirmed through hair strand testing of the older siblings that they have also been exposed to drugs, including heroin, cocaine, cannabis and methadone. It has not been established if the older sibling’s exposure to drugs was through ingestion or if they had been absorbed passively. 1.3 The children lived with their mother and father and had regular contact with their maternal grandmother and her family. The family had been known to both adult’s and children’s services, including children’s social care. The older girls had been the subject of child protection plans from May 2012, but the plans stopped before the birth of Emily. When Emily was born all three girls were the subject of child in need plans. They were discontinued in September 2013. Father was known to agencies due to his long standing drug and alcohol misuse. 2 Summary of the Learning 2.1 This Serious Case Review has identified a number of learning points for the individual agencies involved and for the Middlesbrough Safeguarding Children Board (MSCB). When considering in detail the involvement of MSCB partner agencies with Emily and her siblings it has found that: 3 ⋅ Communication was good in some areas but lacking when it came to being clear about the specific detail of concerns and in sharing concerns with children’s services about adult behaviours. ⋅ Assumptions were made about the services being delivered and about the ability of family members to support and protect the children. ⋅ Assumptions were made about what the wider family knew about the details of the concerns. ⋅ There was a degree of naivety about drug and alcohol use and its impact on the children, and about false compliance from manipulative parents. The professionals involved were working hard but often without the support and challenge they required. ⋅ The impact of a new baby in this family was not adequately considered. ⋅ There was a lack of direct work with the children, and although professionals described the children in detail in their recording, the children’s voices were not clearly sought or stated. ⋅ Professionals rarely consider the possibility that parents on a drug treatment programme may be tempted to use their medication on their children. However this must be seen in the context of the circumstances in this case being unprecedented in the experience of most of those involved in this review. 3 Methodology 3.1 The MSCB agreed that this Serious Case Review (SCR) should be undertaken using the SILP methodology1. SILP is a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in Working Together to Safeguard Children 2013. 3.2 SILPs are characterised by a large number of practitioners, managers and agency Safeguarding Leads coming together for a learning event. All agency reports are shared in advance and the perspectives and opinions of all those involved are discussed and valued. The same group then come together again to study and debate the first draft of the overview report, and to make an invaluable contribution to the learning and conclusions of the review2. 1 The decision to undertake an SCR into this matter was made on 9 October 2014. The delay was due to the need for the MSCB to consider the appropriateness of an SCR in a case that did not automatically meet the criteria for a review of this kind. The Reviewer appreciates the consideration given and agrees that the right decision was made in this case. Once the decision was made, the review progressed in a timely way. The only slight delay being the need to re-draft the terms of reference after additional information emerged in January 2015 in regards to the results of the hair strand testing of Jenny and Molly. 2 The SCR was planned at a scoping meeting held on 11 November 2014 with the MSCB Learning and Improving Practice Group. The Terms of Reference were compiled and the timescale for the review set. Agency reports were requested, along with a chronology of agency involvement. A briefing meeting for Agency Report Authors was held the same day. A learning event was held on 5 March 2015. All the agency reports were available and had been circulated in advance with the chronology. This ensured that all staff attending were able to fully understand the multi-agency information and focus of the review. The event was very well attended by practitioners and their immediate managers. The group included a manager from a local drug agency who had not been involved with the parents but who provided helpful information on drugs and on local drug services. The level of participation and engagement in the event was extremely good. The recall event was held on 16 April 2015. Participants who had attended the learning event considered the first draft of this report. They were able to feedback on the contents and clarify their involvement and perspective. All those involved contributed to the conclusions and the identified learning from this review. 4 3.3 It was agreed that the scope of this review would be from 24 April 2012 to 8 January 2014. The start date is when a strategy meeting was held in respect of Jenny and Molly and the latter date is when it was known that Emily had ingested methadone 3.4 Initially the scope of the review started from the date of the pregnancy with Emily, but since more information has emerged from Cleveland Police in respect of longer term concerns about the older girls and exposure to drugs, the scope was extended. 3.5 The parents were contacted in order to meet with them to ensure their views were considered and heard as part of the review. Two appointments were offered. The first the parents did not attend. The second was cancelled following police advice after allegations that serious threats were made by Father to professionals. 3.6 Maternal Grandmother was visited by the lead reviewer and a representative of the MSCB. She provided useful information and an interesting insight into the case. Details of this will be included throughout this report. 3.7 The Department for Education (DfE) expects full publication of SCR overview reports, working to that requirement, some confidential historical family information will not be disclosed in this report. It is written in the anticipation that it will be published, and contains all of the information that is relevant to the learning identified 3.8 The Police investigation was on-going at the time of the learning events, however the MSCB was informed in 2017 that no further action is being taken. 3.9 The children were the subject of child care proceedings and live with extended family members on Special Guardianship Orders. 3.10 The lead reviewer in this case and report author is Nicki Pettitt, an independent child protection social work manager and consultant. She is an experienced chair and author of SCRs, and is a SILP associate reviewer. She is entirely independent of MSCB and its partner agencies. 4 Family Structure 4.1 The subject children of this review are to be referred to as Jenny, Molly and Emily. The parents of the children are referred to in this report as Mother and Father. Other family members will be referred to by their family title e.g. Maternal Grandmother. 4.2 Mother and Father lived together with the children. They are thought to have been a couple since they were teenagers, although their relationship was said to be ‘on and off’. 4.3 The children and both parents are white British. Their only language is English. This information appears to have been accurately recorded on agency records. They have no known disabilities. 5 The background prior to the scoped period 5.1 Father was well known to Children’s Social Care as a child. This included a period on the Chid Protection Register (as it then was) due to his parent’s substance misuse and domestic abuse. He had issues with alcohol and drugs since he was around 15 years old. He had requested a detoxification programme from alcohol twice during 2009 and once during The final version of this Overview Report was presented to the Middlesbrough Safeguarding Children Board on 18 May 2015. It has been agreed that some additions may be made to this report once the criminal investigation has been completed, including any further information that becomes available during that process and after engagement with the parents. 5 2010, but did not cooperate. He then completed home detoxification programmes in December 2010 and in February 2012 and a hospital detoxification in December 2011, but did not engage with relapse prevention appointments. 5.2 Father was said to have started abusing solvents, cannabis, valium and amphetamines when he was a child. He has been on a methadone programme since 2000 when he completed treatment for heroin and crack cocaine addiction3. He was also being prescribed Tramadol,4 a painkiller, for 10 years. In July 2012 a plan to reduce Tramadol usage was put in place with Father. 5.3 It was a common view amongst the professionals involved with the children and with Father that he was mostly managing his drug and alcohol use. However his GP notes show he had attended his GP in May 2012, that he was diagnosed with depression, was prescribed anti-depressants, and that he had made threats to self-harm. There was also information held by agencies that Father used unprescribed benzodiazepines (diazepam.) On 31 March 2012 Father was admitted to hospital having been found collapsed after heavy alcohol use. 5.4 Father was known to the police due to his use of drugs and alcohol. At the time of the start of the scope period of this review Father was put on a tag and was the subject of a curfew. 5.5 Mother was seen as the protective parent with no drug or alcohol use apparent. What was known however was that she had an addiction to Iron Bru (a soft drink high in sugar, caffeine and quinine.) Her GP records show Mother had post-natal depression after the birth of Molly and that antidepressants were prescribed. Mother was described as having a supportive family however and received help with the children from her Mother. Maternal Grandmother explained that there were periods when she was very involved in her the lives of her daughter and grandchildren, but other times when she did not see them. Grandmother stated she worked long hours and had teenage children of her own, which limited the time available. She also had a difficult relationship with Father and she worried that her daughter appeared to be ‘under his spell’. Grandmother knew he was an alcoholic and this concerned her. She did not know about his drug use. 5.6 A core assessment completed by ChSC in 2012 provides information on the parent’s childhoods, and it is noted that both grew up in homes where alcohol misuse was an issue, and Father often witnessed domestic abuse at home. 5.7 The school near to where the family lived was attended by Jenny for nursery from 2011, as she received a free place from age 2. Although attendance was not mandatory, the school had concerns about her very poor attendance and punctuality, which continued throughout the scope of this review and after she started at the Infant School. 5.8 The children and their mother were registered at a different GP to Father. He was registered with a GP practice that was commissioned as a specialised addictions service. The GP for the children has information in Jenny’s notes that she attended the local hospital on 27 October 2010 with an accidental ibuprofen overdose. Those working with the family during the period of child protection planning were aware of this, but it was not thought to be of significance. Jenny and Molly both received a number of their childhood immunisations late and Jenny was coded on the GP system as a ‘poor attender’. 3 Methadone is used as part of a drug addiction maintenance programme. It is a narcotic pain reliever, similar to morphine; it is used to reduce the withdrawal symptoms when stopping the use of heroin without causing the ‘high’ associated with drug addiction. 4 Tramadol is a moderate strength opiate medication which is used for pain. It was reclassified after 2012 as a controlled drug. It is recognised as a drug of abuse. 6 5.9 The children’s health visitor had concerns prior to the scope of the review. The family often missed appointments, including for immunisations and developmental reviews. The health visiting service were concerned about the family’s insecure and inadequate housing, Jenny’s poor attendance at nursery, Molly’s developmental delay (delayed gross motor skills), Mother’s postnatal depression, and domestic abuse disclosed by Mother. 5.10 After the birth of Jenny four referrals were made to Children’s Social Care (ChSC) in 2008, 2009, 2010 and 2011. They undertook Initial Assessments5 in 2008 and 2010 where home visits were undertaken and discussions were held with Mother, but no further action was taken. In 2008 the parents were drunk in charge of Jenny, in 2009 an anonymous referral was received about suspicious activity at the property, including motorbikes inside the home, and the health visitor was asked to visit, in 2010 when the health visitor raised concerns about Molly’s developmental delay, and in 2011 when they were notified that a CAF (Common Assessment Framework) was to be started after concerns about attendance at nursery were highlighted by an Education Welfare Officer and the health visitor, who were also concerned that Jenny was often tired and lethargic at nursery. 6 Key Episodes 6.1 The time under review has been divided into four key episodes. Key episodes are periods of practice and intervention that are judged to be significant to understanding the way that the case developed and handled. The term ‘key’ emphasises that they do not form a complete history of the case but are a selection of the activity that occurred, and includes the information that is thought to be key in informing the review. 6.2 The first key episode covers from 24 April 2012 to September 2012. This includes the events leading up to Jenny and Molly becoming subject to Child Protection Plans (CPP) and the initial period of the CPPs. 6.3 The second episode covers October 2012 until March 2013, when Mother’s pregnancy with Emily was confirmed until the end of the CPPs. 6.4 The third key episode includes the birth of Emily in March 2013 until the decision to end the Child in Need Plan (CinN plan) was taken on 8 July 2013. 6.5 The fourth and last episode covers the period where there was a continuation of low level concerns despite the closure of the case to ChSC on 30 August 2013, until the incident on 8 January 2014. Key Episode 1: from 24 April 2012 to September 2012. 6.6 Maternal Grandmother had approached a health visitor at the clinic in April 2012 to voice her concerns for the children and their mother. Father was said to be drinking significantly, was using drugs, carried knives, and there had been numerous domestic abuse incidents between Mother and Father, often witnessed by the children. After the health visitor made the referral to ChSC they undertook checks with other agencies and found that Jenny’s attendance at nursery was poor, that she had outstanding immunisations, that the house was in a poor state of repair, and that the children lacked stimulation and structured play at home, and that Molly had delayed gross motor skills when a baby. The family had not engaged with attempts to provide family support via the Children’s Centre or with a CAF undertaken in 2011. 5 An Initial Assessment is a brief assessment of a child’s circumstances following a referral to Children’s Social Care. It will determine if a child is in need, what services would assist the child and whether a more detailed Core Assessment needs to be undertaken. 7 6.7 ChSC visited the family and were concerned at Father’s reaction and Mother’s angry denial of the concerns. Father was so agitated by the visit that the visiting social workers felt, on consultation with their manager, that the children should not remain in the home. Police assisted Mother and the children in a move to Maternal Grandmother’s home. They remained there for 2 days before Mother decided to return home as Father was ‘upset’. 6.8 This resulted in a strategy discussion held on 24 April 2012 and the decision to proceed to an initial child protection conference (ICPC). It was agreed that the children should return to the care of Maternal Grandmother until at least the ICPC. It was noted that Molly’s behaviour had improved while with her grandmother, however when she was taken for her outstanding immunisations she was said to be aggressive and biting. 6.9 In the meantime a referral was made for a Families Forward6 intervention. A 72 hour assessment was made but as the family were no longer thought to be in crisis they did not meet the criteria for intervention. They instead provided a list of tasks for the parents to undertake and shared their view that the children’s needs could be met by universal services and a working agreement with the family. 6.10 The ICPC was held on 15 May 2012. The Police and Families Forward felt that a child in need plan was sufficient, however the decision was made that the criteria was met and Jenny and Molly were made the subject of a child protection plan (CPP) under the category of neglect. A secondary category of emotional harm was agreed. The Agency Report for ChSC stated that ‘the reports to conference from various adult’s and children’s services were informative and covered all relevant issues. The addictions nurse highlighted in her report that ‘heavy alcohol use and intoxication will of course impact on anyone’s ability to parent adequately and safely’. 6.11 A new social worker was allocated after the ICPC and the family engaged well with services in the first period of the CPP. By the first Core Group held on 23 May 2012 the children were spending increasing amounts of time at home with their parents, and then returned to their care. 6.12 The GP notes state that on 28 May 2012 Father took one of the girls to an immunisation appointment and that he was an hour late and smelt of alcohol. The practice nurse contacted the health safeguarding team and spoke to the senior nurse for safeguarding children who advised her to share the information with the social worker. Over the course of the next five weeks the practice nurse made some efforts to speak to the social worker, but did not do so until 2 July 2012. The senior nurse agreed to pass on the information to the health visitor, which she did later. There is no evidence that the health visitor informed the social worker. This information was also not included in the GPs report for the next CP Conference, and the social worker who took on the case in September was not aware of this incident. Around this time the professionals working with the children continued to have some concerns about Father’s drinking, but he insisted he just drank socially and that it was not an issue and this was not challenged rigorously. So even if the information about the visit to the GP had been appropriately shared, it was unlikely to have made a difference at this time. 6.13 Although the parents appeared to be cooperating well with services, concerns about Jenny’s attendance at nursery continued once she had returned to her parents care. The 6 Families Forward are a Middlesbrough service that works with families where the adults are affected by drug and alcohol problems, domestic violence and/or mental health problems. It is an integrated, multi agency team including a Public Health Nurse, Family Support Workers, early years and pre birth support staff, Probation Officer & Clinical Psychologist. 8 parents moved to a new house in June 2012 which was very close to the school, so the continued attendance and punctuality issues were difficult for professionals to understand. 6.14 As part of the CPP both children had child protection neglect medicals in June 2012. Some minor health issues were identified in relation to Molly’s eyes (squint) and hyper-mobility in her joints. Jenny was healthy but it was noted that she was blinking excessively and in view of a family history of eye disorders Mother was asked to consult with the family doctor. The GP was informed of the result of the medical and need for follow-up in these areas, though a delay of some months was noted between the date of the medical and the written information being shared with the GP, the parents and with other professionals. 6.15 A Review Child Protection Conference was held on 9 August 2012. The decision was made for the children to remain subject to a CPP. Molly was due to start nursery and Jenny to move into a full time infant class. It is important to note that Maternal Grandmother was not included in any of the child protection conferences, although she did attend the first three core groups. It would have been helpful to have her attend the conferences as she was relied on to provide support and to undertake a certain amount of monitoring of the children and their care. At the learning events it was agreed that no one really considered what Grandmother knew about the risks, and assumed she knew more than she did. It is significant that she told the lead reviewer that she was not aware that Father had a history of serious drug use and that he was on a methadone programme. She had thought that alcohol and domestic abuse were the reasons for the concerns. 6.16 This is a key practice episode because concerns were identified which lead to an assessment that the children were suffering or likely to suffer significant harm, and they became the subjects of child protection plans. There were some concerns during this period in regards to information sharing, including with Grandmother, and the missed opportunity to undertake full assessments of the parent’s use of drugs and alcohol by Families Forward. Good practice was also identified in regards to the assessment of risk and some assertive work with the family by the social worker and health visitor. Key Episode 2: from September 2012 to March 2013 6.17 Mother’s pregnancy with Emily was confirmed by a midwife in September 2012. At the appointment Mother informed the midwife that ChSC were involved with the family. There is no record of this information being shared by the midwife, however Mother told the children’s social worker of her pregnancy when she visited the family on 14 September 2012. 6.18 School attendance continued to be an issue as the new academic year started. Just during September 2012 the following was noted by ChSC on their visits alone: 14.9.12 - Molly off school with an upset stomach. 19.9.12 - Both girls off with colds 24.9.12 - Both girls absent ‘ill’. The school contacted the social worker on 26 September to state that the children were off that day and to confirm that since the start of the new term Jenny had been present for 8 days and absent for 8, her attendance was therefore just 50%. Lateness was also an issue on the days she did attend. There appears to have been an issue with professionals accepting, to a certain degree, that children are justified being off school when they are ‘unwell’. This was challenged by the staff from the school and the education agency report 9 author who stated that children should generally come to school when unwell, as long as they do not have anything contagious. However it was confirmed that during core groups the message that the children should go to school even if the parents thought they were unwell, and that teacher would send them home if necessary, was consistently given to the parents. At the time the social worker thought that there were other issues that had an impact on the children’s attendance. These were that the children were kept up late and that Mother kept them home to meet her own needs. 6.19 The family cooperated with ChSC and the Family Resource Team who were undertaking parenting assessments at this time. A new social worker became involved in October 2012 and commenced a core assessment immediately. It is noted that the children had been subject to a CPP for nearly 6 months at this stage. The agency author points out that there had been some delay in the case transferring to the team that should have responsibility for children on a CPP, and temporary allocation to a worker who then left. This is why the formal core assessment was delayed. The assessments of Mother and Father’s past history, and their general mental health, were undertaken as part of the core assessment. However there was some delay in undertaking specialist assessments of the parents and no formal mental health assessments were undertaken. 6.20 It was recorded in the record of a Core Group meeting in October 2012 that the parents were asked about where Father’s methadone was stored. They stated that they had a locked box in their bedroom. This is the only record of this issue being discussed. It was not clear in recordings if any professional asked to see the locked box or if it was confirmed with parents that the drugs were always stored there. However at the learning event the social worker who was involved towards the end of the timescale of this review confirmed she had seen the locked box in the kitchen. 6.21 The Safeguarding Family Resource Team (FRT)7 were involved and were undertaking a parenting assessment covering a range of topics such as children’s basic needs, safety, emotional warmth, stimulation, guidance and boundaries. The Agency Author for ChSC states in her report that ‘the outcome of the work demonstrated that parents engaged well with the 7 sessions offered. They had an understanding as to the importance of the emotional warmth children require and they ensured that age appropriate toys were available and had regular family outings. The children were seen and noted to present clean and appropriately dressed but were not given any direct work as part of the programme’. The FRT involvement contributed to the focus of the case shifting to one of parenting support rather than the required risk assessment, and the initial focus and expectations from the ICPC were lost. 6.22 The next months were difficult for the family as Mother was ill with her pregnancy, with severe sickness followed by issues with her pelvis (symphysis pubis dysfunction) which was very painful and made mobility difficult. This condition did lead to a number of requests / prescriptions for codeine over the course of the pregnancy. This did not appear to have raised any concerns however with those involved in managing Mother’s condition. A pre-birth assessment was referred to at this time in professional conversations, but the ChSC author did not find a specific document completed prior to the pre-birth conference, as would be expected. 7 FRT is a ChSC in-house support service providing time limited family support for families with existing social work involvement. 10 6.23 A Core Group was held on 7 November 2012. This was a significant meeting as there was a positive picture emerging of the children and the parents and no concerns were highlighted. This was despite school/nursery attendance being an on-going issue, and despite it being noted that Molly and Jenny had not been taken to appointments for their eyes. The positive nature of the information shared led to a decision being made that mental health assessments for Mother and Father were not required. This is despite the assessments being part of the CPP, and Father specifically requesting an assessment and help with his mental health before the ICPC in 2012. 6.24 The children continued to have high levels of absence from school and were often late. The parents blamed the children for the poor punctuality, saying that the children were slow, liked to take their time doing their hair, and so on. A pattern emerged of Father often being in bed when professionals visited. The excuses were that he was ill, or that he was being kept awake at night by Mother’s sickness. This does not appear to have been challenged or the significance of this included in assessments. 6.25 At the Core Group held on 3 December 2012 it was discussed that Jenny had attended the GP in regards to the concerns about her eyes and there were no issues. This was also recorded in the GP notes but a referral was made by the school health nurse to ophthalmology anyway, as Jenny had also failed the visual test at her school entry assessment. Jenny was not brought to the appointment when it was offered however. Molly was also referred to ophthalmology on 12.11.12 but the parents had not made an appointment through the ‘choose and book’ scheme for her to be seen. It is significant that Jenny was not seen by an ophthalmologist until 26 November 2013. The examination showed very reduced vision in her left eye. She needed a test for cyclo refraction (an eye test to check the health of the eye). The opportunity for correction of the eyes stops at age 7, and Jenny had missed 5 appointments in over a year. 6.26 This issue was discussed at the recall event and it emerged that the school nurse had challenged the parents about the lack of attendance, but they always had an excuse. She also persuaded the ophthalmologist to give another appointment, which was subsequently offered. This should also be seen within the context of poor attendance to ophthalmology appointments across the area, with Did Not Attend (DNA) rates at around 20%. 6.27 At this time the FRT parenting assessment had been completed and was positive. The family were said to have been working ‘extremely well’ with professionals, Father had been consistently engaged with his treatment programme (methadone), the new accommodation was a positive move and the Maternal Grandmother and Maternal Aunts continued to provide support. No further parenting work was thought to be required. 6.28 The core assessment was completed and circulated to Core Group members on 9 January 2013. It is described by the ChSC Agency Author as comprehensive and offering a good insight into the family. At this time there were no concerns for the children, they are said to be well cared for and happy. It was noted that school attendance remained an issue. 6.29 A Core Group was held on 16 January 2013. There is no evidence that consideration was given to the expected baby at this meeting. A further meeting was planned on 21 January 2013 however. It was agreed that an ICPC for the unborn baby would be held on the same date as the next review conference for Jenny and Molly. The relevant midwife was not in attendance at either meeting. The social worker contacted them after the meeting however and verbally shared the pre-birth assessment, which had concluded that the 11 couple were preparing well, engaging with relevant professionals and showed insight into the needs of a baby. 6.30 On 31 January and 3 February 2013 Father attended hospital with abdominal pain firstly and sore ribs on the second occasion. While there Father admitted to previous alcohol detoxification and said he was continuing to drink ‘small amounts.’ The doctors questioned if he had pancreatitis, which is a serious condition which can be due to excessive alcohol consumption. There is no confirmation of this diagnosis available to the review. However when the social worker visited on 4 January Father told her he had fallen on ice and cracked his ribs. 6.31 The only issue of concern at this time, as far as the professionals involved were concerned, was school attendance. On 4 February 2013 Jenny’s attendance was 54 ‘absent’ and 36 ‘late’ from a possible 184 days. This means she had only had full days at school around 50% of the time. The parents continued to blame illness for absences and the children for the poor timekeeping. 6.32 The RCPC on the older children and the ICPC on the unborn baby was held on 7 February 2013. During the meeting the health visitor pointed out that Father smelt of alcohol. He said that he had drunk beer the previous evening. This was dealt with during the meeting but was not included in the record of the meeting. During the learning event the chair acknowledged that it should have been. The decision was made to remove Jenny and Molly from a CPP and it was agreed that the unborn baby would not be made subject to a CPP at birth. All 3 children were to be subject to Child in Need (CinN) plans. The issues with school attendance were noted, as were the risks around Father’s ‘historical’ drug and alcohol misuse. The school had wanted the CPP to continue, but were persuaded to accept a CinN as long as supports for school attendance issues continued to be included in the plan. 6.33 This is a key practice episode because there was a lot of contact with the family and the children, and a positive view was held about the care of the children and the parent’s ability to parent despite historical concerns, particularly Father’s drug and alcohol use. Any assessment of the impact of a new baby joining the household; any meaningful engagement with the children; and any in-depth assessment of both parent’s mental health and Father’s relationship with alcohol at this time were not sufficiently pursued however. The continued concerns about school attendance were not thought to be enough of a concern to warrant a further CPP. Key Episode 3: from 27 March 2013 to 9 July 2013 6.34 Throughout this episode the family continued to receive support from ChSC while the children were on a CinN plan. The decision to continue involvement took into consideration the expected birth of a new baby. The parents stated their plan to continue working with agencies in the interests of the children. It had been agreed that after the birth of the baby a pre-discharge meeting would be held before the baby went home to ensure appropriate communication between professionals. Mother continued to have physical difficulties associated with being pregnant, but attended all ante-natal appointments. 6.35 Core Groups continued to monitor the CinN plan. On 13 March 2013 a meeting was held. The parents did not attend. Concerns about poor school attendance and Father’s drinking, including ‘social’ drinking during the day were discussed. On 19 March 2013 the social worker visited the family and noted the children were home from school due to vomiting. 12 The social worker noted they did not seem unwell however. It is also recorded that Father had a facial injury that he said was due to him falling from a bike. Otherwise there were no concerns about the children or the home at the visit. 6.36 The same day Father attended hospital in regards to the bike fall. A fracture was diagnosed which required surgery. While at the hospital Father disclosed that he was drinking a bottle of vodka and 8 cans of lager a day. It is not clear from the documentation that the hospital was aware that Father lived with his partner and children. The operation was undertaken two days later. The information about the extent of Father’s drinking was not shared with other professionals. 6.37 Emily was born at 36 weeks, Mother was accompanied by Maternal Grandmother and Father at the birth, although Father missed the birth of Emily. It is documented by the midwives that Father appeared to have been drinking, and was clearly intoxicated. It is speculated that this is why Grandmother was upset with him. Grandmother confirmed to the lead reviewer that father had been drinking heavily in the lead up to the birth and continued to drink on the delivery suite. He was swigging from a soft drink bottle which was filled with vodka. The following day the social worker visited the hospital and discussed with Father his drinking the day before. Father stated he had drunk 4 – 5 pints of lager but was not drunk. Mother stated that Father had appeared drunk as he had been using her gas and air. The social worker stated that Father was not to have sole care of the children while Mother was in hospital due to concerns about his drinking. Grandmother and maternal aunt agreed to look after the children. There is no evidence that Grandmother was asked about the incidents on the ward, which might have elicited the information about the extent of Father’s drinking which does not appear to have been shared. 6.38 Appropriate verbal information sharing took place around the birth of Emily. There is evidence that the ward sister shared information on the telephone with the ‘out of hours’ service which covers emergency ChSC duties on evenings and weekends8. This includes the information that Grandmother had passed on to staff on the ward that Father had drunk a litre of vodka and 8 beers the day before attending the birth and continued to drink on the delivery suite. Grandmother had also stated that Father regularly drank excessively and spent around £190 per fortnight on alcohol. This information was not shared with the allocated social worker or any other members of the Core Group however and it has been identified that there appears to have been an issue with the level of detail recorded by the ‘out of hours’ staff which was relied on by all concerned. However the detail of the concerns was not discussed at the pre-discharge meeting held at the hospital. Dad’s drinking had been discussed, but the detail of the financial impact and the exact amount and type of drink does not appear to have been made explicit. It is also noted that the health visitor did not appear to be invited to this meeting. 6.39 The social worker visited the family the day after Mother and Emily had returned home from hospital. There was also liaison between the health visitor and social worker where concerns about the escalation of Father’s drinking were discussed. Neither was aware of the self-reported extent of the drinking however, or the detail of Grandmother’s allegations. The health visitor also discussed the case in her supervision and she voiced her concern about Mother’s ability to protect the children from the impact of Father’s drinking. 6.40 The social worker visited the following week and had no concerns. The health visitor visited the following day for the primary visit to Emily. She attempted to discuss what had 8 Out of hours cover in Middlesbrough is provided by a Tees-wide Emergency Duty Service. 13 happened on the delivery suite but Mother was only keen to say that Father had been very helpful with the children since Emily’s birth. 6.41 In the weeks that followed the birth of Emily there were no further concerns identified about Father’s drinking. The baby appeared to be thriving, and other than on-going issues about school attendance the older girls were thought to be happy and well looked after. On 30.4.13 the allocated social worker visited and informed Mother that the case was to be reallocated as she was leaving. She explained the on-going concerns about Father’s drinking and school attendance, and reinforced to Mother the need for her to continue working with professionals. 6.42 On 3 May 2013 Emily was seen at the clinic and was described by the health visitor in attendance to be ‘jittery’. A family history of epilepsy was reported and recorded. However no further action was taken in regards to this concern. The allocated health visitor remembers discussing this when she went to the family home on 22 May, but this was not recorded. 6.43 A new social worker was allocated and visited the family on 20 May 2013. Again the two main concerns of Father’s drinking and school attendance were discussed. Father said he would drink a few pints with a family member on a Tuesday night, but that was all. The worker said there was a faint smell on Father of what could be alcohol. Father said it was prescribed mouthwash for his gums. There were no other concerns identified at the visit and all of the children seemed well and well cared for. There is no record that Father’s GP was contacted about the prescribed mouthwash. Mother’s GP confirmed during this process that it was highly unlikely that an alcoholic would be prescribed with a mouthwash with alcohol in it. 6.44 A CinN meeting was held on 4 June 2013. An issue was identified with Father taking his methadone at 6.30 am which made him drowsy unable to help with getting the children ready for school. It was agreed that the new social worker should talk to Father’s prescribers about this. School continued to be an issue, with the parents giving constant illness as an excuse for Jenny and Molly’s low attendance. An attendance management meeting was held and the school were planning to provide additional support to get the children to school, including a PSA (family support worker within the school) ringing each morning to wake up the family. 6.45 Father was admitted to hospital on 12 June 2013 after receiving severe dog bites on both arms. He told the doctors that he had been bitten at 6 am that morning trying to stop a dog biting a child. There does not appear to have been any attempt to establish who the child was, which is potentially poor safeguarding practice at the hospital. However the children’s social worker did discuss the incident with Father later, and he stated ‘what if there had been a child there?’ So there may have been a misunderstanding about what Father has said at the hospital. Father later went missing from the ward. He was readmitted the following day but was ‘wander some.’ He then left the hospital late that evening saying he was going home. He returned in the early hours ‘intoxicated’. There is no record this information was shared with any child care professionals. 6.46 Emily was taken to A&E by both parents with a high temperature on 24 June 2013. After being observed on the paediatric day unit she was diagnosed with a viral upper respiratory tract infection and discharged home. Mother later reported it had been suspected meningitis. 14 6.47 On 9 July 2013 a call was made to Cleveland Police to state that Father had threatened an unknown woman with a knife. ‘Words of advice’ were given to Father. This information was not shared with ChSC at the time. 6.48 This is a key practice episode because concerns regarding Father’s drinking remained, although the opportunity to establish just how much he was drinking was missed. Grandmother’s report of the extent of his alcohol abuse was shared verbally with the service providing ‘out of hours’ cover for ChSC, but this was not adequately communicated to the allocated social worker or health visitor and was not put in writing by maternity ward staff. Father’s self-report to the hospital after the bike accident was not shared with any child care professional, and no professional working with the children sought information on Father’s injuries from the hospital. Key Episode 4: from 30 August 2013 to 1 January 2014 6.49 A plan to close the case to ChSC on 30 August 2013 was made as it appeared that Father was managing his drinking and the three children were doing well in the care of their parents. The exception to this was school attendance remaining of concern and some question about attendance at medical appointments regarding Jenny and Molly’s eyes. 6.50 The health visitor saw the family on 9 August and was informed that ChSC were closing the case. While visiting the health visitor was made aware that Emily was being given baby food, although her diet should have been just milk at 19 weeks old. The health visitor recorded her plan to request that the case remained open to a social worker until there was a pattern of full engagement with education. The health visitor made this request, and a compromise was agreed, with the case remaining open until September when the older children returned to school. 6.51 Mother was arrested for theft of an inexpensive item of baby clothing in August 2013. She later reported it had fallen into a fold on the top of the pushchair and she had intended to pay for it. She was given an Adult Caution. At this time it is evidenced that mother was still receiving prescriptions for a relatively large amount of codeine. 6.52 In November 2013 another parent at the school shared concerns that Father was drinking heavily, taking pills, and that there was domestic violence in the household. Later in the month Molly told her teacher that Father stays in bed and drinks ‘mucky beer’. She said that her Mother had told him to stop drinking ‘but he won’t’. The school discussed the concerns with Mother who stated that Father has now stopped drinking and was doing well. 6.53 Around this time the school had concerns about Mother’s relationship with Molly, who she was often very negative to and about. On one occasion when appearing exasperated with Molly, Mum stated that children ‘need Ritalin’. All of these concerns were referred to ChSC who undertook a visit on 6 December 2013. The visit was undertaken at 9.00 am and the social workers woke the family up when they arrived. It was a very difficult visit and Mother was very angry. She left the home at one point to go to the school to complain. The social workers concluded their visit reassured that Mother had calmed down, that Father did not appear to have been drinking and that the children appeared well cared for. Molly had said during the visit that Father no longer drinks the ‘mucky beer.’ It is not clear if the concerns and conclusion of the visit were shared with other professionals working with the family, such as the health visitor. 15 6.54 On 10 December 2013 Father attended his GP surgery intoxicated with slurred speech. A week later he told the addictions nurse at the GP surgery that he had relapsed and taken some heroin the week before. This was not shared with any child care professional. 6.55 On 7 January 2014 Emily was taken to A&E with ear pain and a high temperature, she was diagnosed with an ear infection. She was admitted to the paediatric unit and later discharged with antibiotics. The following day she was brought to A&E by ambulance after being found at home unconscious and cyanosed. She was later diagnosed with methadone intoxication. 6.56 This is a key practice episode because further information was available about Father’s use of drink and drugs, this included Molly making clear allegations about what was happening at home. Although her concerns and the other allegations were discussed with the parents, they were able to reassure social workers that there were no concerns. In regards to Father’s relapse, information was not shared appropriately. 7 Analysis by Theme 7.1 From the information extrapolated from the agency reports, from the discussions at the learning events, and from the meeting with Maternal Grandmother several themes have emerged. These can be summarised as: • Communication and information sharing • Assessments of drug/alcohol abusing parents, including their mental health • The challenge of working with parents who are manipulative or show disguised compliance • The risks to children when a parent is on a methadone programme • Supporting staff undertaking complex case work • Thresholds for CP Plans Viewed from a systemic perspective it is apparent how these themes influenced and impacted on each other and led to the circumstances which are the reason for this review. Communication and Information sharing 7.2 Working Together to Safeguard Children (DfE 2013) states; ‘Information sharing between professionals and local agencies is essential for effective identification, assessment and service provision.” This review has identified several aspects with communication and information sharing that are significant to the management, if not the outcome of the case. There are examples of good practice and areas which require improvement. 7.3 It was acknowledged at the learning event that there were a large number of people involved and that the case was relatively complex. Information sharing between those providing services for the children was relatively good, with regular communication between the school and the health visitor, between the health visitor and the school nurse and between the social worker and the health visitor and school nurse with the exception of the, albeit received late, information about Father taking Molly for her inoculation while smelling of alcohol. 7.4 Issues were identified in the communication between the ‘out of hours’ service for ChSC and daytime professionals. While the information was shared that Father was drunk when Emily was being born, the information about the amount and type of alcohol Grandmother 16 had alleged that he regularly drank was not shared. This was a significant oversight. It is also noted that although her midwife at her booking in appointment was told by Mother that her children had a social worker, there was no communication between that midwife and the social worker or health visitor. The Agency Author states that the midwife showed little professional curiosity about the circumstances of the child protection concerns. It should also be noted that the social work and health visiting staff did not directly contact the safeguarding midwife in a timely way. 7.5 The lack of communication in regards to the information Father shared with various health professionals is also of concern. Before the birth of Emily Father told staff at A&E that he was drinking a substantial amount of alcohol on a daily basis. He also told his GP that he had used heroin shortly before the serious incident in January 2014. These facts were not shared with professionals working with the children. Other issues were identified with the written information sharing from Father’s GP practice to the CinN meeting in May 2013. It did not mention information received from the specialist safeguarding lead midwife and the alcohol concerns regarding Father. The GP practice specialist nurse who wrote the report stated that she had assumed that the information would have been shared with ChSC directly. This should not be assumed. The GP for Mother, when asked about the prescribing of codeine, stated that he was not aware that Father was on a methadone programme. This was of concern as full details of the children’s child protection plans were available on the GP records. At the recall event the group discussed how unrealistic it is to assume that all the GP’s in a practice will have read CPC minutes, and this needs to be taken into consideration when communicating with them. 7.6 Some of the learning identified in the agency report for the GP practice for Father was in relation to the value of staff from that agency attending CP conferences, and not just writing reports. It also identified the need for improved information sharing within both of the GP practices, and the awareness that just writing or placing something in a patient’s notes is not an adequate or effective way to share information. 7.7 Good practice was also identified with regards to information sharing from the specialist drug worker at Father’s GP practice at the time of the ICPC. A full and clear report was submitted to the ICPC which outlined all of Father’s known past and present use of substances. It included an analysis of how his parenting would be impaired by his drug use and drinking. The children’s GP did not mention in their report for a review conference that Father had attended with Molly mid-morning smelling of alcohol however. 7.8 Issues were identified with information sharing between ChSC and the IRO team which may in part be because of the difficulties with the IT system at the time. This led to the IRO who chaired the ICPC not being aware of the previous assessments undertaken on the children before the concerns emerged that led to the conference. The IRO recognised that he relies on what information professionals bring to the meeting to ensure he gets a full picture. He remembered thinking it was unusual for a case to come to ICPC without any previous referrals/contacts. 7.9 An issue was identified in this case and others with the attendance of key people at conferences. The IRO stated ‘if we are going to spend time and money on a children protection conference, the right people need to be there’. He is right. The obvious people missing from the meetings were Grandmother, a representative from Father’s GP surgery, and a professional from drug and alcohol services who would bring specialist knowledge and challenge to the meeting. It has been identified during this process that staff made 17 assumptions about the services offered regarding drug and alcohol issues at the GP practice that were incorrect. 7.10 High caseloads also restricted the amount of time that conference chairs could spend interrogating the IT system in regards to past or on-going work with families. Improvements in staffing levels and planned improvements to the IT system mean that this should be less of an issue in the future. This has also enabled improved systems for communication between IROs and SWs before and between conferences. 7.11 The children did not attend a number of health appointments both before the timeframe of this review and over the years that we have reviewed in detail. There were a number of DNA’s or failure to respond to requests to make appointments with the Ophthalmology Department. This information was not always reported in a timely way. In order to ensure that vulnerable children’s health needs are met information regarding missed appointments need to be shared with the key professionals (most likely to be those on the Core Group). In the case of Jenny’s eyes, her long term heath and development may have been impacted on by the ineffective responses of her parents to the issues identified and the health appointments made. 7.12 Other issues were raised regarding the delay in sending reports, such as the neglect medical reports, and the lack of evidence that minutes/updated plans were being sent out from Core Groups. The SCR was informed however that the newly commissioned ChSC I.T system will help to ensure more efficient recording and distribution of core group minutes and CP plans. 7.13 Lessons learned: • Good communication and information sharing is essential in all safeguarding work, particularly between services for children and adults where there are identified potential parental risk factors. When considering what ‘good’ looks like, it is important that staff understand that they need to share the right information and detail to ensure other services are not overwhelmed. • Professionals need to ask exactly what services are being offered and provided to service users, and not make assumptions about what those services offer. • For a child protection conference and subsequent plan to be effective the right people need to be present and consulted. Assessments of drug/alcohol abusing parents, including their mental health. 7.14 Two initial assessments were completed in 2008 and 2010 after concerns had been brought to the attention of ChSC. The assessments were completed following home visits and conversations solely with mum. These assessments were superficial and were not child focused. They did not involve Father and were limited in their consultation with other professionals, particularly adult services. The assessment undertaken in 2010 did not appear to take into consideration information from the previous referrals, and no pattern was identified. 7.15 The response to the referral from the health visitor regarding Maternal Grandmother’s concerns in 2012 was appropriate and the decision to remove the children and Mother from the house on the evening of the visit from social workers was a good and proportionate one. The Agency Author for ChSC states ‘asking Mother to move with the children would have ensured the workers had time to fully assess the situation, determine 18 the course of action relevant to family need, and afforded the children some familiarity with them going to stay with their grandmother’. The decision to hold an ICPC after Mother returned with the children to live with Father was also appropriate and made in a timely way. The agreement made with the parents for the children to remain with Grandmother until after the conference, with any contact being supervised, was child centred and protective. It was identified that the placement with Grandmother was not made in any formal way, and the Agency Author has reassured the review that the current legal position with regard to the Connected Person’s Policy would mean that the children were placed with Grandmother as Looked After Children. Grandmother told the lead reviewer that she had not received any financial support and that she would not have been able to provide longer term care without such support, due to having to take time off from her work to care for the children. 7.16 The decision to make a referral of the case to Families Forward was a good one. The service could potentially have provided a structured and relevant assessment of the risks to the children in this family. However the 72 hour assessment undertaken decided the criteria for the service was not met as the family were not deemed to be in crisis. The ChSC agency author is right in saying that this was ‘a missed opportunity given the length of time Father was using substances and the addictions nurse’s assessment that it would be impacting on his parenting. It was therefore a poor and flawed assessment.’ The Families Forward work would have provided work on addictions but also on the parent’s co-dependent relationship. Mother’s loyalty to her partner was evident from the emergence of the initial concerns and their relationship and the impact on the children was never explored in detail or challenged as necessary. The agency representative for Families Forward who attended the learning event assured the review of changes to their service and said if the family had been referred at the same stage today that they would meet the criteria. 7.17 It is clear that the expectation of the IRO chairing the ICPC was that the assessment to follow the making of CPPs would include a capacity to change assessment of the parents, and that an assessment of their mental health and drug / alcohol use would be included as part of this, with specialist input. This was included in the written record of the meeting as a recommendation for the CPP. The CPP however included a parenting assessment of the parents. This is a subtle but significant difference. The assessment concentrated on care of the children, both physical and emotional, and the parents engaged. It was agreed at the learning event however that this FRT assessment was inadequate, it had no multi-agency input and it did not explore the family’s values and culture around drink and drugs. The assessment reinforced the positives and added to the general optimism that was developing about the family without providing the challenge and scrutiny of parental risk factors that was required. 7.18 The core assessment involved the analysis of information from the parents own history’s and included details of Father’s past alcohol and drug use, and his version of his current use. This was completed with an underlying positive regard for Father who was known to be in treatment and slowly reducing his methadone. His drinking, while of concern, was thought to be largely managed and on a ‘social’ level. At her visit on 8 November 2012 the social worker completed an alcohol screening tool with Father and he was said to show good insight into his previous alcohol use. This was around 4 months before Father disclosed to staff in A&E that he was drinking a bottle of vodka and 8 cans of beer a day. There was no evidence available to ChSC at this time that Father’s drinking had become a significant issue however. What was not acknowledged at the time was that with his history Father 19 should not have been drinking at all. The impact of Father drinking was underestimated and his claim to have 4 or 5 pints once a week when going out with a member of his family should have been explored further and challenged. 7.19 Mother often made excuses for Father’s drinking and minimised how much and how often he used alcohol. At other times however she alluded to the conflict between them as a result of his drinking and the impact it had on the support he was able to give with the children. This was never properly pursued with her. There was evidence, and it was confirmed at the learning event, that there was a degree of professional disbelief that Father had gone from having a serious alcohol problem to being a social drinker, but there was inadequate exploration and challenge to back up this scepticism. Issues with information sharing in relation to Father’s drinking did not help, but the information that was shared was not used appropriately. The GP report for the RCPC in February 2012 clearly stated that Father having any alcohol intake would be of concern to the GP. To quote the agency author from South Tees NHS Foundation Trust ‘not only was Mother minimising Father’s issues with alcohol, there was evidence that so were professionals. Father smelt of alcohol at various times…including during the RCPC, and this does not appear to have made health professionals wonder what was happening day to day for the children.’ 7.20 A local issue identified is the difficulty of getting an appropriate assessment of parent’s mental health and its impact on parenting without paying for this privately. The social workers reported spending hours trying to access the appropriate mental health services which are required for the parents of their clients. To find a service which will provide an assessment of the impact on parenting of mental health issues is very difficult, but much needed in the area. This was also identified in a thematic government inspection of the relationship between children’s services and adult services for parents with mental health or substance misuse issues undertaken in Middlesbrough in 2013.9 7.21 The drug and alcohol service that Father was engaged with at the time was a GP prescribing service, not a full treatment service which helps patients shift from maintenance to recovery. The childcare professionals involved did not necessarily understand this and thought that Father’s engagement with the service was more significant than it was. The service basically provided him with his methadone and undertook testing to check he had not taken heroin in the timescale covered by the test. It does not appear to have provided any more than this. Father did not take advantage of any other services that may have assisted him in identifying the underlying issues and worked with him on his addictions. 7.22 There was little exploration of violence within or outside of the home in the assessments undertaken. There was evidence that both parents had the capacity for violent confrontation. In relation to Father, over and above his criminal record there were allegations of domestic violence towards his partner (unsubstantiated by her) and an incident reported by Maternal Grandmother that he had picked up a fence post and threatened violence with it. In the case of Mother there were counter allegations that she had assaulted her partner and one particular incident where, in the presence of the social workers, she stormed into the children’s school and sought a confrontation with the staff. 7.23 Mother’s use of codeine did not appear to be an issue that was acknowledged at the time. With hindsight the review was made aware that this was a significant issue, as Mother has 9 As part of this thematic inspection Ofsted inspected 6 local authorities looking at the links between adult and children’s services where children are living with parents with either a mental health problem or substance misuse. 20 since sought support for her codeine and other drug addictions. However it was known that she had an addiction to Iron Bru and she admitted to drinking around 2 litres a day. 7.24 While extensive assessment work was undertaken with the family, it is the view of those involved that the wrong type of assessment was completed. There had not been any concerns about the presentation of the girls; they had always gone to school well dressed. There was also evidence that the children were given affection by the parents and they appeared to be loved. There was good family support from the maternal side of the family. As reflected at the learning event, if staff were asked which of their cases were most likely to end up in a Serious Case Review, these children would not have stood out. 7.25 A disproportionate amount of credit was given to the parents for their clean home and well dressed children, their statements of commitment to the children, and their superficial willingness to work with professionals. What didn’t happen was an assessment of the parents true dependence on substances including alcohol, about the ability of the parents to change in regards to their addictions, an exploration of their co-dependent relationship, and their underlying mental health issues, all of which were likely to have a negative impact on their care of the children. It is important to not just focus on the practical care of the children, but to consider their care in a fuller sense by looking at the consistency of their care, including meeting their health needs, getting the children to school on time, and the wider impact of Father’s lifestyle on the children. 7.26 It has been identified during this review that there was a lack of direct work with the children, and although professionals described the children in detail in their recording, the children’s voices were not clearly sought or stated. It was not known what it was like for the children living with their parents. A number of professionals spent time with the children, but didn’t speak to them to explore their view of the known parental behaviours, including Father’s drinking and the amount of time he appeared to spend in bed. 7.27 The lack of a thorough pre-birth assessment in this case was noted. At the learning event it was discussed and all those present felt that if a family with children on a CPP are expecting another child, a full pre-birth assessment must be completed on that child, which also considers the impact on the rest of the family of a baby joining the household. In this case this was not entirely considered, with the families practical preparations for the new baby reassuring professionals that all would be well. 7.28 By the time the first RCPC was held the family were being seen and presented in a positive light. The IRO told the learning event that the first RCPC is seen by his team as an opportunity to take the temperature of a case. In Middlesbrough it is reported to be very rare for children to be taken off a CPP at this stage. It was clear to the IRO that by the first RCPC that family were working with professionals and doing well, and that the care of the children was not of concern. However it was clear that no capacity to change work had been undertaken and that the core assessment had not been completed. 7.29 The reviewer was told that there is a degree of pressure to get children off a CPP after 2 reviews have been held. Local Authorities are measured on the length of time a child remains on a CPP and IROs are aware of this. In this case Jenny and Molly’s CPPs were discontinued at the second review, despite the imminent arrival of Emily. Having considered this the IRO stated at the learning event that he now always considers making an exception to this practice when a new baby was about to join the family, due to the pressure that this can place on the situation. 21 7.30 The Core Group stated that they were being pragmatic in regards to the decision not to pursue Father’s mental health assessment. With very few resources available locally, lack of knowledge in regards to the seemingly complicated pathways to access such assessments, and Father appearing more stable psychologically, the decision was made that the assessment would not be pursued. There had been a delay in receiving the medical notes from both Mother’s and Father’s GPs. The lack of any current mental health concerns emerging from the medical notes also had an impact on this decision. Soft intelligence was missed about the likelihood that users reducing methadone levels will often rely more heavily on alcohol. Father’s binge drinking, with the accompanying impact it had on his appearances at A&E, was not grasped as representing a significant setback in the families coping capacity. His drunken and abusive behaviour at the hospital at the time of Emily’s birth in January 2014 was a good indicator that he was placing his addiction before the welfare of his family. 7.31 The optimistic view of the family increasingly held by professionals had an impact on the assessments undertaken and the decisions made. Both parents were said to be likeable and professionals believed they were doing the best for the children, with the exception of the school staff who believed that the lack of parental concern about school attendance and punctuality was harmful and who struggled to work with the parents. An analysis of disguised compliance and manipulative behaviour in this case is provided below. However it should be noted here that professionals around the table spoke of the difficulty in moving from a good opinion of a family or individual when new concerns emerge. This helpful quote was provided by the South Tees NHS Foundation Trust author ‘One of the most common, problematic tendencies in human cognition…is our failure to review judgements and plans. Once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’10 This appears to have been the case here. 7.32 The learning event identified that there had been a number of different social workers involved with the family. The handover process can offer a useful opportunity for the new worker to test and challenge what has gone on before. At the learning event the social worker who took over the case from the date of the ICPC remembered being told by the previous worker that the family were nice, that they had had a hard time and were vulnerable, but that the children were doing really well. Father was also said to be stable and they said that they didn’t see the case remaining of concern for long. The fact that the case was held by predominantly newly qualified social work staff brought with it inherent dangers that the optimism of the previous worker would be transmitted to the next one. 7.33 There is no evidence that Father was asked about or tested for using any substances other than heroin and cocaine. It is also significant to note that the tests that were undertaken would only show drug use for the previous three days, and that this was not clarified by the core group at the time. The review shows that Father, and possibly Mother, are likely to have been using other drugs (including alcohol) throughout the timeframe of the SCR. With hindsight it is clear that the substance that actually caused serious harm to the children, methadone, was never seen as a risk in this case. Father’s commitment to his treatment, his good attendance and clean tests for heroin led to a belief that drug use was not an issue for this family. Father was tested monthly while the children were on a CPP and six-monthly otherwise. 10 Fish, Munro and Bairstow ‘Learning Together to Safeguard Children’ 2009 22 7.34 At the recall event it was agreed that the professional network believed, on the whole, that Father’s commitment to his methadone programme was a good thing and a protective factor for the children. There was no challenge or understanding of the length of time he had been receiving the medication, and the risks this would potentially pose to the children both directly or indirectly. 7.35 A report received for this review from the organisation that was commissioned to provide alcohol services until 2012 stated that while Father’s alcohol misuse was seen as problematic for him, the impact of this on the children in the house was not fully considered and acted on. Even when the assessments undertaken did raise concerns for the children these were not followed up with other services. Although it was outside the timeframe of this review, this pattern continued into the period we have considered. The impact of Father’s non-engagement with the alcohol treatment service followed by his admission of increasing alcohol use over the 3 years of their involvement was never considered to be escalating the risks to the children. Action taken for non-engagement was to discharge Father from the service and inform his GP, who also did not consider the impact of this lack of cooperation with alcohol service on the children. 7.36 There are a number of examples where information in regards to Father was not shared appropriately with services involved with the children. There appears to be a lack of ‘think family’ in some key areas and a lack of consideration of Father having children, children who were living with this man with numerous issues of his own to contend with. While reports and assessments stated that parents were engaging well, what became evident during this review was that Father was rarely seen by health professionals working with the children. 9.37 Father was more honest with professionals working with him alone, like the staff in A&E, to whom he confessed he was drinking large amounts of alcohol. It is a challenge to put in place robust and consistent information sharing from adult focused A&E staff to professionals working with children, particularly when the question of who the patient lives with is not routinely asked. 7.38 It was not acknowledged, when talking to Mother about the children, Father and her own issues that Father was regularly upstairs. This would have had an impact on how candid she could be in regards to the impact on the children of his drinking and methadone programme. Mother would regularly minimise the concerns and say Father was doing well. There did not seem to be any attempt to meet with her alone outside of the family home to ensure she could not be overheard by Father. 7.39 Lessons Learned: • Over optimism among some of the workers who engaged with the family led to the view that the parents had the capacity, capability and motivation to improve and maintain the quality of the care that they provided to their children. Professionals must challenge the rule of optimism and test perception against the wider information that is available. • Assessing the impact on parenting of mental health or drug and alcohol misuse is an essential requirement when working with parents with these issues. This work needs to be challenging of parents and child centred. • Professionals need to be aware that negative drug tests do not mean that a service user is drug free, it only shows that they have not used the specific drugs that they were tested for during the previous three days. 23 • It is important to work directly with the children. Observing and describing the children is not the same as speaking to them and ensuring their voices are heard and recorded. The challenge of working with parents who are manipulative or show disguised compliance. 7.40 ‘Disguised compliance’ is a term that can be attributed to Reder, Duncan and Gray11 It involves a parent or carer giving the appearance of co-operating with agencies to avoid raising suspicions, to allay professional concerns, and ultimately to diffuse professional intervention. At the learning event it was clear that in this case both parents had adopted this stance as a way of avoiding and placating the agencies who had voiced concerns about the children. They became skilled in manipulating professionals and were successful at avoiding any real challenge throughout the scope of this review. 7.41 In some cases parents may use anger and aggressive behaviour towards professionals so that they feel unable to carry out home visits effectively and cannot adequately check on the care and safety of children. Professionals were able to engage with the parents without challenge or hostility in the most part, however they were often described as ‘angry’ when challenged about the lack of school attendance. At the first visit in this period both parents were very angry, and Father was so agitated that the social workers feared for the safety of the children that night. Staff at the learning event said they did not feel intimidated however. It was only the school staff who had on-going concerns about his anger. They also reported that Mother was feisty, defensive and often aggressive. The social worker who took on the case and completed the core assessment reported that the previous social worker had said that she felt the school ‘had it in for the family’ and that this was not justified. 7.42 In the most part there was a reported perception that the family had nothing to hide and this feeling was reinforced by the parents’ attitudes even at unannounced visits. The perception that the parents were seeking to comply with services and undertake positive change in their capacity to care effectively for the children was not held by professionals alone. Maternal Grandmother, who had first alerted services to the risks, is reported at Core Group meetings as describing how Mother and Father were showing positive changes in their behaviour, and that her fears for the wellbeing of the children were allayed. When the lead reviewer met her, Grandmother stated that Father was very good at playing the innocent party in all areas. She said she understood how professionals would have ‘the wool pulled over their eyes’ by him, as she had too. She believed the children were scared of him and didn’t dare to tell anyone what was happening at home. She said that even if they were spoken to alone they would not have said anything, due to a combination of loyalty and fear. 7.43 Although he was often upstairs, the social workers, other staff undertaking home visits and the FRT workers completing the parenting assessment felt they knew Father well and that they had enough opportunity to discuss the children with him. He was said to be ‘likeable’ and appeared open about his history. With hindsight it is clear that he just engaged on his own terms and only shared the information he wanted staff to know. He was not seen as manipulative at the time however. His disguised compliance, avoidance and use of anger and intimidation on occasion show he was skilled at deflecting and diffusing concerns. When he was known to have been drinking he would be repentant. Mother was seen to be 11 Peter Reder, Sylvia Duncan and Moira Gray in ‘Beyond blame: child abuse tragedies revisited’ (1993). 24 realistic about her partner and protective of the children. It was the view of professionals that the family were being open and honest. With hindsight it is clear they were not and it raises the very real issue in cases of this type that professionals need to keep a healthy scepticism regarding what they are told and what they observe. 7.44 A report published by ADFAM in 201412 which is extensively quoted below outlines the dilemma for staff working on cases like this one. They recognise the significant quandary for children and family support services, where staff who are motivated to work in this field by their desire to bring about positive change for families, must check themselves to test that the good they see in people is a reality. The theme of optimism and disguised compliance generated a useful discussion at the learning event. Police and Drug Treatment representatives described a more cynical approach in their willingness to trust individuals they come into contact with. This cynicism was often borne out of considerable experience of clients being dishonest or evasive. There is therefore a delicate balance to be drawn between being overly cynical and recognising the potential in individuals to make positive life changes. It is important that families experience optimism from workers who support them to help them to believe that they can tackle the complex problems they face in their chaotic lives. However, this should not be at the expense of a naive trust. Professionals must draw upon all the information that is available to them to challenge themselves and others to ensure that children are living in caring and safe environments. 7.45 It was acknowledged at the learning event that the parents had been skilled at ensuring that professionals were not aware of the drug and alcohol use in the home, the domestic abuse and the general lack of routines. The fact that Families Forward, who are experienced drugs workers, did not recognise the degree of disguised compliance used by the parents is significant. Many of Father’s stories and explanations that were accepted at the time are suspicious now that we are aware of the on-going use of drugs and alcohol. The amount of accidents he had, and how unlucky he seemed getting injuries from slipping on ice, falling off his bike, and being bitten by dogs. All should have made professionals question his lifestyle and sobriety. The family were seen as unlucky and victims rather than chaotic and manipulative. 7.46 The signs of disguised compliance were there at the time. The indifference displayed by the parents in getting the children to school either at all or on time served as an indicator that parents were not making the progress that was required of them, and that they were not heeding professional advice. The school showed tenacity in challenging the parent’s behaviour in this key aspect of their children’s lives, but it was not enough to effectively change the perceptions of others. Father would also often not come downstairs when professionals visited, and as he was not asked to come and join the meeting how he appeared was not considered. When he was seen he was engaged and appeared well. As pointed out in the ChSC report, ‘this could imply that he was choosing when to make an appearance and therefore mask his true behaviours’. What was missing was a consistent robust challenge between professionals to test out beliefs and perceptions, with the mechanism in place to detect key changes in behaviour and the consequent implications for the wellbeing of the children. 12 Adfam is a national umbrella organisation working to improve the quality of life for families affected by drugs and alcohol. 25 7.47 Lessons Learned: • Professionals need to be curious and not accept things on face value. • Professionals must be prepared to challenge their own as well as others’ views, and need support to regularly review cases in a way that encourages staff to question if over-optimism, disguised compliance or avoidance of issues is playing a part. • IROs have the potential to provide an essential independent view to consider if professionals are over optimistic, or if parents are being manipulative and disguising their lack of compliance. To provide this crucial role they need the right information available, including up to date chronologies. • All professionals working with children and families need to be trained and supported, to include the provision of reflective supervision, in the identification and challenge of parents who use manipulation and disguised compliance, to ensure the needs of the child remain the priority. • Schools generally know the children well and their views should always be listened to and considered in assessments and planning. • In order to have the required time to reflect and analyse professionals need effective administrative support, manageable caseloads and effective supervision. The risks to children when a parent is on a methadone programme. 7.48 In 2003 it was estimated that between 250,000 and 350,000 children in the UK were affected by parental drug use. By 2009, a reported 120,000 children were living with a parent currently engaged in treatment and data collated in 2011-12, indicated that 60,596 adults with an opiate problem had parental responsibility and were receiving a prescribing intervention13. Information received from Public Health in Middlesbrough shows that 2600 people are in drug and alcohol treatment in the town and 50% of them have children. 7.49 This SCR has been helped by close reference to a study entitled ‘Medications in Drug Treatment: Tackling the Risks to Children’ which was published by ADFAM in 2014. The report is an in depth study of a number of cases where children have died or been harmed from ingesting Opioid Substitution Treatment (OST) medicines, including methadone. The report includes a consideration of the 17 Serious Case Reviews involving the ingestion of OST drugs by children in the five years from 2009 until 2014. 7.50 The report is very clear that there are risks to children if they are living in households where methadone is used and stored. It states that Methadone is ‘toxic, powerful and a clear danger to children when stored or used incorrectly by their parents and carers’. The report is clear that methadone in particular, ‘poses a significant risk to children and other opioid naïve people’. 7.51 There have been at least 17 fatalities and 5 non-fatal ingestions of OST medication by children during the period looked at in the ADFAM report, the majority of which were methadone ingestions. They state that ‘these figures are of necessity underestimates and exclude ‘near misses’ or incidents that failed to culminate in a serious case review for which there is no data publicly available’. Most of the cases were thought to involve the accidental drinking of methadone by children able to help themselves to the drug. In five of the cases however it was clear that the parents had intentionally given the drug to the 13 Chandler et al (2013) ‘Substance, structure and stigma: parents in the UK accounting for opioid substitution therapy during the antenatal and postnatal periods’ 26 child. In six other cases it was not ascertained how the child had ingested the drug. 7.52 A number of the serious case reviews undertaken into cases like this one have analysed the practice of giving children low doses of methadone or other drugs with the aim of sedating or pacifying them. The ADFAM report states that ‘parents may have a number of ill-informed or incorrect motivations or beliefs relating to this practice, for example that children can cope with smaller doses of a prescribed medication which is used widely and safely by adults’ and that ‘it is a similar principle to other poor parenting practices which use substances to pacify children, like dipping a baby’s dummy in whisky to help them sleep.’ It is noted in this case that Emily had been seen the day before her overdose at the hospital with an ear infection which would have made her fractious and hard to settle. 7.53 The ADFAM report found that in cases where parents deliberately gave their children drugs, ‘professionals involved with the family are unlikely to account for this possibility.’ At the learning event professionals who knew the family said that it did not occur to them that either parent would give drugs to the children. Their shock and disbelief that this may be the case was evident and understandable. 7.54 Other SCRs considered in the ADFAM report have noted the following findings which may be relevant to this case: - ‘Whilst all agencies were vigilant in monitoring for neglect or harm in respect of the child, no assessment had been carried out to mitigate the risk of him actively being given prescription drugs’ (Bradford LSCB) - ‘None of the professionals involved with the family had foreseen the possibility of either child being given methadone by one or other of their parents’ (Bristol LSCB Child K) - ‘It is suggested that practitioners acknowledge to themselves and service users that there are occasions when parents deliberately administer drugs, including methadone, to their children’ (Bristol LSCB Child K) 7.55 As well as studying the relevant SCRs the ADFAM report undertook group interviews with a large number of practitioners in the fields of drug misuse and children’s safeguarding. They found that staff tended to be aware of the risk to children of them ingesting drugs accidentally and where child neglect was an issue. They were less aware of the risk of parents deliberately giving drugs to their children, and the groups found the finding of the SCRs surprising. One said they “couldn’t have dreamed” their clients would engage in this practice. The report stated that professionals did not routinely discuss the dangerous use of using methadone as a pacifier within assessments or key working interventions due to the lack of belief and understanding about this practice. In this case this issue was never considered or discussed amongst professionals or with the family. It was clear from the learning event that such a practice was ‘unthinkable’ to those involved. 7.56 An SCR undertaken by Gloucestershire LSCB engaged with the Mother in the case who informed the review that she believed the practice of administering methadone to small children was not uncommon amongst some substance-misusing parents. This is not something that the local drug agencies in Middlesbrough have considered, however the learning from this review will help to raise awareness of this an issue. It should be noted that without Emily presenting with an overdose of methadone, the possibility of the use of drugs on the children in this family would have been unknown to the professionals involved. There may be a number of other cases where this is an issue. 27 7.57 Lessons learned: • Professionals need to keep a healthy scepticism and always consider the possibility that parents on a drug treatment programme may be tempted to use their medication on their children, perhaps thinking that it will not harm them. • Professionals need to feel confident in addressing with parents the deliberate administration of methadone and other drugs to children. Thresholds for CP Plans. 7.58 A large number of Serious Case Reviews have highlighted issues with inconsistency in the application of thresholds in regards to neglect and poor understanding by professionals of neglect14. A theme that emerged during the learning event was the need for a clear understanding of the thresholds for a CP plan in neglect cases. In many ways this case did not meet the usual and expected criteria for a CPP with the category of neglect. The children appeared to be well looked after. They were clean, well dressed, had age-appropriate toys, and lived in a home that was largely well looked after. Their parents gave the impression that they had their children’s best interests at heart and that they were willing to engage with agencies in order to improve their children’s care. They also had extended family support. 7.59 As shown above however, the parent’s cooperation was on their own terms, and they were able to manipulate staff and show a compliance with services that was false. The identified school attendance issues and poor punctuality, and the missed medical appointments and inoculations were clear symptoms of neglect. This was a family who were not prioritising the needs of their children above the parents own issues. The neglect that Jenny, Molly and Emily were suffering was underestimated. 7.60 The children’s health needs were not attended to as they should have been, with Jenny potentially having long term issues with her eyes due to lack of attendance at appointments for this issue. It is noted that both parents attended all appointments for their own needs however, for example Mother’s health issues during pregnancy. There was a degree of chaos however in Father’s reliance on A&E to meet a number of his health concerns during the time we considered. This is also another indicator of a family in crisis without the ability and commitment to maintaining their children’s care. 7.61 In neglect cases the use of a chronology to reflect on and analyse the care of the children and the significant events in regards to parental risk factors is essential. Although historic concerns were not particularly significant in this case, it would be helpful to build a tool which enabled a shared understanding of the children’s history by incorporating all of the information held on the family across the agencies involved. If a multi-agency chronology which included a focus on lack of compliance was drawn up, including the numerous excuses given for the children to miss school and health appointments, the issues and on-going neglect of the children would have been seen more clearly. 7.62 Without direct work being undertaken with the children it was also hard for professionals to establish the true extent of their neglect. Although there is no guarantee that Jenny or Molly would have told social workers or the FRT workers about what happened behind 14 Learning Lessons from Serious Case Reviews, Ofsted. 28 closed doors, some work with them on their life experiences may have provided a valuable insight into their lived experience. 7.63 There was little questioning of how often the children appeared to be ill, and how often professionals noted the girls seemed pale, lethargic or tired. With hindsight there is a possibility it was due to the substances they may have been ingesting. However even at the time there were questions to answer about why the children were so often ill and tired, and why the parents seemed to find it so hard to get them to school and medical appointments. There was also no exploration of whether the children needed any further medical assessments regarding the reoccurring illnesses. This was probably because professionals did not believe the children were ill. 7.64 It is a dilemma, when things seem to be going well otherwise, to decide to keep children on a CPP plan when school attendance appears to be the only significant factor in a case. However it has been established that had there been an analysis of the families lack of compliance, which went back to their early lack of engagement with the CAF and refusal to engage with family support provided by the Children’s Centre, along with the on-going missed health appointments and school issues, the threshold for a further period of CP planning may be have been met. There was also limited exploration of how the care of the older children would be impacted on by the birth of a new baby. 7.65 The IRO who chaired the conference where the decision was made to take Jenny and Molly off the CPP was influenced by the positive regard for the progress made by the parents in the previous 9 months. He was also aware of the need to ensure dynamic CP planning by not allowing children to remain on a CPP for a long period. He did not have time, with a large caseload, to explore the case recordings, and took what was presented to the conference at face value. It was understandable, in light of the positive assessments and effective disguised compliance from the parents, that Jenny and Molly‘s cases were stepped down to CinN plans that were supposed to be used to continue to work with the family on the school attendance issues. 7.66 The recall event discussed the focus on neglect in Middlesbrough since 2014. A neglect strategy has been written and it is comprehensive. Training has been extensive and widely offered and there has been a good uptake. The impact of this would not have been embedded at the time that the work was undertaken in this case. Those involved in the review felt that practice was improving in this crucial area. 7.67 Lessons learned: • Poor school attendance and punctuality and a pattern of missed health appointments, constitute child neglect. • Staff should not accept assertions and reassurances about taking children to key appointments without checking that that they have happened. • When a new baby is expected in a family, consideration needs to be given to extending the period of the CPP to allow for the impact of the baby to be assessed and monitored. Supporting staff undertaking complex case work. 7.68 It is clear that staff working with families with complex difficulties and child protection or safeguarding concerns require the time to undertake the role, on-going training, support, and the opportunity to reflect on their work. A number of issues have been identified which 29 provide a context around the work undertaken on this case. These include high caseloads, limited management capacity and staffing issues. 7.69 At the time the children were made subject to a CPP the health visiting service was under a lot of stress with a new and complicated IT system (SystmOne) to work on. They were also very short staffed, with around 1/3 of the team off on long-term sick leave. Managers had to move staff across the town to try and provide adequate cover. At this time the health visiting and school health nurse services in Middlesbrough were seen as ‘at risk’ and were the subject of an incident report. However it should be noted that the social worker stated at the learning event that she always felt well supported by the health visitor and school nurse in this case. 7.70 It was shared that community midwives are expected to see one woman every 20 minutes, and during the relatively short appointments no concerns for Mother or the family were evident. 7.71 Father’s GP surgery had a number of key members of staff leave during the period of this review which had an impact on the management of the work and the level of experience within the practice. 7.72 The ChSC agency report informed the review that 2012 ‘saw an unsteady year for the children’s workforce. Agency staff were being recruited, retention of staff was at a critical point and caseloads were high. Providing consistency for families was difficult to maintain and team managers had to work with these inconsistencies on a regular basis’. The staff at the learning event agreed with this analysis and stated that as newly qualified staff they felt they could have had more support. The three social workers that had involvement in the case during the scope of the review were newly qualified. None of their managers had been working in a managerial role for more than 2 years. The agency report and learning event both highlighted the lack of management oversight and decision making in this case and an absence of regular supervision. The social workers did not have the required number of supervision sessions set out in policy. This allowed the social workers, through lack of experience, to begin again when the case was allocated to them, and to maintain their over optimism in regards to the parents. 7.73 It was evident from this review that the MSCB had not been made aware at the time of the difficulties faced by front-line staff due to staff sickness, shortages and demands such as IT systems and reorganisations. 7.74 Staff need help and support to challenge other professionals. A lack of professional challenge was evident in this case. Supervision was also inadequate in regards to providing challenge to staff about the assumptions they were making and the conclusions they reached about this family. The school provided some challenge by questioning the assessments being made and by stating their disagreement in regards to the decision to remove the children form a CPP. However they did not formally escalate their concerns. 7.75 There was a lack of analysis evident across and between agencies. Professionals at the learning event recognised the need to regularly take a step back when working with families to really think about what is happening, to consider the child’s world, and to question their assumptions. They could see the value of regular skilled supervision in helping them to identify their over-optimism and whether clients are exhibiting disguised compliance. They felt that multi-agency group supervision would enable a culture of respectful challenge which could also consider professional dynamics without the 30 presence of children and families. Some changes have been made in Middlesbrough since the time this review considers, and they are noted below at 10.4. 7.76 Lessons Learned: • Regular and effective supervision is essential in giving professionals the opportunity to reflect on their work, and in ensuring that the work undertaken is child centred. • Issues of capacity should always be escalated to senior managers as soon as they become an issue. The MSCB should also be informed of these issues. This is likely to be more of an issue as demands increase and resources are more stretched. 7.77 Good Practice There were a number of examples identified in this case of good practice across all the agencies involved. They include: • Good communication between the health visitor and school, including some joint visiting. • The School regularly and assertively voicing their concerns and keeping a focus on the needs of the child. • Meetings happened on time and visiting was regular, and often unannounced, which is good, particularly when seen in the context of low staffing levels and high caseloads in both ChSC and health visiting services. • A GP practice chased information that was missing from a conference. • The investigation into Emily’s methadone ingestion and the swift actions taken to safeguard Emily and her siblings on the day she was admitted to hospital. • Record keeping was largely good. • The ICPC was well attended, reports were written and the recommended plan was robust. Conclusions 8.1 The potential for parents to deliberately give their children drugs was unprecedented in the experience of all the professionals involved in this case at the time and to those involved in the SCR. It was hard for staff to ‘think the unthinkable’ when they had not been made aware of the potential for such a form of abuse. It is hoped that the learning from this review will alert all professionals in Middlesbrough and beyond, to the potential for children to be given dangerous substances by their parents. 8.2 The review has attempted to avoid hindsight bias which “oversimplifies or trivialises the situation confronting the practitioner and masks the processes affecting practitioner behaviour” (Woods et al15). The learning has been identified in each section above, and the recommendations links to this learning. 8.3 Even without the benefit of hindsight there was evidence available that Father or Mother might pose a risk to children before the incident in January 2014. It is not known if either parent deliberately put Emily’s life at risk, or indeed whether they underestimated the impact of such an action. The ADFAM report quotes a service user who said that ‘opiate users often feel they know more about the use of opiates than practitioners, through their 15 David D Woods et al. Behind Human Error. 2010. 31 own lived experience: they may feel relatively confident in administering a small amount to a child, and having begun the practice of using it as a pacifier, may become increasingly bold in doing so’. 8.4 A number of changes have taken place in Middlesbrough since the serious concerns about Emily, Jenny and Molly emerged in January 2014. This reflects the fact that some of the “best learning from serious case reviews may come from the process of carrying out the review” 16 • IRO caseloads are now 50% lower allowing them more time to ensure they have all the required information for a meeting and to ensure child protection plans are robust. • The GP agency report states that the specialist nurse at the practice has started to place more emphasis on safe storage in her consultations, be more specific regarding documentation of alcohol and opiate use and increased the education regarding alcohol use and methadone in combination. • Middlesbrough ChSC has embedded the ASYE, approved supported year of employment and therefore newly qualified social workers are now offered additional support and guidance from a dedicated training and development officer as well as increased supervision from their direct line managers. • Adult practitioners with experience of substance misuse are now aligned with Safeguarding Front of House services and provide the necessary guidance support and training to both managers and social workers alike. They are also developing a new model that will bring together a think family approach to assessment and intervention where substance misuse is a factor within families. • In 2014 ChSC implemented a system for creating electronic records for all children open to Safeguarding Services. Manual files have been systematically archived via a roll out programme and the workforce has undergone training on how to fully record on the Integrated Children’s System. 9 Recommendations 9.1 It is recognised that actions have already been made in relation to some of the individual agency's identified learning. In addition agency reports included some recommendations which this review endorses. They are attached as an appendix. 9.2 It is acknowledged that the ADFAM report of 2014 that has been extensively quoted in this report and the serious case reviews it studied have made some excellent national recommendations. They include the recommendation that ‘consideration should be given to a short and powerful social media campaign to tackle a culture where administering methadone to children is perceived as acceptable’. This SCR would welcome this action. 9.3 The purpose of providing additional recommendations is to ensure that the MSCB and all professionals in the partner agencies of the Board are confident that the areas identified as of concern in this review are addressed. 16 Brandon et al. Lessons from Serious Case Reviews. 2012 32 Recommendation1 The MSCB to request that Middlesbrough Recovering Together (MRT) reviews all information for service users and professionals regarding drug treatments. They must ensure that leaflets and posters make it clear that giving an OST to a child is extremely dangerous and can be fatal. Recommendation 2 The MSCB to include the risk of drug using parents actively giving drugs to their children is covered in all relevant MSCB training. Consideration should be given to including the request that relevant staff routinely ask parents who misuse substances if they have ever given their children illicit substances. Training could also include the signs and symptoms in children of drug ingestion, and clarity about what professionals should do if they suspect this is happening. Recommendation 3 That the MSCB consider piloting a model of reflective supervision for core groups, to ensure professionals gain confidence in working with parents who are manipulative and show disguised compliance. Recommendation 4 The MSCB should inform all partner agencies of its expectation that all relevant staff working with children should attend MRT drug and alcohol awareness training. Recommendation 5 The MSCB to communicate to ChSC its expectation that consideration should always be given to sharing information with extended family that are being relied on to assist in the safeguarding of children. This should include them being invited to key meetings such as child protection conferences and them receiving information in writing about the concerns and risks. Recommendation 6 That the MSCB undertakes a multi-agency case file audit to consider if there is adequate evidence of the following in agency records: • Reflective supervision • The voice of the child ………………. |
NC52486 | Death of Child F, aged 6-months-old, as a result of head, spinal and eye injuries in February 2021. Learning includes: considering the emotional impact on the parents of an unexpected diagnosis of a serious health condition shortly after birth; the impact of additional costs when children are in hospital for prolonged periods and/or there are practical problems caring for siblings; the importance of midwives and health visitors knowing details of babies' health conditions so they can assess mothers' mental health; benefits of having the same interpreter for parents who need long term support; consider parents' cultural backgrounds and how they might affect their understanding and response to their child's diagnosis; and the benefits of providing written information in parents' first language. Recommendations include: develop training and briefing materials for practitioners about working with Black and Minority Ethnic people; ensure hospitals caring for local children have arrangements in place to improve practitioner awareness about practical and financial help for parents with children in hospital; seek assurance that arrangements are in place to improve practitioner awareness about assessment entitlement for children if they stay in one or more hospital settings for three or more consecutive months and for parents caring for disabled children; consider how best to improve information sharing between neonatal and paediatric intensive care services and midwifery and health visiting services; and ensure hospitals that provide neonatal care for babies have effective pathways to enable staff to break the news and provide prompt support for families whose babies are diagnosed with an unexpected health condition or disability.
| Title: Child safeguarding practice review: Child F. LSCB: Halton Children and Young People Safeguarding Partnership Author: Karen Perry Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 0 CHILD SAFEGUARDING PRACTICE REVIEW Child F Date agreed by the Executive Group for HCYPSP: 07 February 2022 Lead Reviewer: Karen Perry 1 CONTENTS 1. Introduction page 1 2. Details of the family and case context page 2 3. The child’s story page 2 4. Thematic analysis page 4 5. Parents’ views page 15 6. Positive practice page 16 7. Conclusions page 16 8. Recommendations page 17 2 INTRODUCTION 1.1. This Child Safeguarding Practice Review is in respect of Child F who died in hospital age 6 months as a result of head, spinal and eye injuries as well as healing fractures and a previous brain injury caused a few days earlier. His father was convicted of murder. Evidence presented in court indicated Mother knew about the earlier injuries; she was convicted of causing or allowing his death. 1.2. All learning points are listed in section 4, at the end of each of the four themes: response to babies born with health conditions; communication with parents whose first language is not English and consideration of cultural background; how practitioners and agencies worked together, making and responding to referrals; the arrangements to safeguard and promote the wellbeing of Child F and his sibling. What follows is a summary of the most significant learning from this review. 1.3. It is important to consider the impact on parents and any siblings of an unexpected diagnosis of a serious health condition shortly after birth. Where children remain in hospital for prolonged periods parents can face significant challenges due to additional costs, e.g. travel, and practical problems caring for siblings. A child who has been in hospital for 3 months or more is entitled to an assessment of their needs by a social worker, while parents who care for a disabled child are entitled to a carer needs assessment, conducted by an officer from the council’s Disabled Children’s Service. 1.4. It is important to consider parents’ cultural backgrounds; whether and how they might affect their understanding and response to their child’s diagnosis and their expectations of treatment. When using interpreters there are benefits in using the same one for parents who need long term support, and practitioners would welcome training about establishing effective working relationships with interpreters. It is helpful to provide information in parents’ first language, which they can refer back to independently. 1.5. When a child is disabled signs of abuse can be masked or misinterpreted due to assumptions about ongoing health conditions or impairments. It is important to recognise the potential for some Acute Life-Threatening Events (ALTEs) to later turn out to be due to abuse. 1.6. Halton Children and Young People Safeguarding Partnership (HCYPSP) will ensure that learning is widely disseminated locally via practitioner learning events and a seven step guide that will be distributed directly to practitioners as well as being available on the partnership website. To avoid unnecessary disclosure of sensitive information, details in this report regarding what happened focus only on the facts required to identify the learning. The Child Safeguarding Practice Review takes into account multi-agency involvement from February 2020 (earliest contact with agencies due to pregnancy until beginning of March 2021 (2 weeks after Child F presented for treatment for the injuries which precipitated this review). 1.7. Halton Children and Young People Safeguarding Partnership (HCYPSP) agreed to undertake this review using a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted as they did at the time. Practitioners were asked to contribute to most single agency reports and to attend two practitioners’ meetings led by the author of this report, who is independent of this case and all agencies involved with the family. Family members were also offered the opportunity to speak to the lead reviewer. Both parents agreed to do so; their comments are included in section 5. 2. DETAILS OF THE FAMILY AND CASE CONTEXT 2.1. Family members will be referred to by their family relationship to Child F e.g. Mother, Father, Sibling etc. The family are of European heritage, English is not their first language; they arrived in the UK 3 in 2019. Halton has small numbers of people with a BAME1 heritage. Child F had Down’s Syndrome,2 which required intervention for a cardiac anomaly and specialist support with feeding. At the time of the injuries that prompted this review Child F was living with Mother, Father and Sibling. Mother and Father were experienced parents and there had been no concerns about their care of Sibling. Apart from attendance at various outpatient appointments, the main additional care Child F needed was more frequent feeding through a PEG3. He has been described by practitioners as achieving his developmental milestones and been observed smiling, babbling and engaging with his parents. 3. THE CHILD’S STORY 3.1. Child F was born in August 2020 at 37 weeks gestation, having received appropriate ante-natal care. At birth Child F had a cardiac abnormality; he was transferred to the Paediatric Intensive Care Unit (PICU) in the local regional specialist children’s hospital the same day and placed on a ventilator. Mother was discharged home. Down’s Syndrome was also suspected; this was unexpected as the results of the relevant blood test during pregnancy had a shown a lower risk of 1:160. The diagnosis of Down’s Syndrome was confirmed at the regional specialist hospital on the day of admission. 3.2. After 1 month in the specialist hospital, in September 2020, Child F was transferred to the local hospital with a nasogastric feeding tube4 in place. In December 2020, because of concerns about the risk of aspiration5 through the nasogastric tube, Child F returned briefly to the specialist hospital for a PEG to be fitted as a safer method of feeding him. After a multi-disciplinary meeting involving relevant health practitioners, just before Christmas 2020, Child F was discharged home to the care of his parents. Planned input from agencies involved temporary community nursing involvement to support and monitor feeding plus ongoing support from the health visitor plus a range of outpatient appointments over time.6 3.3. Prior to Child F’s discharge from hospital, the health visitor had made a referral to the Integrated Contact And Referral Team (ICART)7 towards the end of November 2020. After screening, the family was referred to Children’s Centre for allocation of an Early Help Officer to complete a Multi-Agency Plan (MAP)8 with the family. This was to incorporate home safety assessment, carers centre support, and referral to the Citizens Advice Bureau (CAB) for advice on finance/benefits. An Early Help Officer became involved in mid-January 2021, she made several enquiries about potential support for the family and completed the MAP in consultation with the health visitor. 3.4. In mid-February 2021, an ambulance was called by relative due to Child F having “collapsed” at home; before arriving at the local hospital paramedics rang this through as a cardiac arrest and reported the incident to the police. As there was no clear medical cause for the collapse, the Acute Life-Threatening Event (ALTE) protocol was initiated by the local hospital. Child F was transferred to the PICU at the specialist hospital where a CT scan revealed the non-accidental head injuries that prompted this review. 1 BAME Black and Minority Ethnic 2 Down’s Syndrome, which is also know as Trisomy 21, is a genetic condition that occurs by chance, and which is associated with a range of health conditions and some level of intellectual disability 3 A percutaneous endoscopic gastrostomy (PEG) is a procedure to place a feeding tube through the skin and into the stomach to provide nutrients and fluids. This also requires care to be taken to keep the skin around the entry site clean 4 Nastrogastric feeding is where a narrow feeding tube is placed through the nose down into the stomach 5 accidental inhaling of fluid into the windpipe and lungs. 6 Regular appointments with cardiac service, paediatrician, and dietician, also gastroenterology physiotherapy and speech and language support, as needed/in due course 7 Integrated Contact And Referral Team. The “front door” to Early Help or Social Work support including safeguarding 8 The Multi-Agency Plan (MAP) is an early help assessment which, provides a standardised approach to identifying risks and strengths for children and families and co-ordinate access to appropriate, timely support to prevent needs escalating 4 3.5. The same day Sibling was made subject to a Police Protection Order and placed with foster carers. The following day the local authority obtained an Interim Care Order for both children. Sadly, within two days it was apparent that Child F would not recover, and he died after life support was ceased. 4. THEMATIC ANALYSIS 4.1. The learning from this review was identified from information and opinions provided in the agency reports and at the practitioner event and from parents. The themes are: Response to babies born with health conditions Communication with parents whose first language is not English and consideration of cultural background How practitioners and agencies worked together; making and responding to referrals The arrangements to safeguard and promote the wellbeing of Child F and his sibling Theme: Response to a babies born with health conditions 4.2. Individuals with Down’s syndrome present a wide spectrum of physical, cognitive, and social characteristics and abilities. However, there are some health conditions which are commonly associated with the syndrome.9 These were considered by clinicians and treatment was provided to Child F for his cardiac condition and feeding difficulties. 4.3. Parents (and practitioners) were expecting Child F to be healthy; hearing their child has health conditions and a lifelong disability to some, as yet not fully known, degree just after birth is a tremendous shock for any parent. The amount of unfamiliar information may be difficult to take in, especially if English is not your first language. Disability charities all describe the same kind of emotions typically faced by parents who have been given a diagnosis recently; shock, disbelief, denial, anger, guilt, feelings of loss for the child (and life) that the parents were expecting, fears about coping and worries about the impact on any siblings. These normal feelings can be more difficult to manage if parents have a different level of understanding or react differently to the diagnosis. In addition, feelings are likely to be influenced by individual attitudes and experience of disability and the reaction and support from the extended family. There are often extra costs and practical problems of caring for a child with health conditions, especially one in hospital. For example, neither hospital was near where parents lived and they did not have a car. Also managing responsibilities of caring for another young child (Sibling) were compounded by covid restrictions which prevented Sibling visiting either hospital with the parents, or relatives accompanying them unless present to interpret. After Child F’s admission to the specialist hospital parents were not able to visit until they had had negative covid tests. 4.4. A leaflet about screening translated into the parents’ first language had been provided to Mother during pregnancy. While providing written information is good practice, parents are not likely to take in much information at this point about a condition which they hope their child will not have. The suspected diagnosis of Down’s Syndrome was immediately shared with Mother after Child F’s birth and the registrar held a detailed discussion with Father a week later. There were at least two other detailed conversations between a paediatrician and parents while Child F was in hospital. It is important for information to be provided repeatedly, partly because it may be difficult to take in, but also because of the evolving nature of the treatment required for Child F’s health conditions. Managers told this review that neither hospital had a specific pathway for “breaking the news” of an 9 Heart anomalies, feeding, speech and language development, sight and hearing impairments. 5 unexpected health condition or disability. As part of their “Tell it right” campaign the Down’s Syndrome Society publish a very useful top tips leaflet, primarily aimed at midwives, which covers prenatal and postnatal discovery of a child having Downs Syndrome. Although specifically written for diagnoses of Downs Syndrome the tips generalise to breaking the news about all health conditions and could be a useful resource both to individual staff and agencies in developing pathways. 4.5. Whilst all hospital paediatric nursing staff are well used to providing day to day emotional support to parents, this, and advice about practical support, is not their primary role. Both hospitals have specialist services to provide additional support to parents and families who need it; the multidisciplinary Complex Discharge Service10 (CDS) at the specialist hospital and the complex needs nurse at the local hospital. Parents would have benefitted from more effective referral arrangements to these services. A written referral to the Complex Discharge Team was made by PICU staff 10 days after admission, followed up by a phone call two days later specifically asking for transport or financial assistance because of parents’ difficulties visiting. CDS staff told this review that this referral appears to have been overlooked and closed without any action due to incomplete handover between staff members associated with annual leave.11 Despite, for example, father subsequently explaining they were struggling for money and the costs of taxis being prohibitive when contacted to ask why parents are not visiting and some concerns recorded in early September 2020 about Mother’s reluctance to engage with Child F, there is no evidence that this lack of involvement from the CDS was identified by PICU staff. Practitioners told this review that the this could have been due to use of different recording systems across the hospital and a primary focus on critical care and in the expectation that Child F would be transferred back to the local hospital. Paediatric Intensive Care staff at the specialist hospital suggested there could be a role for CDS staff to visit the ward on occasion so that parents could approach them independently if they needed additional support of any kind. 4.6. Child F was transferred to the local hospital with a plan to establish feeds. When it became apparent a month later that there were issues with the feeding mechanisms and concern regarding safe discharge, the Complex Needs Nursing Team then became involved as the care needs had increased and the discharge was delayed and more complex than expected. However financial difficulties were not addressed in any way by local hospital until the complex needs nurse provided assistance with a Disabled Living Allowance12 (DLA) application in early December 2020. 4.7. Helping parents to visit hospital is important for several reasons. These include: the need for contact with their baby to promote bonding; to promote their knowledge and confidence in caring for him so that he can be discharged home; to mitigate (financial) stressors which can adversely affect parenting; and to prevent either unfair criticism about lack of visiting, or difficulties for practitioners judging how concerned to be about any lack of visiting. 4.8. Because Child F was in hospital the community midwifery service did not have contact with him. They did have contact with Mother, however the quality of emotional support they could provide was undermined by not knowing the nature of Child F’s health condition. This was because details are provided on discharge notifications, which was not applicable in this case because Child F was still 10 The Complex Discharge Service comprises an Occupational Therapist, Nurse and part time social worker (1 day per week). The role of the team is support with care packages, home assessments, financial grant applications and co-ordination of long stay patients who are unable to be discharged until home and care packages are in place. 11 The Complex Discharge Service Manager intends to discuss the incident with the team and review Standard Operating Procedures to reflect any learning. 12 This is a benefit with a minimum level in 2021 is £23.70 per week which is intended to help with the additional costs of caring for a disabled or sick child where additional care to that required by a normal child has been required for a minimum of 3 months and is likely to persist for a further 6 months or more. https://www.gov.uk/disability-living-allowance-children 6 in hospital aged 28 days when midwifery services cease. Midwives can often rely on getting sufficient information from mothers, but not in this case. The midwife was aware from phone contact with the specialist hospital that the baby was “very poorly” but no details were shared because PICU does not provide information over the phone without verification of identity and a mutually agreed password, which had not been put in place.13 Records show Mother told the midwife she was feeling “nervous” without being sure why. The midwife does not recall this conversation. There is no evidence that this comment was considered either in the context of standard postnatal mental health screening, or the health of the baby; had the midwife known more about the nature of the baby’s health conditions she might have reflected further on the comment.14 4.9. Both midwives and health visiting practitioners told this review that local hospital neonatal services sometimes contact them to share progress and/or concerns. However, their perception was that occasions of contact from the PICU in the regional specialist hospital were very rare and that it would be helpful to have details of health conditions, potential dates for discharge, any concerns and details of health specialities involved in providing services. In this case the usual process for notifying health visitors of admissions and discharges to PICU was not followed on the first and third occasions for reasons which are not known, although practitioners told this review that explicit consideration of which staff on the PICU should do this might improve arrangements. Whilst midwives and health visitors appreciated the challenges of that hospital communicating safely and easily with several different services, they felt that better arrangements for communication and liaison would benefit children and their families. Practitioners suggested the development of a communication pathway, which could include development of generic email addresses for the respective hospital, midwifery and health visiting services. To be effective this would need to be a regionally agreed communication pathway. PICU staff told this review that the password system mentioned previously works well with police and Children’s Social Care staff and should be reviewed for health staff. The hospitals involved in this review will consider what better information sharing with midwives and health visitors should look like. 4.10. During his short life Child F had two health visitors: the second became involved because of a review of caseloads. Both were energetic on allocation in their attempts to find out about Child F’s health condition and progress and consider what support the family might need. The first health visitor made immediate contact with the Down’s Syndrome Association, this resulted in a specialist growth chart some weeks later. In mid-January 2021 further contact by the health visitor 2 established that no written material was available in the parents’ first language. Accordingly, the health visitor went through the website with interpreter’s assistance on her next visit. The complex needs nurse recognised the potential value of peer support for the parents, however, an email contact for another European family with who had a child with Down’s Syndrome was not provided the beginning of December 2020. This was mostly due to the inherent delays by the Down’s Syndrome Association’s attempts to find a willing family and gain consent to share details. 4.11. In the 6 months period between Child F’s birth and death records indicate that parents mentioned financial difficulties (including loss of Father’s job in November 2020) a minimum of five times to different practitioners; staff in both hospitals and the health visitor. The support they received regarding this involved help with completing an application for Disabled Living Allowance (DLA) during December 2020, a Christmas food and toy hamper provided by Children’s Centre Services, and a referral to the Citizens Advice Bureau at the beginning of February 2021. Permission to complete the DLA claim form was not sought from Mother until the beginning of December 2020 and 13 The specialist hospital gets a lot of phone calls from press and the public where it would not be appropriate to provide any information, and information sharing is kept basic as not all professionals would understand the complexities of the health conditions/PICU care 14 There is currently an open action plan for the provision of maternal mental health training for midwives to increase their knowledge and skills when assessing and discussing mental health with mothers. 7 the form completed during early December 2020. This would have slightly reduced any potential entitlement as eligibility for Child F started at age 3 months; to receive full potential benefit a parent or a practitioner supporting them should either request a printed form by telephone or submit a completed form at the 3 month point, as claims for DLA cannot be backdated. Practitioners told this review that they were not aware of this. 4.12. Neither hospital was near the family home and no help towards travel costs15 ever seems to have been considered for a combination of reasons. For example: it was not widely known initially that the parents were dependent on taxis; the lack of involvement by the Complex Discharge Team at the specialist hospital who might have addressed this; the unusual length of Child F’s stay in the local hospital; a misunderstanding that help can only be provided for people receiving benefit due to unemployment, which was not the case for Father until November 2020; and a later reliance on a referral for Early Help, including referral to the CAB. However, no offer of help from the CAB was received until February 2021. The delay appears to have been because making a referral was seen to be the responsibility of the Early Help Officer who did not become involved until mid-January 2021 and who first had to seek parent’s explicit consent to make the referral. This delay was unfortunate because CAB got in touch with the family less than a fortnight from the date of the referral. The expectation in the local hospital is that parents would self-refer to the CAB; there are additional challenges with this for people whose first language is not English. Health visiting staff told this review that where people needed support to self-refer or attend the CAB they had accompanied them. 4.13. Practitioners told this review that whilst most practitioners would have a basic awareness of key welfare benefits, they were unlikely to understand them in detail unless they had specific experience of resolving an issue, and even then their knowledge can get quickly out of date due to benefit changes. The priority therefore is to know about the existence of the most received benefits for sick children and their families and how to access more information and advice about them. As a result of this review local hospital managers have recognised that there is a need to supply more generic information for parents who may be experiencing financial difficulty about potential sources of support and a need to encourage staff to explore potential financial difficulties associated with travel and seek advice (eg from the hospital Safeguarding Team) even if parents are managing to visit and attend hospital appointments as expected.16 At the specialist hospital equivalent advice could be sought from the Complex Discharge Team. Any information proactively provided to parents would need to research any alternatives to the national scheme for those who do not meet the eligibility criteria or for whom public transport is not suitable for some reason. Either the CAB or the Benefits and Welfare Service run by the council might be able to help with the production of information. 4.14. Covid restrictions meant that women were required to attend midwifery appointments alone. This meant that Mother did not have the option to bring a family member with her to provide support and that she was having some difficulties attending due to lack of childcare. All parents with a new baby need some level of practical and emotional support from family and friends. This is especially the case when the baby has health conditions. The parents had a relative who lived next door and at least one other family locally. The health visitor knew about the existence of the uncle that he was regarded by parents as a good source of support from previous records for Sibling; this had been where the family first stayed at the time of their arrival in the uk. Staff at the specialist hospital told the health visitor that that an uncle usually brought parents into hospital daily and that the uncle 15 Father told the CAB and police that the family had spent £4000 on taxi fares 16 This review was told that in practice local hospital staff don’t make a referral to safeguarding for the involvement of the Complex Need Team unless they have concerns about visiting frequency 8 spoke good English. Early Help had been told by the health visitor that there were members of the extended family living close by, and that at the MAP meeting they would have discussed what specific support they were providing or could provide Summary of learning: Response to babies born with health conditions The importance of considering the emotional impact on the parents and any siblings of an unexpected diagnosis of a serious health condition shortly after birth, and the need for clear arrangements that ensure a consistent prompt approach to “breaking the news” and the provision of information, advice and support from birth and in early infanthood. The potential impact of additional costs, eg travel when children are in hospital for prolonged periods and/or there are practical problems caring for siblings The importance of midwives and health visitors knowing details of babies’ health conditions so they can assess mothers’ mental health in the context of having a very ill baby See recommendations C, E & F Theme: Communication with parents whose first language is not English and consideration of cultural background 4.15. Prioritisation of antenatal home visits by the health visitor in response to government guidelines for Covid did not include Mothers whose first language was not English.17 This reduced the opportunities for the health visitor to establish a rapport before birth and proactively assess needs of the whole family. Providing effective services to people whose first language is not English poses several challenges for practitioners. It is harder to contact parents spontaneously for any updates or queries, or to make appointments It is not easy to have the usual informal conversations on the ward to provide advice and emotional support. Nonetheless Mother told health visitor 2 she felt well supported emotionally by hospital staff, and she felt able to express her worries to them about managing the nasogastric tube at home. Practitioners said that this was significant because often parents do not feel able to express such worries for fear of being considered not able to cope. Where parents first language is not English it is harder to explore any unexpected behaviours or comments in a timely way, or to check understanding of information and advice given. Practitioners told this review that when Mother asked if Child F would “grow out of it” they were uncertain whether or not this was a culturally influenced misunderstanding of the diagnosis of Down’s syndrome, although some elements of his health conditions were treatable or would improve over time e.g. the heart condition and feeding difficulties respectively. The need to use some form of communication aid or interpreter, at best, makes appointments longer and at worse reduces the complexity of the conversations. Barriers to easy communication make it harder to build effective partnership working relationships with parents. In addition, written information in the appropriate language is not always available and, when it is, special arrangements must be made to acquire it. Father’s understanding of English is better than Mother’s and practitioners established that he was literate in his first language, which made it possible to provide some information in that language, which the parents could keep and refer to again independently. This included the health visitor providing standard 17 As a result of this review service prioritisation criteria have been amended to include Mothers whose first language is not English 9 information given to all new parents18 and local hospital providing a copy of the “congratulations on your new baby” from the Down’s Syndrome Association. 4.16. Whilst English speaking family members did sometimes accompany parents or make or receive phone calls on their behalf, practitioners do not rely on family as interpreters unless there is no alternative. This is because they may not understand medical terminology and cannot always be relied upon to translate accurately or all of the intended communication by either party. Apart from an initial visit by the first health visitor without an interpreter, for reasons that are not known, all practitioners put arrangements in place to promote communication with Child F’s parents. These ranged from publicly available apps like google translate and “Say Hi” for more straightforward conversations to “language line” and “communicator on wheels”, which are both telephone services and the use of face-to-face interpreters for planned appointments. Hospital practitioners told this review that the questions parents asked suggested they understood what they were being told about Child F’s health. 4.17. Interpreters are contracted by “language line” as part of a pool and tend to work part-time which makes hard to ensure continuity, and practitioners told this review that their experience of using interpreters was that some were better than others. There was also one interpreter that Mother expressed reservations about. Sibling’s social worker managed to arrange with “language line” to use the same interpreter for several contacts with Sibling and told this review that the best approach was to arrange this from the very beginning, which also tended to promote more commitment and flexibility from the interpreter. This was more likely to be productive that the unsuccessful request for the same person again after a positive session, which another practitioner described after specifically involving a female interpreter to visit Mother. 4.18. Practitioners told this review that although some written guidance was available for the “communicator on wheels,” specific training for working with interpreters was not generally available. Training would emphasise the importance of the practitioner setting up any session by describing the scope of the intended conversation, clarifying any relevant context and likely challenges from both parties’ point of view, and checking that there would be no barriers due to attitudes of the interpreter or links in the community, which can be an issue for some individuals, even though they speak a common language. A set up conversation would also usefully include a proactive discussion about any relevant cultural considerations. 4.19. Cultural issues and difficulties in communication seem to have caused some delays in Child F’s discharge from hospital. Hospital staff were worried about parents’ management of the nasogastric tube and ability to summon help if they had difficulties. Mother was more hesitant than Father about Child F having the PEG procedure which was necessary for him to be discharged safely home. This may have been due in part to being used to a different health system in their home country where such procedures would have to be paid for. Practitioners also had no way of knowing the parents’ experience of receiving health services prior to their arrival in the UK, nor how well the family had engaged, which they would have done had the family always lived in the UK. 4.20. In this case, until the incident that prompted this review, there is no evidence of proactive effort by practitioners to find out more about the family’s cultural background and the potential impact on Child F’s care. Practitioners told this review that this may have partly been due to the immediate need to focus on treating and managing Child F’s health conditions. For example, Health Visitor 2 told this 18 The health visitor provided health resources in the parents first language; Safe Sleep’ from the Lullaby Trust and ‘ICON’ leaflet (Infants cry, Comfort, Its OK , Never shake a baby- information for parents to support safe handling of the infant and prevent abusive head trauma). 10 review that on reflection, her initial priorities were Child F’s health needs, obtaining information in the parents’ first language and making a referral to Children’s Services for more support. This meant she hadn’t prioritised finding out more about the family’s culture, not least because understandably she had anticipated an ongoing relationship with them. There is evidence of one occasion where an interpreter volunteered relevant information regarding the potential impact of the parents’ cultural background, and ICART knew that attempts were being made to connect the family with another family from the same background who had a child with Down’s syndrome. 4.21. Practice in this case echoes findings from a recent national report19 into non accidental deaths of babies under 12 months old which found limited evidence that the impact of ethnicity and culture on parenting was being considered. The report concluded that practitioners need more confidence to acknowledge and explore this. For cultural reasons, it was even more important than it usually would be that discussions about Child F’s health were held with both parents; one of the interpreters told staff at the local hospital that in the parent’s country mothers would predominantly care for children so Father would need more involvement in discussions. Staff at local hospital also had experience of working with another family from the same cultural background. That mother had explained that the diagnosis of Down’s Syndrome was not recognised in their country and she had not told the father about it until the baby went home from hospital. 4.22. Practitioners told this review that they would welcome some training about the cultural backgrounds of the small populations of BAME people that had recently begun to arrive in Halton. This would usefully include how to find out about less common cultural backgrounds with which they were (still) unfamiliar. As well as using interpreters to find out more about a family’s background, practitioners suggested seeking advice from adjoining areas with higher numbers of the relevant populations; sometimes this had resulted in key agencies having specialist staff who could be a resource, or there might be a relevant community or faith organisation. However a wider consideration of the relevant community in other parts of the UK could also be helpful, and would have been for this case. Summary of learning: Communication with parents whose first language is not English and consideration of cultural background The benefits of having the same interpreter for parents who need long term support and the need to request this in advance, at first contact with any interpreting agency The value of specific training for practitioners about establishing effective working relationships with interpreters The benefits of “set up” conversations between practitioners and interpreters The importance of considering parents’ cultural backgrounds; whether and how they might affect their understanding and response to their child’s diagnosis and their expectations of treatment The benefits of providing written information in parents’ first language; standard information for new parents and specialist information about any health conditions See recommendation A Theme: How agencies worked together: making and responding to referrals 19 Walters A et al (2021) Fieldwork report: National Review of Non-Accidental Injury in under 1s Child Safeguarding Practice Review Panel 11 4.23. At the end of October 2020, the local hospital consultant requested nursing staff make a referral to the Disabled Children (social work) Team for additional support. No referral was made to Children’s Services for 3 weeks. Delays were caused firstly by misunderstanding about the correct service as the named nurse for safeguarding at the local hospital advised that Child F’s circumstances would not meet the criteria for the Disabled Children’s Team. Although the named nurse was in fact referring to the local authority in which the hospital was located rather than the one in which the family lived, Child F would not meet the criteria there either as the service is for children who require “short breaks” respite care, which is not normally considered appropriate for very young children. A further delay was caused by deciding whether the nursing staff or the health visitor would gain consent and make the referral. 4.24. As carers for a disabled child the parents would have been entitled to an assessment of their own needs for support.20 These are completed by a Carer Assessment and Support Worker from the council. None of the practitioners involved had come across these before. It was not clear what relationship they might have with any Multi-Agency Plan (MAP), or Child and Family Assessments conducted by a social worker, including those Child and Family Assessments which should be completed for children who have been in hospital continuously for 3 months. Child F should have been identified as needing such an assessment (with parental consent) around the time the health visitor made the referral to ICART. Hospitals have a duty under the Children Act 1989 to notify the local authority so that an assessment can check that the child’s welfare is “adequately safeguarded and promoted”. Practitioners who were working with the family were not aware of this. The specialist hospital has arrangements to identify and refer children who have been inpatients for 3 months or more. Managers from the local hospital told this review that the context for this being over looked for Child F was that it is unusual to have a child so long in hospital and recognising the total length of continuous hospital stay was complicated by the previous stay in the PICU elsewhere. Arrangements have been put in place in the local hospital and ICART staff to recognise the 3 month point when applicable for any future inpatient child. 4.25. The health visitor’s referral to ICART was considered by social care and early help managers and passed to the Early Help Support Nurse for detailed consideration. By the beginning of December 2020, the support nurse had gathered further information from relevant agencies and produced recommendations to be undertaken by staff at the local hospital, an Early Help Officer and the health visitor respectively, with some suggested referrals to be made by either the health visitor or the Early Help Officer, to be agreed by them. The list was shared with those practitioners/services and was comprehensive and, in the authors opinion, appropriately in a priority/and or chronological order. However, no explicit priority or timescale was linked to any of the actions, and the referral to the CAB was one of the ones that was for discussion by health visitor and Early Help Officer. 4.26. No Early Help Officer was allocated until mid-January 2021. This appears to have been because when a manager contacted the health visitor to get an update within the expected 2-week timescale for first contact with the family or practitioners working with them, Child F was shortly due to have the PEG fitted and soon to be discharged home. Early Help staff told this review they would have become involved while Child F was in hospital had they had the referral earlier. Whilst the difficulties of attending the discharge meeting subsequently arranged at short notice are acknowledged, the fact that there would be one was foreseeable. It would have helpful for an Early Help Officer (EHO) to have been allocated to attend it to meet the parents and participate in the discussion about support after discharge. It was a positive step by the health visitor to invite the EHO to the meeting: 20 Under the Children Act 2014 A Parents carer needs Assessment should be provided if it appears to LA that parent needs support or if parent requests one. The assessment should consider ‘the well-being of the parent carer’ and ‘the need to safeguard and promote the welfare of the disabled child - -and any other child for whom the parent carer has parental responsibility.’ 12 practitioners told this review that EHOs allocated to children subject to Children in Need or Child Protection plans were routinely invited to discharge meetings at local hospital but not usually otherwise. By the time Child F was discharged it was almost Christmas and the impact of encouragement for council staff to take mandatory unpaid annual leave over the Christmas period means that non-emergency services are not in work for almost 2 weeks, hence delaying allocation until a time which was nearly 2 months after the referral had been made to ICART. 4.27. As the health visitor had not yet been part of the training programme being rolled out to complete MAP assessments, support to complete a MAP was to be provided by the Early Help Officer. However even had the health visitor done the training she might still have requested extra support to get the MAP done in the timeliest way given the complexities of Child F’s needs. Once involved the Early Help Officer was energetic in her attempts to contact parents and relevant agencies/practitioners. The MAP was sent to the parents by early February 2021. Covid restrictions had an impact on the arrangements, preventing the usual home visit and convening of a multi-agency meeting involving the parents to develop the MAP, which would have given the parents more opportunity to indicate what they thought the priorities for support were. In addition, covid restrictions prevented a welcome visit to the sensory room or “soft play” room at the local Children’s Centre and groups for parents run by the Down’s Syndrome Association had been suspended due to the covid pandemic.21 4.28. According to records, initially the plan of the Early Help Officer was to cease the MAP once all agreed referrals had been made; after reflection this was changed to holding a review meeting in 6 weeks. This did not happen due to the incident which prompted this review. Summary of learning: how agencies worked together, making and responding to referrals Where Early Help Officers will be involved in providing support after discharge from hospital there are potential benefits to families of their being invited to and attending discharge meetings. This should be considered even when the involvement is for “early help” rather than Child in Need or Child Protection plan. That a child who has been in one or more hospital settings for 3 continuous months or more is entitled to be offered an assessment of their welfare needs by a social worker. Parents who are caring for a disabled child are entitled to a carer needs assessment conducted by an officer from the council Disabled Children’s Service See recommendation D Theme: The arrangements to safeguard and promote the wellbeing of Child F and his sibling, 4.29. Child F was a new-born baby who was entirely dependent on the care provided by the adults responsible for them. Children under 12 months consistently form the significant minority (approximately 40%) of children subject to Serious Case Reviews/Child Safeguarding Practice Reviews.22 Child F was pre-verbal and could not tell professionals about his lived experience, although there is evidence in a number of agency records of observations of his presentation and the way that his parents responded to him. 21 Since the period covered by the review these have re-opened 22 Sidebotham P et al (2016) Pathways to protection a triennial analysis of Serious Case Review 2011-14 Department for Education and all previous analyses of SCR/CSPRs published by the government of the day 13 4.30. Research shows that disabled children are more vulnerable to abuse than non-disabled children23 The reasons for this include: attitudes and assumptions by practitioners that either believe it does not happen or accept forms of behaviour management that would be seen as abusive for any other child; a reluctance to challenge carers who are already under significant pressure; dependency by the child on others to meet personal care needs; communication barriers; misinterpretation of behaviours (eg self-mutilation, masturbation) that in other children might raise safeguarding concerns; isolation from other children and adults, including the family if the child is in residential care. Although the research relating to children from BAME backgrounds is limited, there is evidence of double discrimination for them if services (including when investigating allegations of abuse) are not sensitive to their cultural and language needs. 4.31. During the police investigation after Child F died it came to light that Father had convictions for domestic abuse against a previous partner in another country. This was not known previously to any practitioner working with the family, had this been known there would have been a heightened awareness about the potential for violent behaviour by Father and possible risks to the children. However there have been no concerns about domestic abuse between Father and Mother known to practitioners and no concerns about Father’s behaviour towards either Child before the injuries which prompted this review 4.32. Studies of Serious Case Reviews have shown that for disabled children, signs of abuse and neglect may be masked by, or misinterpreted as due to health conditions or underlying impairments.24 The term “Diagnostic Overshadowing”,25 which was first used to describe the misdiagnosis of other conditions for adults with learning disabilities may have some relevance in this case in terms of the initial response that Child F received after “collapsing” at home. For example, relatives told ambulance personnel about his heart condition. The non-medical call handler subsequently reported a cardiac arrest to the police in line with the ambulance service guidance. The police closed that first report down in error, without initiating further enquiries with medical professionals at the hospital or liaison with Children’s Social Care to establish the full circumstances as they should have done. The reasons the call was closed are not known, but a relevant context maybe that records show that the ambulance call handler had said “nothing like that” in response to a question about whether there was anything suspicious. This review was told that nursing staff at the local hospital did not initially suspect non accidental injury, although the paediatrician did appropriately initiate the Acute Life-Threatening Event (ALTE)26 arrangements under the then applicable the Sudden Unexpected Death of an Infant or Child (SUDIC) procedure (2019), which involves contacting the police and Children’s Social Care, as there was no clear medical cause of Child F’s condition. This is in place because, for a proportion of ALTE children, further tests do show evidence of non-accidental injuries, which proved to be the case when Child F was transferred to the specialist hospital for treatment. 4.33. After being notified of the ALTE the police attended the local hospital promptly. The police were told by nursing staff that they could not have access to Child F’s clothing and equipment, without a written request from a Chief Inspector or above. This kind of delay can have a detrimental effect on any subsequent criminal investigation; the legal position has since been clarified within the hospital trust that the items could have been released as part of a criminal investigation, this information will be shared with staff as an action from this review. Hospital managers told this review that staff appear 23 Safeguarding Disabled Children; practice guidance (2009) Department for Children Schools and Families 24 Sidebottam P et al (2016) Pathways to harm pathways to protection; a triennial analysis of Serious Case Reviews 2011-14 Department for Education 25Definition of Diagnostic Overshadowing “once a diagnosis is made of a major condition there is a tendency to attribute all other problems to that diagnosis, thereby leaving other co-existing conditions undiagnosed,”Neurotrauma Law Nexus http://www.neurolaw.com/neuroglossary/ cited by Blair J (2018 ) Diagnostic overshadowing; see beyond the diagnosis in Intellectual Disability & Health – March 2018 http://www.intellectualdisability.info University of Hertfordshire 26 the definition of ALTE is “a sudden collapse of an infant requiring some sort of active intervention/resuscitation and subsequent intensive care/high dependency unit admission and remains unexplained”. 14 to have confused the process with that for obtaining medical records, which does require written authorisation. 4.34. After Child F’s death there was a delay in convening the multi-agency Rapid Review meeting which is required under the Sudden Unexpected Death of an Infant or Child (SUDIC) procedures. This was due to confusion about who would convene this meeting. Multi-agency arrangements in the area where the specialist hospital is located are different to those for where Child F lives, as the respective areas are covered by different safeguarding partnerships (and two different police forces). Halton partnership business staff have taken over the responsibility to convene future SUDIC meetings for children in their area who die at the PICU pending a review of this aspect of the pan-Cheshire arrangements. 4.35. In their contact with ICART, the police and both hospitals mentioned the existence of Sibling. Police made contact with ICART via email to request information on the family such as family composition and details for parents and Sibling. The email from the police reports it was an ALTE incident, but which could well progress to a SUDIC. Practitioners told this review that despite a contact being loaded on the electronic record for each child pending further information from Police and ICART, it would have been preferable if ICART had been more proactive, for example by seeking more information by telephone from the hospital and liaised with the police. Although there were no safeguarding concerns known initially, the Emergency Duty Team (EDT) and the police would subsequently have been better placed to respond to both children’s needs once they received confirmation that Child F had non accidental injuries, in the early evening, via the specialist hospital safeguarding consultant. Risks to Sibling were considered by EDT social care staff, the time of day meant that her eventual placement with Emergency foster carers was not until the early hours of the morning. This is not ideal for any child but can happen if it is not known for sure until the evening that a placement will be needed.27 4.36. Local hospital practitioners told this review of their perception that partner agencies are sometimes confused about the expected response to ALTE when there are no immediate safeguarding concerns. This view was shared by the police. Since the death that prompted this review the local Sudden Unexpected Death of an Infant SUDIC procedures have been reviewed and the new ones28 make more explicit mention of ALTE both in the title and the content. However, the document is almost entirely focused on SUDIC, it is very lengthy and not easy to navigate. It is difficult to locate references to ALTE, which do not recognise that despite many ALTEs are the result of NAI, but that this is often not apparent immediately, as in this case.29 The required initial response from ICART, where there are no immediately obvious safeguarding concerns (to check records for current and previous involvement and provide information to hospital staff and the police about the family background), remains the same. Practitioners suggested that there would be benefits in considering separating out the ALTE element from the SUDIC guidance to make them more visible; perhaps developing a standalone flowchart and separate forms rather than having to adapt the ones referring to a child’s death as practitioners currently must. In addition, they suggested for example, that it would be beneficial to convene strategy meetings under the safeguarding procedures as these can be subsequently ceased if they turn out not to be necessary. This suggestion is much more practical than it would have been prior to the development of virtual meetings due to covid. 4.37. The Children Act 1989 requires that the first consideration in placing children away from their parents should be whether they can be placed with other family members. Emergency Duty Team (EDT) 27 Speculative requests for foster carers are hard to manage as many of them are subsequently not required. 28 (Pan Cheshire) April 2021 Sudden Unexpected Death of an Infant (SUDIC)or Child and Acute Life-Threatening Event (ALTE) that are unexplained and/or suspicious requiring resuscitation and intensive care interventions in children 29 Ibid page 59 reference to the guidance being used for “cases of ALTE (Acute Life-Threatening event) where the child may have survived but is highly likely to suffer / has suffered significant harm. 15 staff felt this was not safe or practical at the time of day a placement was needed. The usual local practice is that children placed with Emergency Carers are moved on within 6 days. Sibling stayed with Emergency Carers for 4 weeks, an exception had been made to ensure a placement was found where Sibling could then stay as long as might be needed. Several family members had put themselves forward to be considered as temporary foster carers pending more detailed assessment. Unfortunately, this was not feasible due to the early stage of police enquiries which meant it was not possible to be clear who had had care of Child F during the time when the injuries had been caused. Arrangements were subsequently made for full kinship fostering assessments of those relatives to be undertaken by a social worker who spoke the same first language. 4.38. The local authority was not able to secure a placement with foster carers whose first language and culture was the same as that of Sibling. This would be difficult in most local authorities unless there was a large settled relevant community nearby, which there isn’t in this case. The local authority was able to find a carer from the same background who did not have a vacancy, but who was able to provide advice to the Emergency Carers. Records show that the subsequent foster carers have worked well with members of Sibling’s family members, who have provided food and information about special days in their country of origin. One of the carers has begun to learn Siblings first language. Summary of learning: The arrangements to safeguard and promote the wellbeing of Child F and his sibling Recognition that for disabled children signs of abuse can be masked or misinterpreted due to assumptions about ongoing health conditions or impairments The challenges of agencies working across different geographic or organisational boundaries when different procedures apply in different areas The importance of recognising the potential for Acute Life-Threatening Events (ALTEs) to later turn out to be due to abuse See recommendation B 5. PARENTS’ VIEWS 5.1. The author obtained feedback about services received from each parent separately using video technology. Overall, both parents felt generally felt positive about the care and support they and Child F received after his birth, while he was in hospital and after he came home. Mother said it was important that practitioners provided emotional support for the parents, as well as good care for sick babies and Father said the treatment had improved Child F’s health. Both parents appreciated that practitioners routinely involved interpreters. Mother felt the practitioners she met were helpful and gave her information about how to care for Child F and gave her benefits advice, access to free milk and syringes. Father mentioned appreciating meals being provided for them at hospital and help to apply for the Disabled Living Allowance benefit for Child F. 5.2. Mother said she understood what she was being told about Child F. She felt that she got more information about Child F’s health conditions than she might have received in her country of origin. Specific information she particularly remembered is being given the leaflet (in her first language) about crying and not shaking babies and support to get information from the internet about Child F’s health conditions. Father did not feel the range of health conditions that affected Child F were fully explained to him and seemed to think that these were additional to rather than being associated with the Down’s Syndrome. He felt information was given to his wife primarily rather than him. 16 5.3. Mother mentioned two things as being particularly difficult. One was not having much money so it was difficult to go and see Child F in hospital, especially when he was in the specialist hospital due to the distance. The other was Sibling having to live with Foster Carers, but that her sisters had been able to reassure to reassure her that Sibling was being well looked after. Father asked for information about how Sibling was doing and for a photo of her; these requests were passed onto the social worker. 6. POSITIVE PRACTICE When undertaking a review, it is important to also consider the kind of positive practice that might have broader applicability to protecting or supporting other children and families. This case includes the following examples that have not been previously mentioned in this report. Protective and supportive actions by practitioners Because of Child F’s complex health needs and knowing she would be significantly involved with the family once he was discharged home, the health visitor conducted the primary visit in hospital. instead of waiting until the baby had been discharged, which was more common practice. Trial run of parent administered medication and accessing support arrangements with Hospital at Home nurse as part of discharge planning Detailed schedule of support and visits drawn up and delivered for the early days after Child F’s discharge home. This included weekly visits by health visitor after taking over care from hospital at home team; growth monitoring, on-going assessment of health needs, view of living and sleeping areas and observation of positive interactions with Mother and Father. Child F had also been placed on “open door” with local hospital paediatric service which meant he could be brought at any time without an appointment The Police family liaison officer collected Siblings personal belongings to help Sibling feel more at home with the foster carers. information from health visitor records about Sibling liking drawing was shared with the foster carers Practitioners in contact with Sibling after her admission to care recognised that apparent signs of developmental delay might be temporary due to the trauma of being removed from her family The complex needs nurse recognised that the parents would need help to complete the remainder of the DLA form over and above her completing the section for professionals and arranged for an interpreter to support her to assist them with this The Early Help Officer identified and attended training on working with children and families whose first language is not English The parents were enabled to be with Child F when he died. The CAFCASS guardian appointed for the care proceedings could speak directly to Sibling as she spoke the same language The health visitor made a visit to Sibling within a few days of the placement with foster carers, a 2nd follow up visit a week later The Family Placement service identified someone who spoke the same language to complete the assessments family members as potential kinship foster carers 7. CONCLUSIONS AND LESSONS LEARNED One of the national triennial studies of Serious Case Reviews concluded that “For many of the children, the harms they suffered occurred in spite of all the work that professionals were doing to 17 support and protect them”.30 This applies to this case where there were many examples of positive practice, including support which Mother and Father specifically mentioned they appreciated, and there were no indications that Child F was likely to come to significant harm until the discovery of the injuries that prompted this review. Nonetheless there were examples of where services could have been more proactive in ensuring the family received some elements of support earlier. Consequently, there are some areas of learning which will enable local agencies to improve services for other children who are born with serious health conditions, especially if their families have recently arrived in the UK with English not being their first language. 8. RECOMMENDATIONS The individual agency reports have made single agency recommendations. Halton Children and Young People Safeguarding Partnership Safeguarding Children Partnership (HCYPSP) has accepted these and will ensure their implementation is monitored. To address the multi-agency learning, this Child Safeguarding Practice Review identified the following recommendations for HCYPSP. A) That HCYPSP seeks assurance from partner agencies that they have or will develop training and briefing materials for practitioners about working with BAME people. This should include; a. Input on the cultural background of BAME groups now living in Halton. Training should include how to find out about unfamiliar families’ cultural backgrounds b. meeting needs of people whose first language isn’t English including working with interpreters B) That HCYPSP share the learning form this review with the Child Death Overview Panel (CDOP) and request they ensure this is considered in the current work being undertaken on revision and implementation of the SUDIC procedures. This should include the development and dissemination of a specific ALTE pathway flowchart. The ALTE element might be usefully informed by data collection regarding the percentage of ALTE that are subsequently identified as NAI. The effectiveness of the new guidance might be measured by a baseline audit now regarding awareness of ALTE repeated 12 months after the new procedure has been implemented C) That HCYPSP seeks assurance from all hospitals caring for local children that arrangements are in place to improve practitioner awareness about practical and financial help for parents with children in hospital, this could include requesting an organisation with relevant specialist knowledge to produce briefing materials D) That HCYPSP seeks assurance all hospitals caring for local children and Children’s Services that arrangements are in place to improve practitioner awareness about assessment entitlement for children if they stay in one or more hospital settings for 3 or more consecutive months and for parents caring for disabled children. This will require clarity from Children’s Services about how to manage situations where both assessments might be required. E) That HCYPSP Seek assurance from relevant hospital and community trust health partners that they are considering how best to improve information sharing between Neonatal and Paediatric Intensive Care services and midwifery and health visiting services. 30 Sidebottam P et al (2016) Pathways to harm pathways to protection; a triennial analysis of Serious Case Reviews 2011-14 Department for Education 18 F) That HCYPSP seek assurance from all hospitals that provide neonatal care for babies living locally that they have effective pathways to enable staff to break the news and provide prompt support for families whose babies are diagnosed with an unexpected health condition or disability. G) That HCYPSP seeks assurance from each agency involved in this review that learning points have been identified and action has been/or is being taken to address and disseminate them. |
NC51234 | Death of a 5-year-old boy in June 2018. Mother killed herself and Child H during planned unsupervised contact outside the family home. Parents had separated following incidents of domestic violence by mother against father and Child H's adult half siblings. Maternal history of sexual abuse by her father and mental health problems from 1998; she was treated for depression with anti-depressants up to 2014. Family known only to universal services until April 2018. The family are white British. Findings: information about the mother's mental health history was not passed on to the health visitor so her initial assessment did not take this into account; most professionals did not immediately consider the issue of the mother's employment when assessing risk following the incident of domestic abuse; the DASH risk assessment tool has insufficient focus on emotional abuse and mental health issues and too much focus on physical harm; male victims of domestic abuse do not see themselves as victims; mother's relationship with Child H could be described as enmeshed which may explain the homicide-suicide incident. Recommendations to the LSCB: to require Kent Police to resolve difficulties causing delays in providing CAFCASS with relevant information when they are undertaking safeguarding checks; to ensure when Police Officers take a person to hospital it is possible to pass on relevant information confidentially to a clinician in a speedy time-frame; to develop an increased understanding of the needs of men as victims of domestic abuse and what this means about the nature of services provided.
| Title: Report of the serious case review regarding Child H. LSCB: Kent Safeguarding Children Board Author: Fiona Johnson Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 REPORT OF THE SERIOUS CASE REVIEW REGARDING Child H 2 CONTENTS 1 Introduction 3 2 Summary of Facts 4 3 Views of Family 10 4 Analysis 10 5 Lessons Learned from the Review 16 6 Conclusions 19 7 Recommendations 20 Appendix 1: Bibliography 21 3 1 INTRODUCTION 1.1 Background to the Review 1.1.1 This review was commissioned by Kent Safeguarding Children Board as a Serious Case Review (SCR) following recommendations to the Board’s Independent Chair that the circumstances met the statutory criteria for an SCR because a child had died, and the circumstances of the death indicated it to be the result of abuse or neglect. The criteria being: (a) abuse or neglect of a child is known or suspected; and (b) (i) the child has died1 This recommendation was confirmed by the Chair on 19th July 2018 and was reported to the National Panel on 23rd July 2018; who confirmed their agreement to the decision on the 26th July 2018. 1.2 The Terms of Reference 1.2.1 Under specific terms of reference, all agencies were asked to report on their work under the following headings: - • What was life like for the child in this family? • What was the impact of single-agency and multi-agency working? • How were assessments, including risk assessments, undertaken? • What support was provided to the mother regarding her mental health problems, what consideration was given to how they might impinge on her capacity/role as a counsellor, what impact did the mother’s role have on how agencies responded to concerns within the family? • Did the fact that the father was the victim in the domestic abuse impact on how agencies dealt with the family? 1.2.2 The time frame of the review was from 1st June 2017 to 17th June 2018. In addition, agencies were asked to provide a brief background of any significant events and safeguarding issues in respect of Child H’s immediate family that fell outside the timeframe if agencies considered that it would add value and learning to the serious case review. 1.3 Review Process 1.3.1 The review was conducted using a systems methodology that: - • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and 1 Working Together to Safeguard Children, 2015 4:18 p 76 4 • makes use of relevant research and case evidence to inform the findings. 2 1.3.2 Individual agency reports were received from the following sources: - • Kent Police • Kent County Council (KCC) Children’s Social Work Services (CSWS), Early Help, and Local Authority Designated Officer (LADO) • Education Safeguarding: The Education People commissioned by KCC – including School and Childminding • Kent Community Health Foundation Trust (KCHFT) • District council • A Kent NHS Trust • Primary Care – General Practitioner (GP) services • A third sector counselling service based in Kent where mother was employed • Children and Family Court Advisory and Support Service (CAFCASS) 1.3.3 A key part of the methodology was contact with frontline professionals who had been involved with the family. There were two meetings: a workshop where frontline practitioners and their managers examined inter-agency working; and a recall day, where the same professionals discussed the first draft of the report. 1.3.4 The Lead Reviewer was Fiona Johnson, an independent Social Work consultant who was Head of Children’s Safeguards and Quality Assurance in East Sussex County Council between 2004 and 2010. Fiona qualified as a social worker in 1982 and has been a senior manager in children’s services since 1997, contributing to the development of strategy and operational services with a focus on safeguarding and child protection. She is independent of Kent SCB and its partner agencies, although she previously worked for Kent County Council as the Independent Chair of one of their foster panels. 1.4 Parallel Processes 1.4.1 There were no ongoing criminal proceedings during the review, however, the coronial process was ongoing and had not been completed at the time of writing this report. 1.5 Family Input to the Review The father and adult half-siblings of Child H were invited to contribute to the review and the Lead Reviewer and LSCB Board Manager met with them all, together. Their input to the review is detailed in section 3 of the report. 2 SUMMARY OF FACTS 2.1 Family composition Family member Age at the time of the child’s death Child H 5 years Half-Sibling 1 22 years Half-Sibling 2 21 years Mother 42 years Father 45 years 2 HM Government, (2015) Working together to safeguard children A guide to inter-agency working to safeguard and promote the welfare of children. London: Crown copyright 2015. [accessed 15/6/2015] 5 This was a white British family who were living in owner-occupied accommodation, both parents were in employment (albeit mother had been off work sick for some time), the Half Siblings were also in employment or further education. 2.2 Background History 2.2.1 A significant feature of this review was that agencies had limited information about the family history and until April 2018, the only professionals in contact with the family were the GP, the childminder and school staff. The GP had a full history of mother having mental health problems from 1998; this included her having a paracetamol overdose in 1998, being deemed a high risk for a further overdose in 2004, having a history of sexual abuse by her father and experiencing domestic abuse in her relationship with the father of half-sibling 1 and half-sibling 2. Mother was referred to a psychiatrist in 2004, and in 2005 reported having a car accident, suggesting it was intentional. Following this she was treated for depression with anti-depressants and received psychotherapy; she ceased to take medication for depression in 2014. 2.2.2 Mother became pregnant with Child H in 2012. This was an unplanned pregnancy and did not progress smoothly as Child H was found to be a Cystic Fibrosis carrier3 and mother was treated for probable Idiopathic Thrombocytopenia Purpura4. Midwifery had full access to the GP records and midwives were aware of mother’s past mental health history; there is no evidence of anything untoward regarding this during the pregnancy. After the birth there was routine contact with mother and Child H by GP and midwife, and no concerns were noted. 2.2.3 The health visitor also had minimal contact with Child H. The child was seen for the new-birth visit but did not attend the 2-year developmental assessment. The health visitor was unaware of mother’s history of mental health problems, sexual abuse and domestic abuse as mother did not report any issues and it does not appear that the information was shared by the midwife. Mother did not present as having any problems and so there was no requirement for the health visitor to contact her when she did not bring Child H for the assessment. 2.2.4 Mother was known to the Police because of an alleged historical indecent assault by her father. They also were involved in two further investigations prior to the birth of Child H; one a harassment incident where it was alleged that mother was stealing from a charity, another domestic incident involving her sister; neither allegations resulted in prosecution. 2.2.5 Children’s Social Work Service (CSWS) had only one contact with mother which was a request for respite support in caring for half-sibling 2 who was diagnosed with as having Autistic Spectrum Disorder (Asperger’s)5 and Attention Deficit Hyperactivity Disorder. This was resolved by recommending closer working with school support services. 3 Cystic fibrosis (CF) is a genetic condition affecting more than 10,400 people in the UK. You are born with CF and cannot catch it later in life, but one in 25 of us carries the faulty gene that causes it, usually without knowing. ‘Carriers’ of a faulty cystic fibrosis gene are not affected by the condition. The gene affected by CF controls the movement of salt and water in and out of cells. https://www.cysticfibrosis.org.uk/what-is-cystic-fibrosis 4 Immune thrombocytopenic purpura (ITP) is a condition which causes the number of platelets in your blood to be reduced. ... If you do not have enough platelets in your blood, you are likely to bruise very easily or may be unable to stop bleeding if you cut yourself. https://www.ouh.nhs.uk/patient-guide/leflets/files/12388Pitp.pdf 5 Autism spectrum disorder (ASD) is the name for a range of similar conditions, including Asperger syndrome, that affect a person's social interaction, communication, interests and behaviour. https://www.nhs.uk/conditions/autism/ Attention deficit hyperactivity disorder (ADHD) is a behavioural disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness. Symptoms of ADHD tend to be noticed at an early age and may become more noticeable when a child's circumstances change, such as when they start school https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/ 6 2.2.6 In September 2017, mother started a new job as a children’s counsellor with a voluntary sector provider. In October 2017, mother was on a family holiday abroad and had an accident where she damaged her knee and was off sick from work. From 1st November 2017, there were seven sick notes issued by the GP for mother, and from February 2018 mention was also made of back-ache. From March 2018 mother was treated with amitriptyline (an anti-depressant) for pain relief. 2.2.7 Child H started attending school in September 2017. Mother and father also utilised wraparound childcare through access to a breakfast club, delivered as part of the school’s extended school provision, and with a local childminder. Initially there were problems with Child H’s school attendance (which was 83%). The mother’s explanation was that the absences were due to illness, Child H had a diagnosis of asthma and mother advised that Child H take paracetamol everyday (previously prescribed) due to the child having asthma, however, school staff did not consider this to be appropriate and asked that this be discussed with a health professional. A school health care plan was drawn up and the child’s school attendance improved (remaining above 90%). Child H’s name was also added to the Special Educational Needs Register6, at the parents’ request, but by April 2018 the school had not observed any special educational needs so after informing the parents the name was removed from the register. 2.2.8 Child H had a Ventolin inhaler and the childminder was aware of it, but never used it, as there were no asthma attacks observed. In February 2018, mother responded to a health needs questionnaire sent by the school nursing service requesting support and describing Child H as having autism. In this response, mother said she was in contact with the GP about an assessment, however, there is no evidence that this was requested. In March 2018 Child H was seen by a staff nurse at the GP practice because mother reported that the asthma was poorly controlled, and the child was using an inhaler daily. This was not a positive consultation as mother was very resistant to the advice being given. 2.3 Key episode 1: Domestic abuse incidents (10/4/18 - 12/4/18) 2.3.1 On 10th April 2018, Kent Police were called to the family home by half-sibling 1. There had been a dispute between half-sibling 1 and mother. Mother was wanting respite away from the family home and intended to take Child H with her, but the family would not agree to this. There was also a dispute about the dog (which was owned by half-sibling 2) as mother was attempting to re-home the dog without the agreement of the family. Half-Sibling 1 had attempted to remove the dog and Child H from the argument, and at that point mother punched half-sibling 1 in the back. The Police Officers attending spoke to all family members present and after some negotiation it was agreed that they would escort mother to the hospital (with a neighbour) as the family felt that she needed professional help because she was stressed. The family agreed they did not want mother to be charged but wanted her to receive help for her mental health problems. The Police Officers completed a Domestic Abuse, Stalking and Harassment and Honour Based Violence (DASH) assessment checklist7 with family members and half-sibling 1 and 2 disclosed some past abuse by their mother. Father also reported that mother would threaten ‘to kick the [older] children out of the home’ but said that he would never allow that to happen. 6 Special Educational Needs (SEN) is a legal term. It describes the needs of a child who has a difficulty or disability which makes learning harder for them than for other children their age. Around one in five children has SEN at some point during their school years. http://www.bbc.co.uk/schools/parents/identifying_sen/ 7 A Dash checklist is a risk identification tool that is aimed at enabling front line professionals to identify the risk of serious harm in cases of domestic abuse. 7 2.3.2 Mother was taken to the hospital by the Police but there was no direct handover of information from the Police Officers to hospital clinical staff and mother was left in Accident & Emergency with the neighbour. Mother waited for three hours at the hospital, and when she was seen by the Doctor, she reported that there had been an argument at home and half-sibling 1, who was upset by this, had called the Police. Mother was very tearful and said that she did not feel that she required any mental health services. The Doctor undertook a comprehensive assessment; however, he did not contact the Police as this would not routinely be expected. His assessment was that mother seemed very capable and clear about what had happened. The Doctor did ask about Child H and gained the impression that the child was with father and safe. The Doctors were not aware that mother was potentially a perpetrator of domestic abuse. 2.3.3 On 11th April 2018, father told the GP about the domestic incident the previous day and also contacted CSWS who advised that he seek legal advice regarding ‘custody’ arrangements where Child H would live. Later that day Kent Police were again called to the family home because of a family dispute. On this occasion father called the Police because mother was being verbally abusive and was trying to take Child H from the family home. On this occasion the Police Officers were told that during the dispute mother had said ‘all my kids are dead to me’ the family also said that Child H did not want to leave with mother. The family were clear that they did not want mother to be criminalised but wanted her to leave the property and seek help. The Officers advised mother to leave the property and seek GP help and she complied. A DASH assessment checklist was undertaken and assessed as medium risk; the Officers were informed about two historic incidences, one six months prior where she had thrown a wooden toy at father and another more historic where she threw a laptop at one of the half-siblings causing an injury to the leg. The Officers spoke to father and provided safety advice and signposted him to the relevant resources. 2.3.4 On 12th April 2018, father again contacted Kent Police as mother was refusing to leave the family home. Mother had returned to the home to remove property but would not leave; the couple had decided the previous weekend to dissolve their relationship. The Police Officers who attended that incident advised her to leave and not return and their stance was much stronger and less supportive to the mother than previously, eventually she left. 2.4 Key episode 2: Father takes actions to protect Child H (13/4/18 –16/4/18) 2.4.1 On 13th April 2018, father made an ex-parte8 application to the family court for a Child Arrangements Order (for Child H to live with him) and a Prohibited Steps Order (PSO), to prevent mother removing Child H from the family home or collecting the child from school or the childminder; the court granted a PSO on 16th April. As a result of this application, on 17th April 2018 the case was allocated in CAFCASS9, screened and information was requested from Kent CSWS. From the screening of the application Child H was safe, as the child was in the care of father, who had acted appropriately through seeking protective measures. 2.4.2 On 16th April 2018, a senior practitioner from CSWS contacted both parents to discuss the domestic abuse incidents. The CSWS worker offered to mediate within the family, however, 8 Latin meaning "for one party," referring to motions, hearings or orders granted on the request of and for the benefit of one party only. ... Ex parte matters are usually temporary orders (like a restraining order or temporary custody) pending a formal hearing or an emergency request for a continuance http://dictionary.law.com/Default.aspx?selected=696 9 Children and Family Court Advisory and Support Service. CAFCASS represents children in family court cases in England. Their duty is to safeguard and promote the welfare of children going through the family justice system. CAFCASS Family Court Advisers may be asked by the court to work with families and then advise the court on what is considered to be the best interests of the children – they are involved in three main areas: • divorce and separation, sometimes called ‘private law’, where parents or carers can’t agree on arrangements for their children • care proceedings, sometimes called ‘public law’, where Social Services have serious concerns about the safety or welfare of a child • adoption, which can be either public or private law. 8 father declined as he felt he was managing the situation and monitoring and supervising the contact. At this stage CSWS became aware of mother’s job and advised her that they would be making a referral to the LADO10 service. The CSWS discussed the matter with a LADO but did not make a written referral as that was not the system at the time. The LADO determined there was no need to take action as mother had not been charged or cautioned by the Police. This conversation was recorded on the CSWS database, but the LADO did not record it on their system. The CSWS worker also offered mother support via Early Help Services which she refused. Social work staff undertook checks with Police but there was no contact with health or education professionals and the case was closed on 27th April 2018. 2.4.3 On 16th April 2018, father talked to school staff about the domestic abuse incidents and the PSO. He had emailed them earlier, but the school was closed because of the Easter holidays. They agreed arrangements for collection of Child H from school and childminder. 2.5 Key episode 3: Mother makes homeless application (25/4/18 – 9/5/18) 2.5.1 On 25th April 2018, mother made a homeless application to the local District Council. She alleged emotional abuse by father and said that Child H was living with her and that they were both staying with a friend, she also said she cannot work because of health issues. The same day the GP wrote a letter for mother requesting re-housing because she was homeless. 2.5.2 On the 3rd May 2018, mother met with her line-manager at the counselling service and phased return to work was discussed but mother not able to commit as she felt her health was still too poor. Mother was advised that her statutory sick pay ended on 9th May 2018. 2.5.3 On 9th May 2018, the Housing Officer met with mother at her friend’s house and during the interview identified that Child H was living with father and that there was a court process ongoing regarding where the child should live. 2.6 Key episode 4: CAFCASS and court assessment (8/5/18 - 7/6/18) 2.6.1 The CAFCASS risk assessment was progressed in May 2018. On 8th May Police National Computer (PNC) checks were requested and a further request was made to Kent CSWS for information, as no response had been received to the initial request. On 13th May 2018 Information was received from Kent CSWS stating there had been “Contact from Step- father (father) with concerns regarding mother’s behaviour during contact. Mother advised to seek legal advice. No Further Action.” On 21st May PNC information was returned stating no record in respect of either party. 2.6.2 On 31st May 2018, the CAFCASS worker undertook a telephone interview with father. He advised that the application had been issued as mother had attempted to remove Child H from his care. Child H was distressed by this episode, during which father advised that mother assaulted one of her adult children. The Police had been called and he understood they had taken mother to hospital for a mental health assessment. He made allegations that Child H had witnessed domestic abuse perpetrated by mother against himself and her adult child. He noted that he did not know where mother was living and that she had used social media for family pets to be rehomed. Following the making of the PSO he had supported and facilitated contact between Child H and mother. 10 A Local Authority Designated Officer (LADO) works within each Local Authority area and is there to support staff across all organisations who work with children and young people if any concerns arise regarding any practitioner who works with children and young people. 9 2.6.3 On 4th June 2018, the same CAFCASS worker interviewed mother. She advised that she had medical evidence that she did not have mental health difficulties, and that she had regular treatment for physical injuries sustained in an accident in 2017. There was, she said, no domestic abuse between herself and Child H’s father. She did not believe that father would place Child H at risk of significant harm but expressed concerns about his ability to meet Child H’s medical and dietary needs. Between April and May half term her time with Child H had been supervised by father; in the half term it had been unsupervised. Mother wanted Child H to live with her. A follow up call made by the worker later that day clarified mother’s account of the incident on 11/04/18. Mother denied assaulting her adult child but acknowledged that it was sad Child H had witnessed the incident. 2.6.4 On 7th June 2018, there was a Child Arrangements Order hearing in the Family Court. A different CAFCASS worker met with father prior to the hearing. Father repeated much of the information he shared in the telephone interview; he had legal representation. He had been facilitating supervised contact and had recently agreed to unsupervised day time contact. Father shared new information that mother was a psychotherapist employed by a local community sector organisation providing services to children; that the school informed him that mother had requested they administer paracetamol to Child H on a regular basis and that mother presented with worrying behaviours and narcissistic tendencies. Mother initially declined to meet with the CAFCASS worker, as her solicitor was not present. Her solicitor did not attend court and mother later agreed to speak with another CAFCASS worker. Mother denied the allegations raised by father. She did not share the letter of discharge from hospital but did share two letters, one confirming she was a patient at her GP’s practice, the other she indicated was proof of accommodation. This was not evident from the correspondence which read as if Child H was living in her care. On 7th June, mother was offered temporary accommodation by the Housing Department, however, following discussion with her friend she chose to remain living with her as she said she was in too much pain to move to a new house at that time. 2.6.5 The outcome of the court hearing was that CAFCASS should complete a Section 7 report11. The court also ordered that Child H would continue to spend unsupervised time with mother each Saturday or Sunday and the parents were to attend a Separated Parents Information Programme (SPIP). Mother was unhappy with this outcome as she had expected to leave court with Child H on the day of the court case. She found it difficult to accept that the court would not make a decision that day and was aggressive with the CAFCASS worker who reported that mother expected to have at least overnight contact. 2.7 Key episode 5: Mother meets employer to discuss employment (8/6/18 -13/6/18) 2.7.1 On 8th June 2018, there was further contact between mother and her employer to discuss the results of MRI scans. A meeting was arranged for the 13th June and following discussion about the length of time full recovery could require mother was advised that termination of employment was an option to be discussed. On the 13th June no plan for return to work could be agreed so termination of contract was discussed. 2.7.2 On 17th June 2018, Child H had planned contact with mother. When she failed to return Child H by the agreed time father contacted the Police. Later that evening mother killed herself and Child H. 11 This is a report produced by Cafcass to assist the court making decisions about what is in the best interests of a child – see glossary for more detail 10 3. VIEWS OF FAMILY 3.1 The surviving half-siblings describe mother as a ‘narcissist’12 who was only happy when she was the centre of attention. They said that she had isolated them as children from their wider family. They described an early childhood of physical and emotional abuse. The half-siblings did not appear to be aware of mother’s reported suicide attempts but instead referred to her attention seeking behaviour; they were clear that they did not consider mother’s injury to her knee to be as significant as she reported. They described the domestic incident with their aunt and said that this isolated them further. From discussion it did not appear that the half-siblings had discussed in detail their early childhood with Child H’s father prior to the Child H’s death. 3.2 The half-siblings and father reported that their major concern about mother was the emotional abuse that she would cause Child H. They did not see mother as someone who would deliberately cause Child H physical harm and they did not consider her a risk of suicide. 3.3 The family saw the first incident involving the Police as very significant as they felt mother needed help and that this should have been provided at this point. They were very upset that mother was trying to dispose of the family dog behind their back. They were also upset at the level of physical violence and felt that this was a change and was different from before. The half-siblings felt that their disclosure of previous abuse by mother was very significant for them as they had not previously told anyone. They were concerned that mother should receive help for her problems. 3.4 Once father had applied for the PSO and custody of Child H, he felt he had to do what the court ordered, but he did not see mother as a risk of physical harm to Child H so did not have concerns about the unsupervised contact. His major anxiety was about emotional harm in the longer term. 4 ANALYSIS 4.1 What was life like for the child in this family? 4.1.1 Child H was described by both the school and the childminder as being the “centre of the parents world” and “a very loved child”, almost to a point where parents could at times appear “overprotective”. Child H was clearly a happy child, and until the parents’ relationship deteriorated there were no concerns about the parents’ care from any agency. It is, however, clear that the child had been distressed by witnessing the arguments between mother and father and the childminder reported that the child talked to her about these events and was upset. That the child was able to show this distress, and share it with a known carer, would indicate that this was an unusual event and was not representative of usual behaviour by the parents. The school also reported that once mother had left the household, Child H settled and was seen to be happy in school and progressing well. 4.1.2 The only agencies who had significant contact with Child H in the early years were the school, childminder and GP. With hindsight it is possible there were some concerning aspects to mother’s anxiety about Child H’s health. She seemed very anxious for the child to be identified as having significant health problems including asthma (for which she asked 12 Narcissistic personality disorder involves a distorted self-image. Emotions can be unstable and intense, and there is excessive concern with vanity, prestige, power, and personal adequacy. There also tends to be a lack of empathy and an exaggerated sense of superiority https://www.medicalnewstoday.com/articles/9741.php 11 staff to give the child daily doses of paracetamol) and autism; she also asked the school to put the child’s name on the Special Educational Needs (SEN) register. It is noteworthy that neither the school nor the childminder who had regular contact with the child ever observed an asthma attack nor considered the child to be showing signs of autism. These concerns also do not seem to have been shared by father, and it is possible that mother was using these issues to gain attention from professionals. Whilst this may have been her intention, there is no evidence that there was inappropriate responses by professionals, in fact the school did not give the child paracetamol for the asthma and whilst they added the name to the SEN register this was for a short period and once it was clear that Child H did not have special educational needs the name was removed. 4.2 What was the impact of single-agency and multi-agency working? 4.2.1 There were two main periods of multi-agency working; the first was the immediate response to the domestic incidents between 10th and 12th April 2018 and the second was around the application to the family court by father for a child arrangement order regarding where Child H should live. 4.2.2 The main agency involved with the domestic abuse incidents was the Police and the staff involved on these three occasions worked hard to resolve the disputes between the parents in a way that safeguarded Child H but also addressed the concerns for mother that were being raised by her family. When they attended on the first occasion, on 10th April 2018, they were successful in enabling Child H’s immediate safety. They used the prescribed tools (DASH assessment forms) to gather background information about the family circumstances, and the level of risk posed by mother, which was deemed to be low. This information was shared with CSWS and Health, in a timely manner, in accordance with local protocols. It was not shared with the school as this was not the agreed process at that time. 4.2.3 The Police Officers acted proportionately, and in accordance with the family’s wishes, when they did not pursue prosecution of mother, but instead took her to the hospital in order that she could access mental health support services. Whilst they took her into the hospital, the officers did not talk directly to a health clinician about the reasons they had become involved; this meant that mother was able to present a very one-sided perspective of events when seen by the Doctors and she denied having any mental health problems. The Police Officers involved were clear that when they took mother to hospital it was in order to assist her to access support with her mental health and that if she had been unwilling to go there or leave the family home, they would have considered arresting her. They were also clear that her mental health needs did not warrant Police intervention under the Mental Health Act 1983 (Section 136)13 and it was only under such circumstances they would remain at the hospital and formally handover a patient to the mental health team. Clearly, given that mother waited three hours to be seen at the hospital, this would have added significantly to the time they would be committed, in the event the Police Officers were involved with the family for over six hours. 4.2.4 The Police Officers spoke to the hospital receptionist when leaving mother at the hospital, and the Doctor who saw mother was aware that she had been brought by the Police, and if there was concern contact could have been made to gain more information. As it was mother’s explanation was taken at face value, in part, because she presented in a calm and reasonable manner and did not show any signs of distress or impaired mental health. An assumption was made that as the Police had “dropped her off”, they had no acute concern or information to share. Within the reported information from mother she stated that half- 13 Section 136 is an emergency power which allows a person to be taken to a place of safety from a public place, if a Police Officer considers that they are suffering from mental illness and in need of immediate care. https://www.rethink.org/living-with-mental-illness/police-courts-prison/section-136-police-taking-you-to-a-place-of-safety-from-a-public-place 12 sibling 1 called the Police because of distress about the reports of mother wishing to leave the family home. 4.2.5 The DASH assessment form was used again when the Police were called by father on 11th April because mother was being verbally abusive and was trying to take Child H from the family home. On that occasion the risk assessment was deemed medium indicating that there was increased concern about mother’s behaviour. This information was again shared in a timely manner with CSWS and health professionals in accordance with the protocols in place at the time. When the Police were called for a third occasion on 12th April 2018 the DASH assessment tool was not completed, however, it is noteworthy that the Police Officers were firm in advising mother to leave the property and were clear that if she did not do so she would be arrested. 4.2.6 In ‘Everyone’s business: Improving the Police response to domestic abuse’14 it is stated that the ‘duty of Police Officers when attending the scene of domestic abuse is to protect the victim and any children from further harm. Where a power of arrest exists, the alleged offender should normally be arrested. Police officers should not base a decision to arrest or not to arrest on the willingness of a victim to testify in subsequent proceedings.’ It goes on to state that ‘Here, as in all other areas of Police work, the focus should be on investigating and prosecuting offences (and preventing further offences against persons or property) in the public interest’ and says that ACPO15 guidance ‘that where an offence has been committed in a domestic abuse case, arrest will normally be necessary’. This approach is clarified further in the local Kent Police guidance which states ‘Where a substantive offence has been committed, or is suspected to have been committed, there will be a presumption in favour of arrest; the decision to arrest is for the attending Police Officers. Officers must be able to justify the decision not to arrest where the grounds exist, and it would be a necessary and proportionate response. In some situations, other positive approaches may be more appropriate, i.e. when the behaviour does not amount to criminal conduct’.16 The Police Officers who attended the workshop (who had been present on the 10th April 2018) were clear that they could have used the power of arrest with regards to mother if she had refused to leave the property, but also felt that she was presenting with some mental health difficulties which were best resolved by her receiving medical help, their decision to take her to hospital therefore, appears eminently reasonable. It is not clear that the threshold for arrest would have been met on the two subsequent days despite there being some escalation in the perceived risk of domestic abuse. 4.2.7 The application by father for a child arrangement order immediately triggered a CAFCASS safeguarding assessment which is a multi-agency process in that it requires CAFCASS officers to gather information from other agencies to inform their risk assessment. CAFCASS requested information from CSWS immediately and when this was not received made a follow-up request on 8th May 2018. CSWS confirm that they received two requests for support from CAFCASS, the first on the 19th April 2018 and the second on the 8th May 2018 and report that CSWS responded to these requests on the 3rd May 2018 and 10th May 2018 respectively. However, neither response was loaded onto the databases until 27th and 28th June 2018 due to administrative delays in the team at that time. CSWS confirm that their first response to CAFCASS included the detailed discussions with father about the incidents in April, however, at this time CSWS had also received two Domestic Abuse Notifications (DANs) from the Police that were not shared. The DANs did not, however, hold any additional information beyond that which the father had already shared. Regarding the second response to CAFCASS, this comprised a short summary which did not fully reflect the history held by the CSWS. CSWS was not able to explain why the second response did not include the full detail, apart from to say that that they would not consider the additional 14 Everyone’s business: Improving the police response to domestic abuse ISBN: 978-1-78246-381-8 www.hmic.gov.uk © HMIC 2014 15 Association of Chief Police Officers (UK) 16 Duty of Positive Action (excerpt from DA Policy N07a) Kent Police Procedures 13 information pertinent as the relevant information had already been shared. This was surprising, as the second request from CAFCASS clearly indicated that they had not received a response to their first application for information. 4.2.8 The information from CSWS was particularly important because CAFCASS when requesting information from the Police have a two-stage process. The first is a PNC check which was requested on 8th May and for which a nil return was received on the 21st May 2018. When CAFCASS are aware that there may be information held by the local Police that is not on the PNC, (such as involvement with domestic disputes where no charges are pressed) they make contact direct with the local Police, but this is not done routinely. In this case when the CAFCASS worker became aware (from the telephone interview with father at the end of May) that the Police had been involved she requested Level 2 checks with Kent Police. At that stage the PNC check had shown a nil return, and CAFCASS’ knowledge of Police involvement was based upon father’s disclosure. 4.3 How were assessments, including risk assessments, undertaken? 4.3.1 Routine assessments were undertaken by midwifery, health visiting and the school. None of these assessments highlighted anything of concern and therefore, there were no further risk assessments regarding Child H. It is probable that if the health visitor had been aware of mother’s full mental health history there would have been a further visit and greater consideration of the risk of post-natal depression, however, there is no evidence, even with hindsight, that mother was suffering depression and certainly nothing to suggest concerns about the care provided to Child H during the early years. 4.3.2 The Police Officers involved with the family in April 2018 appropriately completed DASH assessments using the risk assessment tool. They assessed the first incident as low -risk and the second medium reflecting both an escalation in mother’s behaviour but also additional information that was provided by family members. The officers involved were clear about the need to protect Child H and intervened as necessary to support father in achieving this. Good advice was given to him and other family members about how to make the house secure and it was clear that the family were assisted by this which is why father called the Police again when mother continued to cause problems at the family home. 4.3.3 The CAFCASS safeguarding risk assessment, started on 17th April, was significantly undermined by the absence of clear information from partner agencies about the events between 10th and 12th April 2018. The purpose of the safeguarding assessment is to ascertain immediate risk as it is known that relationship breakdown and separation is a time when children are at greatest risk; it is, therefore, crucial that partner agencies share information speedily and in full detail. Parents frequently provide CAFCASS officers with contradictory information and are often critical of each other’s parenting; their task, therefore, is to identify those children who are at greatest risk. In this case neither parent identified risks to Child H of immediate significant harm meaning that in the absence of any contradictory information from other agencies it seemed reasonable to defer further intervention until the completion of the Section 717 report. The CAFCASS officer who 17 Section 7 report by CAFCASS The court will often ask CAFCASS to prepare a report which will assist in determining the outcome of a family court dispute. A CAFCASS officer will prepare this report after meeting with both parties and the child (alone where possible and only If the child has sufficient maturity and understanding). When writing a report, the CAFCASS officer will have specific regard to what is known as the ‘welfare checklist’. The CAFCASS officer, and eventually the Judge, will have considered the following when forming their conclusions: • the ascertainable wishes and feelings of the child concerned (considered in the light of his age and understanding) • his physical, emotional and educational needs • the likely effect on him of any change in his circumstances • his age, sex, background and any characteristics of his which the court considers relevant • any harm which he has suffered or is at risk of suffering • how capable each of his parents, and any other person in relation to whom the court considers the question to be relevant, is of meeting his needs 14 interviewed mother in court on 7th June, attended the workshop, and was clear that her assessment may have been different if she had received a fuller picture of events in April. At this point father reported that mother was working with children and the CAFCASS officer noted that the Local Authority Designated Officer (LADO) needed to be informed of the domestic abuse incidents, however, this was a matter left to be completed as part of the Section 7 report. 4.3.4 One area of risk assessment that was relevant in this case was the need to advise the LADO that a person who worked with children had: • Behaved in a way that has harmed a child, or may have harmed a child • Possibly committed a criminal offence against or related to a child, or • Behaved towards a child or children in a way that indicates he or she may pose a risk of harm to children 4.3.5 The procedures are clear that if the concern is not connected to the person’s employment or work activity, these procedures may also apply: • Where concerns arise about the person’s behaviour towards his/her own children or any other child. The Police and/or CSWS should consider if they need to inform the person’s employer and/or the LADO in order to assess whether there maybe implications for children with whom the person has contact at work • If an allegation relating to a child is made about a person who also undertakes paid or unpaid care of vulnerable adults, Safeguarding Adults’ procedures should be followed.18 4.3.6 A range of professionals were aware that mother had been involved in a domestic abuse incident that had been observed by Child H and that would have caused the child emotional distress. There was also some knowledge of allegations made by the child’s half-siblings of previous abuse when they were children. Two agencies were aware that mother’s employment involved her with contact with children, CSWS and CAFCASS. Professionals in both agencies noted the need to inform the LADO, however, in CAFCASS this was left as an action to be completed as part of the Section 7 report. The CSWS referral was an informal discussion that was not recorded on the LADO system and the LADO decided that they did not need to become involved as the Police had not charged or cautioned mother. The GP and Police were also aware that mother worked as a counsellor (and therefore, with vulnerable people) but not that she had contact with children. None of these professionals involved considered whether a referral to the LADO should be made, or whether Safeguarding Adults’ procedures should be followed. One reason for professionals’ decisions was that mother was known to be absent from work because of her health problems, however, it was also apparent that professionals were less aware of the LADO responsibilities where the behaviour of concern was outside of work. It is possible that this also underpinned the LADO decision although it has not been possible to check this as they have no record of the discussion. 4.4 What support was provided to the mother regarding her mental health problems, what consideration was given to how they might impinge on her capacity/role as a counsellor, what impact did the mother’s role have on how agencies responded to concerns within the family? 4.4.1 Both midwifery and Health Visiting undertook assessments of mother during and immediately after Child H’s birth. The midwives were aware of her mental health history, but • the range of powers available to the court under this Act in the proceedings in question. 18 Kent LSCB Procedures Local Authority Designated Officer (LADO) https://www.kscb.org.uk/procedures/local-authority-designated-officer-lado derived from Working Together 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf 15 this information was not known by the health visitor. No information was requested regarding the midwifery involvement as the birth of Child H occurred outside the terms of reference for this review therefore, there is no evidence to confirm whether the midwife shared the history and concerns relating to mother mental health with the health visitor. However, it is established from the health visitors records that they do not appear to be aware of her history which would have informed their assessment of her health needs. There is no suggestion that mother experienced any mental health difficulties during the pregnancy or after the birth, however, it was judged, with hindsight, that if mother’s mental health history had been known there would have been greater consideration of the possible risks of post-natal depression and closer monitoring of the progress of mother and Child H. 4.4.2 The Police risk assessment was strongly informed by family members’ perspective that mother had mental health difficulties and needed assistance in resolving her personal problems. They were aware of mother’s role as a counsellor and did consider that this might be a contributory factor to her mental health problems along with other identified concerns such as a previous partner who had committed suicide and her inability to work at that time due to an injury. As previously stated, there was no consideration of any risks that might be posed by mother in her professional role and therefore, no referral made to the LADO. 4.4.3 The initial assessment of mother at the hospital was undertaken using a Safeguarding and Managing Risk Tool (SMaRT) which provided a picture of a patient who was communicating well, compliant and reporting stress secondary to relationship difficulties. When assessed by a Doctor three hours past initial registering, that picture appeared to continue to be reflected and the judgement was that there were no acute psychiatric issues so mother could be discharged to a local hotel. The hospital had no record of mother’s employment and therefore, this was not considered in the assessment. Mother was also seen in an Orthopaedic Clinic and it was noted that she had “Finished course of physiotherapy but still struggling”. It was also documented that mother reported she was “struggling”, and the pain was “affecting her life”. Again, there was no record of any discussion with mother about the nature of her employment and no further discussion of her mental health which would have been beneficial. 4.5 Did the fact that the father was the victim in the domestic abuse impact on how agencies dealt with the family? 4.5.1 In their reports all agencies reported that they were clear that their staff treated father in the same way that they would respond to any victim of domestic abuse. This response, however, did not address an issue that was debated in full at the workshop which was that the father did not see himself as a victim and it is probable that the only reason that he involved the Police was because of concerns about Child H. It was noted that the Police Officers in responding saw father as a victim, however, he downplayed his victimhood and the school staff did not feel that he saw himself in that way. At the workshop, school staff confirmed this was a learning point for them as they were not aware that he was a victim of domestic abuse because when they were discussing it with him, mother had left the home. It was noted at the workshop that half-sibling 1 had initially called the Police and without their involvement father may not have disclosed the abuse. 4.5.2 Men do not always see themselves as victims of domestic abuse, at the workshop it was recognised that this is not unique to this case as domestic abuse is not seen as something that men usually experience. This means there is an onus on agencies not only to treat men in the same way that they treat women but instead to acknowledge how difficult it can be for men to report domestic abuse and to take that into account when judging the level of risk associated with domestic abuse incidents. 16 4.6 Identified good practice 4.6.1 The Police Officers who attended the first domestic abuse incident (which was a low-level incident where no issues were clearly identified) provided robust and supportive input to the family. They went above and beyond minimum requirements in their interventions to safeguard Child H and find a resolution that suited the whole family who reported that they found the Police intervention helpful and supportive. They also referred the family to CSWS in a timely manner. 4.6.2 The father was very good at alerting professionals in a range of agencies (school, childminder and CSWS) and the responses to him were consistent and supportive. Child H and the family were also well supported by the school, the medical concerns were managed in a proportionate way and it was clear that Child H was at the centre of their practice. 4.6.3 The assessment that was started by CAFCASS was a strong piece of work and they attempted to gain as much information as possible with which to assess the risks to Child H. 5 LESSONS LEARNED FROM THE REVIEW 5.1 Information sharing between agencies 5.1.1 In this case the GP records included reference to mother’s history and the midwife had direct access to GP records meaning the initial midwifery assessment was fully informed about the possible mental health risks. This information was not passed on to the health visitor meaning that her initial assessment did not take these matters into account. It is not clear why this information was not passed on. Health Visiting input to families is based on how a child and family present when seen but balanced with a knowledge of the family history meaning that it is important that all risk areas are shared by professionals. 5.1.2 An issue that was discussed at the workshop was information sharing with schools regarding domestic abuse incidents. In this case, in accordance with protocols in place at the time, the Police informed health professionals and CSWS about the domestic abuse incidents, but the school only heard about them from father, meaning they had a partial view and possibly were less aware of the risks posed by mother. It was noted that Operation Encompass19 (a process where Kent safeguarding agencies share information about domestic abuse incidents to help protect any children who are involved) is being rolled out across Kent and this will ensure schools are updated about any domestic abuse incident within 24 hours. 5.1.3 A specific difficulty identified in this review was the challenge for Police Officers in passing on relevant information to hospital staff when taking people to hospital on an informal basis. Police Officers, when they detain a person under Section 136 of the Mental Health Act 1983, would escort that person to hospital and then wait until they are seen by a clinician and at that point would share any relevant information. If, however, the individual does not meet the threshold for Police detention but agrees to attend hospital, it is more difficult to arrange appropriate information sharing. The Police Officers involved did escort mother to the hospital and spoke to the receptionist, but it was not appropriate to share more information in a public place. Currently there are no systems in place to enable Police Officers in these circumstances to quickly pass on relevant information to a clinician so that their assessment of the patient can be fully informed. 5.1.4 Another area where information sharing systems need to be improved was the provision of local information between Kent Police and CAFCASS. CAFCASS reported that there can be 19 https://www.kent.police.uk/advice/community-support/op-encompass/ 17 a delay of up to 16 weeks for a return of Level 2 checks by Kent Police and that it was not uncommon for a court order to be needed to guarantee release of the information to ensure CAFCASS was able to complete safeguarding activity. It is apparent that the absence of clear information from CSWS and Kent Police meant that CAFCASS were significantly hampered in their safeguarding assessment. 5.2 LADO referral processes – triggers and recording systems 5.2.1 This review has identified that most professionals did not immediately consider the issue of the mother’s employment when assessing the risks following the reports of the domestic abuse incident. One factor in this was that, whilst most professionals knew she was working as a counsellor, few knew she was working with children. A further issue was that at the time of the incident she was on sick-leave and therefore, it was not deemed an immediate matter of concern. It is noteworthy, however, that few professionals pursued the issue or inquired further as to the nature of the counselling work mother provided, even if not working with children it is probable that she would be working with vulnerable adults. It is also concerning that the LADO response to CSWS when they made contact was that there was no need for any action to be taken. Generally, there was little evidence that the LADO process was well-understood by professionals across agencies particularly when addressing concerns outside the workplace and it is probable that this could be an area for future development. 5.3 Effectiveness of DASH checklist as a risk assessment tool 5.3.1 The DASH risk assessment tool is known to have significant limitations which are identified in a range of research. In summary, it is considered that the DASH Checklist has insufficient focus on emotional abuse and mental health issues when assessing risk, it is too focussed on the risk of physical harm and does not sufficiently address risks associated with coercion and control. Research published by the College of Policing in 2016 concluded that it was ‘not necessary to ask for all of the information contained currently in the 27-item DASH tool during the initial response. In its present form, the DASH is being circumvented in practice and is providing inconsistent data to secondary risk assessors. A more focused frontline tool could more effectively nudge officers out of an incident-driven mind set, towards identifying patterns of abusive behaviour, including coercive control.’ A further weakness identified in this review is that the tool does not ask where the perpetrator of domestic abuse works or if they work with children or vulnerable adults which means that Police Officers are not gathering key information required if they are to determine whether a referral should be made to the LADO. 5.4 Male victims of domestic abuse do not see themselves as victims 5.4.1 Domestic abuse by women against men has been the subject of much debate; one view is that domestic abuse is almost entirely committed by men against women. Another perspective is that domestic abuse is a human problem and that women, on occasion, may commit acts of domestic abuse. Evidence from analysis of data from the Crime Survey for England and Wales indicates that almost three-quarters (74 per cent) of domestic violent crime victims are female and 82 per cent of domestic violent crimes are committed against women. Over a million domestic violent crimes per year (on average) were committed against women, compared to just over 200,000 per year against men.20 Research into 190 male callers to the ‘Domestic Abuse Helpline for Men’, however, shows that a small number of men are seriously abused by women. All callers experienced physical abuse from their female partners, a substantial minority feared their wives’ violence and were stalked; over 20 Untangling the concept of coercive control: Theorizing domestic violent crime, Sylvia Walby, Lancaster University, UK, Jude Towers, Lancaster University, UK, Criminology & Criminal Justice, 2018, Vol. 18(1) 7–28© The Author(s) 2018 18 90% experienced controlling behaviours and several men reported frustrating experiences with the domestic abuse system.21 One explanation for this gender bias may be that men report their own victimisation less than females and furthermore many men do not view female violence against them as a crime. Hence, they differentially under-report being victimised by partners on crime victim surveys. 5.4.2 The relevance of better understanding of the nature of domestic abuse by women to men is twofold; firstly, in order to improve the response to the male victim; but also, to better understand the nature of the risk posed by the perpetrator of the abuse. In this case father felt well-supported by agencies and was acting to protect Child H. It is clear, however, that at least initially he did not see himself as a victim of domestic abuse. One impact of this may have been that professionals also under-estimated the risks and did not fully explore all safeguarding concerns regarding mother particularly in relation to her role as a counsellor. 5.5 How to identify suicidal ideation 5.5.1 Homicide–suicide22 incidents occur mainly in family contexts with a parent killing a child followed by suicide being the second most common form of homicide–suicide after intimate partner murder. A major theme underlying homicide–suicide is one in which the mother views the child as being entirely dependent upon its mother, and therefore, unable to survive without her, even if other carers are available. This is described in research as ‘The maternal protector role is thus threatened by loss of status, finance, health or personal support. This leads to feelings of hopelessness and frustration, making the mother believe she is unable to provide for the child or adequately care for her dependent, provoking a dependent-protective motivation for homicide–suicide. Thus, the intended suicide by the mother is the primary motivation, and the death of the child a secondary consequence’23. Attachment theory would suggest that such cases reflect an enmeshed mother–child relationship, whereby the mother is unable to perceive her child could survive without her. In these cases, the main goal of mothers who commit homicide–suicide is their own deaths and, as such, the killing of their child can be understood as an extended suicide. 5.5.2 In this case there is some evidence that mother’s relationship with Child H could be described as enmeshed. With hindsight her anxiety about Child H’s health (unsupported by evidence of real difficulties) was unusual. Her older children’s description of her as a ‘narcissist’ could also support an overprotective style of parenting. Typically, narcissistic parents are exclusively and possessively close to their children and may be especially envious of, and threatened by, their child's growing independence. This may result in the child being considered to exist solely to fulfil the parent's wishes and needs. 5.5.3 An alternative explanation for the homicide-suicide is that it was spousal revenge intended as a mechanism to hurt her ex-partner; a theory that could be supported by the death having occurred on Father’s Day. 5.5.4 The reality is that mother’s intention is still unknown and as there was no indication prior to the event of her intention to physically harm Child H it is impossible to be clear about her motivation. There was limited evidence that she was suffering from mental health problems prior to her death and, on the one occasion she was formally assessed, she denied any 21 Characteristics of Callers to the Domestic Abuse Helpline for Men, Denise A. Hines Jan Brown Edward Dunning Journal of Family Violence ISSN: 0885-7482 (Print) 1573-2851 (Online) February 2007, Volume 22, Issue 2, pp 63–72 | 22 Homicide: Includes murder and manslaughter, manslaughter defined as ‘an unlawful killing that doesn't involve malice aforethought’, for example manslaughter by gross negligence or by diminished responsibility. Within the workshop there was discussion about whether to use the term ‘murder-suicide’ or ‘homicide-suicide’ – it was agreed that there was insufficient information about Mother’s motivation and therefore, the best term to use was ‘homicide-suicide’. 23 A case series of twenty one maternal filicides in the UK Amy McKee , Vincent Egan Child Abuse & Neglect xxx (2013) xxx– xxx https://www.sciencedirect.com/science/article/pii/S0145213413000367 19 major difficulties. The question of whether mother suffered with any mental health problems or whether there was any form of personality disorder, therefore, remains unanswered. 6 CONCLUSIONS 6.1 Even with the benefit of hindsight there was no evidence of significant abuse to Child H prior to the death. The major issue of concern identified by the father and half-siblings was a risk of emotional harm from mother and neither the family members, nor any professional in contact with the child, observed anything that would indicate the child was at risk of physical harm. As with any review there have been identified some areas where professional practice could be improved, however, there is no evidence that this would have led to a different outcome for Child H. 6.2 The review has highlighted that it is important that family history is given enough prominence by all agencies and is shared with all relevant professionals. This is particularly important at times of crisis and when family circumstances are changing such as when a new child is born. The birth of Child H occurred in 2012 and the mechanisms for sharing information between health professionals has changed. Once a pregnant woman has been booked with the midwifery service; a concerns and vulnerability form will be sent to that woman’s registered GP and the health visitor. This form requests the GP to share and send back all relevant history including information that may impact on the health or care of the mother and baby which would include issues such as previous mental health concerns. This form would also prompt the health visitor to undertake an ante natal assessment. Should the midwife or the concerns and vulnerability form identify any issues that would need additional support then the case would be taken to the multi-agency maternity safeguarding hub. Information is shared in all cases of identified additional vulnerabilities and complex factors and a multiagency plan of support is identified. This ensures that concerns are known by all professionals, risks are identified, and support is given by all relevant agencies. The maternity safeguarding hub runs on a monthly basis and has representation from Health Visiting Services, Kent CSWS, the MIMHS (Mother and Infant Mental Health Service) and the midwifery safeguarding lead. 6.3 There were a number of areas where information sharing between professionals could be improved: The first was when the Police took mother to hospital but did not have a direct conversation with a clinician about the reasons for her coming to hospital because of the absence of systems for speedy confidential exchange of information between Police Officers and medical staff; the second was the delay in Kent Police providing CAFCASS with information when they were undertaking safeguarding checks; and the third was the lack of detailed information provided by CSWS to CAFCASS. 6.4 There are known difficulties with the current DASH checklist which is being reviewed nationally. This review has highlighted its limitations when addressing issues of emotional abuse and coercion and control rather than incidents of physical violence. It has also identified a further weakness in that it does not require professionals to identify the occupation of a perpetrator of domestic abuse, undermining professionals’ capacity to advise the LADO where people working with children are involved in behaviour that is placing children at risk of emotional or physical harm. In the absence of immediate changes to the DASH checklist, which is already lengthy, Police Officers need to be reminded of the importance of obtaining information regarding perpetrators employment when attending domestic abuse incidents. 6.5 There is limited research available for professionals about working with male victims of domestic abuse and there is some debate about the levels of abuse of men by women. The research available, however, does show that men struggle, both with the stigma associated 20 with the concept of being a victim of domestic abuse, but also with the concept of being a ‘victim’. In this case it seemed apparent that the father did not identify himself as a ‘victim’ which may have meant professionals under-estimated the relevance of mother’s behaviour. For this reason, it is important that professionals when working with male victims of domestic abuse are aware that men may minimise its impact. 6.6 Finally the review has identified that there is limited awareness of the LADO process and particularly its relevance when responding to safeguarding issues within the home environment of people whose employment involves them with working with children and vulnerable adults. 7 RECOMMENDATIONS Recommendation 1 That KSCB require Kent Police to resolve the difficulties causing the delays in providing CAFCASS with relevant information when they are undertaking safeguarding checks as part of their initial assessments. Recommendation 2 That KSCB require Kent Police and the four Acute Hospital Trusts in Kent work together to ensure that when Police Officers take a person to hospital it is possible to pass on relevant information confidentially to a clinician within a speedy time-frame. Recommendation 3 That KSCB require CSWS to work with CAFCASS to improve systems to share information effectively and speedily when requests are made as part of safeguarding inquiries. Recommendation 4 That KSCB require Kent Police to work to ensure that when Police Officers are attending domestic abuse incidents, they ascertain a perpetrator’s employment and consider LADO referral. Recommendation 5 That KSCB and the Kent and Medway Domestic Abuse Executive Group develop an increased understanding of the needs of men as victims of domestic abuse and what this means about the nature of services that should be provided for them. Recommendation 6 That KSCB require the LADO service to work with all agencies to improve knowledge and understanding of the LADO process particularly where it applies to incidents taking place outside of the workplace. Fiona Johnson 1st April 2019 21 Appendix 1: BIBLIOGRAPHY Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J. & Black, J., (2008) Analysing Child Deaths and serious injury through abuse and negelct: what can we learn? A biennial analysis of serious case reviews 2003-2005. Nottingham, UK: DCSF Publications Characteristics of Callers to the Domestic Abuse Helpline for Men, Journal of Family Violence ISSN: 0885-7482 (Print) 1573-2851 (Online) February 2007, Volume 22, Issue 2, pp 63–72 | Denise A. Hines, Jan Brown, Edward Dunning, Sylvia Walby, Jude Towers, Lancaster University, UK, Untangling the concept of coercive control: Theorizing domestic violent crime, Lancaster University, UK, Criminology & Criminal Justice, 2018, Vol. 18(1) 7–28© The Author(s) 2018 HM Government, (2015) Working together to safeguard children A guide to inter-agency working to safeguard and promote the welfare of children. London: Crown copyright 2015. [accessed 15/6/2015] HMIC. (2014) Everyone’s business: Improving the police response to domestic abuse ISBN: 978-1-78246-381-8 https://www.justiceinspectorates.gov.uk/hmicfrs/publications/improving-the-police-response-to-domestic-abuse/ [accessed 08/02/2019] Amy McKee , Vincent Egan A case series of twenty one maternal filicides in the UK Child Abuse & Neglect (2013) https://www.sciencedirect.com/science/article/abs/pii/S0145213413000367 Eileen Munro 'Effective Child Protection' 2nd edition, Sage Publications 2008.ISBN 978-1-4129-4695-7 Amanda L. Robinson, Andy Myhill, Julia Wire, Jo Roberts and Nick Tilley, Risk-led policing of domestic abuse and the DASH risk model, © College of Policing, September 2016. https://www.college.police.uk/.../Risk-led_policing_of_domestic_abuse_and_the_DAS [accessed 08/02/2019] 1 |
NC043980 | Report completed at the request of Edward Timpson MP, following the publication of the serious case review (SCR) re Daniel Pelka. Addresses questions raised covering information recording, information sharing and assessments. Findings in relation to recording of information include: high workload and insufficient administrative support in children's services; and the lack of expectation within health services that children's height and weight was plotted over time meant that professionals did not have easy access to a visual record of Daniel's progress and decline. Findings in relation to information sharing include: lack of interoperable information sharing systems between health services; and insufficient training for school staff in relation to their role in the child protection process. Findings in relation to assessments include: lack of effective management oversight and insufficient training in children's services; and failure during school assessments to bring together all known information. Includes a summary of progress made on implementing the recommendations of the SCR up to the end of December 2013. Uses an adapted version of the root cause analysis model.
| Title: Daniel Pelka review: retrospective deeper analysis and progress report on implementation of recommendations. LSCB: Coventry Safeguarding Children Board Author: Jane Wonnacott and David Watts Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. DANIEL PELKA REVIEW RETROSPECTIVE DEEPER ANALYSIS AND PROGRESS REPORT ON IMPLEMENTATION OF RECOMMENDATIONS 23rd January 2014 Jane Wonnacott Independent Consultant – In-Trac Training and Consultancy Ltd David Watts Independent Safeguarding Consultant - Via Safeguarding Solutions Ltd. Coventry LSCB Daniel Pelka Deeper Analysis and Progress Report Page 2 Foreword Coventry Safeguarding Children Board is pleased to publish the independent report of the deeper analysis into the circumstances of the death of Daniel Pelka in March 2012 and in doing so demonstrate our determination to be open and transparent about our work. Alongside the deeper analysis of practice up to March 2012, we are also publishing, in part 2 of this document, a report detailing the progress we have made so far in improving practice within Coventry. The deeper analysis was completed at the request of DFE Minister, Edward Timpson, following the publication of the Serious Case Review in September 2013. The analysis was led by an experienced, independent expert Jane Wonnacott and supported by a small team of professionals who reflected the various disciplines which had been involved in the case. The report sets out a detailed analysis of how services were operating up to 2012 and addresses the issues set out by the letter from Mr Timpson. - why information was not effectively recorded - why information was not shared - why four separate assessments by social care failed to identify the risks to children before he was murdered by his mother and stepfather. The report makes clear how profoundly Daniel's death affected everyone and how there is a tremendous determination across Coventry to understand why some of the systems in place which should have protected Daniel were flawed and why some of the individuals did not deliver the standard of practice required. Part 2 of this document was written by another independent safeguarding expert, David Watts and provides a summary of progress made by partners on implementing the recommendations of the Serious Case Review up to the end of December 2013. Work has started on all 15 recommendations; 7 have been completed in full and 8 others require further action and monitoring by partners and the Safeguarding Children Board. All the partners on the Coventry Safeguarding Children Board have accepted the findings of the deeper analysis report and have reaffirmed their commitment to continue to implement all the actions required to address the 15 Serious Case Review recommendations. The Coventry Safeguarding Children Board will continue to challenge partners and to insist that effective action is taken to continue to improve safeguarding in Coventry and to keep children safe. Amy Weir Independent Chair Coventry Safeguarding Children Board Deeper Analysis Report Jane Wonnacott 24.1.14 Page 3 PART 1 A DEEPER ANALYSIS OF THE FINDINGS OF THE DANIEL PELKA SERIOUS CASE REVIEW Jane Wonnacott Independent Consultant In-Trac Training and Consultancy Ltd Deeper Analysis Report Jane Wonnacott 24.1.14 Page 4 1 INTRODUCTION 1.1 Following publication of the serious case review into the death of Daniel Pelka, the Parliamentary Under Secretary of State for Children and Families wrote to the Chair of Coventry Safeguarding Children Board on 16th September 2013 requesting a deeper analysis of the reasons why practice failures had occurred. This deeper analysis was asked to look specifically (but not exclusively) into: 1. Why was basic information not recorded properly both within and between agencies 2. Why was information needed to protect Daniel not shared between the relevant agencies 3. Why did four separate assessments by children’s social care all fail to identify the risk to Daniel and what was the oversight of those decisions? 1.2 In response to the letter, the Chair of the Safeguarding Children Board commissioned a project team comprising professionals with expertise in safeguarding practice in police, health, education and children's social care. This project team was asked to conduct a deeper analysis with a requirement that a report should be available before Christmas 2013. All members of the project team were completely independent of the case and had no previous links with agencies in Coventry. 1.3 This report is not intended to repeat the findings of the original serious case review but sets out to seek to explain in more detail why specific practice failures occurred at that time. Continuing work is being carried out by Coventry Local Safeguarding Children Board to rectify the practice problems identified within the serious case review and this work is set out in part 2 of this document. 2 PROCESS 2.1 A project plan for the deeper analysis was agreed by the chair of Coventry Safeguarding Children Board with senior managers from the police, relevant health organisations and children's social care. A senior manager in each agency was asked to act as project lead and facilitate the implementation of the project plan within their organisations. This included inviting practitioners still working in Coventry who had been involved with Daniel and his family to meet members of the project team. It was the choice of individual practitioners as to whether they attended and the team were very grateful that so many of them chose to do so. 2.2 A large number of those who were directly involved in the case have been seen. Others working in those services were also spoken to in order to widen our understanding of the context in which events occurred. However, there have been some limitations to this process. There are some people who are subject to other investigative processes; some Deeper Analysis Report Jane Wonnacott 24.1.14 Page 5 of those chose not to attend or to do so in a restricted manner. In addition, there were some difficulties in organising a few of the meetings. All of this has resulted in some frustration for the team but we are still confident that for the most part we have been able to cover most of the issues required to answer the why questions. 2.3 No individual discussions were held with staff from Daniel’s school, as the education consultant on the project team had already been commissioned, via the Council’s Education Department, to speak to school staff. It was not appropriate to repeat this exercise and findings from the interviews have informed this report. The education consultant has also been a full and active member of the project team. 2.4 As well as talking to individual practitioners, the project team worked with a number of focus groups from each organisation (including schools) in order to gain a broader understanding of the context within which similar work takes place. 2.5 Information obtained during the process was grouped using an adapted version of the root cause analysis model developed by the National Patient Safety Agency1. These factors focused on: 1. The nature of the family. 2. Individual practitioners (knowledge, skills and expertise). 3. Team factors (cultures, workload, quality of management supervision and support). 4. Inter and intra professional communication. 5. Organisational and strategic factors affecting practice. 2.6 This report sets out an overarching summary and then specific findings as they apply to the three specific questions asked by the Children’s Minister. 3. Summary of Findings Recording within and between agencies There were delays in recording information on social work records resulting in the social worker carrying out the first initial assessment not having access to all the relevant information about domestic violence. This was due to the challenges involved in managing the volume of information in relation to domestic violence and insufficient administrative support within children's social care. There were unacceptable delays in circulating the minutes of the strategy meeting that considered Daniel’s broken arm and there was insufficient management oversight to make sure that these were circulated. Delays were not unusual at this time mainly due to work pressures within children's social care including insufficient administrative support. There were no family records within community health services resulting in a situation where the school nurse and health visitors did not have a full picture of the family 1 Root Cause Analysis Toolkit, 2004. http://www.nrls.npsa.nhs.uk/resources/?entryid45=59901 (accessed 13.12.13) Deeper Analysis Report Jane Wonnacott 24.1.14 Page 6 circumstances. The lack of a full picture was exacerbated by central allocation of health visitor tasks such as developmental checks or new birth visits, resulting in a lack of consistency in work with the family. The fact that there was no expectation within health that children’s height and weight was plotted over time (for example on a centile chart) and a record kept within their file meant that there was no means of the various health professionals having an easily available visual record that compared Daniel’s good progress in his early years with dramatic decline in the year prior to his death. Recording systems within the school were used inconsistently and did not bring together all information into a central place in order to enable an accurate assessment of need and risk. This was due to lack of effective leadership within the school and insufficient school focused training and external scrutiny in relation to the development of safe effective child protection systems. Information sharing and communication Staffing pressures within health visiting, a delay in receiving information from the police and lack of clarity regarding their role resulted in the health visiting service routinely treating domestic violence notifications as ‘for information only’. Health visitors in receipt of information that should have worried them relied on the police assessment and social workers visiting, rather than being proactive and visiting the family themselves. The use of language including that it was “plausible” that the spiral fracture to Daniel’s arm was accidental had a disproportionate impact on decision making at the strategy meeting. This is not a criticism of the doctor using the term at that time but point of learning for the future. Poor standards of communication relating to problems with information sharing systems between acute hospital trusts and community health services, and the separation of midwifery records from other parts of the system meant that risks relating to mothers mental health and her behaviour whilst pregnant was not known to health visitors or the GP. Such information would not be available within the parent held records. This combined with a lack of a family record within health meant that previous concerns about Daniel were not known to the health visitor carrying out a pre birth visit in respect of Adam. Information exchange at the point Daniel started school was adversely affected by the reliance on paper records within health visiting, the use of an electronic system within school nursing and term time working arrangements for school nurses. Communication between the school nurse and the school was adversely affected by the fact that she was not the usual school nurse for that school and did not know the most appropriate person to speak to. She also did not have the usual informal opportunities to see Daniel within school. Insufficient training for staff within the school meant that they were unclear of their role in the child protection process, who to go to with concerns and what to do if their concerns were not heard within the school environment. Assessments within children's social care There was pressure on the referral and assessment team in children’s social care as a result of staffing problems elsewhere in the service. Management action to improve the consistency of assessments within a pressurised service was misinterpreted by teams Deeper Analysis Report Jane Wonnacott 24.1.14 Page 7 as condoning the production of core assessments which were of poor quality and lacking in detail. There was a lack of effective management oversight within children's social care due to an over-reliance on experienced workers and supervisors who were not sufficiently trained and supported to deliver reflective supervision. Social workers had received insufficient training on the role of the social worker in assessments where a combination of domestic violence, alcohol misuse and parental mental ill health presents a risk to children. The social worker undertaking the second core assessment had received insufficient training in direct work with children including the use of interpreters. The culture at the time of the second core assessment was described as “a core assessment is the answer to everything” indicating insufficient understanding of the role of the core assessment as part of section 47 (child protection) enquiries. Other Assessments The assessment by the community paediatrician was an opportunity to explore whether abuse was one possible explanation for Daniel’s symptoms. It has not been possible to explore in any detail why this did not happen although the paediatrician reports that their actions were partly influenced by poorly kept hospital records, no centile charts within the records and a lack of strategy meeting minutes giving a fuller explanation of the circumstances surrounding Daniel’s fractured arm. Assessments within the school failed to bring together all known information and identify risk of abuse due to fragmented information gathering and recording systems within the school. In addition appropriate professional judgement was not used in the decision not to refer Daniel’s situation to Children's Social Care. 4 WHY WAS BASIC INFORMATION NOT RECORDED PROPERLY BOTH WITHIN AND BETWEEN AGENCIES? Children's Social Care 4.1 In relation to domestic violence referrals, social work managers attended regular joint screening meetings with the police where domestic violence incidents involving children were discussed. At these meetings decisions were made as to whether a referral to children’s social care was needed. Up to 25 cases could be discussed in one meeting and referrals and information on open cases were then entered on the children’s social care records by the social work manager. Due to limited administrative support this process could take up to two days to complete. In Daniel’s case, a delay in entering information meant that the social worker carrying out an initial assessment did not have all relevant information, including allegations about mother’s alleged violent behaviour. 4.2 Within children’s social care the use of chronologies was not common place and these were not recorded on the child’s file and used to inform practice. This was partly due to the change to a computerised recording system which did not easily facilitate the Deeper Analysis Report Jane Wonnacott 24.1.14 Page 8 compilation of a type of chronology that was a useful aid to assessment. As a result, the full extent of the seriousness and extent of the difficulties in the family – particularly of domestic abuse incidents – was not and could not be easily and fully appreciated at a glance. It also meant that connections between what was happening at different points and in terms of contact by other agencies with the family – particularly as and when new concerns arose. 4.3 When a midwife called children's social care with concerns when mother was pregnant with Adam, the social worker failed to link these concerns with the previous records relating to Daniel, including his broken arm and the family’s significant domestic violence history. The project team have scrutinised the electronic record and this can only be explained as human error by a stressed social worker in a team working under considerable pressure. This error may have been made more likely by an approach within the team, which aimed to manage the pressure of work, by only taking immediate referrals where it was absolutely clear that they reached the threshold for children’s social care. Health 4.4 Recording within the health visiting service was evident but it still relies on a paper-based system and there are no family records linking all the children in the family. Therefore, when the health visitor carried out a new birth visit in respect of Adam she was unaware of previous concerns regarding domestic violence in the family or concerns about Daniel’s broken arm. She was unable to record mother’s description of Daniels’s behaviour and eating problems on Daniel’s file at the time as it was boxed up awaiting transfer to the school nursing service and therefore not easily accessible to her. 4.5 The practice of routinely recording a child’s height and weight on a centile chart and keeping a copy of the chart in the child’s health visiting/school nurse record was not common practice within Coventry. There was therefore no visual record that compared the good progress in Daniel’s early years with the dramatic decline across the centiles in the year prior to his death. This lack of use of centile charts is mirrored within the acute hospital and although Daniel had weights recorded on admission and in clinic, again, there was no visual record of these. 4.6 Another factor contributing to poor recording of baseline height and weight measures was the fact that weight had not been recorded at the developmental check (which took place at home) due to the health visitor having no scales available. This was because there were not enough scales for each health visitor to have one set each. 4.7 There are no family records within health visiting or school nursing in Coventry which link the information about the separate children in the family. This meant that although information was recorded on Daniel’s records in relation to domestic violence, the health visitors or school nurses working with other children in the family would not have this information. There were therefore missed opportunities for links and connections to be made about the experience of all the children in the family. 4.8 The project team found several examples where the level of detail in letters to GPs from the hospital was limited. For example, the letter to the GP as a result of the fracture to Deeper Analysis Report Jane Wonnacott 24.1.14 Page 9 Daniel’s arm referred only to the nature of the injury and the fact that follow up appointments had not been attended. It did not refer to any consideration of potential non accidental injury or the strategy meeting. This information was therefore not available to the GP at a later date when Daniel was referred due to eating “problems”. It has not been possible to explore with the individual doctors why this was although discussions with others in the system has suggested that minimal detail in letters from acute trusts to GPs and health visitors is not uncommon practice. 4.9 Midwives do not have access to all the records pertaining to the mother that are held within the hospital and externally, including accident and emergency records. They were therefore unaware of Daniel’s admission with the spiral fracture which in this case resulted in those attending the strategy meeting not being aware of mother’s pregnancy. Within GP practices midwives and GPs use the same record system but they record in different areas of that system, which had the potential for significant information held within one area of the record only being accessed by some staff on a selective basis. Education 4.10 The serious case review identified poor record keeping within Daniel’s school especially in respect of recurrent injuries. This meant that a number of different injuries and at different times were not coherently or sequentially recoded to show the pattern which was emerging over time. The true significance of what was happening and any action which should have been taken following each incident was not written down. Whilst the development of effective systems is the responsibility of school leaders overseen by Governing bodies, there had been no specific training for designated safeguarding leads which focused specifically on the details of setting up a safe child protection system (including recording). There had been a reliance on multi agency training which designated leads are expected to disseminate throughout the school. Whilst such training is important in developing an understanding of the signs and indicators of abuse and working together across agencies, it does not provide the detailed information that all school staff need in relation to identifying concerns and sharing and recording information within the school. Police 4.11 The project team found that basic information about Daniel was well recorded within the relevant police files, however these files were not always reviewed by a manager. For example the police investigation into Daniel’s broken arm was not reviewed by a senior manager and there was therefore no external challenge to the process of investigation or to the decision-making at the strategy meeting. This was because the senior police officer was on holiday and the investigating officer therefore signed off their own investigation. The files within the joint screening team were well kept and showed the reasons for decision made. However, there is again little evidence of managerial oversight, most probably because the officers within the team were considered to be experienced officers and experts within the field. However, training profiles indicate that they had minimal specialist training and were left to run a pressurised service with little Deeper Analysis Report Jane Wonnacott 24.1.14 Page 10 opportunity for development or supervision and management or oversight of their work. 5. WHY WAS INFORMATION NEEDED TO PROTECT DANIEL NOT SHARED BETWEEN THE RELEVANT AGENCIES? 5.1 It should be remembered that from time to time a great deal of information was shared between professionals, particularly in relation to domestic violence, but the information was not sufficiently understood in terms of risk to Daniel or the other children. When information was not shared this was mainly as a result of individual professionals not realising the significance of the information they held, along with information systems that did not facilitate the sharing of information. Important factors affecting the degree to which significance was understood related to experience and training of individual staff, workload and management oversight, as well as the capacity of mother to present well to professionals. Police 5.2 The project team were told that Coventry has the highest rate of domestic violence in the West Midlands and West Midlands Police also have the challenge of working with seven different Local Authorities. Managing the flow of information about domestic violence was therefore a challenge, both within the police force and with partner organisations. Sending information to others will not protect children if those in receipt of information are overwhelmed or unsure about how to understand its significance for their role and there was evidence to suggest that this was the case particularly in relation to the health visiting service. This is explained further below. 5.3 In Coventry in 2008-9 the process for managing domestic violence incidents involving children was that front line police officers attending an incident would complete a risk assessment in relation to the severity of the incident and grade the risk as low, medium or high. It is important to note that this risk assessment tool was a generic one for use in all domestic violence incidents whether children were present or not. It is not designed to assess risk to the children. The quality of information gained at this point was therefore crucial in determining subsequent responses by other in the system. One issue that may have adversely affected the understanding of officers and quality of risk assessments was the fact that English was not mother’s first language. Officers also told us that it was the case that after 5pm there was no easy access to an interpreting service. Officers had to rely on a language line which involves handing over their radios to the adults involved; something that that they are understandably reluctant to do especially when dealing with potentially violent individuals. 5.4 The use of language is important in communication across professions. The risk assessment forms often contained the phrase that the children were ‘safe and well’ (which was the term in general use at the time in the police service) to describe the children. This gave a falsely optimistic view of the impact on children living in situations of domestic violence to other professionals reading this information. They assumed it Deeper Analysis Report Jane Wonnacott 24.1.14 Page 11 meant much more than it ever could, since it was based on the brief encounters police had with the children; and on some occasions, they did not see the children at all. 5.5 Where children were involved, communication by West Midland Police with children's social care regarding domestic violence was via the joint screening meeting. The joint screening team had been set up in Coventry in October 2006 and involved two police officers reviewing all police domestic violence notifications. An administrator from social care was based in the police team and carried out agency checks prior to a meeting which took place 2/3 times a week between a social care manager and the police officer. At this meeting cases were reviewed and decisions made, including whether a referral was needed to children's social care for an initial assessment or whether the case had reached the threshold for section 47 enquiries and a strategy meeting was needed. Health visitors were directly sent notification of all cases involving children. The domestic violence incidents within Daniel’s family were regularly discussed at this screening meeting and it therefore had the potential to be an effective means of communicating between police and children’s social care. An initial assessment by children's social care in April 2008 and a core assessment in November 2009 were both a direct result of discussion at a screening meeting. 5.6 The effectiveness of this communication was however diminished due to pressure on the team as a result of an increase in domestic violence incidents. A report to Coventry Safeguarding Children Board in September 2010 noted that in 2009-10 the number of days between a domestic violence incident and screening was 15 days and this number was gradually increasing. This delay resulted in social workers and health visitors often being unaware of domestic violence incidents until sometime after the event. 5.7 Information exchange by police officers at the strategy meeting which took place as a result of the spiral fracture to Daniel’s arm did ensure that most of the relevant information regarding domestic violence was known to the meeting. However the pressures on the joint screening team meant that information from Warwickshire Police regarding a MARAC2 meeting that had taken place whilst the family were briefly in their area in 2010 had not been processed and was not available to the meeting. It is possible that this may have added weight to the need to initiate a child protection investigation under section 47.3 It was however communicated to the social worker soon afterwards and should have influenced the core assessment that was being carried out. Health 5.8 The delay in processing domestic violence notifications resulted in health visitors receiving the information some time after the event and often the documents arriving in batches. An already over-stretched health visiting service viewed notifications as ‘for information only’ and health visitors mainly relied on the grading given by police officers to determine whether they should take further action such as visiting the home. A risk 2 A MARAC is a Multi–Agency Risk Assessment Conference. At a MARAC, local agencies meet to confidentially discuss high-risk victims of domestic violence who are living within the local area to identify what safety and support mechanisms can be put in place for the victim and families. 3 The National Child Measurement Programme (NCMP) measures the weight and height of children in reception class (aged 4 to 5 years) and year 6 (aged 10 to 11 years) to assess overweight children and obese levels within primary schools Deeper Analysis Report Jane Wonnacott 24.1.14 Page 12 assessment grading designed to assess risk to the victim was therefore used by health visitors to decide whether a response was needed in relation to the children. 5.9 One health visitor commented that when domestic violence notifications first started coming from the police into health, there was no policy guidance as to what to do with them and there was no expectation that domestic violence notifications from the police were for anything other than information. There was no system of these being screened by an experienced health professional, although health visitors could contact their domestic violence lead nurse if they had concerns. Workload pressures affected health visitors’ capacity to process and respond to information and it is clearly the case that during 2008-9 there was no expectation that families where there was recurrent domestic violence might need to be visited and a CAF considered. It is well documented in letters sent by the Chair of the Safeguarding Children Board to the Primary Care Trust at the time, in mid 2011, that there were concerns that the low level of staffing within the health visiting service was adversely affecting child protection practice. 5.10 The use of language by health professionals in sharing information at the strategy meeting appears to have been significant in the way that their views were interpreted by others. The doctor’s comment that mother’s description of the injury was ‘plausible’ appears to have been a major influence in the decision not to pursue section 47 enquiries and it would have been more helpful if the doctors had simply stated that both an accidental and non-accidental cause were possible. It is likely that this combined with the fact the Anna had corroborated her mother’s account resulted in the meeting losing sight of the potential significance of the bruising as well as the fracture and the fact that mother had delayed bringing Daniel to hospital. Information about previous domestic violence (including that perpetrated by mother) was brought to the attention of the meeting and the focus shifted from events surrounding the injury to the issue of domestic violence. 5.11 Ineffective written communication between acute hospital trusts and community services has been referred to above. In addition to the communication from the hospital consultant to the GP in relation to Daniels’ broken arm, on two occasions information from the accident and emergency department regarding mother’s overdose and attempt to run out in front of an ambulance did not reach the health visitor. This would have raised the health visitor’s level of concern, prompted a visit and, when domestic violence notifications were received, most likely have resulted in liaison with children's social care. Social workers may then have been aware of this incident at the time of the first initial assessment. There is a completed fax form in the health visitor notes from accident and emergency outlining the incident, however, unlike every other document in the health visitor file there is no date stamp indicating when this was received by the surgery. The lack of effective use of the paediatric liaison role is reported to be likely to have exacerbated communication problems and would have been an important addition to a reliance on paper based communication methods. 5.12 The period when mother was pregnant with Adam tested the capacity of the health system to link up emerging concerns about one child (the unborn baby) with other children in the family (Daniel and Anna). Sadly, problems with information sharing within health contributed to information about mother’s pregnancy with Adam becoming lost at the time of the fracture to Daniel’s arm. Midwifery information was only available to other professionals within the hospital if requested and the health visitor did not have an Deeper Analysis Report Jane Wonnacott 24.1.14 Page 13 overall picture of family circumstances mainly due to the central allocation system within health visiting. This system means that when a case becomes inactive it effectively has no health visitor; (although one can always be allocated should issues arise for the parent or other professionals) when next activated it may be allocated to any health visitor covering that area. The health visitor who liaised with children's social care after the fracture was not the same one who had visited the family in July 2010 and carried out a developmental check on Daniel and was unaware of the pregnancy. All of this resulted in a serious lack of consistency in staff dealing with the family which made it much more difficult for a coherent and critical assessment to be made particularly when outwardly the household was clean and tidy and there was obviously food available for the children. 5.13 Communication systems between health visiting and school nursing did not facilitate effective exchange of information across the two services. The accumulating concerns in relation to the family as a whole were therefore not recognised as potentially needing either a CAF assessment or, potentially, referral to children's social care. The reason for this was threefold. Firstly, at the time the health visitor conducted a new birth visit in relation to Adam and mother expressed concerns about Daniel’s behaviour and eating problems, Daniel was about to start school and all his records were boxed up awaiting transfer from health visiting to school nursing. Whilst there was a system in p health visitor did not identify potential risk to Daniel from the single event that had come to her attention and the system for retrieving records was not used. Secondly, school nurses work term time only and were not available for a face to face discussion at the time of the new birth visit. Thirdly, communication between the health visitor and school nurse was further hampered by the fact that they do not share the same database/case recording system resulting in delays whilst health visitor paper records are transferred and scanned into the school nursing records. 5.14 Midwifery staff who were concerned about mother’s behaviour on the ward did attempt to find out whether mother was known to police or children's social care, but the response that a core assessment had recently been carried out took the focus away from the current behaviour within the hospital. At the time communication systems between hospital midwifery departments and health visiting services were ineffective. It has not been possible to understand clearly why this was although it is likely that the severely under resourced health visiting service and lack of time to develop effective working relationships may have been a contributory factor The impact of ineffective communication was that when the health visitor carried out the new birth visit and mother spoke to her about problems with Daniel, she was unaware of the incidents that had taken place in the hospital. The ‘start again’ approach to the new birth visit by the health visitor was further exacerbated by the system of central allocation within health visiting, described above since the health visitor conducting the new birth visit did not know the family. There are no family records and she did not have Daniel’s records as he was starting school the next month and they were already boxed up for the school nurse. The health visitor therefore visited knowing nothing about the previous domestic violence or possible non-accidental injury to Daniel. Deeper Analysis Report Jane Wonnacott 24.1.14 Page 14 5.15 Within midwifery services there was a child protection meeting with the named nurse4 every Wednesday. The role of this meeting was to analyse critically all child protection cases and if a referral had been made to children's social care the case will be discussed. However, in respect of mother’s pregnancy with Adam no referral was made and the case was not deemed to be child protection. It therefore may not have been a priority for this meeting and there appear to be no other mechanisms in place for supervision and oversight of cases that are borderline child protection. 5.16 The school nurse who responded to the referral from the health visitor was not the school nurse allocated to Daniel’s school (she was off sick). She was an experienced professional who had attended relevant training in relation to safeguarding and domestic violence. She was persistent in arranging to see mother at home and recalls mother presenting as a “loving mum” who asked the appropriate questions and was not resistant to the idea of a referral to the paediatrician. Mother’s capacity to present as extremely plausible therefore deflected the school nurse from any suspicion that Daniel’s behaviour was linked to neglectful parenting or abuse and did not prompt communication with children's social care. 5.17 The culture within the school nursing service appears to be one of working with parents and the project team were told that it is not unusual for the child not to be seen. School nurses do not routinely do height and weight measurements as this is done as part of the National Childhood Measurement programme. 5.18 The role of the school nurse was influenced by the fact that the school nursing service in Coventry was under pressure; the school nurse in this case being responsible for double the average number of schools identified in a survey of state school nursing in 2005. Pressures resulted in less time being available to follow up individual children. The system has been put further under pressure by the increase in the number of domestic violence notifications arising now from these being sent to school nurses for all children, not just those where there are under 5’s in the family. 5.19 Effective communication can depend as much on relationships between individuals as on systems. Although an experienced professional, the school nurse was not the one assigned to the school and did not have the day to day relationships with individuals which would have influenced whom she chose to speak to. She called the school to discuss Daniel but was unaware that the class teacher was relatively inexperienced and that systems within that particular school meant that the class teacher did not have the whole picture. She has also commented that if it had been her allocated school she would have popped in and spoken to the teacher and seen Daniel. 5.20 Communication with the community paediatrician was hampered by hospital records which were not well ordered and did not contain baseline information about Daniel’s growth and development. The lack of strategy meeting minutes within the records as they had not been sent out by children’s social care also meant that the assessment was not informed by full information about the spiral fracture. 4 A senior nurse with particular responsibility for promoting good practice in relation to safeguarding children within their health trust. Deeper Analysis Report Jane Wonnacott 24.1.14 Page 15 The School 5.21 The reason why the school did not share information about their concerns regarding Daniel seems to have been as a result of poor leadership and practice and a fragmented child protection system within the school which meant that different staff were responsible for different aspects of care. For example different people had responsibility for child protection, health and attendance, the concerns about Daniel were not effectively communicated across the staff team and there was no formal mechanism for gathering information together across the school. 5.22 Staff within the school cannot recollect any training which assisted them in recognising the signs and indicators of abuse and some were unclear about who fulfilled the role of designated child protection officer. The result of this was that even where staff may have had concerns about Daniel they were not sufficiently equipped to communicate their concerns directly to the appropriate person and/or were not confident to question why a referral to children’s care had not been made or advice from children’s social care sought. 5.23 Where systems are ineffective harm can be mitigated by a system of external scrutiny and challenge. In this case there is no evidence of effective external scrutiny or challenge to the school leadership regarding their communication systems from either the local authority or the governing body. Children’s Social Care 5.24 Issues relating specifically to communication and information sharing by children’s social care are dealt with in section 6 of this report since they relate to assessment practice. There clearly were some issues about missed opportunities for communication with other agencies and of assumptions being made incorrectly about the significance of some information which was shared with children’s social care. Communication and joint working between police and children’s social care 5.25 When West Midlands Police sent two officers from the child abuse investigation team to the hospital following the facture to Daniel’s arm, they spoke with mother and her partner and then visited Daniel’s sister, Anna, who was staying with a friend. Anna confirmed the account of Daniel’s injury given by mother. It is a matter of professional opinion as to whether it was best to see Anna swiftly or whether it would have been best to plan a joint interview with a social worker and an interpreter the next day. There are arguments for and against each course of action. We were, however, told that joint visits between social workers and police officers were ‘not part of the culture’, and one social worker commented that the joint training (Achieving Best Evidence) is a waste of time, as social workers are only used to sit behind a one way screen and are hardly ever involved in interviews with children. There are reasons for this, including making sure that the best evidence is obtained where a criminal prosecution is likely, but this approach to joint working means that in this case no consideration was given to the advisability of working jointly to plan conversations with either Anna or Daniel. The focus was on potential criminal prosecution and corroborating mother’s account rather than planning a joint Deeper Analysis Report Jane Wonnacott 24.1.14 Page 16 interview that could have explored broader issues relating to the experience of Anna or Daniel within the family. This issue about the token involvement of social workers in interviewing children with the police was also raised as an area for improvement in the Ofsted Safeguarding and Looked After Children Inspection in 2011. 6. WHY DID FOUR SEPARATE ASSESSMENTS BY CHILDREN’S SOCIAL CARE ALL FAIL TO IDENTIFY THE RISK TO DANIEL AND WHAT WAS THE OVERSIGHT OF THOSE DECISIONS? 6.1 By the time of the first initial assessment in April 2008 there had been seven domestic violence incidents, including two where mother had been allegedly threatening Daniel’s father with a knife. Alcohol had been a feature on all occasions. However, it seems there was a delay in the information from the screening meeting being entered onto the social work record, resulting in the social worker who carried out the initial assessment being unaware of the extent of the violence. 6.2 The social worker who completed the first initial assessment was experienced in working with domestic violence and it is clear that, had she known about mother’s alleged use of knives, this would have changed her assessment and most likely escalated the case to child protection. Instead, she knew that the joint screening process had not escalated the case to one of child protection and approached the initial assessment in line with guidance which was that an initial assessment was a brief assessment 5 designed to determine whether services were required and/or whether a more detailed core assessment should be carried out. The social worker has now reflected that the use of alcohol was not given sufficient weight and believes that one factor influencing this was that in 2008-9 there had been a recent influx of Polish families into the area and professionals were unfamiliar with working with the community. 6.3 The second initial assessment and the core assessment carried out during this period were of very poor quality and part of the problem with the core assessment was that it relies on self-reporting by mother and little or no information from other agencies. There was evidence that the health visitor tried to call the social worker but when she did not receive a response, she made no attempt to visit the family herself, probably due to the pressures on the health visiting service outlined above. It has not been possible to speak to the social workers involved with these two assessments as they are no longer working within Coventry. However, it is clear that the knowledge and skills of the individual practitioners carrying out effective assessments was not of the required standard and this was not identified through management and supervision processes. The social worker who carried out the core assessment was a newly qualified worker and the manager who supervised and signed off the assessment was an agency worker whose contract was not renewed. 5 Framework for the Assessment of Children in Need Para 3.9 Deeper Analysis Report Jane Wonnacott 24.1.14 Page 17 6.4 An additional factor that was likely to have influenced the assessment process at this time was that the referral and assessment team had only been formed as a Citywide team in 2008. Neighbourhood teams were expected to take on longer term work but due to staffing problems they were not able to take on all the cases that needed to be transferred to them. Senior managers decided that all core assessments should be completed within referral and assessment. Although the referral and assessment team was the most stable in terms of staffing, this decision put additional pressure on the team who struggled to maintain both quality and the quantity of work required. Practice standards were developed in September 2009 as part of a LSCB thresholds document in order to assist staff in focusing on the most important elements of initial and core assessment. These standards were not in place at the point that both initial assessments were carried out and it is not clear how well staff had been trained in their use by the time of the first core assessment in November 2009. 6.5 The second core assessment was a pivotal moment in the case when there was the opportunity to recognise that Daniel was being physically abused within the family. Mother was by this time living with MK, her partner who along with mother was eventually convicted of Daniel’s murder. The core assessment took place after the investigation into the spiral fracture to Daniel’s arm and the approach to the assessment would have been influenced by the fact that the decision had been not to continue with section 47 enquiries. 6.6 The knowledge and skill required to undertake social work assessments where there is a presence of substance misuse, parental mental ill health and domestic violence is significant in this case. From a review of the training records the social worker carrying out the core assessment had not attended any of the training on offer in relation to assessing parental substance misuse or mental ill health and had only completed one domestic violence course in 2006, five years previously. They had also only attended one half day session on interviewing children in 2008. If these records contain all staff development activity this is not an adequate level of training for this complex work. The use of assessment frameworks to consider the impact of these factors in children in the family was not evident. None of the assessments carried out by children’s social care used any tools to assist practitioners in this task6. It is widely accepted as good practice that evidence based tools should be used to inform complex assessments so this is a significant gap in practice both within the local system but also by the individual practitioners involved. 6.7 According to the relevant Government guidance - Working Together - in 2011 a strategy discussion should be held whenever there is reasonable cause to suspect that a child is suffering or likely to suffer significant harm7. One of the purposes of the strategy discussion was to decide whether section 47 enquiries should be initiated and therefore a core assessment be undertaken under section 47 of the Children Act 1989 and plan how any such core assessment should be carried out. The conclusion of the meeting in respect of Daniels’ injury was that there was no need to initiate section 47 enquiries but that a core assessment should be carried out under section 17 Children Act 1989. This is an important distinction as it identified Daniel as a child potentially in need of help and 6 These might have included the risk assessment tool developed by Barnados for children living in situations of domestic violence and the resilience and vulnerability matrix (DOH Child’s World Training Materials) 7 HM Government ( 2010) Working Together to Safeguard Children Para 5.56 Deeper Analysis Report Jane Wonnacott 24.1.14 Page 18 services, rather than a child also at risk of, or possibly suffering significant harm. Although theoretically the core assessment process may have been similar whichever route was taken, the fact that this was a child protection case would have allowed potential risk of harm to have been clearly on the agenda in discussion with mother and alerted other professionals to the risks. When problems emerged in mother’s next pregnancy and she later began to describe problems with Daniel’s behaviour and eating patterns, this could have been understood within the context of a child who had previously been considered to be at risk of or possibly suffering harm. 6.8 The strategy meeting minutes noted that ‘it was felt that an in depth assessment of the family was required before ending our involvement’. This indicates that the mind of children's social care had been made up that this was not a child protection issue but the concerns about domestic violence should trigger a core assessment in line with practice standards at that time8. These standards stated that a core assessment should be carried out where ‘children subject of strategy meetings who live in families where there is chronic neglect and domestic violence and where the current circumstances and the strategy meeting assesses that risks fall just short of the need for formal Child Protection Enquiry’. The project team were also told that the prevailing culture within children's social care at the time was ‘a core assessment is the answer to everything’ and this is likely to have influenced decision-making at the meeting. 6.9 The situation was further compounded by a very poor core assessment. The context for the work had not significantly changed from the time of the first core assessment as there was still pressure on referral and assessment due to problems within the neighbourhood teams. Senior managers were aware that there was a variation in the standard and length of assessments and the practice standards issued in 2009 were designed to develop a more consistent and proportionate approach, whilst maintaining important elements of the assessment such as reflecting the views of the child. Unfortunately, an unintended consequence of this was that the term ‘thin core’ became to be used to describe a slimmed down approach to the core assessment process and seems to have become translated in practice into assessments which did not even meet basic standards. As part of this project, ten assessments from this period were audited and only one was rated as good, indicating that this was a more widespread problem than in this particular case. 6.10 Coventry had adopted the signs of safety approach to their work. This should include working openly and honestly with parents and developing plans with the family to keep the child safe. However, because this assessment was not starting from a position of recognising danger to the child there was no such open honest discussion with mother. Two signs of safety rating scales were completed and recorded within the documentation which indicated high risk, although the final conclusion and outcome did not reflect this and the decision was to refer to Citizens Advice Bureau and close the case. The human tendency to use information that confirms an already formed point of view is well documented in the literature 9 and in this case, despite the social worker recording evidence that indicated a high level of concern, the case was closed. 8 Coventry Safeguarding Children Board, Children’s Social Care Thresholds and Practice Standards: September 2009. 9 For example Munro (2008) Effective Child Protection London: Sage Deeper Analysis Report Jane Wonnacott 24.1.14 Page 19 6.11 The focus of the core assessment became housing issues since mother was about to be evicted from her accommodation. The exploration of the impact of domestic violence on the family became lost, even though during the period that the core assessment was being carried out the family were discussed at another joint screening meeting and the papers from this meeting would have been passed to the social worker. This meeting had the information that when, in 2010, mother had lived for a time just over the border in Warwickshire, concerns about domestic violence had been such that she became subject to discussion at MARAC.10 This information should also have been known to the health visitor, as the MARAC minutes clearly state that the health visitor was to be asked to offer support. No attempt was made to gather further information from Warwickshire during the core assessment process. 6.12 Supervision which helps the practitioner to reflect critically on their practice is crucial, particularly in relation to avoiding behaviour which only seeks information to confirm the dominant view. Effective supervision did not take place within children’s social care. One reason for this was that the senior practitioner was regarded as a safe pair of hands and the team manager trusted their judgement. The project team were told that within the referral and assessment team in children's social care workloads were high but social workers received regular supervision. However, staff also reflected that where their manager is also under pressure staff do not wish to burden them with their own stress and complain about an unmanageable workload. Reflective supervision for all social workers, whatever their level of expertise, is crucial and training records indicate that the team manager had not had sufficient training or development in this aspect of their work. 7. OTHER ASSESSMENTS 7.1. As well as the assessments carried out by children's social care the assessment by the community paediatrician was another opportunity to identify the abuse being experienced by Daniel at that time. This was explored as fully as possible in the serious case review although questions remain as to why the consultant did not conclude that abuse was one possible explanation for Daniel’s symptoms. It has not been possible to understand in any depth why specific conclusions were reached about Daniel although the lack of strategy meeting minutes in the medical records meant that a full picture of the issues discussed at that meeting was not readily available. The haphazard nature of the hospital notes and no centile charts within the record also hampered the assessment at this point. 7.2. Assessments within the school were also ineffective at identifying risk and understanding the significance of significant weight loss combined with reoccurring injuries. This has been discussed above as being partly driven by a failure of systems within the school to collate all available information. There was also an error of judgement in not referring Daniel’s situation to social care. 10 A MARAC is a Multi-Agency Risk Assessment Conference Deeper Analysis Report Jane Wonnacott 24.1.14 Page 20 8. CONCLUSION 8.1. It is clear from talking to staff in Coventry that the death of Daniel has affected them deeply and there is a great resolve to try and understand why the systems that were in place to protect children failed in this case, and why some individuals did not succeed in delivering the standard of practice required. There is a strong commitment to work towards improving practice in the future. Almost inevitably there are no easy answers since it is a combination of factors that came together at particular points in time, alongside parents determined to cause harm to a child that resulted in the tragic outcome. 8.2. Human error cannot be eliminated from child protection work and professionals under pressure, poorly supervised or lacking in the right training or experience may from time to time make mistakes. There were examples of errors in decision-making which have been explained as being due to professionals trying to juggle too many competing priorities. The lack of effective management and supervision, partly due to the managers themselves being under stress, compounded the likelihood of error. There is a clear need for strong leadership within all organisations in relation to the management of risk where expectations exceed the resources available. 8.3. The type of abuse inflicted on Daniel by those caring for him is extreme and outside the experience of most professionals. It is therefore an unusual case that tests the effectiveness of child protection processes and reveals weak spots which, for the majority of children, will not have such devastating consequences. Despite the extreme nature of this case there has, however, been the opportunity to learn from a closer examination of why the system did not protect Daniel. It is hoped that this information can be used to strengthen child protection practice both in Coventry and elsewhere. 8.4. There are no additional recommendations that need to be made from this analysis since the original recommendations cover all key areas. This analysis does however provide additional detail for Coventry Safeguarding Children Board which will be used to hold agencies to account in respect of the work they are doing to improve both systems and individual practice. Progress Report December 2013 Page 21 PART TWO: DANIEL PELKA REVIEW PROGRESS REPORT ON IMPLEMENTATION OF RECOMMENDATIONS (DECEMBER 2013) David Watts Independent Safeguarding Consultant - Via Safeguarding Solutions Ltd. Progress Report December 2013 Page 22 1. Introduction 1.1 This report updates the CSCB on progress made by partners on the implementation of recommendations arising from the Daniel Pelka review conducted by Ron Lock and published on 17th September 2013. 2. Methodology 2.1 Further to the interim report provided to the Board dated 18th November 2013, the author has met again with key partners to reflect upon the progress made on the fifteen recommendations within the last four weeks. These have included senior personnel from Coventry City Council (in respect of Children’s Social Care and Education action), West Midlands Police, NHS England, Coventry and Rugby Clinical Commissioning Group and University Hospitals Coventry and Warwickshire NHS Trust. The author was not able to meet with Coventry and Warwickshire NHS Partnership Trust but had a detailed and useful telephone conference call to discuss the recommendations. 2.2 The following analysis briefly summarises key improvements identified and also areas requiring further action. A more detailed breakdown of partner responses against each of the fifteen recommendations from the published review report is also provided. 3. Key Evidence of Improvement 3.1 Since the last progress report key partners have agreed in principle to develop a Multi-Agency Safeguarding Hub (MASH) to improve the effectiveness of multi-agency working in relation to suspected child protection cases, including cases involving domestic abuse. This will comprise a co-located team of professionals and is planned for implementation by September 2014. 3.2 An interim process with identified professionals meeting at least twice weekly to discuss specific cases has been developed until the MASH is operational and this is planned to commence January 2014. 3.2 Police report that all backlogs in circulating domestic abuse reports to partners have been eliminated, thus improving the timeliness of information sharing. 3.3 A system of providing domestic incident reports to schools has been implemented and guidance given to schools’ safeguarding leads advising how to respond/action. 3.4 Key partners have assured the CSCB that where cases are unclear as to the presence of non-accidental injury, these will continue to be regarded as potential child protection concerns and be treated as such until such time as a definitive diagnosis can be made. Progress Report December 2013 Page 23 3.5 Audit processes across the partnership have been amended to improve scrutiny of practice as highlighted by the SCR report. 3.6 There has been ongoing work on the rationalisation of the early help strategy across the children’s partnerships in Coventry. This is expected to be finalised in January 2014. 3.7 Senior membership of the multi agency Domestic Abuse Sub Group has been determined and the Group will be meeting in early in January 2014 to provide specific focus and leadership on domestic abuse issues arising from the review. 3.8 A review of child protection processes and training in schools has been undertaken and the findings of audits undertaken by the Council and by CSCB will be analysed in January 2014. 3.9 CSCB partners have identified and utilised a range of methods to disseminate the findings of this review across the children’s workforce. 4. Key actions requiring attention 4.1 The impetus created by this review must be maintained, particularly in relation to the development of improved information sharing and decision making processes such as the MASH. CSCB to be provided with quarterly progress reports from participating partners. Timescale: Within three months 4.2 The specific work on the domestic abuse process undertaken by the Domestic Abuse Task Group will ensure that the weaknesses highlighted in the review are being addressed in a coordinated way. The CSCB will require periodic reports on progress. Timescale: Quarterly reports from Task Group to CSCB 4.3 The work commenced on rationalising the early help strategy must result in a more transparent and coherent programme with partners across the children’s workforce who clearly understand their roles and responsibilities. Timescale: Quarterly progress reports from Chair of Promoting Children and Young People Well Being Group 4.4 The quality of assessments carried out in Coventry must continue to improve. CSCB to continue to conduct multi agency audits to assess the quality of these and partners to provide periodic evidence of regular audits of practice to ensure continued focus. Timescale: within three months 4.5 The CSCB safeguarding audit of schools to be analysed in January 2014 and findings and actions disseminated. Timescale: Within three months. Progress Report December 2013 Page 24 4.6 The findings of audits undertaken by health partners in relations to specific recommendations from this review to be shared with CSCB to show the level of improvement in safeguarding practice. Timescale: within six months. 5. Recommendation 16.1 There must be a review of the systems which currently exist for the notification and sharing of information in respect of domestic abuse incidents within families to ensure that they generate effective outcomes in relation to the safeguarding of children. The review should particularly focus on: The timeliness of notifications The agency to which they should be distributed, including schools The importance of a focus on the needs and safety of the children The efficiency and effectiveness of the joint screening processes and the responsibility for agree outcomes, and How repeat domestic abuse incidents need to be responded to more holistically 5.1 The first recommendation by the SCR author challenged partners to review the efficacy of the current notification and multi-agency screening process and has been the focus of significant activity, particularly within the police and children’s social care, following on from a multi-agency review of the screening process earlier in the year. 5.2 The police have reported that there is now no backlog of domestic abuse incident reports and that staffing levels have been increased to ensure that all incidents are being reviewed quickly and overseen appropriately by dedicated staff and a qualified detective. Social Care has recruited dedicated practitioners and administrative staff to the screening process, as well as creating an additional team in referral and assessment to provide additional capacity to respond appropriately and quickly. 5.3 There is a secure process in place now to share all incidents involving children with schools and guidance options on how schools should respond back to social care has been circulated to safeguarding leads. Also there is a pathway for those practitioners in health to receive the information, although this is currently only an interim measure and guidance on how this should be interpreted and acted upon across the health economy still requires further clarity. 5.4 To enhance the effectiveness of the screening process further, commitment has been gained between police and social care to create a Multi-Agency Safeguarding Hub in 2014 and funds have been sought and agreed from the PCC Innovation Fund to assist in this development. Partners in health, probation and education are also being approached to become part of this multi-agency co-located approach. 5.5 It is expected that the MASH will become operational by April 2014, but in the interim period an agreement has been made to have a ‘virtual MASH’ operational by January 2014 with police and social care and other partners meeting on a twice weekly basis to review cases and decisions. Progress Report December 2013 Page 25 6. Recommendation 16.2 In order for the LSCB to understand and identify how to improve the multi-agency response to domestic abuse notifications, particularly in respect of the safeguarding of children, then an audit process must be developed to judge how individual agencies respond to notifications which they receive, and as a result, what changes are needed to improve the ways in which agencies individually and collectively ensure that the protection needs of the children involved are being addressed by such responses. 6.1 The CSCB completed a multi-agency audit to look at the responses by agencies from domestic abuse notifications and this information has been used to bring about some of the changes identified. Partners were also asked to comment on how they have embedded response to notifications into their own audit processes. 6.2 Social Care explained their performance management process around referrals which includes analysis of referral volume, timeliness of response and effectiveness of outcome. These have been reviewed and tightened in response to the SCR report. 6.3 Police referred to a process they have initiated that ensures 28 day audits of the screening process, with a first dip sample being undertaken by end of December 2013. This will then become normal monthly practice. Three monthly reviews will be undertaken at senior management level. 6.4 The Hospital Acute Trust has incorporated the findings of the Pelka review into their safeguarding audit (Laming audit) which they conduct periodically within the Trust. The next audit is planned for January 2014. 6.5 In addition, the multi-agency Domestic Abuse Task Group has reviewed its membership and will be meeting in early January 2014 to address key issues from the review. 6.6 CWPT have reviewed and amended their domestic abuse policy to ensure that the Trust Health Visitors, School nurses and other appropriate services e.g. Adults mental health services act upon Domestic Abuse notifications from West Midlands Police and that this includes; documenting children present at the incident in all the children’s records. In addition to within the Trust safeguarding training programme lessons learnt from this case are disseminated which also includes clarification of the MARAC process and staff are conversant and act accordingly upon the receipt of a West Midlands police notification form. To ensure this is embedded in practice an audit of compliance is on the Trust safeguarding Teams audit work plan for May 2014 Further Action identified: 6.7 Agreement to be made regarding 28 day dip sample review at management level to include Police, Social Care and Health. Findings to be reported to CSCB periodically. 6.8 CSCB to receive quarterly progress reports from the Domestic Abuse Task Group. Progress Report December 2013 Page 26 7. Recommendation 16.3 The LSCB needs to demonstrate a clear cohesive understanding of the scope of early help and prevention work to support children living with domestic abuse. 7.1 Again there has been activity in this area to address the issue of early help and prevention when dealing with children living with domestic abuse. Most notably Social Care described the development of increased capacity around support, accommodation and perpetrator programmes. 7.2 A revised model of support and accommodation services is being commissioned which has been co-designed with providers. An increased financial commitment for resources has been agreed to develop a single point of access for accommodation, support for domestic abuse survivors and their children and access to perpetrator programmes. This is all planned to commence by May 2014. 7.3 Social Care also described their increased commitment to the CAF process by increasing the number of CAF co-ordinators working with schools to achieve improvements in the level of early intervention, including those families experiencing domestic abuse. 7.4 However, with regard to the coherent understanding of the early help and intervention process in Coventry, there remain some gaps across the partnership. A discussion at the October 2013 summit of Chief Executives highlighted the need to revise local practice. 7.5 Work is underway to rationalise the early help strategy, which currently sits between the Joint Commissioning Group (Prevention and Early Intervention Sub-group) and the CSCB (Promoting Children and Young People Well Being group). A draft strategy has been developed to merge the activities of these two groups and a meeting is planned for early 2014 to agree this and progress the early help agenda in Coventry. Further Action identified: 7.6 The CSCB will continue to focus attention on the efforts to engage all partners with the early help agenda and request periodic progress reports on the work being undertaken to rationalise the strategic focus across the various Coventry partnerships. 8. Recommendation 16.4 The LSCB will need to be assured by the provision of evidence that assessments undertaken by Children’s Social Care appropriately involve and consult with other agencies and professionals in the completion of such assessments and do so in a timely manner. 8.1 Audits undertaken since the death of Daniel Pelka have shown that whilst improvements have been made Social Care acknowledge that some variable practice remains and they are working hard to remedy this. Progress Report December 2013 Page 27 8.2 Work has been initiated between the CCG and Social Care to improve communication with GPs. GPs and social workers were surveyed to identify the barriers to information sharing and inter professional working between the two groups and a focus group was held between social workers and GPs to seek resolution to the issues. The report of the findings of this piece of work should be used to inform practice development once received by the CCG and Social Care. 8.3 Social Care also report that the awareness raising workshops for staff following the introduction of the single assessment in the summer of 2013 has reinforced the need for good quality consultation and checking with partner agencies. 8.4 Social Care has reinforced this by increased reference in one to one supervision and in team meetings, though observed practice of practitioners and by the revision of the agency’s own S47 audit process to provide senior managers with performance data in this area. Further Action identified: 8.5 CSCB to be provided with performance data from Social Care within the next three months which outlines the findings of s47 audits and identifies improved performance in partner involvement with assessment. 9. Recommendation 16.5 The LSCB must be assured that Strategy Meetings/Discussions are being efficiently and accurately recorded with actions clearly identified for individual agencies or professionals to undertake, and that the record and listed actions are distributed to the relevant agencies in a timely fashion. 9.1 Social Care has assured the CSCB that practice in this area has now been amended and handwritten notes of discussions and decisions made are distributed to attendees at the end of the meeting. These are followed up by typewritten notes. This has been confirmed by a health representative who has attended the strategy meetings. 10. Recommendation 16.6 In instances within a Strategy Meeting/Discussion when medical opinion is inconclusive regarding whether an injury was accidentally or non-accidentally caused, then the follow up interventions with the family must continue to include the child protection concerns as factors and address them rigorously until any new information or assessment discounts them. 10.1 All partners have considered how they might ensure that child protection concerns remain a focus following inconclusive medical opinion on cause of injuries. Social Care has clarified the need for cases to continue at s47 level in such instances and this practice has been disseminated to staff through workshops, supervision and guidance. This has not yet been built into Social Care quality assurance audits of practice but has been highlighted for inclusion for practice audits undertaken from January 2014. Progress Report December 2013 Page 28 10.2 Police also report that this practice has been disseminated to child abuse officers. In addition key messages from the Pelka review (thinking the unthinkable, hearing the voice of the child, what constitutes a safe and well check) are being incorporated into a six minute briefing to all officers and this will be disseminated not only in Coventry but across the West Midlands Police service. 10.3 Health providers talked of reiterating the need for continued vigilance. The Acute Trust has amended its safeguarding audit to ensure that clinical advice meets the Royal College of Paediatrics and Child Health requirements. 10.4 CWPT have reviewed and amended documentation pertaining to consistency to children’s health records pertaining to baseline height and weight assessments to be completed when working with a child with feeding/eating difficulties e.g. height and weight, child protection concerns and reported when the child is referred onto another practitioner when these measurements can be used as comparators, for example in the outpatient setting. Further Action identified: 10.5 Partners to consider how best they can identify these cases in order to evidence how child protection concerns can remain an active part of the ongoing enquiry and assessment and inform the CSCB of how they will be monitoring this in 2014. 11. Recommendation 16.7 Children’s Social Care need to assure the LSCB, via an audit of compliance, that effective processes are in place to ensure that there is appropriate and consistent feedback to professionals who make safeguarding referrals, of the work undertaken in response to those referrals. 11.1 Social Care report that this issue has been disseminated to staff and that a manual process is currently in place to respond to referrers concerns. However it is acknowledged that this system could be more robust and there continues to be variable practice in this area. This is corroborated anecdotally from other partners, most notably from education professionals. Further Action identified: 11.2 It is suggested that Social Care investigates whether there are alternative methods of providing responses to referrers, including whether the electronic social care integrated child system can generate electronic letters that could be utilised. 11.3 It is also suggested that the agency’s audit process be amended to analyse the efficacy of the current system of communication and audit evidence of compliance be made available to CSCB at regular periods. 12. Recommendation 16.8 Progress Report December 2013 Page 29 The LSCB must consider the need to initiate multi agency training or generate professional development opportunities in respect of the detection and identification of severe emotional abuse and neglect in children and young people, and include the details from this case to enhance the learning. The training will need to provide clarity regarding the responses necessary to address such abuse. 12.1 Following early drafts of the review report the CSCB commissioned an external provider to deliver multi agency training in this area. Sessions were delivered in February, April, June and December. 12.2 Emotional abuse and neglect are discussed at every level of CSCB multi-agency training. 12.3 The CSCB Training Sub-Group has discussed the key lessons arising from the review and disseminated these to individual partners for cascade training within agencies. 13. Recommendation 16.9 The LSCB will need to review the adequacy of multi-agency and individual training in respect of domestic abuse and its impact upon children, and promote that such training in the future includes their role in any revised systems for joint screening of domestic abuse concerns. 13.1 The CSCB reviewed and amended its specialised training in this area for the SCR report findings. Scenarios have been developed which take attendees through a domestic abuse incident and how the joint screening process is incorporated in the referral and assessment system. 13.2 The CSCB and Council have also run sessions on the Barnardos assessment tool and the Domestic Abuse, Stalking and Honour Based Violence (DASH). This is being cascaded to other staff commencing early 2014. 14. Recommendation 16.10 The LSCB must review the adequacy of child protection training for school staff in terms of its sufficiency of provision, its take up and of its effectiveness in improving and developing child protection practice. 14.1 A review is currently taking place between schools, the Local Authority and the CSCB to consider how best to meet the specific training needs of the education workforce. This is due to be completed by 31/12/13 and a report will be submitted to the CSCB in early 2014 to propose how to quality assure the training offer to schools. 15. Recommendation 16.11 The LSCB must be assured by the Local Authority that education settings which are under their control, and assured by governing bodies for those schools which are not maintained by the Local Authority, have: - - a robust system for recording any injuries or welfare concerns identified or noticed about a child by staff, and of necessary actions to address those concerns - and that the role and responsibilities of the designated professional for safeguarding are clearly understood and utilised effectively. Progress Report December 2013 Page 30 15.1 A city wide safeguarding audit has been instigated by the CSCB to address the questions posed in this recommendation. The findings will be analysed following the closing date which is the end of the current term. An analysis report will be presented to the Board based upon the self reporting from schools and any actions arising from this analysis will be addressed in the action plan. 16. Recommendation 16.12 The LSCB should monitor developments within the Coventry health visiting provision in ensuring its progressive delivery of the Healthy Child Programme in line with increased health visiting capacity. The Local Area Teams representatives of NHS England on the LSCB will need to ensure that the LSCB receive updates on the progress of such developments. 16.1 Health representatives have made assurances to the CSCB that the planned increases in health visiting capacity are on track to be in place within an agreed timescale. Further Action identified: 16.2 NHS England to provide a formal evidence report to next CSCB meeting to update partners on progress against this recommendation. 17. Recommendation 16.13 Paediatricians and other medical staff who are required to assess the welfare of children who present with unclear concerns, should always consider child abuse as a differential diagnosis as part of an holistic assessment of the child. The LSCB will need to be assured by the relevant health body that this practice has been consistently adopted. 17.1 A clear directive was issued to paediatricians and other medical staff from the Royal College of Paediatrics and Child Health following publication of the serious case review. Health partners have ensured that their staff are aware and adhere to the requirements to consider child abuse as a differential diagnosis in child health assessments. 17.2 The Acute Trust has adapted their safeguarding audit process to ensure that they check that clinical decisions adhere to this directive. Further Action identified: Health partners to inform the CSCB of how they plan to provide clear evidence of compliance against this recommendation. 18. Recommendation 16.14 The LSCB should develop a protocol which will help to ensure that individual agencies consistently utilise interpreter services with families who do not have English as a first language and especially in cases where there are concerns about the welfare of children. The protocol will need to stipulate that interpreters must be used to interview children alone or to enable them to understand their wishes and feelings, when they are the subject of safeguarding concerns. Progress Report December 2013 Page 31 18.1 The CSCB has devised and published its protocol on working with families with families who do not have English as a first language and the use of interpreters. 18.2 Partners have described how they utilise the services of interpreters in understanding the child’s wishes and have stressed that this message has been disseminated to staff working with such families. 19. Recommendation 16.15 The lessons learned from this SCR and detailed in paragraphs 15.1 – 15.14 must be disseminated to relevant staff working with children throughout Coventry, and a process identified to ensure that these lessons have been learned and as far as possible be integrated into safeguarding practice. Particular opportunities should be afforded to those individual practitioners, managers and their teams who were directly involved with Daniel and his family, to consider the findings from this SCR in a learning environment, identifying how to use this as a supportive experience to develop and improve safeguarding practice of children in the future. 19.1 Messages from the report were disseminated to staff across the partnership utilising a range of methods, both written and face-to-face. Key learning has been incorporated in training courses delivered at various levels by the CSCB. 19.2 Practitioners directly involved in the case were given the opportunity to read and digest the messages on practice in advance of publication of the report. 19.3 The CSCB has provided a newsletter outlining key learning from this and other recent reviews undertaken by Coventry. 19.4 The CSCB has been awaiting the messages arising from the deeper analysis on this case before setting briefing workshops on the review. Now that the deep analysis report has been received workshops will be planned for early In the New Year. REPORT ENDS |
NC50841 | Bruising first reported on a 6-week-old boy in March 2016, with further bruising and fractures documented over the next month and six days. Mother had planned a home birth but due to complications Baby Adam was born by emergency caesarean section. At first new birth visit when Adam was 12 days old, parents described how they had been traumatised by the birth; health visitor referred sibling Isaac, a 3-year-old, for assessment as he was still in nappies and not talking. Father was main carer of Isaac as mother worked; he had been in long-term unemployment due to severe chronic ill health. Adam was admitted to hospital three times for unexplained bruising; blood tests and x-rays were carried out to rule out a medical condition. Family of Asian descent. Findings: a hierarchical approach in the working environment leads to professional deference and makes challenging medical professionals and decisions difficult; child protection practice requires collaborative work and professional respect; needs of fathers must be properly assessed and engaged; change to modern service delivery models cannot guarantee continuity of care; service thresholds were applied that did not correspond to the needs described. Recommendations include: all agencies must undertake a review of internal and inter-agency information sharing systems including use of electronic recording, flagging and coding systems; community health visiting and children's social care services must incorporate a 'think family approach' as standard; the LSCB must develop and agree a protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate.
| Title: Serious case review: overview report: Baby ‘Adam’: DOB: 03.01.15. LSCB: London Borough of Tower Hamlets Safeguarding Children Board Author: Briony Ladbury Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. FINAL London Borough of Tower Hamlets Safeguarding Children Board Serious Case Review Overview Report Baby ‘Adam’ DOB: 03.01.15 Independent Reviewer and Report Author Briony Ladbury RN, RM, HV cert, FP certificate, BA (Hons), MSc Published 28 February 2019 Page 2 of 72 Table of Content 1 Acknowledgements ........................................................................... 3 2 Overview Report Author .................................................................... 3 3 Introduction ..................................................................................... 3 4 Family Background and Context .................................................... 7 5 Narrative Summary and Key Episodes .......................................... 7 6 Analysis of Practice ...................................................................... 20 7 Findings, Themes and Recommendations .................................. 50 8 Conclusion ..................................................................................... 65 9 Appendix One - Summary of Recommendations ............................. 66 10 Appendix Two – Glossary ................................................................ 72 Page 3 of 72 1 Acknowledgements I would like to acknowledge the cooperation and support of Tower Hamlets Safeguarding Children Board (THSCB) Serious Case Review (SCR) Panel, who have given their time and generous access to notes and procedures. My thanks also to Monawara Bakht for coordinating the SCR process and to a number of professionals who participated in practitioner interviews and learning events to enable key evidence to be gathered, questioned and represented in this report. 2 Overview Report Author The Independent Overview Writer for this case is Briony Ladbury RN, RM, HV cert, FP certificate, BA (Hons) Protecting Children, ENB Specialist Practitioner Award (Child Protection), MSc in Inter-Professional Practice (Society, Violence and Practice). She has held senior roles within the NHS as a safeguarding children specialist in both strategic and practice contexts, producing and quality assuring NHS contributions to SCRs. 3 Introduction 3.1 Reasons for conducting the Serious Case Review 3.1.1 This Serious Case Review (SCR) was commissioned under statutory guidance in ‘Working Together’ (2015)1 issued by HM Government. Regulation 5 in LSCB Regulations (2006)2 includes the requirement for an LSCB to undertake reviews of serious cases in specified circumstances. One of those circumstances is when children have been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 3.1.2 The purpose of an SCR is to provide a sound analysis of what happened in a particular case and why, and what needs to happen in order to reduce the risk of recurrence. Working Together (2015) stipulates that it should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight Is transparent about the way that data is collected and analysed Makes use of relevant research and case evidence to inform practice 3.1.3 This SCR has been undertaken with these principles in mind. It aims to give an understanding of who did what, the reasons why and the factors that influenced the service delivery to Baby Adam and his family within a specified timescale. 1 Working Together’ to Safeguard Children:A guide to inter-agency working to safeguard and promote the welfare of children (2015) 2 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of the LSCB under section 14 of the Children Act 2004 Page 4 of 72 3.2 Rationale for commissioning a Serious Case Review for Baby Adam 3.2.1 Baby Adam was approximately 6 weeks old when bruising was first reported to a health professional by his mother at a baby clinic. He was subsequently referred for an urgent review at the hospital Emergency Department (ED) following a GP consultation for yet more unexplained bruising when he was nine weeks old. Deliberate harm was first raised as a possibility at this time. Further bruising and fractures came to light over a period of one month and six days, which were duly documented, and medically investigated. A range of health, social care and police professionals became aware of the family during this time. 3.2.2 Bruising in a pre-mobile baby, where there is no convincing explanation as to how the bruising might have happened and no evidence of any medical condition, should be treated with the utmost concern. Pre-mobile infants are physically and emotionally immature and are entirely dependent on their principle carers (usually the parent or parents) to keep them safe and well. They are, therefore, highly vulnerable individuals and the consequences of being exposed to abuse can potentially be very grave indeed. 3.2.3 NHS and social care professionals assessing and working with families with complex histories, that include unexplained bruising and fractures inconsistent with the age or development of a child, are expected to collaborate and act in the best interest of the child by considering deliberate harm as a distinct possibility until it is ruled out. Despite non-accidental injury (NAI) being included in the differential diagnosis3, prompt measures were not taken to protect Baby Adam, who was sent home from hospital and primary health care settings to a risky home situation on more than one occasion. This was due to the belief that a medical cause would emerge. 3.2.4 The management of the case inevitably threw up questions as to how such a small and vulnerable baby could be discharged into a potentially abusive home situation when so many professionals were actively involved in his care. Tower Hamlets Case Review Group (CRG) considered the case at three CRG meetings to decide what multi-agency learning process would be appropriate, particularly as the case had already been subject to NHS Serious Incident investigations. On 7th June 2016, the CRG decided that the case met the criteria for a full multi-agency SCR. An SCR was duly commissioned under the independent Chairmanship of Keith Ibbetson. 3.3 The scope and focus of the Serious Case Review 3.3.1 The scope for this SCR covers a period of three months and twenty days, extending from January 2015, when Baby Adam was born, until after a strategy meeting4 had taken place and a formal investigation under Section 47 of the Children Act 1989 had commenced. Any relevant information prior to those dates is contained in the section entitled ‘Family Background and Context’. 3.3.2 Whilst the timeline for this SCR appears to be short, there was considerable complex activity across and within agencies within the period reviewed. To enable a sharp focus on the most significant events, the review has been split into four important episodes of care which form the key lines of enquiry for the analysis. They are as follows: 3 Differential diagnosis: A systematic process whereby medical practitioners weigh the probability of one disease/cause versus that of other diseases/causes that might possibly account for a patient's symptoms, by using a process of elimination to establish the actual cause or disease., 4 Where information gathered during an assessment (which may be very brief) results in the social worker suspecting that the child is suffering or likely to suffer significant harm, the local authority should hold a strategy discussion to enable it to decide, with other agencies, whether to initiate enquiries under section 47 of the Children Act 1989. Working Together’ (2015) HM Gov. Page 5 of 72 Episode 1: Baby Adam’s birth in January 2015, until he was nine weeks old. Episode 2: The GP consultation for unexplained bruising on 11th March 2015 until 19th March 2015, including the 1st hospital admission, discharge and care at home until Baby A’s outpatient appointment on 20th March 2015. Episode 3: The outpatient’s consultation on 20th March 2015 until 16th April 2015, incorporating the 1st re-call and 2nd admission and discharge from hospital. Episode 4: From 17th April 2015 until 23rd April 2015, covering the 2nd recall and 3rd admission to hospital in relation to increased clinical concern that bruising and fractures may have been deliberately inflicted. 3.4 Agencies invited to participate in this Serious Case Review Organisation Description of Involvement London Borough of Tower Hamlets (LBTH) Children’s social care Hospital Social Work Team Barts Health NHS Trust Royal London Hospital Site Obstetrics and Maternity Services Emergency Department Paediatric Services (in-patient and outpatient) Radiology Department Community Health Services Community Health Visiting Primary Healthcare Services* GP Services Metropolitan Police Service Specialist Crime Review Group Child Abuse and Investigation Team * N.B.Barts Health NHS Trust ceased to be the provider organisation for community health services in March 2016, when the contract was awarded to GP Care Group. Dissemination of the learning and implementation of any actions resulting from this SCR will therefore be the responsibility of GP Care Group. 3.5 How the review was undertaken 3.5.1 The LSCB Board manager was responsible for notifying the DfE and Executive leads of local agencies that a SCR was underway. An Independent Chair was contracted to lead the multi-agency SCR panel for this case and an independent overview author to write the report. 3.5.2 The SCR panel comprises senior managers from agencies who had delivered care to the family. Their responsibilities included preparing and informing front line practitioners of progress, arranging and assisting with practitioner interviews or focus groups and supplying the panel with supplementary documentation and other evidence relevant to the period under review. Page 6 of 72 3.5.3 Information was entered into a multi-agency integrated chronology, which outlined the service interventions occurring within the selected time-scale. Front line practitioners who had most contact with the family were identified and invited to participate in a SCR interview or focus group. Many agreed, and their contribution was invaluable. Some, however had left Tower Hamlets by the time the SCR was commissioned. 3.6 Parallel Investigations 3.6.1 Single agency reports were not requested for this SCR. However, two NHS Serious Incident (SI) Reports had already been completed by the time this SCR was commissioned: one combining Baby Adam’s experience of community health services and the paediatric in the Royal London Hospital (provided by Barts Health NHS Trust at the time of the incident), and the other specifically looking at the Royal London Hospital’s radiological services. 3.6.2 NHS SIs are undertaken when the consequences of an adverse event (or events) to a patient, families and carers, staff or organisations are so significant and the potential for learning so great, that a heightened level of response is justified5. For this case, NHS SI reports were commissioned to examine to determine whether clinical and/or safeguarding systems needed to improve in the hospital and community health setting. 3.6.3 The purpose and methodology for an NHS SI, whilst similar, is not the same as for a multi-agency SCR investigation. Both of the SI reports have been taken into account and considered as part of the evidence for this SCR. However, the analysis in the NHS SI reports has not pre-determined the findings for this SCR, and the SI recommendations already subject to NHS improvement have not been reproduced in this review. Changes to hospital systems arising from the NHS SI investigations, have been summarised at the end of this report. 3.6.4 Patient safety has always been a quality issue for the NHS. Following reforms in 2013 a robust accountability and assurance framework was implemented, which specifically included safeguarding children. All NHS organisations are held to account and are required to be explicit about safeguarding children arrangements in their service specifications and assurance processes. These are regularly reviewed by the relevant commissioning body. Action plans for NHS safeguarding Serious Incidents (SIs) are also an area of interest for the Care Quality Commission (CQC), the current regulator of NHS provided care. In addition progress on the NHS SI safeguarding improvement plan, should be reported to the Local Safeguarding Children Board, along with any new actions generated by this SCR. 3.6.5 Readers are reminded that there was a change of NHS provider for community health services provision in April 2016 and that the current service provider will be the responsible agency for implementing and providing assurance to the LSCB about any of the SCR or SI recommendations attributed to the community health service. 3.6.6 There was no parallel police investigation underway during the time-line for this SCR, primarily because the early management of the case, described in full in this report, meant that opportunities for a criminal investigation were missed. 5 Serious Incident Framework: Supporting learning to prevent recurrence. NHS England (2015) Page 7 of 72 4 Family Background and Context 4.1 Mr and Mrs C, Baby Adam’s biological parents, are of Asian descent. They were both born and brought up in the Tower Hamlets area. They are competent English speakers. They married in 2006 after a two year relationship and lived in a housing association property in the London Borough of Tower Hamlets for the entire period of this review. 4.2 Mrs C worked for approximately five years, initially full-time dropping to part-time hours, as an NHS employee in a local GP surgery. Mr C had been in long-term unemployment due to severe chronic ill health, qualifying for disability allowance which contributed to the family income. 4.3 Baby Adam, the subject of this SCR was born at the beginning of 2015. An older sibling of approximately three years (referred to as Sibling Isaac in this report) was born at the end of December 2011. There is no concerning or significant background information relating to the antenatal period, birth and early years experiences for Sibling Isaac before the birth of Baby Adam. 4.4 Neither of the parents nor the children were known to Tower Hamlets Children’s Services before the events that led to this SCR, and neither were the family known to the police. 5 Narrative Summary and Key Episodes 5.1 The following narrative describes the engagement with services and the care that Baby Adam and his family experienced from his birth to until he became the subject of an Interim Care Order (ICO). The story has been split into four key episodes of care to assist the reader to focus on the most significant events. Episode 1: Antenatal care and Baby Adam’s birth in January 2015, until nine weeks old 5.2 Mrs C attended an antenatal booking appointment at the Royal London Hospital (RLH) maternity unit when she was 12 weeks pregnant. A birth plan for a home delivery was agreed. She attended all of the pre-booked ante-natal appointments. 5.3 After an uneventful pregnancy Mrs C went into labour at term. However, due to an unforeseen obstetric emergency, she was transferred from home to RLH for delivery by an emergency caesarean section. Both mother and baby were deemed fit to go home from hospital at seven days post-delivery. Safeguarding concerns were not identified during the hospital stay. 5.4 There is no record of the post-natal care delivered to Mrs C and Baby Adam at home by the community midwifery service, as the maternity notes have been irretrievably lost. During the post-natal period, notes usually remain within the home (and indeed can be lost within the home). On discharge, they are collected by the community midwife and appropriately filed in the clinical record. What happened to the notes in this particular case is unknown. However, the SCR panel has been assured that this is not a common occurrence and the system usually works well. Page 8 of 72 5.5 The health visitor, who had not met the family before, arrived to complete the new birth visit within twelve days of Baby Adam’s delivery. Both parents and both children were seen. The family were open and engaging and described in detail how traumatised they had been by the delivery of Baby Adam. 5.6 The visit was thorough and included a dialogue with the parents about their own family background and childhood attachment experiences. Mrs C readily answered a question about domestic abuse, responding that her husband was supportive. The health visitor clearly made an effort to engage with Mr C, who, despite suffering from chronic ill health, was the main carer for Sibling Isaac whilst his wife went to work. The plan was for him to take care of both children when Mrs C returned to work. 5.7 The health visitor’s observations of the family did not raise any safeguarding concerns. Apart from a minor feeding problem, the parents appeared to have adjusted well to their new family circumstances. The health visitor was, however startled by the three year old sibling. He displayed unbounded and excitable behaviour throughout the visit, was still in nappies and made no effort to speak. The health visitor decided that the family should receive a universal service6. A plan was also made to liaise with Sibling Isaac’s nursery about his behaviour. On contacting the nursery, it was apparent that nursery staff had similar concerns. The health visitor and nursery agreed he would benefit from a referral to the neuro-developmental clinic for an assessment. 5.8 A repeat home visit was undertaken by the health visitor nine days later. By this stage Baby Adam was just over three weeks old. Mrs C was still experiencing difficulties feeding her baby and complained of feeling tired. This was partly due to the fact that Baby Adam had a congenital tongue tie which affected his ability to feed and partly due to a stream of visiting well-wishers. Mr C continued to support his wife. 5.9 A Common Assessment Framework (CAF) assessment was completed for Sibling Isaac, with full permission from his parents. The health visitor and the Nursery Manager took joint responsibility for the assessment. The assessment was used to refer Sibling Isaac for a specialist speech and developmental assessment. The Health Visitor has since confirmed that Sibling Isaac’s behaviour settled spontaneously within a year of starting nursery sessions probably due to being more stimulated in the nursery environment than when he was at home in the care of his father. 5.10 As no safeguarding concerns were ever identified for Sibling Isaac, and the action of the nursery and the health visitor working together improved his identified health and development needs, his experience has not formed a major part of this SCR. The SCR acknowledges that this is a good example of interagency working. 5.11 Baby Adam’s growth and development in the first five weeks of life were normal, although he did experience feeding problems. He was placed on a health visiting Universal Service pathway, meaning that a full health and development assessment would be offered at six weeks of age. 5.12 The six week developmental check required Baby Adam to be seen by a health visitor and a GP in a clinic setting. The health visitor had some prior knowledge of, but not an established relationship with, the family because she was employed in the same team as the health visitor who had allocated casework responsibility. 6 Universal Service: Healthy Child Programme: Pregnancy and the first five years of life (2009) Department of Health. Page 9 of 72 5.13 During the clinic contact Mrs C mentioned that bruises were appearing on Baby Adam’s face. The health visitor remembers looking over the infant really carefully, and noticing a bruise near to his right eye. A worrying account was given of bruises ‘coming and going’ in the same area of the face. Mrs C was told by the health visitor to discuss the bruising with the doctor when she went in to the examination room for the routine six week assessment. She then entered a note about the bruising into the electronic health visiting record. 5.14 The clinic health visitor, reassured that Baby Adam would be seen and examined by the clinic GP, took no other action. She did however mention the bruising to Baby Adam’s allocated family health visitor when she went back to the health visiting office after the baby clinic had finished. 5.15 The baby clinic GP saw Baby Adam as arranged for his routine six week developmental medical examination. Apart from a small cyst on the baby’s lower eye-lid, nothing abnormal was noted. Mrs C was advised to have the cyst reviewed after six weeks. There is no record of Mrs C discussing the bruise or any previous bruising, and the doctor did not notice a bruise when she undertook the assessment. 5.16 Mrs C visited the family GP surgery after two weeks, rather than six, for the cyst on Baby Adam’s eye-lid to be checked. The consultation was undertaken by a locum GP. During the consultation, Baby Adam’s mother brought the issue of bruising to the attention of the GP, saying that Baby Adam was developing bruises on his arms and legs after being handled. She also gave a history of noticing bruises several weeks earlier, associated with intravenous antibiotics being given in his first week of life. The locum GP noted a small area of bruising on Baby Adam’s right arm. A range of blood tests were requested and undertaken, but the possibility of deliberate harm was not mentioned and no other professional was alerted to this history. Baby Adam and his mother returned home following the consultation. 5.17 The day after the GP consultation, the blood test results were forwarded to Baby Adam’s named GP for review. The haematology report indicated that a possible abnormality was present in one of the blood tests and also pointed out that one test needed to be repeated due to the blood sample being insufficient in volume. The results however, were filed without any other action being taken. Episode 2: From the GP consultation for unexplained bruising on 11th March 2015 until 19th March 2015 5.18 This episode includes the GP’s referral to the Emergency Department, 1st hospital admission, discharge and care at home until Baby Adam’s planned outpatient appointment on 20th March 2015. 5.19 Baby Adam was taken back to the surgery on Wednesday 11th March 2015 for another GP consultation about recurring bruising. The appointment was made following a telephone call from Mrs C who was clearly worried about the bruises appearing on Baby Adam’s body. This appointment was three days after the blood results, from tests taken earlier in the week had been received and filed. Baby Adam was just over two months old at the time and not yet mobile. The consultation was undertaken by a GP who had not seen the infant before. Page 10 of 72 5.20 The consultation centred on mother’s observation of further bruising on the right side of Baby Adam’s head and under his left eye. An examination recorded bruising and swelling over the temple region of his head, and under his eye. Red marks to his left leg were also seen. The medical notes also stated that Baby Adam had not been involved in an accident or accidentally injured in any way. 5.21 The GP telephoned the Royal London Hospital (RLH) immediately to arrange for an urgent paediatric assessment, and during the call suggested that non-accidental injury needed to be considered. A letter was prepared for Adam’s mother to take to the hospital, although no reference to NAI was made. 5.22 Baby Adam arrived for the planned paediatric assessment in the RLH Emergency Department (ED) at 18.44 on the same day as the GP consultation. He was accompanied by his parents. The GP’s referral letter noted unexplained facial and limb bruising. The letter also updated the paediatrician with regards to the blood tests taken the week before and which had not all been completed. 5.23 The paediatric registrar thoroughly examined the child in the ED, taking a full history and making full and contemporaneous notes, including a body map of the bruises. Photographs of other bruises which had appeared during the previous week, and stored on mother’s mobile phone were also shown to the registrar during the assessment. No previous admissions were indicated on the electronic recording system, confirming that this was Baby Adam’s first presentation to the hospital. The Local Authority Children’s social care out of hours Emergency Duty Team (EDT) that provides care when children’s social care offices are closed was contacted to check if he was known. EDT responded to the call by advising the nurse that the family was not known to children’s social care. 5.24 Baby Adam’s parents could not explain how the bruises might have occurred although his father thought he may have caused the redness on the legs, after holding him down in a salt-water bath following a non-therapeutic circumcision. Questions relating to who cared for Baby Adam confirmed that he was cared for only by his parents, mainly by his mother, and he was never left unsupervised in the company of his three year old brother. A plan was subsequently drawn up to admit Baby Adam to the paediatric ward for further investigations, under the care of a paediatric consultant, to rule out potential NAI or other organic causes. 5.25 The paediatric registrar on night duty took over the case once Baby Adam and his mother reached the ward. Further advice was sought from the on-call consultant paediatrician (who also happened to be the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters). The advice was to request additional blood tests to the blood tests and opthalmology review that had already been ordered. Additional tests included a chest x-ray, a computerised tomography (CT) scan of the head, abdominal ultrasound and an extended clotting screen. Possible NAI was clearly being considered at this time, and was explicit on the X-ray request forms. At this juncture, action was taken to inform children’s social care about Baby Adam’s unexplained bruising, initially by telephone and afterwards by means of a completed interagency child protection referral form. 5.26 The consultant paediatrician who would assume lead case responsibility for Baby Adam’s care saw him for the first time the following morning on 12th March 2015. The clinical findings were summarised as ‘unexplained easy bruising’ and the differential diagnosis included non-accidental injury, clotting disorder or a possible abdominal tumour. This was the first time a differential diagnosis had been set out in the notes. A comprehensive paediatric plan was already in place although further investigations were added to the plan, including an ultrasound scan of the abdomen to exclude neuroblastoma, a bone profile and a range of blood tests for other organic causes. Page 11 of 72 5.27 An arrangement was also made for a member of the NHS hospital safeguarding team to gather information from community health colleagues, to help throw light on how the family functioned at home. The family health visitor confirmed that bruising had been identified at the six-week check in clinic, although safeguarding concerns had not been identified for either parent. 5.28 The hospital children’s social work department was also contacted by the paediatricians on the morning of 12th March 2015. By this time the standard interagency referral form sent the night before had been received and a social care contact referral had already been entered onto the Framework I electronic recording system. The standard RLH ‘Interagency Referral Form’ had been e-mailed to the shared NHS and CSC safeguarding inbox situated in the hospital safeguarding team office. The hospital safeguarding team consisted of both health professionals and social workers, however, whilst co-located in the same building, they were not operationally integrated. 5.29 The paediatricians confirmed that Mr and Mrs C were aware that the referral had been made. Children’s social care were updated about the paediatric plan which was for further medical investigations to take place. The discussion was noted on the social work file. 5.30 Later on 12th March 2015 a second ward round occurred. The consultant paediatrician employed to provide advice and professional oversight on safeguarding matters, reviewed the case. Her opinion was that the bruising was most probably due to a bleeding disorder. She suggested that if the consultant paediatrician with lead case responsibility agreed, Baby Adam could be discharged home for the weekend. Meanwhile, the haematologist, who had observed Sibling Isaac being particularly boisterous around Baby Adam, told the consultant paediatrician about what she saw. This was not however, thought to have been significant. 5.31 A skeletal survey had not been undertaken or requested at this juncture. The radiographer having undertaken the head, chest and abdominal x-rays queried the absence of a skeletal survey but was advised by a consultant paediatrician that it wasn’t necessary at that time. 5.32 On the morning of 13th March 2015, when Baby Adam was still an in-patient, the allocated social worker spoke with a paediatric nurse who confirmed that medical investigations were in progress. The social worker requested to be regularly updated. During a follow-up conversation with another nurse later in the day, the social worker learnt that Baby Adam was in the process of being discharged home. The nurse explained that the medical staff thought the bruises were most likely to be due to a medical condition. 5.33 The social worker asked for confirmation that the bruising had not resulted from deliberate harm, stating that if medical causation had been confirmed, the team could not, and would not progress the case. Initially assurance was given by the nurse that this was the case. However, almost immediately after receiving that assurance, another paediatric nurse contacted the social worker to ask exactly why children’s social care could not be involved after Baby Adam had gone home. The nurse explained that the paediatric team would be nervous if social care did not maintain some form of oversight, even though Baby Adam was considered ‘a low index of concern’. Page 12 of 72 5.34 The social worker was puzzled by this assertion and asked for the term ‘low index of concern’ to be clarified. However, no explanation was forthcoming as to what the term actually meant or measured. Management advice and guidance was sought from the team manager who was similarly baffled by the term and how it related to risk, and why a continuing request for social work involvement was being made. 5.35 The social worker continued to ask appropriate questions as to why the doctors were discharging a baby with unexplained bruising into an unknown situation and continued to ask why the medical team thought children’s social care were still needed, if the bruises were deemed to have a medical cause, unrelated to child maltreatment. No clear explanation was forthcoming. 5.36 Based on this confused and conflicted position, the social work team strongly advised the paediatricians not to discharge the infant whilst investigations were ongoing. However, no statutory child protection assessment measures were instigated by the hospital social work team, other than to decide to watch and wait and oppose any potential discharge. EDT were briefed about Baby Adam’s admission should an issue arise at the weekend. The social work team assumed that their advice to the paediatricians not to discharge the baby had been heeded when they left the office for the weekend break. 5.37 Baby Adam’s bruises had started to resolve after his admission and no new bruises had appeared during his stay. Blood tests were also returning satisfactory results throughout the afternoon and the evening of Friday 13th March 2015 (although some results were still outstanding). This was interpreted as a positive sign and during the evening of 13th March 2015, following a review of the case by the consultant paediatrician with lead case responsibility, Baby Adam was discharged into the care of his parents with an appointment to return to clinic one week later on 20th March 2015. 5.38 The medical case file recorded that children’s social care had been informed about his progress earlier in the day. It also noted that they [csc] did not intend to follow up or assess the family until all the medical tests had been completed. As part of the discharge plan, the paediatrician with lead case responsibility arranged for Baby Adam to be included in the weekend handover discussion, in case he should need to return. 5.39 A routine single page ED discharge summary was dispatched to Baby Adam’s GP surgery. On receipt, the administrative clinical coder in the surgery electronically attached the discharge note to the GP record and summarised the clinical information and the social care referral in the contemporaneous clinical notes. The clinical coder recorded the admission as a ‘bruising symptom for review’ but did not assign a safeguarding code to the information. 5.40 The same ED summary, plus additional information in the form of a full history and body maps, was also received by the health visitor, but not until several weeks later on 30th April 2015, although notes suggest the hospital liaison health visitor might have made verbal contact before that. The documents were reviewed by the health visitor on receipt and subsequently uploaded by a health visitor administrator onto the electronic record. The administrator uploaded the information as ‘GP referral facial problems’ omitting any reference to safeguarding concerns. Page 13 of 72 5.41 Following the request from the hospital social work team, an EDT social worker telephoned the paediatric ward on Sunday 15th March 2015 to check that all was well, being totally unaware that Baby Adam had been discharged two days earlier. The EDT social worker was told that all the test results to date had been normal, and that the medical record stated that children’s social care would not be assessing the family. The EDT social worker noted this information and took no further action. 5.42 The hospital social worker telephoned the ward shortly after her return to the office on the Monday morning. Her intention was to be updated on Baby Adam’s situation over the weekend. It was at this point that she discovered that Baby Adam had gone home, contrary to her advice. Questions were asked as to why. The social worker was advised that as the test results being returned were all satisfactory and the paediatric team were of the opinion that as there were no safeguarding concerns, there was no reason to keep Baby Adam in hospital. The discharge summary was copied to the hospital social work team four days after Baby Adam had gone home, on 19th March 2015. 5.43 The GP routinely reviewed the cyst on Baby Adam’s eye lid on Tuesday 17th March 2015, shortly after his discharge from hospital. The admission for bruising was discussed, and the GP was appraised by Mrs C of the paediatric plan and ongoing medical investigations to try to identify a cause. The doctor was also informed that Baby Adam was due for a hospital review in four weeks. However, the next time Baby Adam would be seen by healthcare professionals would be at the planned outpatient appointment three days later. Episode 3: From the outpatient’s appointment on 20th March 2015 until 16th April 2015 5.44 This episode encompasses the outpatient appointment and the 1st recall to hospital, leading to the 2nd admission and discharge from hospital. 5.45 The hospital social worker attended a meeting for management oversight and supervision for the Baby Adam case early on Friday 20th March 2015. The social worker remained anxious about the medical management of the case, particularly as children’s social care had voiced their opposition to releasing the baby from hospital whilst tests were in progress and his situation remained unclear. 5.46 The social worker noticed on the hospital discharge summary, received the day before, that test results remained inconclusive as to the cause of the bruising. A plan to follow up the progress and assess the safety of Baby Adam was agreed. A paediatric appointment had been scheduled for later that afternoon, so the social worker obtained consent from Baby Adam’s mother and the paediatric consultant to be present during the appointment. 5.47 Baby Adam and his mother attended the paediatric outpatients department as planned. An examination by consultant paediatrician with lead case responsibility for Baby Adam found that the old bruises had subsided, although a more recent resolving bruise could be seen on the baby’s left arm. A sub-conjunctival haemorrhage in his left eye was also noted, a sign also suggestive of either a bleeding disorder or non-accidental trauma7. 7 Subconjunctival Haemorrhages in Infants and Children: A Sign of Non accidental Trauma, DeRidder, Catherine A. MD; Berkowitz, Carol D. MD; Hicks, Ralph A. MD; Laskey, Antoinette L. MD, MPH. (2013) Paediatric Emergency Care (2013) V29, p222-6 Page 14 of 72 5.48 The consultant explained to Baby Adam’s mother that the latest blood test results had not found any abnormality, although not all of the test results had been returned. A skeletal survey, a series of X-rays to identify fractured bones, had been ordered for later that afternoon. The reference to the skeletal survey in the medical notes clearly indicated this was to exclude non-accidental injury. The consultant also warned Baby Adam’s mother that if the skeletal survey was abnormal he would have to be readmitted. 5.49 The social worker engaged with Mrs C during the appointment without any reported difficulty. A full social history was taken. There was little in the discussion to raise concern. Baby Adam’s mother was suitably concerned about the recurring bruising, and also talked openly about her older son’s health and odd behaviour. The social worker explained that if the skeletal survey results for Baby Adam were concerning, children’s social care would need to become involved in a child protection capacity. 5.50 On returning to the office, the social worker immediately discussed her conversation in the clinic with her line-manager. Management advice was for the social worker to follow up Sibling Isaac with the health visitor and continue to gather information, including documentation about the current medical investigations being carried out by the paediatric team. 5.51 During the discussion, the social worker expressed an anxiety to her manager about information relating to the case being withheld from the social work team by medical colleagues. These anxieties, born out of an awareness that only some of the medical information had been shared, were subsequently expressed to the medical team and resolved later that day. 5.52 The skeletal survey was undertaken as planned in the afternoon and the films were sent by the radiologist for radiological reporting in the normal way. The consultant paediatrician, along with Baby Adam and his mother waited in the clinic for the report to arrive for some considerable time. Eventually the consultant decided to go in person to the radiology department to get a verbal report. The consultant paediatrician needed the results of the X-rays, as they would determine the next course of action. 5.53 She spoke to a paediatric consultant radiologist in the x-ray department and was reassured that the x-ray pictures looked normal. On the basis of this verbal reassurance, Baby Adam was discharged home by the consultant paediatrician with social care agreement and with an instruction that he should return to the clinic in one month for a review. 5.54 Prior to leaving to go on holiday the consultant paediatrician with lead case responsibility, had a conversation about Baby Adam with her colleague, the consultant employed to provide advice and professional oversight on safeguarding matters. They decided together that a watching brief would be maintained on Baby Adam’s case when the lead consultant was on holiday. This process of case hand-over was quite informal and was not fully documented in any clinical record. The reason for including Baby Adam in the handover discussion was driven by an underlying concern about the unexplained nature of the bruising in the light of normal blood test results and a normal skeletal survey. Page 15 of 72 5.55 Later that evening the skeletal survey was reviewed by another paediatric radiologist in line with the standard reporting system. A written report summarised the findings. This time, the report suggested some periosteal (bone membrane) reaction in both legs. This is commonly seen in babies under six months and on a single x-ray can be hard to distinguish from traumatic injury. In addition, the radiologist reported a possible suspicious area on the left chest wall, explaining that the image might have been masked by a skin fold, making interpretation difficult. Neither of the findings were conclusive evidence of non-accidental injury. 5.56 A recommendation in the written report was to repeat X-rays of the chest and legs after an interval of 10 days, to enable clarification of the initial findings. There was no suggestion of repeating the skeletal survey. The findings in the report were not immediately or verbally conveyed to the paediatrician. The report waited until after the weekend and was eventually read by the paediatrician on Monday 23rd March 2015, after which requests for repeat leg and chest X-rays were sent to the x-ray department. 5.57 Mrs C telephoned the GP on 25th March 2015, to report yet more bruises on Baby Adam’s body. The GP knew that the infant was under the care of the hospital paediatric team and that a social work referral had been made. Mrs C was advised to continue to send photographs of the bruises to the consultant paediatrician as and when they occurred. The GP did not arrange to see the baby in surgery or telephone the paediatric team to alert them to yet more bruises, on the assumption that all that could be done was being done by the paediatricians and social work team in the hospital. 5.58 Baby Adam attended the planned appointment on Tuesday 31st March 2015, eleven days after the skeletal survey, for repeat X-rays. He went home shortly after the X-rays had been taken. The requests for the repeated X-rays did not explicitly draw attention to the differential diagnosis or that non-accidental injury might be a factor in the history. 5.59 After taking the X-rays, the radiographer attempted to make verbal contact with a paediatric radiologist to review and interpret the films, in line with the hospital protocol, but there was no response to the call. Having failed to make contact, the films were put into a system for routine reading and reporting, which did not afford them any immediate attention or priority status. 5.60 Baby Adam also attended the community baby clinic on 31st March 2015 to see the health visitor. At this time he was almost three months old. The health visitor managing the clinic was the same practitioner who had undertaken his six week check. Mrs C explained how Baby Adam was being investigated and monitored closely by the paediatric team for unexplained bruising. New bruising to Baby Adam’s left shoulder was reported and Mrs C also described how the baby cried when he moved, as if he was in pain. She also told the health visitor that social care had been notified of the bruising, but were waiting on the results of medical tests before making a decision on how they would respond. 5.61 The health visitor took the history from mother at face value and recorded the conversation. The information was not shared with a GP, the hospital paediatricians or the hospital NHS safeguarding team, although an informal discussion took place with Baby Adam’s family health visitor who was based at the same office and due to visit later that week. Neither was the hospital social worker informed that Baby Adam had been seen in the baby clinic. Page 16 of 72 5.62 The family received a home visit from their allocated family health visitor two days later on 2nd April 2015. All the members of the family were seen. Both parents described being extremely tired as they adjusted to two children rather than one. They were also anxious about the bruising to the baby which continued to appear and explained how they were sending photographs of new bruises to the consultant paediatrician by email. 5.63 They also confirmed that social care had been notified about the bruising but had not yet taken any action. The role and function of children’s social care, should abuse be suspected, was sensitively explained to the family by the health visitor. However, the health visitor also reassured the family that she was not concerned about their parental care of the baby, and would share this opinion with the social worker. Views were also expressed about Sibling Isaac’s difficult behaviour, which was in the process of being assessed. 5.64 The health visitor observed first-hand how Baby Adam only settled with his mother when he cried for attention. This triggered a conversation with Mr C, who was clearly worried about being rejected by his baby, stating that he thought the baby did not like him. The health visitor reassured Mr C and gave him advice on how he might promote attachment between himself and his new son. She explained that Baby Adam, would inevitably settle more readily in his mother’s presence as she was, at that stage, his primary care-giver. 5.65 The health visitor was satisfied with Baby Adam’s wellbeing and development. The conversation and observations including the recurrent bruising and occasional loud crying were documented in full. The care plan noted that all new bruises should continue to be transmitted to the consultant paediatrician by means of direct email communication. In recognition of the inherent complexities of the case however, the health visitor decided to discuss the family in a reflective supervision session. 5.66 The formal report for the repeated chest and leg X-rays did not arrive until April 13th 2015, a fortnight after they had been taken, and a week over the expected reporting timescale. This delay was due to the films being placed in the routine reporting pile, and being subsumed into a general back-log of cases waiting for review over the Easter weekend, when demand was high and staffing capacity reduced. 5.67 The delayed report had noted healing fractures of the ribs, a sign indicative of non-accidental injury. No other fractures were in evidence. On seeing the X-ray results a decision was made by the paediatric team to recall Baby Adam to hospital and he was readmitted in the evening to the paediatric ward. A paediatric examination on readmission identified swelling over the left rib area. A full history was taken, but an explanation or reason for the rib fractures could not be ascertained. 5.68 The social work EDT was alerted to Baby Adam’s readmission for further medical investigations associated with bruising and identified rib fractures. The advice was for the case to be followed up by the hospital social work team in the morning. Baby Adam was settled into the ward with his mother who was to be resident with him. 5.69 The hospital social work team made contact with the paediatric lead consultant the next day. Records of the conversation strongly suggested that a medical cause was still being pursued. Baby Adam was being depicted as a baby ‘who bruised easily’ and his parents were being described as ‘appropriate, concerned, cooperative and compliant’. Page 17 of 72 5.70 Great Ormond Street Hospital (GOSH) metabolic team were consulted for a specialist opinion as to whether there were any links between the bruising and the rib fractures, however a quick response from GOSH confirmed that the features of the presentation did not suggest an underlying metabolic cause. They did, however suggest further rheumatology investigations as another line of enquiry. 5.71 The social worker advised the paediatricians that in the face of no other explanation, a child protection strategy meeting would need to be convened. The team manager supported this action, and prior to the strategy meeting taking the place, the social worker and team manager had decided in advance that, in the absence of any explanation, Baby Adam needed, at the very least, to be the subject of an assessment to ascertain what level of support would benefit both him and his family as a whole. 5.72 The plan to hold a strategy meeting was discussed with the hospital paediatric team, and whilst wanting to work towards discharging the infant, they were happy to keep Baby Adam in hospital until his circumstances and management were clearer. Contact was also made with the community health visitor who agreed to participate in the social work plan. 5.73 The police were also invited to the strategy meeting, but were of the view that the information they had seen and heard from social care had not clearly explained the rationale for convening it, and unless medical evidence supported non-accidental injury as a concern they would not be able to prioritise or justify an officer attending. This view was reiterated the next day, despite the fact that the strategy meeting had been set. The police recorded these conversations as ‘strategy discussions’. 5.74 The police decision created difficulties for the hospital social work team. Working Together (2015) guidance, and local child protection procedures were clear that, as a minimum, a strategy meeting must be attended by social care, health and police professionals. The fact that the police felt unable to prioritise the meeting rendered the planned strategy meeting as inquorate8, leaving the social work team in a rather awkward predicament. 5.75 To manage the dilemma of being unable to convene the proposed strategy meeting, the hospital social work team decided to go ahead with what they called a ‘professionals meeting’ instead. The so-called professionals meeting, would have no statutory authority or function in child protection terms. 5.76 The professionals meeting held on 15th April 2015, was attended by health and social care staff and Baby Adam’s parents. The specialist nurse employed to provide safeguarding advice and oversight and a new paediatric consultant with limited safeguarding experience, provided the health representation. The meeting was chaired by a social work manager. 5.77 The outcome of the meeting was that the threshold of actual or likely significant harm had not been met. This multi-agency decision was taken despite the history of recurrent unexplained bruising and unexplained rib fractures. It was influenced by a consistent view from those attending, that the unexplained fractures and bruises could not be assigned to the care given by either of his parents. Baby Adam was once again discharged home without a considered child protection plan, although the family was deemed eligible for a child in need (CIN) assessment for possible family support. 8 A local authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the strategy discussion. Other relevant professionals will depend on the nature of the individual case. Working Together (2015) HM Gov. Page 18 of 72 5.78 The professionals tasked with the CIN assessments for both children were the social worker and the family health visitor. They met with the parents after the professionals meeting. The parents expressed their dissatisfaction with their experience of mixed messages and muddled responses resulting in an emergency recall and admission to hospital. They were advised about the complaints system and also of what the CIN assessments would entail. Part of the plan was to repeat the skeletal survey as non-accidental injury had not been entirely excluded. The social worker warned that if child protection concerns emerged, social care would respond with a child protection investigation and invoke the necessary Court orders. Episode 4: From 17th April 2015 until 23rd April 2015 5.79 This final episode extends from the 2nd recall to hospital which led to Baby Adam’s 3rd admission. It includes the immediate management and a follow up strategy meeting to decide whether enquiries under section 47 of the Children Act (1989) should be undertaken. 5.80 The next day on 16th April 2015, a routine paediatric Multi-Disciplinary Team (MDT) meeting took place. Four consultants were present, including the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters and the new consultant, who had attended the professionals meeting. Having reflected overnight, the new and relatively inexperienced consultant expressed misgivings about the decision to send the baby home. The consultant paediatrician employed to provide advice and professional oversight on safeguarding matters was equally concerned, particularly in the light of a combined and continuing history of unexplained bruising and rib fractures. She strongly believed that Baby Adam might have been discharged to an unsafe environment, risking further harm. 5.81 Several telephone calls were placed by the consultant paediatrician employed to provide advice and professional oversight on safeguarding to the hospital social work team throughout 17th April 2015. She insisted that Baby Adam needed to be readmitted urgently. She urged the hospital children’s social work team to rethink the Child in Need threshold and consider a child protection response, suggesting his presentation was could be indicative of non-accidental injury. The social work team were puzzled by the rapid change of medical opinion and were initially reluctant to change the CIN threshold, as no new evidence had emerged. 5.82 Nevertheless, the police were consulted and asked by the social worker to undertake police checks on the parents, which both returned negative results. The social care service manager was also called for advice. He concurred that there was insufficient evidence, and no basis for either an Interim Care Order (ICO) or emergency action unless the medical staff had articulated at least a suspicion that the bruises and fractures resulted from parental care. 5.83 After several hours the social work team finally agreed with the paediatric consultant that it was appropriate for Baby Adam to be recalled for further medical and social work activity. Baby Adam was readmitted for further investigations and a repeat skeletal survey late on Friday night 17th April 2015, at approximately eleven o’clock. EDT were informed of the admission when it took place. It was agreed that Baby Adam would stay in hospital until all the investigations had been undertaken. Sibling Isaac remained at home. A note of the admission was sent to the GP for information. Page 19 of 72 5.84 A paediatric examination was undertaken on 18th April 2015. At this time there were no visible bruises on Baby Adam’s body. The social worker engaged with Mr and Mrs C, who were clearly upset and distressed by the readmission. They also expressed their dissatisfaction in emails to the social worker and health visitor. 5.85 A comprehensive paediatric care plan was drafted and sent to the social work team. The social worker noted and recollected during the SCR interview, that they were advised by a paediatrician to treat the bruising and rib fractures as separate entities, despite unexplained bruising and fractures both being indicative of significant harm9. Even so, child protection measures were clearly assuming a much higher priority for health and social care professionals in the hospital and Baby Adam’s parents were urged by the social worker, to consider options for alternative carers for Baby Adam, whilst a child protection investigation was underway. The conversations with the parents were both sensitive and mindful of the stressful position they were in. 5.86 The social work team sought support from the police for section 47 enquiries to start, by the convening of a strategy meeting to share information and formulate a plan. However the police intimated again, that they might still not be able to prioritise or commit to attending the strategy meeting due to the continuing uncertainty about possible medical causation. They subsequently agreed to attend the strategy meeting on the afternoon of 20th April 2015. 5.87 The strategy meeting was held on 22nd April 2015. Professionals from the three key agencies, health police and social care attended, including the consultant paediatrician with lead case responsibility for Baby Adam, a senior nurse employed to provide advice and professional oversight on safeguarding matters, an officer from the police CAIT team, the family health visitor, allocated social worker and a social care practice manager acting as the Chair. The outcome was to undertake a Section 47 Child Protection investigation. 5.88 Comprehensive notes were taken at the meeting, which included the differential diagnosis, a full chronology of Baby Adam’s contacts with health and social care professionals and accounts from key practitioners who held casework responsibility for the family. Full medical information was requested by the hospital social care team from all of the health service disciplines involved with the family, including photographs of bruises that had been emailed to the Consultant Paediatrician over a period of weeks. 5.89 A plan was formulated that included a child protection medical for Sibling Isaac and an agreement for Baby Adam to remain in hospital whilst enquiries were in progress. Despite the refocus on child protection activity, arrangements and plans with regard to parental access and supervision whilst Baby Adam remained on the ward were not subject to formal discussion, although instructions about seeking an Emergency Protection Order were given to staff, should Baby Adam’s parents try to remove him. Indeed, Baby Adam had frequent unsupervised contact with both of his parents whilst he was in hospital. 5.90 On the 23rd April 2015 a legal planning meeting decided to initiate care proceedings and an Interim Care Order followed on 7th May 2015. Baby Adam was subsequently discharged from hospital into the care of his grandparents on 8th May 2015. 9 Where there are child protection concerns (reasonable cause to suspect a child is suffering, or likely to suffer, significant harm) local authority social care services must make enquiries and decide if any action must be taken undersection 47 of the Children Act 1989 ‘Working Together’ (2015) HM Gov. Page 20 of 72 6 Analysis of Practice Episode 1. How effective was the assessment and planning within universal and community services for the family prior to the onset of bruising? 6.1 In this section, universal and community services are considered to be those which are delivered as of routine to the wider population living in the London Borough of Tower Hamlets. This includes ante-natal, midwifery and post-natal services, community health visiting and primary care GP services. 6.2 Antenatal and immediate postnatal care 6.2.1 Mrs C received standard antenatal care prior to Baby Adam’s birth. There were no indicators that suggested clinical or safeguarding concerns and a homebirth was planned. Mrs C did not receive an antenatal contact from the health visiting service despite it being mandated by the Department of Health (DH) as one of the five key universal health reviews in ‘The Healthy Child Programme (HCP).’10 At the time, Barts Health NHS Trust, along with many other providers in the country, had decided it was unable to provide the antenatal contact due to staffing shortages and a high demand on health visitors to meet other service priorities. 6.2.2 Evidence supporting the health visiting antenatal contact suggests there is a distinct advantage for the practitioner and the family to meet prior to the birth as it enables the emotional wellbeing of the family to be the primary focus without the distraction of a new-born baby. 6.2.3 The demands for health visiting services in this diverse and densely-populated area of east London continue to be a challenge. However ‘GP Care Group’, the current provider of community health services in the borough of Tower Hamlets, have reviewed how the HCP is delivered in the area. Implementation of a new system is underway to provide health visitors with increased information about expectant mothers, so that vulnerable mothers can receive an antenatal contact. However, a universal antenatal visit for all pregnant women is still considered unviable. 6.2.4 The emergency transfer to hospital and subsequent caesarean section was clearly perceived by Mrs C as traumatic. Nine percent (9%) of women who describe their birth as traumatic have been found to experience some degree of post-traumatic stress disorder (PTSD) which, in turn can affect their post-natal recovery. The experience of a traumatic birth can also impact negatively on fathers. Midwives are therefore encouraged to proactively identify women who interpret their birth as difficult or traumatic and screen them for adverse effects before they leave the hospital, in order to consider their ongoing emotional needs11. 6.2.5 No evidence has been found as to how the matter of Mrs C’s traumatic delivery was addressed whilst she was an in-patient in the maternity department, and no information is available regarding the professional interactions between the community midwife and the family, as the notes are irretrievably lost. However, the SCR panel has learnt that in 2016 the hospital maternity department opened a ‘Birth Reflections Clinic’, led by a consultant midwife, to enable families to discuss their birth experience and its impact on their emotional wellbeing. 10 Healthy Child Programme: Pregnancy and the first five years of life (2009) Department of Health 11 Maternal Emotional Wellbeing and Infant Development: A good practice guide for midwives (2012) Royal College of Midwives. Page 21 of 72 6.3 Handover from maternity to community health services 6.3.1 A midwifery discharge note was sent and received by the health visitor, but the information recorded from the birth notification onto the health visitor’s electronic record was both minimal and clinically focussed. Wider social and emotional information including Mr C’s ill health was not included. 6.3.2 This suggests that the handover process from maternity to community health services has not embedded the public health holistic approach recommended by the Royal College of Midwives, which urges midwifery professionals to be mindful of the social and emotional, as well as physical, wellbeing of new parents12. 6.3.3 No comment can be made regarding the care that the community midwives gave the family as there are no written notes available. It is likely, and usual practice that a simple discharge note was left with Baby Adam’s mother to give to the health visitor, but there is no mention of this note in evidence sources received by the SCR panel. Midwives have pointed out however, that the families themselves occasionally mislay the note and it is therefore not always given to the health visitor as expected. It has been confirmed that there was no formal system in place for the community midwife to verbally hand over the case. 6.3.4 The apparent laxity in 2015 with regards to handing over care from midwife to health visitor and the filing and storage of personal and sensitive information is concerning. However the SCR has not been able to ascertain whether this was due to practitioner carelessness, a one off system failure, or a more generalised problem. 6.3.5 Conversations with professionals concerned however, have pointed to the informal handover process being generally accepted as the method of information exchange within and between organisations. It has developed more through custom and practice than by agreed organisational protocols. This does not however, remove the personal responsibility on a practitioner for ensuring information is shared effectively. The failure to record and transfer clinical information can severely disadvantage users of services, and leads to the formulation of care plans on the basis of an incomplete history. 6.4 Application of Threshold for Community Health Services 6.4.1 Barts Community Health Services took over the support of the family 12 days post-delivery when a health visitor undertook a new birth visit. This was within the accepted timescale of 10 to 14 days post-delivery. The new-birth visit is a DH mandated universal health review, designed primarily to assess the health, development, safety and care of the infant. It includes some exploration of the parents’ own childhood experiences and emotional wellbeing which might influence the adjustment of the family to the new arrival. The visit gives an opportunity to offer support, explore concerns and answer questions. The family engaged well during this initial visit, and there is good evidence that the family valued the input from the health visiting service. 6.4.2 A comprehensive record of the family health assessment was subsequently entered into the health visitor’s electronic record. It recorded information about the infant’s health and wellbeing and included mother’s feelings about the traumatic birth and issues regarding initial feeding problems. 12 High Quality Midwifery Care (2014) Royal College of Midwives. Page 22 of 72 6.4.3 The observations arising from the family health needs assessment were analysed and a care plan formulated. Notably, the practitioner recorded concerns about the older sibling’s behaviour and development, which were mentioned by his parents. It became apparent during the visit that Mr C was Sibling Isaac’s main carer and would continue to be so. The health visitor also noted Mr C’s chronic ill-health, which clearly affected his day to day functioning and ability to work, and she also considered how his health might impact on his ability to contain and stimulate a lively three year old. However, Mr C was not discussed with the GP, nor subject to any particular care planning or review to meet his own health and welfare needs as a significant carer. 6.4.4 The outcome of the new birth visit was to offer a Universal Service. The threshold for a Universal Service under the National Health Visiting Service Specification (2014)13 in place at the time, entitled the parents to a service that met the requirements of the national 0-5 years Healthy Child Programme (HCP). This would comprise a further three home visits to the baby at 6-8 weeks, 9-10 months and 2-2 ½ years with a handover to the 5-19 years HCP programme prior to starting school. 6.4.5 The universal threshold is applied to families where no significant vulnerabilities have been identified. It concentrates on specific developmental milestones that are checked at set intervals. Telephone contact with a health visitor could however be initiated by the parent at any time between the set programme. Clinic attendance was encouraged for routine immunisations and ad hoc advice. 6.4.6 It could be argued that the health visitor, whilst noting significant vulnerabilities, had underestimated the potential impact they could have. However, Baby Adam and his family received another home visit within two weeks of the new birth assessment, which was not entirely in line with the Universal HCP schedule. This suggests that the family health visitor had indeed identified needs over and above those which qualify for the minimum Universal care programme. This begs the question as to why the Universal threshold was applied in the first place. 6.4.7 The reasons for the repeat visit, were to seek permission from the parents to undertake a joint assessment with the manager from Sibling Isaac’s nursery, to enable Sibling Isaac’s developmental and behavioural problems to be thoroughly assessed and addressed if necessary. This was in line with the Common Assessment Framework14 (CAF) process and an entirely appropriate action. Once completed the CAF form would be sent to the neuro-developmental clinicians and therapists for follow up. This action was in line with Tower Hamlets safeguarding children guidelines which, in common with many Local Authorities, required referrals to be written in a CAF format. 6.4.8 During the visit, the health visitor recorded further difficulties that were affecting the family’s adjustment to their new circumstances. Mrs C complained of maternal exhaustion, painful feeding problems and Sibling Isaac’s developmental delay and challenging behaviour was continuing to be a significant stressor for the family. It could be argued therefore, that the service threshold for intervention should, at this juncture, have been reviewed and raised to offer an increased Universal Plus service. 13 NHS England National Health Visiting Service Specification (March 2014/15) 14 The Common Assessment Framework for children and young people (2007) the multi-agency assessment component of the Every Child Matters:Change for Children Programme (2004) Department for Children Schools and Families (DCSF) Page 23 of 72 6.4.9 A Universal Plus service is applied when families have known vulnerabilities and require an enhanced level of service comprised of evidence based packages of care to improve family wellbeing. The service provides more rapid expert advice and solutions for parents dealing with specific issues. It also supports children with additional health needs. Applying this threshold would have given formal recognition that additional needs had been identified, enabling the health visiting service to provide more reflexive case management and monitoring. 6.4.10 When asked why the Universal Plus threshold had not been considered, the practitioner recalled pressures connected to staff shortages and sickness absenteeism, meaning that the capacity to deliver such a targeted service was under pressure. However, whilst formally leaving the Universal threshold in situ, the health visitor was confident that mother would request help if needed, and there is some evidence of this happening in practice. Nevertheless consistent application of thresholds is an important systematic means of providing equity and service continuity for families on the basis of need. 6.4.11 With regards to the CAF developmental assessment for Sibling Isaac, the referral was accepted within a fortnight and an appointment was made for the end of May 2015, over two months later. This wait from referral to appointment was not unusually long in national terms. Sibling Isaac, however, improved immensely at nursery and his behaviour and development normalised spontaneously. This suggests that Sibling Isaac’s father, as his main carer, may not have had sufficient parenting capacity to meet his son’s health and developmental needs. 6.5 Engagement of Father 6.5.1 The focus of the family health needs assessment was typical for the service, concentrating primarily on Mrs C and the children. Less emphasis was paid to the health and welfare of Mr C, his role within the family and the impact of his own significant health needs on the safety and welfare of the children. This, despite establishing that he was the main carer to Sibling Isaac and his expressed intention to become the primary carer to Baby Adam as well, when his wife went back to work. 6.5.2 Research suggests that it is only by a holistic assessment, which incorporates each of the individuals within the family unit, that children’s lived experiences can be properly analysed. The matter of health visitors failing to properly engage and involve fathers, however is not uncommon and has been a topic for debate for many years. 6.5.3 In 2013, the nursing research unit undertook a literature review including how health visitors engage with fathers15. The research described a worrying lack of attention to new fathers. Findings suggested that health visiting services in England adhered to a deeply entrenched approach which centred on mothers and their children, despite the HCP insisting on proactive engagement with fathers at every level of health visiting service specifications. However, the report also pointed out that research to support health visitors as to the best way to engage and work with fathers was both limited and relatively new. 15 Why Health visiting? DH Policy Research Programme (2013) Page 24 of 72 6.5.4 The new provider of community services in Tower Hamlets has assured the panel that a new holistic family health needs assessment, inclusive of the needs for fathers has been implemented at the point of the new-birth visit or when children have transferred into the borough from another area. This must be seen as an improvement. However transforming traditional practice and embedding a new culture requires a great deal of practitioner support and education to support the change. The aim should be for fathers to be included in all interactions where possible, not just at selected visits. 6.6 Recording and Exchanging Information 6.6.1 In relation to sharing information between the community health visiting service and primary care, the SCR learned that monthly formal meetings should have been taking place between GPs and health visitors to discuss vulnerable families in common. The expectation was for the discussion to be recorded in the relevant practitioner’s notes. When questioned, the family health visitor is certain that some conversations took place between the GP and herself with regards to Baby Adam and his family, but there is no documented evidence to confirm them in either GP or Health Visitor records. This evidence suggests a more ad-hoc system had been adopted in practice. 6.6.2 A similar ad hoc discussion was said to have occurred between the clinic health visitor and the family health visitor shortly after a routine six week developmental assessment was undertaken, but there is no documented evidence about the discussion in the notes. There is evidence that the recording and sharing of information improved as the case became more complex. 6.6.3 Professional practice guidelines for safeguarding children in primary care16, supported by the Royal College of GPs and the Care Quality Commission (CQC) suggest that GP practices should have a robust system in place that enables regular discussion with key community colleagues about vulnerable people, including children and families that are registered for primary care services. The document also advocates that those meetings should run to an agreed agenda and be properly recorded, to facilitate case continuity, audit and review. The SCR panel has been assured that this type of meeting has now been implemented throughout the primary care system. 6.6.4 The Nursing and Midwifery Guidance17 (2009) for record keeping when Baby Adam was born, up until March 2015 when it was superseded, did allude to nursing professionals using their own professional judgement as to what they recorded in clinical notes. However for safeguarding and promoting the welfare of children, all professional interactions and outcomes are relevant. This is particularly so for babies, who are totally dependent on adults for their health and wellbeing. 6.6.5 Further evidence of ineffective communication and inattention to record keeping and information sharing manifests itself again in the GP and health visiting services after Baby Adam’s admission to hospital for bruising (this is looked at more closely in the next section). 16 Safeguarding Children and Young People: The RCGP/NSPCC Safeguarding Children Toolkit for General Practice (2014) Royal College of General Practitioners. 17 Record keeping guidance for nurses and midwives (2009) Nursing and Midwifery Council Page 25 of 72 6.6.6 An NSPCC study18 looking at the key themes in SCRs for cases involving infants during the perinatal period concluded that information sharing between professionals involved in perinatal care is particularly problematic. This finding is mirrored in this review, and collectively the evidence points to a generalised problem with regards to information management that spans all of the services delivering universal healthcare to Baby Adam and his family. The reason for this has not been explained, but it must be addressed if children are to be adequately safeguarded in the future. Episode 2. How effective was the practice response after the initial presentation of bruising, in various care settings and between different professionals and disciplines? 6.7 Professional Guidance and Local Procedures 6.7.1 NHS services in England are encouraged to follow the practice guidelines set out by the National Institute for Clinical and Care Excellence (NICE). The guidelines are based on research evidence and are considered the most effective and safe options for delivering healthcare. 6.7.2 The safeguarding specific NICE Guidance ‘Child maltreatment: when to suspect maltreatment‘, differentiates between when to consider maltreatment as a possible explanation for a child’s complaint and when to apply a higher threshold of concern and suspect it. The guidance states that clinicians should suspect child maltreatment in a number of circumstances, one of which is bruising, in the absence of an explanation, in a child who is not independently mobile. The NICE guidance is also clear that when child maltreatment is suspected, it should trigger a direct child protection conversation with social care. 6.7.3 The local pan-London Safeguarding Board Child Protection Procedures: Threshold Guidance Document19, designed to assist all professionals in practice, would not have provided clarity about the complex issue of unexplained bruising in a baby either. The document implied that a child protection referral should be considered when a ‘suspicious injury’ has been identified, or when two or more injuries have occurred in a non-mobile baby or child. It also references inconsistent explanations as a risk factor. None of these categories absolutely fitted Baby Adam’s presentation. 6.7.4 Bruising in a young infant is very unusual and occurs in less than 1% of infants who are not independently mobile. All bruising without a clear or observed explanation is highly suspicious of deliberate harm. The younger the baby, the greater is the likelihood that bruising is non-accidental and the potential risk to that baby, who is entirely dependent on his or her primary carers, is also higher. Any bruising in a pre-mobile baby identified in any service setting should therefore be classified as suspicious. It should be carefully managed and assessed, and treated with the utmost caution, as soon as it has come to the attention of professionals. 18 Perinatal healthcare teams: learning from case reviews: Summary of risk factors and learning for improved practice for the health sector (2015) NSPCC 19 Threshold Document: Continuum of Help and Support: London Child protection Procedures (2015) http://www.londoncp.co.uk/files/revised_guidance_thresholds.pdf Page 26 of 72 6.8 NHS Primary Care and Community Services 6.8.1 This section looks at the most relevant services that delivered care to Baby Adam and his family in the universal community setting. This includes two health visitors undertaking different operational roles, one where the family was seen in their own home, and the other within a clinic environment. Other primary care professionals engaging with the family were qualified GPs. Four GPs in total saw the family during the timeline for this review. 6.9 Response to bruising in the baby clinic setting 6.9.1 The first time that recurrent bruising was brought to the attention of a health professional was at the six week baby clinic, located in a GP surgery. The clinic was jointly run, by a GP and health visitor, who were both on site to deliver the standard medical and mandatory health visitor assessment for babies between 6 and 8 weeks of age. 6.9.2 The health visitor appointment preceded the NHS new-born and infant physical examination20 (NIPE) screening examination. This examination has to be delivered by a suitably qualified practitioner in accordance with national guidelines - in this case a qualified GP. 6.9.3 Owing to operational practicalities, mothers and babies could not always see their allocated family health visitor or GP in the baby clinic, which inevitably impacted on continuity of service to a degree. Nevertheless running a service in a familiar setting within a community location is a good operational model, but it relies on good inter-professional communication and team work. 6.9.4 Clinics were generally busy and frequently over-booked. Mothers and babies were allocated clinic ‘slots’ of 10 to 15 minutes with the health visitor, during which time babies were undressed, weighed, measured, dressed and discussed. Overrunning of clinic appointments was common and left little time for the GP and health visitor to discuss any emerging issues arising from clinic contacts. Frequently the two practitioners would not see or speak to each other for the entire clinic session, which is clearly not in a child’s best interest. 6.9.5 A visible bruise near to Baby Adam’s right eye was brought to the attention of the health visitor in the clinic. Other bruises that had previously appeared were also reported but no clear history was taken as to whereabouts on the body these lesions had occurred. The reports of the unexplained bruising were highly abnormal and the health visitor certainly suspected something was wrong, but the significance of the history in terms of child protection was not fully realised. 6.9.6 The health visitor immediately thought the causation of the bruising was organic. When asked why the emphasis was placed on a medical cause, the SCR learnt that the practitioner’s judgement was influenced partly by the demeanour of Baby Adam’s mother, who was described as a caring, concerned, compliant parent, and partly from the health visitor’s past experience of being a paediatric nurse, which had brought her into contact with haematological conditions in children that had presented with a very similar history. 20 NIPE screens new-born babies within 72 hours of birth, and again between 6 to 8 weeks of age for conditions relating to their heart, hips, eyes and testes. This 6-8 week screen is necessary as some conditions appear later in a child’s development. Page 27 of 72 6.10 Holistic family assessment and information sharing 6.10.1 Health visitors as public health nurses are trained in the field of psychosocial health so they can holistically assess the impact of the community and environment on a child’s growth and development. The training adds to, and is different from, any acute nursing experience the practitioner may have. That said, it is unsurprising that the practitioner might have drawn from previous experience. 6.10.2 A systematic comprehensive history and holistic assessment should have been undertaken when the bruising was mentioned to assess whether safeguarding might be an issue. Undertaking such an assessment would have incorporated sensitive questioning and probing into Baby Adam’s lived experience and family circumstances, which might have encouraged a face to face discussion with the GP. However, a longer assessment would almost certainly have exceeded the time limit allocated for the appointment. 6.10.3 The outcome of the health visitor assessment was to go with her initial assumption of an organic cause. She told Mrs C to show the bruise to the clinic doctor when the baby was examined for the six week NIPE test. A record of the bruise and history of previous bruising was entered by the health visitor into the EMIS electronic record. 6.10.4 Suggesting that the GP should review the bruise was a sensible decision by the health visitor. However drawing the GP’s attention to the bruising should have been done by means of a conversation, to ensure that the doctor was fully appraised of the history and current presentation. Instead, the sole responsibility for raising the bruise with the doctor was passed to Baby Adam’s mother 6.10.5 Passing the responsibility for sharing a clinical observation to a parent is professionally risky and unwise. In this case the GP failed to notice the bruise during the six week physical examination and it was not mentioned by his mother either, during the examination. Furthermore, the information about the bruise recorded by the health visitor on the EMIS electronic record was not reviewed by the GP prior or during the NIPE examination. 6.10.6 The SCR learned that despite being co-located, the practitioners in the baby clinic consistently operated entirely independently from one another. The explanation as to why Baby Adam’s mother was left with the responsibility to inform the doctor about the bruise was because the health visitor assumed the GP would see it, and she also felt she had insufficient time to do the job herself. Neither professional seemed to have the time to spare to discuss cases in the clinic environment. 6.10.7 The SCR panel learnt that health visitor notes typed into the EMIS system are seldom routinely reviewed by doctors working in baby clinics, even though the web-based system has a shared access capability. Reading electronic health visitor notes for babies prior to, or during an examination or consultation with a clinic doctor would provide the doctor with the benefit of seeing all relevant background information, and obtaining parental consent from parents to do so, in a clinic setting, should be relatively straight forward, as they are present during the consultation. Indeed refusing consent in itself would provoke concern. 6.10.8 The reality in practice however, is that doctors undertaking routine baby clinic assessments will simply not have time to take the necessary and complicated steps to read the notes of all of the children they are expected to see. This would involve gaining consent, electronically opening the relevant pages, and navigating the system to find the relevant histories and notes recorded by colleagues. In Baby Adam’s case, the GP saw no reason to suspect anything was wrong, as nothing abnormal was suspected or reported beforehand. Page 28 of 72 6.10.9 The overbooking and time allocated for clinic appointments paid little attention to the capacity of the professionals to meet the demand. The sense of running against the clock clearly made the necessary and essential collaboration and information exchange between the practitioners more difficult, and the 6 week assessment of Baby Adam failed to identify the bruise, which in turn created the conditions whereby safeguarding actions would be far less likely to happen. It is extremely important that clinics take into account the time it takes to share and discuss information that enables systematic health and clinical assessments which are consistent and of high quality. Enabling quicker and easier access to electronic information systems would also be beneficial. 6.11 Responding to unexplained bruising in the GP practice 6.11.1 Multiple bruising was brought to the attention of a GP, by Baby Adam’s mother, at a routine consultation two weeks following the six week examination. Visible bruises were noted but did not trigger a safeguarding conversation or any type of inter-professional intervention. The GP has been unable to be contacted to explain why the bruising failed to raise alarm. The single outcome of the visit was for blood tests to be taken which would be reported on the next day. This strongly suggests that the bruising was approached in a purely clinical sense resulting in the ordering of tests to inform a medical diagnosis. 6.11.2 Clearly safeguarding issues were just not considered or suspected in relation to the bruising. This resulted in a missed opportunity for early referral and intervention and left Baby Adam open to serious risk of what could have been a very grave injury. 6.11.3 Established GP practice guidance is clear that GPs should treat bruising in a pre-mobile baby with the utmost suspicion, and in the absence of a reasonable explanation, should take immediate action21. It would have been reasonable for the GP to seek safeguarding advice at this juncture from an NHS safeguarding children health professional. 6.11.4 GPs, who must be trained to level 3 competency, will have been exposed to best practice principles in relation to the identification of physical abuse, but for GPs to be confident and willing to apply that training in practice requires day to day professional mentorship and robust systems and processes to enable them to practice safely and effectively. 6.11.5 Five days after the consultation, Mrs C called the surgery again to report further bruising and Baby Adam was given an urgent GP appointment. A different GP reviewed several bruises on Baby Adam’s body. The presentation was considered unusual, raising non accidental injury concerns in the doctor’s mind that are clearly documented by the GP as an issue that needed to be excluded. The GP arranged for an emergency discussion with a paediatrician at the hospital, in line with good medical managemet. 21 GP practice safeguarding children toolkit (2014) RCGP/NSPCC Page 29 of 72 6.11.6 The GP certainly acted promptly in relation to the concerns, by taking measures to enable the bruises to be seen in the acute hospital setting. By taking this action Baby Adam would be seen by more experienced medical colleagues. The decision and responsibility for any subsequent child protection activity however, was passed to colleagues in the hospital, rather than following best practice guidance, that expects immediate referral to social care for all cases of suspicious and unexplained bruising in a pre-mobile baby. Practitioners must be prepared to take full responsibility for managing a suspicion of deliberate harm in the same rigorous manner as for any other potentially fatal disease.22 6.12 GP safeguarding practice: working with parents 6.12.1 There is no recorded evidence that safeguarding concerns were discussed with Baby Adam’s mother during the GP consultation and a referral to children’s social care was not made, despite the GP’s obvious concerns that the bruises might have been deliberately inflicted. A short referral letter was given to Mrs C to take to the hospital; however it did not mention safeguarding concerns, or give any social information relating to the family who were all registered at the practice. 6.12.2 Where safe to do so, it is best practice for doctors in all settings, including in primary care, to share their safeguarding concerns with the parents and refer their concerns to social care ensuring that their assessment is recorded in full23. Evidence supports that being open with parents does not necessarily damage a working relationship and can actually be of benefit to health and social care professionals, parents and children if and when they need to engage with the child protection system. GPs are no strangers to the concept of leading a courageous conversation, and this must be applied to child protection practice too. 6.12.3 The reasons why the safeguarding concerns were not shared with Adam’s parents, or why a referral to social care did not follow, remains unclear. However past studies have consistently shown that GPs, who have a professional patient-doctor relationship with adults in the family as well as the children, report difficulties in initiating safeguarding conversations as the content is often perceived to be accusatory. In these circumstances, making a referral to children’s social care is frequently passed to colleagues in the acute sector to initiate. It is reasonable to say that child protection work raises a lot of anxiety for GP’s delivering services to a whole registered population, particularly as they may have limited safeguarding experience. This is why training, supervision and mentorship on site are so important. 6.12.4 As mentioned earlier, nominated practice safeguarding children clinical leads are important figures for supporting clinicians with their safeguarding practice in a primary care setting. There is an expectation that every GP practice will have one. Baby Adam’s practice was significantly short-staffed at the time, with only one permanent GP and four locums providing a service. The one permanent GP was undertaking all of the various primary care lead clinician roles, including the lead clinician role for safeguarding children. This would have inevitably weakened the safeguarding arrangements in the surgery. This issue is revisited later. 22 The Victoria Climbié Enquiry (2003) Lord Laming HM Government. Recommendation 83 23 Safeguarding Children - How to Recognise Abuse or a Child at Risk: Patient: a medical resource online for supplying evidence based information on a wide range of medical and health topics. https://patient.info/doctor/safeguarding-children-how-to-recognise-abuse-or-a-child-at-risk Page 30 of 72 6.13 Acute Hospital Services 6.13.1 Baby Adam’s case touched several departments in the hospital. Services were delivered by numerous health practitioners from a range of professional disciplines. These included doctors, nurses, radiographers, paediatric radiologists and paediatric nurses. Some of these qualified health professionals held distinct leadership roles for safeguarding children within the organisation. A social care team for children was also co-located within the hospital setting although it operated within office hours only. This section looks at the inter-departmental activity and the inter-professional practice that occurred in relation to the history of unexplained bruising 6.14 The first Emergency Department contact 6.14.1 Baby Adam’s bruises were initially seen in the ED after a telephone discussion between the GP and paediatric registrar. The baby had not been to the hospital before and there was no hospital record relating to him prior to this visit or any information highlighting a previous concern. He was examined by a paediatric registrar in the emergency department, which is usual practice. 6.14.2 A full history, including a social history was taken, followed by a physical examination. The recording of the consultation was clear and comprehensive and included body maps of several bruises and marks of different ages. The notes recorded that the bruises had started to appear six days previously. Baby Adam’s mother produced photographs of the previous bruises during the examination. The photographs were mentioned in writing within the contemporaneous record. Concerns that the bruising might have been non-accidental was clearly documented. 6.14.3 The plan written by the paediatric registrar was that the child needed to be admitted for a paediatric assessment and investigations. Baby Adam’s parents were advised that tests would be undertaken to look for a blood clotting disorder. They were also informed that children’s social care would need to be alerted to the admission, a routine procedure for any child with unexplained bruising. Tower Hamlets out of hours (social care emergency duty team EDT was also contacted, confirming that the family was unknown to children’s social care services. The paediatric registrar then completed a formal child protection referral form which was dispatched to children’s social services. The NHS professionals in the hospital safeguarding team were also notified by email. 6.14.4 The response to Baby Adam’s bruising presentation in the A&E department was entirely appropriate and there is evidence of a good safeguarding assessment, management and decision making prior to his admission. This is an example of good safeguarding practice. 6.15 First admission to hospital paediatric ward 6.15.1 Baby Adam was settled with his mother into the paediatric ward for the night and his care was taken over by the night duty paediatric registrar. On reaching the ward, it appears that good communication took place between the night duty paediatric registrar and the on call-consultant with regards to any further clinical action that should take place. Page 31 of 72 6.15.2 However, the risks and arrangements regarding parental access on the ward were not systematically assessed or considered, even though non-accidental injury had not been ruled out. Hospital staff admitted that the ward lay-out and day to day routines would almost certainly mean that the infant was out of sight for varying lengths of the time during the day and night. The SCR learnt that the Hospital Trust did not have, and still does not have, a robust parental access and supervision risk assessment or procedure to ensure child patients admitted with safeguarding concerns are not exposed to risk from a possible perpetrator. 6.15.3 The chances for non-accidental injury to an infant being inflicted by a parent or adult carer are manifestly high and past cases have shown that children can, and have, been abused whilst in hospital by family or carers. Any assumption that a hospital must be a safe place is flawed and increases the risk to the child. The hospital has a legal duty to safeguard and promote the welfare of children in their care, and for suspected child abuse cases, care plans should consider the possible risks from visitors and carers whilst in the ward environment. Many hospitals have successfully implemented risk assessment and management tools to optimise safety for child patients admitted to hospital for suspected child protection reasons. 6.15.4 A full examination was undertaken by the paediatric consultant with lead case responsibility the morning after Baby Adam was admitted. The consultant also contacted the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters, for her view on the safeguarding aspects. This was an appropriate and sensible decision. 6.15.5 The differential diagnosis that was made in the light of his presentation, included non-accidental injury. Standard x-rays (Chest and CT scan of head) for suspected non-accidental injury were ordered. The rationale for the x-rays was written on the request form as ‘unexplained easy bruising, rib fractures, ? NAI’. A routine referral for an ophthalmology review to check for bleeding in the eye was also performed to exclude non accidental head injury, alongside other medical investigations for bleeding and clotting defects. 6.15.6 One significant omission was for a routine skeletal survey, a test which has been recommended as best practice for all suspected NAI cases in children under two years of age since 200824. The test is designed to spot bony injuries anywhere in the body. The radiographer contacted a consultant paediatrician once the ordered x-rays had been taken, to check that a skeletal survey was also not required, an appropriate action. The reply, was that a skeletal survey was not indicated. There is a discrepancy in the evidence gathered for this SCR, as to which consultant responded to this enquiry. 6.15.7 This decision was influenced by the medical staff witnessing a very large, unusual and palpable bruise forming when a blood test was taken. This observation weighted the paediatrician’s opinion in favour of a blood or clotting disorder, and the fact that the initial x-rays did not show any abnormality, rather supported that view. 6.15.8 From that time onwards, evidence suggests that NAI as the cause of the unexplained bruising, whilst still part of the differential diagnosis, was not considered with the same rigour as the probability of a medical cause. The paediatric team were convinced a medical reason for the bruising would be identified. This influenced the subsequent decision to discharge Baby Adam home without due regard to a safeguarding plan. 24 Standards for Radiological Investigations of Suspected Non accidental injury: Intercollegiate report from the Royal College of Radiologists and the Royal College of paediatrics and Child Health (2008) Page 32 of 72 6.16 Hospital inter-departmental procedure and guidance 6.16.1 The SCR has learnt that the hospital did not have an agreed child protection bruising in infancy protocol or a procedure that followed best practice guidelines. The accepted protocol for ordering a skeletal survey stipulated that skeletal survey was indicated only for children under one when signs of a fracture were present. This removed the ability to look for evidence of fractures elsewhere, increasing the chance that injuries could be missed. Despite the paediatric assertion that a skeletal survey was not necessary, the radiologist’s report recommended that Baby Adam should have one. 6.16.2 It was right that the radiologist recommended a skeletal survey in the written radiology report, in an attempt to ensure that recommended professional practice guidance was followed. This was all that the practitioner could do. There was no formal mechanism in place for radiology staff to rapidly escalate professional anxieties to enable a professional challenge or managerial discussion about a paediatric decision. The culture at the time was described as one where the paediatricians had the last word. 6.16.3 The paediatricians noted that a skeletal survey had been recommended in the report, but there was no urgency for Baby Adam to return to the radiology department. An appointment was made one week later for the procedure to be done as an outpatient. 6.16.4 A senior member of the radiological team when reflecting on the case confirmed that a skeletal survey should definitely have been ordered before the baby had left hospital. The practitioner also confirmed that radiology staff in 2015 were directed by the paediatricians, and the relationship was not one of professional equals. Several professionals giving evidence to this SCR also hinted that the relationship between the two disciplines was somewhat irritable at times. 6.16.5 The hospital Serious Incident (SI) investigations have recommended that hospital safeguarding practice in general should improve as the standard was below that expected for some very senior staff in particular. There is also a recommendation that that national skeletal survey guidelines should be followed in all cases where NAI is being considered. It also recommends that safeguarding is included in the continuing professional development programmes for radiological staff. 6.16.6 The SI findings also outlined how radiologists and paediatricians need to work in a more collaborative way. However to consolidate a respectful partnership approach, systems and pathways need to be agreed within the radiological department to enable its staff to escalate and challenge decisions that might not be considered to be in a child’s best interest. 6.17 Multi-agency Practice Leading to Baby Adams Discharge 6.17.1 The hospital social work team picked up the child protection referral form relating to Baby Adam on the day after his admission (12th March 2015), but did not make contact with the ward until the next day. A telephone call was made to the paediatric ward by the allocated social worker to seek information and ascertain whether children’s social care needed to take any action in accordance with Section 47 of the Children Act 198925. 25 The Children Act 1989 (s47) allocates duty to local authority to make such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare. Page 33 of 72 6.17.2 The social worker was surprised to hear from nursing staff that Baby Adam was already being considered for discharge because the consultant paediatrician with lead case responsibility had concluded that Baby Adam was a ‘low index of concern’. During the conversation it also became apparent that despite believing that Baby Adam was not at risk, the medical team wanted children’s social care to support the family once they had gone home. 6.17.3 Several attempts were made to clarify exactly what a ‘low index of concern’ meant, but no satisfactory explanation could be given by the nursing staff. It seemed that Baby Adam had been ‘bench-marked’ against a risk index that was totally unfamiliar to the hospital social work team and nursing professionals alike and which left them both baffled as to whether Baby Adam was at risk or not. 6.17.4 The term ‘low index of concern’ was unfamiliar and confused the social work team professionals considerably. It is not a phrase that appears in child protection policy or training. The term, coined in a patient safety framework entitled the ‘Index of Suspicion’26 was used initially in the USA to measure risk in American medical and pharmaceutical settings. The term seems to have been applied by the consultant paediatrician as a descriptor of Baby Adam’s circumstances in a safeguarding context, which, rather than clarifying the position, left the social work team puzzled and unclear as to what to do next. 6.17.5 Using a common safeguarding language to enable effective and collaborative work between staff of different disciplines27 has been accepted as good practice for over a decade. Medical staff will inevitably communicate with medical colleagues for medical purposes using terminology familiar to their own professional background. However, it is important when safeguarding is an issue that doctors and other professionals consistently use only words and phrases common to child protection practice, to facilitate understanding by the rest of the multiagency partnership. It is also important that practitioners in all disciplines take responsibility and question the meaning of unfamiliar phrases until an understanding is achieved. 6.17.6 After a discussion with her team manager, the social worker contacted the ward again. The social worker requested clarification about why the medical team thought that a social care intervention was necessary and pressed for a definitive statement that non-accidental injury had been ruled out. When this was not forthcoming, she challenged the wisdom of discharging Baby Adam at all, and told the paediatric nurse that social care strongly advised against discharging Baby Adam particularly as his bruising remained unexplained and medical investigations were still underway. 6.17.7 A record of this discussion in the medical notes states that the nurse would ask the paediatric consultant to contact the children’s social care manager directly to explain the rationale for discharge, but there is no evidence to confirm that this message was passed on or that a conversation subsequently to took place. However by this stage, it was clear that the professionals on the ward had come to the conclusion that social care would not support the family unless non-accidental injury was implicated. The recorded medical notes also allude to the discharge plan being effectively communicated to social care colleagues, a point which continues to be disputed by the social workers involved. Clearly, a serious miscommunication about the safeguarding risks and implications of the discharge had occurred between the two disciplines. 26 An index of suspicion is defined as ‘awareness and concern for potentially serious underlying and unseen injuries or illness.’ (2012) Institute for Safe Medication Practices, USA 27 Framework for the Assessment of Children in Need and their Families (200) DfE Page 34 of 72 6.17.8 The social worker’s records clearly describe her discomfort about the potential discharge and in response to that concern she alerted the social work EDT office and asked them to keep in telephone contact with the ward over the weekend to check on Baby Adam’s progress. A comprehensive follow-up e-mail was sent by the social worker to EDT including a summary of the advice not to discharge Baby Adam until the medical tests were complete. However, despite obvious professional anxiety and failure to understand why Baby Adam might be discharged into a risky situation, the matter was not escalated by the hospital social work team manager to a more experienced senior professional for direction and legal advice. This would have required a conversation with the social work team service manager responsible for the hospital service, who was located off site in another office. 6.17.9 The social care out of hours Emergency Duty Team telephoned the ward during the weekend as requested by the hospital team social worker, only to be informed that the baby had gone home with a date to be reviewed in clinic after one week. The medical team reiterated to the EDT social worker that there were no safeguarding concerns but investigations for the bruising were ongoing. The contradictory nature of this statement remained unchallenged by EDT. The only action taken by EDT was to make a note for the hospital social worker to follow up the issue on her return to work. 6.18 Professional perception, respect and challenge 6.18.1 There was clearly a very different perception and professional attitude about the risks of discharging Baby Adam from the hospital, and neither discipline had communicated their position effectively. The paediatricians did not consider the risk of NAI would be particularly high, but could not articulate why. In contrast, the social worker thought the baby was at considerable risk as no cause for the bruising had been identified. Effective communication for child protection practice is much more than merely exchanging information; practitioners must ensure that it facilitates and achieves a common understanding about the reasons behind an action. 6.18.2 A SCR discussion as to why the hospital social work team did not escalate their serious concerns about the discharge concluded that the culture within the separated and bespoke hospital based social care service might have been out of tune with the operational norms practiced by other community based social care teams. For example, the hospital team had its own systems and identity, which might not have encouraged business to be discussed outside of the hospital setting. This finding surfaces again at another point in Baby Adam’s story and is discussed later in this report. 6.18.3 A major thread throughout this SCR which applies to most of the agencies involved during this episode of care, is the apparent belief that non-accidental injury needed to be confirmed by a medical diagnosis before child protection activity could be triggered. This stance shaped the multi-agency response and approach to Baby Adam’s situation which in hindsight placed him at considerable risk. 6.18.4 Any presentation of unexplained bruising in a pre-mobile infant is suspicious. Baby Adam’s presentation should have been treated as highly indicative of significant harm until totally excluded by investigation and professional evaluation of a range of relevant medical and psycho-social factors. Child protection activity is not dependent on a medical diagnosis, nor on the opinions of medical professionals alone. Measures to protect Baby Adam should have been taken. Page 35 of 72 6.18.5 It is children’s social care professionals who hold the legal responsibility for deciding when a child protection response is required, and in this case they should have exercised that leadership function more robustly by challenging the paediatric plan at the highest levels. Discharge should not have taken place until after a skeletal survey and after a multi-agency strategy meeting to discuss potential risk and likelihood of harm had taken place. 6.18.6 The hospital social worker learnt about the discharge when she returned to the office after the weekend. She was alarmed that the baby had been discharged and explained during a SCR interview how annoyed she had felt that her advice had neither been respected nor followed by the paediatric team. She also described how the independent action taken by the paediatric team resulted in a rather negative air of mistrust between the professional disciplines. This lack of mutual professional respect is an important feature in this SCR. 6.18.7 The GMC Guidance for protecting children28 clearly sets out that doctors should understand and respect the child protection roles, responsibilities, policies and practices of other agencies and professionals, and cooperate with them. It also urges doctors to be clear about their own role and responsibilities in protecting children and be ready to explain this to colleagues and other professionals. Episode 3. How effective was the practice when Baby Adam attended for the follow-up outpatient appointment and skeletal survey? 6.19 Multi-agency practice relating to outpatients appointment 6.19.1 Baby Adam was to return to the hospital for a pre-planned outpatient’s appointment, including a skeletal survey on 20th March, one week following his discharge from hospital. 6.19.2 On hearing about the outpatient’s appointment the social worker immediately discussed Baby Adam’s case in supervision for management oversight. Information sent to the social worker post discharge confirmed that test results had not indicated a medical cause and non-accidental injury was still a concern. However, the social worker at this time had a deep suspicion that paediatricians were not sending complete and up to date information about the case, a feeling not helped by the circumstances leading to Baby Adams discharge the week before. 6.19.3 The outcome of the meeting was for the social worker to continue to work with the medical team to gain a better understanding of the family and parental account, and the approach being taken by the paediatric team with regards to ruling out non-accidental injury. A general note was placed on file suggesting that the hospital safeguarding team and the social work department needed to agree a protocol already in development to improve how NAI queries were followed through. This suggests that the effectiveness of hospital safeguarding systems had been in question for some time. 28 Protecting children and young people: the responsibilities of all doctors (2012) General Medical Council. Page 36 of 72 6.19.4 Prior to speaking to Baby Adam’s mother, the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters appraised the social worker of the medical investigations, all of which were normal although two were still in progress. This is a good example of multiagency collaboration. The paediatric consultant assured the social worker that the baby would be readmitted, if the skeletal survey due to be taken that afternoon was abnormal. He would also be readmitted for treatment if any positive test results were received that suggested a medical condition was causing him to bruise. 6.19.5 Medical causation was still the primary concern. Mrs C reported that new bruises had emerged through the previous week and the paediatrician explained that nothing wrong had, so far, been discovered in relation to the blood investigations. These two factors taken together should have increased professional suspicion, but questions about possible deliberate harm did not assume a higher priority, from either the paediatrician or the social worker. Instead, the social worker was content to concur with the paediatric plan to continue to look for a medical cause. This is yet another manifestation of the medical model taking precedence over a more holistic ‘think family’29 social approach to assessing risk using a range of past and current information and child protection theory. 6.19.6 The informal verbal report of the skeletal survey given to the consultant paediatrician who had made her way to the x-ray department, was unusual and outside of best practice guidelines. The reasons why the paediatrician went in person to get the result was partly because the paediatrician was concerned about Mrs C and her baby who had been waiting for some time in the clinic, and partly because the doctor was striving to complete outstanding tasks prior to commencing an extended period of leave. Whilst the action was outside of normal practice, it was undertaken in good faith and with good intentions. 6.19.7 The paediatric radiologist told the consultant paediatrician with lead case responsibility that the skeletal survey was ‘fine’ intimating that no abnormalities could been seen. The social worker was promptly made aware that the skeletal survey was normal, after the verbal report was given. This conversation is recorded in the social work file but is absent from the paediatric notes. Giving a radiological verbal opinion on a skeletal survey did not comply with the hospital radiological reporting protocol at the time, which required a more cautious and expert approach for child protection cases and which expected two senior paediatric radiologists to view the images. 6.19.8 The act of being approached and being asked for an opinion on the skeletal survey would have presented a difficult dilemma for the radiologist, who would neither have wanted to appear un-cooperative nor challenge a senior paediatric colleague. However, protocols, including radiological protocols are designed for a purpose, often to ensure patient safety and they must be adhered to. The matter of verbal reporting has been subject to a recommendation for improvement in the NHS SI radiological services investigation. The SCR has been assured that verbal reporting is no longer an option in the hospital. 6.19.9 After the verbal skeletal survey report had been given, the consultant paediatrician who was about to go on leave, handed over the responsibility for Baby Adam’s case to the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters, recognising that the case was unusually complex and required close monitoring whilst she was on holiday. 29 Think Family: Improving Support for Families at Risk. (2009) Department of Children Schools and Families Page 37 of 72 6.19.10 A professional handover to cover absence in principle is good practice to ensure continuity and safety, but it has to be robust. In this case, there are no notes in the paediatric record of how the new bruising and subconjunctival bleed were considered, or what influenced the decision to allow Baby Adam to go home despite recurrent bruising which remained unexplained. Handovers, should be fully recorded with the name of the consultant taking over the case responsibility explicit in the notes30. This particular handover was informal in nature so the responsibility, accountability and planning considerations for Baby Adam whilst the lead consultant was away remained unclear during her absence. 6.19.11 A letter from the consultant paediatrician with lead case responsibility to Baby Adam’s GP, summarising the outpatients appointment, was dictated on the day of the appointment (20th March 2015), however it does not appear to have been typed until 29th April 2015, over seven weeks later. The letter explains that medical investigations for a clotting disorder and non-accidental injury were being undertaken in parallel, but had so far returned negative results. The letter also stated that the social worker present at the appointment would meet the family to offer support. 6.19.12 To draw attention to investigations for a medical cause and non-accidental injury was useful, but the reference to the social worker offering support rather overstated their involvement and would have misled the GP into thinking that a multi-agency plan had been formulated. When letters are written to professional colleagues alerting them to safeguarding concerns, it is important that they are accurate and unambiguous. 6.19.13 Despite the letter being dictated as a means of sharing information with the GP, in reality, it did not facilitate any timely information exchange. Evidence has shown that the letter was delayed and never reached the GP surgery until the beginning of May 2015. Letters at this time were sent off site for typing. 6.19.14 The SCR discovered that two paediatric letters, the outpatient summary dictated on 20th March and another written on April 27th following the Section 47 Enquiry were both typed and dispatched to the GP on 29th April 2015. The time interval suggests they might have both been processed as a priority on that date. It also suggests that an administrative back-log for typing letters, common for many hospital trusts, might have been a factor in this case, causing consultant letters to hang around in the system. In safeguarding terms, all information should be exchanged quickly and efficiently when safeguarding features in the history. As a result of this delay, important medical information about Baby Adam’s outpatient appointment, did not reach the GP surgery until 6th May 2015. 6.20 Response following second radiological review of skeletal survey 6.20.1 A second consultant radiologist examined the skeletal survey images towards the end of the day on 20th March 2015, after the verbal report had been given and after Baby Adam had left the hospital. She pointed out some possible abnormalities of the chest and leg which had simply just not been seen on the first viewing. The recommendation was for Baby Adam to have repeat x-rays to exclude fractures after a further period of 10 days, the standard interval that would enable a more certain judgement. 30 The Victoria Climbié Enquiry Report: Recommendations 76 and 80 Page 38 of 72 6.20.2 There is a difference of opinion as to whether the consultant paediatrician with lead case responsibility was informed about the anomalies on the x-rays as soon as they were discovered and before she left to go on holiday. The radiologist vaguely remembers having a conversation with a paediatrician, but the paediatrician does not remember any such conversation, pointing yet again to the importance of recording all professional interactions. 6.20.3 The written x-ray report was prepared and subsequently read by the paediatric doctors after the weekend on the following Monday morning. In line with the radiologist’s recommendation in the report, further x-rays were ordered. The request form stated that the images were for following up a skeletal survey, but it did not explicitly mention that NAI was being investigated. 6.20.4 The chest and leg x-rays were duly repeated on Wednesday 31st March 2015, eleven days after the skeletal survey was undertaken. The radiographer who took the pictures, and who is not trained to spot abnormalities, made an effort to locate a paediatric radiologist to look at them. However the attempt to locate and speak to a radiologist was abandoned when it became apparent that no one was going to respond to the telephone calls. 6.20.5 In 2015, x-ray requests that clearly mentioned NAI on the form were automatically marked by the radiographer for high priority reporting to meet best practice guidance31. However, as the suspicion of NAI was not indicated on the request form, the films were not prioritised and were placed into the non-urgent pile for routine reporting. The established turnaround time for routine reporting of x-rays was one week. 6.20.6 However, the long Easter holiday weekend that commenced within 24 hours of the x-rays being taken meant that the hospital was operating a reduced out-of-hours service for four days. This put a strain on the staffing capacity of the paediatric radiology department and a back-log of work started to grow over the holiday period. The effect of the Easter holiday resulted in a delay of almost two weeks before Baby Adam’s x-rays could be reviewed by a radiologist. 6.21 Response by GPs following discharge from hospital 6.21.1 A one page A&E summary was dispatched and received by the GP surgery on 13th March 2015 (two days after Baby Adam’s presentation in the ED). The information was summarised and uploaded by a practice clinical coder into the GP electronic patient record. The event was coded as ‘bruising symptom, for review’. 6.21.2 Despite a clear reference to a child protection referral, the summary emphasised the medical investigations and also stated that social care would not be taking action whilst medical investigations were ongoing. This might have contributed to the coder giving the event a clinical code that related only to bruising. The code did not reflect the safeguarding concerns in the summary and it would not have provided a flag for suspected child maltreatment on subsequent visits to the GP. In a modern GP practice, is highly unlikely that the GP would remember or have known about the past safeguarding concern without a flag to act as a reminder. 31 ‘The possibility that a child has been injured non-accidentally should be clearly stated on the radiological request’: Standards for Radiological Investigations of Suspected Non-accidental Injury (2008) Royal College of Radiologists & Royal College of Paediatrics and Child Health Page 39 of 72 6.21.3 Baby Adam had a further two contacts with a GP after he was discharged from hospital; one face to face and the other via a telephone consultation. The GPs that he saw relied on feedback from Baby Adam’s parents to inform their consultation, partly due to the fact they had not received any written paediatric summaries from the hospital on which to base their decisions. Evidence also confirms that the GPs who saw Baby Adam failed to initiate any contact with paediatric colleagues involved in his care, in order to clarify and update the information that they were told. Instead, Mrs C was advised to keep the consultant appraised of any new bruises by forwarding photographs to the consultant’s email address. The GPs would not have known that the consultant was on holiday, and might not be accessing her inbox. 6.21.4 Consideration as to why the GPs thought it reasonable to take complex clinical information about a child from a parent has been discussed as part of this review. The fact that Baby Adam’s mother was a health care assistant in a primary healthcare setting might have influenced this practice, but there is no evidence to corroborate this theory, other than comments from her primary healthcare colleagues who were confident that she always acted in a professional manner and showed a high level of concern for her child. 6.21.5 As for many city-based GP practices, Baby Adam’s GP service was under considerable organisational stress and in a state of flux at the time Baby Adam was discharged from hospital. There was only one permanent GP working in the practice, who held all of the lead clinician roles including for safeguarding. Continuity of care was impossible to organise, with the day to day GP consultations being maintained only by regularly employing locum doctors to cover for medical staffing shortages. Ensuring that the locum doctors had sufficient safeguarding experience and safeguarding children training to the prescribed level would have been very difficult, and it was just as difficult for the lead safeguarding clinician to know just how well complex safeguarding cases were being managed. 6.21.6 As well as clinical staffing problems, the amount of information being generated for the surgery to manage was considerable. Documents were coming from a range of health and social care environments and they all needed to be processed. Organising the paper-work and information flow was challenging both for the administrators responsible for processing it, and for the clinical staff who had very little time to read and digest the content in preparation for a patient consultation. 6.21.7 In Baby Adam’s story, there is some evidence of documents being filed rather than brought to the attention of the clinicians, and of material being processed in a purely medical context when it had safeguarding significance. For example, not all of the documentation pertaining to Baby Adam was scanned into the electronic GP file after it was summarised, and negative investigation results were being viewed as optimistic and normal rather than an important and potential source of suspicion. 6.21.8 As a means of managing the volume of paper-work, the practice employed qualified doctors who were waiting to undertake their Professional and Linguistic Assessments Board (PLAB)32 test prior to registering with the GMC. Their role was to specifically summarise, code and direct the flow of clinical information. However, the effective analysing, summarising and coding of material for complex safeguarding cases, would require a good command of the English language and an understanding of the English child protection system, so the extent to which this system assisted GPs to see relevant safeguarding information is questionable. 32 The PLAB test is the main route by which International Medical Graduates (IMGs) demonstrate that they have the necessary skills and knowledge to practise medicine in the UK. Page 40 of 72 6.28.9 The research document ‘Pathways to harm, pathways to protection’33 published in 2016, looked at the initial impact of large scale health service reform on child protection practice between the years of 2011 and 2014. The report concluded that the fragmentation of health services as a result of the reforms was having a considerable and negative effect on child protection practice generally, and this applied to primary care as well as for any other NHS service. 6.28.10 The authors of the of the research study specifically commented on the increased pressures and changed circumstances and delivery models for primary care services since the NHS reforms were implemented. They alluded to how in the past GP services were regarded as having an important and unique function, capable of bringing together a wealth of in-depth health and social intelligence about families. However, in a modern GP practice setting, this is less likely to be true. 6.28.11 In recognition of the change to the primary care landscape, the authors of the study recommended that LSCBs should work more closely with GPs, their commissioners and other stakeholders to ‘realistically review what can reasonably be expected of GPs as repositories and coordinators of care, and how such expectations can be supported’. For the timescale of this review, all clinicians including GPs had a statutory requirement placed upon them to safeguard and promote the welfare of any child they came into contact with. This has not changed. However the specific difficulties of GPs to meet this requirement has clearly been recognised and the recommendations in ‘Pathways to harm, pathways to protection’ may need to be revisited in the future to enable children to be safeguarded effectively in the primary healthcare setting. 6.29 The NHS community baby clinic 6.29.1 A visit to the community baby clinic occurred two days after the repeat chest and leg x-rays, and twenty days after Baby Adam had returned home from his first admission to hospital. Details of the admission had been entered on the EMIS electronic recording system. The clinic health visitor, who was also aware of the child protection referral, took a first-hand report about the hospital admission from Baby Adam’s mother. 6.29.2 During the clinic contact, Mrs C appraised the health visitor of the paediatric investigations. She also reported that the baby was crying loudly at times, as if in pain, particularly on movement, and pointed out that a fresh bruise had appeared. A combination of bruising and pain on movement is highly indicative of trauma. However, the information was taken at face value and was documented, without any other probing or other action being taken. 6.29.3 The health visitor viewed the new bruise and crying as part of the medical condition already being investigated, rather than a set of new circumstances. Her professional judgement was that she had no role to play, as all the necessary people and professionals were involved already. She had no safeguarding concerns about Baby Adam and did not feel the baby was at risk of harm from his parents. 34 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final Report. Sidebotham P, Brandon M, et al ((2016) University of Warwick and University of East Anglia Page 41 of 72 6.29.4 The reason why the information failed to instigate an action was because the clinic health visitor felt confident that all that should be done, was being done. Whilst it is possible to explain how this assumption was formed, it was deeply flawed. Sharing the observations and information from the contact might have been helpful to the paediatricians and social work team as well as informing her own service. Health Visitors must report any contact with any child where child protection concerns are currently being considered, and follow up all new information, signs or symptoms of non-accidental trauma when they occur. 6.30 Home visit by the NHS community family health visitor 6.30.1 Health visitors, who are allocated home visiting responsibilities, are central to the safeguarding system. They have case specific obligations and their primary task is to promote the health and wellbeing of children during their first five years. Their unique role should enable them to identify need and risk and respond accordingly. They are major players in the multi-agency approach to child safeguarding and contribute to safeguarding assessment and planning processes 6.30.2 A home visit was undertaken two days after Baby Adam attended the baby clinic and three weeks after he was discharged from hospital for the first time. This might have been due to the fact that the discharge notification dispatched by the hospital was subject to a delay, and it was three weeks before it came to the attention of the health visiting service. No explanation has been given as to why there was a gap between the hospital dispatching the note and the health visitor picking it up. 6.30.3 Following up the hospital admission was good practice, but this is best done within a week of the discharge date. A delay of three weeks is excessive when a safeguarding concern has been part of the history. The communication system in place between the hospital and health visiting services must be robust and reliable to ensure the information flow between each service at a pace that will serve the best interests of a child. 6.30.4 At the time of the home visit, Baby Adam was almost three months old. He had a known history of recurrent bruising, and bruises were continuing to appear. His brother, Sibling Isaac, continued to wait for investigations of developmental delay and behavioural problems which were still evident. Parental concerns and stressors had also been identified and were a matter of record. 6.30.5 The home visit discussion incorporated a verbal update from the parents about the medical plan and family’s progress generally. Both parents admitted to being very tired. They confirmed that they were taking responsibility for keeping the clinicians appraised of new bruises by emailing them directly to the consultant paediatrician. Their verbal report was noted, although the detail of the medical plan was not clarified after the visit with either the family GP or the paediatric health visitor at the hospital, who could have liaised directly with the paediatricians to ensure a professional perspective. 6.30.6 During the visit, Baby Adam was again described as crying loudly and this was observed by the health visitor. Loud crying in and of itself is not unusual in an infant of three months. There is no evidence in the notes that relates this comment to the ‘loud crying on movement’ that was expressed in the clinic two days earlier. This suggests that previous electronic notes were not read prior to setting out. Had the history of pain on movement been realised, further questions relating to the crying might have been asked. Page 42 of 72 6.30.7 Further complexity was added to the history when Mr C revealed to the family health visitor that his baby son would only settle with his wife. He described this inability to settle his son as ‘difficult’ and went on to disclose that he thought the baby didn’t like him. This perception, whilst not entirely uncommon for new parents, is irrational and such thoughts require careful monitoring to ensure they don’t become overly negative or intrusive, or escalate to present a potential risk to the infant. This was new information and signalled yet another stressor for the family. 6.30.8 Reassurance and advice about bonding with his son was given to baby Adam’s father, following the disclosure, which was an appropriate response. However, the impact on Baby Adam of the disclosure, for example, how this perception might affect his father’s psychological adjustment to fatherhood, the process of attachment34, or its possible connection to Baby Adam bruises, were not fully explored or analysed. Furthermore, the disquieting remarks uttered by Baby Adam’s father were not discussed with any of the other involved professionals immediately after the visit, being shared for the first time in a subsequent strategy meeting, several days later. 6.30.9 The known and new information that emerged during the home visit did not trigger a risk assessment. Instead, the practitioner told both parents that she had not identified any concerns regarding their care of Baby Adam, an opinion that would be relayed to the social worker at a much later date. The health visitor did however, present the case at a reflective supervision session, due to the complexities of the case. This was an entirely appropriate action and a suitable case to discuss. However, due to a lack of written information about the supervision session, it is difficult to see whether the supervisor provoked a deeper analysis of the family’s circumstances or if the outcome and care plan was challenged in any way. 6.30.10 Despite the growing number of stressors, the care plan remained at a universal service threshold. Much more work could have been done to expand on the facts that were either known or coming to attention during this visit to evaluate potential risks and their effect on Baby Adam’s safety and welfare. 6.30.11 During the SCR interview the practitioner alluded to ‘knowing the family well’ which seems unlikely considering the amount of time spent with them. This notion alone might have led to the optimistic and parent centred assessment formed on the basis of limited information and knowledge, drawn from three home visits and a clinic contact. The relationship between Baby Adam’s parents and the practitioner was thought to be one of trust, however a modicum of professional scepticism and curiosity could have been kept in reserve, particularly as safeguarding concerns remained a feature in the history. In hindsight the practitioner described how she had been utterly convinced that neither parent would harm the baby and how she would take a much more cautious approach in the future. 6.30.12 Health visitors must be clear that their primary task is the safety, health and welfare of the child and ensure that their assessments are first and foremost child centred. Each element of their contacts and assessment should add to the overall understanding of the child’s risk and experience and the context in which they live. Adopting a risk assessment approach and using established risk assessment techniques is a good way of promoting child centred analysis objective care planning. 34 Attachment is the emotional bond formed between a child and his or her care givers through a consistent sequence of affectionate interactions. Page 43 of 72 6.30.13 A study undertaken by the NSPCC in 201535 comments on the superficial nature of many assessments undertaken by health professionals, including health visitors, for infants where a safeguarding issue features in the history. The study notes that risk assessment techniques, essential for evaluating context and cumulative risk are not readily used by health professionals in this country generally. The findings conclude that there is a need for safeguarding and risk assessment training for all health professionals working with complex families. 6.30.14 The analysis and learning for this particular event in Baby Adam’s story mirrors the findings in that NSPCC report. During the timescale of this review health visitors in Tower Hamlets were neither trained nor expected to undertake formal risk assessments to inform their care plans. Skilling health visitors to calculate and manage risk more effectively, particularly where new information and safeguarding indicators like bruises are present would be a useful measure to determine their thresholds for intervention and improve the outcomes for families they are visiting. 6.30.15 Lastly, informing the family that their parenting ability was not in question in such a direct and positive manner has been a topic of discussion during this SCR. Social workers in particular have suggested that such reassurance, based on a short period of observation rather than a robust, objective and systematic risk assessment, not only confused the parents, but was potentially unhelpful when child protection activity was still a distinct possibility. Episode 4. How effective was the multi-agency practice following the discovery of fractured ribs? 6.31 Responses following the review of x-rays and subsequent re-admission 6.31.1 The repeated x-rays of Baby Adams chest and legs that were held up in a reporting queue, were eventually seen and evaluated by the paediatric radiologists thirteen days after they were taken, twice as long as the recommended timescale for routine reporting in national and hospital guidelines. Fractures of the 3rd to 7th ribs were seen and immediately reported to the paediatricians and to social care. The delay in reporting had clearly exposed a risk to Baby Adam for longer than was necessary. Discovery of the rib fractures triggered his second admission to hospital. 6.31.2 Baby Adam was recalled as a matter of urgency on 13th April 2015. This was an appropriate action. He was seen initially in the A&E department where a second social care referral form was completed. The comprehensive referral drew attention to the newly identified fractured ribs and past history of unexplained bruising. It also recorded that a child protection medical examination and skeletal survey had been undertaken and that a previous child protection referral had been sent approximately one month before. 6.31.3 The second referral, made outside of office hours, necessitated a response from social care EDT. Generally an EDT out of hours service prioritises work according to vulnerability and risk, their core tasks being safeguarding advice and risk management. They do not normally intervene or undertake casework already allocated to a social work team for ongoing work. At the time of this admission Baby Adam was known to children’s social care, but had not been allocated for a social work assessment. 35 Perinatal healthcare teams: learning from case reviews. Summary of risk factors and learning for improved practice for the health sector Page 44 of 72 6.31.4 The EDT duty worker made contact with the paediatrician, who provided further information, including that Baby Adam was to be readmitted to the ward for further investigations whilst in a ‘place of safety’. The brief out-of-hours EDT report summarised that the baby had been recalled to hospital in view of fractured ribs which would require further investigation. It recommended that the hospital social worker make contact with the medical staff in the morning to plan further action. The EDT activity in this case, was to take minimal details of the readmission, and pass the responsibility to the hospital social work team, when they opened for business the following day. 6.31.5 The sudden diagnosis of fractured ribs in combination with recurrent unexplained bruising to a pre-mobile infant should have rung alarm bells. They are highly indicative of non-accidental injury. There is no evidence of EDT giving any child protection advice or guidance to the ward staff to ensure Baby Adam would be safe, particularly in relation to parental access and the arrangements for his mother to stay with him overnight. Similarly, no enquiry was made regarding the safety or potential risks to Baby Adam’s three year old brother who remained at home with his father. 6.31.6 At that point of readmission, the cause of the rib fractures remained unknown. They were however very serious injuries and highly indicative of deliberate harm. No consideration had been given to the question of which adult or adults in the family might pose a risk to Adam or to other children in the family network. It is important that the social care EDT operates a system that evaluates the risk of children coming to their attention, to ensure they will be protected effectively outside of office hours, regardless of any other health and social care activity. 6.31.7 Doctor Peter Sidebotham et al36 found that 78% of children subject to a SCR between 2011 and 2014 were known to children’s services at the time they were being abused. The fact that children’s social care are alerted does not in itself prevent further serious deliberate harm. More attention should have been paid by the EDT service with regards to assessing the immediate situation for both children, so a balanced judgement could be made, explained and recorded as to whether or not any urgent safeguarding action was necessary. 6.31.8 The assumption that the hospital ward was a ‘place of safety’ gives the impression that Baby Adam would not have been exposed to risk whilst he was an in-patient. This view, whilst common amongst health and social care practitioners, is false. In reality, the staffing levels in a hospital, particularly at night, do not guarantee the level of supervision required to ensure that the child will be safe. Any suspected NAI case admitted to hospital, should always be subject to a risk assessment to enable the mitigation of any harm that staffing, visitors or architectural layout may pose. 6.31.9 The SCR panel have learnt that the hospital had no professional protocol in place for enabling optimal safety for paediatric admissions where child abuse is suspected. Such a protocol, which should be agreed with social care colleagues, and which should include safety measures for parental contact or visitation, is essential for any paediatric admission when injuries are unexplained and the perpetrators unidentified. 36 Pathways to Harm Pathways to Protection: Review of SCR’s 2011-14 (2016) Dr P. Sidebotham Et Al University of Warwick & University of East Anglia. Page 45 of 72 6.31.10 The hospital social worker responded to the admission and second child protection referral by proposing that a strategy meeting should take place. This was the right decision and was endorsed by a team manager. Invitations were duly sent to the police and NHS colleagues, in line with national and local procedures. 6.31.11 The responsibility for convening and coordinating a strategy meeting or discussion lies entirely with the Local Authority Children’s Services Department.37 The decision whether to proceed to a section 47 Child Protection Enquiry is made on the basis of inter-professional dialogue, multi-agency information sharing and consideration of whether a child might be suffering or be likely to suffer significant harm. Once children’s social care has made the decision to initiate a section 47 Child Protection Enquiry, a multi-agency plan of how the child protection investigation will be conducted, and who will be involved, is agreed by the partnership. Strategy meetings are considered to be the most effective way of bringing professionals together to facilitate good information exchange and face to face discussion. From a police perspective, they also provide an early opportunity for evidence gathering, should a criminal investigation be needed. 6.31.12 Statutory government guidance (2015) and the local London Safeguarding Board Child Protection Procedures (2015) were clear that a strategy meeting should always, as a minimum, include representatives from children’s social care, health and police.38 Guidance and procedures also stated that strategy meetings should be convened ‘whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm’. As a pre-mobile infant, Baby Adam’s history of unexplained bruising and the discovery of subsequent rib fractures, constituted a ‘reasonable cause to suspect’ and met the criteria for convening a strategy meeting in full. Furthermore, non-accidental injury, as part of the medical differential diagnosis from the start of the medical investigation, had never been excluded. 6.31.13 A senior member of the police representing the CAIT service on the SCR panel explained that the case had not met the team threshold for participating in a strategy meeting. This was influenced by several factors, not least, that the information from children’s social care had not clearly set out the facts or the rationale for convening it. It was also influenced by workload pressures that had resulted in strict prioritisation of all work being accepted by the CAIT team, as a measure to manage the high demand on the officers in the service. Lastly, there was a misplaced belief that the case could not be subject to a strategy meeting until and unless the medical opinion judged the injuries to be non-accidental in nature. 6.31.14 However, the police decision to decline the invitation to the strategy meeting not only prevented any chance to secure early evidence of NAI, it ultimately altered the direction of the multi-agency response to the admission, as a statutory meeting without the police was statutorily inquorate. Children’s social care were somewhat dismayed by the police reaction to the invitation, but the decision remained unopposed by children’s social care, despite their overarching responsibility for Baby Adam’s safety. 37 Children's Services Social Care must hold a Strategy Discussion whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer Significant Harm whether or not it appears that a criminal offence against a child has been committed. 38 A local authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the strategy discussion. Other relevant professionals will depend on the nature of the individual case. Working Together (2015) HM Gov. Page 46 of 72 6.31.15 Instead of a robust challenge and escalation for more senior advice and or intervention, to ensure that Baby Adam’s risk was addressed, the team manager, who was responsible for the child protection response under Section 47 of the Children Act 1989, deferred to the police position and advised the social worker to step down the child protection strategy meeting and proceed with a professionals meeting as part of a child in need (CIN) response39. 6.31.16 At the time of this review, the hospital had its own social care team on the hospital site. It had its own identity and culture and a distinct role of providing social work support within the hospital setting. One key safeguarding professional described professional relationships as ‘cosy and overfamiliar’ at times. The team perceived itself as essentially different to the other teams located in the local authority area. The team was self-managed to a large extent, and the day to day practice, supervision and management oversight, remained within the hospital boundaries. 6.31.17 The senior and more experienced accountable service manager for the hospital team was located off site in the main local authority council building, and as such was remote and invisible to the team on a day to day basis. Escalation of a concern for senior management guidance or legal advice might have been seen as more difficult for the hospital team under these circumstances. 6.31.18 Being absorbed into an entrenched hierarchical culture makes professional deference and lack of challenge more likely, and there are clear indicators in the actions taken or not taken by social workers, that deferring to medical (and police) opinion dictated how this case was managed. These issues are covered later in this report as a generalised finding. 6.31.19 Since this SCR has been completed, the social work team structure in Tower Hamlets has been reviewed. The hospital social work service has been disbanded and has been absorbed into community based teams which are expected to adhere to robust borough wide service specifications and a common approach for all children and families in the area. This should support social workers to maintain their professional identity and core purpose. 6.31.20 The so-called professionals meeting took place in the hospital within one day of Baby Adam’s admission. It was chaired by the hospital social work team manager who decided to assign the case a child in need (CIN) response. A newly qualified consultant with limited safeguarding experience represented the paediatric department along with the senior hospital nurse employed to provide advice and professional oversight on safeguarding matters. The family health visitor was there to exchange information and the parents were also in attendance. No formal minutes of this meeting have been submitted as evidence for the SCR suggesting that none were circulated. 6.31.21 The professionals meeting mimicked a strategy meeting to a large extent although the difference in purpose and status was not explained to participants. It has become clear during the course of this review that several professionals attending the meeting were left wondering about what type of meeting they had attended. Many were confused about the status, authority and ownership of the decisions made as a result. 39 Child in need is defined under the Children Act 1989 (section 17) as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Page 47 of 72 6.31.22 Information was freely shared between the various agencies and people attending. Key sources of information such as the observations made by the health visitor during the home visit approximately three weeks earlier, and the fact that numerous photographs of bruises had been taken and sent to the paediatrician, were brought to the attention of hospital social work team for the first time. There is no reference to any information from the GP being sought prior to the meeting. 6.31.23 Despite the presence of bruising and fractures and the absence of an explanation, the outcome of the meeting was for the social work team manager to apply a threshold for child in need of family support under section 17 of the Children Act 198940 with the intention that the health visitor and social worker would provide input to the support programme for the family. 6.31.24 The rationale for the decision was that no evidence had been brought forward to confirm the injuries were attributable to parental care. One senior nurse alone voiced uneasiness about the decision in the meeting, feeling that the injuries had not been treated as the primary concern, but her point was ignored and the consensus of the group was to discharge Baby Adam from hospital and follow up with social work support at home. A social worker from the hospital was allocated to undertake and coordinate the work. 6.31.25 This decision was at odds with the criteria for child protection set out in legislation. The Children Act 1989, requires the local authority to undertake a child protection investigation when there is reasonable cause to suspect that a child is suffering or likely to suffer significant harm. All of the evidence, including Baby Adam’s age and the nature of his injuries indicated that deliberate harm was likely, even if the diagnosis could not be absolutely certain and the identity of the perpetrator could not be proven. All the factors taken together should have led professionals to be even more cautious about Baby Adam’s safety. 6.31.26 Whilst uncertainty is a constant feature in child protection case work, there were sufficient factors in Baby Adam’s case to reasonably suspect child maltreatment. This should have been taken into account and driven the decision. Authorising Baby Adam’s discharge, put him at further risk. 6.31.27 Why the decision was not robustly challenged during the meeting has been frequently raised during the SCR process, particularly as at least two practitioners, who were present at the meeting, have described their discomfort when the decision to discharge Baby Adam from the hospital was made. Neither has been able to explain their failure to challenge the decision effectively or explain why they did not immediately escalate their concerns. On reflection both have learnt that it is vitally important to act straight away and immediately question, challenge and escalate decisions which they consider not to be in a child’s best interest, despite any perceived power imbalance or other influencing factors going on within the room. 6.31.28 ‘Groupthink’41 may well have played a part in inhibiting practitioners to speak out about the decision and some practitioners have suggested that the presence of the parents at the meeting made speaking out even more difficult, particularly as the parents were starting to openly express their complete dismay at how the case was being handled. Many of the professionals shared that point of view. 40 Under Section 17(1) of the Children Act 1989, local authorities have a general duty to safeguard and promote the welfare of children within their area who are In Need; and so far as is consistent with that duty, to promote the upbringing of such children by their families, by providing a range and level of services appropriate to those children’s needs. 41 Groupthink is a psychological phenomenon that occurs within a group of people in which the desire for harmony or conformity in the group results in an irrational or dysfunctional decision-making outcome. First described in Psychologists for Social Responsibility (1982) by Irving Janis. Page 48 of 72 6.31.29 Baby Adam was discharged home on the same day based on the outcome of the meeting, i.e. that the parents needed support and were not deliberately harming him. This suggests yet another example of parent rather than child centred practice. Enabling balanced child centred judgements and avoiding consensus collusion is extremely important in child protection work. Utilising established risk assessment models for formulating plans or by purposefully nominating a ‘devil’s advocate’42 within the meeting to introduce the necessary challenge would help to keep the focus on the child. 6.31.30 The new consultant paediatrician who was at the professionals meeting pondered the decision overnight. By morning he was not convinced that Baby Adam should have gone home. He reported his concern at a routine medical MDT meeting that occurred the following morning. Four paediatric professionals reviewed the case including the specialist paediatrician for safeguarding children. The consensus was that the Child in Need response was incorrect. The paediatricians decided to ask children’s social care to reconsider and step up their response by readmitting Baby Adam and initiating a child protection response. 6.31.31 The consultant paediatrician employed to provide advice and professional oversight on safeguarding matters undertook the responsibility for speaking to social care. What followed was a series of telephone calls and discussions between the hospital social work team and the paediatrician to clarify why Baby Adam needed to be readmitted and investigated for non-accidental injury. 6.31.32 Both the social work team manager and a more senior service manager, who had been consulted about the matter, could not understand why the paediatric opinion had changed from the day before stating that there was no grounds for emergency action unless the injuries were deemed to be non-accidental. This is technically incorrect in that ‘reason to suspect’ significant harm is an acceptable threshold for intervention. 6.31.33 Exactly why the more experienced service manager failed to challenge or test the rationale for applying a no action threshold has not been confirmed. Working assumptions include that he might have been going along with the decision in support of a junior member of staff, or that he honestly believed, from the information at hand, there were no grounds on which to readmit the baby to hospital. The practitioner has not been able to be interviewed to tell us exactly what influenced the conversation. 6.31.34 The paediatricians continued to argue that they could not provide concrete evidence that proved the bruises and fractures had been inflicted deliberately, particularly when medical tests were still underway. However they were concerned that deliberate harm could not, and had not been ruled out and was highly likely to be responsible. 42 Devil’s Advocate: A Group member who is nominated to take the role of critic, to specifically challenge all of the assumptions the group makes. Page 49 of 72 6.31.35 After almost two days of difficult negotiation, described by the paediatrician as ‘tetchy’, an agreement was reached that Baby Adam should be re-admitted for the third time. The significant delay in recalling Baby Adam as a child protection case, was caused purely by medical and social care professionals failing to agree that the injuries might be attributable to the parental care. Whilst these discussions went on Baby Adam remained at risk at home. Medical professionals do not hold the legal responsibility for making child protection decisions, that task lies with children’s social care. The delay was clearly not in Baby Adam’s best interests. Social care must be prepared to act on reasonable cause to suspect, rather than wait for absolutes backed by medical evidence. 6.31.36 Baby Adam was re-admitted late in the evening on Friday 17th April 2015. As for the previous admission social services EDT were informed. However no action was taken by the team, other to ring the ward to check that Baby Adam had not been discharged. There was no risk assessment or questions asked about Baby Adam’s safety on the ward and no questions asked about the safety of Sibling Isaac who remained at home. 6.31.37 There is no evidence that either the community health visiting team or the GP were notified of the sudden admission at the earliest opportunity on the Monday morning. In fact it appears that the health visitor was informed of the admission in an email from Baby Adam’s mother, before a professional contact from children’s social care took place. 6.31.38 During the following week there was a considerable amount of work undertaken by the hospital social work team to engage the family and set arrangements in train for a strategy meeting. Medical professionals and the hospital social care department appeared to work effectively together during this time. 6.31.39 The police initially expressed that they would not attend the meeting unless there was confirmation of NAI or evidence of a crime, but agreed later in the day. Police must be clear that if the local authority decides that it needs to convene a strategy meeting, they are expected to attend. If for any reason this is considered inappropriate, the CAIT should escalate the matter for more senior advice, to confirm whether their reason is justified. 6.31.40 Similarly, if either of the partner agencies (health or police) expresses to a social worker arranging the strategy meeting that they cannot send a representative, the position should be reported to their senior social work manager to enable the position to be challenged. 6.31.41 The strategy meeting was eventually held six days post admission. The time interval between admission and the meeting was due to an intervening weekend and the unavailability of key representatives. Delaying a strategy meeting until all relevant partners can attend is acceptable as long as interagency discussions and cooperation are not put on hold and all children associated with the case are deemed to be safe. 6.31.42 When the meeting took place, it was attended by a range of key professionals including a radiologist, in order to share and question all available information. This was good practice. Minutes of the discussion including the outcome and plan were circulated after the meeting in line with safeguarding children practice guidelines. Page 50 of 72 6.31.43 The outcome of the strategy meeting was for Baby Adam to remain in hospital whilst plans for his immediate safety and arrangements for the medium term were arranged. A Section 47 investigation was initiated jointly with the police. Legal advice was secured and care options were explored. It was at this juncture that a child protection medical was arranged for Sibling Isaac as part of a risk assessment plan. 6.31.44 There is good evidence of consistent and efficient inter-professional practice and assessment throughout the following fortnight, during which an application for a Court order was made. An Interim Care Order was subsequently granted on 08th May 2015 when Baby Adam was discharged from hospital into the care of his grandparents. 7 Findings, Themes and Recommendations 7.1 This section highlights learning points that emerged throughout the analysis and which link to safeguarding and child protection professional practice. Some require the attention of a single discipline or agency in order to establish the relevant change in practice. Other lessons learned require a wider LSCB response as they suggest a generalised improvement is required across the partnership. 7.2 Partnership changes already implemented or in train will be indicated where they apply. 7.3 Learning Point - Professional Deference, Challenge and Respect 7.3.1 The traditional medical model, with its associated institutionalised systems and hierarchies is common in many acute hospital settings. It was the prevalent culture within the Royal London Hospital at the time Baby Adam was a patient. Within this type of working environment, which focuses primarily on medical diagnosis and interventions, doctors are often regarded as the professionals with the most expertise. They are often afforded a status and power superior to that of other professionals. This sets off a set of associated power differentials between and within disciplines which, in a child protection context can result in an over-reliance on medical diagnosis and/or the clinicians managing the medical investigation. This hierarchical approach frequently leads to professional deference and makes challenging medical professionals and decisions especially hard. 7.3.2 It appears that responding to Baby Adam’s needs was hindered by generalised professional deference and lack of challenge. Opinions, actions and instructions issued by senior consultant paediatricians remained unchallenged, even when they were deviating from good practice guidelines. There was also some evidence of tension within and between hospital departments and individuals that must have impacted on working relationships and the ability to work together effectively. This situation was further complicated by the fact that one of the paediatric consultants involved, held the senior leadership and management responsibility for the hospital paediatric medical service as a whole. Page 51 of 72 7.3.3 From evidence given to this SCR, it appears that the hospital job plans for the professionals employed to provide the safeguarding leadership and expertise, lacked clarity and deviated from the recommended national job descriptions set out in the Intercollegiate Document43 in regard to time allocated for the role, and the competencies required to fulfil the responsibilities. The NHS SI investigators included this finding into their report and the issue is already subject to a recommendation and improvement plan (see p9.4, page 63). 7.3.4 The status and power of the paediatric consultants also exerted pressure on the social workers attached to the hospital social work team. Several times during a SCR focus group, social work practitioners expressed their concern about some of the paediatric actions and decisions, which clearly did not seem to reflect good practice and which they judged not to be in Baby Adam’s best interests. However, despite the social work leadership function in respect of child protection practice, they did not challenge the paediatric professionals robustly, and neither were the concerns referred to more senior social care professionals outside of the hospital team for immediate management and intervention. 7.3.5 Similarly there were two occasions where children’s social care accepted a dubious police position without question, which led to a statutory strategy meeting being cancelled. An unconscious but long established perception of police power, built on enforcement and authority might, in this case, have also exerted an undue influence over the hospital social care professionals. 7.3.6 Importing traditional organisational hierarchies into child protection practice with the resulting power imbalances is counterproductive to collaborative work and professional respect. The complex psychosocial nature of a child protection problem cannot be solved by individual expertise alone. It requires a multi-disciplinary response drawn from a range of practice expertise. 7.3.7 Whilst safeguarding and promoting the welfare of a child remains a primary concern for all practitioners, child protection activity, in all but very dire emergencies, relies on the actions and decisions of the local authority children’s social care department, who lead and coordinate the statutory response. Other agencies have a duty in law to cooperate. Professional deference interfered in that process suggesting that roles and responsibilities were confused. Promoting role awareness and understanding agency perspectives and the key tasks and limitations of the various disciplines involved, increases professional respect and reduces the chance of establishing professional deference as a cultural norm. 7.3.8 Since undertaking this SCR the hospital social work department has been closed and the social workers relocated to geographically based community teams. Referrals from the hospital are routed through the Multi-Agency Safeguarding Hub (MASH)44 which serves the borough as a whole. This should help to promote a more collaborative approach that invites discussion and challenge on a more equal basis. 43 Safeguarding children and young people: roles and competences for healthcare staff. Intercollegiate Document (2014). A competency framework agreed by all of the medical Professional Royal Colleges. It applies to all groups, from non-clinical staff to experts and provides information on education and training and role descriptions for health professionals with specific safeguarding responsibilities. It enables staff to understand their responsibilities in in the recognition of child maltreatment and how to take effective action. Page 52 of 72 Recommendation 1a To enable a cultural change and better inter-professional relationships within the partnership, the LSCB and member agencies training and development programmes for safeguarding children should include partner roles and responsibilities, professional limitations and the concepts of professional respect and respectful challenge. Recommendation 1b The LSCB and member agencies must implement systems for escalating professional concerns and or disputes and systems for enabling collective decision making, between and across agencies. 7.4 Learning Point – Communication and Information Sharing 7.4.1 An NSPCC national study looking at the key themes in SCRs for cases involving infants during the perinatal period concluded that information sharing between professionals involved in perinatal care is particularly problematic. This finding is mirrored in this review. Examples of poor communication and information sharing between universal healthcare providers during the perinatal period, for example between midwives, health visitors and GPs were identified throughout Baby Adam’s story. The reason for this has not been fully explained, but it must be addressed if children are to be adequately safeguarded in the future. 7.4.2 With regard to communicating with the family, relying solely on parental verification of medical and/or social care data was deeply flawed and risky. By its very nature, if a safeguarding concern has been raised but remains unexplained, the possibility of abuse by any parent or carer cannot be discounted. Several SCRs in the past have demonstrated how parents might deliberately mislead to avoid suspicion. Any verification of information that relates to safeguarding or promoting the welfare of a child, should be done by means of professional to professional communication. Recommendation 2 Professionals working with vulnerable families, or those where safeguarding has been raised, must be reminded that information needs to be shared or verified by means of professional to professional communication. The practice of relying on a parent to pass information to a colleague or update a progress report where safeguarding might be an issue should cease immediately. 7.4.3 The analysis showed several points in the story where inter-professional communication between key professionals in health and social care settings either didn’t happen at all, was of poor quality or was ineffective. Much of the work undertaken appeared to be task oriented against a particular agency service specification and despite known safeguarding concerns, the outcomes of a number of professional contacts are only recorded in single agency records. This so-called ‘silo’ working is known to adversely affect multi-agency relationships and intelligence sharing, and efforts should be made to ensure practitioners work in an inter-professional context and not in isolation. Page 53 of 72 7.4.4 Professionals must also effectively communicate their actions and interventions with each other and communicate regularly, including whenever the child is seen. This enables a dynamic chronology to be kept on file, keeps the child at the centre of the process and keeps the various professionals delivering care to the family up to date with accurate information. 7.4.5 All case handover processes should be formal and recorded in practitioner notes, particularly when case responsibility is being passed to a new worker for a specified period of time, or when new information indicates a change in family circumstances. Information should include a clear plan and identify any new person who is taking over case responsibility. 7.4.6 When child protection information is to be shared with another discipline, consideration should be given as to what information should be shared and by whom, for example when nurses or receptionists are asked to pass on information for a colleague. In addition, all staff should be kept up to date with plans and actions taken by their agency so that accurate and unambiguous information can be exchanged. Since the completion of this report the hospital have included safeguarding information in the patient safety huddles system45 to ensure staff are updated with accurate and up to date information of children admitted to the ward. 7.4.7 Lastly, practitioners should use language familiar to child protection practice and refrain from using professional jargon that may serve to confuse or mislead. The use of an unfamiliar phrase to describe risk, and a poor understanding generally of the term ‘index of concern’ served only to confuse and delay appropriate safeguarding responses. Recommendation 3 The paediatric hospital service must implement a robust formal handover process and a system that ensures unambiguous, accurate safeguarding and child protection information is passed on by well informed and appropriately trained professionals. 7.4.8 In healthcare settings in particular, notes which indicated previous safeguarding concerns were not always accessed or read by the right clinician prior to face to face contacts with the family. Practitioner time, capacity and the change to modern service delivery models which cannot guarantee continuity of care by one person, were all said to have contributed to this finding. In addition, organisational and technological advances in record management and processing, and the change to electronic record keeping systems, including those for coding, flagging and shared access facilities, have all contributed to practice failures in one way or another. Of particular note is the delegation of information processing tasks to administrators and or third party coders, and the necessary reliance on those individuals to share appropriate information effectively. 7.4.9 A combination of these factors all contributed to professionals not seeing test results or documents that pertained to this complex case. Agencies will need to examine their internal systems and processes to ensure, where safeguarding is an issue, that relevant information reaches the right clinician or practitioner without undue delay. 45 Patient safety huddles are short multidisciplinary briefings designed to give healthcare staff, clinical and non-clinical, an opportunity to understand what is going on with each patient and anticipate future risks to improve patient safety and care. Page 54 of 72 Recommendation 4a All agencies must undertake a review of the internal and inter-agency information sharing systems and protocols in their organisations to assess and understand the nature and extent of barriers or obstacles to the flow of information from one practitioner to another (including the use of electronic recording, flagging and coding systems where appropriate). Recommendation 4b Action must then be taken where necessary to improve the pace and quality of information that is shared within and between agencies for children with complex medical or safeguarding needs, to ensure that it is timely, easily understood and accurate. 7.5 Learning Point – Assessment and Risk Assessment 7.5.1 The assessments reviewed for health and social care were of variable quality. Systematic analysis of background information in terms of the impact on the child did not feature in many of the agency records. 7.5.2 Paediatric medical assessments for example concentrated on clinical evaluation and took an insufficient account of relevant background information and social context and how they might impact on Baby Adam’s safety. This was recognised in the NHS Serious Incident investigations. 7.5.3 Health visitor assessments consisted of detailed descriptions of visits and contacts. However, what the observations meant in terms of the family’s functioning and Baby Adam’s health and wellbeing was far less visible. It was difficult to ascertain the rationale for why an action was taken or not taken, and what the outcome or risks might be. 7.5.4 Social care records were similarly descriptive. They clearly expressed anxieties about Baby Adam, but a standard, systematic and detailed risk analysis was not added to the entries in the contemporaneous record. The notes failed to adequately explain the anxieties in terms of risk of harm, and did not trigger the level of senior management challenge required to keep Baby Adam safe. 7.5.5 Using the fundamental components of likelihood and impact, which underpin any analysis of risk, can lead to more reflective, child-centred care planning. This is particularly relevant for professionals who work with high levels of uncertainty and risk on a daily basis. The SCR panel learnt that Tower Hamlets social workers have recently adopted a restorative practice approach with families, including risk assessment and risk management as part of their solution focussed action planning. Health visitors might also wish to become proficient at using established risk assessment models, to enhance their own assessment and care planning processes. Recommendation 5 The health visiting Service should consider using formal risk assessment models as standard for professional assessments of children where safeguarding concerns are being considered or have been identified. Page 55 of 72 7.6 Learning Point – Professional Optimism and Professional Curiosity 7.6.1 Several professionals described the parents as ‘plausible’ and they honestly believed that the bruising and fractures could not possibly be attributable to the care either parent was giving. The optimistic interpretation of the cooperation and demeanour of the mother in particular, led to insufficient professional challenge and a paucity of information about Baby Adam’s lived experience within his family context. Had this been better explored a child protection referral might have been made. 7.6.2 The parents’ openness and candid discussions about their concerns and worries reassured health and social care professionals who concluded that all was well rather than probing more deeply into how the information might link to the unexplained injuries. Even the inevitable professional dilemma created by the persistent absence of an explanation was never effectively communicated to Baby Adam’s parents, leaving them puzzled at times as to why the baby was being admitted to hospital. Professionals, rather than becoming more curious about the unexplained nature of bruising and subsequent fractures, closed the conversation down. 7.6.3 In addition, the verbal reports taken from the parents about medical interventions were consistently taken at face value by a range of professionals in touch with the family. The detail was neither questioned nor verified by professionals within the multi-agency partnership working with the family in key roles. 7.6.4 Many child abuse cases have featured the plausible and compliant parent. Lord Laming in the Victoria Climbie Enquiry (2003) suggested that ‘healthy scepticism’ and ‘respectful uncertainty’ should also be fundamental to the assessment process. More recently, the Daniel Pelka Serious Case Review (2013) also urged practitioners to ‘think the unthinkable’ to counter the rule of optimism. 7.6.5 To enable workers to see that their optimism may not be a true representation of what is going on, it is important that safeguarding supervision challenges and tests pre-conceived ideas and assumptions made during limited contact. This will ensure the child’s perspective is always considered. Supervision in Baby Adam’s case, both in health and social care settings was poorly recorded and failed to demonstrate the necessary critical thinking, curiosity and reflection essential for safe and effective care planning. 7.7 Learning Point - Engaging with Fathers 7.7.1 Poor engagement of fathers by safeguarding professionals is a common feature in cases of abuse and neglect nationally46 and this national concern is mirrored in this review. 7.7.2 The health visitor in particular noted potential difficulties for Baby Adam’s father, both physical and emotional, and made an effort to reassure him, but other than that there were no ongoing actions or plans specifically focussed to revisit or meet his needs and no contact with other health and social care professionals took place to discuss how he might be supported. 46 Pathways to Harm Pathways to Protection: Review of SCR’s 2011-14 (2016) Dr P. Sidebotham Et Al University of Warwick & University of East Anglia. Page 56 of 72 7.7.3 Practising in this way is however not unusual. Several national research studies have shown that poor engagement with fathers is the norm for the health visiting service in the UK, despite being outlined in the NHSE health visiting specifications since 2014. Research suggests this is due in part to a deeply embedded and long standing culture that defines health visiting as a mother and child service47. Researchers also commented that there is no specific training to prepare health visitors for working with fathers (or men in general) and few examples of policies and strategies for local health services to assess, meet and measure their needs.48 7.7.4 For health visiting specifically, the commissioning of the 0-5 Healthy Child Programme (HCP) shifted in 2015 from NHSE to the Local Authority. The Local Authority as the current commissioners are required to improve services by building on the evidence base that had supported the engagement of fathers as a means to safeguard and promote the welfare of children. This will require specific attention in commissioning intentions and documents. The current provider for the service should also ensure that health visitors are both comfortable and competent to deliver this requirement through systems that improve the family health needs assessment process. 7.7.5 The proactive use of a ‘think child, think parent, think family’49 approach to better understand and analyse the context in which Baby Adam was living will assist NHS practitioners to tailor care plans for each family member and the family as a whole. Taking all family members into account enables both parents to reflect on their situation, recognise their strengths and weaknesses and build on their parenting capabilities. 7.7.6 Similarly, there was very little mention of Baby Adam’s father in the Hospital children’s social work records or the notes made by the EDT duty social worker. This leads to the general conclusion that the needs of Baby Adam’s father were not in mind, explored or completely realised by any agency. They were certainly under-represented in assessments and care plans, in both NHS and social care contexts. This is concerning as Baby Adam’s father’s needs were complex and would undoubtedly have influenced how the family adjusted after Baby Adam was born. 7.7.7 Clearly the system in Tower Hamlets to engage with fathers (or significant male carers) needs to improve across the partnership in Tower Hamlets to ensure that the needs of fathers are properly assessed and taken into account early to promote the detection and prevention of safeguarding issues. Recommendation 6a Community health visiting and children’s social care services, must incorporate a ‘think family approach’ as standard in their assessment and care planning processes to enable the needs of significant adults in families to be identified and planned for. Recommendation 6b The LSCB should seek regular assurance, through a process of audit and practice evidence, that assessment processes include all members of a child’s family, are outcome focussed and result in effective interventions. 47 Why Health visiting? DH Policy Research Programme (2013) 48 Why do UK health visitors not engage with fathers? (2016) Family Included, A project of The family Initiative, London 49 Think child, think parent, think family: a guide to parental mental health and child welfare (2011) SCIE Page 57 of 72 7.8 Learning Point - Responding to Bruising in Pre-mobile Babies 7.8.1 The professional responses from health and social care professionals that Baby Adam received in relation to his bruising were inadequate and likely to have exposed him to further harm. 7.8.2 Professional guidance based on established research urges all professionals in all disciplines to consider unexplained bruising in a pre-mobile infant as highly suspicious and treat all cases as potential abuse until confirmed to be otherwise. Insufficient attention was paid by professionals from across the partnership, to the age and development of Baby Adam when he presented with bruising and the failure to instigate a robust response resulted in Baby Adam’s discharge into a harmful situation on four occasions. 7.8.3 There was a failure to embrace and equally balance all of the probabilities in the differential diagnosis, with undue weighting and confidence being placed upon the probability of a medical cause. When a differential diagnosis for unexplained bruising includes NAI, the probability of deliberate harm must be treated with the same equal vigour and vigilance, as for any other potential cause. 7.8.4 The minimisation of the unexplained bruising is further evidenced when suggestions were put forward to treat the fractures as separate and different from the bruising, rather than a more sinister and additional sign that abuse was happening. This view was not challenged. 7.8.5 There was no standard ‘bruising protocol’ for managing unexplained bruising in the hospital in 2015. However, the Trust is developing one in response to the findings of their own internal SI investigation. Local GPs are also currently in the process of being instructed to refer cases of unexplained bruising in infants to social care in addition to any referral for paediatric assessment. 7.8.6 To date, there is no agreed borough-wide multi-agency protocol in place in Tower Hamlets to ensure a systematic response to children (including pre-mobile babies) who present with unexplained bruising, and the London Safeguarding Board web-site may not be seen as helpful in this respect either (explained below). To enable a truly effective response to unexplained bruising for infants in Tower Hamlets, the LSCB needs to develop a multi-agency protocol for the identification and management of bruising in infancy that incorporates all agencies and services in the local partnership. 7.8.7 Whereas NICE guidance50 is clear that unexplained bruising in a pre-mobile infant is in itself a reason to suspect abuse and a reason to notify children’s social care, the London Safeguarding Board Threshold Guidance51, as it currently stands, is ambiguous about the matter. The document currently states that ‘Any allegation of abuse or neglect or any suspicious injury in a pre- or non-mobile child’ meets the threshold for child protection enquiries under section 47 of the Children Act 1989. It also lists ‘inconsistent’ explanation’ as a risk factor. 7.8.8 However, the emphasis on spoken allegations, actual injuries, and inconsistent explanations, could be misleading in practice. It is the bruising in and of itself, in the absence of any explanation that gives a strong indication (cause to suspect) that a pre-mobile baby is at risk. In Baby Adam’s case there were no allegations, no explanations put forward, nor any recognised injuries, suspicious or otherwise. 50NICE guidance: ‘Child maltreatment: when to suspect maltreatment’ https://pathways.nice.org.uk/pathways/child-abuse-and-neglect‘ 51 The London Safeguarding Board Threshold Guidance - http://www.londoncp.co.uk/files/revised_guidance_thresholds.pdf Page 58 of 72 7.8.9 Several practitioners alluded to the lack of specific guidance with regards to unexplained bruising during their SCR interviews; many thought that an unexplained bruising in infancy procedure would have helped them in practice. There was certainly a reluctance to act without a concrete diagnosis of non-accidental injury which ultimately left Baby Adam in a risky situation. A process to follow might have helped in this respect, and practitioners have told me that robust guidance would have been helpful. Recommendation 7 Tower Hamlets LSCB must develop and agree a local multi-agency protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate. Recommendation 8 Tower Hamlets LSCB Chair to contact the Chair of the London Safeguarding Children Board, to discuss the possibility of adding ‘any unexplained bruising in pre-mobile babies under six months of age’ as a as a single category for action in the London Threshold Guidance Document for tier 4 (p35) ‘Section 47, Children Act 1989: Child Protection Enquiries’ 7.9 Learning Point - Convening Child Protection Strategy Meetings 7.9.1 Decision making within the hospital social work team failed to demonstrate the level of leadership and challenge required for effecting a robust child protection response for Baby Adam. This was particularly noticeable with regards to the time it took to convene a strategy meeting. Whilst grounds for a strategy meeting were met from the time Baby Adam was referred to social care with unexplained bruising, it appeared to be exceedingly difficult for the hospital social work team to arrange one. 7.9.2 The essential strategy meeting, backed by statute and designed to be led by social care to enable partners to share information and decide on action, was cancelled after Baby Adam’s second hospital admission. This was partly because the social care invitation to the police CAIT team failed to articulate the risk clearly, partly because of the police officer’s mistaken belief that medical opinion needed to confirm non–accidental injury and partly because the children’s social work team did not rapidly challenge or escalate the CAITs decision to decline the invitation. 7.9.3 In 2016, the Social Care Institute for Excellence (SCIE) reviewed common practice issues from serious case reviews as part of a Learning into Practice Project (LiPP) funded by the DfE and the NSPCC52. Key findings were published in a briefing to facilitate safeguarding improvement nationally. One conclusion was that strategy meetings had not been convened when they should have been. 7.9.4 Two underlying reasons, given for this conclusion were also evident in Baby Adam’s story. Firstly, the spurious belief that proof of harm is needed before convening a strategy meeting and secondly, that police thresholds and staff capacity might encourage a route of ‘no action’. The LiPP report illustrated the latter point very well in a quote from a social care professional who spoke of how the police were unable to attend strategy meetings which resulted in the police ‘very much dictating 52 www.scie.org.uk/children/safeguarding/case-reviews/learning-from-case-reviews Page 59 of 72 when they [strategy meetings] could happen’. Similar conclusions are found in a recent child protection inspection report for the Metropolitan Police Service, published in 201653. A recommendation from that report suggests that the Metropolitan Police ‘reviews together with children’s social care its responsibilities for attendance at, and contribution to strategy discussions’. 7.9.5 Many of the hospital social work responses were driven by poor individual decisions and actions, influenced by a lack of knowledge of child protection legislation and the failure to adhere to basic child protection principles and procedures. The hospital social work team leadership was weak and deferential at times, and there was a distinct lack of leadership, pro-active intervention, challenge and escalation to more senior social care management tiers for guidance and legal advice when front line social workers were expressing a high level of concern. All of the above, increased rather than decreased the risk to Baby Adam. 7.9.6 Since this review started, the structure for delivering children’s social care in Tower Hamlets has changed. The hospital social work team has been disbanded in favour of a locality based child centred model, including a MASH for responding to referrals. The restructure should provide a more supported model and a less medicalised approach for cases that involve acute hospital care. 7.9.7 All other agencies and professionals in Tower Hamlets must also improve their child protection responses generally, and in particular ensure that they understand their duty to cooperate with children’s social care when they are asked to participate in or provide information for child protection discussions or meetings. Recommendation 9a Tower Hamlets LSCB must remind member agencies about the role and function of child protection strategy meetings, including the leadership function of children’s social care to invite relevant practitioners, and the obligation for Health and Police Child Abuse Investigation Team officers to cooperate/participate. Recommendation 9b An annual LSCB audit of partner attendance and quality of participation at strategy meetings should be undertaken. 7.10 Learning Point: Application of Thresholds 7.10.1 National and local thresholds are put in place to meet a statutory duty for all agencies to provide services that safeguard and promote the welfare of children in whatever context they are delivered. They apply across a continuum of children whose needs range from no recognised additional input being required to those who experience such acute difficulties that a robust social care intervention or child protection measure is warranted. Practitioners in any agency should apply service offers that correspond to locally agreed thresholds, which are set out in local threshold guidance documents. 53 Child Protection Inspections: The Metropolitan Police Service (2016) HMIC Page 60 of 72 7.10.2 Twice in Baby Adam’s story, service thresholds were applied that did not correspond to the needs being described or the evidence that was available. (Once when a health visiting Universal service was applied and another when social care opted for a CIN intervention despite suspicion of NAI). There was also a third time, immediately before Baby Adam’s final admission, when social care professionals at team and service manager level initially disputed that the threshold for urgent safeguarding action had been reached, despite evidence to the contrary. 7.10.3 The professional act of applying a threshold defines the level of risk or need identified for an individual and determines what level of service or response the child and family will receive. It is therefore extremely important that practitioners understand and apply the relevant service thresholds consistently, according to given and pre-determined criteria. 7.10.4 Organisationally and strategically, the application of the correct threshold can influence and assist the measuring and commissioning of services in the area by calculating the demand and level of need within the population as a whole. It is therefore important that they are applied according to standard and agreed criteria. 7.10.5 Questions were raised about the application of a universal health visiting threshold, when the family were reporting additional needs and experiencing a visiting pattern over and above the universal model. 7.10.6 External workforce pressures on time and capacity can and do influence practitioner interpretation of thresholds causing them to be set at a higher level than they should be. A member of the SCR panel alluded to chronic staff shortages and large health visitor caseloads for the timescale of this SCR. This may have been the trigger for the decision to apply the universal service threshold. 7.10.7 Rather than re-assigning thresholds, systemic pressures that affect the ability of professionals to deliver against a standard and locally agreed threshold of need criteria, should be brought to the attention of service managers by practitioners to log as an organisational risk, which needs to be managed accordingly. Recommendation 10 The LSCB should seek regular assurance that agency responses and service offers in Tower Hamlets are consistent with the criteria set out in the local and pan London Threshold Guidance. 7.11 Learning Point - Patient Safety 7.11.1 Acute Hospital 7.11.2 Many of the hospital safeguarding issues mentioned in this report were conclusions in the NHS SI investigations. They have either been improved or are in the process of being improved (see section 9). Other findings for the trust which have emerged from this SCR are included under previous learning point headings, as they apply to more than one agency. 7.11.3 One further recommendation has been made for this SCR, which applies only to the Hospital Trust, that is, to improve the hospital assessment of risk when a child is admitted to a ward with injuries or conditions associated with deliberate harm. Most importantly this protects the child, but it also protects the organisation’s reputation, as by law they have a duty to protect children and promote their welfare. Page 61 of 72 7.11.4 The assumption that a hospital ward is a naturally safe place is not correct, particularly where abuse is suspected and a perpetrator has not been identified. Risk and safety on the ward should be considered on a case by case basis. It should be undertaken in partnership with social care professionals and with EDT guidance when admissions take place outside of normal office hours. Discussions and conversations, and any contingency planning about the child’s safety on the ward should be recorded. Recommendation 11 Barts Health NHS Trust must assure the LSCB that a protocol is in place for children who are admitted for consideration of safeguarding concerns, to ensure that a risk assessment is undertaken for evaluating, mitigating and managing any potential risks on the ward. 7.11.4 Primary Care 7.11.5 Nationally, it is expected that GP surgeries have robust safeguarding governance and practice arrangements, including a nominated safeguarding lead clinician, a safeguarding children policy, regular MDT meetings to discuss vulnerable patients, and resources that promote accountability and safe practice. Evidence for this SCR shows that child protection practice within the GP surgery failed to respond to, or refer Baby Adam’s bruising in a timely manner and he was never discussed in formal multi-disciplinary team (MDT) meeting with the health visitor. 7.11.6 Evidence also shows that the safeguarding lead clinician was the only permanent GP in the practice. He was facing severe challenges in keeping the practice running, and locum GPs had to be employed to cover staff vacancies. Continuity of care and safeguarding discussions and oversight was therefore extremely difficult to organise. The SCR has been told that many issues relating to primary care are currently subject to improvement. Improvement plans are in train for the practice concerned in this case and for the primary care system in general. 7.11.7 A Named GP for safeguarding children is employed by the CCG in line with national guidelines. The post holder is currently providing safeguarding expertise and systems leadership to GP practices in the area. For example GPs have been formally reminded that they must refer suspicious bruising to social services as soon as it presents to them, rather than to pass that responsibility to a hospital colleague. This marginal change should ensure that social care becomes aware of the child at the earliest opportunity. 7.11.8 Further changes also need to happen, particularly implementing the primary care MDT meetings, which help all information known about the child and family in the community to be brought together in one place. This has been made the subject of a primary care recommendation. Recommendation 12 Tower Hamlets CCG and GP’s, supported by the Safeguarding Named GP, should review the safeguarding arrangements in primary care, and in particular, ensure that each general practice is holding and formally recording a regular MDT meeting with health visitors and school nurses to discuss vulnerable families. Page 62 of 72 7.11.9 Community Health Service 7.11.10 Lack of capacity and resources in relation to community health services have featured on more than one occasion in Baby Adam’s journey. It was mentioned in relation to delivering ante-natal contacts, and might have influenced the decision of the family health visitor to apply a universal service when the family had additional needs. There is however, another community service delivery problem that requires remedial action, namely the time constraints imposed on the staff (doctor and nurse) in the baby clinic setting, due to the over–booking of appointments. 7.11.11 Where capacity issues and/or over-booking appear to be impacting negatively on patient safety, they should be escalated, assessed and incorporated into standard NHS organisational risk registers for monitoring and review. Service managers, responsible for service design and evaluation should regularly monitor booking systems and processes to ensure that clinic appointment slots are not becoming overextended to a point where staff cannot manage the demand. Recommendation 13 The number of appointments allocated for local community baby clinic provision should be reviewed by the provider of Community health services to ensure that enough time is being allowed for professionals working in clinic settings to discuss cases and access notes 7.12 Learning Point – Social Care Out of Hours Provision 7.12.1 The out of hours provision from the social care Emergency Duty Team (EDT) at critical times when Baby Adam was either discharged or readmitted to hospital was extremely weak54. The situations for Baby Adam and Sibling Isaac were not explored and potential risks were not effectively calculated. No advice or guidance seemed to be given from a social work perspective and the notes of EDT contacts were extremely brief and uninformative. 7.12.2 Social Care EDT services should not default to a minimal response for enquiries that involve hospital admission. To establish the nature and extent of EDT involvement requires an analysis of risk, to understand the complexity of the circumstances and any associated vulnerabilities of the child or children involved. The assessment outcome and decisions should be justified and recorded, even when it is judged that the case can wait until mainstream services can be provided. 7.12.3 EDT social workers are a good source of advice and guidance for practitioners from other agencies who are working outside of office hours and who are possibly unfamiliar with complex safeguarding work. EDT social workers should take responsibility for ensuring practitioners from other disciplines receive expert and clear social services advice about complicated child protection matters. 54 Social Work Emergency Duty Team operate between 17.00hrs and 09.00hrs every day and 24 hours during weekends and holidays. Page 63 of 72 7.12.4 It is important that Tower Hamlets properly implements a system that records EDT activity in full and is capable of logging, attaching and emailing documentation onto the local case recording system. An identical finding resulting in a similar recommendation can also be found in the Tower Hamlets SCR for Child F (2013). It is reasonable to conclude therefore, that the service has not made the recommended improvements over the intervening two year period.55 The outcomes and quality of EDT practice should, therefore be regularly audited and reviewed to provide assurance to the local authority and the LSCB that the service is safe and effective. Recommendation 14 EDT practice should be regularly (annually) audited to assure the LSCB of its effectiveness to record, manage and minimise child protection risks out of hours. 7.13 Learning Point - Information Governance 7.13.1 The SCR found that many of the health service systems for recording and managing information were inadequate. The quality of information recorded was also poor in places. 7.13.2 The timely transfer of safeguarding information generated by the hospital to professionals who needed to know, was frequently delayed or not prioritised. For the post-natal period, notes were lost altogether and hospital trust still has no idea of where that information could be. 7.13.3 Primary care failed to review, summarise and code information correctly and key test results and written communications were not always scanned into the clinical record. This inevitably meant that information used for informing the GP actions was inaccurate and incomplete and sometimes both. 7.13.4 Contemporaneous clinical notes in any setting should include all exchanges of information and intelligence pertaining to patient care including emailed information from the patient and it is a responsibility of all agencies to process and store information safely according to data protection law. Photographs being emailed to a specific professional’s email box run the risk of remaining unseen at times when the person is absent or on leave and the lack of guidance with regards to how to record and store email messages makes them less likely to be added to the medical record. As emails and other forms of digital communication become the norm, information governance policy and practice must reflect and account for this eventuality. 7.13.5 The increased use of photographs and emails, and how they are recorded, was subject to a recommendation in the NHS SI investigation for the hospital. However, this needs to be broadened to include primary care, health visiting and children’s social care services, who may all need to store such information. 55 http://www.childrenandfamiliestrust.co.uk/wp-content/uploads/2013/08/Child-F-Serious-Case-Overview-Report.pdf Page 64 of 72 Recommendation 15 The CCG and GP practices must review the processes currently in place for managing incoming post, including test results, and the criteria for bringing these to the attention of the relevant GP in the practice. Recommendation 16 GP Care Group and children’s social care must develop or amend their Information Governance Policies to cover the recording, prompt transfer and storage of patient/client emails and photographs. 7.14 Learning Points for the Royal London Hospital: A summary of the findings and recommendations in the NHS Serious Incident (SI) Parallel Investigations for general paediatric and radiological services 7.14.1 In the hospital setting several, but not all, of the findings in this SCR were replicated in the internal Serious Incident (SI) Investigations undertaken at the Royal London Hospital. A range of procedural changes have been implemented as a result of the SI which are outlined below. 7.14.2 Several improvements have been made, or are in progress in radiology department, to bring it into line with the Royal College of Radiologists professional guidelines. For example, the SCR has been informed that verbal radiological reporting of skeletal surveys has ceased altogether in favour of a formal reporting system consisting of routine MDT meetings to discuss radiological findings. 17.4.3 The system for requesting and undertaking skeletal surveys and repeat x-rays has also changed to ensure that the child protection aspects are emphasised. In addition, children are now routinely admitted for skeletal surveys, and are not discharged from hospital without the results being known, and the discharge planning process for cases where child abuse may also be a factor has also improved. 17.4.4 The overall safeguarding governance structure has been reviewed, and the accountability, competencies and responsibilities of the safeguarding professionals employed to undertake safeguarding roles has been clarified and strengthened, to reduce confusion about the respective responsibilities of safeguarding professionals and those professionals providing paediatric care in general. Particular attention has been paid to the amount of programmed activity (PA’s) allocated to the safeguarding Named Doctor role, to ensure that post holders have sufficient time to undertake the tasks and duties outlined in the named doctor sample job description, as specified in the Intercollegiate Document (2014).56 17.4.5 Training is being provided where necessary, including an emphasis on understanding the implications of a differential diagnosis and how concerns must be escalated. As mentioned earlier, a standard trust-wide bruising protocol is also being developed. 56 Safeguarding Children and Young People: roles and competencies for healthcare staff. Intercollegiate Document (2014) Page 65 of 72 17.4.6 New recommendations for the acute hospital service have been made as a result of this review, but have been placed mainly under the relevant theme as most apply to other agencies as well and to all of the hospital services provided by Barts Health in the area. 8 Conclusion 8.1 Baby Adam was a highly vulnerable individual. His age and development rendered him totally dependent on those who were caring for him. The SCR has looked at practice that occurred in his first four months of life, focusing sharply on a period of just under two months from when he repeatedly presented with unexplained bruises to when child protection activity commenced. 8.2 The family was compliant and cooperative throughout and were seen many times by a range of professionals, particularly those delivering health services. Child protection action was eventually taken after an interval of two months that effectively safeguarded Baby Adam and his older brother. Baby Adam has made a full recovery. 8.3 Unexplained bruising was first observed when he was six weeks old. It took another three weeks to bring it to the attention of health, social care and police professionals as possibly indicative of deliberate harm. Tests were commenced to exclude a medical cause and action seemed to depend solely on the medical opinion. Despite good reason to suspect deliberate harm, the child protection aspects of the case did not command the attention they deserved. 8.4 Baby Adam was discharged home from hospital to a potentially risky environment on two occasions, despite having persistent unexplained bruising and a growing number of negative test results that were not able to confirm the bruising was associated with a medical condition. 8.5 He was diagnosed with further rib fractures less than two months after his initial hospital discharge and was recalled. This confirms that he had been discharged to a harmful situation. Following a professionals meeting about the discovery of rib fractures he was discharged again for the third time, despite having a combination of unexplained bruises and fractures, at a time when he was developmentally incapable of moving about independently and after significant family stressors had come to light. 8.6 Several systemic failures were identified that contributed to delays and poor decision making which served to increase Baby Adam’s risk rather than protect him. There were also serious flaws in the interpretation of need and basic child protection measures that influenced individual practitioner responses; many are generalised to more than one agency. These require internal and multi-agency cultural change, system improvement and monitoring. 8.7 Many improvement measures have already been put in place in the light of Baby Adam’s experience and recommendations from parallel investigations. However, other learning points from this SCR will also require attention to ensure the whole safeguarding system works effectively within and across organisational boundaries to ensure babies in similar circumstances are protected. 1 month, 9 days (40 days) nth, 9 End. days (40 days) Page 66 of 72 9 Appendix One - Summary of Recommendations No Recommendation Rationale for Recommendation Responsibility 1a 1b The LSCB and member agencies safeguarding children training and development programmes should explain partner roles and responsibilities, professional limitations and the concepts of professional respect and respectful challenge. The LSCB and member agencies must implement systems for escalating professional concerns and or disputes and systems for enabling collective decision making, between and across agencies. This recommendation aims to improve the working culture and inter-professional relationships within the Tower Hamlets safeguarding partnership. The responsibilities, roles and safeguarding functions of professionals from different disciplines were not fully understood, which led to weak and deferential practice. There was also evidence of failing to escalate safeguarding issues in a timely way, which delayed appropriate safeguarding action. Tower Hamlets Local Safeguarding Children Board 2 Professionals working with vulnerable families, or those where safeguarding has been raised, must be reminded that information needs to be shared or verified by means of professional to professional communication. The practice of relying on a parent to pass information to a colleague or update a progress report where safeguarding might be an issue should cease immediately. Progress reports were taken at face value from Baby Adam’s mother, despite safeguarding concerns being present. A combination of engaging with the parent, but also following up with a professional to professional dialogue enables a more accurate and consistent multi-agency approach and reduces the risk of parents deliberately failing, or forgetting to pass on information or carry out an instruction. Barts Health NHS Trust Tower Hamlets GP Care Group (Health Visiting) Tower Hamlets CCG (Primary Care) 3 The paediatric hospital service must implement robust formal handover processes and systems that ensure unambiguous, accurate safeguarding and child protection information is passed on by well informed and appropriately trained professional. The systems for handing over Baby Adam’s case from one professional, or one service to another in the hospital were underdeveloped. Information was frequently unrecorded, unclear, incomplete or used unfamiliar terminology. The handover process prior to the lead consultant going on leave was particularly poor and did not provide clarity about the transfer, the covering arrangements or the ongoing care plan. Barts Health NHS Trust Page 67 of 72 No Recommendation Rationale for Recommendation Responsibility 4a 4b All agencies must undertake a review of the internal and inter-agency information sharing systems and protocols in their organisations to assess and understand the nature and extent of barriers or obstacles to the flow of information from one practitioner to another (including the use of electronic recording, flagging and coding systems where appropriate). Action must then be taken where necessary to improve the pace and quality of information that is shared within and between agencies for children with complex medical or safeguarding needs, to ensure that it is timely, easily understood and accurate. Key safeguarding information about the family, both clinical and psychosocial was frequently not sought or passed on efficiently to those in the professional network who needed to know. Relevant documentation was frequently lost, misinterpreted, and/or filed within single agency records without being shared or reviewed. Some organisational and administrative systems in place prevented or delayed the passage of relevant safeguarding information. For example, safeguarding codes were not utilised effectively and failed to flag safeguarding issues. Electronic recording systems were not always accessed and internal and external postal systems created a delay as documents and letters ended up in an administrative ‘backlog’. Barts Health NHS Trust Tower hamlets GP Care Group (Health Visiting) Tower Hamlets CCG (Primary Care) Tower Hamlets Council Children’s Services Tower Hamlets Police Child Abuse Investigation Team 5 The health visiting service should consider using formal risk assessment models as standard for professional assessments of children where safeguarding concerns are being considered or have been identified. Practitioner assessments particularly in health and social care records contained a lot of descriptive content, but they consistently failed to systematically analyse the information to calculate the likelihood and impact of risk to Baby Adam within his family context. Tower Hamlets Children’s Social Care has recently introduced a new model of assessment (Restorative Social Work) which incorporates risk assessment to enable child focussed assessments, managed risk and outcome focussed solutions. Being skilled in risk assessment techniques will also benefit health visiting practice and improve the care planning for complex cases. Tower Hamlets GP Care Group (Health Visiting) 6a Community Health and Social Care agencies must incorporate a ‘think family approach’ as standard in their assessment and care planning processes to enable the needs of significant adults in families to be identified and planned for. Health and social work records identified issues that indicated increased parental need. Parental wellbeing and parental stressors and concerns were poorly assessed and were not visible in care plans. Tower Hamlets GP Care Group (Health Visiting) Tower Hamlets Council, Children’s Services Tower Hamlets Council, Public Health Page 68 of 72 No Recommendation Rationale for Recommendation Responsibility 6b The LSCB should seek regular assurance, through a process of audit and practice evidence that assessment processes include all members of a child’s family, are outcome focussed and result in effective interventions. To meet an individual child’s needs requires engagement and follow on action to support the needs identified for significant adults or other members of the family. Tower Hamlets Local Safeguarding Children Board 7 Tower Hamlets LSCB must develop and agree a local multi-agency protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate. The interpretation of unexplained bruising has been a persistent feature of this SCR, and the lack of a standard position regarding unexplained bruising in a pre-mobile baby resulted in Baby Adam being sent home to a potentially abusive environment on four different occasions. The hospital has recently introduced a bruising protocol, but there also needs to be a multi-agency response. This will provide a robust framework for all agencies in the partnership working with children who are totally dependent and therefore highly vulnerable. Tower Hamlets Local Safeguarding Children Board 8 Tower Hamlets LSCB Chair to contact the Chair of the London Safeguarding Children Board, to discuss adding ‘any unexplained bruising in pre-mobile babies’ as a single category for action in the London Threshold Guidance Document, for tier 4 (p35) ‘Section 47, Children Act 1989: Child Protection Enquiries’ During the course of this review, the London Safeguarding Board Child Protection Procedures and The London Safeguarding Board Threshold Document: Continuum of Help and Support, were consulted as key documents for practitioners in Tower Hamlets. Whilst unexplained bruising in a child is mentioned throughout the document, it tends to be linked to suspicion of, or actual injury and does not reflect the different circumstances and vulnerability of very small dependent infants. Unexplained bruising in pre-mobile babies should always be considered as suspicious, until proven otherwise. This is not explicit in the Threshold for tier 4 (p35) ‘Section 47, Children Act 1989: Child Protection Enquiries’. Tower Hamlets Local Safeguarding Children Board Page 69 of 72 No Recommendation Rationale for Recommendation Responsibility 9a 9b Tower Hamlets LSCB must remind member agencies about the role and function of child protection strategy meetings, including the leadership function of children’s social care and the obligation for Health and Police Child Abuse Investigation Team officers to cooperate/participate. An annual LSCB audit of partner attendance and quality of participation at strategy meetings should be undertaken. The leadership function of children’s social care with regards to child protection activity was not fully appreciated. An action to convene a strategy meeting was thwarted by the police CAIT, who declined the invitation to participate, rendering the meeting inquorate. This is not in line with local or Government guidance that requires NHS and Police attendance for all strategy meetings and it resulted in an inappropriate ‘professionals meeting’. Tower Hamlets Local Safeguarding Children Board 10 The LSCB should seek regular assurance that agency responses and service offers in Tower Hamlets are consistent with the criteria set out in the local and pan London Threshold Guidance. Health and social care professionals applied the wrong service thresholds to meet the identified needs of Baby Adam and his family. Applying thresholds consistent with established threshold criteria ensures that children receive equitable services designed to safeguard and promote their welfare. Applying common service thresholds also assists practitioners to organise their work and enables strategic planners to measure and understand the levels of need within their localities. The Healthy Child Programme thresholds correspond to the LSCB and Pan London Thresholds Documents. Tower Hamlets Local Safeguarding Children Board 11 Barts Health NHS Trust must assure the LSCB that a protocol is in place for children who are admitted for consideration of safeguarding concerns, to ensure that a risk assessment is undertaken for evaluating, mitigating and managing any potential risks on the ward. When Baby Adam was admitted to the ward on three occasions, a risk assessment was not undertaken to work out the patient safety issues connected to parental contact and visiting arrangements. A protocol for guiding practitioners on how to consider and mitigate child safeguarding risks during day and night time hours, particularly when a potential perpetrator has not been identified, is an important addition to NHS patient safety responsibilities. Barts Health NHS Trust Page 70 of 72 No Recommendation Rationale for Recommendation Responsibility Implementing a system which prioritises child welfare by proactively assessing and mitigating risk serves two purposes. First and foremost to protect the child and second, to protect and assure the organisation’s reputation. 12 Tower Hamlets CCG and GP’s, supported by the Safeguarding Named GP, should review the safeguarding arrangements in primary care, and in particular, ensure that each general practice is holding and formally recording a regular MDT meeting with health visitors and school nurses to discuss vulnerable families. The primary care systems, processes and support for the GPs involved with Baby Adam were underdeveloped and ineffective, potentially exposing Baby Adam to unnecessary risk. In addition, whilst ad hoc and unrecorded conversations between health visitors and GP’s about Baby Adam were evident, the regular formal MDT meetings, which are a local expectation, appear not to have happened. GPs must be effective safeguarding children practitioners. To maintain the correct level of expertise requires practice advice, training, and on-site organisational and management systems that promote safe practice. Tower Hamlets Local Safeguarding Children Board Tower Hamlets CCG (Primary Care) 13 The number of appointments allocated for local community baby clinic provision should be reviewed by the provider of Community health services to ensure that enough time is being allowed for professionals working in clinic settings to discuss cases and access notes The working conditions (time and capacity) in the clinic were aggravated by over-booking clinic availability. The pressurised nature of the clinic made face to face discussion between the health visitor and GP more difficult. Professionals must have sufficient time to ensure they communicate directly about complex cases or concerns. Tower Hamlets GP Care Group (Health Visiting) 14 EDT practice should be regularly (annually) audited to assure the LSCB of its effectiveness to record, manage and minimise child protection risks out of hours. The EDT involvement at times when Baby Adam was either discharged from or admitted to hospital was minimal and based on requests for action rather than robust risk assessment. Sibling Isaac’s needs were never considered. Tower Hamlets Council (Out of Hours EDT services) Page 71 of 72 No Recommendation Rationale for Recommendation Responsibility Improvement to the EDT service is necessary to ensure that children’s circumstances in Tower Hamlets are properly assessed, and recorded in full, outside of normal office hours. 15 The CCG and GP practices must review the processes currently in place for managing incoming post, including test results, and the criteria for bringing these to the attention of the relevant GP in the practice. Test results were not interpreted in a safeguarding context. Often they were ‘processed’ rather than professionally reviewed. Primary care practice systems must be designed that prioritise safeguarding cases and facilitate expert clinical review by practitioners who are aware of safeguarding histories. Tower Hamlets CCG 16 GP Care Group and children’s social care must develop or amend their Information Governance Policies to cover the recording, prompt transfer and storage of patient/client emails and photographs. Baby Adam’s mother was emailing messages and photographs of bruises to the Consultant Paediatrician’s email address (even when the Consultant was away). All information regarding a clinical matters should be part of the child’s contemporaneous medical record to enable full information to be shared and continuity of care. Safeguarding information obtained via email which has safeguarding significance must also be shared promptly with Children’s Social Care. Barts Health NHS Trust Tower Hamlets GP Care Group Tower Hamlets CCG Page 72 of 72 10 Appendix Two – Glossary CAF Common Assessment Framework CAIT Child Abuse Investigation Team CIN Child in Need CT Computerised Tomography CQC Care Quality Commission DFE Department for Education DH Department of Health ED Emergency Department EDT Emergency Duty Team GMC General Medical Council GP General Practitioner HCP Healthy Child Programme HV Health Visitor LSCB Local Safeguarding Children Board MASH Multi-agency Safeguarding Hub MDT Multi-disciplinary Team NAI Non-accidental injury NHS National Health Service NHSE National Health Service England NICE National Institute for Health and Care Excellence NSPCC National Society for the Prevention of Cruelty to Children PA Programmed Activity PLAB Professional and Linguistics Assessment Board (UK) RCGP Royal College of GPs RCM Royal College of Midwives RCPCH Royal College of Paediatrics and Child Health RCR Royal College of Radiologists RLH Royal London Hospital SCR Serious Case Review SCIE Social Care Institute for Excellence SI Serious Incident(s) SMT Senior Management Team THSCB Tower Hamlets Safeguarding Children Board |
NC52292 | Extensive physical injuries to a 2-year-old boy in April 2020. Learning includes: issues around information sharing, particularly regarding arrangements for transferring community health records and the transfer of cases between local authority areas; issues around the ability and confidence of safeguarding practitioners to recognise risk and act with authority in cases involving both domestic violence and child abuse; the importance of safeguarding practitioners including relevant adult males in their assessments of risk. Recommendations include: review policies covering the transfer and receipt of community health records to ensure the timeliness of record transfer, case closure and escalation; review procedures for the transfer of children in need cases, defining the requirement for formal handover meetings; promote training and awareness raising that reinforces the seriousness of domestic abuse in the context of children's safety; ensure that local threshold tools sufficiently describe the significance of risk associated with domestic abuse, particularly when such abuse forms a repeating pattern; improve how practitioners engage with adult males that are significant to the lives of children.
| Title: Local child safeguarding practice review: Child R. LSCB: City and Hackney Safeguarding Children Partnership Author: Sarah Baker Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Local Child Safeguarding Practice Review Child R December 2021 Rory McCallum, Senior Professional Advisor, CHSCP Sarah Baker, Independent Reviewer 1 Contents 1. INTRODUCTION 2 2. KEY CIRCUMSTANCES, BACKGROUND AND CONTEXT 3 3. VIEWS OF MOTHER 9 4. SIGNIFICANT ADULT MALES 10 5. FINDINGS & RECOMMENDATIONS 13 WHAT WAS THE SUFFICIENCY OF THE TRANSFER PROCESS WHEN CHILD R MOVED INTO HACKNEY? 13 HOW EFFECTIVE WERE INDIVIDUAL AGENCIES AND THE MULTI-AGENCY PARTNERSHIP IN IDENTIFYING POTENTIAL RISK AND PROTECTING CHILD R FROM HARM? 18 DID THE COVID-19 LOCKDOWN ARRANGEMENTS HAVE ANY BEARING ON INDIVIDUAL OR MULTI-AGENCY PRACTICE IN HACKNEY AND / OR THE SERIOUS HARM INFLICTED UPON CHILD R? 23 DID ANY OTHER PRACTICE ISSUES, EITHER SINGLE OR MULTI-AGENCY, HAVE ANY BEARING ON THE SERIOUS HARM INFLICTED UPON CHILD R? 24 2 1. Introduction 1.1 On arrival at the family’s address, paramedics from the London Ambulance Service (LAS) found Child R to be unconscious with extensive physical injuries. He had bruising, lacerations, scabbing to his cheek, a large cut on his back and scarring around the feet. The accommodation was unkempt and there were signs of disturbance. Paramedics contacted the Metropolitan Police Service (MPS). Child R was taken to hospital, where further tests identified a bleed on his brain. 1.2 No explanation was given to the police to account for Child R’s condition or his injuries. Child R’s mother maintained she had not seen anything and that her son was with her partner (Partner 4) prior to the ambulance being called. A witness reported hearing shouting and sounds of a child being hit. 1.3 Child R and his mother had only recently moved to Hackney and were living in temporary accommodation. Risks relating to domestic abuse and concerns about mother’s parenting capacity were evident in the family history. In the days immediately preceding the discovery of Child R’s injuries, reports were made to the police about his safety. 1.4 Following a criminal investigation, Partner 4 pleaded guilty to Grievous Bodily Harm and to causing or allowing a child to suffer serious physical harm. He was sentenced to three years imprisonment. Child R’s mother pleaded guilty to causing or allowing a child to suffer serious physical harm. She was sentenced to two years imprisonment, suspended for two years, and with requirements for unpaid work, rehabilitation, and community service. 1.5 Notwithstanding the impact of the emotional trauma experienced by Child R, he has physically recovered from his injuries. 1.6 Given the circumstances of this case, a Local Child Safeguarding Practice Review (the review) was initiated by the City and Hackney Safeguarding Children Partnership (CHSCP). The review focused on four questions: 3 • What was the sufficiency of the transfer process when Child R moved into Hackney? • How effective were individual agencies and the multi-agency partnership in identifying potential risk and protecting Child R from harm? • Did the Covid-19 lockdown arrangements have any bearing on individual or multi-agency practice in Hackney and / or the serious harm inflicted upon Child R? • Did any other practice issues, either single or multi-agency, have any bearing on the serious harm inflicted upon Child R? 1.7 The review makes six findings and seven recommendations for improving practice. 2. Key Circumstances, Background and Context 2.1 Child R was born in late 2017. He is of mixed White and Black Caribbean heritage and initially lived with his mother and members of his extended family in Lambeth. 2.2 Child R’s mother was 18 years old when she gave birth to her son. As a child, she received support from Lambeth Council as part of a ‘child in need’ plan. There was a noted family history of attention deficit hyperactive disorder, parental mental health issues and learning difficulties. Child R’s mother also reported being physically abused by another family member. 2.3 Child R’s biological father (Partner 1) played no measurable role in his life. Mother’s subsequent partners, however, were all significant in the context of the risks that both surrounded and impacted upon Child R. These adult males had a history of criminality that involved supplying drugs, threatening behaviour, burglary, conspiracy to rob and domestic abuse. 2.4 When Child R was a few months old, his mother asked Lambeth Council for help in finding alternative accommodation (as she wasn’t getting on with her 4 family). This was arranged and in early 2018, mother and Child R went to live in a hostel for young mothers1. Whilst here, she was assaulted by an ex-partner (Partner 2). 2.5 A few months later, Lambeth Council supported Child R’s mother to move again, this time into private accommodation in Croydon. Whilst initially confident, Child R’s mother began to struggle, and the local health visitor made a referral for early help support. This referral was either not received or not acted upon by Croydon Council2. 2.6 Three months later, the health visitor made a further referral highlighting that mother was socially isolated and that this was impacting upon her parenting. The referral also described mother’s epilepsy, obsessive compulsive disorder, anxiety and noted issues with anger. 2.7 An early help practitioner was allocated to work with Child R and his mother in mid-August 2019. Over the next few months, Child R’s lived experience was characterised by a growing level of dysfunction at home. • An ex-partner (Partner 3) was back in mother’s life, and he was being abusive and physically violent towards her. • During a home visit by the early help practitioner and health visitor, mother was seen to be struck with a phone by Partner 3. • On occasions, the family home was observed as having deteriorated and was unkempt. • Mother approached Lambeth Council requesting help to move away from Partner 3 and her address in Croydon. • Concerns were also raised on several occasions about mother’s alcohol use whilst Child R was in her care. 1 The placement was with a not-for-profit organisation, with over 30 years of experience providing housing and accommodation support to predominantly black and ethnic minority women and their families in South London. 2 The review was unable to establish any further details about this contact. 5 2.8 In light of the escalating concerns, the early help practitioner believed that Child R’s case should be ‘stepped up’ for a statutory social work response. Croydon Children’s Social Care (CSC) were not in agreement. The rationale supporting this decision was that Child R’s mother had expressed a willingness to work with early help services but not Croydon CSC. 2.9 Remaining worried, the early help practitioner met with a domestic abuse specialist for further advice. Their analysis was that mother could not manage the risks posed by Partner 3 due to her own vulnerabilities. A focussed risk assessment3 for domestic abuse was suggested, with a view to making a referral to Croydon’s Multi-Agency Risk Assessment Conference (MARAC)4. 2.10 However, prior to this being completed, Croydon CSC were notified of several instances to which the police had been called. These involved reports of Child R’s mother being drunk and unable to care for Child R and a sequence of incidents that included a disturbance and Child R’s mother again being intoxicated (this time at her cousin’s address), Child R’s mother being arrested to prevent a breach of the peace and allegations that Partner 3 had taken Child R. On responding to the last incident, Child R’s mother was observed with facial injuries. She explained these as having been caused in a fight with her cousin. The police did not believe this account and arrested Partner 3. He was later released given the absence of anyone willing to substantiate any allegation. 2.11 A few days later, the police attended mother’s home address once again, this time to arrest Partner 3 who had been recalled to prison. Mother was observed with two black eyes but would not say how these were sustained. 2.12 On receipt of these police contacts, Croydon CSC spoke with Child R’s mother. She denied being the victim of domestic violence and declined consent for an 3 SafeLives Dash risk checklist for the identification of high risk cases of domestic abuse, stalking and ‘honour’-based violence 4 MARACs are regular risk management meetings where professionals share information on high-risk cases of domestic violence and abuse and put in place risk management plans. 6 assessment. This was appropriately overridden, and a statutory social work assessment commenced. 2.13 Whilst Child R’s mother was reluctant to engage, she disclosed that Partner 3 had assaulted her, his friends were making threats and that she had left her home address as a result. Whilst agreeing to receive support from the Family Justice Centre (FJC)5, the social worker believed that Child R’s mother was minimising the domestic abuse she had experienced. 2.14 Continuing the assessment, a plan was made by the social worker to visit Partner 3 in prison and make a MARAC referral. Due to Covid-19, the prison visit did not take place. However, the MARAC referral was made, and the social worker visited mother who was staying with a friend. Soon afterwards, Child R and his mother were temporarily accommodated in Hackney. 2.15 Around the same time, an Independent Domestic Violence Advocate (IDVA) from the FJC was also told by Child R’s mother that she had moved. Mother confirmed she had taken a number of safety steps, including changing her phone, blocking Partner 3’s number and switching off any GPS location services. This provided some reassurance to the IDVA that Child R and his mother were safe. 2.16 On 6 April 2020, the assessment by Croydon CSC was concluded, highlighting that a child in need plan would have been initiated had Child R remained in the area. The assessment detailed that a referral would be made to Hackney Children and Families Services (Hackney CFS). 2.17 However, before this took place, Croydon MARAC made a referral to Hackney MARAC via Hackney’s Domestic Abuse and Intervention Service (DAIS). On 7 April 2020, DAIS forwarded the details of this referral to Hackney CFS. As 5 The FJC is a Croydon based service offering support, comfort and understanding to domestic violence victims and their families. 7 the referral indicated ongoing involvement by Croydon CSC, Hackney CFS decided no further action was needed at the time. 2.18 A few days later, on Friday 10 April 2020, the referral from Croydon CSC was received. This stated that immediate risk had been reduced as Partner 3 was in prison and Child R and his mother were relocating out of Croydon. The history of concerns identified in both Lambeth and Croydon were not included. Croydon CSC indicated that the threshold for child protection intervention had not been met locally and that Child R’s mother was acting protectively. 2.19 Hackney CFS reviewed the referral the next working day, on Tuesday 14 April 2020, and decided to await the outcome of the Hackney MARAC (scheduled for 16 April 2020). The rationale was that the MARAC would be able to provide further details to inform the next steps. In parallel, Hackney CFS made requests for information from the police, probation, and DAIS. 2.20 At the Hackney MARAC, information was shared by DAIS that they had spoken with mother. She said she had a new and supportive partner (Partner 4), although given his identity was unknown, reassurance was limited in this context. An action was agreed for the MARAC chair to try and obtain Partner 4’s details. 2.21 The next day, on 17 April 2020, Hackney CFS made telephone contact with Child R’s mother. She confirmed her relationship with Partner 4, although stated she had not seen him since the beginning of the first Covid-19 lockdown. She denied being in contact with Partner 3 but believed he had been released from prison due to posts seen on social media. The details of Partner 4 were not established. 8 2.22 On Saturday 18 April 2020, an anonymous caller rang Crimestoppers6 raising concerns about the welfare of Child R and his mother. The caller advised that a male at the address was being verbally and physically violent towards them. 2.23 Crimestoppers created a ‘non-urgent intelligence report’ and sent it electronically to the MPS. At the time, there was no 24-hour system in place to triage such reports and it was not seen until the afternoon of Monday 20 April 2020. 2.24 That morning however, a concerned neighbour called the police to report that they could hear what was believed to be a child being beaten. The caller also stated he believed an adult female was being assaulted. During the call, the police operator could hear a banging noise in the background. Officers attended the family’s address and engaged with Child R’s mother at the entrance to her room. Child R was naked from the waist up and a broken mirror was seen. Child R was not spoken to. 2.25 Mother explained that Child R had been throwing a tantrum for around twenty minutes and had finally calmed down around five minutes prior to the police arriving. She explained she was trying to her son dressed and he refused. The police determined there was no risk to either Child R or his mother and no action was taken. 2.26 A Merlin notification7 relating to this incident was completed the same day. This stated ‘Child was screaming while mum was trying to dress him. LAS can 6 Crimestoppers is an ‘independent charity that gives people the power to speak up and stop crime – 100% anonymously’ Crimestoppers will send information to the relevant authority with responsibility to investigate crime. The author understands that each force area have bespoke arrangements to determine how the information is shared with them. In terms of the MPS, it is understood that any information received to Crimestoppers is triaged by them (Crimestoppers) and graded. If an immediate police response is required, then a report is sent with a follow up telephone call to ensure police are aware of the priority required. In cases where they consider an immediate response is not required, an information report will be sent without any need for a follow up call. 7 The ‘Merlin’ IT application is used to record the details of those vulnerable people aged 17 and under via a Pre-Assessment Check (PAC) and for details of vulnerable adults aged 18 or over via an Adult Come to Notice (ACN). MERLIN is also used for the recording and investigation of Sudden Deaths, Unidentified Persons/bodies and other found persons. Reports are recorded on Merlin to enable safeguarding teams to assess any risks or harm to individual children based on the report and any further relevant information. These reports are often shared with partner agencies to ensure a multi-agency approach can be taken to safeguarding. 9 cancel. No offences’. This report was not received by Hackney CFS until 22 April 2020. 2.27 On 21 April 2020, Child R sustained the serious physical injuries resulting in his hospitalisation. 3. Views of Mother 3.1 During her engagement with the review, Child R’s mother shared an account of her experiences and the services that engaged with her and Child R. 3.2 Mother explained that she did not want to become pregnant due to having epilepsy. She reported being shocked when her pregnancy was confirmed and that she received different advice from professionals about whether to have an abortion. Mother said her family were very supportive at this time, but it was a difficult pregnancy in that she had more severed seizures than before. 3.3 Mother said she was the victim of numerous domestic abuse incidents perpetrated by Partner 3. Mother also spoke about being pregnant for a second time and Partner 3 being very angry with her. She miscarried this pregnancy.8 3.4 In response to the abuse from Partner 3, mother said that she tried to tell the police but was told there was no crime so they couldn’t do anything. Mother also said she went back to Lambeth Council seeking help to move. 3.5 Mother said she wasn’t referred to any domestic abuse services (prior to the referral to FJC). She said that she gave both the police and council information about what was happening to her but neither helped. Mother told the review that she hadn’t told anyone else because she felt embarrassed.9 8 Domestic abuse in pregnancy - NHS (www.nhs.uk) 9 SafeLives (2015), Insights Idva National Dataset 2013-14. Bristol: SafeLives. 10 3.6 At the time mother was with Partner 4, she thought he loved and cared for her. She didn’t see his behaviour as being abusive, rather she felt it was her fault, that she annoyed him and that she needed to do better. Child R’s mother reported to the review that she can now see Partner 4 was controlling and manipulative. She had to do as he said, because she was expected to respect him. 3.7 Following sentencing, Child R’s mother undertook the ‘Freedom Programme’10. She said this helped her gain strength, stand up for herself and reach out for help. She said she is fully aware of the impact that the domestic abuse had upon her son who saw her being hit and saw her crying. She said her son “didn’t deserve this”. 3.8 Mother also made the following comments aimed at practitioners working with victims of domestic abuse: • “It might not be a big hint but look at facial expressions. Just because I am smiling it doesn’t mean everything is ok. Give them (the victim) the chance to have the courage to speak up about what is happening to them, listen to them.” • “Not all victims have the courage to speak behind their partner’s back.” • “I wish I had been more persistent, and they might have listened to me - I would be now” 4. Significant Adult Males 4.1 In the context of Child R’s experiences in Lambeth, Croydon and Hackney, four adult males played varying roles in his life. Whilst the full extent of their involvement with Child `R is largely unclear, the following narrative provides a perspective on the dangers that these men posed to Child R, his mother and their previous partners. 10 The Freedom Programme. Learn about domestic violence and abuse 11 4.2 Partner 1, Child R’s biological father, is not known to have played a significant role in Child R’s life. There are no known reports of any domestic abuse allegations involving Partner 1 and Child R’s mother. He does, however, have a criminal history that involves theft, drugs offences and firearms / offensive weapons. 4.3 Partner 2 assaulted Child R’s mother whilst she was living at the hostel for young mothers in Lambeth. An argument took place between mother and another resident (who was the new female partner of Partner 2). The argument appeared to be trivial, although Partner 2 attended the hostel, grabbed Child R’s mother, and punched her in the face. He was arrested, violently resisted, and assaulted three police officers. Partner 2 was charged with the assault on Child R’s mother and separately charged with assaulting the police officers. 4.4 Partner 3 has recorded offences involving theft, drugs, and firearms / offensive weapons. He also has a significant history of domestic violence and abuse. Prior to his relationship with Child R’s mother, Partner 3 had police contact relating to domestic assault allegations with another female partner. In 2016, he was alleged to have falsely imprisoned her after she had ended their relationship. 4.5 In 2017, police responded to a call alleging that Partner 3 had assaulted his partner. On police arrival, the alleged victim was seen to have a lump under her eye and Partner 3 was arrested for assault. The partner stated she had slipped and fallen. In 2018, Partner 3 was convicted for possession of Heroin with intent to supply. He was sentenced to 30 months’ imprisonment. His release condition showed him to be residing with Child R’s mother at her home address. 4.6 In 2020, there were four incidents resulting in police involvement: • The London Ambulance Service (LAS) was called to Child R’s mother’s home address. Mother was pregnant and was bleeding. Upon LAS arrival, Partner 3 was so aggressive the paramedics called police to assist. 12 • Child R’s mother was involved in a domestic incident with another family member where she had been drinking and acting aggressively. This resulted in her arrest. Mother was taken home with Child R by the police, where Partner 3 agreed to take care of them both. Approximately two hours later, mother called police stating that Partner 3 had taken Child R away from her. Upon police arrival, mother had what appeared to be recent injuries to her face, which she claimed to have received during the earlier fight with her cousin. Partner 3 was arrested but no further action taken. • Police re-attended mother’s home address a few days later and arrested Partner 3 who had been recalled back to prison. On police arrival, mother was seen with two back eyes, however, she would not explain how she had received the injuries. • Mother reported to police that she had received threats from Partner 3’s friends that when was released from prison, they would help him take Child R away. 4.7 Partner 4 has a substantial criminal history that includes allegations of assault, burglary, and sexual assault. He is a serial domestic abuser and has been diagnosed with Schizophrenia. His criminal behaviour dates from 2008 when he was just 13 years old. 4.8 The first allegation of domestic abuse resulting in police attendance occurred in 2010. There were three incidents that year that involved serious physical violence, the use of a knife and threatening behaviour against his then partner. In 2017, there were four recorded incidents of domestic abuse requiring police involvement. Again, these all involved serious physical violence and severe levels of harassment. During some of these incidents, Partner 4’s baby was present. In 2019, two incidents of concern were noted. Partner 4’s partner was observed by police officers to have sustained a facial injury after receiving a call about a disturbance at her home address. Another incident involved the following: ‘He (Partner 4) damaged her property, grabbed her by the hair pulling her to the ground threatening her with scissors and a knife. He then assaulted her by 13 banging her head against a wall. He wrapped a phone cord round his hands and held it against her throat. She was further assaulted before she was able to leave the house and contact police.’ 5. Findings & Recommendations 5.1 The review identified three underlying themes when evaluating the sufficiency of multi-agency safeguarding practice involving Child R. • The first relates to information sharing. Whilst a repeating issue in most reviews, this theme primarily concentrates on the arrangements for transferring community health records and the transfer of cases between local authority areas. • The second theme involves the ability and confidence of safeguarding practitioners to recognise risk and act with authority in cases involving both domestic violence and child abuse. • The third theme highlights the importance of safeguarding practitioners dynamically including relevant adult males in their assessments of risk. 5.2 How these themes manifested in practice are set out in the following analysis of the questions posed to the review. They are the key issues for the involved safeguarding partnerships to take forward in terms of learning and improvement. What was the sufficiency of the transfer process when Child R moved into Hackney? 5.3 When considering this question, the review also took account of the family moving between the other local authority areas where they lived. The overall findings align with two of the ‘stubborn challenges’ identified by the Child 14 Safeguarding Practice Review in its second annual report11. These are, ‘understanding what the child’s daily life is like’ and (consistent with the review’s first theme) ‘sharing information in a timely and appropriate way’. In the context of how agencies worked with Child R, these two issues were fundamentally interconnected. 5.4 Finding 1: Poor and untimely information sharing hindered practitioners gaining a full understanding of what Child R’s daily life was like and the potential risks that he was facing. 5.5 Whilst there were several occasions where information sharing could and should have been better, significant disruption was identified in the context of Child R’s community health records. The transfer of these records did not adhere to Public Health England Guidance.12 5.6 For example, following Child R moving from Lambeth to Croydon in early 2019, it took 17 months for his health records to be transferred. By the time these arrived in Croydon, the family had already moved to Hackney. Over this period, there is no evidence that the records were proactively requested by Croydon’s Health Visiting Service or that the health visitors ever made contact. The delay with the transfer of records was reported as being due to an administrative error. 5.7 The consequences of this error meant that the health visitor in Croydon had minimal information regarding the family and therefore limited ability to provide a focused, risk assessed service to a vulnerable family. It is unclear why there were no attempts to retrieve the records or escalate concerns that they hadn’t been received. This could have been raised as an issue during supervision and/or reported as a clinical incident. The background information from Lambeth was significant and could have prompted the Croydon practitioners to seek out help for the family much earlier. 11 The CSPR Annual Report 2020 12 Guidance to support commissioning of the healthy child programme 0 to 19: Commissioning guide 2: model specification (publishing.service.gov.uk) 15 5.8 The delayed transfer of health records was also a feature in the move of Child R and his mother from Croydon to Hackney. It was not until after Child R had been admitted to hospital that the Croydon Health Visiting service contacted its counterpart in Hackney. Indeed, despite the family moving a month before, the national NHS spine still showed Child R’s address as being in Croydon. Whilst a handover report was completed, it took two to three weeks for the records to be finally transferred. The delay was reported as being caused by a backlog due to Covid 19. 5.9 A swift transfer of records at this point is likely to have engaged Hackney practitioners much earlier, with opportunities created to see Child R and gain reassurance about his welfare and the circumstances in which he was living. As it was, health visitors in Hackney were not aware of the family’s residence until the MARAC notification on or around 9 April 2020. 5.10 Recommendation 1: Public Health Community Nursing services engaged in this review should review their policies covering the transfer and receipt of community health records to ensure these are sufficiently robust in respect of defining the process and management oversight of the timeliness of record transfer, case closure and escalation (including systems to request records if not received). 5.11 Less than effective information sharing also featured in the referral from Croydon CSC to Hackney CFS. As part of this process, there was neither the history of domestic abuse included nor an account of the involvement with Child R’s mother whilst living in Lambeth. Overall, the information shared failed to reflect the full reality of Child R’s circumstances and hence limited the understanding of need and potential risk. 5.12 Whilst additional information had already been shared via Hackney’s MARAC, the referral from Croydon provided a degree of false reassurance. The thrust of its detail indicated that mother was acting protectively by fleeing Croydon. Whilst arguably true, when seen in the context of the family’s history, there was more than just the contemporary issues to consider. These do not appear to 16 have been afforded the weight they required. Taking a holistic view, the patterns of previous domestic abuse and mother’s alcohol use were equally significant. Their inclusion, in the opinion of the review, may have facilitated a more proactive response from Hackney CFS. 5.13 As it was, the referral’s ‘tone’ is likely to have influenced the decision to await the outcome of the Hackney MARAC. The rationale for this decision was that the MARAC would help inform the assessment of risk (i.e. likely length of sentence, father’s offending history, mother’s protective capacity). Delaying decision making in this way was not in line with statutory guidance13, but perhaps reflective of the priority that Child R had been afforded based on the information that had been shared. 5.14 Recommendation 2: Safeguarding Children Partnerships involved in this review should seek reassurance that their respective practice guidance and training sufficiently emphasises the need to include relevant historical information as part of making a referral to local authority Children’s Social Care. 5.15 The referral process itself is also believed to have introduced a level of ambiguity about the status of Child R’s case. In the opinion of the review, had this been clearer, it is possible that the quality of information sharing may have been improved and the context of Child R’s needs better understood. 5.16 To explain further, the review was uncertain whether the contact from Croydon CSC was a request to ‘transfer’ Child R’s case or a referral requiring a decision from Hackney CFS about what action was required? There are subtle, yet significant differences between these two processes that involve procedural requirements, the expectations placed upon professionals and importantly, how families should be engaged. 13 Page 35 Working Together 2018 17 5.17 The chronology shows that Croydon CSC correctly completed its assessment despite the family having moved. This concluded that Child R would have been a ‘child in need’ had he remained in Croydon. This information was shared with Hackney CFS as a new referral and was subsequently ‘processed’ as such. 5.18 Arguably, Hackney CFS didn’t need to do this. Had the London child protection procedures been followed, the contact from Croydon could have resulted in a child in need planning meeting being convened by Hackney.14 As it was, practice was focussed on what to do with the referral as opposed to facilitating the smooth transfer of a child with recognised needs into a new area. 5.19 Whilst there are no guarantees this would have changed the outcome for Child R, the focus of practice might have been different. Activity to facilitate a transfer could have concentrated efforts on sharing information, as opposed to determining whether thresholds had been met. The Croydon social worker could have visited Child R and his mother to explain next steps, perhaps undertaking this jointly with a practitioner from Hackney. 5.20 Furthermore, whilst there is no formal requirement to hold a meeting to discuss the transfer of a ‘child in need’, this would undoubtedly have been good practice. The family’s situation was complex and such structured discussions are likely to have helped with understanding Child R’s lived experience and practitioner’s reaching agreement as to what actions were necessary. 5.21 The arrangements to transfer information about Child R should also have been subject to the family’s consent. Whilst similarly applicable in a referral, there was no evidence that this was explicitly sought. Again, had this been done, opportunities are likely to have been created for dialogue with Child R’s mother and observation of Child R. In the review’s opinion, this would have facilitated 14 For children who have moved Local Authority areas, paragraph 6.1.4 of the London CP procedures state: ‘If the outcome of the assessment is that the child should be the subject of an initial child protection conference or child in need planning meeting, then that conference / meeting should be arranged by the receiving authority, i.e. in which they are then to be found / residing’. 18 a more robust ‘handover’ of the case and less reliance on the written referral to convey the needs of the family. 5.22 The review acknowledges the national demand pressures on local authority children’s social care and the workload incentives that might exist to rapidly ‘hand-off’ cases once a family has moved. However, it is at times of transfer that risk can escalate. ‘Relationships with relatives, friends, schools and statutory services are likely to be fractured as a result of such moves; alternatively, those seeking to avoid the intrusion of statutory services may welcome the opportunity to severe relationships with those that have begun to understand them.’15 5.23 Recommendation 3: The London Safeguarding Children Partnership should review the procedures governing the transfer of children in need cases. These should be explicitly strengthened to define the requirement for formal handover meetings when children are on a child in need plan, when they have been assessed as being a child in need (prior to a plan being developed) or when families have moved mid-assessment. Much greater emphasis should be placed on the arrangements to facilitate case closure in one area and a case opening in another. How effective were individual agencies and the multi-agency partnership in identifying potential risk and protecting Child R from harm? 5.24 The review found that the quality of practice was variable in response to domestic abuse and child abuse (the review’s second theme). Weaknesses were evident in both historical practice and the contemporary intervention immediately prior to Child R being hospitalised. 15 6.1.1 London CP Procedures 19 5.25 Finding 2: There was a lack of authoritative practice in response to concerns about domestic abuse and child abuse. This meant that opportunities to help and protect Child R through statutory intervention were missed. 5.26 There is a substantial amount of evidence reinforcing the impact of domestic abuse on the safety, welfare and longer-term development of children and young people. The review does not need to set this out in any detail, other than to reinforce that domestic abuse continues to feature nationally as one of the main issues of concern in cases referred to Children’s Social Care16 5.27 Positively, most, if not all safeguarding organisations will have domestic abuse referenced somewhere within their priority schedule. Indeed, front-line practitioners will ordinarily have opportunities for professional development and access to a range of tools to use when engaging with families. 5.28 With the existence of such arrangements, it is arguable that practitioners should have demonstrated a much more authoritative approach when responding to the concerns involving Child R’s and his mother. The fact that this didn’t happen not only raises questions about practitioner knowledge and competence, but also whether the sheer volume of cases involving domestic abuse have de-sensitised the system. By this, the review suggests a hypothesis that thresholds for concern may be too high given domestic abuse is being encountered on a much more routine basis. 5.29 There were several examples where practitioners should have been more robust in their response to domestic abuse: • An incident of Child R’s mother being hit with a phone by Partner 3 was observed by a health visitor and early help practitioner. There was no evidence of protective action being taken or consideration this should be escalated to CSC. 16 Factors end of assessment CIN 20 • The decision by Croydon CSC not to accept a referral, despite established patterns of concern, police involvement and the identified risk posed by Partner 3, was a missed opportunity to secure a clear plan to help and protect Child R. • The lack of any challenge to this decision was also a missed opportunity, particularly given the advice provided by a specialist domestic abuse practitioner on the level of existing risk. 5.30 Recommendation 4: Local Safeguarding Children Partnerships involved in this review should promote a programme of training and routine awareness raising that reinforces the seriousness of domestic abuse in the context of children’s safety. 5.31 Recommendation 5: Local Safeguarding Children Partnerships involved in this review should satisfy themselves that local threshold tools are sufficiently describing the significance of risk associated with domestic abuse, particularly where such abuse forms a repeating pattern. 5.32 Additional lessons for practice in response to domestic abuse were shared as part of mother’s account to the review. Her statements reinforce the need for all practitioners to recognise the impact of coercion and control. Victims of domestic abuse are unlikely to disclose the harm they are suffering without skilful professional interaction, persistence, and assurances of safety. 5.33 Reading between the lines of what children and families say and communicate (as well as what they do not say) involves time, imagination and the most proficient of relational skills. All safeguarding practitioners have a responsibility to create the conditions in which their talents and resources can focus upon understanding what life is like for children.17 17 The Child Safeguarding Practice Review Panel Annual Report 2020 Patterns in practice, key messages and 2021 work programme. 21 5.34 Linked to the effectiveness of practice in respect of domestic abuse and child abuse is the focus on the perpetrators of such harm. The review makes the following finding. 5.35 Finding 3: Safeguarding Children Partnerships need to find better ways to embed a culture of practice that routinely includes adult males when assessing need and risk to children. 5.36 There were missed opportunities to better understand the patterns of risk that Child R was being exposed to. When reading the stark accounts of the behaviour of mother’s partners, it is perhaps unusual that the professional network didn’t have access to this information, seek it or use it to determine the circumstances in which Child R was living. 5.37 The absence of this ‘chronology of concern’ from the thinking of professionals is relevant to the third underlying theme of this review – the need for practitioners to properly consider the roles of adult males in the lives of children. 5.38 Again, there is comprehensive evidence identifying this as a repeating weakness in practice. This has been most recently emphasised in the Child Safeguarding Practice Review Panel’s report on safeguarding children under 1 from non-accidental injury caused by male carers.18 The narrative in section 16 of this report and its focus on engaging and assessing men is entirely relevant to this review. 5.39 Recommendation 6: Local Safeguarding Children Partnerships involved in this review should all develop a coherent plan for improving how practitioners engage with adult males that are significant to the lives of children. 5.40 Opportunities for practitioners to identify risk were also seen in the days immediately preceding Child R being found unconscious. These largely fell to 18 The Myth of Invisible Men, CSPRP, Sept 21 22 the police and link to the review’s second theme concerning authoritative practice. 5.41 Finding 4: Opportunities were missed to understand Child R’s circumstances in the context of risk. This arose due to a lack of professional curiosity and intervention that failed to put Child R at the heart of practice. He wasn’t seen, heard and helped. 5.42 The anonymous call to Crimestoppers and the subsequent call made to the police were not solely focused on domestic abuse. Both reports indicated that a child was being harmed – child abuse. 5.43 Given this clarity, there was an error in judgement by Crimestoppers to grade its report as ‘non-urgent’. This resulted in no immediate oversight by the police, no immediate response and no help or protection for Child R. The review understands that procedures governing the oversight of Crimestoppers’ reports have since changed, with enhanced scrutiny mitigating the risk of such events being repeated. 5.44 With regards to the direct police report, the initial response was appropriately swift. This appears to reflect the seriousness with which the report was taken, and the fact that a child was involved. 5.45 However, on reaching the threshold of the family’s room, proactivity weakened. Contact with the family did not move beyond the front-door and whilst Child R was seen, he was not spoken to. Opportunities were missed to look more closely at Child R’s physical condition (relevant given the historical injuries that were identified) and mother’s account appears to have been taken at face value. There was a lack of professional curiosity. 23 5.46 Furthermore, whilst details were ‘diluted’ when radioed through19, the concerns were sufficient for officers to have been far more inquisitive in their questioning of mother and observations of Child R. There was equally no attempt to identify the details of Partner 4. Had these been established, they would undoubtedly have prompted a response beyond no further action. 5.47 Unfortunately, this didn’t happen. The police withdrew, the Merlin notification to Hackney CFS was sent late and Child R was seriously harmed the following day. 5.48 The lessons identified from this short window on Child R’s life relate to the importance of basic safeguarding practice. For the police, standards for such practice are clearly set out by the College of Policing20 and MPS procedure. Of critical importance is the need for practitioners to be child centric. However, despite the nature of the reported concerns, at the point of initial contact, there was no evidence that officers made ‘every effort’ to see and speak to Child R or ‘establish that he was unharmed and not at future risk of harm’. 5.49 Recommendation 7: To ensure officers are maintaining a clear focus on the safety and welfare of children, the Central East Basic Command Unit of the MPS should continue its implemented process of dip sampling recordings of Body Worn Cameras. Did the Covid-19 lockdown arrangements have any bearing on individual or multi-agency practice in Hackney and / or the serious harm inflicted upon Child R? 5.50 At the time of Child R’s hospitalisation, England was experiencing its first national lockdown because of the Covid-19 pandemic. The review found that these arrangements had some bearing on practice. 19 . Officers were told that a child was being abused but there was no mention of the male or frequent disturbances. Technical difficulties meant that the lead officer was unable to access and read the full details of the concerns. 20 Police response to concern for a child, College of Policing 24 • Staff shortages caused by the pandemic affected the administration arrangements in several services. For example, despite being approved for transfer in late April 2020, Child R’s community health records were not sent to Hackney until mid-May 2020. Pressure on administration capacity also led to a delay in the circulation of the minutes of the Croydon MARAC meeting on 9 April 2020. These were not published until the 1 May 2020. • Covid-19 restrictions measures meant that the Croydon social worker was unable to visit Partner 3 in prison. Whilst good practice to attempt such contact, this limited the available information within the assessment. It remains uncertain as to what value this would have added to the overall analysis of need and risk. • The Hackney MARAC held on 16 April 2020 discussed 21 cases of which 16 cases included children. This was viewed as a busy meeting and an early indicator of the increasing cases of domestic abuse seen throughout the pandemic.21 • There was no evidence to indicate that Covid-19 influenced the actions of attending officers not to enter the family’s room. Did any other practice issues, either single or multi-agency, have any bearing on the serious harm inflicted upon Child R? 5.51 The review identified two additional practice issues to inform future learning and development requirements across the three boroughs where Child R and his mother lived. 5.52 Finding 5: On occasions, practitioners lacked curiosity about significant aspects of Child R’s mother’s background which impacted on the assessment and planning of services to ensure that Child R and his mother were safe. 21 The National Domestic Abuse Helpline database reported a 34% since the first lockdown in March 2020. 25 5.53 Whilst an issue already identified as part of the police response in April 2020, there were other examples: • During the antenatal assessment, Child R’s mother answered ‘yes’ to Whooley questions22, and disclosed the family had previous social care involvement owing to physical violence perpetrated by a family member when Child R’s mother was aged 7 years. These issues didn’t feature heavily, if at all, when considering what support Child R and his mother might need. • As part of a health visitor assessment, Child R’s mother reported she had epilepsy and was being treated by the specialist service at Kings College Hospital. Given mother was living alone with Child R, there was a lack of exploration about how often the seizures occurred, how well controlled they were and what contingency arrangements were in place to ensure Child R was safe. • There was a repeated lack of curiosity about the adult men involved in Child R’s life. Beyond the Croydon social worker planning to visit Partner 3, there was no evidence of any real focus on what these individuals meant in the context of Child R’s safety and welfare. 5.54 Finding 6: Signs of possible neglect and the identification of patterns of cumulative harm weren’t effectively identified by safeguarding practitioners. 5.55 The patterns of behaviour and dysfunction within Child R’s family appear to have been accepted as the norm. These should have prompted practitioners to focus on the potential impact of these issues in respect of cumulative harm. This was particularly relevant in respect of Child R’s repeated exposure to domestic abuse, neglect, and other Adverse Childhood Experiences. 22 A case finding tool for depression 26 5.56 For some practitioners, deficits in information sharing limited their understanding of these patterns. For most, however, it appears that these issues weren’t being systematically considered as they should have been. 5.57 Understanding the context of a child’s life is key and understanding this context must form a priority for all practitioners. This is not a new feature of good practice and whilst safeguarding can be complex, some of the steps to understand the lived experience of a child are not - see children and families, talk to them and listen to what they are saying. |
NC046140 | Attempted suicide of an adolescent boy in September 2013. The young person's attempt on his life has been linked to a drug influenced psychotic episode. Family were well known to agencies and there had been professional concerns around neglect of the young person and his siblings since 2005. Between 2009 and 2011 the young person was the subject of a child in need plan, a child protection plan, care proceedings and a supervision order. Issues identified include: poor school attendance; offending; substance misuse; mother and young person's lack of engagement with professionals; mother's non-compliance with parenting orders and school attendance; and challenges associated with the significant number of professionals and agencies involved with the family. Identifies learning points including: need for professional awareness about the link between substance misuse and mental health problems and the link between long term neglect and suicide ideation; and need to maintain focus on older children when there are younger children in the family. Recommendations include the development and implementation of a toolkit to help professionals engage with 'hard to engage' young people.
| Title: Serious case review: subject: A Young Person: the overview report. LSCB: Kirklees Safeguarding Children Board Author: Paul Sharkey Date of publication: [2015] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Kirklees Safeguarding Children Board Serious Case Review Subject: A Young Person The Overview Report December 2014 Lead Reviewer and Independent Overview Author: Mr Paul Sharkey (MPA) 2 CONTENTS 1. INTRODUCTION 4 1.1 a) Purpose of the Serious Case Review 4 b) Reasons for the Serious Case Review 4 c) Timescale for the Review 5 2. METHODOLOGY 5 2.1 Terms of Reference 5 2.2 SCR Overview Panel 5 2.3 Review Process 6 2.4 Sources of Information 6 2.5 Parallel Inquiries 6 2.6 Family Involvement 6 2.7 Style and Format of Report 6 3. CASE SUMMARY 7 4. OVERVIEW OF KEY EVENTS 8 5. ANALYSIS OF KEY ISSUES AND LEARNING 16 5.1 Self-harm and Mental Health issues 16 ToR1 a) Self- Harm and Suicidal Ideation 17 Learning points re self-harm and suicidal ideation 18 ToR1 b) Substance Misuse 18 Learning points: substance misuse: 21 ToR1 c) Warning signs of mental health issues 23 Learning points: Mental Health and Emotional Well-being 25 5.2 ToR 2: Multi-agency working with neglectful families 25 Learning points: multi agency working with neglect 27 5.3 ToR 3: Child focus 27 Learning points: the focus on the child 29 5.4 ToR 4: Assessment, planning, implementation and review 29 ToR 4 a) Assessment 30 ToR 4 b) Planning and Implementation 31 3 ToR 4 c) Reviewing 35 Learning points: assessment, planning & review processes 35 6. FAMILY VIEWS 37 7. CONCLUSIONS 39 8. RECOMMENDATIONS 40 Appendix 1: Terms of Reference and Key Practice Episodes 42 Appendix 2: Membership of the SCR Overview Panel and Sources of Information 44 Appendix 4: Learning points from the SCR 45 Appendix 3: Glossary of Terms 49 Appendix 5: References 50 4 1. INTRODUCTION 1.1 a) Purpose of the Serious Case Review This Serious Case Review Overview Report (henceforth referred to as the Report) on the Young Person was commissioned by the Kirklees Safeguarding Children Board in accordance with the HM Government statutory guidance ‘Working Together to Safeguard Children, 2013’. Its purpose is to: ‘Look at what happened in the case, and why, and what action will be taken to learn from the review findings, so that action results in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and there is transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final report of the SCR with the public.’(Working Together, 2013, page 65) b) Reasons for the Serious Case Review This SCR was commissioned by the Kirklees Safeguarding Children Board (KSCB) on 9th January 2014, because the case circumstances met the criteria set out in Working Together 2013: That abuse / neglect was known or suspected: This was evidenced from the on-going service provision to the young person's family in relation to neglect, the fact that the young person had recently been the subject of a Child Protection Plan, and was the subject of care proceedings, at the time of a life threatening incident (hereafter referred to as, the incident. That the child suffered serious injury: This was evidenced by serious injury sustained by the young person in the incident. That there is cause for concern as to the way in which the authority, Board partners or other relevant persons have worked together to safeguard the child: Although the young person's serious injury was self-inflicted, he had experienced the intervention of many services over a period of years. Due to lack of sustained and focused engagement with the young person, opportunities to provide appropriate, timely and effective interventions were missed. 5 c) Timescale for the Review The Review focused on the period from March 2011, when the young person was subject to a Child in Need Plan, to September 2013 when the incident occurred. 2. METHODOLOGY 2.1 Terms of Reference-see Appendix 1 2.2 SCR Overview Panel The SCR Panel (henceforth known as the Panel) comprised senior agency representatives who considered the information obtained from agency chronologies, Individual Management Reviews, the Learning Event and Court documents. The Panel (see appendix 2 for membership) was chaired by Mrs Bron Sanders, who is the Independent Chair of the KSCB. 2.2.1 The Lead Reviewer was Mr Paul Sharkey (MPA)1 who has wide experience of both writing and chairing Serious Case Reviews since 2002. He is presently an independent safeguarding consultant with over thirty years background in both statutory and third sector child protection agencies. He completed the Department of Education/ NSPCC/ Action for Children/ ‘Improving Serious Case Reviews’ course in July 2013 and is on the Association of Independent Chairs of LSCBs register for independent SCR Chairs and Lead Reviewers. He has had no previous involvement with the KSCB or any of its partner agencies prior to this SCR. 2.2.2 The Overview Panel met on the following dates, 10 March 2014, which included Lead Reviewer briefing of IMR authors 1 May 2014 with IMR authors 5 June 2014 with IMR authors 30 June 2014 2 July 2014, Learning Event 31 July 2014 7 August 2014 15 September 2014 5 November 2014 20 November 2014 1 Master’s in Public Administration ( 2007) from Warwick University Business School 6 2.3 Review Process 2.3.1 Individual Management Review [IMR] authors spoke to their reports with the Panel on the 1st May and the 2nd June 2014. Key Practice Episodes2 (see appendix 1) were identified by the Panel and the Lead Reviewer. These informed the basis of analysis of the four Terms of Reference conducted at the Learning Event of 2/07/2014, which all Panel members, IMR authors and relevant front line practitioners attended. 2.3.2 The Learning Event was facilitated by the Lead Reviewer using the analytical techniques in an attempt to understand from a systems view why and how decisions and actions were made within the context of prevailing organisational and agency practices and expectations. The Panel and Lead Reviewer were mindful of hindsight and outcome bias in conducting the analysis. The Panel critiqued early drafts of the Overview Report on 07/08/2014, 15/09/2014, 05/11/2014 and 20/11/204 The Overview Report was submitted to the KSCB on 18/12/2014. 2.4 Sources of Information – see appendix 2 2.5 Parallel Inquiries There were no criminal or care proceedings or other parallel enquiries ongoing at the time of this Review 2.6 Family Involvement The young person was not able to be interviewed and offer his views due to his current circumstances. The young person’s mother, father and extended family members were interviewed and their views are included in the Report. 2.7 Style and Format of Report This report has been written, in a way that is mindful of recent (July 2014) publications3 about the need for SCR Reports to be succinct, shorter and focussed on learning points and lessons. It has also sought to comply with current statutory guidance (Working Together, 2013) regarding reports being written in a way that publication will not be likely to harm the welfare of any children or vulnerable adults and is compliant with the Data Protection Act, 1998. Therefore, identifying information and personal details have been 2 These are episodes from the case that require further analysis and are thought to be significant to understanding the way the case developed and was handled. They are not restricted to specific actions or inactions but can extend over longer periods. See SCIE ‘Learning together to safeguard children, developing a multi-agency systems approach for case reviews (2008). 3 See ‘First Annual Report’ of the National panel of independent experts on serious case reviews ( July 2014) and the DfE Research Report into Barriers to Learning from Serious Case Reviews (July 2014, Anne Rawlings et al) 7 omitted whilst attempting to achieve a balance with the need for public accountability and transparency. 2.8 For the purposes of identity protection and confidentiality a family structure and genogram is not provided in this report. However, a full genogram was compiled as part of the overall review process. 3. CASE SUMMARY 3.1 The young person is an adolescent who comes from a large family and lived with his mother and siblings prior to the incident. He is of White British background, his language is English and he is of no documented religious background. The young person's father left Kirklees before the birth of his son but has maintained contact with him. 3.2 The young person has had considerable involvement with his nearby extended family throughout the timeframe of this review. 3.3 There had been professional concerns around neglect of the young person since 2005 resulting in various attempts at providing family support through Child in Need (CiN) and Common Assessment Framework plans up to late 2011. In addition, the young person had significant school attendance issues by around 2008 which disadvantaged his educational development. He was subject to an Educational Statement for Emotional and Behavioural Difficulties from 2007. 3.4 Multi-agency attempts at encouraging the young person back to school and supporting the family proved unsuccessful and led to him and his siblings becoming the subject of child protection plans under the Neglect category in late 2011. However, sustained improvement was not achieved. The young person became involved with the criminal justice system in the summer of 2012, and continued not to attend school. There were also concerns that he was misusing alcohol, cannabis and MCAT (Mephedrone)4. 3.5 Continuing professional concerns resulted in the local authority deciding to start care proceedings in May 2013 with the intention of removing the young person from his mother’s care. An interim care hearing in the summer of 2013 ordered that he should remain at home with his mother under an Interim Supervision Order pending the final hearing which occurred in late 2013 when he was made the subject of Supervision Order. 4 Also known as 4-methylmethcathinone (aka Miaow or Meow), a legal substance until April 2010. It is a synthetic opiate/stimulant and has been a Class B controlled drug since April 2010. See KFx factsheet, ‘Learning of Substance’ on Mephedrone, website, www. Ixion.demon.co.uk 8 3.6 Throughout the statutory interventions with the family, which included the Youth Offending Team (YOT) supervised Referral Order, the young person refused to engage with the professionals and consequently, very little was known by them about him. 3.7 Whilst subject to the interim supervision order, the young person’s mental health and behaviour suddenly deteriorated in September 2013. This was observed with some alarm by extended family members and his then girlfriend. It was brought to the attention of a YOT health professional (not allocated to the young person and not previously known by that professional) who encountered him a few days before the incident. She made positive suggestions about sources of help and also agreed to meet with him some two days before the incident. The young person did not turn up for the meeting. 3.8 It is likely that the young person had experienced a drug influenced psychotic episode shortly before the incident. He was found by his mother in a life threatening state at home and taken by ambulance to a nearby hospital. 4. OVERVIEW OF KEY EVENTS March-December 2011 4.1 The young person and his siblings had been subject to a Child in Need (CiN) plan since late 2009. Professional opinion in early 2011 viewed the mother’s engagement as sufficient with signs of improvement in her children’s situation. A CiN meeting in March 2011 decided that Children’s Social Care (CSC) should withdraw from the case and step down work with the family to a Common Assessment Framework (CAF). The young person’s mother had disengaged with the Common Assessment plan by the end of March, previous support from a relative had stopped and home conditions were getting worse. A CiN referral was made by the health visitor to CSC in May. A new CiN plan started in mid-July. 4.2 The young person's school attendance remained very poor. He agreed in September to attend a work experience placement at a local college but did not start. Due to continuing concerns for him and his siblings, CSC started a Section 47 child protection enquiry. This concluded that the children's physical, emotional and social needs were not being adequately met and were adversely impacting on their development. In addition, the young person was reported to be using cannabis and other substances. His mother appeared to have minimal understanding of the importance of meeting her children’s needs, and had not co-operated with professionals, or with the various plans. 9 She was arrested in December 2011 for failure to attend a court hearing regarding the young person’s [and other siblings] school attendance. 4.3 The young person and his siblings were made the subjects of Child Protection Plans under the category of neglect in December 2011. There was no record of his views being obtained for the initial Child Protection Conference. The Child Protection Plan included an assessment of his substance misuse, which was to be undertaken by the social worker. 2012 4.4 A parenting assessment was completed by the Family Support and Assessment Worker (FSAW1) in February 2012. It concluded that the mother had some basic knowledge regarding the needs of her children and how to address those needs. However, when it came to putting the knowledge into action or maintaining provisions for them she fell victim to her own inadequacies or wishes. Moreover, she required a large amount of support, to be able to parent and be able to adapt her parenting to keep up with her children’s ever changing needs and development. 4.5 The young person and his family were referred in February 2012 with a view to becoming part of the HUB, a new initiative from Kirklees Children’s Social Care aimed at working with families with entrenched neglect and parenting issues. Based upon the ‘Hackney model’, a team of three workers (a senior practitioner, a social worker and a child care officer, managed by a team manager) was to be assigned to try and improve parenting and achieve better outcomes for the young person and his siblings. 4.6 Following a referral to the YISP (Youth Inclusion and Support Panel)5 in January by the educational access team, the young person was offered a service by the PAYP (Positive Activities for Young People) team. By mid-June, he had only attended one session with PAYP, and was discharged from the service due to lack of engagement. The young person was also allocated a student social worker (SSW1) to try to get him to attend his new educational placement. Several unsuccessful attempts were made over February and March by SSW1, but the young person refused to engage. His mother attended a meeting in early February at a local school about poor attendance and a parenting contract was drawn up. 4.7 The first Child Protection Review Conference met in February and kept the young person on his Child Protection Plan 5The YISP was a programme aimed at reducing youth crime through providing support to young people at risk of committing crime and their families. 10 4.8 The young person was referred to the community dental team at the end of February but did not attend for treatment. His school health records were not passed on to his educational placement resulting in no health information being shared. No mention was made of him at the third core group meeting6 in March and no minutes were received by the health visitor and the school nurse. Overall, the Health Visitor received only six out of thirteen core group meeting minutes. The fourth core group met in mid-April when it was noted that the mother was allowing the young person to come and go as he pleased and was not informing the educational placement of his absence. 4.9 The young person was arrested in late April for behaving in a drunk and disorderly manner and assaulting a Police Community Support Officer (PCSO). He was taken to the Emergency Department of the local hospital and treated for a lacerated eye brow and head injury. He spent the night in Police cells and was released the next day. The hospital and the Police were not aware that he was on a Child Protection Plan. The young person was given a nine month Referral Order in July for his drunken and disorderly behaviour and allocated to a Youth Offending Officer (YOT1). 4.10 The Police visited the young person’s home the day after the drunk and disorderly incident and noted evidence of neglect and a lack of appropriate supervision of the children. A joint Police/CSC home visit was made in early May to undertake a welfare check. The Police served a neglect warning on the mother; however, there was not agreement between the Police and CSC for further action at this stage. A further Police visit in mid-May noted increased concerns regarding home conditions. Given the recent neglect warning the Police considered removing the young person and his siblings under Section 46 (Children Act; 1989) Police Protection powers. A joint welfare visit was suggested to the Emergency Duty Service who declined emergency intervention as ‘work was in progress to improve conditions’ and because it was likely that the children would be returned home unless a planned approach was taken to legal intervention. The Police noted in late May a conversation with the social worker (SW3) that the mother had been given a clear message that childcare matters had to improve otherwise CSC would instigate care proceedings. 4.11 The second Child Protection Review held in May noted that the young person was not attending school and that there had been limited progress made by the mother on routines and boundaries. The mother was not present. The conference decided to continue with the Child Protection Plans and recorded that ‘legal proceedings needed to be urgently considered’, which was the first mention of legal action in this case. The health professionals noted that their 6 A Core Group comprises multi-agency representatives and identified family members, and meets regularly to review the progress of a Child Protection Plan 11 roles and responsibilities were very confusing given the considerable number of professionals involved in working with this large family. 4.12 The Social worker (SW3) took over from SW2 in late May and attended the core group. She stated that a robust support package was required to intensify the help for the family. In addition to SW3, a family support worker and community care officer were to be allocated from the HUB team. 4.13 The core group in mid-June noted that the case was to be discussed with the Kirklees legal team. Concerns remained about home conditions, the young person's poor engagement with Positive Activities for Young People (PAYP) and school attendance. SW3 spoke to the mother about these issues. 4.14 A legal planning meeting was held on 12/07/2012 which resulted in an advice memo being sent by Kirklees legal section to the social worker (SW3) to start the Public Law Outline (PLO) process. The significant harm threshold had been met and psychological and paediatric reports were needed as part of the overall assessment for possible legal proceedings. It was agreed that a detailed ‘letter before proceedings’ was to be prepared setting out all the support that had been offered to date. In addition, a PLO meeting was to be convened to discuss the concerns with the mother who was to be asked to sign a contract of expectations. The social work assessment was to be completed and updated, pulling together the needs of the young person and his siblings, and indicating whether their mother had the capacity to change. Viability assessments were to be undertaken of any family members who may be able to care for any of the children. 4.15 The young person was taken by ambulance to Hospital 2 in mid-July following a reported overdose of MCAT, apparently taken two days previously, and reported regular taking of alcohol. A safeguarding referral was made. The hospital was not aware that he was subject to a child protection plan and CSC was not contacted by them prior to his discharge. 4.16 The July core group meeting was informed that the young person had apparently taken ‘bath salts’ and not MCAT. SW3 said that legal advice was being sought and that there was an intention to start the PLO process. The young person had not attended his YOT appointments in late July and was discharged from the PAYP service because of lack of attendance. 4.17 Professional concerns of neglect, poor home conditions and deterioration of the young person and his siblings’ care continued during August 2012. The Police Safeguarding Unit requested a strategy discussion with CSC and a joint visit to assess the home situation with the possibility of a Police Protection powers being used to remove the children if the situation warranted it. The social work manager was of the view that the Magistrates would not be convinced in granting an Emergency Protection Order on the children in the 12 event that they were taken into Police Protection. It was suggested that a joint visit should take place if the mother did not improve her parenting and care of the children. A joint Police/CSC home visit was made in late September when home conditions were found to be acceptable. However, the mother was served with a second neglect warning stating that she needed to maintain home conditions. 4.18 The young person did not attend his YOT appointments in July and September, and was allocated a new YOT social worker (YOT2).There should have been a YOT assessment (ASSET) completed within twenty eight days of the start of the Referral Order ( two months previously) for the Referral Panel to consider in order to agree a suitable intervention plan. This had not been done. In October, the young person’s lack of engagement with the Referral Order resulted in a YOT Special Panel meeting, which decided to return the case to the Court for breach of conditions. The young person did not attend court in December for breach of his Referral Order. He was arrested and appeared before the Youth Court on 10/12/2012. The court allowed the Referral Order to continue. 4.19 A letter of instruction for a paediatric assessment in relation to care proceedings on the young person was sent in mid-September for filing by the end of November. The core group held on 18/09/2012 noted some evidence that the situation was improving for the young person's siblings. 4.20 A third Review Child Protection Conference was held in October when it was decided to keep all of the children on their child protection plans under the neglect category. Little progress was noted and it was recorded that CSC was continuing to collate evidence with a view to completing the assessments for care proceedings. The mother did not attend. 4.21 The family was referred to the Family Intervention Support Service (FISS) at the end of October. Its purpose was to prevent family breakdown and young people becoming accommodated. 4.22 The mother was arrested in mid-November for non-compliance with parenting orders and school attendance failure for which she received a twelve month community order. The ninth core group met in late November without her in attendance. The young person had not engaged with any of the services offered or mandated. Assessments were on-going with the psychological assessment due in at the end of the month. 4.23 The family were allocated a Family Support Worker on 14/12/2012. The tenth core group met in mid-December with no attendance from the mother or the young person. Concerns were expressed from core group professionals to the CSC about the young person and his siblings’ wellbeing. The response was that assessments needed to be completed before starting care proceedings. 13 Following the receipt of the psychological assessment in mid-December, Legal Services received instructions from CSC to start legal proceedings with a view to removing the young person and his siblings. 2013 4.24 The YOT ASSET was completed in January 2013 and concluded that the young person was at medium vulnerability and thus in need of a vulnerability/ risk management plan. The resulting plan was not dated or countersigned by the manager as required. Nor was there any evidence that it had been subsequently discussed in supervision or been reviewed, despite it stating that there would be monthly reviews. Important elements of the plan included a referral to a YOT specialist substance misuse worker and fortnightly visits and contacts from YOT2, which do not appear to have happened. There was no evidence that the young person had been seen by YOT2 as an obvious requirement of the assessment. 4.25 The YOT report was presented to the YOT Review Panel. The young person and his mother attended the Panel with the former signing a contract. During February 2013 the young person did not engage with his YOT worker and failed to attend meetings. A final warning letter was sent to him on 19/02/2013. 4.26 The social work assessment for care proceedings was completed on 18/01/2013 and concluded that that there were clear and evident concerns about the mother’s abilities to parent her children over the long term, underpinned by her lack of acceptance of these concerns. On 23/01/2013 the mother was informed that she had four to six weeks to show improvement; otherwise the local authority would begin care proceedings with a view to removing the children from her care. The mother signed the PLO agreement with the local authority on 28/01/2013. 4.27 The planned fourth Review Child Protection Conference due for the 29/01/2013 was postponed because the Conference Chair was on sick leave. 4.28 The eleventh core group held on 26/02/2013 expressed significant concerns about the lack of progress regarding the child protection plans for the children. The young person was not in education and was in breach of his Referral Order with the YOT. The Chair of the Review Child Protection Conference was updated by the Legal section on 11/03/2013 regarding care planning. 4.29 The core groups held in February and March voiced continuing concerns to CSC about case drift and lack of progress regarding plans for the children. A letter was sent to the Care Management team leader from the Head Teacher noting concerns about case drift. The Conference Chair was also written to 14 with the concerns. It was noted by YOT2 that in the event that the young person was removed from his mother’s care he would be unlikely to accept a placement and would return home or go missing. 4.30 A social work visit was made on 03/04/2013 to the mother to share the PLO letter. She was reported to have acknowledged the concerns. The young person attended a session with the YOT on 05/04/2013, the first he had attended on his own. However, he failed to attend further sessions in April and was once again in breach of his Referral Order. 4.31 On the 16/04/2013 the local authority legal team received instructions from CSC that care proceedings were to be lodged regarding the young person and his siblings with a plan to remove them from the care of their mother. An e-mail was sent to the paediatrician (PD1) asking for the outstanding report. A legal planning meeting was held on 22/04/2013 and a legal memo was sent to CSC on the same day confirming the plan to lodge care proceedings. Consideration was to be given to the young person either remaining with his family or being offered a foster placement. 4.32 The thirteenth core group was held on 10/05/2013 when the mother was in attendance. It was noted that ‘things appeared to be improving again’. A further e-mail was sent by legal to PD1 in mid-May requesting the paediatric report. 4.33 Regarding contact with YOT2, there appeared to have been none with the young person or his mother since the review panel of 20/03/2013. A Special YOT Panel was held on 20/05/2013 but neither the young person nor his mother responded to the invitation to attend. The decision was made on welfare grounds to allow the order to continue and not return it to court. 4.34 On 24/05/2013 legal proceedings were issued by the local authority in respect of the young person and his siblings. A letter was sent to the young person’s father on 28/05/2013. An allocations hearing took place on the 29/05/2013 when it was recorded that the local authority had planned for permanence for the children away from their mother’s care. The plan for the young person was for him to be placed with a relative on a Supervision Order. 4.35 A five day contested hearing took place in late June with the final hearing set for October 2013. The Children’s Guardian’s analysis suggested that there was little benefit in the young person in moving away and that he could be better safeguarded at home. She recommended an interim supervision order. The Court ordered that the young person remained at home with his mother on an Interim Supervision Order (ISO). The judge suggested that the local authority would not be in a position to persuade the court that the test for interim removal was satisfied at that time. A referral for family support and a family group conference was made by the Court. 15 4.36 The fourth and final Child Protection Review Conference was held on 07/07/2013 when the young person and his siblings were taken off child protection plans. This was because they were now involved in Care Proceedings and were subject to Supervision Orders. This conference was some three months out of time due to the illness of the Conference Chair. 4.37 The young person was seen by the social worker on 11/07/2013. It was reported that he made good eye contact with her and said that he would engage with activities. A YOT review panel was convened on 13/08/2013. Neither the young person nor his mother attended. The Panel had the powers to return the young person to Court but decided not to breach him, but rather to get him through the order as best it could. There was subsequently an unscheduled and unsuccessful home visit made by YOT2 with no reply. 4.38 The family did not attend a Family Group Conference meeting on 19/08/2013 with the convenor as suggested by the Court. By 03/09/2013 the local authority had decided to seek a Supervision Order for the young person, who was to remain with his mother. Events during the week leading up to the incident in early September 4.39 It was only a few days before the incident that the young person showed any signs of self-harming behaviour and suicidal ideation. He had spent time with his extended family and they had become very concerned about the rapid deterioration in his behaviour and mental health, in particular his hearing voices, morbid thoughts and anxieties about his family. The young person’s father was contacted but states he did not receive the sent text. No involved professionals were alerted. 4.40 An extended family member was so worried about the young person’s mental health that he took the young person to the GP surgery on the day before the incident, saying that the young person was hearing voices and had self-harmed. He requested that a GP see the young person but there were no GPs at the surgery at that time. The family member was asked if he wanted to make an appointment. However, the young person refused to go in to the surgery, stating that he was ‘ok’ and no appointment was made. The extended family described being sufficiently concerned to remove the knives from the kitchen. 4.41 On the day of the incident, the young person returned home in the early evening and seemed ‘fine’ according to his mother. She had not heard of any concerns about her son’s well-being from anyone that day or previously. It seemed that the extended family did not have her telephone number to inform her of their worries. She went upstairs a short time later to find her son in a 16 very serious state consequent to the incident. He was taken by ambulance to the local hospital. 4.42 In addition to the concerns identified by his wider family in the few days leading up to the incident, the young person was seen by the YOT health worker (YOTHW1) for his girlfriend. YOTHW1 reported that the young person admitted he smoked cannabis and described prodromal7 psychosis due to cannabis use. The young person was said to be hearing occasional voices. The young person refused to give his surname. His girlfriend said he needed to know where to go to get advice. YOTHW1 gave the young person the details for single point access and said he could also see his GP. The young person told (YOTHW1) he was definitely not suicidal and did not have any thoughts of harming himself. 4.43 YOTHW1 thought that the young person did not indicate or appear suicidal and offered him an appointment for two days later when she was due to see the girlfriend at her YOT appointment. In the event, neither turned up for the appointment but YOTHW1 did manage to speak to the girlfriend that evening who said that she was worried for the young person and could not contact him on the phone but had spoken to an extended family member about her concerns. The girlfriend said that the young person was saying that he was not suicidal, that he had been ‘ok’ when YOTHW1 saw him, but was ’bad’ the next day. The YOT health advisor repeated earlier advice about available support services, Accident and Emergency and the Police, if events reached crisis point, but the young person would not accept help. 4.44 Medical tests conducted on the young person after the incident showed recent cannabis and MCAT (Mephedrone) use, with evidence of self- harming. 5. ANALYSIS OF KEY ISSUES AND LEARNING The following analysis seeks to address and answer the four Terms of Reference (ToR) and relevant key practice episodes (KPE). 5.1 ToR 1: the young person’s self-harming and suicidal ideation: Were there any warning signs of self-harm, suicidal ideation, mental health issues or substance misuse prior to the incident ? If so, how well were they recognised and responded to by professionals? To what extent was the incident predictable and preventable? 7 The term "prodrome" refers to a period of pre-psychotic disturbance, representing a deviation from a person's previous experience and behaviour. As in clinical medicine, prodrome is a retrospective concept, diagnosed only after the development of definitive symptoms and signs. See www.mentalhealth.com/mag1/scz/sb-prod.html 17 The relevant KPE sought to examine agency responses to the young person in relation to his mental health, self-harm and substance misuse. (See appendix 1) 5.1.1 ToR1 a) Self- Harm and Suicidal Ideation There was no evidence to suggest that the young person showed any self-harming behaviour or suicidal ideation until a few days before the incident. There was no evidence to indicate that any of the professionals directly involved with the young person were alerted by the wider family to their concerns around his self-harm and suicidal ideation. The YOT health worker (for the girlfriend) did not think that the young person was suicidal when he was seen a few days prior to the incident. She acted appropriately by offering him an appointment two days later and giving advice about sources of professional support, despite not knowing him. 5.1.2 When the young person was taken to his GP surgery by a family member, the surgery offered an appointment for him when a GP became available but the young person refused the offer of a GP appointment. 5.1.3 Given the late onset of warning signs of the young person’s self-harm and suicidal ideation and that none of the assigned professionals were aware of these, it is concluded that the incident was neither predictable nor preventable. 5.1.4 The evidence suggests that the young person’s self-harming and suicidal ideation were probably elements of a psychotic episode; most likely brought on by his use of alcohol, cannabis and MCAT. The effect of these substances can include psychosis, paranoia and anxieties. 5.1.5 The SCR Panel meeting of 30/06/2014 heard evidence from ‘The Base’ Young People’s Substance Misuse Project about the trend in recent years for young people to use synthetic cannabis, which has been developed to be more potent than the cannabis in use in previous years, but which can have negative effects on mental health which can last up to 9 months and longer. The use of MCAT can lead to dis-inhibited and sometimes criminal behaviour and can result in low mood, anxiety and paranoia. It is believed that young people with psychological vulnerabilities may be more at risk of mental health problems associated with cannabis and MCAT. It is apparent that many professionals are not aware of the impact of the new range of synthetic and often legal drugs which are available in local communities, and the associated risks for the mental health of young people. 5.1.6 Although the young person's self-harm and suicidal ideation are believed to be elements of a psychotic episode triggered by substance misuse, they 18 occurred against a backdrop of long term neglect, possibly compounded by the uncertainty of his family situation. 5.1.7 Research, (see Brandon et al, 2013, NSPCC/University of East Anglia), highlights self- harm and/or suicide as being a possible consequence for adolescents who have experienced long term neglect. 5.1.8 Learning points in relation to self-harm and suicidal ideation: Professionals should be aware of the possibility of mental health problems associated with newly evolved strains of cannabis, and other drugs such as MCAT. Professionals should consider the possibility of self-harm and/or suicide when working with vulnerable adolescents who have experienced long term neglect. 5.1.9 ToR1 b) Substance Misuse There were four missed opportunities for professionals to respond to the young person’s substance misuse, namely; As part of the Child Protection Plan following the Initial Child Protection Conference The two Accident and Emergency admissions As part of the YOT Asset assessment Child Protection Plan: 5.1.10 The young person’s substance misuse was first identified as a concern at the Initial Child Protection Case Conference of December 2011. It was also referenced in the social work report to the Conference which stated that, ‘There is evidence that the young person may be smoking cannabis’. The ensuing outline child protection plan stated that an assessment should be arranged by the allocated social worker of the young person’s substance misuse in order for him to receive support in addressing ‘any assessed needs in this regard’. 5.1.11 In the referral made by SW2 on 15/12/2011 to the Family Support Co-ordination Group for a parenting assessment and support for the mother, the young person’s substance misuse (drug and alcohol) was listed as a risk. However, there was no mention of a request for support on this issue or for consideration of how the risk was going to be addressed. Reference is made in the core group minutes of 18/01/2012 that no one had engaged with the young person so therefore the plan for him to see someone regarding his alleged substance misuse had not been achieved. The substance misuse 19 action should have been considered and followed up at the subsequent Child Protection Reviews but was not. 5.1.12 There should have been a referral made to the Base young people’s substance misuse project. The core group minutes of the 19/07/2012 noted that the young person had apparently taken Radox bath salts rather than MCAT, not realising that the former term was another name for the latter.8 The school nurse did contact The Base (the substance misuse agency for young people aged under 25 years) for information and erroneously learned that young people often thought that ingredients in bath salts produced similar effects to MCAT. She also became aware that a referral to The Base could not be made without the consent of the young person. There was no evidence that a referral to the Base was discussed with the young person by any professional, and he was not offered a service to address his substance misuse. 5.1.13 It is not clear why the young person’s substance misuse was not followed up. It has been suggested by CSC that specific issues relating to the young person were seen to focus on his school attendance and personal hygiene. His needs had been overshadowed by those of the younger siblings. At fourteen years old he was showing clear signs of being a troubled young person. Yet no serious questions - a seeming lack of professional curiosity – were being asked by professionals as to why he had misused alcohol, cannabis and MCAT, what the underlying reasons might be for such behaviour, what the impact of long term neglect was on him and what was the state of his mental and emotional health. Accident and Emergency admissions: 5.1.14 There were two recorded episodes of substance misuse by the young person, namely, being arrested for being drunk and disorderly in April 2012 and an attendance (taken by ambulance) at Accident and Emergency in July 2012 for a reported MCAT overdose and alcohol ingestion. Following the agreed Pathway9 a referral (with consent) should have been made to The Base substance misuse service by Accident and Emergency staff as a result of the July attendance. 5.1.15 The Panel was informed by the Acute Trust that the Nurse Consultant for Accident and Emergency has since developed a pathway for young people attending with substance and alcohol misuse issues and is reportedly working closely with specialist services to ensure that the pathway is embedded into practice. 8 The SCR Panel learnt this at the meeting with the two experts on substance abuse held on the 30.06.14. 9 See the Calderdale and Huddersfield NHS ‘ Protocol for Young People aged less than 16 years presenting to Accident and Emergency due to alcohol/drug excess or with an injury sustained as a result of drugs/alcohol use’ ( June 2012). 20 5.1.16 Because Accident and Emergency staff were not aware that the young person was subject to a child protection plan – due apparently to a problem in transferring the information between the Acute Trust’s external and internal alert register systems – CSC was not alerted to his admission prior to him being discharged. The Panel was informed that the EDIS system (which identifies if a child is on a child protection plan) was audited and problems were identified in information transfer to the internal alert system (i.e. Accident and Emergency). The Acute Trust reported to the Panel that this problem has now been rectified although there have been no recent audits to verify this. 5.1.17 A further issue with the July 2012 Accident and Emergency episode was that the paediatric liaison form alerting the paediatric nurse to the young person’s second admission for substance misuse was not completed. The school nurse was therefore not informed of the issue until her attendance at a core group on 19/07/2012. The Acute Trust has stated to the Panel that proper use of the paediatric liaison form has recently been audited, reviewed and disseminated to Accident and Emergency staff. YOT Assessment: 5.1.18 The YOT Asset assessment completed by YOT2 in January 2013 determined that the young person was at medium risk of harm to himself, based on parental neglect and his substance abuse. This should have resulted in the implementation of a vulnerability management plan that included action to address his substance misuse with a specialist worker. A meeting to set this up did not happen, nor was the draft vulnerability plan signed off by the YOT operations manager, resulting in no effective or timely work being done to tackle the young person’s substance misuse. This omission constituted a breach of YOT policy and practice and marked a missed opportunity to try and respond to his substance misuse and wider welfare needs. There was one substance abuse/alcohol session held on the 21/06/2013 attended by the young person who said that he no longer took drugs as his partner did not want him to. 5.1.19 In seeking to understand why there was no vulnerability meeting and no early referral made to the substance misuse specialist, the Panel was informed that there was a mind-set of getting the young person through the (Referral) Order without risking him becoming more involved in the criminal justice system for what was a relatively minor first offence. This objective influenced the conduct of the case, including failing to make a referral to the substance misuse specialist. 5.1.20 A second factor accounting for the lack of a referral to the substance misuse worker was that the young person had said he would not co-operate and was perceived as hard to engage and non- compliant with professionals. He was 21 only seen once by a YOT worker in the first five months of a nine month order, due to his non-compliance and the change of worker in September 2012. He was returned to Court under breach proceedings in December 2012, and the outcome of that hearing was that his order be allowed to continue. The Asset was not completed until January 2013, the lateness of which would not have facilitated effective engagement with a young person such as this, who would have had issues around trusting adults and little understanding of consequences. 5.1.21 A third factor was that the young person’s case was seen by the agency as low risk of re-offending given that he had offended only once. In pursuing the imperative of getting him through his Referral Order, the YOT neglected consideration of some significant welfare issues, including his substance misuse. This dynamic was reinforced by the absence of any critical management oversight and challenge to the mind-set. 5.1.22 There should have been a vulnerability plan meeting leading to a plan that would have addressed the young person's specific vulnerabilities, involved appropriate specialists; included contingencies and been regularly monitored. Given that YOT2 was a member of the core group the plan could have been incorporated into the young person’s child protection plan. 5.1.23 In addition to the need for an effective vulnerability plan there should also have been a more vigorous effort at trying to engage the young person at an early stage in the Referral Order and rapid follow up action when he failed to comply with conditions. 5.1.24 In conclusion, there were clear and obvious warning signs of the young person’s substance misuse which were recognised by agencies within the core group but were not addressed. There were four known missed opportunities to try and respond to and address the young person’s substance misusing behaviour. The reasons for agencies not responding in a timely and effective manner have been set out in the above paragraphs. 5.1.25 Learning points in relation to substance misuse: Where there is a Child Protection Plan Consideration should be given to the use of an assertive outreach approach in working with ‘hard to reach’ and non-engaging adolescents Focus should be maintained on the young person where there are younger children in the family A referral should be made to the Young People’s Substance Misuse service as part of a child protection plan where substance misuse has been identified as a risk factor. 22 Consideration should be given to understanding the underlying reasons for a young person’s substance misuse. They should be seen as a ‘troubled’ child as opposed to a ‘troubling’ teenager. Effective audit and scrutiny should be provided by Child Protection Review Conferences to ensure that actions have been completed and if not, why not, with recourse to contingencies. Where the Acute Trust is involved There should be adherence to the Pathway for referral to the Base substance misuse service by Accident and Emergency staff where young people have known substance misuse issues. There should be arrangements to test the effectiveness of the Pathway periodically. There should be an effective notification system to Accident and Emergency of children subject to a child protection plan. Accident and Emergency staff should notify Children’s Social Care of admissions when a child is subject to a child protection plan. There should be an effective notification process from Accident and Emergency to the paediatric nurse service of any safeguarding issues concerning children admitted to the department. Where the YOT is involved YOT should have a focus on a young person’s safeguarding and welfare needs as well as offending behaviour. All young people assessed as being of medium risk of harm to themselves should have an effective vulnerability management plan that includes consideration of all relevant safeguarding issues and where appropriate, addressing substance misuse needs. There should be early and assertive efforts at engaging young people on their orders. There should be timely completion of Asset assessments. There should be rapid follow up action to ensure compliance with consequences when young people do not co-operate with orders and their conditions. The YOT should provide effective management oversight, challenge and audit of vulnerability management plans and their implementation. Where appropriate, vulnerability management plans should be incorporated into a young person’s child protection plan. 23 5.1.26 ToR1 c) Were there warning signs of mental health issues? Although the young person showed no signs of having any mental health issues until the days immediately prior to the incident, the evidence indicates that he suffered long term neglect. 5.1.27 ‘Working Together’ (2013) defines neglect as, “The persistent failure to meet a child’s basic and/or psychological needs, likely to result in the serious impairment of the child’s health or development’. Neglect may involve a parent or carer failing to (…..amongst other things….) ensure adequate supervision ….it may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.” 5.1.28 In addition to neglect, evidence from the psychological profile of the young person and his mother undertaken for the care proceedings of 2013 indicated that he became increasingly peripheral within his family and emotionally distant from his mother. However, there is evidence that he spent time within his extended family which may have met some of his emotional and social needs. He also had some contact with his biological father who he stopped seeing at the age of ten, albeit contact was maintained through the sending of birthday and Christmas cards. 5.1.29 The psychological evidence for the care proceedings noted the mother’s parenting style as one of minimal involvement, few boundaries and little emotional warmth”, resulting in the absence of a “secure, stable, boundaried and nurturing environment that is most likely to result in a secure attachment between parent and child. 5.1.30 Research indicates that some of the consequences of neglect (Hicks and Stein:2010:14) for adolescents include poor mental health and are typically shown by anxiety, depression, low self-esteem, proneness to suicide and recourse to risky health behaviours such as drug and alcohol abuse. Depression in adolescents 10 can manifest itself in a sense of hopelessness, social isolation and dropping out of usual activities, substance abuse, self-harm and recurrent thoughts of death and suicide. A recent University of East Anglia/ NSPCC/ report into Neglect and Serious Case Reviews (Brandon et al: 2013) found that neglect can be life threatening with serious outcomes occurring across all ages, including adolescence. Relevant learning points include: Young people with long experiences of chronic neglect and rejection find it very difficult to trust and may present as hard to help 10 See, Adolescent Depression Awareness Program:www.hopkinsmedicine.org/psychiatry/speciality_areas/moods/ADAP/) 24 The root causes of young people’s behaviour needs to be understood so that the responses of carers and professionals do not confirm young people’s sense of themselves as unworthy and unlovable At the age of 16 young people lose the protection of school and have no equivalent protected route to adulthood and few routes out of a neglectful situation at home. 5.1.31 Given the young person's experience of neglect, he fitted the profile of an adolescent who had the potential of becoming vulnerable to mental health problems. A possible opportunity to assess his emotional well-being was through the school nursing service. The school nurse (SN1) was unable to arrange a health assessment for the young person because he was not in school and because of difficulties in contacting his mother. She was also under the mistaken impression that because CSC had made a referral for psychological and paediatric assessments on the young person, this was to include an assessment of his mental health and emotional wellbeing. In the event, this was not the case. 5.1.32 However, she states that she did (in September 2012) make referrals to the health advisors at the Pupil Referral Unit (PRU) and the Youth Offending Team. An attempt was made by the PRU health advisor to see the young person but was unsuccessful because he was not attending the PRU. YOT health records confirm an exchange of information between SN1 and Youth Offending Team Health Worker (YOTHW), but no referral, nor was there anything in the exchange between the health professionals that suggested a referral was needed. 5.1.33 No Further attempts were made to assess his emotional wellbeing. The school nurse and health visitor described a lack of clarity about their roles and responsibilities within the core group and the child protection plan. There should be clarity around the roles and responsibilities of each member of the core group in relation to specific actions for a child on a child protection plan aimed at achieving SMART11 outcomes. 5.1.34 The young person’s emotional wellbeing was not raised as an issue in the original core assessment of December 2011, or in the later social work assessments done for the care proceedings in June 2013. The issue was not considered at the Initial Child Protection Case Conference (ICPC) in December 2011 and a health assessment was not included as an action in the young person’s child protection plan. 5.1.35 Overall therefore, it can be concluded that the young person’s emotional wellbeing was not effectively recognised or responded to throughout the period in question. His experiences of long term neglect were not recognised 11 SMART refers to Specific, Measurable, Achievable, Relevant and Time bound 25 by professionals as having potential consequences for his mental health and emotional wellbeing. 5.1.36 Learning points: Mental Health and Emotional Well-being: Professionals should understand and assess the impact of long term neglect on an adolescent’s emotional wellbeing and mental health. A holistic health assessment that considers emotional wellbeing should be included in the child protection plans of adolescents. There should be clarity as to which professional has responsibility, within a SMART child protection plan for ensuring that a holistic health assessment is completed. There should be a holistic health assessment for all young people subject to YOT vulnerability plans that includes emotional wellbeing. 5.2 ToR 2: Consider the issues around multi agency working with neglectful families, including professional curiosity and the use of case history. How far was the case history used to inform actions and decisions? 5.2.1 The Section 47/core assessment completed by the duty social worker (SW1) for the Initial Child Protection Conference (ICPC) contained a comprehensive chronology that set out the case history of agencies’ involvement with the young person and his family going back to January 2005. 5.2.2 The ICPC minutes make reference to the previous case history and the fact that the mother had not engaged with CiN and CAF and that the home conditions had not improved. These are cited as key factors in the necessity for child protection plans. The evidence indicates that the use of the case history did inform the decision to make the young person and his siblings the subjects of child protection plans. 5.2.3 Thereafter, there are only two instances of use being made of the case history, namely, the legal memorandum of July 2012 to the Care Management Service and the care proceedings of June - November 2013. References to the chronology or case history are not evident in the three Child Protection Review Conferences or the core group conference minutes. 5.2.4 The parenting assessment of March 2012 did not feel confident that the mother would be able to parent without a large amount of support, and be able to adapt her parenting to keep up with her children’s ever changing needs and development. These findings reinforced and augmented what was already known about the mother’s parenting skills from the previous case history. The assessment’s findings should have been considered by the core group and CSC at the subsequent Child Protection Review Conference 26 (CPRC) of the 09/05/2012. This was at a time when the Police had issued a neglect warning to the mother who was also in breach of her parenting order. The parenting assessment was an informative piece of work which should have been included in the (updated) core assessment and planning process for the young person and his siblings. 5.2.5 When the case was transferred to the HUB team in May 2012, with the aim of intensive work on neglect issues, there was little evidence to show that the updated Core Assessment took into account the previous case history in its work with the family. Indeed, the approach taken was consistent with the ‘Start again syndrome’ and the ‘rule of optimism’ (Brandon et al, 2008) sometimes adopted by professionals. 5.2.6 The ‘Start again Syndrome’ tends to occur in families with complex, confusing and overwhelming case histories. One way for professionals to deal with such complexities is to put aside knowledge of the past and focus on the present, ‘here and now’ (hence ‘Start Again’), supporting the parents and not fully analysing their capacity – including a consideration of the previous case history – to care for their children. Starting with a clean slate, can (according to Brandon et al) be prompted by a transfer to a new worker or team, as was the case with the allocation to the HUB in 2012. Referral on to short term, intensive programmes like the HUB can be a coping mechanisms for practitioners and managers who feel overwhelmed by families ( Brandon et al, 2008) but are unlikely to produce the long term changes required to protect children from the harmful impact of serious neglect, as was the case in this instance. 5.2.7 Brandon et al conclude that, ‘The ‘Start Again Syndrome’ prevents practitioners and managers having a clear and systematic understanding of a (long standing neglect) case informed by the knowledge gleaned from past history’. (2008, page 73) 5.2.8 The new workers seem to have focused on the mother and her needs and abilities, in the belief that this would improve conditions for the children, without the balance of ‘respectful uncertainty’ (Laming, 2003) and professional scepticism. However, if the professionals had assessed her ability to change using established tools such as DiClemente and Prochaska’s ‘Stages of Change’ model (see Wikipedia entry for more details), it is likely that her motivation, ability to change and tendency to minimise/deny professional concerns would have been apparent. 5.2.9 An important instance of the family’s case history informing actions and decisions was the legal memorandum of the 20/07/2012 to Children’s Social Care following the legal planning meeting of the 12/07/2012. This evidences consideration of the social work chronology and the history of social work 27 involvement from 2005/06 onwards and notes that, ‘there was a consistent pattern of poor home conditions, chaotic household and poor school attendance………despite the family being offered a lot of support over time there has been consistent non-engagement with regard to the children’s developmental needs’. 5.2.10 One of the challenges of working with neglectful families is the successful coordination of the various professionals, a clear understanding of roles and a shared overview of what progress, if any, is being made. Work with this large family was additionally complicated by the number of professionals involved. In hindsight, the Review concluded that, in an effort to input considerable resources to make a difference, there were times when the numbers of professionals engaged in visiting and setting expectations of the mother became counterproductive. Successful engagement of the mother and coordination of professional became problematic at times because of this. 5.2.11 Learning points in relation to issues around multi agency working with neglect: Professionals should recognise the importance of considering in a timely way a family’s case history as a possible predictor of future capacity to parent Professional should understand the features of the Start Again Syndrome and ensure that this is focussed on in supervision. Consideration should be given to the impact of the number and range of professionals working with neglectful families to ensure that this does not become counterproductive. 5.3 ToR 3: Child focus: How far did the focus remain on the young person, his emotional wellbeing, attachments and sibling relationships? How well did professionals engage the young person and balance the issues of self-determination and his vulnerability as a teenager 5.3.1 The relevant key practice episode examined issues in relation to engaging the young person including consideration of him as a young person who had experienced neglect and its impact on him. 5.3.2 The evidence suggests that professionals were not able to engage the young person to the point where he felt able to participate meaningfully in activities aimed at integrating him back into education provision, helping him access health services, assessing his needs, undertaking a psychological assessment, ascertaining his wishes and feelings or effectively facilitating his Referral Order. Professionals frequently commented that they did not know 28 him and did not have a good enough understanding of him to be able to identify his wishes and feelings. 5.3.3 One of the key negative outcomes for the young person, common to many adolescents who have experienced long term neglect (Stein et al, 2010, Brandon / NSPCC / University of East Anglia, 2013), was a lack of trust in adults including the many professionals who had attempted to intervene in his life. The lack of trust led to a pattern of withdrawal and marginalisation within his immediate family. Although there is evidence that he had developed significant relationships with parts of his extended family, the professional perception was of a ‘hard to reach’ adolescent who did not engage with services. The model of his mother’s inconsistent engagement with professionals may also have reinforced his non-engagement attitude. 5.3.4 The use of non-engagement as a coping strategy is a common feature in adolescents who have experienced long term neglect (Brandon / NSPCC / University of East Anglia, 2013). Professionals trying to help sometimes interpret such behaviour as sabotaging attempts to support a young person and may rationalise non engagement as adolescent ‘resilience’, within an exaggerated ‘self-determining and young person’s rights’ perspective, because they are older and have survived their teens. This can lead to a negative cycle of mutual rejection and resulting lack of effective help for the young person, leading to them becoming even more vulnerable. 5.3.5 There were other factors apart from the absence of basic trust that resulted in the mutual lack of engagement between the young person and the helping network. These included the large number of individual professionals entering the family home and the lack of any tangible consequences in not engaging in his Referral Order or in attempts to get him back into education provision. 5.3.6 Overall, there was little consideration given to understanding the impact of long term neglect on the young person, what life was like for him in his family and which relationships were important to him. There were attempts to get alongside the young person, for example the allocation of the student social worker, but these were not successful, and arguably required more tenacity. In hindsight it may have been beneficial to have had an allocated worker who had consistently focused on him. 5.3.7 Some key findings from recent research into developing routes to effective help and support for children and young people at risk of harm (Children’s Commissioner, October 2013) identified; The importance for professionals to notice signs and symptoms of children’s and young people’s distress and not to rely unduly on the young person to talk about their abuse or neglect. 29 When trusted professionals respond sensitively and show concern for the young person they may begin to talk about underlying problems. Young people valued professionals they could trust, who were effective, knowledgeable and available. Teachers and youth workers were particularly important as people to tell and social workers were valued as being able to provide holistic support. Of central importance was the young person’s past experiences of professionals, as well as their experiences in the family and community, influencing how comfortable they felt about talking and their willingness to trust and talk to practitioners. The crucial importance of an offer of early help. 5.3.8 It is acknowledged that there are significant challenges for professionals in trying to engage adolescents who have experienced neglect. Therefore, creative and flexible methods using techniques of ‘assertive outreach’, that understand the effects of long term neglect and trust issues for adolescents, need to be developed. Professionals need to be more persistent, committed and prepared to invest time in establishing trusting relationships with vulnerable teenagers working alongside them in achieving a balance between autonomy and welfare. 5.3.9 Although outside the timeframe of this Review, a determined and robust offer of early help at the stage when the young person was starting to miss school, may well have prevented, or reduced the subsequent level of his disengagement and reduced the likelihood of further neglect. 5.3.10 It is concluded that the lack of active engagement between the professional system and the young person was a key factor in not being able to get effective help to address his vulnerability and emotional wellbeing during the time frame of this review. 5.3.11 Learning points regarding the focus on the child: Professionals should identify creative and flexible ways of engaging with vulnerable young people which aim to develop trust and show perseverance in the face of dis-engagement In child protection cases where there is difficulty in engaging a young person, consideration should be given to allocating a separate worker for that young person. Professionals should make early, robust and concerted efforts to re-engage young people with school attendance problems. 5.4 ToR 4: Consider assessment, planning, implementation, review, contingency arrangements and decision making. How effective were 30 these in responding to the young person’s needs, particularly in relation to multi-agency child protection and intervention whilst subject to his child protection plan? 5.4.1 The APIR (assessment, planning, implementation, review) framework is a well-established model of case management. This section will examine and analyse each of the elements. ToR 4 a) Assessment 5.4.2 Assessment of a child’s needs, including safeguarding needs provides the foundation of the APIR framework. A sound assessment of a child’s needs, that fully considers the three holistic domains12 of the Assessment Framework as set out in ‘Working Together’ 2013, that includes the wishes and feelings of the child, should result in a robust plan that effectively promotes their wellbeing and safety. A high quality assessment is vital in cases of long standing neglect which are often very complex in nature and background history. 5.4.3 The section 47/core assessment completed by the Duty and Assessment social worker (SW1) for the Initial Child Protection Conference (ICPC) of December 2011 did not include an analysis of the young person’s holistic needs. It focused on educational issues and mentioned concerns around cannabis use. It should have included emotional and behavioural development and an analysis of the nature of the relationship between the young person and his mother. The young person’s views were not obtained as the social worker did not have the opportunity to speak to him. 5.4.4 The assessment report was appropriate for the purpose of the ICPC and concluded correctly, that the young person (and siblings) should be made the subject of child protection plans under the category of Neglect. However, a full core assessment should have been completed soon after the case conference, in accordance with the recommendation of the ICPC and the outline child protection plan. This should have included a holistic assessment of the young person’s needs so as to inform the more detailed child protection plan to be later ‘fleshed out’ by the core group. There was no record that this happened and the assessment remained uncompleted. It was not updated until the care proceedings in January 2013. 5.4.5 In conclusion, the assessment element of the APIR framework was flawed and fell short of the existing agency and West Yorkshire Safeguarding Procedures practice standards. 12 Namely the child’s developmental needs, parenting capacity and family and environmental factors 31 ToR 4 b) Planning and Implementation 5.4.6 The ICPC produced an outline child protection plan which was considered at the first core group meeting on 10/12/2011. There was one action specific to the young person, namely addressing his substance abuse. There was no provision for him to have a comprehensive health assessment. 5.4.7 The child protection plan did not have SMART outcomes. Therefore, it was not clear to the core group what the goals were, who was responsible for achieving them and in what time. 5.4.8 The minuted contingency in the event of non-compliance was that if actions recommended are not followed through the local authority will seek legal advice. If the children are left alone and unsupervised legal advice will be sought regarding immediate protection. 5.4.9 Despite meeting regularly in accordance with safeguarding guidance, the core group did not develop the outline plan into a more detailed Child Protection Plan, nor did the parent of or the young person received a working copy 5.4.10 The first Child Protection Review Conference (CPRC) was held on 10/02/2012. A CSC meeting chaired by the Team Manager (TM2) on the 24/02/2012 agreed on working to a nine point plan that included completion of a social work assessment, a parenting assessment, assessment of family members, including the children’s fathers, and a referral to the EI and TS Family Support Team. There was no mention of the young person’s substance abuse assessment. 5.4.11 There were two recorded supervision sessions held between SW2 and TM2, these being on the 18/01/2012 and the 12/04/2012. The requirement was for monthly supervision sessions to have taken place in February, March and May 2012, in accordance with agency policy. Regular supervision, preferably involving an element of the ‘reflective approach’ between social worker and manager, should have been a key ingredient in effective case planning and intervention, especially in such a complex case as this one. 5.4.12 It had become apparent by the second CPRC held on 09/05/2012 that no real progress had been made with the child protection plan. The mother was not in attendance. FSA1’s parenting assessment completed in March 2012 was negative in regard to her parenting abilities and the outcomes for her children, including the young person. The Early Intervention Family Support Team had not been successful in engaging either the young person or his mother and the Police neglect warning of early May had been issued to the mother. There had also been the ‘Drunk and Disorderly’ incident of late April involving the young person. 32 5.4.13 The Conference Chair (IRO1) had expressed her concerns and suggested that a Public Law Outline should be urgently considered. 5.4.14 A decision had been made in February 2012 for the young person and his family to become part of the trial ‘Reclaiming Social Work (RSW)’ initiative that Kirklees Children’s Services was developing13. The intention was to allocate a small number of cases, including the young person and his family, to a dedicated, small team of workers (referred to as the ‘HUB’) who would work very intensively with particular ‘Child in Need’ and ‘Child Protection Plan’ families to prevent escalation into care proceedings. 5.4.15 SW2 told the Child Protection Review Conference that a decision was due to be made the next day about progressing the HUB approach. SW2 was of the view that the children should remain on child protection and that the HUB could run concurrently. SW2 told the conference that a formal letter would be sent to the mother inviting her and her solicitor to a PLO meeting. It would be explained what was expected of her with the option of going to court if the agreement was broken. 5.4.16 SW2 left the Department on 21/05/2012 and a new social worker (SW3) was allocated to the family the next day (22/05/2012) with CCO2 (a new community care officer) also allocated to the case at this time. The advent of a new social worker and community care officer should have been the occasion for TM2 to have reviewed the case, in the light of the pessimistic findings of the recent child protection review conference (CPRC) and to have developed a revised plan. The (core) assessment had not been completed by the previous social worker (SW2) prior to her departure. There should have been a timely social work assessment completed to inform case planning. 5.4.17 However, a decision seemed to have been taken to continue with ‘more of the same’ (an example of the ‘Start again Syndrome’), by the referral on 30/05/2012 to the Early Intervention and Family Support Team requesting a parent support service. A parenting worker was allocated in August 2012 to assist the mother with identified aspects of parenting but there seemed to be a degree of overlap and duplication with the work of CCO2, the community care officer in the HUB team. The mother was offered a ‘Family Links course’ in August and October 2012, both of which she failed to attend. None of these actions seemed to have been co-ordinated with the existing child protection plan. These family support services were in addition to the parenting work being attempted by the health visitor and the nursery nurse. 5.4.18 There was no record of case supervision between TM2, the social worker and community care officer between May to September 2012. 13 This way of working was commonly referred to as the ‘Hackney Model’, see Community Care 24/10/2013, 06/11/2013 33 5.4.19 The legal planning meeting on 12/07/2012 and subsequent memorandum of July 2012 agreed to convene a PLO meeting, send out a detailed ‘letter before proceedings’ and ask the mother to sign a Contract of Expectations. These actions were standard operating procedures of the PLO process, prior to the local authority starting care proceedings. The core group was told by SW3 on 20/07/2012 that there was an intention to start the PLO process. 5.4.20 However, the three actions were not implemented or completed within two or three months of the meeting as would be expected. There was no record of the rationale not to implement the PLO decision of the legal planning meeting of 12/07/2012. CSC seemed to have come to a view sometime around late July/mid-August 2012 to start to prepare the ground for possible care proceedings on the young person and his siblings. This was reflected in the requests made for psychological and paediatric assessments (21/08/2012 and 14/09/2012 respectively) in order to gather evidence for care proceedings. 5.4.21 At the same time a decision was made to continue the intensive work with the mother in an effort change parenting behaviours and competence. 5.4.22 In relation to the core group and the existing child protection plan, from September 2012, CSC started to play an increasingly more dominant role in the case. Reasons for this included the move towards care proceedings and the process of evidence collation. This development tended to marginalise the non CSC members of the core group and render the existing child protection plan secondary to the emerging PLO process and eventual care proceedings. Non CSC core group members lacked clarity about the role and remit of the HUB and its practitioners, what their roles were within the existing child protection plan and where the PLO process was operationally. 5.4.23 The problematic dynamics operating within the core group were, to a degree, iterated within and mirrored by the HUB team. It’s operation was characterised by a lack of clear leadership, confusion between TM2 and the Consultant Social Worker (CSW1) regarding management oversight and accountability for the case, no evidence of any formal line management supervision, poor recording, lack of a child focused analysis regarding risk to the children, and minimal line management presence in any of the weekly HUB meetings. As a result of concerns about the operation of the HUB, the initiative was closed in January 2014. 5.4.24 Although there were weekly HUB meetings, these tended to focus on practical matters around cleaning up the home and getting the children to school, rather than an evaluative analysis of risk and the impact of parenting on the children. In regard to the social worker (SW3) and the community care officer (CCO2), it is understood that they were both line managed by the consultant social worker (CSW1). She had oversight of two HUBs involving twenty-five 34 cases and because of the volume of work, had limited time to give to this case. 5.4.25 The structural and systemic impediments to decision making and other factors outlined above did not, therefore, make for effective and timely planning by CSC and the HUB between May 2012 to January 2013, with associated implications for effective multi-agency core group working. Thus, for example, it was unclear to the lead reviewer why a family support worker was introduced to the family on 14/12/2012. This intervention served to duplicate the work of the HUB team, and unnecessarily added yet another professional into the many personnel involved with the family. 5.4.26 In December 2012 CSC received the psychological assessment commissioned by the local authority. The local authority’s legal section was instructed on 19/12/2012 to issue care proceedings with a view to removing the young person and his siblings from their mother’s care. The social work assessment was completed on 18/01/2013. However, at this point, and seemingly contrary to the instruction, the social worker was instructed by line management to start the PLO process with the mother. She was informed on the 23/01/2013 that she had between four to six weeks to show improvement. This was retracing work which should have been taken forward in the latter half of 2012. When the core group of 26/01/2013 was told that the PLO process had been initiated, it was confused and concerned about case drift, and wrote to the CSC team leader. 5.4.27 A (PLO) letter was shared with the mother on 03/04/2013, and finally on receipt of the paediatric report, care proceedings were issued on the young person and his siblings by the local authority on the 24/05/2013. 5.4.28 In conclusion, despite regular core group meetings planning and Implementation were rendered less effective by the lack of a SMART child protection plan, the introduction of the HUB team, the resulting marginalisation of the core group and the impact this had on multi agency working. This added to the already existing complexity of working with a large family. Because of structural and systemic factors in the HUB effective planning and implementation were compromised. Case management was marked by case drift and delays in taking decisions, especially around the way the PLO process was managed. The core group was left unclear about the actions and intentions of the HUB team. This episode also highlighted the complexity of managing several processes running in parallel (the Child Protection Plan, the PLO, CSC case management and legal advice) and the need for careful coordination and good communication by the CSC team manager and social worker. 35 ToR 4 c) Reviewing 5.4.29 The absence of SMART outcomes for the young person made it difficult to review his progress around wellbeing and risk reduction. Furthermore, although agency reports were provided to CPRCs, the Child Protection Plan was not systematically reviewed and elements of the plan (such as the young person’s substance abuse) did not get actioned. The Conference Chair should have insisted and ensured that all child protection plans were SMART and that they were reviewed against agreed actions and outcomes. This now happens under the new ‘Strengthening Families’ approach adopted by the Kirklees Independent Reviewing Service. Additionally, the Conference Chairs should have sight of all core group minutes, significant case developments and the single assessment before reviewing a case. This is now possible under the current electronic case recording system. 5.4.30 The Conference Chair (IRO) did attempt to challenge CSC at the May 2012 CPRC regarding lack of progress with implementing the child protection plan and the need to consider the PLO process but without any remedy. It is important that the Child Protection Reviewing Service (CPRS) is respected and supported when it challenges agencies, including CSC and other local authority services. Agencies should respond to advice and concerns from the CPRS in a timely and positive manner with outcomes reported back in writing to the Conference Chair and the core group. There should be recourse to KSCB dispute resolution procedures when necessary. 5.4.31 The final CPRC held on 07/07/2013 was three months out of time and should have been held by mid- April 2013. The CPRS should have ensured that this happened and not have left it to the CSC team manager to decide on the date. Given the written concerns of late March 2013 from the core group to the CSC management about the way the case was being managed a timely CPRC was essential. Arrangements need to be in place to ensure that the CPRS decides on dates of ICPCs and CPRCs and not individual agencies. 5.4.32 In conclusion, the reviewing element of the APIR framework was less effective because the child protection plan was not systematically reviewed to ensure that agreed actions had been completed. 5.4.33 Learning points regarding assessment planning and review processes: Assessment A full, holistic and timely core assessment should be completed within the agreed timeframe after an ICPC ( as set out in the outline child protection plan) 36 The participation of the family and the subject child/young person should be facilitated. The assessment should be quality assured and signed off by the team manager. Planning and Implementation Child protection plans for each child should be child focused and subject to appropriate updating. Parents/carers and children should be fully involved in the production of plans and receive signed copies of the plans Core group members should be clear about roles and responsibilities within the child protection plan. There should be clarity for the core group and parents about contingency actions to be taken to protect children in the event of non-compliance Lack of progress with the plan should be robustly challenged, underpinned by a professional approach of ‘respectful uncertainty’ and professional curiosity. There should be proactive and skilled management oversight with easy access to managers who are familiar with cases and regular high quality ‘reflective’ supervision Decisions should be recorded in a transparent way and communicated clearly to workers, parents, children and core group members PLO arrangements should be fully enacted in a timely and robust manner and incorporated into the child protection plan. Action should be escalated to care proceedings in the event of PLO agreements being breached so as not to delay decisions to protect children's welfare. Review Conference Chairs should review SMART child protection plans. Conference Chairs should have access to assessments, core group minutes and significant developments in the case. Agencies should respond to concerns and recommendations from Conference Chairs in a timely manner with outcomes reported back in writing to the Chair and core group. There should be recourse to the KSCB dispute resolution process in the event of disagreement between the Conference Chair and any agency. Arrangements should be in place to ensure that the Child Protection Reviewing Service decides on dates of conferences and not agencies. 37 6. FAMILY VIEWS 6.1 The young person’s mother was seen as part of this process. She acknowledged that a lot of agencies were involved with the young person and her family. She stated that the young person was not willing to engage with the majority of these professionals. Both the young person and the older two of his siblings found the intrusion into their family life difficult and felt that several people would be in and out of the family home within one day, all saying the same thing. This resulted in the young people not listening or responding to what was said. The young person’s mother also pointed out that it was not helpful that her daughters were told they would end up down the same road as the young person; this was said in front of him. 6.2 She did identify that the young person’s difficulties with school began as soon as he was in reception class. She felt this was because of his August birthday and he was significantly younger than many in his class and therefore struggled and school were not prepared to hold him back a year, consequently he always felt at a disadvantage and quickly became disengaged with the learning process. 6.3 The young person’s mother was very clear that she did not feel anyone could have done any more to get alongside him and that professionals had all tried. The young person did speak to the student social worker, but once the worker qualified he moved on. The young person would not work with the youth offending team as he saw them as an obstacle to him joining the army at 16 because of the order that was in place; he was offered support from the youth services but the activities were not of interest to him. He enjoyed going to the gym and had been committed to that for about one year prior to the incident. The mother indicated that however much support was on offer the young person would only speak to people he wanted to and nothing would alter that. She acknowledged that no one could have anticipated that he would do what he did and that there were no warning signs to suggest any risk. 6.4 The young person’s father was seen as part of the process. He maintained regular indirect contact with the young person up to the incident. He provided relevant information of a personal nature which for confidentiality reasons is not appropriate to include in this report 6.5 The father confirmed that he had been granted Parental Responsibility by the Court but that he was not party to the Care Proceedings. He felt strongly that he should have been, and believes that his contact details were known to the young person’s family. 6.6 The father believes that the signs were there which made the incident predictable or preventable although he does however acknowledge that this is 38 with hindsight and that resource issues were a factor. He said it felt as though the case kept being closed without things being sorted out. 6.7 The father acknowledged the difficulties agencies had engaging the young person, and that they would say they had tried very hard. He considered that everyone is under pressure, but he said they should have continued to try to engage the young person. 6.8 The father said that the young person should have been removed from the environment and that consideration could have been given to placing him within the extended family. The father was clear that he would have offered to help if he had known what was going on. He said he doubts anyone will know why the young person did what he did. The father views the situation as “misadventure” rather than attempted suicide. He thought that the young person’s environment must have been a factor. 6.9 Members of the young person’s extended maternal family were seen as part of the review. One part of the family felt that agencies should have been persistent in trying to engage him. They acknowledged that he would only speak to those he wished to and that he did refuse to work with agencies but felt that this should not have deterred professionals from continuing to try. They felt that he just needed someone to talk to who was there just for him and would listen because they wanted to, not just because it was their job. They did point out that the young person was too old by this point and effective engagement should have happened earlier. They did suggest that moving him from the home environment into foster care or with extended family may have helped to get him back into school. However, they did acknowledge that they would not have been able to make him do what he did not want to. 6.10 The young person had very positive relationships with another part of the wider family and they described him as being very much part of their family. They provided him with a place to be, they talked to him and fed him and he had a very good relationship with a family member of similar age to himself and they spent a lot of time together. They described the young person as a young man who had confidence and who spent time at the gym and getting fit. They felt that the change in the young person’s behaviour was very sudden and recent. They knew in the past he had misused substances but had made an effort to stop, even rejecting cigarettes and it was only the recent change in behaviour that raised their concerns. They had tried to help the young person and contacted other family to alert them to their concern. This wider family did get alongside the young person but were not aware of all the professional agency involvement. Also as it was a sudden and rapid deterioration there was no time to take any other action. The family do not appear to blame 39 anyone for the young person’s situation. They are clear that his paranoid behaviour was unusual and most probably due to recent drug misuse. 6.11 The lead reviewer and the Panel agreed that more effort should have been made by CSC and the Children’s Guardian in 2012/13 to have contacted the father, both for the social work assessment and the care proceedings. The father’s potential significance to the young person and any possible role he might have been able to play in his future care should have been considered. All possible and reasonable efforts should be made to contact fathers (or the absent biological parent) where they are living away from their children, to establish whether it is in the child’s best interests for there to be an appropriate level of involvement. 6.12 Overall, it is considered that more effort could have been made in assessing the significance of the young person’s extended family and the potential for their support in re-engaging him back into education and mainstream social activity. 7. CONCLUSIONS 7.1 The young person showed no self-harming behaviour or suicidal ideation until a few days before the incident. These behaviours were elements of a probable, psychotic episode; most likely brought on by his use of alcohol, cannabis and MCAT. 7.2 Given the late onset of warning signs of the young person’s self-harm and suicidal ideation and that none of the assigned professionals (or, indeed his mother) were aware of these, it is concluded that the incident was neither predictable nor preventable. 7.3 The incident was preceded by a long period of neglect for the young person that could have made him vulnerable to substance misuse and mental health difficulties. His emotional wellbeing needs were not effectively recognised or responded to throughout the period in question. His experiences of long term neglect, low control/low warmth parenting, non-school attendance and substance misuse were not given sufficient consideration by professionals as having potential consequences for his mental health and emotional wellbeing. 7.4 There were missed opportunities to try and respond to the young person’s known substance misusing behaviour and to assess his overall health needs. These were, as part of the child protection plan following the Initial Child Protection Conference of December 2011, the two Accident and Emergency admissions of the 2012 and as part of the YOT Asset assessment. Given the young person’s tendency to withdraw from professional contact there was no 40 certainty that he would have consented to assessment but attempts should have been made nonetheless. 7.5 The inability of professionals to engage the young person was a key factor in not being able to effectively address his problems and needs. Once the young person became disengaged from school, professionals were not able to gain his trust and engage him to the point where he felt able to participate meaningfully in activities aimed at integrating him back into education provision, promoting his safety and wellbeing and effectively facilitating his Referral Order. This dis-engagement resulted in there being insufficient focus on him by agencies, who focused on his siblings and mother. The absence of any real consequences in not engaging in, for example, his Referral Order or attempts to get him back into education provision, were additional factors in the young person’s hard to reach, non-engaging attitude and behaviour. 7.6 Whilst there was a consistent pattern of multi-agency meetings over the period of the review, the assessment and planning processes which underpinned multi-agency working did not adequately focus on the young person's specific needs and did not sufficiently take into account the case history. In addition the large number of professionals involved in work with this large family was an added complexity, and was at times counter- productive. Once the HUB took on intensive work with the family, the core group became marginalised and there was added confusion about the direction of planning when the PLO process was started alongside this work. Bringing in a new team also resulted in the 'Start again syndrome’ and added to the delays in progressing the PLO process. 7.7 The local authority did attempt to safeguard and promote the young person’s welfare by obtaining an interim supervision order in June 2013 which was the only viable legal option open to it. Both the Court and the Children’s Guardian took the view that the young person should remain in the care of his mother whilst on the supervision order. The incident happened during the care proceedings and prior to the final hearing in November 2013. 7.8 The analysis of the pertinent issues in this case has produced a number of learning points and recommendations. The expectation of this Report is for the Kirklees Safeguarding Children Board and its partners to consider how best to take action to improve safeguarding services which promote the welfare of children and protect them from harm. 8. RECOMMENDATIONS 1. The KSCB should ensure that relevant professionals are made aware of the mental health risks associated with new synthetic drugs, and that the Board 41 works with the Children's Trust to ensure that there are strategies in place to raise awareness with young people and communities about these issues 2. The KSCB should ensure that all relevant professionals within the safeguarding partnership access learning on adolescent suicide and self-harm that includes the impact of long term neglect on young people’s emotional and mental health. 3. The KSCB should obtain assurance that the referral pathway to Young People’s Substance Misuse Services is effective and in wide use by professionals. 4. The KSCB should ensure that all adolescents who are subject to a child protection plan for neglect are offered a holistic health assessment which includes their emotional health and wellbeing. 5. The KSCB should arrange for professionals to be aware of the pitfalls associated with the ‘Start again syndrome’ and remind practitioners of the importance of including previous family histories in assessments, especially in long term neglect cases. 6. The KSCB should arrange through the Board to develop and implement a toolkit enabling professionals to engage effectively with ‘hard to engage’ young people 7. The KSCB should seek assurance that there are robust arrangements in place for the timely management of children with school attendance problems 8. The KSCB should endorse the recommendations and action plans of the agencies’ IMRs and obtain assurance: That agency learning is shared with and disseminated widely with staff forthwith; That the KSCB, as part of its learning and improvement agenda, receives regular six monthly reports from agencies on the progress of action plans, dissemination of learning and evidence of the learning having made a difference to the safety and wellbeing of children. 8.1 The KSCB should ensure that the recommendations and learning points are incorporated into an Action Plan which will be monitored and regularly reviewed by the KSCB Serious Case Review Workstream, with referral on to other workstreams as appropriate. 42 Appendix 1: Terms of Reference and Key Practice Episodes Terms of Reference 1. The young person’s self-harming behaviour and suicidal ideation: Were there any warning signs of self- harm, suicidal ideation, mental health issues or substance misuse prior to the incident with the young person and if so, how well were they recognised and responded to by professionals? To what extent was the incident predictable and preventable? 2. Consider issues around Multi-agency working with neglectful families including professional curiosity and the use of case history: How far was the case history used to inform actions and decisions? 3. Child focus: How far did the focus remain on the young person, his emotional wellbeing, attachments and sibling relationships? How well did professionals engage the young person and balance the issues of self-determination and his vulnerability as a teenager? 4. Assessment, planning, implementation, review, contingency arrangements and decision making: How effective were these in responding to the young person’s needs, particularly in relation to multi-agency child protection and intervention between December 2011 and July 20 Key Practice Episodes The five Key Practice Episodes (KPEs) considered at the Learning Event in regard to the Terms of Reference were; 1. Examine issues in relation to engaging the young person. Include consideration of him as a young person who had experienced neglect, and the impact of this on him. Why were there difficulties in engaging the young person? 2. Examine multi-agency planning and intervention within the period of May 2012 – June 2013. 3. What were the opportunities for assessing the young person’s health and wellbeing throughout the period of the SCR? 4. Consider issues around multi agency working with neglectful families. 5. Examine agency responses to the young person in relation to his mental health, self-harm and substance misuse. Regarding vulnerable adolescents and mental health, self-harm and substance; 43 What arrangements are there for early recognition? What access is there to advice and what are the pathways to services for young people, family and friends? What are the levels of practitioner awareness and capacity? What are the learning points? 44 Appendix 2: Membership of the SCR Overview Panel and Sources of Information Membership of the SCR Overview Panel Independent Chair (Ms Bron Sanders, also the Independent Chair of the KSCB) Kirklees Children and Young People Service-Head of Early Intervention and Targeted Support Head of Service, Family Support and Child Protection, Kirklees Council (first Panel meeting only) Kirklees Learning Service Greater Huddersfield and North Kirklees Clinical Commissioning Group; Designated Nurse Locala Community Partnerships; Director of Clinical and Operational Services West Yorkshire Police; Superintendent Head of Integrated Youth Support, Kirklees Council KSCB Manager KSCB Safeguarding Co-ordinator Administrative support was provided by the Business Support Manager of the KSCB. Sources of Information Individual Management Reviews from Kirklees Children’s Social Care/ Family Support and Child Protection, West Yorkshire Police, Locala Community Partnerships, Kirklees Learning Services, Kirklees Early Intervention and Targeted Support Services/ Integrated Youth Support. Composite chronology The Court ‘Bundle’ of relevant documents relating to legal proceedings Minutes of the Initial and Review Child Protection Conferences 45 Appendix 3: Learning points from the Serious Case Review Learning points in relation to self-harm and suicidal ideation: Professionals should be aware of the possibility of mental health problems associated with newly evolved strains of cannabis, and other drugs such as MCAT. Professionals should consider the possibility of self-harm and/or suicide when working with vulnerable adolescents who have experienced long term neglect. Learning points in relation to substance misuse: Where there is a Child Protection Plan Consideration should be given to the use of an assertive outreach approach in working with ‘hard to reach’ and non-engaging adolescents Focus should be maintained on the young person where there are younger children in the family A referral should be made to the Young People’s Substance Misuse service as part of a child protection plan where substance misuse has been identified as a risk factor. Consideration should be given to understanding the underlying reasons for a young person’s substance misuse. They should be seen as a ‘troubled’ child as opposed to a ‘troubling’ teenager. Effective audit and scrutiny should be provided by Child Protection Review Conferences to ensure that actions have been completed and if not, why not, with recourse to contingencies. Where the Acute Trust is involved There should be adherence to the Pathway for referral to the Base substance misuse service by Accident and Emergency staff where young people have known substance misuse issues. There should be arrangements to test the effectiveness of the Pathway periodically. There should be an effective notification system to Accident and Emergency of children subject to a child protection plan. Accident and Emergency staff should notify Children’s Social Care of admissions when a child is subject to a child protection plan. There should be an effective notification process from Accident and Emergency to the paediatric nurse service of any safeguarding issues concerning children admitted to the department. 46 Where the YOT is involved YOT should have a focus on a young person’s safeguarding and welfare needs as well as offending behaviour. All young people assessed as being of medium risk of harm to themselves should have an effective vulnerability management plan that includes consideration of all relevant safeguarding issues and where appropriate, addressing substance misuse needs. There should be early and assertive efforts at engaging young people on their orders. There should be timely completion of Asset assessments. There should be rapid follow up action to ensure compliance with consequences when young people do not co-operate with orders and their conditions. The YOT should provide effective management oversight, challenge and audit of vulnerability management plans and their implementation. Where appropriate, vulnerability management plans should be incorporated into a young person’s child protection plan. Learning points: Mental Health and Emotional Well-being: Professionals should understand and assess the impact of long term neglect on an adolescent’s emotional wellbeing and mental health. A holistic health assessment that considers emotional wellbeing should be included in the child protection plans of adolescents. There should be clarity as to which professional has responsibility, within a SMART child protection plan for ensuring that a holistic health assessment is completed. There should be a holistic health assessment for all young people subject to YOT vulnerability plans that includes emotional wellbeing. Learning points in relation to issues around multi agency working with neglect: Professionals should recognise the importance of considering in a timely way a family’s case history as a possible predictor of future capacity to parent Professional should understand the features of the Start Again Syndrome and ensure that this is focussed on in supervision. Consideration should be given to the impact of the number and range of professionals working with neglectful families to ensure that this does not become counterproductive. 47 Learning points regarding the focus on the child: Professionals should identify creative and flexible ways of engaging with vulnerable young people which aim to develop trust and show perseverance in the face of dis-engagement In child protection cases where there is difficulty in engaging a young person, consideration should be given to allocating a separate worker for that young person. Professionals should make early, robust and concerted efforts to re-engage young people with school attendance problems. Learning points regarding assessment planning and review processes: Assessment A full, holistic and timely core assessment should be completed within the agreed timeframe after an ICPC ( as set out in the outline child protection plan) The participation of the family and the subject child/young person should be facilitated. The assessment should be quality assured and signed off by the team manager. Planning and Implementation Child protection plans for each child should be child focused and subject to appropriate updating. Parents/carers and children should be fully involved in the production of plans and receive signed copies of the plans Core group members should be clear about roles and responsibilities within the child protection plan. There should be clarity for the core group and parents about contingency actions to be taken to protect children in the event of non-compliance Lack of progress with the plan should be robustly challenged, underpinned by a professional approach of ‘respectful uncertainty’ and professional curiosity. There should be proactive and skilled management oversight with easy access to managers who are familiar with cases and regular high quality ‘reflective’ supervision Decisions should be recorded in a transparent way and communicated clearly to workers, parents, children and core group members PLO arrangements should be fully enacted in a timely and robust manner and incorporated into the child protection plan. 48 Action should be escalated to care proceedings in the event of PLO agreements being breached so as not to delay decisions to protect children's welfare Review Conference Chairs should review SMART child protection plans. Conference Chairs should have access to assessments, core group minutes and significant developments in the case. Agencies should respond to concerns and recommendations from Conference Chairs in a timely manner with outcomes reported back in writing to the Chair and core group. There should be recourse to the KSCB dispute resolution process in the event of disagreement between the Conference Chair and any agency. Arrangements should be in place to ensure that the Child Protection Reviewing Service decides on dates of conferences and not agencies. 49 Appendix 4: Glossary of Terms APIR: Assessment, Planning, Intervention, Review CAF: Common Assessment Framework CiN: Child in Need CP Plan: Child Protection Plan CPRC: Child Protection Review Conference CPRS: Child Protection Reviewing Services CSC: Children’s Social Care CSW: Consultant Social Worker FISS: Family Intervention Support Service HV: Health Visitor ICPC: Initial Child Protection Plan IMR: Internal Management Reviews IRO: Independent Reviewing Officer ISO: Interim Supervision Order KPE: Key Practice Episode KSCB: Kirklees Safeguarding Children Board LSCB: Local Safeguarding Children Board MCAT: Mephedrone PAYP: Positive Activities for Young People PCSO: Police Community Support Officer PLO: Public Law Outline PRU: Pupil Referral Unit SCR: Serious Case Review SMART: Specific, Measurable, Achievable, Relevant, Timely SW: Social Worker TM: Team Manager ToR: Term of Reference YOT: Youth Offending Team 50 Appendix 5: References Brandon M. et al (2008): ‘Analysing Child Deaths and Serious Injury through Abuse and Neglect: What can we learn? Brandon M. et al (2013): ‘Neglect and Serious Case Reviews’ NPSCC/ University of East Anglia The Children’s Commissioner (October 2013): ‘It takes a lot to build trust: Recognition and telling: Developing earlier routes to help for children and young people’ Community Care: 24.10.13 and 06.11.13 Diclemente and Prochaska: ‘The Change Cycle’ Wikipedia Hicks L. and Stein M. (2010): ‘Neglect Matters: A multi-agency guide for professionals working together on behalf of teenagers’ Laming H. (2003): The Victoria Climbie Enquiry Department of Education (2013): ‘Working Together to Safeguard Children’ Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG Review Date 1 SCR 026 Case summary: Young person – aged 16 years: sustained life-changing injury following attempted suicide – 09/2013. Family had a long history of agency interventions. SCR 026 / 001 Kirklees Safeguarding Children Board [KSCB] All relevant agencies Findings 1a & 1b: Understanding of adolescent mental health / suicide / self-harm issues and their relation to long term neglect and/or substance misuse Section 5.1 in Overview Report [OR] Key Practice Episode [KPE] 5 Recommendation 1. The KSCB should ensure that relevant professionals are made aware of the mental health risks associated with new synthetic drugs, and that the Board works with the Children’s Trust to ensure that there are strategies in place to raise awareness with young people and communities about these issues. Multi-agency briefing to be provided for front line professionals; raising awareness of emerging synthetic drugs as part of Learning from SCR. CRI/The Base approached for information re strategic event in Jan-15 and other training carried out and who for CRI/The Base to provide briefing paper for inclusion on the KSCB website and in a SCR Lessons briefing paper New synthetic drugs on the agenda for discussion at the June meeting of the Children’s Trust CRI/The Base update: To provide further content including local prevalence, trends, supply, effects, screening, harm reduction, referral & signposting. Other methods by which awareness is raised of NPS includes drop-in’s and group-work within schools, colleges and universities, targeted group-work within children’s homes and hostels, outreach within local communities and the night time economy. Children’s Trust agenda Briefing on Novel Psychoactive Substances provided on 15/10/14. Attendance register provided to KSCB as evidence. NPS training delivered from Feb 2014 to Jan 2015 to 1089 professionals from a range of services. Briefings and training to be arranged for 2015. In January 2015, CRI instigated the development of a NPS strategy and steering group. Awareness raising Mar-15 G R E E N May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG Review Date 2 campaigns delivered to all local stakeholders, including young people and parents via social media and the CRI website. SCR 026 / 002 KSCB All relevant agencies Finding 2: Multi-agency work with Neglect issues Section 5.2 in OR KPE 4 Recommendation 2. The KSCB should ensure that all relevant professionals within the safeguarding partnership access learning on adolescent suicide and self-harm that includes the impact of long term neglect on young people’s emotional and mental health. KSCB to incorporate into multi-agency neglect training KSCB Training courses content has been updated to reflect learning Courses contents Jan-15 G R E E N May-15 Single agency training to incorporate learning into neglect training Learning & Development work stream to discuss at meeting in April 2015. Agenda to include: KSCB Learning & Improvement briefing paper for dissemination to individual agencies Learning & Development work stream agenda – 20 April 2015 Apr-15 A M B E R May-15 KSCB to provide workshop on impact of neglect as part of a Learning from SCR Conference KSCB Lessons from SCRs conference to take place Oct-15. Workshop to focus on impact of long-term neglect. Oct-15 A M B E R May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG Review Date 3 SCR 026 / 003 KSCB Young People’s Substance Misuse Services Finding 1b. Young people’s substance misuse – referral pathways Section 5.1 in OR KPE 5 Recommendation 3. The KSCB should obtain assurance that the referral pathway to Young People’s Substance Misuse Services is effective and in wide use by professionals. CRI/The Base to provide briefing paper for inclusion on the KSCB website and in a SCR Lessons briefing paper CRI/The Base update: Referral details available on CRI website and other local and national web pages including local authority pages, Voluntary Action Kirklees, Alcohol Concern, Talk to Frank, Facebook and Twitter. All aforementioned training programmes include specific information on referral pathways. Generic referral pathway is to contact The base via phone or drop-in. This sits alongside specific referral pathways in existence between The Base and; CAMHS, CHEWS, YOT, TYS, Connect housing, A and E departments, Kirklees college, LAC private and council residential homes plus foster care, CSE Ongoing work to develop a joint pathway between universal education, TYS and The Base. Ongoing work to develop the existing pathway between Huddersfield University and The Base. Ongoing work in an attempt to increase referrals from A&E departments into young person’s drug and alcohol services. Referral source information and numbers from Sept 2013 to Sept 2014 provided to KSCB as evidence. Further information expected to be available by March 2015. Mar-15 A M B E R May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG Review Date 4 hub and PRU’s. KSCB to put the CRI briefing papers and information regarding referral pathway for professionals onto the website CRI/The Base to provide briefing paper for inclusion in the second SCR Lessons briefing paper Apr-15 A M B E R The Base to provide assurance that there is a clear referral pathway, and also information on numbers referral and agency source CRI/The Base approached for information re referral pathways and referral numbers / agency sources. Information to be included in E&E data collection for ongoing monitoring. Information also to be included in KSCB newsletter and on website. Mar-15 A M B E R SCR 026 / 004 Child Protection Review Unit (CPRU) Finding 2: Mental health and emotional well-being: Holistic health assessment to be available for young people subject to a CP Plan Section 5.1 in OR Recommendation 4. The KSCB should ensure that all adolescents who are subject to a child protection plan for neglect are offered a holistic health assessment which includes their emotional health and A holistic health assessment is to be included within the Child Protection Plan where relevant. IRO’s to monitor at review conference Apr-15 A M B E R May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG Review Date 5 KPE 3 wellbeing. SCR 026 / 005 KSCB All relevant agencies Finding 4. Assessment, planning, intervention, review, contingency arrangements and decision making all need to be more robust. Section 5.4 in OR KPE 2 Recommendation 5. The KSCB should arrange for professionals to be aware of the pitfalls associated with the ‘Start again syndrome’ and remind practitioners of the importance of including previous family histories in assessments, especially in long term neglect cases. KSCB Learning & Development to incorporate in courses content into multi-agency training. To be considered at L&D workstream meeting – April 2015 L&D workstream meeting agenda – April 2015 Courses contents updated: Neglect Safeguarding Skills for Managers Mar-15 G R E E N May-15 KSCB Learning & Development to incorporate in courses content into single agency training To be considered at L&D workstream meeting – April 2015 L&D workstream meeting agenda – April 2015 Courses contents Apr-15 A M B E R Social Care to include in Single Assessment themed briefings week Briefings taken place; Social Care to provide dates and evidence of inclusion of issues. Mar-15 A M B E R To be included in the second learning lessons briefing / newsletter Family histories / start again syndrome / long term neglect to be included in the second learning lessons briefing / newsletter Apr-15 A M B E R May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG Review Date 6 Lessons to be used in KSCB Learning from Reviews Conference planning Conference planned for October 2015 Conference Plan Oct-15 G R E E N SCR 026 / 006 KSCB All relevant agencies Finding 3: Maintaining focus on and engaging with, ‘harder to reach’ young people Section 5.3 in OR KPE 1 Recommendation 6. The KSCB should arrange through the Board to develop and implement a toolkit enabling professionals to engage effectively with ‘harder to engage’ young people. KSCB to coordinate a working party to consider current strategies for working with hard to reach young people and develop an overarching strategy KSCB to contact agencies to form a working group to include TYS / IYSS / ‘Missing in Education’ / The Base/CRI / Social Care / Stronger Families / FIP to identify models for evidence based, best practice to develop a toolkit for use with harder to engage young people Jun-15 A M B E R May-15 SCR 026 / 007 KSCB Education Finding 3: Child focus - School attendance Section 5.3 in OR KPEs 1 & 3 Recommendation 7. The KSCB should seek assurance that there are robust arrangements in place for the timely management of children with school attendance problems. KSCB to request a report from the ‘Missing in Education’ team re numbers involved, actions taken and impact. Report requested Sept 2014. Education provided: CME Policy and Procedures Jan 2014 CME guidance for schools Request e-mail trail Apr-15 A M B E R May-15 Evaluation & Effectiveness (E&E) work-stream to Core Data set ready for data. Mar-15 A M B May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG Review Date 7 incorporate data into the Core Data set for monitoring E R SCR 026 / 008 KSCB All relevant agencies Learning & Improvement Section 7.8 in OR Recommendation 8: The KSCB should endorse the recommendations and action plans of the agencies’ IMRs and obtain assurance: That agency learning is shared with and disseminated widely with staff forthwith. That the KSCB, as part of its learning and improvement agenda, receives regular six monthly reports from agencies on the progress of action plans, dissemination of learning and evidence of the learning having made a difference to the safety and wellbeing of children. Lessons to be incorporated into regular KSCB newsletters and briefings papers. Briefing paper widely circulated to agencies in January 2015; next issue due out in April 2015. Briefing papers incorporate a feedback sheet to provided evidence of how learning has improved practice. Apr-15 A M B E R May-15 Learning and Development workstream to incorporate into multi and single agency training L&D workstream to consider at meeting in April 2015. Learning & Development work stream agenda – 20 April 2015 Apr-15 A M B E R May-15 SCR work-stream to monitor progress of identified actions from recommendations via six monthly Action Plan Review meetings. Action Plans Reviews meetings established in 2014. To take place six monthly and to include SCR w/s members and chairs of other work-streams. Review of this Action Plan will be incorporated into the established process. It will be subject to updates from agencies and review in May-15 and Nov-15 May-15 G R E E N May-15 |
NC52315 | Death of an 8-day-old baby in Summer 2017 following head trauma caused by shaking. Learning includes: maternity services should ensure written records reflect the needs of mother and baby; support plans should be clearly documented to ensure links with early help teams; when significant support is in place for a family it is good practice to hold a professionals' meeting before that support network is closed; maternity services must ensure that there is a full transfer of information in cases where a pregnant mother moves from one area to another; where appointments are missed there should be an effective follow up mechanism; health visitors should follow standard operating procedures when a patient is transferred from one area to another; when a pregnant patient fails to attend appointments, it is critical that these failures are correctly recorded and that a follow up is carried out according to procedures; the need for professionals to have a robust discharge plan for mothers to provide protection and support, including who is responsible; professionals in health and social care need to better understand structures and processes to improve information sharing and joint working. Recommends that the local children's safeguarding assurance partnership should ensure that the learning points raised are subject to a SMART action plan.
| Title: Serious case review: overview report: Sarah. LSCB: Children’s Safeguarding Assurance Partnership Blackburn with Darwen, Blackpool, Lancashire Author: Stephen Ashley Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Overview Report: Sarah Author: Stephen Ashley Date: 11th February 2022 Page 2 of 15 Contents 1. Introduction ............................................................................................................ 3 2. The Story of Sarah................................................................................................ 4 3. Key Themes ........................................................................................................... 11 4. Summary ............................................................................................................... 13 5. Recommendations ............................................................................................. 15 Page 3 of 15 1. Introduction 1.1 This serious case review concerns a child known, for the purpose of this review, as Sarah. In the summer of 2017 when Sarah was eight days old she was at the family home with her parents and older sister. At about 10 pm Sarah’s father says that Sarah woke up crying very loudly. Sarah’s father rocked the Moses basket she was sleeping in, but Sarah remained distressed. Sarah’s mother was upstairs when Sarah had woken up. When Sarah’s mother went downstairs, her father passed Sarah to her mother who noticed that Sarah was floppy and lifeless. Sarah’s father telephoned the local hospital and paramedics arrived at the scene. Sarah was taken to hospital. Despite full resuscitation Sarah was declared deceased at 0006hrs the next morning.
Following a post-mortem, it was established that Sarah had a number of injuries including a fractured leg, the conclusion of the pathologist was that Sarah had died from a head trauma caused by shaking. A police investigation resulted in criminal charges being brought against both parents. In January 2022 they were both convicted of causing or allowing Baby Sarah’s death, two counts of causing or allowing serious physical harm to a child and child cruelty. Sarah’s mother was sentenced to 8 years imprisonment and her father to 10 years imprisonment. Lancashire Safeguarding Children Board (LSCB) agreed this case met the criteria laid down in Working Together 2015 for a serious case review to be conducted. The purpose of this serious case review is to establish the role of services and their effectiveness in the care of Sarah, whether information was fully shared by the professionals involved and child protection procedures were appropriately followed. This process ensures that any deficiencies in services can be identified and lessons learned, to minimise the risk to other children or young people 1.2 The author of this report was Stephen Ashley who has extensive experience in the compilation of high-level reports into child protection issues, having been a senior police officer for thirty years and worked for Her Majesty’s Inspectorate of Constabulary. He has conducted several serious case reviews and has chaired several local safeguarding children’s boards. At the time the review was initiated and written, the author was independent of Lancashire Safeguarding Children Board in accordance with Working Together 2015 chapter 4 (10). However, under the new safeguarding arrangements he has since been appointed as the independent scrutineer for the children’s safeguarding assurance partnership in Lancashire. In addition, a review panel was established. Meetings were held at regular intervals and the panel was consulted about the progress of the review and provided further information where appropriate. The panel included a senior manager from each of the key agencies. The Lancashire Safeguarding Children Board (LSCB) business unit supported the panel. 1.3 The methodology agreed by the Lancashire Safeguarding Children Board (LSCB) review panel is based on a model consistent with the requirements of Working Together 2015. It ensures that: Page 4 of 15 • A proportionate approach is taken to the SCR • it is independently led • professionals who were directly involved with the case are fully engaged with the review process • families are invited to contribute Agencies were asked to compile a report detailing their contacts with the individual involved in this case, resulting in a combined chronology of events. In addition, each agency was asked to highlight areas of concern and good practice. Where appropriate, an action plan, detailing those areas for improvement, and the work being undertaken to address those issues, was included. All the agencies that were asked for a report provided the information requested. In cases where further clarification was required agencies responded in an open and honest way. In some cases, where contact with the subjects was minimal, agencies were only asked to provide a chronology. In addition, interviews with front line staff and managers took place. This review was conducted in parallel with a lengthy police investigation. As a result, learning from the review has been acted upon prior to the final completion of the review. Given the protracted nature of this case, the reviewer was asked to produce a shortened version of his review to ensure an accurate record of the agreed learning would be available and to ensure those learning points had been actioned 2. The Story of Sarah 2.1 This section sets out the facts in this case. It begins with a description of Sarah’s parents and the environment she was born in to. 2.2 Sarah’s father lived in the Greater Manchester area. In 2014 Sarah’s father had reported to his general practitioner (GP) that he was in low mood and had used cannabis since he was 11 years old. Sarah’s father was referred into a drugs team for further help. In 2016 Sarah’s father again reported to his GP that he was depressed and using cannabis and was prescribed anti-depressants. The GP treated him for anxiety and depression and noted that he was also consuming excessive levels of alcohol. Sarah’s father was offered, and signposted to, appropriate support. Throughout the timeframe of this review Sarah’s father sporadically reported low mood and cannabis use. Sarah’s mother had lived in Hampshire for most of her life. Sarah’s mother suffered from cerebral palsy that affected her right side. Sarah’s mother was also an epileptic. Sarah’s mother disclosed that in her teens she had suffered from depression and had self-harmed. There was also some evidence that Sarah’s mother suffered a mild learning disability and was autistic. In March 2016 Sarah’s maternal grandmother (referred to as GM1) had reported to Hampshire Children’s Social Care that her daughter was leaving university to return home as she had become pregnant and that she would need a social worker. A social worker was allocated to her. It is understood that Sarah’s mother had met Sarah’s father on the internet, and he was the prospective father. Page 5 of 15 In May 2016 Sarah’s mother moved to the Greater Manchester area to be with Sarah’s father and registered with the local acute hospital. At this point she was 26 weeks pregnant. No mental health, drug or alcohol issues were recorded. In August 2016 Sarah’s sister was born in a Manchester Hospital. Sarah’s mother and sister were discharged from hospital and received universal services1. There is no record of a plan for supporting Sarah’s mother and her new baby, which given the physical issues she faced might have been expected. Learning Point – The Manchester Hospital maternity services should ensure written records reflect the needs of mother and baby. Support plans should be clearly documented to ensure links with Early Help teams. The health visitor conducted regular visits with the family and did not report any particular concerns. Efforts were made to involve the parents in family support, and they were directed towards the Homestart programme, but they failed to engage. In October 2016 GM1 contacted Greater Manchester Police. She reported that Sarah’s father was controlling her daughter and was “kicking her out”, but would not let her take their 6 week old baby with her. Police attended the home of Sarah’s parents. The couple agreed they had been arguing and they both wished to end their relationship. There were no allegations made by either party and they agreed that they would resolve their issues the next morning. Police officers completed risk assessments but were satisfied there was no risk to Sarah’s mother or sister. The following morning GM1 contacted Children’s Social Care (CSC). GM1 made the same allegations that she had to the police regarding Sarah’s father and his control over her daughter. The matter was dealt with by the Emergency Duty Team (EDT). The appropriate checks were made with the police and health services. There was also a referral made to Adult Social Services due to the issues faced by Sarah’s mother. An Early Help Family Support plan was completed. This plan was comprehensive and contained considerable support for the family. Several home visits were jointly conducted by health visitors and social workers and in each case, comment is made on the positive way Sarah’s mother and father interacted with Sarah’s sister. Information was also appropriately shared with the GP. Outreach workers were allocated, and an Early Help plan was developed. It was established that Sarah’s parents had decided to continue their relationship. At this point the family had an outreach worker and were engaged with two children’s centres. They were also re-referred to the Homestart programme. Whilst there is some confusion, Sarah’s mother and possibly Sarah’s father returned to Hampshire to stay with GM1 for an unknown period. The outreach worker continued to engage with the family. 1 Universal services - Universal Services from the health visitor provides the Healthy Child Programme to ensure a healthy start for children and family (e.g. prompts for immunisations, conducting health and development reviews). The health visitor supports parents and facilitates access to a range of community services/resources and refers to the GP where appropriate. Page 6 of 15 When the family failed to engage, the outreach worker followed up missed appointments. Through until the end of 2016 there was good quality and coordinated support provided to the family. Good practice – Good coordination between agencies resulted in effective support for this family. The outreach worker coordinated the multi-agency response and there was strong evidence of good information sharing. At the beginning of January 2017 Sarah’s mother informed a health visitor that she was pregnant. At the trial of Sarah’s parents, it became clear that the paternal grandparents of Baby Sarah took considerable care of Sarah’s older sister and spent considerable periods living with them because Sarah’s mother was clear with them that she could not cope. It was also established that the parents' relationship was a violent one with violent episodes initiated by both parents. 2.4 The facts of this case 2.4.1 Phase one – Pre-birth engagement with Sarah Initially an outreach worker tried to maintain contact with the family. A Team Around the Family (TAF) meeting was arranged by professionals. However, Sarah’s parents stopped engaging with professionals and began missing appointments. By mid-February 2017 Sarah’s parents stated they no longer required additional support and as a result the additional support provided by the children’s centre was closed. Whilst the GP was informed of this decision it would have been appropriate to discuss the issue with other professionals before closing the case. Learning point – When significant support is in place for a family it is good practice to hold a professionals’ meeting before that support network is closed. At the end of February GM1 alleged to midwives that Sarah’s father was controlling Sarah’s mother and isolating her. A referral was made to the Multi-agency Safeguarding Hub (MASH).2 An unannounced visit was undertaken by a social worker to the family home. Sarah’s sister was seen and there were no concerns raised about the family or their care of Sarah’s sister. A Child and Family Assessment (CAF) was commenced. That assessment was completed in April and there was a recommendation that the case was closed. The social worker stated: “It is the opinion of the social worker that the referral information has been unsubstantiated and no indications of control have been noted. [xx] is particularly isolated due to the impact of her reduced mobility has when living in a first floor flat and due to this the family would benefit from a house move, which would enable [xx]’s access to the property to improve. [xx] and [xx] have an allocated health visitor and midwife who are aware of [xx]’s low mood and will continue to monitor [xx]’s mood.” By the time this assessment was completed Sarah’s parents had moved from Greater Manchester to Lancashire and her case had been transferred. The correct process was followed in completing 2 Multi-agency Safeguarding Hub (MASH) - The Multi-Agency Safeguarding Hub (MASH) is the single point of contact for all professionals and members of the public to report safeguarding concerns. Page 7 of 15 a detailed CAF. The social worker had received appropriate supervision and support and there was clear evidence of liaison with midwifery and health visiting professionals. The case was transferred to a Lancashire midwifery service. Whilst the transfer was correctly conducted some important paperwork was not completed. This included the social needs assessment and the psychological profile of Sarah’s mother. The midwife asked Sarah’s mother to book antenatal appointments, but it would have been more appropriate for the midwife to have done this. In fact, Sarah’s mother was thirty-eight weeks pregnant before she attended the community antenatal clinic. Learning point – Lancashire maternity services must ensure that there is a full transfer of information in cases where a pregnant mother moves from one area to another. It is critical that where appointments are missed there is an effective ‘follow up’ mechanism. At the beginning of April GM1 contacted the midwifery service to again raise concerns about Sarah’s father and the fact that he controlled Sarah’s mother. The hospital safeguarding team were informed and a request for information made with a Lancashire Children’s Social Care team. The safeguarding team established that there were no ongoing concerns but noted the previous complaints. At this point the CAF completed in the Greater Manchester area had been received and that provided the information to support the view that no further action was required at this point. By the beginning of May the case had been closed to the Greater Manchester children’s social care team and transferred to Lancashire. At this time an ‘orange alert’ form was raised by midwives. This form highlights that the case needs added attention and is used and monitored by the safeguarding team. On receipt of the medical records by the health visiting team the standard operating procedures require that the health visitor makes contact with the previous health visitor. This does not appear to have taken place. It also requires that a home visit takes place within 10 days, which did not occur. Learning Point – Health visitors should follow standard operating procedures when a patient is transferred from one area to another. During May, Sarah’s mother failed to attend any of the appointments that she had been given. Whilst plausible reasons were given by Sarah’s mother there is concern around the way in which these ‘failed to attend’ (FTA) incidents were recorded. In essence when an FTA incident occurred there was no system to ensure follow up. This has now been rectified and a more robust process is in place. At the beginning of June, Sarah’s mother failed to attend another appointment and the only ‘follow up’ was by way of telephone. Guidance is clear that a home visit should have taken place. Page 8 of 15 Learning point – When a pregnant patient fails to attend appointments it is critical that these failures are correctly recorded and that a ‘follow up’ is carried out according to procedures. In this case some of the policies and procedures in place were not sufficiently robust and should be strengthened. By the middle of June, Sarah’s mother should have been seen for a twenty eight week check, a growth scan at thirty two weeks and a thirty four week check. In fact, Sarah’s mother had not been seen since she had been twenty two weeks pregnant. At this point midwives and health visitors were engaged in exchanging information, but there still appears to be little physical contact with Sarah’s mother or sister. In mid-July Sarah’s mother was seen at an ante-natal clinic. There was a record made that Sarah’s mother was having mobility issues. It was agreed that Sarah’s mother would give birth by way of a pre-planned caesarean section. At this time Sarah’s mother had not had any ante-natal care for fourteen weeks. Whilst it was noted that she had mobility issues there appears to have been no consideration as to whether she would be able to care for her baby. At this time professionals dealing with Sarah’s mother knew of her physical and mental issues. They were aware of complaints around domestic abuse and that Sarah’s father also had mental health issues and abused cannabis. No consideration appears to have been given to a further referral to CSC. If a referral had taken place, and pre-birth protocols regarding child protection followed, a strategy meeting would have been called and a more formal process of providing support and protection provided. Learning point – By mid-July health visitors and midwives were aware of the physical and metal issues faced by Sarah’s mother. They were also aware of the issues previously reported in the relationship between Sarah’s parents. A referral to CSC should have been considered at this point. Sarah’s parents attended hospital at the beginning of August reporting reduced foetal movement and a few days later Sarah was born by caesarean section. 2.4.2 Phase two – Post birth engagement with Sarah The day after Sarah’s birth GM1 again spoke to midwives. GM1 gave specific details of abuse suffered by Sarah’s mother from Sarah’s father. This included threatening texts and descriptions by Sarah’s mother that he had threatened to kill her. GM1 had telephone evidence of the abuse (a screenshot of her phone). GM1 was told to contact the police. The hospital safeguarding team discussed the matter with GM1. The team also sent a risk assessment document to the midwife for completion. They advised GM1 to inform CSC and the police. They also considered making a ‘Clare’s Law’3 application. 3 Clare’s Law - The Domestic Violence Disclosure Scheme (DVDS), also known as “Clare's Law” enables the police to disclose information to a victim or potential victim of domestic abuse about their partner's or ex-partner's previous abusive or violent offending. Page 9 of 15 The midwife asked Sarah’s mother about domestic abuse, but she stated her autism often made her angry and she would then cause arguments. Sarah’s father and GM1 also had a discussion at this time to resolve issues. No referral was made to either adult’s social care or CSC at this point. There was evidence that Sarah’s mother was having mobility issues while in hospital. The midwife raised a number of concerns including the fact that Sarah’s mother suffered from epilepsy, cerebral palsy and autism. In addition, it was noted that Sarah was the second child and the older sibling was not yet one year old, which brought additional pressures given Sarah’s mother has little family support in the area (GM1 lives in Hampshire). Concerns about potential domestic abuse were also raised. It became clear during the parents’ criminal trial that Sarah’s sister was being cared for by paternal grandparents. Two days after the birth of Sarah her father asked for mother and baby to be allowed home and stated he did not want any carers. The safeguarding team made a Child in Need referral to CSC and asked Sarah’s mother about domestic abuse, but she declined to talk about it. A referral was also made to the specialist nurse for learning disabilities. It was unknown by professionals at this time that Sarah’s parents had asked paternal grandparents to take Baby Sarah from them and care for her in Manchester; they refused to do this as would be expected but continued to care for Sarah’s sister. Learning Point – Two days after the birth of Sarah there was no referral to either CSC or ASC. No risk assessment had been completed regarding the potential domestic abuse of Sarah’s mother by her partner or the risks to Sarah. There appeared to be no discharge planning at this point. The case at this point lacked ‘grip’ by professionals who could and should have had a robust plan in place to provide protection and support. Later the same day Sarah’s mother agreed to the referral to adult’s social care, regarding a carer, and the midwifery team also considered a discussion with the hospital adult safeguarding team. The following day a referral was made to CSC. The referral is detailed. A social worker was allocated and attempted to make contact with the hospital. Despite several attempts this was unsuccessful and eventually the social worker made contact with the health visitor. The health visitor stated that she had never met the family and although she had attempted to visit on a number of occasions the family were “never in”. The social worker reports the following in her response to the referral: “[health visitor] stated that there are no safeguarding concerns raised other than the third party report from maternal grandmother that there was DV in the relationship. I advised that mother's health needs needed to be assessed by Adult Social Care as there was nothing to suggest mother was meeting needs and nothing to suggest that father, could not meet his children's needs. I advised [health visitor] that at this time this did not meet threshold for CSC intervention.” Learning point – This shows poor communication between health and the social worker. The social worker made contact but only spoke to a health professional who had had no contact with the family. The social worker correctly identified that Sarah’s mother needed to be assessed by ASC, but because she was unable to speak to the most relevant health professionals. The case should not have been closed without further work. Professionals in health and social care need to better understand structures and processes to improve information sharing and joint working. Page 10 of 15 Sarah’s mother was discharged from hospital. There appears to have been no discharge plan. It is not apparent that professionals understood what support Sarah’s mother was going to receive or whether she was capable of looking after her children. None of the issues raised whilst Sarah’s mother had been in hospital had been resolved. In fact Sarah’s father had demanded the release of Baby Sarah and her mother and was so insistent that security officers were called to the ward to calm him down. Learning point – Information sharing was poor at this stage, no plan was in place to support Sarah’s mother and her children and it was unclear whether domestic abuse issues were resolved. A complete discharge plan should have been in place, and it should have been clear who was taking responsibility to support Sarah’s mother and protect her and her children. CSC and ASC should have been engaged at this stage. Over the following three days visits were made to the family home. There was no reply on any occasion. Community midwives left cards and attempted phone calls without response. Four days after Sarah’s mother and Sarah were discharged from hospital a midwife gained access to the home. This was the first visit by a medical practitioner to the family home. The midwife did not document the visit that day but was contacted by the hospital safeguarding team the following day. The midwife reported that a referral had been made to ASC but CSC had stated the case was closed to them. However, the social worker contacted the police and asked them to conduct a Cause for Concern’ visit. This was very good practice by the community midwives and social worker who did everything they could to gain access to the home. A visit was conducted by the police who were informed by Sarah’s mother that there were no issues. Sarah’s sister was not present at home and was being cared for by grandparents. No further action was taken by the police. The visit took place in the early evening. At 11.00pm that day an ambulance was called to the address as Sarah was unresponsive. Sarah was taken to hospital where she sadly died. Following the death of Sarah, a joint home visit was conducted. The professionals who attended noted that the home was in poor condition stating it was; “dirty, cluttered, untidy and chaotic” and there were possible unsafe sleeping issues in that all of the family appeared to be sleeping in a double bed. As a result of the injuries identified to Sarah, both Sarah’s parents were arrested and a police investigation commenced. Learning point - Sarah’s mother and Sarah were discharged from hospital with no plan by professionals as to how the baby and Sarah’s mother were to be supported and protected. Despite the high risk nature of the case no risk assessment was conducted. There were clear risks that Sarah may be at risk of suffering significant harm, but no strategy meeting took place and CSC were not engaged with the family. There were clear issues around information sharing. No agency took the lead and no escalation took place when concerns by some professionals were ignored. Systems designed to protect children and vulnerable adults were not used by professionals. Page 11 of 15 3. Key Themes 3.1 The application of pre-birth protocols In this case a significant level of support had been provided to Sarah’s parents. This included a significant Early Help package. Professionals had identified that the mental and physical issues facing Sarah’s mother and the mental health issues facing her father would cause potential difficulties in the care of Sarah. This care package remained in place until Sarah’s parents disengaged. When the family moved to Lancashire their records were transferred but there was some confusion regarding where the family were living. On initial booking a number of standard assessments were not completed and GM1 made allegations regarding domestic abuse. This prompted the use of an ‘Orange Alert’ form to raise the profile of the case and ensure that information was properly shared. As Sarah’s mother progressed through the pregnancy she missed appointments on a regular basis, and these were not followed up. By July 2017 there had been no home visits and limited understanding by professionals of Sarah’s mother and the level of competence she had to care for two babies. By June 2017 professionals should have understood the risks to this family. Whilst reports about the first pregnancy and birth in Greater Manchester had been largely positive, professionals had assessed the risks and needs of the family and as a result put in place a comprehensive Early Help programme. On arrival in Lancashire a social needs assessment and a psychological assessment should have been conducted. These documents would have alerted professionals to the apparent needs of this family. Some professionals did understand that there were risks associated with the family and raised an ‘Orange Alert’. It is unclear what effect this had. In May 2017 when Sarah’s mother was five months pregnant the following facts were known: Sarah’s mother had cerebral palsy, epilepsy, mild learning difficulties and was autistic. Sarah’s mother had previously suffered from mental health issues. Sarah’s father had been a cannabis user and had alcohol issues and been treated on numerous occasions for depression and mental health issues. GM1 had made allegations on several occasions that Sarah’s mother was subjected to domestic abuse. During her first pregnancy, and following the birth of her first baby, the family had required significant Early Help support. In addition, it was unclear what the position was regarding housing and the permanency of their future arrangements. There were factors that mitigated the apparent risks. Most notably that professionals in Greater Manchester were positive about the relationship between Sarah’s mother and her baby. There had been no reports suggesting that Sarah was at risk of physical abuse and formal child protection procedures had never been considered. Page 12 of 15 Lancashire Safeguarding Children Board agreed a new pre-birth protocol in March 20174. This built on a previous protocol published in October 2012. This document clearly and simply lays out for professionals the path to be followed where there are concerns about a family prior to the birth of a child. The concerns and circumstances for Sarah and family met the criteria of several examples within the Pre-Birth Protocol where a pre-birth assessment should have been considered. The protocol lists 34 risk factors that might initiate a multi-agency response and 13 of those factors applied in this case. The document also lists protective factors that would mitigate the risk. There are 25 mitigating factors listed of which only 2 would have applied in this case. No consideration was given to the use of pre-birth processes, despite all the known issues. If a pre-birth assessment process had been commenced a meeting of all professionals involved would have been convened enabling the sharing of information and risks. Unfortunately, the pre- birth assessment process for Sarah was not instigated and consequently the multi-disciplinary assessment and planning did not take place. 3.2 Support for mothers with disabilities Sarah’s mother suffered from cerebral palsy, epilepsy and had a mild learning disability and autism. There appears to have been no consideration given to her special needs during her pregnancy. Following the birth of Sarah, a specialist nurse dealing with learning disabilities was available and there was consideration given to contacting that nurse. A referral was made to Children’s Social Care and Adult’s Social Care but the only health professional that was spoken to was a health visitor who had not had contact with the family and had not visited the family home. In fact, the referral was made by nurses at the hospital who had identified that Sarah’s mother had mobility issues. The health visitor was advised that there was nothing more CSC could do and that these two professionals concluded that Sarah’s parents were able to meet the needs of Sarah. Sarah’s mother received disability allowance and Sarah’s father was receiving a carer’s allowance. It was known that the family’s housing situation was unstable, and they might be moving, but it is not clear whether there was any consideration as to the suitability of their accommodation. A social needs assessment was not completed. That document lists pathways that health professionals should follow and if it had been completed would have led to referrals for additional support. Sarah’s mother had clear and identified disabilities and these were not properly assessed, and the correct levels of support were not offered to the family. 4 The protocol was updated again in November 2021 - http://panlancashirescb.proceduresonline.com/pdfs/multi-agency_prebirth_protocol.pdf?zoom_highlight=pre+birth#search="pre%20birth Page 13 of 15 3.3 Hospital discharge procedures Sarah’s mother and Sarah were discharged from hospital with no plan by professionals as to how the baby and Sarah’s mother were to be supported and protected. Despite the high risk nature of the case no risk assessment was conducted. There were clear risks to Sarah but no strategy meeting took place and CSC were not engaged with the family. There were clear issues around information sharing. No agency took the lead, and no escalation took place when concerns by some professionals were ignored. Systems designed to protect children and vulnerable adults were not used by professionals. 3.4 Information sharing There are numerous examples throughout this case of failures in information sharing. Whilst the transfer arrangements between Greater Manchester and Lancashire worked well there is little evidence that agencies worked together. As a result, hospitals, health visitors, midwives, children’s social care and adult’s social care acted in isolation and failed to ‘join the dots’. No agency took a lead to produce a picture of the family and how it was coping. Despite the warning signs and several alerts by GM1, no single agency identified the full risk posed by the parents of Sarah to her and her sister. This case was complicated by the fact that care of the family was spread over three very different areas, but by the time Sarah was born there had been sufficient engagement to build a picture of the family. Professionals had sufficient information to determine whether the parents could cope with a second child joining the family unit, and what support they would need to do this effectively. 4. Summary This case involved a family who had numerous issues that meant they required considerable support from a range of agencies. The parents of Sarah were assessed on several occasions and support was put in place. In fact, there was considerable help made available to the couple and their first child, although their use of this support was sporadic. GM1 made at least four direct complaints to the police and children’s social care about Sarah’s father and allegations of domestic abuse. On one occasion her concerns were supported by evidence. On each occasion professionals responded and visited the family. On no occasion could they substantiate allegations made by GM1 and Sarah’s mother refuted the allegations and made no complaints herself. GM1 did not make any allegations regarding any risks to the children and confined her complaints to the controlling behaviours and threats made by Sarah’s father. Professionals responded to each concern raised by GM1. Whilst professionals did not appear to have sufficient evidence to act on these complaints at the time they were made they should have, taken together, been sufficient to raise the profile of this case in the eyes of safeguarding professionals. In fact, only once did these complaints result in action (the raising of an ‘orange alert’) by professionals. Page 14 of 15 This review has demonstrated that professionals need to radically improve their information sharing. This review has also demonstrated that professionals acted in isolation or without vital pieces of information. In particular, the various alerts raised about the family tended to be dealt with in isolation and as a result professionals failed to coordinate their response and provide all the support that was required. Pre-birth protocols need to be strictly adhered to and more work needs to be undertaken to ensure professionals understand the needs of a new mother suffering with disabilities. In this case Sarah and her mother left hospital without an effective and holistic plan in place, and the professionals failed to ensure that the correct level of support was in place prior to Sarah’s discharge from hospital to enable her to look after her children given her disabilities. This case has highlighted several areas for improvement. They are; • Information sharing • Use of escalation procedures • Understanding transfer arrangements for pregnant mothers from one district to another • The use and understanding of pre-birth protocols • The use of discharge plans for new mothers • Understanding leadership and case management by front line professionals • Understanding the needs of new mothers who have disabilities • Professional understanding of referral processes • Professional understanding of the use of child protection processes • Professionals’ ability to ‘join the dots’ by working closely with other safeguarding professionals and agencies Professionals did not have any clear evidence that Sarah and her sister were at risk of physical abuse by their parents. Interaction between Sarah’s older sister and parents had always been viewed as positive by professionals. Parents had successfully hidden from professionals their inability to care for Sarah’s sister and that paternal grandparents had filled the gaps in parenting. GM1 made several complaints about the controlling nature of Sarah’s father but did not suggest he was violent towards Sarah’s mother or sister. If safeguarding procedures had been followed, and professionals had shared information, there could have been a better programme of support in place for the family. Child protection procedures may have been put in place. Professionals could not have foreseen that Sarah was at risk of her parents allowing or causing her death. The responsibility for the death of Sarah lies with her parents. Page 15 of 15 5. Recommendations Given the protracted nature of this case agencies have already undertaken work to resolve issues raised in this review. There is only one recommendation. Recommendation 1: The Children’s Safeguarding Assurance Partnership should ensure that the learning points raised in this review are subject to a SMART action plan. SCR Overview Report – Sarah - February 2022 |
NC043719 | Death of a 22-month-old boy in June 2010. BDS was found at home with his mother and father, who had died from stab wounds. BDS was taken to hospital, with 16 stab wounds, where he later died. Inquest found that BDS and mother had been unlawfully killed and that father had taken his own life. Father experienced deteriorating mental health in the period between BDS' birth and death. Father had significant contact with agencies and was detained under the Mental Health Act 1983 a number of times. Despite their separation mother supported father in accessing services and periodically allowed him to stay with her; at times acting as an informal carer. Mother raised concerns with family and agencies regarding father's behaviour and did not leave BDS unsupervised with father. The week before the incident mother reported to the police that father had made death threats. This followed father's learning about mother's new relationship and pregnancy. Identifies learning from the review, including: lack of focus on the needs and development of BDS from professionals working with Father; and insufficient recognition of the impact on mother of caring for father. Recommendations include: improved needs assessment for informal carers who provide support to people with mental health problems, particularly where children are involved.
| Title: Overview report: serious case review in respect of a child: BDS 10 LSCB: Derbyshire Safeguarding Children Board Author: Chris Few Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. OVERVIEW REPORT SERIOUS CASE REVIEW IN RESPECT OF A CHILD BDS 10 Born 15 July 2008 Deceased 2 June 2010 White British Chris Few July 2011 (Revised January 2014) CONTENTS INTRODUCTION 1 Introduction 2 Summary of Circumstances Leading to the Review 3 Terms of Reference 4 Review Methodology 4.1 Serious Case Review Panel Chair 4.2 Independent Author 4.3 Serious Case Review Panel 4.4 Review Process 4.5 Parallel Processes 5 Contributions to the Review 5.1 Individual Management Reviews 5.2 Health Overview Report 5.3 Summary Reports 5.4 Other Sources 5.5 Family Engagement OVERVIEW OF AGENCY INVOLVEMENT 6 Geographic and Service Context 6.1 County Context 6.2 Health Service Commissioning 6.3 Health Visiting 6.4 Mental Health Services 6.5 Care Programme Approach 6.6 Derbyshire Constabulary 7 Family Background 7.1 Genogram 7.2 Father 7.3 Mother 7.4 BDS 8 Agency Involvement 8.1 Integrated Chronology 8.2 December 2007 to September 2008 8.3 October 2008 to 21 December 2008 8.4 22 December 2008 to 9 February 2009 8.5 10 February 2009 to 20 August 2009 8.6 21 August 2009 to 31 October 2009 8.7 1 November 2009 to 25 May 2010 8.8 26 and 27 May 2010 8.9 28 to 31 May 2010 8.10 1 and 2 June 2010 ANALYSIS 9 Analysis of Agency Involvement 9.1 December 2007 to September 2008 9.2 October 2008 to 21 December 2008 9.3 22 December 2008 to 9 February 2009 9.4 10 February 2009 to 20 August 2009 9.5 21 August 2009 to 31 October 2009 9.6 1 November 2009 to 25 May 2010 9.7 26 and 27 May 2010 9.8 28 to 31 May 2010 9.9 1 and 2 June 2010 9.10 Diversity Issues CONCLUSIONS AND RECOMMENDATIONS 10 Predictability 11 Preventability 12 Learning Themes 13 Learning from previous Serious Case Reviews 14 Learning from the Individual Management Reviews 15 Focus on the Child 16 Mental Health 17 Support for Carers 18 Risk Assessment 19 Response to Domestic Abuse Incidents involving Children 20 Information Management 20.1 Information Gathering 20.2 Documentation 20.3 Information Sharing 21 Recommendations APPENDICES A Terms of Reference B Genogram C Integrated Chronology D Family Engagement Summary E Agency Individual Management Review Recommendations F Derbyshire Mental Health Services NHS Trust Service Structure and Remit INTRODUCTION 1 Introduction 1.1 The Local Safeguarding Children Board Regulations, 2006, require Local Safeguarding Children Boards to undertake reviews of serious cases. Working Together to Safeguard Children (2010) provides statutory guidance on the criteria for undertaking such reviews and on how they should be conducted. 1.2 A Local Safeguarding Children Board should always undertake a Serious Case Review when a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the child’s death. 1.3 The purpose of a Serious Case Review is to: Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and Improve intra- and inter-agency working and better safeguard and promote the welfare of children.1 1.4 Serious Case Reviews are not inquiries into how a child died or who is culpable. That is a matter for the Coroners and criminal courts, respectively, to determine as appropriate. Nor are Serious Case Reviews part of any disciplinary inquiry or process relating to individual practitioners. 2 Summary of Circumstances Leading to the Review 2.1 BDS was the only child of Mother and Father. He lived with his mother and had regular contact with his father. 2.2 On the morning of 2 June 2010 Police Officers were called to the home address of BDS where they found the bodies of Mother and Father, who had apparently died from stab wounds. BDS had also sustained stab wounds and was conveyed to hospital by ambulance. He was pronounced dead by clinicians shortly after his arrival at the hospital. 2.3 The death of BDS was treated as murder by Derbyshire Constabulary although no-one outside of those who died was sought in connection with the killing. 2.4 The Derbyshire Safeguarding Children Board (DSCB) Serious Case Review Committee considered the circumstances of BDS’s death on 11 June 2010. On the basis that a child had been a victim of homicide2 they recommended 1 Working Together to Safeguard Children (2010) 8.5 2 Working Together to Safeguard Children (2010) 8.9 to Bruce Buckley, the Chair of the DSCB, that a Serious Case Review be conducted. That recommendation was endorsed on 16 June 2010. 2.5 An Inquest was held by HM Coroner in September and October 2013. The jury decided that BDS and Mother had been unlawfully killed and that Father had taken his own life. 3 Terms of Reference 3.1 Terms of Reference for the Review were agreed by the DSCB in accordance with Working Together to Safeguard Children (2010) paragraph 8.20. 3.2 The full Terms of Reference are reproduced as Appendix A to this report. 3.3 In addition to the purposes of a Serious Case Review outlined above it was explicitly stated that the review should establish whether the death of BDS was predictable and / or preventable. 3.4 The subjects of the review are: BDS10 (Child) Born 15.7.08 Mother Born 1971 Father Born 1966 3.5 The Review covers in detail the period from the conception of BDS to 2 June 2010. Relevant information outside of this period is included in summary form. 3.6 At the outset of this Review the Serious Case Review Committee recognised that an immediate review of the arrangements for responding to domestic violence incidents involving children was required. Derbyshire County Council Children and Younger Adults Department, Derbyshire Constabulary, Derby City Children and Young People’s Services Department, NHS Derbyshire County, Derbyshire Community Health Services and NHS Derby City were commissioned to undertake this in parallel with the Serious Case Review. 4 Review Methodology 4.1 Serious Case Review Panel Chair 4.1.1 The Serious Case Review Panel was independently chaired by Sue Richards; Head of Service Children’s Quality Assurance, Derby City Council. Sue Richards is experienced in Serious Case Reviews and chaired the Panel as part of a reciprocal arrangement with Derby City Children and Young People’s Services Department. 4.2 Independent Author 4.2.1 Chris Few was appointed to write this Overview Report at the outset of the Serious Case Review. He has attended all meetings of the Serious Case Review Panel. 4.2.2 Mr Few works independently as a safeguarding children consultant and as Independent Chair of a Local Safeguarding Children Board. His background as a Police Officer includes safeguarding children policy development as well as leadership of child abuse investigation functions and homicide enquiries. He has chaired Serious Case Review Panels, undertaken agency management reviews and prepared overview reports for a number of Local Safeguarding Children Boards and their partner agencies. He has not previously been involved in a Serious Case Review in Derbyshire and has no personal or professional connection with any agency in that county. 4.3 Serious Case Review Panel 4.3.1 The following individuals comprised the Serious Case Review Panel for this Review: Sue Richards (Serious Case Review Panel Chair) Head of Service Children’s Quality Assurance, Derby City Council Supporting People Manager Derbyshire County Council commissioner of services from Amber Trust Assistant Director, Children and Younger Adults Services Derbyshire County Council, (Represented by Deputy Assistant Director) Assistant Director, Quality& Integrated Governance Derbyshire Community Health Services Detective Chief Inspector Derbyshire Constabulary Director of Clinical Quality and Nursing NHS Derbyshire County (Represented by Designated Doctor) Head of Patient Safety & Deputy Director of Nursing and Quality Derbyshire Mental Health Services NHS Trust (Now known as Derbyshire Healthcare NHS Foundation Trust) 4.3.2 All meetings of the Serious Case Review Panel were also attended by the Independent Author 4.4 Review Process 4.4.1 A briefing meeting of the Individual Management Review (IMR) authors was held on 28 June 2010. 4.4.2 Following submission of Individual Management Review (IMR) reports meetings of the Serious Case Review Panel were held on: 17 August 2010 22 October 2010 26 November 2010 27 January 2011 2 March 2011 5 April 2011 4 July 2011 4.4.3 On 21 December 2010 the Independent Author met with the author and commissioner of the Derbyshire Constabulary IMR to clarify content of that agency’s IMR, its interpretation and analysis. 4.4.4 On 21 December 2010 the Independent Author and DSCB Strategy Officer also met with the author of the Derbyshire Mental Health Services NHS Trust IMR and by teleconference with the Executive Director of Nursing and Quality for the Trust who had chaired their internal review. This meeting was to clarify content of that agency’s IMR, its interpretation and analysis. 4.4.5 During the review process the submission of IMR reports which were acceptable to the Serious Case Review Panel was, in some cases, delayed by the process of reconciling these with other parallel processes and the requirements of one agency’s internal governance arrangements. In May 2011 the DSCB also commissioned independent legal advice. The planned completion date for the Serious Case Review was accordingly deferred on three occasions by the DSCB and Ofsted were notified. 4.4.6 The Overview Report was presented to the Derbyshire Safeguarding Children Board and signed off on 12 July 2011. The Independent Chair of the DSCB at that date was Lynn Harris. 4.4.7 Following the Inquest verdict in October 2013 this report was reviewed by the Independent Author and amendments made to take into account those proceedings. In a small number of cases there was divergence, mainly on matters of interpretation, between information provided to the Review and that given to the Inquest; For these recourse was first made to contemporaneous records and where this did not provide a resolution, evidence given on oath was regarded as definitive. 4.5 Parallel Processes 4.5.1 This Serious Case Review has been conducted in parallel with a number of other review processes: NHS Derbyshire County Review of Primary Care management of Father. Derbyshire Mental Health Services NHS Trust Internal Investigation into the Care and Treatment provided to Father. Ref: 2010/66773. 3 Derbyshire Mental Health Services NHS Trust anticipates that an independent review will also be commissioned by the Strategic Health Authority under DoH HSG 94/27. That has not to date been commissioned. Independent Police Complaints Commission Investigation 010/010331. DSCB commissioned multi-agency review of arrangements for responding to domestic violence incidents involving children (see 3.6). 5 Contributions to the Review 5.1 Individual Management Reviews Individual Management Review (IMR) reports were provided by: 5.1.1 Amber Trust Amber Trust is a registered charity which provides support for people with mental ill health to live successfully in their local communities. It employs approximately 35 staff members in Derbyshire. Amber Trust provided Father with support from the 30 March 2009 until 2 June 2010 in connection with his tenancy of a property let by the local housing office. 5.1.2 Derbyshire Community Health Services (DCHS) Derbyshire Community Health Services (DCHS), during the period covered by this review, was the provider of community health services for NHS Derbyshire County (PCT). The organisation provided health visiting services to BDS and his family from the time of BDS’s birth until his death. The organisation also managed the local Minor Injuries Unit accessed by Mother in January and May 2010. 5.1.3 Derbyshire Constabulary Derbyshire Constabulary first became aware of the family consequent to Father reporting to Surrey Police that Mother was missing in October 2008. Subsequent direct involvement was in: o October and December 2008 when Mother sought assistance to address Father’s behaviour; o May 2009 when Father was arrested for theft; o August 2009 when assistance was provided in relation to Father’s welfare; o May 2010 when Mother reported problems with Father. The last contact was in connection with the incident on 2 June 2010 leading to this Review. 5.1.4 Derbyshire County Council, Children and Younger Adults Services (Referred to in the body of this report as Children’s Social Care) Derbyshire County Council, Children and Younger Adults Services provide statutory children’s social care services in Derbyshire County. They received information from Surrey County Council in connection with Father having reported Mother and BDS missing to the Police. They also received a referral from Derbyshire Constabulary regarding threats by Father to kill Mother at the end of May 2010. No services were provided and the only contact with family members was one telephone call to Father in October 2008. 5.1.5 Derbyshire Mental Health Services NHS Trust (DMHS) Derbyshire Mental Health Services NHS Trust (DMHS) provides mental health services to Derbyshire County and Derby City. The Trust provided mental health services to Father from April 2008 until his death. They also had contact with Mother in her role as providing support and care for Father and occasional contact with BDS when he was present with Mother. The IMR was informed by an internal investigation into the care and treatment of Father commissioned by DMHS in parallel with this review. 5.1.6 NHS Derbyshire County – GP services For most of the period under review BDS and his parents were all registered at and received primary heath care from one large GP Practice. The IMR was informed by an investigation undertaken by the Medical Director of NHS Derbyshire County (PCT), into the primary care management of all three individuals. 5.1.7 Royal Derby Hospital NHS Foundation Trust (RDH) Royal Derby Hospital NHS Foundation Trust (RDHFT) is an acute NHS Trust, serving the population in and around South Derbyshire. The Trust provided antenatal care to Mother during both of her pregnancies together with midwifery and routine post natal care in connection with the birth of BDS. They also received BDS and attempted resuscitation on the day that he died. The Trust also had one contact with Father when he attended the Adult Emergency Department with mental health issues in August 2009. 5.2 Health Overview Report - NHS Derbyshire County - 5.2.1 A Health Overview Report was prepared in accordance with Working Together to Safeguard Children (2010). 5.2.2 Compilation of the report was assisted by a meeting on 26 July 2010 convened by the Designated Doctor, to which all health community IMR authors were invited. 5.3 Summary Reports Summary factual reports were submitted by: 5.3.1 Derbyshire Health United (DHU) Derbyshire Health United provides of Out of Hours GP services in Derbyshire County and Derby City. They had telephone contact with Mother on four occasions when she sought assistance in relation to the mental health of Father. 5.3.2 East Midlands Ambulance Service (EMAS). On 2 June 2010 EMAS staff confirmed that Mother and Father were dead, attempted resuscitation of BDS and conveyed him to hospital. EMAS had previously conveyed Father to hospital in August 2009 after being contacted by the Police. 5.3.3 NHS Direct NHS Direct provided telephone advice to Mother regarding a hand injury in January 2010. 5.4 Other Sources 5.4.1 Other documents and sources which informed the Review were: Internal Investigation into the Care and Treatment Provided to Father by Derbyshire Mental Health Services NHS Trust – Ref: 2010/6677. Independent Police Complaints Commission Investigation Report 2010/010331. Derbyshire Constabulary Life at Risk Policy (June 2008). FAX Transmission of Section 17 Child Referral, Ref: 6456/10. Derbyshire Constabulary Domestic Violence Policy (February 2008). Domestic Abuse and Safeguarding Children Protocol Between Derbyshire County Council, Derby City Council, Derbyshire Constabulary, NHS Derbyshire County and NHS Derby City. Derbyshire Mental Health Service NHS Trust Visiting Policy / Child Visiting Procedures (December 2005). Derbyshire Mental Health Services NHS Trust Discharge and Out of Contact Policy and Procedure (October 2008). Telephone interview with Kate Howard, Independent Counsellor by the Independent Author on 20 January 2011. Meetings with members of BDS’ extended family as outlined in this report. Progress Report dated 8 February 2010 by the DSCB Strategy Officer on revising arrangements for the management of Domestic Violence referrals. 5.5 Family Engagement 5.5.1 The extended families of Mother and Father were informed that this Review was taking place at its outset. They were subsequently contacted by the Independent Author and offered the opportunity to contribute to the Review. It was agreed with them that this would be most productive once an initial narrative of events had been established following receipt of the IMR reports. 5.5.2 Family members were recontacted at the beginning of November 2010 and took up the opportunity to meet with the Independent Author and the Strategy Officer of the DSCB. The new partner of Mother was similarly met with at that time. 5.5.3 Information provided by the extended family has been incorporated into and considerably informed the content of this report. A summary of the family members’ perspective on the events leading to the Review is provided at Appendix D. 5.5.4 The Independent Author is extremely grateful to them for their time and the openness of their contribution to the Review. 5.6 As part of planning by the DSCB for the publication of this Review arrangements will be made for family members to receive feedback on its outcome. OVERVIEW OF AGENCY INVOLVEMENT 6 Geographic and Service Context 6.1 County Context 6.1.1 Derbyshire is a geographically large, diverse county with deprived urban and ex mining communities, and also affluent areas, particularly in the more rural west, but where there may be hidden deprivation and isolated hard-pressed farming communities. The health of people in Derbyshire is generally better than the England average, including many children’s indicators. 6.1.2 The tragic event which led to this Serious Case Review took place in a small, quiet rural Derbyshire village. The proportion of children living in poverty in that area is lower than the average for England. 6.2 Health Service Commissioning 6.2.1 Health services for Derbyshire, excluding Derby City, are commissioned by NHS Derbyshire County from a number of provider organisations and NHS Trusts. 6.3 Health Visiting 6.3.1 Health Visiting services are currently commissioned from the provider arm of the PCT, Derbyshire Community Health Services (DCHS). These services are generally provided by professionals co-located with GPs at their surgeries. 6.3.2 Health Visitors have traditionally provided their service in the family home setting. DCHS guidelines4 however state that developmental reviews will only be undertaken in the child’s home if need is identified. This is in line with many other areas of the UK where home visits by Health Visitors are now targeted only to those families with the highest needs, which would not include the family subject to this review. 6.4 Mental Health Services 6.4.1 Mental Health Services are commissioned from Derbyshire Mental Health Services NHS Trust (DMHS). The organisation structure of relevant services provided by the Trust is provided at Appendix F to this report. 6.5 Care Programme Approach 6.5.1 DMHS operates the Care Programme Approach (CPA) as the principal vehicle of care assessment and planning for individuals receiving mental 4 DCHS Corporate Working Best Practice Guidelines (2009) health care. This is a person centred, whole systems approach to care planning and delivery across the individual’s life domains, including housing, employment, leisure, education and other needs. 6.5.2 The CPA operates on a partnership basis to deliver an agreed plan of care. The partnership must, as a minimum, include the service user, any carers and the CPA Care Coordinator. It should also include working relationships with other health and/or social care professionals and relevant organisations. 6.5.3 The Care Co-ordinator’s core functions are to carry out a comprehensive needs assessment; risk assessment, crisis planning and management; assessing and responding to carer’s needs; care planning and review; and transfer of care or discharge5. The Care Co-ordinator is also responsible for identifying and advising on changes in the circumstances which might require review or modification of the care plan. 6.6 Derbyshire Constabulary 6.6.1 Derbyshire Constabulary provide policing services throughout the County. 6.6.2 They attend on average 19,000 domestic violence incidents a year. The number of reports has increased by 6% each year since 2005. 6.6.3 Since 2003 Derbyshire Constabulary have had co-located Central Referral Units which collate and coordinate all police responses relating to allegations of domestic abuse and child abuse respectively. Where children are exposed to domestic violence a protocol is in place outlining multi-agency response arrangements. 6.6.4 The Constabulary records and investigates in the region of 150-160 offences of Threats to Kill6 each year. These involve a range of background circumstances which include those that also meet the criteria of domestic abuse incidents. 7 Family Background 7.1 Genogram 7.1.1 A genogram of BDS’ family, as known to agencies in Derbyshire, is included at Appendix B to this report. 7.2 Father 7.2.1 Father was white British, born and raised as a child in the North of England. He described having a happy childhood and left school with 8 ‘O’ Levels and 4 ‘A’ Levels. His parents were in business and affluent, with both Father and 5 Derbyshire Mental Health Services NHS Trust (2009) Care Programme Approach & Care Management Policies and Procedures 6 Offences Against the Person Act, 1861 his sister being given everything they could want. His religious affiliation is unknown. 7.2.2 After leaving school Father studied graphic design and thereafter visited a number of countries, undertaking a variety of jobs to support his travel. 7.2.3 It was during this period that he met his first wife, to whom he remained married for 12 years. It is reported by Father’s family that his wife was considerably older than him and took all responsibility for running their marriage and business affairs, an arrangement which they believed to have suited Father. 7.2.4 Father had a history of depression, which dated back to at least 1999 when he attempted suicide. 7.2.5 In 2002 Father’s mother, to whom he was very close, died. Health service reports suggest that although he was offered bereavement counselling around that time he never recovered from the upset caused by her death. His father and sister, with whom he had irregular contact during the period covered by this Review, still live in the North of England. 7.2.6 Father has been described by mental health professionals as a “moderately resistant patient who avoided emotion” and by other health staff as “cold”. Family members also found him hard to engage. 7.2.7 Members of both his and Mother’s family have also reported manipulative and egotistical aspects of Father’s personality, although he seems to have been able to conceal these from professionals, and Mother, until early in 2010. 7.3 Mother 7.3.1 Mother was white British and her religion had been recorded as Church of England. 7.3.2 Mother’s father became chronically ill when she was around 12 years of age and she played a significant role with her mother in caring for him. It is believed that this experience had a major impact on Mother, instilling in her a sense of commitment and responsibility for the care of those who are sick. It is clear from the accounts of family members that Mother’s relationship with her father meant a lot to her, and that was behind her commitment to maintaining contact between BDS and Father. 7.3.3 Mother left school at 18 having achieved good results. She then had a number of jobs and travelled extensively before moving to Spain. 7.3.4 In 2004 Mother met Father in Spain when she was exhibiting work at his art gallery. A relationship thereafter developed between them. 7.3.5 Around the beginning of 2007 Mother returned to the UK alone. She obtained a job as Personal Assistant to the Managing Director of a stock broking firm. 7.3.6 Towards the end of that year Father also returned to the UK and sought out Mother. Their relationship was revived and Mother became pregnant shortly afterwards. Mother informed her family that the pregnancy was unexpected but that she welcomed it. Father was reported by family members of Mother to have been “off” regarding the prospect of fatherhood. The mother of Mother has stated that Father urged Mother to have the pregnancy terminated, informing her that he did not think the time was right for them to have a child, but that she refused. Father returned to Spain shortly afterwards. 7.3.7 Whilst pregnant Mother moved to Derbyshire to care for her mother, who had become frail. Father followed her there shortly afterwards. 7.3.8 It is reported by family members that from then on Father did not work. Although he reported that he had a source of income in America and he was receiving benefits in the UK, the majority of his money was used to finance debt repayments in Spain. He is reported to have made no financial contribution to the living expenses of Mother, or BDS once born. 7.3.9 Family members have remarked that Father did not display any form of affection for Mother. 7.3.10 Mother is reported by both professionals and family members to have presented as a happy person who was outgoing, sociable and interested in other people. She was quite tactile in greeting those she knew and would commonly embrace them. 7.3.11 Mother was viewed by professionals as a competent and capable woman, who always placed her child’s needs first. 7.3.12 Family members have also commented that Mother would do anything to avoid a scene, expressed by her mother as the vehement view that “her family were not the sort of people who had the Police visit their homes”. 7.4 BDS 7.4.1 BDS was a white British child. 7.4.2 He was described by health visiting staff as happy and smiling and by the midwifery staff who met him as bright, well behaved and interactive. These views were echoed by family members who describe him as a pleasure to be with, highlighting the sunny disposition evident in the photographs on BDS which were shared with the Independent Author and DSCB Strategy Officer. 7.4.3 Family members also commented that BDS got on well with other children of his age, in particular one of his cousins with whom he had regular contact. 7.4.4 The quality of care provided to BDS by his mother is described by both professionals and family members as being excellent and loving. 7.4.5 It is clear that BDS displayed affection for his father and effective interaction by Father with BDS was noted by some professionals. 8 Agency Involvement 8.1 Integrated Chronology 8.1.1 An Integrated chronology of agency involvement with those included within the scope of this Review is provided at Appendix C. 8.1.2 The following summary of agency involvement is drawn from the chronology. It is divided into largely arbitrary time periods for ease of reading. 8.2 December 2007 to September 2008 8.2.1 On 5 December 2007 Mother booked for her first pregnancy with a Community Midwife at the GP surgery. Mother was recorded as aged 36 years and father aged 41 years at this stage. Little other information was recorded about the couple’s history. 8.2.2 Mother’s antenatal period was unremarkable, apart from investigation for a maternal heart murmur, which was normal. Mother opted not to attend for a screen to assess the risk of Down’s syndrome. 8.2.3 The pregnancy was notified to the health visiting team based at the GP surgery. 8.2.4 On 25 February 2008 Mother attended for her 20 week scan, which was normal. Father accompanied Mother to this appointment but did not interact with the health professionals. 8.2.5 On 29 April 2008, shortly after moving to rented accommodation with Mother, Father sought treatment from GP9. He was prescribed fluoxetine7 and a referral was made to the North Community Mental Health Team (CMHT). The referral was received on 6 May 2008. 8.2.6 On 15 May 2008 an urgent further referral was made by the GP reporting deterioration in Father’s mental health. 8.2.7 On 16 May 2008 Father was assessed by a Community Psychiatric Nurse 2 from North CMHT consequent to the GP referrals. In view of his low mood and suicidal thoughts he was referred to Chesterfield Crisis Resolution and Home Treatment Service (CRHTS). 8.2.8 Father was further assessed by the CRHTS and accepted for short term treatment. The Care Programme Approach (CPA) was engaged and CPN1 was appointed. The CPA formed the framework for all subsequent service provision to Father by Derbyshire Mental Health Services NHS Trust (DMHS). 8.2.9 Father was referred to a Support Worker Anxiety Management & Self Esteem Therapy, operating under the direct supervision of the Care Co-ordinator, for 7 Fluoxetine is an anti-depressant. provision of anxiety management and self esteem therapy. 8.2.10 A FACE8 risk profile completed at this time indicated a significant risk of suicide and self neglect. Father was assessed as posing no risk to children or others. 8.2.11 On 14 June 2008 Father contacted Derbyshire Health United (DHU) with concerns about the side effects of his new medication. He was advised to stop taking it and see his GP the following Monday. His GP was notified of this contact and the advice given. 8.2.12 On 15 June 2008 Father was admitted to the Hartington Unit, Chesterfield, for a 3 week period of assessment and treatment. This followed a worsening of his depression. Father was assessed to be at low risk of suicide and self-harm and was started on Mirtazepine9. He was discharged following some improvement in his symptoms. 8.2.13 Whilst Father was at the Hartington Unit Mother was identified as an informal carer for him, although no formal assessment of her needs in connection with that role was conducted. 8.2.14 After his discharge Father was followed up in the community by the North CMHT. He was also put onto a waiting list for psychotherapy. 8.2.15 On 15 July 2008 BDS was born, weighing 2990g (between 9th and 25th centiles). Father was present at the birth. Mother sustained a post partum haemorrhage after the delivery, and Mother was admitted to the High Dependency Unit with her baby. BDS was breast fed. Both were discharged on 17 July 2008 to BDS’ maternal grandmother’s address, moving back to Mother’s address some time afterwards. 8.2.16 BDS was noted to have positional talipes10 in relation to which Mother was given advice about massaging his foot. Otherwise, the postnatal period was uneventful. Post natal Midwifery contact was provided in line with accepted practice. 8.2.17 The Health Visitor undertook a post natal family assessment using the Framework for Assessment of Children in Need and their Families11. On the basis that the family were meeting BDS’ needs and had no identified unmet need themselves the family was assessed as “low need12” The Health Visitor 8 Department of Health (2007) Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services describes Functional Analysis of Care Environments (FACE) as “a portfolio of assessment tools designed for adult and older people’s mental health settings. It includes both screening and in-depth levels of assessment and contains specialist forms applicable to areas such as substance use, mental capacity, perinatal services and forensic services. The tools meet both CPA and Health of the Nation Outcome Scales requirements. Risk is assessed using the FACE Risk Profile. This may be used either as a stand alone tool or in conjunction with other FACE or local tools. Five sets of risk indicators are coded as present or absent and then a judgment of risk status (0–4) in seven areas (including violence, self-harm and self-neglect) is made. Scope for service user and carer collaboration is built into the system through tailored forms, including feedback on services. 9 Mirtazepine is an anti-depressant. 10 An abnormal position of the foot which would be expected to self correct 11 Framework for Assessment of Children in Need and their Families (2000) HMSO 12 As defined in Derbyshire Community Health Services Practice Guidance ‘Health Visiting Service Contribution recalls that she would have asked a general question about health problems in the family, but was not told of Father’s history of mental illness or his recent hospital admission. The Health Visitor therefore agreed future contacts in line with the Core Programme for Health Visiting Services. Mother is reported to have engaged well with the Health Visiting Service and brought BDS to 18 clinic appointments. 8.2.18 When the lease on the Mother’s rented property ended in the late summer of 2008 she moved to her mother’s address with Father and BDS. There is reference in agency records to Mother looking for child care so that she could return to work. She also secured an arrangement with her employer that would allow her to largely work from home after the birth of BDS. When she did have to work in London a neighbour cared for both BDS and Mother’s mother. 8.2.19 On 3 September 2008 BDS was given his first course of immunisations a week early, at 7 weeks old. This was at the request of Father to accommodate a planned visit to Spain. The Health Visitor sought advice from her manager, who in turn sought advice from the public health Consultant on this. 8.3 October 2008 to 21 December 2008 8.3.1 On 24 October 2008 the family were on a visit to Surrey when Father reported to Surrey Police that Mother was missing with BDS. The reported circumstances were that father woke that morning to find Mother packing with the intention of visiting her brother in Berkshire. She was said to have not waited for Father and to have left whilst he was in the shower. A missing person enquiry, also involving Derbyshire Constabulary and Thames Valley Police, was initiated. 8.3.2 Mother had gone to her brother’s address in Berkshire as planned and arrived there around lunch time. She informed her brother that whilst out the previous evening Father had argued with her and referred to her in a derogatory manner to her friends. She stated that in the morning Father had refused to get up and she had gone to her car with BDS. At that point Father came into the car park, argued with her and threw BDS’ pushchair across the car park towards her. She stated that she was upset by these events and frightened for her safety. 8.3.3 The Police tried to contact Mother throughout the remainder of that day but she did not answer either the telephone or door, fearing that Father had followed her. Thames Valley Police (on behalf of Surrey Police) did make contact with Mother late that evening and visited to speak with her the next morning. Mother informed them that she and Father had argued over the previous few weeks about living arrangements and financial difficulties due to her being on maternity leave. 8.3.4 Mother did not inform the Officers of Father’s actions with regard to the to the Healthy Child Programme’ (2009) and on the basis of Derbyshire Safeguarding Children Board practice guidance “Meeting the needs of children in Derbyshire (2006)” pushchair or report that she had been assaulted by him. That aspect of the incident did not therefore feature in the information passed to Derbyshire Constabulary for inclusion in the closure of their incident record, or in the information later passed to other Derbyshire agencies. 8.3.5 Mother then returned to her mother’s address in Derbyshire with BDS and informed her mother of the events in Surrey. She stated that she had been frightened by what had happened. 8.3.6 From her family’s perspective the relationship between Mother and Father as a couple ended at that point and it is reported that from then on Mother never left BDS alone with Father, even if she was only getting out of her car to visit a shop. She is also reported to have hidden both her own and BDS’s passports at her mother’ house and later at neighbours house fearing that Father might take BDS and return to Spain with him. 8.3.7 Notwithstanding this Mother did indicate to her family that she felt responsibility for looking after Father. She was particularly conscious that Father was the father of BDS and wanted her son to have a relationship with him in the future. 8.3.8 On 26 October 2008 Father arrived outside of Mothers’ mother’s home and having been refused entry, banged repeatedly on the door. Both Mother and her mother were worried about what he might do if admitted. Mother rang Derbyshire Constabulary and reported that Father was outside her address causing a “real disturbance”; and that she was there with BDS and did not feel safe. Mother stated that she had been assaulted by Father in Surrey a few days earlier and that this was being dealt with by Surrey Police. As noted above the Derbyshire Constabulary records held no details of such an assault. 8.3.9 An incident log was created with an opening incident category of ‘Nuisance’. Police Officers attended and persuaded Father to go to a friend’s house in another area of Derbyshire for the night. He was transported to that address by the Police Officers. 8.3.10 The address given by Father was that of Mother’s cousin whom Father had met on one previous occasion. He informed her that he had tried to obtain accommodation at a local budget hotel but they had been full. She reluctantly allowed Father to stay the night at her home. When Mother was informed, the next day, that Father had gone to her cousin’s address she was angry at him for imposing himself and collected him from there. 8.3.11 On 28 October 2008 a fax was received by Children’s Social Care in Derbyshire from Surrey County Council Children’s Social Services Department. This contained a police referral regarding the incident in Surrey. In this it was reported that Father had stated he was not concerned about Mother’s care of BDS but wanted advice regarding obtaining custody. The Surrey Police assessment was that there was no evidence of domestic abuse and no safety concern for the child, but that Father appeared to be using the incident to try to gain custody of BDS. 8.3.12 A Duty Social Worker attempted to contact Surrey Police to gain further information but was unable to obtain a reply and left a message requesting that they make contact. No response was obtained. The Social Worker then telephoned Father, who informed her that Mother and BDS had returned, that they were reconciled and reported that BDS was safe and well. The Duty Social Worker recorded no further action and closed the Initial Contact. 8.3.13 At the end of October 2008 Father started a 10 week course of emotion focused psychotherapy. 8.3.14 On 14 November 2008 the DCHS Named Nurse received a copy of the Surrey Police notification. This was passed to the Health Visitor with a request that it be discussed in their next safeguarding supervision session. It was subsequently agreed that the Health Visitor would speak with Mother regarding the notification. In the interim BDS had been seen in clinic and the Health Visitor waited until she could talk to Mother alone to discuss it, which she did in December 2008. 8.3.15 Following the end of the relationship between Mother and Father he returned to Spain, albeit transiently, in December 2008. Additional support was offered to Father by his Psychologist. This included giving him some coping strategies for after the relocation. Father was then discharged from the CMHT. 8.3.16 On 15 December 2008 a routine review of BDS was undertaken by the Health Visitor. 8.4 22 December 2008 to 9 February 2009 8.4.1 By 22 December 2008 Father had returned from Spain. He had been put on a plane to the UK by acquaintances there owing to his deteriorating mental health. Mother was contacted by these acquaintances who informed her that Father would need to be collected from the airport. Mother did so and took him to her mother’s address. 8.4.2 Mother contacted a CPN at the South CMHT and reported that Father’s mental health had deteriorated. The CPN thereafter contacted Father’s GP and advised that a referral would need to be made via the Crisis Resolution and Home Treatment Service (CRHTS). The CRHTS declined to accept the referral of Father from the GP. This was on the basis that he did not present with enduring mental illness and should therefore be dealt with by the South CMHT. 8.4.3 On 26 December 2008 Mother took Father to the Hartington Unit, stating that she could not cope. She was asked to take him to the Emergency Department of Chesterfield and North Derbyshire Royal Hospital (CNDRH). 8.4.4 At the hospital Mother requested help with Father’s mental health and stated that this made her feel uncomfortable having him at her home. Father refused to get out of Mother’s car, stating he had nowhere to go. Hospital staff contacted Derbyshire Constabulary and reported the situation. The report included that BDS was with Mother, that she was very distressed, and that she did not feel safe driving any further with Father in the car. 8.4.5 Police Officers attended and Father agreed to be assessed by the hospital based Mental Health Liaison Team (MHLT). The Derbyshire Constabulary incident was recorded as one involving mental health issues. 8.4.6 Father declined intervention from mental health services and denied any current thoughts of suicide or self-harm. He stated that he intended to visit his father. The records indicate that BDS’ welfare was considered and that Mothers’ concerns regarding Father and of him being near the baby were explored with Mother. The professionals had no concerns for BDS’ safety. 8.4.7 Later on 26 December 2008 Father contacted Derbyshire Constabulary and stated that he was not doing very well. The Officers who spoke with him identified no concerns for his safety and directed him to the nearest Salvation Army hostel in Nottingham. Father subsequently returned to the hospital Emergency Department. He was regarded as being homeless and given assistance by Derbyshire County Council to access overnight accommodation. 8.4.8 On 27 December 2008 Father travelled to stay at his sister’s address. He was asked to leave there by his brother in law; who woke to find Father standing at the end of his bed staring at him. This caused the brother in law concern for Father being in the house with his niece. Father thereafter stayed briefly with his father before returning to Derbyshire. 8.4.9 A few days later Father contacted a CRHTS CPN. He stated that he had been sleeping rough and had been to the Emergency Department with panic attacks. He was advised that his care would be picked up once a referral was received. 8.4.10 On 1 January 2009 Mother contacted the CRHTS, informing them that Father had reported being mugged and expressing concern for him. She was told that a GP needed to assess him. 8.4.11 Mother contacted Derbyshire Health United (DHU) and Father, described as ‘delirious, restless and confused’ was seen at home by an Out of Hours GP. Mother thereafter stayed with Father until he could be seen by his own GP the following day. 8.4.12 On 2 January 2009 Father registered with the same GP surgery as that of Mother and BDS. Father was seen by a GP 2 a few days later and stated that his depression was worsening. 8.4.13 Father thereafter contacted a CPN in South CMHT and asked that contact be made with his previous Psychologist for information. Father was told to attend an appointment with a Consultant Psychiatrist to facilitate his transfer to that CMHT. 8.4.14 On 20 January 2009 Father attended an appointment with a Consultant Psychiatrist 2 for the north area with a view to his care being transferred to South CMHT. Father was assessed as depressed with no thoughts of suicide. On 26 January 2009 a transfer letter was sent by the Psychiatrist 2 to the Consultant Psychiatrist 1 at the south area in respect of Father. 8.4.15 Between 29 December and 24 February, both Father and GP 9 contacted mental health services on a number of occasions to ask about transfer of Father’s care. Neither was able to obtain information on when Father would be seen by the South CMHT. 8.5 10 February 2009 to 20 August 2009 8.5.1 On 10 February 2009 Father contacted a Counsellor in private practice and sought assistance with worsening depression and suicidal feelings. He explained that he was attempting to access treatment through DMHS but was frustrated at the time it was taking for an appointment to be offered. He provided an outline of his previous treatment history and his social circumstances. This included that he had an infant son. 8.5.2 The Counsellor did not feel able to take on Father as a client but was concerned at the impact his condition may have on BDS, as well as for Father’s welfare. She sought Father’s consent to liaise with DMHS and did so the following day. The CPN who was contacted arranged for Father to be assessed on 24 February 2009. Father subsequently emailed the Counsellor to thank her for the intervention. 8.5.3 On 24 February 2009 Father had an initial assessment by CMHT CPN 4 South. Father was at that time homeless. He was assessed as having an objective low mood with signs of anxiety; thoughts of suicide and active, but undivulged, plans of self harm; and presenting no risk of violence to others. This information was sent to a Consultant Psychiatrist 1 and to a Senior Clinical Psychologist. 8.5.4 Father was reviewed by the Consultant Psychiatrist a few days later and thought to be suffering from a moderate depressive episode. Father’s prescription for mirtazepine was increased and input from the CPN was continued. 8.5.5 On 26 March 2009 Mother contacted DHU and stated that she was concerned about the withdrawn behaviour of Father who was again staying with her. She asked how to access the mental health crisis team if things deteriorated as she was going away for the weekend. She was advised to contact a CPN in the morning (which she did), or to call back if worried. 8.5.6 On 30 March 2009 a Support Worker from the Amber Trust first met Father consequent to a referral from DMHS. The referral was accompanied by details of the DMHS risk assessment. The Support Worker provided Father with assistance to move into a house provided by Amber Valley Housing and maintain the tenancy. Mother acted as guarantor for this tenancy. Regular support visits by Amber Trust staff commenced on 15 April 2009. 8.5.7 BDS continued to have regular Health Visitor clinic contacts for weighing. No concerns for BDS were identified other than an episode of nappy rash. 8.5.8 On 1 May 2009 Amber Trust first had contact with Mother, in this case a telephone call in relation to the support that Father was receiving from Amber Trust. 8.5.9 On 13 May 2009 there was evidence of improvement in Father’s mental health and he was placed on “Open Contact”13 by Consultant Psychiatrist 1. Fortnightly CPN input was continued. Father’s Mirtazepine was reduced. 8.5.10 Over the following weeks concern regarding self neglect by Father was raised with DMHS professionals by the Amber Trust Support Worker and Mother. Assessment by the CRHTS identified low mood, after hearing that his father had suffered a stroke, but low risk of self harm, suicide or risk to others. There is reference to him having nightmares about his son. Visits from Father’s CMHT Support Worker were stepped up and a CPA review was arranged. Father was given contact details for the CRHTS. 8.5.11 On 22 May 2009, Father was detained for shoplifting in a supermarket. Police officers attended and the incident was resolved using the Restorative Justice Model. 8.5.12 Following this Father informed Mother and her mother that he had had a panic attack whilst shopping. He stated that the shop had made him agree not to return as his collapse had frightened other customers. On this basis Mother and her mother agreed to accompany him to out of town supermarkets whenever he subsequently wanted to purchase food. Such trips took place late in the evening as Father expressed worry that he would have a further panic attack if the shop was busy. 8.5.13 On 2 June 2009 the Amber Trust Support Worker contacted Father’s sister regarding his mental and physical health. The sister stated that she wanted no further contact regarding Father. 8.5.14 On 12 June 2009 BDS’ case, which had been open to supervision between the Health Visitor and Named Nurse following the Police referral of the previous November was closed to supervision. 8.5.15 On 17 June 2009 CPNs from the CRHTS and South CMHT visited Father at home. He was discharged from home treatment due to his relative stability and a lack of acute mental illness. 8.5.16 On 26 June 2009 BDS had his routine one year assessment. This was delegated by the Health Visitor to a Community Nursery Nurse. 8.5.17 On 30 June 2009 a CPA Review meeting was held in respect of Father. Along with the Amber Trust Support Worker this meeting was attended by Mother, with BDS. It was agreed that Father would commence therapy with a Senior Clinical Psychologist who would, from that date, undertake the role of Father’s Care Coordinator. The CMHT CPN would accordingly withdraw input and Father was continued on “Open Contact” with Consultant Psychiatrist 1. 13 Open Contact” was an arrangement whereby a case was not formally open to a clinician but the client could access an appointment directly without referral. Whilst common practice in 2009 this practice has been discontinued by Derbyshire Mental Health Services NHS Trust as a consequence of their internal review into this case. 8.5.18 The Senior Clinical Psychologist’s initial formulation of Father’s issues was that he had difficulty accepting life transitions and processing issues emotionally, with an over-reliance on practical problem solving. Further emerging issues were distress intolerance and anxiety. 8.5.19 Into August 2009 Amber Trust support visits to Father increased due to concerns for his well being as his mental health declined. 8.5.20 On 13 August 2009, following a home visit, South CMHT Social Worker 2 referred Father to the CRHTS because of deterioration in his mental health. He was lethargic, preoccupied with losing a property in Spain and having panic attacks. Father had stopped taking his anti depressant medication. 8.5.21 Father was assessed as at significant risk of self-neglect and as presenting a low risk of suicide. A diagnosis of moderate depression and anxiety disorder, with secondary adjustment reaction to change in social circumstances was made and daily CRHTS contact offered. Diazepam was prescribed for symptoms of anxiety. 8.5.22 Mother was contacted by CPN 4 South and asked to provide care for Father by shopping. Consideration was given by the CPN to whether Mother qualified as an Informal Carer. It was decided that she did not meet the criteria for this and she was not acknowledged by healthcare professionals as such in the year before her death. 8.5.23 On 18 August 2009 Father’s neighbour contacted Derbyshire Constabulary and expressed concern for his health. Police Officers found Father unwell and summoned an ambulance to take him to hospital. Father was seen by a CPN from the CRHTS in the Emergency Department. He presented as flat with retarded speech and attributed his condition to anxiety after stopping taking his prescribed medication. He expressed a preference not to be admitted and denied thoughts of self harm or suicide. He was escorted home by the CPN who observed him taking his prescribed medication. 8.6 21 August 2009 to 31 October 2009 8.6.1 On 21 August 2009 Father was assessed at home by GP 1 and Locum Consultant Psychiatrist 1 for admission under the Mental Health Act 1983. This resulted from his presentation with symptoms of severe depression and significant retardation, lack of insight into the need for medication and refusal of hospital admission. The application was not completed because Father agreed to be voluntarily admitted to the Radbourne Unit, Derby. 8.6.2 In an assessment conducted following Father’s admission a low risk of violence to others was identified. There was some concern that Father may harm his child or Mother. This arose from Father’s marked preoccupation with his son and his ability to provide for him. This responsibility, together with financial difficulties, was identified as significant stressors for Father. Protective factors were identified as Mother being supportive, Father’s engagement with community services and his hospital admission. 8.6.3 Further assessment over the next few days on the ward did not identify these risks again and the view was reached that Father posed no risk to others. 8.6.4 Mother was identified as providing significant care for Father. During his stay on the ward, Mother and BDS visited him and it is recorded that these visits took place in the Family Visiting Room although he also had day leave from the ward in Mother’s care. 8.6.5 On 1 September 2009 Father was discharged from hospital. He was prescribed Duloxetine and provided with daily input from the CRHTS, ongoing psychotherapy and anxiety management input. 8.6.6 A discharge letter was sent to the GP, highlighting that Father was deemed as posing no risk of harming himself or others but that there was a significant risk of self neglect. 8.6.7 After short term daily involvement from the CRHTS, Father was discharged from that service to the care of the Senior Clinical Psychologist. Thereafter, for a period of nearly 5 months, Father’s mental health improved and stabilised. 8.7 1 November 2009 to 25 May 2010 8.7.1 On 8 November 2009 Mother and BDS attended a visit to the Senior Clinical Psychologist with Father. Mother tried to support Father to plan contact with his sister and a visit to his father but Father put up barriers to this. Mother is recorded as expressing the view that Father had a dependent personality. 8.7.2 The Senior Clinical Psychologist arranged for a Support Worker to undertake some exposure therapy14 with Father as an adjunct to the work being done by the Clinical Psychologist. 8.7.3 During 2009 Mother met with a former boyfriend from her school days on a number of occasions. By January 2010 they had formed a close relationship and he moved in with Mother. Mother was no longer working and spent her time caring for BDS. She also visited her mother on an almost daily basis and on most days combined this with a visit to Father. 8.7.4 The relationship with Mother and her partner was known to members of Mothers’ family although they were not made aware that he was living with her. Father was not informed of the new relationship at that time and there is 14 Exposure Therapy is a treatment often used for anxiety disorders. The aim of exposure therapy is to enable a person to reduce their fear and anxiety, with the ultimate goal of eliminating avoidance behaviour, for example, drinking alcohol to prevent recurring upsetting memories. Exposure Therapy can be implemented by having a person exposed to thoughts, feelings, or situations that he fears, without avoiding them. This may be done by directly exposing someone to a fearful object, image, or situation (for example, introducing the individual to using public transport, or going shopping) or through the use of the imagination. By being exposed to fear and anxiety, the person can learn that anxiety and fear will decrease on its own, eventually reducing the extent with which specific thoughts, feelings, and situations are viewed as threatening and fearful. Exposure therapy may also be combined with teaching a person different relaxation skills, in order to build coping strategies to facilitate management of anxiety and eliminate avoidance behaviours. no indication of him being informed until May 2010. 8.7.5 On 2 January 2010, following contact with NHS Direct the previous day, Mother attended the Minor Injuries Unit. She reported having trapped her fingers in a loft ladder and a small wound was treated. 8.7.6 On 26 January 2010, during a home visit, the Senior Clinical Psychologist noted a dramatic deterioration in Father’s self care. Father continued to receive weekly input for anxiety management, daily telephone or face-to-face contact with his Amber Trust Support Worker and fortnightly contact with a psychotherapist. 8.7.7 At this time exaggeration in the information provided by Father regarding his background was identified by professionals; for example Father had claimed that his property in Spain was a 20 room villa when according to Mother it was a 3 bedroom house. 8.7.8 On 10 February 2010 Mother spoke with Father’s Amber Trust Support Worker regarding his well being. Mother had concerns about Father’s ability to look after BDS as he was not able to look after himself. She continued to not leave BDS in the sole care of his father. 8.7.9 During February and March 2010 Amber Trust support visits to Father were again increased due to concerns for his well being as his mental health declined. 8.7.10 On 6 March 2010 Father’s Amber Trust Support Worker informed the Senior Clinical Psychologist that she had been unable to gain access to Father’s house on 24 February and 2 March 2010. She reported that Mother had gained access and found Father with no food in the house, lying on a duvet on the floor and asking to be left alone. A joint home visit with the Senior Clinical Psychologist and CPN was arranged for the following day but no response was obtained at Father’s address. 8.7.11 On 9 March 2010 Mother contacted Father’s sister and expressed concern for Father’s mental and physical condition. They made arrangements to meet the Clinical Psychologist and a CRHTS CPN at Father’s address. 8.7.12 Someone was seen in the house but no response was obtained. Keys had been left on the inside of the door locks preventing Mother from gaining access using her key. Mother and Father’s sister requested that the Police were called to secure access. They were reportedly informed by the DMHS professionals that to do so would infringe Father’s human rights. The professionals then left the address. Mother and Father’s sister thereafter purchased some food for Father and left it on the doorstep of his house. 8.7.13 On that date the Senior Clinical Psychologist completed a FACE risk profile of Father, identifying a significant risk of severe self neglect and a low risk of suicide. No risk to BDS was identified. 8.7.14 On 10 March 2010 Father’s sister attempted to contact the Senior Clinical Psychologist by telephone on six occasions, leaving requests that he call her. 8.7.15 On 11 March 2010 access was gained by professionals to Father’s address. A joint medical recommendation for admission under the Mental Health Act 1983 was completed by an Approved Social Worker from the South CMHT with Consultant Psychiatrist 1 and Father’s GP. Father was negative about his current treatment plan. The assessors agreed to give him a further chance to engage over the next 14 days with the South CMHT Support Worker 1. 8.7.16 Mother was present with BDS at the start of this assessment but left after Father attempted to embrace BDS, expressing concern regarding the impact that the situation may have on her child. 8.7.17 On 12 March 2010 Father expressed anger to the South CMHT Support Worker 1 about the events of the previous day. He stated that he felt threatened and that he did not want involvement with CRHTS or his GP. 8.7.18 Over the next three weeks Father was seen by his GP on three occasions and his anger at mental health service provision appeared to have decreased. He was referred by the GP for Cognitive Behavioural Therapy. 8.7.19 Father cancelled an appointment with the Senior Clinical Psychologist on 18 March 2010. His CMHT Support Worker spoke to him offering a further appointment and enquiring after his wellbeing, which was reported as unchanged. 8.7.20 On 22 March 2010 Father met with his DMHS Support Worker prior to an outpatient clinic appointment with the Consultant Psychiatrist. At her encouragement they went for a drink to put him in a social situation. During this activity Father became angry regarding his treatment and his desire to understand his condition; swearing and raising his voice. He then became tearful. 8.7.21 At the subsequent outpatient clinic review with Consultant Psychiatrist 1, Father was angry and dismissive of input from all services. He was recorded as swearing and slamming his hands down. He then “stormed out” of the room. A decision was taken that in view of his anger, CMHT would not see Father at home. 8.7.22 Father continued on his antidepressants but it was speculated that Father may have a Narcissistic Personality Disorder. A plan was made for the Senior Clinical Psychologist to arrange a joint meeting with Consultant Psychiatrist 1 and Father. 8.7.23 The potential diagnosis was further discussed at a multi disciplinary meeting on 23 March 2010 and at a meeting between the Consultant Psychiatrist 1 and the Senior Clinical Psychologist the next day. At that meeting the Consultant Psychiatrist expressed the view that Father’s difficulties related to his situation and personality difficulties, rather than depression. The risk of self harm and suicide were discussed but only self neglect was identified as a concern. It was agreed that inpatient treatment would be counterproductive and that long term psychodynamic psychotherapy would be an appropriate treatment. 8.7.24 The above perspective was outlined in a letter to Father’s GP, with whom he had a positive relationship and was continuing to engage. This letter highlighted a strong possibility of Narcissistic Personality Disorder; characterised by a very idealised view of himself, rigidity of thinking up to the point of lacking any empathy and some evidence of trying to control the whole situation which could be reinforced by his sickness role. 8.7.25 On 29 March 2010 Father’s GP spoke with Consultant Psychiatrist 1 and the following day reviewed Father. The GP felt that Father was stable with no anger. 8.7.26 On 5 April 2010 the CMHT Support Worker 1 contacted Mother. Mother informed her that she had seen Father 6 times during the preceding month and had been taking him food as she believed he was not eating. She had however found food hidden in the house and expressed anger that Father may be manipulating her. Mother stated that she did not want to visit Father further. 8.7.27 The Senior Clinical Psychologist was informed about Mother’s wish to withdraw from Father’s care by the CMHT Support Worker 1. 8.7.28 On 6 April 2010 the GP referred Father for Cognitive Behavioural Therapy. This was on the basis that there had been only a partial response to medication and no response to supportive counselling. 8.7.29 On 13 April 2010 Mother, again pregnant, attended a booking visit with the Community Midwife involved in her previous pregnancy. She stated that the unborn child’s father was her new partner of some 7-8 months. An enquiry was made about domestic abuse and no concerns were disclosed. Mother told her Midwife that she had stood by Father and done her best to support him, but there had been no progress and she wanted a life for herself and BDS. Mother said that the pregnancy was planned and that she was the happiest she had been. 8.7.30 Father was reported to be unaware of the pregnancy at this stage and they discussed telling him after the 12 week scan. The Midwife asked about contact between Father and BDS, and Mother reported no concerns. 8.7.31 Notification of Mother’s pregnancy was forwarded to the Health Visitor with an expected delivery date of 26 November 2010. 8.7.32 On 19 April 2010 the Amber Trust Support Worker contacted CMHT to discuss difficulty in securing Father’s engagement. She was informed of Father’s anger on 22 March 2010 together with the CMHT decision regarding home visits. 8.7.33 On 20 April 2010 the CMHT Support Worker 1 made a number of unsuccessful attempts to visit Father. She informed the Senior Clinical Psychologist of this. He wrote a letter to Father, challenging him over his lack of engagement over the previous few days and about his lack of engagement with services in general. The letter also included reference to the potential change in diagnosis and highlighted the need for further assessment. 8.7.34 On 27 April 2010 a further home visit to Father was attempted by the CMHT Support Worker 1 but although he spoke to her she was refused access. 8.7.35 On 4 May 2010 a CPA Review meeting was held by the Consultant Psychiatrist and Clinical Psychologist. Father had been invited but did not attend. It was recorded that Father’s GP was arranging treatment for him through Improved Access to Psychological Therapies (IAPT)15. Father was discharged by the Consultant Psychiatrist 1. The Senior Clinical Psychologist remained as Father’s Care Co-ordinator. It was agreed that the Clinical Psychologist would write to Father and ask him to contact the CMHT if he required their services; otherwise he would be discharged to the care of his GP. 8.7.36 On 14 May 2010 Mother had a scan at the Royal Derby Hospital, confirming that she was 12 weeks and 5 days pregnant. 8.7.37 On the 20 May 2010 a letter was sent from the Amber Trust to Father. This explained that if Father did not re-engage with the support on offer his period of support from the Trust would be ended. 8.7.38 Around this time Mother visited Father and informed him that she was in a relationship with her new partner. It is reported that Father had little reaction to being informed of this. 8.7.39 On 24 May 2010 Father rang his GP with complaints of headaches and nightmares. He was concerned that if he stopped his medication, he might relapse. An appointment was arranged for 28 May 2010. 8.7.40 During a home visit by his Amber Trust Support Worker on 24 May 2010 Father expressed dissatisfaction with the treatment that he was receiving. Father also stated that he felt isolated and did not know anyone except Mother and BDS. Further, that as Mother had met someone else he was worried about losing contact with BDS and another man taking his role. Father wanted the Support Worker to speak to Mother about his contact with BDS. It was explained to him that this was outside of the Worker’s remit. 8.7.41 On 25 May 2010 Father’s GP contacted Father by telephone and reassured him that the side effects of his medication would be discussed at their appointment. 8.7.42 On 25 May 2010 Father was discharged by the CRHTS as he was not engaging with them. 8.7.43 On that date Father met with Amber Trust support staff and attended an allotment project run by the Trust with service users. Father is described in case records as ‘very sociable and chatty’ during this support visit. 8.7.44 Also on 25 May 2010 Mother attended the Minor Injuries Unit with pain in her left hip and bruising to her right thigh caused when her car door was hit by a 15 The Improving Access to Psychological Therapies (IAPT) Programme is a NICE initiative which aims to improve access to evidence based talking therapies in the NHS by implementing National Institute for Health and Clinical Excellence (NICE) guidelines for people suffering from depression and anxiety disorders. bus. There was no serious injury. She was referred to the GP for review of her hip and the pregnancy. 8.8 26 and 27 May 2010 8.8.1 Around 1530 hours on 26 May 2010 Mother contacted the Senior Clinical Psychologist and informed him that Father had been calling her earlier in the day. Father was reported to have said that he had slept rough, had written a suicide note and stated that his life wasn’t worth living without his son. Mother stated that she had picked Father up and he had refused to get out of her car. The Clinical Psychologist urged Mother to be firm with Father and if necessary call the Police. BDS was with Mother at this time. 8.8.2 In a subsequent text message Mother informed the Clinical Psychologist that she had told Father of her new relationship and that she was pregnant. She wanted the Clinical Psychologist to be aware that Father may need support from the CRHTS. The Clinical Psychologist discussed these events, but not the information that Mother was now pregnant by her new partner, with a CRHTS CPN 4 South and with a Locum Consultant Psychiatrist 1. It was agreed that a joint assessment should take place the next day. 8.8.3 Father maintained his refusal to leave Mother’s car and she drove him to a Police Station. Mother outlined events that day to Police Officers and informed them that Father had a history of depression and a Personality Disorder. 8.8.4 When officers went to speak to Father he initially refused to leave the vehicle, stating that his life was not worth living without his son and broke down in tears. He then began to walk away. Owing to these comments and the information shared by Mother, Father was detained under Section 136 of the Mental Health Act, 198316. He was thereafter taken to the Radbourne Unit, Derby for assessment. 8.8.5 Once at the Radbourne Unit he was assessed by the on call Consultant Psychiatrist 3 and the on call Approved Mental Health Practitioner. The assessment concluded that Father presented no evidence on interview of a major mental illness. Further, that having denied suicide ideation or intent he did not require compulsory admission to inpatient psychiatric care. Father accounted for his behaviour as arising from difficulty in arranging access to BDS. The Police Officers were informed that Father was mentally stable. Father was then released from detention and taken home by the Police. 8.8.6 Staff at the Radbourne Unit stated to the Police Officers that they would inform Father’s GP of the assessment. This was done by fax that evening. 8.8.7 The professionals assessing Father were also recorded by the Police Officers 16 Section 136 of Mental Health Act 1983 provides a power for the Police to remove a mentally ill person from a public place to a place of safety, in order for them to be assessed by a doctor or by an approved mental health professional. The person cannot be detained for more than 72 hours, and any necessary care or treatment should have been arranged within this period. as having stated that Social Care would be informed, although it is unclear whether this related to Children’s Social Care or to services for Father. Within DMHS there is no record of this intention. 8.8.8 On 27 May 2010 Father was discussed within a CRHTS meeting. Attempts were made to reach the Senior Clinical Psychologist to engage him in the discussion but these were unsuccessful. On the basis that Father would not engage with services and that Father was making arrangements with his GP to manage his mental health needs it was decided not to accept Father for home treatment. The planned joint appointment was not pursued on the basis that Father had been assessed under Section 136 Mental Health Act 1983 in the interim. 8.8.9 On the morning of 27 May 2010 Father telephoned Mother to discuss seeing BDS. During the call he abused Mother, resulting in her putting the phone down on him. Later that morning Father again called Mother stating he was outside her house and asking to be let in. Mother contacted Derbyshire Constabulary and informed them that Father was at her address but stated that she did not require Police attendance at that time. 8.8.10 Mother later reported that she let Father in to play with BDS and that they spent the rest of the day together. Mother stated she agreed to this as she didn’t want Father creating a scene again. Whilst at the park together Mother stated that Father said to her “You’re a fucking bitch for abandoning me and getting together with someone else and getting pregnant. I’ve given up everything to be with you, if you’re going to make it difficult, I’ll make it more so, you’ve no idea what I’m capable of, I’ll kill you and take him with me.” 8.8.11 Following this threat Mother collected her partner from his work and together they dropped Father at his home. Mother informed her partner that she had been worried about getting away from Father if she was alone with him and BDS. 8.8.12 Mother is reported by her partner to have taken the threat made to her seriously and attended a Police Station, with him, at 17:13 hours to report this. It is also reported by Mother’s partner that the officer speaking with Mother informed her that Father could either be warned or arrested and sought her views on this. Mother preferred that a warning be given, although her new partner preferred that he be arrested. A witness statement was obtained from Mother. 8.8.13 Over the following hours Father made 23 attempts to contact Mother by telephone, although none of these calls were answered. These were not reported to Derbyshire Constabulary. 8.8.14 Around 20:00 hours on 27 May 210 the investigating Police Officer contacted the Duty Bleep Holder17 at the Radbourne Unit to discuss the outcome of the Section 136 Mental Health Act 1983 assessment of the previous day. She was informed that there was no record of such an assessment. The reason for the enquiry was not requested by the Radbourne Unit bleep holder. On 17 The “bleep holder” is the senior member of staff on duty, responsible for the out of hours management of the Radbourne Unit as a whole. the basis of a definitive statement that the information sought was not available the Police Officer did not share the reason for the enquiry. 8.8.15 After consulting with her supervisor and checking the Police National Computer the Officer formulated a plan to issue a harassment warning to Father. 8.8.16 At 22:10 hours that day two Police Officers visited Father’s home address with the intention of issuing him with a harassment warning18 to prevent any further unwelcome behaviour towards Mother. Father was unco-operative and his demeanour was considered strange. This led the Officers to conclude that he should be arrested and they did so for the offence of Threats to Kill. 8.8.17 Following the arrest of Father, the arresting Officers obtained details from Mother as the basis for completing an electronic Form 621 Domestic Violence Risk Assessment. The risk assessment indicated that Mother was at High Risk of homicide19. 8.8.18 Father was seen by a Forensic Medical Examiner (FME) at the Police Station to assess his suitability for detention and interview. The FME asserted that Father was fit to be detained and interviewed but recommended that an appropriate adult should be made available during interview. 8.9 28 to 31 May 2010 8.9.1 Father was dealt with on 28 May 2010 by a Detective Officer who conducted two interviews with him under caution. Father had a Solicitor and Appropriate Adult20 with him during the custody process. During the interviews Father denied the threats using such terms as “That is absolutely nonsense, that is absolutely nonsense, I’m sorry, that is just pathetic” and went on to say “I would never hurt her, I would never hurt her and I would never hurt (BDS), in fact I’ve never hurt anybody in my whole life.” He also gave an account that differed to that of Mother regarding the events of 27 May 2010, most particularly in relation to events which had not been included by Mother in her witness statement. 8.9.2 Following the interviews the investigating Officer discussed the case with the Custody Sergeant. It was agreed that there was insufficient evidence available to ask the Crown Prosecution Service to make a charging decision. Further enquiries were required and it was agreed that these could not be completed within the available detention period. The Custody Sergeant decided that Father should be bailed for the enquiries to be progressed. 18 Under the Protection from Harassment Act 1997 a warning used by a Police Officer as a means of formally indicating to an individual that their contact with another is unwanted and should cease immediately. Non compliance with such a warning would make the individual liable to arrest and prosecution. 19 The Derbyshire Constabulary Domestic Violence policy (2008) explicitly identifies the Form 621 assessment as relating to risk of homicide. 20 The appropriate adult who attended the interviews and custody process to represent the interests of Father was supplied by the Derbyshire Appropriate Adult Scheme (DAAS). This is an independent scheme provided by a registered charity that can be contacted by custody staff when no other appropriate adult is available to allow compliance with the Police & Criminal Evidence Act. 8.9.3 Father was released from Police custody at 14:50 hours on 28 May 2010 with a requirement that he return on 18 June 2010. The terms of Father’s bail included a condition not to contact Mother either directly or indirectly other than through a solicitor to arrange access to BDS. This was explained to Father in the presence of his Appropriate Adult. 8.9.4 Mother was informed of Father’s release. She stated that she intended to deliver some property from her home to him. This is reported by Mother’s partner as being with the intention of removing any need for Father to visit her address. The investigating officer explained that this was not appropriate given the bail condition and that someone else should deliver the items. Mother’s partner subsequently delivered the property to Father. When doing so he was invited to enter Father’s house to discuss things. He declined to do so. 8.9.5 The Detective Officer progressed some of the outstanding enquiries soon after Father’s release by speaking with Officers involved in previous incidents. Arrangements to obtain a further statement from Mother and to interview her partner, consequent to the information provided in Father’s interview, were made for the following week. 8.9.6 On 28 May Father missed an appointment with GP 1 because he was still in Police custody at the time of the appointment. Father attended later, apologised and made an appointment for 1 June 2010. 8.9.7 The Amber Trust Support Worker visited Father’s address on 28 May but getting no reply left a message stating that she would call again the next day. 8.9.8 In parallel with the ongoing investigation on the morning of the 28 May 2010, the “Form 621” risk assessment was viewed by staff in the Derbyshire Constabulary Domestic Abuse Central Referral Unit (DACRU). The assessment of risk was confirmed as “High”. 8.9.9 Copies of the risk assessment were sent to the investigating Detective Officer and their supervisor. 8.9.10 On 28 May 2010 a fax message headed “Section 1721 Child Referral” which included a copy of the risk assessment together with details of the incident record was sent to Children’s Social Care. The precise time that the fax was transmitted has not been established. 8.9.11 The referral concluded with confirmation of the Police action that Father had been arrested. The referral was sent prior to Father being granted bail and therefore did not include details of this. 8.9.12 On the evening of 28 May 2010, Father’s neighbour called Derbyshire Constabulary. She reported that Father was very upset at being told by the Police that he must not contact Mother or BDS and that he had mentioned feeling like grabbing his son. 8.9.13 Police Officers made attempts to contact Father without success. They also 21 Section 17 Children Act 1989 contacted Mother to check on her welfare and establish whether Father had been in touch with her. 8.9.14 At 01:45 hours on the morning of 29 May 2010 Father answered the door to Police Officers then immediately climbed back into bed. When the Officers went to his bedroom to speak with him he said he was missing his son and had been suffering from depression. He refused any help, including an offer of transportation to the Radbourne Unit. He denied any thoughts of self harm and the Officers found no indication of him intending to do so or to harm anyone else. 8.9.15 Over the weekend of 29/30 May 2010 Father made a large number of telephone calls to his sister during which he is described as having been agitated. Father informed her that he had been arrested for threatening to kill Mother after she had told him she was pregnant by her new partner. He stated that he had not done this and that the Police had let him go as they believed him. Father’s sister contacted Mother who provided her own account of events on 27 May 2010. 8.9.16 On Sunday 30 May 2010 Mother informed her mother of events on 27 May 2010. She also informed her mother that Father had taken to walking to the village where she lived and loitering in the vicinity of her house. She said that she kept the door locked in case Father attempted to enter. Neither Mother nor her partner reported these actions of Father to Derbyshire Constabulary. 8.9.17 Mother also told her mother that she had seen her cousin on Friday 28 May 2010 and had warned her to keep her house doors locked and not let Father in if he called there. 8.9.18 On Monday 31 May 2010 Father again had telephone conversations with his sister. In these he expressed annoyance that Mother had not brought BDS to see him and stated that he intended going to Mother’s address. His sister attempted to dissuade Father from doing so but it was apparent that he was not convinced in this regard. Father’s sister then contacted Mother to inform her of Father’s agitation and the likelihood that he would call at her address. Mother stated that she would lock the door and not let Father in. She also agreed to contact the Senior Clinical Psychologist regarding Father’s condition and request that he telephone Father’s sister. 8.9.19 It is reported that Father did visit the vicinity of Mother’s address on that day and walked up and down outside the house saying “He’s living here, he’s living here”. Father was seen by a neighbour to knock on the door of Mother’s house whilst the occupants were out. Neither of these events was reported to Derbyshire Constabulary. 8.10 1 and 2 June 2010 8.10.1 The fax referral to Children’s Social Care was dealt with on 1 June 2010, the Tuesday after the Bank Holiday weekend. On that date a summary was made by a Business Service Officer within an Initial Contact record. This highlighted that the case had been deemed as High Risk by Derbyshire Constabulary and that the child’s father had been arrested for Threats to Kill. 8.10.2 The Initial Contact record was passed to a duty Community Care Worker who created a Referral and Information record. This reiterated the information from the Initial Contact and added that Mother was still meeting with Father and there were concerns regarding the child’s safety and domestic violence issues. The recommendation was that an Initial Assessment22 was conducted. 8.10.3 A Children’s Social Care visit was planned for 8 June 2010. A letter was prepared to inform Mother of this visit and placed in the post tray on 1 June 2010.23 8.10.4 The Referral and Information record was passed to the Children’s Social Care Service Manager to confirm the action recommended. The Service Manager did so and passed the referral to the Reception and Assessment Team Service Manager incoming work box to await allocation. 8.10.5 On 1 June 2010 Mother sent a text message to Father’s sister informing her that she had spoken with the Senior Clinical Psychologist and that he would be contacting her later that day24. 8.10.6 On 1 June 2010 Father spoke with GP 1 on the telephone. He was distressed, stating that Mother had withdrawn access to his child and that he wanted help. Father also complained about lack of visits from the CMHT and that he had not had any ECT25. 8.10.7 The GP agreed to contact the CMHT and suggested that Father contact the Citizen’s Advice Bureau for legal advice about access. 8.10.8 Later that day Father again telephoned the GP. He complained of severe headache and stated that he wanted to stop his treatment. He was advised to attend the surgery the following day. 8.10.9 On 1 June the Amber Trust Support Worker called at Father’s address but got no reply. She spoke with Father by telephone later that day. Father informed her that Mother had said he could not see BDS, that she had a new family and that he would never see BDS again. Father was described as very upset and anxious. 8.10.10 The Support Worker thereafter contacted Mother who recounted events over the previous week. Mother stated that Father wanted unsupervised contact with BDS but that that scared her. She also stated that she had an appointment to see a Solicitor on 9 June 2010. Mother was concerned that Father would see this as too long a delay and be seen as her being awkward. Mother requested that the Support Worker contact Father and inform him that seeking legal advice had been advised by the Police. When the Support 22 Working Together to Safeguard Children (2010 5.38-47) 23 This letter was never sent, having been retrieved by a Service Manager following notification of the deaths of Mother and BDS. 24 It has since been established that Dr R was on leave that week and that Mother had in fact left a message for him rather than speak directly with him. 25 Father had previously been informed by DMHS professionals that ECT was unlikely to benefit him. Worker recontacted Father he kept repeating “I need to see my little boy”. 8.10.11 Around 21:30 hours on 1 June 2010 Father’s sister contacted Father by telephone. During this conversation Father reiterated concerns about contact with BDS. In contrast to previous contact he was however not agitated; being described by his sister as very calm. 8.10.12 On 2 June 2010 Father was seen by GP 1. Father was distressed. He focussed on his perceived lack of input for his mental health problems, access to his son and the importance to him of ongoing involvement in his son’s upbringing. 8.10.13 At the start of the consultation, Father made what was perceived by the GP to be a verbal threat, stating “This is going to be one of the most important days of your career”. The GP challenged this, saying "that sounds like threat to me. What do you mean?” Father immediately retracted his remarks. 8.10.14 The GP was very concerned that the issue of access to his son could cause significant deterioration. He planned to talk to Father’s Psychiatrist. 8.10.15 A management plan was agreed with Father, including that Father would be reviewed by a different GP the following week, when Father’s GP was on annual leave. The GP also referred Father back for Cognitive Behavioural Therapy. 8.10.16 As Father was leaving, he came back into the room to confirm the arrangements and to thank the GP for the time he had spent with him. He also apologised again for the threat. 8.10.17 Around 07:30 hours on the morning of 2 June 2010 Mother’s partner left Mother’s address for work leaving Mother and BDS at the house. He locked the door behind him and posted his keys through the letter box. 8.10.18 That morning Mother contacted her mother by telephone and arranged to reschedule a planned shopping trip until the following day as it was raining. 8.10.19 Around 11:00 hours that morning a neighbour of Mother heard a female screaming. She looked into Mother’s house through the lounge window and could see the head and shoulders of Mother. Mother shouted to the neighbour to call the Police. The neighbour called 999 at 11:03 hours. This call was graded as requiring an immediate response and Officers were dispatched to the address, arriving at 11:15 hours. 8.10.20 The Police Officers found all doors locked from the inside and all ground floor windows closed. They immediately forced entry to the premises and found Mother, Father and BDS apparently deceased upon the lounge floor. BDS was lying upon his back on the floor having received 16 stab wounds; Mother was kneeling on the floor having received 32 stab wounds; and Father was slumped over on top of Mother having received 18 stab wounds. A knife was recovered from Father’s lap. 8.10.21 An ambulance was summoned at 11:17 hours and the first paramedic arrived at 11:30 hours. Attempts were made to resuscitate BDS at the scene, en route to the Royal Derby Hospital, and then in the Emergency Department. These were however unsuccessful and BDS was declared dead at 12:16 hours. 8.10.22 Mother and Father were confirmed to be dead at the scene at 11:50 and 11:53 respectively. 8.10.23 Both sets of keys for Mother’s house and her mobile telephone were found by Police in Father’s pocket. 8.10.24 The death of BDS and Mother were treated as murder by Derbyshire Constabulary although no-one outside of those who died was sought in connection with the killing. An Inquest was held by HM Coroner in September and October 2013. The jury decided that BDS and Mother had been unlawfully killed and that Father had taken his own life. ANALYSIS 9 Analysis of Agency Involvement 9.1 December 2007 to September 2008 9.1.1 When Mother booked for her antenatal care with the Community Midwife on 5 December 2007 (see 8.2.1) an effective social and family history was not recorded. No information was recorded in respect of Father at that time or in subsequent contacts. Further, although Father attended a number of appointments, neither this nor observations on his role in relation to the pregnancy were documented. 9.1.2 National guidance26 requires a holistic and family based approach. The importance of recording a full history of both parents was also highlighted by a previous Serious Case Review in Derbyshire27. It would be expected that information about the father, including his health, would be asked at the first appointment. 9.1.3 That this did not take place is attributed by the RDH IMR and Health Overview author to the documentation used and accepted practice in the Midwifery Department at that time. 9.1.4 Improved documentation combined with a culture of professional curiosity would present opportunities to gain a fuller picture of parenting capacity and the environment into which the child would be born. This is addressed in the recommendations of the RDH IMR. 9.1.5 Throughout the period under review both the Midwife and Health Visitor remained unaware of Father’s mental health problems. Mother had a number of contacts (e.g. 8.2.18; 8.5.14; 8.7.29) with professionals during which she had opportunity to inform the professionals of this aspect of her life and discuss its impact on her and BDS. She never did. A number of possible reasons for Mother deciding not to do so present themselves but this issue remains unresolved. 9.1.6 Mother is reported to have had a very warm relationship with her Midwife, to the extent of embracing her when they met. She is described by the Midwife in unusually glowing terms. The Health Overview highlights that while the nature of this relationship in part reflected Mother’s nature, it could potentially implicate the Midwife in a culture of over familiarity. The DCHS IMR also highlights evidence that the nature of Mother’s relationship with the Health Visiting team may have blurred professional boundaries. 9.1.7 There is no evidence that this impacted on the gathering of information from Mother but it risked making objective questioning and assessment more difficult. The DCHS IMR makes an appropriate recommendation regarding training in this area. 26 Nursing and Midwifery Council Guidelines for Records and Record Keeping (2008) 27 Derbyshire Safeguarding Children Board Serious Case Review in respect of Baby R (March 2007) 9.1.8 Notification of Mother’s pregnancy to the Health Visiting team (see 8.2.3) did not result in an antenatal visit being conducted as required by the local Core Programme for Health Visiting Services28. There were no identified additional needs and the Health Visitor, incorrectly perceiving her workload to be high29, decided not to undertake the visit. This undermined the intended benefits of the Core Programme; to promote contact with families, the identification of vulnerabilities within them and provision of appropriate services. The Health Visitor’s manager was not made aware of this decision. The issue is being addressed by DCHS. 9.1.9 On 29 April 2008, Father was seen by his GP (see 8.2.5). It is unclear how aware the GP was of Father’s history at the time of making the referral to DMHS. A discharge letter from mental health services in Surrey was received by the GP shortly afterwards. That included a self assessment questionnaire completed by Father which was an effective practice initiative. 9.1.10 The deterioration in Father’s mental health which led to his GP making a further referral to DMHS on 15 May 2008 appears to have been associated with a period when Mother was away from Derbyshire, working in London. This association between the periods of decline in Father’s mental health and the absence of access to Mother is a recurring theme during the period under review. 9.1.11 The DMHS response to Father’s needs following the referral made by the GP on 15 May 2008, (see 8.2.6 to 8.2.10), including engagement of the Care Programme Approach, was appropriate. The assessment conducted identified no risk to children but it would have been appropriate to make the health professionals concerned with Father’s unborn child aware of his situation. Had this occurred it would have enabled a more holistic view of the family to be taken and prompted at least completion of a pre assessment checklist. This is designed to help a practitioner decide if a Common Assessment Framework (CAF) assessment is indicated. 9.1.12 Neither the GP nor the DMHS professionals did so. This lack of focus on the child and the potential impact of parental mental health problems by professionals is a theme that is discussed further in section 15 of this report. 9.1.13 On 15 June 2008, when Mother was 8 months pregnant, Father was admitted to the Hartington Unit (see 8.2.12) for a 3 week period. There is no evidence that the impact of Father’s mental health on his unborn child was considered. The admission was not shared with any professional focussing on that child. 9.1.14 It was identified and recorded (see 8.2.13) that Mother was an informal carer for Father. The National Carer’s Strategy (2008) defines a carer as “someone who spends a significant amount of their life providing unpaid support to family or potentially friends, caring for a relative, partner or friend who is ill, frail or disabled or has mental health or substance misuse problems”. The Trust Care Programme Approach and Care Standards Policy and 28 Derbyshire Community Health Services Core Programme for Health Visiting (2007) 29 It has been established that the Health Visitors workload was in line with 50% of Health Visitors in England and that she was supported by a part time Community Nursery Nurse. Procedures30 state that informal carers providing support for mental health service users will be identified and supported appropriately. It was recorded that Mother had no identified needs. There is no evidence that this position was based on a formal assessment or that Mother was consulted. 9.1.15 The role of Mother as an Informal Carer is a theme discussed further in section 17 of this report. 9.1.16 Information on Mother’s intentions following the birth of BDS (see 8.2.15) was appropriately shared by the hospital with relevant health professionals. 9.1.17 The post natal family assessment (see 8.2.17) undertaken by the Health Visitor did not elicit from either parent information regarding Father’s mental health problems. Routine enquiry at antenatal and new birth contacts regarding parental mental health was included in the Health Visiting Programme until 200931. 9.1.18 The Health Visitor had also, as outlined above, not been informed of Father’s mental health issues by either DMHS professionals or the GP. The Health Visitor was based in the surgery of Father’s GP and had access to his records. There would however have been no expectation that the Heath Visitor would access these records or have an awareness of them unless alerted to the issue. 9.1.19 The approach to future Health Visitor contacts agreed with Mother was appropriate to the level of need identified and in line with relevant policy32. Had the Health Visitor been aware of Father’s mental health issues, an enhanced programme of contact might have been put in place, to support the family and to review the impact on BDS. 9.1.20 Father’s request in September 2008 that BDS receive his immunisations a week early (see 8.2.19) was unusual owing to Father’s determination that this take place and the pressure that he exerted to achieve it. 9.1.21 The DCHS IMR suggests that this indicates that he was not prioritising the child’s needs. It could be equally argued that he was trying to protect BDS prior to a trip abroad. 9.1.22 The Health Visitor appropriately escalated and sought advice on the request. It would also have been appropriate to seek advice from the GP. More effective communication arrangements within the GP Surgery would have facilitated this. It is probable that had the GP been consulted the Health Visitor would have been alerted to Father’s mental health issues. 9.2 October 2008 to 21 December 2008 30 Derbyshire Mental Health Services NHS Trust Care Programme Approach and Care Management Policies and Procedures (2009). This has since been superseded by the Derbyshire Mental Health Services NHS Trust Policy for Assessing the Needs of Carers (2010) which states that carers who provide substantial and regular care for an individual, for which they are not paid a salary or fee, are legally entitled to an assessment of their caring, physical and mental health, leisure, educational and employment needs. 31 With the adoption of the “Tynedale Health Needs Assessment tool” at antenatal and new birth contacts 32 Derbyshire Community Health Services Core Programme for Health Visiting (2007) 9.2.1 The response provided by Surrey and Thames Valley Police on 24/25 October 2008 (see 8.3.1 to 8.3.4) was appropriate. Mother did not report the incident involving the pushchair being thrown by Father as an assault. The reason for Mother subsequently (see 8.3.8) informing Derbyshire Constabulary that she had been assaulted and that this was being dealt with by Surrey Police is unknown. 9.2.2 The referral of information regarding the missing person report to Derbyshire Children’s Social Care and to the DCHS Named Nurse by their corresponding agencies in Surrey (see 8.3.11 & 8.3.14) was effective practice. That Mother had not reported the alleged assault however undermined both the potential for the referral to enhance professional understanding of the family situation and the significance attached to the notification. 9.2.3 The referral was appropriately recorded by Children’s Social Care (see 8.3.11-12). It was identified that further information was required from Surrey. The record should not therefore have been closed without obtaining that information. Further, the suggested motivation for the report by Father was to gain custody of BDS. Although no concerns for the safety of BDS were identified in the referral this should have prompted contact with Mother rather than relying upon an assurance from Father that all was well. At the very least Mother should have been notified that a referral had been received in respect of BDS. The rationale for the decisions taken has not been established. 9.2.4 The case was not subject to oversight and sign off by a manager. This militated against these shortcomings being identified and addressed. 9.2.5 Within DCHS the referral was discussed at supervision (see 8.3.14). It would also have been good practice for the Health Visitor to discuss the referral with the GP. BDS had been seen to be safe and well since the incident and the referral did not identify concerns for his safety. The plan to discuss it with Mother at the next opportunity to see Mother alone was therefore appropriate. The outcome of that conversation was not recorded prior to the case being closed to supervision (see 8.5.12) as it should have been. 9.2.6 When Mother contacted Derbyshire Constabulary on 26 October 2008 (see 8.3.8-10) the recording of the incident as “Nuisance” was inappropriate. The reported situation, that Mother reported feeling unsafe and her reference to being assaulted two days previously should, have prompted recognition that the incident met the criteria for domestic violence33. That Derbyshire Constabulary had no record of such an assault should not have affected this. The incident was also not recognised as involving domestic abuse by the attending Officers. 9.2.7 The approach to dealing with such incidents encompassed by the force’s Domestic Violence Policy was not engaged. The circumstances would not have presented the basis for a different immediate approach or met the 33 Defined in the Derbyshire Constabulary Domestic Violence Policy (2008), in accordance with ACPO Guidance, as “Any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional between adults, aged 18 or over, who are or have been intimate partners or family members, regardless of gender”. criteria34 for referring them to any other agency. Having the incident recorded as Domestic Abuse would however, as identified in the Derbyshire Constabulary IMR, have put the circumstances on the radar of officers dealing with subsequent events. It is unclear why this recognition as domestic violence did not occur. 9.3 22 December 2008 to 9 February 2009 9.3.1 In December 2008 Father was appropriately discharged from DMHS in anticipation of a long absence in Spain (see 8.3.15). 9.3.2 When Father returned shortly afterwards, following deterioration in his mental health, the process of his re-engagement with mental health services was uncertain and protracted (see 8.4.1-15). Neither Mother nor Father’s GP were clear on or able to effectively negotiate the pathway to accessing services over the following weeks. 9.3.3 The DMHS response to the Father’s situation is highlighted by the DMHS IMR as not following agreed procedure in line with the Care Programme Approach standards of good practice. As Father had been discharged only recently he should have been able to resume his engagement with DMHS, rather than being treated as a new referral. It appears that a significant factor in this not happening was that Father was staying with Mother in the one CMHT area whereas services had previously been provided by another CMHT. It would have been appropriate and in accordance with CPA standards for the two CMHTs to have arranged a joint visit to coordinate resumption of service provision to Father. The DMHS IMR does not clarify why this did not take place. 9.3.4 A consequence of the difficulties in Father’s re-engagement with DMHS was that there was no plan of care for him in place over the Christmas 2008 period. On 26 December 2008 Mother contacted the Hartington Unit at Chesterfield to say she could not cope and was advised to take Father to the Emergency Department (see 8.4.3-8). The Derbyshire Constabulary response to Father’s refusal to leave Mother’s car, facilitating Father’s assessment by the hospital Mental Health Liaison Team (MHLT), was properly dealt with as relating to Father’s mental health issues. It seems likely that having handed matters over to the MHLT there was an assumption, reasonable in the circumstances that all issues including consideration of the impact on Mother and BDS would be picked up by those professionals. 9.3.5 Appropriate regard for BDS’ welfare was taken by the MHLT staff (see 8.4.6). On the basis of the information provided, the MHLT assessment of minimal risk seems reasonable, although it should have been more fully recorded. 9.3.6 Neither the mental health professionals involved in these events, or Mother, informed the Health Visitor of the incident. Although no immediate risk to BDS had been identified it should have been recognised that the Health 34 Domestic Abuse and Safeguarding Children Protocol Between Derbyshire County Council Social Care and Derbyshire Constabulary Visitor had a need to know of such an incident involving BDS’ parents. 9.3.7 Following his registration at the Amber Valley GP Practice (see 8.4.12) Father was seen mainly by one GP. That doctor has indicated, although this was not effectively documented, that risk to BDS had been considered throughout the following period but that Father was not considered to present a significant risk. There is no evidence that this consideration extended to the impact that caring for Father would have on Mother and her ability to prioritise the needs of BDS. 9.3.8 Given the established relationship between parental mental illness and increased risk to children35 it would have been appropriate for the GP to discuss this with the family Health Visitor; and following Mother booking with her second pregnancy, with her Midwife. This did not happen and both of these professionals remained unaware of Father’s mental health issues throughout the period covered by this Review. 9.4 10 February 2009 to 20 August 2009 9.4.1 The difficulty in accessing mental health services for Father continued into 2009 and it was February before he was assessed (see 8.5.3-4). This was shortly after a private practice Counsellor contacted by Father intervened (see 8.5.1-2) with DMHS. There is no indication that the concerns for BDS’ welfare expressed by the Counsellor were addressed in the DMHS assessment process. The relevant sections of the assessment record were left uncompleted. 9.4.2 Over the following months the service provided by DMHS was appropriate to Father’s level of need and diagnosis. 9.4.3 From April 2009 the Amber Trust supported Father consequent to a referral from DMHS (see 8.5.6). The referral was accompanied by details of the DMHS risk assessment and Amber Trust relied upon this rather than utilise their own risk assessment process as they should have done. The Amber Trust Support Worker thereafter demonstrated commendable commitment to addressing Father’s needs and engaging with others who featured in his life, particularly Mother. 9.4.4 Mother continued to play a key role in caring for Father and in identifying changes in his condition to DMHS professionals (e.g. 8.5.5 & 8.5.10). There is no evidence that any professional considered the impact that this might have on Mother or BDS. Her role as an Informal Carer for Father was not revisited. 9.4.5 By the end of May 2009 significant concerns for Father were being reported. The DMHS IMR identifies Father had developed a pattern of deterioration in his mental health in response to events or changes that were a source of stress to him. This manifested as refusal to go out, low mood, withdrawal and self neglect. 35 National Institute for Clinical Excellence (NICE) Guidance “When to Suspect Child Maltreatment” (2009) 9.4.6 Information provided by Mother’s family indicates that manipulation of Mother and her mother by Father became an increasing feature of their relationships from this time. This was most notable in Father securing their involvement in late evening shopping trips (see 8.5.11-12) on the basis of a distorted account of his exclusion from a local supermarket. There is no record of this development or its purported basis being shared with DMHS or Amber Trust professionals. 9.4.7 At the beginning of June 2009 father informed a DMHS professional that he was having nightmares about his son (see 8.5.10). The record of this was unsigned and there is no evidence of any action being taken as a result. This represents a missed opportunity to consider specifically the role that BDS played in the mental health of Father, especially as contact and access to his son featured commonly in Father’s conversation. 9.4.8 In June 2009 BDS had a routine one year development review (see 8.5.16). This was delegated by the Health Visitor to a Community Nursery Nurse and the assessment did not include a family health review. This was not in accordance with the Core Programme for Health Visiting. Any proposal to deviate from the Core Programme should have been discussed with the Health Visitor’s manager. This did not take place and the practice was not recognised by the management oversight arrangements in place. Enhanced supervision and case audit arrangements have since been introduced in March and September 2010, along with training for Health Visitors on the Core Programme. 9.4.9 A CPA Review meeting was held at the end of June 2009 (see 8.5.17), when the Senior Clinical Psychologist took over the role of Care Co-ordinator. Thereafter Father engaged with a number of mental health professionals and accessed some therapies offered. He chose his preferred therapeutic modalities, e.g. preferring not to have medication and stopping it on a few occasions. He also requested ECT on a number of occasions. It was properly made clear to Father some of these therapies were not appropriate to his condition. 9.4.10 Contrary to DMHS policies there was no documented CPA Care Plan in place for Father from this point onwards. The DMHS IMR states that the Care Co-ordinator did have a plan, that the involved professionals were aware of their roles and responsibilities and that care reviews were recorded. At the inquest it was reported that day to day communication within the team immediately responsible for the care of Father was good. 9.4.11 The absence of a documented plan would make service provision difficult, particularly in an organisation such as DMHS with many different teams and where professionals from other agencies were involved. It was also likely to affect the ability of professionals providing responses to future crises in Father’s mental health to understand the overall context of his condition and care. 9.4.12 This would undoubtedly have been exacerbated by the disparate record systems operated by DMHS, with seven separate sets of notes on Father held. Some of the records contained duplicated, undated and inaccurately dated documents which were not filed chronologically; along with plan elements which were not ‘SMART’36. This did not comply with the DMHS record keeping policy37. The DMHS IMR rightly recognises the need to resolve this systemic issue and makes an appropriate recommendation in that regard. 9.4.13 Putting Father on “Open Contact”38 with the Consultant Psychiatrist (see 8.5.9 & 8.5.17) was permissible and normal practice within the policies operating at that time. It was however likely to undermine clarity regarding ownership of Father’s care and it is appropriate that DMHS has now discontinued the practice. 9.4.14 By the middle of August 2009 Father’s mental health had again deteriorated, leading to a further period of active involvement by the CRHTS (see 8.5.20-21). In connection with this the issue of Mother being an Informal Carer for Father was specifically considered by a CPN (see 8.5.22). A plan was made to establish if Mother qualified as such and to offer a carer’s assessment. 9.4.15 The CPN decided that Mother did not meet the criteria for being an Informal Carer as she was not a “formal (sic) or regular carer”. This decision was not consistent Mother being the key person supporting and caring for Father. She had provided him with accommodation at her mother’s house, ensured that he had food and intervened when there was deterioration in his wellbeing. This represented a missed opportunity to assess the impact of caring for Father on Mother (and BDS) and to make appropriate support available to her. This issue was not considered again by any professional within the period under review. 9.4.16 Father’s deteriorating mental health and self neglect was accompanied by deterioration in his physical health. 9.4.17 On the evening of 18 August 2009 the service provided to Father by all agencies in response to the neighbour’s concerns for his welfare (see 8.5.23) was appropriate in relation to his mental health. The physical wellbeing of Father should have been given equal consideration and action taken to ensure that this was addressed. A referral to Father’s GP would have been appropriate. 9.4.18 At the Emergency Department Father’s role as a parent was not identified by hospital staff and no consideration was given to the impact that Father’s condition might have on his child. The RDH IMR highlights that the constraints of the Emergency Department recording system may have contributed to this but that embedding a “Think Family” practice culture would avoid the necessity of relying upon such prompts. 36 Specific, Measurable, Achievable, Realistic, Time-bound. 37 Derbyshire Mental Health Services NHS Trust Minimum Standards for Clinical and Practice Records (2008) 38 38 “Open Contact” was an arrangement whereby a case was not formally open to a clinician but the client could access an appointment directly without referral. Whilst common practice in 2009 this practice has been discontinued by Derbyshire Mental Health Services NHS Trust as a consequence of their internal review into this case. 9.5 21 August 2009 to 31 October 2009 9.5.1 On 21 August 2009 Father was admitted to the Radbourne Unit for assessment (see 8.6.1). Consideration had been given by his GP and a Consultant Psychiatrist to formal admission under the Mental Health Act 1983 but this was not pursued after Father agreed to be admitted voluntarily. This was appropriate, as was the decision to keep the issue of compulsory admission under review. 9.5.2 At the beginning of this admission a risk of harm to Mother and BDS, albeit a low one, was identified (see 8.6.2). 9.5.3 Father engaged well during the admission and subsequent risk assessments indicated a rapid reduction in his preoccupation with BDS. The assessed level of risk was accordingly reduced. Notwithstanding this the risk should have been addressed, particularly in relation to the contact that Father was having with BDS during visits to the ward with Mother. It would have been appropriate to have discussed this within the multi-disciplinary team, including Father’s Care Coordinator, and with the Trust’s Named Safeguarding professionals. 9.5.4 Consideration should also have been given to informing Mother of the assessed risk and notifying Father’s GP. Communication to those involved in his care that when Father’s mental health had deteriorated he had been assessed, even transiently, as posing a risk to BDS would have raised awareness of a potential risk during future similar episodes. 9.5.5 BDS’ visits to the Radbourne Unit (see 8.6.4) took place within the Family Visiting Room and he was accompanied by Mother as required by the DMHS Visiting Policy and Child Visiting Procedures39. 9.5.6 There is no indication that the visits were subject of the multi-disciplinary team assessment required by the DMHS policy, which should have included consideration of the risk issues identified on admission. The policy also requires that contact be made with Children’s Social Care and the family Health Visitor to inform the assessment. This did not take place. The DMHS IMR attributes this to a lack of awareness of the policy by staff. This represents a significant missed opportunity to share relevant information which would have alerted both agencies to Father’s mental health issues. It is uncertain whether this would have led to the responses provided to the referrals received from Surrey at the end of 2008 being revisited or to an active response at that time. It would have led to the response provided to future contact with the family being better informed. 9.6 1 November 2009 to 25 May 2010 9.6.1 Although Mother had started a new relationship by January 2010 (see 8.7.3) 39 Derbyshire Mental Health Services NHS Trust Visiting Policy / Child Visiting Procedures (December 2005). These procedures were withdrawn in March 2010 and the procedures subsumed into the Trust’s Safeguarding Children Policy. They were however in force in August 2009. all indications are that that Father was not aware of this at that time. It is unclear when Father did learn of Mother’s new relationship although she had certainly informed him of this by the latter part of May 2010. 9.6.2 Father had seen a range of GPs prior to March 2010, with little continuity. In March 2010, GP1 saw Father and made a deliberate effort to engage him and become involved in his long term management, with some success. It was good practice for the GP to actively work with an individual who was sceptical to encourage engagement and provide some continuity of care. The PCT Medical Director’s review of the medical management by the GP identifies that this was appropriate. 9.6.3 The GP was aware of BDS, having seen him at Father’s home with Mother. He was also aware that although the parents lived apart Mother was keen for Father to maintain contact with his son and facilitated frequent, but supervised, contact. 9.6.4 The GP has stated that he explicitly considered risks to BDS, although this was not recorded. He did not identify a cause for concern and decided not to inform the Health Visitor or Midwife of Father’s mental health problems. It would have been appropriate to do so given the extent of professional involvement with Father and the potential impact on BDS and on Mother’s parenting capacity. 9.6.5 On 9 March 2010 Mother and Father’s sister requested that DMHS professionals call the Police to secure access to Father’s address (see 8.7.11-12). The rationale for them declining to do so was not recorded. It is clear they intended to take further action in relation to Father’s condition but this could have been more effectively communicated to Mother and Father’s sister. 9.6.6 The completion of a FACE Risk Profile in respect of Father (see 8.7.13) was appropriate as was the plan for a joint assessment under the Mental Health Act 1983 the following day. That the profile was undated undermined its ability to enable professionals accessing the records in the future to understand Father’s mental health at that point in time. 9.6.7 On 10 March 2010 the calls made by Father’s sister to the Clinical Psychologist (Dr R) (see 8.7.14) were not returned. The DMHS IMR states that the Psychologist attributes this to an oversight and has apologised to Father’s sister for this. This represented a missed opportunity to obtain input and possibly a fresh perspective from a family member, notwithstanding that the psychologist would not have been in a position to discuss Father’s case with her. 9.6.8 On 11 March 2010 a joint medical recommendation for hospital admission of Father under the Mental Health Act 1983 (see 8.7.15-16). Mother was visiting Father when the health professionals arrived. She left shortly afterwards expressing concern regarding the impact of Father’s reaction on BDS. There is no evidence that this prompted professional consideration of the impact on BDS’ welfare of Father’s condition. 9.6.9 Although angry at the action taken by professionals on 11 March (see 8.7.17 & 8.7.20-21) Father did engage with the Support Worker. By 23 March 2010 (see 8.7.23) it had in any event been decided that inpatient treatment for Father would be counterproductive. 9.6.10 Amber Trust was informed of the DMHS decision not to conduct further home visits on safety grounds (see 8.7.32). Amber Trust staff had seen Father since his outbursts with DMHS professionals and he had not been aggressive towards them. The Amber Trust Support Worker did not therefore consider changes their service delivery were required. This should have been the subject of risk assessment within that organisation. 9.6.11 In March 2010 Father’s condition was discussed by DMHS professionals, including consideration of whether he may have a Narcissistic Personality Disorder or Dependant Personality Disorder with narcissistic traits (see 8.7.22-24). Following the meetings Father’s GP was advised that there was a strong possibility of Father having a Personality Disorder. 9.6.12 Notwithstanding that there was not then or subsequently a diagnosis of Personality Disorder, this new perspective on Father’s condition was not accompanied by a review of his risk profile as it should have been. 9.6.13 The possibility of a Personality Disorder contributing to Father’s condition is discussed further at section 16 of this report. 9.6.14 When Mother booked with the Midwife for her second pregnancy (see 8.7.29) an effective family and social history was not recorded. No information regarding the unborn child’s father apart from his name was obtained. The analysis in respect of Mother booking for her first pregnancy (see 9.1.1-4) is equally relevant to this. 9.6.15 Mother’s reference to having stood by Father and now wanting a life for herself was not understood by the Midwife. She questioned whether this related to financial or career issues and was advised that it did not. Had this been fully explored it is likely that a greater understanding of the relationship with Father of Mother and BDS would have been gained. It is uncertain whether this would have included Father’s mental health issues even if this had been subject of a direct question. 9.6.16 At the start of April 2010 (see 8.7.26-27) Mother informed Father’s CPN that she did not wish to have a role in caring for him any longer. The Senior Clinical Psychologist was informed of this. There is no indication that it was shared with Father’s GP. As Mother had not been identified as an Informal Carer for Father this information had minimal impact on the way the DMHS were responding to Father’s condition or Mother’s role in this. Mother continued to be in contact with the Care Coordinator over the succeeding days regarding the provision of services to Father. 9.6.17 In parallel with Mother discovering that Father had lied to her, professionals also identified a number of discrepancies in the information given by Father. This dated as far back as December 2008, when he informed Emergency Department staff that he had had no previous mental health care. That this had not been detected earlier is attributable to the previously noted inadequacies of the DMHS documentation, making triangulation of information problematic. 9.6.18 During April 2010 there was an increasing disengagement by Father from services (see 8.7.33-34) although his mental health and, through self neglect, physical health were declining. This was accompanied by moves towards disengagement by DMHS professionals. 9.6.19 Key decisions were made at the CPA Review meeting on 4 May 2010 (see 8.7.35) attended only by the Consultant Psychiatrist and Clinical Psychologist. Other potential invitees, including Father’s GP, his Amber Trust Support Worker and Mother were not invited and no arrangements were put in place to facilitate them contributing to the review. Father’s CPN has stated that no others were invited to avoid intimidating Father with a room full of people. The Clinical Psychologist attributes this to an oversight. 9.6.20 At the meeting Father was discharged by the Consultant Psychiatrist. This was not conducted in line with DMHS procedures, which would require a planning meeting attended by Father and significant others including his GP. As Father had effectively ceased engaging with the psychiatrist, a phased discharge was not practicable. 9.6.21 Father’s Care Coordinator also seriously considered complete discharge from DMHS services, with responsibility for Father’s mental health care being transferred to his GP. This was not enacted and the Senior Clinical Psychologist remained as Care Coordinator. Responsibility for management of Father’s condition was however effectively delegated to his GP1 with treatment arranged through Improved Access to Psychological Therapies (IAPT)40. The Senior Clinical Psychologist has stated that this approach was made in recognition of a reasoned decision by Father to access treatment through his GP. 9.6.22 In the context of an emerging view that Father’s condition may be contributed to by a Personality Disorder this delegation was not advisable without robust arrangements being in place to provide advice and support to the GP (see 16.7). 9.6.23 The approach by DMHS was mirrored by Amber Trust (see 8.7.37) later in May 2010, when they wrote to Father advising that they would discharge him if he did not engage with their services. Engagement by Father with this service thereafter showed signs of improvement (e.g. 8.7.43). 9.7 26 and 27 May 2010 9.7.1 Mother contacted the Clinical Psychologist on 26 May 2010 and informed him that Father was refusing to leave her car (see 8.8.1). The advice given, to be firm with him and if necessary call the Police, was appropriate. There is no 40 The Improving Access to Psychological Therapies (IAPT) Programme is a NICE initiative which aims to improve access to evidence based talking therapies in the NHS by implementing National Institute for Health and Clinical Excellence (NICE) guidelines for people suffering from depression and anxiety disorders. evidence that Mother disclosed that BDS was with her. Had she done so it is unlikely that the advice would have been different as there was no indication of any immediate risk to BDS. 9.7.2 The content of the subsequent text message to the Clinical Psychologist (see 8.8.2) was properly identified by him as an issue which was likely to impact adversely on Father’s mental health. The DMHS IMR argues that, based on past behaviour, the impact of this change in social stressors would in all likelihood be withdrawal, rapid deterioration in mood and self neglect. The Clinical Psychologist believed that Father had accepted that his relationship with Mother was over and therefore did not think the development would increase risk from Father. 9.7.3 That the degree and likely permanence of Mother’s estrangement from providing attention to Father and access to BDS might impact on Father in a qualitatively different manner from previous social stressors should have also been considered. 9.7.4 Discussing the development with DMHS Colleagues was appropriate, as was arranging for a joint assessment of Father the next day. The potential effectiveness of this was however undermined by not sharing the information regarding Mother’s pregnancy. 9.7.5 Not informing Father’s GP of the situation undermined the ability of the GP to provide Father with appropriate support in dealing with the development and assess any risks arising from it. Similar considerations apply to the Amber Trust Support Worker not being informed. 9.7.6 The failure to share relevant and significant information is not addressed in the DMHS IMR and the reasons behind it have not been established. 9.7.7 When Mother took Father to the Police Station on 26 May 2010 his detention under Section 136 of the Mental Health Act 198341 and taking him directly to the Radbourne Unit (see 8.8.3-4) was both appropriate and in line with relevant policies. The Derbyshire Constabulary IMR rightly identifies that while the circumstances may have met the criteria for a domestic violence incident the main presenting issue and concern of Mother was Father’s mental health. 9.7.8 Had the incident been classified as one of Domestic Violence it would have engaged the recording and assessment processes applicable to such incidents42. Within these the circumstances would not have led to Mother being assessed as at High Risk of homicide. BDS’ age and Mother’s pregnancy would have triggered a referral to Children’s Social Care. The circumstances did not however meet the criteria for engaging child protection procedures. 9.7.9 The incident classification did not impact on subsequent Police action. The 41 Section 136 of the Mental Health Act 1983 is an emergency power allowing the Police to remove a person who is in a public place and appears to be suffering a mental disorder and to be in need of immediate care or control to a place of safety. The person can be held for 72 hours to allow assessment by mental health professionals. 42 Derbyshire Constabulary Domestic Violence Policy (February 2008). officers who dealt with Father on the following days (see 8.8.12-16 & 8.9.1-14) were aware of the events on 26 May by virtue of the second incident being recorded on the same computer record. This was also included in the referral made to Children’s Social Care (see 8.9.10). 9.7.10 The assessment at the Radbourne Unit by two mental health professionals who did not know him concluded that that Father did not have a major mental disorder or present a risk of suicide that required inpatient psychiatric care (see 8.8.5). 9.7.11 Given the previously noted lack of a unified set of medical notes and the absence of a documented care plan it is unlikely that the assessment considered full information about Father’s background. It would have been robust practice to liaise with Father’s Care Coordinator to obtain an informed perspective on Father’s mental health and the services that were engaged with him. This, in turn, may have led to greater scepticism in their interview with Father. It is also likely that the assessors would have been informed of Mother’s pregnancy and thereby have had a greater understanding of the stressors impacting upon Father at that time. 9.7.12 The DMHS IMR argues that had the assessment been conducted by the DMHS professionals involved in Father’s care the outcome of the assessment would have been the same. The rationale for this is that they had not applied to detain Father under the Mental Health Act 1983 when they had assessed him in March 2010 (see 8.7.15 & 8.7.23). By May 2010 there were significant recent developments in Father’s life which impacted on his mental health and may have changed the view taken by the professionals. 9.7.13 A fax notification of the assessment to Father’s GP (see 8.8.6) was effective practice. This did not identify any risk of violence or to children. 9.7.14 A significant omission by all professionals involved with Father on 26 May was consideration of the impact of his mental health on BDS. There were no indications that BDS was at immediate risk of harm from Father but BDS was exposed to Father’s behaviour in Mother’s car. The incident was also triggered by issues connected with BDS. These factors should have been recognised as having implications for at least the longer term welfare of BDS and, for those aware of Mother’s pregnancy, the unborn child. 9.7.15 On 27 May 2010 a decision was taken not to pursue the plan for a joint assessment or provide a service to Father from the CRHTS (see 8.8.8). This was on the basis that Father would be unlikely to engage, was seeking treatment from his GP and had had a mental assessment in the interim. No contact was made with the Clinical Psychologist, Father’s GP or with Father. The decision could not therefore have taken into account the full impact of development’s in Father’s life on his mental health. 9.7.16 The intervening assessment under the Mental Health Act 1983 only indicated that Father did not meet the criteria for compulsory in-patient care at the time of assessment. The assessment should not have been regarded as a substitute for the more holistic assessment of Father that developments in the professional view of his mental health condition and changes in his social circumstances merited. It also did not obviate the potential for Father to be engaged voluntarily. 9.7.17 On the afternoon of 27 May 2010 Mother visited the Police station to report threats made against her and BDS (see 8.8.9-12). This was treated from the outset as involving domestic abuse. The response provided was therefore within the framework of the Derbyshire Constabulary Domestic Violence Policy43. 9.7.18 The incident was also appropriately recorded as one of Threats to Kill. This should have triggered the robust risk assessment and management procedures, with senior manager involvement, specified by the Derbyshire Constabulary Life at Risk Policy44. 9.7.19 The Derbyshire Constabulary IMR identifies that the underlying purpose of the Life at Risk Policy is to ensure that such threats are subject to an effective risk assessment. This was served by the risk assessment processes engaged under the Domestic Violence Policy. Engagement of the Life at Risk Policy would not have led to a different approach to management of the risk identified. Nevertheless it is appropriate that the action outlined in the Police IMR is taken to ensure that the Life at Risk Policy and Domestic Violence Policy of Derbyshire Constabulary provide a cohesive approach to incidents which fall within the scope of both. 9.7.20 Contact was made with the Bleep Holder45 at the Radbourne Unit regarding the Section 136 Mental Health Act 1983 assessment of the previous day (see 8.8.14). This was effective practice by the Police Officer. 9.7.21 The Officer was not informed that the assessment record was only unavailable to the Bleep Holder because it was held by the clinicians involved. No advice was given on how access might be obtained. This effectively closed down the likelihood of productive information sharing. Providing access to information regarding the assessment would have been beneficial to the Police. An equally important element of the communication would have been discussion of the reason for the enquiry. This was not sought by the Radbourne Unit Bleep Holder or, in light of a perceived definitive statement regarding availability of the information sought, shared proactively by the Police Officer. 9.7.22 If communication had been better it is likely that assessment and management of the risk that Father presented would have taken place in a multi-agency context. DMHS professionals however remained unaware of the events on 27/28 May 2010. 43 Derbyshire Constabulary Domestic Violence Policy (February 2008). This specifies that response requirements for officers dealing with Domestic Abuse incidents as to: Take positive action to ensure the safety of the victim and any children present Take measures to prevent an immediate recurrence Identify all evidence gathering opportunities and ensure that evidence is preserved and secured Ensure that the victim and children are provided with appropriate care and advice Ensure that positive action is taken to arrest and convict the offender. (Emphasis in original document) 44 Derbyshire Constabulary Life at Risk Policy (July 2008). 45 The “Bleep Holder” is the senior member of staff on duty, responsible for the out of hours management of the Radbourne Unit as a whole. 9.7.23 The need for DMHS to improve the means by which other agencies are able to access information held by them is addressed within and subject of a recommendation from that agency’s IMR. 9.7.24 While the Derbyshire Constabulary Domestic Violence Policy provided the overall framework for the Police response to Mother’s report there were aspects to the response which did not adhere to that policy. 9.7.25 Issuing Father with a harassment warning46, as intended by the officers who attended his address (see 8.8.15-16) on the evening of 27 May 2010, would have been inappropriate. The rationale for adopting this approach, only rectified when Father was arrested on the basis that he was uncooperative with the officers, has not been established. 9.7.26 Completion of the “Form 621” Domestic Violence Risk Assessment by the arresting officers (see 8.8.16) was in line with relevant policies, although it incorrectly states that BDS was not present at the time of the incident and does not provide his details. It also refers to Mother by her middle name on a number of occasions, creating a potential source of confusion. 9.7.27 The assessment appropriately classified the risk as High. This was confirmed by all of the relevant staff interviewed in preparation of the Derbyshire Constabulary IMR. 9.7.28 It is noteworthy that the “Form 621” risk assessment tool is specifically identified by the Domestic Violence Policy47 as assessing the risk of homicide (Independent Author’s emphasis) to the victim, in this case Mother. This is however not made explicit on the form itself. It is also apparent from discussion of the Serious Case Review Panel that this understanding is not shared by professionals within Children’s Social Care (and the DCHS Safeguarding Team) who are in receipt of referrals arising from this risk assessment. 9.7.29 Whilst the presence and details of BDS should have been recorded, the tool does not specifically assess risk to any children. This is the responsibility of the Child Abuse Central Referral Unit on the basis of the recorded information. In this regard Derbyshire Constabulary are to implement the ACPO “DASH48” risk assessment tool, which includes an additional focus on children, for use in cases of domestic violence. 9.8 28 to 31 May 2010 9.8.1 The Police interviews of Father on the morning of 28 May 2010 (see 8.9.1) were conducted in accordance with relevant legislation and statutory guidance. Under the “PEACE”49 interview model it is identified as good 46 Under the Protection from Harassment Act 1997 a warning used by a Police Officer as a means of formally indicating to an individual that their contact with another is unwanted and should cease immediately. Non-compliance with such a warning would make the individual liable to arrest and prosecution. 47 Derbyshire Constabulary Domestic Violence Policy (February 2008). 48 Association of Chief Police Officers Domestic Abuse, Stalking and Harassment and Honour Based Violence risk assessment model (2009). 49 The interview model included in Police training programmes. practice to for two Officers to conduct an interview. The reason for a second interviewing Officer not being present is not explained by the Derbyshire Constabulary IMR. Notwithstanding this the interview, reviewed as part of the IPCC investigation, was concluded to have been thorough. 9.8.2 The decision to release Father on bail following the interviews (see 8.9.2) was consistent with the view taken by the Custody Sergeant at the time that the further enquires required and any consequent further interviews of Father could not be completed within the time limits on keeping Father in custody. The Derbyshire Constabulary IMR identifies that Father completely denied making the threats to Mother and that there was very little evidence available to support Mother’s allegation. That which was available is identified by the Derbyshire Constabulary IMR as confused and requiring substantial clarification. It is unclear whether the further planned enquiries would have provided sufficient evidence to enable the case to subsequently be put to the Crown Prosecution Service for a charging decision. 9.8.3 An internal investigation by Derbyshire Constabulary has established that the intention of the Custody Officer in granting conditional bail was to act in the best interests of Mother. 9.8.4 The “Form 621” risk assessment formed the basis for consideration of further action by both the Domestic Abuse and Child Abuse Central Referral Units (see 8.9.8-10). Forwarding details of this and the incident records to Children’s Social Care was in accordance with the relevant protocol50 in place at that time. Making the referral urgently was appropriate and identified by the Derbyshire Constabulary IMR as in line with the assessed risk. 9.8.5 Two practice issues undermined the potential effectiveness of the referral to Children’s Social Care. First, as noted above, the form was not fully and accurately completed. It does not immediately identify that BDS was present at the time of the incidents on 26 and 27 May 2010. 9.8.6 Second, the Domestic Violence Officer’s assessment and confirmation of the risk categorisation had not been completed when it was forwarded to Children’s Social Care. More significantly, as the form was sent before Father was granted bail this was not included. This information was not elicited by Children’s Social Care consequent to their receipt of the referral. 9.8.7 The referral should have also been forwarded to the DCHS Safeguarding Team. Not doing so was attributable to individual practice and has been addressed by Derbyshire Constabulary. If it had been forwarded it is unlikely to have been dealt with prior to 2 June 2010 unless the need for an urgent response was specifically prompted. 9.8.8 Aside from the above practice issues, the domestic violence protocol itself mitigated against the effectiveness of the referral to Children’s Social Care. Key to this is that the process is explicitly, albeit inaccurately, specified on the referral documentation as being directed at the needs of children potentially requiring services under Section 17 of the Children Act 1989. This however 50 Domestic Abuse and Safeguarding Children Protocol Between Derbyshire County Council, Derby City Council, Derbyshire Constabulary, NHS Derbyshire County and NHS Derby City only reflects a number of underlying issues which are discussed in section 19 of this report. 9.8.9 The Police risk assessment identified Mother as at High risk of homicide. The focus of the risk assessment was on Mother and the degree of risk may have been different for BDS. Mother was BDS’ main caregiver and any contact between Mother and Father would almost invariably involve BDS. The assessed risk to Mother must therefore have involved a risk of significant harm to him. 9.8.10 It is the Independent Author’s view that this should have led to BDS being the subject of a referral to Children’s Social Care under Section 47 of the Children Act 1989. That it did not is attributable to the domestic violence protocol arrangements as outlined at 9.8.9 above and in Section 19. The application of thresholds for referral and intervention should be specifically addressed as part of the current review (see 3.6) of arrangements for responding to children exposed to domestic abuse. 9.8.11 The Derbyshire Constabulary IMR asserts that BDS should not have been considered at risk of significant harm. This is on the basis that the phrase used by Father “I’ll kill you and take him” could be open to differing interpretation in relation to risk to BDS; that Father had always shown a caring attitude to BDS and that he had no previous convictions indicating a predisposition to harm his son. There is no evidence that these factors or a lack of confidence in the validity of the risk assessment impacted on the decision making by the Police staff involved. It is the Independent Authors’ view that they do not therefore provide an appropriate basis for believing such risk to be negated. 9.8.12 Derbyshire agencies have Multi Agency Risk Assessment Conference (MARAC) arrangements in place for domestic abuse cases51. The Derbyshire Constabulary IMR identifies that this case could have been considered at a future planned MARAC meeting, although it did not meet the criteria for referral on the information known at 28 May 2010. The arrangements do not include provision for convening an emergency MARAC meeting to discuss a specific case, irrespective of how high the risk is assessed to be. This is considered appropriate. The professional operation response to such cases should already have engaged all relevant partner agencies. 9.8.13 Notifying Mother of Father’s release on bail (see 8.9.4) was appropriate. It was concluded that implementing further security measures was not required. This was on the basis of Mother’s view that she was safe in her home and a number of positive aspects of her home security, including that she was not 51 The use of a MARAC will be specific to adults who are at high risk of homicide or serious harm. If a child is living in a household where the risk to an adult has been identified as serious and a MARAC is to be held, the impact of this level of domestic violence on the child should be assessed and a referral to Children’s Social Care should be made. Children’s Social Care will be invited to the MARAC. (Derby and Derbyshire Safeguarding Children Board Procedures, 2008). Risk for the purposes of deciding whether a case should be referred to a MARAC is assessed by Derbyshire Constabulary using a quantitative assessment tool separate to the Form 621 Risk Assessment, scoring risk out of a potential 24. The threshold for referral is 14 although there is discretion to refer with a lower score. living alone. Better practice would have also considered measures to address risks when Mother was outside of her home. 9.8.14 It was identified that Mother’s mindset was one of wanting to help Father. This was viewed as a risk factor and she was advised not to return Father’s clothing to him (see 8.9.4). It is apparent from the actions of Mother in keeping her door locked and warning her cousin to do likewise that she considered him to pose at least some risk to her and her family. It is however clear that Mother was not fully convinced to avoid all contact with Father and to report any attempt by him to contact her (see 8.9.16-19). Her rationale for not reporting Father’s actions over the following days to the Police is not known. 9.8.15 The Derbyshire Constabulary response to the call from Father’s neighbour on the evening of 28 May 2010 (see 8.9.12-14) was generally appropriate and proportionate. It is unclear if Mother was informed of the remark made by Father and it would have been good practice to do so. 9.8.16 In the absence of Father’s subsequent actions being reported nothing further could reasonably have been done by the Police to address the risk from him. 9.9 1 and 2 June 2010 9.9.1 There was some delay within Children’s Social Care, in recording the Police referral on their systems and agreeing the course of action to be taken (see 8.10.1-2). The Children’s Social Care IMR identifies that this was within the applicable procedural timescales, which require that a decision be taken on how to progress a case within 1 working day. This is technically correct. It would be more robust practice to have arrangements in place to conduct at least an initial risk assessment of incoming referrals prior to weekends. This is particularly so where a bank holiday introduces further potential delay in responding. 9.9.2 Once the decision had been taken that the case required an Initial Assessment (see 8.10.4) placing the referral in a queue for allocation, with no further action being taken until that occurred. This led to no response being given prior to the death of BDS. The circumstances outlined in the referral should have prompted at least contact with relevant health professionals and seeking further updated information from the Police. 9.9.3 The Children’s Social Care IMR appropriately identifies the referral processing system issues behind this as requiring attention. A recommendation is made in that regard. Notwithstanding this it is apparent that three other factors contributed to the lack of a swifter response by Children’s Social Care. 9.9.4 First, resource capacity within the team concerned significantly impacted on their ability to maintain effective standards. The Children’s Social Care IMR makes an appropriate recommendation in this regard. Second, the referral was one of 291 notifications received from Derbyshire Constabulary that month in relation to domestic violence issues and all were headed as referrals under Section 17 Children Act 1989. This level of such referrals is typical. Third, as previously noted, there is a lack of understanding by Children’s Social Care staff of the Police risk assessment process. In those circumstances it is perhaps inevitable that the default position would be other than to conduct the checks with other agencies which would provide a context for effectively risk assessing and prioritising such referrals. 9.9.5 Had the situation of BDS been subject of a referral under Section 47 Children Act 1989, a more urgent response by Children’s Social Care may have been provided. In all likelihood this would have involved a strategy discussion with the Police and at least telephone contact with Mother and the health professionals involved with Father. 9.9.6 A significant consequence of the approach taken was that it did not provide the potential for Father’s GP to be aware of the recent events when he spoke with Father on 1 June and saw him on the morning of 2 June 2010 (see 8.10.6, 8.10.8 & 8.10.12-16). 9.9.7 On 1 June 2010 the Amber Trust Support Worker learned of events the previous week (8.10.9-10). She took the view that Father’s threats had been made in an attempt to manipulate Mother on the issue of contact. The circumstances should have been discussed with the Worker’s manager and advice taken on how to respond. It would have been appropriate to include contact with DMHS and preferably Children’s Social Care in this. 9.9.8 That this did not take place reflects an approach to risk that was earlier evident when decisions were taken to rely on the DMHS risk assessment following acceptance of Father as a client and in response to the decision by DMHS not to visit Father at home. The Amber Trust IMR appropriately makes recommendations in relation to both the recognition of concerns for children and risk assessment. 9.9.9 When Father spoke with his GP on 1 June 2010 (see 8.10.6-8) the doctor was aware of the mental health assessment carried out on 26 May 2010. He was not aware of Mother’s pregnancy or of the subsequent threats and Police intervention. The GP has indicated that risk to BDS and Mother was considered but that Father was not felt to pose such risk. No enquiry was made to ascertain why contact by Father with BDS had been withdrawn. The absence of specific indications of such risk from the professionals who assessed Father on 26 May 2010 was likely to have contributed to the view taken. 9.9.10 When Father saw his GP on 2 June 2010 the perceived threat against the GP seems to have been appropriately explored by him and nothing in Father’s response to this or in their subsequent conversation gave any hint of intended violence. 9.9.11 The response provided by both Derbyshire Constabulary and East Midlands Ambulance Service to the neighbour’s call on the morning of 2 June 2010 was both timely and wholly appropriate. The decision to convey BDS to hospital whilst attempting resuscitation, although not identified as such by the Ambulance Service summary report, was in accordance with the applicable JRCALC52 guidelines. At the Royal Derby Hospital the continued attempts at resuscitation were also timely, appropriate and involved staff of the correct seniority. 9.9.12 It is clear from the circumstances found by Derbyshire Constabulary on that date that, for unknown reasons, Mother had granted Father admission to her home, following which Father had taken action to prevent her leaving. 9.10 Diversity Issues 9.10.1 The requirement to consider diversity issues in relation to the subjects of this Review is included in the Terms of Reference. It is also encompassed within the requirement to prepare IMRs in accordance with Chapter 8 of Working Together to Safeguard Children (2010). 9.10.2 Many of the IMRs do not provide a discrete commentary on their treatment of diversity issues and those that do are largely confined to statements that there were no issues which had a bearing on practice 9.10.3 Ethnicity was generally recorded appropriately by professionals. In addition a number of assessment tools which included identification of other diversity issues were completed. There is little evidence that the impact of such factors on the needs of family members was actively considered. Notwithstanding this, it is apparent from both the content of the IMRs and information provided by those family members interviewed that none of the review subjects had particular needs relating to their ethnicity, gender, sexual orientation, religious identity, linguistic ability or other disability. 9.10.4 The one significant diversity issue in this case was Father’s mental health problems. These were central to the practice of those agencies engaged directly in providing services to him. They were also appropriately considered on each occasion that Father came into contact with staff of Derbyshire Constabulary. 9.10.5 With hindsight, there was also a cultural issue within Mother’s family of avoiding the creation of attention, most succinctly put by her mother that “her family were not the sort of people who had the Police visit their homes”. This is likely to have impacted on the way that Mother approached professional intervention. There is no indication that this was recognised by any professional, the view generally being taken that she was a strong and capable person. This is considered by the Serious Case Review Panel as likely to have led to underestimation by professionals of her vulnerability. 52 Joint Royal Colleges Ambulance Liaison Committee’s (JRCALC) Ambulance Service Clinical Practice Guidelines (2006) CONCLUSIONS AND LEARNING FROM THE REVIEW 10 Predictability 10.1 Hindsight represents a valuable tool for understanding events in reviews such as this and for the analysis from which learning may be achieved. It is however important to apply this with caution, particularly when reaching conclusions on whether events could have been predicted or prevented by the professionals and their organisations. Care has been taken to reach such views on the basis of information which was known at the time, placed within the relevant organisational context. 10.2 Taken at face value the threats reported to the Police as having been made by Father on 27 May 2010 are believed to have been carried out by him on 2 June 2010. The question is therefore whether Mother’s report, in the context of other information available to professionals, provided a basis on which the eventual outcome could have been reasonably predicted. There are a number of factors which suggest that this would not be the case. 10.3 Derbyshire Constabulary receive in the region of 150-160 reports of Threats to Kill” each year (see 6.6.4). Their IMR identifies that this is the only one of those reports over at least a three year period which has been followed by enactment of the threat. The Police had no information from their contact with Mother and Father (see 9.7.17, 9.8.2 & 9.8.17) or regarding Father’s mental health issues (see in particular 9.7.10-12 & 9.7.20-21), which would have effectively discriminated this case from any of the other “Threats to Kill” reports. 10.4 The Police were not informed, and remained unaware, of Father’s actions subsequent to his release from custody, in particular his visits to the locality of Mother’s address (see 9.8.16). 10.5 DMHS professionals, who had most knowledge of Father, remained unaware of the events on and subsequent to 27 May 2010. Other agencies and professionals had at most partial information regarding these events. 10.6 More widely, research53 indicates that the incidence of murder-suicide is stable both over time and throughout the Western world at 0.2 to 0.3/100,000 of population each year. This may seem to present a not uncommon scenario. It is important to recognise that only a small proportion of these, around 6%, involve the murder of a child and still less the annihilation of a family. This equates to less than one such incident every 15 years in a county the size of Derbyshire. That such occurrences may appear to be more frequent is undoubtedly a facet of the media attention which they attract. 10.7 Father and the context of the events which led to this Review share many of 53 SH Friedman et al (2005) Filicide-Suicide: Common Factors in Parents Who Kill Their Children and Themselves, Journal of the American Academy of Psychiatry and the Law, 33:4:496-504 S Eliason (2009) Murder-Suicide: A Review of the Recent Literature, Journal of the American Academy of Psychiatry and the Law, 37:3:371-376 the characteristics of others in which a parent has killed their child and themselves. These include depressive mental illness and involvement with mental health professionals, withdrawal or estrangement of a partner and absence of a prior criminal offending history. It should however be emphasised that only an extremely small number of those individuals sharing these characteristics do commit such acts. 10.8 On this basis the Review has concluded that no individual or agency could have reasonably predicted that Father would kill BDS and Mother, thereafter taking his own life, as is believed to have occurred on the morning of 2 June 2010. 11 Preventability 11.1 Although the actual events on 2 June 2010 were not predictable the risk assessment conducted consequent to Mother’s contact with Derbyshire Constabulary on 27 May 2010 did indicate that he posed a serious risk to her. 11.2 Whilst the focus of the risk assessment was on mother and the degree of risk may have been different for BDS, this must be regarded as involving a risk of significant harm to him, Mother was BDS’ main caregiver and any contact between Mother and Father would almost invariably involve BDS. 11.3 For this and the information available to professionals consequent to the events on 27 May 2010 to have potentially prevented the death of BDS would however have required one or more of the following interventions by agencies, either singly or in collaboration: Restricting Father’s liberty, to the extent that he could not get access to Mother and BDS (either in connection with criminal proceedings or on the basis of his mental health). Surveillance, with an on hand intervention capability, of Father, or Mother and BDS. Mother being convinced that she should actively and effectively protect herself and BDS from any contact with Father. Intervention which would compel Mother to adopt the above approach on the basis of risk posed to BDS Removal of BDS from Mother. 11.4 Derbyshire Constabulary did advise Mother not to have contact with Father following his release from custody. This did not however convince her of the risk that Father posed, to completely avoid contact with him or to report his subsequent actions to the Police. 11.5 The other contingencies at 11.3 above were not legally and proportionately available to the agencies and professionals involved with the family on the basis of information known to them at the time. 11.6 Notwithstanding the above this Review has identified better practice which could have been applied by agencies and professionals between 27 May and 2 June 2010: Sharing by the Clinical Psychologist of information that Mother was pregnant by her new partner, and the potential impact of this on Father, with other relevant health professionals (see 9.7.4-5). DMHS professionals pursuing the assessment of Father planned for 27 May 2010 (see 9.7.15-16). Availability and utilisation of better arrangements for accessing records within DMHS; together to more effective communication with Derbyshire Constabulary on the evening of 27 May 2010 (see 9.7.2-23). Derbyshire Constabulary Officers making a referral to Children’s Social Care under Section 47 Children Act 1989 outside of the domestic violence protocol procedure (see 9.8.10-11 & 9.9.5). Children’s Social Care processing the Police referral more swiftly, conducting lateral checks with other agencies and providing a more urgent and robust response (see 9.9.1-4). In this regard it is clear that even if child protection procedures had been engaged there would not have been immediate grounds for removing BDS from the care of Mother. The Amber Trust liaising with DMHS and / or Children’s Social Care on the content of the communication with Mother and Father on 1 June 2010 (see 9.9.7). 11.7 Prior to the afternoon of 27 May 2010, with the exception of the risk assessment in August 2009 (see 8.6.2 & 9.5.2-3), there were no occasions when professionals could reasonably have predicted that Father posed a threat of serious physical harm to Mother or BDS. 11.8 It should have been identified by those professionals providing services to Father that his mental health problems were likely to impact on the welfare and development of BDS. Key issues were Father’s behaviour, self neglect and suicide ideation, together with Mother’s role as a carer for him. That should have led to engagement of both Mother and the health professionals providing services to BDS in assessing and addressing these issues. 11.9 In this connection some of the IMRs contributing to this Review have not placed sufficient emphasis on the potential for multi-agency arrangements to add value to that of agencies acting in isolation. 11.10 A more robust approach to the impact on Mother herself of acting as informal carer for Father may also have facilitated Mother disengaging from Father’s life. It is unknown what impact this may have had on the eventual outcome. 11.11 In early 2010 DMHS professionals identified that Father may have a Personality Disorder, possibly in conjunction with the depressive illness for which he was being treated (see 9.6.11-13). This Review has not established whether earlier recognition of this possibility or a different response might have impacted on the events under review. 12 Learning Themes 12.1 Underlying the above issues are six themes, albeit in many cases inter-related, within which the main learning from this Serious Case Review is identified: Focus on the child. Mental Health. Support for Carers. Risk Assessment. Response to Domestic Abuse Incidents involving Children. Information Management. 12.2 These are explored more fully in sections 15 to 21. 13 Learning from previous Serious Case Reviews 13.1 A previous Serious Case Review in Derbyshire54, resulting from events which bear a number of similarities to those of this case, identified some of the areas where services should be improved which are reiterated here. A second, earlier Serious Case Review55, whilst arising from somewhat different circumstances also made recommendations on assessment and documentation issues which are relevant to the findings of this Review. 13.2 These Serious Case Reviews led to the implementation of action plans which included: Review of DMHS policies with consideration of including provision for joint assessments with GPs in cases where a patient is reluctant to engage with mental health services. Development of a joint assessment tool for use by Health Visitors, CPNs, Social Workers and primary health care professionals in assessing the needs of children of parents with mental health problems. Inclusion in training and prompts to GPs and DMHS staff that children should not be considered a protective factor for parents who feel suicidal; and of the impact of parental behaviour on children. Inclusion in training provided by the DSCB and to GPs of the need to share information (with Health Visitors and Midwives) regarding parental mental health issues. Highlighting the need to ensure effective information recording and develop systems to monitor compliance. 13.3 The action plans developed have been completed. The underlying learning from these reviews was not however translated through the recommendations into “SMART”56 actions which were likely to embed the intended changes in professional practice. Further, the monitoring arrangements did not ensure that the action taken had impacted on practice and led to improved outcomes for children and their families. 13.4 Consequently some areas for development identified by those reviews remained evident in the way that agencies approached the needs of BDS and 54 Derbyshire Safeguarding Children Board Serious Case Review in respect of Child K (July 2008) 55 Derbyshire Safeguarding Children Board Serious Case Review in respect of Baby R (March 2007) 56 Specific, Measurable, Achievable, Realistic, Time-bound his family. 13.5 It is therefore recommended that: Monitoring by Derbyshire Safeguarding Children Board should ensure that changes recommended by Serious Case Reviews have been fully embedded in practice and have had the intended impact on outcomes for children and their families. The Board should consider what further action may be required to reassure them that the plans from Serious Case Reviews completed during the last four years have met these criteria. 14 Learning from the Individual Management Reviews 14.1 In addition to the themes outlined at sections 15 to 21 the IMRs which contributed to this Review identified a number of other areas where services should be improved. These include: Delivery, Management and engagement with the Care Programme Approach. Delivery of the Health Visiting Core Programme. Avoidance of “Professional Dangerousness”57. Delivery of a ‘Think Family’ approach in urgent health care settings. Electronic inter-agency referral arrangements. 14.2 Recommendations arising from these areas of learning are included in the IMR recommendations detailed at Appendix E. 15 Focus on the Child 15.1 The voice of BDS was not well heard in this case and reports of him as an individual are limited. 15.2 Although too young to talk, more detail of BDS’ presentation could have been recorded and analysed. 15.3 Mother was committed to Father remaining part of BDS’ life, even after her relationship with him ended. 15.4 She was sufficiently concerned about Father’s ability to care for BDS that he was never left in the unsupervised care of his father. Despite this those organisations providing care for Father lacked focus on the needs and development of BDS. 15.5 There were isolated examples of BDS’ welfare being considered, for example when Mother took Father to the hospital on 26 December 2008 (see 9.3.4). The risk that Father’s health problems might pose to BDS welfare and development, both directly or through their impact on Mother’s parenting 57 CALDER M (2008) Professional Dangerousness: Causes and Contemporary Features in Contemporary Risk Assessment in Safeguarding Children. Russell House, Dorset. capacity, was however never properly professionally assessed. A significant factor in this was a concentration on Father’s risk of self harm and of immediate physical harm to others. This was to the exclusion of considering the wider impact of Father’s condition and behaviour. 15.6 Further, no action was taken to share information regarding Father’s mental health issues with any professional who had the relevant remit and expertise to focus on the interests of BDS. This was also the case in relation to the risk to BDS identified August 2009 (see 9.5.2-3). In some cases conscious decisions were taken not to share information. Those professionals mainly involved in BDS’ life, the Health Visitor and Midwife, therefore remained unaware of Father’s mental health issues. 15.7 The lack of focus on BDS was also contributed to by the perception of the professionals involved with Father that through Mother’s capability as a carer she was able to effectively manage such impact. 15.8 Even more concerning was that BDS was on occasion viewed by professionals as a stabilising and protective element of Father’s context, serving to reduce his risk of self harm. This view was inappropriate and demonstrated a serious disregard for BDS’ interests. 15.9 These issues featured in a previous Serious Case Review in Derbyshire (see 13.2). They have also been well rehearsed in the biennial analyses of Serious Case Reviews58, which have identified this as a form of “Silo” practice. 15.10 National guidance on safeguarding addresses and provides guidance on these issues59. Working Together to Safeguard Children (2006) is the version available during most of the review period. It clearly states that although mental illness in a parent or carer does not necessarily have an adverse impact on a child’s developmental needs, it is essential always to consider its implication for each child. 15.11 It is clear that these messages have not led to the requisite focus on the potential impact that adult mental health problems may have on children being embedded in the practice of those professionals working with these adults. 15.12 It is therefore recommended that: Derbyshire Safeguarding Children Board should ensure that all partner agencies working with adults who have mental health problems consistently share information with child health professionals and engage them in assessment and planning processes. This should be in respect of any child with whom the adult has frequent contact, or is likely to have such contact with an unborn child. The default approach to these circumstances should be assessment of the child’s needs under the Common Assessment Framework. This should not be seen as an alternative to referring the child to Children’s Social Care where a 58 For example, Understanding Serious Case Reviews and their Impact. A Biennial Analysis of Serious Case Reviews 2005-7, M Brandon et al (2009) 59 For example, Think Parent, Think Child, Think Family. Social Care Institute for Excellence (July 2009) risk of significant harm is identified. 15.13 It is also recommended that: Derbyshire Safeguarding Children Board should ensure that the need to assess and address the potential impact on children of adult mental health problems is embedded in professional consciousness and practice. The Board should emphasise that children must not be considered a protective factor for adults who are self harming or experiencing suicide ideation. 16 Mental Health 16.1 Throughout the period that Father was engaged with DMHS he was treated for and his care plan focussed on depressive illness. The treatment and management of his condition was in accordance with NICE Guidelines60 for that type of condition. 16.2 In March 2010 it was speculated that Father may have a, possibly co-existing, Narcissistic Personality Disorder or Dependant Personality Disorder with narcissistic traits (see 9.6.11-12). The DMHS IMR identifies that if a Personality Disorder was present this would have explained why his treatment (under the NICE guidelines for depressive illness) appeared ineffective. There was not however, then or subsequently, a firm diagnosis of this and it remains a matter of debate whether such a diagnosis could be sustained. 16.3 A Consultant Forensic Psychiatrist who contributed to the DMHS Internal Investigation is of the view that there were signs of Personality Disorder from Father’s early contact with DMHS in June 2008. There were occasions when his response to treatment did not fit with the pattern of a biological illness and the pattern of his behaviour was often controlling, rather than suggestive of depression. It was acknowledged that there was evidence of Father being depressed and that the two conditions can co-exist. 16.4 Conversely a Consultant Forensic Psychiatrist commissioned by HM Coroner concluded that “The primary diagnosis, in my view, is a severe and recurrent depressive illness and on the evidence available it is not possible to make a diagnosis of Personality Disorder.” The most, in his opinion, that could be said was that “…personality attributes may well have been excessively exacerbated by the depressive illness.” 16.5 Neither professional gave evidence at the Inquest and their differing perspectives therefore remain untested. 16.6 Identification and diagnosis of Personality Disorder is not straightforward and may rely on identification of characteristics that develop over time, often 60 National Institute for Clinical Excellence CG 90 Depression in Adults: NICE Guidance on Depression (2009); National Institute for Clinical Excellence CG 90 Depression in Adults: NICE Guidance on Depression (An update) (2010) requiring recognition of discrepancies between different sources of information. To do this effectively requires coherent and clear recording of information together with triangulation from significant sources other than the service user. It therefore seems likely that the shortcomings of the documentation systems and recording practice within DMHS contributed to possibility of Father having a Personality Disorder not being considered earlier. The DMHS IMR makes an appropriate recommendation for improvements in this area. 16.7 Once the possibility of Father having a Personality Disorder was raised, the investigation of this was undermined by the effective delegation of responsibility for Father’s care to his GP (see 9.6.19-22); albeit this was in recognition of a decision by Father, which he had both the capacity and right to make, to access treatment through that route. It is questionable to expect that the GP would be able to effectively explore the potential diagnosis and, if necessary, develop an appropriate treatment and care regime in the context of normal GP practice without considerable support and advice from mental health clinicians. The DMHS IMR makes recommendations which are likely to ensure that such support is provided. 17 Support for Carers 17.1 Caring for a person with mental health problems may be at considerable personal cost. This is recognised within the National Carer’s Strategy (2008) which defines a carer as someone who spends a significant amount of their life providing unpaid support to family or potentially friends, caring for a relative, partner or friend who is ill, frail or disabled or has mental health or substance misuse problems. It is also reflected in Derbyshire Mental Health Services NHS Trust Care Programme Approach and Care Standards Policy and Procedures61. 17.2 It was known to DMHS and other professionals that Mother was the key person supporting and caring for Father. Assessment of her role as an Informal Carer was considered on two occasions by DMHS professionals (see 9.1.14 & 9.4.14-15). Despite this she was never afforded the benefit of a Carer’s Assessment by DMHS as the lead agency providing mental health services to Father. 17.3 The impact on Mother of caring for Father was also not recognised by his GP or within Amber Trust, although both were equally aware of the extent to which she was undertaking this role. While DMHS had lead responsibility in this regard it would have been good practice for these professionals to have prompted DMHS to offer an assessment. 17.4 That Mother herself did not request a Carer’s Assessment is likely to have 61 Derbyshire Mental Health Services NHS Trust Care Programme Approach and Care Management Policies and Procedures (2009). This has since been superseded by the Derbyshire Mental Health Services NHS Trust Policy for Assessing the Needs of Carers (2010) which states that carers who provide substantial and regular care for an individual, for which they are not paid a salary or fee, are legally entitled to an assessment of their caring, physical and mental health, leisure, educational and employment needs. been contributed to by two factors. First, there is no indication that Mother was aware of the organisational approach to supporting informal carers. Second, her family report that Mother inherently presented as a strong capable woman and is likely to have viewed making such a request as appearing weak. 17.5 Had an assessment taken place there is no guarantee that Mother would have accepted any services offered and it is unknown how these may have impacted on subsequent events. 17.6 Such assessment would however have provided an opportunity to explicitly distinguish between the carer role of Mother and that of a mother who wanted her child to maintain contact with his father. 17.7 In this connection recognition as an Informal Carer would have provided a mechanism through which she could explicitly withdraw, in a supported way, from the expectations placed upon her by professionals and Father. The opportunity to do this may have been taken by Mother, particularly in the spring of 2010 when she had started her new relationship, was again pregnant, identified the extent to which she was being manipulated by Father and informally stated that she would no longer provide care for him. 17.8 The conclusion of the DMHS IMR that anyone providing informal care should be offered a Carer’s Assessment is appropriate, although it is considered that conducting such an assessment should be the default position. Further, ensuring it takes place should extend to all agencies providing services to those with mental health problems. Even if the carer declines to participate the impact of undertaking that role should be assessed and regularly reviewed. 17.9 In addition to its impact on the carer it is clear that undertaking such a role will inevitably impact on the carer’s children. Any assessment of the carer’s needs should therefore also take into account the needs of any children involved. 17.10 It is therefore recommended that: All partner agencies of Derbyshire Safeguarding Children Board providing services to those with mental health problems should arrange for the impact on and needs of those providing informal care to be assessed. Such assessments should be reviewed at least annually. The arrangements should also provide for assessment of any child likely to be affected by the caring role through the Common Assessment Framework. 18 Risk Assessment 18.1 DMHS had in place appropriate risk assessment arrangements and utilised the FACE Risk Profile for the assessment and management of clinical risk. The FACE Risk Profile is a properly validated tool. Such tools are however only as good as their application and the risk management plans that they lead to. The DMHS IMR makes an appropriate recommendation for action to address deficiencies in their risk assessment practice. When implementing that recommendation it should be ensured that all of the following issues are addressed. 18.2 There was an over concentration on assessing risk of self harm and suicide by Father. It is unclear whether Father’s passive aggression in refusing to leave Mother’s car or his angry outbursts in May 2010 were given appropriate weight. This was accompanied by lack of consideration of the longer term impact on BDS of Father’s withdrawal, self neglect and thoughts of suicide, together with the indirect impact through Mother’s role as his carer. 18.3 There was a less than robust response to the, albeit transient, recognition of risk at the start of Father’s August 2009 hospital admission, accompanied by a failure to comply with the risk assessment processes for child visitors (see 9.5.2-6). 18.4 On a number of occasions there were inadequacies in completion of the risk profile documentation. 18.5 In formulating risk profiles there was an over-reliance on self reported information without adequate attention to triangulating this from other sources. This, together with the disparate record systems in place within DMHS undoubtedly delayed recognition that Father had provided self serving misinformation, identification of which should have led to review of his risk profile. 18.6 Finally, Father’s risk profile was not consistently reviewed when his circumstances and presentation changed. In particular the last FACE Risk Profile completed was in March 2010. There were missed opportunities to revisit and update this as the presentation and view taken of Father’s mental health condition, his social context and his behaviour changed. 18.7 It is clear that the risk posed by Father was considered by the GP, most particularly on 1 and 2 June 2010. Where an adult’s mental health problems may impact on a child it would be appropriate to involve those primary health care professionals with a focus on the child in this process. The arrangements outlined in the recommendation at 21.2 of this Review are considered adequate and appropriate to facilitating this. 18.8 The Amber Trust also had available a risk assessment tool. It is however apparent that risk assessment within that organisation was not robustly incorporated into practice, most clearly demonstrated when they were notified of the DMHS decision to discontinue home visits (see 9.6.10). The remit of the Amber Trust for management of risk associated with their clients is somewhat more limited than that of the other professionals and the statutory agencies involved in the care of Father. Nevertheless these issues should be addressed and the action recommended by the Amber Trust IMR is appropriate. 19 Response to Domestic Abuse Incidents involving Children 19.1 The risks to the safety and welfare of children associated with domestic abuse are well established62 and it is commonly a factor in families where serious harm to a child occurs63. Such risks may be of direct physical / sexual harm or from the longer term pernicious effects of exposure to such violence. These are recognised in the Adoption and Children Act 2002 as including impairment suffered from seeing or hearing of the ill treatment of another. 19.2 Exposure of children to domestic abuse is also pervasive. Lord Laming64 highlighted that some 200,000 (1.8%) children in England lived in households where violence is a known risk. Owing to under reporting of such violence the actual number is likely to be significantly higher. 19.3 Responding effectively to cases where children are exposed to domestic abuse requires arrangements to be in place which engage relevant agencies in assessing and cooperatively addressing both risk to the child and their welfare and developmental needs. Responses may thereby be appropriately targeted and prioritised within the resources available. 19.4 In many cases this may be the provision of support services by statutory or third sector organisations on the basis of an initial assessment or engagement of the Common Assessment Framework. In the case of children at risk of significant harm this should however be in accordance with Local Safeguarding Children Board Child Protection Procedures. 19.5 In relation to BDS the Police risk assessment on 27/28 May 2010 did not lead to the engagement of child protection procedures, but was dealt with under the multi-agency protocol between key statutory agencies for responding to children exposed to domestic abuse (see 9.8.5-12). 19.6 Within this there were individual practice issues. That child protection procedures were not engaged however stemmed from operation of the protocol itself. 19.7 It was recognised at the outset of this Review that the protocol arrangements were flawed and the Derbyshire Constabulary IMR identifies that deficiencies in the arrangements had been known for some time previously. 19.8 Significant underlying issues include: A lack of understanding and shared ownership across agencies of the aims behind the protocol. This was exacerbated by the impact on its application of resourcing and defensibility considerations. Screening which involves a risk assessment model that is adult focussed, on which there is no shared understanding across agencies of what is being assessed and which gives too many false indications of high risk. A mechanistic approach to risk assessment and referral that does not involve consideration of the nature of a child’s needs or the service expected from the recipient agencies. Referral processes which conflate risk with the welfare and developmental 62 Working Together to Safeguard Children (2010) 9.17 et seq. 63 For example, Understanding Serious Case Reviews and their Impact. A Biennial Analysis of Serious Case Reviews 2005-7, M Brandon et al (2009) 64 The Protection of Children in England: Progress Report, Lord Laming (2009) needs of children. At a practical level, the use of fax arrangements which tend to introduce delay in the referral process. 19.9 In that regard the decision of the Derbyshire Safeguarding Children Board at the outset of this Review process (see 3.6) to commission an immediate review of the current domestic violence protocol by the Children’s Social Care departments, Police and Primary Care Trusts in Derbyshire and Derby City was entirely appropriate. 19.10 This work must ensure that the multi agency arrangements for responding to children exposed to domestic abuse are underpinned by appropriate application of thresholds for referral and intervention. The review should specifically address this issue. 19.11 Significant progress has been made with that review and led to positive current or imminent service improvements: Children’s Social Care Child Protection Managers and health professionals have been collocated with the Police Child Abuse Central Referral Unit to improve opportunities for advice, support, consultation and information sharing. This should ensure that all referrals contain appropriate information. It has been agreed that all child referral information from the Police to Children’s Social Care should be transferred electronically (replacing current fax systems) and that the Derbyshire County Council Call Centre will then distribute referrals to the appropriate district offices. This includes agreement to pilot secure email software that meets the requirements of both organisations. A senior practitioner grade Social Worker will work in the Derbyshire County Council Call Centre to decide the threshold and route for all children’s referrals. All those directed to Children's Social Care will receive an Initial Assessment; those requiring use of the Common Assessment Framework will be directed to the multi agency teams or to the practitioner most closely involved with the child. The ACPO “DASH65” risk assessment tool for use in cases of domestic violence, and which includes an additional focus on children, is being implemented by Derbyshire Constabulary. 19.12 It is essential that the impact of the developments arising from the review is assessed to gauge whether additional work is required. 19.13 It is recommended that: Derbyshire County Council, Derbyshire Constabulary and NHS Derbyshire County should specifically address the application of thresholds for referral and intervention in their review of the multi agency domestic violence protocol. They should jointly report to Derbyshire Safeguarding Children Board in November 2011 on the outcomes of the review and the impact of the measures implemented as a result. 65 Association of Chief Police Officers Domestic Abuse, Stalking and Harassment and Honour Based Violence risk assessment model (2009). 20 Information Management 20.1 This Review, in common with most similar reviews, has identified deficiencies in the management of information by the agencies involved with BDS and his family. 20.2 Information Gathering 20.2.1 Details of both parents health, background and social circumstances, even if not living together, are crucial pieces of information required to inform any assessment of a child’s situation, including the risk of harm. With the exception of within DMHS this information was not comprehensively gathered or collated (e.g. 9.1.1; 9.1.17). The most significant consequence of this was that Father’s mental health condition remained unknown to the Derbyshire Community Health Services and Royal Derby Hospitals NHS Trust professionals engaged with Mother in connection with BDS and latterly her second pregnancy. 20.2.2 Use of the Framework for Assessment of Children and their Families66 by these professionals should have ensured that this information was gathered as part of their assessment of parenting capacity and environment. However it was not, even following the oblique remarks made by Mother to the Midwife regarding her relationship with Father in April 2010 (see 9.6.15). 20.2.3 This, in combination with the failure of all professionals engaged with Father to recognise that information regarding his mental health should be shared with the Midwife and Health Visitor severely undermined the assessments on which service provision to Mother and BDS was founded. It seems likely, and would have been appropriate, that possession of this information would have triggered engagement of the Common Assessment Framework. 20.2.4 The DCHS IMR effectively addresses these issues, together with that of potential professional over-familiarity which may have contributed to the practice applied. Recommendations on this area of practice are made by both the DCHS and RDH IMRs. These must however be accompanied by robust audit arrangements, as also recommended by the DCHS IMR, in both Trusts. This is addressed by the recommendation at 21.1 of this Review. 20.2.5 A lack of effective information gathering to inform assessments and decision making was also evident within Children’s Social Care in October 2008 (see 9.2.3) and on 1 June 2010 (see 9.9.1 & 9.9.5). In both cases obtaining further information from the referrer and conducting lateral checks with other agencies would have enhanced the quality of the decisions made. The Children’s Social Care IMR makes an appropriate recommendation for improvement in this area of practice. 20.3 Documentation 66 Framework for Assessment of Children and their Families (HMSO, 2000) 20.3.1 A number of organisations have identified deficiencies in the recording of information by professionals around demographic and contextual information. These included the omission of individuals attending a contact, the identification of professionals (both those completing records and those consulted) and detail of conversations. 20.3.2 These issues have made the gathering of information for this Review difficult. More crucially they will have impaired information sharing between professionals and the quality of any resultant analysis and planning. 20.3.3 All agencies have policies on record keeping standards. Maintaining compliance with these standards seems, however, to represent an enduring problem, perhaps inevitably in systems which involve human factors. 20.3.4 This is a recurring theme in cases which are subject of Serious Case Reviews locally67 and nationally. 20.3.5 A key strategy to address this must therefore be to have effective audit and supervision arrangements in place. Many of the IMRs recommend action in this area. This is not however universal. 20.3.6 It is therefore recommended that: Derbyshire Safeguarding Children Board should obtain assurance from all of its partner agencies that they have in place arrangements for the routine audit of recording systems and are effectively addressing practice which falls below expected standards. 20.3.7 The DMHS IMR appropriately identifies that their current case file system (see 9.4.12) is a barrier to such records to effectively supporting practice. Most significantly, in conjunction with the failure, from August 2009 onwards, of Father’s Care Coordinator to ensure that a properly documented CPA Care Plan was available (see 9.4.10), this severely undermined the ability of professionals dealing with Father to readily and effectively understand his former and current circumstances (e.g. 9.7.11). It was also detrimental to identification of discrepancies between elements of the information held (e.g. 9.6.17). 20.3.8 The recommendation of the DMHS IMR for development of a single integrated electronic patient record system is therefore considered appropriate and this should be prioritised by that Trust. 20.4 Information sharing 20.4.1 Safeguarding the welfare of children requires effective information sharing across and within agencies. In this case there were significant failures in information sharing between professionals and agencies providing services to Father and those concerned with BDS. The IMRs appropriately identify that enhancements to the communication arrangements within primary health care 67 Including in, for example, Derbyshire Safeguarding Children Board Serious Case Review in respect of Baby R (March 2007) settings and for providing access to information held by mental health professionals are required. Recommendations are made to address this. 20.4.2 The most significant issue in this case was not however the absence of information sharing arrangements, or the policies and procedures associated with this. It is clear that these were in place and supported by appropriate guidance68. It was the lack of focus on BDS and consequent recognition that information ought to be shared. This has been addressed above. No additional recommendation is therefore made in respect of information sharing. 68 Derbyshire Safeguarding Children Procedures (2008) Information sharing: Guidance for practitioners and managers; Department for Children Schools and Families (2009) 21 Recommendations 21.1 Monitoring by Derbyshire Safeguarding Children Board should ensure that changes recommended by Serious Case Reviews have been fully embedded in practice and have had the intended impact on outcomes for children and their families. The Board should consider what further action may be required to reassure them that the plans from Serious Case Reviews completed during the last four years have met these criteria. Timescale: 6 months 21.2 Derbyshire Safeguarding Children Board should ensure that all partner agencies working with adults who have mental health problems consistently share information with child health professionals and engage them in assessment and planning processes. This should be in respect of any child with whom the adult has frequent contact, or is likely to have such contact with an unborn child. The default approach to these circumstances should be assessment of the child’s needs under the Common Assessment Framework. This should not be seen as an alternative to referring the child to Children’s Social Care where a risk of significant harm is identified. Timescale: 6 months 21.3 Derbyshire Safeguarding Children Board should ensure that the need to assess and address the potential impact on children of adult mental health problems is embedded in professional consciousness and practice. The Board should emphasise that children must not be considered a protective factor for adults who are self harming or experiencing suicide ideation. Timescale: 6 months 21.4 All partner agencies of Derbyshire Safeguarding Children Board providing services to those with mental health problems should arrange for the impact on and needs of those providing informal care to be assessed. Such assessments should be reviewed at least annually. The arrangements should also provide for assessment of any child likely to be affected by the caring role through the Common Assessment Framework. Timescale: 3 months 21.5 Derbyshire County Council, Derbyshire Constabulary and NHS Derbyshire County should specifically address the application of thresholds for referral and intervention in their review of the multi agency domestic violence protocol. They should jointly report to Derbyshire Safeguarding Children Board in November 2011 on the outcomes of the review and the impact of the measures implemented as a result. Timescale: November 2011 21.6 Derbyshire Safeguarding Children Board should obtain assurance from all of its partner agencies that they have in place arrangements for the routine audit of recording systems and are effectively addressing practice which falls below expected standards Timescale: 4 months 21.7 Implementation of the action plans arising from the above recommendations and the IMRs will be monitored by the DSCB Serious Case Review Committee. Progress will be reported to the DSCB Board annually and on completion of the action plans. This activity will be reflected in the DSCB annual report. |
NC044750 | Death of an 11-month-old boy in March 2011, as the result of a serious head injury. Post mortem revealed older fractures and bruising. Mother was arrested under suspicion of causing EY's death. EY was looked after by the local authority until 7 months-old and parents had indicated that they wished him to be adopted; his older brother had not been looked after but parents had considered adoption. Mother concealed both pregnancies, initially concealed the existence of EY from members of her family and later concealed his existence to GP and children centre staff. Injuries to EY were observed by social workers, children centre staff, GP and Health Visitor in the weeks prior to his death. Issues identified include: insufficient recognition of the risks associated with concealed pregnancy; inadequate assessment; superficial engagement with family; underestimation of the risks associated with re-unification following a considerable period of separation; insufficient understanding of role of father and extended family; and non-compliance with child protection procedures in relation to reporting suspicious injuries. Identifies key lessons for practice, including: better coordination of health care for children who are discharged from being looked after; investigation in cases of concealed pregnancy, including the psychological and psychiatric status of parents; and recording in health records that takes account of the needs of other health professionals. Makes various interagency and single agency recommendations, covering: social care, health services and family support services.
| Title: Serious case review: redacted overview report: services provided for EY and OY and members of their families during the period 1 July 2008 – 18 March 2011. LSCB: Windsor and Maidenhead Local Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final version 21 November 2011Redacted - March 2014Serious Case ReviewRedacted Overview ReportServices provided for EY and OY and membersof their families during the period1 July 2008 – 18 March 2011V10Windsor and Maidenhead LSCBIndependent Chair and Serious CaseReview Panel Independent ChairDonald McPhailSerious Case ReviewOverview Report AuthorKeith Ibbetson1Services provided for EY and OY and membersof their families during the period1 July 2008 – 18 March 2011CONTENTSSectionSerious Case Review FindingsPage1.Arrangements for the Serious Case Review (SCR)22.Details of family members and Genogram143.Narrative of agency involvement with the children andtheir family164.Evaluation of the services provided635.Conclusions1616.Recommendations164AppendicesITerms of reference of SCR173IIMembership of the SCR panel174IIIFull list of agency reports and background informationprovided175IVThe contribution provided by the Individual ManagementReviews (IMR)176VBackground documents and references180VIEdinburgh Postnatal Depression screening questionnaire181VIIHeight and weight chart for EY184VIIIBerkshire combined procedures on ‘bruising’185Full recommendations and action plan (recommendationsand actions of the SCR and the IMRs)SeparatedocumentThis report has been anonymised and redacted to ensure that personalinformation about family members that is not already in the public domain is notincluded. The report was written before it was known that the father of OY wasnot the father of EY. He remains referred to as the father in the report as thiswas what professionals believed at the time.21ARRANGEMENTSFORCONDUCTINGTHESERIOUSCASEREVIEWIntroduction1.1This report was prepared for Windsor and Maidenhead LocalSafeguardingChildrenBoard(LSCB)inordertofulfiltherequirements of Chapter 8 of the Working Together guidance.1 Theguidance sets out the arrangements for the local interagencyreview of cases which have given rise to serious concerns aboutthe safeguarding of children and where there may be importantlessons for the local network of agencies with child protectionresponsibilities.Thepurposeofthisreportistohighlightsignificant findings of the review with the objective of improvinglocal child protection practice.1.2The detailed current arrangements for review of such seriouscasesbyLSCBsinBerkshireareintheBerkshireLocalSafeguarding Board Procedures. 2 These reflect national guidanceand the SCR has sought to comply fully with the latest statutoryguidance. The terms of reference of this Serious Case Review(SCR)wereagreedinApril2011inlinewiththestatutoryguidance published on 1 April 2010. The Terms of Reference wereupdated on 23 May 2011 to take account of additional informationabout the case and to ensure that the SCR covered all of the areasin which there was potential learning.1.3ThisdocumentistheLSCBoverviewreportonthe SCR. Itsummarisesandcomplementsthefindingsoftheindividualmanagement reviews conducted by the agencies that were directlyinvolved. The guidance under which the SCR conducted its workprovides for the SCR overview report to be published in full.1.4The review concerns two children: EY was aged 11 months whenhe died on 20 March 2011 and his older brother OY was aged 23months. The children lived with their mother in Windsor andMaidenhead. Their father lived at a separate address in the1 HM Government, Working Together to Safeguard Children – 2010..2 http://berks.proceduresonline.com/chapters/p_ser_case_rev.html3borough as did the mother’s parents who had had some contactwith local services. On the morning of 18 March 2011 EY wastaken to hospital by ambulance. He had suffered a very serioushead injury. This caused his death two days later.1.5At the initial post-mortem examination EY was also found to havesuffered fractures of different ages to his leg and lower arm. Hehadsustainednumerousribfactures,someofthefracturesoccurring at the site of previous fractures. He had large and visiblebruising on his face and forehead and bruises on the trunk. At thispoint little is known about the circumstances of the death, whichare the subject of a continuing police investigation. The post-mortem report indicates that the cause of death was the result ofa ‘significant head injury’, which is ‘virtually impossible to explainother than as the result of non-accidental injury’. The healedfractures are said to have occurred at least two weeks before thedeath of EY. No opinion has been given as to the impact that theseinjuries might have had on EY’s health in the period prior to hisdeath or as to whether the injuries (other than the bruising to theface and head) might have been noticeable. However during thisperiod professionals and members of the public noticed visiblebruising to EY’s head. Section 4.3 of this report evaluates in detailthe reports of these injuries and the response of professionals. Itevaluates the action taken in response to these injuries and thepotential for professionals to have taken steps which might haveled to action to protect EY.1.6The putative father and the maternal grandparents were offeredthe opportunity to contribute to this report but did not take up thisoffer.4The scope, focus and terms of reference of the Serious CaseReview bearing in mind the circumstances of the death ofthe EY and the involvement of agencies1.7Working Together states that the LSCB in the area where the childlived should conduct a SCR when a child has died and ‘abuse orneglect is known or suspected to be a factor in the death’. Thecircumstances fit this criterion. Windsor and Maidenhead LSCBtherefore decided to conduct a SCR. No other LSCB is involved inthe SCR. All of the agencies involved are either located in theborough or health trusts which normally provide a service tochildren and families in the borough and are members of Windsorand Maidenhead LSCB.1.9In reaching the decision the LSCB noted the following backgroundinformation which may have affected professional practice anddecision making in the case and which would require attention inthe review:a number of agencies and professionals with child protectionresponsibilities had been involvedEY had been looked after by the local authority until the age ofseven months although the case was closed by the localauthority three months before he diedEY’s parents had initially indicated that they wished him to beadopteda number of professionals had noticed bruising and scratchesto EY in the weeks before his deathEY’s older sibling OY had not been looked after. Neither of thechildren had been the subject of a child protection plan at anypoint.1.10The recommendation to hold the SCR was made at the SCR groupmeeting on 31 March 2011. The independent chair of the LSCBDonald McPhail made the decision to undertake the SCR on thesame day. Work began at that point to agree the scope and termsofreferenceofthe review.Followingearlymeetings,formalnotifications of the review and the methodology for its conductwere sent to all Windsor and Maidenhead LSCB member agencies.Through a review of agency records the LSCB determined who5should contribute individual management reviews IMRs. A full listof the agencies involved in the review is set out in section 1.15below.1.11The Working Together guidance makes the LSCB responsible fordetermining the scope and terms of reference for the SCR takingintoaccountthecircumstancesoftheparticularcase.Consideration was given to this within the SCR panel and therewas also consultation with participating agencies. The generalterms of reference for the SCR adhere to the objectives for SCRsset out in the Working Together to Safeguard Children 2010:to draw together a full picture of the services providedto establish whether there are lessons to be learned from acase about the way in which local professionals and agencieswork together to safeguard childrento identify clearly what those lessons are, how they will beacted upon and what is expected to change as a result, andhenceimproveinteragencyworkingandbettersafeguardchildren1.12The terms of reference agreed for this review are set out in full ina separate document. Key sections highlighting the focus of thereview are reproduced as Appendix 1 to this document. The Termsof Reference address issues identified in Working Together toSafeguard Children 2010 as being of general relevance and alsoissues specific to the case history. The terms of reference werefollowed by the authors of individual management reviews and theindependent author of this overview report which provides achronological account of agency involvement with the family andthen focuses on the following questions and themes which areevaluated in detail in Section 4:historical information (prior to 1 July 2008) on the familymembers about factors that may have impacted on theparenting capacity of the mother or the fatherthe quality of assessment of circumstance relating to thechildren and their familyfactors that helped or hindered the engagement with the family6how well agencies identified and responded to children’sinjuries and other indicators of harmthe extent of, and professional understanding of, the supportfrom the extended familythe advice that was given and the services offered to theparents concerning adoption issuesrisk factors in the family known to agencies during the periodunder reviewwhether staff and managers dealing with the family had therequisite skills, knowledge and experience to respond to thecircumstances presented by the familywhether sufficient attention was given to issues relating thereunification 3 of EY and his mother following the period whenhe was in foster careThe findingsin relationtothetermsof reference areaddressed throughout section 4 of this report.1.13The overview report also makes recommendations on changesthat need to be made to implement the lessons of the SCR. Thesetake account of the recommendations containedinindividualmanagement reviews and developments in services that haveoccurred since the events in question took place. The SCR eithermakes recommendations on matters that are not already part ofthe work programme of individual agencies and the LSCB, or insome matters it makes recommendations to strengthen work thatis already taking place.Critical periods of agency involvement covered by the SCR1.14The scope of the SCR covered a period of two and a half years,beginning in July 2008. However as the mother had no antenatalcareinrelationtoherfirstpregnancyandnocontactwithagencies with child protection responsibilities prior to the birth ofOY the period covered by the SCR effectively begins with the birth3 Strictly speaking EY was not reunited with his mother. He was placed in foster careimmediately after his birth. This term will be used as shorthand because much of the researchon this issue is relevant to the circumstances of the case. However it is very important torecognise that EY’s mother had never looked after him until she assumed responsibility for hiscare at the age of seven months.7of OY in April 2009. Agencies were asked to scrutinise any earlierinformation in their records. If significant information had beenidentified the SCR panel agreed that it would modify the Terms ofReference accordingly. No significant background information hasbeen identified.Agencies involved by LSCB area1.15Thefollowingagenciesandcontractedprofessionalsprovidedservices to the children and to other family members within theperiodcoveredbythereviewandhaveprovidedindividualmanagement reviews.Berkshire East Community Health Services (which provided thehealth visiting service4)General practice (covering the services provided by four GPpractices)Heatherwood and Wexham Park Hospitals NHS FoundationTrustRoyal Borough of Windsor and Maidenhead CounciloSafeguarding Services 5 (which provides local authoritychildren’s social care services)oServices for Families (which provides and commissionschildren’s centre services and other family services)1.16A number of other agencies had very limited involvement in thecasehistoryandwerethereforeeitheraskedtoprovidechronologies, background information and reports or to contributevia additional discussions with SCR panel members:South Central Ambulance ServiceCombined Legal Services (hosted by Reading Borough Council)limited information was also obtained from the mother’s schoolrecords. This is referred to in section 3 of the report.no faith, voluntary or community groups were identified ashaving been involved.4 Berkshire East Community Health Services (BECHS) merged with Berkshire HealthcareTrust (BHFT) during the course of this review. References to BECHS and BHFT should betreated as synonymous in all documents related to this review.5 This service is referred to as ‘children’s social care’ in the body of the report81.17The Working Together guidance stipulates that a health overviewreport should be prepared on behalf of the commissioning PrimaryCare Trust (now NHS clusters). Their purpose is to provide anoverview of health provision and to identify the key findings fromthe SCR which have implications for NHS commissioning. TheDesignated Nurse for Safeguarding for NHS Berkshire preparedthis report. The findings of the health overview have contributedto the findings of this SCR overview report.Availability of records1.18With the exception of two sets of records all of the relevant healthand medical records were accessed for the SCR. The records notlocated were 1) the father’s paper GP records (the father’s currentelectronic record and summary were available) and 2) somepostnatal midwifery notes on the children’s mother. Although theinability to locate records is always a concern, neither are likely tocontain information which would significantly alter the findings ofthe SCR. OY did not have health visiting records during the periodunder review and EY did not have health visiting records from July2010onwards.Thisisbecausetheywereassignedtocore(universal) health visiting services which meant that the onlyrecords created were the Personal Child Health Record (PCHR)which is often referred to as the parent held record). As a result anumber of contacts with health visitors over the children (usuallyphone calls) were identified as having been recorded in the healthvisitor’s work diary. This is discussed in section 4.11 of the review.1.19All of the other relevant agency records were available for thereview. There are some significant gaps in the records. These andsome discrepancies between records are highlighted either in thenarrative or in the evaluation in this report.9Appointment of the SCR panel, the SCR panel chair and theappointment and role of the independent overview report author1.20A full list of the roles and job titles of SCR panel members iscontained in Appendix 2 of this report. SCR panel members aresenior managers in member agencies or designated professionalswith substantial experience of safeguarding children.1.21The SCR panel was chaired by Donald McPhail, who is also theIndependentChairofWindsorandMaidenheadLSCB.Thisarrangement is consistent with the statutory guidance. He is notemployed by any of the agencies involved in the review. He hassubstantial experience and expertise in child protection services.1.22The SCR overview report was prepared by Keith Ibbetson. He hasno relationship of any kind with any of the agencies involved inthe review or to anyone involved in the case or the SCR. He hasnot previously worked for Windsor and Maidenhead LSCB. He is anexperiencedauthorofSCRsandchairofSCRpanels.Theindependent author has not been a decision making member ofthe panel but has taken the following roles:to attend meetings of the SCR panel and provide professionaladvice as requiredto review the agency management reviews and to seek out andevaluate along with the SCR panel additional relevant materialto corroborate or develop the findings made by agenciesto assist the panel in improving the quality of the agencymanagement reviewsto prepare the overview report on behalf of the panel andfinalise it following panel discussionto prepare the executive summary on behalf of the LSCB1.23Since the decision to hold the review the SCR panel has met onseven occasions in order to:make decisions on the conduct of the reviewmanage the review so as to ensure that it complied with thestatutory guidanceconsider progress in the production of agency managementreviews and chronologies10receive and consider an initial draft of this overview report andof the health overview reportto decide when and how it would be best to engage membersof the family in the reviewto consider and agree recommendationsto consider a draft action planto agree the overview report, the recommendations and actionplan and to agree the executive summary for recommendationto the LSCBQuality of individual management reviews and steps taken toimprove their quality1.24The SCR panel and the overview report writer have scrutinised thequality of the IMRs to ensure that they provide a full and objectiveevaluationoftheworkofeachagency.Thequalityoftheindividual reviews has largely been good and some are consideredto be of a very high quality. They have all made an importantcontribution to the findings of the SCR. All of the review writerswere asked to clarify points of detail in their reports. The SCRasked for a small number of the reviews to be amended andresubmitted because they did not adequately cover areas thatwereconsideredessential.Therehasbeenahighlevelofcooperationinthatprocessandsupportfromalloftheparticipating agencies.1.25A full list of the individual reviews provided, dates of submissionand dates of resubmission of versions is included as appendices tothis report which also contain further comment on their qualityand contribution to the review.Parallel processes that have impacted on the conduct of the SCR1.26Thames Valley Police is conducting the criminal investigation intoEY’s death. The SCR panel and the overview author have receivedupdates on the progress of police enquiries. The enquiries havebeen protracted because of the need to obtain the report of acomplexpost-mortemexaminationwhichinturnreliesoninformation from a number of medical specialists. At the time of11writing the future direction of the criminal investigation is thesubject of discussions with the Crown Prosecution Service, whichis to be expected given the circumstances of the death.1.27Theseniorinvestigatingpoliceofficerhasprovidedtheindependent overview report author with more detailed progressreports on the range of information that has become availableduring the criminal investigation. Whilst the focus of the SCR isthe provision of services to EY and his family, this has allowed theSCR panel and the independent overview report author to feelconfident that the review can take account of any additionalsignificant information that may not have been known to agenciesbefore the death of EY. It also allows the SCR to anticipate anyfurther issues of potential public concern that might emergeduring the criminal trial.Agreed extensions to the normal timescale for completion of theSCR1.28Chapter 8 of Working Together (April 2010) makes the Chair ofthe LSCB responsible for determining what action to take whenthe SCR panel considers that it is necessary to exceed the sixmonth timescale laid down in the statutory guidance for thecompletion of SCRs. 6 At its meeting in August 2011 the SCR paneldiscussed the timescale that would be required for the completionof the SCR. In particular it had become apparent that the post-mortem enquiry had identified that in addition to the injury thatcaused EY’s death there had been injuries of different ages. Thepanel agreed that it would be essential to know as much aspossible about the nature of these injuries and the time bandwithin which they were believed to have occurred in order for theSCR to evaluate the professional practice in the case history fully.1.29The SCR panel has been mindful of the need for member agenciesto take action in the meanwhile in order to learn lessons and toimplementrecommendationswhilethereviewcontinued. The6 Section 8.23 – 8.2412progress made in the implementationof recommendations isreflected in the agency action plans linked to the SCR.Involvement of family members1.30The mother and father of OY and EY were informed in writing thatthe SCR had been initiated. The SCR panel has discussed in detailwhether it would be possible to involve family members in thereview in order to include their perspective on the services thatwere provided. Following discussion with Thames Valley Police theconsensus view of panel members and the overview report authoris that given the specific circumstances of the case it would not bepossible to do this without the risk of prejudicing the criminalinvestigations and any potential criminal trial. This is because inthis case there is a significant overlap between the evidence thatmay be relevant to criminal proceedings and the areas which areof interest to the SCR (such as the observation of injuries to EY byprofessionals and discussions with their mother about them).1.31This position will be kept under active review and it is hoped thataftercriminalproceedingsarecompletedtherewillbeanopportunity to discuss the case with involved family members. TheLSCB has been asked to adopt this report on the basis that it is afull report of the lessons from the SCR at this point and in therecognitionthatadditionalinformationmaysupplementthefindings at a later date.The papers constituting the SCR and arrangements for publication1.32The SCR consists of the following reports and documents:the overview reportthe combined chronology of agency contactsthe individual management reviews (and background reportsfrom agencies with very limited involvement)the integrated multi-agency action planthe draft executive summary1.33A draft executive summary has been prepared for submission withthe SCR papers to Ofsted. The content of the final version of theexecutive summary and LSCB action plan will be finalised for13publication after evaluation by Ofsted. The LSCB wishes to be astransparent as possible about the findings of the SCR in order thatthepublicandotherprofessionalsmayhaveasfullanunderstanding as possible about the case history and about thedecisionsandactionsofpublicbodiesandthecourts.Afterevaluation by Ofsted and the completion of all parallel processes 7the LSCB will therefore give further detailed consideration to thepublication of additional material taking into account the currentcircumstancesofthefamily,theamountandnatureoftheinformation that is already in the public domain, any advice fromcentral government, the views of the father of OY and other familymemberswhoknowthesurvivingchildandanyfurtherinformation that emerges from criminal proceedings.7 In addition to the criminal investigation there are also care proceedings in relation to thesurviving sibling142DETAILS OF FAMILY MEMBERS2.1This information is presented in the following way:details of members of the family who had contact with servicesduring the period under reviewa Genogram of the children’s extended family. This includes allfamily members listed in agency records, though not all hadcontact with agenciesaseparateGenogramshowsthefamilycompositionaspresented by the mother to the Children’s Centre8Details of family membersNameFamily role, relationship andliving arrangement in March2011M/FEthnicity andreligionAge atMarch 2011Child OYSubject of SCR – living with themother in Windsor and MaidenheadMWhite UK23 monthsChild EYSubject of SCR – living with themother in Windsor and MaidenheadDied 20 March 2011MWhite UK11 monthsMotherMother of children – living in familyhome in Windsor and MaidenheadFWhite UKFamilymembersstated that theywere non-practisingChristians(Redacted)FatherFather of children – living elsewherein Windsor and MaidenheadM(Redacted)MaternalgrandmotherLiving elsewhere in Windsor andMaidenhead. Extent of contact andinvolvement with the children at thetime of the deaths was not known indetailF(Redacted)MaternalgrandfatherLiving elsewhere in Windsor andMaidenhead. Extent of contact andinvolvement with the children at thetime of the deaths was not known indetailM(Redacted)15Full Genogram of family members based on local authorityrecords.(Redacted)The mother told the Children’s Centre that EY was called CK and that hewas the child of her cousin and that she was his unpaid childminder. Shenever named the cousin.(Redacted)In July 2010 the mother told her GP that she only had one child, thoughher precise meaning is open to interpretation.163NARRATIVE OF EVENTSA note on terminology – denied and concealed pregnancy3.1Agency records, chronologies and management reviews have usedthe terms ‘concealed’ pregnancy and ‘denial of pregnancy’. Thereis relatively little research dealing with this issue. However onepaper which has been seen by SCR panel members distinguishesbetween the concepts of 1) ‘denial of pregnancy’ in which thewoman has no apparent awareness of the pregnancy for most orall of the pregnancy and 2) concealed pregnancy in which womenknow that they are pregnant and actively conceal the pregnancy. 9There are a number of different explanations proposed as to whyboth phenomena occur.3.2The accounts given by the mother in this case are set out in thefollowing paragraphs as they occurred in the case history. Sheclaimed that she was not aware at all of her first pregnancy (withOY) until she went into labour. Using the terminology proposed byFriedman et al this pregnancy would be categorised as an exampleof ‘pervasive denial’ which occurs ‘when not only the emotionalsignificance but the very existence of the pregnancy is kept fromawareness’. In some cases, weight gain, lack of periods and otherbodily changes may not be present or may be misconstrued and‘even labour pains may be misinterpreted’. 10 However the accountgiven by the father to a midwife shortly after the birth of OYindicates that he thought that the mother might be pregnant atthree months and suggested that she should have a pregnancytest. She in turn admitted that she had a feeling ‘and hoped that itwould go away’. This suggests a concealed pregnancy. The secondepisode would be categorised as a ‘concealed’ pregnancy (thoughthe mother claims that she did not know about it until a weekbefore the birth).9 Friedman, Henegan and Rosenthal, (2007) ‘Characteristics of women who deny or concealpregnancy’ Psychosomatics, 48.2 March – April 200710 Ibid (page 117)173.3In relation to this case history it is not clear whether this is auseful distinction. This is not because it may not be valid butbecauseanycategorisationreliesonthewomanconcernedremembering and giving an honest account of her knowledge andfeelings. The mother in this case misled professionals and friendson many occasions and so her accounts cannot be relied on. Therehas not yet been any opportunity to test the mother’s accountgiven, either in court or in a thorough psychiatric evaluation. Thefathergaveaccountsofhisknowledgeofthepregnanciesimmediately after the birth of EY but then, with the exception ofdiscussions with his GP, he was never subsequently asked aboutthe details of what exactly had happened.3.4In the following narrative the SCR refers to the pregnancies asbeing ‘concealed’. This is because this is the term most widelyused by professionals and the one that was used most widely inthe case records, not because it is accepted that the pregnanciesfit the categorisation used by Friedman et al. At this point it is notpossible to say how much knowledge the mother had of her twopregnancies and if there was a difference between the two. Thereport will also emphasise the practical consequences of both‘denial’ or ‘concealment’ and the risks that this gave rise to for theinfants concerned such as the lack of any antenatal care anddelivery without nursing or medical attention.3.5It is also important that attention is not focused exclusively ondenialandconcealmentsolelyintheantenatalperiod.Thenarrative which follows also shows that the mother continued toconceal the existence of EY from other members of her family foralmost seven months; she denied his existence to herself for longperiods when she did not visit him and by her own admission didnot think about him. On one occasion she denied his existence toher GP and she went to great lengths to conceal his existencefrom the staff and other service users at the children’s centre.3.6Section 4.3 will however refer to the Friedman paper further,particularlytherecommendationsthatitmakesaboutthe18management of the pregnancy and psychiatric and child welfareconcerns when such a pregnancy is discovered or disclosed.Background history relevant to the review:3.7Agency records contain very little information about the lives ofmother and the father prior to the period under review. This is fortwo reasons: Firstly, neither parent had any significant contactwith agencies. Secondly, during the period under review very littlebackgroundinformationabouttheparentsortheirfamilycircumstances was obtained because no detailed assessment offamily circumstances was undertaken. The reasons for this aredescribed in more detail in section 4.3 below.3.8Basic details of family members’ ages and backgrounds are set outin section 2 above. Prior to 2008 the mother attended her GPinfrequently and had no significant health problems. At the age ofeight she had difficulty reading and there were concerns that shemight have dyslexia. There is no evidence of any further actioninvolving health professionals over this. The mother attendedmainstream primary and secondary school and at one point herschool identified her as being listed as having special educationalneeds. These were at stage 1, the lowest level, indicating that theschool would take action to meet her needs within its localresources. No further information is available about this. Whenshe was eight years old the mother was noted by her GP to be‘slow to follow instructions’. The mother left school in 2004 afterher GCSEs. She had been entered for 13 exams but obtained nopasses at grade A-C. There is no indication at all that she had alearningdifficulty.Shewasreportedtobeworkingasareceptionist when OY was born. No previous work history wasobtained. She gave this job up but the records do not stateexactly when.3.9Given the father’s age there are no school records available. Hehas no criminal convictions or record of other contact with thepolice. He was never asked about his background and the only19background information about him is from his GP records. Heattended his GP infrequently for treatment of minor ailments.(Redacted) His handwritten records have not been obtained andmay contain further information but there is no indication that it isof any relevance. (Redacted)The mother and father workedtogether prior to the birth of OY. Some months later the fathertold his GP that he had changed jobs.Agency contact during the period of review covered by thechronologyEvents prior to the birth of EY3.10OY was born at the home of his father. His mother had receivedno antenatal care and (according to the account his father gave tohis GP) the mother gave birth to OY in bed while the father wasasleep. OY was born at 40 weeks gestation and weighed 3.63 kg.The mother had a low iron level there were no other medicalcomplications. The father and maternal grandparents visited thehospital after having been contacted by a midwife. It is not clear ifthe midwife did this on her own initiative or with the agreement ofthe mother. The family were noted to be undecided about whoshould care for the baby. The mother was noted to be ‘dazed’.Midwives referred the baby to the social care emergency dutyteam because there had been no antenatal care.3.11The mother wanted to return to her own home on discharge. Thisis understood to mean her parents’ home, rather than the father’s.The mother was told that social care ‘may visit today’ (at thehospital) but no visit was made as the local authority decided toundertake the initial assessment of the family at home. The socialcarereferralindicatedthattheparentswereconsideringrelinquishing the baby for adoption. During the night of 14 – 15April midwives cared for OY while the mother received a bloodtransfusion.3.12On 16 April the mother and OY were discharged to the maternalgrandparents’ home. The discharge letter sent to the GP identifiedthat the mother had not booked antenatal care and had been20‘unaware’ of the pregnancy. A midwife made a home visit on 17April (day 4). It was noted that the mother was shocked at thepregnancy but there is no further comment on the circumstancesof the birth or the attitude of other family members. A furthermidwifery visit was made the following day and then on day 10(24 April).3.13On 20 April 2009 a social worker SW1 made a visit and saw OYwith his parents. It is not clear where this visit took place. Thematernal grandparents were not seen. The father stated that hefelt trapped and depressed, but that he would offer support. Thefather stated that (as far as he was concerned) the couple had notintended to be in a relationship. The mother said that she hadsuspected that she was pregnant a week before the birth, but didnot tell anyone or do anything about it. The plan noted was that acore assessment would be undertaken and that the mother wouldcare for OY with the help of ‘a lot’ of family members. There is norecord to say exactly what this would mean in practice. The socialworker checked with the mother’s GP who had no significantinformation as there had been no antenatal contacts and nosignificant previous health history.3.14The same day the father saw his GP. This was a different GP tothe other family members and there was never subsequently anycontact between this surgery and other agencies. The father toldhisGPthathehadbeentraumatisedbythebirthofOY.(Redacted) This led to a referral to the Community Mental HealthTeam (CMHT) as there were no appointments available at the GPcounsellor. The CMHT refused the referral on the grounds that thefather did not have severe or enduring mental health problems.The father never subsequently had contact with the counsellor.3.15On 24 April 2009 the midwife discharged OY to the care of GP andhealth visitor. It is not clear what information was shared at thispoint (paragraph 28 in hospital IMR). The new birth visit wascarried out by the health visitor (HV1) on 28 April. Standardhealth checks were made and OY was assessed as requiring a core21health visiting service (i.e. the mother would be left to makecontact with the child health clinic and health visitor as she saw fitand standard developmental checks would be carried out). As aresult no health visiting record was opened and information aboutOY’s health was recorded on his PCHR. There is no indication inthehealthvisitor’selectronicrecordthatthemotherhadconcealed or denied the pregnancy, although the hospital birthnotification states this. There is no indication in the records as towho was present at the visit and it appears to have focusedexclusively on routine child health matters which is surprising andconcerning given the lack of antenatal care and the circumstancesof OY’s birth.This is discussed in the individual managementreview and in section 4.3 below.3.16On 6 May 2009 OY was seen at the child health clinic. He wasnoted to have made good weight gain and was now on the 75thcentile.3.17On 13 May 2009 the social care initial assessment concluded thatthe mother was able to meet the needs of OY with family support.The assessment had been based on one visit to the family, aphone call from the GP and one phone discussion with a midwife.The social worker refers to a discussion with the health visitor butit was not recorded by either professional. The health visitorclearly had no concerns as she had allocated OY to a core service.11 There is a reference to a further planned visit with the healthvisitor to identify any further need for support but there is norecord that a joint home visit took place. The social workerrecorded making a further visit on 4 June 2009 when the motherand OY were seen. The mother reported that the father was‘recovering from his shock’ and her family were supportive. Thecase was closed. The social worker was not aware of the father’s11 At this point as OY had been allocated to a core health visiting service there were noseparate health visiting records created and the health visitor would have had no record onwhich to note this enquiry. The position has changed since the introduction into the healthtrust of the RIO electronic recording system. All children have a RIO record, in addition totheir PCHR.22reaction and (Redacted) feelings and relied on mother to provideinformation about him. There had been no detailed discussionabout the reasons for the concealed pregnancy, despite the lack ofantenatal care and the very unusual circumstances.3.18The view of the manager was that the circumstances of OY did notmeet the threshold for continued social care involvement underSection17oftheChildrenAct1989(i.e.thathewasnotpotentially a child in need). On 25 June a manager decided thatdue to workload considerations the normal closing summary andletters to other agencies to inform them that there would be nofurther involvement would not be written.3.19On 20 May the mother took OY to the health clinic. His weight wasnow on the 90th centile (compared to 50th centile at birth). Whenthe health visitor (HV1) made a home visit on 2 June to carry outthe 6-8 week postnatal review OY was now noted to be on the 98thcentile. That day the mother was screened using the EdinburghPostnatal Depression (EPND) Tool,12 which is reproduced asAppendix 6 of this report. She scored 0 (out of a possible 30).There was no comment on how valid a score of zero might be. Theimplications of this are discussed at section 4.3.19 below.3.20The mother next took OY to the health clinic on 24 June 2009. Atthat point OY’s weight was recorded as being on the 99.6th centile.OY was weighed onfour more occasions before the end ofSeptember and each time recorded as being above the 99.6thcentile. Put in lay terms this meant that in a statistically normalsample of 250 male infants OY would have been the largest orclosetothelargest.OYreceivedhisfirstandsecondimmunisations routinely during May and June 2009. Other thanthe immunisations it is not certain how much direct contact OYhad with health professionals during this time because at theclinics he attended parents would ‘self weigh’ their babies and only12 Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Developmentof the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.23speak to a member of the health visiting team if they hadconcerns. If there were discussions, no concern was recorded onhis records about this very fast weight gain.3.21In September 2009 the mother started to take OY to health andother sessions at a local children’s centre. The registration formgave a Maidenhead address. The mother was quite open with staffthat she had not known that she had been pregnant with OY untilshe went into labour. It was not part of the role of the twomembers of staff at the centre to assess the parents and so thiswas not discussed in any further detail. It is not clear if the fact ofthe concealed pregnancy was seen as being significant. Motherand child attended ‘Family Fit’ sessions which were attendedthroughouttheremainderof2009andthenhealthyeatingsessions until March 2010. Regular attendance at health clinicsthroughout this period recorded OY’s weight as being consistentlyabove the 99.6th centile.3.22The first occasion on which it was recorded that the mother wasgiven advice on diet was at the health clinic on 27 January 2010.OY was not walking at that point and it was hoped that OY wouldnotgainsomuchweightwhenhestartedtomovearoundindependently. On 8 February 2010 he was seen by a healthvisitor (HV2) for his 9-12 month developmental assessment. OYwas noted to be up to date with his developmental milestones andimmunisations. His mother agreed to continue to bring him toclinic to be weighed and he was noted to be attending theChildren’s Centre. This was a continuation of the plan that hadbeen in place since August 2009 which had so far had no impacton his unusually quick weight gain.3.23On 29 March 2010 the mother and OY made their final appearanceat the Children’s Centre prior to the birth of EY. There was norecording of any indication that she was pregnant. On 6 April and22 April 2010 she took OY to the GP and again her pregnancy wasnot noticed.24Significant events between the birth of EY (23 April 2010) and hisreturn to the care of his mother (19 November 2010)3.24The mother had moved to her own flat in November 2009.Confirmation of the details of the move was provided to the SCRby Thames Valley Police and had been established after the deathof EY. Other agencies knew that the mother and OY had movedbut the records gave no details of the date of the move or anyspecific reasons for it.3.25Like his brother EY was born at home. He was larger than hisbrother weighing 4.26 kg (75th centile). The mother and OY werebrought to hospital by ambulance.3.26The circumstances of this birth were different to the birth of OY.The father subsequently told his GP that he had suspected thatthe mother was pregnant, but that she had denied this. She statedthat she had thought she might be pregnant a week before thedelivery,butthatshetooknoaction.Thishistorywasnotobtained at the time but when the father spoke to his GP later andduring the course of the mother’s adoption counselling.3.27The initial referral to children’s social care from Wexham ParkHospital indicated that the mother wished to relinquish her babyfor adoption. The mother had given birth ‘at home’ assisted by thefather and she was believed to have been unaware that she waspregnant. The parents were noted to be in a state of shock. Theystayed in a separate room from the baby at the hospital.3.28Social care identified the case as one that had been open to theservice a year earlier following the birth of OY. A social worker(SW2) and a senior social worker (SW4) saw the mother inhospital with the baby and arranged to accommodate the babyunder Section 20 (Children Act 1989). The mother was dischargedthesamedayandEYwasdischargedtoafostercarerinMaidenhead. EY was not named at this point.3.29The same day (23 April 2010) the foster carer took the baby toregister at her GP (a different GP surgery to the ones used byother family members). She was unable to register the baby as25she could give no first name for him. This is not an unusualcircumstance and often babies are seen by the mother’s GP beforetheir births are formally registered. The receptionist alerted thehealth visitor linked to the practice (HV4) to the baby’s existenceand she started to make enquiries. EY was subsequently allocatedto the caseload of this health visitor in a different team and townto the one dealing with the mother and OY.3.30No further significant events are noted until 26 April 2010 when apostnatal midwifery visit was made to EY at the foster carers’home. A further visit was made on day 5, but the electronic recordholds no significant information about this.3.31On 26 April the foster carers’ support social worker (from thefostering team) phoned her to say that the mother and fathermight want contact that day. This did not happen and it is notclear what discussion had led to this possible request.3.32On 28 April a placement planning meeting was held. This is arequirement for every looked after child. It was attended by thesocial worker (SW2) from the Referral and Assessment Service,the senior social worker (SW4) the fostering social worker, thefoster carer, and the mother and father. This was the first contactbetween the parents and EY since the birth. Neither parent wishedto hold him and his father found it very difficult to be in the sameroom as the baby. The fostering social worker noted that themother was ‘emotionally detached’, though she was noted to actwarmly towards OY.3.33The key decisions of the meeting were 1) to make arrangementsfor routine delivery of health services 2) to support contact withthe parents and 3) to start adoption counselling to help theparents reach an informed decision regarding the long term plansfor EY. Subsequently the mother received a number of counsellingsessions. There were no separate discussions with the father. Hewas always clear in his view that the baby should be adopted.263.34It was also noted that an initial assessment would be undertakenin relation to OY by the Referral and Assessment Team. This wascompleted shortly afterwards and written up and signed off on 20May 2010. It noted that there were no concerns about thecapacity of the mother and father to care for OY, though it is notclear what steps were taken to reach this conclusion. OY wasnoted to be meeting his developmental milestones. At the end ofthe assessment no letters were sent to health agencies informingthem of the reasons for social care involvement or the outcome ofthe initial assessment. The reasons for this are not stated. No coreassessment was undertaken at this point, despite the highlyunusual family circumstances. The needs of OY were not assessedin the context of the complex circumstances surrounding the birthof his brother and the decision that needed to be reached over hisfuture. This is discussed further in section 4.3 below.3.35On 29 April 2010 a midwife carried out a postnatal visit to themother. This was carried out by a midwife in a different team tothe one who had visited EY in the foster home. These were treatedas discrete tasks and the two never spoke to one another aboutthe unusual circumstances of the birth. Neither midwife accessedthe notes relating to the circumstances of the birth of OY. As thereare only the briefest of notes relating to the birth of EY it is notclear whether either of these midwives was aware that there hadbeen a previous pregnancy with no antenatal care.3.36The postnatal visit was six days after the birth and it is not clearwhy there was a delay. It is not stated explicitly in the recordswhere this visit took place (i.e. whether it was at the father’shomeorthemother’sownaccommodation).Therewerenomedical complications. However the mother requested that ‘herhome phone number’ should be deleted from the hospital records.The specific reasons were not recorded though it seems mostlikely that following the first birth the maternal grandparents’home number was on the hospital records relating to the mother27and she wished it to be removed so that they could not accidentlybe made aware of the birth of EY.3.37On 30 April 2010 the social worker (SW2) visited the mother, thefather and OY. When seen alone the mother admitted suspectingthat she was pregnant but concealing it from the father and thatshe had ‘wanted the situation to go away’. She said that she hadbeen relieved to get ‘back to normality’ over the last weekend.The father was not seen alone.3.38On 4 May 2010 the final midwifery visit was made to the mother(day 11). The mother had no identified health problems and wasdischarged from midwifery care. The health visitor for the mother(HV5) was sent a discharge summary from the hospital stating‘baby for adoption’ as a handwritten comment.3.39On 11 May 2010 there was liaison between the Looked afterChildren (LAC) health team and social care to obtain consent forhealth treatment of EY, should it be required. This was a basicprocedure. Otherwise both of the children were seen in their ownway as having routine health needs at this point. EY was a healthychild who was likely to be relinquished by his mother for adoption.OY was understood to be well cared for by his parents. There wasno contact between the health professionals dealing with the twochildren at this point.3.40On 11 May 2010 the social worker (SW2) made a visit to themother and father. The mother said that she intended to name EYand register the birth (which she did on 1 June 2010). At thatpoint the maternal grandparents did not know about the birth ofEY. The social worker stated that the local authority would beseeking legal advice about the need to consult extended familymembers about EY’s future. The father was hostile to this. Mothersaid she understood why this needed to happen and was ‘thinkingof telling them herself’. Father said that if mother did keep thebaby it would completely change his relationship with OY. Thesocial worker recorded that she challenged the father about this28statement because she felt that the father was putting the motherunder a lot of additional pressure.3.41From this time social care staff developed the perception that thefather was bullying the mother. Linked to this was the perceptionthat the mother might want to look after EY if left to come to herown view without pressure from the father. With hindsight it isclear that this was an oversimplification of the situation and thatas a result the social care staff involved paid less attention toother factors relating to the mother. This is discussed in section4.3 below.3.42The social worker found the mother still difficult to engage inconversationthoughshestatedthatshewasworriedaboutlooking after two young children. Both parents were invited toattend EY’s looked after review meeting. The father said that hewould not as he was worried that he would become emotionallyattached to the baby, but the mother said that she intended toattend the looked after review meeting where she would havecontact with EY. The mother did not attend the looked afterreview, though she did visit EY later on the same day.3.43On 17 May the father phoned the social work team manager andcomplained about the proposed plans to involve members of themother’s extended family. He was told that EY had the right tohave his needs considered by the extended family. The localauthority had not taken legal advice on this issue at this point.Discussions about informing the extended family continued untilNovember 2010.3.44On 12 May the health visitor (HV4) made the new birth visit to thefoster home. EY’s weight was on 91st centile and he was allocatedto core health visiting. The health visitor was aware of the socialcircumstances. She made no contact with the mother’s healthvisitor.3.45On 13 May 2010 the hospital discharge summary was sent to themother’s GP. It contained no reference to the lack of antenatal29care or the circumstances of the birth. However it would havebeenclearfrom themother’s GP notesthatshehadagainreceived no antenatal care. The mother was invited to the GP for apostnatal check up.3.46On 17 May 2010 the father attended his GP surgery. He spoke of‘stress’ after the delivery of his second son one year after the birthof the first. The record states that he had helped deliver thesecond baby during the night. He stated that he knew that themother was pregnant but that she denied it when he asked her.He wanted the baby adopted and did not want her parents toknow about the pregnancy. He was advised to tell her parents butwas not keen. He stated that he was awaiting a social servicesmeeting. He did not consult the surgery again about it until 19November 2010, the day that EY left foster care. (Redacted)3.47The first statutory looked after review on EY took place on 20 May2010 at the foster home. EY’s mother did not attend, although shecame to the foster carers’ home after the meeting and saw EY.This was said to have followed a chance meeting with the fostermother the same day. This was the first time she had seen himsince his medical on 28 April and only the second time since hisbirth. The decisions of the meeting were to treat EY as a baby whohad been relinquished for adoption, a pre-adoption medical was tobe booked and adoption counselling was to be arranged.3.48There is some uncertainty as to the understanding that the socialworker had at this point. The decisions of the meeting recorded inthe chronology refer to plans to proceed as if EY were to berelinquished for adoption. This was four weeks after the birth. Atthis time there had been no indication that the mother had anyambivalence about relinquishing EY. However the managementreview refers to ‘parallel planning’, noting the possibility that themother would wish to resume the care of EY. This seems to bebased on the behaviour of the mother when she visited the fosterhome after the meeting when she agreed that she was going toregister EY’s birth and name him. She held EY for some time and30took away pictures taken by the foster carers. She agreed to bookanother contact session having been encouraged by the fostermother that she could visit whenever she wanted. The fostermother invited the mother to take the baby out and establishedthat she was happy to change and feed him if she did so.3.49On 21 May the LAC health team had contact with the fostercarers’GPaskingforEY’smedicalrecords.Themedicalinformation gathering was focused on EY and it was not the role ofthe team to make contact with the mother’s GP.3.50On 24 May the mother’s health visitor (HV5) (who knew themother and OY) attempted a home visit to the mother but she wasnot in. The management review states that this was not repeated.However on 26 May the social worker recorded that she had beentold by the health visitor (HV5) that the mother had given anindication that she was thinking about caring for EY at home. Sofar as can be established this was the first firm indication in therecords that the mother might want to care for EY.3.51On 1 June 2010 the mother had contact with EY at the fosterhome. No further details of this are recorded. The following dayshe attended the looked after child initial health assessment andsawEYagain.Thiswasundertakenbyapaediatricianandattendedby thesocialworker(SW2), themotherandbothchildren. Mother brought the children to the health centre. Motherindicated that she felt under pressure from the father to give EYup and it was recorded that ‘he could be quite domineering’. Shehad not told him that she had recently had contact with EY. Thesocial worker spoke to the mother about a possible referral to theFreedom Programme. This is a programme for women who havesuffered domestic violence, though there was no suggestion thatthe mother had ever been a victim of domestic violence. Thesocial worker thought it could help her become more assertive andconfident. The mother indicated that she might be interestedthough she never asked about it again.313.52This social worker had no further involvement. On 3 June 2010 thecase was transferred to a new social worker (SW5) in the lookedafter children’s team. There was no transfer summary because fora looked after child the case plan was summarised in the decisionsof the looked after review meeting. Subsequently the key issue inthe case was believed to be whether or not the mother wished toresume the care of EY. The issue of the mother’s action inconcealing the pregnancies was only mentioned in social carenotes in one of the adoption counselling discussions.3.53On 8 June the mother cancelled a scheduled visit to EY at thefoster home. She said she was disappointed that she had not seenhim, though the reasons for her cancelling were not noted. Thenew social worker (SW5) visited EY that day as did a member ofthe health visiting team. There were no health concerns about EYat this point or at any stage while he was in foster care.3.54The same day the mother registered herself and OY at a differentGP practice (in Windsor). OY’s records were received at thepractice on 30 September (3 months later) and summarised. Themother’s records did not arrive until 15 April 2011 (after thedeath) after having been chased by the practice. The reasons forthis substantial delay are not clear. The transfer of medicalrecords when patients transfer from one surgery to another isdiscussed in section 4.6 of this report. The mother’s reasons forchanging GP practice at this point are not clear. As her own noteswere never sent to the surgery staff there were unaware of herprevious medical history, including the nature of her pregnancies.3.55On 10 June 2010 the mother had contact with EY at the fosterhome. She had two more visits the following week (13 and 17June) and then two further visits on 24 and 29 June. There are nodetailed notes describing what happened at the visits made inJune. This was the only time in the period in which EY was lookedafter that the mother made any significant number of visits. Thevisits followed no regular patterns and there is no explanation ofthis. After June a number of planned contact visits were cancelled32and the mother did not attend the next statutory review on 21July 2010. The next recorded contact between mother and EY wason 4 September 2010 (after a gap of 68 days).3.56On 10 June a solicitor in the legal department sent an emailasking the social worker to make contact. It is not clear why thiscontact was initiated at this point. There appears to have beenearlier contact not entered in either agency record. The socialworker’s response (recorded in legal but not in social care) wasthat the mother was to receive adoption counselling and that shemightbewaveringaboutEYbeingadopted.Thisaccuratelyreflected the understanding that the social worker had at thispoint. The first entry in social care records in relation to legalservice involvement is after the next statutory review on 21 July.3.57On 25 June the mother had her first adoption counselling session.She had had contact with EY four times in the previous 15 days.She was noted to be ambivalent about the future care of EY.3.58The next social work visit to the mother was made on 1 July. Themother stated that she would ‘eventually’ like to take EY home.Her reasons for not wanting to do so straight away were notestablished. The social worker indicated that she would need todemonstrate this by increasing her contact with EY.3.59The second adoption counselling visit was made to the mother on2July.Shewassaidtobedemonstratingher‘continuingambivalence’ towards EY being adopted. The notes reflect thecounsellor’sperceptionthatthe mother’sconcealmentofherpregnancy was indicative of her tendency to disassociate fromissues that make her anxious. She had a tendency to pretend thatnothing would happen in the hope that her problems would goaway.3.60On 7 July EY’s (HV4) and health practitioner (HP1) made a homevisit to EY at the foster home. It was noted that the mother hadnot taken him for his first immunisations as she had apparentlyundertaken to do. The social worker (SW5) made a statutory visit33the following day. It was not recorded whether the social workerwas informed about the delayed immunisations.3.61On9Julythemothercancelledtheadoptioncounsellingappointment. On 14 July it was noted that the mother had onceagainfailedtotakeEYforhisfirstimmunisation.Shesubsequently provided a consent letter.3.62On9JulythemotherattendedherGPandwasgivenacontraceptive implant. During the consultation she stated that shehad only one child. What she meant by this and why she said itare not clear. The mother had no further consultations in thispractice.3.63On 19 July the foster carers’ supervising social worker (SW3)discussed progress with the foster mother. She reported that themother had not visited for ‘three weeks’. The same day EY’s socialworker recorded that she had indicated to a solicitor in legalservices that the mother did not want EY to be adopted andwished to care for him. This was said to be the reason that themotherhadcancelledthelastadoptioncounsellingsession,though this had not been noted at the time. The legal chronologystates that the mother had said that she did not want EY to beadopted but records that she had not said that she wanted to carefor him.3.64The second looked after review was held at the foster home on 21July. The review was attended by the foster mother, the socialworker, thehealth visitorforEY(HV4) andanindependentreviewing officer (UR). Neither parent attended. The health visitornoted that the mother had not had contact for four weeks. Sherecorded that she voiced her concerns at the review about anumber of aspects of the case history: the concealed pregnancy,the fact that EY had been born at home and rejected or deniedbefore the birth, the lack of contact, the delay in naming the babyand the delay in consenting for immunisations. This was the onlypoint in the case history in which any professional identified and34articulated such concerns. As the review focused on EY it is notclear whether it was recognised that the mother had also deniedor concealed her first pregnancy. The looked after review notedthat legal advice was now being sought as to how to progress theadoption.3.65The child’s health visitor (HV4) was sufficiently concerned todiscuss this with the mother’s health visitor (HV5) who assuredher that she was ‘fully aware of the situation’ and would befollowing up the mother to offer postnatal depression and healthscreening. This was noted to be the last entry in EY’s healthvisiting record and the health visitor had no further involvement inthe arrangements for EY being cared for by his mother. The healthvisitor did not receive minutes of the looked after review and shewas not notified by the local authority when EY was discharged tohis mother’s care in November 2010.3.66The individual management review of social care services statesthat this meeting ‘was unable to confirm a definitive plan forpermanency, owing to(the mother’s)continuingambivalenceregarding adoption’. The record of the meeting states clearly thatthe main decision of the meeting was to ‘secure an adoptionplacement for EY’ and to ‘refer EY to the fostering and adoptionservice for family finding and arrange a permanency planningmeeting to identify permanency planning tasks. The social workerwas asked to inform CAFCASS of the parent’s request for anadoption. At the same time the social worker was to ‘commencetwin track planning’. It is not clear if this is a reference toconsultation with members of the extended family in order to seeof they wished to be involved or a further reference to themother’s ambivalence about the adoption decision.3.67After the review the social worker made contact with the mother,indicating that the local authority was unable to agree a care planas she had not been clear about her agreement to adoption. Shedid not take the other actions agreed at the meeting. The motherasked for further time to discuss this with the adoption counsellor.35The social worker also had contact with the legal department. Thesocial worker provided information about the background to thecase and was advised on the procedure in relation to relinquishinga baby and the adoption process. Legal notes state that the socialworker was advised that as the mother was changing her mindabout the process a clear time-frame should be set in relation toany proposed rehabilitation home, so as to avoid any furtherdelay. If mother failed to work towards the return of EY and therewerecontinuedconcernsaboutherambivalenceabouthisadoption it would be important to consider proceedings to obtain aPlacement Order (this is an order authorising a local authority toplace a child for adoption where there is no parental consent, orwhere consent should be dispensed with). The social worker wasof the view that the maternal grandparents would be supportiveand might wish to care for EY (even though they did not at thattime know about his existence).3.68This discussion is recorded in the social care records and dated 23July, but the content is different i.e. that EY’s extended familywould need to be informed and consulted and that counsellingshould be continued with the mother so that she has every chanceof making a decision that reflected her genuine wishes. The needfor a timescale linked to the need to avoid delay for EY was notedbut no specific timescale was ever agreed between the socialworkerandhersupervisorordiscussedwiththemother.Notwithstanding the decisions of the LAC review meeting no actionwas taken at this point to find a family for EY because of themother’s continued uncertainty.3.69The mother attended the third adoption counselling session thefollowing day (22 July 2010). It was noted that the mother wasstill very confused. She said that when she was not with EY shecould cut off from thinking about him and she did not feel pressureto make a decision. She expressed anxiety about coping with twochildren and what family support she would get. The counsellorsuggested another meeting with the social worker and father to36discuss what support would be in place. At this point the positionwas essentially the same as it had been when the case had beentransferred to the team at the beginning of June. The drift inactivity on the part of the local authority is discussed in section4.4 below.3.70HV5 made a home visit to the mother on 27 July 2010. This visitclashed with an adoption counselling visit so it was rearrangedafter a brief discussion with the mother. She explained that EYhad been the result of a concealed pregnancy and that he was infoster care awaiting adoption. The health visitor noted that themother seemed not to understand how the adoption processwould proceed. The counsellor noted that the mother remainedunable to reach a decision and continued to be worried about howshe would cope with two young children.3.71Thecounsellorconfirmedthatcourtproceedingsmaybeconsidered to secure EY’s future. This would have meant seekingan application for a Placement Order under the Adoption andChildren Act 2002. The mother spoke about going on holiday withher parents during August and indicated that she would not bethinking about EY during this time. The worker noted that themother appeared not to realize the impact on delays for EY, andfailed to internalise discussions following visits. At this point themother had had no contacts in the previous four weeks and shewas proposing to go away for the next four weeks.3.72It is not clear if this information about the mother’s attitude andplans was made known to the social worker responsible for EY orher manager. There are no recordings to this effect. The workerundertaking the adoption counselling, EY’s social worker and hermanager may not have read the two sets of notes which were heldon two different electronic records, but they did have discussionsabout the case as they were sitting in the same office.3.73On 30 July the mother was phoned by the social worker who hadhadtocancelaplannedvisitduetosickness.Themother37indicated that she wanted to give up EY for adoption. On 2 Augustthe team manager of the Child in Need Team confirmed in theelectronic records that a letter had been sent to the motheroutliningthedepartmentalexpectationsregardingthere-unification or adoption of EY. Although there are references to thisletter in the records no copy of it was saved as part of the localauthority records. 13 It cannot be certain what the letter said aboutthe timeline and the options open to the mother or whether itmentioned the need to contact the grandparents. The mother senta text message the same day to EY’s social worker confirming thatshe wanted to proceed with the adoption.3.74In contrast on 6 August the mother told her health visitor (HV5)that she felt ‘detached’. She wanted EY back when she saw him,butdidnototherwisethinkabouthim.Thehealthvisitorencouraged her to visit the local children’s centre to make moreyoungfriends.ShealsocarriedouttheEdinburghPostnatalDepression Scale (EPDS – See Appendix 6) screening, recording ascore of 12 (which is within normal limits). There was a fullassessment of OY who at this point was aged 15 months and saidto be developing well. He was not weighed.3.75The social worker’s next actions are not easy to follow from therecords available. It appears that no further social work action wastaken until 10 August (when there was contact with legal servicesand the foster mother). Legal department records state that on 10August 2010 the social worker was asked for an update on thecase. The social worker told legal services that counselling wascontinuing. The following day the social worker informed the legaldepartment that the mother had decided to relinquish EY foradoption. There is no note of these discussions with legal in socialcare records. On 12 August the legal department advised thesocial worker of the protocol and procedures in relation to the13 Extensive but unsuccessful efforts have been made to find any version of this significantletter. The most likely explanation is that it was typed and sent but not saved properly on theelectronic recording system. However staff recollect discussions about sending the letter andthe mother’s text message would appear to be a response to it38decision to relinquish a baby. A date was needed for the adoptionpanel and CAFCASS needed to be informed of the circumstances(the CAFCASS role would be to obtain consent from the mother).Thesocialworkerupdatedthefostermotheraboutthesedevelopments on 13 August 2010 stating that mother wished tocommence the adoption process, though she gave no indication asto what action would be taken.3.76On 17 August the legal advisor asked whether EY had beenbooked into the Adoption Panel and gave advice about the fostercarers taking him on holiday abroad. There is no parallel recordingabout this in social care. On 20 August the social worker told legalservices that there had been no contact between the mother andEY since 21 July 2010. (This was in fact the date of the last reviewbut the mother had not attended it, her last recorded contact hadbeen three weeks before then). It was stated that the adoptioncounsellor was to offer further counselling sessions when themother returned from her holiday. As the adoption had beenagreed the counselling would have continued with a focus on theimpact of the decision on the mother herself and to make sure thedecision was final.3.77There is no record of the social worker taking any action toprogresstheadoptionthroughoutAugust.Accordingtothemanagement review there was no supervision session during thisperiod (because of leave and training commitments) and it wasnot until September that work was begun in relation to theproposedadoption.Themanagementreviewstatesthatthisincluded the social worker beginning work on a Child PermanencyReport, booking an adoption medical for November 2010 and anAdoption Panel for December 2010. There is no indication as todiscussions taking place about the legal advice about contactingthe maternal grandparents.3.78If the local authority had done this (in order to progress theproposed adoption) it would have opened up the possibility thatthey would have sought to become actively involved and possibly39offered to care for EY. Implementing the legal advice in relation tothis was potentially complex. In the event no progress was madeinrelationtocontactwiththematernalgrandparentsuntilNovember 2010.3.79At this point it appears that the focus of attention in the localauthority was on the difficulty that the mother had had (andperhapscontinuedtohave)indecidingaboutwhethertorelinquish EY for adoption and on the difficulty that she washaving in telling her parents that she had a second child. The legaladvice that had been given was that the focus of attention shouldbe on what was in EY’s best interests and the adverse effect thatfurther delay would be likely to have on him. The question ofwhether the maternal grandparents needed to be involved wasone which needed to be actively addressed by the local authorityfrom the perspective of what it believed was in EY’s best interests.The difficulty that this posed for the mother needed to be takenintoaccount,butitshouldhavebeenarelativelyminorconsideration. This is discussed further in section 4.4 below).3.80On 4 September the mother had contact with EY at the fosterhome, the first recorded contact since 29 June 2010 (almost 10weeks previously). A further visit was made on 11 September.There was no further contact visit until November by which timethe mother had decided that she wished to look after EY.3.81On 10 September legal services sought an update from the socialworker. This was provided on 14 September following the visit tothe family home that day. Again the discussion with legal was notrecorded on the social care files. The allocated social worker(SW5) and the social worker who had been undertaking adoptioncounselling saw the mother and the father. The purpose was todiscuss the local authority’s intention to disclose the proposedadoption to the extended family. The local authority repeated theview that the manager had explained to the father some weeksbefore (i.e. that the mother’s family would be told). This wasbased on an interpretation of the legal advice given, though it was40not stated why the local authority had decided that it would bebetter for EY to disclose his existence to the grandparents (againstthe wishes of the father and in the face of the mother’s failure todo so).3.82The father stated that he felt that it was unfair to tell the familybecause it would be a trauma for them. He spoke of the difficultieshe had had since the birth of EY. He was noted to have dominatedthediscussionandputtingthemotherunderconsiderablepressure. The social workers and the mother spoke of the supportthat the maternal grandparents had already given the family overOY.3.83It is clear that at this point the discussion about contacting thefamily (which the local authority had decided was necessary inorder to progress the adoption) had reopened the discussion aboutthe agreement to the adoption. The mother had made a clearstatement about this at the beginning of August and had thengone away on holiday. There was clearly an assumption on thepart of everyone involved that if the mother’s family knew aboutEY they would offer to care for him or persuade the mother to doso with their help.3.84The outcome of the meeting reported to the legal service was thatthe mother wanted to proceed with adoption, the extended familywould be contacted and that the father was opposed to this andsaid he would be seeking legal advice.3.85On 16 September the mother re-registered at the children’s centreafter a five month break. She may have attended sessions earlierin the month but this was the first time her attendance wasrecorded. 14 Mother attended with OY and did not mention havinghad a second child in between. The mother registered at thechildren’s centre as a single parent with one child living at aWindsor address. The centre worker and the centre coordinatorwere not aware of the birth of EY or of any involvement of14 Given the nature of the service that not recording an individual attendance would not beunusual41agencies in between. Mother attended a variety of sessions withOY and then with EY until shortly before the death of EY. Shebegan a parenting programme run at the centre in March 2011.3.86On 21 September 2010 the adoption counsellor made a furtherhome visit. The mother said that she had not yet informed herparents of the birth of EY but intended to do it ‘next weekend’.She said that if her mother offered her support she said she mightchange her mind3.87On 27 September the social worker provided an update to thelegal department. She stated that the mother would be telling herparents about EY and that she would do so if the mother hadfailed to. No timescale was placed on this.3.88On 28 September the social worker (SW5) made a statutory visitto EY. He was noted to be developing appropriately and wasobserved laughing and smiling and he was able to hold the balloonand other toys. He was able to sit up supporting his weight. Hiscarer had begun weaning him; he had a good appetite and waseasy to feed. EY was reported to be sociable and happy duringmeal times. He was sociable in public and sought out socialinteraction.Thisisanaccountofahappychild,developingnormally and benefitting from good physical and emotional care.There was a minor concern about his ‘tongue tie’ which was saidto be very mild.3.89The social care records contain an email setting out the advicegiven by the legal service on 1 October 2010. It states that ‘thebest course of action is for the social worker to write to themotherstatingthesocialworker’sintentiontovisitthegrandparents to discuss permanency plans’.This part of theadvice is entirely consistent with the legal advice given in July2010 after the looked after review. However the email continuesthat ‘this action should only be taken if this is assessed to be inEY’s best interests and if mum is in agreement with the approach’.This strongly suggests that the mother needed to consent to any42approach to her family. It is very likely that the emphasis placedon securing the mother’s agreement in this email contributed tothe further drift in the case. The SCR believes that the secondaspect of this legal advice did not properly reflect the case law orthe interests of EY. This is discussed further at section 4.4.18below.3.90On 12 October 2010 a further adoption counselling visit wasmade. The mother confirmed that she wanted to proceed withadoption, even if her parents were to offer support. However, themother had still not yet informed her parents of EY’s birth. Themother discussed preferences that could assist in matching EY toprospective adoptive carers. Again it is not clear at this pointwhether there had been liaison between the two social workersinvolved.3.91EY’ssocialworkerdidsetadatetovisitthematernalgrandparents (18 October) but the mother postponed this on themorning saying that her parents were on holiday. The socialworker replied setting a definite date and seeking the return ofadoption medical forms which had been delayed with the mother.On 2 November the mother tried again to delay the meeting onthe grounds that her parents were away again. The social workercalled at their home on 4 November and left a compliment slip.They were clearly not away and phoned immediately to ask whythe social worker had made contact. The next day following afurther discussion with the mother, the social worker informed thegrandparents over the phone about the birth of EY and that hewas in care. The grandparents blamed the father. The socialworker agreed to visit in a week. It is not clear why she delayedher visit by a week. During this period the family took control ofthe situation.3.92On 8 November the mother sent texts to the social worker statingas follows:she wished to have contact with EY the next day43her parents had agreed to support her if she wished to bring EYhomeher heart was also saying that she wished to bring him homeand she was relieved that her parents knew what washappening.At this point the mother had had no contact with EY for nearly twomonths.3.93On 9 November the mother visited EY and after this she phonedthe social worker and told her she wanted to take EY home. Shesaid that her parents had told her that they would give herfinancialandpracticalsupport.Thefollowingdaythefostermother advised her support worker that she had no reservationsabout this. This is discussed in section 4.3 below. The socialworker emailed an update to the legal service on 10 November.This was the last contact with legal advisors.3.94EY was taken to the health clinic on 12 November. He weighed8.72kg (just below the 75th centile).3.95On 12 November a planning meeting was held at the foster carers’home to plan for the discharge of EY to his mother’s care for thefirst time. This was attended by a manager, the social worker(SW5), the senior social worker, the adoption counsellor, themother and the maternal grandparents. There are no details of thearrangements made in the local authority records. The socialworker informed the mother’s health visitor (HV5) the next day byphone but did not consult with the health visitor (HV4) who hadattended the looked after children review and raised concernsabout the mother’s potential capacity to care for EY at the reviewin July. It is impossible to know what she would have said had shebeen asked. However none of her concerns had been addressed inthe intervening four months, EY had grown up considerably andthe mother had had even less contact than during the periodpreceding the looked after review.443.96Between 12 and 19 November (when the handover took place) themother visited on a number of occasions. It is not recorded howlong these visits lasted or what took place in any detail. There isno record of the social worker observing the contact sessions,though she spoke to the foster mother. None of the qualified socialcare staff who had been involved in the meeting visited the fosterhome during this time. The adoption counsellor spoke to themother on 16 November on the phone. She said things were goingwell, although OY had been a little jealous of EY. The fostermotherwaspositiveoverallbutshemadeanumberofobservations which she felt were concerning which she reportedon the phone to the social worker on 18 November. Twice shenoted that the mother kept EY on her lap facing away from her;mother made little eye contact; she did not know how to respondwhen OY was jealous of the attention that she was giving EY andshe was not very effective at stopping OY from scratching EY. Thefoster mother believed that the mother might need advice on‘bonding’. The social worker recorded these comments but it is notclearifsheunderstoodthereasonsforthefostermother’sconcerns or if she discussed them with her supervisor.3.97The foster carer’s observations were very similar to some madelater by staff at the Children’s Centre.3.98So far as can be established the social worker did not see themother and child together or speak directly to the mother betweenthe planning meeting on 12 November and 24 November (fourdays after she resumed the care of EY). During this transitionalperiod there is no record of contact with the father or his attitude.Discussions with the maternal grandparents had triggered themother’s decision to care for EY. They attended the planningmeeting that agreed to the placement of EY with his mother, butthere is no indication any professional had further contact withthem. Their actual role in supporting the care of either child wasnever established.453.99The mother’s health visitor (HV5) visited her ahead of the returnof EY. She made no detailed notes except that she advised aboutplaygroups and reminded the mother of the support available fromthe health visiting team. When interviewed for the SCR she statedthat the mother had talked about her visits to EY at his fosterplacement, she appeared relaxed and happy and she reported thatshe had no concerns about EY coming home.3.100The local authority did not seek legal advice about the position ofEY at this point. If it had done so it is clear that the local authoritywould have been advised that there were no grounds to seek toprevent the mother from taking over the care of EY. He had notsuffered significant harm as he had been looked after in fostercare since his birth. There was no evidence – based on the carethat had been provided to OY by the mother and her family – thatEY would be likely to suffer serious harm in the future. Howeverthere were good reasons to be concerned about aspects of thehistory, particularly the fact that the mother had concealed twopregnancies and the very limited contact that she had chosen tohave with EY when he was in care. There was no question at thispoint of preventing the mother from taking EY home. Attentionshould have been focused on the sort of intervention required inorder to monitor how the mother was able to care for EY, how thechanged circumstances impacted on her care for OY and what sortof provision was needed to best support her in caring for bothchildren.3.101These factors were not identified as significant and EY was placedwith his mother after a brief period of contact visits with no planfor further intervention and no arrangement for coordinating theinputof the professionalsinvolved. Asa result each of theagencies and professionals involved was left to make individualdecisions about how to respond to the family. Other professionalswho became involved (such as GPs who knew little or nothingaboutthechildren)respondedtoeventswithlittleorno46knowledge of the children and their history. This is discussed indetail in section 4.3 and 4.6 below.Significant events between the mother assuming responsibility forthe care of EY (19 November 2010) and 15 December whenprofessionals first observed injuries to EY3.102On 19 November the mother took over the care of EY. The sameday the father visited a locum GP and spoke again about hisfeelings (Redacted), first triggered by the birth of OY. He saidthat he had wanted to give up the boy for adoption but that his‘parents in law’ were not happy about this and wanted to lookafter their grandson. (Redacted)3.103The records of this consultation are confusing because they createthe impression that there was only one child (OY) aged 18months. The reasons for this are not clear but there is no reasontothinkthatthiswassignificantasthefatherhadalwayspreviously been clear about the details of both of the children. TheGP did not discuss this with any other professional.3.104Thefamilyhealthvisitor(HV5)madeahomevisiton23November. She saw both parents and both children. She offeredinformationaboutlocalservicesandadviceonthesupportavailable from the health visiting service. A core health visitingservice was offered. The notes from the health visitor who hadknown EY in foster care were never requested. The father was saidto be ‘very engaged’ indiscussions. None of the potentiallycomplex aspects of the situation were identified or discussed.There was no exploration of the mother’s long standing ambiguityabout caring for EY and the sudden change of mind. There werehuge gaps in the knowledge that the health visitor had about therelationship that the parents had with EY, for example the father’shostility to EY being cared for by the mother and the very largegaps in contact between the mother and EY while he was in care.The local authority had not provided this information and thehealth visitor had not sought information from the local authority47or from EY’s previous health visitor in order to carry out a properassessment.3.105Taking over the care of a child at the age of seven months is achallenging task in any circumstances and in this case there wereadditional complicating factors which needed to be explored andunderstood. The circumstances at the time of this contact meriteda full individual, family and environmental assessment at least ona par with a normal health visitor’s new birth visit. This did nothappen and this is discussed further in section 4.3 below.3.106On24Novemberthesocialworkervisitedthemotherandchildren. The social care management review reports that therewas evidence of positive parenting and attachment observed bysocial worker, though the only example given is that the motherencouraged OY to be gentle with his brother and not to hit him.The mother said that she was following the same routine as thefoster carers and that this was working well. The mother statedthat the father had visited every day to help. He was said to bemaking caring for EY easier by caring for OY. The mother said thatshe had introduced EY to her parents and would be introducinghim to her friends ‘that evening’. She felt that she did not needhelp from any voluntary services and now did not feel concernedabout coping. The social worker assessed all aspects of the careprovided and family circumstances as being positive. She neversubsequently spoke to the grandparents to find out what role theywere playing.3.107The social worker and her managers did not perceive this as beinga potentially complex situation in which they should insist on therebeing a need for continuing involvement to monitor the childrenand coordinate the provision of services to the family.3.108On 30 November EY was taken to the child health clinic. Hisweight was 8.90kgs just below the 75th centile. This showedcontinued growth since his attendance on 12 November.483.1091 December 2010 is the likely first date of EY’s attendance at thechildren’s centre. EY was added to the register when he started toattend regularly in January 2011, but it would not be unusual for amother to bring a child to a few sessions without registering him.The mother did not register EY’s details and told staff at the centrethat he was the child of a cousin whom she was looking after. Shemaintained this deception – which she also told other parents atthe centre - until EY’s last attendance shortly before his death.3.110This was also the date when the mother registered EY at her GP.His records were received two months later. They had not beenreviewed and no summary had been added to the electronicrecord at the time of his death. The GPs at this surgery were notaware that he had been looked after for the first seven months ofhis life and that his mother had only just started to look after him.15 The practice did not have his mother’s records from his previousGP until after the death of EY. The health visitor (HV5) was awareof this history but she did not tell the GP when they laterdiscussed concerns about EY.3.111On 14 December 2010 the LAC health team was informed by thehealth trust’s systems section that EY had returned home. Thissuggests an automatic notification from the information system ofthe local authority to the health trust. The local authority hadinformed the health visitor for the mother and OY (HV5) directly.She did not request the health records from HV4 who in turn didnot know that EY had been placed with his mother.3.112On 15 December the social worker made a visit to the mother andchildren. EY was seen asleep and had scratches on his face whichhis mother said had been caused by OY. The social workerdiscussed routines and coping strategies with the mother who saidthat she was coping well. She gave the mother photos of EY takenby the foster carers. The records do not indicate that the social15 There were however some references to this in EY’s personal child health record and theseare described and discussed in detail in section 1.18 and at several other points in the report.They were not obvious and a number of health professionals did not notice them49worker asked any more about how the scratches had been causedand she did not query the explanation. This was a concerningpresentationwhichmighthavebeenanindicationofpoorparenting or abuse. This was the last social work visit before thecase was closed on 22 December 2010. The social worker neversaw the father or members of the maternal family with EY after hemoved to his mother’s. No evidence was ever obtained (other thanthe mother’s general comments) to establish exactly what role thefather and the maternal grandparents were playing.3.113There was no detailed account of the supervisory discussions thatsupported the decision to close the case at this point. The authorof the social care management review was asked to address thisspecifically with the manager involved who has cited the followingfactors which he believed justified it at the time:the father and the mother’s extended family were seen asinvolved and supportivethe mother was understood to have cared effectively for OYthere were no known history or neglect or abuse or anyobvious risk factor such as mental illness or domestic violencein the familyit was perceived as being a ‘good outcome’ for EY to be unitedwith his mother and family in what was viewed as a stablefamily settingthere was a perception that the history of OY was ‘repeatingitself’3.114Section 4 of this report evaluates these judgements and theextent to which evidence which did not support them was notgiven sufficient weight. The social work supervisor also believedthat there were no significant risks in the mother taking over thecare of EY because he had been an easy infant to look after. Thefact that he had been an easy infant for foster carers to look afterdid not of course mean that he would be an easy child for hismother to look after. This assessment underestimated the specificsignificance or ‘meaning’ that EY may have had for his mother.50This is a recognised factor in many cases in which children arekilled or seriously injured.16 This is discussed further in section4.4 below.3.115EY was taken to a ‘stay and play’ session at the Children’s Centreon 5 January 2011. The children’s centre has two members ofstaff (a worker and the centre coordinator). References to ‘staffmeetings’ in the remainder of this report refer to minuted weeklydiscussions between the two. That day staff observed scratches onEY’s face. They were not viewed as being significant and recordswere only made retrospectively when a second set of marks wasnoticed on 2 February 2011. Staff remember the mother sayingthat the injuries had been caused by EY’s older sister. The exactlocation of the scratches was not recorded. This presentationappears to be similar to the one which the social worker had seenon her visit on 15 December 2010 and should have been viewedas concerning in a child of this age. 173.116On 12 January 2011 EY attended the children’s centre again. Thescratches had faded. The mother now said that she was caring forEY 3 days per week as an unpaid child minder. The informationwas not recorded at the time, though later centre staff took adviceabout this.3.117On 19 January the mother’s GP saw EY with his brother andmothertoundertakethe9–12monthdevelopmentalassessment. This would normally have been undertaken by thehealth visitor, but it was the practice of this experienced GP tooffer this service. He was unaware that EY had been ‘looked after’as he had not received a notification from the looked after healthteam or the social worker and the mother did not tell him. Thesurgery had not at that time received EY’s medical record from hisprevious GP which contains many references to his looked after16 P Reder, S Duncan and M Gray, (1993) Beyond Blame – Child Abuse Tragedies Revisited,Routledge.17 The social worker only saw EY asleep. The children’s centre workers believed that the childthey were seeing was a member of another family.51status.18 The GP did have access to the Personal Child HealthRecord (PCHR) which contains two indications that EY had beenlooked after. The first is a reference to his foster carer in one ofthe health records completed by his health visitor. The PCHR alsocontained a copy of the form giving parental consent to medicaltreatment for a looked after child (which would have been foldedin a separate section at the back of the small ring binder whichholds the record). This was not part of the PCHR which the GPwould normally refer to. The earlier health visitor entries alsomake a number of references to actions that would be taken byEY’s ‘carer’ rather than his mother or parent which at best give aslight clue that he was not living with his mother. The nature ofthis record and the fact that this significant information was notobviously visible is discussed further in sections 4.6 and 4.11below.3.118The GP noted that EY had three scratches on the right hand sideof his head and a bruise behind his right ear (recorded as 2x1cm). He also had fading bruises on his right forehead and rightcheek (measured as 2x7mm) and vertical scratches on his nose.No bruises were noted on his torso, his testes were both down andhisnapkinareawasnotedtobehealthy.EY’sheightwasmeasured as 46cm (75th centile) and his weight was measured asbeing 9kg (on the 50th centile). This was noted to have ‘fallen incentile position slightly’. The GP could tell this from the part of thePCHR that he accessed and he plotted the current weight on theheight and weight chart (See Appendix 7). The notes confirm thatthe GP accepted that the bruises and scratches had been causedby EY’s brother (who was present in the surgery) as he recorded‘2 year old brother-spiteful’ (although OY was not yet age two atthat point). The records note his intention to refer the family tothe health visitor for follow up, which he did.18 These arrived shortly after this consultation but had not been reviewed and summarisedonto the patient electronic record by the surgery at the time of EY’s death.523.119Two days later the GP phoned the health visitor (HV5) anddiscussed his findings. The GP record shows that ‘Health visitor(named) is aware and will visit next week.’ The GP confirmed hisview that OY had caused the bruising and scratches. There is norecord of what HV5 said apart from that she would visit.3.120The scratches seen by the social worker in December 2010 andthechildren’scentrestaffinJanuary2011wereunusualpresentations in a baby of this age. The bruising observed by EY’sGP was the first clear indication of possible physical abuse seen byprofessionals. They occurred 10 weeks before his admission tohospital with serious injuries.3.121The health visitor’s (HV5) notes (which are written up in her workdiary) state that she received the phone call on her mobile phonewhileoutmakingvisitson24January2011.Thereisadiscrepancy in the dates but the content of the GP and healthvisitorrecordingsisconsistent.ShenotedthattheGPhadobserved bruises on EY’s ‘face and head’ during a developmentalcheck. The health visitor’s perception was that she was beingasked to visit to advise on sibling rivalry, not to visit to check onthe bruises. There is nothing in the GP’s notes to suggest that hethought anything more was needed or that he asked for anythingelse to be done.3.122The health visitor (HV5) knew a significant amount about thefamily history at this point, including the fact that EY had been infoster care from birth to the age of seven months. However shedid not explain this to the GP. Although she took the call on hermobile phone while away from her base and she had no access torecords the health visitor did identify the particular child that wasbeing discussed and recalled his circumstances. Her recollection isthat she would have assumed that the GP already knew thisbecause he would have had access to the medical records.3.123The health visitor (HV5) made the requested home visit on 26January 2011 (seven days after the GP consultation). EY was seen53sleeping in his cot during the visit. No details of the bruises wererecorded because the health visitor did not believe that it was hertask to evaluate the bruises. The mother reported that there wereno problems and that she had a lot of support from her family andthe father. It was planned that the mother would attend the childhealth clinic and that she would contact the health visitor if sherequired further support or advice. The health visitor discussed theproblem of ‘sibling rivalry’ and gave what is described as ‘standardadvice’ to the mother. The health visitor recorded in the PCHR thatshe had discussed EY’s ‘excellent weight gain’. It is not clear whythe health visitor recorded this remark or what it referred to. EYwas not weighed as he was asleep and there was no facility to doso on this home visit. This is now described as being a ‘recordingerror’ which the practitioner involved has been unable to explain.3.124This may be significant because – even if it was recorded in error– another health visitor who saw the PCHR might have taken it atface value and been less concerned about the subsequent failureof EY to gain weight at the expected rate. EY was not in factgaining weight. Five days previously he had been weighed at theGPs and his weight was static (representing a fall in percentileterms, though not yet one that on its own would be consideredworrying). The height and weight chart is reproduced as AppendixVII3.125On 2 February the children’s centre worker observed bruises onEY. She did not record a detailed description of these bruises(colour, size or location) and so it is not possible to be certain ifthese were the same bruises that the GP had first observed on 19January or new injuries (or a combination of both). This was thesecond clear indication of possible physical abuse to EY seen byprofessionals, six weeks before his admission to hospital withseriousinjuries.Thiswasthesecondpotentiallyconcerningpresentation at the children’s centre.3.126The appearance of these bruises prompted the worker to make anote of the scratches observed on 5 January 2011. The mother54was attending the centre with both of her children. She gave afalse name for EY and continued to mislead staff about herrelationship with the child. Once again she was asked to registerEY and again she did not complete the registration form. Althoughno record was kept, at around this time children’s centre staffsought advice about the legality of the arrangement (i.e. a womanwho was not a registered child minder looking after the child of acousin for three days per week). The (correct) advice given wasthat it was not illegal so long as no payment was being made. Thisadvice was not recorded. At around this time the parents ofanother child attending the centre reported concerns about thesame bruises. These were backed up by a number of observationsof the mother’s behaviour and emotional responses to EY but werenot acted on by centre staff.3.127On 7 February 2011 the children’s centre coordinator referred themother to attend a parenting course due to be held at the centrein March. The centre coordinator said her reason for referring themother was to positively influence the mother’s parenting skillsandtoimproveherchildmindingskills.Noconcernswereexpressed about the parenting of OY. The underlying reason forthe referral was not disclosed to the parenting team membersrunningthecourse andnoinformationwasprovidedto theparenting team about the scratches and bruises.3.128On 9 February 2011 the mother attended a ‘stay and play’session. This was a busy session, with 12 adults and 15 childrenmarked as attending. On arrival, EY was left in his pushchair withthe hood up facing the wall. During the session the centre workerwent to look at him and observed that he was awake and had twobruises on his face (‘one on the side and one on his forehead’). Atleast one of these bruises must have been a new injury as onlyonebruisehadbeenobservedthepreviousweek.Hewasobserved to be happy when interacting with other adults. On theassumption that these were not the same bruises that had beenseen a week earlier, these were the third indications of possible55physical abuse seen by professionals, and the third concerningpresentation at the children’s centre. The mother was again askedfor her completed registration form and claimed that she hadforgotten to fill it in. She was asked to bring it the next week. Thecentre staff discussed the injuries after the session and the centreworker completed an incident record. This was not part of anindividual record because the children attending the centre did nothave individual records or case files. It was an individual sheet ofpaper (akin to the sort of form that might be used to report anaccident). These forms were filed in broadly chronological order soit was difficult to easily draw together a history of all the incidentsrelating to an individual child. This is discussed further in section4.9 dealing with the training of the staff working at the centre.3.129On 14 February 2011 EY was raised as a concern at the weeklyteam meeting between the centre worker and the coordinator. Theagreed action was ‘awaiting registration form, the mother has it athome and will bring on Wednesday to Stay and Play’. There wasno specific action recorded in relation to the bruises.3.130On 14 February 2011 EY’s former foster mother had a chancemeeting with the mother and EY. The foster carer made no notesof the encounter at the time but at her interview for the SCR shesaid that EY seemed quiet and subdued and that he had ‘lost hissparkle’ and that she wondered how the mother was coping. Sheremembers what she described as a ‘fading bruise’. This is likelyto be the same bruise seen at the children’s centre five daysbefore. She phoned the social worker (SW5) about this on 16February 2011. The social worker made no record of this contactso it is not possible to know exactly what she was told. She latertold a colleague (who made a record of the discussion – seeparagraph 3.140 below) that she phoned EY’s health visitor andleft a message on her voicemail passing on the foster carer’sconcerns and suggesting that the health visitor might visit to seehow the mother was coping. There is no record in the health trustof this voicemail and the health visitor does not recall receiving56such a voicemail. It is not possible to state with certainty whethera message was left or not. This may not have been a new incidentofabuse(becausethebruisemayhavebeenseenbythechildren’s centre a few days previously). However the significanceis that at this point the foster carer and either one or two furtherprofessionals knew about bruises on EY’s face.3.131On 1 March 2011 the social worker was reminded of this incidentby a colleague who had visited the foster carer (for reasonsunrelated to EY). The action taken at that point is described inparagraph 3.140 below.3.132On 16 February the mother attended ‘stay and play’ with OY andEY. Both centre staff observed bruises on EY’s forehead andcheek. These were the fourth indications of possible physicalabuse to EY seen by professionals and the fourth concerningpresentation observed by centre staff. The mother was askedabout them directly. She became defensive (to the point ofwalking away and refusing to discuss it) and said that the bruiseson the forehead were from EY hitting his head on the floor. Duringthe session staff observed that he seemed to have good control ofhis head and neck. The mother said that she did not know wherethe bruise on his cheek came from. EY was fully clothed and noother bruises were observed. The mother again said that theregistration form was at home but she had forgotten it. Inconversation with other mothers and staff, the mother said thatshe was going on a skiing holiday and would not be attending‘stay and play’ the next week. Staff thought that the excuse aboutthe registration form was ‘probably true.’ Another two parentsraised concerns about EY’s bruises. One remarked on his mother’slackofconcernandresponsiveness,theotheronhowhisbehaviour was unusual for a child of his age. The other parents’comments were not written down, but were recalled in staffinterviews for the SCR.3.133The same day the centre manager discussed the case of EY insupervision with her manager, though she did not mention the57name of the mother or the child. It is assumed that this occurredafter the incident that day at the centre.3.134The account that she gave to her manager are not recorded.There are recorded ‘shorthand’ notes of the action agreed but it isnot possible to be certain from the notes what was intended andthis is the subject of disagreement. The meeting record reads‘discuss with carer + then (poss) Mother. HV? Find out who… D Offreferral’.Thesenotesareclearlyopentodifferentinterpretations. The actions taken are likely to be those listedbelow on 16 February.3.135The children centre incident form states that social care wasphoned and gave advice that the registration form needed to becollected and then the parent identified. The parent should bequestioned.3.136The same day (16 February 2011) an access officer in the dutyservice made a record of a discussion in a notebook which mayrelate to these incidents. Access officers are administrative staff,with no social work qualification, who support the referral andassessment service. Responsibilities include answering incomingtelephone calls, acting as a triage for requests for information,recording initial contacts and referrals for the duty social workerand manager. The notes do not name a child and they do notstate who the conversation was with. They refer to a 10 month oldchild who had a fading scratches and a new bruise. It does not saywhere the bruise was located. It gives no indication that there hadbeen a history of bruising and scratches on the child’s face. Thereis no record of any advice given and no record was made on theelectronicsocialcaresystem.Accordingtothesocialcareindividual management review this was not recorded as a contactin the social care Integrated Children’s System because the accessofficer considered the telephone call to be a consultation, ratherthan a referral. The access officer did not discuss the informationthat she had received with a qualified member of staff. This isdiscussed in section 4.9.583.137On 17 February 2011 children centre staff sought advice fromtheir link health visitor (this was a health visitor who offeredsupport and advice to the centre, but she was not one who hadhad any involvement with the family). Attempts were made toidentify EY from child health administration records. As the namechecked was a false name no relevant child was found. Themother’s name was not checked because no one at the children’scentre had any suspicion that EY was the mother’s own child.3.138At around this time the children’s centre coordinator and herservice manager had a follow up conversation. The conversationwas not recorded and could have taken place on 17, 18 or 21February. The centre coordinator agreed that she was confidentabout following the concerns up. Both parties agree about this,despite their conflicting earlier accounts. This was after the call tothe access officer but it is not clear if this preceded or followed thecalls to the healthvisitor and the administrator. The centrecoordinator did not mention the case again to her manager,despite the subsequent failure to identify the child, the refusal ofthe mother to complete a registration form for EY and the furtherpresentations with bruising. The service manager did not ask heragain what the outcome of her actions had been. This is discussedin section 4.9.3.139There are no further entries in any agency records until 1 March2011. That day the mother attended the first session of the TripleP parenting programme run at the centre. Both children were leftin a crèche. There were no negative or significant observationsrecorded.3.140The same day the supervising social worker for the foster carersvisited. The foster mother repeated her account of seeing EY andhis mother to this social worker. The fostering social worker (SW3)in turn contacted the previously allocated social worker (SW5).She said that she had called the health visitor (HV5) and left avoicemail message and that she would chase this up as she had59not heard back. She did not try to contact the health visitor again.The social worker (SW3) did record this conversation.3.141On 2 March the mother attended a further ‘stay and play’ sessionwith OY and EY. The centre worker observed two bruises andscratches on EY’s face. The mother who had raised concerns aboutEY’s injuries did so again. These were not recorded on an incidentform. The incident record states that ‘the mother came with hercousin’s baby. He was taken out of his car seat and played withand he appeared happy. EY had a bruise on his forehead whichwas blue; he also had one on his cheek under his eye. He had twosmallscratches nearhiseye. Ilooked athisnails(unclearwords)…they are fairly long’. The incident record does not recordthe exact location of the bruises. They are likely to be new injuriesas the bruise on the forehead is noted as dark blue. This was thefifth indication of possible physical abuse of EY and the fifthconcerning presentation at the children’s centre. It occurred twoweeks before EY’s admission to hospital with serious injuries. Theaction recorded was for the staff to ‘continue to observe. Gave themother another registration form for him as said she lost the lastones’. The centre worker told the centre coordinator about thebruises some time later in the week. The delay in discussion andthe continued emphasis on asking the mother to complete theregistration form strongly suggests that the staff involved did notconsider the bruising on EY’s face to be indicative of a risk of childabuse.3.142On 8 March the mother attended the second session of the Triple Pparenting programme. OY and EY were left in the crèche. Nothingnegative was recorded or noted. It is not clear why the staff didnot notice the bruises that appear to have been very evident sixdays before.3.143The following day the mother attended a ‘stay and play’ sessionwith OY. It is not known where EY was. There is no indication thatshe was asked (though as he was believed to be the child ofanother woman this would not have been seen as significant).603.144On 14 March EY was seen by a GP (GP4) with a cold and coughwhich his mother said he had had for five days. He was noted tobe ‘alert, interacting and comfortable’ and otherwise well. Giventhe reason for the consultation it is likely that very little of EY’sbody would have been examined.3.145On15March2011themotherattendedthethirdTriplePparenting programme session. OY and EY were left in the crèchewhere staff observed bruises on EY. The incident record noted thatEY had a ‘dark blue bruise on the left side of his face close to hiseyes. He has a lighter bruise on his forehead’. The centre workerhad a look down the front and back of his vest and could not seeany more bruises. No bruises were observed on his legs. Thecrèche staff were very concerned about his bruises as they weresure that EY was ‘very stable sitting up and didn’t fall over’. Theaction noted was for staff to ‘continue to observe him’. This wasthe sixth indication of possible physical abuse of EY and the sixthconcerningpresentationatthechildren’scentre.Theywereobserved two days before he was taken to hospital with seriousinjuries.3.146The following day (16 March 2011) the mother and both childrenattended ‘stay and play’ session at the children’s centre. Staffrecalled in interview that both children seemed poorly and that EYwas lethargic. It is not clear whether the bruises were observedagain. They may not have been recorded because they had beenrecorded the day before.3.147On 17 March 2011 the mother took EY and his brother to a childhealth clinic between 1.30pm and 3.00pm. The clinic was beingconducted by a health visitor (HV7). The health visitor had noprior knowledge at all of EY, his family or his history. She madebrief notes during the clinic in the PCHR and she made a note ofEY’s name in her work diary because she intended to speak to hisallocated health visitor about her observations. EY had beenseriously injured before she was able to do this. Section 4.11 ofthis report will describe in more detail the arrangements for the61clinic and the circumstances in which this health visitor wasworking that day.3.148The most recent recordings on the PCHR had been made by theGP on 19 January and the health visitor (HV5) on 26 January2011. The history of bruising observed at the children’s centre hadnot been recorded in any health record as the true identity of EYhad not been obtained so there could be no consultation with ahealth professional.3.149EY’s weight was recorded in his PCHR and plotted on the weightand height chart. It showed that he had gained only 100 grams inweight since his previous clinic attendance on 30 November. Thehealth visitor recorded EY’s weight as static and advised hismother to bring him to attend for a weight check in four weekstime. EY’s mother stated that he was eating three meals a day andsleeping through the night. EY had dropped two centile bands onthe growth chart since he had left foster care, from just below the75th to between 25th–50th. This was a very noticeable departurefrom the established growth pattern. Visually it is very striking onthe growth chart, shown as Appendix 7, especially since children’sweight does not usually deviate outside one of the marked bands.EY’s plotted line becomes effectively horizontal. As she did notknow that he had been in foster care as a baby this health visitordid not appreciate that the period of static weight coincidedentirely with EY’s period in his mother’s care.3.150The health visitor (HV5) observed EY to have bruising to his face.She noted this on the PCHR, but not the details. During herinterview conducted for the SCR the health visitor recalled that hehad a bruise on his left forehead and a bruise on his left cheekbone. Both were approximately the size of a one – two pence coinand yellow / brown in colour. This was the seventh indication ofpossible physical abuse of EY. It was recorded in EY’s PCHR thathis mother reported that the bruising was a result of a fall at asession at the children’s centre the previous day. The healthvisitor states that she directly asked the mother on two separate62occasions how the bruises were caused, suggesting that she wasconcerned. The mother was adamant that EY had fallen off a toyat the ‘stay and play’ session the day before. The health visitorasked if EY had shown any signs of excess drowsiness or if he hadvomited. The mother stated that he had not and the health visitoradvised her to see the GP if EY showed any of these signs. Thisindicates that she was concerned to establish that there were noconcerning after effects indicative of an injury and to warn themother to watch out for them. This suggests that she was actingon the assumption that the account of the fall was genuine.3.151The mother also stated that OY was very jealous of his brother.The health visitor (HV5) recalls advising her not to leave the twochildren alone together. She suggested the mother enlist morehelp from her own mother to have EY while the mother spentmore time alone with OY. The health visitor recalls that both themother and the children were appropriately dressed and sheremembered that OY spent some time interacting with otherchildren at the clinic. EY was held in his mother’s arms (exceptwhen being weighed). The health visitor made a note of themother’s name in her diary with the intention of liaising with herhealth visitor (HV5). Despite the bruising and the very marked falloff in weight gain the health visitor did not seek advice from thenamed nurse for child protection or from the local authority.3.152On the morning of 18 March 2011 EY was taken to hospital byambulance. Ambulance service records refer to an account of aninjury at a ‘play park’. It is not certain if this refers to thechildren’s centre or not. EY was quickly identified as having aserious head injury. He died on 20 March 2011 and was found tohave suffered a number of other fractures in addition to the fatalhead injury. So far no explanation has been provided as to thecircumstances in which the head injuries that caused the deathand other injuries believed to be of different ages. The mother wassubsequently arrested and is suspected of having caused thedeath of EY.634EVALUATION OF THE SERVICES PROVIDED FOR THECHILDREN4.1Introduction4.1.1ThischapteroftheSCRoverviewreportevaluatestheeffectiveness of the actions taken and the services provided tosafeguardthechildren.Itexaminestheprovisionmadebyagenciesindividuallyandbythenetworkofchildprotectionprofessionalsasawhole.Ithasdrawnextensivelyontheindividualmanagementreviewsanddoesnotrepeatallthefindings of those reports. As well as drawing on the individualmanagement reviews the overview report has taken full account ofdiscussions in the SCR panel meetings as well as discussions withindividual members of the panel and the authors of individualagencyreviews.Anumberofmembersofstaffwereaskedsupplementaryquestionsabouttheirinvolvement.Alloftheauthorities involved have made relevant documents available tothe SCR author and the panel.4.1.2The aim of the SCR overview report author has been to prepare areport that represents shared and agreed findings. If at any pointthere are substantial differences in emphasis and understandingbetween the author and the SCR panel or between panel membersthese are made explicit. The evaluation contained in sections 4.2 –4.12 provides the best account that can currently be given of theeffectiveness of the services provided to the children, based onthe information available from all agencies at this point. For thereasons explained in section 1 it has not yet been possible to takeinto account the views of family members.4.1.3In this SCR the evaluation in the overview report serves twofunctions. Its first objective is to evaluate whether the actions anddecisions of agencies with child protection responsibilities had anybearing on the death of EY. The SCR has sought to establishwhether agencies had any evidence to suspect that the childrenwere at risk of suffering serious harm and whether his death could64have been prevented if agencies had taken different decisions oracted differently. This is the focus of section 4.14 of this reportwhich presents its overall conclusions.4.1.4The second function of the SCR is to provide a wider evaluation ofthe services provided to the children and their family during keyepisodes in the case history. The objective is to identify whetherthere are any lessons that can belearnt so as to improvesafeguardingservices.Theremaybeimportantlessonsforagencies and the LSCB independently of the death of EY.The structure of the evaluation and the topics considered4.1.5This chapter of the SCR overview report addresses all of thematters set out in the specific terms of reference of this reviewand others that all SCRs are required by Working Together toSafeguard Children to address. The evaluation in this chapter ispresented as follows:4.2Concerns about parenting capacity relating to the familyhistory4.3Assessment and decision making4.4Implementation of plans4.5Focus on the child4.6Information sharing4.7Factors that impeded engagement with the family4.8Policies and procedures4.9The skills, knowledge and experience of the staff involved4.10The impact of supervision and management4.11Organisational matters - the impact of resources, lack ofcapacity and other organisational issues4.12The impact of diversity4.13What do we learn from the case?4.14Conclusions as to whether there were missed opportunitiesto protect the children and whether the death of EY couldhave been preventedJudgements about shortcomings in practice and good practice654.1.9The Working Together guidance requires that the SCR shouldbring hindsight to bear in evaluating the actions of professionalsand public bodies.19 Self evidently there is value in seeking to lookback objectively at a case history, with a fuller knowledge of theevents and the actions taken by professionals and knowing theoutcome. As well as the insight that comes from hindsight the SCRis aware of the danger of what is termed ‘hindsight bias’.204.1.10So far as is possible the SCR has therefore sought to avoid this. Itis easy to view decisions as being wrong because we now knowthat they were part of a chain of events that had a tragic outcome.It is harder but much more useful to seek to understand andexplain why actions were taken and decisions were made and toconsider the influences over professionals arising from the contextwithin which they were working. In this way it may be possible tolearn lessons that are relevant to other professionals who findthemselves working in similar circumstances.4.1.11Whenevaluatingtheactionsofindividualpractitionersandmanagers and groups of professionals and agencies the SCR hastaken the following approach:judgements about actions and decisions take into account theinformation that was available to those who took themat points it is necessary to evaluate actions and decisions inrelation to information that was known to the network of childprotection professionals as a whole and would have beenavailable if relevant information had been sought and provided.the review has sought to judge the actions of professionals andagencies against established standards of good practice as theywere believed to apply at the time when the events in questiontook place19 Working Together to Safeguard Children 2010, Chapter 8 describes the evaluation in theoverview report as being ‘the part of the report where reviewers can consider, with the benefitof hindsight, whether different decisions or actions may have led to an alternative course ofevents.20 David Woods et al, Behind Human Error, Ashgate (2010) second edition; Sidney Dekker,The Field Guide To Understanding Human Error, Ashgate (2006)66the evaluation will seek to distinguish and outline the influenceof individual and wider organisational factors in the decisionsand actions takenUnderstandingwhytherewereshortcomingsinprofessionalpractice and in the provision made4.1.12The SCR has identified a number of missed opportunities toprotect EY and his brother. There were also episodes in the casehistory when the standard of provision that was made fell short ofthe expectations that agencies have about how their staff operate.Viewed with hindsight it is usually easy to see what should havebeen done. On the face of it the local child protection proceduresset out the steps that should have been taken and there has beenmuch training for local professionals which was directly relevant totheproblemsthattheywereconfrontedwith.TheSCRhastherefore sought to understand why it was that this case proved tobe very difficult for staff to deal with in situ.4.1.13The approach adopted in this evaluation is a ‘systemic’ one whichpoints up the potential significance of factors relating to the child,the family, the wider professional network and the context withinwhich staff are operating.21 In the biennial analysis of SCRscovering the period 2003 – 2005 Brandon et al 22 identify some 30‘themes’ in the profile of the cases included in their retrospectiveevaluation. These are organised in relation to three domains:‘child factors and experience’, family and environmental factors’and practice / professional / agency factors’. The evaluationhighlights information relating to these factors.21 P Reder, S Duncan and M Gray, (1993) Beyond Blame – Child Abuse Tragedies Revisited,Routledge. This is not the same thing as a ‘systems review’.22 Brandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, and Black J (2007)Analysing child deaths and serious cases through abuse and neglect: what can we learn? Abiennial analysis of serious case reviews 2003-2005. DfES674.2Concerns about parenting capacity relating to the familyhistoryIntroduction4.2.1This section addresses the following points from the terms ofreference:Identify any historical information (prior to 1 July 2008) on thefamily members that may have impacted on the parentingcapacity of the mother, GY, and father, PO;Information about family members before July 20084.2.2There was very little information in theagency records about thefamily lives of the parents in the period before July 2008. Theinformation that there was has been set out in sections 3.1 – 3.4of the narrative above. None points to any indication of risksassociated with the parenting capacity of the father or mother orany significant events in their family history.4.2.3Neither the initial assessments undertaken by the local authoritynor the new birth assessments carried out by health visitorsexplored the family background of the parents in any detail,despite the fact that the mother had concealed two pregnanciesand given birth to two children in circumstances which might haveplaced the children at risk. Midwives usually have their bestopportunity to identify relevant background family information inthe antenatal period, but the mother did not access antenatalcare.Midwivesdidnotrecordanysignificantbackgroundinformation during postnatal care of either child.4.2.4The assessments undertaken in the case history are evaluated inthe next section of the report.684.3Assessment and decision makingThis section deals with the following terms of reference:What were the key relevant points/ opportunities forassessment and decision-making in this case in relation tothe child and family? Do assessments and decisions appearto have been reached in an informed and professional way?Establish the quality of assessment of circumstancesrelating to either and both children and their family;Establish what risk factors in the family were known toagencies during the period under review;Establish how well agencies identified and responded tochildren’s injuries and other indicators of harmDid actions accord with the assessments and decisionmade? Were appropriate services offered /provided, orrelevant enquiries made in light of assessments?Analyse the extent, and professional understanding, of thesupport from the extended familyIntroduction4.3.1Thissectionofthereportevaluatestwodifferenttypesofassessment. Firstly it considers the opportunities that were opento professionals to undertake an assessment of need and potentialrisk in relation to both of the children. This will deal with thefollowing episodes:assessments by midwives immediately following the birthsof the childrenhealth visiting assessments (the new birth assessments andthe opportunity for assessment that existed when EY’smother took responsibility for caring for him at the age ofseven months)the initial assessments undertaken by the local authorityfollowing the birth of OY and again following the birth of EY4.3.2Secondly (from paragraphs 4.3.65 onwards) the report evaluatesthe actions taken by professionals when they were aware ofinjuries to EY.694.3.3Separate consideration is given in section 4.4 to the planning thattook place before EY was discharged to the care of his mother inNovember 2010. This was an opportunity for assessment but nonewas undertaken.Key opportunities for assessment. The quality of the assessmentsundertaken, the decisions made and the services provided as aresultAssessments by midwives4.3.4Midwivesusuallyhavetheirbestopportunity toidentify anyrelevanthistoryandsocialorhealthriskfactorsduringtheantenatal period. This takes place through screening (such asaskingroutinequestionsaboutdomesticviolence)andmoregeneral discussion about the kind and level of support that theparents will have. Missed antenatal appointments, high levels ofanxiety or depression and unusual responses to routine eventssuch as scans often point to concerns. In this case there was noopportunity for midwives to undertake assessments prior to thebirthofthechildrenbecausethemotherconcealedthepregnancies and did not book for antenatal care.4.3.5After the birth of OY the mother and infant spent three days inhospitalandtherewasroutinepostnatalfollowupinthecommunity.Themidwifemostinvolvedinthehospitalimmediately referred OY to social care. It is not clear what sort ofassessment of risk or need had taken place because the actualreasons for the referral were not recorded in the hospital notes.The only detailed account of the behaviour of the mother andother family members during her hospital stay is that the fathercuddled OY.4.3.6Attention during the mother’s hospital stay was also focused to aconsiderable extent on the medical problems that she experiencedas a result of the lack of antenatal care. These were not grave,although she required a blood transfusion which prevented herfrom caring for OY during one night. The individual managementreview focuses on the role of midwives, but OY and his mother70were also seen by doctors during the stay and before discharge.None identified or recorded any risks or concerns.4.3.7The local authority records indicate that the referral was madebecausethefamilywishedtoconsiderrelinquishingOYforadoption and not that there was any immediate concern about hiswelfare or safety. As a result the local authority decided toundertake the assessment at home. The hospital managementreview(paragraph59)findsthat‘variousassessmentswerecarriedoutinrelationtothenewbornrequirementsasrecommended by national guidelines’ and that ‘the decisions aboutassessments and interventions carried out appear to have beenreached in an informed and professional manner’, but there islittle evidence to support this finding because of the lack ofrecords.Themidwivesinvolvedmayhavebelievedthatbyreferring the family to the local authority they had ensured that afull assessment would take place. If so this is the wrong approachtotake.Midwivesshouldhavebeenundertakingtheirownassessment of the history they knew and should have also beenexpecting to contribute to the wider social care assessment.4.3.8Leaving aside completely the question of whether the parentswanted OY to be adopted or not, hospital staff should haverecognised that the potential social and psychological risks for thechild associated with the concealed pregnancy and the lack ofantenatalcarepointedtotheneedforapsychologicalorpsychiatric assessment of the mother and an assessment of thewider family circumstances.4.3.9After the discharge of OY and his mother they were seen in thegrandparents’ home on three occasions by the same midwife. OYhad no health problems and the midwife did not identify anyconcerns about the attitude or behaviour of the mother. When shewascontactedbythesocialworkerundertakingtheinitialassessment on OY she indicated (according to the social workrecords) that she had no concerns. She either did not believe thatthe nature of the pregnancy and the lack of antenatal care71presented a risk or she must have believed that the social workerundertaking the assessment would already be taking this intoaccount. The midwife involved should have recognised the unusualnature of the circumstances, recorded this and underlined it in herdiscussion with the social worker.4.3.10At the time of the birth of EY there were fewer opportunities forstaff working within the hospital to undertake an assessment. Atthe time of OY’s birth the extended family had been contacted bya midwife. It is not clear if this was what the mother wanted orjust the midwife’s instinctive response to the situation. In relationtoEYthemother andfatherpre-emptedthishappeningbyindicating immediately that they wanted EY to be placed in careand relinquished for adoption. The mother later asked for herhome phone number to be deleted from the hospital records andasked not to be phoned there. The reasons for this were neverestablished. There was no opportunity for antenatal assessment orany significant assessment in hospital.4.3.11The postnatal care for the mother and child took place in unusualcircumstances. The mother was at home and EY was in fostercare. The postnatal visits were undertaken by different midwives.There are no postnatal records but it appears that they treated thevisits to the mother and to EY as separate and routine tasks.There were no concerns in relation to either the mother’s or thechild’s physical health. There is no evidence that the two midwivesspoke to one another and neither referred to the records of thefirst pregnancy and the birth of OY. It is not even possible to knowifeitherofthemidwivesrealisedthatthiswasthesecondconcealed pregnancy. There is no evidence that any considerationwas given to making a referral for a psychological assessment ofthe mother. The discharge note sent to the GP in relation to EY’sbirth does not mention the circumstances of his birth or theconcealed pregnancy.4.3.12The individual management review has made recommendationswhich include the following areas of practice and service provision:72policy, procedure and practice in relation to concealedpregnancythe information pathway between maternity services andcommunity practitionerstraining on the importance of information sharingrecord keeping to support holistic family assessmenta checklist form to standardise information on postnataldischargebetter management of referrals to the local authority and otheragenciesThis covers most of the key responsibilities of the obstetric andmidwifery service in relation to safeguarding and interagencyworking.Health visitor new birth assessments4.3.13The individual management review dealing with the provision byhealth visitors refers to the Healthy Child Programme.23 This isreflected in local trust procedures and practice guidelines referredto as ‘Fit for the Future, Universal Children’s and Young People’sHealth Services (Health Visiting)’ November 2010’. All of thesedocuments are rooted in the National Service Framework forChildren, Young People and Maternity Services first published in2004. 24 Although there are variations in the terminology used, allofthesedocumentsstresstheimportanceofthenewbirthassessment visit by the health visitor and all of them underline theneed for a holistic assessment of the needs of the child andparents at key points in the child’s early life.4.3.14Despite the highly unusual circumstances of the birth of OY therehad been no handover of information from the midwives who hadbeen involved to the health visitor undertaking the new birth23 Department of Health (2010) Healthy Child Programme- Pregnancy and the First FiveYears of Life.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118525.pdf24http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_408910173home visit. However the new birth notification to the communityservice noted that the pregnancy had been concealed. The healthvisitor’s (HV1) home visit was undertaken when OY was aged 15days, which is within the timeframe expected locally. However incontrast to the approach set out in local and national guidancethere is no evidence that a holistic assessment of the child andfamily’s needs was undertaken. The records suggest that - despitethe very unusual circumstances of the birth and the lack ofantenatal care - the visit focused exclusively on routine childhealth matters, the interaction that the health visitor observedduring her visit between the mother and the child and the positivereassurances that the mother gave her about the support that shewas receiving from family members. There is no indication in thehealth visitor’s electronic record that the mother had concealed ordenied the pregnancy. There is no indication in the records as towho was present at the visit and no indication of the role andresponse of the father or other family members. The concealedpregnancy was not referred to in the health visiting record. Itappears that it was not viewed as being significant because OYwasassignedtothecorehealthvisitingserviceandnoconsideration was given to the potential psychological needs of themother arising from her behaviour during the pregnancy.4.3.15The health overview report is critical of the standard of practiceevidenced by this visit and identifies a list of issues which shouldhave been explored. Whereas the national and local guidanceemphasises the need for a holistic assessment of needs, this newbirth assessment appears to have been conducted more like atriage exercise to identify serious or pressing problems (which thismother did not seem to have). No clear explanation has beenprovided as to why this happened. It is not clear whether it was aone off example of practice falling short of expectations. There area number of possible explanations. These might include:74The nature of the responses from the mother who was able toreassure almost every professional that she came into contactwith that – despite the history – everything was ‘fine’Thelackofspecificguidanceaboutconcealedpregnancy.However regardless of this the lack of antenatal contacts andthe nature of the birth should have been sufficient to identifythe need for targeted provisionThe workload and capacity of the health visiting service mayhave been a significant factor. This is discussed in detail insection 4.11 below.Personal factors in relation to the health visitor undertaking theassessment4.3.16Neither the management review nor the health overview reportmakes any reference to audit of the standards met in healthvisiting practice. Given the lack of any clear explanation it is arecommendation of the SCR that the health trust takes steps toestablish the quality of new birth assessments in a sample ofcases giving particular emphasis to the wider family, social andenvironmental issues that are highlighted in the national and localguidance. This should include an audit of the quality of informationprovided by midwifery services from contacts in the perinatalperiod. The findings and any recommendations arising from thisaudit should be reported to the LSCB as well as to the trust boardand to commissioners of child health services.4.3.17The new birth visit in relation to EY was carried out by the healthvisiting team in the locality of the foster carers. He was identifiedas being in need of a package of care from the health visitor as alooked after child. The health visitor remained actively involvedand made a useful contribution to the one looked after reviewmeeting to which she was invited. There is no indication that thehealth visitor dealing with the mother and OY was informed aboutthe outcome of the new birth visit to EY by the health visitor whocarried it out (or even that she had been informed about the birthof EY). As a result the mother did not have a new birth visit75following the birth of EY and was only visited by her own healthvisitorthreemonthsafterthebirthofEY.TheBECHSmanagement review identifies the concern about this stating that:‘she was entitled to this visit in her own right and was of highneed due to the circumstances of EY’s birth and his voluntaryplacement in foster care. The mother and OY were at risk ofpsychological trauma and a health visiting assessment, of eachfamily member would have been of benefit at this time. Themother did not have her 6–8 week postnatal review on time; thereis no explanation why this was carried out late and the new birthvisit did not happen’.4.3.18The lack of information sharing between EY’s health visitors was afurther indication of a narrow task-focused approach to the carebeingprovided,ratherthanprofessionalstakingawiderperspective about the needs of both of the children and the wholefamily. Although it was not seen as being the role of the lookedafterchildren’shealthteamtoinformallofthehealthprofessionals involved with the family about the fact that EY hadbecome looked after, it was very well placed to have done so andcould have offered a safety net in the event that other informationsharing arrangements did not work. The role of the team isconsideredmorewidelyinsection4.6whichdealswithinformation sharing.The assessment of postnatal maternal depression4.3.19At OY’s 6-8 week review (May 2010) the mother’s health visitor(HV5) carried out a screening for postnatal depression using theEdinburgh Postnatal Depression Scale (see Appendix 6). The scaleincludes 10 items giving a maximum score of 30 and a cut offpoint of about 12 indicating potential risk of depression. Themother scored zero, indicating that she had no symptoms ofdepression or anxiety whatsoever. Given the concealed pregnancyand the initial conflict over the care of OY this seems verysurprising. In the experience of the SCR panel scores of zero arevery rarely recorded for the EPDS and scores within the normal76range reflect the many potentially unsettling changes that thepostnatal period can bring. Given the history in this case the zeroscore was particularly surprising and may have been an indicationof the mother’s continuing denial of difficulties and problems. Thehealth visitor did not consider this possibility.4.3.20There are other aspects of the EPDS that might have made it aless than reliable indicator of the mother’s state of mind. Thedesign of the EPDS questionnaire makes it extremely easy to ‘rig’.It is self reported and self completed; on every item it is obviouswhat the non-depressed answer is and the scoring system is listednext to the questions.Health visiting assessment prior to and after discharge of EY to hismother’s care4.3.21The mother’s health visitor (HV5) saw her shortly before and afterEY moved to live with her in November 2010. These visits wereorganised on the basis of information received from EY’s healthvisitor (HV4) and it was sensible of the mother’s health visitor toassess how the mother was managing to take on the care of EY.4.3.22EY was a lively, sociable and therefore demanding seven monthold baby. He was already attached to the carer that he had knownsince birth. His mother had never looked after him and had notvisited him for long periods of time. Taking over his care would bea challenging and complex task for any parent and for his motherit might be particularly difficult given that she had denied hisexistenceandthennotwantedtolookafterhim.Inthesecircumstances a visit akin to the type of new birth visit envisagedin the Healthy Child Programme was called for. This did nothappen. The visits that took place provided only a superficialassessment based on brief impressions of interaction and thepositive account given by the mother. The visits did not establishhow little contact the mother had had with EY over the course ofhis life. The assessment is very similar in nature to the new birthvisit undertaken in relation to OY and the initial assessmentscarried out by the local authority which are described below.774.3.23It does not state in procedures or in the Healthy Child Programmethatthesewerecircumstancesthatrequiredamuchmorecomprehensiveassessment.Procedurescannotcovereveryconceivablesituation.Thisshouldnotbenecessary.Healthvisitors’trainingandinparticulartheirknowledgeofchilddevelopment and attachment should have indicated that a fullerassessment was necessary.The initial assessments undertaken by the local authority4.3.24The management review provided by the social care servicerecognises that the two initial assessments undertaken by thelocal authority were missed opportunities to develop an in depthassessment of the needs of the children and the risk factors thatexisted as a result of the concealed pregnancies. The first initialassessment took place immediately after the birth of OY while hewas living at home. The management review states in relation tothe first that ‘this initial phase of social care assessment andinterventioncouldhavebenefittedfromamoredetailedconsideration of the nature / implications of the concealment ofthe pregnancy on the parenting capacity of the family, and acomprehensiveunderstandingofthedynamicswithintheextended maternal family for the long term support for (themother and OY).4.3.25The April 2009 initial assessment document makes references toconcerns about the mental health of both parents, in particularthatthereasonforundertakingtheassessmentwas‘thedepressive state of both parents’. This is a much more stronglystated description of the concern in relation to the mother thananyotherhealthrecordcontains.Theassessmentdocumentcontains evidence that the father spoke to the social worker abouthis feelings of shock and depression in similar terms to thediscussions that he had had with his GP. The record suggests thatthe social worker had no direct discussion with the mother abouther mental health, but that the father indicated that she wasdepressed and that she was ‘seeing a counsellor’ for this. It is very78surprising that this was not followed up with the mother and itwasnotestablishedwhetherinfactthiscounsellingwashappening.4.3.26Thesocial workerwhoundertook the assessmentmay havebelieved that this would be explored further during the coreassessment that she recommended. The manager who reviewedthe assessment did not agree that there was any further role forsocial care. She judged that the circumstances did not indicatethat OY was a ‘child in need’. In theory this was a valid conclusionbut the judgement gave insufficient weight to the very unusualcircumstances and the numerous unknowns in the history. Whenthe case was closed after the initial assessment a manager agreedthat because of resource constraints the social worker did notneed to write letters notifying other agencies of the closure (this isdiscussed as an issue in its own right in section 4.6 below).4.3.27The second social care initial assessment took place after the birthof EY but focused exclusively on the care of OY. The social caremanagement review notes that after the birth of EY there shouldhave been a detailed and comprehensive assessment of ‘all thechildren’s physical and emotional development needs, parentingcapacity (including a detailed assessment of the nature of theparental relationship), and the community and extended familynetworks’. (page 34). The initial assessment that was undertakenfocused exclusively on OY whereas his needs should not havebeen viewed in isolation from the impact of the birth of EY and thefuture plans for EY (which at that time were undecided). Onceagain the assessment undertaken failed to address the concealedpregnancy and the impact that having a brother (whose existencehad at that time not been revealed to other family members)could have on OY.4.3.28The pattern of two concealed pregnancies should without doubthaveledprofessionalstobecuriousaboutthemother’spersonalityandmentalhealth,evenifsuperficiallyshewasoffering good care to OY. A professional consultation with a79psychiatrist or psychologist over this was the absolute minimumthat should have been expected at this point, particularly as themother was undecided about the future care of EY and might wishto resume his care.4.3.29In fact there was an aspect of the health and development of OYhimselfwhichcouldhavegivenrisetoconcernabouthiswellbeing. He had put on weight extremely quickly, consistentlyweighing above the 99.6th centile, despite monitoring by healthprofessionals and attendance at a ‘Family Fit’ and ‘Healthy Eating’sessions at the children’s centre. The overfeeding and very rapidweight gain of OY could have been an indicator of his mother’sdysfunctionalparentingandshouldhavebeenexplored.Responsibilityfornotaddressingthisinarobustwaylayprincipally with health visitors who were monitoring his weight andchildren’s centre staff who saw him regularly. However it is aconcern that a social worker undertaking an initial assessment onachildwouldnotmakesomecommentaboutthiswhencompleting the element of the initial assessment relating to thechild’s health.4.3.30The recommendations in a number of management reviews pointto the need for professionals to recognise the importance ofconcealed pregnancy as a risk factor that should trigger an indepth assessment. Concealed or denied pregnancy is in fact justone example of any number of historic or static risk factors thatmight point to the need for a more in depth assessment whichprofessionals in all agencies and their supervisors need to be opento.Why was there no core assessment undertaken while EY waslooked after4.3.31No core assessment was undertaken during the seven monthsduring which EY was in foster care, despite the fact that his casebecame more, rather than less, complex as time progressed andtheneedtogatherevidenceforpossiblePlacementOrderproceedings appeared to be becoming more, rather than less,80likely. No core assessment was undertaken at that point becauseit was not required by procedures and no one in the local authorityrecognisedthatthecomplexityofthecasemeritedamorethorough analysis. Staff and managers had adopted the view thatthe case would end positively if EY went to live with his mother ashad happened to his brother. This period in EY’s life is discussed inmore detail in section 4.4.The assessment of the role of the extended family4.3.32At no point was there a proper assessment of the role of theextended family, including the role of the father.4.3.33The mother’s extended family were seen as being an importantsource of support for the parents (and particularly the mother) ata number of points in the case history, most critically when theparents decided to take OY home from hospital after his birth andwhen the mother decided to discharge EY from care. Both of theseplans – and the decision of the local authority to close the case inDecember 2010 – relied on the maternal family giving the motherregular support.4.3.34Although the maternal grandparents were seen as being extremelyimportant in the care plans there was minimal professional contactwith them. So far as can be established (based on the chronologyand the management reviews) this was as follows:The maternal family visited the parents in hospital after thebirth of OY (its not clear how many times)the social worker spoke to the maternal grandmother on thephoneafterattemptingtoarrangeameetingwiththegrandparents in early November 2011the maternal grandparents attended the planning meeting atthe foster home on 12 November 2011It is perhaps more telling to set out how they were not involved:so far as can be established the maternal grandparents werenot seen during either of the social care initial assessments,81though both assessments concluded that their role was positiveand importanttheywerenotseenbythesocialworkerduringtherehabilitation assessment (and they did not visit the fosterhome during this period so far as can be established)they were not seen or contacted by the social worker once EYhad been returned to his motherthe details of the parents’ siblings are noted in the social caremanagement review Genogram but they did not feature at allin any agency records4.3.35In addition the maternal grandparents were never seen by healthvisitors.Likethesocialworkerstheyreliedentirelyonthemother’s presentation of her close and supportive family. TheBECHS management review documents how the health visitor whocarried out the new birth visit to the foster carers’ home, wasinformed that the maternal grandparents lived close by and weresupportive. Their details were not recorded’. When the mothermoved home she ‘informed her health visitor (HV5) that hermother was very supportive and helped her with the children; thiswas recorded within the record on 26/01/11. Actual details of thegrandparents were not part of the record’. The managementreview notes that ‘at the last clinic contact, (before the death ofEY)HV7establishedthattherewassupportfromthegrandparents’. The final contact with EY before the injuries thatcausedhisdeathisdiscussedindetailfrom paragraph4.3.onwards and in section 4.11.4.3.36These descriptions are typical of the records across health andsocial care. The mother’s descriptions never went beyond theextremely general, and yet so far as we can see they were neverchallenged and the mother was never asked to describe exactlyhow they helped or how often they visited. The actual nature ofthe relationships was never tested. This was particularly significantas it was clear to social care staff in November 2010 that thegrandparents were hostile to the father, yet the plan was that they82were working closely with the mother (who was in turn relying onthe father) to support her care of EY.4.3.37Sometimes professionals’ misconceptions about the role of theextended family supported and reinforced one another. The 2009social work initial assessment of OY records that ‘health visitorobservation / assessment is that there is positive support to themother from maternal grandparents’. As has been shown therewas no health visitor observation of the grandparents and the only‘assessment’ was the word of the mother.4.3.38In reality no professional knew anything concrete about the rolethat the grandparents really played, except what the mother hadtold them and the commitments that they made at the planningmeeting (which have not been detailed). No one ever explored theparadox that pervades every aspect of the case history. Why wasit – if the mother has such close support from her family – thatshe had been unable to inform them of her two pregnancies? Whywas it that she could not bring herself to mention to them that shehad a second child for almost seven months? Rather than being aclose supportive relationship, this tends to suggest a much morecomplex relationship.Assessment of the role of the father4.3.39Very similar concerns apply to the role of professionals in relationto the father, though there are some distinct aspects. He was seenmore often: at the hospital after the birth of OY in 2009, duringtheinitialassessmentsandindiscussionsaboutproposedadoption of EY. He was seen once briefly by a health visitor (afterEYhadgonehomeinNovember2010).Howevertheoverwhelming majority of references to the father are records ofthe mother’s comments about him. He was taken to have been asupport to the mother in relation to the care of OY, but no onetested what this meant in practice.4.3.40In relation to EY social care staff formed a view early on that itwas largely the result of the father’s influence that the mother did83not want to care for EY or at least that she was ambivalent. Hewas seen and described as ‘domineering’. This led to the ratherunusual approach of asking the mother whether she wanted to bereferred to a domestic violence programme, even though therewas no evidence to suggest that she had been a victim ofdomestic violence. She did not take up the offer. Adherence to theview that pressure from the father was preventing the motherfrom making a free choice about whether or not she wished torelinquishEYhadtwoadverseeffectsontheassessmentsundertaken.4.3.41Firstly the father’s actual circumstances and views were neverproperly assessed. No other information was gathered from him orabout him. Potentially important information about his response tothe births of the two children held by his GP was never obtained.His clear view that the mother could not cope with caring for twochildren was never tested and explored.4.3.42Secondly the adherence of the local authority to the view that itwas largely the father’s influence that was preventing the motherfrom caring for EY led it to give insufficient weight to evidence ofother factors which should have been assessed. For example themother had no contact with EY for nearly 10 weeks between Juneand early September and told social workers that she gave nothought to EY when she was not with him. However domineeringthe father was, the mother’s indifference to EY was not entirelydue to him.4.3.43It is a long established finding of Serious Case Reviews that men(including fathers) are often marginalised in the assessment ofrisk.25 The most recent review of SCR findings adds an additionaldimensionwhichclearlyappliesinthiscase.Repeatingthefindings that there was a dearth of information about men andthat they were often ‘absent from assessment’, Brandon et al alsoidentify the danger of ‘rigid or fixed thinking’ about men ‘who were25 For example Brandon et al, (2009), Understanding Serious Case Reviews and their Impacta Biennial Analysis of Serious Case Reviews 2005-07 DCSF84perceived in a polarised way as primarily ‘good’ men (good dads)or ‘bad’ men (bad dads)’. Paradoxically in this case history thefather was perceived as both ‘good’ and ‘bad’ in different ways butthe complexity of both aspects was never explored. He was ‘good’to the extent that he was believed to help look after the children,though this was never evaluated in detail. He was ‘bad’ becausehe was stopping the mother from looking after EY though his‘domineering’ behaviour. He had his reasons for thinking that thiswas not a good idea. Some of them reflected his own needs, hehad not planned to be in a relationship and have children, butsome of them may have been very sound. These were neverexplored.4.3.44There is a complete contrast to the attitude of the local authorityto the influence of the father over the mother and the influence ofthegrandparents.Assoonasherparentsknewabouttheexistence of EY they persuaded her very quickly that she shouldlook after him. Considerable concern had been expressed aboutthe need for the mother to be able to make a choice free of thefather’sinfluenceandconsiderabletimewasdevotedtocounselling her over this. In contrast the local authority had nodisquiet whatsoever about the mother’s very rapid decision to carefor EY, despite the fact that it was clearly heavily influenced by thegrandparents and despite the fact that she had earlier said thather parents’ attitude would not affect her decision.4.3.45The evaluation in the preceding paragraphs has focused on therole of the local authority because it has the lead responsibility forassessment and decision making. However the weaknesses inrelation to the engagement of the father apply to all of theagencies involved to different degrees:health visitors saw the father only once (November 2010) andotherwisedidnotenquireabouthisroleoracceptedassurances about himthe children’s centre had no contact with the father and thereis no evidence that the mother was ever asked about him85the father’s GPs heard repeated stories from him about theimpact of fatherhood, but they all concentrated exclusively onhis needs as an adult patient and showed no curiosity aboutthe children involvedthe legal advice given does not touch on the role of the father(though his views about adoption were always clear).4.3.46The impact of failing to work with the father is distinctive andimportant in this case history, but the nature of the problem islongestablishedinsafeguardingwork.Agenciesneedtounderstand why it is that despite this being well trodden groundprofessionals once again ignored or marginalised the father inassessment and decision making.4.3.47The BECHS report makes a specific recommendation on the issue.Thelocalauthorityviewisthatiftherehadbeenacoreassessment then the father would have been more fully engaged.Other than this the individual management reviews are not criticalabout the failure to consider or attempt to work with the fatherand they make no recommendations. If agencies feel that theapproach to working with fathers is a ‘one off’ departure fromnormally good practice then they should be asked to demonstratethis to the LSCB. If this is not the case and wider concerns arerecognised then the LSCB needs to consider how it can influenceagencies to address this issue in a more constructive way and tomonitor the way in which agencies do engage with fathers andother carers. The LSCB should do everything it can to ensure thatagencies improve the engagement of fathers in assessments andcontinuing work and the SCR will make a recommendation inrelation to this.Why did no-one attribute sufficient significance to the two deniedor concealed pregnancies?4.3.48Although many agency records note that both children were bornas a result of concealed pregnancies the individual managementreviews note that professionals paid very little explicit attention tothis, beyond the immediate period after the children’s births.86Neitherwasmuchpaidtothepracticalconsequencesofconcealment. The BECHS management review spells these out,including the lack of antenatal care and the birth of two children inpotentially perilous circumstances (paragraph 5.3.6).4.3.49Inordertounderstandaswellaspossibletheprofessionalresponse it is important to be as clear as possible about theknowledgethatprofessionalshadabouttheconcealedpregnancies. In particular it is important to understand whichprofessionals knew about both of the pregnancies. In their studyFriedman et al 26 note a prevalence rate for denied or concealedpregnancies of 0.26% (roughly 1 in 400) of live births, indicatingthat this is a relatively unusual occurrence. They quote anotherstudy with a prevalence rate of 1 in 475. Strikingly the Friedmanstudy makes no reference whatsoever to any women having twosuch pregnancies, though they would not have been able toinclude pregnancies after their study or women who delivered atanother hospital. This strongly suggests that having two concealedpregnancies would be an extremely rare phenomenon and thatindications of risk arising from one concealed pregnancy wouldincrease disproportionately if a mother had two such pregnancies.4.3.50Midwifery staff dealing with the second concealed pregnancy areunlikely to have known about the first, because they did notconsult the mother’s records relating to the birth of OY. Littleuseful information was provided to other health professionals bythe midwifery service and discharge letters did not give sufficientemphasis to this information or highlight it in a way that wouldhave ensured that it was likely to be spotted. This is addressed inarecommendationarisingfromtheindividualmanagementreview.4.3.51The GPs dealing with EY after November 2010 did not know thatthepregnancyhadbeenconcealedthoughtheymighthave26 Op cit ( at page 118)87noticed from closely reading all of the documents in the PCHR thatEY had been in care.4.3.52The health visitor dealing with EY after he had been returned tohis mother knew that his pregnancy had been concealed and thathe had been looked after by the local authority. However it is notclear that she knew that OY’s birth had also been concealed as shehad not dealt with him as an infant. He had no separate healthvisitingrecordandthisinformationwasnotrecordedinhiselectronic records.4.3.53Children’s centre staff knew that the pregnancy with OY had beenconcealed but did not attribute any particular significance to this.The centre coordinator had had only basic safeguarding trainingand the children’s centre worker had received no single or multi-agency training (this is discussed further in section 4.9).4.3.54Local authority records on the two children make it clear that bothpregnancies had been concealed pregnancies though no extrasignificance was attributed to this.4.3.55Professionals only drew attention to concerns associated with thenature of the pregnancies at two points in the case history. Therewas discussion with the mother about her pregnancies in hercounselling about adoption. The mother’s tendency to deny and‘disassociate’ from issues that caused her anxiety and conflict wasnoted but this important insight was never integrated into thethinking of the local authority in terms of how it might affect themother’s ability to look after EY.4.3.56At EY’s second looked after review meeting his health visitorstated her concerns about the history of concealed pregnancy andplacement in care, the delay in naming EY, delay in obtainingconsent for his immunisations and the long periods of time duringwhich the mother had not visited EY. This could have been thestarting point of an analysis linking the mother’s denial of EYduringpregnancytoconcernsaboutherrecentattitudeandbehaviour. A thoughtful assessment would have gone on to ask88questions about the impact of this in the parenting capacity of themother, perhaps not in general, but in relation to EY specifically.Noneoftheotherprofessionalspresentappeartohaveunderstood or felt that it was necessary to take up this agenda.These static or historical risk factors were never treated as beingsignificant. The health visitor did not receive minutes of themeeting and was not invited to participate in further discussionsplanning for the discharge of EY from care. She did not pursue thisfurtherherself.Shemayhavebeenputoffunderliningtheimportance of this when discussing the case with OY’s healthvisitor because when she spoke to her about EY being dischargedfrom care, her colleague told her that she was ‘fully aware’ of thecircumstances.4.3.57Friedmanetalsuggestthatthefailuretoappreciatethesignificance of concealed pregnancy is not unusual. In their studythey found that because the professionals dealing with the birthunderestimatedthelevelofpotentialconcern‘psychiatryconsultationswererarelyrequested,althoughinfantswerefrequently discharged to the care of mothers who had denied orconcealed their existence’. As a result service provision was farlowerthantheresearchershadexpected.Itseemedtobeparticularlyhardforprofessionalstoaddressthisissuewithmothers 27 and that as a consequence ‘the lack of attention to thephenomenon of pregnancy denial mirrors the silent stance’ of themother and family (page 121). It is noted that women who havebeen unaware of their pregnancy or unable to discuss it with theirpartner or parents are likely to be dazed, confused, defensive orblandly reassuring after the birth (or a combination of these). Thesame individual psychological, family and environmental factorsthat led to concealment before birth will often continue to apply.Some women remain in denial even after the birth. Mothers whohaveconcealedtheirpregnancyareunlikelytoseekhelpvoluntarilyandarelikelytobeadifficultclientgroupfor27 The authors focus exclusively on mothers89professionals to engage. In such cases good supervision of staffwill be critical to aid recognition and assist staff in discussing theissue with women.4.3.58An additional factor that may have reduced the likelihood ofprofessional recognition in this case history was that no otherobvious risk factor was present. Insofar as professionals are usedto concealed pregnancy at all they are used to dealing with itwhere there are other clear risk factors which go some waytowardsexplainingthelackofawarenessofsymptomsofpregnancy or poor take up of antenatal services: particularlyparental drug misuse, domestic abuse, mental illness and learningdisability. In recent years professional thinking has been stronglydirected to these risk factors, understandably because they areassociated with the majority of serious and fatal cases of abuse.Brandon et al show that taken together one or more of the firstthree of these factors was present in 87% of the cases subject toSCR during 2003-200528 All of these risk factors will usually intheir own right trigger further assessment and intervention withinwhich the issue of concealed pregnancy may be discussed.4.3.59This case history highlights the potential for serious child abuse incases which do not have the predisposing risk factors mostcommonly associated with the highest levels of risk to children. If87% of fatal and serious cases feature domestic abuse, mentalillnessordrugmisuse,13%featurenoneofthemandprofessionalsneedtocontinuetobealerttounusualpresentations.4.3.60Most of the individual management reviews highlight the lack ofspecific guidance in the local child protection procedures aboutconcealed pregnancy. However ‘concealed pregnancy’ is currentlyincluded as the first on the list of factors that professionals should28 See page 81 of Brandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, andBlack J (2007) Analysing child deaths and serious cases through abuse and neglect: whatcan we learn? A biennial analysis of serious case reviews 2003-2005. DfES90be aware of in relation to risks to the unborn baby and ‘denial ofpregnancy’ is included in the list of parental risk factors pointing tothe need for referral to social care, along with failure to take upantenatal care. In line with this the children were referred to socialcare, but the assessment of risk by all agencies was inadequateand only on one occasion did any professional point to theconcerning factors in the case.4.3.61The case made by the management reviews is that the currentdocumentationdoesnotgivemorespecificguidanceontheassessment of risk where there has been a concealed pregnancy.The LSCB should produce additional guidance on this, but it isrecommended that it is brief and that equal attention is paid to theneed to assist professionals and supervisors to be flexible in theirthinking and to develop their capacity to recognise risk when itarises in cases that fall outside of the presentations that childprotection professionals have become used to dealing with. Inaddition to offering additional guidance on the specific issue ofconcealedpregnancyorganisationsneedtofindawayofimproving the capacity of professionals to identify more unusualpresentations. By their nature it cannot easily be predicted whatthese will be and it is not possible to write guidance about all ofthem.Provision of services as a result of the assessments4.3.62The impact on service provision can be easily and briefly stated.Poor assessment led on several occasions to service provision thatdidnotmatchtheneedsofthechildren.Theindividualmanagement reviews identify these episodes:a proper discharge planning meeting, continuing social careinvolvement and a fuller assessment following the birth of OYwould have been beneficialadditional health visiting provision was merited after the birthof OY and after EY was discharged from careEY should have been treated as a child in need at the pointwhen he was discharged from care914.3.63The final episode listed was a critical turning point in the casehistory. A child in need plan would have enabled provision ofcoordinated support, monitoring of EY’s health and developmentat a level in keeping with his needs and monitoring of his progressthrough periodic review. It would probably have prevented themother from deceiving staff at the children’s centre as to theidentity of the child because there could have been a closeworking relationship between this children’s centre and the localauthority. It would also have offered an easy point of contact forall professionals and prevented the confusion that occurred whenstaff spoke to administrative staff in the referral and assessmentteam.4.3.64The social care management review states that carrying out achild in need assessment and arranging a child in need plan at thepoint when a child ceases to be looked after were proceduralrequirements in the local authority in November 2010 and thatthey are now reflected in statutory guidance. The social worker’smanager knew this but believed that there were so many positivefeatures in the case that it was decided that there was no need tocomply with the procedure. This was because the potential risksassociated with the mother’s long period of little contact with EYand the inherent difficulty of taking over the care of a sevenmonth old child who was becoming attached to another carer werenot recognised or understood.The identification of injuries and other indicators of potential harm4.3.65Thissectionwilldealwiththeactionsanddecisionsofprofessionals in the following episodes in the case history:GP and Health visitor (January 2011)Children’s Centre and parenting programme crèche (January –March 2011)Socialworkerandcolleague(respondingtoinformationprovided by foster carer February 2011)Accessofficer(respondingtoinformationprovidedbythechildren’s centre February 2011)92Health visitor at child health drop in clinic (March 2011)4.3.66Descriptions of all of these events are set out in section 3 above.This section will seek to evaluate why professionals responded asthey did. This will be considered in the context of the local childprotection procedures. The guidance on ‘bruising’ is reproduced asAppendix 8 to this report. It specified that ‘any bruising or othersoft tissue injury to a pre-crawling or pre-walking infant or nonmobile disabled child’ or ‘bruising around the face’ …’must beconsidered as highly suspicious of a non-accidental injury unlessthereisanadequateexplanationprovidedandexperiencedmedical opinion sought’.29 This guidance is discussed further insection 4.8.4.3.67According to SCR panel members the need to refer children undertheageofonewithanybruisingonthefaceforfurtherassessment has been strongly reinforced in all local training,especially for health visitors and GPs.4.3.68EY’s GP recorded bruising and scratches on EY at his 9-12 monthdevelopmental check in January 2011. It is not normal practice forGPstocarryoutsuchassessmentsbuttheGPconcernedcustomarily did so as he had an interest in child health. As thisexamination took place as part of the developmental assessmentthere was an opportunity for a full examination.30 The GP notedbruises and scratches on EY’s face and to his credit made a verydetailed record of them on EY’s GP medical records.4.3.69It is significant that the GP did not summarise them on the PCHRwhich was the record that every other health professional who sawEY would have been most likely to access. The only recording thatthe GP made on the PCHR was to complete the up to date entrieson the height and weight chart. These would be routine actionsarising from the developmental check.29 Berkshire Child Protection Procedures (section 5)30 On 14 March 2011 when EY presented at the GP surgery with cold symptoms it would nothave been necessary to remove his clothes to examine him934.3.70This is significant in relation to subsequent events because had herecorded information about the bruising in the PCHR (whatever hebelieved to be the cause) it might have made a difference to latercontacts of health professionals with EY, particularly to the contactat the health clinic on 17 March the day before EY was admitted tohospital. It is also significant because it indicates that GPs are lesslikely to complete the chronological entries in the PCHR. This mayapply to other doctors and medical professionals as well. It is notclear why this is so but there are a number of obvious possibleexplanations:time constraints make recording duplicate information on tworecords less likelythe PCHR may be seen by doctors as a record of height, weightand development which is largely a tool for parents and healthvisitors rather than acute medical concerns.It may therefore be viewed by doctors as a secondary and lessimportant place to record information than the GP or hospitalmedical records that will be seen by colleagues within their ownsetting.4.3.71Given that so many other professionals will see and rely on thePCHRthisindicatesthatallmedicalprofessionalswhohavecontact with children may need to change their practice and adoptan approach to recording that takes more account of the needs ofother health professionals.4.3.72The GP did not challenge the mother’s explanation that OY (then21 months) had caused the bruising and there is no indication intherecordsorinsubsequentdiscussionswithhimthatheconsidered the possibility of non accidental injury. He made nofurther investigation or evaluation into the cause of the bruising.The GP decided to address the sibling rivalry by referring thechildren to the health visitor for advice. This was an error ofjudgement and it is clear that within the existing child protectionprocedures he should have referred EY to children’s social care. Ifhe did not feel sufficiently sure about the level of concern he94should at the very minimum have sought the advice of a namedprofessionalandreferredthechildforanurgentpaediatricappointment, following up the referral to make sure that the childhad attended.4.3.73The SCR panel believes that the GP would have been more likelyto have been concerned about the bruising and therefore morelikely to have acted in a different way if he had known that EY hadbeen looked after for a considerable period by the local authority.He might have viewed this as an indication of potential risk. Itwouldalmostcertainlyhavereducedanyinhibitionaboutcontacting the local authority if the GP had known that social carehad already been involved. The GP had received no notification ofthe local authority’s involvement either directly from the localauthority or from the health team responsible for looked afterchildren. Both of these issues are addressed further in section 4.6dealing with the coordination of services and information sharing.The GP also had no access to EY’s original medical records whichhad numerous references to him being looked after. This is alsoaddressed in detail in section 4.6 of this report.4.3.74Close examination of the PCHR (which the GP completed) showsthat the document itself did contain a number of entries whichindicate that EY had been looked after:one entry from his previous health visitor is marked ‘in fostercare’the PCHR contains a form with the letter head ‘Windsor andMaidenhead Council’ signed by both parents consenting tomedical treatment for a looked after childthere are a number of entries which refer ambiguously to EY’s‘carer’ (but not foster carer) rather than his parent taking himto appointments4.3.75The SCR has scrutinised these entries and discussed the natureand design of the PCHR at some length to understand why it wasthe GP did not notice them. The entries referring to ‘carers’ and toEY being ‘in foster care’ were made in the chronological contact95section of the record that had been completed by health visitorsandotherhealthpractitioners.Thissectionoftherecordisseparate from the parts of the record that would normally beaccessedinordertoregistertheinformationaboutthedevelopmental check. The looked after consent form is folded in aperspex pocket at the back of the PCHR ring binder where parentsare encouraged to keep appointment letters and other additionalinformation. Important lessons follow from this in relation to thedesign of the PCHR, the recording of key events and history in itand the scrutiny that health professionals give to the historicalinformation already recorded when they use it. Both sets ofentries which gave a clear indication that EY had been looked aftercould in the opinion of the SCR be easily overlooked by the GP.4.3.76A similar argument applies to the health visitor who saw EY on 17March. She would have had much less opportunity than the GP tonotice this significant historical information because of the muchmore limited time that she had with EY and the difficult context inwhich she was working. This is discussed further in section 4.11below.4.3.77It would be unrealistic to expect health professionals to read theentire PCHR at every consultation. This would never be practical.It is clear that the design and use of the PCHR needs to berevisited so as to ensure that any significant information whichcouldinfluencethefutureassessmentofriskisprominentlydisplayedandismuchmorelikelytobeseenbyhealthpractitionerseverytimetheyconsultthePCHR.Thisneedsdetailed work and consultation with all users of the PCHR inprimary care, community health and acute hospital settings. Oneapproach would be to have a sheet containing key informationlocated in the sections of the PCHR which are most commonlyaccessed that all health practitioners are required to review ateach contact. Steps also need to be taken to ensure that alldoctors are much more consistent in their practice in adding96significant information to the PCHR as well as to GP, hospital andclinic medical records.4.3.78Seeing significant historical information (such as the fact that achild had been in foster care from birth) would still of courserequire the correct professional interpretation and action, but atleast one potential barrier to recognition of a risk factor would beremoved by better design and use of records. Section 6 contains arecommendation in relation to this.4.3.79EY’s weight is recorded in the PCHR in a table and in a traditionalheight and weight growth chart (See Appendix VII). These parts ofthe records were seen by the GP who entered the up to dateweight on it. This showed that EY had gained only 100 grams (4ounces) in the seven weeks between 30 November 2010 and 19January 2011. On the weight chart the line of EY’s growth wasnow close to horizontal, instead of matching the percentile linethat it had tracked consistently while he was in foster care). Thispointed to a marked decline in EY’s rate of growth over theprevious two months. This might not have required a referral orfurther action in its own right but it should have raised the indexof suspicion created by the facial bruises in an infant of this age.4.3.80The GP involved was very knowledgeable and experienced. As withthe poor assessments referred to earlier in this report the SCR hastried to understand why the professionals involved found it difficultto take the action that they probably knew was necessary. Againthere may be a number of factors that made it difficult to act inthe way that training, procedures and experience indicate isrequired.4.3.81All of the accounts given about the mother (both prior to and postthe death of EY) indicate that she was capable of being utterlyconvincing, even when she was being untruthful. This will haveplayed a part. It is also important to recognise that many staffwho are involved in providing universal health services for childrenfind it very difficult to voice suspicions of child abuse. This requires97them to switch from their normal care-giving mind set in which itis assumed that the practitioner and the parent are both operatingin the best interests of the child to a mind set based on suspicionof wrong doing. Intellectually it is easy to say that the child is thepatient, that child abuse is a significant cause of child healthproblems and that the interests of the child are paramount. Inpractical terms it often proves much harder for professionals to beprepared to consider abuse as a possible explanation and to act inthe way that they have been trained to act and which they knowthey should.4.3.82Themanagementreviewofprimarycarerecommendstheadoption of a new pathway for dealing with bruising in infancy.The SCR endorses this recommendation. It will be useful toconsiderhowinadditiontothepathwayunderliningtheimportance of referral to social care in appropriate cases thepathway can ensure that medical practitioners feel able to makean urgent paediatric referral in appropriate cases. This is a usefulrecommendation but it is important that the pathway and anytrainingandguidanceassociatedwithitalsoaddressthepsychologicalandinterpersonalbarriersthatcanpreventprofessionals identifying and referring suspicions of child abuse.4.3.83After the consultation the GP spoke to the health visitor, told herabout the bruises and asked her to advise the mother aboutsibling rivalry. There is no discrepancy in the records about thisand the health visitor did what she was asked. As the BECHSmanagement review puts it, ‘the health visitor was not beingasked to check any bruising’. This helps explain her subsequentresponse but it does not justify it. When she visited she did notask to see EY (who was said to be asleep) and instead focused herattention on OY. It is impossible to know how the health visitorwould have reacted had she herself discovered this bruising on anine month old, but her training would have told her to be veryconcerned. As the BECHS management review points out, healthvisitors are qualified, experienced and highly trained professionals98andwiththiscomestheresponsibilitytoexercisecriticaljudgement not only about children and families but also about theopinions of other professionals. Unlike the GP the health visitor didknow that EY had been looked after and she also knew about thatthe pregnancy had been concealed. She does not appear to havetaken the additional risks into account, nor did she inform the GPabout them. There is no reliable way of knowing why she did notdo so. There is significant learning here about the need forprofessionals to be able to challenge one another’s judgement.4.3.84There is no doubt that when she visited EY and OY the healthvisitor should have asked to see the bruising for herself and madeher own judgement. There is no way of knowing what she wouldhave seen. The visit took place a week after the GP consultationand the bruises might have been less marked. However EY wasnoted to have more bruises five days later when he was seen atthe children’s centre so more bruising might have been visible.4.3.85The presentations of bruising and other potential indicators ofabuse at the children’s centre are documented in section 3 above.These incidents included:direct observation of bruises and scratchesreports of concerns from staff running a crèche associatedwith a parenting programmereports of concerns from other mothers4.3.86The individual management review of family support servicesdescribesthesecontacts,thoughtheyarebasedonlimitedrecordsbecausenotallkeyeventswereproperlyrecorded.Accounts given to the police after the death of EY suggest that theseriousness of the concerns of staff and parents exceeded theinformation in the records at the time.4.3.87The mother deliberately deceived both staff and parents at thechildren’s centre by saying that EY was her cousin’s son. Herspecific reasons for doing this are not clear. She also consistentlysaid that EY’s injuries were caused by the child’s four year old99sister or by toppling over. The effect of the deception was to makeit very difficult for the staff to identify EY and contact professionalswho knew him. It may also have made staff more likely to accepther accounts (since a four year old would be more likely to leavebruise marks on a baby than OY who was a toddler). Mostimportantly it distracted staff from concerns about the mother’sown parenting onto an imaginary family. The deceit sabotagedattempts to identify EY but there remain fundamental concernsabout the response of the children’s centre staff to the injuriesthat they and other parents reported. These are comprehensivelyidentified and explained in the family support service individualmanagement review:Recording systems used in the centre were not child-centred –they reported a range of incidents that had occurred in thecentre in date order making it difficult to form a picture of thenumber and range of incidents related to any one child and totrack the actions taken in response to themIndicators of abnormal parental behaviour were recognised asparenting problems and not indicators of possible child abuseAlthough it was highly unusual for other parents to expressstrong concerns about a parent, these concerns were nottreated seriously enough. More weight should have been givento them and they should have been recorded in more detailbecause these parents had more contact with the mother thanthe staff didManagement advice given about the case was not clearlyrecorded leaving room for ambiguity and there was a lack ofpersistence in implementing itThe children’s centre staff and coordinator lacked experienceand training in dealing with child abuse allegations. Thismeant that they were too willing to accept the advice given bythe access officer from social care, even though they say thatthey had misgivings about it100More senior managers had failed to ensure that centre staffadequatelyunderstoodtheirrolesandresponsibilitiesinrelation to child protection. Training for the centre staff andmanager on safeguarding was not given sufficient priorityThe evidence suggests that one reason for this was that thechildren’s centre service was being required to pursue toomanypotentiallyconflictingpolicyandservicedeliveryagendas. This is discussed in more detail in section 4.11It is not possible to be absolutely certain what information wasgiventothesocialcareaccessofficerwhenthecentrecoordinator spoke to her. Even if she believed that the call wasa consultation and not a referral she should definitely havereferred a call about a 10 month old baby with bruises to aqualified member of staff and she should have asked for thename and details of the family members involvedThe roles and responsibilities of access officers in the localauthority social care service were not understood by familysupport service staff and so they believed that they werereceiving advice from a qualified social worker and not anadministrative worker 314.3.88The reasons for these shortcomings are explored in more detail inthe relevant sections of this report.4.3.89Twice staff at the children’s centre sought external support inidentifying EY and responding to the injuries that they had seen.GiventhevulnerabilityofEYandthelackofanyconcreteinformation about who he actually was the centre coordinator andher manager should have placed responsibility for dealing with theconcerns squarely in the hands of the local authority social careservice by insisting on referring the child to a manager in thereferral and assessment service. Staff working in such settings31 The role of the Access Officer in the referral and assessment team was also unclear to healthmembers of the SCR panel and IMR authors demonstrating that this was not an isolatedmisunderstanding of the role. It is noted that this was not a new role or service innovation andthat the same individual had fulfilled the role for a number of years.101need to have the confidence and structures in place to be able todo this in future. The SCR accepts that the recommendationsmade in the family support service should if implemented achievethis so long as the service recognises that it has a specificresponsibility towards vulnerable children. This issue is exploredfurther in section 4.11.4.3.90Section 3. above describes the actions taken by the foster carerand the social worker reporting on her chance meeting with EYand his mother in February 2010. The previously allocated socialworker says that she left a voicemail message for the healthvisitor, but the health visitor made no note of this. If it did containan account of bruising and she did receive it and took no actionthis would be very concerning because it would have been afurther report of bruising, three weeks after the GP report. Havingleft the voicemail message the social worker should have followedit up to establish what had been done. She (and her much moreexperienced colleague in the fostering service) should also havetreated this as a proper referral of possible abuse to the authorityaboutEY.Thepreviouslyallocatedsocialworkerwasveryinexperienced and this is discussed further in section 4.9.4.3.91The final opportunity to identify EY as a child who was at riskoccurred the day before he was taken to hospital with seriousinjuries.Hewasseeninaclinicwithbruiseswhichweredocumented by the health visitor. The health visitor did not knowthat EY would be seriously injured within hours of this consultationand in evaluating her actions this needs to be set aside fromconsideration. The health visitor recognised that the bruising wasconcerning because she says that at two points during the briefconsultation she deliberately and pointedly asked the mother howthe injuries had occurred and the mother twice gave the sameaccount. Essentially the injuries that she saw were of a similarnature to the ones seen by GP and reported to EY’s own healthvisitor two months before and the ones seen at the children’scentre over the previous three months. However the health visitor102did record that EY’s failure to gain weight had now persisted for afurther two months. This should have raised the index of concern.4.3.92The action taken by the health visitor on that day was not inaccordancewiththelocalchildprotectionprocedures.Theseclearly state that she should have referred the injuries to the localauthority that day or at least consulted the trust’s named nurse. Itis clear that this was not due to a lack of knowledge or training.The BECHS management review specifically notes that relevanttraining had been provided to health visiting teams as recently asNovember 2010 but that the health visitors actions ‘did not followthe approach recommended’.4.3.93The health visitor also noted her concerns about the lack of weightgain. EY’s weight had been static for three and a half months andhad declined from the 75th centile to a point mid way between the25th and 50th, a clear indicator of his failure to thrive or a serioushealth problem. She noted her intention in her diary to speak toEY’s own health visitor as soon as possible the following day (theclinic was an afternoon one). Taken in isolation this was a veryconcerning presentation, but not one which required an instantresponse and the health visitor’s decision to note this and discussit the next day with the allocated health visitor was appropriate.Taken together with the bruising the persistent failure to gainweight should have added to the level of suspicion.4.3.94There is no suggestion from BECHS that this health visitor was notcompetent. In these circumstances it is important to understandthe factors that made it difficult for her to act in keeping with herjudgement and training. Some of the factors have already beenidentified:the mother once more gave a convincing but (very probably)untrue account of how the bruises had been caused.thehealthvisitordidnotknowthatthiswaspartofapersistent pattern of bruising or even that the GP and theallocated health visitor had seen bruises in January. There is no103way of knowing whether she might have reacted differently ifshe had known this4.3.95It is also important to be mindful of the context in which thehealth visitor saw EY and the other family members. This healthvisitor had never met EY or his mother before. The contact wasnot planned and she knew nothing of EY’s history other than thefacts she had time to obtain from his PCHR. She knew nothing ofthe nature of the concealed pregnancies. For the same reasons asthe GP she did not know that EY had lived in foster care. The SCRhas also discussed the arrangements for child health clinics suchas the one in which EY was seen that day. In these health visitorsseelargenumbersofchildren,manyofwhomwillnotbepreviouslyknowntothehealthvisitororontheirallocatedcaseload. The clinics are busy, because they are popular and therearefewofthem.Childrenareoftenweighedbyparentsthemselves rather than by health staff and often health visitorsspend as little as 3-5 minutes with a child. Health visitors haveaccess only to the PCHR. As has been described the PCHR may notcontain important information or make it obvious on a quickreview.Dependingonthevenuethehealthvisitorandhercolleagues may have no access to electronic records or any otherbackground information or parental history (or no time to accessthem). Recordings cannot be made on the electronic records andcontact with colleagues (in health and other agencies) is limited tomobile phone.4.3.96There can be no doubt that this is a very difficult environment inwhich to offer a service to vulnerable children, not least because itwill often not be clear whether the child who is being seen isvulnerable or not. The concerns about the difficulty of practisingsafely in this setting are discussed further in section 4.11 whichdealswithcapacityandotherorganisationalmatters.Someaspects of the analysis apply both to these child health clinics andto the children’s centres.104Overall conclusions in relation to assessment of the risks to EY andthe injuries known to professionals4.3.97Overall conclusions in relation to assessment of the risks to EY andthe injuries known to professionals are set out in section 4.14below.4.4Implementation of plansWhere relevant, were appropriate child protection or care plansin place, and child protection and/or looked after reviewingprocesses complied with?Establish what advice was given and what services wereoffered to the parents concerning adoptionEvaluate whether there was sufficient focus on the needsof the child EY in relation to actions taken in relation toadoption by the local authorityEstablish whether sufficient attention was given to issuesrelating the reunification of EY and his mother followingthe period when he was in foster care.Key dates and events4.4.1EY was born on 23 April 2010 and immediately accommodatedwith the agreement of both of his parents. At the placementplanning meeting held five days later it was decided that adoptioncounselling would take place to assist the parents in making aninformed decision about EY’s future. This was the correct course ofaction. Counselling of the mother began on 25 June 2010 after adelay caused by internal confusion about the referral betweenteams. The counselling continued until October 2010 when themother confirmed that she did not want to care for EY, regardlessof any support that was available from her family.4.4.2Following a home visit on 11 May 2010 the local authority took theview that the mother was ambivalent about adoption and that thefather was pressurising her to give EY up. From this point localauthority records show that there was an understanding of thepossible need to involve the maternal grandparents. The reasonsfor doing this were not clearly recorded at the time and legal105advice was later sought to clarify the position. Discussions aboutinforming the grandparents about the birth of EY continued untilearly November 2010.4.4.3The first statutory review took place on 20 May. The parents hadbeen invited but neither attended. However the mother visited thefoster carer later that day and started to have contact with EY.The review minutes note that the mother named EY after thereview meeting.4.4.4The decisions of the review meeting refer to a process of twintrack planning whereby work to secure the adoption of EY wouldproceed alongside counselling of the mother to help her make aninformed choice about adoption. The parents were informed thatlegal advice was being sought to determine whether the localauthority needed to inform the mother’s parents and that thisrelated to the possibility that members of the extended familymight wish to care for EY.4.4.5On 3 June 2010 the case was allocated to a new social worker(SW5) in another team. The initial period of allocation coincidedwith the period in which the mother had most contact with EY. Themother saw EY twice at the end of May and four times in June.Apart from the week before he was discharged to her care inNovember,thiswastheonlyperiodinwhichshesawhimreasonablyoftenduringhissevenmonthsinlocalauthorityaccommodation.4.4.6During this period and early July the mother spoke on a number ofoccasions about how she would like to care for EY, but no definiteplan was made in relation to this. She was encouraged to increaseher level of contact, but did not do so and she did not attend EY’ssecond LAC review on 21 July. The social worker took legal adviceand was advised to set out a timescale for decision making withthe mother in order to avoid undue delay for the child.4.4.7On 22 July the mother expressed her continuing difficulty inmaking a decision, though she admitted that when she was not106with EY she did not think about him and saw no need to make adecision rapidly.On 30 July and 2 August the mother indicated(on the phone and in a text message) that she had decided thatshe definitely wanted to give EY up for adoption. No action wastaken in relation to this during August (when the mother was onholiday with her family) and a further adoption counselling sessionwas fixed for September. It was only in September that discussionbegan about the arrangements for an adoption medical (plannedfor November) and an adoption panel meeting (in December2010).4.4.8Legal services records show that updates were requested by asolicitortwiceduringthisperiod(inmidAugustandmidSeptember). The local authority made a decision in principle on 14September to tell the maternal grandparents about the birth of EYbecause his mother had now agreed that she wanted to relinquishhim for adoption. The mother confirmed on 12 October that shewanted to proceed with the adoption, even if her family offeredsupport in caring for EY.4.4.9The mother continued to delay telling the maternal grandparents.After some delay the social worker forced the issue and informedthem on 4 November. It is not clear what discussions took placebetween the mother and her parents but almost immediately shedecided that she wanted to care for EY. This decision was madebetween the mother and her parents and the social worker playednoactiverole.Thesocialworkermadenorecordofthegrandparents’reasonsormotivation.EYwasplacedinhismother’s care on 19 November following a planning meeting and ashort series of visits to the foster home.Delays in reaching decisions and taking action in relation toadoption4.4.10Based on this summary of the key events it is self evident thatthere was undue delay in making and implementing decisions andin the provision of services. There are a number of reasons whythis happened.1074.4.11Misunderstanding between two managers led to a delay in thereferral for adoption counselling. One manager assumed that averbal request had been accepted while another had expected anelectronic referral for the service. The individual managementreview of social care services indicates how this will be avoided infuture and makes a recommendation in relation to this.4.4.12After the allocation of the case to the new team (following the firstreview)therewereanumberofperiodswhentherewasconsiderable drift in the case. It is accepted that during June themother showed signs of ambivalence about whether or not to carefor EY. She visited him about once a week. This was more than atany other time but it was hardly an indication of a strong desire tolook after him. She signalled a lack of interest in him by ceasingvisits at the end of June and then by not attending his looked afterreview on 21 July. In early August she confirmed her decision torelinquishEYforadoptionandwentaway foramonth.Nosignificant action was taken during this period and when the stepsin the proposed adoption were pencilled in during September thetimescale was protracted. This is attributed to the fact that thesocial worker was given no supervision between 2 August and 10September due to leave arrangements. There were a number ofperiodswhenafterreceivingadviceordecisionshadbeenreached, the social worker took a long time before acting.4.4.13Having achieved some clarity as to the mother’s intentions in lateJuly the issue of adoption was briefly re-opened by the adoptioncounsellor in September. Then the mother confirmed that shedefinitely wanted EY to be adopted, regardless of her parents’views. There was then a delay of almost two months while themother overcame her inhibitions about informing her parents.4.4.14It is clear that on a number of occasions the local authorityallowed its intervention to be unduly influenced by the pace atwhich the mother felt able to move and did not act at a pace thatwas consistent with the best interests of EY. The records and themanagement review strongly suggest that this was largely due to108the inexperience of the social worker. She was not confident aboutwhat to do. Arrangements were made for her to receive practicalguidance from her supervisor and more experienced colleaguesbut they did not result in the action required being taken. Thepoor quality of the supervision and support provided for her isdiscussed further in the sections dealing with supervision andtraining (Section 4.10).4.4.15The legal advice given in the email of 1 October 2010 (see section3.89 above) may also have contributed to this drift because itplaced undue weight on the need for the mother to agree to herparents being involved and consulted. This advice was at oddswith the correct legal position as understood by the SCR which isthat the action of the local authority should always be determinedby what it judged to be in EY’s best interests and that in somecircumstances this might require consulting with members of theextended family without the consent of, or even against thewishes of, the mother.4.4.16The thinking of the local authority in relation to the role of thegrandparents lacked clarity. It should have been clear from anearlypointthatwhateverthedecisionofthemotheraboutadoption, the grandparents needed to be informed about the birthof EY. If he were to be cared for by his mother then thegrandparents would know and they would need to be able tosupport the mother practically and emotionally. If EY was to beadopted careful consideration needed to be given to informing thegrandparents, not least so that they could consider whether theyor other members of the family could care for EY. The view of thesocial worker was that the grandparents were potential carers.Even if this were not an option then legally there might also beother important factors which would point to the need to for thegrandparents to be involved (for example EY’s right to haveknowledge of his family, questions of contact etc). In due coursean adoption panel would need to determine whether adoption wasin EY’s best interests. It would need to know that all of these109issues had been explored and that any proposed adoption matchhad taken these factors into consideration.4.4.17Reviewing the case history it is clear that the local authoritytreated the decision about adoption and the decision to inform themother’s parents as two separate issues: first the mother woulddecide on adoption and then the grandparents would be told whatshehaddecided.Theadoptioncounsellingfocusedonthemother’s views. The contribution of the extended family wasviewed as being something that would come later. In practicalterms these issues needed to be addressed in parallel because theattitudeofthegrandparentswouldinevitablyinfluencethemother’s attitude to adoption.4.4.18This is exactly what happened. As soon as the extended familyknew about EY the mother was persuaded to care for EY.4.4.19It would have been unreasonable to expect a newly qualified socialworker to have thought through this quite complex issue on herown, especially if this was the first adoption case that she haddealt with. This was a set of problems that her supervisor and thestaff in the fostering and adoption service who were advising hershould have recognised at a much earlier point. The failure to doso meant that for some months the actions of the local authoritywere heavily influenced by the pace at which the mother felt sheneeded to make decisions and not by the timescale that wasappropriate for the child.The action taken by the local authority in relation to adoption,including the advice given to the parents4.4.20The preceding paragraphs demonstrate that while the action taken bythe local authority complied with the agency procedures there wasundue delay in implementing the steps agreed.32 The legal advicegiven on 21 July which emphasised the need for a timescale forfurther action to be fixed with the needs of EY in mind was correctand helpful, but it was not implemented. The legal advice given on 132 CAFCASS (who would have had to take the mother’s informed consent to the adoption in aprescribed format) was never contacted at all.110October placed too much emphasis on the need for the mother toagree that her family should be informed. This may have contributedto the drift in the case.4.4.21There are some more general concerns. Much of the legal advicegiven was given in emails, most strikingly the advice given on 1October. This may have led to it being less well considered than itshould have been. Much of the legal advice given was not recorded inthe social care files (or it may have been stored in emails which werenotattachedtothemainrecords).Insofarasitcanbereconstructed accurately the audit trail of emails suggests that moreoften than not it was the legal advisor who was taking the initiativeand chasing progress. This should not have had to happen. Adoptionlaw as it applied to this case is complex and leaves much to thediscretion of the local authority, based on its assessment of thecircumstances of the specific case. On many occasions it is unclearwhether the social worker fully understood the advice that was givenor received clarification from her manager.4.4.22Although it is not explicitly stated the evidence strongly suggests thatthroughout this period the local authority’s actions were based on theassumption that the best option would be for the mother to look afterEY with the help of her parents and some involvement from thefather. The social worker certainly believed that this could happen.The starting point was a legitimate one based on the legal frameworkand research about outcomes for children. It was initially quite rightfor the mother to have the time to make a considered choice aboutadoption. There are sound ethical and legal reasons for this. Therearealsopragmaticconsiderationsbecauseconsentnotproperlyconsideredmightbewithdrawnatanypointwhichcandelayplacement or the making of an adoption order considerably. The localauthority had no evidence that OY had not been cared for properly.4.4.23Although the starting point of the local authority was correct, theconflict between the delay in making a decision and the best interestsof EY had become apparent by the end of June 2010. Evidence aboutthe mother’s lack of interest in him and lack of contact throughoutJuly and August accumulated and should have reinforced this. At this111point the focus of the local authority should have shifted to beexclusively concerned with identifying what was in EY’s best interestsand it should have been more decisive in implementing the plan foradoption that the mother had agreed to. The reasons are not clearbut it is apparent from the records that key professionals in the localauthority continued to think that the best option for EY would be tobe cared for by his mother and wanted her to succeed in being ableto do this beyond the time when an objective and dispassionateassessment of the circumstances would have pointed to the need forthe local authority to pursue other options. The lack of interest andcontact during July – August and the mother’s agreement to adoptionat the beginning of August should have been decisive. It remainsunclear why the local authority did not at that point move aheaddecisively with the planning for adoption.4.4.24The inexperience of the social worker and the poor quality of thesupervision provided to her were clearly significant; the character andpersonality of the mother may have been important (as they were inrelation to the response to the injuries to EY described above). Staffand managers had a sense that this was ‘history repeating itself’ andthat events would follow the same course for EY as they had with OY.4.4.25It is also important to recognise that the situation which the localauthority was dealing with was not commonplace. It is highly unusualfor a healthy newborn baby to be relinquished foradoption incircumstances where the child is not believed to be at risk of harm.Indications are that in the East Berkshire area this might happenonce or twice per year and that there are usually specific cultural andreligious factors 33 involved, which did not apply in this case.4.4.26Was sufficient attention given to the potential difficulty of thereunification of EY with his mother?4.4.27The report will use the term reunification although EY had beenaccommodated since birth and his mother had never cared forhim. The understanding of the local authority in November 2010when the mother stated that she wanted to care for EY was as33 For example a mother with a religious objection to the termination of an unwantedpregnancy might have a clear wish to relinquish a healthy infant from a very early point.112follows. He was developing normally and had no special healthneeds. He was sociable and outgoing and was viewed as being achild whom it would be easy for other carers to look after. It wasbelieved that the mother had been through a similar process inrelation to OY, but her doubts about caring for OY had beenovercome. If she did not want to look after EY it was in large partbecause the father had been ‘domineering’. EY’s mother hadsuccessfully looked after OY with the help of the father andgrandparents and there was no evidence that he had come toharm. No complexities or risks were recognised.4.4.28However there were equally a number of complicating factors thatwere not recognised as being significant. The mother had deniedor concealed two pregnancies. There was no evidence of overtmental health problems, but the two concealed pregnancies mayhave been evidence of psychological conflicts or problems infamily functioning and communication which the mother had notbeen able to resolve. The mother’s indecision over OY had beenquickly resolved and she took him home from hospital aged 3days. Even then the only recorded reason might be consideredunusual (she had noted that OY shared a birthday with hisgrandmother) and the significance of this was not explored. Thiswas very different to the position in relation to EY whom themother had never cared for and not visited for long periods.Repeated comments gave a strong indication that she often hadlittle interest in him and she had twice said (without there beingany evidence of pressure from the father) that she did not want tocare for him. It is a challenge for anyone to take on the care of aseven month old baby such as EY who was beginning to formattachments to its main carer and to actively explore the world.This is recognised by the careful way in which adopters and fostercarers are selected and supported and in which children areintroduced to new carers.4.4.29None of this assessment relies on the benefit of hindsight. Thedifferences should have been obvious. Everything that has been113listed in the preceding paragraph could and should have beenrecognised at the time. All of the knowledge set out above shouldhave been commonplace for experienced social care social workers(such as those in the fostering and adoption service) and thesocial worker’s supervisor.4.4.30It was also wrong to equate what had happened with OY andassume that the same would apply to EY. It is important torecognise that every infant has an individual temperament andpersonality and different children often have a different meaningfor their parent or caretaker. An early review of serious casereviews suggested (albeit speculatively) that the meanings whichsome carers attribute to individual children can lead to them beingsingled out for abuse, in contrast to siblings who are relatively wellcared for. 34 It is not known what specific meaning EY had for hismother. No one asked, but clues might have been obtained by askilful worker.4.4.31The approach that the local authority took followed from theunderestimation of the complexity of reunification in this case. Itwas agreed that EY would move to his mother’s after a shortnumber of contacts which were supervised and assessed only bythe foster mother. The social worker played a very passive role inthis and as far as can be established she did not observe orparticipate in any of the contact sessions that took place before EYwent home. She knew how things were going only through herphone contact with the foster mother. There is no record ofcontact (even by phone) with the mother until after EY movedhome, though this may reflect gaps in recording. The fostercarers’ supervising social worker had one phone contact with themother.4.4.32The contact sessions gave an indication of concerns, such as theevidence of the mother’s difficulties in interacting with EY andmanaging EY and OY at the same time. Given the very limited34 Reder, Duncan and Gray (1993) Beyond Blame: Child Abuse Tragedies Revisited,Routledge (pages 52-59 in particular)114contact that she had previously had with EY it is not surprisingthat the mother had difficulties. The evidence is that these werenoted but that their potential significance was not understood.There is no indication of any discussion with the supervisor aboutthe progress of the reunification. There was no supervision sessionbetween 2 November and 3 December – though it would be safeto assume that the progress of the case was discussed lessformally. It is clear that there should have been a more protractedseries of contacts and a fuller assessment of the circumstances,basedonamorerealisticunderstandingofthepotentialdifficulties.4.4.33There is now an increasing body of research indicating howcomplexthereturnofchildrentotheirfamiliesafteraconsiderable separation can be.35 In Farmer et al’s study of 180reunifications of looked after children, 47% had broken downwithin a 2 year period, and a third of those remaining at homewere receiving care of a ‘poor quality’. Key lessons from theresearch were that:Early and prolonged separation can affect parental bondingSuccess is associated with careful preparation and plan ofsupport and behaviour management, regularly reviewedIn this case some specific negatives could have been identified.ThemotherhadneverlookedafterEYandbydenyinghispregnancy had missed the opportunity to form an attachment tohim in the antenatal period (for example through seeing scans andpreparing psychologically and practically for the baby).4.4.34Careful thought was needed about the mother’s ability to be openand honest with professionals about her feelings in relation to EY.The history of two concealed pregnancies demonstrated that (for35 For example Farmer, E., Sturgess, W., and O’Neill, T (2008) ‘Reunification of looked-afterchildren with their parents: Patterns, Interventions and Outcomes”, Research Brief for DCSF,October 2008. (University of Bristol), it is recognised that not all of the lessons from researchare relevant because EY had not been directly harmed by his mother before separation,however many of the lessons about attachment and separation apply. I am grateful to SallyTrench for bringing this research to my attention115psychological reasons that remain unclear) she was unable to dealwithconflictorconfideinotherswhenshefacedseriousdifficulties. More reflective discussion between the practitionersand supervisors might have predicted that the mother would bevery unlikely to confide in professionals or be open with her familyif problems did develop. So far she had coped with her problemsby denying them to herself and concealing them from others.4.4.35Farmer’s study recommends that local authorities consider thevalue of skilled and purposeful social work to support reunificationpractice.Suchpracticewasabsentinthiscaseanditisrecommended that the local authority develop a plan to ensurethat all relevant staff are made familiar with relevant research andable to apply it. Other agencies who may be involved in thereunification of vulnerable children should consider how relevantstaff can be made aware of the complexity of reunification oflooked after children so as to be able to contribute to discussionand decision making.4.4.36It is important to note that even if there had been a thoroughassessment of risk and needs the local authority would have hadno grounds to prevent the mother taking over the care of EY.However careful observation of the transfer of care would haveprovided a solid basis for deciding if there were any risks and howEY’s needs would best be met over the following months. Acoordinated child in need plan would have allowed his progress tobe monitored and reviewed and would have ensured that therewas a single point of contact for all of the agencies who becameinvolved.4.4.37Health professionals were not consulted about the plan to moveEY to his mother’s. EY’s existing health visitor was not invited tothe planning meeting, though she was told about the decision.There was no coordinated plan to inform all of the relevant healthprofessionals about the discharge of EY from care. Had thishappened it would have assisted in the judgements that they latermade about EY.1164.4.38The looked after children health team played no active role at thistime and it appears that the team only acted when officiallynotified of the discharge some weeks later (apparently through itssystems / IT section). The team had no role in the discharge,because its role was limited to overseeing the provision of childrenwho are looked after. Given the lessons learnt it would be wise toreview the role of this service to consider whether it is possible toexpand its brief to include children who are ceasing to be lookedafter and discharged to friends or family. In this case it wouldhavebeenextremelyvaluableifsomeonehadhadtheresponsibility to ensure that all of the relevant health professionalsinvolved with the family were identified, that they all had relevantbackground information and that they all knew what the plan forthe child was going to be. The SCR will recommend that the localauthority and health commissioners review the role of the lookedafterchildrenhealthteamtoensurethatsuitablehealtharrangements are made for children who are discharged from careas well as those who become looked after.The decision of the local authority to close the case4.4.39The decision of the local authority to close the case was entirelyconsistent with the assessments that had gone before it and theunderestimation of the likely needs of EY that had marked the endof his period looked after by the local authority.4.4.40The social worker made two visits to see EY with his mother andOY after he returned home (on 24 November and 15 December).Theobservationsrecordedonbothoccasionswerelargelypositive. The mother stated that she was following the fostercarers’ routine and that the father was visiting and being helpful.OY was noted to have attempted to hit EY on the head and themother prevented this and showed him how to treat EY gently.The mother claimed that her family were being supportive andthat she was introducing EY to her friends. No further details wereever obtained of the role of family and friends.1174.4.41At the second visit EY was noted to have a couple of scratches onhis face which were said to have been caused by OY. Thisexplanation was accepted without further enquiry. Although thisexplanation was consistent with the behaviour that the fostercarer had previously observed this was a potentially concerningpresentation about which the social worker should have beenmore curious.4.4.42The case was closed on 22 December in the belief that the plan tounite EY with his mother had been successful. The local authoritydid not notify other agencies that the case had been closed. Thelack of communication with other agencies is discussed further insection 4.6 below.1184.5Focus on the childWere practitioners aware of and sensitive to the needs of thechildren in their work, and knowledgeable both about potentialindicators of abuse and neglect, and about what to do if theyhad concerns about a child’s welfare?When, and in what way, were the child(ren)’s wishes andfeelings ascertained and taken account of when makingdecisions about the provision of children’s services? Was thisinformation recorded?Observation of the children to identify needs and risks4.5.1Given the ages of the children establishing their wishes andfeelings through discussion was not possible. Professional practiceshould therefore focus on accurate and thoughtful observation ofthe children and discussion with carers in order to identify theirneeds and the ability of their carers to meet them.4.5.2Observations of OY while in the care of his mother and father waslargely positive and gave no cause for serious concern. OY put onweight very rapidly and this was monitored by his health visitors.His mother was encouraged to attend fitness and healthy eatingsessionsatthechildren’scentrewhichsuggestthatitwasbelieved that this arose due to lack of knowledge about diet andexercise.4.5.3Observation of EY while living in foster care were all very positive,reflecting the very good care that he was receiving and theattachment that he was forming with his foster carers.Professional understanding of possible indicators of abuse andpoor parenting and the action required4.5.4Section 4.4 above deals in full with the possible indicators ofpossiblephysicalabuseandpoorparentingnotedbyhealthprofessionals, children’s centre staff and the social worker. Anumber of professionals failed to recognise potential indicators ofabuse or to act on them in a way that was in keeping with thevulnerability of EY.1194.5.5Staff in the children’s centre noted their concerns about moresubtle signs of emotional abuse and poor attachment (for examplethe fact that EY was left in his pram with the cover pulled upfacing the wall and away from the activities in the centre).However they interpreted these in the light of the mother’sstatements that EY was her cousin’s child. They believed that themother needed help to be a better child minder, and this is whyshe was referred to a parenting programme. Because they hadbeen misled they did not realise that this was a sign of possiblepoor attachment to the mother’s own child. They were not toknowthatthefostercarerhadnotedandreportedsimilarconcerns (the mother not making eye contact with EY and keepinghim facing away from her).4.5.6As well as noticing the bruises on EY the parents of other childrenwho attended the centre raised concerns about the mother’s lackof warmth and responsiveness towards him and about him beinguncharacteristically quiet. These parents had considerably morecontact with EY and his mother outside of the Stay and Playsessions at the centre and so had the opportunity to observe theinteraction over a longer period of time and in a number ofdifferent settings. It was unusual for other parents to raise suchspecific concerns about another parent with centre staff. Thecentre staff appear to have recognised this and that the otherparents were breaking a trust with the mother by going behindher back and raising their concerns with professionals. However ashas been described in section 4.4 above the action they took inresponse to their concerns and those of the other parents was toolimited.A final, poignant clue about the mother’s lack of interest in EY iscontained in the PCHR. The standard booklet has pages on which parentsare able to note developmental milestones in relation to movement, finemotor skills, speech, social interaction and attachment of the infant. Onmost pages the parent has only to add in the age at which their childaccomplishes something; one page invites information about the child’s120favourite games and nursery rhymes. The record is comprehensivelycompleted by the foster carer, but there is only one entry (referring toEY crawling at 10 months) after his mother took over his care. It isunlikely that any busy professional would have looked at this section inthe PCHR, which is clearly intended for parental use. In this case itcontained additional subtle evidence of the mother’s lack of attachmentto EY.1214.6Information sharingWere there any issues, in communication, information sharingor service delivery, between those responsible for workingduring normal office hours and others providing out of hoursservices?The transfer of information and records between GP practices4.6.1The slow transfer of medical records between GP surgeries and thetime taken to summarise them at the receiving GP practice issignificant in the case history. The slow transfer of EY’s medicalrecords from one GP practice to another may have adverselyaffected the way in which his GP was able to carry out hissafeguarding responsibilities.4.6.2The mother registered herself and OY at a new surgery in earlyJune 2010. She had been a patient at the same GP surgery sincechildhood, though there was little significant information heldabout her until she had her first child. The new surgery was nearerher home but her reasons for transferring at this time are notclear as she had moved house the previous November. Herreasons were not established at the time and she was actingwithin the normal parameters of ‘patient choice’.4.6.3Following the transfer OY’s records arrived from the previouspractice on 30 September 2010 (over 3 months later) and weresummarised. The transfer took longer than is normally expected,though there is no evidence that this had any impact on theoutcome of this case.4.6.4The mother’s records had not arrived at the time of EY’s death inMarch 2011 and were only transferred when they were chased bythe practice in April 2011. The reasons for this delay have notbeen established. As a consequence any GP consultations with herwould have taken place without the benefit of notes. Her recordswould not normally have been consulted when the children wereseen so the failure to transfer the notes would not have made acriticaldifferencetotreatmentoroutcomesinthiscase.122Nevertheless in other cases it might – if for example a parentsuffered from a mental illness which was impacting on parenting.4.6.5The mother registered EY at the same surgery on 1 December2010, two weeks after he moved to live with her. The recordswere received 2 months later and had not been summarised at thetimeofhisdeathinMarch2011. Thismay havemade animportant difference to the safety of practice with him becausewhen he was seen with bruising on 19 January 2011 the GP reliedentirely on the information in his Personal Child Health Record andhe had no other background information. EY’s previous medicalrecords contain very clear references to him having been in fostercare. 36 If properly summarised this information would have beenincluded in the computer summary of his records which is openedwhenever a patient is seen. This might well have influenced theactions of the GP who identified bruises.4.6.6In the light of this the SCR has sought to understand in detailwhat the arrangements are for the transfer and summary of GPrecords. In Berkshire GP records are transferred from one practiceto another through the Thames Valley Primary Care Agency (PCA),responding to patients’ changes of GP practice. Patients register atthe practice of their choice and the process of record transfer canonly begin when the practice receiving the patient asks the PCA toobtaintherecords.Accordingtothemanagementreviewofprimary care involvement, the process of recalling the recordsfrom the previous practice and sending them to the patient’s newpractice takes approximately 3-8 weeks when there is an internaltransfer of notes within Berkshire. Transfer from further afieldtakes longer. On receipt the practice is required to summarise the36 The primary care IMR underlines the full extent of the information that would have beenreadily available if the records had been transferred within a reasonable timescalesummarised: On review of the GP records EY’s records were clearly summarised as ‘lookedafter’ as an active problem on the front computer page in the GP records of the first practicehe was registered with. There was a copy of the Health Care Plan in the records from theinitial health assessment on 2/06/10 done by the Berkshire East Health Team for LookedAfter Children and Young people. The foster carer was to facilitate attendance for routineimmunisations and relevant developmental checks.123noteswithineightweeksfromthedateofreceivingthem.Arrangements for summary are the responsibility of individualpractices. GP notes are usually reviewed by a member of thesurgery team who has nursing or medical secretary background.The purpose is to ensure that significant information is enteredonto the computer records of the current practice.4.6.7Some practices transfer information electronically via a nationalsystem called GP2GP which enables the immediate transfer ofcomputerrecords.CurrentlyinBerkshireaboutonethirdofrecords are transferred through this system. Both surgeries haveto be registered for this access and they must use compatiblebrandsofmedicalrecordsoftware.Themanagementreviewindicates that work is being undertaken by the NHS in Berkshire toincrease the participation of Berkshire surgeries in this system.4.6.8The gap of 14 weeks between the registration of EY at a newsurgery and his death during which his notes had not beensummarised was permissible and probably not unusual within thecurrent arrangements. There is no reliable information to indicatehow typical it might be but it is clear that the GP author of theindividual management review of primary care services did notfind it surprising.4.6.9The view of the SCR is that this case history demonstrates thatcurrentarrangementsforGPrecordtransferarenot‘fitforpurpose’ in relation to the protection of vulnerable children. Mostadult patients with complex medical conditions can bring theirneeds to the attention oftheir GP or have carers whoaremotivated to do so. Vulnerable children will not have made thechoice to change GP practice and cannot articulate their needs inthe same way. Vulnerable young infants cannot ask the new GP toget their records quicker and check for significant history. Many ofthe parents of vulnerable children will not be motivated to ask forrecords to be obtained and will not bring relevant information tothe attention of the new GP. Some parents will move house and124change GP deliberately in order to avoid continuing contact withservices.4.6.10The specific concerns in this case need to be put in the widercontextoffindingsfromSCRsaboutthestrongassociationbetween serious child abuse and families who move frequently.Such families are hugely over represented in cases subject toSCRs. Moving frequently is likely to be in part a symptom of otherrisk factors (such as unemployment and poor access to housing)butitalsoexacerbatestheotherriskfactorsinacasebydisrupting professional knowledge of children and involvementwith them. The national review of SCR findings for 2003 – 2005states that ‘the most startling environmental feature was thenumber of families who were noted in reports to have movedfrequently (more than a third of the intensive sample). The needtolocateandprotectchildrenmorerobustlyinthesecircumstances was exemplified in many of the cases.’ 37 (page 47)The follow up study of SCRs 2005 – 7 noted an even higherrepresentation with ‘evidence that almost half of the children andyoung people (45%) had moved numerous times’ (page 42). 384.6.11The movement of families and the slow transfer and summary ofrecords may leave children at risk but also means that GPs are leftprofessionallyvulnerablebecauseasthiscasesoclearlydemonstrates they are working with incomplete information. Aswell as being in the interests of vulnerable children it is in thedirect interests of every GP in the country to take action to resolvethese problems and to press for the policies and practices of allrelevant departments and services within the NHS to be amended.Action is needed at a number of levels:37 Brandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, and Black J (2007)Analysing child deaths and serious cases through abuse and neglect: what can we learn? Abiennial analysis of serious case reviews 2003-2005. DfES38 Brandon et al, (2009), Understanding Serious Case Reviews and their Impact aBiennial Analysis of Serious Case Reviews 2005-07 DCSF125a higher standard should be set for the transfer and summaryof children’s medical records. For the reasons given in thepreceding paragraph there are good practical reasons for GPsurgeries and the NHS to prioritise the transfer and summaryof children’s recordsin Berkshire specific targets need to be set for the take up ofthe GP2GP system and progress needs to be reported regularlyto senior managers in the NHS and to the LSCBother agencies may need to take action to mitigate the riskthat arises in relation to children who have been subject tochild protection plans or looked after by the local authority. Insuch cases the looked after children’s health team needs toplay a more active role and other professionals need to ensurethat they have sent relevant information directly to the new GP4.6.12TrainingandbriefingsessionsarisingfromthisSCRshouldemphasise:the vulnerability of GPs who do not take steps to improve theirsystems for transferring and summarising children’s recordsthe need for other agencies to recognise that they may need totake into account the fact that when families with vulnerablechildren have recently moved the GP may be working on thebasis of partial information 394.6.13The action that can be taken locally will have little or no impactwhen children move across health borders and the SCR will makea national recommendation to the Department of Health on thismatter so that it can address the problem at a national level.Other aspects of information sharing between health professionals4.6.14The father had a different GP to other family members. Section 3of this report notes that the father’s GPs treated his reaction totheconcealedpregnanciesandthebirthoftwochildrenaspotential mental health problems in isolation from the wider family39 For example social workers need to be mindful of this when undertaking child protectionchecks or when a child subject to a child protection plan changes GP126context. The GPs did not show any curiosity about the childreninvolved and did not share any information or make any enquirieswith the local authority or other health professionals. An honestappraisal of this however is that it would be very unusual for a GPin these circumstances to do so, unless there were very seriousimmediate concerns. This does represent a missed opportunity toshare information which GPs can learn from.4.6.15Sections 3 and 4 of this report have noted that the assessmentscarried out in the midwifery and obstetric services were superficialand that professionals dealing with the second birth did not haveaccess to information about the pregnancy and birth of his olderbrother from previous births. The individual management reviewhas noted the lack of useful information highlighting risk factorsand unusual circumstances contained in discharge summaries toGP and health visitors. It has made recommendations on thiswhich the SCR endorses.4.6.16Sections 3 and 4 of the report highlight the lack of communicationbetween health visitors and GPs except on the occasion when theGP asked EY’s health visitor to advise the mother on managementof sibling rivalry. On this occasion the health visitor failed to tellthe GP during their discussion on bruising that EY had been lookedafter. It is not clear whether she had this information to handduring the discussion, though she must have when she saw thefamily.4.6.17Earlier sections of this report have identified missed opportunitiesto share information between the two health visitors involvedbefore his discharge from care and after. The details are fully setout in the BECHS management review:When the previous health visiting team were notified by the LAChealth team that EY had moved, the records were not forwardedto the receiving team…. From the perspective of the receivinghealth visitor ‘there was no communication with EY’s previoushealth visitor and his records were not requested; family contactwas documented in his mother’s record’ (paragraph 5.5.7)127It is clear that both professionals should have recognised the needto transfer the records as a matter of urgency and in a case whichhad complexities there should have been phone communication.The reasons for this shortcoming in the service have not beenidentified, but section 4.11 below will examine more generalconcerns about the lack of capacity in the health visiting servicesand the impact that this may have had.Information sharing between agencies4.6.18The SCR has identified six occasions on which local authoritymissed (or delayed) opportunities to notify health professionals ofsignificantdevelopmentsandtoenablehealthcolleaguestobecome involved in planning and decision making. (1) There wasno discharge planning meeting before OY was discharged fromhospital. Both hospital staff and social care staff could have takentheinitiativetoconvenesuchameeting.Thesocialcaremanagement review rightly recognises that ‘it would have beenmore appropriate if at the point of (hospital) discharge, a multi-agency planning meeting had been arranged, which would haveaffordedaforumthatpotentiallycouldhaveexplored,orhighlighted the need to further examine the implications of aconcealedpregnancy’.Thiswouldhaverequiredthatotherprofessionals were alerted to the significance of the concealedpregnancy and to have recorded and shared their observations ina more systematic way.4.6.19(2) The local authority notified the LAC health team that EY was infoster care on 11 May 2011. This was 19 days after EY becamelooked after. This is discussed further in paragraph 4.6.22 below.4.6.20(3) Other agencies were not notified of the outcomes of the initialassessments of OY or the decision of the social care service toclose the case. This was said to be because of a lack of capacity inthe service at the time. (4) The same occurred in relation to thesecond initial assessment of OY. (5) Health professionals were notconsulted or involved during the process that led to the placement128of EY with his mother. EY’s health visitor was not consulted aboutthe likelihood that EY would be moving to live with his mother.EY’s new health visitor was told about the plan on 12 Novemberbut not involved further in assessment or discussions. There wasthus no agreed plan of support and follow up between the twoagencies. (6) Following EY’s discharge home to his mother thesocial worker and the family health visitor did not communicatewith one another.4.6.21Taken individually some of these episodes could be explained byfactors (such as the lack of resources). Some are consistent withthe overall underestimation by the local authority of the possiblecomplexity of the case. However taken as a whole they form aworrying pattern, bearing in mind that no manager or qualityassurance system identified any of these episodes as being aconcern. This suggests that some staff and managers may haveunderestimatedthevalueofconsultingcolleaguesinotheragencies andinformingother agencieswhat action thelocalauthority is taking. This is potentially harmful if it leaves otheragencies believing that the local authority is still involved indealing with a case when its involvement has actually ceased. Thelocal authority needs to be satisfied that this is not a morewidespread problem.The role of the looked after children’s health team4.6.22TheagreedEastBerkshireIntegratedCarePathwaysystemrequires that social care notify the LAC health team within fivedays that a child becomes looked after. Notification consists of acompleted notification form and a signed consent for LAC healthcare. In this case the LAC health team became aware that EY wasin foster care following communication from EY’s health visitor(who had discovered it fortuitously at the GP surgery). Officialnotification was not received until 11 May 2010; 19 days after EYbecame looked after. This could have resulted in late provision ofLAC health services and a late medical assessment. EY’s GP was129officially informed of his looked after status by fax on 21 May 2010(a delay of a further 10 days).4.6.23While EY was looked after his health needs were appropriatelyaddressed. The LAC health team were notified that EY was tomove to live with his mother and brother on 12 November 2010.On 22 November the team received a further message from socialcare that the pre-adoption appointment arranged for that day wasto be cancelled as the mother was taking EY home. The team onlythen communicated the plan for EY to live with his mother to thehealth visitor who had been working with EY on 10 January 2011by email. She already knew this.4.6.24TheBECHSmanagementreviewcommentsthat‘therewasevidence of liaison between the health visiting team and socialcare and the LAC health team and social care’. The social carereview makes no specific mention of communication with the LAChealth team. Close examination of the reports and the chronologyindicates that while the LAC health team was effective in itsresponsibilities towards EY whilst he was looked after (for exampleby arranging and conducting his LAC medical examination) itplayed only a marginal role when he ceased to be looked after. Inrelation to his discharge from care the LAC health team played norole in ensuring that all of the health professionals who were to beinvolved had access to all of the relevant information.4.6.25Until now the scope of responsibility of the LAC health team hasbeen limited to the health of children who are looked after. Thisreflects the exclusive focus of guidance on the health of childrenwho are in care rather than the health and safeguarding of youngchildren who are being discharged from care. For example theextremely extensive NICE guidance 40 on the health of looked afterchildrenandtheassociatedselfassessmenttooldocontainreferences to placement of children on care orders with family(because services and support tend to be poorer than in foster40 NICE (2010) Promoting the Quality of Life of Looked after children and young people, NICE/ SCIE public health guidance No 28130placements) and to children leaving care age 16-18 (mental healthsupport for adolescents, transition to adult services etc). Howeverthey do not address the sort of simple, practical issues that wererelevant in this case history - such as the need to notify all thehealth professionals involved when a child is discharged from careand make sure that they know relevant history and are involved inthe child in need plan.4.6.26It is clear from the findings of this SCR that – taking particularaccount of the slow movement of records between GPs and thepoor communication between health visitors – there would beconsiderable value in reviewing the remit of the LAC health teamso as to consider whether it can take more responsibility for 1)identifying all of the health professionals who need to be notifiedof the fact that a child is ceasing to be looked after and 2) sharingkey information with them. The SCR recognises that broadeningthe remit of the team might require additional resources ordifferent use of resources. It also recognises that regardless of theremit of the team and the procedures that are in place thesuccessful performance of all tasks will rely on close working withallocated social workers who need to appreciate the importance ofthere being a coordinated health input to children who return totheir families after being looked after.1314.7Factors that impeded engagementIdentify factors that helped or hindered the engagement withthe family4.7.1The narrative in section 3 of this report shows that professionalsachieved only a very superficial understanding of the lives andhistory of the individuals with whom they had contact. This hasbeen emphasised in the health overview report but it appliesequally to other professionals as well. The result is that – with theexception of the period when EY was in foster care - none of therecords of the professionals involved or the interviews with themconducted for the SCR process give any detailed knowledge of thedaily lives of EY and OY and the care that they received.4.7.2The principal reason for the very superficial engagement of thefamilywithprofessionals.Thesocialworkerundertakingtheadoption counselling with the mother did point out to her that shehad a tendency to deny or disassociate herself from anything thatshe found difficult. With this exception the professionals involveddid not appreciate that it was necessary to seek a closer or morechallenging engagement with the mother and other members ofthe family. This was because professionals largely underestimatedthe potential complexity of the circumstances that they weredealing with and the potential concerns. The details of how andwhy this occurred have been set out to the extent that it ispossible to do so at this point in section 3 and section 4.3 (dealingwith assessment).4.7.3Specific opportunities to understand the tensions and conflicts thatsurroundedtheconcealmentoftwopregnanciesandtheunexpected births of two infants were missed. The only member ofthe family who gave a frank account of how the birth of thechildren had affected him was the father. When he gave accountsto his GPs they were not shared with other professionals involved.When he spoke to social care staff his frankness and the strengthof his feelings were interpreted as him bullying the mother who132wasmuchyoungerthanhimandperceivedasbeingmorevulnerable.4.7.4Shortcomingsinprofessionalpracticeoccurredwithinanorganisational context which sometimes made it more difficult forprofessionals to engage with the family. Sections 4.2 – 4.12 ofthis report sets out the findings of the SCR in relation to these.Rather than repeat these findings (or anticipate them in detail)this section of the report will highlight some of the key findingsand point out why they made engagement with the family moredifficult.4.7.5There was a pervasive belief among social care staff that it wouldbe beneficial to EY to be united with his family and no risks wereidentified in doing this. This was not challenged from within theservice. This has been discussed at length in section 4.4 above.Sections 4.9 and 4.10 deal with the skills and knowledge of staff,their training and supervision. Professionals in other agencieswere not concerned with decision making about EY’s future in thesamewaybuttherearealsoconcernsabouttheskillandknowledge that they brought to bear.4.7.6Thelackofcapacityinthehealthvisitingserviceimpairedengagement with the mother and opportunities to reflect on thecircumstances faced by staff and the history. This is discussed indetail in section 4.11. This section of the report also evaluates indetail the impact of the settings within which some staff operated– with particular reference to the child health clinic and children’scentres.4.7.7On a number of occasions professionals might have engaged moreeffectively if they had had access to relevant information thatmight have influenced their decision making. This is considered indetail in section 4.6 which deals with information sharing.4.7.8Contact with family members may shed more light on theirattitudes and beliefs. If at a future time there is an opportunity fordirect contact with family members there may be scope for more133learning for the SCR. However it is also apparent from the caserecords and from interviews with some staff that the character,personality and background of the mother played a significant roleat key moments in the case history. She maintained a polite butextremelysuperficiallevelofengagementwithmostoftheprofessionals that she encountered. The relatively comfortableeconomic circumstances of her and the family may have played apart in shaping the response of professionals. This is considered insection 4.12 dealing with ‘diversity’.4.7.9It must also be recognised that the mother deliberately andpersistently deceived other parents at the children’s centre andthe staff there as to the identity of EY and her relationship withhim. The evidence strongly suggests that she repeatedly gavefalse accounts of the cause of EY’s injuries, while at the same timebringing EY to settings where his injuries would be noticed. At thispoint it is not possible to fully understand what her reasons werefor acting as she did or the different factors that may have shapedher behaviour. However it is clear that the mother’s compliancewith many services disguised poor parenting and a high level ofrisk to her younger child.1344.8Policies and proceduresDid the organisation have in place policies and procedures forsafeguarding and promoting the welfare of children and actingon concerns about their welfare?Was the work in this case consistent with each organisation’sand the LSCB’s policy and procedures for safeguarding andpromoting the welfare of children, and with wider professionalstandards?Single and multi-agency safeguarding procedures and guidance onthe bruising4.8.1Local multi-agency child protection procedures contain guidanceon how to respond to safeguarding concerns, including bruising.They specify that ‘any bruising or other soft tissue injury to a pre-crawling or pre-walking infant or non mobile disabled child’ or‘bruisingaroundtheface’…’mustbeconsideredashighlysuspicious of a non-accidental injury unless there is an adequateexplanation provided and experienced medical opinion sought’. 41The relevant section of the procedures is included as Appendix 8.4.8.2However carefully written and crafted, the wording of procedurescan always be improved. However these procedures leave thereader in no doubt as to the particular vulnerability of younginfants and the potential significance of bruising. Bruising on theface of a 9 – 11 month old child requires referral to the localauthority and detailed evaluation by a doctor with expertise inchild protection.4.8.3With one exception the individual management reviews confirmthat the staff had access to the local interagency child protectionprocedures and that all of the staff involved had attended multi-agency or professional training which underlined the importance ofmessages about the significance of bruising in infants. A numberof SCR panel members and management review authors were ableto confirm details of the training provided, in particular training for41 Berkshire Child Protection Procedures (section 5)135health professionals in late 2010. There is no doubt that thesemessages had been strongly underlined.4.8.4The review of provision by family support services indicates thatthe children’s centre child protection policy was inadequate insome respects, for example not indicating what arrangementsshould be made when the designated professional was absent.However these were not aspects of the procedures that impacteddirectly on this case. It is more likely that in relation to thisservice, members of staff had received insufficient training tocarry out their responsibilities. This is discussed further in thesection on training and organisational issues. The managementreviewoffamilysupportservicesaskstheSCRtoconsiderproviding more detailed guidance on thresholds for referral to thelocal authority. The view of the SCR is that this exists in thecurrentmulti-agencyproceduresandthatfurtherdetailandreinforcement needs to come through training and managementadvice within the service. Access to multi-agency training wouldbring greater clarity about the roles and responsibilities of otherprofessionals and referral arrangements.4.8.5The case history underlines that however sound procedures aretheydonotremovetheneedforindividualstoexerciseprofessional judgement. Referringtotheexistingprocedures:what for example is an ‘adequate’ explanation for a bruise? Themost important issues are (1) the way in which that judgement isexercised and (2) the context within which judgement needs to beexercised - an important component of which is the access toadvice and additional information that informs the judgement. Inrelation to EY it was the manner in which professional judgementwas exercised which gives cause for concern rather than thewording of the procedures. The case history demonstrates that ona number of occasions professionals were too willing to accept themother’saccountsofhowbruiseshadbeencausedwithoutremaining sufficiently sceptical and without taking further adviceor seeking further information. In one instance a health visitor was136working in a setting which did not make it easy to do this. Whilstsome revision or extension of the procedures might be helpful it istheir implementation by staff in day to day practice which needs tobe the main focus of learning and activity as a result of this SCR.Professional initiative4.8.6Sometimes additional action is required which goes beyond whatis written in procedures and cannot be anticipated in detail bywritten procedures. There is no procedure to say that a 7 monthold who has lived in foster care since birth but is now being placedin the care of the mother should have a new birth visit and a fullfamily health assessment akin to the one that a child wouldnormally receive at 15 days. However it should have been withinthe professional experience and knowledge of the health visitorinvolved to recognise this. Procedures cannot be written to alertprofessionalstoeveryconceivableunusualorunexpectedcircumstance.The need for additional procedures and guidance4.8.7All of the individual management reviews recommend the need foradditional multi-agency procedures to be produced dealing withdenied or concealed pregnancy. This will assist local professionalsby underlining the importance of denied and concealed pregnancyand by setting out minimum steps that are required or need to beconsidered. In particular the procedures should underline theimportance of closer working in such cases between professionalsinvolvedinchildren’sservicesandperinatalmentalhealthservices. The SCR endorses these recommendations and suggeststhat the work to produce brief procedures on this should beundertaken on a multi-agency basis.4.8.8The health management reviews indicate that there would bevalueindevelopingamoredetailed‘pathway’forthemanagement of bruising. The SCR endorses this and wishes tounderline that this will be of value so long as it addresses thepsychological barriers that may exist which make it more difficult137for GPs and others to recognise abuse and make referrals as wellas the managerial and administrative aspects of the problem.4.8.9There are wider concerns highlighted by the case history whichrelate to the difficulty that many professionals had in consideringthe possibility of child abuse as an explanation for bruising and theease with which they arrived at and accepted benign explanationsfor injuries to a child without being more sceptical and withoutconsulting colleagues. These wider concerns need to be addressedthrough the continuing supervision and training that takes place inindividual agencies and the LSCB and they cannot be addressedthrough specific procedures. The briefings and training undertakenin relation to this SCR need to underline the continual need forscepticism,cautionandconsultationbeforearrivingatfirmjudgements.Theywillunderlinetheneedforcontinuingprofessionalopennesstopresentationsthatdonotfittheestablished picture of a ‘high risk’ case.1384.9The skills, knowledge and experience of the staff dealingwith the familyEstablish whether staff and managers dealing with the familyhad the requisite skills, knowledge and experience to respondto the circumstances presented by the family.Staff levels of experience and skill, the training and support givento staff4.9.1Each of the individual management reviews comments in detail onthe skills, knowledge and experience of the staff dealing with thecase. The main issues arising from these evaluations are set out inthe following paragraph.Social work staff4.9.2The social care management review states that ‘social workersandsocialcaremanagers…wereknowledgeableandhadundertakenappropriatetrainingaboutpotentialindicatorsofabuse and neglect’. It goes on to state that the allocated socialworker who was involved in the case from May 2010 onwards wasnewly qualified. It says that she received ‘additional training anddevelopment opportunities … through a Newly Qualified SocialWorker training programme’. The management review details thecontent of this programme which seems to be very relevant,though it is not stated how much of this the worker concerned hadcompleted.42 It is stated that in addition an arrangement wasmade whereby she was ‘supported in developing her knowledgeconcerning adoption through close liaison with experienced staffinvolved through the Fostering Adoption and Respite Service’ andit is understood that the relevant staff were easily accessible tooffer advice.4.9.3Inprinciplethiswouldappeartobeanidealarrangementreflecting the lack of experience of the allocated social worker. In42 Completion of CWDC Induction workbook, training on roles/responsibilities within thedepartmental structure, planning interventions, chronology, remaining child focussed/hearingthe voice of the child, risk assessment and analysis, recording skills, Section 47investigations, report writing and analysis, challenging skills, managing difficult behaviour,presentation skills, and assessment framework. The worker concerned had not completed anumber of key modules including recording skills (!), presentation skills, s47 investigations,and assessment framework, suggesting that she was allocated this case because it wasconsidered straightforward139practice the evidence of drift in the implementation of plans, thefailuretochallengethemotheroverherdelayandtheunderestimation of the indicators of possible concern (all describedin detail in section 4.3 above) strongly suggest that at her stage ofprofessional development this individual worker did not have theskill and knowledge necessary to undertake the work with EY andhis family. Perhaps the clearest symptom of this was the tendencyto hold back from actively engaging in the case, for example bynot visiting the mother and EY together during the period beforethe rehabilitation, relying only on the comments of the foster carerand not engaging directly with the grandparents to assess theirrole much more fully.4.9.4From the information that is available it is not clear how far thiswas due to her lack of experience or whether it is more significantthat everyone involved in the case in the social care serviceadopted the basic attitude previously identified that it would be apositive outcome if EY were to be cared for by his mother and thatthere were no potential risks or complications in allowing this tohappen. This points to the failure of her supervisor and othermuch more experienced colleagues to identify potential difficultiesand to challenge the superficial assessments that were produced.Supervision and management involvement is discussed further insection 4.10.Children’s centre staff and managers4.9.5The management review of family support services addresses indetail the question of the skills, knowledge and training of the twomembers of staff involved.4.9.6The centre coordinator had been working in adult education andfamily learning prior to taking up her posts. This involved ‘co-ordinating, designing and delivering training for adults to improvetheir basic skills’. Nationally and locally this is not unusual inchildren’scentreservicesbecausepromotingthelearningofparents, improving their ability to gain employment and helping140themlearnhowtosupporttheirchildren’slearninganddevelopmenthavebeenimportantpolicyobjectives.Themanagement review recognises that in children’s centres that donot provide nursery or child care ‘the primary relationships … arewith parents rather than children’. It is suggested that althoughtraining was provided in early years development the lack of aprofessional background specifically within children’s services mayhave impaired the capacity of the staff to safeguard EY. Forexample, this was the first possible child protection matter thatthe centre co-ordinator had referred to social care in her career.Thiswouldbeunusualforsomeonewithmanagementresponsibility in a children’s setting. When she made the referralthe manager assumed that she was taking advice from a qualifiedmember of staff and she was surprised that she was not asked forEY’s name. However she did not have the confidence to challengethe approach taken or to ask to speak to someone more senior. 434.9.7These are very specific examples that relate to the referral ofconcerns to social services. However it seems very likely that thecoordinator’s lack of experience in managing a setting attended bychildren contributed to a wider lack of focus on the needs ofindividual children. Examples include: the repeated failure to insistthat the mother provided registration details of EY; the reliance onrecordingepisodesofbruisingindateorderas‘incidents’alongside incidents about other children and parents, making itdifficult to focus on the sequence of events for an individual child;and the lack of training of staff over safeguarding. The centrecoordinator has subsequently acknowledged not feeling confidentin her role as the designated person for safeguarding. A managerfrom a background providing services to children is much morelikely to have regarded safeguarding training as an absolutepriority.43 The local authority had also wrongly believed that the role of the Access Officer was widelyunderstood. This is discussed in section 4.111414.9.8This is not to suggest that a manager from an adult learningbackground could not fulfil the responsibilities of a children’scentre coordinator in a child centred manner. It indicates thatother things being equal he or she would need additional training,support and monitoring to be able to do this. The individualmanagement review recognises that more account needs to betaken of this in relation to the recruitment and training of centrecoordinators in future. Because of its location the coordinator inthis centre was also disadvantaged by being professionally isolatedfrom others carrying out the same role who may have been ableto offer useful peer support.4.9.9The children’s centre worker had training in early years teachingand had previously worked in a role with families and children withadditional needs. However for a number of reasons she had notattended the level one safeguarding training required for her post.This was in part due to a misunderstanding as to which agencywas responsible for providing it but it is also stated that the centrecoordinator did not give this sufficient priority because the centreworker’spredecessoralsoreceivednospecificsafeguardingtraining.Thecentrecoordinatoralsofailedtoensurethatinformationaboutbasicchildprotectionresponsibilitieswasincluded in the centre worker’s induction training so she had notbeen made aware of basic documents on safeguarding or theLSCB’s policies or how to access them.4.9.10The family support service as a whole did not have sufficiently wellorganised arrangements for ensuring the take up of training Thecentre worker’s lack of training had not been identified in theregular audit of staff training because staff lists were not up todate.Health professionals4.9.11Theindividualmanagementreviewsstatethatthehealthprofessionals involved had the requisite skills, experience andtraining. The BECHS management review confirms that ‘eachmember of staff involved with family was up to date with their142safeguarding training’. The GP who examined EY two monthsbefore his death was regarded as being highly knowledgeable inrelation to child health and all of the other GPs involved hadattended relevant training in the recent past.4.9.12If key health professionals had relevant skills, knowledge andtrainingtheninsofarasthereareshortcomingsintheirperformance attention must be paid to the wider organisationalcontext within which they were working to establish whether thereare factors which may have made it more difficult for them toapply this knowledge and skill in practice. The arrangements forGP record transfer and the reticence of the GP to identify childabuse have been discussed in section 4.6 above. Section 4.11whichdealswithorganisationalandmanagementissueswilldiscuss the likely impact of the long standing under capacity of thehealth visiting service and the potential impact on the work ofhealth visitors of working in some child health clinics.1434.10Managements and supervisionWere senior managers or other organisations and professionalsinvolved at points in the case where they should have been?Was there sufficient management accountability for decisionmaking?Agencies and services in which there was no management orsupervisory input4.10.1GPs do not receive supervision, though they are able to consult anamed GP or a paediatrician colleague for advice about thesafeguarding of children. None of the GPs involved in this casehistory did so. It would have been relevant for the GP to havesought advice when he identified the bruises on EY in January2011.4.10.2Midwives operate as autonomous professional practitioners and donot receive supervisioninthe sense that most professionalsoperating within child protection services would understand it. 44 Ifthey have concerns about safeguarding, midwives should consultthe named midwife, but understandably this was not viewed asnecessary in this case. In relation to both children appropriatereferrals were made to the local authority. However the conductand recording of midwifery assessments fell short of the standardsrequired.4.10.3Health visitors are required to attend supervision over casescausing child protection or welfare concerns at least every fourmonths (or when specific problems occur on cases). This case wasnever considered complex or concerning enough to be discussed insupervision.Social care supervision4.10.4Records have been provided which show that EY was discussed intensupervisionsessionsbetweenthesocialworkerandhermanager during the period late May 2010 (when the case wasallocated) and late December 2010 (when the case was closed).44 They are required to meet a mentor annually for the purpose of professional developmentand registration144The sessions were usually held three weekly but there were twogaps of approximately six weeks because of the annual leavearrangements of the social worker and her manager (these werefrom 2 August – 10 September and from 24 September – 3November).Theextendedgapsareinappropriateforaninexperienced worker.4.10.5The individual management review states that the content ofsupervision (as recorded) focused exclusively on the practicaltasks that needed to be undertaken. It notes that little attentionwas paid to exploring any potential risks or complexities in thecaseandthatthesupervisordidnotchallengethepositiveassessments made by the social worker. Both the social workerand her manager appear to have shared the same set of positiveassumptions about the potential for the mother to take on thecare of EY.4.10.6In addition the review of the chronology and the sequence ofdecisions and actions by the social worker in section 3 of thisreportsuggestsstronglythatthesupervisionwasalsonoteffective in ensuring that practical tasks were undertaken withinthe timescales agreed and required by the case. The evidencestrongly suggests that the social worker struggled to understandthe tasks that needed to be carried out. It is not clear if sheunderstood the legal advice that she had been given. It alsosuggests that she lacked the confidence to engage members ofthe family in the positive and constructive way that was necessaryor to challenge the mother’s delay in consulting her family. Theevidenceavailablestronglysuggeststhattheinputofhersupervisor failed to recognise and address these problems. Noevidence has been provided to indicate that the performance ofthe supervisor involved is satisfactory across the range of hisother tasks so it is not clear if this was an isolated episode.Family support service supervision and management1454.10.7Theevaluationwhichfollowsdrawsonthefindingsoftheindividual management review. This offers a very detailed andthoughtfulaccountofthearrangementsforsupervisionthatexisted in the family support service. In particular it has sought tounderstand the nature of the supervision provided within thechildren’s centre and between the centre coordinator and hermanager and the impact that this may have had on the capacity ofthe centre coordinator to pursue the concerns about bruising onEY.4.10.8The arrangements for supervision of the children’s centre workerare shaped by the nature of the service. The centre had one fulltime worker and one co-ordinator (working the equivalent of 4days per week). It is clear that the concerns about EY wereregularly discussed between the two members of staff either inweekly ‘team meetings’ or as they arose. Actions were agreed, atfirst for the worker to take in discussion with the mother and laterfor the centre coordinator to take forward to discussion with hersupervisor. The incidents of bruising to EY would have beenmentioned as part of a wide ranging discussion about all of thecentre’s activities and arrangements. So far as can be establishedthecentrecoordinatorhadinformationaboutallrelevantdevelopmentsandtookresponsibilityfordealingwiththem.However there were shortcomings in the actions that she took(which are identified in sections 3 and 4.3 of this report) and inthe action of her supervisor and her own line manager.4.10.9The Children Centres Programme Manager and the Children’sCentre Coordinator had experience of managing universal servicesor parent focused services rather than services which held caseresponsibility for individual vulnerable children. The managementdiscussions about EY reflect this experience. The Children’s CentreProgramme Manager was made aware of the concerns about EY inearly February (when a pattern of injuries had emerged). She andthe coordinator discussed the action that the centre coordinatorshould take twice during February 2010. Shortcomings in the146notes of her response make it impossible to know exactly whatactions were agreed. The Programme Manager was sufficientlyconcerned to follow up her instructions a few days later, but againshe made no detailed notes of the discussion and so it is not clearwhatfurtheractionswereagreed.Themanagementreviewrecognises that this was unsatisfactory and that in future seniormanagers in the service need to be trained to provide supervisiononindividualcaseswhichismoreakintothesafeguardingsupervision that is provided in health or social care4.10.10During the period when EY was being discussed action was beingtaken in the family support service to address the perceived underperformance of the centre coordinator. This had begun in August2010. As a result of this she was given notice in early March that aformalreviewofhercapabilityasamanagerwouldbeundertaken. On 9 March 2010 the centre coordinator resigned,giving two months’ notice. The individual management reviewnotes that the relationship between the centre coordinator and hermanager deteriorated as a result of the monitoring that was beingundertaken. It is suggested that this may have contributed to herfailure to have a further discussion about the injuries to EY after17 February. After the two discussions were held dealing with EYin early February there were no further discussions about EYbetweenthecentrecoordinatorandhermanagerafter17February. At a one to one meeting with the coordinator in earlyMarch the service manager did not take further steps to find outwhat had happened in relation to EY. This meeting focused almostexclusively on the overall management of the children’s centreservice and the transitional arrangements that needed to be madefollowing the coordinator’s resignation.4.10.11Althoughthecircumstancesdescribedareveryspecific,thisanalysis is valuable because it demonstrates that it is importantfor managers who are dealing with poor performance and widermanagement issues not to lose sight of concerns relating toindividual children’s cases while dealing with wider matters.1474.10.12Themanagementreviewmakesanumberofspecificrecommendationsinrelationtomanagementandsupervisionwhich the SCR endorses.Involvement of senior managers and professionals4.10.13The Programme Manager referred to in the preceding paragraphswas the only person more senior than a first line manager to knowabout the case. The case was not recognised as being one thatcarried any significant degree of risk and it should have beenadequatelymanagedthroughthenormalsupervisoryandmanagerial arrangements in agencies.Other action that may be required under agency management andhuman resources procedures4.10.14It is not the purpose of the SCR to evaluate the competency andconduct of individual staff members and professionals in the casehistory or to make recommendations in relation to this. However itis consistent with the functions of the LSCB to seek assurance thatagencies have taken appropriate action if they believe that there iscause for concern over the competency or conduct of individualswho have been involved. As part of the process of finalising theSCR the LSCB has therefore sought assurance from the employingagencies and commissioning bodies involved that they have takenanyactionthattheyconsidertoberelevantinrelationtoprofessional conduct, disciplinary or competency procedures inrelationtoindividualstaffandmanagersandindependentpractitioners who were involved in the case history.1484.11Organisational matters - the impact of resources, lack ofcapacity and other organisational issuesWere there organisational difficulties being experienced withinor between agencies? Were these due to lack of capacity in oneor more organisations?Was there an adequate number of staff in post? Did anyresourcing issues such as vacant posts or staff sickness havean impact on the case?Introduction4.11.1This section addresses four wider organisational matters that theSCR believes had an impact on the services provided to EY and hisfamily:the lack of resources in the health visiting service relative todemand for servicesthe arrangements for child health clinicsaspects of the development of children centre policyaspects of the organisational arrangements and capacity insocial care.These are reviewed in turn.Capacity in the health visiting service4.11.2The individual management review prepared by BECHS gives aclear account of the resource constraints affecting health visitingprovision. In January 2011 the average caseload of children underthe age of five per full time equivalent (FTE) health visitor post inthe service responsible for making provision for EY and OY was669. This figure is said to be typical of the service throughout theperiod under review by the SCR. This is 67% higher than theagreed government target for health visitor caseloads which is forcaseloads of 400 children per FTE health visitor. This was cited byLord Laming in his review of child protection services and wasadoptedbygovernmentfromstudiescarriedoutbytheCommunity Practitioners’ and Health Visitors’ Association. It istherefore to be treated not as an ‘ideal’ but a level consistent withgood professional standards of work. It is clearly a challengingtarget.1494.11.3Although there are regional and local variations the statistics forEastBerkshiremirrorthenationalpicture.Asallpostsarecurrently filled in the service this indicates that establishmentfigures have been set too low and caseload expectations too high.The management review reports that work is currently under wayin East Berkshire to revise the establishment and caseload figures.The service has a target to recruit an additional 36 whole timeequivalent health visitors which is designed to reduce caseloadnumbers to approximately 350 children under five years of age(per FTE). It is noted in the management review that at a nationallevel efforts to increase health visitor numbers have not met withsuccess.4.11.4It is very likely that in combination with other factors the capacityof the health visiting service had an impact on the quality ofprovision made in this case. Sections 3 and 4.3 above outline theshortcomings in service provision by health visiting staff. Thesecentreonthepoorassessmentsofneedandrisk,poorcommunicationofinformationandthefailuretorespondappropriately to potential indicators of risk. There can be no doubtat all that while other individual and case specific factors alsoappliedtheexcessiveworkloadofhealthvisitorswillhaveadversely affected practice. The management review recognisesthis stating that:‘should the health visiting teams (have) had caseload numberscloser to national recommendations, this would have allowed moretime for planned visits to the family, more time for reflection onthe case, more time for planning and more time for effectivecommunication between the teams’.4.11.5During its discussions the SCR panel has also recognised that highcaseloads can have other negative effects on the way in the healthvisitors are working with families and managing their work. Thechronology and management review highlights how many of themost significant communications in the case history were onlyrecorded by health visitors ‘in the health visitor’s work diary’150because many calls are received on mobile phones, children hadno records or because health visitors did not have the opportunitytorecordeventsinthechild’srecords.45Ifhealthvisitorshabituallyrecordimportantinformationinthiswayitwillsignificantlyincreasethelikelihoodofitnotbeingproperlyrecorded,accessedbycolleaguesandsharedwithothersappropriately.4.11.6The management review of health visiting provision explains thatchildren and families receive a health visiting service drawing onthe skills of different members of the health visiting team andattending child health clinics that may be staffed by any one of anumber of health visitors. This approach is commonplace and hasmuch to commend it. However the potential for a number ofdifferentpractitionerstobeinvolvedwithafamilyfurtherunderlines the need for comprehensive recording that is accessibleto all team members. The use of work diaries to record importantinformation is of greater concern given the team approach toservice delivery. The SCR will recommend that the trust reviewsits expectations of the recording practice of health visitors andgives clear instructions to health visitors as to how they use workdiaries for recording, taking full account of the practice of skillmixed team working.4.11.7It is striking that the health visitors involved in the case did notbelieve that their caseloads had negatively impacted on them. Themanagement review reports that:Each health visitor stated that they were in a position to offerextra input to the family and they were also in a position toprovide this extra input within their caseload …. This is why theydid not feel that capacity impacted on their evaluation of theservice they delivered to the family. (The mother) did not wish tohave extra services from the health visiting team; which is herprerogative. They would feel capacity is an issue if they have45 Key events include: the home visit made to the mother prior to EY moving to live with hismother; the referral of bruising by the GP and the clinic contact with EY the day before hishospital admission.151assessed a family as requiring extra input, but were not in aposition due to staffing levels to offer input to a family. (emphasisin original)This should give rise to heightened concern because the staffinvolved have not recognised that basic standards of assessmentand information sharing were not met. The lack of provision isattributed to the mother’s choice whereas in fact this has nobearingonthepoorqualityandlackofbreadthoftheassessments carried out, the failures to share information or thefailure to recognise indicators of risk. The individual managementreview indicates that action is under way to recruit additionalhealth visitors. It gives no indication of timescales, success or lackof it so far or future milestones. The management review makesno recommendation in relation to health visitor recruitment. Thismay be because the trust is satisfied with the progress that isbeing made. The issue of health visitor recruitment and standardsof practice is of great significance for safeguarding services. In thecircumstances the LSCB needs to be satisfied that it understandswhattheimpactoftheshortfallofhealthvisitorsisonsafeguarding services, the steps that the managing trust is takingto mitigate risk and the progress being made in recruitment. Arecommendation is made in relation to this.The trade off between accessibility and safety of services – childhealth clinics4.11.8EY was seen at a child health clinic the day before he wasadmitted to hospital with the injuries that caused his death. Theright course of action would have been for the health visitor torefer the child to local authority social care services because of thebruising that she observed. In seeking to understand why anexperienced and knowledgeable practitioner did not do this theSCR has considered the context in which this consultation tookplace.4.11.9The clinic setting is described in the management review asfollows:152Every health visitor will take it in turns to work at a clinic on a rotabasis. Health visitors may not have had any previous contact withparents attending clinics as parents are able to drop into any clinicacross the area; they may or may not be familiar with the familyhistory. With large numbers of families accessing some clinics, thecontact time with the health visiting staff may be reduced to 3-5minutes for face to face contact time. The health visitor may notbe privy to the family’s history or be familiar with otherprofessionals’ concerns because they only have access to thePHCR for information where limited information about thecircumstances of a family is recorded.’4.11.10Suchclinics(anumberofwhicharelocatedincommunitybuildingsratherthanhealthcentres)havebeendevelopedbecause they are an efficient way of using scarce health visitortime and because they are readily accessible to families. Theapproach has much to commend it but there is also a danger thatit may negatively impact on the service provided to vulnerablechildren. It is not that such services are not safe, but there arefeatures of the desire to make them as accessible as possible thatmayhavemadethemlesssafe.Thetradeoffbetweenaccessibility or efficiency and the safety of some aspects of theserviceiswellestablishedintheliteratureonaccidentinvestigation and it would be naïve to think that it might notequally apply in some measure to this form of health provision. 464.11.11In the circumstances the health trust should investigate howhealth visitors and other staff working in accessible outreachservices can be helped to offer a safer service to vulnerablechildrenandbeabletorecogniseunusualandconcerningpresentations. Aspects of the design and operation of the clinics,including access toinformation aboutfamilies and access tocolleagues should be considered and the staff who are involved inrunningthemshouldbecentrallyinvolvedindiscussions.46 David Woods et al, Behind Human Error, Ashgate (2010) second edition; Sidney Dekker,The Field Guide To Understanding Human Error, Ashgate (2006)153Discussions about the clinics should be linked to discussions aboutthe tools that health staff use at them such as the PCHR.4.11.12In addition staff in other agencies working with vulnerable childrenneed to understand better how these clinics operate. For examplethe practice of parents attending a clinic, weighing their own babyandcompletingthePCHR(withouthavingcontactwithaprofessional) might be the norm for health professionals but is notwell understood by many other professionals. Other professionalssuch as social workers could very easily assume that a child whosePCHR showed that he had been to a child health clinic had beenexamined by a professional. This might influence their decisionsand actions. It is essential that when service innovations inservices take place other professionals are kept up to date, even ifthe service involved does not consider them to be controversial.4.11.13Similar concerns apply to the role of the Access Officer in thesocial care referral and assessment service. Even though thisarrangement is reported to be a long standing one neither thechildren’s centre worker nor a number of SCR panel members andauthors of management reviews were aware of the roles andresponsibilities of the Access Officer in the referral and assessmentservice. The SCR makes recommendations in relation to both ofthese issues.The impact of the scope and pace of children’s centre developmenton the safety of services for vulnerable children4.11.14The section of this report on the skills and training of staff andmanagers has highlighted some shortcomings in the managementand oversight of the children’s centre attended by EY and hismother. The management review of family support services hasidentified that the very rapid scale and pace of children’s centredevelopment made the service more prone to these weaknesses.4.11.15The individual management review identifies that the scope andresponsibilities of the manager responsible for children’s centreswere substantial:154‘In addition to overseeing the entire programme (10 children’scentres), this role also directly line manages the four RBWMmanaged centres and until January 2011 was responsible for thecapital build programme for new Phase 3 centres. The failure tospecifically check and monitor policies and procedures within anRBWM managed centre would indicate that there was insufficientdifferentiation between the roles of directly line managing somecentres and performance managing others. The intense demandsof completing the capital build programme [for Children’s Centres– KI] during 2009-11 placed a very high level of demand on the(manager) that made it difficult to thoroughly manage thosecentres that were already open.4.11.16Thesafeguardingofvulnerablechildrenattendingchildren’scentres and the training of staff and designated professionals wasstated by government to be a priority for the centres. Howevergiven the scope and pace of the development that has taken placethere was always a potential for conflict between the objective ofrapidly developing highly accessible services and maintaining atight focus on the needs of individual vulnerable children. In thiscontext it is easier to understand that in one children’s centre thesafeguarding of a child was compromised because staff lackedsome of the requisite skills and training and the performancemanagement of this centre had not identified those weaknesses.4.11.17This is a significant issue because large numbers of children attendchildren’s centres and their focus is increasingly on vulnerablechildren.Thepotentialtensionbetweendevelopingeasilyaccessible services and safeguarding the most vulnerable childrenneeds to be addressed. The management review makes a series ofrelevant recommendations on the steps needed to ensure thatsafeguarding practice improves in children’s centres and the LSCBwill monitor progress in the implementation of these closely.155Capacity in the social work teams involved with the family4.11.18The management review of local authority social care provisionindicates that the referral and assessment team was experiencingproblems of capacity in early 2009 leading to decision not to notifyother agencies about the closure of the case after the initialassessment of OY. The SCR is satisfied through the informationprovided by Ofsted unannounced inspections of social care (whichfocus largely on these duty arrangements) that these problems ofcapacity no longer apply. Both published inspection feedbackletters identify improvements in the service since early 2009 andneither identifies priority actions that need to be taken by theauthority. 4747 http://www.ofsted.gov.uk/local-authorities/windsor-and-maidenhead1564.12DiversityWas practice sensitive to the racial, cultural, linguistic andreligious identity and any issues of disability of the child andfamily, and were they explored and recorded?4.12.1The potential significance of ethnicity, religion, disability in relationto the case history has been considered carefully in all of theindividual management reviews. EY’s mother and father and thechildren were recorded by all agencies as being of White UK origin.There was no record of any disability or any other informationpointing to possible social exclusion. With the exception of thechildren’s centre, professionals recorded no information about theeconomicstatusofthefamily,thoughhomevisitsbyallprofessionalsconfirmedthatthemotherandfatherwereeconomically comfortable.4.12.2GP records contain basic information about the ethnicity of themotherandthechildren.TheBECHSandHeatherwoodandWexhamParkHospitalsNHSFoundationTrustmanagementreviews comment on the lack of detailed background informationabout the family in the agencies’ records. This should be treatedas indicative of the lack of information about the family and theverylimitedassessmentsthatwerecarriedout,ratherthanrevealing anything specific about the assessment of diversity.4.12.3Thesocialcarereportdemonstratesthatinrelationtothepotential adoption of EY the parents were consulted as to theirviews about the sort of family that they wanted EY to be placed in.They reveal that the parents did not firmly hold or activelypractice any religious beliefs and broadly speaking wanted EY tobe in a family that bore some resemblance to the mother’s family.4.12.4The mother and children had most contact with staff at thechildren’s centre. Interviews with staff confirmed that ‘the familywere not observed to be in any financial distress. The childrenwereobservedas“nicelydressedandwithageappropriateclothes”andthemotherwaswellpresentedandpaidcloseattentiontoherappearance.Themothershowedstaff157photographs from her skiing holiday taken in February 2011’. Oneof the parenting workers described the mother as a ‘young,attractive, chatty girl’ who ‘perhaps did not need the Children’sCentre as much as others and was not necessarily looking for helpbut more of a social life’. The father and mother were both inemployment at the time of the birth of OY. It is not recorded inany agency record but it has been confirmed since the death of EYthat the maternal grandparents have a successful business.4.12.5This relative economic wellbeing in comparison to many familieswho need targeted support services or have a looked after child islikely to have been the most significant aspect of the family’scircumstances, so far as their interaction with professionals isconcerned. The review of family support services includes thespeculative, but perfectly plausible, comment that: ‘this financiallystable well presented image was a contributory factor in thechildren’scentre’sunderestimationoftheriskfactorsandvulnerability of the family and made it less likely that staff wouldbe suspicious of the information given’.4.12.6It is very possible that the same sort of factors may haveinfluenced the assessment of the social care staff and the positiveviews of the foster carer about the prospects for the successfulplacement of EY with his mother.4.12.7The social background of the family was another factor thatmarked this case out as being unusual because as has been notedabove none of the risk factors most commonly associated withchild death and serious child abuse were present.1584.13What do we learn from the case?Are there significant lessons for the way in which organisationswork individually and collectively to safeguard children?Key lessons for safeguarding practice4.13.1There are significant lessons for the way in which organisationswork to safeguard and promote the welfare of children. Thefollowing areas have been highlighted in this report and theindividual management reviews:staff in all agencies need to recognise the significance ofconcealed and denied pregnancy – including in unusual casessuch as this where the usual factors associated with concealedpregnancy (learning difficulty, drug misuse and mental illness)are absent. It is highly unusual for a mother to have twoconcealed pregnancies.the circumstances surrounding any concealed or deniedpregnancy need to be investigated in detail, including thepsychological and psychiatric status of the parentsthe new birth health assessment in relation to OY was verylimited and failed to take account of wider family factors thatmight have impacted on healththe initial social care assessments of OY were of limited value.The complexity of EY’s circumstances merited a coreassessment. Although there was no procedure to require this,professional judgement should have identified the case as acomplex one which merited a fuller assessment.involvement of the father and members of the extended familywas very limited in this case. Better engagement would haveadded to the assessment of risk and needprofessionals should not underestimate the risks associatedwith the re-unification of a child with parents after aconsiderable period of separation (or as in this case when aparent has never had responsibility for the child). Thedevelopmental needs of the individual child, the meaning forthe parents of the individual child and the child’s history of159attachment need to be evaluated in detail even when there isno obvious indication of risk.professionals in three different settings – the GP practice, thechildren’s centre and a child health clinic – did not comply withthe child protection procedures and the training that they hadreceived and did not report suspicious injuries to social care.Professionals need to have the skill and confidence to take theaction required to protect children when faced with confidentand convincing parents who are denying the harm done tochildrenthere was a lack of curiosity about scratches on the face of aninfant which should have been recognised as an unusual andpotentially concerning presentationif professionals are not sure that a referral to the localauthority is required then they must consider alternatives suchas referral for a paediatric opinion or taking advice from anamed professional or another more experienced colleague.the current system for the transfer of GP records is not fit forpurpose as it relates to the needs of vulnerable children. Itmay place some children at risk and the delays that arecommonplace mean that the service offered by GPs may beseriously impaired. Current arrangements make GPsprofessionally vulnerablethe coordination of health care for children who are dischargedfrom being looked after needs to be better coordinated and therole of the LAC health team should be reviewed to take thisinto account. All of the health professionals who will beinvolved with a child and its family need to be informed aboutthe relevant history and know which other professionals areinvolved with the childsome aspects of professional practice were made more difficultby the context in which professionals were required to workwith vulnerable children. When services – such as child healthclinics and children’s centres - are developed with a view to160maximising the accessibility of services to families, agenciesneed to ensure that staff and managers are trained andsupported so that they can continue to meet the needs ofvulnerable children who attend themnewly qualified social work staff dealing with children’s casesrequire a high level of supervision tailored to their individuallevel of competence, skill and knowledge.1615ConclusionsThis is a summative section that should comment on whetheragencies – individually or collectively - could have predicted thatEY was at risk of significant harm and whether his death couldhave been prevented. Is important to base this judgement onwhat was known (or should have been known) at the time ratherthan with the benefit of hindsight.Missed opportunities to identify the risk to EY and protect him5.1.1The professionals involved underestimated the complexity of thefamily circumstances because they did not understand the level ofconcernthatwasassociatedwiththemother’sdenialorconcealment of her two pregnancies.5.1.2When considering the rehabilitation of EY to his mother the localauthority made overly positive assumptions and paid insufficientattention to the negative features of the case history, such as thelong periods when EY’s mother did not visit him and had littleinterest in him.5.1.3There were no grounds to prevent EY returning to the care of hismother but the complexity of the background and the evidencethat the mother had little positive interest in EY indicated the needfor careful monitoring of his health and development and the carethat he was provided after his placement with his mother. Thereshould have been a coordinated child in need plan linked to asimilar plan for his health needs.5.1.4Four weeks after he moved to live with his mother professionalsnoted scratches on EY’s face. Four weeks after this, bruises werenoted on his face and head. EY’s mother usually stated that thesehadbeencausedbyhisolderbrotherorbyfalls.Someprofessionalsfoundtheexplanationsconvincingbutthesepresentations were highly suspicious. EY’s age and circumstancesmarked him out as being extremely vulnerable. The professionalsinvolved should have responded differently and they should havebeen reported to the local authority so that child protectionenquiries could be undertaken. At the very least professionals162should have taken advice from a member of staff or a professionaladvisor with expertise in child protection or referred EY for apaediatric assessment. There were two occasions on which healthprofessionalsmissedopportunitiestoprotectEYandseveraloccasions when he attended a children’s centre and both the staffand other mothers identified suspicious bruises.5.1.5When the children’s centre sought advice from the local authoritythe centre coordinator spoke to an unqualified member of staffwithout realising this. She was unhappy with the advice given, butdid not challenge it. The systems in place in the local authority forscreening calls were not clear to other professionals.5.1.6The post-mortem findings show that EY’s death was caused by avery serious head injury. He had numerous bruises on his face,head, chest, back and legs when he was brought to hospital veryseriously injured. EY had also suffered a number of fractures thatpredate his death by at least two weeks. It is not possible to datethese injuries more precisely so some or all of them may be olderthan this. However taking only the two week period before hesuffered the injuries that caused his death the agency records listthe following episodes in which he was examined or bruising wasnoted or discussed:2 March 2011 – two bruises and scratches observed on EY’sface at children’s centre14 March 2011 - EY was seen by a GP with a cold and cough.No detailed examination of his body would have taken placebut he was noted to be ‘alert, interacting and comfortable’ andotherwise well15 March 2011 – crèche workers at the children’s centrereported bruises to EY’s forehead and cheek. A crèche workerchecked his legs, back and chest and found no other bruises16 March 2011 - the mother and both children attended thechildren’s centre. Both children seemed poorly and EY waslethargic. It is not clear whether the bruises were observed163again. They may not have been recorded because they hadbeen recorded the day before.17 March 2011 the mother took EY and his brother to a childhealth clinic. The health visitor (HV7) examined him briefly andnoted two bruises on his cheek and forehead.5.1.7None of these incidents was reported to the local authority. If thathad happened or EY had been referred for a paediatric assessmentthe bruises would have been investigated. Given EY’s age andvulnerability it is very likely that a full child protection medicalexamination would have been undertaken. In the circumstancesthis would very likely have included a skeletal survey (an x-ray ofthe whole body). This would in turn have very likely identified theolder fracture injuries and this is likely to have led to action beingtaken to protect EY.5.1.8The conclusions of the SCR are that 1) over the long term therisks to EY were underestimated 2) when he moved to live with hismother he should have been closely monitored because of theconcerns about the circumstances of his birth and his mother’sfailure to visit him for long periods when he had been looked after3)inthetwoweeksbeforehisdeathprofessionalsmissedopportunities to intervene which, if they had been taken, are verylikely to have led to the detection of serious injuries and wouldprobably have prevented his death.1646RecommendationsOverview Report1.The LSCB should oversee the production of the proposed ‘pathway’ for themanagement by health professionals of bruising so as to ensure that it isconsistent with sound multi-agency child protection practice.2.BHFT should establish the quality of new birth assessments in a sample ofcases giving particular emphasis to the wider family, social andenvironmental issues that are highlighted in the national and localguidance.3.The LSCB should use ensure that agencies improve their engagement withfathers and other male carers in all aspects of child protection work.4.The LSCB should produce multi-agency guidance on the assessment andmanagement of need and risk where there has been a denied or concealedpregnancy.5.Health commissioners and provider trusts should review the current designand use of the PCHR.6.The local authority should ensure that all relevant staff are made familiarwith relevant research on reunification and are able to apply it.7.Health commissioners and provider trusts should ensure that professionalswho may be involved in the reunification of vulnerable children are awareof the complexity of reunification of looked after children so as tocontribute effectively to discussion and decision making.8.RBWM, BECHS and NHS should review the role of the looked after childrenhealth team to ensure that suitable health arrangements are made forchildren who are discharged from care as well as those who become or arecurrently looked after.9.a) The LSCB should make known the specific concerns about the impact ofthe slow transfer and summarising of GP records in this case to theDepartment of Health and ask it to take action to improve the system at anational level.b) The current standard for the transfer and summary of GP medicalrecords should be reviewed and a lower target time set should be set.c)NHS Berkshire should set challenging targets for electronic transfer ofpatient notes between GP practices in Berkshire. Progress should bereported regularly to senior managers in the NHS and as appropriate tothe LSCBd) Training and briefing sessions arising from this SCR should emphasisethe impact of this issue on children and the vulnerability of GPs who donot take steps to improve their systems for transferring andsummarising children’s records.10.BECHS should give clear guidance to health visitors on the use of workdiaries to record information about service users and contacts with otherprofessionals.11.BECHS should provide a full report of the current capacity of the healthvisiting service to the LSCB identifying implications for safeguarding andindicating the steps being taken to recruit health visitors and to mitigatethe impact of staff shortages.16512.BECHS should publicise the arrangements for its child health clinics toother professionals working with vulnerable children, including the practiceof self weighing.13.RBWM should publicise the role of Access Officer in the social care referraland assessment service to all other professionals working with vulnerablechildren.14.BECHS should review the current arrangements for child health clinics inthe light of the findings of the SCR.Health Overview Report - NHS Berkshire15.Providers of child protection training to staff in the health services acrossBerkshire must provide assurance to the Local Safeguarding ChildrenBoards and to NHS Berkshire that strategies are developed to evaluateand assess the impact of child protection training.16.BHFT must review the clinical supervision policy specific to child protectionto include the requirement for discussion about children born followingconcealment of a pregnancy and also children returned to their birthfamilies.17.Midwifery services should consider the implementation of clinicalsupervision specific to child protection for midwives.18.Training is commissioned to support health visitors to undertake fullyinformed risk assessments which follow with appropriate actions andidentified expected outcomes for children.19.Quality performance indicators to include a range of measures such asaudits of standards and outcomes for children must be developed by thePCT for all contracted health services, including GP services, to assure thePCT, as the current commissioners of health services, that robustmechanisms are in place to support health professionals in theidentification of families with vulnerable children and risks to the childrenare rigorously managed.20.The LAC Team in BHFT undertakes the self assessment tool offered byNICE Public Health Guidance 28 (2010) to benchmark the current healthservices for looked after children alongside the services offered byChildren’s Social Care.Berkshire Healthcare NHS Foundation Trust21.All key practitioners directly and indirectly involved in the IndividualManagement Review are debriefed and informed of the review findings.22.BHFT procedures will mirror updated LSCB pre-birth procedures andinclude specific information and action to take in the event of a23.All health visiting teams will be briefed about action take in the event ofobserved bruising on an infant.24.A pathway will be developed for specific action to take in the event of anobserved injury on a baby, infant or child.25.Health visiting teams will be briefed on current research and the potentialimpact concealed pregnancies may have on the welfare of children at theAnnual Safeguarding Forum November 2011.16626.Families in which a child has moved home following foster placement willbe targeted for extra intervention, including monitoring the child’s healthand development.27.Recommendations from this review will be incorporated within practiceguidance for health visitors and disseminated to health visiting teams.28.There will be a review of ‘flagging’ systems used within the Personal ChildHealth Record and a review of professional input at ‘self-weighing’ clinics.29.A pathway will be developed for the transfer of records between healthvisiting teams.30.The revised health visiting documentation will include recommendationsfrom the individual management reviewHeatherwood & Wexham Park Hospitals NHS Foundation Trust31.HWPHFT should review its policy and procedure to incorporatemanagement of concealed pregnancy.32.HWPHFT should review its current procedures on the information pathwaybetween maternity services and community practitioners to ensure it is fitfor purpose. This should include senior managers and practitioners acrossthe service.33.HWPHFT’s Safeguarding children training should emphases the importanceof information sharing with other agencies e.g. GPs, Health Visitors, LACNurse, Social Care together with good practice examples.34.HWPHFT’s record keeping standard should ensure that information ofinteraction between child, parent (s) and other family members; isincluded in the patient record.35.HWPHFT’s should review its process for disseminating information to otheragencies.36.HWPHFT should use a standard checklist form that should be completedfollowing postnatal discharge of clients; and implement a sign off proformachecklist for completion following postnatal discharge of clients.37.HWPHFT should amend the record keeping standard to ensure thatreferrals to the local authority and other agencies are noted in the patientrecord.Primary Care38.GPs should organise a formal mental health assessment of any womanwho conceals a pregnancy, unless referral to mental health services hasalready been made.39.The Designated and Named Professionals should review clinical guidelinesfor bruising in infancy, and distribute any revision to all primary carepractices.40.All primary care practices should put in place processes to ensure all newpatients’ records have been received into the practice within three monthsof registration with the practices.16741.Berkshire Shared Services should improve uptake of electronic transfer ofrecords with Berkshire through GP2GP transfer.42.Primary care practices should be encouraged to use a generic emailaccount to enable them to share concerns about children and families withhealth visitors.Children’s Social Care Services, Royal Borough of Windsor &Maidenhead43.Social Care will compile and disseminate local good practice guidance forthe staff, including the provision of training on concealed pregnancy andbirth.44.Social Care Services and partner agencies involved with children who arein-patients in health setting should agree a protocol to ensure thatappropriate services are invited/involved in discharge planningarrangements.45.Social care should ensure that all relevant agencies involved with childrenwho are discharged from the care of the Local Authority should be invitedto attend/actively involved in discharge planning arrangements.46.Social Care to ensure, as per regulations and guidance, that all childrenwho are Looked After by the Local Authority should have a comprehensiveCore Assessment.47.Social Care to ensure that internal referral systems in PARIS IntegratedChildren’s System are fully understood by managers, and implemented ina timely fashion.48.Social Care teams should ensure that formal letters, as per regulationsand guidance, are sent to key agencies informing them when social careinvolvement is ending.49.Social Care teams should ensure that, as per regulations and guidance, allchildren with Looked After status should be considered as a child in needwhen discharged from care for at least a three month period.50.Social Care and partner agencies will agree a step-up/step-down protocolconcerning the use of the CAF.51.Social Care Referral and Duty Team to establish written guidance for roleof Access Officer, particularly in relation to contact/ referral arrangements.52.Social Care to ensure that partner agencies are aware at the point ofcontact that the Access Officer in Referral and Duty Team is not a qualifiedsocial worker.53.Social Care to ensure that all aspects of learning regarding legal adviceand contact with extended family members, for children who may beadopted, is incorporated into local policy and practice.54.Social Care to ensure that case file and supervision recording policy andpractice is reviewed to ensure that case file recording is comprehensiveand contemporaneous.55.Protocol between social care and local CAFCASS service concerningnotifications for children relinquished for adoption to be established andimplemented.168Family Support Service, Royal Borough of Windsor & Maidenhead56.FSS standards of practice are developed clarifying which injuries in infantsshould trigger a referral to social care.57.Children’s centres review their record keeping template and processes forincidents/concerns.58.Clarification is provided for children’s centres on what to do if a member ofthe public raises safeguarding concerns about a child.59.The Parenting Team review their referral processes for early interventionparenting groups.60.Mechanisms to ensure greater oversight of children’s centres’ safeguardingpolicies are developed.61.The FSS Safeguarding Policy and Procedures is fully implemented acrossthe whole service.62.Recruitment and professional support for Children Centre Coordinators inRBWM managed children’s centres are reviewed.63.Training is provided for FSS managers on the role of supervision insafeguarding.64.Procedures for accessing Level 1 Safeguarding training are clarified andaudit processes strengthened.65.A standardised FSS induction process is implemented and monitored.169ADDITIONAL RECOMMENDATIONS MADE BY THE OVERVIEW REPORT AUTHORAND THE SERIOUS CASE REVIEW PANELWhy is a recommendationrequired?Recommendationmade toIntended impact –local or nationalRecommendation1.The response of professionals tobruising of an infant wasinadequate and led to failures toprotect EYLSCBBerkshireThe LSCB should oversee the productionof the proposed ‘pathway’ for themanagement by health professionals ofbruising so as to ensure that it isconsistent with sound multi-agency childprotection practice.2.The quality of the health visitornew birth assessment was poorin this case. Assessments of thehealth needs of infants in thecontext of wider familyfunctioning are a criticalopportunity to identify needs andrisks to children.BHFTEast BerkshireBHFT should establish the quality of newbirth assessments in a sample of casesgiving particular emphasis to the widerfamily, social and environmental issuesthat are highlighted in the national andlocal guidance.3.The father was not engaged fullyin the work by staff in anyagency. None of the professionalswho received information fromhim showed sufficient curiosityabout the needs of his childrenand the wider familycircumstancesLSCBWindsor andMaidenhead – allagenciesThe LSCB should use ensure that agenciesimprove their engagement with fathersand other male carers in all aspects ofchild protection work.4.The significance of two concealedpregnancies was underestimated.A number of agencies believethat their staff need moreguidanceLSCBWindsor andMaidenhead – allagenciesThe LSCB should produce multi-agencyguidance on the assessment andmanagement of need and risk where therehas been a denied or concealedpregnancy.170Why is a recommendationrequired?Recommendationmade toIntended impact –local or nationalRecommendation5.The design of the PCHR impairedthe easy access to importantinformation about the child’shistory.Doctors are believed not to makefull use of the PCHRAll health agenciesEast BerkshireHealth commissioners and provider trustsshould review the current design and useof the PCHR.6.The risks associated with the‘reunification’ of EY wereunderestimated by the localauthority and staff did not applyrelevant knowledge of this issueRBWMWindsor andMaidenheadThe local authority should ensure that allrelevant staff are made familiar withrelevant research on reunification and areable to apply it.7.There was no multi-agencyassessment of the risks of‘reunification’Healthcommissioners andprovider trustsBerkshireHealth commissioners and provider trustsshould ensure that professionals who maybe involved in the reunification ofvulnerable children are aware of thecomplexity of reunification of looked afterchildren so as to contribute effectively todiscussion and decision making.8.The LAC health team played noeffective role in the discharge ofEY to the care of his mother as itwas not part of the brief of theteam to do so.RBWM and BECHSWindsor andMaidenheadRBWM, BECHS and NHS should review therole of the looked after children healthteam to ensure that suitable healtharrangements are made for children whoare discharged from care as well as thosewho become or are currently looked after.9.The system for the transfer andsummary of GP records impairedthe practice in this case and isnot fit for purpose in relation tothe needs of vulnerable childrenDepartment ofHealthNational9 a) The LSCB should make known thespecific concerns about the impact of theslowtransferandsummarisingofGPrecords in this case to the Department ofHealthandaskittotakeactiontoimprove the system at a national levelNHS BerkshireBerkshire9 b) The current standard for the transferandsummaryofGPmedicalrecords171Why is a recommendationrequired?Recommendationmade toIntended impact –local or nationalRecommendationshould be reviewed and a lower targettime set should be set.NHS BerkshireBerkshire9 c) NHS Berkshire should set challengingtargets for electronic transfer of patientnotes between GP practices in Berkshire.Progress should be reported regularly toseniormanagersintheNHSandasappropriate to the LSCBLSCBWindsor andMaidenhead9 d) Training and briefing sessions arisingfromthisSCRshouldemphasisetheimpact of this issue on children and thevulnerability of GPs who do not take stepsto improve their systems for transferringand summarising children’s records.10.Many important contacts withBECHS staff were only orprimarily recorded in their ‘workdiaries’.BECHSEast BerkshireBECHS should give clear guidance tohealth visitors on the use of work diariesto record information about service usersand contacts with other professionals11.The issue of health visitorrecruitment and standards ofpractice is of great significancefor safeguarding services. In thecircumstances the LSCB needs tobe satisfied that it understandswhat the impact of the shortfallof health visitors is onsafeguarding services, the stepsthat the managing trust is takingto mitigate risk and the progressbeing made in recruitment.BECHSEast BerkshireBECHS should provide a full report of thecurrent capacity of the health visitingservice to the LSCB identifyingimplications for safeguarding andindicating the steps being taken to recruithealth visitors and to mitigate the impactof staff shortages12.The current arrangements forcommunity based child healthclinics (including self weighing)BECHSEast BerkshireBECHS should publicise the arrangementsforitschildhealthclinicstootherprofessionalsworkingwithvulnerable172Why is a recommendationrequired?Recommendationmade toIntended impact –local or nationalRecommendationneed to be understood by otherprofessionals working withvulnerable childrenchildren,includingthepracticeofselfweighing.13.The role of Access Officer in thesocial care referral andassessment service was poorlyunderstood.RBWMWindsor andMaidenheadRBWM should publicise the role of AccessOfficerinthesocialcarereferralandassessmentservicetoallotherprofessionalsworkingwithvulnerablechildren.14.The circumstances in which staffwere working in the health clinicin which EY and his family wereseen shortly before he wasseriously injured were notconducive to the identificationand assessment of risk tovulnerable children, particularlywhen taken in combination withthe current design and use of thePCHR.BECHSBerkshireBECHSshouldreviewthecurrentarrangements for child health clinics in thelight of the findings of the SCR.173Appendix ITerms of reference of SCRThe full terms of reference of the SCR are set out in a separate document. The focusof the SCR is as followsThe review will address all of the areas required by Working Together to SafeguardChildren – 2010. In addition it will focus on the following:1. Identify any historical information (prior to 1 July 2008) on the familymembers that may have impacted on the parenting capacity of the mother,GY, and father, PO;2. Establish the quality of assessment of circumstance relating to either andboth children and their family;3. Identify factors that helped or hindered the engagement with the family;4. Establish how well agencies identified and responded to children’s injuriesand other indicators of harm;5. Analyse the extent of, and professional understanding of, the support fromthe extended family;6. Establish what advice was given and what services were offered to theparents concerning adoption issues;7. Establish what risk factors in the family were known to agencies during theperiod under review;8. Establish whether staff and managers dealing with the family had therequisite skills, knowledge and experience to respond to the circumstancespresented by the family;9. Establish whether sufficient attention was given to issues relating thereunification of EY and his mother following the period when he was infoster care.The review will consider in detail relevant events from 1 July 2008, the perceivedstart of the pregnancy of the elder child and 18 March 2011 prior to theinvolvement of emergency service.The review will consider the circumstances of both children.174Appendix IISCR PANEL MEMBERSHIPAgencyDesignationDonald McPhail, ChairChair of LSCBNHS Berkshire EastDesignated PaediatricianRoyal Borough of Windsor andMaidenhead CouncilHead of Services to Children andYoung PeopleRoyal Borough of Windsor andMaidenhead CouncilHead of Safeguarding andSpecialist ServicesThames Valley PoliceDetective Chief InspectorThames Valley Probation TrustSenior Probation OfficerBHFT (Community Health Services)Assistant Director, Children’sServicesATTENDEES AT SOME OR ALL PANEL MEETINGSProfessional advisor to the panelLSCB Business ManagerDesignated Nurse Child Protection, NHSBerkshire.Health Overview Report AuthorAdministrationLSCB Secretary175Appendix IIIList of documents provided for the SCRIndividual Management ReviewsBerkshire East Community Health Services 49 (which provided thehealth visiting service)General Practice (covering the services provided by three GPpractices)Heatherwood and Wexham Park Hospitals NHS Foundation TrustRoyal Borough of Windsor and Maidenhead CounciloSafeguarding Services 48 (which provides local authoritychildren’s social care services)oServices for Families (which provides and commissionsChildren’s Centre services and other family services)Background reports on agency involvementSouth Central Ambulance ServiceCombined Legal Services (hosted by Reading Borough Council)48 This service is referred to as ‘children’s social care’ in the body of the report49 Berkshire East Community Health Services (BECHS) merged with Berkshire HealthcareTrust (BHFT) during the course of this review. References to BECHS and BHFT should betreated as synonymous in all documents related to this review.176Appendix IVAgencyEvaluation of the contribution made by the individual management reviews (IMR)to the findings of the SCR1.Berkshire EastCommunity HealthServicesThe IMR was prepared by the Named Nurse Team Lead Child Protection for the trust. Shewas not involved in the case and had no line management responsibility for the servicesprovided for the family. She has considerable experience as a child protection specialist. Thereport was authorised by the Managing Director Berkshire Healthcare NHS Foundation Trust- Community East.The IMR provides a very detailed account of the involvement of health visitors and thelooked after children health team. It makes a thorough appraisal of the strengths andweaknesses of the input of the services concerned. This IMR has enabled the SCR tounderstand the settings within which health visiting teams are working and the impact thatthis may have had on their work. The IMR also deals openly with the difficulties posed by thelarge caseloads of health visitorsThe recommendations of the IMR follow from the learning. The SCR overview report hasmade additional recommendations which go beyond those contained in the IMR because itwas able to locate the impact of shortcomings in the services provided by health visitors andthe LAC team within the wider context of the case history.The IMR makes clear how information was obtained from staff and records. The IMR statesthat ‘each health visitor had managerial presence at the interviews’. It is not entirely clearwhat this means, however the SCR author is concerned that this may not be the best way toenable professionals to participate fully and freely in process whose aim it to learn lessons. Itis suggested that the trust should review this process in the event that future IMRs arerequired.2.General PracticeThe IMR was prepared by the Named Doctor Child Protection Berkshire East PCT-Bracknelllocality. The author is also an experienced GP partner. The report is authorised by theMedical Director Berkshire PCTs Cluster. The author was not involved in the case and had noline management responsibility for the services provided for the family.The IMR provides a very detailed account of the contacts that a number of GPs had with the177AgencyEvaluation of the contribution made by the individual management reviews (IMR)to the findings of the SCRchildren and their parents. In particular there is a detailed account of the contact that theyounger child had with his GP in which bruises were identified. This has enabled the SCR tounderstand the circumstances in which this happened and the judgement that the GP made.It is clearly recognised that the findings of this report and those of the health overviewreport and the SCR overview report are in parts at odds with one another. The overviewreports are clear that this presentation should have been referred to the local authority or atleast for an urgent paediatric assessment. The IMR focuses on the perspective and normalworking practice of GPs and seeks to understand why it was that the GP acted as he did. Itrecognises that GPs are much more comfortable making referrals to medical colleagues thanto social care about bruised children. This is not what the procedures say should happen,however recognising this is absolutely vital learning for the LSCB. The IMR and the overviewreports all make recommendations, complementing one another, which address this issue.The different perspectives contained in the IMR and the overview reports complement oneanother and enable the SCR as a whole to understand the pressures that some healthprofessionals feel when considering the need to refer children to social care and how this canbe addressed in day to day working. This leads to recommendations in all of the reports forwork on a ‘bruising pathway’.The GP IMR also recognises that delays in transferring and summarising records had animportant impact on the case history. It is extremely helpful that this issue as beenhighlighted. In relation to this the recommendations of the SCR overview report go beyondthose made in the IMR, recognising the national context of this problem and the need tomake challenging recommendations to the NHS locally and nationally. This is understandablebecause it is only when an overview of this issue is available from the case history as awhole that its significance in the outcome of the case is apparent.3.Heatherwood andWexham ParkHospitals NHSFoundation TrustThe IMR was prepared by the Lead Named Nurse for Safeguarding Children for the Trust.The Lead Named Nurse had no direct or indirect involvement to the case or line managementresponsibility for the staff involved, and is thus independent from the case. The IMR isauthorised by the Director of Nursing.The IMR provides an account of the brief contact that the trust had with the children andparents. It is hampered by the fact that on in relation to the younger child contact was only178AgencyEvaluation of the contribution made by the individual management reviews (IMR)to the findings of the SCRvery brief and no postnatal records could be found.Unusually there were two concealed pregnancies which meant that the mother had noantenatal care. This would normally be the period in which midwives establish informationabout risk factors. The IMR identifies that staff identified the basic level of concern arisingfrom the concealment of pregnancies and made appropriate referrals to the local authority inrelation to both children. Beyond this however midwives played very little role in activelyassessing the circumstances in any depth, for example the reasons for the denial orconcealment of pregnancy. There were shortcomings in the information shared with otherhealth professionals.These findings are reflected in wide ranging recommendations made by the IMR aboutrecording and the entire information pathway between antenatal services and communityhealth services.4.Royal Borough ofWindsor andMaidenhead CouncilServices for FamiliesThe IMR was prepared by the Family Support Manager. The author had had no contact withthe family and no direct involvement in this case during the timeframe covered by thisreview. However she manages a large service area within the local authority which includesthe Children’s Centre programme and the Parenting Team. She has also had someinvolvement in human resources procedures in relation to staff who feature in this review. Assuch the author is not independent of the line management of the case, though she is in asenior position with a degree of distance from the events under review.The SCR Panel and the independent author were aware of this once the first draft of thereport had been prepared and aware of the potential for there to be a conflict of interests.However the SCR panel and the independent overview report author are of the view that thereport is a frank and insightful one which has not been compromised by the position of theauthor in the local authority management structure. In the view of the panel and theindependent SCR author the report fulfils the requirements of Working Together because itlooks ‘openly and critically at individual and organisational practice and at the context withinwhich people were working to see whether the case indicates that improvements could andshould be made and, if so, to identify how those changes can be brought about’ (paragraph8.34). The report has been closely scrutinised both within the SCR process and within thelocal authority to ensure that it meets the requirements of objectivity.179AgencyEvaluation of the contribution made by the individual management reviews (IMR)to the findings of the SCRThe findings of the review have been of great value to the SCR. The review has describedand analysed practice and service provision at a detailed and ‘micro’ level carefullyreconstructing through interviews and records the events under consideration. This is aconsiderable strength because it has enabled the SCR to understand how – in the day to dayworking of staff in the children’s centre – opportunities to refer the child were missed.However it also offers strategic oversight of the way in which the children’s centre servicehas been developed and scope of responsibility of middle managers in the service and theculture of management in the service. There are some particularly valuable insights such asfor example how the focus on performance management led to individual cases not beingdealt with properly in supervision. The report proposes detailed solutions to the problemsidentified in the recommendations that are made. It is likely that the detailed workingknowledge brought to bear on the analysis has outweighed any disadvantages that arisefrom being part of the service that is being scrutinised.5.Royal Borough ofWindsor andMaidenhead CouncilSafeguarding ServicesThe IMR was prepared by the Safeguarding Service Manager who is responsible for QualityAssurance, Development, and Planning. The author was not involved in the case and had noline management responsibility for the services provided for the family. The review wasauthorised by the Head of Safeguarding and Specialist Services.The IMR provides an account of the involvement of the local authority safeguarding servicewith both of the children and their parents. It identifies the key decisions and actions of thesocial care staff involved and the underlying rationale for them. Through interviews with staffand review of records the IMR identifies the key belief of local authority staff. This was that itwould be a good outcome to the case if the younger child were to be returned to the care ofhis mother. The IMR identifies how local authority staff did not recognise the manyconcerning factors in the case history pointing to the mother’s lack of interest in her youngerchild. It demonstrates clearly the need for a child in need plan to support and monitor thechild when he was placed in the care of his mother.180Appendix VPolicy and research referencesResearch and resources referred toBrandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, andBlack J (2007) Analysing child deaths and serious cases through abuse andneglect: what can we learn? A biennial analysis of serious case reviews 2003-2005. DfESBrandon et al, (2009), Understanding Serious Case Reviews and their Impacta Biennial Analysis of Serious Case Reviews 2005-07 DCSFCox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnataldepression: Development of the 10 item Edinburgh Postnatal DepressionScale. British Journal of Psychiatry, 150, 782-786.Sidney Dekker, The Field Guide To Understanding Human Error, Ashgate(2006)Department of Health (2010) Healthy Child Programme- Pregnancy and theFirst Five Years of Life.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118525.pdfFarmer, E., Sturgess, W., and O’Neill, T (2008) ‘Reunification of looked-afterchildren with their parents: Patterns, Interventions and Outcomes”, ResearchBrief for DCSF, October 2008. (University of Bristol)Friedman, Henegan and Rosenthal, (2007) ‘Characteristics of women whodeny or conceal pregnancy’ Psychosomatics, 48.2 March – April 2007NICE (2010) Promoting the Quality of Life of Looked after children and youngpeople, NICE / SCIE public health guidance No 28P Reder, S Duncan and M Gray, (1993) Beyond Blame – Child AbuseTragedies Revisited, Routledge.Unannounced inspection reports on RBWM http://www.ofsted.gov.uk/local-authorities/windsor-and-maidenheadDavid Woods et al, Behind Human Error, Ashgate (2010) second edition;Procedures and process governing the conduct of the Serious CaseReviewHM Government, Working Together to Safeguard Children – 2010.Berkshire Child Protection Procedureshttp://berks.proceduresonline.com/chapters/p_ser_case_rev.html181Appendix VIEdinburgh Depression Scale(or Edinburgh Postnatal Depression Scale)DATE COMPLETED_____________As you have recently had a baby, we would like to know how you are feeling.Please CIRCLE the number next to the answer which comes closest to how youhave felt IN THE PAST 7 DAYS, not just how you feel today.IN THE PAST 7 DAYS1. I have been able to laugh and see thefunny side of things.0 As much as I always could.1 Not quite so much now.2 Definitely not so much now.3 Not at all.2. I have looked forward with enjoyment tothings.0 As much as I ever did.1 Rather less than I used to.2 Definitely less than I used to.3 Hardly at all.3. I have blamed myself unnecessarily whenthings went wrong.3 Yes, most of the time.2 Yes, some of the time.1 Not very often.0 No, never.4. I have been anxious or worried for no goodreason.0 No not at all.1 Hardly ever.2 Yes, sometimes.3 Yes, very often.5. I have felt scared or panicky for no verygood reason.3 Yes, quite a lot.2 Yes, sometimes.1 No, Not much.0 No, not at all.182IN THE PAST 7 DAYS6. Things have been getting on top of me.3 Yes, most of the time I haven'tbeen able to cope at all.2 Yes, sometimes I haven't beencoping as well as usual.1 No, most of the time I havecoped quite well.0 No, I have been coping as wellas ever.7. I have been so unhappy that I have haddifficulty sleeping.3 Yes, most of the time.2 Yes, sometimes.1 Not very often.0 No, not at all.8. I have felt sad or miserable.3 Yes, most of the time.2 Yes, quite often.1 Not very often.0 No, not at all.9. I have been so unhappy that I have beencrying.3 Yes, most of the time.2 Yes, quite often.1 Only occasionally.0 No, never.10. The thought of harming myself hasoccurred to me.3 Yes, quite often.2 Sometimes.1 Hardly ever.0 Never.183Scoring and Other InformationResponse categories are scored 0, 1, 2, and 3 according to increased severity of thesymptom.Items 3, 5-10 are reverse scored (i.e., 3, 2, 1, and 0). The total score is calculated byadding together the scores for each of the ten items. Users may reproduce the scalewithout further permission providing they respect copyright (which remains with the BritishJournal of Psychiatry) quoting the names of the authors, the title and the source of thepaper in all reproduced copies.The Edinburgh Postnatal Depression Scale (EPDS) has been developed to assist primarycare health professionals to detect mothers suffering from postnatal depression; adistressing disorder more prolonged than the "blues" (which occur in the first week afterdelivery) but less severe than puerperal psychosis.Previous studies have shown that postnatal depression affects at least 10% of women andthat many depressed mothers remain untreated. These mothers may cope with their babyand with household tasks, but their enjoyment of life is seriously affected and it is possiblethat there are long term effects on the family.The EPDS was developed at health centres in Livingston and Edinburgh. It consists of tenshort statements. The mother underlines which of the four possible responses is closest tohow she has been feeling during the past week. Most mothers complete the scale withoutdifficulty in less than 5 minutes.The validation study showed that mothers who scored above a threshold 12/13 were likelyto be suffering from a depressive illness of varying severity. Nevertheless the EPDS scoreshould not override clinical judgement. A careful clinical assessment should be carried outto confirm the diagnosis. The scale indicates how the mother has felt during the previousweek, and in doubtful cases it may be usefully repeated after 2 weeks. The scale will notdetect mothers with anxiety neuroses, phobias or personality disorders.Instructions for users1. The mother is asked to underline the response which comes closest to how she hasbeen feeling in the previous 7 days.2. All ten items must be completed.3. Care should be taken to avoid the possibility of the mother discussing her answers withothers.4. The mother should complete the scale herself, unless she has limited English or hasdifficulty with reading.5. The EPDS may be used at 6-8 weeks to screen postnatal women. The child healthclinic, postnatal check-up or a home visit may provide suitable opportunities for itscompletion.Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression:Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal ofPsychiatry, 150, 782-786.184Appendix VIIHeight and weight chart from Personal Child Health Record of EY19 November – EY moved to live with motherAll previous weights on 75th centile30 November 2010 Child health clinic 8.9KgAge 32 weeks 75th centile19 January 2011 GP developmental check 9.0 KgAge 38 weeks mid point 50th – 75th centile17 March 2011 Child health clinic 9.0KgAge 47 weeks mid point 25th – 50th centileIt is important to note that this is a substantially enlarged version of part ofthe original document185Appendix VIIIBerkshire combined safeguarding proceduresSection 4.6 on ‘bruising’ - current at January 2011Children can have accidental bruising, but the following must be considered as highlysuspicious of a non accidental injury unless there is an adequate explanation provided andexperienced medical opinion sought:Any bruising or other soft tissue injury to a pre-crawling or pre-walking infant or nonmobile disabled childBruising in or around the mouth, particularly in small babies which may indicate forcefeeding2 simultaneous bruised eyes, without bruising to the forehead, (rarely accidental,though a single bruised eye can be accidental or abusive)Repeated or multiple bruising on the head or on sites unlikely to be injuredaccidentally e.g. the backThe outline of an object used e.g. belt marks, hand prints or a hair brush (a pinchcauses small double bruises, a punch or kick causes an irregular bruise with a palercentre, gripping causes ovals from fingertips or lines between fingers)Linear pink marks, haemorrhages or pale scars may be caused by ligature, especiallyat wrists, ankles, neck, male genitaliaBruising or tears around, or behind, the earlobe/s indicating injury by pulling or twistingor slappingBruising around the faceBroken teeth and mouth injuries (a torn frenulum - the flap of tissue in the midlineunder the upper lip - is highly suspicious in non-mobile children, but frequently occursaccidentally in mobile children)Grasp marks on small childrenBruising on the arms, buttocks and thighs may be an indicator of sexual abuse |
NC043782 | Serious injury of a 5-month-old baby boy in December 2011. Injuries are likely to impact on Child H's long term development. Medical report concluded that Child H was subjected to an escalating pattern of physical abuse thought to have occurred within 10 days of the incident. Mother and father were both arrested on suspicion of causing grievous bodily harm; neither were ultimately prosecuted due to insufficient evidence. History of: paternal and maternal excessive drinking; acrimonious separation; conflict in the parental relationship; father's previous prison sentence for violent assault; and regular admittance of Child H to hospital, including six overnight stays. Issues identified include: irregularity in Child H's care and lack of opportunity for one consistent carer to develop a close attachment with him or to understand his developing needs; insufficient attention paid to the impact of parents' backgrounds on their parenting capacity; and lack of attention paid to issues of cultural identity and its potential impact on both parents and their parenting. Recommendations include: review of teenage pregnancy policy, focusing on the role of the Common Assessment Framework; and training for staff across agencies, to ensure that the racial and cultural needs of families are met.
| Title: Serious case review: overview report: re Child H: born July 2011: significant injury: late December 2011 LSCB: Wiltshire Safeguarding Children Board Author: Ron Lock Date of publication: [2013] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review OVERVIEW REPORT Re Child H Born July 2011 Significant injury: Late December2011 Independent Chair – Prity Patel Independent Overview Report Author – Ron Lock September2012 2 Content Introduction 1.1 – 1.8 Page 3 Terms of Reference 2.1 – 2.9 Page 5 Genogram Page 12 The Facts: - Background Information 3.1 – 3.4 Page 13 - Period of Review 3.5– 3.53 Page 14 The Children’s Experience 4.1 – 4.4 Page 21 Analysis: Extent of knowledge of background information 5.1 – 5.10 Page 21 Antenatal and post natal care 6.1 – 6.14 Page 24Assessment activity 7.1 – 7.30 Page 28 Understanding of thresholds 8.1 – 8.8 Page 35 Sensitivity to child’s needs 9.1 – 9.3 Page 36 Communication and information sharing 10.1 – 10.8 Page 37 Race and Culture 11.1 – 11.2 Page 39 Management/Supervision 12.1 – 12.5 Page 40 Organisational issues 13.1 – 13.5 Page 41 - Lessons Learned 14.1 – 14.11 Page 42 - Recommendations 15.1 – 15.8 Page 43 3 Introduction 1.1 This Serious Case Review relates to the circumstances which led an infant, aged 5 months (who will be referred to as Child H in this report) to receive significant injuries which were thought to be the result of abuse. The medical report considered that Child H had “been subject to an escalating pattern of non-accidental injury” and the range of injuries were thought to have occurred sometime within the preceding ten days. Both the father and the mother were arrested on suspicion of causing grievous bodily harm and Child H was placed in Local Authority care following the need for surgery to deal with his injuries.Ultimately the Crown Prosecution Service (CPS) considered that there was insufficient evidence to support a criminal prosecution of either parent in respect of the injuries to their child. 1.2 As a pregnant teenager, the mother lived in a supported housing project (mother and baby unit) and she was discharged back to live there with Child H following his birth. The father who was a little older than the mother, lived elsewhere. Following disagreements between the parents over the care of Child H, the father became the main carer for their baby by the time Child H was approximately 6 weeks old,using the support of a member of the extended family to help care for his baby. This arrangement was supported by Children’s Social Care (CSC) and the Police at the time. 1.3 Prior to the eventual significant injuries to Child H, whilst his father was the primary carer, he was taken to hospital on several occasions because of medical concerns, firstly about breathing issues, then regarding vomiting blood and on a further occasion because of a bruise behind the ear. Whilst some concerns were raised because explanations did not always fully match the presentation of Child H, these were not considered to relate clearly to child protection concerns. During the time that the father was the main carer for Child H, a Core Assessment had considered him to be a competent father and that should Child H be returned to his mother, that child protection procedures would be put in place. 1.4 Because the serious nature of Child H’s eventual injuries were very likely to be the result of abusive care and have an impact on his long term development, and additionally because there were a number of agencies involved in providing services to the parents and their child, the Wiltshire Local Safeguarding Children Board (LSCB) decided that this case met the criteria for a Serious Case Review (SCR) to be undertaken. 1.5 The criteria, established in relevant government guidance, states that an LSCB should consider whether to conduct a SCR whenever “a child sustains a potentially life threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect; and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children.”1 1.6 The purposes of this Serious Case Review reflects the relevant government guidance to: - 1 Paragraph 8.11, Working Together to Safeguard Children – Dept. for Children, Schools and Families, March 2010 4 - Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; - Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and - Improve intra and inter-agency working to better safeguard and promote the welfare of children.2 1.7 In order to undertake the SCR,each agency that had some direct involvement with the childand his family was required to undertake an Individual Management Review (IMR) to look openly and critically at its practice in relation to their involvement with the family. In undertaking this, each agency was also required to produce a chronology of its contact with the family. The managers/officers conducting the IMRs did not at the time immediately line-manage the practitioners involved and were not directly concerned with the services provided for the Child H or his family. 1.8 Senior representatives from relevant organisations in Wiltshire were brought together to form a SCR Panel in order to review and analyse the material from the IMRs. An independent safeguarding consultant with a professional background as a child care lawyer, Prity Patel, was commissioned to be the chair of the SCR, and Ron Lock, an independent safeguarding consultant with extensive professional experience in safeguarding children and young people, was commissioned to detail the analysis and findings from this SCR and complete the Overview Report. _____________________________________________________________________ 2 Paragraph 8.5, Working Together to Safeguard Children – Dept. for Children, Schools and Families, March 2010 5 Terms of Reference 2.1 Time Period 2.1.1 The time covered by this SCR includes the period of time from when the antenatal services provided to the mother up until Child H being placed in foster care following his injuries. 2.2 Agencies required to provide Individual Management Reviews Wiltshire Council - Children’s Social Care Wiltshire Council - Schools and Learning General Medical Practice Sirona Care and Community Child Health Royal United Hospital Bath NHS Trust University Hospitals Bristol NHSF Trust Wiltshire Police Great Western Hospitals Foundation NHS Trust – Midwifery services Great Western Hospitals Foundation NHS Trust – Children and Young People’s Community Health Services Greensquare Group/Spitz Support Service 4Children Wiltshire Probation Trust Wiltshire Council - Integrated Youth Services Wiltshire Council - Housing Options and Homes 4 Wiltshire Additionally the South West Ambulance Trust were contacted for information although there was no significant involvement to require an IMR to be undertaken. 2.3 The Serious Case Review Panel 2.3.1 The SCR Panel included the following: - - The Designated Nurse, Safeguarding Children - (NHS BaNES/Wiltshire) - Head of Service, Community Safeguarding - Wiltshire Children’s Social Care -Detective Inspector, Public Protection Unit - Wiltshire Police - Designated Doctor, Safeguarding Children - Sirona Care and Community Child Health - Head of Strategic Housing - Head of Service - Early Years and Childcare, Wiltshire Council - Assistant Chief Executive - Wiltshire Probation Trust - Virtual School Head Teacher – Wiltshire Council - LSCB Development Manager Business and Administrative Support: - - LSCB Business Manager - LSCB Administrative Assistant 2.3.2 All the Panel meetings were chaired by Prity Patel, an independent safeguarding consultant, and the independent overview report author was in attendance at all of the panel meetings. 6 2.4 Independence 2.4.1 All authors of the IMRs were independent of the services delivered to the family and the details of their independence were clarified in each of the IMRs. 2.4.2 The chairperson of the SCR Panel was independent of all professional agencies in Wiltshire and her background is as a child care lawyer, and as an independent consultant. Her previous work has included involvement in SCRs either as the chair or overview author but had not done so previously in Wiltshire. 2.4.3 The overview report writer was independent of all professional agencies in Wiltshire and had been the author of a previous SCR in Wiltshire. His background as an independent safeguarding consultant has included involvement in numerous SCRs either as author or chair. 2.5 Terms of Reference for the SCR to consider Specific Issues: - A1: Consider what relevant information was known to agencies about the background of the two young parents and whether this should have indicated that they would be likely to require additional support in caring for their first baby A2: Was the level of both ante and post natal care provided appropriate and sufficient to meet the needs of the parents and their new baby, were any risk factors noted? A3: What was the effectiveness of the interagency response to Child H’s admission to hospital in October 2011and injuries sustained in November 2011? A4: Is there a thorough understanding of thresholds and safeguarding responsibilities both intra and inter agency? General Safeguarding Issues B1: Were practitioners sensitive to the needs of the children in their work, knowledgeable about potential indicators of abuse or neglect, and about what to do if they had concerns about a child? B2: Did the agency have in place policies and procedures for safeguarding children and acting on concerns about their welfare? B3: What were the key relevant points/ opportunities for assessing risk and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in a timely, informed and professional way? B4: Did action accord with the assessments of risk and decisions made? Were appropriate services offered/ provided, or relevant enquiries made, in the light of assessments? 7 B5: Where relevant, were appropriate child protection or care plans in place, and child protection and/ or looked after reviewing processes complied with? B6: When, and in what was the Child’s lived experience, their wishes and feelings ascertained and considered? Was this information recorded? B7 Were more senior managers, or other agencies and professionals, involved at points where they should have been? B8: Was the work in this case consistent with agency, LSCB and South West Child Protection policy and procedures for safeguarding children, and wider professional standards? B9: Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded? B10: Were there any issues in communication, information sharing or service delivery between those working office hours and those providing out of hours services? B11: Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Were there staffing or resource issues? B12: Was there sufficient management accountability for decision making? 2.6 Methodology/SCR process 2.6.1 There were five SCR Panel meetings overall from April – August 2012, although there was an additional briefing meeting for the IMR authors as well as a workshop to provide support and advice once IMR authors had begun their work. 2.6.2 The completed IMRs were presented to the SCR Panel by their respective authors over two meeting days on the 7th and 15th June 2012 and the deadline for completion of the final drafts was 29th June 2012. 2.6.3 The first draft of the Overview Report was considered at the Panel meeting on the 6th July 2012 and the second draft on the 6th August 2012, by which time a draft Executive Summary and the Health Overview Report had been produced and were reviewed. Each panel member had taken responsibility to provide the final quality assurance of particular IMR reports and these were reviewed alongside the quality assurance by the Panel of the action plans. The final presentation to the LSCB of the Overview Report and Action Plans took place on the 7th September 2012. Following discussion at the LSCB meeting, the Overview Report was further revised for completion by the 21st September 2012. 2.7 Parallel processes 2.7.1 During the SCR process, Police investigations were continuing in terms of endeavouring to identify who had caused the injuries to Child H, and evidence was provided to the CPS in respect of these investigations. By the end of the SCR process,the SCR Panel was informed 8 that the CPS had decided not to pursue criminal proceedings in respect of either parent. Whilst the SCR Panel were kept up to date with any progress in respect of criminal investigations, these did not have any impact on the work of the SCR Panel or compromise the process. 2.7.2 Whilst care proceedings were being undertaken in respect of the child, these did not have any impact in respect of the SCR process. 2.8 Involvement of the family in the process 2.8.1 Family members were informed of the SCR and given literature explaining the process and were also formally invited to attend. The LSCB Development manager met with the parents separately to explain the process and to encourage them to contribute. Additionally a member of the extended family, who had periods of time caring for Child H, was invited to contribute to the process. Although separate meetings were arranged on neutral premises for the parents and the aunt, it was only the mother who attended her meeting. Her contributions to the SCR have been included within the content of the report. 2.9 Individual Management Reviews 2.9.1 All of the Health IMRs have been reviewed by the Health Overview Report author and are included in her report and so this section will not include any analysis of these. The Health Overview Report author has made additional recommendations for each health IMR and these will be forwarded to the respective health organisations for their consideration for further action. Therefore their own IMR recommendations will remain as those which will be subject to Action Plans and to the scrutiny of their management and the LSCB regarding their completion. Wiltshire Council (Children’s Social Care) 2.9.2 This IMR is well structured in terms of the factual aspects of the case and is explicit within the analysis of some of the failings of practice that occurred in this case. This was especially so in respect of poor quality assessments which did not identify key risk factors, and a failure to prioritise the needs of Child H by social workers. No reasons are given why there is no genogram as part of the IMR whereas the family relationships are quite complicated with the involvement of some extended family in the care of Child H, which would have benefited from the development of a genogram. 2.9.3 There is some acknowledgement within the report of some organisational issues which may have impacted on the operational practice within the case which gives some understanding of why practice did not reach the required standards at certain times. Whilst the lessons learned are contained within the body of the report rather than being explicitly stated, the recommendations do reflect what needs to change in the future. Wiltshire Council – (Schools and Learning) 2.9.4 This IMR reflects the education history of both parents and gave some very useful background information about their upbringing and childhoods. There was less of a 9 requirement to analyse the professional practice within the schools and education welfare services because it predated the time frame covered by this SCR. Some useful recommendations were nevertheless made to improve recording processes and how to track vulnerable children. Wiltshire Police 2.9.5 This IMR provides detailed information about Police involvement with this family and gives useful analysis of the Police interventions. The Police had full information about the father’s history of criminal convictions for assault and did share this with Children’s Social Care (CSC) although the IMR does identify how there were gaps in respect of multi-agency information sharing which did not support efficient decision making within the Strategy Meetings held. A separate Genogram was supplied separately by the Police to support the work of the SCR Panel but is not included in the IMR 2.9.6 The recommendations relate specifically to the learning identified within the IMR and importantly relate to information sharing processes, additionally proposing a move to co-located premises with CSC. Although there is a Police IMR recommendation to improve Strategy Meetings, this is also a recommendation for this Overview Report. Greensquare Group/Spitz Support Service 2.9.7 This IMR reflects the work of the mother and baby unit who provided the supported accommodation for the mother when she was pregnant and then again for her and the baby following Child H’s birth. The report does not contain a genogram and may well reflect the service’s lack of knowledge about the extended family. The report does appropriately highlight how practice could have been improved on occasions, and in particular of the need for greater risk assessment processes. Some areas of new practice are helpfully highlighted 2.9.8 In many respects the recommendations reflect a need to review basic safeguarding practice and improve these when necessary. It is apparent that the experiences of the mother and baby unit in respect of this case have generated some useful learning opportunities for the service. 4Children 2.9.9 This IMR reflects the involvement of the local Children’s Centre in the provision of some support services to the family. This involvement was not a consistent one although outreach workers were involved with the family at some key events. Some gaps are identified in taking action at appropriate times whereas some positives were identified in the purposeful information sharing by staff and the keenness to involve other agencies. Again there is no Genogram included in the IMR. 2.9.10 The recommendations appropriately reflect the IMR’s learning in the case which primarily focus on the work of outreach workers and of improving internal recording practice, (importantly in capturing the child’s voice) and in terms of the interface with external agencies. 10 Wiltshire Probation Trust 2.9.11 Probation’s involvement was prior to the time period for the SCR although their work with the father gives some useful background information in terms of the father’s offences and his response to Probation supervision. Whilst the IMR identifies some very good practice in their work with the father as a young man, there is a question raised about the inappropriate use of the Multi Agency Public Protection Arrangements (MAPPA) although this would not have made any realistic difference to later events in the case. Recommendations are appropriately made although the impact these will have on the service is less clear. Integrated Youth Services 2.9.12 This IMR reflects the mother’s involvement with Connexions, the Host Family scheme and on one occasion with the Teenage Pregnancy Coordinator. Despite this only amounting to limited direct involvement, some useful analysis is nevertheless provided in terms of professionals only focussing on the “here and now” rather than considering the broader context of the family. The Youth Offending Service did not have any contact with the father due to the low level disposals in terms of the offences. 2.9.13 Some useful recommendations have been made to try to address some of the key areas of early help which could have been improved in this case i.e. the use of the Common Assessment Framework and in terms of the Team around the Child processes. Wiltshire Council - Housing Options and Homes 4 Wiltshire 2.9.14 This IMR reflects some good detailed analysis of contact and meetings with the parents although they did not provide housing services directly to the family. Despite the limited involvement, some learning has emerged and an innovative recommendation about wanting to shadow other agencies is made in order to attempt to improve shared understanding of the practice of colleagues. Health Overview Report 2.9.15 This report is a thorough piece of work in bringing together the analysis across the health agencies and raises some additional areas of analysis based on the broad knowledge of health practice by the author and on further examination of some of the health records. To some extent this has extended what was known at the outset of the SCR and added to information not otherwise included in the Overview Report. 2.9.16 Key areas of analysis reflect that health professionals did not appear to have a clear understanding of multi-agency thresholds for intervention and that there was generally an over optimistic view of the parenting abilities which remained throughout the work with the family, and with the father particularly. In fact it is identified that there was insufficient assessments undertaken. The Health report also comments on the inconsistencies of the Strategy Meetings from the health perspective – this is taken further by recommendations within this Overview Report. 11 2.9.17 Apart from new recommendations made to each of the Health agencies, this report makes separate recommendations which generally relate to the broader dissemination of the learning from the case and how these need to feed into commissioning and contractual arrangements as well as future health governance structures. Genograms 2.9.18 There is a lack of genograms being provided by the majority of the IMRs which tends to reflect the lack of detailed knowledge held by agencies about the extended families of the parents. Nevertheless the IMR authors should still have provided a genogram even if very limited information is known. For future reference the LSCB’s SCR sub group will need to reinforce to agencies in future SCRs of the importance and value of always including a genogram of the agency’s understanding of family relationships in respective IMRs. _____________________________________________________________________ 12 13 Genogram A paternal aunt provided much support to the father in the care of Child H Maternal aunts did provide support to the mother There was no period of time when the parents jointly cared for Child H – the parents had separate accommodation The Father Child H The Mother 14 3. The Facts Background Information 3.1 Re The mother: As a child, the mother attended school locally and went on to local college where she attained a qualification in Child Care. There were no concerns identified about her development, behaviours or social relationships 3.2 When the mother became pregnant with Child H, she was living with a member of her external family but moved out once it became known that she was pregnant. The mother gave details of what happened at this time in her contribution to this SCR. 3.3 Re The father: The father’s school life was curtailedafter experiencing fixed term exclusions before again being permanently excluded in his secondary school. 3.4 As a young adult, the father had criminal convictions for violent offences for which he was sentenced to prison from late 2009. He was released on license for 3 months after serving less than a year in prison.Overall the father’s compliance with the condition of his license period was good, and when this ceased in the summer of 2010, his offender manager assessed him as presenting a medium risk of re-offending. At this time the father said that he had significantly reduced his alcohol intake and that following the help received whilst under license, he had learned how to manage his anger and stay in control of it most of the time. Period of Review – December 2010 – January 2012 3.5 In early 2011, the mother undertook her antenatal booking at 10 weeks pregnant. The father’s name and address were noted as the mother’s partner. As this was a teenage pregnancy, the need for a Common Assessment Framework (CAF) was cited. From the booking in appointment, a letter was sent to the GP, health visitor and local Children’s Centre to inform them of the pregnancy. A Pre-CAF report was sent to the Supporting Young Parents project worker. 3.6 The mother made contact with the duty social worker for Children’s Social Care (CSC) to request help with accommodation whilst she was temporarily staying with friends. She was later seen by a housing options advisor, with the mother saying she was homeless. Arrangements were made for an Initial Assessment to be completed, which was undertaken by a social worker from CSC. 3.7 The mother moved into a Supported Housing project (the mother and baby unit)which provided accommodation for women aged between 16 and 24 years who are pregnant or who have one young child. With accommodation successfully arranged, the case was closed by CSC. 3.8 An appointment was set up for the midwife to meet with the mother to undertake a Common Assessment Framework (CAF), although the mother did not attend. It was recorded by midwifery services in April 2011that as the mother had moved to the supported housing that a CAF was no longer needed as the mother“was directly involved” with CSC. 15 The records noted the name of the social worker who had recently completed the Initial Assessment. 3.9 Soon after this, the father was arrested after being found in possession of a controlled drug for which he was later give a caution. 3.10 Child H was born on the in the summer of 2011. Because of his low birth weight, Child H was placed in the Neonatal Intensive Care Unit (NICU) where he was visited by both parents. The mother remained on the post natal ward at this time. The Children’s Centre received the Pre CAF assessment form on the following day. 3.11 The mother was discharged home to the mother and baby unit whilst Child H remained in the NICU. Child H was noted as irritable and “jittery” over a period of time, although it was not recorded that this was discussed with the mother prior to the baby’s discharge from hospital. Although the health visitor was contacted to enquire about the mother’s circumstances, she had not by this time met her. 3.12 The Children’s Centre outreach worker carried out a Pre-CAF assessment with the mother ten days after the birth,who said she was enjoying her new life as a mum and was visiting the NICU daily. The father was also visiting daily. 3.13 Child H was discharged from hospital and a home visit to the mother and baby unit by the NICU outreach worker noted that the parents were confident of making up feeds and bathing the baby. The father was there on this occasion although he was not allowed to reside in the accommodation. Further contact noted that the mother and the baby had settled well and that the father was very supportive. 3.14 The Police were contacted late at night to say that the father had taken Child H, (when he was just over two weeks old) from a party that the mother had been attending, apparently without the mother’s knowledge. A number of enquiries were made by the Police through the night and the father was located the following day. He maintained that he had taken Child H becausethe motherand others had been drinking at the party and he did not feel it was appropriate that Child H was there. He said he informed those at the party of his intentions. There were no concerns about the care of Child H whilst in the care of the father who confirmed that he would be returning the baby later that day. 3.15 The Police simultaneously made a referral to CSC regarding the incident and included information that the father may be involved in drugs. CSC staff spoke with the support worker at the mother and baby unit who spoke very positively ofthe mother’s parenting. 3.16 The NICU outreach worker visited later that day with knowledge of the recent incident, and saw the mother and the father with Child H who was reported as doing well and that he was gaining weight appropriately. It was noted that the mother was quiet, appeared upset and had a bruise on her right cheek. Following the visit, the outreach worker contacted the social worker to gain further information about the recent incident. The health visitor also visited on the next day to undertake a new-birth visit and she reported seeing both parents, and that they appeared to be caring for the baby together. A tense atmosphere was 16 recorded. The manager of the mother and baby unit reported that the father had so far been an attentive caring partner and father. 3.17 At a home visit a week later by the Children’s Centre outreach worker, the mother said that she and the father were no longer together but that they were on good terms over access to Child H. The NICU outreach worker visited soon after and reported that Child H was thriving. 3.18 After a telephone call from the father to the health out of hours service, he expressed concern that Child H (who was approximately 4 weeks old at this time) was inconsolable, crying and had vomited – he was advised to take the baby to the local hospital which he did that evening. Child H was admitted to the ward for observation and both parents were seen by the doctor, although they said they were not together as a couple. The father later told the staff nurse that he was concerned over the level of care that the mother was giving to Child H, notably the baby’s hygiene and the cleanliness of bottles. He also said that the mother was drinking and using drugs. Child H was discharged as being well on the following day to the father with instruction for him to inform the mother and that he had the discharge summary document. The children’s ward nurse telephoned the health visitor to inform her of the discharge and the health visitor expressed concerns over the discharge into the care of the father, who did not have Parental Responsibility at that time, and referred to the recent incident when it had been claimed that he had “abducted” the child, of which the ward had not been previously aware. 3.19 Two days later he health visitor completed a pre-CAF assessment checklist and described how the father had developed a positive relationship with Child H and that the mother had struggled with sole care and needed support. The health visitor had visited the mother and baby unit and seen mother and baby and was concerned about hygiene in the bedroom. The checklist referred to CSC involvement and that no CAF would be completed until “child protection status clarified” but that the health visitor would not be able to provide the additional services needed for the baby. It was understood that Child H was now in the care of the father and a member of the extended family, but there were no details of the address. 3.20 On the same day as the health visitor contact, Child H was readmitted via the father and kept in overnight at the regional hospital.Whilst the reasons for this were unclear in the records, it appeared to be a request had been made for the father to return Child H to the hospital, once the hospital had become aware of the recent incident when it had been said that the father had taken the baby from the mother’s care without her permission. The mother seemed to be unaware of her child’s current whereabouts. The health visitor raised concerns with CSC as did the regional hospital. The consultant community paediatrician later made a referral to CSC saying that the care arrangements for Child H were chaotic. The paediatrician was concerned that the father was difficult to contact and was concerned whether he was feeding Child H properly. The father had however told the paediatrician that the motherwas unfit because of drinking and drugs (cannabis), which she later denied. There were concerns by the paediatrician about the level of conflict between the parents at this time. 17 3.21 Strategy Meetings/Discharge Planning Meetings were held, the first between CSC and the Police and then in the hospital with paediatric input. In the hospital meeting, both parents were in attendance. A decision was reached for Child H to be discharged to the mother, with which the father was in agreement. It was also decided that an Initial Assessment would be undertaken followed by a further Strategy Discussion. The Police gave information to CSC about the father’s previous offences, which they recorded as an offence relating to violence and as a caution for a drugs offence. The Initial Assessment was completed by the following day and concluded that the mother was going out too often, drinking and leaving Child H with other carers and that the father was sometimes taking care of the baby without the mother’s knowledge and being un-contactable. It was decided that a Core Assessment should be undertaken. 3.22 Two days later, the Police were asked to provide a welfare check in respect of Child H after a relative of the father had reported the mother to be out drinking, with concerns regarding who the child was left with. Child H was found at a local address safe and well and asleep with sufficient milk and clothing, being cared for by an 18 year old. 3.23 There were concerns noted in a conversation between the Children’s Centre outreach worker and the mother and baby unit regarding the mother’s drinking, and that she had recently returned home intoxicated. The Core Assessment began at the end of August 2011 and a few days later, the health visitor expressed concerns to the social worker about the mother failing to engage with services and that she may be drinking heavily. The father was described as a positive influence. 3.24 Whilst Child H was in the care of the father, he called the ambulance service because the baby was said to be blue, although on attendance it was found that this was not because of breathing difficulties but because the baby was hungry and had worked himself into a state as a result. The paramedic helped the father to make a bottle and to then feed and wind the baby (who was now approximately 6 weeks old). The ambulance service contacted the Police and CSC to inform them of the visit – the father was described as “clueless” to the Police. The father was due to take Child H back to his mother later on the next day. There was a discussion between the Police and Emergency Duty Service of Children’s Social Care (EDS) – Child H and the father were later seen by the Police with no child protection concerns noted. 3.25 Although there was a pre-arranged visit for the social worker to see the mother she was not at home and had apparently been staying with various friends since a recent fire at the mother and baby unit which had made it impractical to reside in her room at that time – she was unable to be located or contacted by phone. The father continued to express his concern for the mother’s ability to care for their baby. The social worker advised the father that if he had doubts about the mother’s care of Child H when she picks him up from contact, then he would be entitled not to return him. On the following day the social worker advised the father to seek legal advice. 3.26 Less than a week after the visit by the ambulance service, Child H was seen at the Minor Injuries Unit (MIU) out of hours service in the early hours of the morning with breathing difficulty, with the father saying that the baby had “squeaky breathing” since the recent fire 18 at the mother and baby unit. No child protection concerns were noted – there was nothing recorded about the cause of the breathing difficulty. 3.27 On the dame day,a Strategy Discussion was held at the instigation of the Police between the Police Child Protection Investigation Unit and the manager of the CSC referral team, when it was acknowledged that Child H was now with the father who was said to have Parental Responsibility, and that Child H would be at risk of significant harm if returned to his mother. It was agreed that if the mother attempted to remove Child H or if she approached the Police in getting the child back, that she would be advised it would be a legal matter and that she would have to pursue the matter through the courts. The Police records noted that there would be an Initial Child Protection Conference (ICPC) called by CSC. 3.28 Mrs B was advised the next day of the stance taken by CSC and the Police of supporting the father, but she denied to the social worker that she drank when she was looking after Child H. She was advised to see Child H at the father’s home under supervision and that the father would be seeking a Residence Order. The social worker recorded that the mother appeared not to take the concerns sufficiently seriously. 3.29 Later that day, Child H was again taken to the regional hospital with breathing difficulties after first being referred there by the GP following the attendance at the MIU the previous day. However the father did not arrive at the hospital at the expected time and needed to be contacted - he said was delayed by transport difficulties. Child H was detained overnight and discharged back into the care of the father on the following day. 3.30 It wasduring mid- September 2011that the father registered Child H with his own GP (Child H had previously been registered with his mother at a different surgery). The health visitor contacted the new surgery to explain that the father had become the main carer because of concerns about the mother’s care. The father’s surgery held information in respect of his previous excessive drinking and his prison sentence for a violent assault. 3.31 Shortly after, the father visited the Housing Options service and spoke with an advisor. He told the advisor that the social worker had awarded him sole custody of his son until a court order. The housing advisor tried unsuccessfully to contact the social worker to clarify the situation. 3.32 There was a change of health visitor in late September ’11 and the new health visitor saw Child H and the father at a relative’s home a few days later– The father’s own home was in a flat with a relative although he was said to rarely stay there. Child H was said to be clean and appropriately dressed and reaching his milestones. The father and child were soon after seen by the social worker, when the father was viewed as competent and managing well. He was said to be staying with this relative at the moment. The mother was separately seen by the social worker – she had weekly contact with Child H, supervised by the relative in her home, but had not attended recently. The mother claimed that the father had been out drinking whilst Child H was in the care of the relative. 3.33 At aged 3 months, Child H was admitted to hospital with a history of vomiting blood – the explanation given by the father was thought unusual by the paediatrician. On examination, 19 it was considered that the bleeding may have been caused by an ulcerated area at the back of the throat, but otherwise unexplained. The community paediatrician noted “not definite NAI3 but unexplained” and contact was made with CSC to inform them of the admission. However, the medical view was ultimately that there was no child protection concern associated with Child H’s condition and he was discharged back to the father and CSC were informed of this decision and a discharge summary was sent to the GP a week later. 3.34 The baby was readmitted a day after his discharge for continued concerns over vomiting blood and was discharged again two days later. Child H was referred to the Ear Nose and Throat specialist at the regional children’s hospital as a result. The paediatric consultant told the CSC assistant team manager that there was no concern at this stage and that there were no signs of non-accidental injury. Child H was discharged back to his father. During his time in hospital, the mother had been told she could visit but that she would need to be accompanied by a social worker. When Child H attended the ENT appointment just over a week later, no abnormalities were found. Child H was seen at the GP surgery at this time for routine immunisations-there was no record of any discussion about the recent hospital admission or which parent was present at the consultation. Information about Child H’s attendance at the ENT appointment was not sent to the GP for a further 3 ½ weeks. 3.35 The Core Assessment was completed by early November 2011 which concluded that the father was providing good care of Child H and that should he be returned to the care of the mother, then child protection procedures would immediately be put in place. The assessment also concluded that the father had no offences which would be concerning in relation to caring for a child. The case was closed by CSC although the father wanted support regarding financial assistance and although given advice, was unhappy about the lack of social work support continuing. 3.36 Soon after the case being closed by CSC,the outreach worker from the Children’s Centre was told by a colleague who had former contact with the father,to be aware when visiting him alone. 3.37 The father attended the local MIU on the early afternoon in lateNovember 2011with a head injury to Child H which was said to have been caused by the father slipping in the bath with Child H on his chest, and Child H knocking his head on the side of the bath. The father had sought advice from the health visitor before taking the baby to the MIU. Child H was referred to the regional hospital although by 8.10 pm, as he had not arrived, the EDS was contacted who then located the father by phone at 9.45pm, who said he was now on his way to the hospital – he said that he had transport difficulties. 3.38 On arrival at the hospital at 11.50 p.m., it was noted that Child H had bruising around the side of his head and ear. It was noted that the explanation for the history was not consistent in some of the detail about what actually happened in the bath to cause the injury. Also, because of the unusual shape and location of the bruise, as well as the delayed presentation, the consultant community paediatrician completed a child protection medical report and in a discussion on the ward on the following day with the EDS social worker,it was 3 Non Accidental Injury 20 agreed for them to discuss with the Police for further investigation. The social worker then discussed the situation with the Police and it was then agreed via a Strategy Discussion over the telephone, that Child H would be discharged back to the father but on the expectation that he would be going to his relative’s home. According to the Police records of this discussion, the paediatrician was said to have remained a little concerned in that the unusual shape of the bruise did not quite fit with the explanation, but did not however consider that the Police should be interviewing the father about this incident.Subsequently the Police decision two days after the bruising had initially been reported was that there was no further action for them as the injury was “as a result of an accident”. 3.39 The health visitor again spoke with the father over the phone two days later and he explained how Child H had recently been kept in overnight following the head injury. The health visitor arranged to visit in a month’s time. 3.40 At this time the health visitor provided information to the council housing service via letter confirming that the father was the main carer for Child H due to safeguarding concerns regarding the child’s mother, and that the father was applying for Residence Order and had full support from CSC. The information included that currently the father was living in a shared flat which was overcrowded.On the same day, the housing officer spoke with the CSC duty officer who confirmed that Child H resided permanently with the father. 3.41 The health visitor told the social worker that she was clear that she did not have any concerns about the father’s parenting and thought he acted appropriately over the recent incident (bruise to the head/ear) and had contacted her at the time. 3.42 Following the recent hospital admission,a pre-arranged welfare visit was made to the relative’s address by a social worker (not the same social worker who had completed the recent Core Assessment). The father was not present at the meeting and did not arrive as planned during the 45 minutes that the social worker was there. Child H was also not present in the home. The relative reported that the mother’s attitude had changed and that contact was now going well. Feeding of the baby was discussed, with the agreement for the social worker to contact the health visitor about this, which happened the next day. Following this contact, the case was closed by CSC. 3.43 On the same day, the GP received detailed information in a report from the paediatrician about Child H’s recent hospital admission and of the concerns about the bruising. On the same day Child H was seen in the surgery for routine immunisations – this was two hours after the paediatric report had been received. It was not recorded that there was any discussion about the recent injury to Child H and again it was not recorded which parent attended with the child. (It was presumed to be the father as this was the GP surgery that he and Child H were registered with). 3.44 As part of the process of planning a joint home visit between the health visitor and the Children’s Centre outreach worker, the outreach worker told how she had recently been told not to visit the father alone due to concerns that he had a violent history,and was known for his drug use. The health visitor advised the outreach worker to contact CSC with this information. 21 3.45 When the outreach worker contacted CSC in mid-December 2011,she was told that the case had been closed and that this information would not be taken “due to data protection”. This was apparently due to the information being viewed by the social worker as hearsay. This decision was challenged by the outreach worker and later by her manager although this did not change the outcome. CSC did not have a record of this conversation. The outreach worker informed the health visitor of the contact with CSC and that they were aware of the father’s history but that the case was closed. The health visitor had not been previously informed of the case closure. 3.46 Child H did not attend for his outpatient appointment at the hospital the next day - a letter was sent as notification of the non-attendance to CSC and to the (previous) health visitor. 3.47 Three days later, the health visitor and Children’s Centre outreach worker undertook a joint home visit and saw the father and Child H. The baby was asleep on his front and the fatherwas reminded that he had previously been told that this was inappropriate. Re the recent missed hospital appointment, the father claimed that he had been given incorrect information about this. He said that he enjoyed being a dad and that he continued to be supported by his extended family. Child H was recorded as being sick and appeared to have a rattley cough, finding it difficult to breathe. The father was advised to call the GP and make an appointment and told that both workers were worried about Child H. It was decided that the outreach worker would speak with CSC, with Housing and with the Benefits section, as the father claimed that he had no money. There was also a plan to complete a CAF at the next contact which was to be at the Children’s Centre. The father did not later attend the surgery with Child H as advised. 3.48 On the same day, the outreach worker spoke with the community police officer to request a check be undertaken in respect of the father as she was concerned that he may have an offending history and that he would gain a Residence Orderin respect of Child H. 3.49 Just prior to Christmas 2011, the mother took Child H to the MIU as she was concerned about bruising on him when she was having contact. On initial examination, it was noted that Child H had various bruising his head and body. At some stage the father joined the mother when Child H was being examined. Following admission to the ward at the hospital, because of his medical condition he was then transferred to the regional children’s hospital and admitted into intensive care. 3.50 The matter was referred to CSC and the Police on the same day as the admission because of the severity of the injuries and because they were thought likely to be the result of abuse. Arrangements were put in place for neither parent to have contact with Child H on the ward unless supervised by CSC – they were both told of the concerns about the cause of the injuries. A Strategy Discussion was also held on the next day. 3.51 The child protection medical report described a severe traumatic injury to one part of Child H’s body and that other injuries, including a number of fractures, reflected that Child H had been subject to an escalating pattern of non-accidental injury. Both parents were arrested and both denied harming Child H. They were released on bail with the condition of no contact with Child H unless directed by CSC. Arrangements were made for the mother to 22 sign an agreement for Child H to be retained in the care of the local authority (Section 20, Children Act 1989) 3.52 Child H underwent a full skeletal x-ray and MRI which identified a range or injuries and fractures, all thought to be the result of abusive care. It was estimated that all the injuries would have occurred over the preceding 10 days. A further Strategy meeting was held at the Bristol Hospital at the end of December 2011. 3.53 Child H was subsequently discharged from the hospital and was placed in foster care. Three months later, Child H was made subject to an Interim Care Order. __________________________________________________________________ 4. The Child’s Lived Experience 4.1 It was apparent that Child H had a difficult and traumatic first five months of his life which began with his premature birth and initial stay in the intensive care unit at the hospital. From the age of one month, attendances at hospital became a regular feature for Child H in that he was admitted overnight in hospitals on a further six occasions before his final admission with the serious injuries. 4.2 Despite the good work undertaken by hospital staff, hospital admissions would inevitably have generated some levels of insecurity for Child H. This needed to be linked with the insecurity of his home life reflected by the apparent chaotic lifestyle of his parents. It was significant to note that overall Child H was seen by 27 different doctors and 12 paediatricians. 4.3 Child H had numerous “homes” in his first five months with either his mother or his father as his main carer, and at times with babysitters overnight or in the care of two particular relatives. In this way there was less opportunity for one consistent carer to develop a close attachment to Child H and for them to get to understand his developing needs and personality, or for Child H to feel security in any consistency of emotional and practical care. 4.4 Furthermore, Child H was often unwell, and needed to be checked on one occasion by the GP after having been sleeping next to a room that caught on fire. It was also apparent that his feeding at times was inconsistent with a particular occasion when the father called the ambulance because of the amount of distress that Child H was suffering – the fact that the reasons for his distress was because he was hungry was initial evidence of some of the inattentive care he experienced. Analysis NB: Whilst it was clear from the medical assessment of Child H’s injuries, that these could not have been accidentally caused, the following analysis of professional interventions with the family does not imply that one or other parent, or any other person, was responsible for causing the injuries to their child. 23 5. The extent of background information known to agencies about the young parents and whether this should have indicated that they would likely require additional support in caring for their first baby. 5.1 For the link to be made about whether the background information about the parents was indicative of whether they were likely to require additional support to care for their first baby, firstly such knowledge needed to be available or sought by relevant practitioners, and then for use to be made of any such information in making a judgement about future parenting. 5.2 The background information in respect of the father should have raised serious questions about his ability to care for a baby without some form of support or guidance. This would have been especially important as he became the main carer for Child H for much of the five months before he was seriously injured. It was not apparent that the father had any previous experience of caring for a child before he became the main carer for Child H, or that he had previously experienced any parenting modelling behaviours. 5.3 The agencies which knew much of the background information were Wiltshire Schools and Learning via his education records, his GP, and then the Youth Offending Service and Probation regarding their involvement with the father in relation to his offences for assault. However, none of these agencies were involved at a time when he and the mother were expecting their child or at any time following Child H’s birth, so were not in a position to make any links with future parenting. In fact Probation identified the father as “medium risk” of harm to members of the public and as a “low risk” to children. The latter reflected that at that time the father had no contact with children and that he was not likely to do so in the immediate future. In fact his period of supervision by Probation ended almost a year before Child H was born. The GP surgery was however the only professional service which knew the background and was providing services to the father during the period of the mother’s pregnancy and then following Child H’s birth. 5.4 When the mother booked for her antenatal care, the father was identified and basic information of name and address was sought and obtained, but no information was sought about his background or about the strength of their relationship or how long they had been together. Because of the amount of information that needs to be collected by the midwife at this time, there may not have been time to approach this area of questioning about social history. Whilst information in respect of domestic abuse was given to the mother, it was not apparent that questions were asked about this as required by local procedures in respect of unborn babies. The mother may have talked of her partner’s background if asked about domestic abuse and it was apparent that she knew some information about his history as she had mentioned to the social worker at the time of the Initial Assessment regarding her homelessness that he had been in prison and had used drugs. In fact in her contribution to this SCR, the mother said that she did not know of any of the father’s criminal history of violence at that time, but just that he had previously used drugs.The ante natal process did not unfortunately elicit any information from the mother about her partner. She had however attended a domestic abuse workshop whilst resident in the mother and baby unit. Staff at the mother and baby unit considered that the mother“had a clear understanding 24 about domestic abuse and what was acceptable and what was not.” Staff also reported that the father was caring and supportive and that there was no conflict in the parental relationship in this early stage. 5.5 The fact that the father presented as attentive and supportive throughout much of the pregnancy meant that concerns were not identified, although he was aggressive and rude to ward staff when frustrated at a delay in discharging the baby home following the birth. However, this would not necessarily have been enough to trigger further enquiries about his background. It was apparent that questions were asked about the father’s alcohol and drug use but no concerns were raised by the information he or the mother gave in response. 5.6 Therefore the father became a parent without any involved professional during the ante natal stage knowing of his offences for violence and for a background of some substance misuse. Potentially more robust questioning and probing by maternity services professionals and by the health visitor could have highlighted some of this background, but his overall presentation during this time suggested that he would be a reasonably competent and caring father.He was also described as “charming” by staff at the mother and baby unit. 5.7 Nevertheless when the father registered Child H with his GP soon after he became his main carer, then here was an opportunity to make the link with his background and the impact this could potentially have on his parenting ability. The GP Practice however did not make the links and it was not apparent that the information in the father’s records of his violent background were accessed and reviewed when he presented as a carer of a young child on his own. The father had himself told the GP that there was CSC involvement and yet this still did apparently prompt a review of his records or if this was done, then it would have been concerning that no link was made about his background and his likely need for support as a lone parent. 5.8 Of course the Police had access to the father’s offending history, but they did not become involved with the family until just two days after Child H was first discharged from hospital, when there was the incident of the father allegedly taking the baby from the mother’s care without her knowledge. The Police accessed the father’s history from the Police database whilst they tried to locate him and once Child H had been found, a referral was made to the Child Protection Referral Unit which was then shared with CSC. It was not apparent however that all the background information was in fact shared along with the referral to CSC, with reference only being made at this time to potential drug use by the father. As part of CSC’s involvement at this time, the concerns about drug use did not seem to raise concerns about his parenting abilities, in that no questions were asked of him about this.It was apparent that the EDS saw their role at this time as simply ensuring that the crisis was over, and they were reassured that the baby had been returned to his mother’s care, and on enquiry, her abilities were described as “brilliant” by the mother and baby unit staff. 5.9 It was two weeks later when a further referral was received following Child H having admissions to hospital and concerns about the chaotic relationship of the parents. On this occasion the Police shared the convictions regarding violence and some intelligence in respect of the father. This new information to CSC should have led to more detailed enquiries about his background, as it was very relevant to his continued and future parenting 25 ability, particularly in the circumstances of the couple’s chaotic lifestyles at that time, and that Child H was only one month old and therefore extremely vulnerable. The opportunity to uncover and consider the background in more detail lay in the completion of the Initial Assessment and Core Assessment which was to follow. This is dealt with later. 5.10 Little was known of the mother’s family history by professionals although there was nothing specific in her background to raise concerns about her future parenting. However, the lack of parental support to the mother and the fact that the mother was a teenagerat the time of her pregnancy, were nevertheless risk factors in themselves which warranted further exploration which should have alerted the midwife to be more enquiring. Generally however, the mother presented fairly positively in the ante natal stage and appropriately attended appointments. The midwife expected that there would be a CAF undertaken as this was viewed locally as good practice in respect of a teenage pregnancy, and that ultimately this would raise important information about relevant background information. However, the midwife missed an opportunity on this early occasion to fully explore the mother’s background and to begin to make some assessment of her future parenting skills. Unfortunately, for a range of reasons, a CAF was not eventually completed and so no understanding of the mother’s social history was gained at any sufficient level to help assess her future needs as a potentially vulnerable teenage mother. 6. The appropriateness of ante natal and post natal care – was it sufficient to meet the needs of the parents and their new baby, were any risk factors noted? 6.1 The first supportive initiative for the mother as a pregnant teenager was for her homeless status to be addressed, and the housing advisor, in line with the protocol at that time, arranged a joint CSC assessment of the mother’s needs. Supported lodging (the mother and baby unit) was then appropriately found for the mother. Whether the Initial Assessment by CSC at this time should have broadened its areas of assessment, was a separate issue, and there were clearly some communication difficulties between the Housing Options service and CSC in terms of who was taking the lead in the work with the mother and then in relation to links with the mother and baby unit. Nevertheless, in terms of the overall outcome for the mother, this seemed an effective set of interventions to resolve the accommodation problems within a reasonable period of time. 6.2 Therefore, for much of the ante natal period, the mother was resident in the mother and baby unit and this meant that resources for personal support were available. In fact a support plan was completed when she entered the project which included attendance at workshops as well as one to one support and some group activities with the other young mothers/mothers to be. It appeared as though the mother did not make use of all of the opportunities, but those that were mainly provided were in respect of her life skills and Benefits. This was primarily because she entered the project very early in her pregnancy. Overall however, the mother did not consistently engage with the project, not attending activities if she did not have to. 6.3 The mother came under the care of the teenage pregnancy team although at the time of her booking and subsequent delivery, a teenage pregnancy policy was being developed, and was eventually completed in September 2011, shortly after Child H’s birth. The new policy 26 would have generated the expectation for longer booking-in and subsequent appointments, and so in this way the mother did not receive the enhanced midwifery response which was deemed appropriate soon after. 6.4 However, the mother’s teenage status meant that her circumstances were formally reported to the specialist support midwife; vulnerable groups/safeguarding (SSMVGS) and it was identified that the local Children’s Centre would be informed and that a CAF would be later completed. Additionally, information about the pregnancy was sent to the GP and to the health visitor, and the Connexions service also became aware. In this way therefore it appeared as though a reasonable package of support was to be available to the mother as a potentially vulnerable young mother to be. 6.5 Interim arrangements were in place prior to the Teenage Pregnancy Policy coming into use which meant that a Pre CAF was completed and sent to the young parent’s project worker and also communicated to the Connexions worker. The purpose of a Pre CAF is to help practitioners to decide whether a full needs assessment via the CAF is needed, although in these circumstances it was being shared with other professionals, which according to the relevant IMR was to “ensure that a CAF started”. In fact it appeared as though a form with just the name and address was sent, presumably as a marker to start the process. There was an opportunity here for a Team Around the Child approach to be taken as early as February 2011 when the Pre CAF was initially shared among the professionals. 6.6 These arrangements appeared overly complicated, and in fact did not lead to the completion of a CAF. There appeared to be an expectation locally that a full CAF would be completed for a pregnant teenager, although it was not a procedural requirement. In fact from the booking-in appointment, there appeared to be some reliance on the later completion of a CAF as a way of collecting and checking out background information, rather than undertaking all this at the booking-in appointment. It was appropriate that referrals were made to CSC for help for the mother in respect of her accommodation needs but it was because of CSC’s involvement that at the 22 week ante natal appointment, the midwife noted that a CAF was not needed because CSC were now involved. Conversely, the health visitor recorded that a CAF was not needed because of the mother’s age – clearly in her eyes the CAF related to the mother rather than the unborn child. If there had been sufficient concerns about the unborn child, then there was the potential to request a pre-birth risk assessment, although it was apparent that the health practitioners and the mother and baby unit did not consider that the threshold had been reached for such a request. A CAF, even undertaken in respect of the mother as a young person could still have addressed the support needs required for both her and Child Has a new baby. 6.7 The assumption by the midwife about CSC’s continued involvement and therefore no need for a CAFwas inappropriate and should have been checked out by the midwife contacting the social worker directly. In fact CSC involvement had been solely focussed on the accommodation problems and once solved, closed the case. It was shortly before the decision not to proceed with a CAF, that CSC had ceased their involvement. This was poor and ineffective inter agency working and therefore an opportunity was lost to have had greater exploration of the mother’s needs as a young person in her own right as well as in 27 respect of her unborn child. Whilst this might have been accomplished via a CAF, the Initial Assessment by CSC in February 2011 did not include any analysis of any need for future parenting support although it recommended further contact with the Children’s Centre and the midwife. The assessment did however refer to the child’s father in that the mother said he had been in prison and had used drugs, but there was no follow up on this information in terms of what it might mean regarding future care of the baby. 6.8 The current policy for teenage pregnancies4 identifies the “completion of a CAF to identify fully the needs of the young parent”, but lists this as a “Best Practice Point” rather than a formal requirement. It would therefore still be conceivable that a midwife or health visitor can decide against a CAF if it is believed that an assessment of higher threshold is being undertaken or that there is CSC involvement. The key issue here is that confirmation of other interventions should be sought and recorded before any such decision is made. The IMR in respect of midwifery services is however confident that a CAF would be completed regardless of CSC involvement and that the process is now consistently embedded in practice by midwives. The Children’s Centre recognised the confusion over the use of the CAF in this case but additionally commented that the CAF pathway process is still not being followed, with referrals being received in various formats frommidwives. 6.9 In other respects, the ante natal care given by practitioners was appropriate and the mother attended the majority of her appointments, often with the father present. Generally no concerns emerged about her commitment to the baby and regarding her parenting abilities.In her contribution to this SCR, the mother spoke of how she was very confident at that time, and felt supported by the mother and baby unit staff, and how she had expressed this to the midwife. 6.10 The mother had delivered her baby early which added an additional risk factor to the circumstances and subsequently the mother received a high level of initial post natal support. This linked with Child H being detained in the NICU and the mother being seen by the midwife in the Day Assessment Unit (DAU) on five occasions, although none of these were when the mother had care of the baby. The midwife then did a home visit at 13 days post natal, following discharge from hospital the day before. The NICU outreach team also provided a service following discharge as per a protocol for the early discharge of low birth weight infants and this meant that Child H and the mother were seen on three occasions at the mother and baby unit. 6.11 In effect, for the first month following Child H’s birth, post natal support to the family was quite extensive, firstly from within the NICU which provided high quality medical and nursing care, but then, following discharge, from the NICU outreach service, the midwife, the Children’s Centre outreach worker, the staff from the mother and baby unit and the health visitor. Communication between the relevant professionals was therefore important in order to coordinate the different services which were available, but also to share information about the limited background information known about the family. However whilst there was evidence of information sharing, there was much less evidence of 4 Teenage Pregnancy Policy – Great Western Hospitals NHS Foundation Trust and Wiltshire Community Health Services, Maternity Services – Approved 9.9.11. 28 anycoordination of services – the lack of a CAF had undoubtedly made this process more difficult. 6.12 It was not apparent that information was shared by the midwifery service to the NICU, who were not aware that the mother was residing in a supported housing project. Additionally NICU staff did raise any concern about Child H’s presentation as “jittery” in the post natal period. Whilst this could have potentially reflected that Child H was experiencing withdrawal from medication/drugs taken by the mother, the concern should have been shared with relevant professionals and made known to the mother. The lack of information from midwifery services did not help the NICU to decide how to deal with this issue, although contact could have been made with the midwife to ask if there had been concerns about such matters in the ante natal period. It was unclear from the midwifery notes whether the aspects of baby-care training were to be covered by the NICU, although this was the expectation. In fact NICU did undertake this role, and noted that both parents cooperated with this. However this should have been formally checked out to avoid any false assumptions being made. 6.13 One of the important aspects of post natal care is the effectiveness of the liaison between the midwife and the health visitor to ensure an efficient handover. On this occasion the baby was discharged into the care of the health visitor following the final visit by the midwife on the day after hospital discharge. This was done via letter to the GP and health visitor but there was no verbal handover and no understanding by the midwife of what the visiting patterns of the health visitor and the NICU outreach staff would be. The Teenage Pregnancy Policy which was not approved until after Child H’s birth, identifies the need for the midwife to have “verbal and written liaison with the health visitor” and so this was presumably seen as good practice even before the policy was developed. A discharge planning meeting would have been helpful in these circumstances in order to identify and share any possible risk factors, but primarily to coordinate the post natal support to the family and to be clear, with the mother in supported housing, how the father was to be involved in the care of the baby. However it is not apparent that there is any particular criteria for arranging a discharge planning meeting – perhaps the need to always give this active consideration should be contained within the Teenage Pregnancy Policy. The Policy currently refers to the importance of multi-agency involvement and the need to ensure that all health professionals are updated regarding safeguarding, but makes no comment about the value of discharge planning meetings. 6.14 It is important to note that during the ante natal and early post natal stages that the father was well engaged in the processes. The lack of involvement of fathers has been identified as a failing in many Serious Case Reviews nationally, but in this case there was good evidence of his involvement. To some extent this was due to the father’s keenness to be involved, but he was clearly included in advice and support given to the mother. However, information regarding his involvement and contribution to sessions with the midwife was not always recorded, which then detracted from what could be learned about his parenting abilities and the part he would play in the direct care of the baby. Although the health visitor recorded a tense atmosphere at her birth visit to both parents, she should have 29 explored this with them, a longside discussion about the alleged incident at the party when the father took the baby off for the night, which had taken place the previous day. 7. Assessment Activity:- What were the key relevant points/opportunities for assessing risk and decision making in this case? Do assessments appear to have been reached in a timely fashion and did actions accord with the assessments and decisions made?In particular what was the response to Child H’s hospital admissions in October and the injuries in November 2011? 7.1 Apart from the ante natal stages when opportunities were missed to undertake detailed assessments of parental social history and any impact on parenting, once Child H was born the first opportunity to assess any level of risk within this young family occurred less than a week after Child H had been discharged from hospital following his birth. This was the occasion when the father took Child H away from the party that the mother was attending and the Police were called to locate him. Generally this incident was handled well by the Police, and CSC were informed but did not consider that their direct involvement was needed and were reassured by the mother and baby unit’s positive view of the mother as a new parent. However new information about possible alcohol misuse by the mother, as well as tension between the couple, suggested that the situation had changed since the mother first entered the mother and baby unit, and so this was an opportunity for the mother and baby unit to undertake a fresh assessment and if necessary to have created a new management plan. 7.2 Overall there appeared to be a settled outcome from this incident and it was not apparent that much more needed to be done at that time by either the Police or CSC. The NICU outreach workers were informed and the support staff in the mother and baby unit were also aware. The health visitor was also informed, so in this way all the key professionals involved with Child H were made aware. However the health visitor’s visit to the couple the next day was a missed opportunity to explore the tensions in the relationship and of any possible impact on the baby’s care. Interestingly, as further incidents of concern developed, this incident was generally looked back on as some evidence of the mother’s poor parenting and alcohol misuse rather than a potentially irresponsible act by the father in taking a small premature baby, only a few days since hospital discharge, away from his mother. In her contribution to this SCR the mother claimed that there was no danger to her baby in her presence at the party on this occasion. Clearly both parents have given different versions of the same incident, which in summary probably reflected a certain level of inappropriate behaviour on both their parts. Had the health visitor discussed the incident with the parents at her visit, a greater understanding of the incident may have emerged. 7.3 In essence all of the hospital admissionswhich Child H had were, to varying degrees, key opportunities for assessment and decision making. In all there were seven hospital admissions, although two of these related to quick readmissions for similar reasons. In summary these were: Approx Age of child Duration Details 1 month Overnight Child H crying and inconsolable – had vomited 1 month Overnight Hospital asked the father to return Child H – had 30 become aware of previous abduction incident 2 months Overnight Breathing difficulties 3 months Overnight Concerns about vomiting blood 3 months 2 nights Continued concerns about cause of vomiting blood 4 months Overnight Bruising to the head and to the ear 5 months 10 days Extensive injuries – considered non accidental 7.4 It was the early hospital admissions which led to referrals being made to the Police and CSC from the paediatrician regarding the conflict between the parents and of their apparent chaotic lifestyle. When linked with the previous incidentof the father taking the baby at the party, and the descriptions by him of the mother’s neglectful care, a worrying picture was emerging, and so this was an appropriately made referral. Core Assessment 7.5 Following the Strategy Discussion, the decision for CSC to undertake an Initial Assessment and then a Core Assessment was a sound one. It was clear that full information was needed about the parental backgrounds, though more particularly about their relationship and their respective parenting strengths and weaknesses and from this of any potential risks to Child H. 7.6 Unfortunately the Core Assessment was of very poor quality in terms of its collation of information and its analysis, though it gave a very positive view of the father as a “capable and competent father” and that “since he has been in his father’s care, all Child H’s needs have been met appropriately, adequately and consistently”. Soon after the assessment began, it was considered that Child H’s needs were being more appropriately met by the father being his main carer, rather than by the mother. The positive views of the father were balanced by a view of inadequate care and attitude by the mother to the baby to such an extent that it was recommended that child protection procedures be instigated if she again became regularly involved in Child H’s care. It was questionable whether there was the evidence for such a strong stance to be taken, but if there were these levels of concern then there was enough to warrant an Initial Child Protection Conference to be called. There was however no reference to any discussion about the need to consider this. 7.7 Of significant importance was the information gained from the Police of the father’s offending history, although it was not clear if all the specific details of this were given. Nevertheless, it was clear that the father had a history of some violent offences although it was not apparent that these were discussed with the father and there was no evidence that information was sought from the Youth Offending Service or Probation, whereas, based on the information from the Police, the social worker should have realised that they were very likely to have been involved. These agencies had information about the father’s challenges in trying to control his anger, and the level of violence from the father’s offences was of a very concerning level. Understanding the possible impact on parenting of this background should have been a key component of the assessment and yet the recorded analysis was that “no offences would be concerning in relation to caring for a child”. Such a sweeping statement could not realistically be made in respect of either the violent offences or the 31 drug offence. This was an unacceptable finding in these circumstances – as a minimum the detail of the offences should have been recorded, and without these the assessment gave an overall false positive picture of the father’s background and of his parenting ability. Additionally the language used by the social worker in the assessment was misleading, as the statements which were made gave the impression that greater detailed information was gained by the social worker in order to make such a positive analysis of the father. 7.8 The CSC IMR gives a detailed analysis of the poor quality of this Core Assessment– in effect it did not meet basic professional standards. The Core Assessment should have been completed by mid-October although it was not finalised for a further three weeks. However for the period of time that the assessment was being conducted, a number of incidents occurred which gave additional material that should have been used to inform the assessment. For example, there were occasions when incidents occurred which showed that the father sometimes could not provide basic care such as feeding – in fact the paramedics described him as “clueless” in this regard on one occasion. The father had also proved elusive at times of requests for hospital admissions for Child H and it was not clear where he was actually living with Child H, who he was living with, and the amount of support he was in fact receiving from any of his relatives. 7.9 Professionals other than the social worker had spoken of the father having commitment to the baby and of demonstrating good parenting abilities and there were clearly examples of this when seen by practitioners. It was apparent that not only was the father able to demonstrate his own child care abilities, he was also clear in his negative view of the mother as a parent. Whilst the mother’s behaviour and commitment to her baby was concerning at this time, it was difficult to understand how she could be seen so positively in the ante natal and early post natal stages by health professionals and the Supported Housing staff, and yet within a month, her care was seen as so neglectful as to warrant child protection responses if she resumed care of her baby. It should have been seen as an essential component of the assessment to get as accurate a picture of her situation as possible and of her attitude to parenting, without so much reliance on the father’s views of her. In essence the Core Assessment did not include the mother in any meaningful way and was very positive in respect of the father, and negative in respect of the mother, and only evidence and analysis to support these views were promulgated. In her contribution to this SCR, the mother said that she recalled having very little contact with a social worker and that it was the father who told her that his care of the baby was being supported by CSC. 7.10 For the Police and CSC to agree at this time to support a plan for the father to be the main carer for Child H was premature in that there was still much un-assessed information before such a confident position could be taken. The father then went on to use this “support” to confirm to other professionals that he was now the main carer and that he had somehow been approved by CSC, and for example sought housing for him and Child H based on this situation. 7.11 Although CSC stipulated the need for supervised contact for the mother with the baby, it was not managed in any formal way and apparently left to the father and one of his extended family (who was supposed to provide the supervision) to manage this. Certainly 32 the mother in her contribution to this SCR said that she was not formally told by CSC about contact arrangements and that this was left to the father to explain this. The fact that she had contact of just one hour a week was not in itself a child focussed approach to the situation and was effectively compromising any attachment development between the mother and her son. Although this contact was eventually extended to a two-hour session a week, in agreement with the father and his aunt, who by now was saying that the mother was managing the baby well, this was still a very small amount of contact and something that professionals should have helped to resolve. Hospital Admission re breathing difficulty 7.12 The cause of the breathing difficulty for which Child H was briefly admitted at age 2 months, was not found, although the father had mentioned that Child H’s breathing was not right following the recent fire in one of the bedrooms at the mother and baby unit. This admission followed increased concerns being presented by the father about the mother’s care of the baby and of her drinking and socialising behaviours. He had expressed concerns about Child H’s condition and care when handed over to him for contact, and then on this occasion took him to the local out of hours service. 7.13 By this time a further Strategy Discussion had been initiated by the Police following the involvement of paramedics recently, though with the information about the latest concerns about the mother’s care, this was felt sufficient to support the father retaining the care of Child H. Nonetheless, the Police record of this discussion was that CSC would set up an Initial Child Protection Conference (ICPC), although there was no corresponding record of this decision in the CSC files, and in fact no ICPC was set up. This was significant conflicting information about an important decision. Hospital Admissions - October 2011 7.14 These admissions related to the occasions of Child H bleeding from the mouth and the inability to identify the cause. Whilst the hospital records show that there were some concerns about the potential of NAI as a cause, this view tended to recede, but it was nevertheless appropriate that information in respect of the admission was relayed to CSC. There was some confusion however, in that whilst the first contact from the paediatrician expressed some concerns about the bleeding, a second call just 12 minutes later to seek clarification from the paediatrician emphasised to the social worker that this was not a child protection matter and was being dealt with by an ENT referral. It appeared as though the communication from the hospital was for information sharing purposes rather than a referral to CSC, who did not take any action as a result. The eventual letter to ENT did say that a Strategy Discussion had been held in respect of the incident but did not explicitly say that there had been any child protection concerns. In fact there had not been a Strategy Discussion although the local hospital had initially shared information about the bleeding which in reality could not have been described as a formal discussion in this way. This was one of the examples of confusion among agencies about what constituted a Strategy Discussion. CSC took no further action in respect of this incident and in this way appeared to have deferred to the medical view as being the determinant that there were insufficient reasons to be concerned about the care of the baby. 33 7.15 Although the GP saw Child H a few days after receiving the discharge summary from the Hospital, for routine immunisations, this once again appeared to the GP as insufficient reason to review the father’s records and consider the potential importance of his history now that some initial concerns were being raised about his childcare abilities. This was evidence of the GP surgery receiving information without any apparent analysis of it or of using it to inform how to respond to Child H and the father in the most effective way. This was also a missed opportunity to check with CSC about their role with Child H and to ensure that they were aware of the father’s background. 7.16 At Child H’s attendance at ENT just over a week later, no concerns were noted. The referral letter to the ENT Dept. did give helpful background social information and whilst it did not specify if NAI had specifically been considered as a differential diagnosis, the letter did imply this by saying that no bruises had been found and that the frenulum was intact. There was a significant delay in the sharing of the outcome of this appointment with the referring doctor, as the letter giving this information was dated three weeks after the appointment. No concerns about a delay were however raised within the referring hospital’s IMR. 7.17 Whilst these hospital admissions did not eventually generate child protection concerns, actions could have been taken for the health visitor to be alerted, either by the hospital or CSC, and for her to make contact with the father and Child H in order to ensure that he was managing the baby satisfactorily at this time. In fact the discharge reports were sent to the health visitor who received them within a few days. The respective IMR does not comment on whether it would have been appropriate practice for an immediate follow up visit to have been made by the health visitor, although in the circumstances this would have been a reassuring action to take. The health visitor did undertake a “routine visit” three days after the ENT appointment, and although an important link could have been made with the hospital admissions, the opportunity was not used and there was no record that the “bleeding” incidents were discussed. Hospital Admission – November 2011 7.18 This admission related to the head injury, said to have been caused while the father was in the bath with the baby. Not only were there concerns about the injury itself, but there was significant difficulty in locating the fatherin order to get him to take Child H to the hospital for a detailed examination. As the initial examination by the MIU recorded that there was a suspicion of a skull fracture, it is difficult to understand why the initiative was left with the father, who had no access to transportation, to take Child H to the regional hospital some miles away. In effect approximately 10 hours elapsed before the father arrived with the baby at the hospital after he had been located by EDS and told to attend. 7.19 In the hospital there was noted to be an inconsistency in the account given about how the bruising to the head and ear occurred. However, the inconsistencies in the explanations were not significantly different, but nevertheless appropriately raised concerns. Whilst no skull fracture was identified, a referral was therefore made to the out of hours CSC – (EDS). A Strategy Discussion followed on the next day, as Child H had been detained overnight. However, it was apparent that the Strategy Discussion was in two parts, firstly between the Paediatrician and CSC, and then later between CSC and the Police. 34 7.20 The paediatrician understood that after the first meeting, that CSC would discuss with the Police, the need for further investigation, potentially a child protection investigation under Sec. 47 of 1989 Children Act. However in the later meeting, an agreement was reached between CSC and the Police that there would be no need for a Police investigation, and their involvement in this incident ceased at this point. The Police recording of the circumstances of this hospital admission made no reference to the possible different accounts for the injury, nor for the delayed presentation at the hospital. This is difficult to understand as these were the two key factors which had raised the child protection concerns. Also the Police made no links in asking what had happened to the ICPC as an outcome as they understood it from a previous Strategy Meeting. 7.21 In agreement with CSC, the hospital then discharged Child H back to his father, but with the proviso that both went to stay with the relative who had previously provided support. The recently completed Core Assessment gave such a positive view of the father, that this no doubt had an influence regarding the confidence of discharging the baby back to his father. 7.22 The father explained that he first sought advice from his health visitor about where to take Child H with the injury. In fact it was because the father had quickly contacted the health visitor which led to some sense of reassurance that the father had acted responsibly at the outset. It was in a telephone conversation with the father a few days later that the health visitor agreed to visit in a month’s time – she was now aware of the recent admission and so these circumstances should have led to a home visit being undertaken as soon as was practicable to do so. When the duty social worker contacted the health visitor on the next day their records showed that the health visitor did not have any concerns about the father’s parenting and that the differences in explanations for the injury could be accounted for and that she believed his actions in response to the injury had been appropriate. She also confirmed that he had contacted her at the time of the incident 7.23 Once again the GP saw Child H for routine immunisations less than a week after this incident and although the GP surgery had only received detailed information about the hospital admission on the same day as the immunisations were undertaken, this still represented a missed opportunity for the GP to again make the links with what was known about the father’s past, or at least to make contact with other agencies to clarify the current view about any risks to Child H. In this way the GP surgery was a passive recipient of information which took no proactive initiatives to consider if there were any risks to Child H or to consult with professional colleagues. 7.24 The outcome from this injury and hospital admission, as decided between the agencies, was for CSC to undertake a “parenting assessment” although what this meant in practice was unclear as it does not have status as a formal assessment. In effect, what transpired was a “welfare visit” by the social worker to see the father, along with the relative with whom he was to be staying with, and Child H. In fact only the relative was present despite this being a pre-arranged visit. This was not a good indicator of the father’s commitment to engage with the social worker and to discuss all that had recently happened. As there was no further action from CSC, this was a most ineffective response to the recent concerns, and certainly did not match the agreement to assess the situation and particularly the parenting 35 of the father. The health visitor was advised by the social worker that the assessment had not been undertaken, but between them did not agree any possible further response or completion of the work. Strategy Meetings/Discussions 7.25 The purpose of a Strategy Discussion is to share available information and primarily to agree the conduct and timing of any criminal investigation as well as deciding whether a Section 47 child protection investigation is needed and if so, plan how this should be undertaken5. However it was not always apparent in the management of the risks as they emerged in this case, that the purpose of the Strategy Meetings/Discussions was clear, what the outcomes were and how actions were to be recorded and monitored. 7.26 Potentially a Strategy Discussion could have been called at the time of the alleged “abduction” of Child H from the party, although the efficient response by the Police probably negated the need for one. The other Strategy Discussions which took place were appropriate and demonstrated a commitment to joint agency information sharing and decision making. 7.27 However, their status was sometimes confused in that the meetings were occasionally also referred to as “discharge planning meetings” or “multi agency meetings”, and the representation at such meetings did not always reflect the expected purpose. The confusion about the status of these meetings and the outcomes was compounded by the lack of formal minutes being produced by CSC as the lead agency, which were needed to identify agreed actions. 7.28 This sort of confusion appeared to exist to some extent in the other Strategy Meetings/Discussions, for example in November 2011 when two separate meetings were held, and in the latter meeting it was concerning that the Police did not seem to be made aware of the reasons for the child protection concerns. 7.29 With the lack of recorded decisions or actions and who was responsible for them from the meetings, then it was difficult for professionals to monitor what had been achieved or if appropriate actions had been taken. For example, the quality of the Core Assessment did not reflect the concerns from the earlier Strategy Meeting, there was no ICPC as expected by the Police after the September meeting, and the “parenting assessment” did not take place as agreed following the November meeting. It was also concerning that the Strategy Discussions tended to focus on the particular presenting incident rather than taking a more holistic perspective and considering past concerns and historical information. The final Strategy Discussions were however effective in achieving appropriate outcomes. 7.30 By the time that the decision had been made at the end of December 2011 to transfer Child H to the regional children’s hospital, discussions between CSC, the hospital and the Police had identified the likelihood of NAI as a cause of these significant injuries, and yet the father was allowed to accompany Child H in the ambulance. Whilst the father would not have been 5 Paragraph 5.57, Working Together to Safeguard Children – Dept. for Children, Schools and Families, March 2010 36 on his own with Child H in the ambulance, it was a contradiction to identify possible NAI concerns and allow one of his parents to accompany Child H so soon after the injury had been discovered. 8. The Understanding of Thresholds:- Was the case consistent with agency, LSCB and South West CP Procedures and wider professional standards? Did agencies have relevant Policies and Procedures in place and were practitioners knowledgeable about potential indicators of abuse or neglect? 8.1 All IMRs referred to appropriate internal safeguarding policies and procedures being in place to support the work of their staff, and that overall their safeguarding training needs were met. Whilst there was a housing protocol for teenagers jointly created with CSC, the IMR for Housing Options considered that this needs reviewing and updating. Additionally, IMRs generally were confident that the staff involved in working with the family were knowledgeable about potential indicators of abuse and neglect. Nevertheless there were errors of judgement by some practitioners in this case, and so this reflects not only the importance of update training but also the pivotal role played by supervisors and line managers in helping staff to retain an enquiring and objective mind set when working with families, particularly those who for much of the time appear to operate just below the threshold for child protection. 8.2 The complicated process about the Pre CAF, and of some mixed understanding about the need to conduct a CAF as best practice in respect of a teenage pregnancy, has already been referred to. It was apparent that the lack of a coherent policy at that time, being substituted with interim arrangements, impacted on this. The CAF could have been completed by the Midwife or the Connexions advisor for the mother, and if a CAF had been completed during the ante natal, and potentially early post natal, stage, then it could have been influential to practitioners in understanding the dynamics and needs of the family, and how to address them. 8.3 Also, from a health visitor perspective, the IMR considered that the case should have met the criteria for the “Universal Partnership Plus” category6, which would have meant that there would have been greater direct involvement with the family than actually occurred. However these threshold criteria were not established until a few weeks after Child H’s birth, and the IMR does not explain if the new thresholds could have immediately been utilised with families. It was however apparent that the circumstances of Child H’s care were not taken seriously enough and that the optimistic views about the father’s parenting did not seem to lead to a robust assessment of what his support needs would be as a parent. 8.4 For the case to have reached the child protection threshold, then this would have been more achievable if the earlier threshold levels of the CAF, perhaps then moving to a Team Around the Child process, had been activated. Although there were a number of agencies 6. The 3 levels of need are Universal, Universal Plus (for children with additional needs that can be met by the HV service) and Universal Partnership Plus (for children with complex needs requiring a multiagency approach). 37 involved soon after Child H’s birth, there was no coordination of this work and no one agency or professional taking a lead. It appeared that once CSC became involved, no matter how fleetingly, that inappropriate assumptions were made that the case was being fully managed by them. 8.5 The latest local Multi Agency Threshold Documentwas produced in September 2011, and this does provide clarity regarding about the role of CAF and the Team Around the Child, and also makes reference to Multi Agency Forums, (MAF) which would have seemed ideally placed to coordinate work and to support decision about appropriate referrals to other agencies if needed. However, there was no reference to the use of this process in any of the IMRs, which may have been because processes such as the MAF were not operational at this time. 8.6 Paediatric staff appropriately made referrals to CSC in a timely fashion on each relevant occasion, and Strategy Discussions/inter-agency meetings were regularly held to consider new concerns, and yet the case did not formally reach the threshold for child protection interventions until the eventual very serious injuries to Child H at the end of 2011. However, based on an accumulation of the concerns, the threshold for an ICPC had been reached some months earlier, evidenced by the incidents of concern that had taken place. 8.7 There appeared to be a number of reasons for the lack of progress to the child protection threshold. Firstly, the positive views that had developed in respect of the father as a parent became a dominant feature among a number of professionals. The findings of the Core Assessment created an over optimistic view of the father and his parenting which permeated other considerations of possible concerns as they arose. Key information, such as the father’s offending history, was not shared with practitioners outside of the Police andCSC, which would have created contra indications to the positive views that were being generated of him. 8.8 Additionally, incidents of concern tended to be seen in isolation and the lack of an ICPC meant that a more holistic view was never taken. Until the final admission to hospital, there was never a definitive view taken about whether the earlier hospital admissions and other incidents in relation to Child H, reflected child protection concerns, although on occasions questions were appropriately raised in this regard. Nevertheless the purpose of Sec 47 enquiries is to enquire into concerning circumstances that are not otherwise clear, and the details of this case met these criteria, but on no occasion were child protection enquiries formally taken up. One major reason for this was probably the inefficiency of the Strategy Meetings/Discussions and the lack of follow up on outcomes. To some degree, it appeared that the fact that a Strategy Discussion had been held was in itself reassuring to professionals that the case was being appropriately managed. 9. Sensitivity to the needs of the child 9.1 There was clear evidence of the sensitivity to Child H’s medical and emotional needs by the hospital staff during his numerous hospital admissions. This was supported by referrals to appropriate agencies when necessary. Similarly the hospital staff were mindful of the 38 contact arrangements for parents and extended family and managed them well when there were particular concerns about the cause of Child H’s injuries. 9.2 Because Child H was a young baby at this time, then inevitably much of the professional focus was on the parents. However there could have been greater description of Child H in the records or of observations of how he presented. The NICU outreach workers clearly gave attention to Child H and monitored his development, as did the health visitor, recording this accordingly. The staff at the mother and baby unit as well as the Children’s Centre worker were alert to Child H’s situation and care. The Children’s Centre IMR recognised the need for staff observations of the baby to be more consistently recorded in the records of visits. The NICU outreach worker and the health visitor witnessed tense relationships between the parents, with the outreach worker also noticing on one occasion that the mother had a bruised cheek. Neither workers appeared to address this with the parents, nor try to understand what the impact of this tension may have upon Child H. The reasons for not doing so were unclear but it clearly represented a missed opportunity to gain greater insight into their difficulties. To have discussed with the parents how their relationship would affect Child H’s emotional security may have helped them to consider how to manage any differences.Information about the injury to the mother should also have been forwarded to CSC although whether it would have elicited any formal response was questionable. 9.3 There were occasions when Child H should have been seen more regularly by professionals, but because the father was quite elusive, and professionals were not persistent enough, this did not always happen. For example, CSC social workers only saw Child H on three occasions and for their final visit, there was a failure to see him despite this being an agreed assessment visit following Child H’s hospital admission after sustaining bruising.It was an agreed outcome between the Police, the hospital and CSC of the need for this “parenting assessment” to happen, and yet it was clearly ineffectual to undertake the visit to the relative’s house without the child or father present and then not to return to see them as a matter of urgency. Clearly, observation of the child should have been an essential component of such a visit.There was also no evidence that the failure to see Child H was fed back to other agencies apart from the health visitor– overall this was very poor practice. Additionally there seemed to be very few, if any occasions when the father’s flat was visited, even though this was where Child H lived for much of the time. Also although the relative was seen as a supportive influence in the care of Child H, this person was not interviewed by a social worker or health visitor in terms of background and suitability. 10. Communication and information sharing among professionals, including those providing out of hours services 10.1 Because the case did not formally reach the child protection threshold and also because the implementation of a CAF was bypassed, with no Team Around the Child process enacted, then in effect there were no professional forums to support efficient communication and the sharing of information. This was a failing of the inter agency practice in this case which no doubt had a significant impact on information sharing. With hindsight, it was apparent that some agencies (as noted in their IMRs) would have wanted more information shared with 39 them by the statutory agencies, and perhaps to have had invitations to the Strategy Meetings which were held. However, this appears to reflect some of the confusion about the role of such meetings, which had a purpose much more than just information sharing. The absence of other professional meetings to coordinate the community service provision to this family may have led to the inappropriate expectation that the Strategy Meeting format could or should have filled this gap. 10.2 There were certainly occasions when agencies such as Housing Options, the Children’s Centre and the mother and baby unit, felt that they should have been provided with more information, particularly by CSC or some of the health practitioners. Because the case, in the eyes of CSC, did not meet the threshold for child protection, then they likely perceived their accountability for information sharing to be less at this lower level. However there were certainly occasions when the lack of a continuous service by CSC was linked to the fact that support services were already being provided, so this did bring with it the responsibility to share proportionate information to enable other agencies to effectively provide their services. 10.3 There were occasions when CSC did not feedback to professionals who had referred incidents to them, and this should have been undertaken as part of safeguarding procedures. Also there was a strong sense among some of the community support agencies that their staff most often had to take the initiative to obtain information which was not readily forthcoming from CSC. As an example within the Housing Options service, they reported difficulties in receiving information and updates from CSC, but also recognised that their organisational structure meant that it was less clear to them who had responsibility for chasing up and challenging any perceived lack of shared information. Furthermore, at the time of the Core Assessment, the social worker did not seek information from the range of agencies who held information about the family currently or in the past. In this way other agencies did not have an opportunity to contribute to the assessment and embark on a process of sharing information. The only recorded communication was when the social worker wrote to the health visitor to request information for the Core Assessment, but there was no written response although there were telephone conversations noted to have taken place in relation to this. 10.4 Despite the lack of professional forums to share information and coordinate services, there was a significant amount of professional communication that nevertheless went on, especially between the Children’s Centre, the health visitor and the mother and baby unit, alongside communication with the hospital outreach staff when necessary. For example the IMR in respect of health visiting notes that the liaison between professionals either by letter or telephone was “prolific”. Overall this level of communication was commendable and gave evidence of the commitment of practitioners to work as collaboratively as possible. However this could have been achieved much more effectively if formal processes within the framework of Child H as a “child in need” or as a “child in need of protection”. 10.5 There was one occasion when the Children’s Centre outreach worker was made aware of unconfirmed information that the father may have a violent background, and shared this with the health visitor. This was appropriate as they often undertook joint home visits to 40 see the father and the baby. When the outreach worker tried to get this information confirmed by CSC, the duty worker refused to do this and said that as the information was hearsay, that they would make no record of the enquiry. As the CSC IMR has found no record of this conversation on their files, then it was apparent that no record was made. As a minimum however this contact should have been recorded, and the response by the social worker was generally very unhelpful and not made in the spirit of effective multi agency working. It could be argued that the Children’s Centre needed confirmation of some detail of past offences as they were endeavouring to provide an important service to the father as the sole carer of a baby, and so it would have been relevant to have shared proportionate information in order to support that work. 10.6 This case featured occasions when inappropriate assumptions were made by practitioners about another agency’s actions or the delivery of services. The main example of this was when the CAF was not progressed because of the inaccurate assumption about CSC involvement. Additionally there was some misinformation contained in records which again led to assumptions being made about the status of services to the family. For example, the GP records noted incorrectly that the father was “under child protection” and also that “Dad had custody” of Child H. Whilst the GP IMR identified that they were given no explanation by other agencies about the change of “custody” from the mother to the father, in effect it was an important enough issue for the GP surgery to have made enquiries. Whilst the GP surgeries did have some involvement with the parents and some limited contact with Child H, in effect they were quite peripheral to the work that was going on in the community, and although the father’s GP surgery was in receipt of information from Child H’s hospital admissions, and could have linked this with the information they held about the father, there was no action by way of follow up. There was also no evidence of regular communication taking place between the health visitor and the GP or vice versa. It was concerning that whilst the GP surgery could have played an important role as part of coordinated services to the family, they remained outside any multi agency working. This would clearly be unhelpful for effective safeguarding practice in the future. 10.7 As referred to previously, there were some issues about the perceived inadequacy of information sharing and liaison between the Midwifery Service, the Hospital and also with the health visitor. However, a new “Liaison Pathway”7 has recently been developed to support and improve liaison between midwives and health visitors, so it should address some of the shortfalls in communication which occurred in this case. 10.8 There was considerable involvement in out of hours services by the Police, CSC (via the EDS) and health services, and generally the communication was effective between the relative agencies and in the process of informing their counterparts who worked in office hours. Inevitably because of the limited staff resources available out of hours, then there were some challenges in terms of inter-agency communication not always being timely or detailed, but generally the overall response to Child H’s needs out of office hours, was effectively undertaken. 7 Midwifery – Health Visitor Liaison Pathway – Wiltshire, Swindon and N. E. Somerset – March 2012 41 11. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded? 11.1 There was clearly the potential within this family that the issue of race and ethnicity could have had an impact on the parent’sindividual self-esteem, upon their relationship or upon their parenting capacity. The parents had different cultural and racial backgrounds, and the Core Assessment should have explored issues of cultural identity and its potential impact upon both parentsand their parenting abilities. Similarly, interventions by other professionals should have given attention to these issues 11.2 Overall therefore, the issue of race and identity was given scant regard by agencies working with the family when it had the potential to be a significant issue. 12 The role of management and supervisory practice 12.1 In terms of paediatric involvement and more generally in relation to Child H’s hospital attendances, then it was considered by the respective IMRs that there was appropriate management oversight and accountability for decision making. Generally their actions were in line with procedural expectations and they provided a proactive and effective response to Child H’s needs. 12.2 It was apparent that for a number of agencies, the fact that Child H’s circumstances did not formally reach a child protection threshold, meant that the case was not raised in supervision, and management support was not sought to advise on interventions with the family. However, had there been greater management oversight at the early stages of intervention, this might have ensured the completion of a CAF and of a move to establishing a Team Around the Child process. In fact the issue of inappropriate assumptions again featured in this respect with for example the midwife not mentioning the case to supervisors because there were no adverse concerns and because of the expectation of a CAF being completed by others. Although the complexities of the Pre CAF and CAF processes at the time make it difficult to identify which agency or practitioner needed to progress this work, in effect no such initiatives were instigated, and there should have been some level of management accountability for this failing. At a later date, when concerns began to accumulate, then the health visitor did appropriately seek advice from the safeguarding nurse 12.3 In respect of CSC involvement, senior management were not involved until the serious injuries occurred which led to Child H being hospitalised and then placed in Local Authority care. However there should have been much greater involvement of first line managers than otherwise happened in this case. There was insufficient management oversight which allowed such a poor quality Core Assessment to be completed and which very much set the tone for future involvement, particularly with the father being viewed as such a positive figure. If the social worker had been challenged about some of the findings and asked to provide the evidence for these or for any contra indicators, then the frailty of the analysis would have been exposed. The way in which the Core Assessment was written presented challenges for management oversight for instance when it stated that the father’s past 42 offences were not relevant, without the report giving the detail of what these offences were. 12.4 Similarly, there was insufficient management oversight and accountability for the final contact that was made to the relative’s home following a clear action from the November Strategy Meeting, which not only failed to see the child but also failed to see the father. It was very concerning that there was no recording of how a decision was made not to follow up this abortive visit or to reconvene a Strategy Discussion. Overall, the CSC IMR identified that supervision arrangements were “not adequate” due primarily to organisational issues and that the case suffered from the lack of a consistent manager to overview the work being undertaken. 12.5 From a Police perspective, the IMR commented that staff resources did not allow for each Strategy Meeting/Discussion to be quality assured or have management oversight for the decisions reached, but that this was not seen as a deficit and there was consideration that the Police staff involved were nevertheless sufficiently trained to make appropriate decisions or to escalate to more senior management as necessary. Because no Sec 47 investigations were commenced following any of the Strategy Meetings/Discussions then no referrals were passed to the Police Child Abuse Investigation Team so in this way there was no specialist child protection input to the process. However some actions which the Police understood were due to follow Strategy Discussions, such as the ICPC and the “parenting assessment”, did not in fact take place. In particular, it appeared as though there was no management oversight which picked up the lack of an ICPC taking place and no enquiry therefore made of CSC in respect of this. 13 Organisational and contextual issues 13.1 The IMR for CSC has identified that the internal organisational changes being made in 2011, in particular with the Referral and Assessment teams being centralised and combined under one manager, had an impact on the quality of service delivery. As part of staff changing their location and preference of which type of service provision that they wanted to work in, the IMR stated that the skills of the staff within these Referral and Assessment teams did not fit well with the requirements and challenges of this area of social work practice. 13.2 Additionally the role of assistant team manager (ATM) in Wiltshire, which in effect is the first line manager role, was compromised in that only two of the five ATM posts were operational during the latter half of 2011, meaning that there was a lack of consistent supervision practice, as well as insufficient capacity to provide the necessary oversight and quality assurance of practice. 13.3 Whilst the Annual Children’s Services Assessment by Ofsted in July 2011 identified that children’s services “perform well” and that the contact, referral and assessment arrangements were “satisfactory”, it did identify areas for development. However the Safeguarding Inspection conducted in early March 20128 found that safeguarding practice 8 Wiltshire Inspection of safeguarding and looked after children - Care Quality Commission/Ofsted – published April 2012 43 was “inadequate”, and of particular relevance to the practice issues in this case, identified inadequacy “in the level and robustness of managerial oversight and decision-making” and that this lack of challenge led to poor quality core assessments. Whilst this case did not reach the child protection threshold, which was the area of practice that this inspection primarily focussed on, the findings in this case nevertheless support the analysis of poor quality assessments and insufficient management oversight as being key factors in thwarting the child protection threshold being reached. 13.4 As a result of the Inspection findings, an Improvement Plan has been drawn up and at the time of writing, is being established with a range of actions accompanying it. This work will therefore need to be born in mind in the consideration of recommendations from this SCR so as not to create unnecessary duplication. For example, a number of areas of improvement identified by Ofsted as priority actions would reflect similar learning from the professional practice in this case. 13.5 Whilst there were staffing difficulties in both the health visiting and the midwifery service, it was not considered that these impacted on the services given to the mother, the father and Child H. The fact that the NICU and the midwifery services are managed by different health organisations, was nevertheless considered to have created communication difficulties between respective practitioners within this case, and potentially will continue to do so in the future unless it is addressed. A new Health Visiting Strategy was implemented in October 2011, and the IMR author considered that this “may well have impacted on staff and caused some frustration and feelings of disempowerment” at the time. 14 Lessons Learned and areas for development The IMRs have separately identified some important lessons and areas for development, although some of the key lessons learned when considering the analysis of individual and inter agency practice in this case can be summarised as: - 14.1 It is potentially dangerous practice for professionals to make assumptions about the actions or decisions of other agencies or other practitioners, without checking out the accuracy of that assumption with the other agency involved. 14.2 To take an optimistic stance in respect of parenting by a professional, and to not support this with objective evidence, or to not identify contra indicators, will inevitably compromise the assessment, and potentially retain a child in an at-risk situation. 14.3 Being sensitive to a baby’s needs should be reflected by practitioners seeing the infant as often as possible and recording and commenting on their presentation, behaviours and relationships and responses with carers. To not do so will mean that interventions are not child focussed and will leave practitioners unable to have any understanding of the child’s lived experience. 14.4 Organisational restructuring can have the impact of disrupting front line services in such a way that the quality of child care practice can be significantly compromised in the short term. 44 14.5 If terminology used by professionals is ambiguous, such as “welfare visit”, “discharge meeting” or “parenting assessment” then it will likely mean different things to different professionals and potentially give false assurances that certain actions to address the risk to a child will be or have been undertaken. 14.6 Initial and Core Assessments which fail to seek information from other agencies and practitioners known to have worked with the family, will lead to an incomplete analysis of parental strengths and weaknesses, and therefore compromise the validity of any findings. 14.7 For any professional practice to be effective, first line management oversight and quality assurance processes need to be consistently applied. When this does not occur, any shortfalls in direct practice will not be picked up, with the likelihood that there will be a significant risk of safeguarding concerns going undetected. 14.8 In the early stages of this case, the explicit support by CSC for the father to retain care of his child, was not only misinterpreted by the parents regarding the formal authority of this, but it also generated confusion between professionals which impacted on the later management of the case. Professionals must therefore be completely clear about the messages given to parents regarding the actions being undertaken on their behalf, checking out what the parents understand about the status of any support and if possible to put this in writing, so as to avoid any later possible confusion or misinterpretation. 14.9 For practitioners not to take account of racial and cultural issues will not only undermine any assessment of need or risk, but giving the issue insufficient sensitivity and attention may adversely influence the quality of any professional relationship that can be developed with a parent or child. 14.10 If escalation processes are not used by practitioners and managers to effectively challenge the professional practice or decisions of another agency, then poor or inappropriate practice will go unchallenged and potentially leave a child in an at-risk situation. 14.11 If agreed threshold arrangements are not employed in respect of early intervention services such as CAF, then this will significantly impact on the types of services, or lack of them, which will follow. Whilst Munro speaks of the “child’s journey”9, in this case Child H’s “journey” took the wrong course from the outset. 15. Recommendations 15.1 Wiltshire LSCB needs to be assured by its constituent members and via reports from the Safeguarding and Improvements Board, that they have fully considered the individual “lessons learned” identified above within this Serious Case Review and accommodated them where relevant within the “Improvement Plan” identified from the most recent Ofsted safeguarding inspection. 15.2 The LSCB will need to commission an audit of the use, effectivenessand understanding of Strategy Meetings among agencies and their staff, and based on its findings, issue clear 9 The Munro Review of Child Protection – The Child’s Journey – July 2011 45 direction and guidance about their purpose, criteria and management in order to establish efficiency in their pivotal role as part of safeguarding practice. 15.3 The recently published Teenage Pregnancy Policy needs to reviewed in the light of the findings in this case, particularly in respect of the role of the CAF, and then the Policy’s use and effectiveness audited in order to demonstrate that it is enhancing service delivery. 15.4 An audit should be undertaken to identify that effective communication is taking place: - -between agencies at the time when Initial and Core Assessments are undertaken, - or when referrals are made to Children’s Social Care and feedback of the outcomes of actions needs to be made back to the referrer. 15.5 Multi agency guidance needs to be developed and issued in respect of Hospital Discharge Planning Meetings, in particular regarding the criteria for their use when children are identified in addition to any medical needs as being vulnerable or at potential risk of significant harm. The guidance should identify who should attend such meetings, and how decisions which are made or actions agreed, are recorded and monitored. 15.6 Constituent agencies will need to demonstrate to the LSCB that their staff are sufficiently and effectively trained in order to address the racial and cultural needs of families who they work with, and provide evidence that their service delivery reflects this. 15.7 The LSCB needs to be assured that the threshold criteria for prevention and early help services are clear to agencies and reflect effective multi agency coordination of services and of the effective use of the CAF. Evidence will need to be provided which demonstrates that multi agency forums are operating effectively at the prevention and early help level and that in relevant circumstances, they effectively identify and provide information to support any need to advance interventions to the status of child protection. 15.8 The LSCB needs to be assured by its constituent agencies that they have escalation procedures in place which have been disseminated to all staff who are additionally given sufficient support to be able to use them with confidence when necessary. Ron Lock 21.9.12 |
NC050509 | Injuries indicative of physical and possible sexual abuse of a 7-year-old boy in May 2019. Learning includes: practitioner knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability to address children's needs; when a school records safeguarding concerns in the CPOMS electronic system, used by many schools, to report, record and track safeguarding concerns, they should notify key professionals and record any discussions and plans made between agencies; the need for clear terms of reference for safeguarding teams in schools; seek out information about significant people in a child's life in order to recognise risks posed by some men; information about commissioned services proposed by schools should be provided to parents; designated safeguarding leads should have access to opportunities to develop their practice; well-kept records in schools are vital to keep children safe; professionals need to be supported to remain curious about children's lives. Recommendations for the safeguarding partnership include: assurance sought through the local workforce safeguarding strategy, that agencies provide briefings and access to training supporting culturally competent practice; seek assurance that all professionals, including safeguarding leads in schools, are well equipped to work with diversity, culture and ethnicity in safeguarding work; explore how supervision, team learning, training and programmes can help professionals improve their skills as professionally curious practitioners in relation to relation to 'significant males'; ensure a robust system for quality assuring safeguarding audits and action plans in schools and partner agencies.
| Title: Serious case review – Jacob 22. LSCB: Manchester Safeguarding Partnership Author: Linda Richardson Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Manchester Safeguarding Partnership Serious Case Review – Jacob 22 This report was commissioned and prepared on behalf of the Manchester Safeguarding Partnership Independent Reviewer: Linda Richardson Published 25th May 2022 2 This page is left blank 3 Contents 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 2. The circumstances which led to this review 3. Family Involvement 4. The approach used 5. Parallel proceedings 6. What was known to agencies 7. Significant Dates 8. Analysis of Practice KLoE 1: How well agencies understood threshold criteria and adhered to multi-agency safeguarding procedures? • Immediate response to the discovery of Jacob’s injuries • School’s awareness of Jacob’s previous injuries • The role of Commissioned Service Provider in School1 • The response of health colleagues • Jacob’s immunisation history KLoE 2: What influences may have impacted upon professional-decision-making • Understanding school’s response • School’s understanding of Jacob’s needs • The role and function of Designated Safeguarding Leads (DSLs). • The role of males in families • Professional bias and cultural relativism1 KLoE 3: The extent to which professionals collaborated and worked together • Liaison between agencies • Collaboration between professionals • School’s relationship with CSC KLoE 4: Managerial Oversight and Supervision • Accountability and Governance • Supervision and support for DSLs • Keeping and maintaining records 1 Cultural relativism is the idea that a person's beliefs and actions should be understood based on that person's own culture, rather than be judged against the criteria of for example, the culture and practice within the UK. 4 KLoE 5: Jacob’s voice and the extent to which professionals were curious about his lived experiences • Keeping the child in focus 9. Concluding remarks 10. Summary of Learning Points 11. Recommendations Appendix 1: Agencies represented on the review team. --------------------- Key: Subject: Jacob (not his real name) Mother of Jacob MJ Birth Father of Jacob BFJ Partner of mother PMJ Children’s Social Care CSC Primary School SCH1 Primary School (DSL LEAD) DSL1 Designated Safeguarding Lead DSL2 Designated Safeguarding Lead DSL3 Designated Safeguarding Lead DSL4 Designated Safeguarding Lead DSL5 Class teacher CT1 Teaching Assistant TA1 Commissioned Service Provider CSP CSP1 Social Worker CSW1 Health Visitor Area1 HV1 Health Visitor Area2 HV2 General practitioners GP1, GP2, GP3, and GP4 Practice Nurses PN1, PN2, PN3, and PN4. 5 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews (SCRs) 1.1. From June 2018, under revised legislation2, LSCBs, set up by local authorities, began their transition from LSCBs to safeguarding partner arrangements. LSCBs were required to carry out all of their statutory functions, including, where the criteria was met, commissioning SCRs until the point at which the new arrangements began to operate in their area. 1.2. The main responsibilities of LSCBs at the time this SCR was commissioned were to co-ordinate and quality assure the work of member agencies to safeguard children. The statutory guidance, which accompanied legislation and underpinned the work of LSCBs, set out its expectation that LSCBs should maintain a local learning and improvement framework so good practice could be identified and shared. 1.3. In situations where abuse or neglect of the child is known or suspected and children die or are harmed, LSCBs were required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce any future risk of harm to children. There was an expectation that these processes known, at the time, as Serious Case Reviews (SCRs) were transparent, with the findings shared publicly. 1.4. Manchester Safeguarding Children Board (MSCB)3 commissioned this SCR in September 2019 in line with statutory guidance in place at the time.4 The statutory guidance has now been updated and arrangements for undertaking local reviews where a child has died or been seriously injured have been amended. Local reviews in future will be referred to as local Child Safeguarding Practice Reviews. 2. The circumstances which led to this review 2.1. Jacob is thought to have been around one year old when he and his mother (MJ) moved from Eastern Europe to the UK in 2013. They moved to join Jacob’s father (BFJ) who was already resident in the country. Jacob came to the attention of statutory agencies in May 2019 when he was 7 years old and his mother MJ, and her then partner, PMJ, took him to A&E, with a leg injury. 2.2. Due to significant discrepancies in the accounts given by Jacob, MJ, and PMJ, hospital staff contacted police and Children’s Social Care (CSC) to report concerns about possible non-accidental injury. A further medical examination found Jacob to have a number of injuries indicative of physical and possibly sexual abuse. MJ and PMJ were arrested and charged under section 5 of the Domestic Violence, Crime, and Victims Act 2014. Both adults were remanded in custody and Jacob was accommodated5 by the local authority. 2 Children Act 2004, amended by the Children and Social Work Act 2017, 3 Now referred to as Manchester Safeguarding Partnership (MSP) 4 Working Together to Safeguard Children 2015 HMSO, 5 A local authority has a duty to accommodate a child, when there is no one with a legal responsibility able to care for the child. 6 2.3. Jacob was not known to children’s services but he did attend primary school (SCH1) and agency records indicated a number of absences from school for what appear to be typical childhood ailments. According to medical records, health professionals saw Jacob only occasionally but neither they nor SCH1 recorded any concerns about Jacob’s behaviour, well-being or safety. 2.4. Such were the concerns about Jacob’s injuries, seen in May 2019, that a decision was taken in June 2019, endorsed by the independent chair of MSCB at the time, that the criteria for a Serious Case Review (SCR) was met. It was agreed that the period under review should be from January 2018 around the time when MJ was believed to have started a relationship with PMJ, to May 2019, when the extent of Jacob’s injuries came to light. Agencies were asked to include any relevant background information, which was pertinent to the review. 3. Family Involvement 3.1. The Safeguarding Partnership Coordinator from Manchester Safeguarding Partnership (MSP) contacted MJ to explain the purpose and process of the serious case review. In June 2020, MJ indicated to Jacob’s social worker that she would like to contribute to the review. 3.2. MJ was contacted by the independent reviewer and, in light of Covid 19; a WhatsApp video call took place in July 2020. As agreed with MJ, the independent reviewer took notes of the conversation and these were copied and sent in an email to MJ a few days later. MJ was encouraged to share these with her sister and/or her legal representative. 3.3. The independent reviewer initially established the extent to which MJ was able to converse in English and offered the services of an interpreter, but MJ indicated she was keen to continue the conversation and both parties were able to communicate without any difficulty. 3.4. Comments made by MJ have been incorporated into this report at key points in the narrative. However MJ clearly indicated she felt she had good relationship with staff in school and she did not feel that any professional could have done more to help, as no one suspected PMJ of hurting Jacob. 4. The approach used 4.1. An independent lead reviewer with no links to any of the agencies involved was commissioned to work with a review team. This reviewer was also tasked to write an independent report and identify any findings, which could help to improve practice when working with children and families. 4.2. A review team of senior professionals representing the agencies that were or had been involved with the family was established. Their role was to provide a source of high-level strategic information about their own agency and their involvement with Jacob and his mother through their contributions to the SCR process and the submission of an Agency Learning Report. The review team analysed data, appraised practice, and are in agreement with the content and findings of this report. The agencies represented on the review team are listed in Appendix 1. 4.3. Members of the review team also identified practitioners from their own agencies who knew Jacob and/or his mother and other significant members of the household. The review team met with some of these practitioners to explain the SCR process and held conversations with four professionals from 7 SCH1 and CSP. Whilst, the onset of the Coronavirus impacted upon the direct and ongoing involvement of professionals, the review continued, albeit at a slower pace than planned. 4.4. The review team identified some initial lines of enquiry as the review team began to pull together information about agency involvement. This approach allowed a wider exploration of events rather than a pre-determined focus on very specific issues without understanding what happened, when and why. The review team agreed that key areas to explore were: • To what extent agencies demonstrated understanding and adherence to multi-agency safeguarding procedures and was there a common understanding and application of threshold criteria? • What training and had been delivered and how effective was this? • What were the indicators that abuse was happening and were these well understood? • How did opportunities to understand the child’s lived experience inform professional curiosity and thinking? • Were there any specific organisational challenges to information sharing? • Were there any aspects of diversity that impacted upon the approach to the child and family? 5. Parallel Proceedings 5.1. Jacob now lives with his father and father’s partner and is subject to 12 month Supervision Order. He has supervised online contact with his mother. PMJ is currently serving a custodial sentence for neglect offences against Jacob. 6. What was known to agencies (taken from Agency Learning Reports, the integrated chronology and conversations) Greater Manchester Police (GMP) 6.1. There is no evidence to suggest that GMP were involved with this family or with PMJ prior to Jacob presenting at hospital in May 2019. NCA Pennine Acute Trust-Hospitals 6.2. When Jacob was 3, he was taken to hospital by his birth parents with an injury to his thigh, staff at the hospital were told he had fallen from a trampoline. Jacob was found to have a fracture of his thighbone and was treated with an above-the-knee cast. Agency records indicate there were no concerns or queries about the nature, site, or explanation of the injury. Jacob was seen at follow up visits at the outpatient’s clinic in June and July 2015 as expected6. Jacob was also taken to hospital in September 2016 by his parents with ear pain and fever. He was treated at the time with antibiotics. 6.3. In May 2019, Jacob was taken to the hospital by MJ and PMJ with a leg injury. Explanations for the injury were inconsistent and statutory agencies were swiftly contacted in line with child protection procedures. Health Visiting (Area1) 6 Having made further enquiries about this accident, the review team made a decision not to include this incident in the review. 8 6.4. Jacob was in receipt of universal health services in Area1 where he initially lived with his birth parents. Agency records indicate the family engaged well with HV1. The family moved to Area2 in September 2015. Health Visiting (Area2) 6.5. The Health Visiting team in Area2 received health records from Area1 in September 2015. The first visit to the family by HV2 took place one month later. Given there were no concerns noted in medical records, this was in line with expected practice. Jacob was seen in the presence of his mother, his maternal aunt, and an unnamed friend of his mother. Jacob was noted to have fully recovered from his accident earlier in the year and was described as ‘bright, alert, and playful’. He was heard to speak only his mother’s first language and records refer to the positive interaction that was observed between Jacob and his mother. There was no information recorded about BFJ. Health advice was given about Dentists, GP, and local services. MJ did not have a ‘red book’, the Parent Held Child Health record and according to agency records, when asked, MJ said she was taking Jacob’s immunisation history (from his birth country) to the GP. HV2 referred Jacob for his BCG vaccine. 6.6. Jacob was assessed and was noted not to have any unmet health needs so health visiting took place as would be expected for a child receiving universal health services. HV2 was notified of Jacob’s visit to A&E for ear pain and fever in September 2016 and that he was treated with antibiotics. In line with expected practice, no follow up visit by HV2 was made. School Health Service7 6.7. Jacob was transferred from the Health Visiting service to the School Health Service in February 2017. At this stage, any concerns held by health visitors about the child or family circumstances are usually shared with the school nurse. There were however no concerns shared about Jacob and neither was there any reference to, or discussion about, Jacob’s immunisation history. 6.8. In July 2017, when he was five years old, Jacob received full health screening checks including vision and hearing, both of which were satisfactory. This is standard practice and offered to all children on school entry. Jacob had also taken part in the National Child Measurement Programme (NCMP), which is provided as part of the universal school health programme, his height, weight and body mass index (BMI) were recorded on 3 occasions. Jacob’s height was noted to be above average and his BMI within healthy limits. Jacob’s immunisation history was, unusually, not picked up when he had his health screening checks. GP Practice 6.9. According to the integrated chronology, the family first registered with a Group Practice (GPP1) in June 2014. Jacob’s medical records appear to have been accessed by GP1 in August 2015, 14 months after the family registered with the practice, but there are no notes to suggest any consultations had occurred. The review team were advised that records can be accessed for a number of reasons, data collection, follow up checks, but as GPP1 has now closed and records provide no additional detail, it has not been possible to verify why Jacob’s records were accessed then and on other occasions too. 7 Manchester School Health Service is part of the Children’s Community Health Services Directorate and consists of School Nursing and Healthy Schools and Healthy Weight Project Team 9 It is possible that records were consulted in response to queries about Jacob’s immunisations, but this cannot be verified with any certainty. 6.10. In September 2015, the first letter was sent to the family by GPP1, reminding them about Jacob’s immunisations. Jacob was then 3 and half years old. Medical records were accessed again in November 2015 by Practice Nurse (PN1) but again no entries were made to explain why the records were accessed. One week later, Jacob was seen with his mother by the TB nurse at a local medical centre and was given a BCG vaccine. Upon checking Jacob’s medical record, the TB nurse noticed that Jacob was not up to date with immunisations and promptly and appropriately contacted PN2 at GPP1 to bring this to their attention. There is, however, no evidence that this communication prompted any action by the practice. 6.11. Records suggest it was not until October 2016, that another letter was sent to parents regarding Jacob’s immunisations. Jacob was seen a few days later by GP2 because of his ongoing cough and sore throat. Notes do not specify who brought Jacob to surgery and there are no observations recorded about Jacob. His outstanding immunisations were not picked up at this consultation. 6.12. According to agency records, GP3 telephoned MJ from the surgery three weeks later, but received no answer. A few days later, another letter was sent to the family requesting that Jacob be brought to the clinic for a flu-jab. His immunisations were not mentioned in the letter. In March 2017, medical records indicate that BFJ took Jacob to the surgery because his cough and cold were not clearing up. Jacob was seen at that time by GP4. Notes from the consultation indicate that BFJ was advised that Jacob’s symptoms could be viral but there was ‘nothing to worry about’. One week later, records refer to BFJ bringing Jacob back to the surgery for his immunisations. He was seen by PN3 who recorded that Jacob continued to have ‘loose stools’ and ‘looked pale’; he was not however referred back to the GP, which would, given his age, be expected practice. Jacob’s immunisations were appropriately postponed and another appointment made for two weeks later. The appointment was not kept. 6.13. By April 2018, Jacob, age 6 years old, had still not received his immunisations. According to agency records, the GP practice tried, unsuccessfully, to make contact with MJ again by telephone. Contact was also attempted, to no avail, two months later in June 2018. 6.14. In September 2018, the family was sent a letter informing them that medical services would in future be provided by a different medical practice – GPP2. The review team was able to establish that GPP1 was closed following significant and ongoing concerns reported by CQC8 around quality and patient safety. 6.15. Medical records indicate that Jacob was seen at GPP2 in March 2019 by PN4, when MJ took him to the surgery because of ear pain and, according to agency records, ‘bleeding from both ears’. Jacob was diagnosed with an ear infection. Bi-lateral bleeding from both ears was observed alongside a note in the medical records, which confirmed that bleeding had not happened with any of Jacob’s previous ear infections. There is no record of his immunisations being discussed. 8 Care Quality Commission monitors, inspects and regulates health and social care services. 10 Primary School: SCH1 6.16. Jacob started in reception class in September 2015. In his first year, Jacob’s attendance at school was 91%. School records indicate he had 33 authorised absences due to ill health. This pattern was repeated in Years 2 and 3, although his attendance was then in the region of 94%. Whilst references have been made to holding conversations with MJ about Jacob’s attendance, there are no records, which capture the content of these discussions. 6.17. Jacob was described as a quiet child who initially struggled with language and academic work. Although not assessed, as would be expected, Jacob was placed on the SEN register and received one to one intervention to help with his academic progress. 6.18. In March 2017, Jacob was found during afternoon play in the playground with his trouser and underwear down to the floor. There are no further details provided about this incident and nothing to suggest Jacob’s behaviour raised any concern or that it was discussed with MJ. 6.19. A CPOMS9 entry on February 2019 refers to Jacob being seen at school with a ‘cut/bump’ on the back of his head and ‘red marks’ above and below his eye. Records state that when asked, Jacob said he fell against a cupboard but did not know how the ‘marks’ on his eye had happened. Jacob was apparently then seen by DSL1 and said he had fallen against a wall. School records also refer to Jacob talking about a ‘strong man’ who looked after him when his ‘mummy was at work’. Agency records note that MJ was contacted and told about the injury, which in their view needed treatment. MJ came to collect Jacob from school. It is unclear from records what conversations, if any, were held with MJ about PMJ who was apparently looking after Jacob that morning. The CPOMS entry also referred to Jacob, saying on the previous day, he was hungry and had not had breakfast. He was given something to eat that day by school staff. No further details are recorded. 6.20. In March 2019, school records refer to TA1 noticing ‘blood’ coming from Jacob’s right ear. Jacob was seen by DSL2 but she told the lead reviewer that she did not see any blood only ‘a yellowish red discharge’. According to records, Jacob said that ‘the man’ had ‘stuck a stick’ in his ear and ‘dried blood’ was also seen in Jacob’s other ear and Jacob confirmed the man had ‘put a stick’ in that ear on another day. Records refer to Jacob clearly being distressed and wanting reassurance that MJ would come to take home and that if the ‘man’ came to take him home, Jacob did not want to go with him. MJ collected Jacob from school and later contacted DSL2 to confirm that Jacob had been seen by his GP and had been diagnosed with an ear infection. 6.21. DSL2 spoke with MJ a few days later to ask about Jacob describing her partner as ‘that man’ and was apparently told by MJ that Jacob and her partner ‘do not get on’. MJ explained that her partner had changed rules in the home and Jacob had never settled with him. Records suggest that MJ gave her verbal consent for her details to be passed to the school’s commissioned social work service, so the family could receive social work support from CSW1 around the relationship between Jacob and PMJ. 6.22. According to school records, Jacob attended school every day between 3 May and 24 May 2019 when school broke up for the half term holiday. 9 CPOMS is an electronic system used by many schools, to report, record and track safeguarding concerns. 11 After School Club (ASC) 6.23. Jacob attended after-school club usually three days per week. According to records, Jacob was ‘quiet’ at after school club but this was in line with how he presented at school during the day. Jacob was described as ‘quirky’ although there is no additional information provided to explain more about this description. He was also described as being mischievous at times. Jacob was noted to be always hungry and staff often wondered if he had eaten school lunch. There are no records to indicate that staff noticed any marks or bruises on Jacob which gave rise to concern. 6.24. Jacob was observed by staff at the after school club to have a warm and reciprocal relationship with his mum who usually collected him after sessions. PMJ apparently collected Jacob from school only on 2 or 3 occasions and only when they had been previously informed by MJ. Staff noted there were no outwards signs of affection between Jacob and PMJ on those occasions. Agency records were not available to confirm the dates when PMJ picked him up from school and notes shared with the review team refer only to ‘the man’ who picked him up after school. No other details are provided and the absence of these records is not in line with expected practice. Commissioned Service Provider (CSP) 6.25. CSP is a charity which, under the auspices of a larger organisation, provides a commissioned social work service to schools in the Manchester area and works with families and children who may be experiencing difficulties. 6.26. According to CSP records, CSW1 was invited into school in April 2019, to attend a meeting with DSL2. At the meeting, CSW1 was asked to make contact with MJ to discuss the CSP service and offer to do some work around family relationships, given that Jacob referred to PMJ as ‘the man who lives with us’. The DSL confirmed that MJ had given her consent to SW1 making contact. The record of this conversation does not contain any detail of what information was shared with CSW1 and how much CSW1 knew about the two previous incidents. In speaking with the review team, CSW1 advised that DSL just mentioned that SCH1 felt some work around family relationships would be useful, and no other details were shared or sought. At that stage CSW1 agreed to only make contact with MJ to tell about the services the agency could offer. 6.27. Agency records suggest that CSW1 made at least three attempts to speak with MJ by telephone but her calls were not returned. CSW1 later spoke with DSL and it was agreed that MJ would be invited into school after the half term holiday to discuss what support CSW1 could provide and to obtain MJ’s written consent for any work that might take place. 7. Summary of significant dates (taken from Agency Learning Reports, the integrated chronology and conversations) 2013: Jacob and his parents moved from Eastern Europe and came to live in Area1 June 2015 Injury due to ‘fall from trampoline’ Aug 2015 Family moved from Area1 to Area2 Sept 2015 Jacob started in reception class at SCH1 2017 Relationship between MJ and BFJ ended. MJ met PMJ Late 2018 PMJ moved into the family home with MJ and Jacob. 12 Feb 2019 Jacob found to have a wound at the back of his head. When asked he said he was spinning around and fell. He was noted to also have a ‘red mark’ above and below his eye. MJ was advised to take Jacob to A&E. Mar 2019 Jacob was noticed to have a ‘bleeding ear’ and told CT1 that ‘the man’ had put ‘a stick’ in his ear.’ Dried blood was also seen in Jacob’s other ear. Jacob became distressed when he thought he would have to go home with ‘the man’. Jacob was seen the same day by a Practice Nurse at the GP surgery and an ear infection in both ears was diagnosed. Mar 2019 MJ told DSL2 that Jacob had not settled with PMJ. MJ agreed to DSL2 passing on her details so CSW1 could get in touch to offer support with family relationships, MJ did not respond to messages left by CSW1. May 2019 School broke up for half term holiday. (24th) May 2019 MJ and PMJ took Jacob to hospital (29th) with a leg injury. Multiple and relatively recent injuries were discovered on Jacob’s body, limbs, face and neck. 8. Analysis of Practice 8.1. The purpose of SCRs is to support improvements in safeguarding practice. This means it is not enough just to describe professional activity in a case or to identify elements of practice that were problematic without seeking to understand why they occurred. The analysis needs to explore what systems were in place and what may have influenced professional activity and decision-making at key points in work with the family. 8.2. It is also important to be aware how much hindsight can distort judgement about the predictability of an adverse outcome. Once a serious injury or harm to a child is known it can become easy to look back and conclude that certain actions or the absence of these, were critical in leading to that outcome. The review team was mindful of the dangers of hindsight bias but wanted to understand why certain actions and decisions would have made sense at the time and importantly, what systemic factors in place then, might still be impacting upon practice in Manchester in 2020. 8.3. The analysis is structured around five key lines of enquiry (KLoE), which provided a framework with which to appraise practice. The KLoEs are listed below and an appraisal of practice under each key line of enquiry follows. KLoE 1: How well agencies understood threshold criteria and adhered to multi-agency safeguarding procedures KLoE 2: What influences impacted on professional judgements and decision-making KLoE 3: The extent to which professionals collaborated and worked together KLoE 4: Managerial oversight and supervision KLoE 5: Jacob’s voice and the extent to which professionals were curious about his lived experiences 13 8.4. KLoE 1: How well agencies understood threshold criteria and adhered to multi-agency safeguarding procedures? Immediate response to the discovery of Jacob’s injuries 8.4.1. Manchester Safeguarding Partnership’s procedural guidance for agencies who have concerns about a child’s development, welfare or safety, identifies five levels of need. Levels 1 and 2 relate to needs which can be met by universal services or by a single agency, whilst Level 3 and 4 relate to the needs of children or young people who would benefit from a coordinated programme of support from more than one agency, perhaps using a multi-agency early help assessment. Level 5 is where the local authority receives or gathers information which suggests that a child or young person is at risk of, or suffering from, significant harm due to abuse and/or compromised or absent parenting. 8.4.2. When Jacob was taken to the hospital by his mother and PMJ in May 2019, it was the middle of the half term holiday and Jacob had not been in school since the previous week. As MJ worked, Jacob had been left in the care of PMJ, as had happened previously. 8.4.3. An X-ray showed that Jacob had a fractured tibia. However, the radiographers acted swiftly and demonstrated best practice when they noted bruising on Jacob’s face and became concerned about the conflicting and changing accounts by MJ and PMJ as to how the injury had happened. They shared their concerns about possible non-accidental injury with paediatric colleagues and this led to a child protection referral in line with child protection procedures. The response by the police and CSC was prompt; Jacob was subject to a full medical examination, which found evidence of a number of injuries suggesting physical, and possibly sexual, abuse. Both MJ and PMJ were arrested and Jacob was accommodated by the local authority and placed with foster carers. School’s awareness of Jacob’s previous injuries 8.4.4. As part of the police investigation, various graphic images and video clips were obtained from PMJ’s phone and these included photos and concerning videos in which Jacob was seen being humiliated, sometimes naked and sometimes with what appeared to be excrement on his hands, mouth and buttocks. According to Police records, these images and clips had been sent to MJ but it has not been possible to confirm which had actually been seen by MJ, who indicated that those she had seen did not cause her alarm. 8.4.5. Information presented by CSC to support a rapid review meeting, referred to a video clip on PMJ’s phone, showing Jacob with a ‘black eye and in school uniform’. Further enquiries by the review team confirmed however that these details were in fact incorrect. The information shared by police actually referred to Jacob being seen on a video clip on a Sunday in January, ‘clothed’ but with ‘an injury to the left side of his cheek bone towards the eye area’. The review team was satisfied that the reference made to Jacob wearing a school uniform was a recording error. 8.4.6. There are no entries in school records to suggest that Jacob attended school with a facial injury in January 2019. From information in the attendance register, Jacob was in school every day that month so it would be expected that any injury to the face or around the eye would have been observed and recorded. The video clips and images are, at the time of writing this report, in possession of the Criminal Prosecution Service (CPS) so it has not been possible to clarify these details at present. 14 8.4.7. The medical report seen by the review team describe numerous bruises on Jacob, ‘too many to count’. Some were recent, over his right and left cheek, ears, and shoulder with tiny red spots 10 evident on the skin, other bruises showed evidence of yellowing and so were of differing ages. Some bruises were found in usually protected areas such as ears, trunk and cheeks and some had a clear pattern suggesting inflicted or non-accidental injury. The examining doctor also found right cheek bruising typical of a blow with open hand with pale finger spaces in-between. Both ears had bruising front and back, suggesting a forceful blow or pinch. These features also suggested non-accidental injury. 8.4.8. There were some injuries to Jacob around his genitals and buttocks, but the cause of these could not be established. Although indicative of possible sexual abuse, this could not be confirmed evidentially and without any disclosure from Jacob then or since, evidence of sexual abuse was found to be inconclusive. The review team queried to what extent Jacob’s language and/or learning difficulties may have impacted upon his ability to express himself during his interview with the police and social worker following the arrest of MJ and PMJ. This was considered an important point and the review team queried whether Jacob would have had the language to describe what may have happened to him. The review team was reassured by police colleagues that Jacob’s cultural background and his ability to communicate in English were carefully considered prior to his ABE11 interview. The possibility of using an interpreter had been carefully considered but the interview team were confident in Jacob’s ability to express himself clearly. 8.4.9. Most of Jacob’s physical injuries appeared underneath his clothing and would, it seems, not easily have been seen when at school. Many, although not all, of the bruises appeared to have been inflicted over a period of a week or two and some perhaps only a few days earlier. From records seen by the review team, bruising to Jacob’s face and neck may have occurred in the days since school had broken up, with the exception of four small, fading circular bruises on Jacobs’ jawline, indicative of him being gripped by his jaw. These bruises would likely have been noticeable whilst he was in school. There are however no record of these marks in Jacob’s record on CPOMS and neither CT1 nor TA1 can recall noticing anything to cause concern and indicated that had they done so it would have been reported. 8.4.10. It was confirmed that children undressed for PE in the classroom and DSL1 advised that any obvious bruises on Jacob’s limbs would have been seen and recorded. Neither CT1 nor TA1 can recall seeing any marks or injuries on Jacob which caused concern, although as was pointed out, with a class of 30 + children, unless very obvious and brought to their attention, they would not necessarily have noticed any bruises. DSL2 told the review team that she could remember TA1 expressing some 10 These small red or purple spots on the skin, called petechiae are caused by a minor bleed from broken capillary blood vessels and are associated with bruising and are a known indicator of abuse. British Medical Journal ‘Bruising in children who are assessed for suspected physical abuse’ (2014) 11 Achieving Best Evidence (ABE) interviews are conducted in line with government guidance when police and social workers are investigating allegations of abuse against children. 15 concern about Jacob; TA1 told the lead reviewer this would have been in February when she shared her concern with DSL2 in relation to Jacob’s head injury and recorded this on CPOMS. 8.4.11. There are no records in CPOMS of any bruises or marks seen on Jacob other than those noted on body maps in February and March 2019. The ‘red’ marks seen on Jacob’s eye, when the cut on his head was noticed, did not spark any curiosity as to what these might be or how or if they could be linked to his head wound. There was no discussion with MJ as to whether she had taken Jacob to A&E and no follow up conversation when Jacob did not appear at school the following day. There were no further enquiries by either of the DSLs, as to what may have happened to Jacob, and his head wound and the ‘red marks’ on his eye were just noted in CPOMS and no further action was taken. 8.4.12. School staff spoken to as part of the review, were adamant that they had no reason to suspect that Jacob was at risk of harm by PMJ or by anyone else. The lead reviewer was told that Jacob seemed happy at school and when he occasionally talked of PMJ, he did not give the impression of being fearful of him, TA1 recalled that Jacob would often do press ups to show staff how ‘strong’ he was and it was assumed that this was something that came from PMJ. Staff were unaware that PMJ was not a long standing partner of MJ and said they had no reason to be concerned about his relationship with Jacob. MJ was observed to be a caring parent and her responses to what had happened to Jacob seemed appropriate. Both CT1 and TA1 indicated an understanding of what to do if they were worried about any child in school. 8.4.13. It was clear from speaking with the DSL1 and DSL2 that they understood the process for making referrals, but had developed a very clear view as to which referrals would be accepted by CSC and which they would be advised to manage at a lower threshold level. The review team was given examples by DSL2 of where, in her view, concerns and referrals, with firmer evidence than was apparent in Jacob’s case, had not received the expected response from CSC and it was apparent that this influenced the actions taken. 8.4.14. It was this perception which seemed to have led all five DSLs in SCH1 to conclude in February and in March that CSC would not progress their referral as the threshold for intervention had not been met. This conclusion was reached based on the lack of any prior concerns about Jacob’s well-being or behaviours; the school’s positive view of MJ and her observed warm and caring relationship with Jacob and the ‘plausible’ explanations of the circumstances surrounding Jacob’s head injury, and the fact that MJ had later said his ‘bleeding’ ears had been seen by the GP. Both DSL1 and DSL2 said they believed the ‘stick’ to which Jacob referred, was a cotton wool bud, used to clean his ears; they suggested that Jacob would not know what these were called, hence his description of a ‘stick’. MJ later confirmed to SCH1 that they used these buds at times to clean Jacob’s ears. DSL1 and DSL2 told the review team that they did not have any evidence to suggest Jacob was at risk of harm and neither did they believe him to be so. 8.4.15. There are no records which offer a rationale for the decisions taken or details of exactly when these discussions took place, but the review team was told that all five DSLs agreed that the threshold for a referral to CSC was not met, calling into question their understanding of thresholds and the role of CSC. The responsibility for deciding on the significance and implications of injuries to a child lie with the statutory authorities, and what happened to Jacob - injuries to the back of his head and to 16 the face, - should at the very least have sparked a degree of ‘respectful uncertainty’, especially given the presence of a ‘new’ male in the family who, it seems, was previously unknown to SCH1. 8.4.16. The concept of ‘respectful uncertainty’ should lie at the heart of all professionals working with children where parents are asked to account for their children’s behaviour, or in Jacob’s case, injuries, or absences from school. The term was first used by Lord Laming12 almost two decades ago but it continues to be as relevant to current professional practice as it was then. It reminds professionals of the importance of critically evaluating information given to them by parents and keeping an open mind before accepting, at face value, what they are told. Jacob’s injuries should have led to, if not a referral, then certainly a conversation with colleagues in CSC. 8.4.17. Alongside the incident in February, was Jacob’s distress the following month at the thought of going home with PMJ, a relatively unknown male. This should have prompted the DSLs to question what might be happening at home for Jacob and what it meant when MJ said that her partner and her 7 year old son ‘did not get on’. It was clear to the review team that MJ’s comments were of some concern to DSL2 which is why CSW1 was asked to work with the family and ‘assess and review relationships in the family’. Despite the agreed protocol between SCH1 and the commissioned service that no work would begin with families without a signed contract, CSW1 agreed to make contact with MJ to talk about CSP and the services on offer. This information should have been readily available in school. MJ did not respond to CSW1’s attempt to make contact and this meant that no direct work was undertaken with the family, during what is now known as a critical period, between March and May 2019. 8.4.18. MJ told the independent reviewer that she could not recall any conversations about, or contact with, a social worker from CSP, neither could she remember any conversations with DSL2 about needing help with relationships in the family. MJ told the lead reviewer that PMJ and Jacob got on very well and were always doing things together, and there had been nothing in her life with PMJ which caused her concern which is why she never suspected him of hurting Jacob. MJ said she enjoyed good relations with school staff and Jacob was very happy at school. 8.4.19. Making a judgment call about what might be happening in a family is not easy for any professional working with children. It is especially challenging for school staff that have hundreds of contacts with children every day and yet need to pick up and respond to any cues, which suggest a child might be struggling or hurting. The challenge of making these judgment calls should not be underestimated. The review team understand that all five DSLs in SCH1 discussed whether a child protection referral to CSC was required and this would indicate that there were some questions about Jacob’s care and well-being. The DSLs were however, clearly reassured by the agreement of a qualified social worker - CSW1 - to make contact with the family, but the lack of clarity about the status of that contact and the absence of any written agreement with MJ about what the work should entail meant important information was not shared and this left Jacob vulnerable. 8.4.20. The DSL’s believed that Jacob was not risk of harm and concluded therefore that there was no need to liaise with CSC, or even make contact with the cluster group in their locality to discuss whether a child protection referral should be made. If, as was the case with Jacob, schools do not refer or make contact with CSC, because they believe a case will not meet the required threshold, 12 Victoria Climbié Serious Case Review Lord Laming 17 divergent views will not be explored, DSLs will not be supported and some children may be left at risk. 8.4.21. During the course of this review and in response to learning emerging from it, front door arrangements for agencies to make contact with CSC to explore child safeguarding or safety concerns have been strengthened through the development of an Advice and Guidance Service.. This provides professionals in all agencies with easier access to more informal advice and guidance from CSC. This development is to be welcomed, offering as it does, opportunities to further enhance partnership working, especially between schools and CSC. Learning Point 1: When concerns about children arise and agencies are considering whether a referral to CSC should be made, or are uncertain about next steps, the starting point should always be a dialogue with CSC so agencies can make informed decisions about the appropriate course of action. The role of CSP in SCH1 8.4.22. Like many other schools in the North West, SCH1 contracts CSP Schools Service to provide social work and therapeutic services to pupils in need and their families. Referrals for social work support are made to CSP with the written consent of parents after which the usual procedure is for the CSP worker assigned to the school, to approach the parent and discuss and agree in more detail, a tailored package of support. 8.4.23. It is important to note that, although most of the staff working for CSP are social work qualified, their role in the charity is to offer support to families under Level 1 or 2 and only very occasionally under Level 3. CSP social workers, the review team was told, are not used as a substitute for contact with statutory agencies whose role is to investigate and assess risk of harm to children. Both DSL1 and DSL2 confirmed they did not use CSW1 to assess risk in families, and acknowledged that if CSW1 identified risks in work with families, these would be recorded on a [CSP] Safeguarding Report Form, discussed in detail with the DSL, and shared with the CSP manager. CSW1 would also report directly to CSC. 8.4.24. Although there are no details of the conversation, the review team was told by DSL2 that MJ agreed that some support to help with Jacob and PMJ’s relationship might be helpful and she gave verbal consent for her details to be passed to CSW1. CSW1 advised the review team that without any written agreement, she was only intending to make contact with MJ to explain what support might be available to the family. Whilst, aware that Jacob had talked about the ‘the man in the house’, had an ear infection and a ‘stick’ had been put in his ear, she was not made aware of any safeguarding concerns but neither is there evidence that she questioned this or sought to clarify if Jacob was open on CPOMS, only believing that her initial role was to talk with MJ about her role in CSP. 8.4.25. CSW1 told the review team that she had worked for the school for around five years and had confidence in DSL2 so the request in March to help with family relationships was in line with other work she had undertaken in that school and others. CSW1 told the review team that she would not have begun any work with the family without a written agreement. When MJ did not respond to her overtures, CSW1 was not concerned as not all families respond when first contacted. A 18 discussion with DSL2 in early May, the details of which are not recorded, led to a decision that MJ would be invited into school by DSL2 to meet CSW1 after the school half term break. 8.4.26. CSW1 was very clear about the thresholds for referral to CSC but indicated there was nothing in her conversation with DSL that alerted her to any risk for Jacob and had any such information been shared, she would not only have urged contact with CSC before she became involved with the family, but would also have suggested the school arranged an earlier meeting with MJ. CSW1 was not aware that Jacob was open on CPOMS, which would have highlighted some safeguarding concerns. CSW1’s manager told the review team that CSW1 referred more families to CSC than any other workers in the team and was confident that she both understood thresholds for referrals and consistently worked to multi-agency safeguarding procedures. In this case, however her practice fell below expected standards. 8.4.27. In response to learning from this review, CSP has now improved its systems to ensure that any contact their social workers have with families or are asked to have with families, even to explain the services the agency can provide, are documented regardless of whether the case is ‘formally’ opened to the agency. The response of health colleagues 8.4.28. When Jacob was seen by PN4 in March 2019 because of ear pain and ‘bleeding’ from both ears, medical records indicate he was diagnosed with an ear infection. Whilst ear bleeds can be a characteristic of ear infections, bi-lateral ear bleeding is unusual and can be symptomatic of trauma in response to a physical injury. There is no evidence to suggest that PN4 looked for or noted the presence / absence of other features such as bruising which may have supported or dismissed trauma as a possible cause for the ear bleeds. This was a missed opportunity to query with MJ in more detail, and possibly Jacob, what had happened to cause both ears to bleed. Medical notes do not however indicate any safeguarding concerns and PN4’s diagnosis and treatment appear to have been endorsed by GP5 with whom PN4 consulted. The issue of bilateral ear bleeding and the potential link with injury and trauma has been identified as a learning point from this review which will be taken forward in the agency action plan. Jacob’s immunisation history 8.4.29. As part of the Healthy Child Programme (HCP) Health Visitors and School Nurses are commissioned to promote immunisation and GPs are responsible for the provision of the immunisations. As a child becomes school age, school nurses would expect a one to one handover from the HV if there are any health or safeguarding concerns and sharing information about a child’s immunisation history would usually be part of that discussion. There is no evidence to suggest that HV2 raised Jacob’s lack of immunisation with the school nurse as might be expected or that Jacob’s immunisations history was picked up at his health screening checks in July 2017. MJ was asked to complete a parental questionnaire and answered ‘No’ to the question ‘Has your child had all their immunisations’. Yet, this was not followed up with MJ. 8.4.30. It would be expected that when any child attends for a medical consultation, immunisation histories are checked but it appears this did not happen when Jacob was brought to either GPP1 or GPP2 surgeries. These were missed opportunities and the review team was unable to determine why Jacob’s immunisation history was not addressed by health and medical practitioners. 19 8.4.31. There is no evidence to suggest that MJ contacted the surgery any time to cancel Jacob’s appointments or to inform them she would not be attending. If she did get in touch these contacts are not recorded. Cancelled and ‘did not attend’ appointments are common, especially in GP settings, but without a system to flag up their cumulative significance, Jacob’s medical needs relating to his immunisations, somehow got lost along the way. The absence of any medical records from his home country, clearly led to drift, further compounded by the family transferring from one medical practice to another. However, there is little to evidence that MJ was actively encouraged to have Jacob vaccinated or that either medical practice sought to involve as might be expected, the health visitor or later the school nurse to find out a little more as to why Jacob was not being immunised. 8.4.32. The GP role in safeguarding children who are or may be neglected is underpinned in some practices by alert systems that provide good oversight and tracking of risks to children who fail to attend hospital appointments, miss their immunisations or who are not brought to routine appointments. There is no evidence to suggest that GPP1 had such systems in place. Expected practice would be for Jacob’s immunisations to have been discussed within the medical practice by the wider multi-disciplinary team (MDT)13 to agree a way forward and also to consider the possibility that this could be neglect and possibly a safeguarding issue. Learning Point 2: Without robust systems in place for a child’s immunisation history to be flagged in medical records, the health needs of some children may be overlooked. Where a child does not have an immunisation history, professionals should always explore the reason for this with parents. 8.5. KLoE2: What influences may have impacted upon professional-decision-making School’s understanding of Jacob’s needs 8.5.1. Hindsight bias can seriously affect people's appraisal of a decision when it is followed by an adverse outcome, but the quality of decisions made by professionals in all agencies is inevitably affected by the many influences to which decision makers are subject 14. The review team explored the influences existing at the time to better understand the rationale for the school’s decision not to refer or liaise with CSC about Jacob’s family situation when it would have been appropriate to do so. 8.5.2. SCH1 is a large primary school, with staff managing complex situations and challenges on a daily basis. The school has a number of children from Eastern Europe and are fortunate in that they also have a teaching assistant that speaks the same language as MJ and who, the review team was told, has a good understanding of the culture from the region where she lived. At the beginning of 2020, there were 4 children in school on Early Help programmes, 6 children on Child in Need plans but no children on child protection plans. Given the demographic and the challenges of working with such a large and diverse group of children, the review team, thought this number seemed unusually low. According to agency records, SCH1 made 12 referrals to the MASH team between Sept 2016 and March 2018, 10 of which led to assessments by CSC. This would suggest that not only were most 13 Multi Disciplinary Teams (MDTs) work with GPs to provide enhanced access to health and social care services within a primary care setting. 14 Decision‐making under uncertainty in child protection: Creating a just and learning culture. Munro: Child and Family Social Work (2018) 20 referrals deemed appropriate by CSC, it also brings into question the view expressed by the DSLs, referred to earlier in this report, that many of their safeguarding concerns were not shared by CSC. 8.5.3. Records suggest that Jacob was placed on the Special Education Needs (SEN) register at a time when the SEN Coordinator (SENCO) was on maternity leave. There is no evidence that he was ever formally assessed and it is therefore unclear whether Jacob’s perceived difficulties were to do with a learning difficulty or the fact he was using English as a second language. Jacob was, however, provided with one to one support until he reached Year 3 when focused support was given in small groups with other children. 8.5.4. The review team was told that Jacob was a quiet boy but as his language skills developed he began to talk with staff and play more confidently with other children but there was it seems, never any indication he was troubled. His relationship with his mum was observed as being warm and affectionate and MJ would frequently attend events and parents evenings at school. MJ herself said she believed that Jacob loved school and she appreciated the calls she received from staff to let her know how he was doing. 8.5.5. Despite the significant number of absences from school, the review team was told that MJ always kept the school informed and would contact school by text, phone or occasionally visits to explain why Jacob would not be in school on a particular day. When MJ occasionally reported she had taken Jacob to the GP, she was asked to provide evidence of prescribed medication for Jacob, although this request does not always appear to have been followed up by school. On one occasion records indicate that MJ came into school, with a bottle of Amoxyicillin, showing Jacob’s name but the date was obscured and could not be seen. There is little to suggest that Jacob’s absences, his frequent bouts of colds, coughs, sore throats and tummy upsets, were seen as anything other than the usual childhood ailments. 8.5.6. Staff spoken to as part of the review were asked to reflect on why Jacob’s absences did not generate greater concern. The review team was told by DSL2 that she believed there was a view held by some staff, supported by their experiences of working with other families from Eastern Europe, that parents from these countries were ‘known’ to ‘mollycoddle15’ their children and keep them off school for longer than necessary. If this view did indeed hold sway, then it could explain why Jacob’s regular absences were not considered concerning enough to discuss formally with MJ or refer Jacob to the school nurse, who was in school for a few hours every week and easily contactable. The need to be sensitive to cultural differences is an essential component of best practice but the possibility that Jacob’s frequent absences from school were attributed to a cultural norm, rather than considering other explanations was of concern to the review team. 8.5.7. SCH1 is a primary school with a diverse pupil population. The review team was told that SCH1 prides itself on its cultural competence, being respectful of, and responsive to, the beliefs, practices, and cultural and linguistic needs of the children and families who attend the school. Interpreters are regularly used to overcome any communication barriers and although Jacob began school with very limited English, it appears that MJ could communicate reasonably well and there were never any concerns about communication between school and family. The stereotyped assumption that families from Eastern Europe ‘mollycoddle’ their children would certainly not have helped to raise 15 ‘mollycoddle’ means to treat someone in an over-indulgent and over-protective way 21 concerns about Jacob’s persistent ailments and this, together with the unusually small number of children known to statutory services suggests some work may be needed with staff in school to improve understanding about the impact of stereotyping and bias, especially in relation to safeguarding and vulnerable children. The issue of professional bias is further explored later in this report. Learning Point 3: Without challenge, a practitioner's knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability and willingness to address the health, safety and well-being needs of children. 8.5.8. The school nurse (SN1) in post during the period under review has now left her employment. At the time, SN1 was contracted to work 4 days per week for the Trust and spent 3 hours on a set day each week at SCH1. She would also have been available via email or phone at any time during the working week. Whilst it would not be expected that a school nurse would be aware of every child who was poorly and absent from school, Jacob’s frequent absences due to ill-health could usefully have been brought to the attention of SN1. Certainly, best practice would have been that SN1 was notified when Jacob was ‘opened’ on CPOMS but SCH1 did not appear to have any formal system for discussing, on a regular basis children about whom there were concerns and where input from SN1 could be of benefit. Neither is there evidence that the GP sought to consult with a School Nurse about Jacob’s immunisations. 8.5.9. Jacob’s ‘accident’ in February and his ‘ear infection’ in March were, according to agency records, discussed with MJ. Although not recorded in any detail, the explanations given were seen as plausible. Staff at SCH1, referring to their own experiences of parenting, agreed that given Jacob’s language difficulties, the ‘stick’ to which he referred was probably a cotton wool bud used to clean the discharge from his ears and MJ indicated as much when she was contacted. Jacob’s distress that he would have to go home with ‘that man’ was attributed to him being poorly and wanting to be with his mum. This may well have been the case but school staff made a comfortable ‘fit’ with what they observed and what they were told and by doing so, avoided having to consider another and possibly harsher reality. 8.5.10. A degree of healthy sceptism would have been expected at this point, given the research about risks posed by some non-related males who come to live in families where there are children. Unchecked assumptions can inhibit professionals from focusing on the child and family and this limits communication and exploration about what may be happening for a child in their family. 8.5.11. Although MJ gave the independent reviewer different information, CPOMS records indicate that MJ told DSL2 that Jacob ‘did not get on with her partner’. Jacob’s needs at this point were clearly recognised by DSL2 and were appropriately recorded on the school’s safeguarding reporting and recording system. However, DSL2’s conversation with MJ about the involvement of CSP was not formalised through a signed contract and MJ’s ‘agreement’ was accepted at face value. The ensuing discussion with CSW1 was on a similar ‘informal’ basis and consequently the work that may well have been helpful to Jacob was not prioritised by CSW1 so drift and delays occurred and DSL2 believed contact was being made with the family. 22 Learning Point 4: When safeguarding concerns lead to children being ‘opened’ in CPOMS, key professionals should be notified and any discussions and plans made between agencies, should be formalised and recorded so there is clarity about who is doing what, when and why. The role and function of DSLs 8.5.12. The role of the Designated Safeguarding Lead (DSL) in schools is specified in the Children Act 2004. This states that every school has a ‘named’ DSL who holds responsibility at both a strategic level within the school and on a day-to-day basis and ensures that effective arrangements are in place to safeguard the welfare and safety of children and young people. Whilst the activities of the designated safeguarding lead can be delegated to appropriately trained deputies, the ultimate lead responsibility for safeguarding and child protection, must remain with a named designated safeguarding lead and this responsibility should not be delegated.16 8.5.13. In SCH1, the lead DSL was the Headteacher, DSL1, whilst DSL2 had operational responsibility for managing safeguarding issues on a daily basis. Three other members of the senior management team were also identified as DSLs and had apparently been trained at the required level to take on the DSL role. The review team understood that these five individuals essentially worked as the safeguarding team and were each expected to offer guidance and support to school staff and keep abreast of any safeguarding concerns, which staff recorded on the CPOMS system. 8.5.14. The review team did not find any evidence that a clear system was in place for quality assuring this process or ensuring the checks were done systematically and on a daily basis. DSL1 was of the view that their arrangements worked well and information was shared and discussed appropriately. The rationale for having five DSLs, described in the school’s safeguarding policy, was to ensure decisions could be discussed within the team , thus creating a shared responsibility. The importance, however, of having a lead DSL who makes the final decisions and leads on action is well researched and is explicitly described in the statutory guidance produced specifically for education. 17 Although DSL1 formally held this role, the review team were informed that some safeguarding decisions were delegated to DSL2. 8.5.15. The review team was told that all five DSLs met on a weekly basis as part of the Senior Leadership Team. Safeguarding issues were apparently discussed on a regular basis and were, it seems, always a standing item on the agenda. There were however no minutes of these safeguarding discussions available or provided to the review team and none were recorded on the CPOMS system. Learning Point 5: Safeguarding teams in schools, whatever their size, should have clear terms of reference to provide focus and structure for the ‘team’ and to ensure that decisions and discussions about safeguarding concerns are carefully considered, properly recorded and regularly monitored. A system should also be in place to quality assure records and decision-making. Skills and knowledge base of professionals 8.5.16. The review team was told that all DSLs had received specific training for their role in 2018, provided by the local authority. All staff had also received safeguarding training from an experienced external 16 Keeping Children Safe in Education (2018, 2019) 17 Keeping Children Safe in Education (2019) 23 training provider, well-known to, and quality assured by MSP. The s17518 audit for 2017-2018 was completed by SCH1 in line with statutory requirements and highlighted training needs around the use of CPOMS and monitoring actions when concerns about children emerged. There does not seem to have been an action plan produced following this audit which would have been best practice and would certainly have strengthened safeguarding practice in SCH1. 8.5.17. In the UK, it is not a legal requirement for a parent to have a child immunised. Whilst parental refusal to vaccine, in itself, may not constitute medical neglect, it could be an early indication of neglect and/or that the family need access to support services and healthcare professionals need to be particularly alert to and curious about, a child’s immunisation history. The CQC19 expects all healthcare providers, including GPs, School Nurses and Health Visitors to protect children and young people from harm, and help improve their wellbeing. Current guidance 20 sets out ‘minimum training requirements’, emphasising the importance of maximising flexible learning opportunities to acquire and maintain knowledge and skills, drawing upon lessons from research, case studies, critical incident reviews and analysis, and serious case reviews. 8.5.18. MSP seeks assurances about training from partner agencies through three pathways: Section 11 audits, annual reports from partner agencies and feedback and evaluations of training opportunities through a training report produced by the multi-agency Learning and Development group. In effect, the partnership relies on self-reporting from agencies as to the quality and effectiveness of the training offered to, and taken up by the workforce. The role of males in a family 8.5.19. Men play a very important role in children’s lives and have a great influence on the children they care for or with whom they are in regular contact. Despite this, research and SCRs suggest men are too often ignored by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers and female carers. A repeated finding21 is how often fathers and male figures are absent in recordings, assessments and care plans. When protecting and supporting children, practitioners in all agencies need to proactively assess and where possible engage with all significant men in a child’s life, understanding that some ‘may pose risks, some may be assets to the family, and some may incorporate aspects of both’. 8.5.20. Staff at SCH1 were clearly curious as to why Jacob referred to PMJ as ‘that man’ and the ‘ ‘strong man’ who took care of him when ‘mummy was at work’. The curiosity did not however extend to finding out more about him – even to the extent of checking out his correct name with MJ, which remained misspelt in school records and on CPOMS. The review team had a sense from documents and conversations that school staff held a view that MJ’s partner, whoever he was, not their concern. 18 The S175 section of the Education Act 2002 requires School Governing bodies to carry out an annual review of their School’s Safeguarding practice and to provide information to their Local Authority regarding how the duties set out in the guidance have been discharged. 19 Care Quality Commission (CQC) monitors, inspects and regulates health and social care services. 20 Roles and competencies for child safeguarding training are outlined in ‘Safeguarding children and young people: roles and competences for health care staff (2019) 21 Hidden men: learning from case reviews. NSPCC April 2015 24 8.5.21. There can be a reluctance on the part of professionals in agencies to ask or seek information about partners or other adults who are living in the family and/or who may be significant figures in a child’s life; asking about the status of key relationships can be seen as intrusive. The review team was told by school staff that if the practice of checking out family relationships and who is who in families was to be adopted, they would be altering records on a weekly if not a daily basis. However, this is less about repeatedly changing school records, rather it is about knowing what is going on in a child’s life and being aware of the well-researched risks that are posed to children by some ‘new’ or relatively unknown partners or adults in families, some of whom can wilfully inflict physical and sexual harm on children with whom they have contact. 8.5.22. It cannot be known that if SCH1 had sought to discuss MJ’s partner with MJ, Jacob’s abuse at the hands of PMJ, could have been avoided. However, had more information been gathered about his relationship to Jacob and there had been greater curiosity about his role within the family, staff may have been better equipped to talk more purposefully with Jacob about what might be happening at home. Learning Point 6: If professionals in contact with children do not purposefully and intentionally seek out information about who are significant people in a child’s life, the specific risks posed by some men are more likely to go unrecognised and this will leave some children vulnerable. Professional Bias 8.5.23. Whilst staff were curious about why Jacob did not use PMJ’s name, they were less curious about PMJ himself and his role within the family. Professional curiosity is the capacity and communication skill to explore and understand what is happening with an individual or family. It is about enquiring deeper and using proactive questioning and challenge and understanding one’s own responsibility and knowing when to act, rather than making assumptions or taking things at face value. 8.5.24. The term ‘rule of optimism’ is used to describe the tendency of professionals working with children to favour the most positive interpretation of a parent or adults’ behaviour. This was evident when SCH1 accepted MJ’s explanation about Jacob’s head wound in March 2019, even though she was not present at the time and there were inconsistencies in the accounts provided by PMJ and Jacob. MJ’s description that PMJ had probably focused more on clearing up the coffee that Jacob had spilt, rather than checking to see if he was OK was readily accepted by SCH1 and was recognised and described as a ‘male thing’. 8.5.25. Given the nature and location of Jacob’s injuries – one on the face and the other on the back of the head, Jacob’s response and the involvement of an unknown male in the household, school staff should have demonstrated greater curiosity about PMJ, but were it seemed reassured by MJ’s response in coming into school and offering an explanation about what had happened. When Jacob on another occasion did not want go home with ‘the man’ staff assumed that he wanted his mum because he was poorly. This may well have been the case but at that time, given what had happened only 2 or 3 weeks earlier, staff should have been alerted to other possibilities and explored the extent to which they were willing to acknowledge some uncomfortable warning signs. 8.5.26. The review team was told that Jacob was very attached to his mum and the affection between the two was evident. MJ was described as always pleasant and cooperative with staff and was able to converse reasonably well in English; she apparently always attended school activities. DSL1 and 25 DSL2 agreed that, on reflection, this possibly drew them away from any thoughts that Jacob might be at risk from unsafe parenting. The review team was told that there was never any evidence to suggest that MJ avoided contact with school and it was never considered a possibility that Jacob was being kept off school to avoid scrutiny of any bumps or bruises. The view that MJ was being overly protective of her son, if this view did indeed exist, would certainly have influenced staff into believing that mum was very much a protective factor. Research22 suggests that initial impressions of a parent, such as whether they are ‘cooperative and responsive’ influences the perceived engagement by the parent and this can reduce a professional’s perception of risk leaving children unseen and unheard. 8.5.27. A key theme in the existing research on professional reasoning and judgement is a tendency towards confirmation bias where professionals arrive at a conclusion about an individual and fail to see evidence, which challenges that initial view. The review team acknowledged that in a busy school, with lots going on and a reasonably responsive parent, who was cooperative and involved in school activities, staff, without any challenge, could be less likely, to adopt a questioning approach and therefore continue to take what they were told by MJ at face value. Learning Point 7: A cooperative and responsive parent has considerable power to disarm and distract professionals from exercising professional curiosity and questioning what may be happening a family and this can leave children at heightened risk. 8.6. KLoE 3: The extent to which professionals collaborated and worked together Liaison between agencies 8.6.1. Multi-agency working is about providing a seamless response to vulnerable children and their families. Jacob was in receipt of universal services and seen regularly by school and occasionally by health colleagues. 8.6.2. Given the number of absences from school on health grounds, 33 in Year 1, 15 in Year 2 and 18 in Year 3, expected practice would have been for SCH1 to make contact with their school nurse to establish if Jacob had any ongoing health needs which were not being met. This did not happen as SCH1 were reassured by MJ always keeping the school informed Jacob about why he was not at school and Jacob’s school attendance did not meet the threshold for monitoring absences. Jacob was under regular review through the SEN process and did not, it would seem, present as a ‘poorly’ child. 8.6.3. School nurses deliver universal and targeted services working across education and health, providing the link between school, home, and community. They are responsible for delivering programs to improve health outcomes for school age children and young people aged 5-19. This includes school entry screening and immunisations, therefore had contact been made with SN1 by SCH1 or by GPP2, Jacob’s immunisation history would undoubtedly have been highlighted. 22 Making Threshold Decisions in Child Protection: A Conceptual Analysis. Platt and Turney (2013) 26 8.6.4. The role of the school nurse has changed significantly over the last decade. Research23 suggests that the role is exceptionally diverse, and many have described the service as being stretched, over burdened and under resourced with most of their work focusing on safeguarding and child protection. However, there is no evidence to suggest in this case, that SN1 was unavailable and although not able to contribute directly to this review, there is little to suggest any attempts were made by SCH1 to make contact with the school nursing service, or that SN1 was asked to make contact with Jacob and MJ. 8.6.5. As part of the Healthy Child Programme (HCP)24 Health Visitors (HV) and School Nurses (SN) are commissioned to promote immunisations which GPs provide. When Jacob moved into the Manchester area, expected practice would be that the GP shared ‘movement in’ information with the HV and when Jacob attended school, this information would be shared with the SN. There is no evidence of this in the HV or SN records and the review team was unable to determine why this information was not shared. It would have been helpful if the medical practitioners when trying to fix up appointments for Jacob’s immunisations had made contact with HV1 and later SN1 to find out whether they were aware of the family and were able to offer any insights into Jacob’s situation. Had there been any communication between the GP surgery, HV1 or HV2 and SN1, Jacob’s immunisation history would have emerged. The review team was unable to clarify exactly why contact was not made with SN1. Learning Point 8: The significant changes in the remit and function of school nurses together with an overwhelming demand for their service may have left some professionals less clear about the valuable service these professionals continue to provide and the additionality these roles bring to multi-agency working. 8.6.6. CSW1 had worked with the school for almost 5 years and working relationships were described as good. The review team understood that the commissioned service is used to provide a support service for children and families and although the service, as mentioned previously, is not intended to provide supervision to staff in school, advice and guidance is occasionally sought from CSW1, especially when CSC referrals are being considered. The review team understand the work undertaken by CSW1 was discussed with the DSLs at termly review meetings. Records from the termly review in April 2019 refer to CSW1 making ‘contact with [MJ] in Year 2 to offer parent’s support’. 8.6.7. Speaking with the review team CSW1 reflected that with hindsight, Jacob’s reference to ‘that man’ and MJ’s comments about him never settling with PMJ should perhaps have ‘rang alarm bells’. When CSW1 was unable to make contact with MJ over a period of several weeks, this did not raise any concerns for CSW1 or DSL2 but for different reasons. CSW1 was not concerned about non-contact because her initial task was only to talk with MJ about CSP1 services. CSW1 was also aware that it was not unusual for families not to respond immediately to initial contacts even when they had agreed for their contact details to be passed on. 23 BMC Nursing s’ perspectives on the role of the school nurse in health education and health promotion in England: a qualitative study (2016) 24 Manchester Local Care Organisation (MLCO) Document 2018 – “Communication between General Practitioners and Health Visiting Guidelines 27 8.6.8. DSL2 was unaware, at least initially, that MJ was not responding to CSW1 but even so, having discussed the family with CSW1, she was reassured that CSW1 was ‘involved’ and was attempting to make contact. Whist there was very clearly mutual respect between DSL2 and CSW1, the informality of this arrangement meant that no one held responsibility for progressing work with the family. The absence of any clear plan, focus or agreed timeline meant that no work was undertaken with the family or Jacob by any professional during the 8 weeks following MJ’s assertion that PMJ and her son ‘did not get on’. The circumstances which led to the involvement of CSW1 was recorded on CPOMS and discussed with other DSLs, the agreement should however have also been overseen by DSL1. 8.6.9. The dilemma of how to engage with resistant families whilst also maintaining a critical focus on whether parental avoidance is happening is found in research25 and suggests that professionals can often place too much reliance on ‘knowing’ the parent and fail to consider that families can be resistant to contact from professionals and are able to develop skilful strategies for keeping them at arms length. DSL2 and CSW1 did not consider the possibility that MJ may have deliberately been avoiding contact with CSW1 even although she appeared, in the words of DSL2 , to have been ‘open and honest’ about Jacob and PMJ and appeared keen to receive support to improve the relationships in the family. MJ’s lack of response to CSW1 was not seen by either professional as in any way significant and highlights the problems that can occur when the nature and status of agreements about interventions are unclear. 8.6.10. The reason for the involvement of CSW1 was not as well considered as it might have been and the lack of any signed agreement by MJ allowed work with this family to drift. Without any clearly defined plan there was no ongoing focus on what was happening in Jacob’s life but the apparent co-operation of MJ and her willingness to meet with CSW1 clearly provided some reassurance to DSL2, an issue already highlighted in Learning Point 7. Learning Point 9: Where schools propose parents engage with any of their commissioned services, clear information about that service should be provided by the school so parents can make an informed decision as to whether they wish to engage with that service and for what purpose. Any agreement should be captured in a written contract. School’s relationship with CSC 8.6.11. SCH1 described their relationship with CSC as good, with DSL2 having regular contact with colleagues in that agency. There was an awareness of the wider pressures on the front door of children’s services which in SCH1’s view meant that sometimes children and families did not get the help they needed early enough to prevent difficulties escalating. SCH1 considered they were fortunate in having their own resource, provided by CSP, to provide early help to families at levels 1 and 2. Nevertheless, there was still a frustration that when SCH1 had shared concerns with CSC, the responsibility for working with the child and the family had been passed back to them. In the light of that experience, SCH1 considered they acted appropriately by commissioning CSW1 to work with the family. 8.7. KLoE 4: Managerial Oversight and MASH 25 Ofsted, 2008, Evaluation of 50 SCRs 28 Accountability and governance 8.7.1. Governing bodies and proprietors in schools are required to have a senior member of the board take leadership responsibility for their school or college’s safeguarding arrangements and ensure that a senior manager within school has lead responsibility for safeguarding and child protection, i.e. a senior DSL.26 In SCH1, the Headteacher held this role. The school was inspected by Ofsted in November 2017 and was rated as ‘Good’, with effective safeguarding arrangements in place. 8.7.2. In 2018, CSW1 was asked by DSL1 to sit on the board of governors, which, with the support of her line manager, she agreed to do. Although she did not hold the role of lead safeguarding governor, she nevertheless brought her social work background, knowledge and expertise to her governor role and in any other circumstance, such an individual would be a welcome addition to any board of governors. However, the obvious conflict of interest of CSW1 also being a commissioned provider to the school was not as well understood as it might been even though it had been explored by CSW1’s line manager, the agency HR manager and DSL1. In effect this meant that as a governor CSW1 was quality assuring safeguarding arrangements in school and her own practice. The situation has now been rectified and CSP have ruled that staff working in schools cannot sit on the board of governors of any school commissioned by the agency. This issue did however, raise questions for the review team as to how well governors understood their safeguarding responsibilities and, notwithstanding the Ofsted report from 2017, how well they were able to discharge these with confidence. Learning Point 10: Governing bodies in all schools have a responsibility to ensure they are well equipped to discharge their safeguarding responsibilities and that robust systems are in place to quality assure safeguarding arrangements in their school. Supervision and support for DSLs 8.7.3. Although an analysis of schools in Manchester who completed the 2018/2019 s175 safeguarding audit indicated that 90% of staff received supervision, the review team was made aware that the DSLs in SCH1 did not receive any formal supervision sessions from DSL1. Neither did DSL1, as the lead, have access to supervision or support around her own practice and decision-making. School staff have more access to children than any other social care provider and are well placed to pick up on mental health issues, trauma, neglect, abuse and generally safeguard children. Whilst other emotionally intense professional roles such as social workers and health care practitioners have structured opportunities to reflect with an experienced senior colleague, on their practice and decision-making, the support needs of DSLs have not always been recognised. 8.7.4. Supervision ensures cases don’t drift, maintains the focus on the child, and helps professionals to find out the evidence base for assessment and intervention. Whilst forthcoming statutory guidance does not, worryingly, refer to the importance of supervision for DSLs in schools, there is nevertheless an acknowledgement by well-informed professionals, that DSLs should be given the time, resources and support to effectively discharge their safeguarding responsibilities. There is a Safeguarding in Education team in Manchester who provide this support to Manchester schools and who facilitate meetings for DSLs, but SCH1 had not availed themselves of the support offered. 26 Keeping Children Safe in Education 2019 29 8.7.5. The review team was struck by the impact on DSL1 and DSL2 of what happened to Jacob and their sense of bewilderment that, despite their training and considerable experience, they had, on this occasion, not believed that Jacob was a child at risk of harm. Both professionals were able to helpfully reflect on this and concluded that they had, with hindsight, accepted MJ’s explanations too easily and had not considered Jacob’s life from his perspective as well as they might have done. It should be noted that the review team were advised that actions of DSL1 and DSL2 to seek the involvement of CSP without reference to CSC were supported by other DSLs in school. 8.7.6. The role of CSP in supporting families in SCH1 is to be welcomed, but it might be helpful if the role is more clearly defined as access to the ‘CSP social worker’ may be seen as a shortcut to help DSLs with their decision-making and assessment of ‘risk’ in families. This is not appropriate and is not in line with the service level agreement seen by the review team. CSW1 confirmed she has regular supervision with her manager who has oversight of her work and case records. As she did not get to meet MJ or Jacob, her manager was simply informed that she had not been able to make contact with the family and no further discussions took place around her role with the family or the purpose of her involvement. 8.7.7. CSP has now strengthened their referral process to ensure that the information shared is detailed and accurate and there is greater clarity around roles and respective responsibilities and the purpose of any contact with families is discussed in supervision. These changes will, going forward, strengthen existing relationships between SCH1 and CSP and lead to improved outcomes for families. 8.7.8. All education staff struggle at times to deal with the complexity of their pupils’ lives, alongside the requirement to achieve the required academic outcomes and the subsequent workload and associated stress that comes with that. However, some roles, such as DSLs need to make difficult decisions and are more likely to regularly encounter incidents of high emotional impact, this means that supervision for these key roles is essential if children are to be well-protected and the need for early intervention responses recognised. 8.7.9. During the lockdown period, the Safeguarding in Education team have been consulting with DSLs on a weekly basis to offer support and pick up any complex safeguarding issues. Such an approach is to be welcomed and clearly recognises the support that DSLs require so that they can discharge their safeguarding responsibilities effectively. Learning Point 11: Without systems and formal opportunities to reflect on their practice and decision-making and be helpfully challenged about their thinking, human errors are more likely to occur. Best practice means DSLs have access to opportunities to develop their practice, and be both challenged and supported in relation to the professional judgements they make. Keeping and maintaining records 8.7.10. There are no records in either CSP or SCH1, which capture in any detail the discussions held between DSL2 and CSW1. The review team understand from CSW1 that although she kept notes for herself as to the work required, she was unable to upload these onto Lamplight27 because there was no consent form or referral to ‘open’ the case on the CSP system. The CSP procedures seen by the review team did allow for contact to be made with families without this document although 27 This is the recording system used by CSP 30 social workers were required to obtain signed consent forms before any actual work began. In this respect CSW1 did not work outside of her agency’s procedures. 8.7.11. However the system in place at the time provided no means by which the details of initial pre-referral contact with families could be recorded without the family being ‘opened’ on the system and the only way of ‘opening’ the case was via a signed consent form. This effectively left some contacts with family’s undocumented and not subject to managerial oversight or discussion. 8.7.12. CSP have now changed their procedures to ensure that all initial or informal conversations about families are documented and their recording systems have been adapted to make this possible, ensuring that any amendments to the system are GDPR compliant. Case file audits have also been strengthened to ensure that all relevant and significant information is recorded on case files. 8.7.13. Well-kept records are essential to safeguarding children and young people. It is easy to overlook the significance, value, and complexity of case recording, and to treat it merely as an administrative task. Good record keeping, as a key aspect of a school’s accountability to children and their families help DSLs meet their responsibilities to respond appropriately to concerns for children. The review team was told that reporting concerns is the responsibility of every member of staff and some training had been given to staff about the CPOMS system, introduced in 2017, to ensure they know when and how to record concerns about a child, however small or apparently insignificant. 8.7.14. CPOMS is an established and effective case management system if used properly. It allows for staff to add any concerns to the system, within a restricted area and for the DSL to ensure that all entries are noted, addressed and actions, and the rationale for these, recorded. The records kept in relation to Jacob, where they existed were minimal. PMJ’s first name was spelt incorrectly in all the entries, implying that no one had been curious enough to find out some basic information about this individual. The absence of any records of meetings with MJ or minutes of the weekly DSL discussions, which can easily be stored on the CPOMS system, demonstrated practice that fell well below expected standards. This should have been addressed by DSL1 whose responsibility it was to maintain managerial oversight of the records on CPOMS, and to be assured that decisions and actions were appropriate and/or followed through. 8.7.15. The need for the lead DSL to monitor records and reflect on what is or might be happening to children about whom there are concerns is a key aspect of the lead DSL role, providing as it does, a check and challenge function which helps to avoid professional complacency and drift. The review team found no records or evidence of a system, which demonstrated that the lead DSL regularly monitored CPOMS28 entries, but neither was there evidence that the safeguarding school governor had oversight of how well the CPOMS system was being used. The roles of the 5 DSLs in SCH1 were not well defined and therefore, responsibilities of who was doing what in terms of recording were not clear. 8.7.16. Despite a very positive Ofsted report in 2017, which stated that the leadership team in SCH1 ‘has ensured that all safeguarding arrangements are fit for purpose and records are detailed and of good quality’, the review team are of the view that in this case, record-keeping did not meet expected standards. Practice around recording practice has however now been reviewed and strengthened 31 with staff being skilled-up to make better use of CPOMS and systems introduced to ensure concerns are appropriately addressed progress monitored. Learning Point 12: Well-kept records are tangible products of concerns, interventions, and actions taken to safeguard and protect children and it is vital that they are recognised as such. Without systems in place in schools to ensure these records are kept up to date and carefully maintained, work to keep children safe will be compromised and likely to be less effective. 8.7.17. Recording practice can be viewed by professionals as a time-consuming activity but it is only by keeping accurate, relevant, and up to date records that patterns and cumulative information emerge and the child’s experiences can be understood and shared when necessary with other agencies. 8.8. KLoE 5: Jacob’s voice and the extent to which professionals were curious about his lived experiences Keeping the child in focus 8.8.1. Much of the existing research and evidence on communication with children and young people comes from inquiries into child abuse and serious case reviews. A persistent finding in reviews of cases where children have been seriously harmed is that professionals have not adequately engaged with, or related to, the children concerned.29 These reviews have invariably contained scenes where professionals were in the presence of abused children, but they did not get close enough to discover what was happening in their lives. 8.8.2. The review team has not been provided with any first-hand information about Jacob - what he looked like, who his friends were, what he enjoyed doing at school - other than the comments he apparently made in response to questions about injuries. By February 2018, Jacob had attended SCH1 for eight school terms and until then, there had been no significant concerns raised about Jacob, his well-being, safety or how he was parented. 8.8.3. The review team was informed that all children attending SCH1 receive a home visit when they first begin in reception class and although these visits are not recorded, any observed or emerging concerns are shared with the SEN/DSL as appropriate. Jacob received 1-1 intervention in his first year to help with his language and academic progress and this continued in Year 2. Although Jacob remained on the SEN register, he was never formally assessed, but by being on the register, the review team was told, his progress was supported and monitored. 8.8.4. The references in agency records to Jacob being ‘quirky’ and having indicators which could indicate he had a form of Aspergers 30 would suggest that Jacob was seen in some way as being ‘different’ but even given the diverse population of children on roll at school, the review team was told he did not ‘stand out ‘in any way. 8.8.5. The fact that Jacob was on the SEN register, together with his frequent absences on ill health grounds, and the fact that from March 201731, he was open on CPOMS, would however suggest a 29 How children become invisible in child protection work: Findings from research into day-to-day social work practice, British Journal of Social Work, (2016) 30 Asperger’s syndrome is a developmental condition characterised by significant difficulties in social interaction and nonverbal communication, along with restricted and repetitive patterns of behavior and interests. 31 Previous incident when Jacob was found in the playground with trousers and underwear pulled down. 32 vulnerability that was not recognised by school staff as well as it might have been. It would have been helpful had school staff been a more curious about Jacob’s continued absences and sought to understand more about his lived experiences. 8.8.6. There is no evidence to suggest that staff at school sensitively reached out to Jacob to find out what his life was like at home. Jacob’s voice is not evident in any school records seen by the review team and there was a sense from conversations with some staff that these types of sensitive conversations were regarded as belonging in the social worker’s domain. In fact, any ‘trusted adult’ in school could have taken time to establish a rapport with Jacob and learnt a little more about his lived experiences; what he saw, heard, and experienced at home on a daily basis. 8.8.7. School staff are understandably anxious about initiating these types of conversations with children, being acutely aware of the danger of treading into investigative territory. Whilst acknowledging the caution needed before any child is spoken to about home and family, the review team was of the view that staff in school could have done more to talk with Jacob and listen to what he was saying and importantly, perhaps what he was not saying. The notion of ‘invisibility’ does have some explanatory power in how Jacob was not ‘seen’ by school staff in the most rudimentary sense even though he was right in front of them. Any reservations the DSLs might have had about adopting this course of action could easily have been allayed by contact with CSC. Instead, MJ’s account, and not Jacob’s, became the narrative which described Jacob’s life at home. Learning Point 13: Unless practitioners are supported to remain curious about the lives of children and recognise the importance of trying to understand what is happening in a family rather than making assumptions or accepting things at face value, harm that some children are experiencing may not be recognised. 9. Summary 9.1. This review provides a reminder for all professionals of how easy it is to lose sight of a child’s day-to-day life. There were some fundamental weaknesses in the safeguarding systems in SCH1, which meant that what might have been happening to Jacob at home was not well considered or explored. 9.2. The central and universal positioning of schools is key to effective safeguarding practice, located at the heart of the community, schools provide a consistent, accessible, and supportive environment throughout a child’s schooling. Staff are able to observe a child’s development, witness interactions between the child and their parents either end of the school day, and monitor their health, safety and wellbeing. They are in a particularly advantageous position for children to seek help and support from adults they may trust. This makes the safeguarding role of school staff and particularly DSLs, as a collective group, highly valuable in the effective delivery of collaborative safeguarding practice. However without appropriate checks and balances, good partnership working with other professionals and crucially, without opportunities for reflective and challenging supervision, errors in professional judgment can too easily occur and this can leave some children, like Jacob, vulnerable. 9.3. The review team appreciated the extent to which key staff in SCH1 and CSP talked openly and honestly about their practice and decision-making. Their reflections and insights indicated personal 33 learning which alongside changes within their organisations can serve only to strengthen safeguarding arrangements in their respective agencies. 34 10. Summary of Learning Points Learning Point 1: When concerns about children arise and agencies are considering whether a referral to CSC should be made, or are uncertain about next steps, the starting point should always be a dialogue with CSC so agencies can make informed decisions about the appropriate course of action. Learning Point 2: Without systems in place for a child’s immunisation history to be flagged in medical records, the health needs of some children may be overlooked. Where a child does not have an immunisation history, professionals should explore the reason for this with parents. Learning Point 3: Without challenge, a practitioner's knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability and willingness to address the health, safety and well-being needs of children. Learning Point 4: When safeguarding concerns lead to children being ‘opened’ in CPOMS, key professionals should be notified and any discussions and plans made between agencies, should be formalised and recorded so there is clarity about who is doing what, when and why Learning Point 5: Safeguarding teams in schools, whatever their size, should have clear terms of reference to provide focus and structure for the ‘team’ and to ensure that decisions and discussions about safeguarding concerns are carefully considered, properly recorded and regularly monitored. A system should also be in place to quality assure records and decision-making. Learning Point 6: If professionals in contact with children do not purposefully and intentionally seek out information about who are significant people in a child’s life, the specific risks posed by some men are more likely to go unrecognised and this will leave some children vulnerable. Learning Point 7: A cooperative and responsive parent has considerable power to disarm and distract professionals from exercising professional curiosity and questioning what may be happening a family and this can leave children at heightened risk . Learning Point 8: The significant changes in the remit and function of school nurses together with an overwhelming demand for their service seems to have left some professionals less clear about the valuable service these professionals continue to provide and the additionality these roles bring to multi-agency working. Learning Point 9: Where schools propose parents engage with any of their commissioned services, clear information about that service should be provided by the school so parents can make an informed decision as to whether they wish to engage with that service and for what purpose. Any agreement should captured in a written contract. Learning Point 10: Governing bodies of schools have a responsibility to ensure they are well equipped to discharge their safeguarding responsibilities and that robust systems are in place to quality assure safeguarding arrangements in their school. Learning Point 11: Without systems and formal opportunities to reflect on their practice and decision-making and be helpfully challenged about their thinking, human errors are more likely to occur. Best practice means DSLs have access to opportunities to develop their practice, and be both challenged and supported in relation to the professional judgements they make. 35 Learning Point 12: Well-kept records are tangible products of concerns, interventions, and actions taken to safeguard and protect children and it is vital that they are recognised as such. Without systems in place in schools to ensure these records are kept up to date and carefully maintained, work to keep children safe will be compromised and likely to be less effective. Learning Point 13: Unless practitioners are supported to remain curious about the lives of children and recognise the importance of trying to understand what is happening in a family rather than making assumptions or accepting things at face value, harm that some children are experiencing may not be recognised. 11. Recommendations Multi-Agency Recommendation 1: MSP should consider how it can be assured that the Advice and Guidance Service (AGS) is working well and agencies are accessing the service responsibly and within appropriate timescales. In relation to: Learning Point 1: When concerns about children arise and agencies are considering whether a referral to CSC should be made, or are uncertain about next steps, the starting point should always be a dialogue with CSC so agencies can make informed decisions about the appropriate course of action. Multi-Agency Recommendation 2: MSP should seek assurance, through the current Workforce Safeguarding Strategy, that all agencies provide their workforce with briefings and access to training which supports awareness and the development of culturally competent practice. Specifically, MSP should seek assurance that all professionals, including safeguarding leads in schools are well-equipped to work with diversity, culture and ethnicity in safeguarding work. In relation to: Learning Point 3: Without challenge, a practitioner's knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability and willingness to address the health, safety and well-being needs of children. Multi-Agency Recommendation 3: Learning from this review echoes repeated findings from national serious case reviews in relation to ‘significant males’ and the need for professionals to have a healthy scepticism about the what they are told by parents/carers about significant adults in their family. MSP should explore in some depth how supervision, team learning, training programmes, and other approaches, can be utilised to help professionals improve their skills as professionally curious practitioners in ways that are safe, supportive and challenging. 36 In relation to: Learning Point 6: If professionals in contact with children do not purposefully and intentionally seek out information about who are significant people in a child’s life, the specific risks posed by some men are more likely to go unrecognised and this will leave some children vulnerable. Learning Point 7: A cooperative and responsive parent has considerable power to disarm and distract professionals from exercising professional curiosity and questioning what may be happening a family and this can leave children at heightened risk Multi-Agency Recommendation 4: MSP should promote awareness across the partnership of the importance of immunisations for children and the necessity of exploring with all parents, whatever their culture or background, their child’s immunisation history. Learning Point 2: Without systems in place for a child’s immunisation history to be flagged in medical records, the health needs of some children may be overlooked. Where a child does not have an immunisation history, professionals should explore the reason for this with parents. Multi-Agency Recommendation 5 a) MSP should ensure the system in place for quality assuring safeguarding audits and action plans in schools and partner agencies, is robust. b) MSP should seek confirmation how the learning points below and which relate specifically to schools will be addressed. In relation to: Learning Point 4: When safeguarding concerns lead to children being ‘opened’ in CPOMS, key professionals should be notified and any discussions and plans made between agencies, should be formalised and recorded so there is clarity about who is doing what, when and why Learning Point 5: Safeguarding teams in schools, whatever their size, should have clear terms of reference to provide focus and structure for the ‘team’ and to ensure that decisions and discussions about safeguarding concerns are carefully considered, properly recorded and regularly monitored. A system should also be in place to quality assure records and decision-making. Learning Point 9: Where schools propose parents engage with any of their commissioned services, clear information about that service should be provided by the school so parents can make an informed decision as to whether they wish to engage with that service and for what purpose. Any agreement should be captured in a written contract. 37 Learning Point 10: Governing bodies in all schools have a responsibility to ensure they are well equipped to discharge their safeguarding responsibilities and that robust systems are in place to quality assure safeguarding arrangements in their school. Multi-Agency Recommendation 6 MSP should consider whether any actions are needed to ensure that professionals in all agencies fully understand the role, remit and function of School Nurses In relation to: Learning Point 8: The significant changes in the remit and function of school nurses together with an overwhelming demand for their service may have left some professionals less clear about the valuable service these professionals continue to provide and the additionality these roles bring to multi-agency working. Recommendation: Clinical Commissioning Group Actions should be taken to remind health professionals about a link between bi-lateral ear bleeds and trauma. (see para 8.4.28) End/ 38 Appendix 1 Agencies represented on the Review Team Diocese /Commissioned Service Provider Greater Manchester Police (GMP) Manchester City Council – Childrens Social Care (CSC) Manchester City Council – Education Team Manchester University NHS Foundation Trust (MFT) Manchester Health & Care Commissioning (MHCC) Northern Care Alliance (NCA) |
NC043754 | Death of a 3-month-old baby boy, presented to hospital unconscious and not breathing, in January 2013. Baby F's father was arrested on suspicion of murder and bailed without charge. Baby F's parents were both Polish and had been living in the United Kingdom for 6 years; both had two older children from previous relationships who were all residing in Poland at the time of the incident. Issues/lessons identified include: access to interpreter services and the impact on communication between parents and services; difference in cultural approaches to possible non-accidental injuries between hospital and police staff; the inability of professionals to identify when a strategy meeting is required; and where opinion of cause of injury is unknown or conflicting, professionals should proceed as if injuries are inflicted. Makes various interagency and single agency recommendations, covering children's services and health services.
| Title: Serious case review: overview report V4: Baby F. LSCB: Rochdale Borough Safeguarding Children Board Author: Graham Yip Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Rochdale Borough Safeguarding Children Board Serious Case Review Overview Report V4 Baby F Chair LSCB: Jane Booth Chair SCR: David Hunter Author SCR: Graham Yip Date: September 2013 2 CONTENTS Section Page Number 1. Introduction 3 2. Serious Case Review Process (SCR) 3 2.1 Decision to hold an SCR 3 - 4 2.2 Membership of the Overview Panel 4 2.3 Terms of Reference 5 - 6 2.4 Documents Reviewed 6 2.5 Family Involvement 6 - 7 2.6 Parallel Process 7 2.7 Media Interest 7 2.8 Genogram 7 3. Family Background 7 - 8 4. Overview of what was known 8 - 15 5. Commentary on IMRs 15 - 22 6. Critical Analysis against Terms of Reference 22 - 40 7. Lessons Learned 40 - 43 8. Conclusions 43 - 44 9. Recommendations 44 Single Agency 44 - 46 Multi-Agency 46 - 48 Appendix A Genogram 3 1. Introduction. 1.1 The principal family members referred to in this report are: Baby F . White British/Polish. Deceased Birth Mother. Mother of Baby F. White Polish Birth Father. Father of Baby F. White Polish 1.2 Baby F, a boy, was born in North Manchester General Hospital in autumn 2012. Both parents are Polish nationals who have been resident within the Rochdale area for some 6 years. Following his birth, Baby F and his parents lived at Address 1. 1.3 At 1528hrs, Saturday 19th, January 2013, Greater Manchester Police (GMP) received a 999 call from North West Ambulance Service [NWAS] informing them that a three month old baby was unconscious and not breathing at Address1. 1.4 Baby F was taken to North Manchester General Hospital Accident and Emergency Department, before being transferred to the Royal Manchester Children’s Hospital, where he received specialist intensive medical treatment. It was very strongly believed by medical professionals that the injuries to Baby F were inflicted and therefore non-accidental. 1.5 Birth Father had been alone with Baby F immediately prior to the incident when Baby F had become unconscious and unresponsive. On Friday 25th, January 2013 both Birth Father and Birth Mother were interviewed under caution by Officers from GMP. Both parents were legally represented and had the services of an official interpreter 1.6 On Wednesday 30th, January 2013, following discussions between health professionals and the parents of Baby F over the serious condition over their son, Baby F was extubated, and was certified dead at 22.55hrs. 1.7 To date the Home Office Pathologist who undertook the post mortem examination of Baby F has deferred his decision regarding cause of death until the outcome of additional specialist medical examinations have been undertaken 1.8 On Friday 8th, February 2013 Birth Father was arrested and interviewed by officers from GMP on suspicion of the murder of Baby F. Birth Father was legally represented and had the services of an official interpreter. Birth Father was subsequently bailed without charge until Monday 28/10/2013. 2. Serious Case Review [SCR] Process 2.1 Decision to hold a SCR 2.1.1 On 28/2/13 Rochdale Borough Safeguarding Children Board Serious Case Review Screening Group was convened to consider whether a Serious Case Review should be undertaken. The Panel took into account the following: The circumstances of Baby F death. Medical evidence available. Suspicions that Baby F had been the subject of abuse. 4 2.1.2 The panel concluded that the criteria for undertaking a Serious Case Review had been met. A decision was therefore made to recommend that a Serious Case Review be undertaken. 2.1.3. On 25/3/13, the recommendation of the Serious Case Review Screening Group was approved by the Independent Chair of the Safeguarding Board. 2.1.4 On 26/3/13, Ofsted were informed of the decision to undertake a Serious Case Review. 2.2 Membership of the SCR Overview Panel [The SCR Panel] 2.2.1 The Panel consisted of: David Hunter Independent Chair Detective Inspector GMP Acting Head of Safeguarding Children Pennine Care NHS Foundation s Trust Designated Doctor Heywood, Middleton and Rochdale Clinical Commissioning Group [HMR CCG] Designated Nurse HMR.CCG. Head of Safeguarding RMBC Children’s Services Manager RMBC Interim Head of Service Care for Children RMBC Business Manager RBSCB Administrator RBSCB Cultural Advisor Lay Member Principal Solicitor (Advisor to Panel) Rochdale Metropolitan Borough Council [RMBC] Senior Solicitor (Advisor to Panel) RMBC (From 30/7/13) Graham Yip Independent Author 2.2.2 The RBSCB was satisfied that the Independent Chair and Author had the appropriate experience and independence to undertake their respective roles. 2.2.3 The Panel met on 6 occasions, and attendance was initially variable, an issue addressed by the Independent Chair of the SCR. 2.2.4 Following quality assurance by the CIG, the Overview Report, Executive Summary and Multi-Agency Action Plan were scrutinised by RBSCB on 19/09/2013, where after a thorough debate the documents were approved for submission to the Department for Education. 5 2.3 Terms of Reference 2.3.1 Terms of Reference 2.3.1 The following terms of reference were agreed at the Panel’s first meeting on 08/05/13. Purpose The purpose of this Serious Case Review is to: Establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children; Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and as a consequence; Improve inter-agency working and better safeguard children. Working Together to Safeguard Children 2010 Chapter 8.5 Timeframe The period under review is: From your agency’s first contact with any of the core family members, to Baby F’s death on 30.01.2013. Agencies will also consider any contextual information outside of this time frame in relation to the core family members who are listed below. Such information should be included as a synopsis at the start of the narrative section of their IMRs. Core Family Members Baby F Birth Father Birth Mother Specific Terms of Reference 1. How did agencies respond to Birth Mother’s pregnancy? 2. What steps did agencies take to discover the family’s background and what influence did any findings have on their assessment and decision making? 3. What were agencies assessments of the parenting abilities of both parents and how did agencies identify and manage any risks? 4. Was agencies management of risk in compliance with their procedures and those of RBSCB? 5. To what degree, did agencies in gathering information, making assessments and delivering services take account of issues such as: - race and culture [including isolation], language [including interpretation services], age, 6 disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery? 6. What child protection procedures did your agency follow after Baby F was admitted to hospital and were they fit for purpose? 7. To what extent did agencies communicate effectively and work together to safeguard and promote the continued wellbeing of Baby F? 8. What lessons have agencies learned from this Serious Case Review? 9. Provide examples of good and poor practice where evident. 2.3.2 Other Considerations The Overview Report will consider whether the death of Baby F was predictable and/or preventable. 2.4 Documents Reviewed Individual Management Reviews [IMR] 2.4.1 IMRs were submitted from the agencies listed below: Greater Manchester Police Rochdale Borough Council Children’s Services Central Manchester University Hospitals NHS Foundation Trust Pennine Care NHS Foundation Trust Pennine Acute Hospital Services NHS Trust GP Service Other Documents 2.4.2 Information was also received from: Health Overview Report Minutes of Strategy Meeting held on 22/1/13 2.5 Family Involvement 2.5.1 In line with the expectations of Working Together (2010), early consideration was given by the panel to seeking a contribution to the Serious Case Review from family members. The panel agreed that the family members who should be invited to contribute should be Birth Mother and Birth Father. The panel was keen to establish the parent’s views in respect of the support they had received from different services in helping them to look after their baby, and whether language barriers impacted upon the support they received from different services. 7 2.5.2 The Independent Chair of the Serious Case Review panel has written to the parents of Baby F, in Polish, introducing himself, and informing them that a Serious Case Review is being undertaken and what the purpose and process of a Serious Case Review is. In addition the letter also sought the parent’s involvement within the SCR process. 2.5.3 Given the ongoing criminal investigation the Chair of the panel sought the advice of the Greater Manchester Police Senior Investigation Officer, with regards to meeting with the parents of Baby F. The Police advice was that a meeting with the parents of Baby F could potentially compromise any future criminal proceedings. 2.5.4 The panel accepted the Police advice and as a result concluded that it would not be helpful to contact the parents of Baby F in these circumstances. 2.5.5 The panel agreed that following the Police investigation and any potential future court proceedings, further consideration would be given to contacting the parents of Baby F, to see if they would be willing to make a contribution to the SCR at that stage. The panel agreed that that if this was the case, and new information was received which could lead to further learning, the Panel would reconvene to consider how best the learning could be taken forward, including the possibility of an addendum to the Overview Report. 2.6 Parallel Processes 2.6.1 Greater Manchester Police have commenced a criminal investigation to determine how Baby F died. Birth Father was arrested on suspicion of murder, and subsequently given Police bail. At the time of this report he remains on Police bail. 2.6.2 HM Coroner for Rochdale has opened and adjourned the Inquest. 2.7 Media Interest 2.7.1 There appears to have been no reports in the media of the death of Baby F or the police investigation. This is very likely to change if Birth Father is charged and/or when the inquest takes place. 2.7.2 Any subsequent media interest will be handled by RBSCB. 2.8 Genogram 2.8.1 This appears at Appendix A 3. Family Background. 3.1 Birth Mother and Birth Father are both Polish nationals, who have been married for some 6 years. They came to the United Kingdom in November 2006. The couple settled in a part of the Greater Manchester area, within a well established and large community of Polish and other East European nationalities. 3.2. Both Birth Mother and Birth Father each have two children from previous relationships in Poland, three of whom are of adult’s age and one is a teenager. All four reside in Poland and are not subject of this Serious Case Review. 8 3.3. Birth Father is employed as a Production worker. Birth Mother runs her own small business. They have resided as a couple at Address 1 since September 2012. 3.4 Following the death of Baby F, Birth Father was arrested by Greater Manchester Police on the Suspicion of Murder of Baby F. He was subsequently given Police bail. At the time of this report he remains on Police Bail. 3.5 Prior to the incident of Saturday 19th, January 2013, neither parent was known to Children’s/Social Services in the United Kingdom. The panel initially requested that enquiries be undertaken in Poland to establish if either parent were known to the Polish Children/Social Services. However as the SCR progressed, the requirement for this action to be completed diminished. 3.6 Although present within the United Kingdom since 2006, English is an additional language to both parents, a fact recognised by most agencies dealing with the family. 3.7 Birth Mother discovered she was pregnant with Baby F in January 2012. 3.8 Baby F was born in autumn 2012, at North Manchester General Hospital, without any complications 4. Overview of what was known 4.1 Introduction 4.1.1 The combined chronology which is attached as Appendix B to this report, details the relevant contact incidents between Baby F, his parents and each respective agency. With the exception of the Police IMR, each IMR and the Health Overview Report includes a full detailed chronology and narrative containing all the information regarding the agency’s involvement with Baby F. GMPs chronology is embedded within the narrative section of the Police IMR. This Section will therefore focus on highlighting the key events and contacts with the family. Section 6 will critically analyse these events and contacts. 4.2 Period up to the Birth of Baby F 4.2.1 The first contact between the family of Baby F and agencies, at which the existence of Baby F was identified occurred on 5th, January 2012, when Birth Mother presented herself to a Midwife at the local children’s centre in Langley, Middleton. 4.2.2 It was estimated that Birth Mother was in the early stages of pregnancy. It was recorded at this appointment that Birth Mother did not speak English and was accompanied by a family friend, not further described, who translated for her. The Midwife at the children’s centre formally referred Birth Mother onto Maternity Services, and an appointment was made for a booking interview with a request for an interpreter to be present. 4.2.3 On 1st, March 2012, Birth Mother was seen by her General Practitioner. The GP made the relevant referrals for ante natal care for Birth Mother and her unborn child. There was no mention of the Doctor being a Polish speaker, or of an Interpreter or English speaking friend being present at this appointment. 4.2.4 On 19th, March 2012, Birth Mother attended at North Manchester General Hospital for a maternity booking appointment. An Interpreter was present. A full obstetric and 9 medical history was taken. The existence of two “children”, residing in Poland by a previous relationship, was identified. Due to Birth Mother’s obstetric and medical history she was referred to Consultant Obstetrician, to review her medical condition and to discuss mode of delivery. 4.2.5 On 26th, March 2012 Birth Mother attended at North Manchester General Hospital following her involvement in a Road Traffic Collision. Medical examinations and further attendances at the Early Pregnancy Unit at NMGH over the following days established Birth Mother had suffered only minor injuries. 4.2.6 From 2nd April 2012 to 17th, September 2012, Birth Mother continued to receive ante natal care from the Community Midwife and Consultant Obstetrician. At all key times the services of an interpreter were utilised. 4.2.7 Baby F was born at NMGH. The baby weighed 7.3lbs. Birth Father and an Interpreter were present during the relevant periods. 4.2.8 During the ante natal period of Birth Mother there were no potential safeguarding issues identified. 4.3 Period from Date of Birth October 2012 to Saturday 19th, January 2013. 4.3.1 Baby F was born and continued to thrive on the post natal ward. Staff on the post natal ward described how Birth Mother “was delighted with her baby and observed her taking and sending photographs of Baby F to her family in Poland”. 4.3.2 Whilst on the post natal ward midwifery staff noted that on one occasion communication with Birth Mother was difficult due to the language barrier, whilst other staff spoke of being able to hold limited conversations in English with Birth Mother. 4.3.3 Birth Mother and Baby F were discharged home from NMGH. 4.3.4 Between the period 13/10/12 – 26/10/12 the Community midwife visited or saw Baby F and his mother on 4 occasions. On each occasion the community midwife noted that Mother and baby were doing well. It was recorded that the community midwife provided Birth Mother with routine advice about care of herself and the baby and contact numbers for registering the Baby F with a General Practitioner and Children’s centre. The health records are unclear, but it would appear that no interpreter was present during these visits. 4.3.5 On 26/10/12 Birth Mother and Baby F were discharged by the community midwife into the care of the Health Visitor. 4.3.6 On 25/10/12 Health Visitor 1 (HV1), undertook a primary birth visit at the home address of Birth Mother and Baby F. It was recorded that there had been no contact between the Heath Visiting Service and Birth Mother during the ante natal period, due to the failure of the existing administrative systems that did not ensure that all routine notifications of pregnancy are forwarded by the Ante Natal Booking Clinic to the Health Visiting Team. Ante Natal Contact is a requirement of the Universal Service offer in the Health Visitors Service specification. 10 4.3.7 During the primary birth visit the Health visitor screened Birth Mother for post natal depression. No concerns were identified. The Health visitor also completed the Common Assessment Framework check list in respect of Baby F. 4.3.8 The Birth Father was not present during the visit, and no assessment was made about his background and role within the family. The genogram for the family was not completed. 4.3.9 No interpreter was present during the primary birth visit. Birth Mother was present with Baby F. An unidentified ‘male friend’ was present in the house. Birth Father was out at work. The Health Visitor recognised that Birth Mother was a Polish speaker, but felt that she could converse with her, particularly with the assistance of the ‘male friend’, who was fluent in English. 4.3.10 Following the primary visit the Health visitor, in accordance with the Health Visiting Service specification, assessed the family for the Universal Offer. Explanatory Note The Health Visiting Service is commissioned to provide social and emotional well being advice and/or intervention to children and families in their early years of life in accordance with 4 progressive levels of Service. 1. Communities. 2. Universal Offer – to lead and deliver the Healthy Child Programme.( 2009) 3. Universal Plus Offer –to provide and coordinate tailored packages of additional care to vulnerable families 4. Universal Partnership Plus – intensive multi agency targeted care packages. HMR Community Healthcare clearly identifies that where English is an additional language within a family, the family should be assessed as requiring the Universal Plus offer. 4.3.11 On 28/11/12 the Health Visitor contacted Birth Father and Birth Mother by telephone to update them on the routine blood screening test results for Baby F. The Health Visitor spoke to both parents on the phone. She was advised that Baby F was well and the parents had no concerns. The Health Visitor informed the parents that there would not be any further visits or calls and that should they require any further advice or support, they should take Baby F to the baby clinic. No interpreter was involved in this telephone conversation as the Health Visitor felt there were no communication difficulties. 4.3.12 On 9/12/12 Birth Mother and Baby F attend the GPs surgery for a post natal examination. Both mother and child were viewed as having no health problems. The GP received the consent of Birth Mother to have Baby F vaccinated. The first vaccinations were administered on this date. There was no evidence from the health records that the GP was a polish speaker, or used or considered using the services of an Interpreter. 4.3.13 On 16/1/13 Birth Mother took Baby F to the GPs surgery to receive his second set of vaccinations. 11 4.4 Period from 19/1/13 – to date of Death 4.4.1 At 1528hrs, North West Ambulance Service contact Greater Manchester Police to inform them that they are dealing with an incident of a 3 month old child, unconscious and not breathing at Address1. Attempts are made by passing neighbours and arriving paramedics to resuscitate Baby F 4.4.2 At 1550hrs.Baby F arrived via ambulance at the Accident and Emergency Department of North Manchester General Hospital. On arrival waiting medical professionals recorded that Baby F had ‘no pulse rate or respiratory effort’. Baby F was given drugs and fluids for resuscitation and was intubated without complication. 4.4.3 Doctor 10 (DR10), a Polish speaking Doctor within the A&E department, took a history of what had occurred from Birth Father. It was recorded that Birth Father informed the doctor that Baby F took a feed at 1400hrs, after that he went sleep. When Baby F woke at 1500hrs, the father placed him in his arms whilst he prepared a milk feed. Baby F then developed a sudden cough and shortness of breath. He became floppy, limp and was not breathing. 4.4.4 At 1609hrs, 19/1/12 Detective Sergeant 1 (DS1) and Detective Constable 1 (DC1) attend at the hospital. They spoke with an A&E Consultant 1 (A&EC1). They subsequently record on the Police incident log that “no suspicious circumstances and no requirement for a scene”. 4.4.5 At 1812 hrs 19/1/13 DS1 updated the Police incident log with the following” The child is to be transferred to a neo natal paediatric unit for further treatment and CT scan when his condition has stabilised . The Doctor stated that he believed that the child’s condition was due to an infection” 4.4.6 At 1819hrs 19/1/13, DS1updated the Police incident log with the following” Consultant Paediatrician 1 (CP1) examined the child and stated that there were no signs of any external marks or injuries other than what had been received from medical treatment” The Police incident log at this time also recorded the information that Detective Chief Inspector 1 (DCI1) had been appraised of developments by DS1. A decision was made to remove Police Officers from the scene at Address 1. 4.4.7 Following resuscitation Baby F was investigated further with blood tests, chest X ray and a Computerised Tomography (CT) scan. Blood tests showed that Baby F had suffered a cardiac arrest. The X ray showed Pulmonary Oedema (swelling of the lungs), but no fractures. The CT scan showed Right extradural and subdural haemorrhage and Left sub arachnoid haemorrhage. The CT scan was undertaken at 1835hrs. 4.4.8 At 1838hrs Police Constable 1 (PC1), who was at NMGH on an unrelated incident, was approached by medical staff treating Baby F and requested the details of the CID officer dealing with the incident involving Baby F. The Officer recorded in his Police notebook” Poss (possible) non accidental” 4.4.9 At 1855hrs 19/1/12 CP1 telephoned Children’s Services Emergency Duty Team regarding Baby F’s injuries and his belief that they were potentially non-accidental. At approximately the same time a similar request was made to Greater Manchester Police to attend the hospital. 4.4.10 Between 1859hrs and 1909hrs two entries were made on the GMP incident log they recorded the following information “…from the doctors, this injury is non accidental. 12 PC2 will re-start the scene. DC2 is aware and will contact the hospital shortly”, this followed by the following entry “… child has come back from CT scan and the injury shows a severe inter cranial bleed” 4.4.11 EDT Social Worker 1 (SW1) responded to the call from CP1 and attended NMGH. 4.4.12 DC2 attended the Hospital. Prior to doing so she liaised with the duty DCI1, who advised that she should attend with a member of the Divisional Public Protection Investigation Unit (PPIU). None were available at that time. 4.4.13 Upon attending the Hospital DC2 and SW1 spoke with CP1. SW1 made a verbatim note of the account of Baby F’s medical history and condition. Within her notes SW1 recorded the sentence “There is no evidence at present to suggest Baby F has been subject of NAI – nor is there evidence to state he has not”. 4.4.14 What is termed a ‘multi agency meeting’, by the GMP IMR author, was held between CP1, SW1 and DC2. The meeting was not a formal strategy meeting as defined in Rochdale Borough SCB safeguarding procedure or Working Together 2010. 4.4.15 The meeting was timed by the Police at 1900hrs, whilst CP1 in a statement to Police after the death of Baby F recorded the meeting as taking place at 2000hrs. The SCR Panel would have expected that a written record of what occurred at this ‘multi agency meeting’, what actions or decisions were agreed and whether those actions/decisions had been circulated to all relevant agencies, would have been made. The SCR Panel requested sight of any formal record of this meeting. It was subsequently established no formal record of this meeting was made. 4.4.16 The verbatim notes made by SW1 were forwarded as part of a referral email to Children Services First Response team. The notes made by SW1 were not shared with any other agency. 4.4.17 At 2000hrs, 19/1/13 CP1 made the following entry on the PAHT case notes” Discussed with Social Services. Explained that Non accidental injury has to be ruled out” 4.4.18 At 2145hrs, Saturday 19th, January 2013 Baby F arrived at the Paediatric Intensive Care Unit (PCIU) at Royal Manchester Children’s Hospital (RMCH), following transfer from NMGH. 4.4.19 At an unknown time on Sunday 20/1/13 CP1, NMGH made a written Child Protection Referral to Children’s Services on Baby F’s admission to hospital and his concerns that the brain injuries maybe non- accidental in nature. This was written confirmation of the verbal referral of 19/1/13. 4.4.20 At 0840hrs and 0848hrs, 20/1/13, DC3 sent 2 emails to Children’s Services EDT providing a summary of what had occurred to date, an overview of the family history and an update on the medical condition of Baby F. The email timed at 0840hrs concluded with the reference “the injury was non accidental”. The subsequent email timed at 0859hrs, 20/1/13 requested a joint visit to the Hospital. 4.4.21 At 1310hrs, 20/1/13 another, what the Police IMR author refers to as a ‘Multi agency meeting’ was held at RMCH. DC3, DR12, EDT SW2 and SW3 were present. The meeting was not a formal Strategy Meeting as defined in RBSCB Multi - Agency safeguarding procedures. The SCR Panel would have expected that a written record of what occurred at this ‘multi agency meeting’, what actions or decisions were agreed and whether those actions/decisions had been circulated to all relevant 13 agencies, would have been made. The SCR Panel requested sight of any formal record of this meeting. It was subsequently established no formal record of this meeting was made. 4.4.22 At approximately 1325hrs, Sunday 20/1/13, DC3, DR12, EDT SW2 and SW3 met with Baby F parents in the presence of an interpreter at RMCH. A medical update on Baby F was provided to the parents. It was agreed that that the parents of Baby F would have supervised contact with Baby F. The parents agreed to that decision. The SCR Panel would have expected that a written record of what occurred at this meeting, what actions or decisions were agreed and whether those actions/decisions had been circulated to all relevant agencies, would have been made. The SCR Panel has requested sight of any formal record of this meeting. It was subsequently established no formal record of this meeting was made 4.4.23 At 1740 DC3 was contacted by Staff Nurse 3 (SN3) regarding the supervision arrangements for Baby F. DC3 was informed that Nurses would not be responsible for the supervision of the parents. SN3 confirmed that DR12 had not documented any decision regarding the supervision of the parents of Baby F. 4.4.24 At 1750hrs, Sunday 20/1/13 DS2 contacted SN3 to inform her that GMP would not be supervising the parents visits to Baby F. DS2 records his rationale in his policy book -“I explained that the consultant had said that there would be supervised access but had not requested police assistance. I also outlined that the parents had had unsupervised access for a prolonged period of time since the child was admitted to hospital” He further added “ Decision made not to PPO the child as there was no immediate risk to the child . EDT SW (Emergency Duty Team Social Worker) was in agreement and involved in the decision making” Explanatory Note. Section 46 of the Childrens Act 1989, creates a power for Police officers to remove and accommodate children in cases of emergency. Although it is not an actual order , the exercise of this power has become known as the ‘Police Protection Order’. The main provision of the Section allows a constable who has reasonable cause to believe that a child would otherwise be likely to suffer significant harm, he may (a) remove the child to suitable accommodation and keep him there; or (b) take such steps as are reasonable to ensure that the child’s removal from any hospital, or other place, in which he is then being accommodated is prevented. 4.4.25 At 1940hrs, Sunday 20/1/13, DC3 received a telephone call from Paediatric Registrar 3 (PR3), who expressed concerns over why Baby F had not been made subject of a Police Protection Order, and queried why the Police were treating the incident as “an injury with an unknown cause whereas the hospital were treating it as a non accidental injury” 4.4.26 In response to PR3 telephone call, DC3 contacted DS2 and made the following entry in her daybook- “No changes to be made as yet. Police have no grounds to PPO the child as the cause of injury has not been ascertained”. 4.4.27 At a time to be established on Sunday 20/1/13, but believed between 1725 and 2010hrs, PR3 completes a Child Protection Proforma. Within the document he 14 recorded the following information ‘Baby F is to be treated as a child with a non accidental injury until proven otherwise’ Explanatory Note. A Child Protection Proforma is an internal Health document used by examining Doctors as a medical checklist where NAI is suspected. The document is retained on the medical notes of the child, and the information is used to inform all medical reports to other agencies. 4.4.28 At 1310hrs, Monday 21/1/13 Children Services Team Manger 1 (SWTM1) reviewed the information gathered by EDT in respect of Baby F. SWTM1contacted DC3 by telephone for an investigative update. Following that conversation the following entry is recorded on ICS as her management decision – “Baby F is three months old, he has been found with Birth Father at home unresponsive. He (Baby F) has had a heart attack and was later found to have a brain bleed. No trauma evident and organic reasons are being explored. The Police are taking the lead as of yet no Child Protection concerns are established. Home conditions are good and previous care of baby F appears to have been appropriate” 4.4.29 At 0700hrs, Tuesday 22.1/13 DS3 an experienced PPIU supervisor came on duty. The officer reviewed the incident involving Baby F, and obtained medical and Children’s Services update. The officer identified that a formal strategy meeting in accordance with established Child Protection policies and procedures had not been undertaken. She arranged for an urgent Strategy Meeting to be undertaken at 1200hrs Tuesday 22/1/13 at RMCH. This is the first time any professional in this matter had made mention of a Strategy Meeting, as defined by the Children Act 1989. 4.4.30 At 1200hrs, Tuesday 22/1/13, DS3, Investigative Support Officer 1 (ISO1), SW4, SWTM1, SGN2 and CP2 attended the strategy meeting. CP2 states in her expert opinion that the injuries sustained by Baby F were as a result of being violently shaken, but that being dropped could not be ruled out. A number of actions were allocated to partner agencies. 4.4.31 At the Strategy Meeting it was agreed that that Children’s Services would assume the role of main point of contact for information sharing regarding developments in Baby F condition and the investigation. It was further agreed that a Section 47 Enquiry would commence. The SCR Panel have been given access to the ICS record of this strategy meeting. 4.4.32 An action from the Strategy meeting held on 22/1/13 was that Children Services would provide to the PICU and the Safeguarding Children’s Team the outcome of discussions regarding the supervision of Baby F parents. 4.4.33 At 1915hrs, Wednesday 23/1/13, following discussions, Children’s Services and the Police met with the parents of Baby F. An interpreter was present. The reasons for parental supervision were explained to the parents and it was agreed that they could visit Baby F between 0900hrs- 2000hrs. 4.4.34 On Thursday 24/1/13 following discussions with SWTM1 and CP2 supervised contact that afternoon and evening were suspended. 4.4.35 On Friday 25/1/13 Children’s Services Service Manager 1 (SM1) spoke with CP2 by telephone. It was agreed that supervised contact between Baby F and his parents would cease. SM1 made the following record” Following prior discussion SW4 and 15 SWTM1 have had with CP2; CP2 agreed Birth parents presented little or no risk to Baby F on the ward, she agreed Birth parents should be treated with dignity in their last hours with Baby F and agreed Children’s services were taking appropriate action. Children’s Services has assessed Birth Parents as behaving entirely appropriately and were very loving and supportive to Baby F. Baby F was not expected to live very long. It was agreed supervision of contact would be ceased”. Children Services record that the Police “were spoken to” about the decision. 4.4.36 At 1252hrs, Friday 25/1/13 Birth Father was interviewed by Police under caution. His solicitor and an interpreter were present throughout. Birth Father provided a detailed account of his background and the events of 19/1/13. He denied causing Baby F any harm. 4.4.37 At 1847hrs, Friday 25/1/13 Birth Mother was interviewed by Police under caution. Her solicitor and an interpreter were present throughout. Birth Mother provided a detailed account of her background, pregnancy and Baby F habits and demeanour. She recalled the events of 19/1/13. She denied causing Baby F any harm. 4.4.38 At 2255hrs, Wednesday 30/1/13, Baby F died at RMCH. 4.4.39 On Friday 8th, February 2013, Birth Father was arrested on suspicion of the murder of Baby F. He was interviewed in the presence of his solicitor and an interpreter. He denied the offence maintaining he did not harm Baby F. He has been given Police bail. At the time of this report he remains on Police bail 5 Commentary on the IMRs 5.1 Rochdale Children’s Services IMR 5.1.1 Rochdale Council Children’s Services have provided a chronology and Individual Management Review for this Serious Case Review. 5.1.2. The report has been prepared by an Independent Consultant with experience of Serious Case Reviews. The author has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence. 5.1.3 The report was countersigned by the Assistant Director, Childrens Services, RMBC. This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence. 5.1.4 The IMR draws on both written records and direct interviews with 2 members of staff and telephone interviews with 5 members of staff. The IMR author responded to requests for further information, and with the assistance of SCR Panel members made a number of significant amendments , which led to the production of a more critically focused and pertinent IMR . 5.1.5 Rochdale Council Children’s Services Department had no contact with Baby F or his family until the events of the 19th, January 2013. From that date to the date of Baby F death on 30th, January 2013, Children’s Services had continued contact with Baby F and his family. . 5.1.6 The IMR is open and critical in its analysis of the service provided and has identified key areas for improvement. The IMR author has highlighted weaknesses in individual practise, non adherence to existing child protection policies and procedures and the 16 importance of timely and accurate record keeping. These issues are subject of appropriate scrutiny, but additional critical analysis around the limited explanations offered by staff for individual failings would have enhanced the learning opportunities within the IMR. The commentary on the role of EDT staff and the access they have to the ICS computerised system, was extremely helpful, bring clarity to what had been a confused and conflicting picture. 5.1.7 There is evidence within the IMR of staff reflective learning. 5.1.8 The lessons learned and recommendations are compatible with the analysis 5.2. Greater Manchester Police IMR 5.2.1 Greater Manchester Police have provided a chronology and Individual Management Review for the Serious Case Review. 5.2.2 The report has been prepared by a Detective Inspector from the forces Major Crime Review Unit. The author has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence. 5.2.3 The Report was countersigned by the Force Review Officer who had no direct knowledge or involvement of the services provided to Baby F or his family. 5.2.4 The IMR author has not prepared a comprehensive chronology as required by Section 8.9 Working Together to Safeguard Children 2010 and RBSCB Multi agency procedures. The chronology consists of two entries, which does not accurately reflect the interactions that GMP had with the family of Baby F or other agency partners. The IMR author has provided an explanation that the chronology reflects the only two recorded incidents reported to Police which involved Baby F and his family. The author adds that contents of additional incident logs and associated documents are detailed in the narrative section of the IMR to avoid repetition. 5.2.5 The IMR authors view is supported by the Force Review Officer who undertook the quality assurance of the IMR. The Force Review Officer quotes the under mentioned principle from the North West Safeguarding Steering Group Learning and Development Framework: "The approach taken on learning and reviewing should be proportionate to the scale and complexity of the issues being examined." 5.2.6 The Force Review Officer states that he believes that within its current format the GMP IMR adheres to the aforementioned principle, and that any further work in relation to the chronology is duplication for its own sake and adds nothing to the learning outcomes. 5.2.7 The SCR Panel noted the point but felt the IMR would have benefitted from a full chronology. 5.2.8 The IMR draws on both written and computerised records and direct interviews with 7 members of staff. The author responded to advice and feedback from the panel and consequently included additional information and analysis to strengthen the report. 17 5.2.9 Prior to the events of the 19/01/2013 GMP had no involvement with Baby F. However between August 2008 and August 2010, GMP had contact with the Birth Father on 4 occasions as a victim of crime (Theft of Motor Vehicle), or as a complainant in incidents of Anti Social Behaviour. 5.2.10 The IMR is open and critically analyses the failure of Police Officers to follow existing Child protection procedures and policies particularly in relation to the requirements of calling a strategy meeting, and the need to accurately record and share with colleagues the decisions and actions agreed at such meetings. 5.2.11 The IMR would have benefited from greater analysis of the reasons why officers, including senior officers and those in specialist public protection roles, did not identify that a strategy meeting was required in accordance with established child protection policies. 5.2.12 The IMR contains evidence of officer’s reflective learning within their decision making processes and acknowledgments that if faced with similar circumstances they would adopt a different approach. 5.2.13 The IMR author highlights the clear non adherence to established child protection procedures in respect of the requirements to ensure that strategy meetings are called, as a significant learning episode for staff. However the IMR contains no recommendations. 5.2.14 The IMR author provides a commentary that the issues identified within this SCR are similar to issues identified in two previous SCR. (Child K 2011, a Tameside LSCB SCR, and Child W 2012, a Manchester LSCB SCR) Those SCRs made respective recommendations to GMP in respect of how to conduct inter agency strategy meetings, and the requirement for GMP to devise a standard method of how to record the discussions, actions and outcomes of strategy meetings. The IMR author then lists a host of training initiatives that GMP have undertaken since 2012/13 to address those recommendations. As a result the IMR author concludes that there is no new learning from this SCR and no requirement for recommendations. 5.2.15 The Force Review Officer concurs with the IMR author that the IMR does not need recommendations, believing that duplicating recommendations for its own sake within the SCR has little merit when work has been undertaken and is ongoing to finalise the same issues. 5.2.16 The SCR Panel believe that there are significant areas of learning around strategy meetings, which while similar to previous ones, are not identical and for that reason makes its own recommendations for GMP. 5.2.17 The panel accept that GMP has instigated training and awareness events to spread the learning from previous SCRs to staff. However the findings from this review, which examined events from early 2013, suggest that GMP’s initiatives are not yet fully embedded in practice. The SCR Panel’s recommendations should not be seen as a duplication of effort, rather a catalyst and a recognition of what still needs to be achieved. 5.3 Pennine Care NHS Foundation Trust IMR – (Health Visiting Service) 5.3.1 Pennine Care NHS Foundation Trust have provided a chronology and Individual Management Review for this Serious Case Review. 18 5.3.2 The report has been prepared by a Registered Nurse and Health Visitor, with extensive experience of Child safeguarding. The author has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence. 5.3.3 The report was countersigned by the Acting Head of Safeguarding Children for the Trust. This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence. 5.3.4 The IMR draws on both written records and interviews with 6 members of staff The IMR author responded to requests for further information and made a number of amendments to the IMR in the light of feedback from the Panel. 5.3.5 There is evidence within the IMR of staff reflective learning, most notably the Health Visitor who undertook the primary visit. 5.3.6 The Health Visiting Service had two contacts with Baby F and his family. A primary visit on 25/10/12, when Baby F was seen in the presence of his mother and an unknown male. The second contact was via telephone on 28/11/12. 5.3.7 The IMR provides a comprehensive and detailed review of the service provided. It is an open and reflective IMR, which provides an overview of the expected standards and a commentary on the individual practice against those standards. It recognises missed opportunities in service provision and offers credible explanations for those individual and organisational failings 5.3.8 The IMR author has made use of appropriate research to emphasise the learning evident within the IMR. 5.3.9 The IMR is of a high standard and evidences an organisation willing to learn. The lessons learned and the recommendations flow from the critical analysis. 5.3.10 The SCR Panel have noted that many of the recommendations within this IMR have already been implemented. 5.4 Heywood, Middleton and Rochdale Clinical Commissioning Group .General Practitioner [GP] IMR 5.4.1 Heywood, Middleton and Rochdale Clinical Commissioning Group have provided a chronology and Individual Management Review for this Serious Case Review. 5.4.2 The report has been prepared by the Designated Safeguarding Nurse. The author has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence. 5.4.3 The report was countersigned by the NHS HMR CCG Board Lead for Safeguarding This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence. 19 5.4.4 The IMR draws on both written records and a direct interview with 1 member of staff The IMR author responded to requests for further information and made a number of amendments to the IMR in the light of feedback from the Panel. 5.4.5 General Practitioners within HMR CCG had contact with Baby F, or his parents on 10 occasions starting in 2009 when Baby F’s parents registered with a GP surgery. 5.4.6 The IMR is open and critical in its analysis. It provides a critical account of the GP services provided to the family. It rightly highlights the complete absence of the use of interpreting services by General practitioners in this case. This is a significant issue when dealing with patients who have English as an additional language, and the considerable impact that such omissions can have when attempting to build up a robust family history. An explanation is sought from the Lead GP for safeguarding who explains that GPs have difficulty in accessing Interpreter Services within the Rochdale Borough. 5.4.7 The IMR author utilises excellent reference material to assist her critical analysis in quoting Lord Lamings 2003 recommendation - “It is not appropriate for friends, relatives or other practitioner colleagues to be used to interpret for the patient”. 5.4.8 The IMR makes 2 recommendations which flow from the author’s critical analysis and identification of lessons learned. However the significance and importance of General Practitioners not using interpreter services/ or not being able to access interpreter services for patients cannot be underestimated in terms of the safeguarding agenda. As a result the SCR Panel have inserted an additional recommendation. 5.5 Central Manchester University Hospitals NHS Foundation Trust (CMFT) IMR 5.5.1 CMFT has provided a chronology and Individual Management Review for this Serious Case Review. 5.5.2 The report has been prepared by the Named Nurse Safeguarding Children. The author has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence. 5.5.3 The report was countersigned by the Medical Director. This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence. 5.5.4 The IMR draws on both written/computerised records and interviews with 2 members of staff. The IMR author responded to requests for further information and made a number of amendments to the IMR in the light of feedback from the Panel. 5.5.5 CMFT had contact with Baby F and his family from 19/1/13 to the date of his death 30/1//13 5.5.6. The IMR report is comprehensive and detailed. It has a clear focus on understanding why established safeguarding policies need to be adhered to, and the potential vulnerabilities of not doing so. The IMR is both open and critical in its analysis phase. 5.5.7 The lessons learned and recommendations are compatible with the analysis. 5.6 Pennine Acute Hospitals NHS Trust IMR 20 5.6.1 Pennine Acute Hospital NHS Trust have provided a chronology and Individual Management Review for this Serious Case Review. 5.6.2 The report has been prepared by a Consultant Midwife. The author has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence. 5.6.3 The report was countersigned by the Head of Safeguarding. This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence. 5.6.4 The IMR author responded to requests for further information and made a number of amendments to the IMR in the light of feedback from the Panel. 5.6.5 The IMR draws on both written/ computerised records and interviews with 2 staff members. 5.6.6 There is no evidence within IMR of staff reflective learning. 5.6.7 The Pennine Acute Hospital NHS Trust, had contact with Birth Mother from January 2012, when Birth Mother utilised the Maternity and Midwifery services, and an additional contact when Baby F was admitted to the Accident and Emergency department of NMGH on 19/1/13. 5.6.8 The IMR is open in its approach, and provides an overview of the expected standards the respective health services provide. It recognises and highlights missed opportunities, but fails to critically analyse and reflect upon those missed opportunities. The IMR fails to provide credible explanations for individual and organisational failures. 5.6.9 There is an absence of relevant lessons learned, and the IMR makes no single agency recommendations. The SCR Panel believe that there are significant areas of learning within the Pennine Acute Hospital IMR which should be translated into single agency recommendations. 5.6.10 The SCR Panel have included a number of recommendations within the section ‘Recommendations’ 5.7 Health Overview Report 5.7.1 The commissioning Health Overview Report for HMR CCG is produced in accordance with Working Together to Safeguard Children 2010, Chapter 8 – 8.30, and compiled using the agreed template and guidance designed and developed by the North West Designated Professionals in 2010. The template was subsequently agreed by the RBSCB. 5.7.2 The purpose of this report is to add value to the learning from health services and to review and evaluate the practice of all involved health professionals , including GP’s and providers commissioned by the CCG, with a particular focus on how effectively health organisations interacted together. The overview report will consider whether additional recommendations could and should be made, and if so, how from a commissioning perspective these changes will be brought about. 21 5.7.3 The Health Overview Report author has established her independence and expertise necessary to undertake the task. 5.7.4 The report was countersigned by the Executive Nurse, NHS, HMR, CCG.This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence. 5.7.5 The IMR draws on the Individual Management Reports submitted by the Health Agencies involved with this SCR, and conversations with IMR authors and panel members 5.7.6 Overall the HOR author reports that the healthcare provided to Baby F and his family from all health services was appropriate and followed expected health practice. 5.7.7 The author identified to two themes which emerged following an examination of the Health family information: Interpreter Services. The use of Interpreter services is not clear across Provider health services. Whilst policy and procedures exist, there is evidence of a clear disparity of the use of interpreters in the community setting by health practitioners and their use in the acute hospital settings. There is evidence that family and friends of the family were being used as interpreters. This has been identified as a practice which falls below expected standards. This could be justified during the emergency clinical assessment of Baby F during the first 24hrs of his hospital admission, but there were other circumstances identified when this was not appropriate the cases of GP services there was no evidence that the use of Interpreters was considered. Information Sharing. There is clear evidence of delays in information being shared between maternity and Health Visiting Services in respect of Routine Notification of Pregnancy and the Mothers Discharge. 5. 7.8 The HOR lists the recommendations made by each of the Health agencies who have submitted an IMR as part of the SCR process. The recommendations are commensurate to the HOR findings. 5.7.9 The HOR author provides a relevant commentary on the absence of recommendations within the Pennine Acute Hospitals Trust IMR. 5. 7.10 The HOR author makes one additional health recommendation within the HOR. 5.7.11 In summary the HOR is a good document which has added value to the individual health submissions. 6. Critical Analysis against the Terms of Reference. 6.1 Introduction The terms of reference appear below in bold lettering followed by the Overview Panel’s critical analysis, some of which is appropriate to more than one term. Where this happens, a best fit approach has been taken. 22 6.2. How did agencies respond to Birth Mother’s pregnancy? 6.2.1 Overall those agencies within the SCR who responded to the health care requirements of Birth Mother’s pregnancy did so in an appropriate and professional manner. All Birth Mother’s clinical and medical requirements were met. 6.2.2 There is evidence within the IMRs of the Health Agencies that health professionals involved with Birth Mother’s pregnancy recognised the requirement to utilise interpreter services, particularly during the antenatal phase of Birth Mother’s pregnancy. 6.2.3 The Health Visiting IMR author highlights the fact there is no evidence of notification of Birth Mother’s pregnancy to the Health Visiting Service from the Ante Natal Booking Clinic. As a result there was no contact between the Health Visitor and the Birth Mother in the ante natal period. 6.2.4 Good Practice Guidance (Department of Health, Healthy Child Programme 2009), acknowledges that positive outcomes for children can often be determined in the ante natal period. 6.2.5 This was a missed opportunity to undertake an assessment of the parents during the ante natal period. It may have led to a greater understanding of the parent’s social history and the identification of any additional needs, in particular language barriers. This point is both recognised and accepted by the IMR author and the Health Overview Report author. 6.2.6 The Health Visiting Service IMR highlights that routine notifications are not received for every pregnancy from the ante natal clinic, and when received details such as expected date of delivery are often missing. In addition it is highlighted that staff within the Health Visiting service fail to escalate such administrative errors to line managers. Appropriate recommendations are contained within the IMR to address this issue. 6.2.7 The issue of routine notifications from the ante natal clinic to the Health Visiting Service has not been recognised within the Pennine Acute Hospitals IMR. There are no recommendations contained within the Pennine Acute IMR. The SCR Panel will address this issue under SCR Panel recommendations. Recommendation 33 6.3 What steps did agencies take to discover the family’s background and what influence did any findings have on their assessment and decision making? 6.31 Prior to the incident on 19/1/13, which initiated this Serious Case Review only the Health professionals involved had opportunities to collect information on Baby F and his parents. It is recognised that an effective social history of a family will help in the identification of need, and how agencies can best organise service provision to cater for those needs. 6.3.2 The GP IMR provides the first examples of what will be a recurring theme within this Overview Report. Birth Father and Birth Mother are Polish nationals for which English is an additional language. When the parents first registered at a GPs surgery in 2009 the requirement for an interpreter was recognised, yet not responded to. On that occasion a medical history of both parents was obtained by the GP, utilising the parents to act as each other’s interpreter. 6.3.3 In November 2012, Birth Mother, Birth Father and Baby F re-registered at a General Practitioner surgery. The family completed a standard information form for new 23 registrations with the GP. The form was taken away by Birth Mother and Birth Father. The completed form provided a more detailed family history providing details of their arrival in the United Kingdom and details of Birth Mother’s two children who were resident in Poland. It did not provide the same information for the Birth Father. The document was not translated into Polish. The panel questioned how accurate and comprehensive the information provided was. 6.3.4 The GP IMR and Health Overview Report author has clearly articulated within both reports that GPs missed opportunities to provide a more detailed assessment of the family. The IMR author makes sensible recommendations to resolve those concerns. 6.3.5 On 5/1/12 Birth Mother attended at the Children’s Centre, Middleton, where the Midwife assessed Birth Mother as being 7 weeks pregnant. A family friend attended with Birth Mother. The midwife acknowledged on this first meeting with Birth Mother that English was an additional language and that the services of an interpreter would be required to ensure that she had a full understanding of her condition and the care available and provided to her. The Pennine Acute IMR records that an interpreter was present with Birth mother throughout her ante natal care by the maternity Service. This is an example of good practice. 6.3.6 The Booking in Midwife obtained from Birth Mother a wealth of personal and family medical history which could have an impact upon her pregnancy and the health of the unborn baby. However the midwife failed to ask Birth Mother questions around the role of the Birth Father and Domestic Violence. The omission is rightly documented within the Pennine Acute IMR, and an explanation provided. However the SCR Panel believe a specific recommendation is required within the IMR. This will be addressed under SCR Panel recommendations. Recommendations 23 and 24. 6.3.7 An explanation was offered that the Midwife did not have an opportunity to speak with the Birth Mother alone. The Good Practice Guidance (Department of Health 2012) does support not asking the individual in the presence of another person. However the guidance also states that there is a need for opportunity to be created at a later time to ask this question of all pregnant women during the antenatal period. Did the fact that an independent interpreter was present with Birth Mother at subsequent ante natal appointments prevent that happening? If so, what is the advice to staff on how to seek information about Domestic Violence from women who have English as an additional language and require the services of an interpreter? 6.3.8 The panel reflected on the issue of whether the presence of an independent interpreter with Birth Mother at subsequent ante natal appointments adversely affected the midwifery staff s ability to ask the relevant questions about Domestic Violence. The IMR author has not within the IMR made any single agency recommendations. This will be addressed under SCR Panel recommendations. Recommendation 23. 6.3.9 Birth Mother gave birth to Baby F in October 2012. Birth Father and an interpreter were present with Birth Mother at NMGH. 6.3.10 Following the Birth of Baby F and the subsequent post natal care at the hospital, the panel noted the stark difference in the provision of interpreter services to Birth Mother. Whereas those staff providing ante natal care clearly identified the need to provide Birth Mother with interpreting services those engaged in providing post natal and community care singly failed to recognise this important issue. 24 6.3.11 The Pennine Acute IMR provides commentary on the fact that whilst on the post natal ward, the Sister in charge believed that Birth Mother’s English was of sufficient standard to understand “instructions, information and advice”. In addition between 13/10/12 and 26/10/12 the Community Midwife saw or visited Birth Mother and Baby F on 4 occasions. No interpreter was present during these visits. The Community midwife reported that “she could hold limited conversations with Birth Mother about key aspects of her care and felt that Birth Mother understood what she was saying to her”. 6.3.12 The panel were concerned as to how the Ward Sister and Community Midwife came to their respective decisions about Birth Mother’s fluency in English. Decisions that are in clear contradiction to what is recorded on Birth Mother’s ante natal record. The SCR Panel queried whether ante natal patient records are forwarded in their entirety to staff providing post natal care. The Pennine Acute Hospital IMR does not contain any recommendations. The issue of ensuring post natal staff recognise the need to utilise Interpreting Services will be subject of a SCR Panel recommendation. Recommendation 34. 6.3.13 On 25/10/12 a Health Visitor undertook a primary visit with Birth Mother and Baby F at address 1.Unbeknown to the Health Visitor, Birth Mother’s discharge notification pack included information that Birth Mother required the services of an interpreter. The IMR Author reports that it is not uncommon for the discharge notification packs from Maternity Services to Health Visiting teams to be subject of delay. The IMR author makes appropriate recommendations within the IMR to address this issue. 6.3.14 The primary visit was therefore undertaken without the services of an interpreter. An ‘unknown’ male was present in the house who spoke fluent English. This male has never been identified, nor has his relationship to Birth Mother or Birth Father established. This is worrying given the well documented dangers of hidden males (Brandon et al 2010; Ofsted 2010, Ofsted 2011) 6.3.15 The assessment undertaken by the Health Visitor recorded the family’s ethnicity and recorded that Birth Mother had 3 children living in Poland. The Review has established that Birth Mother has 2 children living in Poland. The SCR Panel do not believe that Birth Mother provided inaccurate information, as she would know how many children she had. It highlights the fact that inaccurate information was recorded on such a fundamental issue, and is clear evidence of the requirement to provide interpreting services for those patients who have English as an additional language. 6.3.16 The Health Visitor did not complete a genogram which would have aided a fuller assessment. The Birth Father’s history was not explored and only his name and date of birth was recorded. The IMR author comments upon this weakness and links the omission to a previous recommendation within a SCR. The IMR author makes appropriate recommendations to address this issue. 6.3.17 The Health Visiting IMR author views this primary visit as incomplete. A view shared by the SCR Panel. The assessment failed to take due cognisance of English being an additional language for the family. As a result the family were assessed as requiring the Universal Offer of support, when the assessment should have assessed them as requiring Universal Plus Offer, in accordance with the Health Visiting Service Specification. 6.3.18 Had the family been assessed correctly they would have received a second home visit by the Health Visitor some 6 weeks after the primary visit. This could have provided a more opportune occasion for a more detailed assessment of the family 25 and their needs to be undertaken, especially as the Health Visitor would have now been in possession of the invaluable information that Birth Mother required the use of an interpreter. This was a missed opportunity. 6.3.19 Within the Health Visiting IMR the author provides a helpful contextual overview of the organisational changes that were occurring within the Health Visiting Teams during 2012/13 which provides an explanation as to how service delivery was being prioritised. 6.3.20 Following Baby F admission to Hospital, his medical needs were appropriately assessed and catered for. 6.3.21 All agencies within the SCR have been able to describe the systems that are in being to collect information about the family composition and circumstances to assist the assessment making process. Despite this, relevant agencies have highlighted the missed opportunities that existed to obtain greater detail that would allow a clear family history to emerge. The importance of securing a clear family history is recognised as the first step in understanding and recognising potential vulnerabilities in children. 6.4 What were agencies assessments of the parenting abilities of both parents and how did agencies identify and manage any risks? 6.4.1 Prior to the incident on 19/1/13, health agencies contact with Baby F and his Birth Mother were very favourable. It is acknowledged by health agencies that assessments undertaken may have been more rigorous and complete, but there were no indications that Birth Mother was not coping, or Baby F was in any way vulnerable. 6.4.2 When Birth Mother attended at the ante natal clinic at the Children’s Centre on 5/1/12, Birth Mother was in terms of the Department of Health definition, an ‘older mother’, being aged over 27years. The panel are aware that Birth Mother has two grown up children in Poland the youngest being born almost two decades ago meaning that her maternity experiences were not current. The SCR Panel were concerned that there appeared to be no assessment of the Birth Mother’s age or the impact of being an older mother in a different country/culture than her previous pregnancies, in respect of her health and emotional wellbeing. 6.4.3 Significantly, neither the Community Midwife nor the Health visitor who undertook the primary visit saw the Birth Father or would appear to have discussed and explored with the Birth Mother the role Birth Father was undertaking in parenting Baby F. 6.4.4 It is a matter of record that Serious Case Reviews undertaken across the Country have persistently identified that all sources of information should be used to inform assessments and that there is a failure to take men into account in assessments. (Brandon et al 2010; Ofsted 2010, Ofsted 2011). The SCR Panel felt it would have been advantageous had investigations been undertaken to establish Birth Father’s role and influence. 6.4.5 On his admission to RMCH Hospital, CMFT staff initiated Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008) “and the “Guidance for inter agency working between health staff and the Police in Child Protection Investigations in severely ill or injured children Central Manchester University Hospitals NHS 26 Foundation Trust (CMFT), produced January 2012 by CMFT and Greater Manchester Police”. This is viewed by the panel as good practice 6.4.6 It is evident that there was detailed discussion between all agencies around the need to balance the parent’s wishes to be close to their dying son, with the need to safeguard Baby F, albeit this came several days after his admission to hospital. The requirement for parental supervision was agreed. The panel took cognisance of the fact that RBSCB does not have a ‘Parental Supervision of Children In Hospital’ policy parental supervision in hospital policy, but expressed concern that once a decision to have the parents of Baby F subject of parental supervision, that supervision should have been put in place as a matter of urgency. In this case Baby F was in the presence of his unsupervised parents for 95 hrs before supervisory staff were in place. The SCR Panel view this as poor practice. 6.4.7 The decision to remove the requirement for the parents of Baby F to be supervised when visiting their son on 25/1/13 was appropriate, sensitive and compassionate without any significant compromise to his safety. 6.5 Was agencies management of risk in compliance with their procedures and those of RBSCB? 6.5.1 It is evident from the individual Health IMRs and the Health Overview Report, that overall, clear assessments of risk were undertaken in respect of Baby F. Those assessments were undertaken promptly and were compliant with established procedures. 6.5.2 There were two areas of procedures within health that caused the SCR Panel a little concern. Within the Pennine Acute Hospital IMR it is acknowledged that Birth Mother was not asked by the booking midwife questions regarding Domestic Violence/Abuse. It is acknowledged within the IMR and an explanation given. However it is within the knowledge of SCR Panel members that this omission has been highlighted in a previous Single Agency Report – case of DS. The IMR author would appear not to have established that point or made a suitable recommendation to highlight the issue. 6.5.3 The second procedure relates to the primary visit undertaken by the Health Visitor to Birth Mother and the absence of an assessment of the Birth Father, his background, and his role within the family. The IMR author helpfully acknowledges that this important aspect of assessment of family need has been subject of a recommendation within a previous SCR (Children Q and R in 2012). The panel were reassured by the IMR author’s appraisal of the issue, the presence of an appropriate recommendation, and the information of forthcoming governance meetings to discuss the work undertaken to address this issue. 6.5.4 Staff within the Royal Manchester Children’s Hospital responded to the potential risk of harm to Baby F by initiating the guidance within Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008) “and the “Guidance for inter agency working between health staff and the Police in Child Protection Investigations in severely ill or injured children Central Manchester University Hospitals NHS Foundation Trust (CMFT), produced January 2012 by CMFT and Greater Manchester Police”. 6.5.5 It has become evident during this SCR that Rochdale Borough Safeguarding Children Board, does not have Parental Supervision of Children In Hospital policy. 27 6.5.6 It was clearly a source of great frustration to hospital staff that despite repeated requests to Children’s Services and the Police to act within the guidelines established within these two documents, no timely response was achieved. The SCR Panel agreed that this state of confusion is a direct result of professionals failing to recognise the requirement to call a strategy meeting in accordance with established RBSCB child protection policies. 6.5.7 Prior to the 19/1/13 Children Services had no contact with Baby F or his family. The Police had come into contact with the father of Baby F, but only as a victim of a crime and a witness to incidents of anti social behaviour. Following Baby F admission to hospital with unexplained injuries, both agencies responded promptly to those reports 6.5.8 By 1900hrs, 19/1/13 sufficient information was in possession of the Police and Children Services about the nature of Baby F injuries and the potential risk that maybe posed to him by either or both his parents, for a strategy meeting to be convened in accordance with existing child protection policy and guidelines . 6.5.9 Meetings did take place between the Police, Children Services and Health Professionals at 2000hrs 19/1/13 and the following day at 1310hrs 20/1//13. These meetings did not constitute a strategy meeting. The failure to convene a strategy meeting in these circumstances is a fundamental failure to adhere to a key child protection policy. It is highlighted by the SCR Panel as an example of poor professional practice. 6.5.10 Both the Childrens Services and the Police respective IMRs acknowledge that a strategy meeting should have been convened on the evening of 19/1/13 , and the failure to do so meant that existing child protection procedures were not adhered to. 6.5.11 The SCR Panel were confused and concerned by the entry within the Children Services IMR at Paragraph 8.6. - “EDT staff can access ICS to see records but cannot input into the system. As a Strategy Meeting has to be triggered by the entry to the ICS record the EDT team cannot record having organised or held one”. This was a view expressed by staff to the IMR author. However the SCR Panel sought and obtained absolute clarity from the Interim Head of Service Care for Children, that this situation was not the case. At present all RMBC childcare sessional workers working within EDT can read and write to ICS. However Agency staff who work on an ad hoc basis within EDT have read access only to the ICS. Confirmation was received by the SCR Panel that the EDT Social Workers who were on duty during the relevant periods of this SCR had full access to the ICS system. The SCR Panel were informed of the ongoing work within EDT to have all staff trained to both read and write to the ICS system. 6.5.12 The SCR Panel are clear in their opinion that a strategy meeting was required by the evening of 19/1/13. The meeting, and the subsequent meeting on 20/1/13, do not amount to strategy meetings in accordance with RBSCB child protection policy. As a result the SCR Panel believe that in this respect Children Services and GMP, they did not effectively manage the risks posed to Baby F in compliance with existing RBSCB Child Protection policy and procedures. 6.6 To what degree did agencies in gathering information , making assessments and delivering services take account of issues such as ; - race and culture(including isolation), language ( including interpretation services), age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery? 28 6.6.1 All agencies recorded the fact that Birth Mother and Birth Father were White Polish nationals, who spoke English as an additional language. 6.6.2 With the exception of the GP IMR, all agencies recognised that Interpreting services would be required when dealing with the Birth Parents. The author of the GP IMR rightly highlights the situation that no attempts were made by GPs to access interpreting services for the birth parents, which led on one occasion to the unacceptable situation of the respective parents being used as interpreters for each other. The apparent reluctance of GPs to utilise interpreting services is addressed within the IMR recommendations. 6.6.3 During Birth Mother’s pregnancy with Baby F, Maternity Services providing ante natal and labour services, recognised that English was an additional language to Birth Mother and promptly ensured that interpreting services were in place for future visits by the Birth Mother .This provides clear evidence of a service recognising and responding positively to the diversity needs of a service user. 6.6.4 In terms of the provision of interpreting services to Birth Mother there is a stark contrast between the service provided by the ante natal service to that provided by the post natal and community midwife service. At no time during Birth Mother’s contact with either service are interpreting services utilised. Staff within those agencies made assumptions, based on unknown criteria, that Birth Mother could speak and understand English to a satisfactory level. The SCR Panel can find no evidence that staff within the post natal and community midwife service undertook any exercise to ensure that Birth Mother understood the information being communicated to her. 6.6.5 The SCR Panel questioned how there could be such a distinct difference in the service provision in respect of interpreting services between the ante natal service and the post natal and community midwife service. The issue is not addressed within the Pennine Acute Hospitals IMR, but will be subject of a SCR Panel recommendation. Recommendation Number 34. 6.6.6 The Health Visitors IMR provides evidence of how a failure to recognise the cultural needs of a family can have a direct result on assessment of need and service provision. The family were assessed for the Universal offer. The Health Visiting Service specification identifies that where English is an additional language the assessment should be one of Universal Plus services. 6.6.7 Following Baby F admission to Hospital it is evident to the SCR Panel that all agencies involved recognised the language barriers faced by the parents of Baby F. Health professionals at the Royal Manchester Children’s Hospital utilised the CMFT Interpretation and Translation services and applied the CMFT interpretation Policy (March 2012) 6.6.8 Although agencies recognised the language barriers faced by the parents of Baby F, there were occasions when agencies recognition of those language barriers differed. Within the Children Services IMR, a commentary is provided of how Social workers attending the strategy meeting on 22/1/13, recognised the need to ensure that interpreting services were utilised to ensure that the parents of Baby F fully understood the implications of the Child Protection and Investigative processes that were being undertaken by the respective agencies. It was perceived by Social Workers that Police Officers present at the strategy meeting did not agree with that assessment of the parents vulnerabilities. As a result appropriate challenges were made between agencies, and the matter was escalated to senior management for 29 resolution. The use of respectful and appropriate challenge is viewed by the SCR Panel as an essential part of good interagency working. 6.6.9 The provision of interpreting Services does not guarantee that the information being provided has been processed and understood by the distressed family members, particularly when the information is of such a sensitive and emotive nature. There are clear examples within the CMFT IMR and Children Services IMR of how Health and Social Work professionals recognised this issue and sought to establish the parents understanding of what was happening to their son. This is viewed as good practice 6.6.10 The Children Services IMR provides additional evidence of support to the parents of Baby F in ensuring that they had an understanding of the legal and child protection processes that were in being. This included providing the parents with a list of solicitors who provided a foreign language service. In addition Children Services staff recognised the religious needs of the family and facilitated contact with the Hospital chaplain. This is viewed as good practice. 6.7 What child protection procedures did your agency follow after Baby F was admitted to hospital and were they fit for purpose? 6.7.1 When Baby F was taken to the accident and emergency Department at North Manchester General Hospital, the focus of all health professionals was on the welfare of the child and efforts to sustain his life. 6.7.2 Greater Manchester Police were the first agency to respond to investigate the circumstances surrounding Baby Fs injuries rather than his immediate medical requirements. The immediate response is in keeping with established Police procedures. Police Officers are sent to the address to secure the premises and any potential crime scene. Duty CID officers are despatched to the hospital to commence the investigation, and specialist officers from the Forces Public Protection Investigation Unit are contacted and made aware of the incident. In addition two Detective Chief Inspectors are made aware of the ongoing incident. 6.7.3 GMP have not submitted as part of the Serious Case Review process a comprehensive chronology, and therefore the Overview Author is confined to assessing Police activity and decision making activity against the narrative contained within the IMR submitted by GMP. 6.7.4 DS1 and DC4 arrive at the NMGH at 1609hrs, some 19 minutes after Baby F was admitted to the hospital. The officers speak to A&EC1 .At 1735hrs DS1 updated the Police Incident log ( FWIN 1446 19/1/13), with the following entry: “...full update to follow, no suspicious circumstances and no requirement for a scene”. 6.7.5 At 1812hrs DS1 provides a more detailed entry on the incident log: “...from consultation with A&EC1, he stated that the prognosis of the child was hopeful as although on a respirator the child was trying to breathe himself and had a pulse on arrival at the hospital. The child is to be transferred to a neo-natal paediatric unit for further treatment and CT scan when his condition has stabilised. The doctor stated that he believed that the child’s condition was due to an infection”. 6.7.6. As a result of DS1 conversation with A&EC1, DS2, PPIU, makes the following untimed entry into his daybook sometime after 1600hrs, 19/1/13; 30 “Informed from the C.I.D. that the child with the injury re FWIN 1446 19/01/13 has been examined by consultants at the hospital and the diagnosis is biological not an injury and that police attendance is no longer required; not being treated as suspicious by hospital staff. No further involvement required by the PPIU at this time 6.7.7 As a result of these logs, and after consultation with DCI1, the secured scene at Address 1 was released and Police investigations were ceased. 6.7.8. Due to the absence of a comprehensive Police chronology, the Police IMR is not explicit as to what the focus of initial Police activity was. There is no mention of treating this incident as a “Non Accidental Injury”, or Criminal assault. The fact that a potential ‘crime scene’ was established and protected is indicative of a cautious approach to a suspicious incident. However that cautious approach was allowed to drift. At this stage of the incident the SCR Panel formed a view that the Police decision to accept a preliminary medical explanation, without the benefit of test results and the result of a CT scan, of which they had knowledge of, was premature. 6.7.9 It was within the experiences of all SCR Panel members that children can present at Hospitals with no visible injuries, yet have sustained life threatening internal injuries. 6.7.10 The SCR Panel also commented on the actions of A&EC1 the A and E Consultant who initially provided the information to Police Officers that a possible cause of Baby F condition was an infection. Although the Doctor agreed that a CT scan should be undertaken, the SCR Panel raised the issue of what safeguarding training is provided to A and E staff. A&EC1’s initial professional judgement may have been that the Baby F condition was as a result of an infection, (sepsis), but felt that he should have inserted into his opinion the safeguarding caveats in respect of undertaking a differential diagnosis to eliminate injuries linked to child abuse. 6.7.11 The conversation between the Police and A&EC1 highlights different cultures in medicine and policing in respect of injuries to children. The Police mindset in this incident is almost one of wanting an unequivocal diagnosis of NAI before taking investigative action. Medical diagnosis of NAI is difficult in babies, and A&EC1 mention of Sepsis undoubtedly wrong footed the attending Police Officers. The SCR Panel speculated how inquisitive the initial Police Officers who attended the Hospital had been. Did they specifically ask A&EC1 how the injuries could have been inflicted? If they didn’t ask, it is the opinion of the panel that they should have done. There appeared to be reluctance amongst those Police Officers and Social Workers attending at the Hospital within the first 48hrs to ask relevant questions of medical staff in respect of possible causes for injury. 6.7.12 Baby F underwent a CT scan at 1835hrs, 19/1/13. The results showed that he had ‘Acute right extradural and subdural haemorrhages and quantilateral left subarachnoid haemorrhages’. 6.7.13 At 1838hrs, PC1 is at NMGH on an unrelated matter when he is approached by medical staff treating Baby F, requesting that the CID are contacted in relation to the medical condition of Baby F. An entry timed between 1859hrs and 1909hrs, on the following comment is placed on the Police Incident log: “... from the doctors, this injury is non-accidental. PC2 will re-start the scene. DC2 is aware and will contact hospital shortly” 31 6.7.14 At 1855hrs 19/1/12 CP1 rings Children’s Services Emergency Duty Team regarding Baby F admission to hospital. The Emergency Duty Team Social Worker SW1 takes the call and makes her way directly to NMGH. 6.7.15 DC2, an Officer with limited safeguarding experience attended the Hospital. Prior to doing so she contacted DCI1 who suggested that she should attend with a member of the PPIU. The officer sought that assistance. However PPIU staff go off duty at 2000hrs each day. The SCR Panel were surprised that a specialist unit tours of duty did not go beyond 2000hrs.This is subject of a recommendation under SCR Panel recommendations. Recommendation number 27. 6.7.16 The SCR Panel queried whether DC2 sought additional advice from her immediate supervisors or DCI1, on discovering that no PPIU staff were available to accompany her to the meeting. It is clear from DCI1 initial instruction that he believed a ‘specialist’ was required at the meeting. It can only be a matter of speculation, but would the presence of a member of the PPIU team at the meeting on 2000hrs 19/1/13 have made a significant difference in respect of the requirement to convene a strategy meeting? 6.7.17 At this stage in the proceedings the medical evidence indicates that Baby F has suffered significant harm, the Police have recorded within their incident log that Doctors believe this to be a NAI, and Police have re- established crime scene security measures at Address1. Section 47 Children Act 1989 procedures should also have been followed and a strategy meeting called. 6.7.18 At approximately 2000hrs, Saturday 19/1/13, what is termed a ‘multi agency’ meeting within the Police IMR is held at NMGH. DC2, SW1 and CP1 are present. Despite the information that at this stage is known about the injuries to Baby F, and the comments from CP1 that “ NAI could not be ruled out”, neither the Police nor Children Services initiate the existing RBSCB Child protection policies and procedures in respect of calling a strategy meeting. The SCR Panel felt that this was a significant oversight by both agencies, a fact recognised and accepted by both the respective agencies. 6.7.19 Rochdale Borough Safeguarding Children’s Board Child Protection Procedures states: “2.4 Strategy Discussions Involving the Children’s Social Care Department, the Police and Other Agencies 2.4.1. Whenever the Police or Children’s Social Care have reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion between them and other agencies or professionals, as appropriate, in particular any referring agency. Where a medical examination may be needed, the relevant paediatrician/doctor should be included in the strategy discussion. 2.4.2. A strategy discussion will take place, whenever a referral and an Initial Assessment (or new information on any case open to Children’s Social Care) indicates that a child is suffering, or is likely to suffer, significant harm. 2.4.3. A strategy discussion may take place at a meeting, or by telephone. Any information shared, or decisions reached, and the basis for those decisions, should be clearly recorded by all parties to the discussion. 2.4.4. The strategy discussion should be used to: 32 a) share available information; b) decide whether Child Protection Enquiries under section 47 of The Children Act 1989 should be initiated, or continued if they have already begun; c) decide whether or not any enquiries/investigation are to be carried out jointly by Children’s Social Care and the Police; d) discuss how to proceed in a way which will not place the child or others at further risk (e.g. where there is domestic violence); e) plan how enquiries should be carried out, and by whom; f) discuss arrangements for any necessary medical treatment; g) agree what action is needed immediately to safeguard the child, and/or provide interim services and support; h) decide on the most appropriate timing of parental involvement; i) determine what information about the strategy discussion will be shared with the family, unless such information sharing may place a child at risk of significant harm or jeopardise Police investigations into any alleged offence(s) General 2.5.1. Those conducting Child Protection Enquiries regarding any individual child should always consider the need for protection of any other children in the alleged abuser’s home, extended family, work or community life.” 6.7.20 The aforementioned extract from RBSCB Child Protection policy and procedures was in being during the time of this incident. In July 2013, The Greater Manchester Safeguarding Partnership produced almost similar guidance for LSCBs within the Greater Manchester area, and Paragraphs 5.56 – 5.60 Working Together 2010, provided similar guidance to practitioners. 6.7.21 There can be no doubt that the staff, who attended the meeting at 2000hrs, 19/01/13, at NMGH, did so with the best of intentions. However the meeting that took place failed to address key concerns that would develop into significant issues over the next 2/3 days. These included who was the lead agency, arrangements for supervised visits and the communication issues with the parents of Baby F. 6.7.22 The lack of a strategy meeting meant that full consideration was not given to all the child safeguarding /protection issues, and that Police and Children’s Services activity was not carried out under the protection and accountability of the formal strategy meeting. The framework of policy and procedures are there to protect the child, but also the agency professionals working with and for that child. 33 6.7.23 The SCR Panel recognised the initial confusion and uncertainties that existed when Baby F was first admitted to Hospital, but the strategy meeting is the framework for working and delivering outcomes around that uncertainty. 6.7.24 The SCR Panel can find no minutes of the meeting held at 2000hrs 19/1/13. What does exist are notes made by SW1 and an updated Police incident log made by DC2. The SCR Panel felt that neither written record established and recorded the fact that this was a NAI investigation. Indeed there is almost a suggestion that there are more plausible medical reason for the injuries sustained by Baby F. These record entries may well have influenced other colleagues thought processes. 6.7.25 Baby F was transferred to the PICU AT Royal Manchester Children’s Hospital late on Saturday 19/1/13. 6.7.26 On the morning of Sunday 20/1/13, following consultation between DCI1 and DCI2. It was agreed that DS2 from the PPIU would assume control of the incident. Despite receiving an up to date briefing it is unclear from the Police IMR whether GMP are actively dealing with this incident as a NAI. The panel raised concerns that despite the input of two DCIs and a D/S Sgt from the PPIU, there was no recognition that a strategy meeting should have been called the previous night, and no suggestion, direction or advice that Police staff should initiate a strategy meeting on that Sunday. The issue of guidance to staff on conducting strategy meetings is addressed under SCR Panel recommendations. Recommendation Number 25. 6.7.27 At 1310hrs, Sunday 20th, January 2013 another ‘Multi agency meeting’ is held at RMCH. DC3, DR12, EDT SW2 and SW3 are present. This was another missed opportunity to adhere to the existing RBSCB Child protection procedures and policies. 6.7.28 The two missed opportunities to call a strategy meeting by the Police and Children Services are viewed as significant failings by the SCR Panel. What occurred later that afternoon provides cogent and compelling evidence of why professionals to need to adhere to existing child protection policies and procedures. 6.7 29 At 1740 20/1/13 DC3 is contacted by SN3 regarding the supervision arrangements for Baby F. DC3 is informed that Nurses will not be responsible for the supervision of the parents. SN3 confirms that DR12 has not documented any decision regarding the supervision of the parents of Baby F. This confusion and lack of clarity emanates from poor record keeping and communication with those who attended the meetings and those tasked with undertaking relevant actions. 6.7.30 At 1750hrs, Sunday 20/1/13 DS2 contacted SN3 to inform her that GMP would not be supervising the parents visits to Baby F. DS2 records his rationale in his policy book -“I explained that the consultant had said that there would be supervised access but had not requested police assistance. I also outlined that the parents had had unsupervised access for a prolonged period of time since the child was admitted to hospital” He further added “ Decision made not to PPO the child as there was no immediate risk to the child . EDT SW (Emergency Duty Team Social Worker) was in agreement and involved in the decision making”. 6.7.31 The SCR Panel present this as yet another example of where an opportunity was missed to initiate a strategy meeting. Health professionals are clearly concerned over the issue of supervised visits. The Police are unaware of who was tasked to provide staff for those unsupervised visits. There was no consideration of calling a strategy meeting in person or by telephone to resolve this pressing issue. Within the Police 34 IMR it is recorded that DS2 decision making was ratified by DCI2. The SCR Panel felt that this was additional evidence that guidance around how to manage strategy meetings is required within GMP. 6.7.32 The SCR Panel were concerned about the arrangements for the supervised visits of the parents of Baby F. The panel can find no record of the rationale for the supervised visits, who was to undertake the responsibilities of the visits and whether the parents of Baby F had been consulted in any way. Clearly a decision had been undertaken to supervise the parents, but some 4 hrs after the 1310hrs meeting, with the parents present at his bedside, no supervision was in place. This was an unacceptable situation and potentially placed Baby F at risk of further injury. 6.7.33 At 1940hrs, Sunday 20/1/13, DC3 received a telephone call from PR3, who expressed concerns over why Baby F had not been made subject of a Police Protection Order, and queried why the Police were treating the incident as”an injury with an unknown cause whereas the hospital were treating it as a non accidental injury” 6.7.34 In response to PR3 telephone call, DC3 contacted DS2 and made the following entry in her daybook- “No changes to be made as yet. Police have no grounds to PPO the child as the cause of injury has not been ascertained”. The SCR Panel are in agreement that the Police were right not to initiate powers under Section 46, Childrens Act 1989, but not for the reason provided by DC3. 6.7.35 The SCR Panel once again regard this conversation as another missed opportunity to call a strategy meeting. Concerns are being voiced by a Health professional around Police action and the status of the Police investigation. The Police response to the Doctor is somewhat muted Some 24 hrs after Baby F had been admitted to hospital the Police are unable to confirm that their investigation is one based on a NAI. 6.7.36 During the events of Sunday 20/1/13, the timings cannot be accurately established, CP1 at NMGH, completes and submits a child protection referral in respect of Baby F. The referral raises concerns that the injuries to Baby F are non accidental in nature. The concern raised by a health professional should have instigated a strategy meeting in accordance with established child protection policies. The failure to do so is regarded by the SCR Panel as poor practice. 6.7.37 At 1310hrs, Monday 21/1/13 SWTM1 reviews the information gathered by EDT in respect of Baby F. SWTM1 contacts DC3 by telephone for an investigative update. Following that conversation the following entry is recorded on ICS as her management decision – “Baby F is three months old, he has been found with Birth Father at home unresponsive. He (Baby F) has had a heart attack and was later found to have a brain bleed. No trauma evident and organic reasons are being explored. The Police are taking the lead as of yet no Child Protection concerns are established. Home conditions are good and previous care of baby F appears to have been appropriate” 6.7.38 The SCR Panel viewed the review of the case undertaken by SWTM1 as not being effective. A call was made to the Police, and medical information was received from the Police. There was no attempt to corroborate what medical information had been obtained from the Police by direct contact with the health professionals who were caring for Baby F. Limiting the information gathering to a conversation with a Police Officer, was a significant failing, and a missed opportunity to acquire the holistic overview of Baby F’s medical condition, and safeguarding requirements. An effective 35 review of this case must surely have raised the issue of a failure to adhere to existing RBSCB child protection policies and procedures in respect of calling a strategy meeting. In addition there is no mention of the issue of parental supervised visits. Some 24hrs after the 1310hrs, meeting of Sunday 20/1/13 supervised visits have still not been commenced. The SCR Panel view this episode as another missed opportunity to call a strategy meeting and continued poor practise in respect of absent parental supervision. 6.7.39 At 0700hrs, Tuesday 22/1/13 DS3 an experienced PPIU supervisor paraded for duty. The officer reviewed the incident involving Baby F, and obtained medical and Children’s Services update. The officer identified that a formal strategy meeting in accordance with established Child protection policies and procedures had not been undertaken. She arranged for an urgent strategy meeting to be undertaken at 1200hrs the same day at RMCH. This is the first time any professional in this matter has made mention of a Strategy meeting. Within DS3 policy book the following entry is found “Reviewed case, concerns by myself in relation to a possible NAI, Treat as such unless proven otherwise”. The SCR Panel recognise the leadership displayed by DS3, but would highlight that it took 4 days for a GMP Officer to recognise and succinctly sum up the nature of this investigation. 6.7.40 At 1200hrs, Tuesday 22/1/13, a formal strategy meeting in accordance with RBSCB policies and procedures was held at RMCH. At this meeting CP2 provided expert medical opinion that the injuries to Baby F were as a result of being violently shaken, but that being dropped could not be ruled out. 6.7.41 Within Children’s Services IMR, at the strategy meeting, held on 22/1/13, it was agreed that that Children’s Services would assume the role of main point of contact for information sharing regarding developments in Baby F condition and the investigation. The SCR Panel expressed the view that following the confirmation of a NAI injury that the Police should have assumed lead status. 6.7.42 An action from the Strategy meeting held on 22/1/13 was that Children Services would provide to the PICU and the Safeguarding Children’s Team the outcome of discussions regarding the supervision of Baby F parents. The SCR Panel noted that despite discussions unsupervised visits continued. 6.7.43 At 1915hrs, Wednesday 23/1/13, following discussions, Children’s Services and the Police met with the parents of Baby F. An interpreter was present. The reasons for parental supervision were explained to the parents and it was agreed that they could visit Baby F between 0900hrs- 2000hrs. The SCR Panel noted that the parents of Baby F agreed to the time constraints placed on visits to their son. In light of the emotional stress that the parents must inevitably have been suffering, did they fully comprehend and understand what was being asked of them and was it appropriate to ask them? 6.7.44 The panel queried whether, at this time, due consideration had been given to the needs, emotional and physical, of the parents to be with their son during his last few days of life. Supervised visits consisted of 11hrs of access. The SCR Panel were concerned that the hours of supervision had been formulated for the benefits of agencies and not for the wellbeing and best interests of the parents and Baby F. Was consideration given to having interpreters present for 24 hours day, which would have afforded the family more time to spend with their son? 6.7.45 On Thursday 24/1/13 following discussions with SWTM1 and CP2 supervised contact that afternoon and evening were suspended. The SCR Panel remain unclear as to 36 what the decision making process was for this decision, who was involved and where are those decisions documented. The SCR Panel regard this as another example of poor record keeping. 6.7.46 On Friday 25/1/13 SM1 spoke with CP2 by telephone. It was agreed that supervised contact between Baby F and his parents would cease. The SCR Panel are in agreement that the decision to review parental supervision in this matter was good practice. 6.7.47 However the SCR Panel were concerned as to how the decision making around parental supervision was undertaken. There is a clear record of Health and Children’s Services involvement, but no mention of whom within the Police Service agreed the decision. There is no mention of this decision within the Police IMR and in the absence of a comprehensive chronology from the Police it is not possible to check what is recorded on Police systems. The SCR Panel consider this an additional example of poor record keeping. 6.7.48 The issue of supervised parental visits to Baby F is has been a significant feature of this SCR. Hindsight has shown that had agencies initiated a formal strategy meeting on 19/1/13, the issue of supervised visits would have been agreed as part of the strategy meeting agenda. 6.7.49 Without the benefit of a formal strategy meeting, health professionals at the RMCH rightly referred to the two existing policies which provide guidance and advice regarding parental supervision. These policies are “Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008) “and the “Guidance for inter agency working between health staff and the Police in Child Protection Investigations in severely ill or injured children Central Manchester University Hospitals NHS Foundation Trust (CMFT), produced January 2012 by CMFT and Greater Manchester Police”. 6.7.50 The CMFT IMR presents evidence of concerned Health professional s seeking the support of colleagues from the Police and Children’s Services to implement the supervised visits under the auspices of the aforementioned policies. The confusion that existed prior to the Strategy meeting of 22/1/13 remained in place until the decision to remove parental supervision was formally agreed on 25/1/13. 6.7.51 The SCR process has established that Rochdale Borough Safeguarding Children Board is not a signatory to either of these two policies. This will be addressed as a SCR Panel recommendation. Recommendation Number 41. 6.7.52 The Police IMR acknowledges that there were missed opportunities to call a formal strategy meeting on the evening of 19/1/13 and the morning of 20.1.13. However the IMR does not analyse why the officers involved did not instigate a strategy meeting and why more Senior Officers who are clearly aware of the Baby F incident fail to recognise the need to call a strategy meeting in accordance with existing child protection policies. This includes two senior officers holding the rank of Detective Chief Inspector and a Detective Sergeant posted within the PPIU. This will be addressed as a SCR Panel recommendation. Recommendation Number 25. 6.7.53 The Children Services IMR acknowledges that there were missed opportunities to call a formal strategy meeting on the evening of 19/1/13 and the morning of 20/1/13. The IMR provides limited explanations as to why Social workers failed to recognise the need to call a strategy meeting in accordance with existing child protection policies. 37 The limited explanations provided by some of the staff involved would have benefited from greater critical analysis in order to maximise the learning opportunities from this SCR. This will be addressed as a SCR Panel recommendation. Recommendation 29. 6.7.54 The Children Services IMR recognises that as a result of the failure to convene a timely strategy meeting there were inappropriate time delays in addressing the pressing issue of parental supervision. The IMR author highlights Children’s Services approach to this issue as a good practice example. However there is no explanation or analysis as to how a child, identified as requiring parental supervision, is unsupervised with those parents for some 95 hrs before supervisory staffs are in attendance. (2145hrs, 19/1/13 – 1915hrs, 23/1/13). This will be addressed as a SCR Panel recommendation. Recommendation 41. 6.7.55 When Baby F was taken to North Manchester General Hospital on 19/1/13 and following his subsequent transfer later that day to the PICU at Royal Manchester Children’s Hospital, he was the subject of expert medical treatment, and the outcome for Baby F would not have changed. However the SCR Panel are clear in their belief that Baby F’s welfare was potentially compromised by the non adherence to existing child protection policies, particularly in relation to the absence of a reasoned decision making process on whether /how to provide adequate parental supervision arrangements for Baby F. 6.8 To what extent did agencies communicate effectively and work together to safeguard and promote the wellbeing of Baby F? 6.8.1 Overall the health family shared information well and worked effectively with other agencies. There were a number of exceptions. 6.8.2 The SCR Panel noted that those services providing antenatal care to Birth Mother quickly identified the need for interpreting service and ensured that those services were in place for Birth Mother at subsequent appointments. Yet correspondingly ,following the birth of Baby F, those tasked with providing post natal care and community midwife care, provided no interpreting service to Birth Mother at all. The SCR Panel questioned how effective the communication channels were between ante natal and post natal services. 6.8.3 It is highlighted within the Health Visiting IMR and the Health Overview report that there are delays in the Health Visiting Service receiving discharge notification packages from Maternity Services and that the detail contained within the packages can be of variable quality. 6.8.4 In this case information within the Notification package contained relevant information that Birth Mother required the services of an interpreter. That information was not known to the Health Visitor who undertook a primary visit to Birth Mother. As a result the Health Visitors assessment of the family dynamics and parenting ability was limited due to the lack of interpreter involvement. The Health Visitor assessed the family as requiring the Universal Offer, when the Health Visiting Service specification identifies that were English is an additional language for a family, the assessment should be one of Universal Plus Offer. 6.8.5 Both the Health Visiting IMR author and the Health Overview author have indicated that work is inbeing to rectify these issues as part of the Healthy Child Programme. As a result no formal recommendation has been made within the Health Overview 38 report. However the SCR Panel have initiated a SCR recommendation in respect of this ongoing work. Recommendation Number 33. 6.8.6 Following Baby F admission to hospital on 19/1/13 there is some evidence of effective communication and multi agency working. However there are examples of poor communication and ineffective multi - agency working. Notably, the hospital messages about the potential NAI nature of the injuries to Baby F were fairly consistent after about 1900 hours on Saturday 19/1/13, post the CT scan of Baby F. Those messages were not effectively transmitted between GMP and Childrens Services, as evidenced by the Childrens Services managers note on the Monday that there were no concerns re cause of injuries. 6.8.7 The SCR Panel have been critical of the lack of adherence to RBSCB child protection policies in respect of arranging Strategy meetings. However the SCR Panel take full cognisance of the fact that those agencies did meet on the evening of 19/1/13 and thereafter. Information was exchanged and the wellbeing of Baby F was at the centre of multi agency discussions and activity, albeit the supervision issues were not adequately dealt with. 6.8.8 There are examples of significant lapses in communication which led to interagency disagreements. Decisions regarding the parental supervision of Baby F parents were not communicated effectively to health professionals caring for Baby F, who felt, with some justification, that existing policies directed towards the supervision of parents with children in hospital were not being correctly adhered to. 6.8.9 Health professionals despite being present at meetings on 19/1/13 and 20/1/13 did not believe that the Police and Children Services were treating the injuries to Baby F as NAI, despite the medical evidence present. This led to an exchange of phone calls on 20/1/13 between the Police and Health professionals. 6.8.10 There is evidence within the Children Services IMR of appropriate challenges following inter agency disagreement. 6.9 What lessons have agencies learned from this Serious Case Review See section 7. 6.10 Provide examples of good and poor practice where evident? 6.10.1 The following examples of good and poor practice have been extracted and condensed from contributory reports and are presented by agency. 6.11 GMP 6.11.1 Good practice is identified within the leadership displayed by DS3, in reviewing the case of Baby F, and implementing the requirement to convene a strategy meeting in accordance with established child protection procedures. 6.11.2 Poor practice is identified in the failure of staff to recognise the need to initiate a strategy meeting in accordance with established child protection procedures. 6.12. Rochdale Children’s Services 39 6.12.1 Good Practice has been identified in the areas of Information gathering at the commencement of the incident. When all agencies involved worked quickly and effectively to gather information about Baby F and his parents. 6.12.2 Good practise was also identified in the daily review of the requirement to maintain parental supervision for the parents of Baby F, following the strategy meeting of 22/1/13 6.12.3 The recognition of the cultural, language and faith needs of the family of Baby F by Social Workers is highlighted as good practice. 6.12.4 The effective and appropriate use of challenge by Social Workers in this SCR is highlighted as good practice. 6.12.5 Poor practice was identified in the failure of staff to recognise the need to convene a strategy meeting in accordance with established child protection procedures. 6.12.6 In addition the incidents of poor record keeping by Social Workers, particularly on the ICS system is highlighted as poor practice. 6.13 Pennine Care HHS Foundation Trust IMR – (Health Visiting Service) 6.13.1 No examples of good practice are highlighted. 6.13.2 Poor Practice was identified in the current weaknesses within the administrative systems to marry up Discharge Notifications with Health Visitor Primary Pack. 6.13.3 The decision not to utilise interpreting services for a family, for whom English is an additional language was a breach of existing policy and is viewed as poor practice. 6.13.4 The limited assessment undertaken to establish the family dynamics of Baby F’s family, particularly in relation to the role of Birth Father is viewed as poor practice. 6.14 Heywood, Middleton and Rochdale Clinical Commissioning Group .General Practitioner [GP] 6.14.1 No examples of good practice are highlighted. 6.14.2 Poor Practice was identified by the reluctance of GP’s to utilise interpreting services for a family, for whom English is an additional language 6.14.3 The failure to ensure that a robust family history was obtained for the family of Baby F is viewed as poor practice. 6.15 CMFT. 6.15.1 Good practice was identified in recognising the cultural and language requirements for the family of Baby F. 6.15.2 The adherence to existing Parental Supervision policies is viewed as good practice. 6.15.3 The recognition that this incident should be treated as NAI at an early stage is viewed as good practice. 40 6.15.4 Good Practice has been identified in the area of Information sharing amongst agencies during Baby F period in hospital. 6.15.5 No examples of poor practice are highlighted. 6.16 Pennine Acute Hospital NHS Trust 6.16.1 No examples of good practice are highlighted. 6.16.2 Poor Practice was identified by the reluctance of post natal to utilise interpreting services for a family, for whom English is an additional language 7. Lessons Learned 7.1 Introduction 7.1.1 The following lessons which are judged particularly relevant to the terms of reference have been extracted and condensed from contributory reports and are presented by agency. 7.2 GMP 7.2.1 GMP report that no new learning has been identified during the course of the SCR. 7.3 Rochdale Children’s Services 7.3.1 The substantive lesson is that EDT staff did not recognise when a Strategy Meeting was needed. 7.3.2 In cases of conflicting or unsure medical opinion as to the cause of serious injuries in children, professionals should proceed as if the injury was inflicted. 7.3.3 The importance of clear and timely communication between Children’s Services and hospital staff to ensure a prompt and appropriate response to children who require protection. 7.3.4 In conducting Child Protection inquiries, whenever possible, managers and social workers should contact medical staff directly and not take decisions based on third party information. 7.3.5 Social work managers and staff should ensure records are kept of all telephone calls between agencies. Social work managers and staff must ensure the accuracy of records. 7.3.6 When Senior Managers intervene directly in a case they should ensure a record of the intervention is added to the record 7.3.7 Children’s Services Senior Managers should ensure there is effective communication between the EDT and First Response Team 41 7.4 Pennine Care HHS Foundation Trust IMR – (Health Visiting Service) 7.4.1 There is a need to review the process of receiving notifications of pregnancy from Pennine Acute NHS Trust and the quality of information contained within them. 7.4.2 There is a need for an ante-natal pathway or guidance in the HMR borough that details the requirements for the transfer of care from the midwife to the health visitor. Ante-natal guidance to be updated to include promotion of and the importance of involving birth fathers. 7.4.3 There is a need for mothers’ discharge notifications following delivery to be received in a timely manner in the Primary birth packs. 7.4.4 There is a need to consistently use interpreters where English is a parent’s second language in order to complete an effective assessment of the need for the appropriate level of health visiting services. Interpreting policy needs to be in place 7.4.5 That the use of genograms to record family and household structures must be completed within the HV records. Recommendations about an audit of record-keeping and findings need to be implemented across PCFT. 7.4.6 There is a need to ensure comprehensive, structured assessment at the primary visit; this should as a matter of routine include Birth fathers. The pre-CAF checklist needs to include the domains of parenting and wider family and environmental factors. 7.4.7 Babies under one year are a vulnerable group and there is a need to ensure that health visitors understand their responsibility in relation to any interim guidelines to deliver the universal health visiting service. 7.4.8 Consideration needs to be given to the importance of prevention of Shaken Baby Syndrome and the education of parents. This should be reviewed at regional level. 7.4.9 All staff need to escalate failures in processes to managers so that action can be taken. 7.5 Heywood, Middleton and Rochdale Clinical Commissioning Group .General Practitioner [GP] 7.5.1 The need for GPs to actively engage in building robust family histories of their patients 7.5.2 There is a need to review the procedures for the use of interpreters within GP surgeries. 7.6 CMFT. 7.6.1 In light of this review the existing Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008) “requires urgent review. Its initial review date was 2009 42 7.7 Pennine Acute Hospital NHS Trust 7.7.1 The assessment of Birth Mother’s interpreting requirements should have been assessed more fully by staff providing post natal services. 7.8 Health Overview Report 7.8.1 The use of Interpreting Services is not clear across providers of health services. 7.8.2 Highlights the continued delays in information sharing between Maternity Services and Heath Visiting Services. 7.8.3 A recognition that that frontline health practitioners continue to demonstrate a lack of ‘professional curiosity’, when undertaking assessments of the role males play in the care of children. 7.9 SCR Panel 7.9.1 A significant finding of the SCR is the inability of professionals to identify when a strategy meeting is required. Within a matter of hours of Baby F being admitted to hospital, a CT scan identified the presence of significant trauma injuries. At that stage professionals had sufficient information to hand to identify that this was a child protection case that required the convening of a formal strategy meeting. The lesson learned is that recognising and initiating a strategy meeting would have provided professionals with the framework to undertake all the necessary and relevant actions in a reasoned, comprehensive and proportionate manner, avoiding the potential for significant issues to be overlooked. 7.9.2 The mindset of professionals to Baby F’s medical condition appeared to be overly influenced by a desire to have a definitive opinion from health professionals that his injuries were NAI. The lesson is that by adopting this ‘wait and see’ approach, Baby F was exposed to potential additional harm because his parents had unsupervised access to him for a significant period. 7.9.3 There are examples within the SCR of the failure of agencies to identify the requirement to utilise interpreting services for service users for whom English is an additional language, often in breach of existing policy and procedures. The lesson for professionals is to embed the culture of utilising interpreting services into everyday practice so that assessments that are undertaken in respect of family history and required service provision are as accurate as possible. 7.9.4 Although RBSCB are not signed up to the Manchester Safeguarding Board policy on parental supervision, there is a policy of treating each case of parental supervision on an individual case basis. Within this SCR the issue of parental supervision of the parents of Baby F lacked focus, clarity and leadership, prior to the convening of a strategy meeting on 22/1/13. The learning from this SCR is the requirement to have a written policy which clearly identifies all the administrative and logistical requirements of undertaking such supervision. 7.9.5 There are several examples within the SCR were professionals failed to maintain accurate records of meetings held, decisions made and actions agreed. Significantly where computerised information systems are in being, it is essential that they are populated with timely and accurate information. The lesson for professionals is that 43 the failure to maintain and record information accurately can lead to confusion, ineffective assessments of need and poor decision making, all of which potentially compromises the health and wellbeing of children. 8. Conclusions 8.1 At no time during Birth Mother’s pregnancy with Baby F, or any period of his short life prior to 19/1/13, did any Agency identify the existence of any safeguarding concerns in respect of Baby F. 8.2. The circumstances which led to the hospitalisation of Baby F, and his subsequent death, remain the focus of a Police criminal investigation. The exact cause of his death has yet to be determined by the Home Office Pathologist in this matter. 8.3 Rather uniquely for a Serious Case Review, the concerns of agencies involved in this matter are triggered on Baby F’s admission to NMGH and his subsequent transfer to the RMCH on 19/1/13. At this time Baby F is receiving expert medical attention. However Baby F’s wellbeing was potentially compromised by the inability of professionals to put in place timely and effective parental supervision arrangements. 8.4 The SCR was therefore focused on a post incident event. With a focus on whether Agencies followed established Child protection policies and procedures 8.5 At the crux of this review has been has been the issue of how responding individuals from Agencies failed to instigate strategy meetings in adherence with established Child Protection Procedures of RBSCB and their own respective agency. 8.6 Individual professionals from all agencies involved in this incident were subject of managerial oversight, yet inappropriate decision making persisted. Managers have a responsibility to ensure that their staff work within established frameworks. Moreover tangible managerial grip must be an integral element of managerial oversight. 8.7 Failing to identify and recognise when a strategy meeting is required is a serious mistake which goes to the heart of child protection. 8.8 The framework of policy and procedures are there to protect the child, but also the agency professionals working with and for that child. Failing to recognise the requirement for a strategy meeting or seeking appropriate supervisory advice, can lead individuals professionally vulnerable. 8.9 All agencies have accepted that there were individual failings, and many professionals involved with Baby F and his family have as part of the SCR and learning process, reflected on their decision making processes. 8.10 However there is a need to balance and put into a perspective what occurred in the 48hrs following Baby Fs admission to hospital on 19/1/13. Adherence to the existing child protection procedures relating to strategy meetings was not achieved, but professionals undertook pragmatic decisions and actions to safeguard Baby F and provide support to his family. At all times professionals had Baby F’s wellbeing at the heart of their decision making. Sadly even if the requirement to undertake a strategy meeting and timely and effective parental supervision had been adhered to, the outcome for Baby F would not have altered. 44 8.11 Cause/effect: Preventable/Predictable An important question for the SCR Panel, the RBSCB and for the wider community is whether the death of Baby F could have been predicted or prevented. Prior to the events of 19/1/13, agencies in contact with Baby F and his parents did not have a single child protection or safeguarding concern. What occurred on the afternoon of Saturday 19/1/13 is the subject of a criminal investigation. This report provides the supporting analysis that Baby F’s death was not predictable and therefore could not have been prevented by the professionals involved with him. 9. Recommendations 9.1 Single Agency Greater Manchester Police No Recommendations. Rochdale Children’s Services 1 Adoption of Parental Supervision of Children In Hospital Policy. 2 Children’s Social Care staff Inc EDT staff to understand the importance of compliance with procedures and accurate recording 3 Children’s Social Care staff Inc EDT staff to comply with the requirement to convene, chair and record the outcomes of strategy meetings or discussions in all cases where there is reasonable cause for concern that a child is at risk of significant harm. Pennine Care HHS Foundation Trust IMR 4 The process of routine notification of pregnancy to health visitors from Pennine Acute NHS Trust be reviewed. 5 The community boroughs review and benchmark their progress towards the pathway for the transition of care from the midwife to HV. 6 Existing universal and safeguarding guidance on the content of health visiting ante-natal contacts be updated and harmonised across the community boroughs to include Birth fathers. 7 Existing guidance on Primary visits be updated and harmonised to include the assessment and promotion of the Birth fathers role. 8 The system of receiving and processing mothers’ discharge notifications is reviewed to ensure timely receipt by health visitors. 9 PCFT should agree guidance for the use of interpreters. 45 10 The findings of the lessons from the Trust’s Safeguarding Record-keeping Audit (when completed) be disseminated to and embedded with services. 11 The Draft Interim Guidance for the delivery of the Universal Pathway, HMR Health Visiting Service be completed, approved and disseminated to the HV teams. 12 All staff to be reminded to use the Incident Reporting system according to PCFT criteria and escalate failures in processes to managers. Heywood, Middleton and Rochdale Clinical Commissioning Group General Practitioner (GP) 13. There is a need review the availability of Interpreter services to GP practices across the Rochdale Borough 14 The content of the new patient registration form requires further review to ensure that GP practice has information to inform clinical assessment of each patient registered. Central Manchester University Hospitals NHS Foundation Trust (CMFT) 15 That Medical and Nursing staff working on the Paediatric Intensive Care Unit are made aware of, and can access the MSCB Supervision of Parents of Children and Young People in Hospital – Multi-agency Protocol and the Guidance for inter-agency working between health staff and Police in Child Protection Investigations in severely ill or injured children, Central Manchester University Hospitals NHS Foundation Trust 16. That the MSCB Supervision of Parents of Children and Young People in Hospital – Multi-agency Protocol is reviewed and updated in light of the learning from this IMR Pennine Acute Hospital NHS Trust IMR No Recommendations Health Overview Report 17 All health services commissioned to provide health care need to provide assurance that practitioners have access to the use of interpreters for all patients for whom English is an additional language. 9.2 SCR Panel/ Multi-Agency Single Agency Recommendation. HMR CCG. 18 HMR CCG should provide information to the RBSCB on the extent to which GPs are accessing Interpreter Services for patients, whose first language is not English. 46 Pennine Acute Hospitals NHS Trust 19 Pennine Acute Hospitals NHS Trust to reinforce to all midwives and community care staff of the requirement to ensure that all assessments as a matter of routine should include the role of the Birth Father and any other males associated with the family. GMP 20 GMP to reinforce to all operational officers of the need to recognise when a strategy meeting is required in accordance with established Child Protection procedures. 21 GMP to reinforce to all operational officers engaged with child protection duties, of the need to ensure that when dealing with a suspected NAI incident, in the absence of a definitive medical diagnosis, the default position must always be the requirement to initiate a strategy meeting in accordance with established Child Protection procedures. 22 GMP should undertake a review of the shift pattern performed by staff within the PPIU. 23 GMP to reinforce to all operational officers, of the need to provide and maintain accurate records of meetings, decision making and interactions with key individuals and partner agencies. Childrens Services 24 Children Services to reinforce to all Social Workers, engaged with child protection duties, of the need to recognise the legal framework in which they operate and to identify when a strategy meeting is required in accordance with established Child Protection procedures. 25 Children Services to reinforce to all Social Workers, engaged with child protection duties, of the need to ensure that when dealing with a suspected NAI incident, in the absence of a definitive medical diagnosis, the default position must always be the requirement to convene a strategy meeting in accordance with established Child Protection procedures. 26 Children Services to provide guidance to all Social Workers, engaged with child protection duties, of the need to provide and maintain accurate records of meetings, decision making and interactions with key individuals and partner agencies, on the ICS record of the respective child. Multi Agency/SCR Panel recommendations. 27 Rochdale Borough Safeguarding Children Board to arrange a timely, reflective learning event in relation to Baby F’s case. This event to involve all the key practitioners, using the principles outlined in the Munro report to maximise reflective learning. 28 Pennine Care NHS Foundation Trust and Pennine Acute Hospitals NHS Trust should provide information to the RBSCB on the progress of work being undertaken to improve information sharing between Maternity Services and the Health Visiting Service, in relation to the issues of routine notifications of pregnancy and the timely and accurate provision of discharge notifications. 47 29 Pennine Acute Hospitals NHS Trust should provide information to the RBSCB on the extent to which Community Midwifery Services are accessing Interpreter Services for patients, who have English as an additional language. 30 Pennine Care NHS Foundation Trust should provide information to the LSCB on the extent to which the Health Visiting Service are accessing Interpreter Services for patients, who have English as an additional language. 31 GMP and Rochdale Children Services to provide information to the RBSCB on the progress they have made in re- enforcing to all operational staff of the need to recognise when a strategy meeting is required in accordance with established Child Protection procedures. 32 GMP to provide to the RBSCB a report on the Forces intentions in respect of the production of a comprehensive chronology, as part of the IMR process. 33 Midwifery Services, Pennine Acute Hospitals NHS Trust to provide information to the RBSCB on how staff approach the issue of domestic violence./abuse when dealing with patients who are constantly accompanied during medical appointments. 34 All partners engaged with RBSCB, to provide evidence to the RBSCB of the presence of an Interpreter’s policy which caters for those people who have English as an additional language. 35 All partners engaged with RBSCB, to provide confirmation that their staff receive guidance on how to work effectively with Interpreters. 36 Children Services to provide information to the RBSCB on the progress made to adopt the Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008), and what guidance is provided to Social Workers on how to discharge the logistical requirements of parental supervision. 37 Children Services to undertake a review of the commissioning, oversight and authorising aspects of the Individual Management Review process. 38 GMP to provide information to the RBSCB on the progress of the training programme initiated by the Force to raise awareness of the role , responsibilities and management of Strategy Meetings in respect of Child Protection investigations. 48 Appendix A |
NC048210 | Death of an eight-week-old child in October 2013. The cause of death was unascertained but neglect was a strong feature in the family. There were six children in the family aged between 13 years and 8 weeks. The family had been known to universal agencies since 2001 for: late booking of pregnancies; failure to attend health appointments/school; house fires; domestic violence; inadequate housing/frequent moves; poor child supervision; and low level neglect. The children were placed on the child protection register under the category of neglect for six months in 2007. A Safe at Home assessment took place six days before Child F's death where it was noted the child was asleep in bed surrounded by pillows next to a hot radiator. Issues identified include: variable information sharing from agencies to children's social services (CSC); inconsistent and idiosyncratic thresholds were applied within CSC and did not take sufficient account of identified risks from the past; behaviour of sibling 2 was not seen in the context of the circumstances in which he was living; lack of escalation between or within agencies; flawed management decisions to close episodes of social care involvement; poor recording practice within social care; and delay was a recurring factor. Recommendations include: to improve local arrangements and responses to domestic violence; to provide a robust system for reviewing and recording information within the health visiting service; to provide IT systems that support professionals to accurately record and share information; to ensure the tools for assessing risk and neglect are available for all professionals to use.
| Title: Serious case review: Child F. LSCB: Luton Safeguarding Children Board Author: Nicki Walker-Hall Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Luton Safeguarding Children Board Serious Case Review Child F Nicki Walker-Hall Feb 2016 Feb 2016 1 CONTENTS EXECUTIVE SUMMARY 3 1 FULL REPORT 9 1.1 Reason for the Review 9 1.2 Methodology 9 1.3 The Serious Case Review Process 9 1.4 Period Covered by the Review 10 1.5 The Family 10 1.6 Family Involvement in the Review Process 10 1.7 Limitations 11 2 SYNOPSIS OF PREVIOUS INVOLVEMENT 11 3 CONCISE NARRATIVE 12 4 APPRAISAL OF PRACTICE 16 4.1 Introduction 16 4.2 Luton and Dunstable 17 4.3 Cambridge Community Services 17 4.4 Urgent Care Centre 20 4.5 GP Practice 21 4.6 Education 22 4.7 Police 24 4.8 Children’s Social Care 24 4.9 Children’s Centre 27 2 5 THEMATIC ANALYSIS INCORPORATING THE TERMS OF REFERENCE 28 5.1 Response to neglect 28 5.2 Referrals and Information Sharing 30 5.3 Assessments 33 5.4 Managerial Oversight 34 5.5 Ethnicity, religion and language needs of the family 35 5.6 Voice of the Child 36 6 CONCLUSION 36 APPENDICES 39 Executive Summary 3 Context This serious case review (SCR) was initiated by Luton Safeguarding Children Board (LSCB) following the sad death of Child F at home, in October 2013, at the age of eight weeks; the review is about the family. The cause of death was unascertained however neglect features strongly in the background to the family. This review makes reference to a recent Child E SCR. The Child E SCR had similar features of neglect but differed as a criminal prosecution was sought. The Child E SCR was taken into consideration when the decision was made that this case met the criteria for an SCR. The Children There were six children within the family; at the time of Child F’s death their ages ranged from 13 years to 8 weeks. All the school age children attended the same school throughout their childhoods. Summary of Case Prior to the review period This family were known to agencies in Luton from 2001. Concerns identified were: Late booking for pregnancies Failure to attend health appointments/ school Head injury (Child 2) reportedly as a result of a fall off the settee Ingestion House fires Domestic violence Inadequate housing/ frequent house moves Poor supervision of the children The children were placed on the child protection register under the category of neglect for a six-month period from April 2007. Following de-registration concerns continued and the case remained open to the local authority social care long term team. During this period sibling 2 had two attendances at A&E, school requested a professional meeting to discuss concerns including, falling asleep in class, head lice, presenting hungry, no coats, tired, poor lunchboxes, turning up with the night before McDonald’s boxes, tummy aches, injuries and there was a suggestion by the social worker that the case should again be considered under child protection arrangements. Following discussion with the manager the Social Worker was advised to arrange a package of intensive support to reinforce the previous work from 2007 – this did not happen. The school drew up a contract with the family in an attempt to address the concerns. During the review period The review period is from January 2010 until 17th October 2013, the date of Child F’s death. The case was closed by Children’s Social Care (CSC) at the start of the review period. The 4 closure was made by a team manager who had no contact with professionals or the family. The family did not comply with the contract drawn by school; they agreed to take certain actions but then didn’t follow through with them and avoided further discussions. Other issues noted in school during the review period are as follows: All children illness, housing issues children reported as presenting dirty and arriving late stating that there was no one up at school time to help them on-going concerns regarding health, hygiene, attendance, safety, and supervision Parents failure to attend meetings and were non-compliant Sibling 1 presenting hungry sibling 2 presenting with a burn to his neck, head lice and no socks sustained a burn to his arm not-collected from school presented without a coat or jumper, prolonged toothache low self-esteem self-worth withdrawn and upset suspected to be lying or stealing in school, fighting talking of injuries sustained from his younger brother, including a scar from a penknife and sibling 3 ill-fitting shoes and head lice Some health professionals had concerns regarding late or cancelled development checks, late immunisations, no access visits, neglectful home, no answer to telephone calls, failure to respond to child’s health needs, refusal of home visits, no improvement in home, safety in the home and multiple house moves. The Police attended two domestic violence incidents between father (the alleged aggressor) and mother, at or near the home and a domestic dispute in a vehicle. The Urgent Care Centre and GP practice were aware of delayed immunisations, non-attendance at scheduled appointments, and loss of medication. The health visitor, nursery nurse and children’s centre had concerns around safety in the home including safe storage, clutter, sleeping arrangements, lone parent, lifestyle impacting on child and domestic violence. These issues are largely the same as those which led to child protection registration in 2007 and whilst some assessments were made none were triggered by indicators of neglect; no 5 one assessed these issues as meeting the threshold for child protection and no interventions were introduced by children’s social care to address the children’s needs or improve their lived experiences and outcomes. Child F was last seen by professionals 6 days prior to death at a Safe at Home1 assessment, Child F was asleep in bed surrounded by pillows next to a hot radiator; overheating in babies has been linked to cot deaths. Advice was given and information shared within health. On the day of Child F’s death he was found by father on the bed deceased. Summary of Findings Some of the findings within this case are for single agencies, others relate to wider multi-agency issues. Neglect was not hidden in this case but when assessed was graded as ‘low level’ by CSC. The pervasive nature of long term neglect was not recognised. There were factors present in this case that are known to be potentially life threatening in the first year of life; those factors were known to practitioners involved in the case. Some action was taken with a Safe at Home assessment however the concerns identified within the assessment were not referred, as per policy, to CSC for investigation. Information sharing from agencies to CSC was variable, information sharing from CSC to partner agencies was poor and there were limited attempts by CSC to gather information from partner agencies during assessments. The Midwifery Service demonstrated good information sharing with CSC at the point of Mother’s pregnancy booking appointments and when the children were born, opportunities to share information about address changes and admissions were not taken. The lack of response to the Birth Notification following sibling 5’s birth left the family without a health visiting service and no health visitor input until aged 1. At times school shared information with health which should also have been shared with CSC. Health visiting, children’s centre and Urgent Care Centre staff did not share information with CSC when indicators of neglect were known to them. Thresholds being applied within CSC throughout the period under review were inconsistent, idiosyncratic, and focused on immediate presenting problems without evidence of taking sufficient account of identified risks from the past. Social Workers in the Referral and Assessment Team report there was an understanding that if possible assessments ‘should not be triggered’. The lack of response from CSC to neglect acted as a barrier to other agencies, in particular the school, further referring concerns; a comprehensive assessment was not completed. The school were left to manage the issues they referred without the support of CSC and without the case being managed within a statutory framework. The threshold applied to Domestic Violence (DV) incidents within CSC appears different to those applied for neglect as all DV referrals triggered a response and initial assessment. There was also a lack of CSC response to physical burns and injuries, with no consideration 1 A Safe at Home Assessment is completed to identify hazards in the home and provide useful tips on how to eliminate or minimise the risk of an accidental injury 6 of the need for Section 47 inquiries to be initiated or the need for medical opinion to be sought. Tools available to frontline practitioners were not generally used, for example no DV tool was used as part of an overall assessment, no vulnerability assessment tool was used by health visiting and no neglect assessment tools were used by any agency as part of an assessment of neglect – Graded Care Profile would have been useful at a number of points. CSC did not recognise the need to complete a core assessment until 2013. Behaviours of sibling 2 were not seen in the context of the circumstances in which he was living. A number of factors influenced this. A lack of intervention from CSC, the criteria for CAMHS provision and a culture of school learning mentors working exclusively to the requirements of head teachers, meant that sibling 2’s behaviour was left to school learning mentors to address when specific health services may have been better placed to undertake this work. There was limited direct school nurse input throughout the period of the review. Escalation, there was no consideration that the indicators known to CSC required any social care intervention until the core assessment in 2013. The school, in particular made significant efforts to involve CSC but a lack of response meant over time they either gave up, changed focus onto the children’s behaviours or ended up taking on more responsibility than they should. In total there were six referrals made. When external agencies received inadequate responses to their concerns there is no evidence they challenged the response, sought child protection supervision or requested their concerns be escalated. Frontline staff within Education did escalate their concerns to the Head Teacher in-line with expected practice at that time however at the time there was no culture of escalation within or between agencies. Management Decisions to close episodes of social care involvement were flawed. On the first occasion (January 2010) the decision to close does not reflect the true level of concern within partner agencies, regarding the family, at that time. The decision was made on a single agency basis. Assumptions were made that no agency contact in the preceding ten months equalled no concern and led to an overly optimistic response. It appears partner agencies were not aware a decision was being made to close the case or that the case had remained open, therefore there was no opportunity to challenge CSC when this decision was made. On the second occasion (Summer 2013) the manager believed a child in need meeting had been held as instructed. The closing summary is based on beliefs that agencies agreed there had been an improvement in the situation for which there is no evidence. There is only one supervision session on the children’s CSC case file, when a core assessment was in progress, demonstrating a lack of managerial oversight of the case. Recording practice is a concern. Recording within social care was poor and did not assist managers in their decision making. Conversations between all professionals often went unrecorded. The Referral and Assessment Team did not record all contacts to the Team. Recordings that were made were not balanced and according to social workers were 7 focussed on negative rather than positive aspects of the family thus skewing the readers’ view of the family. Additionally the voices of the children were either not sought or didn’t feature within records meaning their experiences, wishes and aspirations were largely absent from assessments. The dynamics within the family were not represented in any records. Delay was a recurring feature. The failure to follow through recommendations of the S47 assessment (2013) as a result of staff sickness, confusion around a child in need meeting, poor recording and a belief that external agencies had indicated the children’s situation had improved, left known concerns unaddressed; as a consequence the children were left in unsatisfactory circumstances. Relevance to wider context of safeguarding children where neglect is an issue It has not been possible to conclude whether the sad death of Child F could have been prevented by the professionals involved as the cause of death is unascertained. What is clear is there were a number of factors known to increase the risk of child death present in this case. Brandon et al indicate that “To guard against catastrophic neglect, children need to be physically and emotionally healthy and have a safe, healthy living environment”2. Child F was not living in a safe, healthy living environment; this was known to some professionals but was not addressed prior to his death. The response to neglect within this case brings into question whether other children may be suffering as a result of unrecognised neglect? During the period under review there were some underlying issues across Luton impacting on professional’s response to neglect. The lack of experienced trained professionals able to recognise and respond to indicators of neglect and use the locally preferred neglect tool meant the cumulative impact of neglect was unknown. There is evidence that policies and procedures designed to protect vulnerable children were not followed and the advice from some managers, at times, acted as a barrier to social workers in the Referral and Assessment Team initiating assessments. There is evidence in this case that the children were left living in risky and neglectful situations without this prompting referrals or assessment. 2Brandon, M., Bailey, S., Belderson. P and Larsson, B, (2014) The Role of Neglect in Child Fatality and Serious Injury. Child Abuse Review, Volume 23, Issue 4, pages 235–245, July/August 2014 8 The NSPCC in a systematic review of all Serious Case Reviews in 2009-2011 concluded that practitioner’s needed to be supported by a system that allows them to make good relationships with children and parents and supports them in managing the risks of harm that stem from maltreatment, including harm from neglect and the way that neglect can conceal other risks and dangers. The review has been aware throughout its work of the Serious Case Review undertaken in relation to Child E, who died in early 2014, which reached very similar findings. It has not been in a position to consider how far these difficulties have been addressed. The review has heard that there remain difficulties in recruitment in some key areas and high proportions of newly qualified staff. In the absence of improvements in staff skill and training and better managerial oversight the risk that a similar episode could occur remains. What will the LSCB do in response to this? Sections 4 and 5 set out findings and challenges for Luton LSCB. The LSCB has prepared a separate document which describes the actions that are planned to strengthen practice in response to the findings and recommendations of this serious case review. 9 Full Report 1.1 Reason for Review 1.1.1 This review was commissioned by Luton Safeguarding Children Board (LSCB) following the sad death of Child F on 17th October 2013. Child F died at home at the age of eight weeks. The cause of death was unascertained however neglect features strongly in the background to the family, (though it was not cited as a contributory factor in the death) and there were concerns this case had similar features to the Child E SCR a further review being conducted concurrently featuring neglect. Although the Child E SCR had similar features of neglect it differed as a criminal prosecution was sought. The Child E SCR was taken into consideration when the decision was made that this case met the criteria for an SCR. 1.1.2 The Serious Case Review Group met in September 2014 following referral from the Child Death Overview Panel (CDOP) and agreed that the death was consistent with the Local Safeguarding Children Boards Regulations 2006 (Regulation 5) that requires a Serious Case Review be undertaken where the abuse or neglect of a child is known or suspected and the child has died. 1.2 Methodology 1.2.1 This review has made use of the underlying principles of a systems based review exploring the multi-agency system in place to support families and safeguarding children. The methodology is contained in full as appendix 1 and was underpinned by the requirements contained within Working Together 2013.3 A Review will: Recognise the complex circumstances in which professionals work together to safeguard children; Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Be transparent about the way data is collected and analysed; and Make use of relevant research and case evidence to inform the findings. 1.3 The SCR Process 1.3.1 The LSCB brought together a panel of experienced managers and professional advisors to oversee the review. The membership of the panel is contained as appendix 2. The panel drew up terms of reference and these are included in their entirety in appendix 3. These provided a framework for the single agency reports, Individual Management Reviews (IMRs) commissioned from the agencies that had 3 Education Department (2013) Working Together to Safeguard Children: a guide to interagency working to safeguard and promote the welfare of children. London NB: This methodology meets the requirements of Working Together (2015) which came into force during the period of this review. 10 contact with this family. 1.3.2 These reports made use of existing records, policies and procedures as they related to the professional response to this family, and interviews with the professionals directly involved in the case. The panel met on a number of occasions to review the single agency reports, develop an analysis and to consider the draft reports provided by the overview author. The overview author accompanied IMR authors in interviewing some key individuals and managers. The analysis and conclusions of this report have been reviewed to ensure they are reflective of the experiences of the professionals involved. 1.4 Period Covered by the Review 1.4.1 The review covers a 46 month period of time from January 2010 leading up to and including the October 2013, the date of the critical incident. 1.4.2 The government has introduced arrangements for the publication4 in full of Overview Reports from Serious Case Reviews. This report has been written in the anticipation that it will be published. Consequently the information in the report: Is appropriately anonymised; Takes reasonable precautions not to disclose the identity of the children or family; Protects the right to an appropriate degree of privacy of family members; Avoids the possibility of heightening any risk of harm to these children or others. 1.5 The Family The family were of Pakistani origin although mother was born in the UK. 4 See Working Together 2013 Child F Died aged 8 weeks Relationship to child subject of review Age at November 2013 Mother 31 Father 32 Sibling 1 13 yrs. Sibling 2 12 yrs. Sibling 3 11 yrs. Sibling 4 8 yrs. Sibling 5 3 yrs. Mat Grandmother Not known 11 1.6 Family Involvement in the review process Family members were offered the opportunity to contribute to the review and meet the reviewer on two occasions. Regrettably this was not taken up and the family has subsequently left the UK. 1.7 Limitations 1.7.1 A number of professionals who were involved in this case no longer work for their respective agencies, namely the health visitor, a social worker and some education staff. Whilst these practitioners have not contributed to the review their managers have provided additional contextual information so as to enable the review to understand practice at the time, capture learning and inform recommendations. Other staff were absent from work during the period when the review was being undertaken. 1.7.2 Lack of family involvement has limited the authors’ understanding about how professionals attempted to work with family members, as well as reducing the opportunity to talk to the older children about their lived experiences. 1.7.3 Aspects of the family e.g. origin, race, religion and culture have been difficult to explore as a result of limited professional and no family involvement. 2. Synopsis of Previous Involvement 2.1.1 This family was known to agencies from 2001 when Mother made a late booking with the antenatal service for her first pregnancy with Sibling 1. Late booking was a feature of her first four pregnancies. There were further indicators of neglect known to services within health including failure to attend routine health appointments, a head injury and an ingestion of body lotion for Sibling 4. 2.1.2 The family were referred to Children’s Social Care in 2004 however it was not until two house fires in 2006 that there was any significant involvement. The Police investigated the main fire; it was suspected sibling 2 had played with a lighter leading to the fire. Attending Police officers raised concerns regarding the state of the home and noted child protection concerns around supervision and possible neglect. Although parents were interviewed no charges were brought. 2.1.3 The case proceeded to child protection conference in April 2007; concerns, at that time, included inadequate accommodation, state of the family home, poor supervision of the children, children not brought to health appointments, immunisations out of date, and marital stress. In light of these concerns all the children were placed on the Child Protection Register under the category of neglect for a six month period. 2.1.4 During this period of registration Child 1 sustained a burn; there were conflicting 12 accounts of how the burn occurred. There were incidents of Domestic Violence5 but despite these concerns those involved felt the family were making progress. Following removal from the Child Protection Register the Long Term Team6 continued to work with the family under a family support plan and working agreement undertaking parenting assessments, relationship work between the parents, budgeting, housing support, legal status support for Father, and keeping safe work with Child 1 until closing the case in 2010; at which point there had been no input for 10 months. 2.1.5 Between Oct 2007 and Dec 2009, there were at least 8 contacts into CSC relating to Domestic Violence, injuries, and failures to attend. School also made at least 2 contacts to health and made multiple attempts to set up a professionals meeting in order to discuss and manage their continued concerns. 2.1.6 The school made a decision in December 2009 to put in place a contract between the parents and school; a single agency attempt to manage the deteriorating situation when other avenues seemed to be limited. 3 Concise narrative of professional involvement with the family 3.1.1 This outline of the professional involvement with Child F and family covers a 46 month period from January 2010 up to October 2013, the date of the critical incident. The records pertaining to all the children have been reviewed and where deemed relevant will be referred to. This section does not provide any comment, analysis or conclusions as these are set out in the subsequent sections of the report. January 2010 3.1.2 At the start of the time frame Siblings 1, 2, 3 and 4 were an open case to children’s social care long term team. There was no evidence of social worker involvement and no direct work for 10 months prior to the case closure by a team manager, not an allocated social worker, and this was without discussion with partner agencies. November 2010 3.1.3 Police reported a domestic violence incident between mother and father where mother was assaulted, to CSC. Mother declined to make a complaint. Father was arrested for common assault. CSC completed an initial assessment, but took no further action; family workers within the school were noted to be taking action to improve the children’s attendance. The police took no further action as they deemed the incident did not pass the threshold test for prosecution. July 2011 – March 2012 3.1.4 Mother was seen by a community midwife; she was reportedly 8 weeks pregnant with Sibling 5. The midwife completed an information sharing form because there had been previous social services involvement. She discussed it with a social worker 5 Domestic Violence is a pattern of behaviour which involves violence or other abuse by one person against another in a domestic setting 6 Long Term Team provided long term support to families in line with their assessed needs 13 from the Referral and Assessment Team and was informed the case had been closed; she shared the information with health visiting. 3.1.5 Mother attended all her antenatal appointments. Sterilization was planned but later declined just prior to delivery. The midwife visited mother and sibling 5 three times prior to discharge. 3.1.6 In January 2012 there was a contact to CSC with general child care concerns, no action was taken. September 2012 – November 2012 3.1.7 Sibling 5 had a nine day hospital admission for viral meningitis, receiving IV fluids and antibiotics. Mother accepted the offer of some weaning support from the health visitor which was later declined. 3.1.8 CSC were informed the family were to be evicted but record this as ‘for information only’. Sibling 2 was reported to be fighting in school on two occasions. On one occasion no adults came to collect the children from school and sibling 2 had been given this responsibility despite being unwell. There were general concerns regarding the children’s presentation; father was seen to be rather forceful to sibling 2 over a forgotten jumper. 3.1.9 Poor school attendance was believed to be impacting on sibling 1’s ability to sustain friendships. December 2012 – February 2013 3.1.10 Sibling 2 was referred to CSC after talking in school about injuries sustained from his brother using a pen knife. CSC sent the family a supervision letter reminding them of their ‘responsibilities’. No assessment was completed and the school were informed no further action was to be taken. Mother complained to school regarding the referral. 3.1.11 Sibling 5 presented with health concerns; Salbutamol had been lost in a house move. Sibling 5 failed to wait; the health visitor was informed. Sibling 5 failed to attend a follow up audiology appointment; the health visitor completed a Pre CAF checklist7. 3.1.12 There was a DV referral in respect of mother. Mother reported she was 4 months pregnant and scared to return home, she requested hostel accommodation. Mother indicated significant relationship difficulties; the case was referred to the Honour Based Violence (HBV) team. A home visit followed; father was deemed capable of caring for the children, hostel accommodation was subsequently declined by mother who returned to the family home. A strategy meeting was held (s47), an assessment completed which concluded the incident ‘did not put the children at risk’. No offences were noted and the Police decided no further action was needed. 3.1.13 Ongoing concerns regarding ‘low level’ neglect, disguised compliance, and the demeanour of the children were referred for prevention and early intervention and a meeting arranged. The 1st meeting was cancelled by the social worker, the 2nd 7 Pre CAF checklist - seeks to standardize for all agencies the information that is being recorded by professionals about a child. 14 meeting was cancelled by mother and the 3rd meeting was attended by a newly allocated social worker. 3.1.14 Sibling 5 had a respiratory tract infection and attended A&E. The health visitor was informed. Sibling 1 was seen by the school nurse and growth monitored. The community midwife completed a pregnancy booking at home, completing an information sharing form regarding the DV which she sent to the health visitor. 3.1.15 Sibling 3 attended with swollen genitalia and was admitted to the children’s ward where child protection issues were considered and excluded, she denied anyone had hurt her. Paediatricians concluded she had possible gratification syndrome, this was reported to the social worker and it was agreed this would be assessed as part of the section 47 enquiries. The health visitor tried to act on the community midwives notification of DV by visiting the family but they were first away and then out. 3.1.16 The social worker visited sibling 3 in school and referred the child to the school nursing team for assessment. Concerns continued with regards to sibling 2’s behaviour, he was getting into fights, displaying poor behaviour, and had very low self-esteem. School family support workers worked with sibling 2 who responded well to praise and targets. March 2013 – July 2013 3.1.17 The health visitor gained access to the home. Missed audiology appointments were discussed and sibling 5 was re referred. Mother was asked about DV. Mother was aware of where to seek help and support and was strongly advised to attend all appointments. Mother indicated she was 12 weeks pregnant, under the midwife, and due to be evicted due to rent arrears; they were seeing the council that day. Following two failed visits the 1 year developmental check was completed by the community nursery nurse; no concerns were noted. 3.1.18 School contacted the social worker for an update on progression of the Section 47 assessment and were informed there was to be one further visit and then the Intensive Support Team (IST) were to work with the family. 3.1.19 A child in need meeting was convened by the school; inviting the school nurse, who shared the recording on SystmOne with paediatric audiology, child health and health visiting. The planned child in need meeting did not take place having been cancelled once by the social worker and once by the parents. 3.1.20 There were address changes x 2 within a month. 3.1.21 Sibling 5 continued to have health problems, was admitted for shortness of breath and discharged on oral steroids and inhalers. 3.1.22 There was a domestic dispute in the family vehicle at Luton town centre. No offences were noted and no information was shared with other agencies. 3.1.23 Sibling 5 attended audiology clinic and was referred to Ear, Nose and Throat (ENT) (copied to GP, H/V and parents) for further assessment and treatment and discharged. Sibling 5 subsequently attended ENT, moderate hearing loss remained but she was developing well. Parents were to observe and review in 6 months. 15 3.1.24 Sibling 3 failed to attend for the result of her endocrine test. There was a plan to invite for further appointment in 6 months’ time; this didn’t happen. 3.1.25 CSC received a letter from Housing re Section 184 homeless application. There were further concerns regarding Sibling 2’s behaviour in school, he was verbally abusive to two girls in his class. Mother continued to access midwifery care. 3.1.26 A health visiting handover sheet was completed following reallocation due to the family’s move. The school nurse chased up new address details and requested the date for the child in need meeting; school agreed to inform when it was received. 3.1.27 The school nurse contacted the Referral and Assessment Team. There was confusion around the date the next child in need meeting would be held following cancellation. She was informed the last social care visit was in February 2013 and the case was now closed. The Section 47 was recorded as complete, however on further exploration the core assessment was not complete nor was a pre-birth assessment in respect of Child F. Mother was due to give birth in September. The Referral and Assessment Team worker planned to speak to her manager and contact the school. 3.1.28 Confusion regarding the family’s address led to ineffective visits by professionals. The community midwife continued to home visit. The family moved again. August 2013 – October 2013 3.1.29 Child F was born by planned Caesarean Section at 37 weeks weighing 2.65Kg. Whilst mother was an inpatient father reportedly became ‘distressed’ on the postnatal ward about Child F’s feeding and a perceived lack of support towards mother; he was swearing at staff and security were called. Mother and baby were discharged two days later with a verbal handover between midwifery and the health visitor. The community midwives continued to home visit until day 10. 3.1.30 In September the health visitor did a joint home visit with the community nursery nurse, Child F appeared content and alert. A home visiting questionnaire was completed. Mother indicated she often had mood swings but was fine with plenty of family support. Father smoked and domestic abuse was identified. Safety around the home was discussed and a Safe at Home visit was to be arranged. Vulnerability Risk Assessment (VRA) was not completed at this point. Mum was encouraged to attend child health clinic. 3.1.31 There were concerns regarding sibling 2 not going into school; on one occasion he ran off from school staff. Mother was visited at home and abdicated responsibility to the school. School contacted the health visitor and class teachers were asked to monitor closely so a concise chronology could be collated. 3.1.32 A Sure Start family worker and fire officer attempted to complete the Safe at Home visit but got no access. 3.1.33 The school family workers visited the home because the children were late for school. They noted the outside of the home was untidy with a full open dustbin and four black bags surrounding the bin. The lid of the bin was open; on top were uncovered nappies with flies around them. The family workers were concerned as it was suspected the children were alone. Mother eventually came down and 16 explained she was tired and had been upstairs with baby. The school left a message for the health visitor. 3.1.34 Child F attended the Urgent Care Centre and was diagnosed with possible infantile colic, prescribed infacol and nasal drops and advised to see the GP as required. 3.1.35 Sibling 2’s behaviour continued to be challenging in school; he was rude and aggressive towards adults. 3.1.36 The school nurse contacted the Referral and Assessment Team for update and was informed the S47 had been completed. Significant improvements were reported by the Referral and Assessment Team and the case closed. The school nurse had no outstanding concerns so closed the episode of care. 3.1.37 At the same time school had become increasingly concerned, they contacted the health visiting service. The school family worker shared concerns regarding the school age children’ attendance, lateness, presentation and walking to school on their own. The health visitor subsequently made a cold call with no access. 3.1.38 The health visitor persisted doing an unannounced joint visit with the nursery nurse. Concerns from school were all discussed but were denied by mother who stated she would be removing her children from the school. Risks in the home were identified and discussed, cigarettes butts were strewn all over the lounge and close to the window curtain. Mother blamed the smoking on her brothers, and was reminded of the dangers and of the fire in a previous house. A Safe at Home visit by Sure Start was arranged for 11th October 2013. Mother agreed to tidy the home; the health visitor planned to review and complete a Graded Care Profile. Mother agreed to attend ‘Stay and Play’ sessions at the health clinic however did not attend. The health visitor shared the outcome of the visit with the family worker at the school. 3.1.39 A professionals meeting was arranged for the 18th October 2013. Child F was seen again in the Urgent Care Centre with a history of crying when awake for 3/52; treatment for colic had no effect. Reassurance was given and a GP review advised. 3.1.40 Initially there was a no access visit by Sure Start for the Safe at Home assessment, however it was completed later that day. As well as safe storage issues there was no safety gate or smoke detector. Child F was asleep in bed surrounded by pillows next to the hot radiator – this was discussed as unsafe. 3.1.41 This was the last professional contact prior to the death of Child F. 4.0 Appraisal of practice 4.1 Introduction 4.1.1 The following section will appraise the practice of those agencies involved with the family. It will make reference to the IMRs provided by each organisation, adding context, where appropriate, to makes sense of what may have influenced practice and decisions made. Comment will be made on any systems issues that have been identified and raise issues for consideration by the LSCB. 17 4.2 Luton and Dunstable University Hospital 4.2.1 The community midwifery service demonstrated some good practice in regards to information sharing. They made good use of the historical information held within the service to inform their decision making, communicating with Children’s Social Care at the beginning of each pregnancy and at discharge. There was opportunity for increased communication with involved agencies during Child F’s pregnancy e.g. on admission to hospital of mother and when the family changed address. 4.2.2 An incident of father swearing on the ward requiring security to be called, was communicated to the social worker however this information was not shared with the GP or other involved professionals. No attempt was made to discover whether this information was acted upon. 4.2.3 Following sibling 5’s birth in March 2012 a birth notification was received by the health visiting service as is usual practice. The notification did not trigger the usual health visiting response and it is not clear it reached any health visitors caseload. This was not believed to be a widespread problem, however it was significant as it reduced the potential to offer early advice, support and help. 4.2.4 In line with procedures a safeguarding referral was made by a nurse following the attendance of child 3 with swollen genitalia, however when the results of the endocrine screen rule out an underlying endocrine problem no further contact was made to CSC, nor was the outcome of the referral sought. This brings into question whether the hospital continued to retain some responsibility for the problems they referred until it knew action had been taken (see section 5.2). Issues for consideration by the LSCB Is the system within the hospital and between the services sufficiently robust that all births are notified to health visiting services? 4.3 Cambridge Community Services 4.3.1 The services offered by this agency were health visiting (including community nursery nurse) and school nursing. The children’s records were available for review however mother’s historical paper records were unavailable to the IMR author making it difficult to get a full picture of the family dynamics and history prior to 2010. 4.3.2 During the period under review this family did not receive the level of provision to match the apparent needs of the children and family. 4.3.3 There was no involvement of health visiting services from the start of the review period until March 2012 despite the birth of sibling 5 and the historic neglect concerns. The lack of response to the birth notification for sibling 5 resulted in sibling 5 not receiving even the universal offer. Had notification been responded to, alongside the previous information on the family, this should have resulted in prioritisation for a new birth visit. This would have afforded an opportunity for assessment that was missed 18 4.3.4 The health visiting service received notification of a number of A&E and Urgent Care Centre attendances before an attempt was made to see the family. Each notification provided opportunity for assessment. It is not known whether identified poor administration systems led to a situation where the health visitor was unaware of the A&E notifications or if a clear decision was made not to follow these up. 4.3.5 Notably, once a decision was made to follow these notifications up, there is evidence of cold-calls and a number of appointments being made followed by non-attendance and no access visits; this further delayed the health visitor seeing child 5, thus child 5 was not seen until aged 1 year. 4.3.6 The case never moved from the universal service offer, the lowest level of involvement afforded to all families. The following concerns were known to the service: Development checks late or cancelled Late immunisations No access visits Neglectful home No answer to telephone calls Failure to respond to child’s health needs Refusal of home visits No improvement in home Grubby appearance, clothes not fit for purpose as reported by the school Eviction Multiple house moves Domestic violence 4.3.7 The family should have been assessed as requiring greater input from the service, however the lack of assessment of risk would appear to have been a contributory factor. Tools were available e.g. a Vulnerability Risk Assessment (VRA) or a Graded Care Profile (GCP), use of which would have benchmarked the standard of care given to the children and provided opportunity for dialogue with the parents. An intention to use the Graded Care Profile was never followed through, this mirrors the findings in the Child E review. There were few staff who had been trained to undertake Graded Care Profiles and consequently the use of the Profile had fallen into disuse. 4.3.8 Once the health visitor gained access to Child 5, issues known to the health visiting service prior to the visit were not documented as being addressed e.g. domestic violence and the health needs of all the children. Additional issues noted during the visit did not lead to a vulnerability assessment being completed nor were they flagged as a concern to CSC. The health visitor was however persistent in pursuing Child 5 attending audiology testing and eventually succeeded. 4.3.9 On one occasion the health visiting service was informed of a Domestic Violence incident by the midwife and followed this up with a discussion with mother during a routine visit; this was good practice. Health visiting were aware that CSC knew of the 19 incident but made no direct contact with a social worker; as a result they were unaware a S47 assessment was in progress. 4.3.10 The health visiting service was informed of an incident where father was agitated and had to be removed by security whilst Child F was in Hospital to the. This is not documented within CCS records and it has not been possible to discuss this further with the health visitor. What is known is the administrative support for this health visiting team was part-time and located away from the team thus making communication and recording more complex; the author cannot be confident the system supported effective communication between the professionals. 4.3.11 Poor recording was evident when children’s centre staff report discussion with the health visitor and community nursery nurse following a Safe at Home Assessment. This was not recorded and there was no evidence the health visitor acted upon the information received. Co-location of services can be a positive aid to communication but there is a danger that it can unwittingly lead to informal communication through closer relationships which then goes unrecorded. 4.3.12 It is important to understand the context within which CCS was working throughout the review period as this reportedly had a significant bearing on practice. Strategic reorganisations, changes in governance arrangements and a change of provider at the beginning of the review period had a negative impact on both the delivery of strong and consistent leadership and management across CCS and the community health economy and staff morale. 4.3.13 In 2011 the government published A Call to Action which led to a substantial increase in health visiting numbers across England. For Luton this meant a workforce growth of 260%; from 26.88 WTE health visitors as at 31.1.2012 to 70 WTE by 31.3.15 which has not quite been achieved. Previous reports had recommended average caseload sizes of around 300/WTE (CHPVA 2007). By 2013 the caseload sizes had decreased from 600 to 455/WTE as more health visitors came into practice. In order to train more health visitors the number of Clinical Practice Teachers (CPT) was increased and the clinical practice teaching model amended from a 1:1 to a 3:1 relationship with additional clinical support being provided by health visiting mentors. At that time the qualifying criteria to undertake health visiting training changed and the course was open to all registered nurses irrespective of date of registration to the NMC. Anecdotal feedback from the CPTs and experienced health visitors within Luton suggests that, at the time of writing, there had been a negative impact both on the workload of experienced health visitors and the level of experience of newly qualified health visitors. 4.3.14 In addition one health visiting team worked separately from the other four teams; with an acting up team lead for two years. There was a high turnover of staff within this team and insufficient support; this coupled with a reduced amount of administrative support appears to have had a negative impact on the consistency and quality of practice; this family were served by health visitors from this team. As of April 2015 there continued to be challenges within the services including stability with regard to commissioning arrangements, management structures and difficulties 20 with recruitment and retention of front line practitioners. There has been a recent review of CCS and recommendations made. 4.3.15 When a proposed multi-agency meeting called by the school was cancelled due to lack of social work attendance, there was no evidence that advice support or consultation was sought by the health visitor or the school nurse or consideration that any further action or intervention was necessary. A contributory factor may well have been the lack of support within the team at that time however the result was the drift in this case went unchallenged by both the health visiting and school nursing services. Issues for consideration by the LSCB Are the local arrangements and responses to domestic violence robust and do they enable those professionals in a position to respond and support those affected by domestic violence to do so? Is CCS making progress on the recommendations from the service review (April 2015)? Are the progress reports from CCS identifying the weaknesses as well as strengths? Is the LSCB challenging the details in the progress reports? Are the LSCB clear what aspects of the Healthy Child Programme are being delivered? Is the LSCB assured the services within CCS are delivering a service which meets the local populations’ needs? Is the system for reviewing and recording information within the health visiting service needs sufficiently robust that all verbal contacts are recorded, written contacts are acknowledged and both receive an appropriate response? 4.4 Urgent Care Centre 4.4.1 The Urgent Care Centre provides a bridging service between General Practice, Out Of Hours GP services (GP OOH) and the acute setting of the hospital Emergency Department. This family appropriately used the Urgent Care Centre when they were unable to get an appointment with their own GP or the practice was closed. 4.4.2 Although the centre had limited involvement with the family during the period under review a number of issues, such as delayed immunisations, non-attendance at scheduled appointments and loss of medication were known and as such were evidence to indicate some level of neglect within this family. These issues were recorded on SystmOne8and technically available to GPs if they used the same system. This was not the case for this surgery. 4.4.3 Of note even use of SystmOne does not mean GPs would automatically see information recorded by other professionals as theses entries appear in separate sections of the record. This means just recording electronically does not enable others to effectively follow up concerns. 8 SystmOne is a centrally hosted clinical computer system used by healthcare professionals in the UK predominantly in Primary Care. 21 Lack of active information sharing meant information known within the Urgent Care Centre was isolated from health partners and other agencies; staff were not taking an active role in safeguarding. When issues were noted staff did not establish if these were being addressed and there was also no consideration of the need to refer what was known to other services, including CSC. Issues for consideration by the LSCB Are staff within the Urgent Care Centre being enabled to actively share information through conversations with involved practitioners? Are Urgent Care Centre staff fulfilling their safeguarding children responsibilities in line with LSCB policies and procedures? 4.5 GP practice 4.5.1 The GP practice had limited involvement with the family and was marginal to the direct work that was being carried out by other agencies in relation to the children. The practice saw the children for routine asthma checks, post-natal checks and childhood ailments only during the period under review. 4.5.2 The practice received information regarding delayed immunisations, non-attendance at scheduled appointments and loss of medication that indicated some level of neglect within this family. This information was within the children’s individual records as a result of notifications of attendances at A&E, the Urgent Care Centre and through midwifery, however the GP did not piece all the information together. The GP was on a different electronic recording system to other health services and could only access the midwives information as they were able to input directly on the system. 4.5.3 There was no system to assist the GP to link all the information within the family and as a result they did not identify any issues which prompted discussion with other health colleagues or CSC. The GP practice were unaware of any involvement of CSC throughout the children’s lives and therefore weren’t aware of other agencies concerns regarding neglect nor that they had been on the child protection register or open to the long term team. The GP was only aware of one domestic violence incident between the couple inputted by the midwife, but was not aware of whom was the victim and who the perpetrator. On one occasion CSC records indicate ‘the surgery’ reports no concerns; there is no corresponding record in the GP IMR which suggests poor recording practice when enquiries are made. 4.5.4 It is usual for GPs to hold all the information regarding the health of all their patients. The system within this GP practice did not assist them to do so; this was coupled with the GPs not seeing it as their role to pull this information together. A lack of information sharing and gathering from other agencies meant the GP practice did not have information on the known social circumstances and were not able to contextualise new information they received. 22 4.5.5 GPs are often seen as the health professionals who hold the greatest information in health; this was not the case here. Sometimes, as in this case, the GPs do not know families well. When seeing someone for a consultation GPs have approximately ten minutes which provides little time for any discussion over and above the presenting health issue. GPs as health providers were expected to follow DoH (2005) guidance around Routine Enquiry regarding domestic violence and abuse in all health settings and be prepared to offer support and guidance, alongside recognition of the risks posed, there is no evidence this was done. When violence is known, GP’s need to be further enabled by their partner agencies to respond to incidents of domestic violence. The lack of information from the police and CSC regarding domestic violence incidents coupled with, no information being shared regarding the incident on the maternity ward where father is removed by security limited the GPs knowledge of the issues within the family and opportunities to discuss this further were lost. Issues for consideration by the LSCB Are arrangements in place between the CCG, GPs and NHS England to raise the quality of GP engagement in safeguarding? Are current safeguarding processes and practices across agencies in Luton including the sharing and gathering of information from GPs and GP practices? 4.6 Education 4.6.1 All the school age children within this family went to the same school within Luton and were therefore well known to the school. The school worked very hard throughout the period of the review to meet the needs of the children and adopted a child focused approach. 4.6.2 The school were well placed to identify and respond to issues of neglect and made a number of contacts to Children’s Social Care prior to and during the review period; they often got a poor response. Indeed just prior to the period under review, they put in place a contract with the parents as a single agency attempt to manage the deteriorating situation within school when other avenues seemed to be limited; sadly, on this occasion if they had contacted Children’s Social Care they would have been made aware the case was still open. The inconsistent response to school staff referrals clearly impacted on their actions, Children’s Social Care had demonstrated a clear lack of acceptance and progression of referrals in the past. The thresholds being used within CSC were not clear to all agencies and escalation processes were yet to be embedded in practice, this coupled with no culture of challenging CSC decisions left school in an almost impossible situation. 4.6.3 The school contract was a simple tool to assist the school and family to be clear around expectations. It articulated schools expectations around homework, reading, presentation and routine, breakfast and bedtime routines and involving sibling 1 in family life at home; it set out key areas the family were to work on, however when the family failed to adhere to this contract no further consideration of referral to 23 children’s social care was made thus leaving the children’s needs unassessed and unaddressed. 4.6.4 When school staff reached the limits of what they could achieve, they did try to involve others e.g. health visitor. However, despite school continuing to share their concerns other agencies didn’t always act, and at times children’s social care involvement was required. Again, as a result of previous responses by children’s social care to schools concerns, school became inconsistent in their decision making as to whether to refer their concerns. 4.6.5 On subsequent occasions when school did inform and refer issues to children’s social care, the response received did not result in an improved situation for the children. No supervision was sought around this case, however there was no robust process around supervision at this time. 4.6.6 In addition, during the review period, school had many leadership changes. At each point of change, processes within the school also changed resulting in a perceived disruption to general safeguarding delivery. 4.6.7 When CSC failed to report back from meetings or on actions they were taking, the school made little attempt to ascertain the outcomes. The school should have satisfied itself that social care were taking action. The school chronology demonstrates the school had identified numerous neglect concerns around attendance, presentation, hunger, do not attends, disguised compliance, illness, avoidance and house moves. Such issues appear to have persisted as far back as 2007 when the family where removed from the CP Register (category of Neglect) with little change. 4.6.8 The school recognised that the family needed more support and services but it is only with the benefit of hindsight, after Child F’s death, the school recognises they were dealing with a case of continued neglect. Staff stated there was little if any training available at that time in relation to the cumulative impact of neglect and while they continued to report into social services there was little evidence of concerns being raised from other agencies. The escalation process which enabled practitioners and agencies to escalate their concerns if they were not happy with the response was not commonly used at that time, it is now embedded in the practice of the school. 4.6.9 While school staff considered initiating a CAF and completing a GCP at different points, family engagement was such that this did not happen. 4.6.10 The school continued to hold and tried to manage the family and issues known to them. Over the review period, the school put in place a number of single agency interventions in an attempt to improve and sustain improved outcomes for the children and family. 4.6.11 The school took the lead on multiple occasions to try to arrange professional meetings. Whilst significant concerns were noted and work was done with sibling 2 by the Family Workers that brought about improvement in his demeanour and behaviours, this was not sustained when the family’s home circumstances changed following eviction. 24 4.6.12 There were, at times, alternative options open to school. They could have involved the school nurse. They did consider making a referral to CAMHs for psychological and behavioural support for sibling 2, but the case didn’t meet the threshold however there was no consideration of a referral to paediatrics for medical opinion on injuries. Issues for consideration by the LSCB Are school staff being enabled to challenge partner agency decisions and escalate their concerns? Are the pathways for referrals within and between services across Luton that support children and young people, clear to all agencies? 4.7 Police 4.7.1 The Police had limited involvement with the family but did visit and have access to the family home following two domestic violence incidents and a joint visit with Children’s Social Care. These visits provided opportunities to speak to the children, view their living conditions, assess their interactions with their parents and consider any risks there maybe. 4.7.2 As per protocol, on each occasion the police attended the home address due to a domestic abuse situation a referral was made to Children’s Social Care as a result of children being present or their living conditions. The DASH9 risk assessments for these incidents were graded as medium which didn’t meet the threshold for MARAC10. There were no criminal proceedings brought. 4.7.3 Police contacts with the couple away from the home received a different response with no referral to CSC. 4.7.4 There are comments regarding the untidiness of the house which were recorded in a child at risk report submitted alongside the referral. However there was opportunity to secure evidence of the conditions by means of either photographs or video footage, which should be submitted along with the child at risk report and used in the decision making as to whether there were grounds for criminal proceedings; this was not taken. 4.8 Children’s Social Care 4.8.1 Children’s Social Care were involved with this family for a number of years from 2004 including a brief period where the children were placed on the child protection register under the category of neglect in 2007. 4.8.2 At the point this review commenced a single agency decision was made, at team manager level, to close the case. Lack of intervention for an extended period led the manager to believe there were no ongoing concerns and make the decision to close the case. Children’s Social Care were working in isolation from their partner agencies and a lack of data gathering by the manager coupled with incomplete information 9 DASH (2009) Domestic Abuse, Stalking and Harassment and Honour Based Violence 10 MARAC – Multi-Agency Risk Assessment Conference 25 sharing from partner agencies led to an, at best, optimistic view that no contact meant all was well in the family. 4.8.3 On both occasions the case was closed to Children’s Social Care the decision to do so was taken by a manager following a period of inactivity with no recorded or verified evidence of an improvement in outcomes for the children, and therefore cannot be justified. 4.8.4 The case was opened on two occasions during the period under review, on both occasions this was as a result of domestic violence incidents. Multiple referrals for other issues, e.g. eviction/homelessness, physical injuries and significant concerns for the children did not lead to re-opening of the case suggesting domestic violence was seen as a greater risk than other forms of abuse and the threshold being applied inconsistent. 4.8.5 An initial assessment following the first domestic violence incident sought no information from health visiting, a decision was taken on this incomplete assessment that no further action was required. 4.8.6 There was a pattern where opportunities for assessments were largely not taken and assessments, when started, were not thoroughly executed. The following issues were noted: inconsistent data gathering e.g. information gathered from school but nothing from health, absent or poor risk assessments and where risks were identified these were not followed up with a constructive plan of intervention, where intervention was identified as necessary, delay in progression of the referral to another service and their refusal to accept the referral on the basis of the completeness /accuracy of the assessment, led to no further action 4.8.7 General issues within the referral and assessment team in terms of sickness and high caseloads were compounded by poor recording practice and infrequent supervision for all but very ‘high risk’ cases. There was evidence on file that this family was discussed in supervision on just one occasion during the S47 assessment in 2012. Whilst a document containing supervision standards was in place, those involved indicated an absence of awareness for some staff of their existence. In discussion it was clear that the standards around supervision were frequently not achieved as although supervision was generally arranged, because of pressures of work it was often cancelled. 4.8.8 The social worker who conducted the S47assessment from December 2012 did not have information from health visiting and the GP as they had not been successful in obtaining that information before a period of absence. Coincidentally there was an attendance for sibling 3 in February 2013 at A&E with swollen genitalia during this assessment which hospital staff referred to Children’s Social Care and were informed it would be addressed as part of the section 47; there records demonstrate no evidence it was. 26 4.8.9 The assessment was clear regarding the families need for support noting, ‘the family are just about managing with five children now’, and ‘the family will be stretched beyond their capabilities with the arrival of a sixth child’. However it was also noted that concerns were ‘not at the level of child protection’ but ‘issues need to be addressed’. There was no core assessment completed. There was delay in onward referral for support from the Intensive Support Team (IST) which was, in turn, refused on the basis the assessment was incomplete and out of date; IST requested a Core Assessment and Pre-birth Assessment be completed to identify strengths and that a plan be formulated to address the concerns before they would accept the referral; this never happened. 4.8.10 It is important to recognise the context within which the service was working. The Referral and Assessment Team had several changes to the structure of the team. During the review period the Team were restructured from being just the Assessment Team to becoming the Referral and Assessment Team and had developed a backlog of work. There were a significant number of inexperienced staff coupled with a high staff turnover. It was also considered that the workloads were very high. In early 2013 a number of staff left the team because they did not feel comfortable with the change of role and the Team were carrying a number of vacancies. There were issues about staff sickness and this included the allocated worker for this family being absent for two significant periods of time. There were four different groups of workers undertaking duty on a weekly basis with little consistency in how the Team presented to outside agencies who would often speak with a different worker each time they made contact, even about the same child. This inconsistency was exacerbated by the fact that each Deputy Team Manager responsible for duty had a different approach and this was reflected in their interpretation of the threshold criteria. 4.8.11 Individual social workers felt under pressure to avoid ‘triggering an assessment’ during the review period when there were particular pressures with workloads. This mirrors the findings in a 2012 Community Care survey of 242 social workers, where 60% said they felt pressure to “downgrade” neglect and emotional abuse cases and 59% said that it was “quite” or “very” unlikely that children’s social care would respond swiftly to children suffering neglect11 suggesting this was a national issue and not unique to Luton. 4.8.12 This stance meant social workers were left looking at ‘alternative interventions’ and ‘managing risks differently’. In addition there were few staff who had been trained to undertake Graded Care Profiles and consequently it had fallen into disuse. As a result of lack of activity in the case, the absence of the assessing social worker, a misconception that a child in need meeting had gone ahead and the issues had resolved to a level that other professionals had no concerns, the case was once again closed. As in the previous case closure this was done by a manager with no direct involvement with the family and based on flawed understanding rather than 11 Community Care (2013) Social workers unlikely to act quickly on neglect cases. 27 information recorded on the case file. Despite all the contributory factors it remains difficult to understand how the manager came to their decision and with hindsight they recognise this was neither appropriate nor acceptable. Issues for consideration by the LSCB Are all contacts and referrals receiving a proportionate response from the Referral and Assessment Team in accordance with LSCB procedures? Are current supervision policies including a requirement to discuss cases of neglect? Is current supervision practice within CSC meeting internal supervision Standards? If not what are there barriers to achieving the Standard? Are the systems and process in place to monitor the progression of all cases open to children’s service aiding safe practice? Does the system identify period of inactivity in a case to prompt a review of the case? Are step up and step down arrangements within C & LD contributing to delay in transfer and acceptance of cases and the offering of support and services to families? 4.9 Children’s Centre 4.9.1 The children’s centres involvement was limited to a Safe at Home assessment requested by the community nursery nurse working as part of the health visiting team, five weeks prior to Child F’s death. The referral contained limited information but stated ‘previous history of domestic abuse’ ‘past history of fire in the home in a previous house’, the identified needs are listed as ‘safety concerns’ with the support required. There was no indication the children had previously been on child protection plans. There was no challenge to the level of information provided at referral. 4.9.2 Children’s centre workers were persistent when initial attempts to complete the assessment were not successful. The assessment took place six days prior to Child F’s death and concentrated on what was visually noticeable in terms of clutter, unsafe storage of cleaning fluids, make-up etc. and unsafe sleep position of Child F on the bed next to a hot radiator. There was ready acceptance of the explanation given that Child F usually slept in a Moses basket without checking this further. 4.9.3 The results of the assessment were shared verbally with the health visitor and community nursery nurse later the same day; there was no record of any planned intervention agreed by the health visitor or community nursery nurse. The arrangements for information sharing between the Children’s Centre and the Health Visiting service were often informal and may have been due to their co-location, however these informal discussions were not always recorded resulting in incomplete case files. 4.9.4 The workers from the children’s centre did not sufficiently identify or respond to the indicators of neglect identified during the safe at home assessment. As in the Child E SCR, which also included a safe at home assessment, the author concluded that whilst this was ”a potentially useful assessment the findings needed to be 28 incorporated into a wider and more holistic understanding of the children’s day to day experiences”. This did not happen in either case and the lack of referral to Children’s Social Care meant there was no joined up assessment and analysis of the environmental, child and parenting factors. 4.9.5 The children centre workers relied heavily on an assumption that the health visitor had more influence when working with families and as such felt the parents would be more likely to listen to the advice offered from this service. This coupled with a culture of avoiding initiating CAFs indicated a lack of understanding of their roles and responsibilities when it came to safeguarding children within a multi-agency context, this may have been due to lack of confidence or avoidance of actively managing safeguarding concerns. Brandon et al., (2009)12 in their research found practitioners can lack confidence in taking responsibility for the assessment of the impact of neglect on a child’s development, believing that someone else is better placed to act or make a decision. 4.9.6 The staff within the Children’s Centre did not seek support and supervision with regards to this case. Supervision was commissioned for the staff but was not used when concerns emerged. Issues for consideration by the LSCB Are Children’s Centre staff clear in regards to their individual responsibilities to safeguard children and act upon information they receive as part of their work? Have Children’s Centre Staff got the confidence and skills to be able to independently make safeguarding referrals? 5 Thematic analysis incorporating the terms of reference 5.1 Response to Neglect 5.1.1 The effect on practitioners of working in areas of high poverty and deprivation appear to have played a significant role on practitioner’s understanding of and response to neglect; the two issues need to be separated. As Rosenberg and Cantwell cited in The Bridge report on Baby Paul (1995) state, “The distinction must be made between neglect caused by financial poverty, which can be alleviated by financial help, and that caused by emotional poverty. These may co-exist but relief of the former condition does not relieve the latter.” 5.1.2 There was a consistent and worrying lack of recognition and robust response, across the agencies, to multiple indicators of neglect. The nature of the concerns identified, began to change over time. This might have been as a result of lack of action by Children’s Social Care. The schools focus shifted onto the behaviours of the children rather than the neglect issues within the family. All agencies were aware of some of the indicators of neglect, Children’s Social Care were aware of them all. The response 12 Brandon M, Bailey S, Belderson P, Warren C, Gardener R. and Dodsworth J.(2009). Understanding Serious Case Reviews and their impact. 29 of agencies to neglect across Luton needed to become active and pre-emptive. The following list demonstrates the indicators of neglect known to Children’s Social Care at the point in June 2013 when the case was closed: Inadequate housing (two bedroom property). Child 5 sharing parent’s bed. Numerous changes of address / evictions. Significant rent arrears. Financial uncertainty / unemployment. Hazards at home (e.g. wires from ceiling near top bunk). Poor school attendance for all of the children. Unsure as to who was to pick up the children (left at school late on occasions). Child 2’s aggressive behaviour in school. Few toys or games at home. Concern about lack of stimulation at home. Parents not supporting education of children (no homework, etc). Parents refusing help with resources at home for children. Parents do not engage with professionals in school. Not attending meetings. Inadequate or poor and dirty clothing. Children arriving at school unfed. Unhealthy environment Children quiet and withdrawn. Suffering episodes of ill-health. Prescribed medication lost Children expected to take inappropriate responsibility. Little guidance or routine for the children. Oldest child living away from immediate family and ‘detached’ Parents providing inadequate supervision 5.1.2 These indicators were classified as ‘low level neglect’ and there was no recognition that these children might be in need of protection. The pervasive and accumulative nature of neglect was not responded to by agencies with a statutory duty to do so. In addition sibling 3 was exhibiting self-gratification behaviours, without an underlying medical condition (there was no further exploration of the cause). There were recorded incidents of domestic violence perpetrated by father on mother and sibling 2 had physical injuries that went without investigation. 5.1.3 As in the Child E case, which also featured neglect, the tools available to assess neglect in Luton were not used in this case, and although during the course of 2015 plans were being put in place to ensure professionals used appropriate tools to assess neglect, as of October 2015 they were not being used consistently across Luton. The vulnerability risk assessment tool available to health visitors was not completed and was only completed if the health visitor deemed it necessary. The home safety assessment was completed however the findings needed to be incorporated into a wider and more holistic understanding of the children’s day to day experiences. No professional group used the Graded Care Profile. Staff were unable to use this tool unless they had received training – training was ceased and whilst there are now 30 plans to reintroduce the training, the fast and continuous turnover of staff needs to be recognised. The lack of use of neglect tools led to individual practitioners making subjective, and what may be perceived as personal judgements as to whether the children circumstances were neglectful or not. 5.1.4 There appeared to be a somewhat narrow understanding of what constituted neglect. In interview, a social worker stated it didn’t appear a neglectful home, when she visited. Professionals were aware of numerous house moves leading to instability for the family and severe over-crowding but the impact of these issues was not explored nor were they considered neglectful and therefore not shared with other agencies or referred to Children’s Social Care. In contrast when a school family worker visits there was a clear description of both the garden, the home and the children. Issues for consideration by the LSCB Is there agreement amongst partner agencies on the most appropriate tools to use to assess risk and neglect? Are the tools for assessing risk and neglect available to all professionals to use? Are there sufficient numbers of staff trained in the use of these tools? Is there clear guidance on use of these tools? Has usage been audited? Are professionals learning from national research on neglect? How can professionals be better supported in Luton and within their organisations to identify and respond to neglect? 5.2 Referrals and Information Sharing 5.2.1 In general there was an inconsistent approach to information sharing and making referrals, by all agencies. Referrals and information sharing were seen as singular events rather than a continual process requiring, at times, further contact to be made when new information came to light or to ascertain the progression and outcome of referrals and assessments. 5.2.2 When referrals were made or information was shared with Children’s Social Care, this was not sufficiently considered in the context of what was already known about the family. Information was not used to form an overall picture of the children’s lives and lived experiences. There was only one referral that identified a core assessment was needed. 5.2.3 The Police were consistent in referring domestic violence incidents in the home to Children’s Social Care however this was not extended to the incident outside the home. The system for sharing information about Domestic Violence did not ensure that professionals working with the children in other agencies received this very important information. For instance the health visiting and school nursing service did not routinely receive this information and had mother not been pregnant no health professional would have been notified. 31 5.2.2 The school were frequent referrers of their concerns to Children’s Social Care however the lack of positive response and action to address the concerns or even accept the contact as a referral, acted as a barrier to further referrals. They became inconsistent in their information sharing, sharing some concerns but not all and not always following up the outcome of their referrals. In a bid for external assistance in managing their concerns the school had discussions with other agencies in isolation from Children’s Social Care; those agencies were similarly limited in the actions they could take. 5.2.3 According to the Education IMR, in September 2010 a call was made into Children’s Social Care following the presentation of sibling 2 with a burn. Advice was reportedly given and followed by the school. This advice didn’t include the seeking of a medical opinion. There was no corresponding record of this contact within Children’s Social Care and the contact was not progressed as a referral. This contact was an opportunity to review concerns, investigate and assess the risks for the children. 5.2.4 Information shared with Children’s Social Care regarding eviction and homelessness was not viewed as a referral but for information only; again there was opportunity to assess the impact of this change in circumstances on the children and family. 5.2.5 No information is shared, or referral made to Children’s Social Care latterly regarding the concerns and safety issues within the family home from either the health visitor, nursery nurse or children’s centre worker. As in Brandon et al. (2013)13 “Professionals were tolerant of dangerous conditions and poor care”. 5.2.6 There was no active information sharing by Urgent Care Centre staff throughout the review period. 5.2.7 There was no evidence ante-natal services were provided with the history of the family from other professionals, however the community midwife made good use of her access to the G.P notes during both of the pregnancies. This allowed her to gain information regarding previous medical history and to place a copy of this information in the hospital maternity record. Ante-natal services advised Children’s Social Care that mother was pregnant with sibling 5 and was attending appointments; this is recorded on the CSC file. 5.2.8 There was no evidence that a birth notification was known to or acted upon by the health visitor and no direct handover between services. The impact of this was the health visiting service were not triggered to offer a service and sibling 5 received no health visiting service. 5.2.9 There was clear communication from ante-natal services to CSC and the health visitor during Child F’s pregnancy. The community midwife also advised them of the birth of Child F although this was not recorded on the CSC file. The community midwife completed information sharing forms for both the pregnancies in the review period which were shared with health visiting by the safeguarding team, and the G.P was given a copy by the community midwife. In addition the issues raised in the 13 Brandon, Bailey Belderson, and Larson (2013) Neglect and Serious Case Reviews 32 information sharing forms by the community midwife were discussed via the phone with social care. 5.2.10 Opportunities for further information sharing during Child F’s pregnancy were missed. The community midwife knowing the family were an ‘open case’ should have advised when the family moved house and the hospital midwife should have referred the concerns regarding fathers behaviours on the ward during the pregnancy. 5.2.11 There was no evidence that ante-natal services were part of the section 47 strategy meeting following the domestic violence incident during Child F’s pregnancy, nor had they received information from the police or CSC. Instead the midwife, unacceptably, found out this information from mother a month later when she visited the family home for a routine ante-natal visit. 5.2.12 On discharge of Child F from midwifery care the community midwife handed over the care to the named health visitor via the telephone; this had a positive outcome with health visiting services pursuing access in a timely manner. However the community midwife did not share information of changes of address with other involved professionals or agencies and this contributed to delay. 5.2.13 All the above facts demonstrate an inconsistent and concerning level of information sharing. 5.2.14 Lack of recording of information shared by partner agencies has led to incomplete records within CSC, the GP practice and CCS. This is significant in terms of being able to make a holistic assessment based on all that was known and was especially concerning within Children’s Social Care who were reliant on this information to identify deteriorating situations, effectively assess the level of risk, and establish whether the threshold for a Section 47 enquiry had been met. Issues for consideration by the LSCB Is the system and process around notification of all Domestic Violence incidents within Luton sufficiently robust that it ensures information regarding all violence between couples is being shared with agencies able to support and assist? Are the IT systems being used across Luton supporting professionals to accurately record information? Is recording practice across Luton ensuring information being shared between agencies is both recorded and used to inform assessments and action plans? Are agencies in Luton continuing to own concerns they have identified post referral to CSC? Do they remain proactive after making a referral? Is new information received by an agency post referral being shared with those making assessments of risk? Are referrers following up the outcome of their referrals to Children’s Social Care? 33 5.3 Assessments 5.3.1 There were many opportunities for assessments to be completed across all agencies throughout the period of the review. Each of the events highlighted within the concise narrative provided an opportunity for professionals to undertake an assessment however during the review period there was only one developmental assessment, an incomplete core assessment and a home safety assessment. 5.3.2 Staff were not sufficiently curious when there were changes in the family’s circumstances. In the context of this case, an occasion when the community midwife visited mother at her mother’s home should have evoked the question, why. The community midwife stated in interview that there were no concerns about the family situation, home environment or presentation of mother’s other children. Brandon et al. (2013)14 in their study of serious case reviews found that households where there were more than four children were at increased risk and that a healthy environment was a key safety feature. However during Child F’s pregnancy the family moved numerous times, the reasons for this were not explored by health staff nor the impact assessed. In addition Children’s Social Care staff talked of the family’s living circumstances being ‘temporary’ but on further exploration the family had been in ‘temporary’ accommodation for 18 months; a large proportion of a childhood. 5.3.3 Post Child F’s birth the health visitor identified some key safety issues however a Vulnerability Risk Assessment (VRA) was not completed. Given the known concerns and without access to the health visitor it is difficult to understand why. In addition mother identified she often had mood swings; no assessment of her mental health was completed. Mother identified she had family support but the nature of this support was not explored further. Mother was encouraged to attend the child health clinic the following week however it’s unclear whether the health visitor took into account mothers’ reluctance to attend appointments or engage with professionals. The co-existence of domestic abuse and poor mental wellbeing are known to have a significant impact on children’s outcomes and parent’s capacity to provide appropriate care. The impact of living in these circumstances for these children was not assessed or addressed. 5.3.4 CSC had opportunities to undertake assessments on all occasions they were contacted by other agencies. Only domestic violence incidents sparked them to do an initial assessment. There was limited data gathering and the assessments were concluded with limited information from health. Initial assessments did not reflect on what it was like for these children living with domestic violence and abuse – something they had witnessed throughout their lives. There was lack of analysis of the potential impact of the parent’s behaviours and the living conditions on the children’s safety, wellbeing and future outcomes. Research highlights how difficult it is for children living in households where domestic violence and abuse features. The 14 Brandon, Bailey Belderson, and Larson (2013) Neglect and Serious Case Reviews 34 domestic violence and abuse risk assessment completed by the Police was not used in the context of a wider holistic assessment. 5.3.5 Contacts from housing were marked as for information only but should have been opportunities to proactively work with this family. Brandon et al15in their analysis of serious case reviews indicated the most startling environmental feature was the number of families who were noted in reports to have moved frequently (more than a third). 5.3.6 The reasons for eviction, and the impact of poor and inadequate housing was never assessed properly. Issues around the couples’ finances were not explored and a number of house moves in a relatively short time frame should have elevated the case into statutory processes. 5.3.7 Research tells us one important way for children to stay safe is for their living conditions to be safe and healthy. A safe living environment is a basic precondition for a safe relationship between children and their caregivers thus the need for decent living conditions for these children.16 The chronology indicated an escalation in other concerns when frequent house moves commenced, with an increase in failures to attend health appointments, deteriorating behaviours of sibling 2, illness for sibling 5 and lack of engagement of the parents. The children’s experience of the house moves, the reasons for these moves and the impact on the children and family are not known. Issues for consideration by the LSCB Are agencies taking sufficient account of historical information when determining if an assessment is required? Are professional’s sufficiently curious and taking account of the risks and impact of inadequate housing, poor living conditions, evictions and house moves on children? 5.4 Managerial Oversight 5.4.1 There was little evidence of managerial oversight within any organisation. Actions taken were largely by frontline practitioners. Where managers were involved in decision making within CSC this did not result in positive progression of the case. Decisions were made in the absence of the allocated social worker and in isolation from partner agencies (see section 4.8); managers did not ensure the actions they recommended had been completed prior to case closure. 5.4.2 Frequent changes in Head Teacher meant issues raised by teachers did not receive a consistent response. Mangers within all Health Organisations had no awareness of 15 Brandon, M. et al.(2008). Analysing child deaths and serious injury through abuse and neglect: what can we learn?: a biennial analysis of serious case reviews 2003-2005. 16 Brandon, M. et al. (2011) Neglect and serious case reviews Systematic analysis of neglect in serious case reviews in England 35 this family as it had not been raised in supervision because frontline practitioners did not recognise the need. 5.4.3 The manager within Children’s Social Care who closed the case in 2013 indicated she felt pressurized to close cases at that time. It has been acknowledged that this was not appropriate but it is felt that Managers are now having a better overview of cases and are more ‘hands on’ in relation to signing off decisions. Issues for consideration by the LSCB Is sufficient account being taken by agencies of the risks posed when there are changes to structures and key roles? Is the process for case closure in CSC ensuring needs identified during assessments for individual children and their families have been addressed? Are managers making sufficient use of recorded information? Do policies and procedures assist professionals to safely close cases and direct them to address gaps in information through contact with partner agencies before a case can be closed? Are partner agencies being notified of case closures? 5.5 Ethnicity, religion and language needs of the children and family 5.5.1 All of the agency Management Review’s indicate there were no specific concerns about how organisation responded to the cultural needs of the family. Their country of origin was noted and the language spoken. Both mother and father were Urdu speakers, the midwife was an Urdu speaker but indicated she had no need to do so as mothers English was so good. 5.5.2 No consideration was given to father’s level of understanding; when he was upset on the ward no interpreter was used. Without access to the family this could not be explored further. Mother and father were noted to be first cousins, but the relationships and dynamics within the family were only partially explored when mother spoke to workers when there were considerable relationship problems. There was suggestion that mother felt under some pressure from within her family to remain within the marriage. 5.5.3 Fathers English was reported to be not as good as mothers, the impact of this was not assessed however the school made arrangements for an interpreter on one occasion and on other occasions mum took on this role. All interventions and communications from the school were reported to be fact based as they would be for any family involved; recording suggests the needs of the family were taken into consideration by the school. 5.5.4 CSC records contain little comment despite sibling 1 living with maternal grandmother for much of her life; the notes were generally inadequate and not comprehensive and in the absence of any comprehensive assessment the issue of 36 culture both within the family unit and with the extended family was not adequately explored. 5.5.5 When Child F died leaflets to explain Sudden Unexpected Death in Infancy and the processes that would follow, were not available to the family as they had not been translated into Urdu; this was identified in the regulation 28 coroner’s report to prevent future deaths. Issues for consideration by the LSCB Are agencies taking sufficient account of parents’ level of understanding if their first language is not English? Are issues of ethnicity and culture being adequately assessed? Are agencies providing information leaflets in all the main languages spoken across Luton? If not is there a system for sharing the information through an interpreter? 5.6 Voice of the Child 5.6.1 There was little understanding of the children’s views and little evidence that professionals used opportunities to talk to the children about their experiences e.g. the impact of multiple house moves, the impact of living in cramped circumstances. This mirrors the findings of five evaluations completed by Ofsted in 2010 that concluded there was a failure to see, listen to or take account of the perspective of the child or children at the centre of a review. (Ofsted 2011). 5.6.2 In 2013, as part of the S47 enquiries the social worker did speak to the children. They spoke fondly of their father but not so much about mother. Sibling 1, although living away from the home did have a relationship with her siblings and visited the family almost daily. The reviewer was told that within Children’s Social Care records there was greater emphasis on the negatives within the family rather than the positives; this has also had an impact as aspects of the children known to the worker not being recorded. 5.6.3 Due to the limitations as discussed in section 1.7 it has not been possible to gain a greater picture of the children. Issues for consideration by the LSCB Are professionals taking opportunities within their work to see, listen and take account of children’s perspectives? 6. Conclusion 6.1.1 It has not been possible to conclude whether the sad death of Child F could have been prevented by the professionals involved as the cause of death is unascertained. What is clear is there were a number of factors known to increase the risk of Child Death present in this case. Brandon et al (2014) indicate that “To guard against catastrophic neglect, children need to be physically and emotionally healthy and 37 have a safe, healthy living environment”.17 Child F was not living in a safe, healthy living environment. 6.1.2 The response to neglect issues within this review brings into question how much continuing risk there is in other cases? It is too early to be confident that learning as a result of this and the Child E case have effected a change in response to neglect. 6.1.3 During the period under review there were significant issues within services across Luton. The lack of experienced trained professionals able to recognise and respond to indicators of neglect and use the locally preferred neglect tool meant the cumulative impact of neglect was unknown. There is evidence that policies and procedures designed to protect vulnerable children were not followed and the advice from some managers, at times, acted as a barrier to social workers in the Referral and Assessment Team initiating assessments. 6.1.4 There is evidence in this case that the children were left living in risky and neglectful situations without this prompting referrals or assessment. 6.1.5 The NSPCC in a systematic review of all Serious Case Reviews in 2009-2011 concluded that practitioner’s needed to be supported by a system that allows them to make good relationships with children and parents and supports them in managing the risks of harm that stem from maltreatment, including harm from neglect and the way that neglect can conceal other risks and dangers. 6.1.6 The review has been aware throughout its work of the Serious Case Review undertaken in relation to Child E, which occurred in early 2014, and reached very similar findings. It has not been in a position to consider how far these difficulties have been addressed. The review heard as of October 2015 that there remain difficulties in recruitment in some key areas, (health visiting, midwifery and social workers) and high proportions of newly qualified staff. If there is an absence of improvements in staff skill and training and better managerial oversight the risk that a similar episode could occur remains. 17Brandon, M., Bailey, S., Belderson. P and Larsson, B, (2014) The Role of Neglect in Child Fatality and Serious Injury. Child Abuse Review, Volume 23, Issue 4, pages 235–245, July/August 2014 38 39 Appendices Appendix 1 – Methodology The methodology used to conduct this review involved all involved agencies producing a chronology. The chronology was then integrated. All agencies were to produce Individual Management Reports based on the template provided. An Overview Author was appointed who had sight of individual agencies associated policies and procedures, recent local serious case reviews, audits, and some service reports to the LSCB. The overview author conducted conversations with practitioners and managers from Children’s Social Care and Community Health Managers to gain context. The serious case review panel provided scrutiny to the draft Overview Report. 40 Appendix 2 – Panel Membership Independent Chair, SCR group Business Manager, LSCB Designated Doctor, Luton CCG Safeguarding in Education Manager, LBC Det. Superintendent, Beds Police Principal Solicitor, LBC Designated Nurse, Safeguarding Children, LCCG Senior Learning & Development Officer, LBC/LSCB Learning and Improvement Coordinator LSCB Social Worker, Early Intervention Team, LBC Administrator, LSCB 41 Appendix 3 – Terms of Reference What information about the history of the family was provided to ante-natal services by other professionals? How did it inform the care provided? How was relevant information transferred from ante-natal services to other professionals (including particularly the health visitor and GP)? How successfully did the new birth visits and other early health assessments identify all of the relevant issues? Did this lead to appropriate service provision for the children in the family? How were concerns about possible neglect addressed? (this should include all possible signs of neglect including for example poor physical conditions, presentation of children, DNAs, poor attendance and take up of services) How were concerns identified in the school addressed? What was the role of professionals based in the school in identifying and responding to safeguarding and wider welfare concerns? How were concerns held by the school brought together with those of other professionals? How did the local authority become involved? Were the thresholds used correct? If not, what factors influenced decision making? How were decisions about reducing the level of intervention by the local authority made? When this happened was it justified by the positive indicators about the health and well-being of the children? Did the agency have information relevant to domestic abuse in the family? How were these concerns addressed? How were the particular ethnic, religious and language needs of the children and family identified and understood? Has your review of practice established any other significant findings? What arrangements were in place for the supervision of staff during the period under review and how were they implemented? In relation to each of the findings set out above please explain the individual, team and wider organisational factors that influenced the provision made? What lessons has the agency learnt as a result of the review of services provided to the family? What improvements can the agency make immediately? Has the review conducted by the agency identified any wider lessons for safeguarding services? |
NC045636 | Death of a 1-week-old in April 2013. Baby A was admitted to hospital following a cardiac arrest and later died, following the withdrawal of life support. Coroner's Inquest concluded no explanation for cause of death. The Crown Prosecution Service took the decision that there would be no criminal proceedings in respect to the death of Baby A. Mother had a history of abusive relationships and had received support for a long-standing heroin addiction for a number of years. Mother was well known to children's social care. Baby A was the subject of a Child Protection Plan at the time of the incident and had been discharged from hospital, post-birth, into the care of maternal grandparents. Mother's eldest child and Child C were also living with maternal grandparents at this time and mother's second eldest child was living with their father. Child C was subject to Child in Need or Child Protection Plans for most of their life prior to the incident. Identifies findings, covering: assessment and planning; collaborative working; practice and professional judgement; and management and supervision. Makes various interagency and single agency recommendations.
| Title: The overview report of the serious case review in respect of: Baby A and Child C. LSCB: Sunderland Safeguarding Children Board Author: Linda Richardson Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review for Baby A and Child C Published 25 November 2014 Sunderland Safeguarding Children Board (SSCB) is publishing the Serious Case Review Overview Report for Baby A and Child C. Please note the following documentation which constitutes the whole Serious Case Review: • SSCB Overview Report (Document 1) • Why Questions Report by Core Assets (Document 2) • Addendum to the Overview Report (Document 1) • Sunderland Children’s Services Progress Report and single agency Action Plan (Document 3) 2 The Overview Report of the Serious Case Review in Respect of Baby A and Child C This report is the property of the Sunderland Safeguarding Children Board and is confidential. Its contents, which have been anonymised, may only be shared with appropriate representatives of the recipient agencies for the purpose of improving childcare services and inter-agency working. The Publication date is 25th November 2014 February 2014 3 Contents 1. Introduction 1.1. Summary of Circumstances leading to the Serious Case Review 1.2. Decision to hold a Serious Case Review 1.3. Independence 1.4. Serious Case Review Panel 1.5. Methodology 1.6. Publication 2. Review Process 2.1. Scope of the Review 2.2. Involvement of Local Agencies 2.3. Review Schedule 2.4. Parallel Processes 2.5. Cross Boundary Issues 2.6. Family Engagement in the Serious Case Review 2.7. Workforce Engagement 3. Family Circumstances 3.1. Genogram 3.2. Family Composition 3.3. Relevant ethnic, cultural or other equality issues 3.4. Background Information 3.5. The Family’s Perspective 3.6. The Experiences of Children within the Household 4. Information known to the agencies 4.1. Introduction 4.2. Prior to Time period under Review 4.3. Time Period under Review 5. Individual Management Reviews (IMRs) 5.1. General Comments 5.2. Children’s Services: Children’s Social Care 5.3. Children’s Services: Primary School and Children’s Centre 5.4. Northumbria Police 5.5. Northumbria Probation 5.6. Health Overview Report 5.7. City Hospitals Sunderland NHS Foundation Trust 5.8. South Tyneside NHS Foundation Trust Community Health Services 5.9. General Practitioner 5.10. Place 1 – Substance Misuse Treatment Provider 5.11. Place 2 Children’s Services 4 6. Further information provided to the Overview Author 7. Critical Analysis • Assessments and Planning • Multi-Agency Collaboration • Practice and Patterns in Professional Judgement • Management and Supervision • Contextual Issues 8. Findings 9. Conclusion 10. Recommendations 10.1. Multi-Agency Recommendations 10.2. Single Agency Recommendations Appendix 1 Terms of Reference Appendix 2 Genogram 5 1. Introduction 1.1 Summary of Circumstances leading to the Serious Case Review (SCR)1 1.1.1. LB has a long-standing history of substance misuse and has self reported using cocaine, cannabis and heroin since she was 16 years old. She has experienced five pregnancies: her eldest child, (Child J), lives with the maternal grandparents and Child P, the second oldest, lives with the birth father. 1.1.2. The third child, Child C, aged 4 at the time of this review, lived with LB until early 2011 when the child was made subject to a Child Protection Plan 2, following concerns about LB’s substance misuse. LB agreed Child C should live with the maternal grandparents until further assessments were concluded. Several months later, Child C returned to live with LB and the Child Protection Plan was changed to a Child in Need Plan3. Three months later, further concerns were raised about LB’s substance misuse and Child C was again made subject to a Child Protection Plan and returned to live with maternal grandparents under Section 204 (s20) of the Children Act 1989. The 4th pregnancy resulted in a miscarriage in 2012. Baby A was born in March 2013. 1.1.3. LB received specialist clinical and community treatment in relation to her drug addiction for several years, but struggled to stay free of illicit drugs for any significant length of time. In summer 2012, LB began a relationship with NX, following his release from prison for selling Class A drugs. She became pregnant but suffered a miscarriage early in the pregnancy. She and NX married later that year and Baby A was born in March 2013. As a result of continuing concerns about mother’s substance misuse, the baby was made subject to a Child Protection Plan and was discharged from hospital into the care of the maternal grandparents in March 2013, under s20 of the Children Act 1989. The Local Authority continued with plans to pursue care proceedings in respect of Baby A and Child C, both of whom remained in the care of the maternal grandparents. 1.1.4. In late March, Baby A, at one week old was admitted to the local Accident and Emergency Department in a critical condition. LB reported that she had been feeding Baby A at around 9.00pm. The grandparents were in the home but were not in the room. LB said she had placed Baby A to her chest to wind and cuddle the child and after 5–10 minutes, had noticed the baby was not breathing and appeared limp. Her parents were alerted and the ambulance service was called, during which time the maternal grandfather tried resuscitation. The baby was still not breathing upon arrival at hospital and was placed on a respirator where breathing was finally restored. There were significant concerns about brain damage given the length of time Baby A had been without oxygen. 1 Names, dates of birth and some family details have been changed to preserve anonymity. 2 When there are concerns that a child is, or may be at risk of significant harm, a multi-agency case conference can decide to make the child subject of a Child Protection Plan. This is to ensure that all parties, including parents, do what is needed to make sure the child is kept safe. 3 When a multi-agency conference believes that a child requires extra support to help his/her developmental needs, a Child in Need Plan will be put in place. 4 Under Section 20 of the Children Act 1989, children and young people can be accommodated by the Local Authority with the consent of those with parental responsibility for the child. 6 1.1.5. Baby A died early April 2013 following the withdrawal of life support. 1.2. Decision to hold a SCR 1.2.1. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 requires LSCBs to undertake reviews of serious cases in specified circumstances and to ‘advise the Authority and their Board partners on lessons to be learned’.5 1.2.2. A SCR is one where: a) abuse or neglect of a Child is known or suspected: and b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.2.3. A Case Review sub-committee of Sunderland Safeguarding Children Board (SSCB) held a scoping meeting on 24th April 2013 and determined that the circumstances surrounding the death of Baby A met the criteria for holding a SCR. The Independent Chair of the LSCB endorsed the recommendation on the same day and a SCR Panel was established to lead the review. 1.2.4. The decision to hold this SCR was also influenced by the similarities between this case and other reviews relating to babies under the age of one year. The LSCB was concerned about the extent to which lessons from previous reviews did not appear to be impacting positively on front line practice. 1.3. Independence 1.3.1. In order to ensure objective debate and challenge, the LSCB: • Commissioned an independent person not connected or employed by any of the reporting agencies, to chair the SCR Panel • Commissioned an independent author, not connected or employed by any of the reporting agencies to write the Overview Report • Made it clear to agencies that Individual Management Report (IMR) authors were not to be involved in the case or in its line management • Confirmed that SCR Panel members had no prior involvement with, or line management responsibility for Baby A, Child C and family 1.3.2. The SCR Panel Chair was Cath McEvoy who is currently the Safeguarding Operations Manager for North Tyneside Children’s Services. Ms McEvoy has worked in social work for 24 years in a variety of roles. She has been a Senior Manager within North Tyneside for nine years and has chaired a number of panels as an independent chair around the North East region. 1.3.3. An Overview Report was commissioned from Linda Richardson, an independent safeguarding consultant registered with the Health Care Professionals Council, and who has authored previous SCRs. Mrs Richardson is an accredited reviewer under 5 Working Together to Safeguard Children 2013 HMSO Publication. 7 the Social Care Institute for Excellence (SCIE) Learning Together Programme. 1.3.4. It was agreed that upon submission of all relevant material, the Overview Author, in accordance with the themes outlined in the Terms of Reference appended to this report, would produce the Overview Report to be presented to the LSCB in early 2014. 1.4. Serious Case Review Panel 1.4.1. The SCR Panel consisted of representatives from the following agencies: • Independent Chair • Northumberland and Tyne and Wear NHS Foundation Trust • Northumberland Probation Trust • Northumbria Police • Sunderland Social Care - Safeguarding Service - Education Safeguarding Team • Sunderland Health, Housing and Adult Services • City Hospitals Sunderland • LSCB Business Manager • LSCB Lay member • Legal Advisor to the LSCB • Public Health Commissioning Manager (Specialist Advisor on Drug and Alcohol use) 1.5. Methodology 1.5.1. The decision to hold a SCR was taken, some two weeks after the launch on 15th April 2013, of the revised statutory guidance Working Together to Safeguard Children 2013. 6 The SCR Panel decided to undertake the SCR using the methodology outlined in 2010 statutory guidance, being mindful of the need to reflect on the quality of their services and undertake a ‘rigorous, objective analysis’7 as well as exploring systemic influences which may have had a bearing upon practice and decision-making. 1.5.2. The Panel have, throughout this SCR reflected on the chosen methodology and with hindsight have agreed that a sharper, more focussed review in future may remove the need for such a lengthy and detailed report without compromising any of the valuable lessons to be learnt. 1.5.3. A timetable for the SCR was established and circulated to all agencies involved with the family. Each agency undertook an Individual Management Review (IMR) and was asked to produce a report, which was to offer a critical reflection on that agency’s contact with family members. The IMR reports were submitted to the SCR Panel for scrutiny and challenge before being passed to the independent author for comment in this Overview Report. 6 Working Together to Safeguard Children 2013: Department for Education HMSO. 7 The Munro Review of Child Protection: Final Report May 2011. 8 1.5.4. Three sessions were delivered to IMR authors to explain what the Panel expected in terms of their management review, to check on progress and to offer help and support for the production of good quality, critically reflective reports to the Panel. 1.5.5. SCR Panel meetings and other meetings relating to the SCR process took place on the following dates: 24.04.13 - Initial Scoping meeting 25.07.13 - SCR Panel 06.09.13 - SCR Panel 27.09.13 - SCR Panel to consider IMRs 07.11.13 - SCR Panel to consider IMRs 07.11.13 - Meeting between LSCB Chair, Case Review Chair, Independent Panel Chair, Overview Author to discuss findings and issues from process 16.12.13 – Meeting between Case Review Chair, Independent Panel Chair, LSCB Business Manager and Overview Author (telephone conference) about findings and recommendations 23.01.14 - SCR Panel to sign off final draft of Overview Report 1.5.6. The Overview Report addresses the areas identified in the Terms of Reference, but has adopted a more analytical and comprehensive structure in order to draw out clearly the learning from the case. The report examines and evaluates individual professional practice, and offers comment where practice may have been influenced by organisational culture, processes and systems within and between agencies. 1.6. Publication 1.6.1. This review will be published once this report has been accepted by the LSCB. However, In order to preserve the anonymity for the children in this family, the SCR Panel decided to: • Use pseudonyms for the names of the children and remove any reference to genders • Avoid the use of exact dates in some reporting • Avoid any details which would provide information about local services leading to recognition of the children in the review 2. Review Process 2.1. Scope of the Review 2.1.1. The SCR Panel determined that learning could be maximised by reviewing the period from 1st January 2011 – 5th April 2013 as this would allow reflection on practice and decision-making during key periods when Child C was subject to both Child in Need and Child Protection Plans. 2.1.2. Terms of Reference were agreed and these are included in Appendix 1 of this report. These Terms of Reference fall into five distinct categories and the Panel 9 agreed that the independent author should comment on these categories as part of the Overview Report.8 • Assessments and Planning • Multi-Agency Collaboration • Management and Supervision • Practice and Patterns in Professional Judgement • Contextual Issues 2.2. Involvement of Local Agencies 2.2.1. The following organisations are known to have been involved with the family and have submitted IMRs or information: Place 1 •••• Place 1 City Council Social Care Safeguarding Service (CSC) •••• A Primary School and Childcare Centre •••• Health - NHS Foundation Trusts - GP - Midwifery Services - Place 1 Substance Misuse Treatment Provider (P1-SMTP) - Place 1 Clinical Commissioning Group (CCG) – Health Overview report •••• Health, Housing and Adult Services Drug and Alcohol Team (letter only) •••• Pharmacy (letter only) Place 2 •••• Place 2 Children’s Services •••• Place 2 Drug and Alcohol Service (letter only) •••• GP (letter only) •••• Northumbria Police •••• Northumbria Probation Service •••• North East Ambulance Service (letter only) 2.3. Review Schedule 2.3.1. A detailed review schedule was agreed which allowed for the SCR to be completed well within the timescales outlined in statutory guidance. However, the poor quality and delayed IMR submissions from Children’s Social Care (CSC) and Children’s Services Education resulted in the Panel returning these reports and amending the timescales for the SCR. This is commented upon later in the report. 2.3.2. Prior to the Overview Report being submitted to the SCR Panel in January, two family members contacted the Overview Author to request a meeting with the author and the SCR Chair. These meetings took place at the end of January and 8 The SCR Panel was able to reflect on the Terms of Reference throughout the process and concluded that learning would maximized if the detail of these were subsumed in the Overview Report under these five distinct categories. 10 contributed to a further, but necessary delay in the submission of this report to the LSCB. 2.4. Parallel Processes 2.4.1. During the course of this SCR, Panel members were kept informed of the ongoing criminal investigation by the local Police and the arrangements to ensure the safety and wellbeing of Child C. The Crown Prosecution Service took a decision in May 2013 that there would be no criminal proceedings in respect of the death of Baby A. 2.4.2. Child C was accommodated with Care Proceedings about to be initiated when Baby A died. 2.4.3. The Coroner’s Inquest recorded a narrative verdict on the death of Baby A concluding that there was no explanation for the cause death. 2.5. Cross Boundary Issues 2.5.1. This SCR required some collaboration with another Local Authority a few miles away in (Place 2). Relevant information across boundaries was shared, although not always in a timely manner. There was however no active involvement by (Place 2) Local Authority in relation to Child C and Baby A. Further information is included in this report. 2.6. Family Engagement in the SCR 2.6.1. Soon after the death of Baby A, the LSCB Business Manager and the Chair of the SCR Panel visited the parents and the maternal grandparents to advise them that a SCR was to take place. The comments made by the family at that time are included in this report. 2.6.2. Parents of Baby A and Child C and the maternal grandparents were contacted again on three subsequent occasions and were offered various options to contribute to this review. The father and maternal grandmother (MGM) eventually came forward in late December 2013 and meetings took place in mid-January, which importantly allowed this review to consider learning from the family’s perspective. 2.7. Workforce Engagement 2.7.1. The IMR of each agency describes the extent to which staff were involved through interviews. As part of a quality assurance process, the SCR Panel have a system whereby staff and managers are asked to give feedback on their experience of the SCR process and identify what learning they consider to have taken place. 2.7.2. The LSCB has arranged for feedback sessions for staff who worked directly with the family. This is to ensure that all staff who were interviewed are provided with an opportunity to discuss the findings from the SCR and the Panel can explore to what extent the findings are a reflection on general practice across the Authority. Learning and Improvement workshops for all frontline practitioners have been 11 planned from May 2014. These will take place monthly. 2.7.3. Given concerns of the LSCB about the apparent failure to learn from previous reviews, the Board is now developing a clearer strategy for dissemination and an audit tool to monitor how the Board can be assured that lessons from this and other Case and Serious Case Reviews are embedded into day-to-day practice. 3. Family Circumstances 3.1. A Genogram is provided in Appendix 2. 3.2. Family Composition (and key) Mother LB Married NX in December 2011 Lives in Place 1 Child J DoB: 1998 Lives with Maternal Grandparents Child P DoB: 2002 Lives with Father PS Child C DOB: 2008 Father AH Lives with Maternal Grandparents Baby A March 2013 died April 2013 Father NX Father to Baby A NX Lives in Place 1 with LB Maternal Grandfather MGF Lives in Place 2 Maternal Grandmother MGM Lives in Place 2 Paternal Great Aunt ST Lives in Place 2 3.3. Relevant ethnic, cultural or other equality issues 3.3.1. All the agencies identified Baby A, Child C and their parents as White British with English being their first language. There are no religious beliefs or affiliations recorded. The family live in a relatively deprived area with high unemployment and low-level crime. Parents are known in the community to have been involved in drugs for several years and Police visits and raids are a regular aspect of their lives. 3.3.2. Both maternal grandparents live in Place 2 in their own home, which is comfortable, well-furnished and located within a residential area. Both adults are in paid employment, which involves regular shift work. There are no religious beliefs or specific affiliations recorded. 3.4. Relevant Historical Information - LB 3.4.1. LB had no involvement with social work services in her childhood and reported a positive relationship with her parents until she became pregnant, just before her 16th birthday. Records indicate that LB felt she was not ready to become a parent but her mother refused to sign the consent papers for a termination. LB told social 12 workers that she began using drugs to cope with pressures of caring for her child and ‘mixing with the wrong crowd’. LB’s relationship with the baby’s father ended before Child J was born in 1998. 3.4.2. Child P was born in 2002. Social Care records indicate that Child J and Child P lived with LB and PS, the father of Child P. However, agency records are confusing as to how long they lived together as a family. What seems clear is that there were episodes of domestic violence and concerns about drug use, although the impact on the children is not recorded in any detail. It would appear that both children went to live with maternal grandparents at various times until Child P, aged four years old went to live with PS, the birth father. It seems there was intermittent contact at that time between Child P and LB. Child J remained living with maternal grandparents under a Residence Order9 and as LB would regularly visit the home of her parents, it is to be assumed that she had ongoing contact with Child J. 3.4.3. Child C was born in 2008 to LB and AH. Reports document concerns about drug use and domestic violence and LB ended the relationship although AH remained living in the area. 3.4.4. Various reports refer to LB’s later relationship with JE. This lasted for approximately three years during which time JE physically abused LB. In November 2010, LB was referred to a Multi-Agency Risk Assessment Conference (MARAC) 10 where she was assessed as being high risk. This assessment was later downgraded to low risk when LB refused to accept Police support or protection. LB was discharged from MARAC when the relationship with JE ended. 3.4.5. LB has received support for her long-standing heroin addiction from P1-SMTP11 at various times since about 2007. This involved regular testing and substitute prescribing of Methadone taken under the supervision of a named pharmacist. 3.4.6. LB appeared in Crown Court in February 2007 for an offence of Burglary and received an 18 months Community Order with requirements of Supervision, and a Drug Rehabilitation Order with a requirement to attend a Drug Awareness Programme. 3.5. Involvement of CSC prior to January 2011 3.5.1. A Probation Officer referred LB to CSC in December 2007 following allegations of domestic abuse by AH, father to her unborn baby (Child C). CSC took no action as records state they were led to believe that she was living in another area at that time. There is nothing to evidence they passed this information on to the area office where LB was reputed to be living. A further referral was made in February 2008 and notes refer to a Core Assessment being undertaken and the unborn Child C being made subject to a Child in Need Plan. In April 2008, an Initial Assessment was undertaken in response to concerns about LB’s drug taking and the impact this 9 A ‘Residence Order’, agreed in court, is used to decide where a child will live, and with whom. 10 Multi-Agency Risk Assessment Conferences (MARACs) are regular local meetings where information about high-risk domestic abuse victims (those at risk of murder or serious harm) is shared between local agencies. 11Which provide pharmacological and psychosocial interventions, with clinical specialism in community alcohol detoxifications and low threshold prescribing. 13 would have on her child. A decision was taken to continue with the Child in Need Plan. This Plan was discontinued in October 2009. 3.5.2. On 25th August 2010, concerns were again raised about LB’s drug taking. Records indicate that LB was taking heroin alongside her Methadone prescriptions. In response to these concerns, a decision was taken to make Child C subject again to a Child in Need Plan. This commenced on 3rd November 2010, two months before the time period for this SCR. 3.6. Relevant Historical Information – NX 3.6.1. NX is the third child born to his parents in Place 1. His father is currently serving a 12-year custodial sentence for rape and sexual assault. According to Probation reports, NX struggles to accept his father’s guilt. He continues to visit his father in prison. 3.6.2. NX is the father of six children from three previous relationships. According to records, Child B came to live with NX, aged 11. No records were made available which indicate what contact, if any, NX has had with his other children. In 2009, NX was arrested and convicted of supplying heroin. He received a five-year prison sentence. NX claimed that he took responsibility for the offence but it was his partner at the time that was dealing in drugs. NX was released from prison on license in February 2011 after which time he began a relationship with LB. 3.7. Involvement of CSC with children of NX prior to January 2011 3.7.1. No additional information was provided. 3.8. The family’s perspective 3.8.1. The Business Manager of the LSCB and the Chair of the Case Review Sub–Group met with LB, NX and the Grandparents shortly after the death of Baby A. At that meeting, the parents felt they had been unfairly treated and had been asked to ‘jump through hoops’. They said that even when they had done all that had been asked of them, they still ‘lost their children’. They were advised about the possibility of a SCR taking place and assured they would be given an opportunity to contribute to that process. 3.8.2. In January 2014, the Chair of the SCR Panel and the Independent Author met with the MGM at her request. The meeting lasted for over an hour during which time the SCR process was explained and MGM was given an opportunity to discuss her views about what had happened in her family over the last 2-3 years. MGM explained she hadn’t been able to make contact earlier as they were still coping with the aftermath of the death of Baby A. Maternal grandfather (MGF) was at work and couldn't meet with us. 3.8.3. Meeting with MGM MGM acknowledged that her daughter had difficulty in staying away from drugs especially heroin and understood that this had impacted significantly on decisions taken by the authorities in respect of Baby A and Child C. Nevertheless, MGM 14 believed that her daughter had not been given enough help to stay drug free and that there had not been enough efforts made to explore how LB could have been supported to look after Child C. MGM said she believed that the strong relationship between LB and Child C had also not been recognised. MGM and her husband are both in employment and have worked shifts for many years. Asked how she managed to work, care for her grandchildren and support her daughter, MGM replied. “Well you just do don’t you”. She said her sister-in-law was a good support and as a family they had never considered that Child C or Baby A would go to live anywhere else if LB wasn’t allowed to care for them. MGM described her daughter as a good mother but agreed there were times when she, as a grandparent worried about Child C. She described LB as sometimes appearing ‘sleepy’ and this was when she worried most about her grandchild. She described NX as a good support for LB and thought he should have been considered as a carer for the children. LB sees Child C a couple of times a week but isn’t permitted to take him out or spend time alone with him and this MGM felt, was sad as Child C is close to LB. She said she could not see a time when Child C would return to LB’s care, as her daughter seems unable to sort out her dependency on drugs. MGM described Child C as a lovely child, doing well at school, who seems happy to live with grandparents. The child likes seeing mum but now doesn’t expect to go home with her when she leaves. The relationship between Child C and Child J is a good one. MGM said care of both children is shared between herself and her husband and her sister helps out as and when needed. MGM said that when she agreed she would look after Baby A, she had never thought it would be for the long term. She had thought it would just be until LB sorted herself out. She said she had gone to many multi-agency meetings and always believed that LB would end up caring for her children, especially after her marriage to NX. When Baby A was born, MGM said she didn’t see the social worker and she and her husband went to collect Baby A and LB from the hospital to bring them to her house. The social worker did not visit and although MGM knew LB couldn’t take the baby out, she was never told not to leave LB alone with the baby. She said it was never made clear to her what they meant by ‘supervising’ LB’s contact with her baby. MGM said she had not received any information about the cause of Baby A’s death and did not know what happened. They were upstairs in the house when Child J shouted for help, having found Baby A seeming lifeless. MGM said the family were devastated by the death. LB had been unable to cope with the loss and MGM suspected she was still taking drugs, although she was always fine when she came to visit Child C, about twice a week. MGM said she wasn’t surprised that LB had not made plans to meet with us, although she felt that it would be good for LB to do so and she would urge her to get in touch. Child J was still deeply upset at the death of Baby A and is receiving support and help from school. Asked what might have made a difference to the outcomes for both Child C and Baby A, MGM couldn’t be specific but only reiterated that LB should have received more help when she needed it. 15 MGM did want it recorded that she was deeply unhappy with Children’s Services in [Place 2] when they insisted that Child C be moved from her care after Baby A’s death. She was particularly concerned when they tried to insist that Child J also had to move, although this didn’t happen as Child J refused to move. Child C went to stay with the Aunt (ST) for a couple of days before moving back. MGM said the social workers were insensitive and had caused the children even more distress. MGM was advised about the report and when and how it would be published. She was also informed that a report would be sent by LSCB to her home and she and her husband could also call into the office if she or husband wished to read it just prior to the publication date. Contact details were passed to MGM for future contact and a request was made for LB to make contact if she felt able to do so. 3.8.4. Meeting with NX, father to Baby A NX had already spoken with MGM when we arrived and indicated he was clear about the SCR process. He gave apologies for LB and said she had not been able to face meeting with us. NX said he continues to be concerned about LB and confirmed she still struggles with heroin use, despite her efforts to stay ‘clean’. NX confirmed he neither takes drugs nor drinks alcohol but intended to help and support LB for as long as she needed it. NX was adamant in his view that neither he nor LB had been given a chance to parent Child C or Baby A. He confirmed he had attended parenting classes as requested, undergone counselling and attended multi-agency meetings but said he never felt the social worker listened or took his wish to care for both children seriously. He specifically said that the social worker had never observed Child C with LB for any length of time and had she done so, she would have seen the positive caring relationship that LB had with her child. Asked about sessions with the social worker, NX said there weren’t many three-way meetings and neither he nor LB ever felt really supported by her. He wasn’t able to be more specific but cited times when the social worker (social worker 3) hadn’t kept appointments or had failed to turn up at meetings. He referred to the parental assessment, which had been undertaken and said that both he and LB had been told the assessment was positive but then a decision was still made for Child C to go and live with the MGM. He felt this decision was never fully explained and expressed his frustrations about the whole process. NX acknowledged the risks involved in children being around adults who were taking drugs, but said LB always looked after Child C well and with his help, they both could have cared for Child C. NX said neither he, nor any of his children, had any involvement with social workers and he thought this would have been taken into account when he married LB. It was, he said, much later when he discovered the extent to which CSC were involved in the life of LB and Child C. For several months he had not been aware of their involvement. He said LB had not always been honest with him but once he became aware of what was happening, he was 16 determined to get involved. NX acknowledged he wasn’t always able to attend all the meetings due to ‘other commitments’ but said he had tried to get to these as often as he could. NX was very annoyed about a hair strand test to which he was subjected some time prior to the death of Baby A. The Overview Author was unaware of this incident. NX said the test had come back positive for himself but clear for LB. NX had found confirmation that his hair strand could have been contaminated if he was living in the same house as a drug user. However, his issue was with CSC who had shared that information with members of his wider family. NX was advised to continue with the complaint procedure against the Local Authority and take legal advice in terms of any redress. NX said he blamed many people for the death of his baby, the social workers, the hospital staff and he also blamed LB. He said this was his last chance to have another child and asked if it was now known exactly what had happened. NX was unclear about the exact circumstances leading up to Baby A’s death and the author was not able to offer any additional information. NX said he wanted to challenge the length of time the ambulance took to reach Baby A. He said he had received the phone message that something was wrong when he was in the bath. He had immediately got out of the bath, got dressed and drove from Place 1 to the home of the maternal grandparents in Place 2 and arrived just as the ambulance was drawing up outside. NX queried that it should take so long to respond to a 999 call. NX was advised this was new information and further enquiries would be made by the Safeguarding Board. These enquiries revealed that the ambulance arrived nine minutes after the family rang 999, which is one minute outside timescales for the ambulance service to respond to calls of this nature. Concerns expressed by NX have been shared with the ambulance service. NX was advised about the SCR report and when and how it would be published. NX said he would like a copy sent to his address. Contact details were passed to NX for future contact and a request was made for LB to make contact if she felt able to do so. 3.8.5. The experiences of children within the household The SCR Panel considered whether it was necessary for the author to speak with any of the above children to ascertain their views. The Panel and the author agreed at the outset, that any information about the children’s views should be ascertained from the IMR reports. Child C 3.8.6. It is, nevertheless, a striking feature of this review that there have been no attempts by any agency to establish the views of Child C, or seek to understand what life must have been like for this child, moving backwards and forwards between mother and grandparents. Even from the Children’s Centre and nursery school, there is little information provided which helps the author gather a picture of what Child C was like and how the child coped and importantly, what impact mother’s substance misuse had on the child. This is a significant omission in all of the reports and 17 particularly so in relation to the IMR from CSC, where it would be expected that the social worker would have had the child’s ‘wishes and feelings’ and also those of the half-siblings firmly at the centre of the assessment processes. Child J and Child P 3.8.7. There are no significant references to either child in relation to Child C or Baby A, despite the fact that they are family members with whom Child C and Baby A would have had contact. 4. Information known to Agencies 4.1. Introduction 4.1.1. A full, combined chronology was prepared to inform this report, detailing the relevant contact episodes between the children, their parents and extended family members and each agency. Each IMR report and the Health Overview Report included a detailed chronology and a very brief narrative containing information about the agencies’ involvement with the children. 4.1.2. Child C was subject to Child in Need or Child Protection Plans for most of their life and consequently many multi-agency meetings took place to consider how best the child could be protected and their health and development assured. This section records and comments upon significant events and work undertaken by professionals in the time periods between these key meetings. 4.1.3. It should be noted that the names used by professionals to describe various multi-agency meetings are neither consistent nor always correct. This report attempts to use the correct name for the meeting even though this might differ from the names used by some agencies in the combined chronology. 4.2. Prior to Time Period Under Review 2002 – 2007 LB’s drug use, her association with drug users and the domestic abuse she suffered from the fathers of her two older children are recorded in CSC and Health agencies’ records. December 2007 Probation Officer made a referral to CSC in [Place 1] concerned about domestic abuse and impact on unborn Child C. LB was found to be living in [Place 2] at the time so no further action was taken. There is no evidence to suggest this information was passed to [Place 2] by CSC. February 2008 Probation Officer made a second referral to CSC following concerns about drug use, domestic violence and impact on unborn Child C. A Core Assessment was undertaken and records indicate that a Child in Need Plan was put in place. April 2008 Child C was born. 18 April 2008 Initial Assessment. Concerns were raised about mother’s drug taking and the impact on Child C. May 2008 Child Protection Strategy Meeting. Child C continued to be subject to a Child in Need Plan. June 2008 Initial Assessment. Child C continued to be subject to a Child in Need Plan. June 2008 Decision taken to transfer ‘case’ to a CAF12 process for package of services to be identified. July 2008 Decision taken to return Child C to Child in Need Plan as circumstances ‘are not appropriate’ for CAF team. October 2009 Child in Need meeting. Manager’s decision was taken to end Child in Need Plans for Child C. Records indicate this was in response to LB being ‘clean’ from heroin for three months. August 2010 Initial Assessment. Concerns were raised about mother’s drug taking and the impact on Child C. September 2010 Child Protection enquiries were made following concerns about mother’s drug taking and the impact on Child C. Decision was taken not to progress to an Initial Child Protection meeting. November 2010 Child in Need Plan for Child C implemented. 4.3. Time Period under Review 4.3.1. Child in Need meeting: 6th January 2011 Present: Not clearly documented but LB did not attend and notes refer to social worker, Children’s Centre (nursery) and P1-SMTP. Information pertaining to this meeting has been extracted from notes from other agencies and not from records from CSC, as these were unavailable. Records refer to: • LB failing to attend this meeting or keeping planned appointments with Health Visitor, social worker or P1-SMTP 12 The CAF is a standardised approach to conducting an assessment of a child's additional needs and deciding how those needs should be met. http://webarchive.nationalarchives.gov.uk/20080804182823/everychildmatters.gov.uk/deliveringservices/caf/ 19 • P1-SMTP advising that they had information that LB was taking Child C out at night to sell drugs • P1-SMTP were advised to liaise with social worker re: testing and progress and asked to confirm reliability of this information 4.3.2. There would appear to have been no discussion around the impact of mother’s actions on Child C and no reference to historical information, which suggests this ‘relapse’ was predictable. There is no recorded discussion about Child C’s attendance at nursery or whether P1-SMTP should have alerted CSC when LB failed to keep her appointments. This suggests that the Child in Need Plan lacked clarity about the roles and responsibilities of professionals and indicates there was poor collaboration between agencies. The concerns did not generate a home visit despite the fact that no professional had seen Child C since before Christmas. 4.3.3. On 10th January 2011, LB’s previous drug tests were returned to P1-SMTP from the drug testing company and showed a positive result for Methadone and opiates. However, this information was not shared with the social worker until 12th January 2011 following LB’s appointment with P1-SMTP. LB confirmed she was using intravenous heroin – injecting into her groin – and had been for the last four months. She admitted she was also using other drugs including Diazepam and Amphetamine. LB advised she had last injected heroin some two hours earlier and yet was described by P1-SMTP worker as being ‘coherent’ and seemingly ‘not under the influence’. This piece of information is important as it is fair to assume that not all professionals would be able to detect that LB was under the influence of opiates, an issue further explored under Section 7. There was no discussion about Child C or how LB was managing to care for her child; this would suggest that the P1-SMTP practitioner did not have the wellbeing of Child C high on her agenda. 4.3.4. P1-SMTP appropriately contacted the social worker and although it is not clear just how much information was shared re: poly-drug use, the social worker was advised about LB’s continuing drug use and that her Methadone dosage was to be increased to support her withdrawal from heroin. The records do not indicate any sharing of information about Child C. 4.3.5. The Health Visitor had another failed appointment on 11th January 2011 and could not gain access when she called to the home. She contacted the nursery where she learnt that Child C had not attended since before Christmas. LB had made contact with the nursery and advised that Child C had been unwell and this was also the reason why she had not attended the planning meeting on 6th January 2011. The Health Visitor promptly contacted the social worker and followed this up with an e-mail, expressing her concerns that LB was not complying with Child in Need Plans nor keeping agreed appointments. The social worker responded to the e-mail saying she had also visited that day and had not gained contact. She advised the Health Visitor that she was to have supervision the following day. 4.3.6. The social worker met with her line manager on 12th January 2011 and a decision was taken to proceed to a child protection enquiry under Section 47 of the Children 20 Act 198913. The combined multi-agency chronology indicates that the social worker made a child protection visit later that day where she was introduced to LB’s new partner KR. LB refuted the suggestion that she took Child C out to buy or deal in drugs although she admitted she was using heroin. LB was informed that a child protection investigation was underway and she was given the option for Child C to stay with the maternal grandparents whilst these continued. The chronology indicates that LB was distressed and concerned about the impact of this decision on her family, although it is not clear whether this referred to her parents or to her immediate family. 4.3.7. No records have been made available to the author which detail how and when Child C was moved to the maternal grandparents’ home or what discussions took place about concerns, care or supervision arrangements. The status of this arrangement is unclear and as there is no mention in records of a Viability Assessment being undertaken, or whether Child C was to be placed with grandparents under s2014, it must therefore be assumed this move was registered as ‘informal family care’. This in itself is of some concern as there appears to have been no detailed assessment undertaken to explore whether the grandparents were able or willing to look after Child C and what impact this could have had on Child J. 4.3.8. On 16th January 2011, P1-SMTP received a written copy of an agreement signed by LB in the presence of the social worker, whereby LB agreed not to use illicit substances but would contact her social worker if she were in any difficulty. A copy of this agreement has not been seen by the author and is not referred to in the CSC IMR. It is difficult to understand the purpose of this signed agreement if indeed it only related to LB promising not to take drugs. What should have been shared was an agreement between LB, the grandparents and CSC about the care, safety and contact arrangements for Child C and what support the maternal grandparents could expect from the Local Authority. The Local Authority in [Place 2] should have been informed that Child C was now living in their area. This information was not shared. 4.3.9. The Health Visitor informed the social worker that she had contacted LB on 16th January 2011 to make an appointment for the following day and had been advised that LB was living with her mother in [Place 2]. There are no records to indicate that the Health Visitor visited the home of the MGM the following day and the issue of why this did not happen is not explored by the IMR author. Was this because it was out of area? 4.3.10. Upon learning, via e-mail, that a s47 investigation has been initiated, the Health Visitor replied with some general information about Child C, presumably taken from records, as she had not recently seen Child C. The Health Visitor advised that Child C was up-to-date with immunisations and developmentally within the expected range, although a referral was being made for speech and language 13 Section 47, Children Act 1989 places a duty on the Local Authority to make enquiries if they have information which suggests a child, living in their area, has suffered or is likely to suffer significant harm. 14 Section 20, Children Act 1989 is a voluntary agreement between a Local Authority and a parent where the Local Authority agrees to look after a child or young person. 21 assessment. She expressed concern about Child C being appropriately stimulated if nursery attendance lapsed due to the distance involved. 4.3.11. The Health Visitor contacted the manager at the Children’s Centre and was advised that Child C usually attended fairly regularly although often arrived late, sometime between 10 and 11. Records about Child C refer to a child who is sociable and confident. The child had not attended since before Christmas and the manager expressed the view that there seemed to have been some ‘family issues’ after Christmas but she did not give or was not asked for more information. There is no evidence that this information was shared with the social worker. 4.3.12. Whilst information from the combined chronology suggests there were no outstanding matters in relation to background checks of AH, LB or KR, no information appears to have been recorded about the outcome of any assessment. 4.3.13. Records indicate the social worker made another Child Protection visit on 19th January 2011 and saw both LB and Child C. The author presumes this visit took place at the maternal grandparents’ home, but there is no reference to either grandparent being at home. The house was described as clean and appropriate and Child C was recorded as playing quite happily with toys in the corner. LB stressed her commitment to stick to her treatment plan, as she ‘couldn’t lose’ Child C and claimed future tests would be returned negative. It has not been possible to access any records, which indicate whether any discussions with family members took place and there is nothing in the CSC IMR, which indicates any attempt to gather grandparents’ views or assess how the changes may have been affecting Child C and also Child J. 4.3.14. On 21st January 2011, LB tested positive for Cannabis and Methadone. At her appointment with P1-SMTP on 24th January 2011, she tested positive for Methadone and Benzodiaphines, a substance that was not prescribed to her. An oral swab was sent for analysis. LB explained she was living at her mother’s home and it is fair to assume that she was caring for Child C but the P1-SMTP practitioner does not pick up this issue. 4.3.15. On 26th January 2011, the Health Visitor saw Child C at nursery to undertake an assessment. Child C was described as clean and dressed in well-fitting clothes. Height was on the 0.4th centile and weight on the 2nd centile. At two years nine months, speech was recorded as being immature, but a referral for a speech and language assessment had been made. 4.3.16. Drug tests from LB were returned on 28th January 2011 and indicated a positive result for Buprenorphine, a substance that was not prescribed to her. P1-SMTP did not contact the social worker with this information 4.3.17. Initial Child Protection Conference (ICPC) 4th February 2011 Present: (Independent Chairperson, LB, P1-SMTP, Nurse, social worker, Health Visitor 1, Police, Children’s Centre. Records refer to: • Child C doing well developmentally but needing some help with glasses and speech and language 22 • A good relationship noted between Child C and LB and the ongoing support by maternal grandparents was recognised • LB’s attendance at this meeting and ‘three clean tests’ were positively noted • Risks around LB’s continued drug use, her past history, abusive relationships and failing to engage with services • Child C to be placed on a Child Protection Plan under the category of Neglect 4.3.18. Given LB’s history, the professionals at the Conference were overly optimistic basing their views on incorrect information. Those present were also very naïve about LB’s ability to stay drug free for any significant period of time. The focus remained on her willingness to engage with services and attend for planned and random testing. There is no recorded discussion about the consequences of LB not keeping to the agreed plan, nor was there any challenge about why, given her past history, she was now more likely to remain drug free than before. There was no indication why, given that Child C was living with grandparents, they were not present at this Conference. There was no discussion as to the status of this arrangement with grandparents; this is a significant omission and leaves Child C in a vulnerable position. 4.3.19. Between 4th February 2011 and the Core Group meeting on 18th February 2011, LB’s drug treatment was discussed in group supervision at P1-SMTP on 9th February 2011. A plan was identified for continuing work with LB and the practitioner was advised that she should attend all Child Protection meetings. This was good practice and gave practitioner 3 a clear role. The Health Visitor liaised with the GP and the required referral was made in respect of Child C’s physical development. LB continued to test positive for drugs during this period. There is however, no information pertaining to any visits by the social worker to LB or her parents, or to any work undertaken directly with Child C. It is not clear what role the maternal grandparents were expected or willing to take. It appears that LB was living with her parents and taking responsibility for Child C’s care. 4.3.20. On 11th February 2011, LB attended P1-SMTP and talked of taking legal advice to secure contact with her second eldest child, Child P. She expressed frustration that her social worker had failed to keep an appointment the previous week. On 15th February 2011, LB’s test results indicate a positive result for Buprenorphine, a substance that was not prescribed to her. 4.3.21. Core Group meeting 18th February 2011 Present: LB, social worker, Health Visitor, Nursery officer, Nursery Manager. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • P1-SMTP not attending meeting • LB advising that her relationship has ended with KR and she was fearful of Child C’s father (AH) • Child C and LB living with the maternal grandparents who it appears were unaware that LB had tested positive for drugs • Social worker to undertake police checks on all adults having contact with Child C • LB to continue with drug testing 23 • Public Law Outline (PLO) meeting to be held in respect of Care Proceedings for Child C 4.3.22. There appears to have been no challenge to LB in respect of her testing positive for opiates. P1-SMTP did not attend despite an agreement to do so as discussed in practitioner’s supervision session on 9th February 2011. Records also indicate that the social worker agreed to advise the maternal grandparents that LB is continuing to test positive for drugs. It appears from the chronology that they were not aware of this and yet they are presumed to be a protective factor in Child C’s life. There is no explanation as to why these significant family members are not attending any meetings in relation to Child C. It is also unclear to what extent the MGM was supervising LB’s care of Child C. There is little evidence that the progress of the Core Assessments was discussed at this meeting. 4.3.23. A Child Protection Monitoring visit took place on 24th February 2011 and in the combined chronology, it is noted there were ‘no issues’ in relation to Child C’s social, emotional or behavioural development. However, these records do refer to Child C sleeping on a pull out bed with LB. MGM and LB were advised by the social worker that the Core Group’s decision was that the ‘arrangement’ had to continue for a further four weeks to ‘ensure LB cannot relapse’. There are however, no records which explain why the social worker offered this information and where the ‘four week’ timescale came from. 4.3.24. The following day, LB reported to P1-SMTP and had an oral swab taken. It was agreed that they would discuss test results showing positive results for Buprenorphine at next meeting on 4th March 2011. LB talks of difficulties in her relationship with her mother. This was not reported to the social worker. On 4th March 2011, at her appointment with P1-SMTP, LB described to her practitioner her unhappiness that her social worker had cancelled the last appointment. It is not clear from records whether this refers to a recent cancellation or is the same one LB reported on 11th February 2011. LB denied any illicit drug use but there is little evidence of any challenge from practitioner 1. At this stage LB was collecting her prescription daily and asked to be placed on a twice-weekly collection. It was agreed that this would be discussed at next visit. On 8th March 2011 P1-SMTP received a test result, which indicated no illicit substances. The drugs company was asked to recheck the last positive result for LB. On 9th March 2011, LB’s key worker at P1-SMTP was changed for the third time. 4.3.25. The Health Visitor saw LB and Child C on 9th March 2011, although it is not clear where this visit took place. Child C was recorded as being ‘bright and chatty, sociable and confident’. The Health Visitor described LB’s relationship with Child C as ‘lovely and warm’ but offered no further information, which would help others understand what she meant by this description. LB advised she has not seen her social worker since she moved house. This was the first indication that LB had moved and it is unclear how long it had been since LB saw her social worker. Neither the Health nor the CSC authors address this issue in their respective reports, it is significant as reading the chronologies it appears that the Health Visitor was the only practitioner actually ‘working’ with the family. 24 4.3.26. LB attended P1-SMTP on 11th March 2011 and her earlier positive test results were discussed. LB denied using Buprenorphine and stated she didn’t know what this was. This is highly unlikely given LB’s background but this comment was not challenged. Practitioner 5 did make it clear however, that if she attended every appointment for four weeks and all tests were negative then LB could return to twice-weekly pick-ups [for her Methadone prescriptions]. LB and practitioner 5 agreed that LB would attend P1-SMTP every Friday morning at 10.30am and also when asked to call in for another random test. This is an example of good practice and had the Child Protection Plan been more focused, this expectation would have been made explicit so all professionals were aware of the arrangement. Practitioner 5 contacted social worker 2 to discuss the session and was asked to produce the last four months of testing results in preparation for the next Core Group meeting on 18th March 2011. 4.3.27. Core Group meeting 18th March 2011 Present: Not clearly documented but notes refer to LB, P1-SMTP, Health Visitor and social worker. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Child C benefiting from nursery placement • Child C continuing to live with maternal grandparents • Agreement that a Risk Assessment would be undertaken and completed within two weeks. This appeared to be in relation to Child C staying with LB unsupervised • LB not to have any contact with ex-partner KR • Need for Police checks on grandparents • LB to undergo weekly swab and urine test. (Notes from P1-SMTP, however indicated that a private conversation between practitioner 5 and social worker took place and it was agreed that LB would be subject only to swab tests15.) It is unclear whether or when LB was informed of this decision • LB to comply with random drug testing • LB to register Child C with Dentist • LB to register Child C with nursery in Place 2 4.3.28. There is no information contained in the IMR from CSC about this Core Group meeting, either in terms of the information shared or in relation to any dissent or agreed outcomes. It is difficult to understand why the IMR author for CSC, would not explore in detail the effectiveness of these meetings and to what extent they served to secure better outcomes for Child C. The Core Assessment, and the Risk Assessment related to the adults with whom Child C is in contact were not discussed. LB and her positive drug tests were not addressed, discussed or challenged. 4.3.29. P1-SMTP received a letter from the drugs testing company indicating that LB’s tests were clear and this appears to set the scene for continuous confusion amongst professionals in future about tests which showed ‘false positives’. This undoubtedly made it easier for LB to subsequently challenge tests, which showed a 15 Swab tests cannot be falsified unlike testing for urine, which could belong to another individual. 25 positive result and created the possibility of doubt in the minds of professionals about the extent of her drug taking. 4.3.30. On 22nd March 2011, the social worker visited LB and Child C, presumably at the grandparents’ home. Records in the combined chronology state that as wider family members were present it was ‘not appropriate’ to discuss the Child Protection Plan. There is nothing to indicate that the social worker asked to speak with LB or the grandparents on their own. The social worker had last visited four weeks earlier and this was the first visit after the Core Group on the 18th February 2011. It is unclear how LB would have made sense of what was happening given that she and the grandparents had been told in February that Child C would remain with grandparents for another four weeks. Child C was described as talkative throughout visit and was playing with books and toys. Date to start Risk Assessment at nursery was discussed with LB, although it is unclear why such an assessment would ‘start’ at nursery, and not have started at this visit. 4.3.31. P1-SMTP received information on 23rd March 2011 from a client, an ex-partner of LB who made threats to ‘stab and kill’ any service user he saw with her. Practitioner 6 attempted to contact LB several times and she eventually attended alternative P1-SMTP premises with a male substance user who was on a Drug Rehabilitation Requirement Order (DRR). Child C was present. It is clear at this stage that LB was not co-operating with the Child Protection Plan and was placing Child C at risk by associating with known drug users, but P1-SMTP do not share this information with the social worker and there is no reference to Child C’s behaviour, appearance or wellbeing during the time LB was at these premises. 4.3.32. LB was asked by practitioner 1 on 23rd March 2011 to return the following day for tests, which she did, and she met with practitioner 5. She was informed about the threats but appeared unconcerned. She was told that the social worker would be informed about her visit the previous day in the company of adult on a DRR order. LB asked for a reduction of her Methadone, as she wanted to come off drugs completely. She asked to be considered for twice-weekly pick-ups. LB was advised this would be discussed with another practitioner and that she would be contacted to call in the following week for a random test. There is no mention of the agreement made on 11th March 2011 with practitioner 5 and it is unclear how these agreements were recorded and how different practitioners at P1-SMTP would access these records. 4.3.33. A social worker visit was made at some time the same day to undertake a Risk Assessment. The home was described as clean and well presented. Children’s books and toys were in evidence and Child C’s bedroom was noted to be ‘appropriate’. If this visit was part of an assessment process it would be expected that detailed notes would be available, but these were not recorded and neither are there references to these in the CSC IMR. 4.3.34. LB test results returned on 26th March 2011 and were positive for heroin and Buprenorphine. This information was not shared with the social worker. LB was called in for random drug testing on 29th March, 30th March and 5th April 2011 but gave excuses as to why she could not attend. This information was also not shared with the social worker. 26 4.3.35. Child Protection Review Conference 6th April 2011 Present: Independent Chairperson, LB, Health Visitor 1, social worker 2 and Children’s Centre. Records refer to: • Nursery advising that Child C presents clean and tidy and is meeting milestones • LB being concerned at the absence of anyone from P1-SMTP • P1-SMTP’s report. The report expressed the view that LB was not under the influence of substances when she attended her appointments. She was described as presenting well and being communicative, keeping P1-SMTP informed and responding well to treatment. The report refers to a lapse in January 2011 but that LB had attended special key worker appointment regarding lapse prevention • LB was reported as being good at attending her appointments and has been ‘committed to addressing her illicit drug use’ • LB and Child C continuing to live with grandparents until the ‘Child Protection assessment’ was concluded • An assessment being undertaken in LB’s home • Child C continuing on Child Protection Plan • Growth to be monitored by nursery, plus monitoring when Child C is wearing glasses • Next meeting 14th April 2011 4.3.36. The report from P1-SMTP is overly optimistic, factually incorrect and failed to address LB’s lack of co-operation with random drug testing agreed at the Core meeting on 18th March 2011. The Independent Chairperson had telephone contact with P1-SMTP in relation to non–attendance at Child Protection Conference and was advised that practitioner 4 was on sick leave. 4.3.37. The Independent Chairperson was advised that LB’s mother was questioning the validity of drug testing and LB was receiving mixed messages from P1-SMTP. It is possible that this is a typing error as there is nothing in any records, which indicates the Independent Chairperson, had a conversation with the maternal grandparents. It is possible that LB herself raised the query about the validity of drug testing. There appears to have been a challenge by the Independent Chairperson about the failure of P1-SMTP to arrange random sampling and yet from P1-SMTP records, it is clear that LB was asked to attend for random drug tests but that she failed to attend or respond to calls from practitioners on several occasions. There is clear evidence of inconsistent practice by professionals – LB is advised at meetings, and appears to agree, that she must attend for planned and random drug testing. However, when she fails to comply, she is not robustly challenged or informed about the consequences of her failing to comply with the requirements in the Child Protection Plan. This is a pattern evident in all LB’s contact with professionals, a pattern that continues to be repeated until the death of Baby A in April 2013. 4.3.38. The Review Conference notes refer to the various ‘tasks’, which have been ‘achieved’ since the Initial Conference in early February. However, there is little discussion as to what ‘achieved’ means and scant evidence that any of these will lead to sustained and improved outcomes for Child C. 27 4.3.39. LB attended P1-SMTP on 7th April 2011 and there was discussion about reducing the Methadone prescription and LB moving to a twice weekly pick up. There was no reference to the agreement made between practitioner 5 and LB on 11th March 2011. 4.3.40. Social worker records refer to an assessment session on 7th April 2011, but it is unclear where this assessment visit took place. The report provided to the Review Conference on 6th April 2011, refers to ‘assessments taking place in LB’s home’, this would imply that LB is taking Child C to her home. If the meeting did not take place at LB’s home, then there was little value in assessing LB’s parenting skills when she was living with her parents. The issue of how best to assess LB’s parenting skills should have been addressed at the Initial Child Protection Conference and the details discussed in depth at the subsequent Core Group meeting. 4.3.41. The social worker records refer to LB and Child C both being observed and that Child C responded well to LB. The house was described as appropriate with ‘toys and books’ in evidence. Child C was ‘smart and happy to talk’ and was wearing glasses, encouraged by LB. The phrase ‘toys and book in evidence’ is beginning to be used too often and without any further information becomes meaningless. 4.3.42. Core Group meeting 14th April 2011 (Information Sharing meeting) Present: LB, Health Visitor and Children’s Centre worker. This should have been a Core Group meeting, but it appeared that only LB, the Health Visitor, and the key worker from the Children’s Centre attended the meeting. The social worker did not attend and therefore the meeting was designated as an ‘information meeting’. LB was described as very unhappy with the non-attendance of other professionals. The Health Visitor agreed to write to P1-SMTP and the Team Manager of CSC to express concerns about the failure of these agencies to ensure representation. There would appear to be no minutes of this meeting but records from Health Visitor notes, and from the Children’s Centre refer to the speech and language appointment for Child C sent mistakenly to Children’s Centre, LB reported that she continued to attend appointments and her results were clean and LB also shared that the Police raided her home the previous week but no drugs had been found. There is no indication that there was any discussion about Child C or where this child was when the Police raided the home. 4.3.43. Between 14th April 2011 and the Core Group held on the 12th May 2011, discussions took place between the Independent Chairperson, CSC and the manager of P1-SMTP around safeguarding responsibilities and the importance of managerial oversight and regular attendance at meetings. This was an appropriate challenge by the Independent Chairperson and led to improved attendance at future meetings. 4.3.44. On 4th May 2011, a Child Protection Monitoring visit took place at LB’s home. It is unclear when a decision or an agreement had been made that Child C could stay/visit LB at her own home. Records describe Child C as playing in the garden so ‘not appropriate’ to discuss concerns but ‘no issues’ with presentation. It is 28 difficult not to assume that these visits are purely functional in that they allow the recording of a ‘visit’ to be made prior to a multi-disciplinary meeting. There are no records that outline the purpose, content or outcome of this or any other visit. This is not only poor practice, it is practice which leaves Child C vulnerable and gives mixed messages to LB about the purpose of these visits. 4.3.45. LB has not been tested since 27th April 2011. 4.3.46. Core Group meeting 12th May 2011 Present: Not clearly documented but notes refer to LB, Health Visitor, social worker and Children’s Centre. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Child C doing well and assessed as being age appropriate in terms of development • LB being advised about importance of her attending sessions at P1-SMTP • LB’s explanation about her missed appointments and her confusion about when she was to be tested over Easter period • Social worker leaving on 20th May 2011 but advising that outcome of Risk Assessment would be available for a sharing of information meeting on 19th May 2011 • LB being advised by social worker that if she associated with [named] adults 1 or 2, this would adversely impact on Risk Assessment • Information from P1-SMTP suggests that LB has tested for Methadone only since January 2011, but missed appointments are not addressed and neither is the positive test result on 26th March 2011 • Next Core Group meeting 9th June 2011 4.3.47. Between 12th May 2011 and the Core Group meeting on 9th June 2011, LB failed to keep her agreed appointments for drug testing. On one visit to P1-SMTP, she expressed her frustrations to practitioners and described feeling down and dejected. She said that she had done everything that had been asked of her and yet she did not feel her situation was progressing. This is an understandable point made by LB given that her missed appointments do not appear to have been challenged by other professionals and she was present at the last meeting to hear P1-SMTP confirm tests indicated she had been free from illicit drug use since January. LB expressed concern over the uncertainty about what was happening and the impact this was having not just on Child C but also on Child J. LB was advised by her practitioner at P1-SMTP that she must demonstrate compliance through attending for regular and random drug testing. LB was also advised that she would have another Key Worker at P1-SMTP. This would be her third change of worker in five months. 4.3.48. LB was not given any information about her new social worker and there were no social work visits during this time period. Despite the information shared at the Core Group meeting on 12th May 2011, the meeting to discuss the outcome of the Risk Assessment on 19th May 2011 was cancelled and the outcome of the assessment was not subsequently shared with LB or any professional. It would appear this assessment had been ‘lost’ if indeed it was ever undertaken. The absence of a robust and qualitative Risk Assessment at this stage was a significant 29 failing, which led to poor quality decision-making and confirmational bias on the part of professionals, an issue explored, further in Section 7. 4.3.49. During this period, the Health Visitor noted LB’s demeanour and LB is described in records as being ‘down, agitated and not herself’. LB’s history of having deep vein thrombosis (DVT) was discussed and LB was advised to seek medical attention and ensure that her own health needs were not neglected. There was continuing confusion as to who was the new social worker and attempts by the Health Visitor to find out more information were unsuccessful. The Health Visitor was unable to confirm arrangements for the Core Group meeting, which had been planned for the 9th June 2011. This is evidence of a lack of managerial oversight. This was a child subject to a Child Protection Plan and arrangements should have been made earlier to allocate the case to another social worker and as a matter of good practice, to arrange a handover visit. Significantly, the social worker that was leaving had a supervision session two days before she was to leave her post, her first such session in three months. 4.3.50. There is little in the records to suggest there were any major concerns about Child C. The child appeared to be meeting milestones and was often described as a happy sociable child. It is of some concern that there was so little information about Child C and how the child’s care was managed when his grandparents were working shifts. 4.3.51. Core Group meeting 9th June 2011 This meeting took place as planned on 9th June 2011, attended only by nursery staff, LB and the Health Visitor. LB was recorded as being upset and distressed at the non-attendance again of a social worker and P1-SMTP. There were no apologies from P1-SMTP and no explanation as to why there was no representation from CSC. The Health Visitor attempted to contact CSC but was unsuccessful in finding out what had happened. This is very poor practice and highlights that the support and facilitation of Core Group processes are not working. This again gives mixed and unclear messages to LB. There are no records of any discussion about Child C at this meeting. Neither of these issues were explored in the IMR report for CSC. 4.3.52. Between 9th June 2011 and the next Core Group meeting on the 24th June 2011, another social worker was allocated to the family (social worker 3), but it would appear that there was no introductory or transfer visit to LB, Child C or maternal grandparents. According to records, LB was advised by P1-SMTP of the name of her social worker and the date of the next Core meeting. Social worker 3 visited the nursery on the morning of the 24th June 2011 where Child C’s relationship with mother was described as positive. 4.3.53. The Health Visitor persisted in her attempts to find out date and time of Core Group meeting. She left messages for the social worker, which were not returned. When contact was eventually made on 23rd June 2011, the Health Visitor was informed the Core Group would possibly take place the following day, but this could not be confirmed. The Core Group meeting did however go ahead on the 24th June 2011 but without the Health Visitor in attendance. 30 4.3.54. LB did not attend for any appointments with P1-SMTP during this time period. Whilst there was conversation between the social worker and the practitioner at P1-SMTP, LB’s failure to keep to regular appointments was not discussed. 4.3.55. Core Group meeting 24th June 2011 Present: P1-SMTP, Nurse, LB, social worker 3 and Children’s Centre. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Child C doing well, developmentally and socially, described as being a confident child. Had been toilet trained by LB and always appeared clean and well dressed • LB said Child C had bonded well with Child J but she was concerned that both children were getting used to being cared for full-time by her and she was worried about the effect it would have on both children when she and Child C returned home in the near future • LB’s view that the living arrangements were an additional pressure on her parents and LB feeling she had done all that was asked of her and no progress appeared to have been made • P1-SMTP felt LB was coping well with her treatment but needed to be aware of how her feelings and frustrations might make it difficult for her not resume her drug use • The Risk Assessment, which would confirm whether Child C could live with LB in her own, had not been completed • Social worker said that all plans were being satisfactorily progressed. LB’s next appointment with social worker was 28th June 2011 • Next Core Group meeting was agreed for 21st July 2011 4.3.56. There is significant evidence of professional complacency here, which suggests that members of the Core Group were unclear about their roles and the function and purpose of Core Group meetings. Whilst LB was not challenged about her failure to attend for regular and random drug testing, neither was there any professional challenge about individual agency performance. There is no recorded challenge at this meeting in respect of the long-awaited Risk Assessment, originally expected by mid-April, and neither was there a clear understanding about what factors would indicate sufficient progress so Child C could return home to live with LB. The role of grandparents as protective factors was not considered in any sense and it is unclear to what extent they were involved in caring for Child C. There is a sense of the same meeting being repeated over and over again with the same goals being identified but little to evidence that any progress was being made. In this respect LB’s frustrations and comments are quite understandable. What remains clear is that the focus was on mother and not on the safety and welfare of Child C. 4.3.57. Between 24th June 2011 and the next Core Group meeting on 21st July 2011, LB failed to keep her appointments at P1-SMTP and test results on an earlier swab indicated the presence of opiates. This information was not however shared with the social worker at the time. Practitioner 10 sought to keep in contact with LB, reminding her of the need to comply with the Child Protection Plan and the Treatment Plan. LB had face-to-face contact on 19th July 2011 where she again 31 voiced her frustrations at everything taking so long. There is no evidence of challenge in respect of LB’s missed appointments. 4.3.58. During this period, the Health Visitor wrote formally to the social worker expressing concerns about the Core Group meetings, the absence of the Risk Assessment and the general drift and delay in moving things forward. The letter was copied to the Team Manager in CSC and the Health Visitor’s own line manager. This was good practice. 4.3.59. Core Group meeting 21st July 2011 Present: P1-SMTP, LB, social worker and Children’s Centre. Records refer to: • LB’s frustration at not being able to move to her home and having to take two buses to take Child C to nursery • Child C continuing to thrive, displaying good social skills and development • P1-SMTP report that LB’s treatment continues to progress and she was engaging well. LB had recently reduced Methadone with no reported ill effects and continued to provide samples, which ‘proved’ she was free from illicit drugs • Health Visitor’s concern about the absent Risk Assessment. The completed Risk Assessment had been forwarded to a Team Manager who was on sick leave. Social worker agreed to locate this and forward to Core Group members for comments • Agreement was reached that if Risk Assessment was satisfactory then Child C could return home with LB and that this ‘case’ had taken too long to conclude 4.3.60. The minutes for this Core Group were made available to the author. They are shocking in terms of their brevity and lack of focus and analysis. It is significant that there were more details about this meeting in records from other agencies than are provided in the minutes provided by the social worker as chairperson. It is unclear how those present could conclude, without a completed Risk Assessment or the absent Core Assessment that Child C could return home providing ‘the Risk Assessment was satisfactory’. For children subject to a Child Protection Plan, any analysis of risk should be a multi-disciplinary process in which all professionals and parents participate. The actions agreed in this meeting suggests that the Risk Assessment was considered to ‘belong’ to CSC and any recommendations were foregone conclusions not requiring input or challenge from other key parties. It is difficult to understand exactly what progress had been made and what was different from previous concerns highlighted earlier in the year. There is evidence here of questionable decision-making and again points to the dangers of Child Protection Plans lacking focus and direction. 4.3.61. Between 21st July 2011 and the Core Group meeting on the 17th August 2011, LB tested positive for opiates but denied any illicit drug use. She suggested that her self-medication - co-codamol - for her DVT was probably interfering with results. P1-SMTP later rang LB to advise that the drug company had later confirmed that this test should in fact have shown a negative result. LB claimed she could not understand how the original test proved positive for opiates and was described as being relieved to hear this result. There was no challenge to LB during this 32 conversation in respect of her failure to keep her appointments at P1-SMTP. This information was not shared with the social worker. 4.3.62. A Child Protection Monitoring visit took place on 25th July 2011. LB shared her frustrations about her previous social worker not keeping in touch. She also raised the issues of minutes of Core Group meeting going to wrong address, despite all previous minutes being addressed correctly. The social worker is recorded to have discussed the ‘assessment’ with LB but there are no details provided in relation to this conversation. The home was described as being clean and well presented with more than enough food in the home. LB referred to wear and tear in her carpet and this suggests that the visit took place in LB’s home and indicates that Child C was spending time at LB’s home. Child C was described as playing with B, a female adult friend of LB’s. It is highly likely that this person was the daughter of NX. 4.3.63. NX was released from prison having served 25 months of a five year sentence for supplying Class A drugs. 4.3.64. The Health Visitor saw Child C and LB at the Children’s Centre and LB reported positively on her engagement with P1-SMTP, although this was not substantiated from an external source. Both mother and child continued to live with maternal grandparents, although the Health Visitor had not seen Child C at the grandparents’ home. 4.3.65. Core Group meeting 17th August 2011 Present: social worker, Children Centre Key Worker, and Health Visitor Not present: LB, P1-SMTP worker. Records refer to: • Social worker sharing with meeting that the Risk Assessment is ‘missing’ • LB not present as she was taking her children on a trip • No concerns from professionals about LB’s parenting • LB testing negative for drugs • Those present are advised by Health Visitor that LB has new boyfriend [NX] who has been to prison for drug dealing, although he denies using drugs • Reference to the need for him to be assessed • An agreement that social worker start rehabilitation plan for Child C to be returned to LB’s care 4.3.66. The minutes provided by CSC are even shorter than minutes from the previous meeting and the date is incorrect. Since the last meeting LB had missed appointments and the ‘missing’ Risk and Core Assessments had not materialised. It is difficult to understand why the professionals at this meeting agreed to continue with the rehabilitation plan without seeing or discussing a Risk Assessment and, significantly, without LB being present. There would appear to have been no challenge to this decision. Undoubtedly, there was firm-ground intelligence to suggest that Child C was doing well, meeting milestones and developing physically and emotionally. What was not addressed however was the fact that Child C was living with grandparents so the issue of LB’s parenting remains an unknown factor. Furthermore, there is considerable naivety, accompanied by a degree of optimism about LB being allegedly ‘drug free’. Random drug sampling for LB had not proved conclusively that she was not using drugs as she had consistently and persistently failed to attend for these tests when requested. The additional risk factor of a 33 boyfriend on Licence for drug offences seriously questions LB’s ability to remove herself from the drug community, but this appears to have been only a minor consideration according to the notes from the meeting. 4.3.67. Between 17th August 2011 and the Child Protection Review Conference on 2nd September 2011, practitioner 10 contacted LB to discuss her non-attendance at appointments. LB had left a message saying she was unable to keep her appointment on 22nd August 2011 as she was seeing a solicitor about access to Child P and was discussing the situation with her social worker later that day. LB was challenged about this with practitioner 10 advising that he had tried to contact the social worker and a voice message had confirmed she was on leave from 18th August 2011 until 29th August 2011. LB however, was insistent that she had an appointment with her social worker and according to records from CSC; a Child Protection Monitoring visit did take place on 22nd August 2011. It is possible that the social worker made this visit just prior to taking leave, although this is not an issue referred to or explored by the IMR author. The author of the Health Overview report however, refers to the answer machine message as evidence that LB was not being honest when she said she had an appointment with her social worker later that day. 4.3.68. There are several comments in reports, which refer to LB being ‘manipulative’ and not to be trusted. Yet, professionals regularly took the word of LB without checking back with others to confirm what they had been told. There is also evidence, which suggests that LB was actually truthful on some occasions about when she was taking drugs – she admitted several times to P1-SMTP about what she was doing and whilst she was adept at providing excuses for non-attendance for drug testing, she rarely missed her appointment at multi-agency meetings. 4.3.69. Whilst records pertaining to LB’s drug use go back to 2007, there is little information and analysis provided about the impact of this on Child C. It must be questioned therefore whether a negative impact was assumed because LB was a drug user, as opposed to a negative impact being identified following careful observation and assessment. Without further detail in relation to Child C or LB’s previous children, the presence of professional bias16 must be considered as a factor alongside the possibility of LB’s engagement with professionals being seen as ‘disguised compliance’17. 4.3.70. Following the social worker visit on 22nd August 2011, LB and Child C were described as ‘fine’ and the plan for rehabilitation was discussed with LB being informed that at the next Child Protection Review Conference, Child C would come off the Child Protection Plan and move to a Child in Need Plan. LB reluctantly shared the name of NX but said she only saw him at weekends when Child C was not present. Clearly, the social worker was confident that the decision of the Review Conference would support the views of the Core Group and the message to LB was unequivocal despite the presence of another male adult in the life of Child 16 Professional bias occurs when professionals hold onto a particular view about a situation or an individual and do not consider other alternatives, which may challenge this view. 17 ‘Disguised compliance’ involves a parent or carer giving the appearance of co-operating with professionals to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention. 34 C and one who had clear links to the drug community. There was no discussion around grandparents and how they were coping with having LB and Child C living with them and importantly, what their views were about LB having ‘sole’ care of Child C and returning to live with them at home. This is very poor practice. 4.3.71. The Probation Officer for NX discussed with him the impact of his offending on his children. NX did not discuss his developing relationship with LB and it is not clear whether information about past and present relationships would as a matter of routine, have been explored during this session. 4.3.72. Child Protection Review Conference 2nd September 2011 Present: Independent Chairperson, LB, social worker, Health Visitor, P1-SMTP. Staff from Children’s Centre are not in attendance. Records refer to: • Risk Assessment on LB’s ex-partner had been ‘lost’ in the system but was deemed to be no longer necessary as they did not have any contact with Child C • Social worker had visited LB at her home and noted no issues with Child C in terms of behaviour or development • Agreement that a Risk Assessment on NX would be required if the relationship with LB developed • Positive reports in respect of Child C’s development and wellbeing. Minor physical problems with speech and hearing had been addressed • LB had not attended her appointments with P1-SMTP for almost four weeks although she apparently kept in regular contact with her key worker Decisions taken: - Child C be removed from Child Protection Plan to Child in Need status - LB to move back home within two weeks with Child C - Social worker 3 to continue involvement to offer stability and consistency - Core Group/Planning meetings to be held every four weeks - LB to engage with P1-SMTP, keeping all appointment and providing tests - Health Visitor to make follow-up meeting with LB at next Core Group Meeting - Representation from Child C’s new nursery to join Core Group - Work with the family not to cease without agreement from all professionals 4.3.73. It is unclear how a decision could be taken to return a child back to mother’s care without the completion or sight of a risk assessment. Furthermore, despite the requirement for LB to attend for regular drug testing, she had not attended for almost four weeks. The decisions taken at this review meeting appear to have been endorsed by those present without challenge. 4.3.74. The combined chronology however, refers to the Health Visitor notes in which she refers to ‘professional anxieties’ about the decision to change Child C’s status from Child Protection to Child in Need. The Health Overview report refers to the Health Visitor’s attempt to challenge this decision, which was overruled by the Independent 35 Chairperson, but this information is not contained in either the combined chronology or the Health IMR report. 4.3.75. There is no reference to any assessment of LB’s parenting ability or capacities and the Core Assessment had still not been shared with any professionals, if indeed it had been concluded. It is difficult to understand exactly what had changed since Child C was made subject a Child Protection Plan in February. Child C was then reported to be developing well and meeting milestones, there were no concerns about their behaviour or health and LB continued to struggle with her drug addiction. Whatever the tests may indicate, past history of LB’s addiction and research available about addictive behaviours would suggest that the risk of lapse or relapse was ever-present. Consequently, it would have been more appropriate for professionals to consider how Child C could be kept safe rather than the broader focus of making sure that LB was drug free. 4.3.76. Child in Need meeting 15th September 2011 Present: social worker, Health Visitor and P1-SMTP. Records refer to: • LB’s continuing non-attendance at P1-SMTP • Risks of LB not engaging with P1-SMTP were acknowledged • Noted that Child C had one known contact with NX • Meeting rescheduled as LB was not present 4.3.77. Between 15th September 2011 and the Child in Need planning meeting on 22nd September 2011, LB was contacted by P1-SMTP about her missed appointments and why she did not attend Core Group meeting. LB said that she forgot about the meeting. NX discussed with his Probation Officer the effect of his father’s conviction on his family. He reported he was living at his mother’s home. The developing relationship with LB was not mentioned. 4.3.78. The Health Visitor rearranged a visit and agreed to see LB and Child C at Children’s Centre instead of LB’s home. There is no explanation for this change in arrangements but this was a missed opportunity – the Health Visitor should have been curious about the change in arrangements and ensured that a home visit took place given that Child C had only recently moved back to live with LB. 4.3.79. The social worker visited LB and saw Child C at home. LB said that Child C was finding it difficult to adjust to the new nursery and became physically ill on arrival so LB had kept the child at home. LB was reminded about the importance of keeping appointments. LB acknowledged this. She advised the social worker her relationship with NX was progressing and agreed that NX would need to be assessed given his contact with LB. Also agreed that the new nursery should be informed of Child C’s Child in Need status. LB had clearly arranged a transfer to a new nursery near her home and understood the reason for staff there to be informed about Child C’s Child in Need status. 4.3.80. Child in Need meeting 22nd September 2011 Present: LB, social worker, Health Visitor and P1-SMTP. It is not clear why there is no representation from Child C’s new nursery. Records refer to: • LB sharing information about NX 36 • LB being advised that NX was not to stay overnight until Police checks had been complete • LB not fully engaging with P1-SMTP, she missed four appointments but a recent urinalysis tested positive for Methadone only • LB agreed to keep appointments with P1-SMTP • Child C was unable to settle at new nursery • LB to keep Core Group informed 4.3.81. There was no challenge to LB in respect of her missed appointments and again a surprising degree of optimism and naivety is apparent. There was no discussion around whether the missed appointments could be an excuse to mask drug taking or to what extent urinalysis was the best test on which to base a view that LB was drug free. The roles of P1-SMTP as specialist in this field does not appear to have been used as a resource to assist the professionals develop their knowledge around this issue. 4.3.82. There is no reference to a Child in Need Plan, no goals or targets were identified and no discussion around how best agencies could work together to support LB and ensure Child C was well and safe in her care. The minutes of this meeting briefly refer to a list of actions and statements and are an example of very poor practice in terms of understanding the role and function of professionals supporting a Child in Need Plan. It is apparent upon reading the various IMR reports that many practitioners did not know the name of the meetings they were attending or their related terms of reference. As there was never any clear challenge to the ineffectiveness of these meetings, this suggests that the poor practice highlighted in this SCR may well reflect practice elsewhere in the Authority. 4.3.83. Between 22nd September 2011 and the next Child in Need meeting on 20th October 2011, LB tested positive for opiates on two occasions, but she denied illicit drug use, despite the tests results being confirmed by the Drug Testing Service. A urinalysis for one of these tests indicated only the presence of Methadone suggesting either [another] flaw in the drug testing process or that the urine samples provided by LB were not hers. LB kept one appointment with P1-SMTP on 3rd October 2011 and insisted she was drug free explaining that she would not use heroin ‘this close to the case being closed’. At an appointment with P1-SMTP the following day, LB again denied using illicit drugs and an agreement was reached that LB’s prescription for Methadone would be gradually decreased and would be reviewed at a later date. LB agreed to keep appointments with practitioner 10 on Tuesdays and Fridays. 4.3.84. In supervision, practitioner 10 confirmed he was unsure whether LB was going through a difficult time but expressed concerns and highlighted the pattern of LB’s disengagement with services when pressure was removed. A subsequent test result for LB showed presence of opiates and Methadone. Practitioner 10 then tried to contact LB on at least six occasions following her non-attendance for drug testing. This information was not shared with the social worker. 4.3.85. Just before the meeting on 20th October 2011, LB contacted her key worker at P1-SMTP to explain she had been to visit Child P in [another area]. This information was neither shared nor clarified. 37 4.3.86. The Police received information alleging that NX was harassing his former partner and mother of his children. This allegation was taken seriously and a notification was sent through to CSC. It would appear that this information did not trigger a link to LB and Child C. 4.3.87. The Health Visitor made a home visit on 7th October 2011 to assess Child C’s health and development. No concerns were identified. Child C was reported to be well settled into nursery. LB talked about recent test results and again insisted she was drug free. It would have been difficult for the Health Visitor to challenge this statement, as there had been no information circulated from P1-SMTP about LB’s tests. This left the Health Visitor having to accept LB’s version of what was happening and reduced the impact of joined up interventions by agencies. A discussion took place about Child P who is living with their father elsewhere. 4.3.88. Child in Need meeting 20th October 2011 Present: Not documented but notes make reference to: LB, social worker 3, Health Visitor and Practitioner 10, P1-SMTP. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refers to: • Information that LB was pregnant by current partner but had not booked with GP or Midwife as she planned to change GP • LB and partner are happy with news and will marry soon • LB advised she was to stay with grandparents for a while as their shift patterns meant they needed help with Child J. LB will also care for Child C at same time • LB reported that Child P now lives with father some distance away in [another area] but LB will have contact every holiday • Health Visitor reported no concerns re Child C’s welfare or progression. Developmental tests show Child C is developing as expected • Practitioner 10 advised that LB had not attended since 4th October 2011 despite requirement for her to attend twice a week. LB’s last two swabs tested positive for heroin • LB denied taking illicit drugs and insisted tests were ‘wrong’. Practitioner 10 asserts that recent events suggest a relapse. LB advised that solicitor had said she is not legally obliged to take these tests. However, LB acknowledged why she was required to take these • LB advised that her new partner is willing to work with her and help her treatment • Decision that Child C would remain on Child in Need Plan • Social worker 3 apologised for not visiting since last meeting. The Risk Assessment on NX is still outstanding and this would be progressed as a matter of some urgency • LB agreed to engage fully with P1-SMTP and treatment plan and attend twice a week on Tuesday and Friday • LB to register with GP and have pregnancy confirmed • Next Core Group meeting 16th November 2011 38 4.3.89. There is again little evidence of challenge and focus from this meeting. Without any plan or contingency agreements, interventions were piecemeal and there is a sense that professionals were repeating the same actions recorded in previous meetings and yet optimistically, expecting a different outcome in relation to LB’s engagement with services and her ability to remain drug free. 4.3.90. Between 20th October 2011 and the next Child in Need meeting on 16th November 2011, LB registered with new GP surgery and her Methadone treatment was noted. Whilst the notes clearly indicate that LB already had three children there was no check to ascertain where these children were living. This information should have been routinely collected. LB’s pregnancy was confirmed and notes indicate a referral was made to the Community Midwife, although there was no referral letter. The Health Visitor contacted the Specialist Substance Misuse Midwife (SSMM) and discussed the situation re: LB and her unborn child. 4.3.91. A visit by the Health Visitor on the 8th November 2011 was recorded. The house was described as clean and warm. Child C had gained only a little weight but LB insisted that the family and Child C had a nutritional diet. LB advised that she had been attending her appointments with P1-SMTP and that NX had stayed over the previous night. There was no challenge by the Health Visitor about this overnight stay despite the agreement made at the meeting on 22nd September 2011. Had the Health Visitor been more sceptical she may have assumed that NX stayed there more often than LB was saying and took the opportunity to explore this whilst she was there. LB’s pregnancy and health needs were discussed and LB was advised about dangers of smoking when pregnant. 4.3.92. P1-SMTP were persistent in their efforts to make contact with LB who failed to keep any appointments with them until 15th November 2011. On this occasion she arrived at P1-SMTP premises with a friend and saw practitioner 9. Child C also accompanied LB to this appointment and was described as looking physically well and acting appropriate for that age. LB‘s pregnancy was recorded as being obvious and practitioner 9 was informed that the expected delivery date was 18th June 2012. 4.3.93. In response to a challenge about non-attendance, LB said she had been threatened at her last visit to the pharmacy to collect her Methadone prescription and was fearful about returning. She had also recently been robbed but had not contacted the Police. No further explanations were forthcoming. It was noted that LB had been out of treatment since 4th November 2011 and LB stated she had been buying Methadone off the streets but had not been taking heroin. She was unable to give a urine sample but gave an oral swab and was asked to return that afternoon for an appointment with a Doctor who would reinstate the treatment plan. LB was advised that a urine sample would be necessary. LB asked to collect her prescription from a different pharmacy and she was informed that she would be required to attend on a daily basis to collect her medication. 4.3.94. P1-SMTP were advised by another P1-SMTP that LB had been in custody three nights previously but had been released without charge. However, whilst there she had twice tested positive for opiates. Conversations between P1-SMTP and SSMM highlighted P1-SMTP’s ‘grave’ concerns about LB being ‘off script’ and the impact this could have on her unborn child. P1-SMTP made a Child Protection referral to 39 CSC on 15th November 2011. It is unclear whether they discussed this referral with the social worker. 4.3.95. This information was later shared with the Health Visitor who made an unannounced visit but did not make contact with LB. There are records, which detail good information sharing between P1-SMTP, Health Visitor, the Community Midwife and the SSMM. The Health Visitor contacted social worker 3 and outlined her concerns that LB was not complying with Child in Need plan and expressed the view that in her opinion the Child Protection threshold has been reached. Social worker 3 agreed with this view and a decision was taken to discuss this further at the next planning meeting. The Health Visitor appears to be co-ordinating contacts and ensuring various colleagues are kept informed. This is to be applauded, as without this persistence, it is possible that the social worker would not have picked up the growing number of concerns. 4.3.96. Following this conversation, social worker 3 made an unannounced visit on 14th November 2011. LB stated that she had ‘given up’. She alleged that someone was threatening her when she arrived to collect her prescription and that she had been buying Methadone off the street. LB advised social worker 3 that she and NX were arrested on 11th November 2011 for conspiring to sell Class A drugs but no drugs were found and no further action was taken. LB gave conflicting explanations about this incident. It would be expected that this information would prompt further discussion and challenge from social worker 3, especially in relation to the impact on Child C. However, there are no records, which confirm such a conversation took place. 4.3.97. At this stage, the social worker should have contacted the Police to gather more information about the arrest as she only had LB’s version of what had happened. The Police clearly did not consider it relevant to inform CSC about their actions so it must be assumed that neither LB nor NX were with Child C when they were arrested. 4.3.98. Child in Need meeting 16th November 2011 Present: Not clearly documented but notes make reference to: Health Visitor, LB, practitioner 10, and P1-SMTP. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • LB failing to take Child C to a planned appointment • LB giving ‘inconsistent’ information regarding care of Child C • LB was tearful, irritated and threatened to leave meeting saying that ‘minds had been made up’ • Child C was agitated at meeting, but was clean and appropriately dressed • Child C has poor weight gain – only 12 ozs in five months • LB had not attended for testing as agreed. LB claimed this was due to harassment by another P1-SMTP service user • P1-SMTP confirmed that LB had tested positive for heroin the previous day but reported she was now back on ‘script’ and ‘appeared stable’ • LB had admitted injecting heroin whilst Child C was at school and also buying Methadone 40 • LB recently arrested for supplying Class A drugs though claimed this was a misunderstanding. LB had £600 in her possession at time • Meeting suspended due to Child C’s agitation but LB advised that as she was not complying with agreed plan, the Child Protection Plan would be resumed if the social worker manager agreed • This was explained to LB as needing to keep unborn child and Child C safe. Records indicated that LB understood this 4.3.99. Even given a clear indication by LB that she is taking heroin, the notes from this meeting suggest a paralysis on the part of the professionals and particularly the social worker. The term ‘appears stable’ seems overly optimistic given LB had been using heroin 24 hours earlier. The concerns shared with the social worker before the meeting on the 16th November 2011 should have alerted her to discuss these with her line manager before the meeting so a plan of action was ready to discuss with LB. Child C clearly left the meeting with mother and returned to live in an almost identical situation which had in January, pre-empted the child’s move to the maternal grandparents’ home. There was no discussion at this meeting about the need for any safety planning for Child C and this highlights yet again the failure to place Child C at the centre of these interventions. It might also be questioned why there was no managerial presence at any of these meetings, especially given the inexperience of the social worker involved. 4.3.100. Between 16th November 2011 and Child Protection Strategy meeting on 24th November 2011, results from the swab taken from LB on 15th November 2011 showed positive testing for heroin, opiates and Methadone. 4.3.101. LB miscarried her baby on 19th November 2011. 4.3.102. LB attended an appointment at P1-SMTP three days later and rearranged her appointment to collect her Methadone prescription. She advised that her mother was arriving to look after Child C as she was still distressed and finding it difficult to accept she was no longer pregnant. 4.3.103. Child Protection Strategy Meeting 24th November 2011 Present: Not clearly documented but notes make reference to: Health Visitor, Police, social worker, Nursery and practitioner 12 (on behalf of practitioner 10), P1-SMTP. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Background information and Police checks • Questions over whether Child C was with LB when she was arrested • Concerns raised over drug use and dealing from home address • Concerns raised that partner of LB is possibly supplying drugs to his eldest child and to LB • Daughter of LB’s partner is often in household and is collecting Child C from nursery • Social worker to discuss with LB that she allows Child C to live with grandparents on an s20 (voluntary placement). Grandparents to be involved in this discussion. If LB does not agree then Court proceedings will commence 41 • Child Protection proceedings to be commenced. Initial Child Protection Conference to be held in 15 days • Situation to be discussed with Legal Team 4.3.104. The Police provided additional information, which suggested there were concerns about the possibility of LB and NX being involved in supplying Class A drugs. There was little information about Child C shared at this meeting and the risks to the child’s welfare and safety were not made explicit. Plans were not made to ensure the child was kept safe whilst further enquiries were made. Neither was there a record of any discussion or reference to LB’s miscarriage and to what extent if any, this may have been linked with or attributed to, her drug taking. 4.3.105. Between 24th November 2011 and the Initial Child Protection Conference on 14th December 2011, LB withdrew consent for Child C to again live with the maternal grandparents, explaining that as her parents worked full-time, this would require her to move to [Place 2] so she could care for Child C. LB did not want to do this given her relationship with NX. A decision was taken that the social worker would visit on a daily basis until the Child Protection Conference in five days’ time. However, two days later Child C was staying with grandparents as LB had been ‘detained’ in hospital after needing medical care after her miscarriage. There are no records to advise how long Child C stayed with grandparents but by 5th December 2011, the child was recorded as being seen at home with his mother. 4.3.106. The CSC report states that a legal briefing took place sometime after the strategy meeting but before the Child Protection Conference. The Local Authority was advised they did not have enough evidence for an application to remove Child C on an Interim Care Order and a decision was therefore taken to instigate Public Law Outline (PLO)18 procedures. 4.3.107. LB did not keep appointments with P1-SMTP or take Child C for a paediatric appointment. This was the second missed appointment for Child C. LB left a voice message for the Health Visitor explaining she was very busy as wedding to NX was going ahead on 9th December 2011. 4.3.108. A planned visit by the Health Visitor on 5th December 2011 found LB keen to talk about her forthcoming wedding but not the Child Protection concerns raised at the last meeting. Child C was recorded as not being their normal happy self, had a runny nose and LB said the child had been off school for two weeks due to having a cold. This does not appear to have been challenged by the Health Visitor who was informed that the eldest child of NX (17 years) was asleep upstairs. LB said she was collecting Methadone daily and refused to accept that her lifestyle posed a risk to Child C. Records indicate the Health Visitor was of the view that LB did not appear to be under the influence of drugs. 18 Public Law Proceedings are commenced under section 31 of the Children Act 1989 where the Local Authority takes the view that it is no longer possible to safeguard and promote the welfare of the Child promoting his/her upbringing by his/her family without a care or supervision order. 42 4.3.109. Practitioner 10 attempted to contact social worker 3 to discuss his concern that LB had not attended for testing since 16th November 2011. These concerns had been discussed in a supervision session and he was encouraged to persist in trying to contact social worker 3 to query how Child C was being protected whilst still in the care of LB. 4.3.110. NX and LB were married on 9th December 2011. 4.3.111. Child C continued to attend nursery every afternoon but usually arrived late. There were no behavioural issues although records continued to refer to a delay in speech and language. NX informed his Probation Officer of his marriage and LB’s miscarriage and was told that the Offender Manager will have to make contact with CSC as he is on Licence. NX replied that he did not believe they are involved. 4.3.112. Initial Child Protection Conference 14th December 2011 Present: Not clearly documented but notes make reference to: LB, Health Visitor, social worker, Nursery and practitioner 12 (on behalf of practitioner 10), P1-SMTP • LB admits smoking heroin whilst Child C is at nursery • Notes refer to there being no therapeutic work with LB since May 2011 due to LB’s ‘disengagement’ • Views expressed that LB is not honest with services • No record of information from Legal Services • LB to keep all appointments relating to Child C’s health • Should be a written agreement as to who will take and collect Child C from Nursery • Child C to be subject of a Child Protection Plan under the category of Neglect due to: - LB’s continuing to test positive for drugs - Recent marriage to NX and unassessed risks posed by this relationship - LB inability to impose boundaries on Child C - LB minimising professional concerns • First Core Group meeting 20th December 2011 4.3.113. This was the third time that Child C had been on a ‘Child Protection Plan’ but like previous occasions, the plan was simply a list of tasks to be achieved within a given period. There was no attempt at clearly defining expected outcomes and no way of reviewing or monitoring progress. For example, notes describe that LB and NX were to ‘fully engage with Children’s Services’ but the notes failed to say for what purpose, what this entailed, why it benefited Child C and how this ‘engagement’ would be reviewed and measured. There is a sense of this being almost a ‘start again’ process19 with all previous knowledge about professional interventions and LB’s ways of responding to these being ignored. Once again, the focus related mainly to LB and NX and drug taking. 19 This is a situation where children suffered long term neglect and children’s social care fail to take account of past history and they adopted a ‘start again’ approach’ Brandon et al Biennial Review 2003- 2005. 43 4.3.114. On 20th December 2011, LB attended for urine test at P1-SMTP. This tested positive for Methadone only. 4.3.115. A PLO meeting was held on 20th December 2011. The Senior Solicitor for the Local Authority forwarded a Pre-Proceedings letter to the author. LB attended this meeting and was advised that if the outlined concerns were not addressed then the Local Authority would proceed with Care Proceedings in order to safeguard and protect Child C. It is unclear whether these were additional concerns or those identified in the Child Protection Plan. 4.3.116. Core Group meeting 20th December 2011 - held in LB’s home Present: Not clearly documented but notes make reference to: LB, NX, Health Visitor, social worker, and practitioner 10, P1-SMTP. Information pertaining to this meeting has been extracted from notes from P1-SMTP records. Records refer to: • Child C seen as bright and sociable and interacting well with both LB and NX • Information re: NX’s back ground shared with his permission – he has served 28 months of a five year sentence for supply of Class A drugs • Agreed that NX’s Probation Officer would be asked to join Core Group • LB and NX agreed to a Parenting Assessment, which would conclude in March 2012. This would be undertaken by social worker who would also visit family twice a month • LB to attend P1-SMTP twice weekly for planned and random urine testing • LB happy to engage with Child Protection Plan 4.3.117. There remained vagueness to these plans, a point already addressed several times previously in this report. The focus remained mainly on the adults and not on Child C. There was no discussion about the need for safety plans for Child C, which given his age and vulnerability was a serious omission. LB and NX agreed to take part in a three month Parenting Assessment. It was not made explicit exactly what professionals were looking for, how their parenting would actually be assessed and what would be involved. There was also a lack of curiosity from professionals as to what this assessment would entail and what model would be used in the process. 4.3.118. Between 20th December 2011 and 11th January 2012, LB did not collect her Methadone prescription and was out of ‘script’. She was contacted by P1-SMTP and attended an appointment on 28th December 2011 as agreed. LB advised she had been using ‘left over’ Methadone and was advised that this was not acceptable as this would count as illicit drug use. Urinalysis tested positive for Methadone only. LB later attended Doctor’s appointment and was given a new prescription to be collected daily. A further test on 30th December 2011 also tested for Methadone only. LB attended three further sessions with P1-SMTP and was noted to be in a good mood and feeling positive. Tests were positive only for Methadone. 4.3.119. The Health Visitor made a home visit and appeared to have a productive discussion with LB, discussing the Child Protection Plan and consequences for Child C if LB did not keep to agreements. LB appeared to understand this. Health Visitor was also able to discuss the impact on Child C when LB was taking drugs. Health Visitor later had supervision and reported that in her view NX may have been a positive influence for LB. She was urged to persist in obtaining copies of assessments especially in relation to NX. 44 4.3.120. A Child Protection Monitoring visit took place on 11th January 2012. Social worker 3 saw Child C who presented as ‘fine’ and ‘very talkative’ and showed social worker 3 his room. Written agreements and assessment sessions were discussed with LB who was reminded that failure to keep to the plans would be considered as a risk factor to Child C. Records do not indicate whether NX was present and it must be assumed he was not party to these discussions. There was a distinct lack of engagement with NX, notwithstanding the absent Risk Assessment agreed earlier in the year. There was clear evidence that NX was now part of Child C’s life and yet there appears to be very little effort made to engage him. There is a substantive body of research20,21 highlighting the marked failure of health and social care professionals to engage with fathers and men in the lives of children where there are child protection concerns; this knowledge should have alerted professionals to the need to take a more pro-active stance in seeking to find out more about NX, although it may have been assumed this would have been achieved through the Parenting Assessment. 4.3.121. Child C is attending school but often arrives late. Reports indicate that child appears happy to attend school. Speech and language development was being addressed. 4.3.122. Core Group meeting 23rd January 2012 Present: Health Visitor, Class teacher and Headteacher, social worker, P1-SMTP and LB. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Reports refer to: • Issues around Child C’s weight • P1-SMTP confirmed that LB had attended all sessions and tests showed negative results for opiates or other drugs • LB discussing her emotions and being open with P1-SMTP worker • LB advised that Child P was staying with her at weekends. Those present agreed that care of Child P would be included in the Parenting Assessment. • Records note that LB now has care of all three children on Sunday afternoons • Social worker advised that there were no current concerns and notes refer to professionals remarks that Child C appears to be thriving physically, emotionally and socially 4.3.123. The fact that LB now has care of all three children at times fails to raise any concerns. Professionals appeared reassured by the social worker comments. 4.3.124. Between 23rd January 2012 and 9th February 2012, LB tested positive for illegal substances and informed P1-SMTP that NX’s eldest child had been banned from home as she was using Cocaine. P1-SMTP discussed LB’s recent lapse but this was not shared with social worker. Social worker 3 made a home visit on the same day but LB’s recent tests were not discussed. Social worker 3 arranged to visit the following week to pursue the assessment. This presumably means the Parenting Assessment. 20 Scourfield, J. (2001) Constructing men in child protection work, Men and Masculinities. 21 Improving the engagement of fathers in child protection (2010) National Institute for Social care and research. 45 4.3.125. Child Protection Monitoring visit 9th February 2012 Social worker arrived for Child Protection visit. LB had written it down for following day. Child C was present and house was clean and tidy. LB advised that NX’s daughter had started using drugs and so she is no longer allowed in their house. Session rearranged for 13th February 2012. 4.3.126. LB’s tests from 9th February 2012 confirm presence of opiates, heroin and Methadone. P1-SMTP asked the Drug Testing Service for confirmation of result. Practitioner 16 at P1-SMTP informed practitioner 10 that clients had identified LB as a drug dealer who had a driver who waited in the car while she was dealing. Practitioner 10 tried to contact social worker 3 but was unsuccessful. It might have been useful if P1-SMTP had also e-mailed social worker with this information given there was a monitoring visit taking place the following day. It would also have been useful if the social worker had made contact with P1-SMTP prior to her visit to learn more about LB’s recent engagement with P1-SMTP. This is evidence of poor collaboration and solo working of agencies. 4.3.127. Child Protection Monitoring Visit 13th February 2012 • Social worker visited. Saw Child C who was asleep • LB was getting ready for visit to solicitor • House clean and tidy and social worker recorded ‘no issues to note’ 4.3.128. There is so little information provided from this and other visits that it is difficult to ascertain their purpose. There is no information recorded which relates to a plan of any sort and the visit has the appearance of a brief visit to check that nothing untoward has happened. This is extremely poor practice and raises a question about social work intervention and what this actually means. There is little to evidence that any ‘social work’ is undertaken with LB. The failure to be clear about the purpose and planned outcomes for each visit suggests that the social worker was merely monitoring what was happening rather than actively seeking to achieve change through the social work relationship. It is possible that other professionals assumed that there was more to these social work visits than actually took place but this was never discussed or challenged in multi-agency meetings and highlights the ineffectiveness of the plans made to protect Child C. 4.3.129. Supervision of the social workers is recorded as happening only four times during the period under review. It is questionable as to how the work undertaken by social worker 2 and social worker 3 was monitored and supported and what opportunities took place for reflective practice. The lack of managerial oversight is also significant given that a Letter before Proceedings had been issued and LB had been formally advised of the implications of not adhering to agreements. It is clear that there was no understanding between agencies or amongst professionals as to what behaviours or actions would trigger an [earlier] application to court to begin Care Proceedings. 46 4.3.130. Core Group meeting 20th February 2012 Present: Health Visitor, Class teacher and Headteacher, social worker, P1-SMTP and LB. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Social worker 3 informed Core group that the Parenting Assessment was progressing as planned • Information shared about NX’s eldest child being asked to leave the home due to drug use • Discussion about accessing help from P1-SMTP for NX’s eldest child • LB disputing results of recent drug tests. P1-SMTP confirming that urinalysis showed presence of Methadone only • LB being advised that NX’s daughter was not to have unsupervised contact access to Child C • LB did not want NX’s Probation Officer to attend group but was informed this was required. LB advised that NX should also attend • Child C attending nursery late every day but was described as bright and lively but still small for age • LB informed those present that NX will adopt Child C on 21st February 2012 • After LB had left meeting, information was shared by P1-SMTP that a service user alleged that LB was dealing in drugs in [another] area • Social worker to pursue this 4.3.131. Between 20th February 2012 and Child Protection Review meeting on 2nd March 2012, Northumbria Police call at LB’s house following referral from a drug dependency centre concerned about Child C and LB’s drug addiction. Police note house clean with lots of food and Child C well and ‘outgoing‘. LB and NX not pleased but accepted visit as routine. According to the combined chronology Police undertake a ‘welfare visit’ the following day, but it is highly likely that this is one and the same visit. 4.3.132. Child Protection Review meeting 2nd March 2012 Present: Health Visitor, Class teacher and Headteacher, social worker, P1-SMTP and LB. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Parenting Assessment completed on 22nd February 2012 and this was recorded as ‘positive’ • Health Visitor reported that Child C’s weight is still low but there are no [other] physical problems. Referral to be made to dietician. Other milestones achieved • Nursery reports no educational difficulties. Child C is sociable and can form ‘strong bonds’ but punctuality is still an issue • P1-SMTP treatment plan for LB continues but LB disputed a recent result, which tested positive for heroin. P1-SMTP will discuss Methadone reduction at LB’s request • LB is required to have oral swabs not urine tests • Assessments in relation to NX’s daughter continue • Child C to continue on Child Protection Plan under category of Neglect 47 • After LB left room, information is shared that LB and NX are still under surveillance, as Police believe they are dealing in drugs and are monitoring the household 4.3.133. The information from Northumbria Police does not appear to have raised concerns and no action or immediate home visit was made. A further PLO meeting was planned for 13th March 2012. The feedback from the social worker that the Parenting Assessment was ‘positive’ is puzzling given the information recorded from this and previous meetings. It was clearly not shared with or circulated to other professionals and there is no recorded discussion about the conclusion of this assessment. 4.3.134. Core Group meeting 15th March 2012 Present: Not clearly documented but notes make reference to: Health Visitor, social worker, (who had returned previous day from leave of absence), and practitioner 10, P1-SMTP. Apologies were received from LB. Information pertaining to this meeting has been extracted from notes from other agencies as records from CSC were not available. Records refer to: • LB gave apologies for her absence as she had to seek medical attention for her DVT - Health Visitor to contact hospital to see if LB sought medical attention • Child C had attended eye clinic and needs to continue to wear glasses • Still attending school but arrives late, three absences due to illness • Child C talks at nursery about NX’s daughter sleeping at their house • P1-SMTP advise that LB has not been tested since 2nd March 2012 • Information shared that LB accessing needle exchange services in [area] • PLO meeting planned for 13th March 2012 had to be rearranged. Now planned for 2nd April 2012 • Conflicting information about LB engaging with drug services • Suggestion that LB may be pregnant (although it is unclear whether this was information shared by LB and with whom) 4.3.135. Records suggest that LB was seen in nursery after this meeting and P1-SMTP opportunistically took mouth swab. P1-SMTP records note there was no-one else present and LB willingly agreed to the test. It is unclear why the PLO meeting was adjourned for a further two weeks given the information shared at this meeting and previous meetings. 4.3.136. Between 15th March 2012 and 2nd April 2012, Health Visitor confirms that LB did not attend hospital appointment for DVT on 15th March 2012. Results from the swab taken by P1-SMTP on 15th March 2012 showed positive for heroin, opiates and Methadone. This does not appear to have been shared with social worker 3. LB attends for an appointment with practitioner 11 on 20th March 2012 in the presence of a friend and Child C. LB was described as looking well and admitted to recently smoking heroin. There are no records of any challenge or any observations concerning Child C. This information was shared with social worker 3 the following day who stated that ‘care proceedings would be instigated’ to remove Child C from the family home if LB did not agree to place Child C with MGM. 48 4.3.137. Social worker made a home visit on the same day and LB was asked to agree to Child C going to live with MGM. LB was upset but reluctantly agreed and Child C was voluntarily accommodated under s20 of the Children Act 1989. LB rang her mother and explained about testing positive for heroin. It would appear that social worker 3 took Child C to grandparents’ home on 21st March 2012 and records indicate the child appeared unperturbed during the journey. The situation was discussed with the MGM and she confirmed that she could care for Child C for a few days until she returned to work, after which time Child C would have to be cared for by the paternal aunt, ST. Social worker advised that transport to and from nursery would be arranged, as would relevant checks on ST. Aunt later telephoned to confirm her agreement with this plan and indicated they wanted to make sure Child C stayed in the family until things were ‘sorted’. 4.3.138. On the same day a Regulation 2422 Assessment was started. There is no evidence that a Viability Assessment had been undertaken, perhaps because it was assumed that as Child C has lived with grandparents previously it was not required. The Regulation 24 Assessment should have been completed within 16 weeks but in July 2012, the Fostering Officer records that the maternal grandparents ‘do not feel the need for the in-depth assessment needed for relatives now’ and consequently the assessment on the maternal grandparents remained incomplete with no checks undertaken with the home Local Authority and significantly no liaison with social worker 3 in respect of information about family background and family dynamics. The Fostering Officer could not state why this assessment was incomplete and the IMR author does not explore this in any detail. Checks have now been introduced to make it more difficult for this error to happen in the future. 4.3.139. Social worker 3 received a call from MGM on 26th March 2012 saying she was unsure whether she or the aunt could look after Child C for longer than a few days. Social worker agreed a visit to discuss. It is not clear when or if this visit took place and the reservations from the MGM and aunt do not appear to have been shared with colleagues in the Fostering Team or with the line manager despite their importance and significance. 4.3.140. Test results from 15th March 2012 on LB confirmed positive for heroin, Codeine, and Morphine. P1-SMTP made telephone contact with LB after non-attendance and received text message from LB blaming P1-SMTP for telling social worker about her drug use. LB claimed to have lost trust in P1-SMTP. Social worker 3 contacted P1-SMTP asking for full chronology of LB’s treatment plan and her engagement with it. This was forwarded to social worker 3 on 29th March 2012. 4.3.141. The Safeguarding Nurse read the minutes from Conference and Core Group and in supervision session discussed her growing concerns with Health Visitor. The Health Visitor was requested to put concerns in writing to social worker 3 so they are available for the PLO meeting. 22 A ‘Regulation 24 assessment relates to the temporary approval of a relative, friend or other person connected with a child where the Local Authority is satisfied that certain conditions have been met. 49 4.3.142. The Health Visitor wrote to social worker 3 asking for clarity around a number of issues relating to assessments, boundaries for Child C and LB supervising contact between Child C and NX’s eldest child. 4.3.143. NX asked to be considered as main carer for Child C but social worker 3 advised this was not possible due to his background. Social worker 3 began a dialogue with NX’s Probation Officer who stated that NX appeared unaware of situation with CSC. Concerns about Child C were shared. Probation Officer advised that NX was not a drug user and expressed view that he is low risk to children. 4.3.144. On 28th March 2012, the Placement and Resources Panel (PARP) agreed to Child C being placed with maternal grandparents. Although the CSC IMR states that a Risk Assessment was attached to the paperwork, this related to the risk posed by the placement itself rather than any analysis focused on the risk posed to the children if they remained living with their parent. This template has now been amended to include the reason why the placement is needed and any actual or perceived risk to the child if there is contact with the parent. 4.3.145. It is perhaps significant to note that the Panel did not comment on the incomplete Fostering Assessment, if indeed they noticed. 4.3.146. CSC IMR records that the Parenting Assessment on LB and NX was concluded on 2nd February 2012 and the Assessment recommendation was that Child C should continue to be cared for by the maternal grandparents and Care Proceedings would be initiated. It is unclear why this report appears to contradict the feedback given by the social worker in early March, which described the Parenting Assessment as ‘positive.’ The report is over 20 pages long but most of the content is extracted from files and records and simply replicates historical information already known to professionals. There is no reference to the fact that LB may be pregnant. There is a brief analysis consisting of one side of A4, which leads to the conclusion that the Local Authority should pursue Care Proceedings. It is a very poor analysis and contributes little in terms of assessing parental capacities of either LB or NX. 4.3.147. PLO meeting 2nd April 2012. No details were provided of this meeting other than a record stating that Care Plans should be provided by 16th April 2012. It is unclear whether LB’s pregnancy was mentioned. 4.3.148. In early April, following several texts and calls, P1-SMTP contact social worker 3 concerned about LB’s disengagement with services and discussing P1-SMTP having to close case given LB’s engagement was only on a voluntary basis. A Child Protection Monitoring visit was made on 10th April 2012 at grandparents’ home. LB, NX and grandparents were present but LB and NX stayed only a few minutes to sign paperwork. Child C was seen and described as looking well. There is no discussion recorded about telephone conversation on 26th March 2012 and no records are made of any discussion with the grandparents. It is unclear whether they were made aware of the need for them to be fully assessed as kinship carers. 4.3.149. A Looked after Child Initial Health Assessment was undertaken on 11th April 2012. Records describe Child C as confident and independent, progressing well developmentally and no concerns were identified. A Child Protection Monitoring 50 visit took place on 16th April 2012, noted that Child C was well presented and there were no concerns recorded. 4.3.150. LB made contact with P1-SMTP on 16th April 2012 saying she would like to come in for an appointment later that week and asked to see practitioner 5. However, on the same day LB’s GP was contacted advising that LB had dropped out of treatment and was no longer receiving medication from P1-SMTP. 4.3.151. Core Group meeting 17th April 2012 Present: Not documented but notes make reference to: [replacement] Health Visitor 2, LB and social worker. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Temporary Health Visitor 2 attending in place of Health Visitor 1 • LB expressing a wish to re-engage with P1-SMTP • Child C reported to be expressing emotionally distressing behaviour when with LB who has unlimited access. NX also visits at grandparents’ home • CSC plan to seek Supervision Order • Conference date to be brought forward for discontinuation of the Child Protection 4.3.152. There was no discussion about Child C’s behaviour but the records infer that Child C’s distress was a result of the ‘unlimited’ contact with LB. While this may have been a factor, other possibilities e.g. separation and loss of contact with mother were not explored. 4.3.153. Between 17th April 2012 and the Review Child Protection Conference on 30th May 2012, the Local Authority instigated Care Proceedings in respect of Child C. Social worker 3 visited maternal grandparents and was informed that neither grandparent wanted to be full-time carers as they both worked and the aunt, ST was covering childcare to help out. This discussion and its outcome were not recorded in any detail and although a ‘fostering visit’ was scheduled for 11th May 2012, there is no record of this visit taking place in the combined chronology or in the IMR report. The Local Authority where Child C was living was not notified that a child subject to a Child Protection Plan had moved into their area. 4.3.154. NX discussed the situation with his Probation Officer and reported that he was motivated to work to help LB get Child C returned to her. 4.3.155. A Child Protection Monitoring visit took place on 14th May 2012 and social worker 3 recorded that Child C was unwell but wanted to go to school so social worker 3 transported the child to nursery. No other information was available regarding this visit. 4.3.156. Core Group meeting 15th May 2012 cancelled. No details are provided. 4.3.157. On 29th May 2012 Child C was made subject to an Interim Supervision Order. The Child Protection Plan was ended at the Looked After Child review, which took place the following day. 51 4.3.158. Looked After Child Review 30th May 2012. Information extracted from CSC records. Present: Independent Chairperson, social worker, Probation Officer, School The minutes from this meeting were not made available to the author. No details are available from other agencies other than notes extracted from the Probation IMR, which states that Child C was to stay with grandparents. The Health Overview report indicates that Health Visitor 2 was advised on 11th June 2012 that a Review Child Protection Conference had taken place on 30th May 2012 and a decision taken that Child C was now a Looked After Child. There is no explanation or discussion of this decision in the CSC IMR. In many cases where a child who is the subject of a Child Protection Plan becomes Looked After, it is no longer necessary to maintain the Child Protection Plan. However, given that Child C remained living with family members and had regular contact with LB, it may have been advisable to continue with the Child Protection Plan. In the absence of any detail or information in the CSC IMR, the rationale for this decision is unclear. The group was advised that a Kinship Assessment was underway for the maternal grandparents. The ‘shared’ care between grandparents and aunt was not discussed. 4.3.159. LB attended Drug Service 2 and tests are positive for Methadone only. LB expressed concern about Methadone use and discussed trying alternative therapies. She was referred to different services. 4.3.160. The temporary Health Visitor visited Child C at maternal grandparents’ home on 19th June 2012 and recorded that Child C was eating breakfast and ‘presented well’, although MGM said Child C was showing some signs of anxiety and was nail biting. Maternal grandparents noted to be caring for all three of LB’s children. The issue of maternal grandparents indicating they could not care for Child C on a long-term basis does not appear to have been addressed. 4.3.161. Care Planning meeting 20th June 2012 Present: Not clearly documented but notes refer to LB, Health Visitor, social worker, Nursery staff. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Child C showing signs of anxiety, biting nails and sleepwalking. LB was upset by this information. Said she and Child C had never been apart before • Records note that this arrangement would ‘not be for too long’ • Maternal grandparents had been assessed as foster carers • An advocates meeting to take place on 27th June 2012 and a Court Hearing on 3rd July 2012 • LB using a private drug testing company. CSC required hair strand testing • LB asked for NX to be assessed as a carer for Child C 4.3.162. Between 20th June 2012 and 16th July 2012, LB confirms to Drug Service 2 that she is still using heroin and is struggling to stop. She said she had informed CSC and her solicitor. She was advised that being open with professionals was important. The drug service made an appointment for her to see a doctor four days later and recommended she sought treatment for an infected site on her arm. LB kept the appointment and agreed a new treatment plan. Tests were negative for opiates. LB 52 attended one other appointment but cancelled and rearranged a third as a result of ‘childcare’ difficulties. 4.3.163. Child C was noted to be presenting well at school, receiving additional help for maths and literacy and also receiving information about Stranger Danger given the number of adults collecting the child from school. The fact that this was a Looked After Child appears to have been overlooked and left Child C in a very vulnerable position. This issue should have been highlighted and explored by the IMR author. 4.3.164. Care Planning meeting 16th July 2012 Present: LB, NX, Health Visitor, Probation Officer, social worker, Headteacher, and School Nurse. Information pertaining to this meeting has been extracted from notes from other agencies and not from records from CSC. Records refer to: • School has concerns about different people collecting Child C • Attendance is good and Child C is a described as happy child, intervention for listening and attention skills are continuing • LB and NX are to have a psychological assessment but remain concerned about pending Court Proceedings and when Child C can be returned to their care • Concerns about LB’s drug use and missed appointments are noted • NX will be assessed as a carer for Child C 4.3.165. There was no information about Kinship Assessment on maternal grandparents and any comment or challenge regarding the plan to assess NX as a carer for Child C, despite the outcome of the Parenting Assessment completed three months earlier. 4.3.166. Between 16th July 2012 and the Care Planning meeting scheduled for 13th August 2012, LB was offered a revised treatment plan, which did not involve Methadone. She admitted she was still using heroin. LB talked to her advisor about her feelings and concerns and was reminded about the need for Child C to be kept safe. The increased stress on LB in relation to the pending Court case was noted. Upon collecting medication at the pharmacy, LB tried to conceal some medication in a bag, (as opposed to taking the medication on site) and when challenged said she might be pregnant and the dosage made her sick. A pregnancy test confirmed that she was pregnant. This information was promptly shared with the Drug Testing Service and LB was asked to attend for another appointment the following day. There was no contact between drug service and the social worker during this period. The doctor did however contact LB’s GP to advise of their involvement and stress the need for careful prescribing. 4.3.167. LB continues to miss planned appointments with drug service 2. 4.3.168. Care Planning meeting 13th August 2012 at GP surgery Present: Not clearly documented but notes refer to LB, Health Visitor, Drug Service Worker and Clinical Co-ordinator from Drug Service 2. Information pertaining to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • LB confirming her pregnancy • LB not wanting to engage with P1-SMTP but agreeing to liaise with SSMM (Specialist Substance Misuse Midwife) 53 • Psychological Assessment to be undertaken in respect of Court Hearing • Court Hearing in November 2012 • Health Visitor to contact SSMM • Child C continue to live with grandparents 4.3.169. Drug service 2 referred LB back to P1-SMTP where she attended a Doctor’s Review on 6th September 2012. LB attended a first meeting with Community Midwife. LB referred to Consultant-led clinic for vulnerable women. Issues around DVT were not recorded although Midwife obtained a detailed history, including LB’s drug use. There is no reference to any contact with SSMM. 4.3.170. A supervision session is noted in the combined chronology for CSC, although this session is not referred to in the CSC IMR report. The author assumes this session refers to supervision between social worker 3 and her Team Manager (SS). The notes refer to the need to follow Unborn Baby Procedures and state that three sessions have been completed in relation to NX’s Parenting Assessment. There is also a note, which relates to recordings and where these should be stored on the system. The social worker was advised that hair strand testing should be a requirement for LB. 4.3.171. A Looked After Child Review on 12th September 2012 is recorded in the combined chronology but it is likely that the information in these records referred to a conversation between the Community Midwife and the Health Visitor, possibly in preparation for a forthcoming Review. Records refer to the Health Visitor being informed that any referral to the SSMM needed to go through the GP. It was also confirmed that the maternal grandparents were not planning to apply for a Residence Order in respect of Child C. The Health Visitor formally handed over the care of Child C due to their age, to the School Nurse. 4.3.172. By the 14th September 2012 LB had again dropped out of treatment but P1-SMTP continued to maintain contact due to her pregnancy, despite LB continuing to engage and disengage herself from the services offered. 4.3.173. Documentation from P1-SMTP indicates LB’s continued drug use and missed appointments between 12th September 2012 and 7th November 2012. During this period, Health Visitor 1 transferred Child C to School Nursing Service and a handover summary was shared and signed. A new Health Visitor was allocated to the family in respect of the unborn child, with Health Visitor 1 declining to continue work with family citing ‘this was the right time for a change’. This demonstrates good reflective practice with the Health Visitor acknowledging that long-standing work with a family may not always be in the interests of either the family or the worker. The Community Midwife made a referral to CSC, copied to the Named Nurse and Midwife, the SSMM and Health Visitor 3, presumably expressing concerns about LB’s drug use and the impact on the unborn baby. 4.3.174. According to the CSC report, this referral triggered an ‘Initial Assessment’ by social worker 3 on unborn Baby A. However, the Assessment was not signed off by a manager or entered onto the case management system by social worker 3. This Assessment should have been completed within 45 days but in fact was not completed until early February 2013, which is significantly outside timescales. 54 4.3.175. The School Nurse arrived for a Care Planning meeting on the 18th October 2012 but no meeting had been organised. She is informed several days later that the next meeting will take place on 7th November 2012. This is not the first time there has been confusion about meetings; this highlights the importance of meetings being properly co-ordinated if they are to be effective in any way and highlights again the absence of any managerial oversight. 4.3.176. Court Hearing October 2012. No details of this Hearing have been provided to the author. However, records in the CSC IMR suggest that it was at this Hearing that a decision was taken that LB and NX should be subject to psychological assessments. 4.3.177. Care Team meeting/Pre-Birth Multi-Agency meeting 7th November 2012 Present: LB, P1-SMTP, School Nurse, Midwife, Deputy Head, social worker. Records refer to: • Information reviewed by agencies • LB paying for private counselling sessions - no further information is sought or provided • Information shared from Court Hearing, which required that LB starts drug counselling for three months and she and partner undergo a psychological assessment. • LB admitting to still using heroin and agreed twice a week testing • No significant concerns re: Child C at school or in relation to his wellbeing or development although concentration and retention of information is an issue • LB has daily-supervised contact with Child C at her mother’s home • Social worker reported she has observed contact and has no concerns about the relationship between LB and Child C • (Fostering) and Adoption Panel will take place on 12th November 2012 • LB is 15 weeks pregnant • Health Visitor asked about plans for the unborn baby and was informed these could not be confirmed that day but a pre-birth conference would take place on 5th December 2012 4.3.178. The author of the IMR report for CSC refers to not being able to locate the notes from this meeting. However, the Overview Author was sent a copy of the notes written by social worker 3, although other requested minutes were not forwarded. This highlights a systemic failure in the organisation if significant records cannot be easily located and retrieved. Whilst problems with the information systems in Local Authorities are well documented, this issue nevertheless can significantly impact on practice and decision-making. 4.3.179. Maternal grandparents were approved as Connected Carers for Child C on 12th November 2012 and the decision approved by the Local Authority on 20th November 2012. 4.3.180. Looked After Child review 14th November 2012 Present: Not clearly documented but notes refer to LB, NX, MGM, Independent Chairperson 1, Health Visitor 2, P1-SMTP and School Nurse. Information pertaining 55 to this meeting has been extracted from notes from other agencies, as records from CSC were not available. Records refer to: • Independent Chairperson 1 (chair) reviewing the Care Plan for Child C who remains on an Interim Supervision Order • LB and NX being advised that there were two possible outcomes in relation to Child C: the child could return to the care of LB full-time or would continue to live with grandparents • Independent Chairperson being advised of LB’s pregnancy although this was noted at the Care Planning meeting in August 2012 • LB has daily contact with Child C under supervision and advised she is paying for regular sessions with psychiatrist. Social worker 3 agreed to look into this • NX asked if he could have unsupervised contact with Child C. Social worker 3 agreed to look into this • Concern raised about the number of different practitioners LB sees at P1-SMTP 4.3.181. On the 9th November 2012, the Health Visitor has telephone supervision and advises her line manager that the unborn baby would be ‘integrated into the ongoing Care Proceedings for Child C’. Given, that a child must be born before Care Proceedings can be instigated, it is unclear whether this was a misunderstanding on the part of the Health Visitor or she had been given misleading information by the social worker. The Health Visitor is reminded by her supervisor to make sure there are timely birth and conference arrangements to safeguard the unborn baby. 4.3.182. NX’s eldest child was arrested in November 2012 on suspicion of possession of drugs. She was found to have drugs hidden in underwear. 4.3.183. Between 14th November 2012 and the Care Planning meeting on 5th December 2012, LB continued to miss appointments at P1-SMTP and they contacted the SSMM to share their concerns. There is evidence of good information sharing between health colleagues and P1-SMTP. 4.3.184. The Health Visitor’s supervisor discussed concerns regarding Child C and the unborn baby with her line manager – the Safeguarding Nurse Advisor on 28th November 2012. She was advised that the Unborn Procedures should be followed and these would likely lead to an Initial Child Protection Conference. The supervisor was also advised to ensure that the Health Visitor liaised with the social worker to ensure these procedures were followed. Given the delay and drift already evident, concerns should have been escalated at this stage and discussions initiated at more senior level. 4.3.185. The SSMM was unsuccessful in her attempts to contact LB regarding missed appointments. 4.3.186. Care Planning Meeting 5th December 2012 Present: Social worker, Midwife, Health Visitor, Student Nurse, School. CSC records refer to: • LB had kidney infection and did not attend. NX had work commitments 56 • No significant concerns about Child C although concentration appears to be an issue. LB asked to sign an Individual Education Plan for Child C • No goals or progress were identified in these brief notes Notes from other agencies refer to: • LB continuing to use heroin • Unborn baby placed on ‘system’ in line with procedures • Child Protection proceedings to be instigated when LB has reached 26-week gestation. A Case Conference will be arranged • NX to be assessed as carer for baby • Risk identified and remain unchanged • Initial Assessment to be carried out in relation to unborn child 4.3.187. Between 5th December 2012 and 5th February 2013, LB continued to avoid testing but admitted to still using heroin. Practitioner 18 discussed with practitioner 17 the need to check urine samples with pregnancy testing to ensure the urine samples belong to LB. NX told his Probation Officer that he and LB were doing all they could to prove they could care for Child C, but he was expecting that the arrangements with the maternal grandparents would continue long-term with LB and NX having contact. The assessment for NX to be carer for his baby when born remained outstanding. It is difficult not to question whether the Parenting Assessment/Carer Assessment/psychiatric tests etc., were platitudes intended to diffuse the concerns and anxieties of LB and NX. It is understandable that LB and NX perceived they were being asked to jump ‘through hoops’ without any realistic hope of Child C and their baby being allowed to live them. 4.3.188. Team Manager 3 in CSC confirms on 13th December 2012 that they will progress to an Unborn Baby Conference due to serious concerns about LB’s unborn baby and the fact that Care Proceedings were already underway in respect of Child C. 4.3.189. Records suggest that Child C was at home with LB and NX on Christmas Eve but there are no records to confirm whether this arrangement had been discussed or agreed with the social worker. On 26th December 2012, LB attended A and E department of local hospital with a swelling in her leg which showed evidence of DVT. She was advised to attend Maternity Unit after treatment with anti-coagulants but failed to attend. The Delivery Suite Co-Ordinator tried unsuccessfully to contact LB but her calls and messages went unanswered. Several attempts made by the Community Midwife and the SSMM to contact LB were unsuccessful and notes through the door were not possible as letterbox was sealed from inside. These efforts demonstrate persistency and good practice. Concerns increased as it became evident that the unborn baby was at high risk due to LB’s DVT and anaemia. LB failed to follow up treatment. P1-SMTP received a telephone call from social worker 3 to advise that the Care Planning Meeting due to take place on 8th January 2013 was cancelled. The reason for this is not clear and is not picked up by the IMR author for CSC. 4.3.190. LB continued to avoid antenatal and P1-SMTP appointments. P1-SMTP are informed that LB had attended a needle exchange service and obtained needles under her maiden name and were informed that LB was injecting into her groin. P1-SMTP shared concerns with social worker 3 who advised she would inform the 57 Local Authority Solicitor. Social worker 3 telephoned LB to discuss concerns but her phone was answered by someone else. Social worker 3 contacted NX to advise of missed appointments and growing concerns. NX claimed not to know about these and said he would get LB to get in touch. 4.3.191. LB attended high-risk clinic on 15th January 2013 and was advised by Consultant that he planned to deliver her baby at 38 weeks. At this point LB was 28+ weeks. LB was advised about importance of keeping appointments and was described as looking unwell and low in mood. She admitted recent use of heroin. LB said she had no recent contact with social worker. 4.3.192. There are no details in CSC IMR about the Court Hearing on 16th January 2013, but P1-SMTP records indicate that LB contacted them to advise that NX had been in Court to hear that the baby will be removed at birth and she had until 2nd April 2013 to ‘turn things around’. 4.3.193. The Health Visitor made an antenatal visit on 18th January 2013. LB was not in but NX was at home. The Health Visitor completed the necessary paperwork with NX and offered to return if LB would like a visit. This was the first recorded opportunity that a professional other than the Probation Officer has had to talk with NX, and whilst NX helped the Health Visitor to compile a genogram and complete the Family Health Assessment Tool, there is no record to suggest that this opportunity was used to discuss professional concerns and the increased vulnerability of his unborn child, especially in relation to the higher risk of Sudden Infant Death Syndrome. NX’s eldest daughter was present and records indicate her baby was due the following month in February 2013. Social worker 3 was not advised that LB was not present for this visit. 4.3.194. LB attended a P1-SMTP appointment three days later on 21st January 2013 and confirmed she had recently used heroin. She blamed the social worker for this as she stated it was her way of coping with the stress of learning that her baby would be removed at birth and NX would not be allowed to care for his child. LB was clearly challenged by practitioner 18 at P1-SMTP and given an unambiguous message about the damage to unborn babies of continued drug use. LB was advised that P1-SMTP would contact the social worker to advise of LB’s continued use of heroin. NX and LB attended another appointment at P1-SMTP on 25th January 2013 and NX stated he believed that social worker 3 held a grudge against himself and LB. On 4th February 2013, LB was contacted by practitioner 18 to ask if she would like an oral swab test prior to the meeting the following day. LB refused but agreed to a urine test. 4.3.195. Care Team Meeting and Pre-Birth Multi-Agency Meeting 5th February 2013 Present: LB, NX, P1-SMTP, School, Health Visitor, and social worker 3. Undated CSC records refer to: • LB’s continued use of opiates • P1-SMTP now only doing oral swabs • HV’s meeting with NX • Child C doing well with 94% attendance at school • NX asking P1-SMTP if he could attend a drug abuse awareness course 58 • Social worker 3 to follow up information from the parenting class that NX completed Notes from other agencies refer to: • Social worker 3 stating that the Initial Assessment was complete and there would be an Unborn Baby Conference held within two weeks (Health records) • Next Court date was 6th February 2013, though this would likely be adjourned • LB and NX described as challenging and arguing that social worker 3 only focused on the negatives in the family and had advised NX that the only way he could care for his baby would be to leave LB. Social worker 3 disputed that she had said that to NX (P1-SMTP records) • Plan outlined for unborn baby (Health records) 4.3.196. Notes extracted from other agencies records refer to a Child Protection Plan being outlined but the Overview Author has not had sight of these, despite requests being made for copies of all minutes. The information recorded in paragraph 4.3.189 above highlights the importance of maintaining careful records of meetings. The CSC notes do not mention unborn Baby A despite the meeting being called a pre-birth meeting, yet records from P1-SMTP and Health clearly indicate some information was shared. The Unborn Baby Conference was well overdue and no explanation was offered and no challenge recorded. It is possible that the Care Planning meeting on the 5th December 2012 was considered by CSC to be the Pre-Birth conference, but this confusion only serves to highlight that social worker 3 was unclear about procedures and her line manager should have identified this. 4.3.197. Between 5th February 2013 and 7th March 2013, LB tests were contradictory and there were suspicions recorded that LB was submitting someone else’s urine for testing. NX continued to attend a drug awareness course and a parenting awareness course and attended P1-SMTP with LB for at least three of her appointments with P1-SMTP. LB attended her antenatal appointments. 4.3.198. Social worker 3 received a call from SSMM on 13th February 2013, confirming she was able to attend the Initial Child Protection Conference on 28th February 2013. Although social worker 3 had not requested a Conference she nevertheless informed other professionals and as she was unable to attend on the said date, arranged for another colleague to attend on her behalf. 4.3.199. According to the combined chronology, a supervision session took place between social worker 3 and her manager on 26th February 2013, the day before social worker 3 took a two-week leave of absence. Records in the chronology refer to social worker 3 being informed by her manager that the pre-birth assessments should be written up and birth arrangements confirmed, but there is no evidence at this stage that the pre-birth assessment had been completed. The Unborn Baby Child Protection Conference for Baby A was already outside timescales. 4.3.200. In the IMR report, however, the author confirms having sight of the supervision record for social worker 3 which took place in February, but writes ‘Neither Child C nor unborn Baby A were discussed during February’s supervision’. This significant discrepancy is neither challenged nor addressed by the IMR author and leads the 59 SCR Panel to conclude that the IMR report was written without reference to the combined chronology. 4.3.201. The Child Protection Conference confirmed by social worker 3 before her leave, did not take place when it became evident that the planned Conference was actually for another family with the same surname. An Operational Manager subsequently proceeded to request an Initial Child Protection meeting in respect of unborn Baby A. This was planned for 15th March 2013, the day after social worker 3 was to return from leave. 4.3.202. Care Planning meeting/ Pre-Birth Multi-Agency meeting 6th March 2013 Present: LB, NX, P1-SMTP, School. Incomplete draft minutes (written by a social worker covering for social worker 3) refer to: • Child C still attending school and has good attendance. Described as a happy child willing to try new activities. Child C is on special needs register but developing well, although has some problems with concentration • No Birth Plan being available, No ICPC report shared. PLO - no assessment commenced • Both parents attending joint counselling with P1-SMTP which ends on 15th March 2013 • LB and NX express frustration at the way their ‘case’ is being managed. Said that social worker had not attended any contact sessions to ‘observe parenting’. Parents do not know what plan is for baby • They are given information about the complaints procedures 4.3.203. Despite the birth being imminent - LB was in her 36th week of pregnancy - the Initial Child Protection Conference had still not taken place and consequently no birth arrangements were agreed. The pre-birth assessment had not been completed or shared with any professional. There is a strong sense of drift here with neither the social worker nor her line manager acting with any urgency. There have been no visits with parents to discuss the Local Authority’s position and no record of any contact with the maternal grandparents to discuss Child C and the future. 4.3.204. The absence of any birth arrangements was discussed in supervision between Health Visitor 3 and the Safeguarding Nurse Advisor. Health Visitor 3 was asked to urgently liaise with Midwife and social worker 3 in regard to these arrangements. At this stage, the Safeguarding Nurse Advisor should have escalated her concerns to a more senior manager in CSC especially given the number of times this issue had been raised both on an individual basis in supervision and in multi-agency meetings. 4.3.205. Practitioner 18 from P1-SMTP shared her report with LB and explained why she would be recommending that the baby be made subject to a Child Protection Plan. 4.3.206. Records in the combined chronology indicate that a fraught telephone call took place on 14th March 2013 between a social worker and LB. LB refused a meeting at her mother’s home to discuss the conference report and was distressed and angry when advised that the baby would be removed from her care at birth. LB advised that her mother would not let that happen and ended the telephone conversation. It is not clear if this social worker was social worker 3 who had returned to work only that day, or a colleague standing in for her. 60 4.3.207. Initial Child Protection Conference 15th March 2013 Present: LB, NX and their legal representatives, Health Visitor, SSMM, Midwife, P1-SMTP, social worker, Legal, Independent Chairperson. Records refer to: • Confidential information shared at Conference prior to LB and solicitor arriving at meeting. Information about NX’s father was withheld • Court Proceedings being underway in respect of Child C • Independent Chairperson expressed concern about lack of information in relation to LB’s health care, especially in relation to her DVT • P1-SMTP were asked to provide confirmation about results of testing • Social worker shared information about concerns and LB’s long and sustained history of drug use, her disengagement with services and her repeated failure to regularly keep appointments with P1-SMTP and remain drug free for any significant length of time • Those at the Conference were told that LB had failed to put the needs of her unborn child first and had continued to use illicit drugs throughout her pregnancy • Risks identified and all professionals agreed that even ‘given the strengths’ the unborn baby should be made subject to a Child Protection Plan under the category of Neglect • NX had requested again to be assessed as carer for baby. LB asked that her parents also be assessed as carers • Social worker advised that CSC would be going to Court to remove baby at birth: however LB agreed that baby could go and live with grandparents. Her mother had sent a letter confirming that she would agree to this arrangement Records indicated desired outcomes: - LB to be clean and sober from all illegal substances: Ongoing - NX to gain clear understanding on needs of children: by 1st April 2013 - Birth plan to be produced and shared with professionals: within two days - Care Proceedings to be initiated immediately after birth to ensure baby is safe: by first core group meeting - NX to continue to attend drug awareness course so he can understand more about heroin use: ongoing - LB and NX to complete psychological assessment: by 26th March 2013 - Placement for unborn baby confirmed within four days - All health appointments to be kept by LB: ongoing 4.3.208. This meeting was delayed by 90 minutes, as the social work report was not prepared. Social worker 3 had in fact returned from a two-week leave of absence only the previous day and would have been unaware that the Conference was taking place. It would not be expected that she would be up-to-date with events and would certainly not have had time to prepare a Conference report. This issue should have been addressed prior to the Conference and suggests once again a serious lack of managerial oversight. A pre-birth assessment had still not been completed. 61 4.3.209. Core Group meeting 18th March 2013 Present: LB, SSMM, and social worker. Records refer to: • Birth arrangements agreed • Baby will be induced and NX will be present at birth. Only named family members would be allowed to visit • LB will breast feed and will be given support to do this • Upon discharge, the baby will be placed in care of maternal grandparents on a s20. They will supervise all contact between LB and the baby. LB will stay with her aunt so she can be close to the baby • If LB tests positive for any illicit drugs, then all contacts with the baby would be supervised by CSC • LB would be tested before and after her admission to hospital 4.3.210. The plan lacks key detail about communication between agencies and how LB would be monitored whilst in hospital and crucially the extent to which the maternal grandparents would be able to supervise LB’s contact with her baby. There was no discussion about Child C. Notes refer rather optimistically to the changed attitude of LB and NX. LB tests results on the same day indicated the presence of opiates, but these were not discussed with LB when she next attended an appointment at P1-SMTP two days later. 4.3.211. The CSC report states there was no written Risk Assessment completed in respect of Baby A, the inference being that some sort of Risk Assessment was undertaken but it was not recorded. A Regulation 24 Assessment should have been completed in respect of this placement and this would have included a Risk Assessment. The Placements and Resources Panel (PARP) should also have been advised about the placement so information about Child C’s placement was known. The IMR author notes that further work has been undertaken to ensure there is now greater clarity about when it is necessary for social workers to attend PARP. However, the Local Authority in [Place 2] where the maternal grandparents lived should also have been informed that Baby A was being moving into their area. 4.3.212. NX’s mother was given permission to visit but not once the baby was discharged. NX asked social worker 3 how long LB had to produce clean tests before she could take care of the baby. This answer to this question, if given, was unrecorded. 4.3.213. SSMM followed up with social worker 3 her concern about supervision of LB whilst in hospital and explained that there may only be two staff on duty. Social worker 3 advised that as it was a controlled environment she was satisfied with that level of supervision but she would talk to her manager. SSMM could have challenged this decision but it is possible that she was waiting for social worker 3 to come back with her manager’s decision. Social worker 3, however, did not make that call, and SSMM should have escalated her concern at that point. The SSMM entered a note in hospital records to ensure that toxicology reports were performed on admission and on discharge. This did not happen and is a serious omission as LB could have been using drugs whilst in hospital. LB was receiving a daily prescription of Buprenorphine from P1-SMTP, which was collected at a specified pharmacy. 62 4.3.214. LB gave birth to Baby A in late March (Day 0) and was admitted to the postnatal ward for 72 hours so Baby A could be monitored and checked for Neonatal Abstinence Syndrome. LB was helped to breastfeed and the baby was given top-up feeds. There is no reference to the baby being transferred to the Neonatal Unit, which given the safeguarding concerns would have been advisable. The Emergency Duty Team were informed of the birth so the social worker could be informed as soon as possible. There are no records to indicate which family members visited, but social worker 3 was noted to have attended on Day 3 although she had no discussions with any ward staff regarding LB and the care of her baby. 4.3.215. LB and the baby were discharged on Day 4. LB advised ‘she was unable to stay’ and left without receiving her medication and prescriptions and without being subjected to any toxicology tests, despite notes placed on her records. P1-SMTP were not contacted about her discharge and LB returned home without her prescribed medication leaving both Baby A and LB in a very vulnerable position. 4.3.216. Records do not state who collected LB and Baby A or how they travelled to the maternal grandparents’ home, although MGM provided this information much later. Social worker 3 was not involved in the discharge arrangements but in line with procedures, she should have made a home visit that day. Given that Baby A was a child subject to a Child Protection Plan, it is of concern that the social worker did not visit on day of discharge or visited Baby A at the home of the maternal grandparents. The IMR author does not comment on this practice or explore why social worker 3 did not visit or even if she knew the procedures required her to do so. 4.3.217. LB’s GP was sent discharge information and the postnatal transfer letter and Postnatal Vulnerability Assessment, which advised that Baby A was subject to a Child Protection Plan. However, given that the baby was to live with maternal grandparents, this information should have been sent to the GP practice in the area where Baby A would live. 4.3.218. LB and Baby A were seen by the Community Midwife on Day 6 at the home of the maternal grandparents where both were present and LB was observed to be feeding Baby A with formula milk. LB said that Baby A was also taking 2-3 ozs of breast milk every two or three hours. Baby A was weighed and noted to have lost 12% of birth weight; arrangements were made to reweigh the baby within the next 24–48 hours, although in line with the Community Health Surveillance (CHS) guidelines 23 for managing weight loss in newborn babies, Baby A should automatically have been seen every day for 10 days. Given mother’s substance misuse, this weight loss could have been an indicator of neonatal abstinence withdrawal and should have alerted the Community Midwife to potential risks. 4.3.219. At this visit, it would have been appropriate for the Community Midwife to share with the maternal grandparents and LB, the risks related to co-sleeping and Sudden Infant Death Syndrome (SIDS) for newborn babies, especially in relation to babies born to mothers known to be drug users. The ‘Give Me Room to Breathe’ 23 CHS Guidelines “Prevention and Management of Excessive Weight loss in the Breast fed Newborn”. 63 campaign had been launched in 2011 and provided important information about sleeping arrangements for young babies. It is unclear why the Community Midwife did not share this information with LB and her parents, especially as Baby A was a vulnerable baby and therefore a high risk. If this information was shared, it was not recorded. LB and her parents were given a number to contact Midwifery staff should they have any concerns. 4.3.220. P1-SMTP contacted LB late March and advised her that the test results from two tests taken earlier in the month had been confirmed as positive for heroin and this would be included in Court reports. LB was distressed and said she was going to lose everything. P1-SMTP attempted to contact social worker 3 but received no answer so e-mailed the information to her. 4.3.221. P1-SMTP contacted SSMM to advise that LB had not waited at the pharmacy for her medication. They also stated that they had been unaware that LB had been discharged from hospital and had learnt of this when they rang LB to discuss her medication. LB had contacted the pharmacy that ascertained that she had not been prescribed any medication from the hospital but she was unwilling to wait for a prescription to be arranged. LB later attended the maternity unit for medical checks and told the Midwife that the pharmacy had been unable to dispense her medication, as the hospital had not arranged a prescription for her on discharge. The Midwife talked with a Consultant but LB was advised they could not arrange a hospital prescription, as there was no way of confirming whether LB had medication from elsewhere. By this time, it was afternoon on Easter Saturday so the pharmacy would not be open for another three days. Upon reading reports, there is a sense that LB may have desperately been trying to get hold of some medication although she was clearly too impatient to wait at the pharmacy for a prescription. 4.3.222. Baby A, aged one week, was admitted to Paediatric Intensive Care Unit at the Royal Victoria Infirmary following a cardiac arrest and was reported to be in a critical condition. Baby A was not breathing upon arrival at hospital but breathing was finally restored via a respirator. However, given the length of time without oxygen, the medical staff advised there would be brain damage. 4.3.223. The necessary paperwork for Baby A to be placed with the maternal grandparents under s20 had not been completed, alongside a failure to notify key people and services, including the CSC in the area where Baby A was living. Social worker 3 had claimed she was unaware of what had to be done although her manager contradicted this and stated she had advised social worker 3 and had assumed the necessary paperwork had been completed. The implication of this is that when Baby A was admitted to hospital, it was not known they were a Looked After Child and neither was the Local Authority aware that a Looked After Child had moved into their area. 4.3.224. A Strategy Meeting was held on 2nd April 2013 attended by key agencies. At the meeting, information was shared about the events leading up to Baby A’s admission to hospital. Baby A had suffered a catastrophic collapse whilst unsupervised in LB’s care. LB had explained that she was feeding Baby A and had pulled the baby to her chest for winding and after 5–10 minutes realised the baby had stopped breathing and called for help from her parents who were upstairs. Her 64 eldest child, J however reported coming into the room and seeing Baby A lying over LB’s knee and looking pale. LB appeared drowsy. 4.3.225. The decisions made at the meetings were that: • LB and NX could have two hours supervised contact each day at hospital, including weekends • Contact between LB, NX and Child C to be supervised until further work was undertaken with maternal grandparents • Maternal grandparents and J to have open access to Baby A 4.3.226. Baby A died early April 2013 following the withdrawal of life support. 5. Individual Management Reviews (IMRs) 5.1. General Comments 5.1.1. It is crucial that professionals and organisations protecting children reflect on the quality of their services and learn from their own practice and that of others. Working Together to Safeguard Children 2013 states ‘Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children. These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved locally in cases. Everyone across the country has an interest in understanding both what works well and also why things can go wrong’. 5.1.2. The LSCB Business Manager and the SCR Panel offered direction and assistance to the IMR authors, and stressed the importance of reports being quality assured and signed off by senior managers before the final submission. The SCR Panel considered that some reports were below the expected standard and were left to pragmatically accept some of these even after further rewrites and amendments. 5.1.3. Although the quality of the submitted IMR reports varies, they are all largely descriptive documents with very little evidence of critical reflection. It is apparent that the IMR authors were not skilled or well practiced in writing analytical reports and confused presentation of facts and descriptions of practice with analysis and critical reflection. In order to qualify as a ‘critical’ review, authors are required to go beyond simple descriptions of what happened and critically examine practice and procedures, not passively accepting everything that has been read or was said, but questioning, evaluating, making judgements, finding connections and identifying any patterns or themes. In this way the analysis aims to contribute to both organisational learning and the development of professional practice within a single agency. This is an area the LSCB should consider as a matter of some urgency especially given the very poor quality of reports received from key statutory agencies where detailed analysis of data is essential for strong performance and good quality services. 65 5.1.4. There were no outstanding IMRs. Whilst some authors described poor practice and identified various shortcomings and occasionally the steps taken to remedy these, they often failed to explore the possibility of any systemic factors, which may have impacted upon practice, performance or outcomes across other areas in the organisation. Consequently, learning where it occurred remained person centred rather than system centred. This was reflected in the nature and type of the recommendations made which focused largely on the need for better training, improved procedures and further reviews [of services, systems or practice]. 5.1.5. Some of the authors of the IMR reports were not appropriately qualified and/or sufficiently experienced to effectively undertake a management review within their own agency. This posed particular challenges where individuals were placed in the position of having to question the practice of their senior managers. 5.1.6. Given the poor quality of the IMRs it is clear that within Sunderland, there is a worrying lack of understanding on the part of senior managers across all agencies about their responsibility to sign off and quality assure IMR reports. None of the IMRs received by the author had the signatures of senior managers, and this raises questions for the Overview Author and the LSCB as to whether they agree with, and will progress, the recommendations made. Sunderland LSCB procedures makes clear that IMR reports should be signed off by a Senior Manager in the organisation prior to submission to the SCR Panel and in doing so they confirm the report meets required standards and the contents and recommendations are acknowledged and accepted by the organisation. 5.1.7. The process of individual agency quality assurance became an identified concern during this Review as it became apparent that some of those tasked with undertaking the quality assurance of reports may not have had a full understanding of the requirements of that role. In future, it may be of benefit if a briefing session is held with those responsible for quality assuring single agency reports relating to SCRs. Multi-Agency Recommendation 1 5.1.8. Not one of the IMR reports which contributed to this review provided the author with a pen picture of Child C. Whilst there are some descriptions about Child C’s physical development and educational needs, there is very little to help create a picture of what Child C was like; how the child felt about what was happening and what impact the mother’s drug addiction actually had on the child’s attachment and emotional development. It is worth noting Lord Laming’s comments that although made in 2009 are pertinent to this and every other SCR. ‘the failure of all professionals to see the situation from the child’s perspective and experience; to see and speak to the children; to listen to what they said, to observe how they were and to take serious account of their views in supporting their needs is probably the single most consistent failure in safeguarding work with children’ 5.1.9. It is not acceptable to note that Child C ‘was only three or only four’, there are a myriad of different ways professionals can gather information about how a child, 66 even as young as Child C, was feeling about things happening around them. The failure to consider the child’s experience is a significant omission in these IMR reports. Further brief comments on individual IMR reports are made below. 5.2. Children’s Services: Children’s Social Care (CSC) 5.2.1. The copy of this IMR report made available to the Overview Author is unsigned by a senior manager in the organisation. The SCR Panel reservedly and reluctantly accepted this report, given that it had already been submitted late and was re-submitted following substantial amendments. 5.2.2. The IMR was assigned to a principal social worker who also worked as an independent practitioner assessing prospective adopters and foster carers. It is the view of the Overview Author that this practitioner had neither the experience nor the seniority to undertake the IMR on behalf of CSC. It is of concern to note that despite three layers of management above the principal social work post, there was no other individual who could undertake the Review. The delays in this report being submitted and accepted by the SCR Panel and the frequent and many amendments to it, suggest a lack of senior managerial oversight and commitment to the SCR process that is of some concern. It should be noted that amendments to the IMR report were being sent through to the Overview Author as late as two weeks before the Overview Report was due to be submitted. This is an issue that must be addressed between the LSCB Chair, the Director of Children’s Services and the Chief Executive as a matter of some urgency. 5.2.3. As the key statutory agency, it would have been useful if more detail had been provided about concerns identified in 2009 – 2011, even though this was outside the time period of this review. Although there are references to ‘concerns and neglect’ there is very little information provided in the IMR, which helps the reader, understand the evidence which led to these conclusions, other than the fact that LB was a drug user. 5.2.4. The author attempts to review practice across three service areas, CSC, Fostering Service and the work of the Independent Reviewing Officers. Learning would have been enhanced had the reviews of each of these services been undertaken separately or at least presented in three different reports/sections. 5.2.5. Whilst there are references in the CSC IMR report to pressures of work there are few details which relate to any broader contextual issues, which may have impacted upon practice. Issues, for example, such as the need to recruit social workers from overseas, the challenges in retrieving information from the case management system and the high caseloads of Independent Chairperson(s). These are missed opportunities to examine and highlight where organisational factors may have impacted on performance, especially for example in relation to the restructuring of front line services in 2012. 5.2.6. Figures from national research highlight a continuing rise in the number of referrals, Initial Assessments and Core Assessments between 2009 and 2011 across other 67 Local Authorities but these influences, if they impacted on services in Sunderland are not explored. 5.2.7. The recommendations, of which there are 25, focus predominantly on training, amending procedures and reviewing processes. It is concerning to note that some of the recommendations relate to what might be regarded as expected practice such as the need for Operational Managers to discuss vulnerable babies in supervision sessions and workers needing to follow procedures. Without the IMR author exploring why these practices do not happen routinely, the recommendation and others like it, become a tick box exercise in which the lessons, although identified, are not well understood and therefore not embedded into operational practice. This has significant implications for CSC and should also be addressed as a matter of some urgency. 5.2.8. The IMR report is largely descriptive and fails to offer a critical analysis of practice and systems in CSC. Whilst the author does identify some areas where practice falls below expected or required standards, there are few attempts to explore why certain actions or decisions are taken or what systemic factors may have influenced practice. In particular the following questions are not explored in any depth and as such offer opportunities for learning and improving practice are severely curtailed. Further urgent consideration should be given to consider: • Why were managerial oversight and supervision arrangements so inadequate, given the LSCB had undertaken an exercise relating to supervision in the recent past? • Given that effective records contribute to better outcomes for children, why were records, minutes and plans of key meetings not available and why, when some were submitted, were they so poor? • Why are arrangements for chairing and note taking at various meetings so inadequate? • Why are the training opportunities provided to frontline practitioners and the learning from research and reviews not leading to improved practice? • High caseloads are known to be linked with practice that leaves children vulnerable. Are senior managers aware of areas/teams where caseloads are unacceptably high? • What factors mitigated against expected practice in this case? • The inadequacy of Independent Reviewing Officer resources has been raised by the LSCB on a number of occasions, why has there been no effective action to date? 5.2.9. Given, these issues are related to practice and systems with the lead agency and as such should be addressed as a matter of some urgency. Multi-Agency Recommendation 2 5.3. Children’s Services: Primary School and Childcare Centre 5.3.1. The SCR Panel reservedly accepted this report, it having been substantially amended following the first submission. There is no signature on the IMR report to indicate it has been accepted by a senior manager. 68 5.3.2. The SCR Panel had expressed concerns about the selected author of this report given her lack of expertise in Child Protection and the lack of seniority in the organisation. This author required considerable support in writing this report and it is to her credit that she persevered and eventually submitted the report by the extended deadline. However, it is concerning that the [organisation] fails to recognise just how important these reports are in terms of improving practice and achieving better outcomes for children. 5.3.3. It is evident that the author is unfamiliar with the SCR process and with Child Protection and Child in Need procedures in general. The report contains a vast amount of information and the author has clearly been vigilant in following up gaps and areas of uncertainty. It is in this IMR that there are the first, albeit brief references to Child C, whom the child likes and what toys are favourites. The author refers several times, appropriately to the view that within a multi-agency context, it is the mother and not Child C who is the centre of focus. 5.3.4. What is missing in this report is the reflection and critical challenge. On page 23 for example, the Teaching Assistant working with Child C advises the [IMR] author that she is only there to support the child in terms of academic needs. This statement should have been challenged and the individual asked about the extent to which she understood her safeguarding responsibilities. It would then have been useful to explore to what extent, if any, this view of safeguarding [as being someone else’s responsibility] was commonplace across the school and the Authority and the implications of this for children in Sunderland. 5.3.5. Although the author does try to address a number of identified failings, such as the poor recording practices and the failure to ensure appropriate and timely sharing of records when Child C is subject to a Child Protection Plan, the author does not explore what gets in the way of these practices occurring routinely. 5.3.6. There are seven unnumbered recommendations and although these follow the template provided by the LSCB, they do not provide any information about the intended impact of the recommendation. This makes it difficult for action plans to be measured against improved outcomes for children and young people. 5.3.7. The Overview Author would advise strengthening the recommendation, which relates to Child Protection files and records. 5.4. Northumbria Police 5.4.1. The Police IMR was written by the Major Crime Review Advisor, whose role is to conduct Management Reviews within Northumbria Police. The extent of this author’s experience is not recorded but it is fair to assume given her role, that the IMR author is suitably qualified to undertake the independent management review for this agency. There is no signature on the IMR report to indicate it has been accepted by a senior manager. 5.4.2. The IMR report was submitted on time but the SCR Panel were concerned to note there were no lessons to be learnt and questioned the absence of any recommendations. A revised report was submitted which the SCR Panel accepted. 69 5.4.3. The report is brief and addresses the key points. However, further reflection and exploration of the importance of good liaison between statutory agencies where families with children are under surveillance would have been useful. 5.4.4. There is one recommendation that appropriately highlights the importance of Police Officers attending Initial Child Protection Conferences and the IMR confirms that action has already been taken by Northumbria Police to address this issue. 5.5. Northumbria Probation 5.5.1. The author of IMR report is a Reviewing Manager for Northumbria Probation Trust and is suitably qualified and experienced to have undertaken this review. There is no signature on the IMR report to indicate it has been accepted by a senior manager. 5.5.2. The author provides a brief description of the work undertaken by the service clearly highlighting where practice fell below expected standards and the steps that have been taken to remedy this. The author does not explore however, whether the issues of concern, such as recording, risk assessments and lack of home visits might also be happening elsewhere in the Probation Service and this leaves the review lacking in any critical analysis of why the ‘experienced’ Probation Officer failed to undertake, what the author considers to be some basic tasks. 5.5.3. The author explores the difficulties of not having good quality minutes of Core Groups circulated promptly and suggests that a pro-forma to be used for Probation staff. However, the issue of why the concerns about the minutes were not escalated to senior managers is not explored. There is reference to a Child Protection Register and it is not clear to which register this refers, given that this is terminology is no longer used for children requiring protection. 5.5.4. An exploration of the Probation Officer’s role in Core Groups would have been useful in that the knowledge, held by and given to the Probation Officer in this case was of considerable significance in respect of NX’s role within in the family of LB. 5.5.5. There are three recommendations, which are too vague, and although there are references to some changes in future policy these are not described or explained. 5.6. Health Overview Report 5.6.1. This report was written by the Head of Safeguarding for Sunderland NHS CCG who was appropriately experienced and well qualified to undertake the review. The report was submitted on time and accepted by the SCR Panel. 5.6.2. The IMR author highlights that clear lessons are to be learnt from this review and identifies areas where practice needs to develop. The author stresses the importance of good quality supervision in Health Visiting, Midwifery and Drug Treatment Services to minimise the chances of bias and errors in reasoning occurring, but like other authors there is no real explanation as to why this kind of supervision does not happen routinely. The author does however, infer in the 70 concluding section that inappropriate staffing and a lack of resource may impact on health practitioner’s ability to deliver robust and effective services. 5.6.3. The recommendations from the individual health IMR authors are endorsed by the Health Overview Author who makes a further ten appropriate recommendations. 5.6.4. The Overview Author would suggest a recommendation that supervising personnel are reminded about the LSCB’s escalation policy. 5.7. City Hospitals Sunderland NHS Foundation Trust 5.7.1. This IMR report was undertaken by a Senior Midwife who confirmed she had no prior involvement with the family as either a practitioner or a manager and was appropriately experienced to undertake this review. There is no signature on the IMR report to indicate it has been accepted by a senior manager. 5.7.2. The report provides clear information about contact with LB and Baby A and the author offers some thought as to why some practices did or did not happen, for example the problems about where notes about safe sleeping were located on breast feeding records and how short staffed units would make it difficult for LB to be properly monitored whilst in hospital. However, there is no discussion as to whether the midwifery team did enough to ensure that LB and her parents were fully informed about the risks to Baby A. 5.7.3. There are no references made by the author to previous reviews in Sunderland where vulnerable babies have been injured or died. The author does not comment on to what extent, if any, the learning from those reviews impacted on current practice or is linked to the recommendations included in this report. 5.8. South Tyneside NHS Foundation Trust Community Health Services (includes School Nursing and Health Visiting Services) 5.8.1. The IMR author of this IMR report is a Lead Nurse Safeguarding (Named Nurse) and has substantial experience in safeguarding children within health settings and has been involved in other SCRs for another Local Authority. 5.8.2. The report provides detailed information about the involvement of practitioners from the Community Health Services with Child C and Baby A, LB and NX. The author stresses the consistent level of support offered by Health Visiting Services to this family but, for example, fails to explore why concerns were never escalated to a higher level within CSC. There are no references to learning from previous SCRs even though, like this review, they related to the death or neglect of vulnerable babies. 5.8.3. The IMR author does however, highlight that the team in which the Health Visitors were working was under considerable strain due to pressure of work and being short staffed. This, the author reports, was remedied when additional appointments were made to the team. Also, during the period of this review, the author states there was a national drive to improve services within the health sector through the standardisation of activities and processes. The IMR author notes the significance 71 this had for the Health Visitor role, especially the introduction of the Early Warning Assessment Tool and acknowledges the impact this would have had on workloads. 5.8.4. The author makes five recommendations which are too vague and do not state specific outcomes. The Overview Author would advise on a sixth recommendation, which relates to the timely use of the LSCB’s escalation policy. 5.8.5. There is no signature on the IMR report to indicate it has been accepted by a senior manager. 5.9. General Practitioner 5.9.1. This IMR was undertaken jointly by the Named GP Safeguarding Children and a Designated Doctor for Child Protection, neither of whom had any clinical involvement with Child C or Baby A, prior to Baby’s admission to Paediatric Intensive Care Unit in April 2013. 5.9.2. The report confirms that the GP had limited involvement with any safeguarding processes for Child C or Baby A. LB was however noted on their records as being a vulnerable woman with a history of domestic abuse and substance abuse. However, this information clearly ‘flagged’ on records did not prompt a referral to CSC when she became pregnant or when she sought support for insomnia. The authors appropriately comment that ‘there was distinct lack of social enquiry for the family’ but there is no discussion around this issue and whether it is a regular feature of this Practice or others in the area. The authors do not explore the relationship between Midwives and GP although they do point out that the GP appeared to see the child processes as being the responsibility of other members of the Primary Health Care Team. The issue of the GP failing to submit a report to the Child Protection Conference in March 2013 is noted. 5.9.3. The authors propose eight recommendations all of which are endorsed by the Health Overview Author. 5.10. Place 1 – Substance Misuse Treatment Provider 5.10.1. An independent consultant undertook the IMR for P1-SMTP with experience in Chairing and writing SCRs. There is no signature on the IMR report to indicate it has been accepted by a senior manager. 5.10.2. The report is largely descriptive and whilst this provides some useful information, there is an absence of any critical analysis. It would have been helpful to explore some of the challenges faced by P1-SMTP in offering a service to LB and yet also being expected to be aware of the needs of Child C. There is at times, a stark difference amongst the practitioners in terms of how they work and this issue is not explored. 5.10.3. There is little critical reflection on there being so many different practitioners working with LB and the fact that this seemed to allow her to dictate her treatment and the times she would come in for testing. 72 5.10.4. An exploration of the value of drug testing would have been helpful and brought much to the debate about the validity of this approach when working with parents who misuse substances and where there are children involved. 5.10.5. The safeguarding supervision appears to be of a good standard and this is to be commended, although comments by the author as to why the practice of some practitioners failed to meet the required standards would have been helpful. 5.10.6. The author makes four recommendations. A fifth recommendation should include the need for P1-SMTP to examine how it ensures that staff remain child focussed in their work with substance users who are parents. 5.11. Place 2 Children’s Services 5.11.1. This report was written by the Strategic Manager Safeguarding Children in [Place 2] Children’s Services. There was limited involvement for this Authority with either Child C or Baby A. Nevertheless, the IMR author identifies, two key lessons in relation to this SCR; the need for liaison and good communication sharing between professionals when children are moved across Local Authority boundaries and secondly when a child is moved into an area under a Child Protection Plan, the host Authority should be notified of any Strategy Meetings and take action if such notifications do not occur. 5.11.2. The IMR author makes three recommendations related to the involvement of [Place 2] Local Authority with this family, which are relevant. 6. Further information provided to the Overview Author 6.1. The LSCB provided details of three previous reviews to the Overview Author. These had been undertaken between 2011 and 2013 and were held in relation to the death, injury or neglect of three babies under the age of one. The LSCB had, in response to the findings from these reviews, delivered a series of workshops to frontline practitioners to disseminate the lessons learnt and to highlight practice issues in relation to working with families with vulnerable babies and where domestic violence and substance misuse were evident. 6.2. Following the death of Baby A, the LSCB were concerned to note that there were many similarities with previous reviews and were anxious to examine why changes in practice did not appear to have taken place or had not been sustained. The Overview Author was asked to consider this issue as part of the Overview Report. 7. Critical Analysis 7.1. This analysis is based on discussions in the SCR Panel, the individual agency contributions to the Review and the author’s own contributions and research. The analysis also takes into account significant information provided by the LSCB 73 relating to previous reviews with similar circumstances to those relating to the death of Baby A. 7.2. The SCR Panel and the LSCB Chair decided to undertake this SCR in line with previous guidance published in 2010. This process required each agency to undertake a management review of their involvement with the family and produce an individual agency report to contribute to the Review process. There are however shortcomings in this process which have been acknowledged by the LSCB and the Department for Education. The revised 2013 statutory guidance encourages a more systemic way of undertaking Reviews and allows scope for LSCBs to consider other more effective ways of learning. 7.3. The aim of a systems approach to Case and Serious Case reviews is not limited to understanding and describing what happened but is also about asking why particular actions or decisions made sense at the time and what factors influenced those actions. The IMR authors for this review were asked to consider these factors in their reports but in general, the reports fail to address these issues from a systemic perspective. 7.4. The Overview Author has considered all of the Terms of Reference, and with agreement of the SCR Panel, offer comments in this section under five specific headings: • Assessments and Planning • Multi-Agency Collaboration • Practice and Patterns in Professional Judgement • Management and Supervision • Contextual Issues 7.5. Where specific issues of failings have been identified, these are recorded as Findings and underpin the recommendations made later in this report. 7.6. Assessments and Planning Finding 1 The absence of any robust multi-agency assessments to inform the development of good quality plans and decision-making left Child C and subsequently Baby A vulnerable. Finding 2 Without skilled and experienced chairs, the multi-agency meetings lacked focus and direction leading to unspecified outcomes and poor reviews of progress. Assessments 7.6.1. There is increasing concern about the negative effects on children when parents or other members of their households abuse alcohol or drugs or engage in other illegal drug-related activity. 24 A consistent finding across all biennial reviews of 24 Hidden Harm: Responding to the Needs of Children of Problem Drug Users (2003) – a report of an inquiry by the Advisory Council on the Misuse of Drugs London: Home Office. 74 completed SCRs is of a significant proportion of children in households where one or both parents misuse illicit drugs and/or alcohol. 25 The original analysis conducted for the NSPCC in 2011 estimates that 19,500 babies less than one year old were living with a parent who has used Class A drugs in the last year. 26 7.6.2. It is acknowledged that not all substance users have problems with parenting. However in many cases, it is necessary to make an assessment which includes the substance use and behaviour of the parents, and any impact from this upon their parenting capacity, before deciding what help, if any is required, and whether Child Protection Procedures should be initiated. The purpose of any assessment is to assess the effects of substance misuse upon a parent’s ability to maintain consistent and adequate care for their child. ‘There is a reasonable basis in research to suggest that a child whose parent is misusing substances is at increased risk. Substance misuse can demand a significant proportion of a parent’s time, money and energy, which will unavoidably reduce resources available to the child. Substance misuse may also put the child at an increased risk of neglect and emotional, physical or sexual abuse, either by the parent or because the child becomes more vulnerable to abuse by others.’ (V Lewis 1997) 7.6.3. The idea of professional or organisational assessment is an inherent feature of social work practice. Indeed it is considered ‘a core social work skill’ (Crisp et al, 2003, p iv) and as identified in the above text is fundamental to safeguarding children whose parents misuse illegal substances. A key feature of this review is the number of assessments, which were lost, mislaid or simply never completed by CSC. Yet, it is these assessments, which were essential for the development of robust plans and quality decision making in relation to Child C and Baby A. 7.6.4. It should be noted at this point that, with the exception of a Parenting Assessment dated 26th March 2013, neither the author nor the SCR Panel have seen any of the Assessments undertaken by CSC and which are referred to in some reports. Neither, it would seem have the IMR authors had sight of these or if they have, they failed to comment on either the quality or the content of the assessments. 7.6.5. At the outset of the time period under review, Child C was subject to a Child in Need Plan. 7.6.6. Child C has been the subject of various assessments since birth and it is of concern that the detail of these is not referred to in the CSC IMR report. There is evidence to suggest that a negative view was established about LB’s parenting capacity and her drug use as early as 2008 and that view does not appear to have changed. Research27 into human reasoning tells us that once a judgement has been formed it becomes very difficult for people to re-evaluate it or accept any evidence that challenges it. The pattern of responding to LB would also support this thinking as all of the interventions, repeated time and time again, focused on one aspect of her 25Neglect and Serious Case Reviews University of East Anglia, (2012). 26 All Babies Count NSPCC Publication. 27 Human Reasoning and Cognitive Science Bradford Books Keith Stenning (2012). 75 behaviour - substance misuse and the need for regular testing, so it could be seen that she was not using illicit drugs. The assumption, without any clear assessment, was that if LB could ‘prove’ she was not using drugs, her child could be safely returned to her care. 7.6.7. In the IMR reports, frequent references are made to this child, which imply that when living with LB, the child’s needs were neglected, yet what this means is unclear. Other records point to the fact that the child’s developmental milestones were generally met, the child was lively and active and had a strong attachment to LB and home conditions were adequate. 7.6.8. The decision to make Child C subject to a Child Protection Plan in February 2011 under the category of Neglect, was made on the basis of LB’s ‘lifestyle and her failing to engage with services.’ It was decided, appropriately, that a Core Assessment28 should be undertaken by the social worker and LB agreed that Child C would remain at the home of the maternal grandparents until this assessment was completed. The Conference also requested that a risk assessment (in relation to adults in contact with LB) was also completed. 7.6.9. At the Child Protection Review meeting in April 2011 however, neither assessment materialised and no challenges were made or questions asked by the Independent Chairperson about their absence or progress. However, notes of that review meeting state ‘Core assessment to be undertaken… and completed by April 2011’, suggesting that elements of these minutes were cut and pasted from the February document and/or that a discussions about the assessments had taken place but were not recorded. Both options are poor practice and the IMR author for CSC does not comment on this practice or offer any explanation for it. It is simply noted in the IMR report that in terms of the risk assessment the Team Manager could ‘not recollect why it did not take place’. The Core Group was eventually advised in July 2011, that the risk assessment agreed in February, had been forwarded to a senior manager who was on sick leave and the document could not be located. Several weeks later the group was informed that the assessment was ‘lost’. 7.6.10. There are several more references to the need for assessments throughout this time period which then never materialise or were not progressed: when LB first began her relationship with NX; when they married; when NX asked to be a carer for Child C and when he asked to be a carer for Baby A. At various times Health Visitor 1 tenaciously questioned progress about the agreed assessments but this did not have any impact. At this point concerns should have been escalated to a more senior level using the LSCB’s escalation policy. 7.6.11. Both LB and NX agreed to undergo a Parenting Assessment in December 2011 and this was completed in March 2012 by social worker 3. Having initially reported to the Core Group with LB in attendance, that the Assessment was ‘positive’, the final recommendation in the report concluded that Child C should continue to stay 28 The Core Assessment, was used until April 2013, and was a more in-depth assessment than the Initial Assessment. The purpose of a Core Assessment was to gather detailed information about a child's developmental or welfare needs and circumstances and the parents' capacity to respond to those needs, including the parents' capacity to ensure that the child is safe from harm now and in the future. 76 with maternal grandparents and Care Proceedings were to be progressed. This assessment is of extremely poor quality and offers little analysis or reflection on the parenting capacity of either adult. It simply reiterates much of the information contained in other files and offers no insights or comments for example, about NX not having any contact with five of his children. Given that Child C was having regular contact with mother, this could have provided a rich stream of information about: the parents’ attachment to the child; the quality of LB’s parenting skills or her ability to develop these skills and the quality of her interactions with her own mother and children. If any of these issues were taken into account, it is not evident from the available information. 7.6.12. The IMR author for STNHSFT comments that in her opinion, the multi-agency assessment of risk for Baby A was clearly evident and was identified at ‘key’ multi-agency meetings. It is unclear whether this comment refers to an actual document not seen by this author or to an ‘understanding’ of risk by those present at multi-agency meetings. The view is expressed by the IMR author that the analysis of risk did not always reflect the level of risk and she relates this particularly to the health risks posed to Baby A, given LB’s addictive behaviours. 7.6.13. The Overview Author has had sight of minutes from the Core Group meeting on 5th December 2012, the ‘Care Team’ meeting on 5th February 2013 and the ‘Care Planning’ meeting on 6th March 2013, all of which are headed ‘Child C and Unborn Baby A’. There is no reference in any of these minutes to the risks posed to unborn Baby A, despite the known risk indicators related to substance misuse and the impairment on parental capacity and consequently the dangers of co-sleeping, all of which increase the risk of Sudden Infant Death Syndrome. Professionals should have been alert to these risks and those in relation to LB’s contact with Baby A if she was still using opiates. These should have formed the basis of the Child Protection Plan. There is no exploration in any of the IMR reports as to why these risks were not explicitly discussed but it seems possible that as Baby A was being discharged into the care of the maternal grandparents and not to LB and NX, the level of risk was minimised. It may also have been assumed that as LB had given birth without mishap to three children previously, the risks to LB having contact with Baby A were small. 7.6.14. What is clearly apparent however, is that there was no multi-agency discussion as to whether Baby A being placed with maternal grandparents was the right decision, there appears to be an almost palpable sense of relief which ignored the fact that until the day of the Child Protection Conference in March 2013 the maternal grandparents had not clearly indicated they would care for Baby A on a long-term basis. 7.6.15. The failure to undertake a Pre-Birth Assessment was a serious omission and one, which the Midwives and Health Visitor brought to the attention of the social worker on more than one occasion. These concerns should have been escalated at an earlier stage to a more senior manager within CSC. The failure to undertake this assessment impacted on the plans made for Baby A and consequently areas of high risk were left unexplored. 77 7.6.16. The IMR author for CSC notes that the Initial Assessment for Baby A was started on 26th September 2012 and ended on 4th February 2013. Although well outside of the seven-day timescale, this assessment is described as having a ‘significant amount of information’ within it, most of which was used for the Child Protection Conference held in early March. There were also two Pre-Birth Assessments entered onto the Children’s Case Management system but neither had any information and both were ‘ended’ on the system. The author does not explore this further to consider whether this relates to a systems failing and/or human error. These Assessments were not signed off by a manager. 7.6.17. It is difficult to understand why these assessments were never undertaken and how professionals were able to make plans and decisions without any assessment information to aid their thinking. These questions do not appear to have been considered by the IMR authors in any depth and are missed opportunities for the SCR Panel to gain any insight about how professionals viewed the case as it was unfolding. 7.6.18. The absence of/or poor quality assessments is also a significant issue in relation to the work of the Fostering Team. The Regulation 24 Connected Person Assessment should have started when Child C was placed with the maternal grandparents in March 2012 and been completed within 16 weeks. This Assessment however was not concluded for 30 weeks. Although the required Police and CRB checks were undertaken, the Local Authority in [Place 2] were not contacted and some important information which related to this placement was not identified. The Fostering Officer did not read the Parenting Assessment report in respect of LB and NX and eventually submitted a weak and incomplete report, without a detailed risk assessment, to the Fostering Panel. Although the IMR author identifies this as poor practice, there is no exploration as to why this officer did not follow procedures or complete the necessary paperwork. The Fostering Panel should also have challenged the parts of the report that were not completed but this did not happen and again the IMR author does not seek to understand or explain this practice. 7.6.19. Once it became apparent at the Initial Child Protection Case Conference on the 15th March 2013 that the maternal grandparents were willing to care for Baby A in addition to Child C, a Viability Assessment should have been undertaken by the social worker and a Regulation 24 Assessment undertaken by the Fostering Team. The failure to embark on either course of action has been attributed by the IMR author (CSC) to the fact that a Regulation 24 Assessment had already been undertaken for Child C and had been presented to the Fostering Panel in November, only four months previously. This is an error of judgement given that the Regulation 24 Assessment had been undertaken in relation to Child C’s placement and would not have taken into account the pressures on the grandparents caring for or supervising the care of a vulnerable baby. Neither could it have considered the impact on Child C and Child J. A more up-to-date assessment would also have highlighted the emerging problems related to Child J and substance misuse, a factor which may well have influenced the decision to place Baby A with the maternal grandparents. 7.6.20. Even without these assessments however there were already known interacting risk factors in relation to Baby A which increased the risks of Sudden Infant Death 78 Syndrome and practitioners especially from health and social care would have been aware of these. There is no evidence in either Midwifery or Health Visiting records to suggest that parents and grandparents were told of these risk factors or that any discussions were held or observations made, about where Baby A would sleep. 7.6.21. It is clear that in this case there were significant issues in relation to assessments within CSC, but given that it is a requirement that all Core Assessments, Risk Assessment and Pre-Birth Assessments are authorised by a manager, it must be questioned why the poor quality and incomplete assessments were not picked up through managerial oversight. There is an inference that pressure of work impacted upon the performance of the Team Manager, but the poor quality of the IMR report for CSC leaves this as an open question to be addressed at later stage by senior managers within CSC. 7.6.22. Ofsted in their Inspection Report for Sunderland in 2012 concluded that in Sunderland ‘all assessments clearly identify risk and protective factors and include contributions from partner agencies who are involved with the family… [but] the overall quality requires improvements‘. These reflect some but not all of the findings in this Review so other explanations need to be sought which helps those involved with the family understand more clearly what happened and why. Multi-Agency Recommendation 3 Planning 7.6.23. The approach to assessment inevitably has a consequent impact on all subsequent planning and interventions with a family. Child in Need and Child Protection Plans represent the framework in which improved outcomes for children can be secured. Plans are developed and implemented through the functioning of the Core Groups and Child in Need meetings. In the case of Child C and Baby A, however, there was no evidence of a purposeful framework underpinning the interventions that were put in place. Plans were not amended in the light of new information and they were largely ineffective. 7.6.24. Much of the planning in relation to Child C was of a short-term nature and reflected the immediate position rather than planning for the child’s safety in the long-term. The IMR author for CSC refers to both Child Protection and Child in Need Plans but states that these were not outcome-focused. The reason for this is not explored. 7.6.25. As has already been commented upon elsewhere in this report, plans were too general in content and not specific enough to know when tasks had been achieved and when progress was satisfactory. For example, some ‘tasks’ were written as follows: • LB and NX to fully engage with Children’s Services (CSC) (14th November 2011) • LB to commit to working and submitting tests with P1-SMTP on a weekly basis and to participate in random drug testing (4th February 2011) • Social worker will type something up for Conference re: past risk assessments • LB asked about detox. Social worker will follow up (7th November 2012) 7.6.26. A particular disadvantage was the lack of a full diagnostic assessment of the level and significance of LB’s drug taking and the impact this had on Child C. This 79 prevented any clear planning taking place as to what interventions would be necessary to support LB and what opportunities would allow LB to demonstrate how she could care for Child C and Baby A and contribute to their well-being and healthy development. What these plans did not address or make clear to LB and NX was what ‘safety and healthy development’ would look like and how ‘success’ could be measured in terms of building and sustaining future safety for the children. 7.6.27. The absence of robust plans or agreed birth arrangements for Baby A left health professionals having to chase up information and challenge decisions which they felt were inappropriate. Birth arrangements were discussed at the Core Group meeting on 18th March 2013 attended by the social worker, LB and the SSMM but clearly these arrangements were not discussed in detail. This left the SSMM having to later raise concerns about supervision of LB after delivery and try to ensure toxicology testing before LB’s admission and on discharge. This was particularly important as LB had been informed that if she tested positive for opiate use, all contact with Baby A would be supervised by CSC. 7.6.28. The lack of attention to these details left Baby A vulnerable. Whilst the baby was kept in hospital for five days to monitor the impact of neonatal abstinence withdrawal, there is little to evidence that the time was used to discuss with LB, the impact on her baby if she continued to use opiates on top of her prescribed medication. Neither does it appear that any information was given to her about safe sleeping arrangements and the high risks for Baby A of SIDS. These factors should not have been left to chance but should have been addressed in a carefully considered Child Protection Plan. The reasons why this did not happen is not explored by the IMR author despite the brief reference to staffing issues on the ward at the time. 7.6.29. The risk of neonatal abstinence withdrawal was clearly recognised. Risk indicators can present until day 10 and include difficulty in feeding and weight loss. Although the IMR author clearly highlights that procedures were not followed, Baby A should have been visited every day for 10 days, there is no information for the Overview Author and the SCR Panel to understand why the Community Midwife did not follow procedures and it is the ‘why’ of this practice that should have been explored by the author. 7.6.30. There was clearly a lack of planning and little foresight in terms of LB’s own health needs and these issues led to confusion for professionals about LB’s treatment plan and her need for prescriptions before leaving hospital. There are no records, which evidence that any thought was given to discharge arrangements. Baby A was subject to a Child Protection Plan and it was not known at the time how the baby was transferred to the maternal grandparents. It is a matter of some concern that the social worker was not there on discharge and failed to visit the home of the maternal grandparents within 24 hours. 7.6.31. The specific interventions – Child in Need and Child Protection Plans - did not involve maternal grandparents or the aunt, or consider how these adults as a naturally occurring network around Child C, could commit to ensuring the child’s future safety. It is unclear why these important family members were not involved in exploring what safe care would look like for both Child C and Baby A and how it 80 could be achieved. There is no exploration about why they were not invited or whether they chose not to attend the many meetings concerning the care of Child C and later Baby A. These issues are not examined in the CSC IMR or explored in any depth in the IMR reports despite these family members being identified as key protective factors in the lives of Child C and Baby A. 7.6.32. There are inferences in the CSC IMR that there were tensions between LB and her mother but these are not explored in any detail in the IMR nor in any multi-agency meetings. There are no references to LB’s relationship with her sister and it is unclear whether there is any contact at all between the siblings. Despite the apparent tensions the grandparents and the aunt are clearly committed to Child C and Baby A whatever difficulties they have with LB and her drug taking. This in itself presents a significant picture of the dynamics of the extended family, which merited further reflection and should have been a key feature of both Child in Need and Child Protection Planning. 7.6.33. Despite the lack of meaningful outcomes from the interventions agreed in multi-agency meetings in 2011, the same interventions and plans continued throughout 2012, indicating a lack of a review about the plans and how or if these were effecting change. This is a serious omission, which led to Baby A being placed with the maternal grandparents, albeit on a Child Protection Plan but without any robust assessment being undertaken. 7.6.34. The author has not had sight of any actual plans but has seen minutes from Child in Need and Child Protection meetings where the ‘plans’ appear to be a list of actions, tasks and broad goals. Clearly specified outcomes were not recorded making it almost impossible to measure progress and review the effectiveness of interventions. What is striking in this review is that what was known about LB’s parenting capacities and lifestyle in February 2013 is not significantly different to what was known in April 2008. This suggests that planning was not effective and assessments not robust enough to inform good quality decision–making throughout the period under review. Had longer-term planning been considered, for example in February 2011, alongside a robust assessment of risk, the need for Child C to be placed for the second time on a Child Protection Plan in December 2011, may have been avoided. 7.6.35. When Child C was made subject to Child Protection Plan in February 2011, LB agreed to the child being placed with her parents but the status of this placement is not explored and there is no reference to a s20 agreement, a viability assessment or a Regulation 24 Assessment. It would seem that because LB had given her consent for Child C to live with close family, the risks were thought to have been removed and the need for the Local Authority to consciously consider whether Child C’s case would meet the threshold for Care Proceedings was negated. The subsequent discussion with the Legal Department should have triggered a greater degree of reflection and encouraged a more robust long-term planning process, with clearly defined and measurable outcomes, but this does not appear to have happened. 7.6.36. The decision to instigate PLO procedures was made following a legal briefing on 14th December 2011 just prior to the Initial Child Protection Case Conference for 81 Child C. By March 2012, the Local Authority had decided to instigate Care Proceedings, but these were not progressed until May 2012. The Team Manager attributed the delay to capacity issues in the Legal Team but the IMR author (CSC) appropriately notes that having the consent of the parent for a s20 meant there was less urgency, as the child was ‘probably considered effectively safeguarded’. The author would question the validity of this assumption, as the risks related to where Child C was placed and with whom had not been properly assessed. 7.6.37. Child C was made subject to an Interim Supervision Order on 29th May 2012 and a decision taken the following day at the Looked after Child (LAC) Review meeting to end the Child Protection Plan. There is no clear rationale offered for this decision but there is a question as to whether Child C’s status as a child needing protection became more obscure as a result of this decision. The fact that they were a Looked After Child seems to have contributed to the view that the child was safe and would continue to be so. However, the risks related to the regular contact with LB were minimised and not adequately assessed, factors which are also apparent when Baby A was placed with grandparents after the discharge from hospital. 7.6.38. Despite professional views to the contrary, some records suggest that LB and NX were co-operating with services. LB believed that providing she could demonstrate she was ‘clean’ for a period of time, her child would be returned to her care and there was a rationale for this view given her past history with professionals. For Baby A, it is fair to assume both parents also thought their baby would be returned to their care once they were able to ‘prove’ they could be responsible parents. However, given the lack of clearly defined plans and specified outcomes, it is easy to see how these parents might have understood that they were working towards shared and agreed goals, whilst the professionals thought differently. Good quality plans can minimise confusion and mistrust. 7.6.39. LB agreed to voluntary care for both Child C and Baby A but there do not appear to have been any contingency plans in place in case consent was at any time withdrawn. This was short sighted and could have led to a crisis situation if the maternal grandparents had at any time said they were unable or unwilling to look after either child or if LB or NX had decide to remove either child from the care of the maternal grandparents. 7.6.40. The action plans seen by the Overview Author for this and other reviews are extremely poor. They tend to be formulated from more of a strategic perspective rather than from an operational one and this left the detail of what had to be done, and the measurement and evaluation of progress vague and unfocussed. There was also a widely-held assumption, clearly evident throughout the IMR reports, that the responsibility for the production and management of these plans lay with CSC, rather than with Core Groups or care teams. This view should be challenged as for Child in Need and Child Protection Plans to be effective, they need to be of good quality and ‘owned’ by all the parties involved, including the parents. This is a vitally important issue and one which should be carefully considered by LSCB and its partners. Multi-Agency Recommendation 4 82 Assessment of Parenting Capacity 7.6.41. Key research findings relating to assessments of parental capacity include the importance of understanding the basic requirements of parenting and of considering the parent’s ability to change (Jones, 2009) 29. In relation to LB, professionals did not do enough to ensure that LB and NX fully understood their concerns and what was expected of them in terms of their parenting. Both LB and NX were subject to a psychological assessment during Care Proceedings in October 2012. This report suggested that further psychological testing would be of benefit to determine the likelihood of LB being able to address her addiction in a reasonable timescale for Child C and Baby A. A three month timescale was proposed but there is little to evidence this information was acted upon. 7.6.42. Despite the views of professionals to the contrary, neither LB nor NX were given what might be called 'managed opportunities' to change. ‘Support’ was offered on the basis of drug testing and ‘Child Protection monitoring visits’ only. What both adults needed was to be informed and helped to understand what needed to change, how change would be assessed or measured and over what time scale. Equally important, was a need to understand what support they could expect and the consequences if no or insufficient changes were made. There are various models which can be used to assess motivation and readiness for change and to help individuals engage with professionals but these were never discussed or explored. 7.6.43. Research suggests that an outcomes-focussed approach may be particularly appropriate when working with families for whom parental substance misuse is an issue. One of the key challenges in thinking about outcomes in the context of parental substance misuse is the existence of many competing needs, including those of the parent, the child and the family/extended family as a whole. Meeting these needs is a challenge. While acknowledging this tension, evidence suggests that working in an appropriate way with the parent can lead to improvements in the outcomes for the child. However, research suggests that while remaining child-centred, work with families affected by substance misuse inevitably requires a large amount of direct work with parents and this was not evidenced in this SCR, despite a considerable amount of commitment from Health professionals and P1-SMTP. 7.6.44. It seems possible, that without clear and focussed plans, professionals made assumptions about what work was being undertaken and with whom, calling into question issues about multi-agency collaboration. 7.7. Multi-Agency Collaboration Finding 3 A lack of robust multi-agency challenge and collaboration across agencies regarding decisions, plans and thresholds resulted in ineffective interventions. (Also identified in Learning Lesson Review 2013) 29 Jones, D. (2010) Assessment of parenting. In: Horwath, J. (ed.) The child's world: the comprehensive guide to assessing children in need. London: 83 Finding 4 A lack of clarity about roles and responsibilities inhibited good communication information sharing and progress. Partnership working 7.7.1. Research 30 suggests it is important that professionals from all agencies work collaboratively, sharing knowledge and expertise if children are be supported and protected. Agencies have a collective responsibility to protect children and this demands effective communication and co-ordination of services at both strategic and operational levels. Professionals also have a shared responsibility to arrange appropriate packages of support for vulnerable families. 7.7.2. As a consequence of Child C being subject to Child in Need and Child Protection Plans, formal partnership working between agencies was in place throughout the entire period covered by this review. Initially, four key agencies formed the basis of the multi-agency partnership, Children’s Social Care (CSC), Health Visiting Services (HV), the Children’s Centre (CC) and P1-SMTP (a substance misuse treatment provider). 7.7.3. As Child C grew older, a key worker from the Primary School replaced the Children’s Centre involvement and a School Nurse became involved. Once LB’s pregnancy was confirmed in September 2012, Midwifery Services were active in working with LB. The Probation Officer became involved only in the latter stages of the review. 7.7.4. The GP did not attend any meetings in relation to either Child C or Baby A but was kept informed by the Health Visitor 2. The Practice also received regular updates from P1-SMTP so they were aware of LB’s substance misuse. However, this knowledge did not trigger a referral to CSC when it became known that LB was pregnant in 2012. The IMR author (GP) also notes the absence of any communication between the Midwives and the GP and points out that good practice would suggest that regular multi–disciplinary meetings in the Practice should take place so that information could be shared about vulnerable children. The IMR author identifies a number of weaknesses in systems and practice, which limited their contribution to this review but suggest a numbers of ways these could be addressed and these if implemented, would enhance communication and information sharing for the benefit of vulnerable children and their families in future. 7.7.5. Northumbria Police did not attend any of the three Initial Child Protection Conferences but gave apologies and explained their informed decision not to attend was based on an examination of what, if anything, they could contribute. In response to more general concerns about the absence of Police attending Child Protection meetings, Northumbria Police reviewed their organisational structures to align the teams with a geographical area and attendance at these Conferences have now increased. 30 Safeguarding in the 21st Century – Where to now Research in Practice 2010. 84 7.7.6. The Core Group comprising of social worker(s), Health Visitor(s) and P1-SMTP representatives remained relatively stable until the end period of this Review. 7.7.7. Despite significant efforts from some individual practitioners, a lack of multi-agency collaboration was clearly evident. Over 35 multi-agency meetings took place between January 2011 and April 2013, yet it would be difficult to describe the work undertaken as being collaborative. Multi-agency working is about different services joining forces in order to work effectively with children and families. Upon reading the various IMR reports however, there is little evidence of joined-up working, or indeed joined-up thinking. That is not to say there was no collaboration between agencies at times, the communication between P1-SMTP and the Midwifery practitioners in the period leading up to Baby A’s birth was an example of good information sharing and the liaison between Health Visitor 1 and the Children’s Centre helped to keep Child C in focus, but these examples are more about shared communication between individual practitioners rather than an outcome of effective multi-agency working. 7.7.8. From a procedural perspective, the actions undertaken by professional workers when concerns about Child C and unborn Baby A were raised were timely and responsive. The appropriate multi-agency meetings were established and initial meetings took place regularly within agreed timescales. What is more important however, is the quality of partnership working and the extent to which partners were or were not involved in the subsequent planning and how this impacted on decision making. 7.7.9. Reading the IMR reports, there is a sense that a mechanistic approach predominated and it could be argued somewhat provocatively that professionals seemed to have attended the same meeting almost 30 times over. Whilst there was a clear commitment from practitioners to, in the main, attend these meetings and contribute to them, there were few imperatives to challenge or question their continued focus. A degree of ‘group think’ appears to have emerged in which members of the group failed to question whether planned interventions were working or if the group’s accepted wisdom about the best course of action should be reconsidered. The ‘accepted wisdom’ in this case was that LB had to continue taking drug tests until she had stopped her substance misuse for an unspecified period of time. However, the lack of challenge in this respect may also have centred around the professionals not reflecting for themselves about their own role and widely held assumptions, an issue further explored below. 7.7.10. There were some challenges made, across agencies and within individual supervision sessions but these related broadly to procedural and administrative issues and on the whole emanated from health colleagues. Roles and responsibilities 7.7.11. The value and purpose of multi-agency meetings lies not simply in their taking place, but in the opportunities afforded to having active, reflective and robust discussions about how to best safeguard a child’s interests. What was missing in work with this family was any sense of cohesion between practitioners; there was no sense of team working and little evidence that practitioners were working together towards the same goal. Roles and responsibilities were never clarified 85 and a lack of role demarcation led to fragmented and piecemeal interventions. Health Visitor 1, for example, appeared to be doing many of the tasks more commonly undertaken by the social worker, that of co-ordination and liaison and yet this does not appear to have been challenged or raised as an issue. In contrast it is difficult to be specific about the social work input as there are few details about how the social workers were actually working with LB, what they were doing and what this achieved. 7.7.12. The involvement of Children’s Centre and nursery staff at the Primary School from both agencies appears peripheral and passive. Despite their skills and knowledge about Child C – they knew Child C better than any other professional – they do not appear to have been instrumental in helping other practitioners learn more about what life was like for this child or asked to undertake specific work which would keep the child in focus. There is little evidence of their active involvement in multi-agency meetings but this is not explored in the Children’s Services Education IMR. Both the Children’s Centre and the Primary School were key agencies yet the minutes of Core Groups and Child in Need meetings do not reflect this, further highlighting that LB was the focus of interventions and not Child C. There is little in the IMR report for Education to suggest any specific concerns in relation to Child C, although the likelihood of significant harm is inferred through the many references to LB‘s drug taking and life-style. References to LB from these professionals are broadly positive indicating she did engage with both the Children’s Centre and the Primary School. 7.7.13. Northumbria Police also remained on the periphery in this case despite the concerns around drug dealing and criminal activity. There is no sense that as an agency the Police were working in partnership with others despite the reports provided and their involvement in strategy discussions. 7.7.14. Communication is identified within literature as the most common facilitator of multi-agency work and good communication is considered key to its success. Coupled with this, is the need for clarity of purpose through the establishment of clear and shared aims and objectives. These aspects were all missing in this case and continued to be so throughout the entire period under review. Practitioners did not always have the right information about what was expected of them or what their colleagues had been told by LB and this led to professionals working in ‘silos’ as sole practitioners. 7.7.15. It is clear from reading reports from various agencies that interventions with this family could have been more effective if the professionals had been supported to actually work as a team and shared knowledge and understanding of some of the issues. A key area of learning emerging from other SCRs, known to the Overview Author, is that professionals very often do not know or understand how other agencies work and very rarely do they ask. For this case, individual practitioners were in the main, very knowledgeable about their specialist area and yet this valuable expertise was not shared for the benefit of joint working. The knowledge held by P1-SMTP practitioners about substance misuse should have had more of an impact on decision-making reminding others about addictive behaviours and how this could impact on compliance and timescales. Similarly, the Health Visitor and social worker might have shared more about neglect and its impact on the 86 developing child and the importance of P1-SMTP practitioners having the child’s needs at the forefront of any work they undertook with LB. Significantly, what emerges throughout this Review is that the social workers were perhaps not as clear as they should have been about their role in co-ordinating work and keeping the child in focus. There is much to learn about multi-agency working from this Review. 7.7.16. For partnership to work, and this includes parents, there must be clear communication channels and agreements of who does what and by when and most importantly, agreement about what ‘success’ will look like. All this needs to be co-ordinated and as the key partner agency, this was the role of CSC. Given however, that Child Protection and Child in Need processes are not solely the responsibility of CSC and the importance of ensuring there is a genuine sense of joint responsibility, the Overview Report includes a supporting recommendation for multi-agency practice. Multi-Agency Recommendation 5 Reflection and Building Hypotheses 7.7.17. It is apparent from the IMR reports that there has been limited reflection from practitioners about their role in multi-agency decision-making and why they did not recognise or challenge the lack of leadership in meetings or the lack of progress. These are issues, which should have been explored in more detail by the IMR authors, as they are fundamental to learning about whether things need to be done differently in future. 7.7.18. The multi-agency meetings focused on describing events or behaviour most often related to LB but there is no evidence to suggest these opportunities were used for reflection and analysis or to develop hypotheses. The evidence from this Review suggests that the information recorded at meetings or the assessments, to which they referred, were largely variations of the same information recycled and reiterated. There was certainly no sense that within single or multi-agency settings, narratives were emerging in which new insights were encouraged or developed. 7.7.19. In these conditions, it is perhaps less surprising that much of the practice reflected in this case was one dimensional and static and led to a preoccupation with LB and her substance misuse. As a direct result, other ways of working with family members including NX and extended family members, were never explored and significantly the notion of exploring what ‘safety’ would look like for Child C was never given prominence. The view that ‘safety’ meant being removed from mother’s care was sadly found to be flawed given that Baby A died whilst with LB in the maternal grandparents home. 7.7.20. Munro (1999) highlighted that failing to revise risk assessments and judgement, is a common error amongst professionals in child protection work and one, which was not always recognised. The value of using hypotheses in work with families is widely reported but in the author’s experience is rarely used to its best advantage in multi-agency work and this approach would have been helpful in work with this family. Multi-Agency Recommendation 6 87 Chairing of meetings 7.7.21. Chairs of meetings and especially those chairing Child Protection Conferences must push themselves to encourage dissent and be open to challenge, sometimes even adopting a ‘devil’s advocate’ position to facilitate this process. There is not enough evidence of such practice in this review, although there are examples of the Independent Chairperson challenging a lack of information or non-attendance from a specific agency. Nevertheless, the chairing of the Child Protection Conferences and reviews were not sufficiently robust and allowed a naive optimism to emerge as the risks to Child C were minimised and remained unassessed. Minutes were not routinely circulated within acceptable timescales and tasks identified at previous meetings were not routinely followed up. 7.7.22. The IMR author fails to explore any of these factors in sufficient depth and does not offer any reference to the report prepared by an Independent Chairperson and colleague in November 2012, for LSCB. This report highlighted some of the barriers and difficulties facing Independent Chairperson(s) and in response the LSCB developed an action plan to address some of the issues identified. However, the Overview Author has had sight of this action plan and notes that of 17 recommendations only three actions have been signed off to date. 7.7.23. The Independent Chairperson chaired a relatively small number of meetings; most were chaired by the social workers. The Overview Author would suggest there is an urgent need to improve and expand the skills and knowledge of practitioners tasked with responsibility of chairing multi-agency meetings. Multi-Agency Recommendation 7 Records of meetings 7.7.24. Another key issue relates to not only the chairing of multi-agency meetings and the formulation of effective plans but also how those meetings and key actions are recorded. The minutes of the Initial Child Protection Conference meeting on 4th February 2011 for example record that all agencies present agree with the plan but the records, while providing background detail shows little in the way of any analytical thinking. The minutes from the Core Group and Child in Need meetings, which have been seen by the Overview Author and the SCR Panel, are woefully inadequate, although the author is aware that new formats for these were introduced in 2012. Even so, it is clear that records of meetings were, too often, seen as just an administrative task rather than an essential tool to support multi-agency work with families. 7.7.25. The Children’s IMR author states that ‘minutes [of conferences] do not reflect the discussion in any detail’. She goes on to say ‘individual comments, opinion and professional judgement within the conference are not documented as the minutes are not verbatim’. 7.7.26. Whilst it is clear that multi-agency meetings and Conferences cannot be recorded in detail, there must be a more effective way of recording how and why certain decisions are reached. This is absolutely crucial, especially if parents and others cannot attend, as they need to be able to understand the rationale behind certain actions. The responsibility for disseminating these records lies with CSC and it is 88 clear from IMR reports that this is an issue that is of some concern to partner agencies, leading to individuals maintaining their own records for their files. 7.7.27. It is worthy of note that if this Overview Report had to rely solely upon records from CSC and the related IMR report, many details would not have been available. If practitioners are not confident about the process for disseminating timely and quality records of meetings then they will take their own notes - and it is clear that they do - and use these as their own agency records. This makes it more likely that judgments, decisions and agreed actions will be open to interpretation by individual practitioners. Having based much of this report on records from key meetings and the records in files, the author is struck by inconsistencies and dissonance between what was inferred, what was actually said and what professionals and LB understood what was agreed. 7.7.28. In the STNHSFT report, for example, there is a sense that Health Visitor 1 was deeply frustrated by what she seemed to think was unnecessary ‘drift and delay’ and her concerns are clearly evident from that agencies’ IMR report. Yet, there is no evidence of dissatisfaction or frustration evident from the notes of multi-agency meetings and no records to suggest these minutes were challenged. 7.7.29. These findings indicate a significant flaw in the way information is shared and recorded at multi-agency meetings. Enabling all the contributors to feel confident about their individual contributions and encouraging healthy debate and challenge is not an easy task, but it is made all the more difficult if there is poor or non-existent record keeping. The extremely poor quality of the records of meetings accessed by the author and the absence of robust plans that are easily understood by all parties are significant failings which were not without impact on LB and consequently Child C and Baby A. Multi-Agency Recommendation 8 7.8. Practice and Patterns in Professional Judgement Finding 5 ‘Professionals did not fully understand or effectively assess, LB’s capacity to change her behaviour within Child C’s timeline and this left Child C and Baby A vulnerable.’ Finding 6 Professionals were falsely reassured about Baby A’s safety even though, or possibly because of, the baby was the subject of a Child Protection Plan. 7.8.1. Quality assessments and good planning are important, but they are not the only factors that affect outcomes for children. A number of other factors are involved including parental behaviours and importantly, their motivation to change. Recent research by Ward et al31 on infants at risk of significant harm found that most parents, if they are going to make positive changes in caring for their children, have done so within six months. 31 Ward et al. 89 7.8.2. Concerns about LBs drug taking and the impact on Child C were addressed through Child in Need and Child Protection processes at various times over a six-year period. Professionals working with LB however, had unrealistically high expectations of what she could achieve and adopted a ‘natural love’ bias which mistakenly assumed that she would stop taking drugs, if to continue doing so, meant she would lose Child C and later Baby A. 7.8.3. LB had been using drugs since she was in her late teens and contrary to some reports, was often honest with professionals admitting that she used drugs, usually heroin, when she was stressed or worried. It is highly likely that this was an over simplification and LB, like many individuals with addictions, significantly minimised her dependency on illegal substances. Drug dependency is a chronic relapsing condition, typically marked by dramatic swings between relative stability and chaos. Despite the experiences of the professionals involved, it is clear from records that they believed LB could stop using drugs with support and by changing her behaviour and lifestyle. Throughout the period under review, professional efforts focused on LB. Whilst this is recognised in several IMR reports, the authors do not reflect on why the parent and not Child C remained central to their efforts. 7.8.4. Child C was described in reports as meeting developmental milestones, being small in weight and needing help with speech in development but in general was seen as a sociable and confident child. It is possible in perceiving Child C to be progressing ‘reasonably’ well, and without any crisis or incidents upon which to focus, professionals found it easier to turn their attention to LB and it was her need to have Child C returned to her care that dominated their work. This perspective can be evidenced from minutes of multi-agency meetings and was reflected in the recordings from key agencies. 7.8.5. During the period under review, January 2011 to April 2013, thirty-five multi- agency meetings took place, the vast majority of which related to Child C, yet a significant number of the notes from the meetings centred around LB. Whilst drug testing suggested that she could respond to treatment and refrain from substance misuse for several weeks, records also show she was unable to sustain this for any significant period of time and was unreliable at keeping random test appointments. This pattern, evident over several years and occurring through five pregnancies was not given due prominence and in relation to Child C, allowed the case to drift. The professional pre-occupation with LB’s substance misuse and testing overshadowed a more objective examination of her capacity, willingness and motivation to change. This led to professionals repeating the same interventions over and over again and yet expecting a different outcome. 7.8.6. Brandon et al32 consider the importance of analysing rather than simply identifying what is known about a family’s history and warns without such an analysis there is a risk of falling into the trap of what is referred to as the ‘start again syndrome’. Whilst the existence of previous evidence of poor and compromised parenting should not mitigate against the possibility of change, agencies should also be aware of repeat patterns of behaviour. There is no evidence of this issue being 32 Understanding Serious Case Reviews and their Impact – A biennial Analysis of Serious Case Reviews 2005-2007. 90 explored in any depth either in multi-agency meetings or in individual supervision sessions. 7.8.7. The term single loop learning describes a process commonly used in social work interventions. It means that professionals work with parents to help them understand why there are concerns, what they need to do and what needs to change to keep their child safe and well. Whilst the author would question to what extent this occurred in work with LB and her family, the process is well understood in social work settings. Whilst, this approach is valuable, Munro (2011) suggests that professionals should take the time to question and challenge the assumptions and beliefs that underpin the work they do with families - a form of ‘double loop’ learning. 7.8.8. If we extend this approach to work with LB, professionals assumed the issue was LB’s drug taking and therefore efforts were concentrated on and around that perceived problem. Had they either collectively or individually been encouraged to challenge their thinking they may well have been reminded that the reason for their involvement was about how to keep Child C safe and well in both the short and long term. As a result of the parent and not the child being at the centre of their work, professionals failed to consider how Child C could be kept safe in the future even if LB did not or could not stop her substance misuse. The focus on LB’s needs and vulnerabilities overshadowed other hypotheses as to what future safety might look like not only for Child C but also for Baby A. 7.8.9. The ‘neglect’ identified as the reason for both children being subject to Child Protection Plans, was not at the chronic end of the spectrum, and the willingness of the grandparents to care for their grandchildren appears to have led to a sense of complacency on the part of CSC. The long-term needs of the children were not considered in enough detail and neither were the emergent patterns of repeat behaviours and professional responses. The emphasis on short-term solutions and the apparent unwillingness to think about the long-term needs of both children, suggests amongst other factors, the possibility of professional bias. 7.8.10. There is little information recorded in the IMR reports about why, in this particular case, there were concerns about the impact of LB’s substance misuse on her ability to parent Child C and Baby A. This is not to suggest the concerns were not justified, but highlights the lack of clear and concise recording, which explained the rationale for the involvement of services and the progress that was or was not being made. Professionals need to be mindful of the dangers of making assumptions without assessments and using intuition as the only basis on which to make judgements. Whilst intuition has a place in the reasoning processes that are needed, drawing as it does on professional life experience and practice knowledge, it is prone to bias and may lead to premature or inaccurate judgements. 7.8.11. There are many contradictions apparent in reviewing professional involvement with Child C and Baby A. On the one hand there were health and social care professionals expressing concerns about LB’s drug taking resulting in Child C and later Baby A being made subject to Child in Need and Child Protection Plans. Conversely, there was also a willingness to consider that LB’s many missed appointments at P1-SMTP were inconsequential as long as the drug tests when 91 they were undertaken could show that she was ‘clean’. This led to the absence of ‘healthy sceptism’ and a naive optimism which resulted in Child C being subject to Child in Need and Child Protection Plans for almost four years since birth and little, if any change, being noted in mother’s substance misuse. 7.8.12. Whilst professionals need to develop ‘a dialectic mindset’ in which there is a constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events, without structured opportunities to explore these issues further, certain biases emerged which impacted on the failure to make timely and appropriate decisions. This is clearly evident in work with this family. 7.8.13. Research suggests that professionals need to take active steps to work against ‘our human tendency to seek only the information that we wish to find’, and confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on with the plans without question or challenge. Fish (2009) writes ‘one of the most common, problematic tendencies in human cognition ... is our failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’ 7.8.14. Whilst there are descriptions in the IMR reports about LB failing to engage with services or professionals, there are virtually no records, which describe her personality or personal characteristics. What does emerge however is a picture of a mother clearly addicted to opiates, who did not want to relinquish care of her child/children and tried to convince professionals that Child C and later Baby A, should not be removed from her care. 7.8.15. Confirmation bias33 is the tendency to focus on evidence that is consistent with already held views or preconceptions and ignoring evidence, which contradicts this view. This bias may have prevented professionals from asking questions about what Child C meant to LB and importantly, what she meant to that child. The issues of Child C’s emotional care and security were not routinely explored despite information, which suggested there was an attachment and a bond between mother and child. It is important to note here that the author is not suggesting that the eventual steps taken to safeguard and protect both Child C and Baby A were inappropriate but that a more questioning and reflective approach, would have identified the need for securing a stable and nurturing environment for Child C and possibly Baby A, at a much earlier stage. 7.8.16. There was a significant lack of interest in, or information about NX, although he was the father of Baby A. Apart from an antenatal visit by Health Visitor 3 in mid-January and his visits to his Probation Officer, there appears to have been no visits undertaken by the social worker or any other professional, with the primary purpose of getting to know more about him and to explore his position within the family. There is no information about why he has no contact with any of his children and although there are several references to his eldest daughter, there are no descriptions about the quality of that relationship. There are references in IMR reports to his being a good influence on LB, he was noted to have given up work so 33 Gambrill, E.D. (2005) ‘Decision-making in child welfare: errors and their context’, Children and youth services review, vol 27, 4, 347–352. 92 he could better support LB and he wanted to act as a carer for both Child C and Baby A, yet there was little written about any face-to-face family meetings with NX being present. 7.8.17. The Overview Author is mindful of research, which suggests a tendency on the part of professionals to ignore the role of significant or transitory males in families and focus their efforts on mothers, despite the contact these men have with children in those families. The term ‘hidden male’ is now common parlance and there is recognition that the role of the partner/father/husband in the family must be properly assessed to not only identify potential risks but also to explore their new and emerging role in relation to children within the family. 34 Given that LB and NX were married in December 2011, there are surprisingly few records which would indicate he was regarded as a significant individual in the lives of either Child C or his own child, Baby A and this is a serious omission which is not explored any of the IMR reports. The other male about who very little is mentioned is the maternal grandfather, despite his key role in offering care to three of his daughter’s children. 7.8.18. The issue of practice knowledge in relation to substance misuse, neglect and vulnerable babies is a key issue in this Review and one which has been identified in other reviews in Sunderland. It would appear that there was an absence of underpinning knowledge and awareness in relation to these interrelated risks despite the work of the LSCB in bringing the learning from previous reviews to the attention of frontline practitioners. It is significant that IMR authors did not refer to learning from these reviews or comment on the role for supervision in providing an opportunity to reflect on how local and national learning is used effectively in driving up the level of expertise of practitioners. Multi- Agency Recommendation 9 7.8.19. Good assessment is a complex activity. It involves the systematic and purposeful gathering of information, more than simply gathering 'facts'. It requires a range of knowledge and skills including the capacity to think analytically, critically and reflectively. What is significant in this Review is the absence of any of this type of work or any records of ‘social work practice’. It is difficult to review what work was actually undertaken with any family member and although the IMR author for CSC comments on the social worker not having an appropriate level of understanding about key procedures, she does not explore in any detail the comment made by social worker 3 that her experience in USA was of a different kind of ‘social work’ and she was used to a more ‘hands on approach’ as opposed to undertaking assessment and analysing facts. It is possible that these details do exist and are not referred to in the IMR report, but that in itself is a concern and calls into question the IMR author’s understanding of what constitutes an IMR. 7.9. Management and Supervision Finding 7 There was a concerning lack of managerial oversight in CSC which led to drift and delays and a failure to take protective action despite clear indications over a six 34 Cheshire and Knowsley Child Development Programme: The Hidden Male: A study of Merseyside Serious Case Reviews 2009. 93 year period that the parent was not capable of changing her behaviour to meet the needs of Child C and Baby A. Finding 8 Robust managerial practice, which supports reflective supervision, is central to supporting critical thinking and good assessments in multi-agency work but in CSC, good supervision and case audit in this case, did not take place. Managerial Oversight 7.9.1. Besides supporting frontline staff, managers have a duty to monitor the functioning of the organisation and to check that responsibilities are being met. There is evidence that managers within the Community Health Services and P1-SMTP had some managerial oversight in respect of the work undertaken by their frontline practitioners, but even so there was little challenge from the managers in Community Health Services about the drift in this case. Although the Health Visitors were advised by their managers at times to put their various concerns in writing, the managers themselves did not escalate concerns at any time to the respective managers in CSC. These actions should have been taken, especially when it became apparent that agreed assessments had not taken place or agencies had not been consulted about their contents. 7.9.2. Whilst some managerial oversight is evident from other IMR reports, there is far less to evidence robust managerial oversight in respect of the work undertaken by social worker 2 and social worker 3 and given the lack of experience of social worker 3 in working in the UK, and this is of some concern. Research35 suggests that while managers in all agencies who work with and on behalf of vulnerable children cannot be expected to micro-manage or know the detail of every case in their area, they do need to ensure that quality assurance systems are in place so that team leaders and front-line staff can readily identify where things are going wrong at an early stage and can take early corrective action. CSC were involved in the life of Child C for almost all of the child’s life and yet failed to seek measures over several years which would have offered the child stability and protection and would undoubtedly have highlighted risks to Baby A at a much earlier stage. 7.9.3. The advice from the Legal Section that suggested there was not enough evidence to seek Interim Care Orders should have alerted management to examine why that evidence was not available, given professionals concerns and their involvement over such a significant length of time. There is no evidence to suggest that the drift, clearly evident in this case, was ever explored but neither does the IMR author seek explanations from practitioners or managers to understand what factors might have influenced professional judgements in this case. 7.9.4. As the lead agency, there should have been much greater scrutiny around the assessments and why they were not completed or undertaken. The messages from the IMR report is that the manager was not aware that the assessments had not been completed and were outstanding. Equally there was no managerial oversight into how and why certain decisions were or were not made. This is extremely poor 35 (House of Commons Health Committee 2003). 94 practice and left Child C and Baby A in a vulnerable position. Acknowledging the points made above about micro-management, there were however, enough indicators in this case to suggest that managerial oversight should have been a high priority - the substance misuse, neglect and the impact on children under five years old, vulnerable babies, these are all key risk indictors well evidenced in research. This, together with a social worker inexperienced in UK social work practice and being unfamiliar with child protection procedures and presumably national research, should have led to significantly more involvement from the Team Manager and greater oversight that is apparent from IMR report. 7.9.5. In this SCR, the Overview Author and the SCR Panel are concerned to note that this Review and others like it highlight the same issues, many of which relate to poor practice in CSC. If the reasons for these shortcomings are not explored and addressed by senior management, similar errors will keep occurring and this will leave children at risk and vulnerable. 7.9.6. The failure of the IMR author (CSC) to explore these important issues again brings into sharp focus the importance of agencies understanding what is required from them in the SCR process. It also highlights the importance of selecting the right person at a senior level in the organisation to undertake these reviews. This is not a direct reflection on the competence of the IMR authors who produced the reports for CSC, it is however a challenge to senior management to question and review their commitment to the SCR process. 7.9.7. Given the findings from previous SCRs in Sunderland and in the light of Edward Timpson’s letter36 to the Chair of Bradford LSCB, the Overview Author would urge an early meeting to include the LSCB Independent Chair, the Chief Executive and Director of Children Services to discuss and agree a way of addressing and progressing the issues related to CSC and outlined in this report. Multi-Agency Recommendation 10 Supervision of practitioners 7.9.8. A key line of enquiry in this SCR is the extent to which practitioners had ‘sufficient and appropriate supervision’ and whether this ‘promoted critical reflection’. 7.9.9. ‘Supervision’ has different meanings and formats for the various agencies that make up the safeguarding partnership. Its components vary between settings, however the Children’s Workforce Council has provided a helpful definition, which identifies three key aspects, “Line management, which is about accountability for practice and quality of service. This includes managing team resources, delegation and workload management, performance appraisal, duty of care, support and other people-management processes. Professional supervision (sometimes described as case supervision) with workers or groups of workers to enable and support quality practice. A key aspect of this function is reviewing and reflecting on practice issues. This may include reviewing roles and relationships, evaluating the outcomes of the work and maximising opportunities for wider learning. Continuing professional development of workers to ensure they have the relevant skills, 36 https://www.gov.uk/government/publications/serious-case-review-for-hamzah-khan-government-response. 95 knowledge, understanding and attributes to do the job and progress their careers. Constructive feedback and observation of practice should be part of the learning process for workers and supervisors.” 7.9.10. In considering the role of ‘supervision’ in this section of the analysis, the term will be used to encompass more than just individual supervision within the line management context, but also any other models that incorporate the functions as outlined above. 7.9.11. Reflective supervision is the regular collaborative reflection between a practitioner and supervisor that builds on the supervisee’s use of thoughts, feelings and values within a service user. Importantly reflective supervision provides the support needed by practitioners who are exposed to the intense emotional content and life experiences related to their work with families. 7.9.12. Evidence from the IMRs suggests that formal supervision took place regularly for the Health Visitors, the School Nurse and Midwifery staff, the practitioners in P1-SMTP and for some staff within the Children’s Centre. Staff within the Primary School had less structured opportunities but did have access to their Designated Officers and the Education Safeguarding Team when necessary. It is not possible to say whether during these sessions there were opportunities for reflective supervision, as the authors of the relevant IMRs did not address this issue in sufficient detail. Whilst the author of the STNHSFT does describe supervision of Health Visitor 1 as being reflective, there is no detail given or exploration of what is understood by this and the author then moves on to refer to issues around accountability and processes. 7.9.13. The supervision of Health Visitor 1 at times appeared challenging and probing, but there is little to evidence that supervision offered Health Visitor 1 the opportunity to reflect on her work with LB and Child C despite evidence of frustration and waning energy. There are inferences that the relationship between Health Visitor 1 and her line manager was not a strong one and this may have led to the decision of Health Visitor 1 in November 2012 to decline to continue to work with the family when LB’s pregnancy was confirmed. The IMR author does not explore this issue; nevertheless there is evidence that within health settings there is a strong commitment to supervision both in terms of clinical practice and managerial accountability, although the latter appears to be cited more frequently. 7.9.14. The group supervision sessions in P1-SMTP were regular and relevant and offered appropriate guidance and challenge to practitioners, which allowed them to usefully contribute to Core Groups and Child in Need meetings. However, there were several occasions when information was not shared promptly and practitioners failed to ask about or comment about Child C. The IMR author does not comment on these issues and neither does she comment upon the shortcomings and limitations of group supervision in terms of reflective practice. 7.9.15. The effective supervision of practitioners within CSC is a crucial feature in safeguarding children. The guidelines and procedures for the Department state ‘Supervision must allow time to address the monitoring of casework, management of time to complete organisational tasks arising from that casework, [and should] 96 include, supportive and challenging reflective practices to assist staff to consider their practice and professional development thinking’. The IMR author states that she could find no evidence that this was being consistently followed for any of the workers involved but does not consider why this should be the case. 7.9.16. Social worker 2 had only two recorded supervision sessions between February and May 2011. Social worker 3 had supervision on 28th August 2012, 26th February 2013 and 12th April 2013. Some supervision notes were available to the IMR author and she states that only in the February 2013 session with social worker 3 was there any evidence of some reflective supervision, although she also notes that ‘neither Baby A or Child C were discussed at that session’. 7.9.17. The Team Manager made significant comments about workload pressures and how these were impacting on her own performance, presumably meaning she didn’t have time to offer supervision to social worker 3 or monitor her work on a regular basis. These issues however were not explored in sufficient depth and neither was there a detailed exploration of the quality of supervision that Team Manager received from her line manager. These are the pivotal issues, which should have been analysed by the IMR author in order for the SCR Panel to better understand why certain practices happened and the extent to which they may have reflected on wider practices across the Authority. 7.9.18. The Independent Chairperson was able to produce only one supervision record and informed the IMR author that whilst he was aware of the Department supervision policy, he could only recall receiving two supervision sessions in 2012 and two since April 2013. He informed the IMR author that the consequences of his high caseload and his manager working part-time made it ‘very difficult to fit in regular meetings’. The IMR author makes no comment on this issue despite the policy statement of the Department and evidence-based research, which clearly links quality supervision with positive outcomes for children. 7.9.19. The Fostering Officer was able to produce only one supervision record, which related to the time period under review. Whilst the IMR author explores the content of that session and the subsequent sessions which took place from November 2012, she does not comment on the quality of these or explore to what extent supervisory practices across the Fostering Team offered scope for reflective practice. 7.9.20. It is apparent that there was a lack of managerial oversight in CSC, the Independent Chairperson Service and the Fostering Team. There is no evidence that the supervision where it occurred led to reflection about the overall approach being taken: the effectiveness of the Child in Need and Child Protection Plans; the need to review assessments of family members or to provide challenge to the optimistic mindset that has been identified within this report. It is not apparent either that key points in the history of the case which might have triggered a more comprehensive analysis, for example, the plan to return Child C home in September 2011, and the decision to place Baby A with the maternal grandparents led to such critical reflection. 7.9.21. There is clear evidence that supervision did not provide adequately challenging and reflective opportunities for those working directly with LB, her children and other 97 family members. The absence of any real engagement with the maternal grandparents and the apparent reluctance on the part of professionals to consider that LB continued to use heroin and would be unable to stop the addiction within Child’s C timeframe, was not addressed and should have been a key challenge in supervision for all the practitioners. 7.9.22. It is important to consider the possibility that the relationship between a practitioner and a manager can lead to ‘common thinking’ and therefore reinforce the sense of certainty that a worker may have developed about a case over time. This is a persuasive view especially given the way in which the same interventions and the same decisions were made to little effect over a two-year period. There is evidence here to suggest that supervision did not succeed in robustly testing out ideas or challenging hypotheses. However, the IMR authors in general offer no reflection on these issues and offer no discussion about how their organisation can develop and improve the skills and knowledge of managers and practitioners especially in applying lessons from research and local reviews and national SCRs. The message from literature would suggest it is not compliance with procedures that leads to the best outcome for children, but the depth and quality of professional practice and this is an issue, which should be further explored by the LSCB, especially given the findings from other reviews in Sunderland. 7.9.23. Whilst supervision of frontline practitioners has been the predominant focus, the supervisory needs of their immediate line managers also requires comment. The skills and training of managers in providing supervision has not been raised in any of the IMRs but it is an issue of some concern given the comments noted above. Robust senior management is required to support line managers whose responsibility it is to ensure practitioner’s work is consistent with statutory guidance and in the best interests of children and young people. It is of extreme concern that this review has highlighted such poor practice, especially in the lead statutory agency and steps should be taken by senior management to address this issue. 7.9.24. This review has identified various aspects of practice, both for front line practitioners and in relation to management structures, which suggest that reflection and review is not considered as a priority. Fundamentally this raises the question of the effectiveness of supervision arrangements where safeguarding children is concerned. 7.9.25. Reflective thinking and supervision can be achieved within a wide variety of such models, including peer supervision, team approaches and self-directed learning. Notwithstanding the fact that the LSCB has developed and reviewed Supervision Standards as recently as 2012, it is the view of the author that before making significant changes to the details or models of supervisory practice, partners within the Safeguarding Board should ensure there is a shared agreement on the underlying principles for supervision and consider the development of a shared strategic approach to this process. Multi-Agency Recommendation 11 7.9.26. Finally, irrespective of what approaches are adopted in theory, in order for practitioners to develop the sort of reflective practice being promoted in this review, they will only be able to achieve this with the explicit and continuing commitment of 98 the LSCB member organisations to create the time and space for them to practice in this way. 7.10. Contextual Issues Finding 9 There was evidence in this case that frontline practitioners repeated errors previously highlighted in research and local reviews, suggesting that learning from these processes was not reaching professionals or impacting on their performance and decision making. 7.10.1. An OFSTED inspection of Safeguarding and Looked After Children services in February 2012 stated that the overall effectiveness of safeguarding services were ‘good’. The inspection report commented on a number of issues pertinent to this review: • need to ensure that all assessments take into full account the views of children and families • need to ensure that all Child Protection Plans are specific and measurable including clear timescales for action and that all core group discussions are effectively minuted so that progress can be monitored more effectively • review the chairing of Conferences to ensure that they are chaired by professionals who have the requisite experience and expertise to undertake this role • inconsistent evidence of first line management oversight in case records 7.10.2. In October 2011, Ofsted published a national report37, which referred to 471 SCRs evaluated by Ofsted between 2007 and 2011 concerning 602 children, 210 (35%) children were babies under the age of one year. This had been a consistent pattern across the four-year period. These figures have implications for practitioners and the report highlights include some key messages, which not only have a bearing on this review but also are clearly linked to findings emerging from it. The Ofsted report states that: • there were shortcomings in the timeliness and quality of pre-birth assessments • the risks resulting from the parents’ own needs were underestimated, particularly given the vulnerability of babies • the role of the fathers had been marginalised • there was a need for improved assessment of, and support for, parenting capacity • there were particular lessons for health agencies, whose practitioners are often the main, or the only, agencies involved with the family in the early months • practitioners underestimated the fragility of the baby • there is an increased risk of Sudden Infant Death Syndrome where babies are born to mothers who have substance misuse addiction 37 Ages of Concern: Learning Lesson from Serious Case Reviews October 2011. 99 7.10.3. The issues raised in this SCR – poor quality assessments, lack of robust planning and review, ineffective multi-agency collaboration and lack of managerial oversight and a stark failure to place the children at the centre of their work are failures identified in a range of research literature. These are also issues, which have been identified previously as failings within this Local Authority and therefore leads to the question of why problematic practice does not appear to be changing. This issue has not been robustly explored in any of the IMR reports and the failure of senior management to sign off and take responsibility for the contents of these reports highlights a significant challenge for the LSCB in executing its function to hold agencies to account for their safeguarding practices. 7.10.4. In the absence of any analysis or suggestions by the IMR authors, the Overview Author would suggest that understanding what needs to change is easier than knowing how to change and the LSCB would benefit from an overhaul of the way in which reviews are conducted and lessons are disseminated. Since this SCR began another SCR has been commissioned and a different approach has been agreed. This is to be welcomed and will create a more inclusive approach to learning than the model used for this SCR. 7.10.5. However, the challenge will still remain as to how learning about what works or what needs to be done differently, transfers to frontline practice in single agency and multi-agency work. Having had sight of various action plans and had access to the extensive work undertaken by the LSCB over the last two years, it seems clear that a different approach is required to minimise the chance of the same errors in practice reoccurring in the future. From the author’s experience, the key factors which inhibit learning across organisations are, lack of effective communication, lack of clarity about what needs to change, the absence of review mechanisms and limited opportunities for practitioners to discuss what is changing and why, and importantly, what they now are required to do differently. 7.10.6. It would be of benefit for the LSCB to review the process through which case reviews are undertaken and examine more effective ways of disseminating information so practice outcomes improve. Multi-Agency Recommendation 12 8. The Findings 8.1. The Findings Assessment and Planning Finding 1: The absence of any robust multi-agency assessments to inform the development of good quality plans and decision-making left Child C and subsequently Baby A vulnerable. (Also identified in Learning Lessons Review 2012) 100 Finding: 2 Without skilled and experienced chairs, the multi-agency meetings lacked focus and direction leading to unspecified outcomes and poor reviews of progress. (Also identified in Learning Lessons Review 2012) Multi-Agency Collaboration Finding 3: A lack of robust multi-agency challenge and collaboration across agencies regarding decisions, plans and thresholds resulted in ineffective interventions. (Also identified in Learning Lessons Review 2012) Finding 4 A lack of clarity about roles and responsibilities inhibited good communication information sharing and progress. Practice and Patterns in Professional Judgement Finding 5 Professionals did not fully understand or effectively assess, LB’s capacity to change her behaviour within Child C’s timeline and this left Child C and Baby A vulnerable. Finding 6 Professionals were falsely reassured about Baby A’s safety even though, or possibly because of, the baby was the subject of a Child Protection Plan. Management and Supervision Finding 7 There was a concerning lack of managerial oversight in Children’s Social Care which led to drift and delays and a failure to take protective action, despite clear indications over a six year period that the parent was not capable of changing her behaviour to meet the needs of Child C and Baby A. Finding 8 Robust managerial practice, which supports reflective supervision, is central to supporting critical thinking and good assessments in multi-agency work but in Children’s Social Care, good supervision and case audit did not take place. (Also identified in Learning Lessons Review 2012). Contextual Issues Finding 9 There was evidence in this case that frontline practitioners repeated errors previously highlighted in research and local serious case reviews, suggesting that learning from these reviews was not reaching professionals or impacting on their performance and decision making. 8.2. Good Practice (this is practice where individual practitioners do more than is required as part of their role or service standards) 8.2.1. Health Visitor 3 undertook liaison role with agencies when information need to be shared. 101 8.2.2. The efforts made by the midwifery team to share information and to alert LB to concerns about the DVT were commendable, as were the attempts and the tenacity of the SSMM to put in place safety arrangements for Baby A in the hospital and on discharge where these had not been considered in the Pre-Birth Assessment. 8.2.3. There were also good examples of challenging practice from some practitioners in P1-SMTP although this was not consistent across the service. 9. Conclusion 9.1.1. It is important to be aware as Munro (2011) states just how much hindsight distorts our judgement about the predictability of an adverse outcome. Once it is known there is a tragic outcome, we can look back and believe we can see where practice, actions or assessments were critical in leading to that outcome. Munro writes that hindsight bias ‘oversimplifies or trivialises the situation confronting the practitioner and masks the processes affecting practitioner behaviour before the fact. Hindsight bias blocks our ability to see the deeper story of systematic factors that predictably shape human performance’. 9.1.2. It is reasonable to conclude that had the various assessment processes been conducted more thoroughly, the complex mix of risks and vulnerabilities surrounding Child C and Baby A would have been more readily identified. This in turn would have led to more realistic evaluations and subsequently better planning about how to safeguard the children if the risks were not managed in a timely way, or they increased. What is clear from this Review is that work with all vulnerable children and their families must be focussed and this requires leadership and direction. In this case, the leadership that should have been provided by CSC was absent. Equally, although professionals in other agencies may have recognised drift and risks, their managers did not escalate these and a sense of complacency developed which left Child C and Baby A vulnerable. The importance of frontline practitioners having access to good quality supervision cannot be underestimated and there is evidence in this Review that the benefits of reflective supervision are not well understood. 9.1.3. Consideration has been given as to whether the death of Baby A was predictable. Predicting the likelihood of such an outcome for a vulnerable baby is difficult to achieve with any meaningful degree of accuracy. The risks to Baby A were considered significant enough to make the child subject to a Child Protection Plan and arrange a placement on discharge with the maternal grandparents. It is understandable that these arrangements gave professionals a sense of security, especially knowing that maternal grandparents were caring for two other of LB’s children. It is unclear from records or reports to what extent the parents and the maternal grandparents were alerted to the increased risks to Baby A, compared to other babies. Neither are there records which suggest they were reminded about the complex effects of chaotic or polydrug misuse which can induce drowsiness/deep sleeping and might have impaired the parenting capacity of LB, but it is not possible to conclude that had they been so informed this would have led 102 to a different outcome for Baby A. The Coroner’s verdict indicates that Baby A died as a result of natural causes and not as a result of neglect or abuse. 9.1.4. The impact of not having outcome focussed plans derived from good assessments and the fact that the absence of these was not noticed or challenged, both within agencies and collectively, led to a distinct lack of clarity about the purpose of intervention. This, together with the fact there were no ‘incidents’ relating to the children, blunted the practitioners’ awareness of the risks involved allowing the case to drift and the specific risks to Baby A remaining unassessed. 9.1.5. The poor quality of the IMR reports in terms of offering critical and reflective insights into frontline practice highlights a significant challenge for the LSCB, which needs to be urgently addressed if future reviews are to lead to better outcomes for children and young people. 9.1.6. The SCR Panel informed the Overview Author that the failure of CSC to meaningfully engage in this Review has been evident in other reviews, despite efforts by the LSCB to seek responses, which demonstrate an awareness of failing and poor performance and a commitment to improve practice at both operational and managerial levels. The poor quality in general of the submitted IMR reports has been noted, but the Overview Author would stress that in relation to the CSC report, the identification of some significant systems and practice issues should be of pressing concern to senior managers within that service. 9.1.7. Given the findings from this review process and the fact that some of these are also to be found in other reviews, which have, taken place over previous years, the Overview Author, supported by the SCR Panel would urge that the work outlined and the recommendations listed below are addressed as a matter of some urgency. The resulting Action Plan should be robust and actively supported by senior managers from all partner agencies. 10. Recommendations 10.1. Multi-Agency Recommendations Multi-Agency Recommendation 1 a) The LSCB should be confident that partner agencies understand their role in contributing to SCRs and have skilled personnel able to undertake critical analysis of practice and produce high quality reports when required. b) Senior Managers in all partner agencies should be reminded about their responsibilities to sign off these reports thereby confirming acceptance of quality and contents. Multi-Agency Recommendation 2 The LSCB should as a matter of some urgency require CSC to respond to the questions raised in 5.2.8 within a specified timescale and then consider how partners can work collaboratively to address the emerging issues. 103 Multi-Agency Recommendation 3 The LSCB should examine the processes it has in place so the Board can be assured that statutory assessments and those agreed at multi-agency meetings take place within agreed timelines, are robust and of good quality. LSCB should also ensure that effective escalation policies are in place and well understood by all partner agencies. Multi-Agency Recommendation 4 a) The LSCB should re-evaluate how multi-agency plans relating to children in need and child protection are formulated and recorded, using where possible an agreed template which places the child first and foremost at the front of the deliberations and allows for realistic and meaningful monitoring and review. b) The LSCB should ensure there is a robust process for regular scrutiny and challenge of these plans, including those that are developed and utilised by the Board. Multi-Agency Recommendation 5 The LSCB should ensure that frontline practitioners have a clear and detailed understanding about the safeguarding responsibilities and expertise of colleagues attending multi-agency meetings and this information is used to justify attendance, rationalise allocated tasks and confirm areas of joint responsibility. Multi- Agency Recommendation 6 The LSCB should explore the advantages of requiring multi-agency meetings to state the hypothesis38 or hypotheses that form the basis of their Child in Need or Child Protection Plan. Multi-Agency Recommendation 7 The LSCB should consider ways in which the Board can be satisfied that practitioners who chair multi-agency meetings relating to the safeguarding of children and young people, have the requisite skills, knowledge and confidence to do so assertively. Multi-Agency Recommendation 8 The LSCB should redesign the systems in place for recording and disseminating information from any multi-agency meetings to ensure these are robust and effective. Multi-Agency Recommendation 9 The LSCB should seek agreement from partners that all vulnerable babies under the age of one are discussed as a matter of routine in supervision, and assessment of risk discussed and recorded. Multi-Agency Recommendation 10 The LSCB should as a matter of some urgency and in line with its statutory functions39 establish a meeting to include the Chief Executive and the Director of 38 “a proposition made as a basis for reasoning,..a starting-point for further investigation from known facts”. 39 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006. 104 Children’s Services to agree a way of addressing and progressing the issues outlined in this report, especially in relation to 9.1.7 of this report. Multi-Agency Recommendation 11 The LSCB should develop learning opportunities for managers across all agencies to improve their skills and knowledge about reflective supervision and the links this has with better outcomes for children. Multi-Agency Recommendation 12 The LSCB should design more effective ways to ensure lessons from reviews and research are disseminated to frontline practitioners so improved practice and better outcomes for children and young people can be assured. 10.2. Single Agency Recommendations (these are copied directly from the IMR reports) Children’s Services: Children’s Social Care (CSC) 1. The fostering service must ensure that all foster carers have the Out of Hours telephone number and understand its use. All foster carers and professionals must be made aware of Out of Hours service and how to access it. The number should be included in social workers’ voicemail messages on both landline and mobile telephones. 2. The process for sending notification letters when children are placed or foster carers are approved outside Sunderland must be strengthened. Appropriate notifications must be sent to all relevant parties for all foster carers approved and children placed outside the boundary of the Local Authority. Business support need to save copies of the letter to ESCR, copied to the social worker and make a case note to the effect that it has taken place to ensure that information sharing is clearly evidenced. 3. The Council’s Fostering Service needs to improve the quality of Connected Persons’ assessments. The Fostering Service should develop a Quality Assurance process to ensure that all Connected Person’s assessments meet statutory requirements, including adherence to timescales. The Fostering Panel must ensure that reports are of an acceptable standard. The standard of Connected Persons assessments must be improved. All reports should provide comprehensive details about family history and the relationships and dynamics of those involved. Fostering officers must talk to the child(ren(s)) social workers and check CCM, to ensure that any assessments already undertaken inform the assessment. Home local authority checks must be undertaken without exception and prospective Connected Person’s assessments must not be taken to Fostering Panel for approval without this information being included. 4. Ensure that the Placement and Resources Panel (PARP) risk assessment includes any risks to child from previous caregivers, including during contact. The PARP Risk Assessment must be amended to reflect risks to the child by their previous care givers and any risks surrounding contact arrangements. 5. There must be a clear procedure for Operational Managers to take responsibility for information sharing if social workers change teams. A formal transfer process for workers transferring between teams needs to be developed and implemented. Consideration needs to be given to any particular issues 105 pertaining to their caseload, their professional skills and abilities and any developmental or personal issues that will impact on their abilities. 6. A written Contact Plan must be in place for all looked after children to ensure that all parties are fully aware of the contact arrangements. Written contact plans must be completed for all contact arrangements at the start of a placement, with consideration being given to location, time, venue and frequency of contact as well as appropriate supervisors and the risks for the child depending on who is supervising. The contact plan must be shared and signed by all parties at the point of placement. 7. All reports for Family and Friends placements must be supported by clear evidence of need for placement and how the placement will meet the child’s needs. There needs to be a more explicit explanation within the SLAC 199 paperwork as to why a child is becoming looked after and information regarding the family and risks posed. Without this information the placement must not be signed off by the senior manager. There must also be clarity re the process for placing a second or subsequent child within a connected foster carer’s household. 8. There must be a discharge meeting attended by a social worker for all babies who are not being discharged home to parents. A review of the discharge from hospital process is required. Procedures need to address safe sleeping, visiting arrangements, contact expectations and procedures for discharge. 9. Child Protection Conference Chairs need to ensure that a Birth Arrangements Form is always completed and signed at Initial Child Protection Conferences for unborn babies. If for any reason a birth arrangements form cannot be completed at an Initial Child Protection Conference it needs to be completed immediately afterwards. 10. Procedures for children becoming looked after need to be clear. A review of procedures for children becoming looked after needs to be undertaken, with particular consideration to the process surrounding children being accommodated with s20 consent of their birth parents and the attendance of workers at PARP. 11. The system for storing documents on children’s case files should be standardised. A review needs to be carried out of current recording systems, including ESCR, CCM, SWIFT and the ongoing use of paper case files in the fostering service. All word documentation currently used to complete assessments, investigations, reviews and plans must be re-integrated into the database system of CCM to ensure that reports are linked to the child they are being created for and saved appropriately. 12. Notifications for children placed out of City, children with Child Protection Plans living outside Sunderland and out of City foster carers must be evidenced on case files and foster carers’ files. All social workers and managers must be reminded of the need to follow LSCB procedures in relation to notifying the relevant people about children with Child Protection Plans living outside the Local Authority boundary, children placed outside Sunderland and foster care living outside the city. 13. The vulnerability of unborn babies and very young babies must be highlighted. Operational managers must discuss all unborn babies and vulnerable babies at every supervision. They need to be sure that all vulnerable baby cases are following the correct procedures and that all risks and factors pertaining to the specific case have been considered. These discussions need to be taking place 106 between the social worker managing the case and their own supervisor so there is a clear understanding of any issues throughout. This has already been implemented in relation to unborn babies but needs to be extended to include all vulnerable babies up to the age of one. 14. Supervision files must evidence that staff receive regular supervision in line with supervision policy. All staff must have regular, recorded supervision in line with the supervision policy. All case discussion must be saved onto the relevant child’s file and all information pertinent to the worker must be saved into their personal file. 15. The Case File audit system to be reviewed to ensure that social workers receive timely feedback on audits completed. Currently the audits focus on a selection of cases rather than the caseload of one worker. The audit system needs to enable managers to identify and address any areas of practice which are not meeting required standards or where a worker requires further training or support. 16. The process for booking Initial Child Protection Conferences needs to be strengthened. The Independent Reviewing Team must have sight of a completed s47 document before an Initial Child Protection Conference is able to be arranged. 17. A review of the format of conference minutes needs to be carried out to see whether it is possible to highlight discussions so workers are able to see patterns and repetitions in the events. 18. There should be a review of the level of support for Operational Managers. A review must be undertaken of managerial responsibilities and ways in which support can be provided to ensure that all cases are understood and managed appropriately. The caseloads of the newly appointed senior social workers, created to take on the responsibility of Deputy Managers in all teams, need to be adjusted accordingly to ensure that they are able to fulfil their new role. 19. The interim management arrangements for the Children’s Independent Review Team need to be resolved. Urgent resolution must be found to the current interim arrangements surrounding the temporary management of the Independent Reviewing Unit. 20. Measures should be put in place to ensure that staff who are put at personal risk through their work are fully supported. Senior managers must put in place mechanisms to ensure that there is sufficient emotional as well as practical support in place for staff who are put at personal risk through their work. 21. There should be a review of the risk assessment template to ensure it covers all risks to a child. Currently there are a number different templates in place. These should be standardised to ensure that all risks are properly evaluated. 22. There should be a review of all training that incorporates information regarding substance misuse. Currently training courses either focus on the presentation of young people who may be abusing substances or the hidden harm caused by those misusing substances. Training needs to ensure that all elements are considered at all training so as many workers as possible are alerted to the risks both to and from an individual so that the additional risks posed to vulnerable babies, including the dangers of co-sleeping, are highlighted. 23. The views of social workers need to be taken into consideration when planning the training programme. A social work representative should be appointed to the Training Development Group. A social worker will be able to support any development of training to assist and promote the best ways in which to 107 safeguard children. The needs and issues for frontline workers will be able to be voiced. Training courses need to be reviewed to consider if they are as effective and efficient as possible to make attendance and accessibility as straightforward as possible for workers which will also impact the number of workers able to enhance their skills and knowledge, which in turn will improve outcomes for children. Additional actions recommended by Overview Author Further consideration should be given to consider: • Why were managerial oversight and supervision arrangements so inadequate, given the LSCB had undertaken an exercise relating to supervision in the recent past? • Given that effective records contribute to better outcomes for children, why were records, minutes and plans of key meetings not available and why, when some were submitted were they so poor? • Why are arrangements for chairing and note taking at various meetings so inadequate? • Why are the training opportunities provided to frontline practitioners and the learning from research and reviews not leading to improved practice? • Are high caseloads accepted by senior management if this leads to poor practice and leaves children vulnerable? • What factors mitigated against expected practice in this case? • The inadequacy of IRO resources has been raised by the Board on a number of occasions, why has there been no effective action to date? Northumbria Police 1. The need to ensure that where possible and appropriate an Officer attends the ICPC in order to provide details of family member’s involvement with the Police and to ensure that the Police participate in the decision-making process and subsequent recommendations. This action has already been addressed following the alignment of two PVP teams to Sunderland Local Authority and will be monitored on a monthly basis to ensure compliance. Northumbria Probation Trust 1. With regard to Probation Officer 1, the recorded information relates to a personal issue not a Trust wide issue. This is currently being addressed through an action plan under Capability procedures. 2. With regard to practitioners accessing LSCB training, the Organisational Development Manager is working across all six LSCBs in the Trust area to develop a consistent and effective system to ensure that Probation staff attend appropriate courses. 3. However, there are issues that need to be picked up and reinforced in the forthcoming revision of the Safeguarding Children Policy, currently being undertaken by the Safeguarding Communities Manager. The first concern is how Probation staff deals with the lack of minutes from Core Group Meetings. A proforma will be introduced to ensure that decisions made and actions allocated are recorded. Reinforcement of the importance of home visits, the need to register on the Child Protection Register and ensuring that all relevant information with regard to children is on file. These have been raised with the 108 Safeguarding Communities Manager, and will form part of the revised policy due to be launched in the autumn following Board approval. As a result of the latter, a firm date cannot be given. Additional actions recommended by Overview Author • Improve the Action Plan so it is ‘SMART’ thus allowing for robust monitor and review. Place 1 Substance Misuse Treatment Provider 1. Arrangements to be developed within the Information Technology system of P1-SMTP to allow the easy copying of e-mails into case recording. 2. To be included within safeguarding training for P1-SMTP staff, a session explaining the differing meetings and the purposes of these meetings within the Child Protection arena. If this is already part of the training then refresher events should take place within the agency. 3. Discussions to be undertaken by senior management of P1-SMTP to establish a system of receiving information from MARAC meetings especially where a service user may be at risk of harm. 4. Arrangements to be formulated within the safeguarding procedures to allow for staff from P1-SMTP to be included when Birth Plans are agreed. Where P1-SMTP staff are involved with a mother then they should be part of the Birth Plan unless there is good reason for them not being so. Additional actions recommended by Overview Author • A fifth recommendation should include the need for P1-SMTP to examine how it can ensure that staff remain child focussed in their work with substance users who are parents. Place 2 Children’s’ Services 1. Place 2 Children’s Care to ensure that all team managers and social workers are reminded about their responsibilities under the cross boundary procedures. 2. Real Service to Review Circle of Support to include genogram. 3. Place 2 EDT to advise substantive and sessional staff of the need to personally ensure that there are no outstanding safeguarding issues in relation to children and young people rather than rely on information from partner agencies. Children’s Services, Education 1. All Designated People and Nominated Deputies for safeguarding and SENCOs to have a secure understanding of the thresholds for neglect and the impact within education. 2. All Designated and Nominated Deputies/SENCOs to have a secure understanding of the impact of drug taking during pregnancy on children and its impact within education. 3. Children subject to Plan when transferring to a new setting must be formally handed over to the new receiving school or settings, Designated People and Nominated Deputies to ensure they are safeguarded. 4. Within all meetings of children subject to Plan appropriate educational progress information for pupils must be identified and discussed. 109 5. Quality assure random education files for children subject to Plan during Education Safeguarding Team and Early Years Quality Improvement Support Programme audits. 6. Enhancing Early Years practitioners’ understanding of the need to and methods of accessing pupil voice. Additional actions recommended by the Overview Author • The Overview Author would advise strengthening the recommendation, which relates to Child Protection files and records. City Hospitals 1. Any baby who requires continuous supervision for safeguarding purposes should be transferred to the neonatal unit following delivery. 2. Any baby born to a substance misuse mother to be transferred to the neonatal unit for assessment of withdrawal. 3. Review and update ‘Substance Misuse’ Guideline. 4. Review and update of the ‘Prevention and Management of Excessive Weight loss in the Breast Fed Newborn’ guideline. 5. Pre-discharge planning meetings to be arranged for all discharges were a relative is providing supervision. 6. GP patient records and archived information to be accessed by team midwives. 7. Postnatal handheld records to be reconfigured to clearly display safe sleeping arrangements for babies. 8. Mandatory one-to-one Clinical Supervision for safeguarding at induction for newly qualified midwives. Additional actions recommended by Overview Author • There should also be a recommendation, which relates to the timely use of the LSCB’s escalation policy. General Practitioner 1. Practices to share information with professionals where there are vulnerable patients. 2. GP’s to be aware of the need to enquire about domestic violence and that this is an ongoing issue, not a one off event. 3. Primary care team within the practice must be compliant with LSCB procedures. 4. All practices to hold regular multi-disciplinary meetings. 5. Health professionals to give consideration to the THINK family approach to patient care. 6. Practices to open communication with midwives, either through MDT meetings or improving access to records for EMIS. Midwives to improve the quality of the antenatal vulnerability assessment score and ensure this information is shared with GP’s. 7. Records for all family members where there are issues such as drug misuse, or domestic abuse to be flagged in a manner that any health professional reading the records is aware of the problem. 110 8. GP’s to review record keeping and ensure that the records are kept in a manner that all clinicians are clearly able to ascertain a patients circumstances and that information can be effectively shared. NHS Trust 1. Practitioners be clear about the aim and expected outcomes from safeguarding supervision. 2. Supervisors will be clear about their role and accountability when delivering supervision. 3. Practitioners should clearly demonstrate their specific health roles when a member of a Multi-Agency Meeting. 4. Health Visitors will take opportunities to actively interact with children. 5. Workshops will be made available for STNHSFT practitioners on the effects of Substance Misuse on Families and Children. Additional actions recommended by Overview Author • These five recommendations are too vague and do not state specific outcomes – these need to be ‘SMART’ recommendations • There should also be a recommendation, which relates to the timely use of the LSCB’s escalation policy. Clinical Commissioning Group (CCG) 1. STNHSFT to develop a system of peer review for safeguarding supervision arrangements to ensure the service delivered is consistently of a high standard. 2. STNHSFT to ensure there is effective communication between Safe Care Leads/Modern Matrons and the Safeguarding Team to ensure staff who are not able to meet the needs within their caseloads are identified and appropriate support and supervision can be made available. 3. CHS to review the drug testing arrangements available in community and hospital maternity settings. 4. CHS to ensure that accountability arrangements for Named Professionals are clear when advising on babies within the NNU. 5. In reviewing their substance misuse guidance CHS will ensure appropriate information is included on risk/harm minimisation for breast-feeding mothers who continue to misuse substances. 6. CHS to undertake an audit to ensure that all babies subject to a Child Protection Plan are seen daily for 10 days post-natally within the community. 7. CHS to review how safe sleep messages are delivered to all parents/carers 8. Drug Treatment Services will ensure that details of children of substance misusing parents/carers who accompany them to appointments are documented in records and this information is passed to the social worker. 9. Drug Treatment Services will share information regarding potential criminal activity of their service users who have care of children with the local Police and with the allocated social worker. 10. LSCB to develop multi-agency risk/parenting assessments incorporating the knowledge and skills of all core group/care team members. 11. LSCB to ensure the birth arrangements plan covers discharge arrangements specific to how the baby will be transported, and by whom on discharge. 111 Additional actions recommended by Overview Author • The Overview Author would suggest a recommendation that supervising personnel are reminded about the LSCB’s escalation policy. 112 Appendix 1 Terms of Reference: Baby A and Child C Practice and Patterns in Professional Judgement a) Were practitioners aware of and sensitive to the needs of Baby A and Child C and where appropriate, were Child C’s wishes and feelings ascertained and taken into account when making decisions about the provision of services? b) Was practice sensitive to racial, cultural, linguistic and religious beliefs? c) Were practitioners knowledgeable about the potential indicators of abuse and what to do in response to concerns? Specific attention should be paid to professional understanding and training around neglect. d) What role did human factors such as confirmation bias and situation awareness play, if any, to the achievement of robust and effective safeguarding practice in this case? Assessment and Intervention e) How effectively did planned and responsive services recognise and manage issues of need and risk; including the ability to recognise the impact of parenting issues, such as parental mental health issues, parental substance misuse and criminality. f) When considering the circumstances of the children, did the agencies’ assessments include an appropriate assessment of risk? Specifically: • Were the child protection investigations, which led to Child C being made the subject of a Child Protection Plan for the first and second time, thorough and robust? • Was the child protection investigation, which led to Baby A being made the subject of a Child Protection Plan in 2013 robust and thorough? • Did all relevant agencies make appropriate contributions to the child protection investigations? • Was a robust antenatal assessment undertaken in respect of Baby A and did it result in appropriate planning and decision making for the baby? • Did all of the agency’s assessments give appropriate consideration to the potential impact of a new baby on the extended family, particularly in light of the following: - The long standing concerns about parenting capacity - The pre-existing concern for the children’s safety - The fact that grandparents decided to care for Baby A at a late stage - The evidence with regard to the vulnerability of babies 113 • Was there an analysis of risk in the context of neglect for Child C and Baby A? • Did assessments pay appropriate attention to the role of both of the fathers for the children? • How effective were the drug screening/drug monitoring processes in assisting professionals to have a clear assessment of mum’s substance misuse? Decision-Making g) Were decisions reached appropriate and justifiable at the time? • Did the risk assessment result in robust birth planning arrangements? • Did all agencies involved with the family attend and contribute appropriately to the Initial Child Protection Conference in December 2012 and March 2013? • Was the decision to discontinue the Child Protection Plan for Child C in 2011 based on a robust assessment of risk? • What impact, if any, did the four day Easter weekend have on the safety of Baby A? • With regard to the Letter before Proceedings (both in terms of issuing it and not progressing it), were the decisions made appropriate and justifiable at the time? • How were these decisions reached? • Was the assessment process with regard to this robust and based upon sound evidence of change? h) How effectively did the MARAC arrangements safeguard mum in 2010? i) Were agency procedures for safeguarding children followed appropriately in relation to the decisions made in this case and was practice compliant with Working Together 2010 and relevant multi-agency safeguarding children procedures? Multi-Agency Collaboration j) Core Group Meetings/Cross Boundary Working •••• Were Core Group meetings held within timescales? •••• Was there appropriate membership of and attendance at the Core Group meetings? •••• Is there evidence of outcome focussed planning to implement the co-ordinated Child Protection Plans for Baby A and Child C? •••• How did Core Group members feel about their contribution to the group, and did they feel able to challenge the views of other members? •••• What capacity did professionals have to challenge decisions and actions in relation to safeguarding Baby A and Child C and the professional understanding of their responsibilities with regard to this in the LSCB procedures? 114 k) Were decisions made and actions taken concerning failure to engage, appropriate and justifiable at the time? Management and Supervision l) Was supervision undertaken with staff in line with the agencies’ supervision policy and is there evidence of reflective supervision where appropriate? m) Were senior managers or other organisations and professionals involved at points in this case where they should have been? Contextual Issues n) Were there any issues within the individual agency e.g., high level of staff vacancies, which may have impacted on the ability of the service to effectively meet the needs of Baby A, Child C and the family. October 2013 115Appendix 2 GENOGRAM MGF BX NX m. Dec 2011 d. April 2013 MGM ST Aunt Child J Child P Child C Baby A LB Child Child 116 Addendum to Overview Report in respect of Baby A and Child C 1. Background 1.1. The Overview Report for Baby A and Child C was completed early 2014 and signed off by Sunderland Safeguarding Children Board (SSCB) in February 2014. 1.2. The Serious Case Review (SCR) process was concluded well outside the 6-month time frame due to delayed Individual Management Review (IMR) reports and in particular to the SCR Panel’s dissatisfaction with subsequent rewrites of the Children’s Services Social Care report. The SCR Panel had reluctantly accepted the last report submitted by the IMR author when it was advised by the manager representing Children’s Services, on the Panel, that the report had been agreed with her senior manager and additional work could not be undertaken without a further and significant delay of the SCR40. 1.3. The SCR Panel deliberated this issue and concluded that the timescale for the SCR should not be extended again. Further feedback was given to the Children’s Services representative and the Overview Author agreed to consider and include any amendments to the IMR report should these be received before December 2013. There were however no further amendments made to the IMR report although the related action plan was later forwarded to the author. 1.4. The Overview Report highlighted the shortcomings of the Children’s Services IMR and advised an urgent and immediate consideration of several unanswered ‘why’ questions in respect of practice and systems. The Director of Children’s Services41 having advised SSCB that an independent body, ‘core assets’ 42 , had been commissioned to undertake a ‘Safeguarding Review’ of systems and practice in Children’s Social Care, subsequently informed the Board that as part of that process, ‘core assets’ would also seek to address the ‘why’ questions contained in the final SCR report. 1.5. A decision was taken a short time later by the [then] Chair of the LSCB, the Executive Director of People’s Services and agency leads, to delay publication of the SCR Overview Report until ‘core assets’ had completed their analysis. 1.6. The SSCB Chair and SSCB Business Manager later approached the Independent Author to discuss how best any findings could be incorporated into the SCR report. Whilst unable to agree to a request that the original report signed off in February 2014, be amended to include ‘new’ information, the author did agree to write an addendum to the Overview Report in response to any subsequent findings. 40In effect, this delay occurred anyway following a decision by the LSCB Chair and Director of Children’s Social Care not to publish until Children’s Services had undertaken further work. 41Now known as the Executive Director of People Services. 42http://www.coreassets.com. 1171.7. The findings from the ‘core assets’ review were accepted by Children’s Services and formed the basis of what shall be referred to in this document, as the Children’s Services’ Review report (CS Review report). This was forwarded to the [new] SSCB Chair and the Independent Author on the 18 July 2014. The report did not clearly identify what changes had been implemented and did not include an action plan. A further delay was incurred whilst these documents were prepared. 1.8. The Independent Author subsequently received a report from Fiona Brown, Chief Operating Officer, and People’s Directorate in mid-August and this offered a chronology of actions implemented to date (FB1) and an action plan (FB2). 1.9. The SCR Panel was reconvened on 23 September 2014 to sign off the Addendum Report written by the Independent Author, although it should be noted that not all those present at the meeting had been forwarded copies of the Chief Operating Officer’s report or action plan, i.e. FB1 or FB2. It was agreed however that these documents would be appended to this report without any additional changes and circulated to the SCR Panel. 2. General Comments 2.1. The documents forwarded by the Chief Operating Officer would suggest that the decision to undertake an independent review of safeguarding practice in Children’s Social Care has led to a number of improvements specifically around service delivery and quality assurance arrangements. These changes, whilst long overdue given the findings of previous case and SCRs and previous challenges from LSCB43, are to be welcomed. 2.2. Having met with family members in relation the SCR for Baby A and Child C, at the end of 2013 and discussed with them the SCR process and issues around publication, the Independent Author remains concerned about the length of time it has taken to complete this SCR and publish its findings. Recommendation 1: There would be merit in an open and honest discussion between LSCB partners about the circumstances, which led to the significant delay in the publication of this SCR to ensure similar patterns, and practices are not repeated in subsequent reviews. 2.3. The CS Review report very helpfully provided a critical analysis of practice and systems and goes a considerable distance in answering the ‘why’ questions originally presented to SSCB. That this report has been produced now and not as part of the SCR process highlights that this information was indeed available when the SCR was being undertaken, but the IMR author44, through lack of experience, appropriate guidance or seniority was unable to access it and senior managers crucially failed to see the relevance and importance of this information being required as part of the IMR report. 43According to documents seen by the author. 44The IMR author who wrote the report on behalf of Children’s Services was a Principal Social Worker, not a senior manager in Children’s Services. 118 Recommendation 2: It is noted that a new Management Development programme has been commissioned which includes a module on SCRs. This programme needs to ensure that managers understand the significance of SCRs and their role as key contributors to the SCR process. Recommendation 3: Senior Managers in Children’s Social Care should consider how they can be kept better informed about the process, progress, and outcomes of SCRs. They should identify what immediate steps should be taken if issues affecting progress, and which relate to their representatives, are brought to their attention. 2.4. The CS Review report appropriately highlight that the recommendations contained in the [original] IMR for Children’s Social Care lacked the necessary focus and rigour needed to bring about effective change in social care practice. The amended action plan (FB2) forwarded by the Chief Operations Officer is more robust and together with the Improvement Plan 45 should help Children Services move forward in improving practice. Recommendation 4: Senior managers in Children Services need to assure themselves that the actions arising from this and other SCRs are realistic and achievable and there are stringent and on-gong monitoring systems in place to ensure changes in practice are sustained. 3. Findings from Children Services Review Report The information contained in the CS Review report offers details in response to the ‘why’ questions posed in the Overview Report. Additional analysis is provided in the main body of the text. It is not the intention of the author to reiterate the findings in this addendum but the same headings are used to capture what appear to be the significant findings, which require further consideration, by SSCB. The headings used are as follows: • Quality Assuring practice • Management oversight and supervision • ICT and case management systems • The role and function of the IRO/CP Unit • Social care caseloads • Impact of training on practice 3.1. Quality Assuring Practice: Finding 1: The absence of a coherent and robust quality assessment framework led to practice and service failings going unrecognised. 45This is a Strategic document emerging from a review of Children Services. 119Why this is significant: In order to measure performance and deliver quality services, Children’s Social Care need objective or more effective ways to assess how well they are doing and monitor changes over time. Measuring the impact of service delivery is central to achieving improved outcomes for children. This requires a strong quality assurance system to be in place that evidences that services are being delivered effectively and to standards that enable children’s welfare to be safeguarded and promoted. The CS Review report offers a number of organisational and external factors which explain why such a framework was either not working or was not in place in Children’s Social Care. These issues are noted to have been addressed and are being addressed through the following actions: • The Quality Assurance role of the Children’s Independent Review Team has been strengthened (FB1: implemented May- June 2014) • All completed assessments for Looked After Children and Child Protection are monitored by Independent Reviewing Officers and Child Protection Conference Chairs (FB1: implemented July – August 2014) • A Quality Assurance Sub-group is to be formed to analyse and report on data to Senior Managers (FB2: Action 7) • A caseload management system will be implemented across social care and this will be monitored through the QA framework. (FB2: Action 6) Issues for consideration by SSCB: • Is the Board confident that the Quality Assurance framework proposed or amended by Children’s Social Care is robust? • Was the Board aware of the shortcomings in Children’s Social Care quality assurance framework? If so, how was this addressed and if not, why was this not picked up through the Board’s own audit processes? • In what way can the Board evidence that its own arrangements for auditing and review are now robust and effective? 3.2. Management Oversight and Supervision: Finding 1: As above Finding 2: Regular high quality and organised supervision was compromised by the ever-increasing demands in the Local Authority and strong leadership to champion the supervisory process was missing. Why this is significant: The absence of managerial oversight and reflective supervision was a key factor in this SCR and a range of internal and external constraints were identified as being contributory factors. Managers and social work staff work will continue to work within a climate of increasing uncertainty and organisational challenge and unless senior leaders regard the supervision of staff as a key priority, some managers will elect to prioritise other aspects of their managerial role. Despite evidence of good quality practice in some teams, an audit 120in Children’s Social Care undertaken in May 2014 highlighted that good supervisory practice is not consistent across the Authority. These issues are noted to have been addressed and are being addressed through the following actions: • All teams now have senior social workers and senior practitioners increasing the team manager’s capacity for effective managerial oversight. (FB1: Implemented May - June 2014) • Introduction of a new mandatory Management Development Programme for Team Leaders. (FB1: Implemented May - June 2014) • Confirmation that Team Managers and Senior Social Workers are expected to sign off all assessments. (FB1: Implemented July – August 2014) • The supervision model and policy document are to be reviewed and protocols developed as required by December 2014. (FB2: Action 2) • All babies under 2 year old are to be discussed in Supervision. (FB1: Implemented May – June 2014) • Arrangements for transition and case handover will be reviewed by December 2014. (FB2: Action 5) • Senior Managers now seek evidence that Social Workers receive regular supervision. (FB1: July- August 2014) • Weekly briefings for teams are to take place so staff can be informed of policy changes. (FB2: Action 7) • In terms of risk management, Monday morning meetings will take place to support the allocation of cases to ensure that there are no unallocated CP cases. (FB1: Implemented July – August 2014) Issues for consideration by SSCB: • The LSCB has set standards for supervision practice across all partner agencies, how does assure itself to what extent is it possible to monitor these arrangements? • Does the Board commend other supervision models? • Do Senior Managers receive supervision and training in relation to their safeguarding responsibilities? • How does the Board ensure it is kept informed about the number of unallocated CP cases and the rationale for this practice? 3.3. IT and Case Management Systems: Finding 1: As above Finding 3: Difficulties in recording, storing, and retrieving key data compromises the ability of Social Workers to quickly and purposefully locate important information about a child’s journey and therefore impacts on the quality of social work practice. This was clearly an issue in this SCR. Why this is significant: The Integrated Children’s System, commonly known as ICS, has been a point of controversy in children’s social care across the UK since its 121creation. Although, the Government initially was very prescriptive with ICS requirements, Councils were eventually given the ability to adapt their own services to meet their own local needs. The confusing and complex information management system(s) in Sunderland, (although by no means the only Local Authority to have this problem) was a contributory factor in respect of the poor quality of information accessed by the IMR author for social care. The CS Review report states this as ‘being an information management system, which does not support a safe systematic and orderly storage of a child’s file and weakens quality assurance’. These issues are noted to have been addressed and are being addressed through the following actions: • Social workers have been instructed to store all completed documents in ESCR to facilitate retrieval. (FB1: Implemented May- June 2014) • Version 28.2 of CCM is planned for implementation in the autumn of 2014 and this will make storage and retrieval more straightforward. (FB1: Implemented/confirmed July – August 2014) • A data cleansing exercise will be undertaken and file structures revised. (FB2:Action 8) Issues for consideration by SSCB: • How will the Board monitor the impact of this new system in terms of multi-agency working? • Is there any way the Board can support Children’s Social Care in terms of information management? • Has the Board a robust and comprehensive management information system of its own? 3.4. The Role and Function of the IRO and Child Protection Conferencing Unit Finding 1: As above Finding 4: The high caseload of Independent Reviewing Officers (IROs) combined with inadequate arrangements for administration, and the case recording system being applied compromises the ability of this unit to fulfil its core quality assurance and scrutiny functions. Why this is significant: The CS Review report indicated that on average IROs in Sunderland hold the equivalent of 102 children46 this undoubtedly impacts upon their capacity to undertake their role effectively and continues to be an issue despite the recent increase in staffing. This issue requires further review. The IMR for Children’s Social Care highlighted significant issues around the supervision of experienced IROs and it appears that this will remain an issue as yet another interim manager is appointed to the unit. This will be the third interim manager in two years. 46The national average is around 50 – 70 cases for each Independent Reviewing Officer. 122 Finding 5: The failure of Children’s Services to provide sufficient administrative support to facilitate the delivery of an efficient and effective review service impacts on effective planning and is not cost or service effective. Why this is significant: The IRO service does not have a dedicated administrative resource. The CS Review report highlights that there is some admin support from a limited number of staff within a pooled admin team but this is subject to availability. This means IROs and Conference Chairs retain overall responsibility for most administrative tasks relating to the management of reviews and conferences, and this again can impact on their ability to perform their role effectively. These issues are noted to have been addressed and are being addressed through the following actions: • Increase in the establishment of the IRO service. (FB1: Implemented/confirmed March- April 2014) • A revised quality assurance framework and quality standards for the administration of the IRO service will be developed and implemented by December 2014. (FB2: Action 4) Issues for consideration by SSCB: • How does the Board monitor the effectiveness of multi-agency meetings? • Is the quality of these regularly reviewed and monitored? • Is the Board working with Children’s Social Care to improve templates, agendas and format for multi-agency meetings? • Do partner agencies contribute administrative support for multi-agency meetings, if not why not? 3.5. Impact of Training on Practice Finding 1: As above. Finding 6: Children’s Social Care need to develop better and more systematic means of providing opportunities for their staff to reflect, develop curiosity, and enhance their clarity of thinking and practice. Why this is significant: Developing professional wisdom around safeguarding is nurtured through supervision and various learning opportunities. The dynamics involved in safeguarding; the ease with which the focus on the child can be lost and unhelpful mindsets unknowingly developed e.g. rule of optimism, start again syndrome, desensitization poor standards, are realities that affect all practitioners. Training courses are only one way that adults learn, peer supervision, action-learning sets, coaching and mentoring can also be of value. These issues are noted to have been addressed and are being addressed through the following actions: 123• A service-wide training need analysis is to be undertaken across Children’s Social Care which will lead to improved training opportunities and improved practice. (FB2: Action 3) • Action Learning Sets and Road shows will be rolled out across teams. (FB2: Action 7) Issues for consideration by SSCB: • How are multi-agency training programmes devised and how does the audit and quality assurance framework impact on these? • How does the Board ensure that learning from SCRs is shared across the whole authority and is embedded and sustained in frontline practice? • To what degree do audits test out whether learning from case and SCRs are discussed in supervision? • To what extent is the Board confident that senior managers in partner agencies understand and acknowledge the significant SCRs? • Senior managers who make decisions about budget and resource can be divorced from the practice implications that those decisions create, how does the Board deal with this challenge? 3.6. Partnership working: how well professionals and organisations work together Finding 7 Author’s Comment: There is an observable tension between Children’s Services and partnership agencies, which is not helpful and which undoubtedly makes working in this complex and challenging area of work even more challenging. Why this is significant: Children and families need professionals and organisations that work well together to promote their wellbeing and safety. Failing to work collaboratively continues to be a key message from SCRs and this can take various forms including not only practical working arrangements, but also the mindset in which organisations and professionals approach what they do. Silo thinking and practice, blaming other agencies, poor information sharing, lack of professional confidence and leadership, and unclear or unresolved safeguarding thresholds were all reported in this SCR. Issues for consideration by SSCB: • In what way might SSCB facilitate improvements in working relationships between partner agencies? • How might Board structures, systems and sub-groups be developed to encourage more integrated practice across different disciplines as well as agencies? • Do key parties understand the challenge and scrutiny function of LSCB, is there any way that this understanding could be strengthened to foster and improve collaborative relationships? • Is the Board confident that the developing Resolutions Policy will be effective in ensuring that agencies comply with, and are committed to, SSCB policies and procedures? 124 4. Conclusion 4.1. The CS Review report asks why the SCR process was concluded without key questions being answered. This is a pertinent question but one, which should be discussed in SSCB, taking into account the first recommendation highlighted in 2.2 above. Having read the reports from previous case and SCRs, it is clear that many of the issues in relation to Children’s Social Care and outlined in the Overview Report for Baby A and Child C, had been raised previously and had not been addressed. It was also evident from having attended the SCR Panel meetings for this SCR, that partner agencies were in general, dissatisfied with the perceived failure of Children’s Social Care to continually address identified failings in practice and systems. These issues again, should form the basis of further discussions also taking into account the comments in 3.6 above. 4.2. The actions taken by the Executive Director and his team during the last 6 months demonstrate a strong commitment to address many of the issues highlighted in this SCR and in the previous reviews, which have been undertaken in Sunderland. The changes and proposed changes are noted. The SSCB should ensure however, that these developments remain under scrutiny, to ensure that good practice is sustained and can be identified in future SCRs. 4.3. The CS Review report and the chronology of actions taken to date together with the action plan for Children Services are welcomed. It would however be useful if all three documents could be merged into one report so partner agencies and others can more easily recognise what was required, the achievements made to date and the work yet to be accomplished. Linda Richardson, Independent Overview Author 25 September 2014 1 May 2014 Prepared by: Rosie Rae & Richard Burrows Report for Sunderland City Council: Executive Director People Services Re Children’s Safeguarding response to “why” questions raised in the SCR Overview Report re Baby A & Child C 2 Introduction 1.1 Baby A died in April 2013 and in February 2014 Sunderland LSCB subsequently completed a Serious Case Review (SCR) into the circumstances surrounding the death (and the involvement of services with sibling Child C) This was in accordance with Regulation 5 of the LSCB Regulations (2006). 1.2 There is a requirement for the LSCB to undertake a serious case review in cases where a child has died or been seriously harmed in circumstances of abuse or neglect and there may be cause for concern about the way agencies have worked together to safeguard the child or children. 1.3 The serious case review for baby A was commissioned and undertaken in accordance with statutory guidance, assuring independence through the appointment of an independent SCR panel chair and independent author. 1.4 The purpose of SCR’s is not to establish who is responsible for any death or injury, nor intended to attribute blame. They are conducted in order to enable a critical analysis of local multi agency practice and to ensure that lessons learned are identified and shared in order to improve practice. 1.5 The decision to hold a SCR was determined only two weeks after the launch of revised statutory guidance (Working Together 2013), the SCR panel decided to adhere to the previous SCR guidance in Working Together (2010). That is to say the requirement for Individual Management Reports (IMR’s) from agencies involved and an independent Overview Report. The LSCB were also mindful of the revised guidance that advocates a more systems based review. There is an acceptance by the LSCB in hindsight that a sharper methodology would have produced a more succinct and complete report overall. 1.6 The overview report was completed in February 2014 but somewhat unusually, given that the purpose of a SCR is to draw out all key learning points, the final version of the report contained a number of unanswered challenge questions directed toward Sunderland Children’s Social care (SCSC). 1.7 The ‘why’ or challenge questions posed by the LSCB are both pertinent and relevant and a detailed response to the individual questions provided by Children’s Social Care is attached as Appendix 1. However, the underlying issues identified are inter-related and cross cutting hence the main body of this report has been compiled in order to respond to the challenge questions posed by the LSCB under the following key headings; • Quality assuring practice • Management oversight and supervision • ICT and case management systems • The role of the IRO/CP Unit • Administration arrangements for the IRO CP service • IRO capacity and adequacy • Social care caseloads • Impact of training on practice 3 Exploring the LSCB challenge or the “why questions” 2.1 The Children's Social Care IMR and the LSCB Overview report both accurately identify shortcomings in local practice with regard to this case. It is also accepted that the Social Care IMR is incomplete in as much as key questions are left unanswered. 2.2 It may never be possible to wholly answer all of the questions pertaining to the case of Baby A and Child C, as some of the key personnel involved have moved on, and the information recorded about some elements of decision-making is weak and lacks supporting rationale. The issue of the quality of recording is addressed in some detail within the SCR overview report and in the Children’s Social Care response to the challenge questions. 2.3 Many of the local case review findings replicate themes identified in national serious case reviews. This is not offered as mitigation it simply provides context and highlights the challenge for local partnerships and systems in quality assuring safeguarding practice. This is particularly relevant with regard to the following themes; • Management instability and lack of oversight and supervision arrangements • Quality and timeliness of assessment • Absence of practice challenge and quality assurance scrutiny • Over optimism and family history not being taken into account (start again syndrome) • Drift in care planning /lack of focus and clarity in plans • Inexperienced staff lacking the confidence and competence to deal with complex cases • Disguised compliance • The invisible child and an absence of child centred practice. 2.4 Fundamentally, the factor that allowed practice issues to go unrecognised and therefore unchallenged within the case of Baby A and Child C overall was the absence of a robust quality assurance system within Children’s Social Care and therefore to some extent in joint working arrangements. Quality Assuring Practice 2.5 A robust performance management and quality assurance framework enables early identification of deviations from accepted standards and tolerance levels. This is an essential element of good safeguarding practice. The capacity for human error means that even the most effective practitioner cannot be considered infallible and given the complexity and demands placed upon safeguarding and child protection services, mistakes and oversights are always possible and in some respects may be 4 considered inevitable. This is particularly relevant where additional factors in the work environment or organisation influence practice capacity and delivery. 2.6 This case review and the subsequent external review by Coreassets identified that the quality assurance framework within children’s social care had become fragmented and is recognised as requiring urgent review. This fragmentation has occurred due to a number of contributory organisational and external factors; • The loss of an experienced and competent data analyst through restructuring • The internal case file audit programme being compromised, both through the way information were recorded on ICS, but also the loss of the key analyst post above. Audits were undertaken to some extent but seemingly without rigour or consistency, and once uploaded to the system, in the absence of a suitably qualified person (above), key findings were unable to be retrieved in order to understand the relevance to local practice. • The absence through ill health of the quality assurance lead officer • The way that the ICS system was used locally by practitioners and management. This approach compromised the ICS system gate-keeping measures and therefore the ability to track the child’s journey as part of audit and broader quality assurance measures. This approach entailed word documents being used to maintain case management records, as opposed to the formatted ICS fields. This approach was undertaken in an attempt to manage the limitations of the existing version of ICS (due for upgrading in summer 2014). • The quality assurance, scrutiny and challenge functions of the IRO/CP service being compromised through limited capacity and high caseloads. This was exacerbated by a lack of adequate administrative support. • High case loads and issues with recruitment, sickness and absence placed pressures on the service overall. • Management restructures disrupted the continuity of management oversight at some levels and temporarily reduced management capacity overall as new structures ‘bedded in’. • Regular supervision in line with accepted LSCB standards was not being routinely applied; there was no consistent supervision model in place across the services. This despite some previous significant investment in supervision training. • Reductions in the levels of administrative support across the service significantly increased the time social workers needed to spend on administrative functions. Management Oversight and Supervision 2.7 Evidence of management oversight and supervision was largely absent in the case of Baby A and Child C. Supervision where it was recorded was scant and of variable quality across all officers involved in the case. This is attributed predominantly (but not wholly) to reduced management capacity during that time frame, with some posts being lost in restructuring, a level of disruption as new restructuring arrangements were bedding in, and long term sickness absence of a senior manager. 5 2.8 The Social Worker initially involved in this case had qualified in the USA and recently joined Sunderland children’s social care. The IMR author identified that while this was an experienced qualified social worker, there were some cultural differences with regard to practice and the application of thresholds, (in neglect for example) which had not been considered in induction. 2.9 There were no concerns with regard to high case load in the case of baby A, with only 17 cases allocated to this member of staff. However managers were unaware of factors and pressures within the social workers personal life that could have had an impact on her practice and decision making. It is recognised that adequate supervision arrangements would have provided not only an opportunity for reflection and challenge on case decisions, but also identification of both cultural practice differences and additional training or support required. It is accepted that this was not the case. 2.10 Supervision enables social workers to develop good practice and exercise professional judgement and discretion in decision-making. The absence of sound supervision in the case of Baby A and Child C meant that opportunities to reflect on or challenge practice were overlooked. 2.11 The Coreassets case file audits undertaken in May 2014 showed that the quality and regularity of supervision remains variable, with some evidence of good clear directive supervision and management oversight but this was not consistent over all cases audited. 2.12 It is important that supervision is consistent and takes place regularly, that both the manager and the practitioner have time to prepare for the supervision session, and that this is then recorded appropriately. 2.13 Children’s social care have signed up to and remain committed to compliance with the LSCB standards for supervision, they have previously invested in supervision training to support that standard. In the light of the audit findings, and the changes in management staff, further training may be required to support the implementation of a standardised supervision model. Information technology and case management 2.14 The information management and case recording system applied by children’s social care is the Northgate Swift/ICS system, which is also referred to locally as CCM. The current version of ICS was heavily criticised as being unwieldy and cumbersome, with system pre-determined forms/formats that were not considered to be user friendly,(feedback from service users,professionals and Ofsted (2010/11). 2.15 This criticism led to children’s social care senior management team advocating the use of an ‘alternative recording system’ from early 2012, which circumnavigated the set parameters of ICS. This involved transferring the format for children’s plans and assessments into word documents. As these documents cannot then be uploaded to ICS they must be stored separately in the Electronic Social Care Records drive (ESCR) which is a cumbersome and time consuming measure. This was proposed by senior management as a short term solution to overcome the ICS shortcomings pending further investment and the implementation of ICS 6 upgrades to a more user friendly version (28.2) due in summer 2014, (not yet implemented). 2.16 Northgate ICS and other comparative systems, set service parameters as part of a broader quality assurance process, and in essence play a role in “gate keeping practice”. System parameters effectively reduce opportunity for deviation from procedures and accepted practice. For example, a request to convene a child protection conference cannot be progressed without confirmation on the system that a Section 47 strategy meeting has taken place, similarly the completion of assessments cannot progress without management sign off, ensuring a level of quality assurance. Also, significantly and most importantly the system enables a file structure that follows the child’s journey through service involvement. 2.17 In addition to the information stored in ESCR, and ICS, some case information pre-dating 2012 is held in E- Files. The indexing and file structure within this system is not reliable and data retrieval problematic. Workers also routinely stored (and at the point of this review and subsequent audit continued to store) ‘live’ reports in another word folder called current files. Once any documents, including assessments and plans are complete they should be uploaded to ESCR, which creates a PDF document. However, there is no standard file structure within current files and therefore no cohesive approach to how information is filed, and in practice finalised documents are not always uploaded to ESCR. Case summaries and chronologies are not consistently applied and the capacity to follow the child’s journey across disjointed systems is compromised as a result. 2.18 In summary, four individual non-standardised information and case recording systems are applied. This creates opportunity for both key information to be ‘lost’ across the systems, and for case recording and assessments to be overlooked or simply not completed. Information retrieval is laborious and unreliable, and can significantly limit social workers ability to locate and consider case history in order to inform their practice. 2.19 The removal of systemic gate-keeping parameters that promote compliance with procedures creates an opportunity for noncompliance and undoubtedly compromises efforts to quality assure practice through case file audit and management oversight. 2.20 The system of uploading to ESCR is highly time consuming, and as the document are PDF’s, they cannot be amended or edited and this contributes to staff opting to hold completed documents in current files folders as opposed to ESCR in accordance with policy guidance. 2.21 This system places extra and unnecessary demand on social workers, IROs and managers, (already under considerable time restraints due to high caseloads and the complexity of many cases). It is a contributory factor to the quality of information being recorded and the reliability or accuracy of information that is able to be retrieved from the system. This was identified as a factor in the challenges 7 faced by the children’s social care IMR author in trying to gather adequate information for her report. 2.22 The Core Assets auditor identifies this as “being an information management system, which does not support a safe systematic and orderly storage of a child’s file and weakens quality assurance”. 2.23 This may have been a contributory factor in the family history not being taken into account in the case of Baby A and Child C. It would have certainly compromised management oversight and ability to routinely monitor the quality of assessments or identify and challenge delays or drift in the case plans. This, combined with limited capacity in administration support, and relatively high social worker caseloads would also have had an impact of the standard of minutes and record keeping. The Role of the Independent Reviewing Officers (IRO) and Child Protection Conferencing Unit. 2.24 The IRO is a statutory post whose primary function is to quality assure the care planning and review process for children in care, ensuring that the wishes of each individual child are given full consideration. 2.25 When a child first becomes looked after a named individual must be appointed as the IRO for that child (S25a (1) CYP Act 1989). They have a responsibility to review and monitor the performance of the local authority in respect of each child’s case. They should also; • Promote the voice of the child • Ensure plans are based on detailed and informed assessments and provide a real response to the child’s needs • Offer a safeguard to prevent drift in care planning and service delivery to children looked after • Monitor the activity of the local authority as corporate parents. 2.26 The role of the IRO is a specialist function which may require them to challenge senior local authority managers. There is a specific requirement for them to be authoritative professionals with at least the equivalent status as an experienced social care manager. 2.27 The IRO is responsible for the effective chairing of each looked after child’s review meeting. In order for these meetings to be productive and sensitive to the needs of the child, time and careful preparation is required (IRO Handbook). IRO must have the capacity to be able to; 8 • Speak with the child before the review (and good practice is to also speak to them between reviews) • Speak to the social worker 15 days before the reviews. • Scrutinise any relevant reports, plans and assessments, including personal education plans, health plans and medical assessments 2.28 The IRO manager has additional line management and supervision duties and is also required to produce an annual service report. That annual report should include outcomes of quality assurance audits undertaken by the unit, service performance data and identify whether resource issues are putting the quality of service delivery at risk. 2.29 The IRO Handbook (7.15) estimates that a caseload of 50-70 looked after children for a full time IRO would represent good practice in the delivery of a quality service, enabling them to meet the full range of functions required of them. 2.30 Child Protection Conferences are convened where concerns have been substantiated and it is judged that a child is suffering or likely to suffer significant harm. The Role of the Child Protection Conference Chair is; • To review all relevant documentation in preparation for the Conference and Review, including the social workers report and any assessments and plans. • To meet with the family prior to the conference and their role in it. • To agree issues of attendance and participation of family members • Ensure the child’s voice is heard • Ensure consideration to any individual or cultural needs, including any requirements for disabled participants • Chair the meeting, setting out its purpose for all participants and ensure that families are involved in the planning • Make a final decision about child protection plans. • In many areas, in addition to the above responsibilities the CP Chair quality assures conference and review minutes. 2.31 In Sunderland (and many other authority areas) the roles of the IRO & Child Protection Chair have been merged into one unit with shared responsibility for CP and IRO functions. Administration of the looked after child reviews and child protection conference process 2.32 While Sunderland CP/ IRO unit are able to draw admin support from a limited number of staff within a pooled admin team this is subject to availability, they do not have dedicated administrative resources. There are a number of issues with this approach, not least that IRO/CP officers in addition to their core role are spending valuable time on administrative functions such as managing the bookings of rooms for meetings, sending out meeting invitations and typing up 9 minutes. There is as a result a sense that the administrative functions and standards may not be wholly coordinated or consistent across the service. 2.33 The role of the minute taking of a child protection conference carries a significant responsibility in ensuring key confidential and sensitive information is recorded, and requires a high level of competency to produce reports to an accepted standard. The information content of conferences can be distressing and this should be considered in relation to the resilience of the record takers. There are inherent benefits with regard to coordination and maintaining quality standards in having some consistency and continuity in the minute takers. 2.34 The IRO/CP Manager also identifies the impact of limited administration resources elsewhere within children’s social care as having a negative impact with regard to the quality of reports, records, minutes and key documents overall. 2.35 The IRO handbook (7.3) states that the local authority has a responsibility to provide sufficient administrative support to facilitate the delivery of an efficient and effective review process and sets out key standards for the administrative process. The handbook also directs the IRO manager to inform the local authority of any shortfalls in this provision and I am advised that this action was undertaken but remained unresolved at the time of the Coreassets review. IRO/CP Chairs Capacity and Adequacy of the Service 2.36 All of the staff in post meet the standards required for their role as IRO/CP Chairs. No performance issues have been reported as part of this review. The arrangements, in respect of chairing these meetings are therefore considered adequate, (subject to capacity and adequate support being provided). 2.37 Following the Sunderland Ofsted inspection in 2012, there was the first of two subsequent reviews of the IRO/CP service that led to the staffing establishment being increased by one full time equivalent post. 2.38 During 2013 there was a significant increase in the numbers of children entering the care system; this prompted the LSCB to raise a formal challenge as to whether the IRO/CP service had capacity to respond to the rise in numbers and still deliver against their core quality assurance function. A second service review was undertaken and this resulted in a further increase in the staffing establishment, taking the total staffing establishment to 8 FTE. 2.39 The service has had three different managers since 2012 with the substantive manager retiring in September 2012, two interim managers have held the post between then and May 2014. At the time of this report a third interim is about to be appointed until a substantive manager is appointed. This level of change will have undoubtedly impacted on the stability of the unit. 2.40 The IRO/CP access the ICS/ESCR systems to record and check information pertaining to the child’s journey as part of their core function, the time requirements and limitations of this have been previously explored. 2.41 The staffing establishment of the IRO/CP services currently stands at 8FTE, yet there are 318 children (May 2014) subject to children protection plan and 499 10 children with looked after status (May 2014). Given the combined role of the unit this is equivalent to each officer holding a caseload of 102 children compared to the advised caseload of 50-70 children. 2.42 The high caseload, combined with the inadequate arrangements for administration, and the case recording system being applied undoubtedly compromises the ability of this unit to fulfil its core quality assurance and scrutiny functions. 2.43 The time span between 2012 and 2014 also spans the scope of the serious case review. The issues outlined above must be considered as contributory factors in both the absence of quality assurance and challenge of practice and also the quality of some of the records of formal meetings. These form part of the LSCB challenge questions regarding case records and arrangements for minute taking. Social Care Caseload levels 2.44 Social workers caseloads in Sunderland over the last two years have ranged on average between 20 and 35 per social worker, the increase in numbers of looked after children have placed additional pressures on capacity. Social care managers have endeavoured to manage the demands of this through a form of caseload management that considers case allocations balanced against the experience of the social worker and the complexity and level of risk of the case, however the rigour of this approach is untested in this review. 2.45 While this number of cases being held is comparable with many other authority areas it is acknowledged both nationally and locally as being too high. Social workers with caseloads exceeding 25 have very limited capacity to bring about change in families at the level and intensity needed to tackle complex high-risk needs. The administrative and associated business support issues notwithstanding, this pressure is exacerbated where there are high sickness levels, challenges with recruitment and high turnover of social workers as appears to be the case in Sunderland. 2.46 The case load of the Social Worker primarily involved in the case of Baby A and Child C was not considered to be high, as she was only case holding 17 cases. 2.47 We are given to understand that as part of the revised Recruitment and Workforce Development Strategies further research is planned to explore the issues impacting upon recruitment and retention, alongside a review of existing induction arrangements, training and development and career pathways within Social Care. The Impact of Training on Practice 2.48 It is concerning in the light of the recurrent themes in national SCR’s that practice does not appear to change in the light of the lessons learned. However, this appears to be a challenge nationally and is not unique to Sunderland Social Care. 2.49 There are number of ways of measuring the impact of training; 11 • Through built in evaluation measure at the point of training delivery that are then revisited at later date and this may need to be considered by both the LSCB and single agencies. • Reflection during supervision in relation to specific case discussions • Case file audit findings testing the impact of training and then reflected on with the worker or workers concerned. The latter two areas are identified as requiring strengthening in children’s social care. 2.50 The LSCB has a responsibility to ensure training is in place but this does not remove the employing agencies responsibility to ensure adequate training is provided to ensure a confident, capable and competent workforce. Within the findings of the Baby A case review there were some identified concerns with regard to social workers knowledge in respect of the impact of substance misuse, disguised compliance, and the vulnerability of babies under 12 months old alongside further quality issues with regard to assessments and the identification and management of risk. 2.51 Noting the pending review of the Workforce Development Strategy the Council may also wish to consider the value of conducting a training needs analysis of all staff, to accurately identify training requirements, and also exploring opportunities for action learning sets in relation to the above topics. Commitment needs to be given to enabling workers to prioritise training and this will present significant challenge given current caseloads and service demands. 2.52 The implementation of the LSCB Learning and Improvement Framework will be of added value locally in ensuring lessons learned are translated into improved practice. Conclusion 2.53 In exploring the underlying factors which compromised practice in this case it is apparent that the recommendations for children’s social care currently included in the overview report may lack the necessary focus and rigour needed to bring about effective change in social care practice. 2.54 The SCR process in this case has been compromised in that key questions remained unanswered at the point of the completion of the current version of the overview report. There are further implications to be carefully considered by the Local Authority and the LSCB if this report is to be published in its current form. Further consideration is also needed as to how the responses to the ‘why’ questions’ are to be shaped into robust and cross cutting recommendations forming part of the overview report and associated action plan, and it may be that there is a need to re-enter the SCR process to conclude this satisfactorily. 2.55 The wider safeguarding system and partnership relies as much on confidence and trust as they do on robust systems, processes and quality of professional practice. It is important that the further response by children’s social care results in a shared and clear view from all concerned that the recommendations from the SCR result 12 in improvement that promotes confidence in single agency and joint working arrangements. 2.56 Identified practice issues will be shared with social care staff without further delay and looked at within the context of the recurrent themes found in previous reviews undertaken in Sunderland and also in national serious case reviews. . Appendix 1 Sunderland Council Children’s Safeguarding Service response to the “why” questions asked in the Baby A and Child C Serious Case Review Overview Report. Meg Boustead. 1. Why was managerial oversight and supervision arrangements so inadequate, given the LSCB had undertaken an exercise relating to supervision in the recent past? 1.1 This section considers the reasons why management oversight was not good enough in this case. It also explains why supervision standards were not adhered to, and considers current arrangements for supervision across the service. 1.2 It is fully accepted that the level of management oversight in this case was not at the level that is expected by the service. None of the assessments, including the parenting assessment completed in early 2012 and the subsequent pre-birth initial assessment were signed off by the team manager, as they should have been. Also delays in completing the pre-birth assessment and arranging the pre-birth conference were not challenged. The individual team managers and senior management have accepted responsibility for these oversights. The wider systemic reasons why team managers are not always able to provide the level of management oversight that is expected are being addressed through external review. There is recognition nationally that the role of the team manager in a Child Protection Team is a particularly demanding one. In Sunderland each of the 5 child protection team managers has responsibility for between 200 and 300 children and young people. The demands made upon Child Protection team managers have increased over the past 2 years, as there has been an increase in the number of care proceedings being initiated and overall the number of children in care has increased by 25%. There is acknowledgement that team managers need additional support to enable them to discharge their responsibilities as consistently and effectively as they would want to. Consequently since September 13 2013 all of the teams now have at least one Senior Social Worker in post to provide additional management capacity. There is also a plan in place to increase the amount of administrative support available to Team Managers that will increase their capacity to provide effective managerial oversight to the teams. 1.3 Since the events described in this Serious Case Review all team managers and senior social workers have been directed to ensure that they quality assure and sign off all assessments. Developmental work has been undertaken with social workers and managers to increase their understanding of issues of risk to vulnerable babies. Since July 2013 there has been a requirement that all Child Protection Team Managers discuss all unborn babies in each social worker’s supervision. This was extended to babies under 2 in December 2013. Managers have been reminded to scrutinise the detail of plans for vulnerable babies living in Regulation 24 / Connected carer settings and to ensure that all plans for children in these circumstances detail contact supervision arrangements and evidence that carers are aware of their responsibilities and are capable of carrying these out. Team Managers are required to sign off these plans, and any pre-birth arrangements forms, prior to the discharge of a baby from hospital to family placements. The senior managers are also checking in their 1 to1s with Team Managers that the vulnerable babies’ protocol is being followed. 1.4 In addition Child Protection Conference chairs and Independent Reviewing Officers (IROs) now ensure that they have sight of all completed assessments, for child protection and looked after children respectively (previously if assessments were completed between reviews meeting the chairperson did not always see them). This will ensure that the quality of assessments is also monitored by the Independent Reviewing team for children who are either subject to child protection or are looked after. Further consideration is being given as to how similar arrangements can be developed for children who are subject to a Child in Need plan and Early intervention services. 1.5 As a result of this Serious Case Review we have put in place a new mandatory Management Development programme specifically for Team Managers in Children’s Social Care. The programme includes modules on learning from Serious Case Reviews, assessment, supervision and quality assurance. 1.6 The requirements for professional supervision of social workers, fostering officers and Independent Reviewing Officers are clearly laid out in our Supervision Policy that stipulates that supervision should be held at least 10 times per year. Although the policy complies with the LSCB’s supervision standards, it is recognised that supervision does not always take place at the frequency stipulated due to the workload pressures on team managers. The frequency of supervision is discussed by Senior Managers in formal 1;1s with Team Managers. Team Managers now have to provide evidence to Senior Managers that supervision of social workers is taking place. There is evidence of good supervision taking place across the 14 service, but this cannot be consistently evidenced at present, as other aspects of the system require development. Compliance with the supervision policy will be monitored through a supervision monitoring spreadsheet where planned and delivered supervision will be recorded. The quality will be monitored through a dip sample of supervision files. All managers will receive externally commissioned training on supervision on 19th June 2014. 1.7 There was a particular problem with the supervision of the IROs/Child Protection Chairs as there had been a part time manager in post between October 2012 and December 2013, which meant that this team were not receiving supervision as regularly as they should have been. Since January 2014 there has been an experienced interim full time Independent Review Team manager in post and regular supervision now takes place. During the same time period there had been a change in manager in the fostering team and management arrangements are now stabilised .We are therefore reviewing and strengthening our practice on supervision audits as an integral part of our new quality assurance framework. 2. Given that effective records contribute to better outcomes for children, why were records, minutes and plans of key meetings not available and why when some were submitted were they so poor? 2.1 This section explains why the records and plans for some key meetings were not available, and considers the process of recording the outcomes of such meetings and what has been done to improve this since the events described in the serious Case Review. 2.2 There are 3 related reasons why it was not possible to locate the minutes of all core group meetings, and some other meetings, in this case. These are, firstly, the way in which these documents were stored, secondly the number of different places where these records are held, and thirdly, in the case of core group minutes, the ability of social workers to make an accurate record of such meetings. The first reason is that the records are currently quite difficult to store in the electronic case file management system. Until February 2012 the assessments and plans were linked to what was the Integrated Children’s system, (ICS) now known as the Children’s Case Management system (CCM). However CCM (due to the difficulties with the nationally designed “exemplars”) did not create user-friendly documents and the service was criticised by Ofsted in 2010 and 2011 for this. Therefore the assessment formats, and individual children’s plans were removed from the CCM system between March and May 2012. The documents were instead replicated as Word documents, making them easier to complete and to read. The revised documents were welcomed by families, social workers and 15 other professionals. However the new challenge that this created is that these documents are not now linked into CCM so have to be stored separately in the Electronic Social Care Record (ESCR) which is a cumbersome and time consuming process. 2.3 The second, linked, reason is the number of systems where documents are stored, which can make locating documents difficult. The Individual Management Review Author of the Social Care report explained in her report that part of the difficulty in locating records of meetings is that there are 4 separate places where these are stored on the current electronic case files. As well as CCM itself, and the linked ESCR, there are also e-case files (a separate system that has not been used since 2012 although it is still holds some historical information). One of the problems with the e-case files, was that in the past information was not always indexed properly, sometimes making retrieval problematic. The other place where documents are stored are the social workers’ “Current work” files, which are working files where unfinished documents not yet ready to store in ESCR are held. This is a temporary situation until the new version 28.2 of CCM is implemented in August 2014. Version 28.2 will reconnect key documents to the CCM system and make storage and retrieval more straightforward. In the meantime all social workers have been instructed to make sure that they store all completed documents in ESCR to facilitate retrieval. Additional administrative support has been deployed to assist with moving finished documents from social workers personal work files to ESCR. 2.4 The third reason particularly relates to Core Group meetings, in that the social worker has to chair and take the record of the meeting at the same time. Consequently the record is not always of the quality that is required. At the time of the Serious Case Review it also had to be typed, correctly stored and then circulated to the other Core Group members by the social worker. (In some core groups other core group members from other agencies offered to take the notes of the meeting, which freed the social worker to chair, but this was not routine practice). Inevitably the competence of social workers in completing, typing, storing and circulating these records varied, particularly in the face of competing priorities on their time. A Core Group Meeting template has now been introduced to encourage consistency in the format. This is designed to assist social workers with the task of making a record of the outcome of core group meetings and improves the quality of the content. Business Support staff now type the minutes of the core group, save them into ESCR and distribute then to the core group members. 2.5 There are 4 different types of meetings; the first two are Child Protection Conferences and Looked after Reviews, which are both chaired by a team of Independent Review Officers (IROs) and Child Protection Chairs. In relation to the records of Child Protection meetings, these meetings are minuted by a team of 16 minute takers, most of whom are experienced and competent. There is still some variation in the quality of the minutes of Child Protection conferences and this is being addressed through the Children’s Independent Review Team Quality Assurance framework. As a result of this Serious Case Review the Child Protection Conference agendas, report formats and the template for the minutes have all been reviewed and strengthened in order to improve the outputs of Initial and Review Child Protection Conferences, in particular by making child protection plans more outcome focused. The minute takers now save the minutes of all Child Protection Conferences into the Electronic Social Care Record (ESCR) this is part of the electronic file for the child or young person. 2.6 Minute takers do not attend Looked After reviews, which are often less formal meetings and the child or young person is encouraged to attend. Consequently the record of these meetings is made by the Independent Reviewing Officer (IRO) and then typed afterwards. These records are then filed within the Electronic Social Care Record (ESCR) this is part of the electronic file for the child or young person. The difficulty locating some of the records of LAC reviews in this Serious Case Review has led to Business Support staff in the Children’s Independent Reviewing Unit being instructed to store all LAC Review minutes in ESCR, and this is now in place. 2.7 The 3rd type of meeting referred to in the SCR is the Strategy meeting. These meetings are normally chaired by Team Managers or Senior Social Workers and are recorded by minute takers. The minutes of Strategy meetings are recorded on a template agreed in December 2012. The format for recording the minutes of Strategy meetings and the process for circulating and storing them has been reviewed and strengthened, additional administrative support is being put in place to help ensure that strategy meeting minutes are returned to the minute taking service to enable speedy circulation and electronic filing. Business support resources have been identified to assist with this. 2.8 The 4th meeting type is the Child Protection Core Group. In common with many other areas, there is an on-going problem with social workers needing to chair the core group and keep a record of core group meetings. Until recently there was an additional burden on social workers, as they had to also type and distribute the notes of these meetings to attendees. However business support has now been put in place to type, circulate and electronically file core group minutes. There has also been further discussion with some SSCB partner agencies about other core group members taking notes at Core Group meetings in order to reduce the burden on the social worker. 2.9 Compliance with all of the above will be tested through the case file audit process, which is currently being strengthened. Case file audits are being carried out by managers and the findings are communicated to social workers so that and gaps or issues can be addressed. 17 3. Why are arrangements for chairing and note taking at various meetings so inadequate? 3.1 This section considers arrangements for chairing and minuting the 4 types of meetings detailed in 2.1 above. Generally the arrangements for chairing and recording Child Protection Conferences and Looked after Reviews in Sunderland works very well. All of the Child Protection Conference Chairs and IROs meet the requirements of Working together 2013 and the IRO Handbook. They are all very experienced at chairing meetings and complaints from service users or professionals about the conduct of the meetings are very rare. However following the criticism of the practice of the Child Protection chairs / Independent Review Officers within the Serious Case Review, the quality assurance role of the Children’s Independent Review Team has been reviewed and strengthened as it was recognised that they were not always providing sufficient challenge within the system. As Child Protection Chairs they are now more regularly raising Quality Performance Reports in relation to Child Protection Conferences and as Independent Review Officers (IROs), they are invoking the IRO Dispute Resolution protocol if there is any delay in plans for looked after children. The challenges they make are recorded in the Children’s Independent Review Team Challenge log as well as being recorded on the individual case files of children and young people. As described, in 2.4.and 2.5 above, arrangements have now been put in place for the Child Protection Conference minute takers to save the Conference minutes in ESCR, and for business support staff to save the Review record for LAC Reviews in ESCR, ensuing that there is a clear record and facilitating retrieval. 3.2 In addition, as part of the implementation of the recommendations from the Serious Case Review, the LSCB is reviewing the agenda, report format and the template for the minutes of Child Protection Conference are all being reviewed in order to strengthen and improve the outputs of Initial and Review Child Protection Conferences, in particular by making child protection plans more outcome focused. 3.3 As explained at 2.6 above, Strategy meetings are normally chaired by Team Managers or Senior Social Workers and recorded by minute takers. The minutes of Strategy meetings are recorded on a template agreed in December 2012. As a 18 result of this Serious Case Review the format for recording these minutes and process for circulating and storing them has been reviewed and strengthened. 3.4 As outlined in 2.7, core group meetings are chaired by social workers. The competency of individual social workers in chairing core groups will vary. Consequently training for social workers in chairing core groups is being provided as part of the Children’s Safeguarding Workforce Development plan 2014/15. This will include re-enforcing the requirement for social workers to be open to professional challenge from other core group members and the need to avoid being defensive when challenged. Until recently the social worker not only had to make the record of the meeting but also had to distribute and file this record. The minutes are now recorded on a template which ensures consistency in the format and promotes quality in the content they are given to business support staff to type, distribute and file. 4. Why are the training opportunities provided to frontline practitioners and the learning from research and reviews not leading to improved practice? 4.1 Until 2012 the training programme in place for social workers had a broad focus which reflected the wider models of professional practice and standards in place at the time. However during 2013, the early responses to the Munro Report (2011) begun to impact on provision and the training provided placed more emphasis on social workers being responsible for their own professional development. Social workers were provided with access to research and learning through Community Care Inform, an online leaning resource, and a range of e-training was provided, which has benefits in terms of accessibility. However this did leave a current gap in training opportunities for more experienced social workers and managers which we are addressing via the Management Development Programme and the 2014/2015 training programme, which includes externally commissioned training on assessment, which is being delivered in June 2014. It is recognised that more single agency training is required alongside the SSCB training programme. Consequently the Workforce Development strategy has been revised and updated, reflecting the changes in practice development nationally and the new social work career pathway that will be put into place over the next year. This will include the requirement for all social workers to maintain appropriate levels of child protection knowledge, including attendance at relevant SSCB training events, and personal reflection on their professional development. This will be identified through the Annual Appraisal and regularly monitored through supervision. The revised supervision audit process will check that this is in place for all social work qualified staff. 4.2 All Children’s Social Care staff are encouraged to attend SSCB training and attendance is monitored through the SSCB. The Children’s Social Care Individual 19 Management Review identified that the social worker and the two team managers had attended relevant SSCB training and departmental training. The social worker and her manager were also both booked onto the SSCB Vulnerable Babies workshops that were being held at the time of Baby A’s death but unfortunately were not scheduled to attend until after the events that led to the Serious Case Review. The SSCB is in the process of putting in place an audit to evaluate the effectiveness of training which will at first be used to evaluate SSCB training but can then be used to measure the effectiveness of single agency staff development, and this will compliment planned revisions to internal arrangements outlined above. 4.3 The learning from this Serious Case Review had already begun to be disseminated to the teams prior to the Learning and Improvement workshops hosted by the SSCB, in September and October 2013. The Head of Children’s Safeguarding and the Assistant Head of Children’s Safeguarding met with each of the CP teams about the initial learning from the SCR, including the requirement to follow the Vulnerable Babies Protocol, and the involvement of other agencies, especially midwifery, in pre-birth assessments. The learning from the SCR, and the Single Agency Action plan arising from the SCR has been shared with all Children’s Social Care Team Managers 5. Are high caseloads accepted by senior management if this leads to poor practice and leaves children vulnerable? 5.1 In relation to this Serious Case Review, the Children’s Social Care single agency management review author specifically asked the social worker about her workload at the time of the events described in the Serious Case Review, and she reported that she felt that her caseload at the time (17 cases) was manageable. However caseload sizes are an issue in Sunderland as elsewhere. 5.2 Overall most social workers’ caseloads are more manageable than they were 3 or 4 years ago. Caseload sizes were shared with the SSCB Vulnerable Babies Group in November 2013; at this time average caseloads in the child protection teams were approximately 25. There was a regional exercise on caseload size undertaken at this time and caseload sizes in Sunderland were in line with those across the Region. Although social work caseloads do fluctuate in size and complexity, and at times there is variation between teams, there is recognition that for some social workers they are still too large. Caseloads fluctuate in relation to demands on the service and the recent increase in number of Looked After children has inevitably had an impact on caseloads. Current caseload sizes in the Child Protection teams range between 22 and 29, but are over 30 in some instances. 20 5.3 Caseload sizes are actively managed by moving cases between staff, on occasion moving staff between teams to address a workload imbalance, and when necessary employing additional agency staff. Agency social workers are also used to cover for long-term absences and fill any gaps; there are currently 8 agency social workers in the service. The safe management of higher caseloads is dependent upon the experience of the individual social worker and the quality of the manager overseeing the work. More experienced managers are more able to support staff with higher caseloads than less experienced managers. The current structure is designed to have the Senior Social workers having reduced caseloads and taking on a quality assurance function alongside the Team Manager. Where the senior social workers are able to fully realise their role the team managers are able to operate more effectively. 5.4 Individual poor practice is not tolerated and disciplinary measures are put in place if practice falls below the acceptable standard and cannot be addressed by the worker and manager together. Although the skill mix across the social work teams has improved, the imperative to continue to recruit and retain experienced social workers remains as much a priority as ever. Children’s Social Care currently has 14 vacancies, 9 posts were recruited to in March 2014 and these staff are beginning to come into post. Of these new staff, 7 are newly qualified and 2 are experienced social workers. There is a further round of recruitment currently underway targeted at attracting experienced social workers. 6. What factors mitigated against expected practice in this case? 6.1 Although the practice identified in this Serious Case Review is not standard practice across the service, it does demonstrate weaknesses in the quality assurance mechanisms in place to ensure consistency of practice. There has previously been recognition that there is a significant challenge in relation to improving the consistency of quality of social work across the service. This was recognised by the Ofsted Inspection of Safeguarding and Looked after Services in February 2012, and continues to be evident through case file case file audits and management reviews. Some progress has been made, but due to the combination of staff turnover, volume of work/caseload sizes, problems with the Children’s Case Management (CCM) case system and sometimes-stretched management capacity, progress against these objectives has been slower than planned. 6.2 It is very difficult to say exactly why the failings that characterise this case occurred. The Individual Management Review Author did try to outline some of the reasons underlying what went wrong with the management of this case. One of the problems was that there was no handover between the two-team managers when the social worker moved team in October 2012. This was because the first team manager was on sickness absence at the time the social worker transferred 21 team. Both the team managers acknowledge that had this handover taken place the support needs of the social worker would have been more fully explored and the second team manager would have made fewer assumptions about the competence of the social worker to complete the tasks she had been assigned. The 2nd team manager fully acknowledges that she should have identified the lack of robust assessment at a much earlier stage. The capacity of team managers to provide sufficient critical challenge and the lack of challenge from other parts of the system, notably the CP Chair/IRO has been described above. These constitute missed opportunities and the response to this learning is being embedded across management and social workers. 6.3 A broader understanding of the reasons why practice in this case fell short of what is expected from staff and managers can be seen in the wider context of the other changes taking place across the service at the time. The immediate impact of 3 key managers leaving the service at the same time in September 2012 needs to be seen in the wider context of overall reduced management capacity due to implementing the new structure, at the same time as a reduction in the availability of key support services such as business support, training, and performance management. These factors were cumulatively significant in there effect on our capacity to maintain consistent levels of oversight in this case. 6.4 The lack of a robust quality assurance process throughout the child protection system at the time meant that the failings in this case were not identified until after the sad events that precipitated the review. This has led to the need for a full review of the QA framework in place across Children’s Social Care, including the fostering service and the Children’s Independent Review Unit. 7. The inadequacy of IRO resources has been raised by the Board on a number of occasions, why has there been no effective action to date? 7.1 As outlined in 3.1 above the current Child Protection Conference Chairs and IROs are all experienced at chairing meetings and meet the requirements of Working together 2013 and the IRO Handbook. The team is very experienced and knowledgeable, however there has been an issue about their capacity to provide effective challenge in relation to Child Protection and looked after planning. The service has benefited from additional resourcing and has implemented a range of measures to improve effectiveness. Regular reports from the IRO service to the SSCB will seek to provide further evidence and assurance of these improvements. 7.2 Since the Ofsted inspection of Safeguarding and Looked After services in February 2012 the capacity of the Children’s Independent Review Team has been reviewed twice, both times leading to an increase in the establishment. An additional permanent full time IRO post was created in 2012, bringing the capacity 22 to 7 full time equivalent. However with the increase in number of looked after children over the course of 2013 the capacity of the Children’s Independent Review Team again became stretched. Therefore an additional member of staff was seconded into the service on a temporary basis in January 2014.This post has now been established on a permanent basis, increasing the permanent establishment to 8 full time equivalent IRO/CP Chairs. 7.3 During 2013 the LSCB raised concerns about the capacity of Child Protection Chairs to carry out their quality assurance functions. Since the full time manager has been in post the quality assurance role of the Child Protection Chairs/IROs has been reviewed. The size of the establishment will be kept under review to ensure that there continues to be sufficient capacity in the service to provide effective challenge to both the Child Protection and looked after systems. 7.4 Between late 2012 and the end of 2013 there was also an issue in relation to the management capacity of the team, which was reduced following the early retirement of the Independent Review Team Manager in September 2012. A temporary part time interim management arrangement had been put in place while an alternative service delivery model was explored. This was reviewed in late 2013; an experienced full time interim manager has been in post since January 2014 and the permanent manager post is now being advertised. 1 Chronology of actions taken by Executive Director of People Services in response to the serious case review of Baby A and Child C as at 30th July 2014 In seeking to achieve the best possible outcomes for all people in the city, the People Directorate was formed in the autumn of 2013, with a remit which would see it embracing an open culture, be outward looking, and welcome the views and opinions of all stakeholders. Therefore in response to concerns expressed, the Executive Director informed a Sunderland Safeguarding Children’s Board of his intention to undertake a review of the service and subsequently wrote to partners and stakeholders inviting views and contributions in order to inform the terms of reference. Partners responded positively to inform the terms of reference and the Chair of the Safeguarding Board also submitted a report to the SSCB in December on ‘Concerns re: multi-agency working’ which further informed the terms of reference. The Executive Director drew up draft terms of reference by the end of December 2013 and during January 2014 sought advice on how best to deliver the review. Advice was sought via ADCS, LGA and SOLACE as well as taking soundings from colleague DCS’s. The outcome of the discussions led to the conclusion that a 2 stage approach would best deliver what is needed. The first stage would focus on the Council’s Safeguarding Service, its effectiveness and how it interacts with partners, including the response to a set of why questions posed by the Chair of the SSCB. The second stage would be a Peer Review to look at the Safeguarding system in its wider since and is scheduled for the autumn. Progress over the last six months The pace of change in Children’s Safeguarding Services can be illustrated below:- 1 March – April 2014 • In order to assess and address issues raised in relation to the Local Authority’s Safeguarding Services response to a serious case review, an independent organisation was commissioned to undertake a review. The review commenced in March, it concentrated on a number of “why” questions that had arisen from the services IMR report into the Baby A and Child C serious case review. • Since the Ofsted inspection of Safeguarding and Looked After services in February 2012 the capacity of the Children’s Independent Review Team has been reviewed twice, both times leading to an increase in the establishment. In particular in relation to the increase in number of looked after children over the course of 2013 an additional member of staff was seconded into the service on a temporary basis in January 2014.This post has now been established on a permanent basis, increasing the permanent establishment to eight full time equivalent IRO/CP Chairs. 2 2 May - June 2014 • Draft Action Plan from the review received mid-July. • All teams have a senior social worker and senior practitioners increasing the team manager’s capacity to provide effective and managerial oversight to the teams. • All team managers and senior social workers quality assure and sign off all assessments. Work has been undertaken with social workers and managers to increase their understanding of issues of risk to vulnerable babies. There is a requirement that all Child Protection Team Managers discuss all unborn babies in each social worker’s supervision and this has been extended to babies under two. • The quality assurance role of the Children’s Independent Review Team has been reviewed and strengthened. • Introduction of a new mandatory Management Development programme specifically for Team Managers in Children’s Social Care. The programme includes modules on learning from Serious Case Reviews, externally commissioned assessment training, supervision and quality assurance delivered from June 2014. • All social workers were instructed in June 2014 to store all completed documents in ESCR to facilitate retrieval. 3 July – August 2014 • Child Protection Conference chairs and Independent Reviewing Officers (IROs) now ensure that they have sight of all completed assessments, for child protection and looked after children respectively. • Team Managers now have to provide evidence to Senior Managers that supervision of social workers is taking place. • The Child Protection Conference agendas, report formats and the template for the minutes have all been reviewed and strengthened to make them more outcome focused to improve the outputs of Initial and Review Child Protection Conferences. • A full time manager is in post and the quality assurance role of the Child Protection Chairs/IROs has been reviewed and the permanent manager post is now being advertised. • Regular meetings with early intervention services to step down cases safely. 3 • Risk management approach each Monday to support the allocation of cases no unallocated child protection cases. • A range of improvements on templates has been made; A Core Group Meeting template to assist social workers with the task of making a record of the outcome of core group meetings and improves the quality of the content. Business Support staff now type the minutes of the core group, save them into ESCR and distribute then to the core group members. • All team managers and senior social workers quality assure and sign off all assessments. • Version 28.2 of CCM is planned for implementation in the autumn of 2014; this will reconnect key documents to the CCM system and make storage and retrieval more straightforward. Fiona Brown Chief Operating Officer People’s Directorate 4 APPENDIX 4 Action Plan re: Safeguarding Children service, Sunderland City Council Recommendations Actions required Outcome required Responsible Person Timescale Evidence of Action taken Aug 1014 Monitoring of implementation 1Information packs provided to foster carers and children in care, and professionals will be updated to ensure they are fully aware of the role of the Out of Hours service and how to access it. Landline and Mobile phones for workers all to have a message that carries the out of hours number. Induction packs provided to foster carers and looked after children include OOH number OOH Contact number is listed on website All foster carers looked after children and professionals to have out of hour’s information. Service Manager Lynne Goldsmith September 2014 Landline / Mobile phones now have appropriate messages. Audit / spot check of phones to ensure all workers undertake change 2. The supervision model and policy will be reviewed and implemented consistently across service areas in accordance with LSCB standards. Cases of babies under 1 year of age will routinely be discussed in supervisions Review and re-publish the supervision policy to ensure all members of staff receive quality supervision that is commensurate with their role and responsibility to safeguard children. Review the training The quality of social work is improved as a result of quality supervision which includes personal and professional development issues as well as casework discussion. In supervision staff are supported and challenged to ensure that the HOS safeguarding December 2014 The supervision policy has been recirculated. Supervision training was delivered in June 2014. Managers are required to discuss all cases of babies under 12 months in supervision from July 2013, and this was extended to all babies under 24 months in December 2013 Case file audits 5 programme on supervision for social care staff to support improved supervision in the following; reflective practice, impact challenge, risk analysis, developing SMART actions and appropriate recording. Ensure the quality of supervision is included in the case file audit programme. needs of the child remain at the centre of their social care practice. Compliance with supervision policy is monitored through 1;1 meetings with senior managers. 3. A service wide training needs analysis is to be undertaken across children’s social care and early interventions services; staff training pathways and mechanisms to measure impact on practice will be developed and training provided. TNA undertaken. Training requirements for staff identified. Training budget reviewed. Rolling programme developed and in place The quality of social work is improved through learning. Stephen Mason Service Manager August 2014 September 2014 October 2014 TNA tool has been developed and will be circulated and analysed by September 2014 . Followed up through annual appraisals 4. The IRO/CP service will be reviewed; this will ensure adequate capacity is available to perform core functions and will include Service review undertaken. Staffing capacity agreed IRO/CP unit able to fulfil core functions to a high standard as part of the broader quality assurance of HOS Service Safeguarding December 2014 Arrangements for the administration and case information of CP conferences and LAC review have been strengthened. Monitored through case file audit 6 administrative support. A revised quality assurance framework and quality standards for the administration of the service will be developed and implemented. Standards for administration function agreed and in place. IRO/CP quality assurance process established. children’s services. The permanent IRO manager post is currently out to advertisement, and the unit is currently being managed by an Interim Manager. Report templates have been revised to improve recording standards. Arrangements for note taking at core groups are being shared across partners reducing the burden on social workers, these are typed up by admin and uploaded to the case files and circulated appropriately A revised QA framework and dispute resolution procedures in the IRO units QA role is strengthened and a challenge log is now maintained with details of practice challenge also entered on the child’s care file. The signs of safety model of child protection conferencing is being considered as part of the broader improvement plan, and this decision will influence the revision of plan templates. 7 5. Arrangementsfor transition and case handover will bereviewed and protocols developed as required. Develop robust protocols for managing case transfers between teams and individual workers, ensuring this also allows for absence through annual leave or sickness, and aligned to the Step Up/Step Down protocols.. Children and families experience seamless transition through services. Opportunities for children to ‘fall between services’ are minimised. Head of Service Safeguarding December 2014 Regular meetings with early intervention help enable more robust step down and this is impacting on case- loads. Childs experience monitored through case file audit and quality assurance processes 6. A Case load management system will be implemented across social care and monitoring and reporting caseload levels will form part of the quality assurance framework. Develop an accepted model of case load management in consultation with staff and unions. Case loads are effectively managed according to capacity, competency, and experience of social workers Head of Service Safeguarding December 2014 Pending the development of a formal case load management system case loads are more closely monitored and currently stand at between 22 & 29 in child protection cases on average. Regular meetings with early intervention help enable more robust step down and this is impacting on case- loads Case load levels reporting forms part of quality assurance framework. 7. A robust quality assurance framework will be developed across children’s social care and early intervention services. This will identify measure and risk owners Review and revise the council’s quality assurance framework so that it meets statutory requirements and ensure it is implemented across children’s services. The council is able to quality assure the child’s journey through services Head of Safeguarding December 2014 A quality Assurance sub group is formed and tasked with developing a framework. Operational procedures are in the process of being finalised Weekly performance data is provided to senior managers and discussed at the weekly Regular reporting is visible, including reporting to the LSCB 8 SMT Risk management approach to Child protection allocation of cases introduced and information reported to the Head of service weekly. 7.Operational guidelines will be provided to all staff to ensure they are aware of requirements and expectations in LAC care planning, including formalising contact arrangements, placements out of area, assessments (including PARP) emergency placements, and requirements under section 20 and Reg. 24. Develop operational guidance for all staff On good practice and clear understanding and expectations of LAC Care Planning. Action Learning Sets and Road Shows are rolled out across teams.. Finalise review of Permanency Strategy. Children and young people’s needs are better understood and effectively addressed through robust assessment and care planning. The views and wishes of children are fully explored in assessment and care planning. Children and families/carers understand care plans and are involved in achieving good outcomes. Service Managers Lynne Goldsmith & Sheila Lough December 2014 Operational procedures are in the process of being finalised Weekly briefings planned to provide staff with clarity of changes to policy. Case file audits 8. The ICS case recording system will be reviewed to determine its suitability for purpose. A data cleansing exercise will be undertaken and appropriate file structures agreed. Operational guidance will be provided to ICS review undertaken & decision made regarding suitability or alternative commissioning. Data cleansing exercise undertaken to ensure all records are held appropriately. Case information management systems will support improved management oversight throughout the child’s journey through services. All safeguarding Service Managers December 2014. August 2014 (70% complete) 8 additional admin staff have enabled a data cleansing exercise to be undertaken between April 2014 & August 2014 which has also established an appropriate structure for case file management on ICS pending a system upgrade due later this Autumn. Social workers have been Case file audits & staff feedback. 9 ensure all staff are aware of the requirements and expectations of using the system effectively Staff are advised of interim recording requirements. July 2014 (complete) given operational guidance on case information management. 9. All assessments, plans (including court plans) statements and review reports are to be signed off by service managers. System gatekeeping mechanisms will enforce this post 2016. Interim guidance issued to managers and social workers Assessments are undertaken appropriately and quality is improved and consistent across service area. Head of Service Safeguarding December 2014 Every team now has allocated Principle SW’s &a Senior Practitioners – management capacity improved as a result. All assessments and plans are signed off by managers & Senior Practitioners- improving QA processes. Briefings have been delivered to all managers regarding the understanding of risk of vulnerable babies and compliance with pre- birth assessments and discharge arrangements. Case file audits 10.All social workers and managers to be reminded of need to follow child protection procedures especially in relation to notifying appropriate people about children subject to CP planning living outside the local authority area. Reminder made to all staff through team meetings. Check of all children currently placed outside area to ensure host authority is aware. Ensure that procedures are accurate with regard to post birth hospital discharge Host Local Authorities are aware of all children with child protection plans in their area. Compliance with child protection procedures. Vulnerable children are safeguarded effectively. HOS Safeguarding February 2014 Checks have been made to ensure all host authorities have been made aware of children subject to CP residing outside the Sunderland area. Lessons learned from the SCR have been shared with staff who are also encouraged to attend the LSCB briefings. Staff have been reminded of the need to comply with CP Regular case file audits as part of QA systems 10 arrangements procedures. Notifications and compliance with policy, in regard to CYP subject to CP plans moving to another LA |
NC042860 | Summary of a review into the death of a 6 month old boy on 22 December 2011 following complications from a head injury. The mother's partner was charged with Section 18 Assault (Causing Grievous Bodily Harm) and subsequently charged with Child A's murder. Child A's mother had routine contact with health services during her pregnancy and after Child A's birth and at no point were there any safeguarding concerns. Mother of Child A met her partner in October 2011 on the social networking site, Facebook. An allegation of sexual assault had been made against mother's partner in June 2011, leading to his dismissal from his role with a voluntary sector provider of services to adults with learning disabilities; this information had not been passed to the Independent Safeguarding Authority. Mother's partner was babysitting on 17 December 2011 when Child A was taken to hospital after suffering a head injury and cardiac arrest; it is not known whether mother's partner had moved into the family home at this time. Review considers issues of information sharing between agencies; systems designed to identify individuals who could provide a serious risk of harm to others, including the Multi Agency Public Protection Arrangements (MAPPA); and, use of social networking sites. Key recommendations include: development of the educational aspect of the Local Safeguarding Children Board's e-safety policy; development of greater understanding and communication of ideas and improvements between Adult and Children's safeguarding systems.
| Title: Executive summary of the serious case review in respect of Child A LSCB: North East Lincolnshire Local Safeguarding Children Board Author: Sian Griffiths Date of publication: 2012 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 2 July 2012 Executive Summary of the Serious Case Review in Respect of Child A This Executive Summary has been prepared on behalf of North East Lincolnshire Safeguarding Children Board. Page 2 of 14 GLOSSARY FAMILY: Child A: Subject MA Mother of Child A MP Partner of MA FA Father of Child A MPExP MP’s ex-partner CExP Son of MP Acronyms: A & E Accident and Emergency ACPO Association of Chief Police Officers CPS Crown Prosecution Service CRB Criminal Records Bureau EMAS East Midlands Ambulance Service GP General Practitioner IMR Independent Management Review ISA Independent Safeguarding Authority LSCB Local Safeguarding Children’s Board NLaG Northern Lincolnshire and Goole Hospitals NHS Foundation Trust OFSTED Office for Standards in Education OOH Out of Hours service for Children’s Social Care PCT Primary Care Trust PPU Police Public Protection Unit SCR Serious Case Review SCRP Serious Case Review Panel TOR Terms of Reference NELSCB North East Lincolnshire Safeguarding Children Board Page 3 of 14 1. Introduction 1.1 This report summarises the findings of a Serious Case Review that was undertaken during 2012 following the death of Child A. 1.2 Child A lived with his mother (MA) in North East Lincolnshire. On the evening of 17th December 2011, his mother’s partner (MP) was babysitting for Child A, who was 6 months old at the time. MP phoned MA, and then on her instruction, phoned the 999 service stating that Child A was not breathing. A Fast Response Vehicle and an ambulance arrived within minutes and Child A was taken to the local hospital where it was identified he had suffered a head injury and cardiac arrest. Child A was later transferred to a specialist paediatric unit at Sheffield Children’s Hospital, but died on 22nd December 2011 when the decision was taken to withdraw artificial life support. 1.3 On 18th December 2011, MP was charged with Section 18 Assault (Causing Grievous Bodily Harm) relating to Child A’s injuries and was subsequently charged with his murder. 1.4 A Serious Case Review Group met on 9 January 2012 to consider whether a Serious Case Review should be undertaken. In making its decision the meeting took into account the criteria outlined in Working Together 2010. In particular, the meeting identified the following criteria as having been met: “a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect”. 1.5 The purpose of a Serious Case Review is to: Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children. Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result and As a consequence, improve inter-agency working and better safeguard and promote the welfare of children’ 1.6 A Serious Case Review Group met on 9th January 2012 and recommended to Martin Wright, Chair of the Safeguarding Children Board, that a Serious Case Review be undertaken. The Chair endorsed this recommendation. During the course of this Review Mr Wright stepped down from the Chair’s role and the Review was then overseen to completion by the Vice Chair, Craig Ferris, with the agreement of the incoming Chair, Sue Woolmore who took up post on 15th June 2012. Page 4 of 14 1.7 A Serious Case Review Panel was set up to manage the Review and an Independent Panel Chair, Colleen Murphy and Independent Author, Sian Griffiths were appointed. Ms Murphy and Ms Griffiths both work as Independent Social Workers and are experienced in the undertaking of Serious Case Reviews. Neither the Independent Chair nor the Independent Author has any relevant professional or personal connection with any of the agencies involved in this Review. 1.8 The members of the Serious Case Review Panel were: Colleen Murphy Independent Chair Head of Safeguarding and Youth Offending NE Lincolnshire Council Asst. Director of Assurance & Adult Safeguarding NE Lincolnshire Care Trust Plus. Director Humberside Probation Trust Head of Integrated Family Services Integrated Family Services Designated Doctor, Child Protection/Consultant Paediatrician North Lincolnshire and Goole Hospitals NHS Foundation Trust Detective Chief Inspector Humberside Police Designated Nurse NE Lincolnshire Care Trust Plus. Consultant, Lincolnshire Children's Services. Lincolnshire County Council 1.9 The Serious Case Review was prepared in line with the requirements of Chapter 8 of Working Together, including case specific terms of reference. The Terms of Reference identified that the time period for consideration by the SCR should begin with the approximate date of Child A’s conception and conclude a week after child A’s death ie: 1st September 2010 - 31st December 2011 1.10 The specific terms of reference in relation to Child A were established as: TOR 1: Did each agency have in place policies and procedures to safeguard the welfare of children and vulnerable adults, and were they applied appropriately in this case? TOR 2: Did agencies have the opportunity to work together to promote the welfare of Child A? TOR 3: To what extent did agencies communicate across sector and local authority boundaries in order to promote the welfare of children and Page 5 of 14 vulnerable adults, and were there any barriers to achieving effective communication? TOR 4: What information was known to each agency regarding any aspect of safeguarding risk (relating to adults and children), and was this shared and managed responsibly? TOR 5: What was known about how well (or not) Child A’s family was supported or isolated? TOR 6: Did agencies respond to the known and presenting needs of Child A and the family? TOR 7: To what extent did services take account of issues such as: race & culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery in relation to their service user? TOR 8: How attuned are agencies to the risks that can be posed through use of social networking sites? TOR 9: To what extent did services have an understanding of the children and vulnerable adults that they were working with, their experiences and views, and how did this inform practice and progress? TOR 10: For IMR reports are there any common themes from previous SCR’s which your agency has acted on? 1.11 The Panel considered Individual Management Reports, including a full chronology of involvement with the family and critical analysis of the services from the following agencies: Humberside Police Lincolnshire Police Northern Lincolnshire and Goole Hospitals NHS Foundation Trust East Midlands Ambulance Service North East Lincolnshire Council Children’s Centres North East Lincolnshire General Practitioner Services North East Lincolnshire Council Children’s Health Provision 1.12 A Health Overview Report was prepared by North East Lincolnshire NHS Care Trust Plus, in order to provide an overview of all the health provision concerned. 1.13 It was identified that MP had previously lived in Lincolnshire and therefore enquiries were made with the Lincolnshire Safeguarding Children Board as to Page 6 of 14 any current or historical involvement with agencies in that area and reports requested from 2 relevant agencies as a result. 1.14 The Panel also identified a number of agencies who had had some contact with either Child A, MA or MP but where that contact did not justify a full IMR. These agencies therefore were asked to provide chronological and other relevant information within a brief report. The agencies concerned were: The agencies who provided brief reports were: NAVIGO (Provider of Mental Health Services in North East Lincolnshire) North East Lincolnshire Children’s Services Lincolnshire Children’s Services Sheffield Children’s NHS Foundation Trust The Armed Forces Welfare Service Voluntary Sector Provider of services to adults in Lincolnshire 1.15 The Lincolnshire County Council Safeguarding Adults Team had had some limited involvement as a result of an allegation made against MP which led to a criminal investigation. The Lincolnshire County Council Safeguarding Adults Team was therefore asked to provide a short chronology of their involvement. 1.16 Other parallel processes were taking place during the course of this Review. MP was charged with murder following the death of Child A and was awaiting trial. The trial took place at Hull Crown Court and on 27th June 2012 MP was convicted of the manslaughter of Child A. He had separately been charged with two offences under the Sexual Offences Act 2003 for an unrelated incident for which criminal court proceedings were also ongoing. An inquest into the death of Child A had been opened and adjourned pending the outcome of the criminal proceedings. 1.17 Careful consideration was given to seeking the involvement of Child A’s family in this Review in order to maximise learning. It was agreed that the mother of Child A, the father of Child A and MP should all be informed that the Serious Case Review was taking place. It was also agreed that the mother of CExP should be informed prior to the publication of the Review. 1.18 The panel particularly wished to seek the involvement of the mother of Child A as the key family member who may be able to contribute regarding the role played by the agencies concerned. However, this was not possible prior to the completion of the review due to the risk of potentially compromising the proceedings. It was therefore agreed that MA would be invited to meet with the Independent Chair and Author after the criminal proceedings were completed. It had been agreed that any further learning arising out of this meeting would be shared with the Serious Case Review Panel. Following the trial MA confirmed that she would like to take part in such a meeting and Page 7 of 14 arrangements to do so were made with her, however MA did not attend. Further attempts were made to contact MA and a second meeting offered, but MA did not respond. The review was therefore unable to benefit from her involvement. 2. Summary of events and the involvement of services The following information is a summary of the circumstances and events as they are known to the agencies involved with the family of Child A. 2.1. Child A was a white British boy who lived with his mother and her parents for the first couple of months of his life and then moved with his mother into their own home locally. It is understood that his maternal grandmother supported Child A’s mother throughout. Child A’s father is understood to have had no involvement with his son during his life. There was at the time, and remains now, no information to suggest that Child A or his mother had any particular needs or vulnerabilities that would indicate a requirement for specialist or additional services. 2.2. Child A was known only to health services and the Children’s Centre, from where most of those services were provided. Neither Children’s Social Care nor any other specialist service had any reason for involvement with Child A prior to the incident which resulted in his death. 2.3. MA had routine contact with health services during her pregnancy with Child A and after his birth, none of which resulted in any safeguarding concerns. The only potential issue of concern was that in November 2010 MA told her GP that she had been hit by her partner. This information was not passed on, however shortly afterwards she identified herself as now being a single parent and there was no further information to suggest that she was at risk of further assault. Child A was registered with the local Children’s Centre and was seen regularly by Health Visiting Services. Child A was developing as would be expected and there was no information to suggest any reason to be concerned about his care. 2.4. It is understood that MA and MP met via the social networking site Facebook some time around October 2011. It is not known when, or indeed if, MP moved into the family home, only that he was babysitting for Child A on 17th December 2011. 2.5. Little information is known regarding MP and none of the agencies in North East Lincolnshire were aware that he was in a relationship with MA. What is now known to this Review however is that prior to moving to Grimsby, MP had been living in Lincolnshire. MP served in the Armed Forces between 2009 and 2010, he was married at that time and the couple had a child CExP. MP’s service with the Armed Forces was terminated in June 2010 after he had spent a period absent without leave and was consequently assessed as unsuitable for the army. 2.6. It is further known that MP was employed from April 2011 as a sessional worker by a voluntary sector provider of services to adults with learning Page 8 of 14 disabilities1. His role was to support adults in their own homes. In June 2011 a female service user made an allegation of sexual assault against MP. He was bailed by the police whilst they investigated the allegations and in February 2012 MP was charged with two offences under the Sexual Offences Act 2003. At the time of writing the criminal court proceedings were still ongoing. The criminal charge was outstanding at the time the SCR took place. However, MP was subsequently found not guilty following a trial. 2.7. The allegations were referred by the Voluntary Sector Provider, as expected, to the Lincolnshire County Council Safeguarding Adults Team who provided support to the service user throughout the investigation. MP was suspended from his employment immediately following the allegations and dismissed in November 2011. In August 2011 he separated from his wife and moved to Grimsby. 2.8. At just before 11pm on 17th December 2011 MP, who was babysitting for Child A, phoned MA and told her that Child A was not breathing. She told him to call 999 which he did. A Fast Response Vehicle arrived two minutes later and an ambulance within 8 minutes. Child A was taken to hospital in Grimsby and from there transferred to Sheffield Children’s Hospital. Child A had suffered a non-accidental head injury and cardiac arrest. 2.9. Shortly after Child A’s arrival in hospital a Staff Nurse in the Accident and Emergency department of the hospital approached a police officer who was attending another incident and informed the officer that there were concerns that the injury was non-accidental. The Officer contacted the Police Command Centre and an investigation was immediately initiated by the Major Incident Team. In the early hours of 18th December 2011 MP was arrested on suspicion of causing Grievous Bodily harm, with which he was later charged. At a subsequent court appearance MP was charged with murder. MP was convicted of the manslaughter of Child A on the 27th of June 2012 following a trial at Hull Crown Court 2.10. On 17th December and in the following days, information was established as to whether he was known to other agencies, including the police. Formal safeguarding procedures were instigated leading to this Review. 2.11. On 22nd December 2011 Child A died following the withdrawal of the artificial life support on which he was reliant. 3 Key Issues Arising from the case 3.1. The information provided to this review has been subject to analysis, both within the Individual Management Reviews and by the Serious Case Review Panel, leading to this Overview Report. 1 The Voluntary Service Provider is not identified in this Review in order to protect the identity of the service user concerned. Page 9 of 14 3.2. Unlike the majority of children who are the subject of Serious Case Reviews, it is evident from the history of Child A’s brief life, that he was a child who at no point gave cause for concern to the agencies. There was neither at the time, nor with hindsight any information to suggest any concerns about his wellbeing prior to the catastrophic injury that resulted in his death. 3.3. The IMRs have identified that their agencies had suitable policies and procedures for safeguarding the welfare of children. There was, however, no basis for implementing any safeguarding procedures. Practice by the professionals concerned was largely of a good standard, in line with the service standards and expectations. Medical care provided to Child A following his injury was of a high standard and the police response to concerns raised by the hospital was swift and appropriate. 3.4. One issue that required attention has been identified in relation to the service provided by the GP, in that when MA disclosed possible domestic violence, the GP did not forward this information to other health professionals who were involved with MA. It is not clear if appropriate support or advice was given to MA, potentially representing a missed opportunity to support her and safeguard her unborn child. However, given that MA shortly afterwards was no longer in the relationship and there were no further known occurrences, it is quite clear that even had the midwife been given this information she would not have had reason to intervene further and this issue had no ultimate effect on the events that led to Child A’s death. Nevertheless this has been identified as something for future learning within the Health Overview report and is subject to a recommendation as a result. 3.5. Having considered the information that was available to agencies at the time and also with hindsight, the Review has reached the conclusion that there was no information to suggest that Child A could be at risk from MA, his primary carer. 3.6. The Review gave significant consideration as to whether any information regarding MP could, or should have raised safeguarding concerns or triggered action by any agencies. In doing so, the Review was mindful that MP was still awaiting trial for the murder of Child A and therefore was not making any assumptions as to whether he had in fact committed the offences for which he was charged. The focus was to consider whether in light of the information known to the Review it would have been reasonable, prior to 17th December to consider him a potential risk. 3.7. None of the agencies within North East Lincolnshire were aware of MP’s relationship with MA prior to 17th December. There was no basis on which they would have been required to seek information about any new relationship in which MA was involved. It is for a child’s parent to make decisions regarding who should care for their child. Safeguarding agencies would have no basis to intervene without specific information that a parent was recklessly putting their child at risk. Page 10 of 14 3.8. MP became known to a limited number of services in Lincolnshire arising out of the allegation of sexual assault in June 2011. The voluntary service provider who employed MP informed Lincolnshire Police and the Lincolnshire Adult Safeguarding Team immediately they were aware of the allegation and suspended MP. MP was dismissed from his employment in November 2011. The Voluntary Sector Provider had undertaken full reference and Criminal Records checks before employing MP and nothing of concern had been discovered. 3.9. The only process which was not followed correctly at the time was in relation to the Voluntary Service Provider who omitted to tell the Independent Safeguarding Authority, the body which makes decisions about barring people from working with children or vulnerable adults. The Voluntary Service Provider has accepted this was a mistake and taken remedial action. However, even had this referral been undertaken at the correct time, it would not have impacted in any way on the outcome for Child A, as MP was in a personal relationship with his mother, not an employment relationship. Had MP applied for further employment with children or vulnerable adults, the enhanced CRB check would have identified that he was currently under investigation for a serious sexual offence. 3.10. Whilst there was an 8 month gap between the allegation of sexual assault and MP being charged with a criminal offence, this was a result of the need to obtain specialist forensic reports and advice and the Review was satisfied that no criticism could be made of the police as a result. MP was subject to police bail, with proportionate conditions, during the investigation period and there were no other restrictions that could be placed on him in this regard. 3.11. The Review has considered in detail the current systems designed to identify individuals who could provide a serious risk of harm to others, for example the Multi Agency Public Protection Arrangements (MAPPA), or the 2 systems for disclosing information to the relevant members of the public: the Child Sex Offender Disclosure scheme and the Domestic Violence Disclosure scheme. None of these systems would have been applicable to MP as he had no history of offending. The Review is fully satisfied that there was no further action that the Voluntary Service Provider, Lincolnshire Police or Lincolnshire County Council Safeguarding Adults team could, or should have taken, which would have identified MP as a future risk to children or impacted on the ultimate outcome. 3.12. It is widely accepted that the prediction of the risk of harm by individuals is a complex and imprecise activity with the most accurate results arising out of the use of detailed assessment tools combining statistical calculations in depth clinical assessment. MP had, and at this time, still has no convictions of any nature. Whilst the allegations of sexual assault inevitably raise questions for his capacity for harm, this alone could not lead to a presumption that MP was a greater risk of physical harm to a child. 3.13. Finally the Review has reflected on whether the adults’ use of social networking sites played any significant role in these events given an emerging Page 11 of 14 recognition nationally of the particular risks this form of communication can pose. There is no information available to the Review that MA or Child A were targeted deliberately by MP via social networking. 3.14. The use of social networking sites as a means to meet a partner may carry different risks than other means. There may, for example be an illusory sense of transparency created by the process in which individuals can post their own version of themselves which may differ greatly from reality. There may also be a lack of information about family, work or friends which would provide a fuller context. However, no route to meeting a partner can be presumed to guarantee safety for the individual or their children. The degree to which an individual parent is alert to the potential risks of introducing another adult into their household is not something which agencies can control. This Review has concluded that there is potential for some limited educative work with parents as a result so has made a relevant recommendation. However, it is important that the likely impact of this should not be overstated. 3.15. In the absence of any known risk in relation to any of the adults concerned there was neither the reason nor the practical means to assess the potential for such a catastrophic injury to Child A. Child A’s death can be better understood as an unanticipated crime rather than as an unidentified safeguarding failure. 4. Priorities for learning 4.1 On the basis of the information available to it, this Review has concluded that the events that led to Child A’s death could not have been predicted either at the time, or with the benefit of hindsight. Direct lessons for the agencies are therefore limited. Two specific areas of vulnerability have been identified in relation to the GP service and the Voluntary Service Provider and recommendations made as a result. The remaining single agency recommendations relate to consequential learning about a range of practice such as will always arise from a Review of this nature. 4.2 Recommendation 4 from the Health Overview has been particularly commended to the Safeguarding Board given the significant role of GPs in contribution to safeguarding and the risks to any service during times of transition. 4.3 Two multi agency recommendations have been made, the first being a quite practical recommendation to develop the educational aspect of North East Lincolnshire Safeguarding Children Board’s e-safety policy. 4.4 The second recommendation, whilst on the face of it perhaps appearing a purely procedural one, has the potential to provide the basis of the most significant future learning. The Serious Case Review Panel considered that one of the most valuable aspects from an agency perspective arising out of this Review was the development of greater understanding and cross fertilisation of ideas and improvements between the Adult and Children’s safeguarding systems. North East Lincolnshire Adults and Children’s Page 12 of 14 Services felt that this was something that could have wider long term benefits for the way in which they worked together and for this reason identified the value of sharing this report with the Adult Safeguarding Boards in both authorities as well as the Children’s Safeguarding Board in Lincolnshire. 6. Recommendations for individual agencies The following recommendations were made arising out of this Review and endorsed by the Serious Case Review panel. A detailed Action Plan including timescales has been prepared in relation to each of the recommendations. Recommendation for the Voluntary Service Provider (made by the Overview Report): The Voluntary Service Provider to review its procedures for referring to the Independent Safeguarding Authority, and its successor, in order to satisfy itself that the procedures are adequately robust. Recommendations for North East Lincolnshire Children’s Centres: 1. Training needs assessment for front line children’s centre staff to be part of their annual appraisal, to include consideration of LSCB domestic violence and the impact on the child levels 1 and 2. 2. Continue to develop a multi-agency pre natal parent craft programme for all first time parents to be commencing September 2012 3. Include within home safety sessions advice on the use of social networking sites and keeping personal information safe. Recommendations for East Midlands Ambulance Service: 1. Ensure a safeguarding referral is completed after child death or prognosis, where this is unexpected. 2. Emergency call taker to have refresher training regarding the importance of initiating bystander CPR as soon as possible within the cardiac arrest situation by using “repetitive persistence”. 3. Re-enforce the importance of managers to be present at Police interviews. Recommendation for North East Lincolnshire General Practitioner Services: The lead GP will work with Designated Professionals and other safeguarding children leads to ensure all GPs and primary care understand and act on the need to share information with relevant professionals where there are safeguarding concerns and in particular where there are concerns in respect to Domestic Violence. Recommendations for North East Lincolnshire Children’s Health provision: Page 13 of 14 1. Children’s Health Provision will review and develop new guidance for staff in respect of both clinical practice and safeguarding in order to improve and sustain the quality of services. Safeguarding practice and supervision will be a focus for audit annually during the 2012/13 calendar year 2. Children’s Health Provision will work with midwifery leads to ensure that information sharing and the transition process between midwifery and health visiting is reviewed and recommendations made for a clear and robust process of transition and information sharing. 3. Children’s Health Provision will work with the CTP and Primary Care to strive towards all children having electronic SystmOne “shares” in place and where a practice uses EMIS, evidence of information sharing in line with the agreed process. 4. The community Children’s Safeguarding Team will raise awareness with staff through training about potential risks of social networking sites. Recommendations for North East Lincolnshire NHS Care Trust Plus (produced by the Health Overview Report): 1. North East Lincolnshire Care Trust Plus will through the Lead (Named) GP and Designated Professionals, and in collaboration with safeguarding children leads, ensure all GPs and primary care staff understand and act on the need to share information with relevant professionals where there are safeguarding concerns, and in particular where there are concerns in respect to Domestic Violence. This will be addressed through a review of accessibility of GP and primary care training which will be completed by September 2012 with a roll out of training by March 2013. 2. North East Lincolnshire Care Trust Plus will ensure that robust processes are in place by September 2012 for a written report completed by midwifery service identifying issues of concern, in respect to the health and/or welfare of mother, baby and family, in all circumstances, on transfer from midwifery to health visiting care. This will include the completion of a “nil” report where there are no identified concerns 3. North East Lincolnshire Care Trust Plus will work with provider organisations/services using SystmOne, to ensure that by March 2013, all barriers are removed, to the creation of a single, accessible record which reflects all the patient’s needs, including the impact of parental and environmental issues on children, and provides a full account of all activity to promote the health, and welfare, of children 4. North East Lincolnshire Care Trust Plus, through the Designated Nurse and the Lead (Named) GP, will work to develop, by October 2012, a localised template for a practice specific safeguarding children policy, and encourage adoption by all general medical practices. Page 14 of 14 5. North East Lincolnshire Care Trust Plus, through the Lead (Named) GP, working in collaboration with other relevant practitioners will by October 2012, develop a template for practice based protocol for the robust assessment and follow up of positive test results, and patient failure to attend appointments. The Overview Report made two further multi-agency recommendations designed to support future learning within the agencies working across children and adult’s safeguarding in both North East Lincolnshire and Lincolnshire. Recommendations for the Voluntary Service Provider 1. The Voluntary Service Provider to review its procedures for referring to the Independent Safeguarding Authority, and its successor, in order to satisfy itself that the procedures are adequately robust Recommendations for North East Lincolnshire Safeguarding Children Board: 1. The North East Lincolnshire SCB to review its ‘e-Safety strategy’ to develop and include opportunities for awareness raising of the potential risks to adults and their children when initiating relationships as a result of contact via social networking sites. 2. The North East Lincolnshire SCB to share the Serious Case Review Overview report with the Lincolnshire and North East Lincolnshire Adult Safeguarding Boards and the Lincolnshire Safeguarding Children Board immediately, in order to share the learning |
NC52796 | Three cases where babies sustained injuries believed to be non-accidental in 2022. Considers and compares the learning from previous reviews with the learning in respect of the 2022 babies, to enable reflection on the impact they have had on practice and safeguarding systems in the partnership, and where progress is still required. Learning themes include: impact of a parent's own vulnerabilities, including their poor childhood experience of being parented and on-going mental health issues; domestic abuse and violent behaviour, both historic and on-going; thresholds for neglect, including consideration of accidental injuries as a sign of neglect and understanding of cumulative harm; consideration of the child's lived experience; the need to engage with and consider the father of a child, or the partner of a mother who lives with, or spends a lot of time with the family (including same sex partners); the need for relationship-based practice, with children, with parents and the wider family and across agencies. Recommendations for the partnership include: to ask the national Child Safeguarding Review Panel to request that the Department of Health provides clear clarification to GPs regarding how they can safely and legally record information on adult records when there has been domestic abuse; consider alternative models of professional challenge, for example Portsmouth Safeguarding Children Partnership's model 'Re-think'; help professionals to ensure that practice is both culturally and individual family sensitive and that safeguarding responses are consistent, including professionals working with families having a safe space to consider their own values and biases.
| Title: Thematic review: babies who sustained injuries. LSCB: Bradford District Safeguarding Children Partnership Author: Nicki Pettitt Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. THEMATIC REVIEW BABIES WHO SUSTAINED INJURIES Nicki Pettitt 1 Thematic Child Safeguarding Practice Review on behalf of Bradford District Child Safeguarding Partnership. Babies who sustained injuries Author – Nicki Pettitt Contents Introduction page 1 The previous reviews page 2 The 2022 families considered page 3 Process page 3 Learning page 4 Recommendations page 26 Introduction 1. The Bradford District Safeguarding Children Partnership agreed to undertake a Child Safeguarding Practice Review (CSPR) to consider the local systems and practice when a new baby is expected or born to a family where there are predisposing risks and vulnerabilities. Three different cases where babies sustained injuries that are believed to be non-accidental were looked at in detail, and then considered alongside learning identified locally in previous reviews. The aim of the review was to consider how the safeguarding partnership can ensure and embed the changes in practice and systems that are required. 2. While there are findings from the three 2022 cases, the main aim of the review was to consider and compare the learning from previous reviews and enable reflection on the impact they have had on practice and safeguarding systems in Bradford, and where progress is still required. A Serious Case Review was undertaken in 2017 (Alice) and a learning review which considered four babies with injuries was undertaken in 2019. The new cases considered in 2022 found similar themes and learning. 3. There have been a significant number of babies with serious injuries since the 2019 review that have not been the subject of a CSPR. The Partnership agreed to consider these three children in detail however, as there were known or knowable vulnerabilities in the cases which resonated due to the similarities with the previous reviews. It was thought that a thematic review of this type would identify what the continuing issues with practice and systems are in Bradford. The previous reviews 4. The headline issues for the families considered in the previous reviews in Bradford were in the following areas: • Parents own vulnerabilities, including their own poor childhood experience of being parented, including abuse and neglect, victims of abuse through exploitation, mental health issues and substance abuse • Domestic abuse and violent behaviour 2 • Thresholds for neglect, including consideration of accidental injuries as a sign of neglect and understanding of cumulative harm • The existence of previous concerns about the children and their siblings, including injuries/bruising 5. Additional specific learning for systems and practice related to: • Limited seeking of or consideration of the child’s voice or lived experience from professionals involved in the cases • Underestimation of the impact of the mother’s vulnerabilities on the child/ren, and overoptimism about their ability to parent and protect their child/ren • Little evidence of the father or non-birthing partner being considered, despite a number having significant vulnerabilities that could be a risk • Timing and quality of pre-birth assessment • Limited involvement of adult services in children’s assessments and planning particularly regarding adult mental health • Procedures not being followed, including for the assessment of non-mobile babies with injuries, including bruises, burns and scalds • Gaps in required information sharing • Meetings being held when required, including strategy meetings • Drift and delay in assessments and plans • Lack of quality supervision that encourages professional curiosity and robust analysis • Gaps in key record keeping • Professional inconsistency due to staff turnover in key agencies and inexperience 6. The consideration of the 2022 babies shows that many of the issues continue to be a challenge in Bradford, as will be shown below. There is also evidence that, while subsequent babies have been injured, there has been some progress since Alice was injured in 2017. This review has also provided an opportunity to consider the impact of COVID-19, as the three babies were receiving services during the pandemic. The 2022 families considered1 Child 1 Considered at a Rapid Review meeting in March 2022, following the identification of severe injuries on the seven-week-old baby which were reported to be ‘overwhelmingly suggestive of physical abuse’. (Facial and mouth injuries, bruises, multiple rib fractures of different ages and a fractured clavicle.) Child 1’s mother has older children who were not in her care at the time of the pregnancy with Child 1. Both parents have a history of domestic abuse in previous relationships and mental health issues. Child 1 is mixed parentage, white and Asian British and was receiving ‘universal services’ at the time of the injuries. Child 2 1 All of the families considered were English speaking and there was no requirement for an interpreter. 3 Considered at a rapid review meeting in March 2022, following the identification of injuries to the four-month-old child. (Fractured femur and torn frenulum.) Following a pre-birth assessment, Child 2 had been made subject of a child in need plan. The mother had much older children who were not in her care at the time of Child 2’s birth, due to previous safeguarding concerns. Domestic abuse featured in the parents’ relationship and in the past relationships of both parents, including reported incidents of violence where the mother was the alleged perpetrator. Substance misuse was a concern for both parents and alcohol abuse a concern for the mother, along with long term mental health issues. Child 2 is of mixed parentage, white and Asian British. Child 3 Considered at a rapid review meeting in February 2022, when the 11-month-old had injuries that were thought to be non-accidental. (Bruising and healing rib fractures.) Child 3 lived with their mother and older school age sibling who had health needs. Both children were the subject of child protection plans due to emotional abuse with the risk of physical abuse highlighted. There had been an agreement that pre-proceedings work should be started under the Public Law Outline due to the extent of the concerns, which included domestic abuse from a new partner, mother’s reported aggression, alcohol and cannabis use, and poor mental health. The mother also had an older child who has not been her care since birth. Child 3’s father was not identified but is known to be Asian. Child 3 is of mixed parentage, white and Asian British. The Process 7. An independent chair2 and an independent lead reviewer were commissioned3 to work alongside local professionals to undertake the review of the three 2022 babies and to consider what they tell us about the current state of practice and systems in Bradford, bearing in mind the learning from previous reviews. The information provided to the three Rapid Review meetings was considered and additional information was requested from individual agencies as required. The reports and plans from the historic reviews were also considered. 8. Professionals involved at the time were involved in three case specific face to face group discussions with the lead reviewer that focused on practice in the cases and the wider system. A panel of managers and safeguarding leads from partner agencies worked with the chair and lead reviewer to consider the identified learning from the 2022 cases, to reflect on the known historic concerns identified in the Alice and four baby reviews, to consider evidence of progress, and to identify where continued improvement actions are required. 9. The lead reviewer had hoped to meet with the three 2022 families, to consider whether there is any additional learning from their perspective. A meeting was held with the mother of Child 3, and her views are included in the report as relevant. The parents of Child 1 and Child 2 did not respond to attempts to meet with them. 2 Nicki Walker-Hall is a previous Designated Nurse for Child Protection. She is an experienced safeguarding consultant who undertakes both children and adult safeguarding reviews. Nicki is entirely independent of the BSCP. 3 Nicki Pettitt is an independent social work manager and safeguarding consultant. She is an experienced lead reviewer and is also entirely independent of the BSCP. 4 Consideration of the learning 10. By considering each of the three 2022 baby’s, there was detailed and case specific analysis and the identification of learning. This was then considered alongside the reports produced from the Alice SCR and four babies learning review, with the aim of considering where there are continuing areas of practice or systemic concerns and whether further improvement actions are required. 11. The learning from the Alice SCR and four babies review was compared with the learning in respect of the 2022 babies, in the following areas: Impact of a parent’s own vulnerabilities, including their poor childhood experience of being parented4 and on-going mental health issues 12. While the three 2022 babies received significant injuries, the learning is largely in respect of practice with families with young babies where there is domestic abuse along with parental mental health concerns, and in two of the cases alcohol or substance misuse. When there are these predisposing issues in their family, these babies are more likely to be injured, which need to be considered alongside other issues such as poverty, poor housing, and the absence of support from friends and family.5 13. Although the 2022 children and their families were receiving services at different levels in the system, there were several similarities regarding the existence of predisposing risks; this reflected the learning from Alice and the four 2019 babies. All three 2022 cases show the need for professionals to know, consider and share historic and current issues that may have an impact on the parenting of a baby, both pre and post birth. While there were examples of information being sought and shared, there were also gaps in professional understanding of the case history both in respect of the parent’s vulnerabilities and the care of the older children in the families. 14. All the mothers in the 2022 cases had older children who did not live with them. When this is the case, it is important to check agency records and ask for information across agencies, to understand the circumstances of this, and for details of the mother’s care of their older children. It was only in the family of Child 3 that the mother was caring for an older child at the time of the birth of the baby and when the injuries were sustained. There were serious concerns about the neglect of that child, and he was the focus of much of the professional interventions, even after the birth of the baby. 15. Mental health problems were an issue for all the 2022 mothers. All had medications provided by their GP, but secondary mental health services were not involved at the time of the injuries to the children. Mental health concerns also featured in the histories of the men in two of the cases considered, according to the GPs of the father of Child 1, Mother 3’s new partner and the father of Child 3’s sibling. 16. Parental alcohol and /or substance misuse featured in the cases of both Child 2 and Child 3. There is evidence of ‘historic’ crack cocaine use by Child 2’s mother, which was not known by those involved pre-birth with Child 2, despite her telling the nurse at her GP surgery in October 2019 that she had been using the drug recently. There was also evidence that alcohol was an issue. Again, this was not particularly known or considered by those involved at the time, and the impact of drinking on her parenting was not prioritised when Child 2 was the subject of assessments or when on a CiN plan. Child 2’s father was known 4 including abuse, neglect, and exploitation 5 https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/physical-abuse/#risk 5 to the police for suspected cannabis cultivation and supply. There were no other indicators that he was misusing substances, but this required consideration in an assessment. 17. There had been long term concerns about Child 3’s mother’s alcohol and cannabis use. In 2019 there was a report from her second child’s junior school that he was bringing cannabis into school. Her new partner had a similar history and had been referred to services in respect of this on several occasions. 18. Professionals need to be trauma aware in respect of the children they are working with, but also when considering the parent’s early experiences. Professionals must ask about a parent’s own experience of being parented and other childhood difficulties and agency records need to be checked. This information then needs to be considered when undertaking an assessment of a child where potential parenting concerns have been identified and shared with other the professionals involved. The mother of Child 3 told the review that no professional acknowledged the experience she had in her teens of having a child with severe disabilities that she was unable to care for. 19. Little was known about the childhoods of the adults living with Child 1, 2 and 3. There was no significant children’s social care involvement in their early years, but there were indicators that some of them had experiences that were potentially damaging and traumatic. Mother 1’s own mother had serious mental health issues and she had become pregnant with her first child when she was 16 years old. The police shared information with the review about persistent domestic abuse in the home where Mother 2 grew up, and she had also first become a parent when still a child herself. Mother 3 was known to services as an older child due to concerns about her mental health, missing episodes, and alcohol use. It can know be seen that she was likely to have been a victim of abuse through exploitation and was first pregnant at age 15. She told the review that she was physically and emotionally abused throughout her childhood. All the mothers were victims of domestic abuse in previous intimate relationships. (Domestic abuse will be considered further below.) Comparison with previous reviews The impact of childhood trauma and adversity when adults enter a relationship and have children of their own is relevant and significant when working with a family in respect of their children, as are the ongoing mental health and substance misuse issues that challenge the parent’s. This was also the case with Alice’s mother in 2017, where were significant predisposing vulnerabilities that could be a risk to a baby, which were known to professionals but did not have an impact on their plans for Alice. Despite Alice being the subject of a child protection plan at birth, the review found that the parent’s vulnerabilities and the impact on a care of a new baby were not robustly considered and that earlier opportunities to take action, prior to her injuries, were not taken. What needs further consideration?* The three 2022 cases show that there continues to be a need for professionals across Bradford to consistently consider and understand how a parent’s vulnerabilities and experiences of trauma as a child and an adult pose a potential risk to their child/ren. Staff turnover, high workloads, and the impact of COVID-19 on ways of working, and limited access to training are likely to have had an impact. To improve practice in this area, this review suggests consideration of the following: 6 • Sharing the learning from these reviews as case examples during training and other development opportunities • Professionals need to be curious about the parent’s history in all cases where there are potential safeguarding concerns. This includes rigorously checking agencies records wherever possible • Professionals to be aware of the impact of childhood experiences and trauma, and of their responsibility to seek and share information from agency records and any new assessments, while being aware of the need to avoid stigmatising parents such as those who are care experienced • Professionals need confidence and skills and must be supported to have open and difficult conversations with families, including about the need to explore their own history of childhood trauma. This will improve their understanding of the impact of their difficult experiences on their parenting, show the need to seek and gain support to mitigate the impact, and to highlight on-going vulnerabilities such as their mental health or alcohol/substance use • Relationship-based practice should be promoted across all relevant agencies. Relationship-based practice is founded on the notion that a practitioner’s relationship with the family is the most powerful tool to facilitate change. A balance of trust, empathy, partnership, and appropriate authority can be reparative and effect timely change for children. It includes being clear about the consequences if change cannot be achieved. Child 3’s mother told the review that she was unable to trust any of the professionals involved, partly due to her own childhood experiences, but also due to the high turnover of staff and her view that professionals were untrustworthy and disingenuous about their plans to remove her children. She said that she would have been more receptive to an experienced worker who spent time getting to know her. • A partnership-wide commitment to provide targeted early help support to vulnerable families, including trauma informed parenting support • There is a need for agencies to consider how to rectify the impact of staff turnover and the loss of experienced professionals due to retention issues • Provision of challenging supervision of safeguarding cases when a professional is considering the impact of a parent’s vulnerabilities on their child/ren to avoid over optimism, underestimation of the impact, parental avoidance and the need for effective challenge when there are concerns about the actions of other agencies and the effectiveness of a plan for a child • Professional challenge must be seen as an essential part of an effective safeguarding system. While there is evidence of challenge and escalation at all levels across agencies, there is no one system that records when it is used, and some of the professionals involved in the cases being considered shared that they did not always escalate concerns either informally or formally when they disagreed with another professionals. Why this is the case should be explored further and other models of professional challenge should be considered, for example the Portsmouth Safeguarding Children Partnership’s model ‘Re-think’6 which encourages and promotes challenge and reflection between professionals 6 https://www.portsmouthscp.org.uk/wp-content/uploads/2021/09/7.21-Resolution-of-concerns-1.pdf 7 • There is a need to consider the human impact of working in safeguarding work in Bradford, including fatigue and emotional self-protection which can lead to a degree of acceptance of safeguarding issues such as neglect and domestic abuse – this needs to be acknowledged and professionals supported to reflect on this and understand the risks through reflective supervision and meetings with managers which includes tracking performance and transparent discussions about a practitioners need for support, learning and development, which may involve observations of practice in some agencies • Improved professional awareness of the need to consider available information on fathers/partners at all stages of intervention with families and meaningfully include fathers/partners in work with families. (Also see below section) • Consideration of children and family cases with good outcomes and where there has been positive multiagency practice in order to learn from what works well • The need for a review of the effectiveness of the district wide ACES Trauma & Resilience Strategy, which was agreed in 2021, but has not yet been embedded. It was written as it was recognised that with a comparatively young population and high levels of deprivation, the number of young adults (and therefore parents) with ACEs was likely to be high and would have a big impact on health in the city. The strategy includes a policy and procedure for implementation and aims to have a workforce that recognises the need to be ACE and trauma aware, but is currently impacted by on-going concerns about recruitment and retention however Domestic abuse and violent behaviour 20. One of the major issues that all three 2022 cases had in common was domestic abuse, both historic and on-going. The same was the case for Alice and the four babies in the previous review. The significance of domestic abuse in a family as a possible indicator of risk to young children, certainly of emotional harm but also potentially of a physical injury, is evident. The latter is not entirely based on evidence but the 2021 national CSPR The Myth of Invisible Men7 states that while evidence of a link between domestic abuse and physical abuse of children is ‘weaker than might be expected’ this may be due to a lack of research into this issue. The report adds that despite this lack of evidence, professionals ‘intuitively’ hypothesise that there is likely to be a link between ‘the commission of domestic abuse (against an adult) and real or potential abuse to children’. This CSPR was undertaken prior to there being clear information about how and who inflicted the injuries on the three children being considered in 2022, but the evidence of domestic abuse amongst the adults in the families considered required further analysis at the time. 21. The parents of all the 2022 children had been in abusive relationships prior to the relationships where the children were conceived. Some of them were known to have witnessed domestic abuse and suffered emotional harm in their own childhoods, and there is the potential that the others did too, although this was not known at the time. This experience in childhood will have had an impact on the parent’s own emotional development and expectations of relationships. There is a view, and it is often found in safeguarding reviews, that if a child witnesses’ domestic violence and abuse, they may be more likely to reproduce this 7https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1017944/The_myth_of_invisible_men_safeguarding_children_under_1_from_non-accidental_injury_caused_by_male_carers.pdf 8 behaviour as adults in an ‘intergenerational cycle of violence’8 than those who grew up without this experience. Some of the parents considered by this review also had police involvement for perpetrating violence outside of an intimate relationship, including the mothers of Child 2 and Child 3. 22. The father of Child 1 lost his job as a care worker due to concerns about the use of unauthorised restraining techniques and implied issues with his anger. This happened just weeks after the baby was born and prior to the injuries being identified. This could have led to increased stress, financial concerns, and worry about the impact of the dismissal of him finding a new job. This was not known to those providing services to Child 1 and their mother at the time9. As well as these concerns about him at work, there were previous allegations from past partners about him being domestically abusive, and the year before the baby was born his parents (the baby’s grandparents) alleged he was violent to them. As there were no children in his family at the time, this information was not shared. 23. Domestic abuse, like parental mental health, is likely to be an issue that reoccurs over time. Without evidence of challenging and effective specialist input to help both the perpetrator and victim, they will continue to be vulnerable to current or future relationships being abusive. Any plans for children need to realistically consider the likelihood of on-going or future domestic abuse. This is even when, as in the case of Child 2, the mother is convincing in her determination to separate. In that case there was a degree of professional optimism, and no robust consideration of how realistic the separation was, particularly when the baby was the partner’s first child and when the mother had little other support. The decision not to have an Initial Child Protection Conference (ICPC) in respect of unborn and new-born Child 2 was taken without significant historical information being considered, without any engagement with the father/perpetrator, and despite concerns about engagement from the mother with several professionals, including domestic abuse services. 24. Professionals need to understand and consider the history of domestic abuse in the relationship and in previous intimate relationships, consider other indicators of aggression or violence, and be realistic about the likelihood of domestic abuse reoccurring. In the case of Child 1, both parents had been in abusive relationships previously. The mother had been asked several times, by routine questioning during the pregnancy, about her relationship with her new partner. She was consistently insistent that while domestic abuse had featured with her first husband, she was safe and had no concerns in her current relationship. Routine questioning is expected practice in Bradford when a woman has contact with health professionals and her partner is not present. This includes midwives, health visitors, GPs and when presenting at hospital. 25. Routine questioning about domestic abuse can give a woman permission to speak about abuse, however The Myth of Invisible Men report found that there is ‘limited capacity to develop trusting relationships with parents’ and that routine questioning rarely leads to a woman disclosing and to ‘different service responses.’ However, the Department of Health NICE guidance is quite specific about the benefits of routine enquiry into domestic abuse and the risks of relying on targeted enquiry due to stereotype and professional bias. 8 NSPCC report Research Review: Early Childhood and the ‘Intergenerational Cycle of Domestic Violence’ Nov. 2019 9 The agency where the father worked dealt with the matter internally and did not inform the safeguarding adults service. This has been taken up with the agency. There is a possibility that had this information been shared with the LADO in adult’s services, this information may have been shared with children’s services as the father had a young baby. 9 In their review into the death of Star Hobson, the national CSPR panel reinforced the importance of health routine enquiry about domestic abuse. 26. It is thought that victims may avoid reporting or disclosing domestic abuse due to the fear of CSC involvement with their children, which is something that the professionals involved with the three children in this case felt was an issue in the cases and more generally. Domestic abuse was the focus of professional interventions in respect of Child 2 and their mother. The case was referred to MARAC on several occasions because of the identified risk to her and a pattern of her disengaging with services and reconciling with her partner. The Rapid Review meeting recognised that there should have been more MARAC referrals due to the number of further high-risk assessments from police officers, that some of the assessments were wrongly graded as low or medium risk, and that not all the of incidents resulted in information sharing with CSC. There was, again, a view that Mother was willing to cooperate with police action and it appears that she was persuasive in her statements that she intended to permanently separate from the baby’s father, despite her actions contradicting this. Her history of always withdrawing her support to a prosecution should have been taken into consideration on every occasion. There was a perceived understanding that she felt she was protecting herself and Child 2 by refusing to accept help, but there was a need to focus on the risk of the abuse continuing and the harm this would inflict on both mother and child, as well as the known increased risks following separation. A strategy meeting was held in January 2022, following several violent incidents and information that the couple were living together despite the mother agreeing to cooperate with domestic abuse services and the child in need plan that required her to remain separated. Again, professionals believed the mother now planned to permanently separate and agreed that the CiN plan should continue rather than an ICPC being held. This may have been a case of confirmation bias, where professionals dismiss or underplay the significance of information which does not support a plan. There were two further domestic abuse incidents known to professionals before the injuries to Child 2 on 22 February 2022. 27. Child 3’s older sibling had been living in a household with both his parents where serious domestic abuse featured, and he was a victim of that abuse. The level of risk was high, and the case was the subject of a MARAC in 2020. There were long term concerns about the behaviour of Child 3’s sibling, including regular aggressive and emotional outbursts that were an indicator that he had suffered and continued to suffer trauma at home. After the sibling’s parents had separated, on-going neglect was an issue, linked to his mother’s physical and mental health concerns and cannabis use, and there were indicators of physical abuse. At the age of seven he was recorded by the police as the suspect in several incidents, including displaying aggressive behaviour to his mother, and to children and properties in his neighbourhood. There was an understanding that he was impacted by his home situation, but there was also a degree of child-blaming which needed to be challenged by all professionals. The review has found that there was significant emotional abuse and neglect in respect of Child 3’s older sibling prior to and following the birth of Child 3, that had not been sufficiently identified and assessed both in regard to the impact on the older child or the likelihood of neglect of the new baby. This will be analysed further below. There was assertive practice when Mother 3 had a new partner, and it was recognised that he may pose a risk. It was important to consider how the mother would cope with the limitations on contact imposed in respect of the new partner 10 however, and how this may impact on the children. Plans need to be transparent and realistic in expectations and clear about how success will be measured. 28. Domestic abuse is undoubtedly a significant issue for families and for professionals in Bradford. West Yorkshire Police had the highest rates of domestic abuse-related crimes in England and Wales in 2020 and 2021. Anecdotally there is a view that it is one of the biggest challenges for professionals who are safeguarding children in the city. This is not just a local issue, as shown in the 2022 national CSPR10 ‘Child Protection in England’ which identifies ‘a need for sharper specialist child protection skills and expertise, including in respect of domestic abuse.’ None of the three 2020 cases considered were straightforward, with multiple parental vulnerabilities, some of which are known to increase a person’s risk of experiencing domestic violence or abuse, such as ‘having a long-term illness or disability, including mental health problems.11 Expertise in responding to domestic abuse and systems that enable the issue to be addressed effectively are both required. 29. As a way of trying to deal with the high number of referrals for consideration at the MARAC12 (multi-agency risk assessment conference) locally, there have been recent changes to the process. While the identification of high-risk cases and a wish to consider them in a multi-agency forum is positive, the significant demand has reportedly had an impact on the quality of multi-agency information sharing, reflection and plans made in the MARAC meetings. The relevant board is aware of concerns about capacity of the meetings, and the need for consistent chairing and improved outcomes/impact of MARAC meetings on the protection of victims, including children in the family. This system pressure has a related impact on victims and perpetrators in high-risk cases not always getting the services they need. The Bradford District Safeguarding Children Partnership need to be aware of the impact on safeguarding children of the systemic problems. The review that considered the death of Star Hobson, a Bradford child, recommended that domestic abuse services needed to be reviewed and commissioned that ‘guide the response of practitioners and ensure there is a robust understanding of what the domestic abuse support offer is in Bradford. This should lead towards a coordinated community response by providing a bridge between services. Immediate action should be taken to provide multi-agency practitioners with guidance and/or training, supported within supervision, to enquire about domestic violence in mixed and same sex relationships, to develop safety plans for victims and their children and support perpetrator interventions.’ This work is ongoing, so no further recommendations are made in respect of domestic abuse in this review. 30. The 2022 National CSPR has published a practice briefing on safeguarding children in families where there is domestic abuse. The key findings are in respect of the lack of understanding of domestic abuse evident within multiagency meetings and plans, no ‘whole system’ approach that safeguards children as well as adults, and an overemphasis on physical violence and lack of consideration of the dynamic of the situation. This briefing needs to be considered alongside both the learning from this review and the work being undertaken following the review into the death of Star Hobson to align any changes required. 10https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1078488/ALH_SH_National_Review_26-5-22.pdf 11 Recognising and responding to domestic violence and abuse. Quick Guide. SCiE 2020 12 A multi-agency meeting to share information on high-risk domestic abuse cases and agree co-ordinated action plans to safeguard the adult victim. Children are also considered. A CSC representative attends and the health representative shares outcomes with the relevant health visitor and/or school health nurse. 11 Comparison with previous reviews The reviews completed on both Alice and the four babies included concerns about domestic abuse and violence between the parents/adults and the impact on the children and on their non-abusing parent’s ability to prioritise the care of their child. There was also identification of gaps in the professional knowledge about the impact of domestic abuse and the potential risks to children. One of the cases in the four babies review included a young and vulnerable mother who was left to supervise contact between the baby and her violent ex-partner, In another, the father was known due to his violent behaviour, but this risk was not robustly considered, even when there was a prior injury to the baby. There was some good practice identified in the 2022 cases. Routine questioning about domestic abuse was largely evident. The health visitor for Child 1 was tenacious in completing an ante-natal appointment where questions were asked about the older children and previous domestic abuse, and professionals who met the lead reviewer were clear that domestic abuse is a serious child safeguarding issue. What needs further consideration? * Work is being completed regarding the professional response to domestic abuse in Bradford following the national CSPR in 2022. This should include consideration of the following reflections made during this review: • A subgroup of the Domestic Abuse and Sexual Violence Board is reviewing the current MARAC process. This should include consideration of both the whole system arrangements and the minutiae of MARAC practice in order to ensure the required improvements and impact. An update on this work should be shared with the Bradford District Safeguarding Children Partnership. • Clear instructions are required about expected information sharing about domestic abuse incidents and MARAC plans with professionals working with all members of the family, including GPs. It is recognised that how and where this is recorded on a patient’s record will provide a challenge for Primary Care, but this should not get in the way of good information sharing and improved awareness of domestic abuse in a family. • While a better MARAC process will consider high risk cases, there is a need for a review of the domestic abuse strategy and the documents that support it, that will provide appropriate services at all levels. This should include prevention work for those identified as at risk of domestic abuse through to the high-risk cases, and early interventions for those where lower-level domestic abuse is an issue. • Consideration should be given to the attitude of practitioners to domestic abuse in Bradford, given its prevalence, and whether this has an impact on risk assessment and children’s plans. • Child victims of domestic abuse who have lived in households where domestic abuse occurs are at increased risk of domestic abuse in their own future adult intimate relationships. The Bradford District Safeguarding Children Partnership should work with agencies to promote the need for preventative work with high-risk groups, such as care leavers and children previously subject to a child in need or child protection plan due to domestic abuse. Preventative resources including about healthy 12 relationships and how domestic abuse can be avoided should be targeted to these children in order to have the most impact • Consideration should be given to how help can be provided when there are early indicators of domestic abuse in a relationship, including services providing evidence-based work with perpetrators • Information and research about the recurring nature of domestic abuse within a relationship and the likelihood of both victims and perpetrators entering new relationships which are abusive need to be shared with parents and professionals, and requires consideration when a relationship breaks down • When a pregnant woman shares that she has been the victim of domestic abuse in a previous relationship, midwifery and health visiting services need to consider what additional support may be required • Multi-agency meetings such as core groups and child in need meetings need to provide the space for professionals to consider if over optimism or confirmation bias is an issue when working with families where domestic abuse occurs • Plans for working with families where domestic abuse is an issue should be bespoke and include; an assessment of what the abuse involves, as all circumstances are different; the likely impact on the child in the family; and measurable outcomes. The review into the death of Star Hobson highlights the need for professionals to seek a thorough understanding of the relationship between the adults, including those in a same sex relationship Thresholds for neglect, including consideration of accidental injuries as a sign of neglect and understanding of cumulative harm 31. When domestic abuse is evident in a household, there is the risk that other safeguarding concerns may be marginalised. Neglect was clearly an issue / risk for the child/ren in both family 2 and family 3. The history in respect of the siblings of Child 2 required consideration and sharing across those involved both pre and post birth, along with the consideration of what had changed to consider if there was any risk to the baby expected by Mother 3. The complexity of the case was partly due to the older children living in different parts of the country, where the mother had also lived for some years prior to her returning to Bradford in 2020. Information seeking and sharing across local authority, health and police areas can be difficult and it is therefore not always prioritised by busy professionals. As Mother 2 was not caring for any children at the time of her return to Bradford, there was no need or justification for information sharing at that time, although there was evidence that it was sought and considered during the pregnancy, which is good practice. 32. During her pregnancy with Child 2 there were concerns about domestic abuse with the child’s father. This, and the previous concerns led to a social work assessment being undertaken pre-birth. A strategy meeting was then held due to concerns about her sporadic engagement with ante-natal care and domestic abuse support and her known mental health issues. Consideration was given to holding an Initial Child Protection Conference (ICPC) due to worries that the unborn baby could be ‘at risk of physical harm, neglect and emotional harm’ due to concerns about domestic abuse and the mother’s mental health. There was some understanding of the mother’s issues with alcohol, and this was discussed at the strategy meeting as there had been alcohol involved in some of the domestic abuse incidents. But there was no consideration of the recent serious substance misuse. As stated above, there was information available in the GP records that 13 Mother had been using crack cocaine as recently as October 2019. This information was not known so was not considered when the decision was made to work with the family on a Child in Need basis rather than holding an ICPC, and there was no exploration of how Mother had avoided the use of substances since then, if this was indeed the case. 33. The social work manager chairing the strategy meeting recognised concerns regarding the lack of meaningful cooperation from Mother 2 and recorded their view that an ICPC be considered. It was agreed that a joint visit from the social worker and the health visitor should be undertaken first. During this visit there is evidence that domestic abuse was the focus. The mother stated that she was separated from her abusive partner, and that there had not been any incidents reported for three months. This was seen as positive, and it was agreed that a CiN plan was sufficient for the baby when it arrived. The risk of neglect due to mother’s issues was not the focus of the visit or the decision making about an ICPC. The fact that the mother was also voicing her willingness to engage with the CiN plan was also taken into consideration. There is little evidence that her mental health, or evidence of recent alcohol and substance misuse was considered sufficiently, with the domestic abuse seen as the prime concern. There was also no evidence of the father of the baby being seen by professionals in respect of the plan either pre or post birth. The decision was made without consideration of the other agencies who were involved in the strategy meeting, and there was no further strategy meeting held despite a change in the plan form the first. 34. There was evidence that Child 3’s mother struggled to meet the needs of her school age child, and there was a need to consider the impact on that child of a new baby and a view on the likelihood of the new baby being neglected and potentially harmed due to the known issues with mother’s care of her older child. Child 3 was made the subject of a child protection plan when they were six months old, due to ongoing concerns about the care the older sibling was receiving from their mother. The information shared with the review clearly identifies significant neglect of Child 3’s older sibling. There had been a referral from the mother’s GP during the pregnancy requesting a social work assessment pre-birth, due to an awareness of on-going concerns about the care of her older child and mother’s own vulnerabilities, which included the impact of her physical health difficulties and mental health concerns. Information available in the GP records included a report written in 2019 following a referral for psychology input to improve the mother’s engagement, help with pain management, and reduce admissions for her health condition. The report outlined several concerns including her difficulty in regulating emotions, particularly in relation to anger, and issues with her cognitive functioning. What it did not include was consideration of the impact of these issues on her parenting. There is no evidence that this potentially concerning information was specifically requested from the mother’s GP or shared by them when she was pregnant with Child 3 or more generally when concerns were being considered in respect of the older child. The case would have benefitted from full consideration of what was known about the mother’s health, mental health, and cognitive ability, along with an understanding of the medication / drugs she was taking, both prescribed and otherwise, and the impact on her parenting. Comparison with previous reviews In respect of Alice, there were two pre-birth assessments undertaken, both of which identified significant concerns about the mother’s ability to meet her own needs and her capacity to parent. This led to a child 14 protection plan being made pre-birth. The mother’s apparent improved engagement with the assessment led to a view that she would work with professionals and that she should be given a chance to care for the baby. This was similar to what happened with Child 2 in the 2022 cases, where the mother’s apparent willingness to cooperate with assessments and a CiN plan led to a continued pursual of this intervention even when there was evidence of poor engagement and increasing risks. Those involved explained that Mother 2 was likeable and was never avoidant, aggressive or rude to professionals. It was rightly understood that she had experienced loss and trauma. She was also reassuring regarding her separation from her partner and her relapse plan regarding alcohol. Like for Alice and the four babies, there were issues with the timeliness and quality of prebirth assessments in respect of both Child 2 and Child 3. There was also drift and delay in respect of Child 3. There were a number of incidents of concern in respect of Child 3’s older sibling in the months prior to the injuries to Child 3, including injuries to the sibling which were thought to be due to lack of supervision rather than physical abuse, although with hindsight this has been reconsidered. In this case the focus was largely on the sibling and the mother’s own complex needs, rather than on Child 3, although there was good child centred practice from the health visitor, as will be outlined below. Despite information that could indicate a risk of harm to Child 3 from the time of his mother’s pregnancy with him, it was not until much later that a specific assessment was completed that considered Child 3’s needs and resulted in a child protection plan, which was again dominated by the concerns about the older child. There were also indicators and discussion that Child 3 needed to be subject to the Public Law Outline13 (PLO) but this did not happen until after he was injured. (See below) What needs further consideration? * Dissemination of information and learning from reviews is key to communicating expected and the need for improved practice. Partner agencies should consider how they can, both together with other partners and internally, effectively disseminate this learning. This should include consideration of previous attempts with a view to understanding what the barriers have been. There is a need for all partner agencies to consider how they can ensure that their relevant professionals are aware of: - the threshold for neglect - the indicators of neglect - the existence of the neglect tool kit - the risk to children of cumulative harm when a child is neglected over time - the links between neglect and other forms of abuse - the possibility of professional desensitisation when working with families where neglect is a concern There is a need for consideration of significant harm from neglect for children where there are recurring issues with injuries, lack of supervision, and poor attendance at school and at health appointments. 13The PLO sets out the duty of the Local Authority pre-proceeding - when they are considering making a care application. 15 Professionals need to be clear about the significance of the cumulative impact over time of neglect, and avoid incident led practice. All meetings held need to reflect the voice of the child and their lived experience as part of the meeting and this needs recording specifically. There must be effective challenge when language or discussions are child blaming. There is also a need for relationship based and skilled social work engagement with parents to consider if they understand what neglect is and understand the impact it will have on their children. There is a complexity to working with different communities across Bradford, and this brings a risk of making cultural assumptions. All professionals need to be helped to understand the traditional, established and emerging communities in Bradford to ensure that practice is both culturally and individual family sensitive but that safeguarding responses are consistent. In the three families the mothers were white, and the fathers were black Asian. Information is available that in all three cases there was limited, if any, support from the children’s wider maternal or paternal families. The complexity of the adult relationships, including the impact of having a child who is mixed parentage in traditional communities where this is disapproved of, needs to be considered and discussed with families in order to understand the lived experience of the children and the impact on them. This will also involve professionals working with families having a safe space to consider their own values and biases. These cases show the need for information sharing from and with the parent’s GPs in assessments and when considering the potential impact on children of the parent’s vulnerabilities. Consideration of the child’s lived experience 35. It is not easy to consider and understand a child’s lived experience when the contact is predominantly with the parent/s and when the child is pre-verbal or guarded with professionals, as was the case for Child 3’s sibling. Practice and systems need to be child centred and must consider a child’s lived or likely lived experience when there are dominating adult issues. As well as understanding the parent’s vulnerabilities, all professionals need to be aware of the impact of these matters on the children. When the parent’s relationship includes domestic abuse, when there are mental health issues and when there is substance/alcohol misuse it is essential that professionals have a child centred approach and are able to put themselves in the child’s position when considering how they experience the adult issues. 36. In the case of Child 3, there was an older sibling and there was evidence that they were safeguarding concerns in the home prior to and after the birth of Child 3. The child was at school and there were issues with his attendance that were not considered to be a sign of neglect at the time. The links between poor attendance and attainment are compelling, with consequences for a child’s longer-term outcomes. The NSPCC highlight ‘the failure to ensure regular school attendance that prevents the child reaching their full potential academically’ as one of their six forms of neglect.14 Children with long term health needs are more vulnerable to neglect and the impact can be more severe. Child 3’s sibling had a long-term genetic health condition and had been referred for an assessment by CAMHS for ADHD and autism. As well as poor school attendance, there was a lack of consistent attendance at health appointments which the child was 14 ‘Role of Schools, academies and colleges in addressing neglect.‘ NSPCC 2013 16 required to be brought to by his carer to manage his health condition. He was also noticed to have tooth cavities and an abscess due to neglect of his dental health. 37. There are also frequent observations made from professionals on the difficult interaction between the older child and his mother. He was very vulnerable and those who knew him well were concerned about the impact on him of his experiences. It is interesting to reflect on the four child protection medicals for potential physical abuse undertaken on the sibling in the months following the birth of Child 3. The incidents leading to the medicals were an indication that when injuries were seen or when the child had said he had been harmed (for example that his mother had hit him on the head with an x-box controller) there was a hope from the professionals involved that medical evidence of physical abuse would be identified. It was not and there was a tendency to wait for another incident in the hope that evidence would emerge. This shows two things, that there can be an over-reliance in the system during an investigation on findings during the child protection medical that there has been a non-accidental injury (also found in the Star Hobson case) and that child protection practice in this case was incident based and did not consider the long-term evidence of neglect and emotional harm that the sibling was experiencing and that Child 3 was also likely to experience in his mother’s care. Each incident or episode of concern needs to be examined with an understanding of what the child has experienced before to assess whether a multitude of factors, when considered together, constitutes significant cumulative harm15. 38. The national Safeguarding Practice Review Panel’s annual report published in May 202116 stated that ‘the recognition of cumulative neglect and its impact continue to be a key challenge for practitioners’ nationally’ and this has been found in this review in the case of Child 3’s brother. This a key issue for safeguarding partners, as the life-time impact on children of long-term and recurring neglect cannot be underestimated, with outcomes for these children likely to be exceptionally poor. As well as considering neglect as a standalone issue, there is evidence that other forms of abuse can co-exist with neglect, with these children more likely to experience physical harm and sexual abuse. 39. Consideration of how the arrival of a new baby would impact on the care of the older child, as well as the likely lived experience of the new baby, required consideration pre-birth in the case of Child 3. A growing family can often mean that a situation that was just good enough for a child can become more concerning and pre-birth assessments that focus on this are required. The focus on the sibling and on the many needs of Child 3’s mother meant that the assessments and plans did not provide a clear understanding of what a day in the life of Child 3 involved when he was in the care of his mother. The focus of assessments and plans was on addressing the behaviour of the older child and limited consideration of the impact on the baby. The review was told that there continues to be work required in Bradford to ensure that pre-birth assessments are of a consistently good quality, with sufficient curiosity and focus on the likely experience of a baby in a family. There is a need for monitoring of compliance with the multi-agency practice guidance for pre-birth assessments. 15 Bromfield and Higgins in Australia first introduced the terms ‘cumulative risk’ and ‘cumulative harm’ in 2005 when they point out that ‘the effects of patterns of circumstances and events in a child’s life which diminish their sense of safety, stability and wellbeing. Cumulative harm is the existence of compounded experiences of multiple episodes of abuse or layers of neglect.’ 16https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984767/The_Child_Safeguarding_Annual_Report_2020.pdf 17 40. There was evidence of good practice in respect of Child 3 from the health visitor involved with the family following the child protection plan being made. When a child becomes subject to a CP plan in Bradford their allocated health visitor changes. The team working with such families are experienced child protection practitioners and the health visitor working with Child 3 received specific supervision on the case from Little Minds Matter17. She described to the review the power and insight gained from a session described as ‘be Child 3 for two minutes.’ This gave her the impetus to challenge the lack of progress in respect of the plan for the child. She contacted the child protection conference chair and lobbied for legal advice to be sought by the Local Authority. The Safer Bradford process for escalating a professional disagreement was not used. Comparison with previous reviews The Alice review found that the main professional focus had predominantly been on the mother rather than the baby. Yet there was still a gap in knowledge about Alice’s mother’s mental health and no timely assessment of her potential learning disability. This is often found in case reviews nationally and was also evident in the four cases review completed in 2019. The mothers of Child 2 and Child 3 had several significant vulnerabilities and needs, which took up a lot of professional time and focus. In neither case was the baby’s voice nor lived experience captured, until later with Child 3 when there was good practice from the newly allocated health visitor during the period of child protection planning. She effectively considered and communicated the child’s lived experience, the strength of this piece of work may have led to a refocused child protection plan, or care proceedings, due to the likelihood of ongoing significant neglect had the injuries not occurred when they did. The Alice review concluded that professional training and development must highlight the risks associated with fixed thinking and the need for professional inquisitiveness and challenge. For Child 3’s older sibling, there had been a number of concerns over many years, none of which met the threshold for safeguarding actions. There was the opportunity to consider his lived experience. There is evidence of references to his behaviour being the problem, not the parenting he received. There was some challenge of this, but for years it did not result in a plan that addressed this. What needs further consideration? * Consideration should be given to the good practice in respect of the model used to understand Child 3’s likely lived experience being used more generally across services to improve professional insight into a child’s world. All child protection conferences, core groups and child in need meetings should have a section where those in attendance think about what they have heard through the eyes of the child/ren in the family. As considered above, there is a need for professional challenge when a plan is not progressing and there are continued or escalating concerns about a child/ren. As the current model for challenge is rarely used, there is a need to reenergise professionals in respect of this important safeguarding procedure, with consideration of a new process. 17 Little Minds Matter is a Bradford NHS initiative that supports parents, carers and professionals to help babies get the best possible start in life. They offer direct work with families and consultation and training to professionals. 18 Considering men/fathers/partners 41. The household of Child 1 consisted of the baby and their mother and father. Child 1 was her father’s first child. He was caring for her when medical advice was sought, and the injuries were found. The household of Child 2 consisted of the child and his mother. However, his father was known to spend time there, despite denials to professionals. Child 2’s father also has no other children. Child 3 lived with his mother and a school age sibling. Mother 3 had a new partner who was thought to be a concern as he was not having contact with his own children, largely due to domestic abuse. CSC agreed with Mother that prior to a risk assessment the new partner should not have contact with the children. 42. It is common in SCRs and CSPRs to find learning regarding the need to engage with and consider the father of a child, or the partner of a mother who lives with, or spends a lot of time with, the family (including same sex partners.) This review is no exception. There are identified barriers to sharing information and seeking information about fathers and partners, and it continues to be a dilemma for professionals. Information was held about some of the men in these cases which was not known to those who had responsibility for the children, including when there was a CiN or CP plan in place. 43. There is a national issue regarding GP and other health records for the men in a family, and how these can be accessed and considered. This is particularly an issue when the men are registered at a different GP surgery to the children and their mother and has been identified as requiring further work nationally. GPs are in a unique position regarding safeguarding as they often have oversight of a person’s whole life history. They receive copies of correspondence from many agencies and can provide details of historic vulnerabilities and risks, as was the case with information held on the mother of Child 2. The records held by GPs enable them to consider current information alongside this history, but only if they are asked. 44. There was good GP engagement with this review, and they were able to reflect on some of the barriers they face, particularly in relation to domestic abuse. GPs in Bradford are not always contacted when there is a section 47 investigation if they are the GP for the subject children’s father. They do not routinely receive domestic abuse notifications from the police if their patient is the perpetrator, and they are not informed when the children of a male patient are made the subject of a CP plan. While health staff and those working predominantly with adults are being asked to ‘Think Family’ it is also important for professionals working with children to ‘Think Father’. The health visitors involved in the three cases confirmed that they can have access to a mother’s GP records but not the fathers or partners. 45. Professionals are right to be concerned about where they record of domestic abuse information on a patient’s electronic medical record, particularly if they are a perpetrator of domestic abuse. The Royal College of General Practitioners (RCGP) guidance about this issue was updated in 2021. It acknowledges that the way information is recorded on the record of victims, perpetrators and child victims must not increase the risk of harm to victims, as perpetrators may not know that their victim has disclosed domestic abuse and may not be aware of any services being provided. The guidance acknowledges the challenges of the sometimes-limited IT systems being used but has provided helpful advice about how to ensure that practice is as safe as possible. It includes an awareness that patients can now access some of their medical records online, and the need to ensure that no safeguarding information is included in the accessible area 19 of the file. There is no guidance in respect of the move to full access to patient files as this is not yet law, but it something that the national CSPR panel need to be aware of. 46. While there must be consideration of the need for consent, which should be recorded, when there are or have been safeguarding issues in a family, the lack of consent should not impede information sharing. As the national panel says in the 2022 review Child Protection in England, ‘time and again we see that different agencies hold pieces of the same puzzle, but no one holds all of the pieces or is seeking to put them together.’ To ensure that children are appropriately safeguarded, the aim should be to encourage and support professionals to clarify what ‘pieces’ are known to their agency, share these ‘pieces’, and work together to see the ‘whole picture’ without fear of reprisals or breaking data protection legislation. 47. It is expected practice that midwives and health visitors enquire after the health and mood of mothers following the birth of a child, and standard tests are undertaken for post-natal depression. It is not usual practice for professionals to enquire about the father or non-birthing partner’s mental health. Practice following the emergence of COVID-19 made this even less likely as a lot of contact from health professionals was by telephone with the child’s mothers. Difficulties can emerge after the birth of a child for fathers (or other secondary carers) as well as for mothers. This can include relationship issues, concerns about the amount of responsibility that children bring, and a lack of confidence in the role. There is increasing evidence that fathers/non-birthing partners can suffer with a form of PND18 and this always needs to be considered. It is particularly important where there is previous evidence of mental health difficulties in the secondary carer. The NICE guidance on antenatal and postnatal mental health does not mention fathers, and awareness of this as an issue is low19. This is even though the numbers of men who become depressed in the first year after becoming a father is double that of the general population. First time fathers are particularly vulnerable. Professionals need to be aware of this as a possibility, and consider it when engaging with families, particularly where there are predisposing vulnerabilities, including domestic abuse. 48. Both the fathers of Child 1 and Child 2 were first-time parents. The pregnancies and births were at a time of uncertainty and there were some limitations to services due to Covid 19. The father of Child 1 had a history of mental health problems and anger control that was not known to the professionals working with the family. He was also living with a partner with mental health challenges of her own. In the case of Child 2, there was a history of maternal mental health problems, substance and alcohol abuse, and information about the mother’s care (and neglect) of her older children. Both the mother and father had been in previous relationships where domestic abuse featured, and a robust and transparent consideration of the risk that the father may pose was required. There was a delay in identifying the father which impacted on this, but even when it was established, there was little done to engage with him. The strategy meeting agreed that the couple must separate, and it was then the mother’s responsibility to safeguard the baby. 49. It is not yet known how the three babies being considered in 2022 were harmed, and whether ‘coping with crying’ was relevant. Babies cry and parents need to be able to deal effectively with this. This is more of a challenge for those who have stresses and vulnerabilities and where there are issues in the adult 18 Research available from the National Childbirth Trust (NCT) found that more than 1 in 3 new fathers (38%) are concerned about their mental health. The research states that one in 10 fathers have PND and appear more likely to suffer from depression three to six months after their baby is born. 19 Community Practitioner magazine November 2018 and #HowAreYouDad? campaign 20 relationship, including concerns about domestic abuse. There was some evidence that ‘coping with crying’ was discussed in these cases. The ICON20 ADD model is being relaunched, which should make a difference. But not always with both parents. In the case of Child 1 there was very limited contact with the father, for Child 2 there was no contact with the father, and in the case of Child 3, the identity of the baby’s father was not disclosed by the mother, and she was largely worked with as a single parent. Comparison with previous reviews In the Alice review and the four babies review, there was little evidence of the father or non-birthing partner being considered, despite a number having significant vulnerabilities that could be a risk to a child. This was the case with the 2022 babies, particularly regarding Child 2. The father did not respond to the attempts to engage him, despite the efforts of the social worker as part of the child in need plan post birth. If fathers or other non-birthing parents are going to be treated equally, there needs to be efforts to ensure they are aware of agency expectations and any attempts to engage them need to be meaningful, even if the plan is that they will not live with the child. Any ongoing contact needs to be considered when there is a history of violence in a relationship, as it is known that even in cases where domestic abuse is a concern, there can be ongoing contact between the children and their fathers, as was the case for Child 3’s sibling and his father. The mother told the review that her elder child had witnessed domestic abuse throughout his life and that this led to him being aggressive and often abusive to her. She said there was little curiosity about her injuries, and that it was hard to share the information with professionals, so no meaningful support was provided. It has been noted in the previous cases, and those being considered in 2022, that there was an absence of wider family support for these families. This issue always needs considering when working with a family at any point in the system, but certainly when there are concerns and vulnerabilities. The reasons for this should be part of any assessment, including if the choice of partner had an impact. It is noted that this can be an issue in traditional communities when the child is mixed race and needs to be explored on both a case by case and a wider basis. What needs further consideration? * Agencies need to consider how they can ensure that the mental health of a father or non-birthing parent is considered after the birth of a baby. The review was told that the learning from the 2020 national CSPR (The Myth of Invisible Men) has been incorporated into training. Consideration therefore needs to be given to what the barriers have been to this having an impact in its own right, but also when considering how to disseminate and incorporate the learning from this review into briefings and training. Professionals need to consider the impact on a child of experiencing domestic abuse, and the possibility that they will mirror what they have seen and be aggressive to their carer. 20 https://iconcope.org/ 21 The Bradford Partnership needs to consider how it can ensure that professionals consider any race or cultural aspects in families, including the impact on wider family support and the way that the child may be seen by both sides of their extended family and communities. Assessments and planning 50. There was a verbal domestic abuse incident between Child 1’s parents when she was four weeks old. The information was not shared by the police with any other agencies, including the health visitor who had recently visited the family. Two weeks later, in January 2022, the GP spoke to a parent about the child during a telephone appointment for reported concerns about Child 1’s crying ‘particularly when held by her father’. Over-the-counter medication was prescribed for colic and constipation, and the GP suggested contact with a health visitor to discuss feeding and latching issues. There is evidence that the family tried to speak to a health visitor the same day, but as a family receiving universal services, this was not straightforward. They had to go through the duty system and speak to a health visitor they did not know. It was recorded that a suggestion was made to return to the GP if the symptoms got worse. This was an opportunity to discuss ‘coping with crying’ with the family. This did not happen, but it is possible that it would have if the health visiting service was aware of the recent domestic abuse incident. 51. At the beginning of the COVID pandemic, NHS England asked all GPs to undertake remote triage. The combination of the continuing need to limit COVID infections in 2021 and 2022 and general service pressures meant that GPs did not always see a patient (including babies) face to face, although it is acknowledged that this is best practice. The Rapid Review undertaken in respect of Child 1 stated that a significant impact of the COVID pandemic has been that clinicians have had to take on more risk by managing more children remotely. It is not known however if Child 1 had received the older rib fractures at the time of the remote appointment or if this would have been identified had there been a face-to-face consultation. It is unlikely, as there are rarely external signs when ribs are fractured. However, it would have been helpful for the GP to know about and consider the domestic abuse when examining the baby. 52. Assessments need to include the reconsideration of previous information or concerns alongside any new information or incident. None of the three 2022 children had any known injuries prior to the incident that led to this CSPR. However, in Family 3 there was a clear indication that Mother required significant support in respect of her care of the older child, and not enough consideration was given to the impact on that child of a new baby and the impact on the new baby of the ongoing issues in respect of mother’s parenting of their sibling, and knowable information about his aggressive behaviour. 53. When a parent has health or mental health issues, all professionals with safeguarding responsibilities for the children need to ensure that they find out and share what the known issues are, to optimise consideration of the impact on their parenting. Any specialist assessments need to be shared and considered by those responsible for the children. There is also a need to ensure whole system awareness and connectivity between services working with adults and those working with children when a safeguarding adult issue occurs which may have implications for a child. 54. Those involved in the three cases told the review that there are administrative issues with the updating and sharing of plans for children and the records of meetings, particularly strategy meeting, child in need plans and core group minutes. This hinders information sharing and ownership of a child’s plan. There is a multi- 22 agency commitment to ensuring that plans are outcome focused and evidence improvements for children, but the administration of this remains an issue. GPs fed back to the review that they would welcome knowing if a child is on a Child in Need plan, and it is good practice to share plans with GPs, but this does not happen regularly. These are reportedly long-term issues within Bradford that are being considered by partner agencies with the aim of improving the sharing and flagging of key information to ensure that vulnerable children are identifiable to all the professionals who have contact with them. 55. The schools attended by the sibling of Child 3 reported that information sharing and timely updating across agencies needs to be improved to ensure that all those working with the family are aware of what the child’s lived experience is, as this has an impact on the child’s behaviour in school. Comparison with previous reviews The learning identified in the cases of Alice and the four babies reviewed the following year included the identification of; issues with the timing and quality of pre-birth assessments; inadequate involvement of adult services in children’s assessments and planning, particularly regarding adult mental health; gaps in information sharing; underestimation of the impact of the mother’s vulnerabilities on the child/ren; and overoptimism about their ability to parent and protect their child/ren. When assessments were completed following injuries in non-mobile babies, procedures were not followed. Drift and delay were also evident in assessments and plans. These issues were less evident in the 2022 babies, however as shown above, there were opportunities to seek information from other agencies and within agency records which were not always taken, for example the GP information held on Mother 2, and the drift and delay that was apparent with Child 3. In the Alice review there was learning identified about the use and timing of the PLO alongside child protection planning, and how it ‘makes sense to professionals and parents. There is a need to ensure that agreements made in the PLO process are communicated to other agencies. Unlike child protection planning, the PLO process is effectively single agency as it is between the parents and the local authority. There are benefits to the PLO planning reflecting the CP planning process and including other professionals in the plan and expectations from the PLO process. In the case of Child 3 there had been agreement that the PLO process should be started in respect of Child 3 and the sibling, but this was delayed and had not yet begun when the injuries occurred. This was the subject of professional challenge. In Alice’s case there were gaps in the pre-birth assessments, including the absence of information from adult services, particularly mental health services and the police in respect of both parents. An extensive plan of support was put in place, but when Alice received an injury21 at 12 weeks old, she was initially allowed to return home with her mother without a strategy meeting and S47 investigation being held. There were no concerns about the response to the injuries in the 2022 cases, with all the cases receiving an appropriate response when the initial injuries were suspected/identified. Child 2 was on a child in need plan. This is not always as well communicated to professionals as child protection planning. The best practice in child in need planning is where it replicates the CP system in 21 A bruise to her eye area. 23 respect of written plans, regular reviews of the plan with the family and professionals involved, and robust information sharing. What needs further consideration? * Consideration must be given to improved information sharing about a child in need plan and improved engagement across agencies, including adult services. The aims should be: - All child in need plans need to be recorded, updated and circulated to the family and relevant professionals - The relevant professionals, including the GPs of the children and the parents, must be aware of children are on a Child in Need plans. They then need to ensure that the plans are on the records of the children and the parents. Consideration of who shares this information and how this happens must be made on a case-by-case basis. For many children the health visitor may be in a good position to do this - Consideration to be given to how child in need plans can be shared with GPs when a child is over 5 years old - Professionals need to be aware that an existing or previous child in need plan indicates that there are or have been concerns about a child, and that this may indicate risk in the future Although a child has an allocated social worker when they are on a child in need or a child protection plan, there is a clear multi-agency responsibility for the child and the plan. Professionals who see the child more and know them better are essential to the process and need to ensure their voice is heard and to take responsibility within the planning. Other issues considered 56. One of the biggest challenges in child protection work is working with families who are hard to engage, who engage sporadically, who are reluctant to accept support or who respond to professionals with anger and aggression. The level of engagement, particularly between child in need and child protection, is often based on the willingness of the family to engage. In the case of Child 2, the mother’s voiced willingness to cooperate and her wish to separate from her partner determined the level of involvement and the decision to hold an ICPC was changed to a child in need plan. It had been some years since the mother had cared for children and she was given the benefit of the doubt. Later when it became apparent that she was unable to separate and that the domestic abuse was continuing, a strategy meeting again agreed that a child in need plan remained the appropriate course of action for the child, despite evidence of parental disengagement. There were also issues with the father’s lack of engagement with the police which led to no action regarding his breach of bail conditions. 57. As stated in the 2022 national review Child Protection in England, ‘at its heart, child protection practice requires consummate skill in blending ‘care’ and ‘control’ functions, helping families to protect children. This can only be achieved by building trusting relationships with parents and children whilst recognising that how things appear may not be the reality of a child’s experience.’ As stated above, the need for relationship-based practice, with children, with parents and the wider family and across agencies is essential to 24 improving the safeguarding of children. The focus on direct engagement will also ensure a more motivated workforce and will have a positive impact on recruitment and retention, which has been an issue locally. 58. Positive experiences of management support and supervision, both individual and group, also has an impact on staff morale and is more likely to help retain staff in areas of high need. The review that was undertaken by the national CSPR panel in 2022 following the death of Star Hobson noted that in Bradford CSC at the time of Star’s death that there were ‘significant problems with workforce stability and experience, at every level’. This remains a concern. Comparison with previous reviews The Alice SCR and the four babies review identified issues with the impact of a lack of quality supervision that encourages professional curiosity and robust analysis, issues with record keeping, and the impact of turnover of staff in key agencies and inexperience across a number of professions. There was also a concern that professionals had not felt able to challenge the plan for Alice to continue living with her mother, despite apparently not agreeing. In the case of Child 3 in 2022 there was good practice regarding professional challenge. Although there was no evidence of any impact on practice, it is noted that homelessness or a move of home was evident in the Alice review, as it was in the case of Child 2 and Child 3. It is well known that insecure housing, moves of accommodation and related professional changes/transfers can have an impact on child development and increase isolation for families. The sibling of Child 3 had a change of school when he was already struggling both socially and academically, and there were changes of health visitor for the baby. What needs further consideration? * The COVID-19 pandemic has apparently had an impact on training in both routine and specific safeguarding matters across partner agencies in recent years. This is relevant to both single and multiagency training. The review was told that a process of review has been undertaken in respect of Partnership training. Good quality supervision is key to effective safeguarding practice and needs to be in place. It supports and challenges staff in and across agencies, monitors practice and record keeping and encourages reflection and risk identification. Improving the recruitment and retention of key staff across the safeguarding system, such as social workers, may require a redesign of the service, and consideration of locally based service delivery through smaller teams, such as social work pods22. Conclusion and recommendations 59. The 2022 national CSPR Child Protection in England has recommended that Multi-Agency Child Protection Units, with integrated and co-located multi-agency teams staffed by experienced child protection professionals, are established in every local authority area. This has not yet been agreed by central government and an update is required regarding this. What the proposed system will not achieve however 22 Social Work Pods: A Team Around the Relationship. ‘An emotionally informed thinking space’ providing ‘organisational containment’ (Ruch, 2007). 25 is better assessment and support before a child protection matter has been identified, which this review has found was required in the three cases considered. 60. It is not the place for a single local CSPR to recommend whole system changes, but it is clear that there is both the need and the appetite in Bradford to consider significant changes. Inter-agency and community relationships also need to be improved to better safeguard children. This is seriously impacted by the ‘churn’ in key staff and managers. Child 3’s mother told the review she has lost count of the number of professionals involved with her family. Making the working environment in Bradford one where staff want to work and want to stay is essential. This will provide continuity to children and families and retain essential experience in the city’s key agencies. There was a view from professionals that large city-wide services do not enable the development of relationships in communities and promote local knowledge. Some parts of the UK have developed decentralised services and teams working in pods and / or community hubs with experienced line managers. They report improved multi-agency relationships and staff who are more satisfied in their work, which leads to benefits to children and families in the community. 61. This CSPR has considered the learning from three cases and has identified learning that will be helpful for the wider system. The national Child Safeguarding Practice Review Panel published a briefing paper in 2021 that considered the impact on families and services of the COVID-19 outbreak to that point. The analysis shows that COVID-19 exacerbated risk due to an increase in family stressors (including an increase in domestic abuse and mental health concerns) limitations to wider family support, children not being seen as regularly, and difficulties with the requirement for ensuring safe professional practice. The children being considered in this review were born and receiving services at the later end of the pandemic, where services were still being impacted and where there remained uncertainty about what would happen. The NSPCC23 identified that when adequate support was not available during the pandemic, ‘such tensions may lead to mental and emotional health issues and the use of negative coping strategies.’ The review has not specifically identified learning in respect of COVID-19 but recognises the additional strain that it put on both families and services at the time. 62. Single agency learning has been identified during the review and recommendations have been agreed to address these, including single agency SMART action plans. There has been cooperation with this review from partner agencies, which was essential in establishing the learning from these cases. 63. It is clear from consideration of these cases that there remain a number of areas of practice that require improvements, despite the efforts of partner agencies and the Partnership to ensure that the learning from reviews is disseminated and that recommendations have been implemented. Considering why previous learning has not made an impact on practice needs further consideration and is one of the main findings from this review. 64. There is a lot of work taking place in Bradford regarding domestic abuse, and this review will not replicate recommendations. 65. The following recommendations are made however: Recommendation 1 23 NSPCC June 2020 Isolated and Struggling Social isolation and the risk of child maltreatment in lockdown and beyond. 26 That consideration is given to how to implement the suggestions included in the analysis sections of this report entitled ‘what requires further consideration’ (see*) in order to improve practice in and between partner agencies. Recommendation 2 That a task group is established to explore the following issues that this report24, along with multi-agency discussions, have highlighted: • why the changes suggested in previous SCR/CSPRs have not had a sufficient impact? • how the partner agencies in Bradford manage change? • what the process needs to be for disseminating learning from CSPRs and other quality assurance activities? • communication within and between agencies Recommendation 3 That the Partnership asks the national Child Safeguarding Review Panel to request that the Department of Health provides clear clarification to GPs regarding how they can safely and legally record information on adult records when there has been domestic abuse in a relationship. 24 There are other reviews being completed in Bradford at this time and there is a plan to consider this recommendation being made across the reviews. |
NC50570 | Neglect of five siblings aged between 6-weeks and 9-years-old from June 2015 to December 2016. In December 2016 teachers noticed a bruise on child Q2's ear who told them his mother had caused it. This precipitated a Section 47 investigation. Police officer and social worker visited the home and discovered four further siblings living in poor conditions being severely neglected. Parents were arrested and children made subject to Police Protection. Health visitors had previously recorded the house being dirty, smelling and having flies at new birth home visits in June 2015 and October 2016. Family moved local authorities in June 2016. School records describe child Q1 and child Q2 as smelling unclean. Father had a 13-year-old child from a previous relationship and had been refused contact. Mother reported low mood and told health visitor that Father had a learning disability. The family is White British. Findings include: limited information sharing about indicators of neglect when children moved within and between local authorities; indicators of neglect were normalised by professionals working in areas of high deprivation; absence of professional curiosity. Uses the Significant Incident Learning Process (SILP) methodology which focuses on why those involved acted in a certain way at the time. Recommendations include: information sharing processes for children moving between local authorities should be reviewed; barriers to effective use of tools to support the early identification of neglect should be identified; learning, including the recognition of dental health as an indicator of neglect, should be shared across the workforce.
| Title: Serious case review: Family Q: overview report. LSCB: Telford and Wrekin Safeguarding Children Board Author: Cath Connor Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Family Q OVERVIEW REPORT Lead Author: Cath Connor PhD Version 3.4 FINAL Signed off by Telford & Wrekin Safeguarding Children Board on 2nd May 2018 2 Contents 1 Introduction ................................................................................................................................... 3 2 Process ........................................................................................................................................... 5 3 Family Structure ............................................................................................................................. 7 4 Introduction to the Case ............................................................................................................. 7 5 Background information from LA1 prior to the scoped period ............................................. 8 6 Key Episodes.................................................................................................................................8 7 Analysis........................................................................................................................................13 8 Organisational Context and impact on practice.................................................................29 9 Good Practice identified ......................................................................................................... 320 10 Conclusion..................................................................................................................................31 11 Opportunities to improve practice ........................................................................................ 332 3 1 Introduction 1.1. This Serious Case Review (SCR) is in respect of five children made subject to Police Protection1 and taken into the care of the Local Authority due to neglect by their Parents. The children were aged between six weeks and nine years old at the time of their removal from the family home. 1.2. Telford & Wrekin Safeguarding Children Board (TWSCB) considered the circumstances of the children and agreed that the criteria for carrying out a Serious Case Review as defined by Working Together to Safeguard Children 20152 had been met. 1.3. TWSCB recognised the potential to learn lessons from this review regarding the way that agencies work together in Telford & Wrekin (LA2) and Bedford Borough (LA1) to safeguard children. The purpose of a Review as outlined by Working Together is ‘to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organizations should translate the findings from reviews into programs of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’(p73). Good practice and learning identified by this review are outlined within this report. 1.4. This review established that observations recorded by professionals were not identified as potential indicators of neglect and that information and evidence available to agencies was not assessed or shared. A summary of the key findings from this review are: There was limited information sharing about indicators of neglect when the children moved within and between local authorities There was a lack of holistic assessment of the family. Each child was seen as an individual and there was very limited information about Father Home visits by different professionals were task focussed and undertaken in isolation Information provided by Mother was accepted without further enquiry and there was an absence of professional curiosity There was limited understanding and appreciation of the lived experience of the children Indicators of neglect were normalised by professionals who spoke about their work in areas of high deprivation Available tools to support the early identification, assessment and analysis of neglect were not routinely used by professionals 1 Section 46 of the Children Act 1989. Under this law, the police have the power to remove children to a safe location for up to 72 hours to protect them from significant harm. 2 A guide to inter-agency working to safeguard and promote the welfare of children, HM Government 4 Engagement of parents that may have indicated disguised compliance was not explored or assessed throughout the timeline for this review There was little evidence that practitioners had the confidence to exercise professional uncertainty and challenge explanations provided by Mother 1.5. The following definition of neglect from UK statutory guidance3 was used throughout the review process to guide discussion and analysis; The persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: provide adequate food, clothing and shelter (including exclusion from home or abandonment); protect a child from physical and emotional harm or danger; ensure adequate supervision (including the use of inadequate care-givers); or ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child's basic emotional needs. 1.6 The extent and significance of neglect in children’s lives has been a key and recurrent theme within Serious Case Reviews. A recent analysis found that neglect was apparent in the lives of nearly two thirds (62%) of the children who suffered non-fatal harm, and in the lives of over half (52%) of the children who died4. 1.7 There is significant evidence to demonstrate that neglect has the potential to compromise progress across the seven dimensions of development identified in the Assessment Framework: health, education, identity, emotional and behavioural development, family and social relationships, social presentation and self-care skills5. 1.8. Neglect has serious consequences for children and young people of all ages however there is evidence to suggest that it has a particularly adverse impact on 3 Working together to safeguard children. Statutory guidance on inter-agency working to safeguard and promote the welfare of children. DfE, 2013 p86 4 Pathways to harm, pathways to protection: A triennial analysis of serious case reviews, 2011 -2014. Sidebotham P et al. DH 2016 (p43) 5 Ibid. P8 5 the development of very young children6. This is an important factor of relevance to this review as much of the involvement of professionals within the time line focussed on the wellbeing of new born babies and very young children. 2 Process 2.1. TWSCB agreed that this Serious Case Review (SCR) should be undertaken using the Significant Incident Learning Process (SILP) methodology. SILP is a learning model which engages frontline staff and their managers in reviewing cases, focusing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in Working Together to Safeguard Children 2015. 2.2. The SILP model of review adheres to the principles of; child focussed proportionality learning from good practice the active involvement of practitioners engaging with families systems methodology 2.3. This review required the completion of Agency Reports followed by a Learning Event which was attended by practitioners, managers and agency safeguarding leads from LA2 and LA17. Participants involved in the initial Learning Event were invited to a Recall Event to study and debate the first draft of the Overview Report. The contribution of all those involved enabled a greater understanding of the context in which practitioners and managers worked and maximized opportunities for organizational learning. 2.4. Due to ongoing criminal investigations there was a delay in meeting with the parents). The author and representative from the WSCB met with parents at the end of the SCR process. It is important to note that whilst parents provided a different explanation to that of professionals about some of the factual details8 they were in full agreement with the findings and recommendations of this review. The information provided by parents will inform the dissemination of learning from this review. 6 Missed opportunities: indicators of neglect – what is ignored, why and what can be done? Brandon M, Ward H et.al. Research Report DH Nov 2014 7 The Learning and Recall events were facilitated by Donna Ohdedar, Head of SILP. The Report Author was Cath Connor, a SILP associate reviewer. Both Donna Ohdedar and Cath Connor are independent of TWSCB and its partner agencies. 8 For example; Mother said that she advised professionals that her step grand mother had died and not her mother, parents said that they made efforts to have the dogs removed from the family home whilst in LA1 and parents were clear that if asked they would have complied with an Early Help Assessment. 6 2.5. It was agreed that the scope of this review would be from June 2015 when the Health Visitor in LA1 requested a new birth visit, to December 2016 when the Section 47 investigation commenced and resulted in the children being placed in foster care. This period includes the family’s move from LA1 to LA2 and the birth of Q4 and Q5. 2.6. Relevant information prior to these dates9 was also considered and included an anonymous referral to the NSPCC in 2012 due to concerns about neglect, records of School 1 attended by Q1 and Q2 and observations by the Health Visitors of home conditions following the birth of Q3. 2.7. It is important to note that during the timeline considered within this review the family resided in LA1 for twelve months and LA2 for six months. This review was commissioned by the LSCB in LA2 as the children were taken into care whilst living in this area. It is important that the LSCB in LA1 consider the findings of this review and have an opportunity to respond to recommendations for the improvement of practice. 2.8. The decision to undertake a Serious Case Review was made by the Independent Chair of Telford & Wrekin Safeguarding Children Board. Mother and Father were informed about the review and were updated regarding progress by TWSCB. 2.9. The Terms of Reference considered throughout this Review and addressed by authors of Agency Reports were: 1. How well did agencies recognise neglect at various key points? Were assessment tools used? Did assessments inform analysis? 2. How was the family history incorporated into assessments? 3. To what extent did practitioners Think Fathers? 4. Evaluate the response of agencies to emerging concerns. 5. What did agencies know about the children’s lived experience? Did this have an impact on the services provided and work undertaken? 6. Analyse transition arrangements (including information sharing) within and between areas. 2.10. Much consideration was given to obtaining the wishes and feelings of the children in a way that was meaningful, child-focused and least likely to cause additional distress. Children’s Services remain involved with the family and following significant reflection it was decided not to involve the children directly in the review process. On balance it was thought that would be likely to risk further trauma at what is known to be a difficult time. It was considered unlikely that information provided by the children would change the learning identified. 2.11. Prior to publication Mother and Father stated their agreement with the findings and recommendations of the Review. 9 When the family were living in LA1 7 3 Family Structure 3.1. The subject children will be referred to as Q1, Q2, Q3, Q4 and Q5 aged between six weeks and nine years old.10 The parents of the children are referred to in this report as Mother and Father. Other family members will be referred to by their relationship to the children e.g. Maternal Grandmother and Maternal Aunt. 3.2. Mother, Father, Q1, Q2, Q3 and Q4 lived in LA1 until the family moved to LA2 in 2016. 3.3. The Children, Mother and Father are White British and of no religion. 4 Introduction to the Case 4.1. Information about possible indicators of neglect with specific reference to home conditions was detailed in records of the Health Visiting Service in LA1 and LA2. Some information had been provided by the Midwifery Service in LA1 and subsequently recorded by the Health Visitor. 4.2. There were issues regarding the hygiene of Q1 and Q2 whilst attending School 1 in LA1. These were not considered sufficient to require a referral to children’s services and were addressed directly with Mother. 4.3. Q3 and Q4 were born in different areas within LA1 in 201411 and 2015 respectively. The family moved home on two occasions during the time line considered within this review and Q5 was born in LA2 in 2016. 4.4. In December 2016 School 2 in LA2 made a referral to Children’s Social Care as Q2 had a bruise on his ear and said that Mother had caused it. A joint Section 47 investigation took place between the Police and Children’s Social Care. 4.5. When Police Officer 1 and Social Worker 1 entered the family home in LA2 they found that the children were living in extreme squalor in a dirty and potentially dangerous environment. Dogs had defecated in the house and were also neglected. The Police Officer and Social Worker were surprised to see that Q2 had four siblings as information on the initial referral noted that Q2 lived alone with Mother and Father. Immediate action was taken to ensure the safety of the children and they were made subject to Police Protection and taken into foster care12. Mother and Father were arrested and subsequently pleaded guilty to child neglect. At the time of writing this report sentencing had not taken place. 10 At the time of removal from the family home 11 The birth of Q3 is outside of the time frame considered by this Review 12 The following day Parents agreed to voluntary accommodation of the Children under Section 20 Children Act 1989 8 5 Background information from LA1 prior to the scoped period 5.1. The Family became known to the Health Visiting Service following the birth of Q2 in 2011. In 2012 an anonymous referral was received by the NSPCC for concerns regarding neglect. There was communication between a Social Worker and Health Visitor and following initial enquiries no further action was taken. 5.2. Records from School 1 attended by Q1 and Q2 detail concerns regarding thepersonal hygiene of Mother and the cleanliness of Q2 who was reported to smell of faeces on one occasion. Mother explained to family practitioners at the local Children’s Centre that she forgot to wash Q2 as she had been upset by the landlord saying the family had to move house. Mother was referred to the Citizens Advice Bureau. 5.3. In 2013 during the 2yr targeted development review for Q2, Mother informed HV113 that she was a carer for her husband who had a learning disability. Mother also explained that a friend had made the referral to the NSPCC as Mother was of low mood at the time because she was unable to visit her Father who was ill. This was the last routine contact by the Health Visiting service as part of the Universal Provision of the Healthy Child Programme14. 5.4. HV2 made a new birth visit to Q3 in April 2014. The house was noted to be cluttered and dirty and the furniture heavily chewed by the family dog. Mother had cleaned the floor just before the visit. Mother told HV2 that the family was about to be evicted and HV2 advised mother not to leave Q3 alone with the dog. There was no arrangement for further contact with the Health Visiting Service. 5.5. HV2 attempted to arrange a further home visit six weeks later and was informed that the family had moved into another privately rented house in a different part of LA1. HV2 advised Mother that a Health Visitor from the new locality would contact to offer support. There was a lack of information in Health Visitor records about the handover of care from one locality team to another in LA1. 5.6. Mother attended a drop in well baby clinic with Q2 and Q3 in the new locality in LA1and HV3 completed a transfer in assessment. HV3 did not have access to electronic information about the observations made by HV2 on the New Birth Visit and would have been dependent on Mother self reporting in the clinic. Parents did not respond to the letter offering a one year review for Q3 in March 2015. 13 HV 1 to HV6 worked in LA1, HV7 to HV9 worked in LA2 14 Healthy child programme from 5 to 19 years old. London: Department of Health 2009 9 5.7. Mother booked late for antenatal care with Q4 and explained that this was due to a family bereavement. The late booking in pregnancy pathway was initiated and no concerns were identified. 5.8. Mother attended the GP surgery many times with Q1 and Q2 suffering from recurrent urinary tract infections and upper respiratory tract infections, however, this was not identified as a cause for concern. 6.0 Key Episodes 6.1. The period under review has been divided into five key practice episodes of significance to the development of the case: Telephone contact between HV 4 and HV 5 (located in the MASH) in LA1 Overnight Hospital admission of Q3 in LA1 Family move from LA1 to LA2 Home visits following the birth of Q5 until the children were removed from the family home in LA2 Safeguarding referral from Primary School 2 in LA2 regarding Q2 6.2. The key episodes detail practitioner and agency involvement thought to provide maximum opportunity for organisational learning and the improvement of systems and processes to safeguard children. The key episodes do not form a complete history. Key Episode 1: Telephone contact between HV4 and HV5 (located in the MASH) in LA1 6.3. Midwife (MW) 1 made a home visit in May 2015 when Q4 was three days old. It was recorded15 that the house was ‘messy and untidy’, a request to view the bedrooms was declined and there were a lot of closed circuit television (CCTV) cameras outside the house. Mother refused further visits by MW116. 6.4. MW2 made a home visit when Q4 was 10 days old. It was recorded that the home smelled of dogs and Mother reported that the hoover was broken. The children were observed to be dressed in clean and appropriate clothing. 6.5. In June 2015 HV4 was unable to arrange a new birth visit for Q4 as initially Father was resistant and there was no response to subsequent telephone calls. HV4 liaised with MW2 who informed of concerns due to the late booking for ante-natal care following a family bereavement. HV4 recorded that parents had refused MW2 entry 15 This information was gained from telephone discussion between HV4 and MW1 and was recorded by HV4 16 Mother said that she only refused further visits from MW1 and had agreed for any other professional to visit the house 10 to the family home following discharge from hospital because they said that the house was messy. 6.6. HV4 made a new birth home visit when Q4 was 16 days old and recorded that there was an ‘overwhelming atrocious smell’ and the house was dirty and untidy17. The day following the new birth home visit HV4 discussed concerns by telephone with HV5 based in the Multi Agency Safeguarding Hub (MASH). It was thought that Mother would be very resistant and unlikely to engage with an Early Help Assessment (EHA). The Health Visitors agreed that it would be appropriate to set objectives to improve home conditions at the next visit which had been arranged for six weeks later and consider escalation if improvements were not made. Recorded actions included; to involve the Community Nursery Nurse and contact the school attended by Q1 and Q2. 6.7. HV 4 informed Mother of concerns regarding the home conditions and arranged a further visit in five weeks’ time. Q4 and Mother were identified as requiring Universal Plus level of service18. Mother subsequently cancelled the scheduled visit by HV4 stating that Maternal Grandmother had died. 6.8. In September 201519, HV4 made a home visit and further concerns about home conditions were recorded20. Mother said that Q4 had not received vaccinations because the GP had requested identification for Q4 to enable Mother to register the child at the surgery. Mother told HV4 that Father was not at home at the time of the visit as he was obtaining the necessary paperwork for the GP. The children were noted to be playing happily. Key Episode 2: Overnight Hospital admission of Q3 6.9. In June 2016, Q3 was admitted to Hospital overnight in LA1 and diagnosed with a viral infection. Concerns were raised about Q3 who was noted to be drinking sugary fizzy drinks and wearing clothes which smelled of smoke. It was recorded that Mother was unkempt and wore dirty clothes. The hospital Safeguarding Nurse liaised with the Health Visiting Service and spoke with HV6 who arranged for a Community Nursery Nurse to visit. 6.10. Q3 was not seen by the Community Nursery Nurse although attempts were made by telephone and letter to arrange a development check for Q3. Two months later 17 It was recorded that a large amount of small objects, nails, nuts and rubbish were at toddler height. 18 Universal Plus threshold is met when there are any factors that impact on the health of the family e.g. poor housing, mental ill health, A progressive service with increased visiting depending on the needs of the family should be offered 19 After a number of failed attempts to reschedule the cancelled visit 20 House was said to be extremely dirty and mother had sprayed deodorant immediately before the visit to disguise the smell 11 following unsuccessful attempts to speak with Mother on the telephone, HV6 informed the GP of non-attendance at the development check. Key Episode 3: Family move from LA1 to LA2 and information sharing 6.11. The Q family moved from LA1 to LA2 in June 2016. It was not clear if this was a planned move although Mother had informed the Family Support Worker at School 1 that the family would be moving to LA2 to be nearer to family support. 6.12. Immediately prior to the move to LA2 Mother was referred by the GP to Maternity Services in LA1 for an emergency scan which confirmed a pregnancy of 22 weeks gestation. Mother was referred for antenatal care and there was no further contact between Mother and Maternity Services in LA1 regarding the pregnancy with Q5. 6.13. Mother presented at Maternity Services in LA2 when 31 weeks pregnant with Q5. A social history was taken, and health advice shared. Mother said that she was not allowed to book for antenatal care or provided with any paperwork by Maternity Services in LA1. Mother disclosed that Father had a 13 yr old daughter and was refused contact by his ex-partner. There was no communication between Maternity Services in LA1 and LA2. 6.14. In August 2016, Mother registered with the GP in LA2 as she was pregnant with Q5. Q1-4 were not registered with a GP until late November 2016 and some of the children were not up to date with their immunizations. 6.15. At the end of the Summer term in 2016, an application was received at LA2 for a Primary School Place for Q1 and Q2. Places were allocated at different schools21 and both attended the new school in October 2016. The School Nursing Service in LA2 became aware of Q2 in January 2017 following an invite to a Strategy Meeting and became aware of Q1 when health records were received from LA1 and the children were in the care of LA2. 6.16. It was made explicit in records transferred by School 1 in LA1 to Schools 2 and 3 in LA2 that there were no safeguarding concerns22. Whilst attending Primary School 1 in LA1 both children were reaching the expected level of development for their age and Q2 exceeded the expected level in two areas. Records indicate that Q2 smelled of urine at times, both children were described as having grubby uniforms and smelling unclean and of stale smoke. The class teacher for Q1 spoke to Mother about Q1 attending school with head lice and hair that was not brushed. 21 There were limited school places available when the application was received and Q1 was allocated a place at School 2 and Q2 was allocated a place at School 3 22 School records include a series of boxes to tick if there were safeguarding concerns and the box to note there were no concerns had been ticked 12 Key Episode 4: Home visits following the birth of Q5 until removal of the children from the family home in LA2 6.17. In October 2016, The Community Midwife made two home visits when Q5 was 2 and 3 days old and it was recorded that Mother was “happy at home and supported by family”23. The Community Midwife was unable to access the home for a subsequent visit24 at 11 days old. Mother visited the clinic when Q5 was 13 and 17 days old. As Q5 had regained birth weight, care was handed over to the Health Visitor for further advice and monitoring. 6.18. HV8 was unable to access the family home at the end of October for a pre-arranged New Birth Visit to Q5. HV8 completed the New Birth Visit a few days later and recorded that the Moses basket was “unclean and sheet on the mattress was stained” there was a “very strong smell with flies inside the house”, a dog was shut in an adjacent room and the kitchen was extremely cluttered. Mother informed HV8 that the family had just moved into LA2 and were living with Maternal Grandmother whilst the house, rented through a private landlord, was being re-decorated. It was recorded that Mother received a lot of support from Maternal Grandmother and Father. 6.19. HV8 noted that mother showed emotional warmth to Q5 and that birth weight had not been regained but the midwife was visiting the following day. Mother told HV8 that she had four other children living with her (Q1-4) although none were seen on this or subsequent visits. 6.20. During a second home visit25 on 9.11.16 HV8 recorded that Q5 was appropriately dressed for a cold day and looked clean although flies remained in the house and there was a strong smell. Mother advised that flooring in the house was being replaced that week and the family continued to live with Maternal Grandmother. 6.21. HV9 and a practitioner from the Newborn Hearing Screening Service made separate home visits on 12.11.16 and 17.11.16 to repeat the hearing screen. There was no information recorded about home conditions following either visit. 23 Shrewsbury and Telford Hospital NHS Trust Agency Report p4 24 Visit had been arranged over the telephone 25 To complete a hearing screen 13 6.22. In November 2016 HV7 made a home visit to complete the six week review for Q5 and it was recorded that the visit was conducted at the home address. Concerns about home conditions were recorded and it was noted that there was a “strong smell of animal urine”26 and internal doors and floors required replacing. Mother did not express any concerns about Q5 who was observed to be bright and alert. HV7 did not plan to make a further visit and the next scheduled contact was the one year review for Q5. Key Episode 5: Safeguarding referral from Primary School 3 regarding Q2 6.23. Shortly after Q2 started at Primary School 3 Mother told the Head Teacher that Q2 was upset as another pupil had flicked his ear. The Head Teacher made significant efforts to try to identify who this was27 Q2 did not identify anyone and did not talk to staff at any time about bullying at school. 6.24. In December 2016, Primary School 3 made a referral to Family Connect to advise that Q2 had a bruise to the ear and had told staff that Mother did it. The referral noted that Q2 had no siblings and lived with Mother and Father. In response to this referral safeguarding records were opened at Primary School 2 and 3. 6.25. It was decided at a Strategy Discussion held on the same day 28 that the threshold had been met for a Section 47 joint investigation29 Q2 had disclosed to teachers that his mother had caused the injury, but he did not repeat this to the Police Officer and Social Worker during the Section 47 Investigation30. Mother tried, without success, to divert Police Officer 1 and Social Worker 1 from making a home visit. 6.26. Mother attempted to contact Father to inform him that she was returning home with representatives from the police and social services. Initially Police Officer 1 and Social Worker 1 were refused entry by Father who was said to be very aggressive. On entering the house it was evident that Q2 had four siblings found to be severely neglected and living in very poor conditions. The youngest three children were below school age and said to be dirty and in a state of undress. Sleeping arrangements for the children consisted of badly stained quilts on the floor surrounded by dog faeces. There was insufficient food in the house and it was decided that it was unsafe for the children to remain at home. Parents were arrested on suspicion of neglect and the children made subject to Police Protection. The following day Parents agreed to the children being 26 Mother said this was due to one of the dogs being incontinent 27 The Head teacher took Q2 round the playground and around the classes and repeated this a couple of days later. 28 Strategy discussion between the Harm Assessment Unit, Family Connect and Children’s Services. 29 The Local Authority have a statutory duty to carry out a Section 47 Enquiry where there is reasonable cause to suspect that a child is suffering or likely to suffer significant harm 30 Mother was not present at the time Police Officer 1 and Social Worker 1 spoke to Q2. 14 accommodated by LA231. Four dogs in a state of neglect were also removed from the family home. 7 Analysis 7.1. The analysis section of this report will consider the Key Episodes with reference to information provided by practitioners and managers who attended the Learning Event and Recall Event and information contained in Agency Reports prepared for this Review. The views of Parents will be incorporated into this Report prior to publication. 7.2. Specific themes emerged following systematic analysis of all the available information, guided by the Terms of Reference for this Review. Exploration of each theme enabled rigorous examination of practice and identification of opportunities to improve the systems to safeguard children across LA1 and LA2. 7.3. Whilst analysis of the themes will be presented separately it is important to note that each theme impacted on the others in a systematic and dynamic way. Professional recognition of neglect influenced the effectiveness of assessment and adequacy of information sharing within and between agencies which in turn informed the understanding that professionals had about the lived experience of the children. 7.4. The themes identified were: recognition of neglect effectiveness of assessment, and use of available tools information sharing, inter and intra agency communication professional understanding of the children’s lived experience, and parental engagement and professional challenge Recognition of neglect 7.5. During the period of consideration for this review there were indicators of potential neglect which were not identified as such by professionals working with the family. Information that was known and action(s) taken by practitioners during the timeline of relevance for this review is included at Appendix (i). 7.6. Given information that was known to practitioners at the time of this review and taking into account the context in which professionals were working it was evident that there were missed opportunities to share information and assess professional observations appropriately. The omission to identify neglect was not specific to one agency or an individual, and emerged within this review as an issue, of relevance to agencies in both LA1 and LA2. 31 The children were accommodated under Section 20 of the Children Act 1989 15 7.7. It is important to note that neglect is a strategic priority for both TWSCB and BBSCB. Much work is taking place within both LA1 and LA2 to ensure that agencies respond appropriately and in a timely way to identify and address neglect. Early recognition of neglect is a strategic aim within the neglect strategy for both areas and a specific focus of work for the TWSCB Neglect sub-group. Both TWSCB and BBSCB have implemented the Graded Care Profile 2 (GCP2)32 as the primary tool to assess and measure when children are at risk of neglect. During the time period covered by the review the TWSCB were in the early stages of implementation of the tool. It is acknowledged, that at the time, not all professionals in LA2 had received training on the tool. Professionals from LA1 involved in this case had not completed GCP2 training. 7.8. Neglect is the most common form of child maltreatment in England and features in over 60% of serious case reviews. The challenge for professionals with safeguarding responsibilities to identify neglect has been illustrated in various high profile cases. A recent study to assist practitioners with recognition of the indicators for actual neglect and risk factors associated with a likelihood of significant harm or future harm is of relevance to this review33. There were indicators of neglect and evidence of risk factors within the timeline for this review in both LA1 and LA2. 7.9. Brandon et al. 201434 acknowledged that health and education professionals and social workers often find it difficult to identify indicators of neglect or recognise their severity. One characteristic of neglect that contributes to this difficulty is that unlike physical abuse for example, the experience of neglect rarely produces a crisis that demands immediate attention. This was of particular relevance in this review as professionals in LA2 only became aware of the extent of neglect experienced by the children in the Q Family during enquiries to explore an allegation by Q2 of physical abuse by Mother. 7.10. There was an immediate response to the allegation by Q2 which resulted in the home visit by Police and Social Worker and led to removal of the children from the family home. Prior to this incident concerns about home conditions had been recorded by HV7 and HV8 in LA2 although it is important to note that for two visits Mother said the family were not living at the property and this had been accepted35. 32 The Graded Care Profile is an assessment tool to assist practitioners to identify when a child is at risk of neglect. The GCP2 is an authorised update of the original tool 33 Missed opportunities: indicators of neglect – what is ignored, why and what can be done? Research Report. Brandon M, Ward H et al. DH Nov 2014 34 Ibid p7 35 Mother said that she panicked when asked about home conditions and did not think it would be believed that the family were living elsewhere 16 7.11. In LA1 concerns regarding home conditions were recorded by Health Visitors and Midwives however the possibility of inadequate home conditions being linked to chronic neglect was not explored. It is important to note that, had practitioners in LA1 shared information in an effective and timely way, there may have been a more robust response to home conditions observed by practitioners in LA2. 7.12 The ability of professionals involved in this review to identify neglect was influenced in part by the following factors: normalisation of inadequate home conditions, involvement of different professionals, increased focus by professionals on the completion of mandatory visits and lack of professional curiosity. Each factor will be discussed below. a) Normalisation 7.13. At the Learning Event professionals from both LA1 and LA2 said that they were accustomed to working in areas with large numbers of children and high deprivation. It was noted in Agency Reports that child protection notifications were a daily occurrence at School 1 in LA1 and Schools 2 and 3 in LA2 had a high number of children subject to Child in Need and Child Protection Plans. 7.14. The Healthy Child Programme sets out the good practice framework for prevention and early intervention services for children and young people 5-19. It is emphasized that all staff in school should be sensitive to the warning signs of possible abuse or neglect for example poor physical care, smelly and/or dirty clothes, poor dental care and untreated caries36. It is acknowledged that failure to provide appropriate health care, including dental care is a form of neglect. The dental health of Q1 and Q2 was very poor and they required treatment which included extractions when taken into care. Although the children were only at school in LA2 for a short period and were said to be very quiet during this time, practitioners expressed surprise at the learning event that they had not noticed the tooth decay as it was described as very extensive. There are many possible reasons why the tooth decay had not been noticed by practitioners and it is important to acknowledge the possibility that when working daily in areas of high deprivation practitioners may become less alert to potential indicators of neglect. 7.15. Managers responded quickly to learning from this review and training will be offered to all schools to highlight the significance of dental health as a potential indicator of neglect. Consideration about wider dissemination of learning from this review is included in Section 10 (Opportunities to improve practice). 7.16. At the Learning Event practitioners37 from LA1 acknowledged that conditions observed during home visits to the Q family home were no worse than what they 36 Healthy child programme from 5 to 19 years old. London: Department of Health 2009 p85 37 Including Health Visitors in LA1 and LA2 and teachers from School 1 who visited the children at home in LA1 prior to starting school 17 had seen at other houses38. Some practitioners explained that they were working with other children and families assessed to be at greater risk and had to be prioritised over the Q children. It was acknowledged in an Agency Report from LA139 that critical reflection in supervision may have challenged and exposed the practitioners’ normalized view in this case. 7.17. Working with children and families within high levels of deprivation may have contributed to lack of professional sensitivity to possible indicators of neglect such as home conditions and physical presentation of the children including dental hygiene. It was acknowledged in an Agency Report from LA1 that ‘observations made by HV4 give a concern that the home environment was hazardous for a cruising baby and potentially harmful to the health of all the children’. It was acknowledged in an Agency Report from LA2 that professional ‘observations of home conditions in November 2016 evidenced that the physical environment the children were living in was not satisfactory’. 7.18. It is possible that as professionals in both LA1 and LA2 were accustomed to working in areas of high levels of deprivation that this experience impacted on their acceptance of what was reported as inadequate physical conditions within the home in which the Q family lived. In addition records from LA1 evidenced that there were also concerns about the physical presentation of the children at school however these were managed internally and not identified as potential indicators of neglect. b) Involvement of different professionals - lack of consistency 7.19. Home visits were completed by three different professionals in LA1. In LA2 three different Health Visitors and a Hearing Screener, visited the Q family home on five occasions during October and November 2016. Home conditions were not monitored and this was due in part to the involvement of different professionals and omission to read notes from previous visits. Whilst records evidence that conditions were inappropriate and potentially unsafe (LA1) and not satisfactory (LA2) for young children, they were not recognized as such and this resulted in a lack of urgency and appropriate action to keep the children safe. There was no evidence in agency records in LA1 or LA2 of a discussion with Parents about changes that were required to ensure the wellbeing and safety of the children. 7.20. In the time considered by this Review, practitioners were operating in challenging circumstances as detailed in Section 8 (Organisational Context) of this report. Nevertheless in LA1 the number of professionals involved with the family contributed to observations being made in isolation and the opportunity to assess whether conditions had improved or deteriorated was not taken. In LA2 it was evident, from 38 Mother said that it was clear that the family were in chaos and not coping and Parents said they did not know what help and support would be available and felt that professionals had walked away 39 Essex Partnership University Foundation Trust 1-19 Team p12 18 information available to this Review that HV8 had intended to monitor home conditions although it was understood that the family were living with Maternal Grandmother at the time. HV8 was not available for work at the time of the six-week review for Q5 and this was undertaken by HV7. It was recorded that the review took place at home and there was no evidence that HV7 took into account previous observations made by HV8 which resulted in an inconsistency of approach to address home conditions. 7.21. It was noted in a previous SCR40 that adoption of an incident by incident approach even when there were reports of the family home being dirty, untidy and smelling of faeces prevented escalation by practitioners to meet the needs of the children concerned. Managing incidents in isolation could also be described as a form of silo practice with agencies and individuals working independently with very little discussion or sharing of information. This was a finding in the TWCSB SCR for Child B published in June 2015. Findings from the current Review indicate that there were missed opportunities for agencies to work effectively in partnership which is likely to have limited the ability of practitioners to recognise potential indicators of neglect in both LA1 and LA2. c) Focus on tasks - completion of mandatory visits 7.22. All contacts between Health Visitors, Community Midwives and the Q family were part of the mandated elements of the Universal Healthy Child Programme41. It was acknowledged that there was a heightened managerial focus on team and individual performance in LA1 and practitioners were working under significant constraints which were likely to have had an impact on the service offered to the family. 7.23. The increased focus on delivery of the full Universal Offer and drive to improve performance in LA1 may have reduced the capacity of practitioners to think beyond the immediate task, identify additional needs and vulnerabilities and manage complex cases. It is possible that the pressure on professionals resulted in them seeing the case within a narrow frame of their own professional background which has been identified as another form of silo practice by Sidebotham et al (2016). In addition, the NICE Guidelines on Child Abuse and Neglect (NG76) highlight the importance of critical thinking and analysis and guards against over reliance on protocols, proformas. d) Lack of professional curiosity 7.24. There was very little evidence of professional curiosity throughout the timeline considered for this Review. Practitioners42 who attended the Learning and Recall 40 Child A 2014 NOT TWCSB 41 Antenatal health promoting visits; new baby review; 6-8 week assessment; 1 year assessment; and 2-2½ review; 42 Health visitors, midwives, GP and teachers 19 events stated that they accepted information provided by Mother as they had no reason to think it was incorrect. Professional readiness to accept parental explanations without showing any curiosity about whether the explanations are correct has been a consistent finding within Serious Case Reviews43. On several occasions, Mother provided information to professionals which was incorrect and served to deflect attention from indicators of neglect and effectively distance the children from contact with professionals as detailed in the paragraph below. 7.25. In LA1 home visits were made by HV4, MW1 and MW2. Refusal of the Parents to allow professionals to access the family home on discharge from hospital44 or to allow MW1 to see the sleeping arrangements for Q4 did not result in further assessment or professional curiosity/concern about the possibility that home conditions were unsuitable. It was unclear if consideration had been given to the vulnerability of newly born Q4 given the seeming reluctance of Parents to work with professionals. In LA1 Mother cancelled two home visits by professionals stating there had been a family bereavement when this was not the case. 7.26. In addition, when Mother registered with the GP in LA2 she did not disclose that she had other children who also required registering with the GP although there was space on the form to do so45. In LA2 Mother informed HV8 that she was living with the children at Maternal Grandmothers which was in fact not correct. 7.27. The ante-natal booking for Q5 in LA2 took place at a weekend when fewer midwives were available. Further enquiries could have been made at a later date about Mother’s maternity care in LA1 to inform a future care plan. There was no documented evidence to indicate professional curiosity about information shared by Mother regarding the move from LA1, lack of maternity records and reasons for Father not having contact with his daughter from a previous relationship. It was unclear if the Midwife considered seeking additional advice via safeguarding supervision; however, it was reported that there was limited availability of safeguarding supervision at this time and this had been recorded as needing improvement on the service at risk register. Midwives caring for women should have accessible safeguarding supervision to reflect and identify whether additional support is required to prevent escalation of risks to the unborn and siblings within the family. 7.28. In LA2 workforce constraints resulted in practitioners working with a high case load and a significant number of children and families with complex needs and 43 Pathways to harm, pathways to protection: A triennial analysis of serious case reviews, 2011 -2014. Sidebotham P et.al. DH 2016 44 Because Parents said the house was messy 45 Mother said that she assumed this information would have been transferred when the family moved from one GP to another. 20 vulnerabilities. Delivery of core contacts placed the team under physical strain and emotional stress. This may explain why practitioners focused on the contacts that they had been allocated to complete and the opportunity to make links with previous home visits was not taken. 7.29. There was no evidence from LA1 or LA2 that professionals critically reflected on their practice or exercised professional curiosity. The importance of professional curiosity and questioning and lack of confidence of some professionals to challenge parents was highlighted in a report published by the NSPCC (2014)46. 7.30. It is expected that Health Visitors have access to clinical and managerial supervision and at least three-monthly safeguarding supervision47. There were significant organizational constraints which impacted on the supervision of Health Visitors in LA1. The provision of effective managerial and supervisory oversight would have increased the opportunity to robustly challenge the normalization of home conditions and the absence of professional curiosity which, in this case, appears to have put the wellbeing of children at risk. Whilst safeguarding supervision was available to Health Visitors in LA2 concerns about home conditions were not discussed with a Safeguarding Children’s Supervisor48. Effectiveness of assessment 7.31. Professional observations were not recognised as possible indicators of neglect which impacted on the effectiveness of decision making. This was a significant factor which contributed to the lack of assessment by practitioners. 7.32. In June 2015, following a New Birth home visit in LA1 HV4 recorded that the house was dirty and untidy with an “atrocious smell”. The next day HV4 contacted HV5 at the MASH and proposed undertaking an Early Help Assessment (EHA). It was thought that Mother would be very resistant to this and unlikely to cooperate. The Health Visitors were aware that Midwifery colleagues had experienced difficulty in accessing the family home49 and this information appeared to have weighted their decision not to progress an EHA at this time. It was noted in the Agency Report50 that the practitioners appeared to have lost sight of the potential detrimental impact of inadequate home conditions (as indicated by the accumulated facts) on three young children. The potential lack of engagement by Mother in an assessment was not considered as an additional risk factor likely to increase the vulnerability of the children. 46 Realising the Potential: Tacking child neglect in Universal Services, Haynes, A. (2014) NSPCC 47 National Health Visiting Service Specification 2014/15, NHS England 48 Every HV and School Nurse in LA2 has an allocated Safeguarding Children Supervisor. 49 Mother said that visits tended to be early in the morning when she was taking the children to school. Father was unable to support with this. 50 Essex Partnership University Foundation Trust 0-19 Team, p6 21 7.33. Use of the referral pathway in LA1 into the MASH or completion of an Early Help Assessment would have been a more appropriate and proportionate response to the lived experience of the children. At this time the MASH was in the first six months of development and the MASH Health Visitor was new to the role. It was noted in the Agency Report that lack of clarity about the role of the Health Visitor in the MASH, together with previous experience of cases not meeting the threshold of intervention by Children’s Social Care, strongly influenced the misplaced mutual conclusion that the case did not warrant a referral to MASH at this time. There is evidence to suggest that assumptions by professionals which prevent indicators of neglect being acted upon include a reluctance to refer based on previous experience of referrals not being accepted51. Reassurance was provided by Managers during the process of this Review that correct procedures are now established and would be followed by relevant practitioners. 7.34. In June 2015, at the time of the second home visit52 undertaken by HV4 in LA1 it was evident that little had changed. Q4 had not received vaccinations and Mother had taken active steps to disguise the smell immediately prior to the visit. The children were reported to be clean and playing happily and no further visits were planned although Q4 was assessed as requiring Universal Plus level of service. This was not an adequate response and it would have been more appropriate to undertake an Early Help Assessment to fully assess the family circumstances and support the Parents to make appropriate changes to ensure that the needs of the children were met. 7.35. At the learning event practitioners stressed that there were no concerns regarding the behavior of Q1 or Q2 at school in LA2, and they did not stand out as at risk of neglect. It is likely that there was a false sense of reassurance as there were no overt signs of neglect and presentation of the children did not raise concerns. 7.36. In October 2016, following the birth of Q5 in LA2 HV8 made two home visits to Q5 and Mother. Records of the visits include factual observations of home conditions which evidenced little improvement between the visits. Mother was not asked about the lack of improvement which was possibly due to HV8 believing the family were living with Maternal Grandmother at the time. Completion of an EHA was not considered. 51 Brandon M, Bailey S, Belderson P, Warren C, Gardener R. and Dodsworth J. (2009). Understanding Serious Case Reviews and their impact. London: Department for Children, Schools and Families Missed opportunities: indicators of neglect – what is ignored, why and what can be done? Research Report DH Nov 2014. Brandon M, Ward H et.al. 52 After a number of failed attempts to re book the cancelled scheduled visit 22 7.37. At the end of November 2016 (ten days before the children were removed from the family home) HV7 completed the six week review for Q5. It was recorded that the visit took place at the family home. From information contained in Health Visitor records which noted the presence of a strong smell of animal urine, it was evident that the home conditions remained unsuitable and unsafe for children particularly Q5, a new baby who was exposed to unsafe and unhygienic conditions. 7.38. Mother was not offered a further appointment to review progress and this was a significant omission. The author of the Agency Report53 in LA2 noted that it was evident that ongoing targeted support was required to ensure that the children’s needs were met and it was not appropriate that Q5 was assessed as requiring a universal service. 7.39. The Graded Care Profile 2 had been implemented in both LA1 and LA2 at this time and could have been used to explain to parents the changes that were required to benefit the children. At the Learning Event it was noted that 58 practitioners had completed training by November 2016 regarding the use of GCP2 in LA2 and there was ongoing training provided in LA1. There was no reference in records of the Health Service to the use of guided conversations to inform family assessments and care planning. In addition, there was a lack of evidence in Health Visiting Records in LA1 and LA2 of the expected use of prescribed documents for assessment. 7.40. At the Learning Event, it was acknowledged by practitioners and managers in both LA1 and LA2, that the use of tools to support the early identification of neglect, specifically GCP2 was not embedded across the authorities. Currently enquiries are being made to fully understand why efforts to implement the GCP2 have not been fully effective. At the Learning Event it was suggested that there remains lack of understanding about the value of the GCP, some practitioners believe the tool is labour intensive and there are also concerns that resources would not be available to meet assessed needs. 7.41. Maternal Aunt brought Q1 to and from Primary School in LA2 as children of her own also attended. There were no concerns regarding Maternal Aunt or her children and professionals at the Learning Event indicated that this may have contributed towards their overall positive perception and assessment of Q1 and the family. 7.42. In June 2013, prior to the timeline for this review, Mother had advised HV1 in LA154 that she was a carer for Father as he had a learning disability. This information was not considered further and should have made a difference to the assessment of risks and vulnerabilities and informed the understanding of additional support needs for the whole family. 53 Shropshire Community Health NHS Trust p10 54 At the 2 year development review for Q2 which took place at the family home in LA1 23 7.43. There was little mention of Father in the records of Mother or the children. Routine enquiries were made at the new birth visit for Q5 in LA2 and basic details about Father were included in records made by Health Visitors. The need for practitioners to be more inclusive of Fathers in their assessments and interventions with families was identified as a learning need in a recent SCR in LA155. Omission to assess the contribution that Fathers can make to safeguard children as well as identifying potential risks that Father’s may pose has been a consistent finding within Serious Case Reviews56. It is important that the LSCB’s reflect on why the Father of the Q children was hidden throughout the timeline of this Review, given the available knowledge and professional understanding regarding the importance of involving fathers. 7.44. There were missed opportunities by practitioners in both LA1 and LA2 to initiate an Early Help Assessment which would have supported gathering of information about all family members. This was a significant omission which impacted on the support provided to the children and family. Given the lack of assessment there are many unanswered questions which would have informed this review which include; parental capacity, relationships within the family, support of extended family, wishes and feelings of the children. This information was potentially knowable to practitioners but unknown during the timeline for this review. 7.45. It was noted in an Agency Report57 from LA1 that management of this case by 0-5 practitioners fell short of effective practice to identify likely child neglect and provide a timely and proportionate effective response to ensure the well-being and safety of this large sibling group. 7.46. Previous SCR’s58 completed by TWSCB made a similar finding regarding the omission by practitioners to complete timely multi agency assessments. TWSCB will be keen to fully understand why this finding has persisted and this will be addressed Section 10 (Opportunities to Improve Practice). Information sharing: inter and intra agency communication 7.47. Most of the Agency Reports prepared for this review highlighted limitations in information sharing which impacted on the understanding that professionals had of the family, assessment of concerns and subsequent provision of support. There were examples of ineffective information sharing within agencies, between agencies and between LA 1 and LA 2, as discussed below. 55 BBSCB Baby Sama, 2017 56 Hidden Men: Learning from Serious Case reviews. NSPCC, 2015 57 Essex Partnership University Foundation Trust 0-19 Team, p 20 58 Child A 2016 and Child B 2013 24 a) Inter-agency Information Sharing 7.48. It was acknowledged in Agency Reports that there were some inaccuracies in recording by professionals which impacted on information sharing. Information pertaining to one child was on the record of a sibling and some information pertinent to all siblings was only recorded on the record of one child. Consequently, some of the records for the Q children were incomplete and others inaccurate. This hindered professional analysis of information, as evidenced when in LA1, HV6 was contacted by the Hospital Safeguarding Nurse to share concerns about the presentation of Q3 and Mother during the hospital admission. Previous observations of home conditions had only been written in the record for Mother and Q4. As HV6 did not check the records of siblings’ this information did not inform analysis and decision making following receipt of information from the Safeguarding Nurse. Had information about poor home conditions been recorded on all children’s records, it is likely that the information received by the Hospital Safeguarding Nurse59 would have been considered to have greater relevance and importance. At the Learning Event practitioners acknowledged that sometimes it can be difficult to check the records of all relevant children when discussing the case with another professional. 7.49. Professionals, particularly those undertaking home visits in LA1 and LA2 appeared to be working in isolation and there was a lack of consistency of approach and limited information sharing which resulted in issues identified in one visit not being addressed in the next. This was particularly evident between the home visits made by HV7 and HV8 immediately prior to removal of the children from the family home in LA2. There was little evidence of information sharing within Maternity Services in LA1 to clarify why Mother did not present for ante-natal care following the emergency scan at 22 weeks gestation. Whilst Mother did present at Maternity Services in LA2 this was not known by the GP who made the emergency referral or Maternity Services in LA1. There does not appear to have been any effort within LA1 to ensure the safety and whereabouts of Mother and her unborn baby. 7.50. It was the view of professionals at the Learning Event that a missing alert should have been raised to ensure that Mother and Unborn Baby were effectively safeguarded. b) Information sharing between agencies 7.51. The Health Visitor records from LA1 do not contain any information from local Midwifery services regarding ante natal care. It is unclear whether this was due to a lack of communication by Midwifery Services or a failure to scan communications onto Mothers electronic record. 7.52. Following the discussion60 between the Hospital Safeguarding Nurse and HV6 in LA1 there appeared to be a de-escalation of concerns. The referral by HV6 to a Community Nursery Nurse did not result in the provision of additional support to the 59 About Mother and Q3 appearing unkempt and wearing dirty clothes and Q3 drinking fizzy drinks 60 About observations regarding Q3 during the hospital admission in LA1 25 family. There was a delay of two months before the GP was informed of non-attendance at the development check arranged by the Community Nursery Nurse. It was acknowledged within the Agency Report61 that given the concerns expressed by the hospital for Q3 this response was not adequate or timely. HV 6 did not discuss this case with her manager as it was not one of her active cases and it was thought that the Safeguarding Nurse would have made a direct referral to Social Care had the concerns been significant. 7.53. Information shared verbally between agencies in LA1 lacked clarity at times and practitioners had a different understanding of what was agreed. The conversation between the Hospital Safeguarding Lead and HV6 appears to have been misinterpreted and there was no record of the discussion. HV6 thought this was a request for health promotion/education and not a referral for the assessment of home conditions. The assumptions and expectations following this discussion were not clarified by either professional. 7.54. Information sharing between HV4 and MW2 in LA1 was reactive and it was noted in the Agency Report62 that it is expected that the observations and experiences of the Midwifery Service are proactively shared with relevant agencies during the antenatal and post-natal periods. There was a missed opportunity for both Midwifery and Health Visiting services to undertake a joint comprehensive assessment. This would have enabled the exploration of factors such as late presentation in pregnancy, significance of the family bereavement and missed ante natal appointments and may have resulted in an opportunity to explore the provision of Early Help. 7.55. Records made by HV4 in LA1 noted the intention to involve the Community Nursery Nurse and contact the school attended by Q1 and Q2. These actions were not completed and there was no discussion with the school nurse on the same team as Health Visitor 4. Pressure of work and lack of experience were identified by practitioners at the Learning Event as the key reasons why actions had not been followed up. It is important to note that service managers have a responsibility to ensure effective service delivery and it appears that there was an omission to provide sufficient oversight and support for a practitioner who had limited experience. 7.56. This Review has highlighted an issue around internal communication between the Health Visiting and School Nursing Service in LA2 as the older children (Q1 and Q2) were not seen by School Nursing even though Health Visiting colleagues were aware of the older siblings since October 2016. A recommendation63 has been 61 Essex Partnership University Foundation Trust 0-19 Team, p7 62 Essex Partnership University Foundation Trust 0-19 Team, p10 63 Appendix ii details all recommendations made by single agencies during the Review process 26 made to implement a formal system of communicating this information between agencies to ensure children are not missed and their needs are addressed. 7.57. At the New Birth Visit for Q5 in LA2 Mother informed HV8 that she had four other siblings living with her (Q1-4). The siblings were not seen by a Health Visitor even though two siblings were under five. There was a delay in requesting the records from the previous Health Visitor service following registration of the children with the GP in LA2 due to the system in place in LA2 at that time. The need to clarify a timescale for transfer-in visit once a child under five has moved into the area to prevent delay and drift was identified as a single agency recommendation as a result of this review. 7.58. The only information held by Primary School 2 and Primary School 3 in LA2 was contained in the normal admission form completed by parents when children were admitted to the school. There was no information about siblings and it was noted in the referral to Family Connect by School 3 that Q2 lived alone with Mother and Father. Whilst this did not appear to impact on the outcome of the referral practitioners were not prepared to encounter a large sibling group during the Section 47 Enquiries. c) Information sharing between services in different areas 7.59. Effective partnership working and information sharing is essential when families move areas to ensure continuation of support and intervention to address the health and social care needs of vulnerable children. There was an absence of proactive information sharing between all agencies in LA1 and LA2. 7.60. Midwifery Services in LA2 omitted to contact Midwifery services in LA1 following the weekend booking for antenatal care when Mother was pregnant with Q5. This would have highlighted historical inconsistent engagement with health services and provided an opportunity to enquire about social history and develop a clearer understanding of why the family had moved and the needs of the children. 7.61. As Q3 and Q4 were not registered at the GP practice a transfer-in visit with the Health Visiting Service was not arranged and Health Visiting records from LA1 were not requested. This was a missed opportunity to assess the health needs of the children and identify strengths and vulnerability factors within the family. It was acknowledged that children can be missed or become invisible as happened to Q3 and Q4 if the transfer in appointment with the Health Visitor is dependent on registration with a GP. A recommendation to review the Health Visitor allocation system when new children move into LA2 has been made by the relevant agency as a result of this Review. 7.62. It was highlighted during this review that difficulties in transferring data between GP practices may constitute both a clinical and safeguarding risk. Historical safeguarding issues may not be immediately evident which would limit the ability of a practitioner to make an informed and holistic appraisal of any situation. There 27 was no information in the GP medical notes in LA2 from either the Health Visitor or Midwife to indicate any concerns regarding home conditions. 7.63. When Mother registered with the GP in LA2 a request for medical notes was made to the GP in LA1. There was no evidence of curiosity by the GP in LA1 about why the medical notes for the children had not been requested at the same time as Mother’s. The system for transfer of information was dependent on Mother providing information about the children, as this did not happen effectively, the children (Q3 and Q4) were hidden from professional view. It is important that learning from this review informs system change regarding transfer of records between GP surgeries and registration of new patients to reduce the possibility of children being missed when families move areas. 7.64. The Nursery in LA2 was not informed by other agencies that Q3 had been taken into care and were told by Mother when enquiring where Q3 was for attendance monitoring. The Nursery should have been informed more promptly by agencies involved and this would have avoided a very difficult conversation between Mother and staff member. 7.65. There are clear pathways for transfer in and out of Health Visitor records however these were not followed in LA1 and LA2 due to staff leave and capacity issues. Improvements to the transfer process when children move areas have been made during the process of this Review and are detailed in Appendix ii. Professional understanding of the children’s lived experience 7.66. There was very limited understanding of the children’s lived experience and absence of the voice of the child was noted in the Agency Record for School 1 in LA1. In addition, there was over reliance on Mother’s explanations about home conditions, cleanliness of the children, non-attendance at medical appointments64 and late booking for ante natal care in pregnancy. 7.67. Q1 and Q2 attended the same school in LA1 and different primary schools in LA2 for nine weeks before the incident which resulted in them being taken into care. They were described by the respective schools as quiet children who settled in well and quickly made a small group of friends. Q1 and Q2 were not identified as being in need of additional intervention or support. 64 Ante-natal care and immunisations for the children 28 7.68. Q1, Q2, Q3 and Q4 were not seen by the School Nurse or Health Visitor in LA2. Health Visitor records contained minimal references to the physical presentation of Q5. Following the new birth visit the emotional warmth shown by Mother towards Q5 was noted by the Health Visitor and at the six week check Q5 was described as bright and alert. 7.69. Although Q3 had only attended Nursery in LA2 for a short time individual plans had been put in place to provide support with speech and language and staff appeared to have a good understanding of his likes and dislikes. It was noted in the agency report that staff linked the support provided to activities of specific interest to Q3 which included cars, small world play and outdoor play. Nursery staff met the physical needs of Q3 when required which included nappy changing, providing dry clothes and at times washing Q3. 7.70. Information recorded by Health Visitors in LA1 and LA2, following home visits, evidence that the physical environment was inadequate and unpleasant for young children. There appears to have been no consideration given to the physical and emotional impact on the children living in inappropriate physical conditions. There was an absence of professional reflection about emerging concerns and the impact of these on the children. 7.71. There was little information about the children having access to toys or appropriate stimulation and there was no information about the interaction between the siblings as they were not observed playing together. At the Learning Event Social Worker 1 (LA2) reported that when asked if they wanted anything the older children had asked for a hairbrush and socks, basic requirements which had not been met. 7.72. Whilst professionals had contact with the children, work was not conducted in a way that was consistently child focussed. The lived experience of the children was not at the forefront of the practitioners practice and there was a missed opportunity to provide timely and proportionate planned intervention. 7.73. Listening to the voice of the child is a strategic priority within the TWSCB’s Business Plan and it is a concern that this review found that there was limited understanding of the children’s lived experience. There is extensive evidence which highlights the importance of professionals with responsibility for safeguarding children having an understanding of their lived experience65. Statutory guidance emphasises the importance of remaining child focussed and ensuring that the child is at the centre of all decisions which impact on their lives66. In addition there have been many examples from serious case reviews of the serious and potentially fatal 65 Developing an effective response to neglect and emotional harm to children. NSPCC, 2008 Gardner R 66 Working together to safeguard children. DfE, 2015 29 consequences when professionals lose sight of the children whom they have a responsibility to protect67. 7.74. Understanding the lived experience of the child is a complex process and the importance of professionals having a child centred approach is well recognised. All the themes considered within the analysis for this review have impacted on the ability and capacity of professional understanding of the life of the Q children. Parental engagement 7.75. Difficulty engaging with avoidant families and failure to provide sufficient challenge to parents have been identified previously in research and serious case review reports68. 7.76. Efforts were made by both Mother and Father at times to divert the attention of professionals away from the family home and the children. There was little evidence of effective challenge by professionals and on one occasion following a challenge by MW1 in LA1 Mother refused further visits from MW1. 7.77. Father refused to book a new birth appointment for Q4 in LA1 stating that Mother was not available and there was no consideration given to whether Father was being obstructive69. On two further occasions in LA1 Mother did not allow professionals to have access to the family home stating that it was messy. Mother also refused Midwife 1 permission to view the bedrooms during a new birth visit when Q4 was three days old. Events were recorded factually without reference to the additional vulnerability of a new born baby. There was a missed opportunity to reflect whether additional support was required or if Mother was being deliberately obstructive. 7.78. Mother informed the HV8 at LA2 that the family was living with Maternal Grandmother whilst the family home was being decorated. There was no consideration given to whether the family required additional support and a referral to Early Help Services was not made. Mother was described by practitioners as articulate and persuasive at the learning event. When asked about the CCTV outside the house Mother said Father had a pushbike stolen and had always had CCTV. It was noted in an Agency Report from LA1 that there was professional concern building that parents may be avoiding professional’s access to the family home as conditions were poor. There was an omission to develop an effective response to the emerging concerns of professionals detailed within Service Records. 67 In the child’s time: professional responses to neglect. Ofsted 2014 Missed opportunities: indicators of neglect – what is ignored, why and what can be done? Research Report DH Nov 2014. Brandon M, Ward H et.al. 68 Learning Lessons from Serious Case Reviews 2009-2010, Ofsted 69 Father had a Learning Disability and suffers from anxiety 30 7.79. Practitioners accepted Mother’s explanations of events and there was no evidence of professional curiosity from practitioners in LA1 or LA2. The NICE Guidelines on child abuse and neglect highlights the principles of effective work with parents and carers. Development of a good working relationship involves working in a way that enables trust to develop whilst maintaining professional boundaries and maintaining professional curiosity and questioning while building good relationships.70 7.80. Due to lack of assessment and absence of professional challenge, the motivation, intent and capacity of Mother and Father are unclear. Whilst there were incidents that could be described as disguised compliance71 it is important to exercise caution as there was no plan for the parents to comply with and lack of information about the capacity of Parents to meet the needs of the children in their care. 7.81. Mother cancelled appointments with professionals on two occasions stating there had been a family bereavement. At the Learning Event it was confirmed that Maternal Grandmother was still alive although mother had cancelled an appointment by a Health Visitor in July 2015 stating that she had died. There was no evidence within records that professionals had considered the impact of bereavement on the family or an understanding that bereavement is likely to be accepted by professionals without further enquiry and could in this case support concern for parental disguised/ non-compliance. 7.82. Mother initially attempted to deter the Police Officer and Social Worker from visiting the family home and then pre-warned Father that she was returning home with professionals. Father was aggressive towards Police Officer 1 and Social Worker 1 and initially refused them permission to access to the family home. It is reasonable to conclude that the behavior of both Mother and Father may have been an indication that they recognized the home conditions were unacceptable for the children. 7.83. It was likely that the behavior of parents which ranged from prevention of professional access to the family home to cleaning immediately before visits and attempting to disguise smells was illustrative of disguised compliance as noted in an Agency Report72. This was not addressed effectively by professionals. 70 Child abuse and Neglect NICE Guideline (NG76) 2017 https://www.nice.org.uk/guidance/ng76/chapter/Recommendations 71 The term is attributed to Peter Reder, Sylvia Duncan and Moira Gray who outlined this type of behaviour in their book Beyond blame: child abuse tragedies revisited 72 Essex Partnership University Foundation Trust 0-19 Team, p13 31 8 Organizational Context and impact on Practice Local Authority1 8.1. During the timeline of relevance for this Review there were significant challenges to the delivery of services by the 0-19 team in LA1 which had an impact on workloads and team dynamics. The team had moved base in April 2015 to co-locate with the link team. Health Visitors had further to travel for visits and were encourage to mobile work and attend the base for support and supervision. 8.2. Management changes to increase support were experienced as disruptive to daily practice by some practitioners. This may have compounded the pressures experienced due to high case load as a result of staff shortage due to vacancies and long term leave. It was acknowledged in the Agency Report that staff morale was low and anxiety heightened. 8.3. Significant staff shortages and a change in line management impacted on service delivery. One of the health visitors had recently returned from long term sick leave and reported that there was a lot of pressure from management to improve team performance and undertake the mandated key visits. In addition, there was significant emphasis on discussing baby brain development and other key issues at the mandated visits. At the time antenatal appointments were only offered to families with identified vulnerabilities73. 8.4. The new team manager had not been aware of the expectation to delegate supervision and had struggled to supervise a team of 26. Management supervision had focused on cases in the Universal Partnership Plus category, operational contractual targets and mandatory training compliance and sickness management 8.5. There had been a significant investment in training and development to enable health visitors to undertake comprehensive family assessment. Further investment has been made into the development and support of professionals through a comprehensive supervision system it was reported that practitioners made appropriate use of ad hoc supervision. 8.6. In LA1, there was a lack of clarity about the role of the Health Visitor in the MASH. The Health Visitor was new in post and the MASH was being developed. Local Authority 2 8.7. In LA2 the health visiting team responsible for Q3, Q4 and Q5 were operating with a significantly reduced staffing capacity with less than half the team working74. In addition, one health visitor was covering another post within the service whilst working their hours within the team. 73 At the time of the review performance for ante natal visits was 50%. Current performance for ante-natal visits is 91% and 97% of post natal visits are made within14 days as of September 2017 74 In November 2016 1.6 health visitors were covering a case load of 950 children 32 8.8. In an attempt to address challenges in delivering the service, the manager worked on the case load herself and also asked another team to provide cover. Concerns about service delivery had been made verbally by the team manager to their line manager however the internal reporting system (DATIX) had not been used. Had a DATIX report been completed this would have highlighted the risks to the team and caseload on a formal level and additional support could potentially have been provided. 8.9. Subsequent to the timeline for this review two Health Visiting teams were amalgamated and changes were made to the allocation and staffing of the caseload. The two teams continue to operate from different bases and whilst there are plans to co-locate, work continues to be delivered in isolation. 8.10. It was acknowledged in the agency report and by practitioners at the Learning Event that ongoing difficulty with recruitment means that the vulnerability of the case load currently remains the same as at the timeline for this review. 9 Good Practice identified 9.1 Within the SILP learning model, equal emphasis is given to what worked well in a case as to any shortcomings in practice. Within this case the following areas of good practice made a difference in this case; HV2 contacted the midwife to obtain information when struggling to arrange a home visit. The Head teacher at Primary School 3 in LA2 made significant attempts with Q2 to identify peers that Mother alleged had been bullying him. Police Officer1 and SW1 in LA2 insisted that the children were visited at the family home and were not influenced by Mother. Police and Children’s Social Care in LA2 worked effectively without delay to ensure the children were safeguarded. 10 Conclusion 10.1 This Review has benefited from the generous participation and reflections of practitioners and managers at the Learning and Recall Events. Effort has been made within this Review Report to build on similar findings from local and regional serious case reviews with reference to relevant research. Consideration has been given to the current work plan of TWSCB to ensure that recommendations complement and enhance work in progress and avoid duplication. 10.2 Whilst it is evident that the early identification of Neglect is a strategic priority for both TWSCB and BBSCB there are significant issues which have had a negative impact on this work. Training programmes have been provided in both LA1 and LA2 however this review has highlighted that efforts to embed the use of GCP2 have had limited impact. 33 10.3 This Review has highlighted the importance of undertaking a holistic assessment of children and families when there are emerging concerns. Completion of a thorough assessment in this case would have furthered understanding of the needs and additional vulnerabilities of the children including pre-birth. In the absence of a comprehensive assessment there was an over reliance by professionals on the explanations provided by Parents and the physical presentation of the children. 10.4 A holistic assessment would have identified a pattern of parental engagement which included; non-attendance at development reviews for the children, reluctance to allow professionals into the family home and critically in this case long standing history of poor home conditions and inadequate explanations provided by Mother. 10.5 This Review found that there were indications of parental disguised compliance. However, in the absence of professional challenge, critical reflection and full assessment, the intent, motivation and capacity of the Parents were not known. The impact on Mother of caring for a very young family and a partner with additional needs whilst moving house on two occasions was not known. 10.6 From information provided to this review it could be inferred that mother and Father were engaged in disguised compliance however it is not possible to conclude this with absolute confidence for reasons outlined above. Whilst disguised compliance emerged as a possible contributory factor in this case this must be considered alongside other findings which included; absence of professional challenge, omission to share information, missed opportunities to identify neglect and limited understanding of the lived experience of the children. Each finding had some influence over the decision making and intervention of practitioners in LA1 and LA2. 10.7 It is important to acknowledge that the findings within this Review are similar to those identified in previous national SCR’s. In addition, information sharing, the importance of remaining child focussed and adoption of a critical questioning approach to Parents are relevant to the safeguarding responsibilities of each agency involved in this review. 10.8 Identification and intervention in neglect cases is complex and multifaceted. It is important that all partners in LA1 and LA2 share responsibility to ensure that the systems to ensure early identification of neglect are as robust and effective as possible. 11 Opportunities to improve practice Single agency action plans resulting from learning from this Review are available as Appendix (ii). 34 11.1 Recommendations: The TWSCB and BSCB request that partner agencies review early help policy and information sharing processes regarding emerging concerns about neglect (which include dental health) when a child moves within and between local authorities. The TWSCB Chair and relevant managers should work with local and national forums to improve information sharing processes regarding emerging concerns about neglect (which include dental health) when a child moves within and between local authorities. The TWSCB and BSCB identify with partner agencies the barriers to effective use of tools to support the early identification, assessment and analysis of neglect, specifically, Graded Care Profile 2. The TWSCB and BSCB ensure that risk factors and indicators of neglect are consistently identified and assessed across partner agencies and that any professional normalisation of neglect is robustly challenged. The TWSCB and BSCB seek assurance and evidence from partner agencies that the lived experience of children is central to holistic and timely assessments when there are possible indicators of neglect. The TWSCB and BSCB monitor the implementation of single agency action plans. TWSCB and BSCB ensure that learning from this review is shared across the workforce specifically the recognition of dental health as a potential indicator of neglect. Family Q SCR - Appendix (i) Information known by practitioners and agencies and action taken 1/4 Date Service Information Action June 2015 Health Visiting HV4 Father reluctant to arrange new birth visit , mother said to be unavailable. No response to subsequent telephone calls HV4 liaised with MW2. June 2015 Midwifery MW2 Late booking in pregnancy Q4 due to family bereavement missed antenatal appointments. Refusal to access home for new birth visit as parents stated it was messy HV4 contacted when unable to access family home and information was shared June 2015 Midwifery MW1 Home visit Q4 three days old, house messy, mother refused access to bedrooms and refused further visits by MW1. MW1 recorded CCTV outside house Emerging concern parents are preventing professionals access to the family home due to poor conditions (Explore at Recall) June 2015 HV4 New birth home visit, observed house dirty and untidy with overwhelming atrocious smell. Mother spoke about birth control Recorded action to contact community nursery nurse and school attended by Q1 and Q2 (no evidence these actions were completed). Birth control not followed up. Next visit arranged end July – 6 weeks later June 2015 Day after home visit noted above Health Visiting HV4 and HV5 HV4 contacted HV5 in MASH to discuss case; Internal discussion not referral in although HV4 recorded that threshold for referral had not been met. Professional view that Mother would be resistant to EHA Agreement to monitor conditions in 6 week visit. HV4 recorded that threshold for referral to MASH not met. June 2015 Midwifery MW2 Home visit Q4 10 days old house musty, smell of dogs, hoover broken. Children dressed in clean appropriate clothing Q4 and Mother assessed level of support; Universal Plus July 2015 GP Q4 seen by GP appears to be 2 centile drop in head and length circumference. Information not shared with HV and no follow up (Explore significance at Recall Event) September HV4 Scheduled HV was rearranged, Mother Q4 remained at Family Q SCR - Appendix (i) Information known by practitioners and agencies and action taken 2/4 2015 cancelled due to family bereavement. Q4 not up to date with immunizations as GP needed ID before registration at surgery. Mother advised that Father was obtaining ID. Ongoing concern re. home conditions reported to be extremely dirty with multiple bits over the floor. Smell less though Mother had sprayed deodorant before visit. Children said to be clean and playing happily Universal Plus and one year targeted review to be next contact September 2015 – June 2016 Primary School 1 LA1 Q1 and Q2 were reaching the expected level of development for their age and Q2 exceeded the expected level in two areas. Records indicate that Q2 smelled of urine at times, both children were described as having grubby uniforms and smelling unclean and of stale smoke. The class teacher for Q1 spoke to Mother approx. 5 times regarding Q1 about attending school with head lice, hair not brushed. June 2016 Hospital staff LA1 Q3 admitted overnight, wheezing and was noted to be drinking sugary fizzy drinks and wearing clothes which smelled of smoke Mother was unkempt and wore dirty clothes Safeguarding nurse informed HV6 who referred to Community Nursery Nurse for dietary advice July 2016 Community Nursery Nurse No response to phone calls sent letter with appointment for Q3 development check in August. Q3 not brought for development check August 2016? Midwifery Service LA2 Mother presented 31 weeks pregnant with Q5. Mother said LA1 refused to book for pregnancy or provide notes as Mother had said she was moving. Explanation of Mother accepted without further exploration September 2016 Health Visiting HV6 LA1 Unable to contact parents tried five different telephone numbers on record Informed GP of non attendance at Q3 development check. September 2016 Health Visiting LA2 HV1 Arranged appointment for ante natal care Q5 was cancelled (unclear who by) Mother did not respond to messages visit not rearranged September -December 2016 Early Years Setting Q3 attended nursery 15 hrs weekly attendance 74%. Concerns noted re communication and interaction with peers. Three incident records concerning; unpleasant smell, unclean bottom, damp jumper. Three accident reports; scratch on leg Mother informed occurred on way to nursery swelling to top lip and right cheek Additional support offered re communication and language development. Concerns monitored internally, recorded that threshold for nursery to referrer to Family Connect was not met. Family Q SCR - Appendix (i) Information known by practitioners and agencies and action taken 3/4 Mother informed occurred on way to nursery Q3 bit own arm during session at nursery October 2016 Community Midwife Home visit – Q5 2 days old no concerns noted Home visit – Q5 3 days old Slight physiological jaundice noted Advice provided and appointment made for further checks on day 5 at Maternity unit – Mother attended and no ongoing concerns October 2016 Community Midwife Home visit as arranged – day 11 post natal care. Unable to access home. Left note asking Mother to rearrange appointment October 2016 Maternity Unit Mother attended with Q5 at day 13 and day 17 No concerns noted, hand over to Health Visitor for advice and monitoring October 2016 Health Visitor HV3 Telephone call and home visit to try and arrange new birth visit, no contact. Home visit took place a week later. Mother advised four other children living with her. Poor home conditions observed, flies , smell, dirty Moses basket, private landlord Mother advised was living with maternal grandmother whilst house was decorated Further appointment for hearing screen one week later November 2016 Health Visitor HV3 Hearing screen completed – inconclusive. Home conditions poor, smell and flies noted. Mother advised that she was still living with MGM and flooring in the house was to be replaced that week Repeat hearing screen arranged for 5 days later November 2016 HV4 Home visit -second hearing screen inconclusive and referral made to new born hearing screener New born Hearing Screener repeated test and obtained clear responses No comments about home conditions made by HV4 or new born hearing screener Discharged to routine health surveillance November 2016 HV2 Home visit to complete six week review for Q5. Q5 reported to be bright and alert, No further visit arranged. Next planned contact was Family Q SCR - Appendix (i) Information known by practitioners and agencies and action taken 4/4 immunisations discussed. Home conditions; strong smell animal urine, undecorated, Mother advised internal door to be fitted and floors replaced before Christmas one year review for Q5. Information about open clinics provided December 2016 School Police CSC Ten days after the HV by HV2 Q2 attended school with bruising to his ear and said that Mother had done it. Strategy discussion and joint S47 enquiries took place. At home visit children made subject to PPO as conditions unsuitable and unsafe. Parents arrested for neglect and children taken into care of LA2. 1/6 Family Q SCR - Appendix (ii) Single Agency Recommendations Shrewsbury and Telford Hospital NHS Trust Recommendation Detailed actions Person responsible Timescales Desired Outcome Embed the safeguarding supervision policy into Midwifery practice Capacity to offer safeguarding supervision will be considered in the review of models of Maternity care. Further safeguarding supervision training will be offered to Community Ward Managers and other interested Midwives to increase the capacity to offer safeguarding supervision. Named Midwife for safeguarding 31st March 2019 Safeguarding supervision becomes mandatory every 3 months for all community Midwives. Safeguarding supervision to be mandatory every year for hospital Midwives and Dr’s. When women move across Local Authorities routine enquiries will be made with the appropriate Health services to gain more information SOP to be developed to support recommendation Case scenario to be shared in safeguarding training 2017/18 Named Midwife for Safeguarding 31st March 2019 A request for relevant records from the original service will be made when notified of the move. A prompt appraisal of the safety and wellbeing of the unborn will be undertaken on all Mothers who move into the County during pregnancy. A verbal and / or written handover of care will be given to Health services receiving a pregnant woman from Telford and Wrekin into a new local Authority. 2/6 Telford and Wrekin Clinical Commissioning Group Recommendation Detailed actions Person responsible Timescales Desired Outcome To raise concerns of availability and/or delay in To bring to the agenda of the next NHS England Designated Nurse, CCG January 2018 NHS England to escalate/ raise with Capita providers medical records availability and Shropshire Community Health NHS Trust Recommendation Detailed actions Person responsible Timescales Desired Outcome 1. To ensure that a transfer in visit is offered to children who have moved into area within an agreed timescale (of receiving the notification). Shropshire 0-19 Service Manager and Professional Lead) & 0-19 Manager Telford and Wrekin and School Nurse Professional lead 31.01.2018 For all children to be offered a transfer in contact within an agreed timescale. 2. To review the process for children transferring into area who have not yet registered with a GP practice Shropshire 0-19 Service Manager and Professional Lead) & 0-19 Manager Telford and Wrekin and School Nurse Professional lead 31.01.2018 For all children to be allocated to a health visiting caseload and be offered core contacts as per the Healthy Child regardless of registration with a GP. 3. To ensure an agreed process is in place between school nursing and health visiting teams to ensure children who have transferred into area are notified to the respective team. Shropshire 0-19 Service Manager and Professional Lead) & 0-19 Manager Telford and Wrekin and School Nurse Professional lead 31.01.2018 For all children who transfer into area are notified to the respective school nursing and/or health visiting team as soon as they are identified. 4. For staff and managers to be reminded to complete a Datix incident report when risks are identified that impact on service delivery. Shropshire 0-19 Service Manager and Professional Lead) & 0-19 Manager Telford and Wrekin and School Nurse Professional lead 31.01.2018 For risks to service delivery to be recorded on the Datix incident reporting system. For risks to be mitigated and teams supported. 3/6 transfer of GP records from out of area to NHS England. Regional Safeguarding forum meeting delay concerns from practice managers/ front line practitioners. Telford and Wrekin Early Years Settings Recommendation Detailed actions Person responsible Timescales Desired Outcome Find out more about a child’s family. To develop ‘registration’ and ‘All About me’ forms to incorporate siblings and others in the household Nursery manager 30/11/17 To have a deeper understanding of the children’s home and daily lived experiences. To utilise the ‘Child Journey’ threshold document. To refer to threshold document when making referrals. Staff to be updated. Document to be downloaded. Nursery manager and DSLs 30/11/17 To be better prepared when making referrals to Family Connect, through a improved understanding of the threshold document. Learn more about GCP2 DSL’s to attend GCP2 briefing Nursery manager December 6th 2017 To develop an understanding of this assessment tool. Team member to attend GCP2 training Allocate funding for training Nursery manager February 28th or March 29th 2018 To have a better understanding and ability to utilise the GCP2 tool. To continue to develop and monitor child protection policies and procedures Update forms processes regularly Nursery manager and DSLs Ongoing That robust systems continue to maintain a culture of safeguarding vigilance. Disseminate learning of the SILP process to all Early Years and Childcare providers. Incorporate learning from the SILP process into Designated Safeguard Lead in Early Years and Childcare Settings training, Designated Safeguard Lead in Early Years and Childcare 2 Yearly Update training. Early Years & Child care Team Leader) December 1st 2017, March 12th 2018 and ongoing Raise the importance of robust record keeping and the SILP processes. Telford and Wrekin, Education, Access and Inclusion Recommendation Detailed actions Person responsible Timescales Desired Outcome 4/6 Review the number of Designated Safeguarding Leads trained at the schools This will be raised as a reminder for all schools at the DSL update Head has implemented for the school. Group Manager will raise with all schools Head acted immediately. Group Manager will address before December 2017 All schools are aware of considering the number of DSLs they have being proportionate to the needs and size of the school Ensure that schools have a means to capture low level messages and information shared in conversation with parents. This will be raised as a reminder for all schools at the DSL update Head has implemented for the school. Group Manager will raise with all schools Head acted immediately. Group Manager will address before December 2017 Schools have a means to check on all concerns and be able to monitor is needed. Bedfordshire, Families First Recommendation Detailed actions Person responsible Timescales Desired Outcome To complete a full assessment of the family well-being to safeguard children. Nursery staff to complete home visits to understand the home learning environment To increase Staff confidence in the EHA process and tracking intervention and outcomes Partners are clear about the Information sharing procedures in the working together guidance Senior Managers to complete GCP2 training Nursery Manager Deputy Chief Executive Senior Management Team Senior Managers Spring Term 2018 December 2018 Ongoing Spring Term 2018 Home visit programme All staff confidently tracking progress through Team around the family meetings and updating action plans. A holistic assessment is completed. Ingle Agency reccomendations Staff confident in identifying neglect and how to remove it. Review Safeguarding Policy and Procedures Review and ratify policy at the Trustee Meeting in Spring 2018. Deputy Chief Executive Spring 2018 Charity trustees, staff and volunteers have up to date knowledge and understand processes. 5/6 Complete early concerns and safeguarding audits for all service areas. Nursery Manager Spring Term 2018 Policy and procedures are effective and working in practice. Essex Partnership University Foundation Trust 0-19 Team Recommendation Detailed actions Person responsible Timescales Desired Outcome 1. Review use of the assessment and planning documentation as integral to assessments as part of Family Partnership Model and Ages and Stages questionnaires. Audit to assess the take up by professionals using the Family Partnership Model inclusive of the supporting assessment and planning documentation Deputy Director of Children’s & Specialist Services Jan 18 Assess the effectiveness of implementation of the Family Partnership Model 2. Review use of the Graded Care Profile 2 (GCP2, tool to measure neglect) Audit the use of the GCP2 tool available to practitioners and how this is being used to inform comprehensive family assessments and tailored interventions. Deputy Director of Children’s & Specialist Services February 2018 Assess the effectiveness of using the tools 3. When vulnerability is identified the progressive process of ongoing assessment and tailored interventions needs to replace the practice of defaulting to a ‘targeted’ Universal assessment as the sole means of intervention with immediate effect. 0-5 professionals will be required to undertake comprehensive assessments of families when vulnerabilities are identified. Update to be delivered to staff to clarify factors that contribute to creating vulnerability Monitor through the peer review process. Deputy Director of Children’s & Specialist Services November 2017 Assurance that families with identified vulnerabilities will be provided with a comprehensive assessment and tailored interventions. This includes the universal HCP provision. 6/6 4. EPUT BCHS staff, including the Health Visitor in MASH need to be confident and clear of their responsibility, using the Local Authority Threshold Documentation about when to direct referrals to either MASH or Early Help. In addition to this staff must be clear regarding the importance of consulting safeguarding professionals if there is a doubt that the referral will not be accepted. The role and responsibilities of the Health Visitor in MASH needs to be refined and communicated to EPUT BCHS professionals. So that professionals direct their enquiries to the appropriate Named Safeguarding Professionals in the Trust when they have uncertainly about safeguarding concerns. Deputy Director of Children’s & Specialist Services With support of Head of Service Safeguarding Children November 2017 Professionals make safeguarding enquiries to the appropriately qualified Named Safeguarding Professionals. 5.The process which supports EPUT BCHS 0-19 Service Team Managers oversight of cases in the progressive HCP needs to be reviewed for effectiveness The Team Manager’s oversight of cases needs to be reviewed to ensure that it provides robust line of sight and is supportive of both the practitioners and managers responsibilities Deputy Director of Children’s & Specialist Services March 2018 Team Managers have appropriate line of sight for case management, which is deliverable. 6.EPUT 0-19 service managers need to reflect on the change management processes that supported the relocation and merge of this team. To extract the learning to assist with future management of change. Critical reflection on the management of change to support staff to adopt new ways of working. Deputy Director of Children’s & Specialist Services Jan 2018 To inform future change management 7. Review the EPUT 0-19 electronic patient record to ensure it is maximising the S1 potential to enable front line practitioners to work effectively and efficiently. Review current layout of the record and identify improvements that could be made. Check best practice elsewhere in relation to use of the S1 record by Health Visiting teams. Implement improvements to the record. Deputy Director of Children’s & Specialist Services Feb 2018 To improve the electronic record so that it better enables practitioners to work effectively and efficiently. |
NC048208 | A life-threatening asthma attack experienced by a teenaged boy in December 2014; at the time he was visiting relatives who did not seek medical help for around 18 hours. After being treated in hospital the young person was taken into care due to concerns about his health and the cumulative effects of neglect. The young person lived with his mother and her partner, and did not know his father. He suffered from long-term asthma and severe eczema which was being treated at a satellite dermatology clinic. He and his mother had Common Assessment Framework (CAF) support between 2009-2012. Issues include: from early age, professionals held information about the young person which was not shared; professionals had limited understanding of the young person's lived experiences; treatment for the young person's eczema was provided by a medical team that primarily worked with adults, and had limited knowledge of how chronic conditions can affect a child's life and age appropriate pathways for support. Uses the Social Care Institute for Excellence (SCIE) Learning Together model to identify findings for the local safeguarding children board (LSCB), which can be used as a basis to make the local safeguarding system safer. These include: professionals need to be confident to raise questions about family or household members who could pose a risk of harm to a child.
| Title: Serious case review report for Halton Safeguarding Children Board on Young Person. LSCB: Halton Safeguarding Children Board Author: Fran Pearson and Jan Horwath Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 To what extent is Early Intervention in Halton child-focused in addressing adolescent neglect? SERIOUS CASE REVIEW REPORT FOR HALTON SAFEGUARDING CHILDREN BOARD ON YOUNG PERSON 2 Structure of the Report Section 1: Why this case was chosen for review Section 2: The methodology and the review process 2.1 The purpose of Serious Case Reviews 2.2 The Review Team and Case Group process 2.3 Case reviews and the light they shed on systems and reliability 2.4 About Halton 2.5 Involving the child and family 2.6 Any documents read during the review Section 3: The Findings 3.1 Summary of the case 3.2 Key dates 3.3 Appraisal of the professional practice - a synopsis 3.4 Summary of the Findings 3.5 The Findings in detail Section 4: References 3 Section 1 1.1 Why this case was chosen for review In December 2014, the Young Person had an exacerbation of his asthma, which went untreated overnight and into the following day, whilst he was staying with a family member. By the time an ambulance was called, the Young Person's life was at risk. The Young Person was admitted to hospital, and the information gathered by professionals raised concerns about whether this teenager had been neglected. Working Together 2013 was the child protection guidance in use at the time that a decision was made about taking the Young Person's case forward for review. All processes went through the structures of the Halton Safeguarding Children Board, and complied with Working Together. Children's Social Care division at the local council sent in a notification to the Safeguarding Board and requested that the Critical Incident Panel, which is part of the Board, met to consider the case. The Critical Incident Panel recommended on 22nd January 2015 that the criteria for a SCR were met - and the independent Chair of the Board agreed with this. Section 2: Methodology and the review process 2.1 The purpose of Serious Case Reviews Working Together 2013 said the following about the purpose of Serious Case Reviews:
Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children. (Working Together 2013:65) and Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together 2013:66) Once the board chair had agreed that the criteria were met for a Serious Case Review (SCR), a further decision was made to use a systems methodology called Learning 4 Together, developed by, and commissioned through Social Care Institute for Excellence, for the SCR. Merseyside and Cheshire safeguarding children's boards had recently agreed to build their capacity to carry out systems reviews, and were part way through training in the Learning Together methodology at the time the SCR for the Young Person was commissioned. The Lead Reviewers were: Fran Pearson an independent safeguarding professional and accredited and experienced Learning Together reviewer, and being mentored by Fran following the regional training - Professor Jan Horwath - recently retired, but at the time the review started, Professor of Child Welfare at the University of Sheffield. Neither are employed by organisations involved in the review, nor have any conflicts of interest. Previous contacts in the region amount to Jan Horwath having done some development work around neglect, and Fran Pearson having delivered the Learning Together foundation course to a regional group. The following professionals made up the Review Team of local managers to support the Lead Reviewers: Business Manager Halton Safeguarding Children Board Operational Director Children & Families Halton Borough Council Safeguarding & Quality Assurance Manager Halton Borough Council (first part of the review only) Headteacher of the Virtual School Halton Borough Council Detective Inspector (reviews) Cheshire Police Designated Nurse, Safeguarding Children NHS Halton Clinical Commissioning Group Designated Nurse, Safeguarding Children NHS Halton Clinical Commissioning Group An introductory workshop took place on 22nd April 2015, and the final meeting of the Review Team took place on 26th November 2015. The Review Team met five times to steer the work. The Lead Reviewers and Review Team carried out individual conversations with a total of 10 professionals who had worked with the Young Person. A workshop was held with a wider group of professionals and their managers to gather more data about local practice. An 5 extraordinary meeting of the Halton Safeguarding Children Board on 2nd October 2015 allowed the Lead Reviewers to share early Findings with the Board and develop the strategic implications of these findings as a result. The following professionals made up the Case Group Paramedic North West Ambulance Service Paramedic North West Ambulance Service Family Support Worker - a role in existence at time of work with the Young Person - now in a different role Halton Borough Council Social Worker Halton Borough Council Social Work Team Manager Halton Borough Council Common Assessment Framework Adviser - a role in existence at time of work with the Young Person - now in a different role Halton Borough Council Learning Mentor Secondary School Assistant Head and Safeguarding Lead Secondary School Consultant Dermatologist Hospital NHS Trust Dermatology Nurse Hospital NHS Trust School Nurse Community Services NHS Trust The child's perspective: involving the Young Person and his family in this Serious Case Review The Young Person agreed to meet with members of the Review Team. His mother and partner also met with the same Review Team members. The Young Person is a thriving young man now, and his very troubling eczema is improved almost beyond recognition. He very helpfully was able to give an account of some of the day-to-day difficulties of living with eczema when he was younger, which are reflected in the Findings. The Review Team would like to thank the Young Person, in particular, for his participation. 2.4 Documents read during the review The Lead Reviewers checked out or clarified some of the impressions formed during 6 individual conversations and workshops by reading: Closing Summary - Family Support Service Consultation by CAF Support Worker x2 Because the response to the Young Person was around early help, and because assessments and documenting of professional responses were at a much less developed stage for early help in Halton than they are now, there was relatively little written material available to the Review Team. The record from a Strategy Meeting about the Young Person was also used for reference. 2.3 Case reviews and the light they shed on systems and reliability A case review plays an important part in efforts to achieve a safer child protection system. Consequently, it is necessary to understand what happened and why in the particular case, and go further to reflect on what this reveals about gaps and inadequacies in the child protection system. Using the Social Care Institute for Excellence (SCIE) Learning Together methodology, the particular case acts as a ‘window on the system’1. For this to happen, the review uses the case of the Young Person as its starting point - but the review itself was in equal part about trying to understand what the usual practices in Halton are, and to give some messages about them to the board. These messages are presented as ‘Findings’, and the aim of structuring the report in this way is to give the LSCB some insights into what commonly influences professional practice, and outcomes for children. The Safeguarding Children Board in Halton can then potentially use the findings as the basis to change how the local safeguarding system works, and to make it safer. The Learning Together systems model categorises findings as follows: Tools Family-professional interactions Management systems Patterns of multi-agency working in response to incidents/crises Patterns of multi-agency working in longer-term work Innate human biases (cognitive and emotional biases) This is so boards can identify and prioritise which areas of their multi-agency safeguarding systems present the most risk - and in turn, which are the greatest priority to address and change. In what way does this case provide a useful window into our systems? 1 C. Vincent : Analysis of clinical incidents: a window on the system not a search for root causes 2004 7 The local Critical Incident Panel identified the following questions as ones that the Serious Case Review could usefully cover: The cumulative effect of neglect The appropriate use of the safeguarding framework - as the case was managed solely within the CAF framework despite child welfare concerns being evident Use of escalation processes between agencies Supervision and support of staff working with families at the lower end of the levels of need framework A possible lack of child-centred focus in multi-agency partnership working The impact of parental mental health Understanding adolescent development and promoting resilience Disguised compliance/measuring the sustainability of any improvements in the care of the young person The approach of professionals to men in the family network (which the Review Team later extended to a consideration of other family members and friends) These questions are addressed in the report. The Critical Incident Panel raised two other aspects of the Young Person's case for consideration: To understand whether the young person was a Young Carer To consider the role of the GP The Young Person's case did not provide sufficient information to draw conclusions about either of these two issues. Section 3: The Findings 3.1 Succinct summary of the case Between Christmas 2014 and the New Year the Young Person , a teenager, experienced a life-threatening asthma attack. The Young Person was sleeping at the house of a relative when his asthma became problematic. Adults in the house did not seek medical help for around 18 hours. An emergency call was eventually made to the ambulance services but no staff were available to respond. A rapid responder arrived 34 minutes after the call was made, followed by two paramedics in an ambulance. The Young Person at this stage was near death. The Young Person responded quickly to the interventions of the paramedics and was taken to hospital and admitted. The paramedics and medical staff were worried about the Young Person’s low weight, poor physical appearance, acute eczema and the lack of concern by his mother for his health and well-being. A referral was made immediately to Children’s Social Care by one of the paramedics. The Young Person, at the time of the incident, was living with his mother and her partner. He did not know his father. The Young Person had been living with both asthma and eczema 8 since early childhood. Although the asthma was controlled, the eczema flared up constantly, despite increasingly specialised and targeted interventions at a 'satellite' dermatology clinic. Satellite clinics are now an established health service practice, where members of a specialist team come out of their main base and see patients for appointments in other settings. The Young Person had been the subject of a CAF (a multidisciplinary plan to provide early help services on a voluntary basis to a family) for 3 years between 2009 and 2012. The CAF support consisted of parenting and family support work and was discontinued because the case was considered ‘stuck’: a range of services had been provided with little effect on parenting and the relationship between the Young Person and his mother. At no point, prior to the life-threatening episode, did the Young Person's situation trigger professional concerns to warrant escalation to a s17 or s47 assessment under the Children Act 1989. 3.2 Key dates in the practice by professionals 2009 - end of 2012 The Young Person is offered help via the Common Assessment Framework Summer 2010 The Young Person begins attending a dermatology clinic because his eczema is of a severity that can no longer be managed via the GP practice First attendance from hospital chronology was 10/06/10 Sept 2012 Last known CAF meeting: professionals discuss whether the CAF is effective, and agree to ask advice from the 'Think Family' forum Oct 2012 The 'Think Family' forum considers The Young Person's case. Escalation to safeguarding is not recommended. December 2012 The Young Person’s eczema is flaring up and steroid treatments continue January 2013 Eczema clinic – steroid treatment ended and the Young Person's skin described as 'much better on body but not face'. ‘treatment reviewed and advice given’ Feb 2013 Family support worker writes closing summary June 2013 Dermatology satellite clinic; eczema has cleared up July 2013 A new partner has moved in with the Young Person's mother; so housing benefit has stopped Nov 2013 The Young Person is back to the dermatology satellite clinic - his skin has deteriorated again and he has a 9 secondary infection Jan 2014 Seen at dermatology satellite clinic and meets specialist dermatology nurse for first time March 2014 First visit to the main hospital Dermatology clinic to start what are intended to be 25 sessions of light treatment March 2014 Same day goes to hospital satellite Dermatology clinic for education session April 2014 Education Welfare Officer becomes involved because of drop in school attendance. Requests a health care plan from dermatology clinic June 2014 The Young Person is seen at dermatology satellite clinic, and his eczema is infected. Undertaking Light therapy, and advised to take antihistamines. The consultant worries that the Young Person is not following his treatment plan because of a reluctance to take tablets, and refers him to psychology services - the referral is sent back because it is made to an adult team who do not see under 18s 1 July 2014 The Young Person is seen at dermatology satellite clinic and the area of infection has improved though his eczema is still extensive. The light therapy has been discontinued due to infection. His treatment plan is reviewed, and he is started on steroids. 18 July 2014 The Young Person is seen at dermatology satellite clinic. The nurse sends his treatment plan, with a covering letter, to school nurse, GP and Education Welfare Officer, specialist light therapy nurse and mum. The Review Team tracked this, and only GP records showed it logged on files, with no trace of it in the other services. August 2014 The Young Person is seen at the dermatology satellite clinic. His eczema had completely cleared after steroids but is deteriorating again. A new treatment is discussed to commence after blood tests Sept 2014 The Young Person is seen at the dermatology satellite clinic and his eczema is stable 7 October 2014 The Young Person has an asthma review – by healthcare assistant at the GP practice 10 30 October 2014 The Young Person is seen at dermatology satellite clinic - his eczema is under control 18 December 2014 The Young Person attends the nurse led blood monitoring clinic – because he is on immuno-suppressants. His ears are noted to be red and crusty, with active eczema on his face and torso. His medication reviewed and treatment plan provided. Last day of school term - and although the Young Person did not attend school due to his medical appointment, school staff did deliver a hamper to the family home and saw the Young Person briefly on the doorstep. 28th December 2014 Incident of a life-threatening asthma attack for the Young Person and admission to hospital 29th December 2014 Social worker visits the Young Person on the ward; professionals hold a strategy meeting 2.2 Appraisal of professional practice in this case 2.2 Appraisal of professional practice in this case In late 2012, when the review period begins, the use of the Common Assessment Framework - the voluntary early help process for children and families - was not having the effect it was meant to have on the lives of families and children in Halton. This had already been recognised by the Halton Safeguarding Children Board, and substantial changes were under way to support professionals in using the process more extensively and more effectively. Finding 4 explores the extent to which the efforts to change the way early help is delivered in Halton has been effective; and what safeguarding risks still exist in relation to the early intervention process. The Young Person and his mother were receiving early help interventions during the period when the LSCB identified the CAF process was not operating effectively. By the end of 2012, the Young Person had been 'on a CAF' for longer than any other child in Halton and the case was considered ‘stuck’ by the workers. Whilst the Young Person’s mother remained in contact and engaged superficially with professionals, interventions were having little impact on improving the Young Person’s mother’s parenting and the quality of her relationship with the Young Person. Amongst the changes to early help services in Halton at the time was the creation of a panel of managers to advise on situations like the one with the Young Person, where early help interventions were having little impact. The Panel met in October 2012 and made the decision to close the case to the Family Work Service as there were no obvious ongoing concerns and there was no reason to escalate to Children’s Social Care. But the decision was made with limited understanding of 11 the Young Person’s life, the extent of neglect, and the world as he experienced it - as considered in Findings One and Three. The Review Team found that from a very early age, professionals held information about the Young Person that did not come to the attention of the Lead Professional CAF - for example, the Social Landlord, who managed the family home; the Housing Officer who was aware of the family’s debts; the School Nurse who had history dating back some years; the GP practice and CAMHS (child and adolescent mental health services) who received a referral from the GP. The consequence was that a number of practitioners were working with the family on specific problems in a vacuum. Finding Three considers the ways in which children and their needs can become invisible or forgotten when this takes place. In addition, the two main professionals allocated to work with the Young Person and his family were quite inexperienced, and did not appreciate, at the time, that the superficial engagement by mother with professionals did not necessarily lead to changes to the lived experience of the Young Person. Finding Two considers the issues of identifying superficial compliance by parents, particularly in relation to assessing behaviour change in early help programmes. Finding Four also explores why the status given to early help work at the time may have inhibited these professionals from asking more forcefully for the engagement of colleagues in other agencies with the Young Person's CAF, and considers what the latest signs are that early help work is gaining more status in Halton. After the closure of the CAF and the ending of family support work, there was, for much of 2013, what to professional eyes looked like ‘a period of calm’ in the Young Person's life. On closer examination though, the Review Team considered that this was a period when the Young Person was being neglected. For example, in July 2013 there was a significant development at home, as the new partner of the Young Person's mother moved in and as a consequence Housing Benefit ceased which caused the family financial problems. The Review Team did not think that professionals were aware of this and therefore could not assess the impact that this might have had on the Young Person. Finding Three covers this, as does Finding Five, which considers the impact of hidden household members on the lives of young people, and how effectively this is assessed in early help services. Throughout the period under review, the Young Person was seen regularly at a predominantly adult dermatology 'satellite' clinic, rather than at a location further away with more paediatric services. Most NHS trusts operate satellite clinics in an attempt to either provide services closer to patients' homes, or to share specialist expertise more widely - for example Moorfields Eye Hospital has a growing network of satellite clinics. In the Young Person's case, the professional decision to use the satellite clinic was to try and make it easier for the family to keep appointments. The 10-minute slots allocated for each patient meant that discussion had to focus on the medical condition and its treatment and did not leave sufficient time to explore wider issues although the Young Person was not getting the help at home to consistently manage his eczema, and the environment at home was not one that made this likely. The consultant made a referral to adult psychological services because the Young Person complained that he could not take tablets easily and this was impacting on his treatment. The referral was, however, declined because the Young Person was under 18. No advice was given, however, to the consultant as to an alternative and more appropriate source of support for the Young Person. Finding One addresses the importance of recognising and addressing the impact of a chronic health condition on a 12 young person’s lived experience. There was a mismatch between the Young Person's needs, resulting from his eczema, and the services provided - for example an education session delivered by dermatology professionals to the family emphasised the importance of regular routines when the concerns were more about the Young Person and his mother’s motivation to engage with the treatments. Finding Two also explores this. By January 2014 the Young Person’s eczema was out of control again and he subsequently began light treatment, which required frequent attendance at hospital during school hours. In April 2014 an Education Welfare Officer noted the Young Person’s falling attendance during a routine check of pupils whose attendance had dropped by more than 10%. The Education Welfare Officer contacted the dermatology nurse, who in turn sent out copies of the comprehensive health care plan for the Young Person. The plan did not reach the Education Welfare Officer, key individuals at school, nor the school nursing service. This was a missed opportunity to identify the ways in which these agencies, together with the GP and the dermatology clinic could work together to develop a multidisciplinary approach towards meeting the Young Person's health needs. Part of the difficulty in directing information to the correct person resulted from organisational change - as did other examples during the period under review. Finding Six explores how information about children and young people is not shared when robust systems do not exist for multi-agency information–sharing during times of organisational change. On the 28th December 2014 the life-threatening event that triggered this Serious Case Review took place. The Young Person was staying with a relative and had a severe asthma attack - from the Young Person's account at the time, his asthma had become problematic at least twelve hours previously, and it does not seem that the adults he was staying with appreciated the risks attached to this, or responded until he became so ill that someone dialled 999. It subsequently emerged that the Young Person did not have at least one, if not both of his prescribed asthma inhalers with him as one had run out and the adults around him had not made arrangements to replace it. When a Rapid Response Vehicle and ambulance arrived (outside timescales for such a callout) the Young Person was dangerously ill. Significant efforts were made at the Ambulance Trust to identify professionals who could respond, and the paramedics who attended were very experienced. All their expertise was needed to stabilise the Young Person and get him to hospital. Finding Seven examines the risks to children's lives that can arise at exceptional periods of demand when the whole local system for emergency and urgent care is lean and efficient, but very occasionally does not have the slack in the system to respond. One of the ambulance staff appropriately made a referral immediately by telephone to the trust's central point for reporting concerns about children or vulnerable adults. This professional also confirmed when making the referral that it should be graded as 'urgent' despite the Young Person currently being in a place of safety. This was tenacious and good practice because it reflected accurately the level of concern that the professionals from the trust felt about the Young Person. The paramedics noticed that the Young Person was significantly underweight, as well as being struck by the severity of his eczema. At a strategy meeting the following day, professionals began to address a discrepancy which for the Review Team remains unanswered. This discrepancy was between the view of the professionals working with the 13 Young Person prior to the incident, and of those who saw him during and shortly after it. For example, the social worker visited the Young Person on the ward before the meeting. She noticed immediately that he was very thin, and had severe eczema on the parts of his body that were visible. She was, like the hospital staff and paramedics, also concerned by the lack of interest in the Young Person shown by his mother. School staff who saw The Young Person daily, had not had cause for concern about his eczema when they last saw him, ten days previously. They were also more positive about the relationship between the Young Person and his mother. One of the paramedics went above and beyond anything that was expected by bringing in some of her own children's Christmas presents to the Young Person on the ward, as a result of hearing the Young Person's account of his Christmas at home. Professionals were provided with an account of the referral, concerns relating to eczema and asthma. All professionals agreed that the current situation would raise concerns for the Young Person's safety, were he to return home. The conclusion of the meeting was to take the unusual step in Halton, of removing a teenager from his mother’s care. This was not the initial view of all the professionals, but willingness to examine the evidence and listen to the professional opinions of others enabled consensus to be reached. 2.3 Summary of Findings Findings Category Finding 1: Treatment of young people with eczema, focuses on their physical health needs when they are seen in adult satellite hospital outpatient clinics in Halton. The consequence is that their other needs are marginalised or neglected. Management systems Finding 2: With the early help aspects of all services in Halton, there is a balance to be struck in the system between accountability for what is delivered, and making sure that those things which are most easily measurable do not become the only things that are counted. Management systems Finding 3: The presssures of work for those delivering early help services in Halton mean practitioners work in isolation rather than collaboratively, with the consequence that professionals focus on their own, agency-specific tasks, and are less likely to prioritise the Patterns of multi-agency working in longer-term work 14 need to work with other professionals. Finding 4: Practitioners within the multi-agency network perceive the role of Lead Professional to be one with limited status, with the consequence that individuals in the role do not feel confident to escalate concerns about colleagues in other agencies - inhibiting multi-agency efforts to provide the right help at the right time. Patterns of multi-agency working in longer-term work Finding 5: Are professionals in Halton who deliver universal and early help services sufficiently confident to raise questions about family and household members who could pose a risk of harm to the child or young person - with the consequence that they leave these young people vulnerable to abuse and neglect? Family / professional interaction Finding 6: There is not a robust system for multi-agency information sharing during organisational change, with the consequence that information about individual risk to children can be passed on, but does not always receive the analysis of risk that is needed for safeguarding decisions. Management systems Finding 7: The whole emergency and urgent care system that includes Halton, is designed to be lean and efficient - and the risk in the system is that exceptionally, when the whole system is under extreme pressure, the efforts of dedicated individuals in the ambulance service cannot compensate for the risk that arises from having such a lean system. Management systems 2.4 The Findings in detail This section represents the main learning from this case review for the LSCB and partner agencies. Each finding is set out in a way that illustrates: 1) How does the issue feature in this particular case? 2) How do we know it is not unique to this case? What can the Case Group and Review Team tell us about how this issue plays out in other similar cases/scenarios and/or 15 ways that the pattern is embedded in usual practice? 3) How prevalent is the pattern? What evidence have we gathered about how many cases are actually or potentially affected by the pattern? How widespread is the pattern? Is it found in a specific team, local area, district, county, region, national? 4) What are the implications for the reliability of the multi-agency safeguarding system? The evidence for the different ‘layers’ of the findings comes from the knowledge and experience of the Review Team and the Case Group. Finding 1: Treatment of young people with eczema, focuses on their physical health needs when they are seen in adult satellite hospital outpatient clinics in Halton. The consequence is that their other needs are marginalised or neglected. Category of Finding: Management Systems The service for young people with eczema in satellite clinics in Halton is commissioned in such a way that provision is by a medical team with expertise primarily of working with adults. When this occurs the focus is on addressing medical needs. Yet, chronic health conditions, such as eczema and asthma, can affect every aspect of a child or young person’s health and development. For example, Suris et al., (2004. P.941,) in a systematic review of the literature, found that chronic health conditions such as eczema, 16 can have an effect on adolescent development, self-image, identity, educational attainment, family and peer relationships. They conclude that adolescence is a time of rapid change and turmoil and ‘that teenagers with chronic conditions have an additional burden‘. If the ‘burden’ is to be minimised it is essential that commissioners and providers of medical services for young people with eczema and other chronic health conditions, either through satellite or mainstream clinics, ensure staff are in a position to identify the effects of the condition on the general wellbeing of the young person. Moreover, having identified these wider needs, the services should be responsive and support young people with these conditions and their families. How did this feature in the case? The Young Person gave the Reviewers a vivid, detailed account of the impact of eczema on his daily life whilst he was living at home. He described how painful it can be when the eczema flares up and that he has a complex treatment regime that needs to be completed at least three times daily. The regime is lengthy and tedious and sets him apart from his peers. He talked about the problems he sometimes has sleeping, wearing clothes, walking and carrying things. When his eczema is evident he is embarrassed about his appearance and described wearing long-sleeved tops to cover both his eczema and the special garments he has to wear. He also described how he did not go swimming and disliked undressing for sports activities because he was embarrassed by his appearance. Indeed, he only began to swim, an activity he stated he really enjoys, when he moved to the foster home and his eczema had cleared up. Although the Young Person described his experiences to the Reviewers with very little prompting he was not provided with opportunities at the satellite clinic to explore the impact that his condition and treatment regime was having on his life. The Young Person told the Reviewers that the focus was on the physical management of his treatment regime. Indeed, the Consultant only referred the Young Person to the Adult Psychology Services because the Young Person became aggressive when informed swallowing tablets would be part of his new treatment regime: the Young Person has difficultly taking tablets. Further, the health care plan constructed by the Specialist Nurse only focused on the conditions necessary - regular bathing, application of creams and so forth – required to ensure the Young Person gained maximum benefit from his treatment regime. How do we know the issue is not peculiar to this case? The Review Team heard from the case group that the satellite service is constructed in such a manner that consultations with doctors are limited timewise– ten minutes – for each patient. Bearing in mind the short time available and the number of patients the Consultants are expected to see at these clinics, they prioritise medical assessments and interventions. In addition, the Review Team was informed that the satellite eczema clinic is a clinic for both children and adults, and the area of expertise of the staff is 17 predominately in the treatment of adults. The staff, however, have all received Level Two safeguarding children training – that is training for those in direct contact with children and their families covering indicators of abuse and neglect and referral processes. Although Hospital 1 has a range of children’s and adolescent services the clinic operates under adult services delivered by another trust. As a consequence data regarding the number of children and young people seen at this clinic was not made available to the named nurse at Hospital 1. Hence, other young people with eczema may not have had their broader needs identified or met. In terms of the different chronic health conditions, the Review Team heard that practice was variable depending on the way that agencies commissioned and structured services. As a consequence those commissioned, provided and delivered as part of one Trust’s children and adolescent services, such as clinics for young people with diabetes and epilepsy, were far more likely to identify and know how to meet the developmental needs of the young person. Those provided by other trusts in outreach clinics may not come under the same scrutiny. Since the Review was initiated a safeguarding pro-forma has been developed by the Specialist Dermatology Nurse and will be used to identify any potential or existing safeguarding concerns amongst young people seen at the clinic. These concerns are then raised with the Named Nurse at the hospital. It appears that the consultant and specialist nurse in the dermatology clinic were not aware of the role of the named nurse. Has anything been done to ensure raised awareness for staff in clinics such as the dermatology clinic? Members of the case group recognised that staff, such as the Specialist Nurse and the Consultant should be aware of the CAF process and be expected to participate in this if they have a part to play. But information regarding the existence of a CAF is often not known by hospital staff. There was a view that the GP and/or school nurse should ensure that the Lead Professional is informed about hospital involvement in order to ensure hospital staff can play an active role. How widespread is the pattern? Satellite outpatient clinics are becoming increasingly common as a response to Government expectations of local services for local people. In these cases the providers may be from different trusts and as a consequence there is limited whole system overview. Senior agency representatives in Halton also recognised the lack of accessible, onsite paediatric support and guidance can lead to a dominant medical focus in the management of chronic health conditions amongst young people. The Review Team heard from the Case Group that the situation can be exacerbated if a satellite clinic caters for both adults and children and is staffed by a medical team with adult expertise. The Review Team recognised that there are distinct advantages for families of locally based out-patient clinics. Children with chronic health conditions are likely to have to attend out-patients frequently and local clinics mean easy access, lower transport costs, and for young people, less time out of school for appointments. However, for 18 commissioners and providers of outpatient services for young people with chronic health conditions, these considerations have to be balanced against ensuring the provision of a child-centred service. Such a service requires immediate access to the diverse range of services that are on hand in a regional hospital, such as paediatric dermatologists, social work and psychological services. The Review Team heard, for example, that young people seen at Alder Hey Children’s Hospital are serviced by a multidisciplinary team who aim to provide a ‘holistic care to patients, families and carers.’ (Alder Hey Children’s Hospital, 2015). Children and young people receiving treatment at the dermatology clinic at another nearby hospital - Hospital 2 - are seen by a medical team who have ready access to onsite advice and guidance from the named professionals and social work team. The Review Team were informed that the Trust have begun to consider how service provision can be improved for children with chronic health conditions. They have identified a need to review the information provided to the Named Nurse regarding children and young people seen in adult clinics. Second, they intend revising the provision of safeguarding training. Those who see children in adult clinics will receive training for those working with children and families (Level3 training) rather than the Level 2 training for those in contact with children and families, which is the case currently. How prevalent is this issue? The local, regional and national prevalence of chronic health conditions, including eczema and asthma, amongst young people is difficult to assess because of the lack of data. However, researchers estimate between 7-15% of the adolescent population are affected depending on the conditions included (Suris et al., 2004; Compas et al., 2012). Moreover, ‘Chronic illnesses and medical conditions present millions of children and adolescents with significant stress that is associated with risk for emotional and behavioural problems and interferes with adherence to treatment regimes’ (Compas et al., 2012 p. 455) In April 2013 there were estimated to be 31, 200 children between 0-19 years of age living in Halton. Taking an average of the estimated prevalence of chronic health conditions, 3,000 children and young people could be living with such a condition. Why does it matter? A safe system is one in which commissioners and providers of health services recognise the impact or potential impact of chronic health conditions on the child’s emotional, behavioural and psychological needs. With this in mind, they should ensure that those delivering services, albeit it centrally or from satellite clinics, have the time, resources, knowledge and skills to identify these young people’s additional needs and ensure an appropriate response. The response could be through the provision of direct services such as support groups, multi-agency working or referral to other agencies. If satellite 19 clinic provision does not facilitate the identification and response to these additional needs young people may not have the opportunities to achieve their potential. In addition, it is well understood that those whose needs are neglected during childhood and adolescence are vulnerable to mental health and other problems. These are likely to not only affect their lives but will have repercussions for their families and wider society. Finding 1: Summary of risks Children and young people with chronic health conditions are likely to have a variety of additional needs as a result of the ‘burden’ (Surris et al. 2004) of their condition. A failure to recognise and address these needs can result in child neglect. A safe system will reliably identify and respond, not only to medical needs, but also to the wider needs of young people with chronic health conditions. Finding One, however, has identified that professionals in contact with children and young people with these health conditions in satellite clinics focus on meeting medical needs and do not consider or address the young person’s other needs. Questions and considerations for the Board Does the Board know how many children and young people with chronic health conditions who are seen in clinics that do not come under the Child and Adolescent Service umbrella? Does the Board agree commissioners and providers should ensure those working in satellite clinics treating young people with chronic health conditions have a responsibility to identify and, where appropriate, address the young person’s wider needs? Are those responsible for commissioning and providing satellite clinics attended by young people who have chronic health conditions aware that a failure to identify and address the young person’s wider needs constitutes neglect? Can Board members provide evidence that young people with chronic health conditions seen in satellite clinics for chronic health conditions have their needs, over and above medical needs, identified? What services are available to support young people with chronic health conditions explore and address the impact of the condition on their daily lives? How responsive are services in allowing young people to discuss wider needs and to understanding how chronic health conditions impact upon their daily lived experience? 20 Finding 2: With the early help aspects of all services in Halton, there is a balance to be struck in the system between accountability for what is delivered, and making sure that those things which are most easily measurable do not become the only things that are counted. There is an early help component to most children's services in Halton, and currently the effectiveness of such services is measured by indicators that relate to service throughput rather than child-focused outcomes. As a consequence the impact of the family’s involvement with the service on the quality of life for each child in the family is marginalised or ignored and children may continue to have unmet needs. Parents who receive early help services need to have both motivation and ability to work on a voluntary basis with service providers to meet the needs of their child. Some parents who do not have this capacity may present as dis-engaged, aggressive or non-compliant and are relatively easy to identify. There are, however, parents who do appear to engage with services and complete tasks, such as attending every session of a parenting programme, yet, this does not necessarily lead to improvements in outcomes for children. This may occur because the parents do not have the ability to ensure the needs of the child are met. Alternatively, they may lack the motivation to make changes and therefore engage tokenistically: this is known as ‘superficial compliance’ and may result in little changing for the child or young person. Category of Finding: management systems How did this feature in the case? There is evidence, throughout the period under review, that professionals were working in organisations delivering early help services that did not use child-focused outcomes to measure effectiveness. Moreover, because of the lack of attention to child-focused outcomes the staff had not received adequate guidance and training to assess meaningful engagement by the Young Person’s mother with services. The Family Support Worker, for example, commented that at the time she was working with the Young Person she was not aware of superficial compliance. Both the Learning Mentor and Family Support Worker, implementing the CAF during the period under review, equated parental engagement by the Young Person’s mother with her maintaining regular contact with them regarding the Young Person, taking the Young Person for hospital appointments and contacting them for assistance. However, during this period the Young Person’s mother did not actively work with these professionals to meet the Young Person’s needs. For example, her attendance at CAF meetings was sporadic and she focused on her own unmet needs rather than those of the Young Person. As a consequence the home conditions and general physical care of the Young Person were 21 not addressed and he continued to be neglected. The CAF ran for three years before the workers viewed the case as ‘stuck’. Their reasoning for this was that they had exhausted the services available and did not know what other services could be provided. The CAF was closed at the Think Family Forum. The failure by the Young Person’s mother to engage meaningfully with existing services and the impact this failure was having on the Young Person and the quality of his lived experience was not taken into account. How do we know it is not peculiar to the case? Members of the Board, the Review Team and the Case Group recognised that for a number of agencies, quantitative measures are required by regulators, commissioners and providers to demonstrate service effectiveness. This in turn encourages a focus on measurable indicators such as service throughput. They gave a number of examples of this occurring in health, education and voluntary services. These measures included: levels of school attendance; attendance at hospital clinics; keeping appointments; attendance at parenting groups; information provided to families. The Review Team heard from the Case Group that the focus on these types of measures results in the marginalisation of the impact of service input to qualitative outcomes for children. How widespread is the pattern? The Review Team were informed by the Case Group that task completion and compliance by parents are frequently used by service commissioners, providers and regulators as indicators of effective practice across Halton: for both early help and child protection interventions. However, tools such as the Graded Care Profile, introduced by the LSCB, are enabling different services to provide practitioners with a standardised multi-disciplinary tool enabling them to focus more on outcomes in cases of neglect of younger children. The tool, however, is not designed to identify signs of adolescent neglect. In addition, the Review Team learnt that the introduction of chronologies into CAFs makes it easier for practitioners to establish what works with a family. What is crucial, according to the Case Group, is that all service providers ensure staff are aware of these tools and how to use them. The Case Group also told the Review Team that service providers have not provided practitioners with standardised tools to assess either parental engagement or the impact of interventions on outcomes for children. Since the period under review lead professionals involved in CAF who believe they are ‘stuck’ with a case can present the case at a Working Together meeting. The purpose of the meeting is to: Review CAFs…. in circumstances where they are facing barriers to achieving positive outcomes for the child and family. Multi-agency colleagues can advise how to eradicate barriers to progression including allocating additional early intervention services, where appropriate. (Halton Working Together Meeting Guidance) The Review Team recognised whilst this may ensure the needs of children in ‘stuck’ cases are identified others may be ignored. For example, when parents have completed 22 a parenting programme the case may be closed as a successful intervention without any evidence being obtained that the learning from the programme has resulted in improved outcomes for children. How prevalent is the issue? The prevalence of early help interventions focusing on completing actions alone is evident in the findings of the recent Ofsted (2015p.18) inspection of early help interventions in 56 cases taken from 12 local authority areas. Where CAFs were in place they found: ‘Plans were too often a list of actions that did not identify the outcome to be achieved for the child or how these actions would improve the child’s circumstances. Many made the assumption that the issue would be remedied with the action taken; for example, many required a parent to attend parenting sessions. While the parents may have attended, there was rarely subsequent analysis about whether this attendance had improved either the parenting or the child’s circumstances and experiences’. With regard to child neglect, Ofsted (2014) in a report based on evidence drawn from 124 cases, found that in almost half the assessments practitioners did not convey or consider the impact of neglect on the child. They also found parental lack of engagement was a common feature with few multi-agency groups having clear strategies for tackling non-compliance. They also found that professionals did not consistently challenge parents and as a consequence cases drifted. Woolmore (2016) has written about 'The Safeguarding Blindspot' when 'Collaborative early help intervention services are being offered to families with complex needs who often do not cooperate, creating the "No Further Action" child' . Woolmore says that: Early help practitioners usually lower paid than colleagues who deal primarily with child protection cases, find themselves working with 'targeted families' who are complicated. It's not uncommon for families being offered early help to have been previous, if not frequent, users of statutory services. There may also be a history of 'disguised compliance' in previous relationships with professionals. Why does it matter? A safe, safeguarding system is one in which the emerging developmental needs of children are identified and met by universal and early help services. When this takes place children and young people are more likely to achieve their full potential. 23 Identifying and meeting emerging needs is particularly important in potential cases of child neglect to avoid drift, neglectful behaviours becoming entrenched and a deterioration in the child’s situation. As Daniel et al., (2011p.17) note: ‘In relation to ongoing child development and well-being it is the chronic nature of neglect that is particularly corrosive’ A safe system, for identifying parental neglect should be accountable for its effectiveness. One of the things that such a system needs to do is to create the best chance of neglect being identified and addressed before the circumstances become chronic. Such a system needs to strike a balance between accountability for delivery, but also making sure that the things that are easily measurable do not become the only things that are measured. If service effectiveness continues to be measured in terms of through-put alone then the maximum benefits of the service to children and families may not be realised. As a consequence managers and practitioners may be deceived into assuming they are being effective. In the words of one member of the Case Group we will just continue: ‘putting square pegs into round holes’. Finding 2: With the early help aspects of all services in Halton, there is a balance to be struck in the system between accountability for what is delivered, and making sure that those things which are most easily measurable do not become the only things that are counted. Summary of risks A safe system, for identifying parental neglect should be accountable for its effectiveness. One of the things that such a system needs to do is to create the best chance of neglect being identified and addressed before the circumstances become chronic. Such a system needs to strike a balance between accountability for delivery, but also making sure that the things that are easily measurable do not become the only things that are measured. Questions and considerations for the Board Is the focus on task completion and service throughput as measures of service effectiveness a known issue? Is there consensus amongst Board members that this is an issue that matters? Has the Board made previous efforts to ensure that service providers and commissioners use child-focused outcomes? 24 Are tools and frameworks made available by providers of early help services so they can measure outcomes for individual children? Are guidance and tools made available by service providers so that practitioners assess parental engagement? Does the Board know what kind of information it should collect in order to learn if the multidisciplinary early help system is improving in terms of measuring child-focused outcomes? Finding 3 The presssures of work for those delivering early help services in Halton mean practitioners work in isolation rather than collaboratively, with the consequence that professionals focus on their own, agency-specific tasks, and are less likely to prioritise the need to work with other professionals. Category of Finding: Patterns of multi-agency working This finding recognises the pressures placed on those delivering universal and early help services. This can result in different services focusing on the immediate problem they are presented with rather than taking a more multi-agency holistic approach to the child and their family. When practitioners focus purely on the immediate issue they are working in isolation and the needs of neglected children may become marginalised or forgotten rendering the child and their situation invisible to the workers. When this occurs the health and development of the child is affected in both the short and longer term. How did this feature in the case? During the period under review the Young Person’s repeated eczema flare-ups exercised the Dermatology Team. Rather than identifying what may be causing these flare-ups, the Young Person and his family received an ‘education’ session with the Specialist Dermatology Nurse. They attended the session but it centred on the application of creams, garments etc. A number of professionals held information that would have enabled the Dermatology Team to make a more informed and appropriate intervention. The Learning Mentor, for example, had knowledge, gained from the Family Support Worker and Child and Adolescent Mental Health Services Worker, that the relationship between the Young Person and his mother was impacting on his treatment regime. The Housing Officer was aware of the home conditions and financial issues, the Education Welfare Officer knew about school attendance, and the GP had knowledge about the asthma and its management. Despite the involvement of these other agencies the Dermatology Team worked in isolation, as did the other professionals. When the Specialist Dermatology Nurse did attempt to share information, through the circulation of the comprehensive health plan, the information was only received by the GP: it did not reach the other practitioners in contact with the Young Person and his mother. As a 25 consequence valuable information about the Young Person and his situation was not exchanged and the Dermatology Team continued to work in a vacuum. How do we know it is not peculiar to the case? The Review Team heard that all too often professionals providing universal and early help services, because of the pressures of work, focus on their specific role and area of expertise. As one participant put it ‘we end up taking a silo approach’. As a consequence they are not alert to other factors that indicate a child is being neglected. This situation can be exacerbated if systems are not in place to ensure practitioners are aware of the involvement of other professionals. The Case Group reported that it also occurs when practitioners are so busy they do not prioritise attendance at CAF meetings. Also, the Lead Professional may struggle, because of conflicting demands on their time, maintaining ongoing contact with all the practitioners interacting with the family. The Review Team also heard from the Case Group that one of the consequences of routine use of the Framework for the Assessment of Children in Need and their Families is that professionals, even though they may work collaboratively, tend to focus on the needs that they are primarily responsible for addressing rather than taking a holistic approach. Hence, health care professionals will pay attention to health needs and tend to focus on keeping appointments, picking up prescriptions etc. As one practitioner stated at the group they do not ask ’so what?’ for example, is attendance at appointments making a difference? Are the family using the creams prescribed? Service leaders in Halton, who made up the Review Team, recognise some of the challenges identified above and have begun to address these through multi-agency investment in the Contact and Referral Team that initially assess the needs of children and families . This investment is already beginning to improve the mapping of local needs and co-ordinated delivery of early interventions through CAF. Key to this development is increased oversight and collaboration between adult and child service providers. How widespread is the pattern? The Review Team and Case Group indicated the focus on addressing immediate, seemingly relevant issues was widespread amongst early help service providers. Whilst recognising professional curiosity is important, they identified a number of organisational influences that can lead to practitioners working in isolation on the problem that is presented to them. These include: hospital doctors in out-patients only having a ten minute slot for each out-patient at clinics and as a consequence they do not have the time to explore issues in-depth; practitioners, such as housing officers, not being clear about who to go to for advice and how to share information; teaching unions varying in terms of what teachers and other school staff can do with regard to home visits; the various family members seeing different doctors in the same practice so no-one gets a comprehensive overview; practitioners not having access to supervision and support within their work setting that goes beyond exploring the presenting problem. A 26 reluctance on the part of some practitioners, such as nurses in hospitals to question and challenge parents was also highlighted, with some practitioners feeling they do not have the confidence because of a lack of knowledge and skills to ‘probe’. The Review Team also heard about good practice. For example, the ambulance crews described, at the Case Group, how they are called out to people who really do not need an emergency ambulance service but have other needs such as loneliness, fear of being ill or not knowing who to turn to. They recognise that they need to be curious as to why people are presenting in the way they do in order to get to the cause of the problem and prevent it re-occurring. How prevalent is the issue? The Ofsted (2014) study of neglect found that assessments often focused on parents' problems and needs meaning the impact of these issues on children were marginalised. Brandon et al., (2013) found, in their analysis of serious case reviews involving child neglect, that practitioners often lack the confidence to take responsibility for assessing the impact of particular problems on a child and their development. The workers believe they do not have the expertise to do so and that other practitioners are better placed to act in these cases. A study by Nfer, LARC and RiP (2015) of early intervention in cases of neglect found teachers and early help practitioners were less likely than those working in health services to contact other practitioners about early concerns. Multi-agency working was considered to be a significant barrier to early help provision for those working in education services. Health practitioners in particular identified workload and time pressures as significant barriers to providing early help. The researchers also found staff shortages, high caseloads and pressure to meet targets meant practitioners have less time to work collaboratively with the family and other professionals. Why does it matter? This finding is not about the effectiveness of the Common Assessment Framework in Halton, but is about a broader pattern of how the pressure of work in any particular agency can make it more likely that people focus on their own agency-specific tasks, and are less likely to prioritise the need to work with other professionals. Neglecting families often stagger from one crisis situation to another. Moreover, the parents can present as very needy and lead chaotic lives (Crittenden, 1995; Horwath 2007; 2013; Daniel et al., 2011). As a consequence it is all too easy for practitioners to work in isolation and focus on the crisis situation or the presenting problem, such as rent arrears, practical problems with medical treatments and so forth. When this occurs practitioners fail to gain a comprehensive picture of what is taking place and do not tackle the underlying issues. This matters because as a consequence early help practitioners are missing opportunities to identify and tackle underlying neglect and the 27 impact of this on the child. As this quote from a young person who used ChildLine (2015) highlights: ‘No one asked me what was going on. I felt worthless and alone. Nothing was working in my life.’ Collaborative working is particularly important in cases of child neglect because of the complex nature of the family problems and the different ways in which it can impact on the children in the family. Bearing in mind what is known about the behaviour of neglectful carers a safe system is one in which service commissioners and providers recognise that a holistic approach is required if early help provision is to be effective in cases of child neglect. A safe system is one in which agencies value multi-agency working and ensure practitioners’ have the opportunity to work collaboratively to share information and gain a comprehensive appreciation of the presenting and underlying issues impacting on the health and wellbeing of the child. In a safe system practitioners have the time and opportunity through, for example, reflective supervision to question why parents behave as they do and how this behaviour affects the individual children in the family. Providers also ensure that practitioners have the knowledge and skills to challenge family members and demonstrate a healthy scepticism questioning what is actually going on within the family and why. Finding 3: The pressures of work for those delivering early help services in Halton mean practitioners work in isolation rather than collaboratively, with the consequence that professionals focus on their own, agency-specific tasks, and are less likely to prioritise the need to work with other professionals. Summary of risks This finding is not about the effectiveness of the Common Assessment Framework in Halton, but is about a broader pattern of how the pressure of work in any particular agency can make it more likely that people focus on their own agency-specific tasks, and are less likely to prioritise the need to work with other professionals. . Questions and considerations for the Board Are the pressures on those providing early help such that they need to be addressed in order to ensure a safe system? 28 What are the barriers to delivering comprehensive early help interventions that address fundamental problems? Is the Board clear about the role of individual agencies with regard to providing early help in cases of neglect? What evidence is there that those delivering early help services have quality training, supervision and support? Does the Board know what type of information might tell them about improvements in relation to this finding? Does the Board have access to this information currently? What changes to information collection and analysis is required? Finding 4 Practitioners within the multi-agency network perceive the role of Lead Professional to be one with limited status, with the consequence that individuals in the role do not feel confident to escalate concerns about colleagues in other agencies - inhibiting multi-agency efforts to provide the right help at the right time. Category of finding: Patterns of multi-agency working in longer-term work Despite guidance and a comprehensive programme of work in Halton to change the way Early Help is delivered, this work is not yet embedded, and individuals taking on the crucial role of Lead Professional do not always have the confidence to challenge those in a child's network who they see as expert around a particular aspect of a child's needs. Findings 1, 2 and 3 have addressed qualitative aspects of practice in relation to Early Help and adolescents. This Finding seeks to get underneath the issues of professional status and confidence in carrying out a role that is central to the provision of Early Help - that of the Lead Professional. How did this feature in the case? The member of school staff who was given the role of Lead Professional felt as though other professionals disappeared, and the school was left managing the Young Person's CAF. This was a risk given the flow of information from specialist services, for example dermatology, involved with the Young Person. Rather than pursuing these individuals the Learning Mentor took a view that it was other professionals' job to cover expert or specialist assessments, so he did not escalate any concerns he might have been holding about others in the Young Person's network, nor did he feel able to tackle the issue that during the time of the Young Person's CAF up to the decision in October 2012 to close it that there was "Never one stable set of people round the table - and as a partner, that is disheartening". 29 How do we know this Finding is not peculiar to the case? Practice has changed in some respects now - for example the Lead Professional in the Young Person's case told the Review Team that in 2015 it was much easier to escalate a 'CAF' case than it had been in 2012. The Halton Levels of Need Framework was revised and launched in April 2013 to support all agencies and services to meet the needs of children, young people and their families to ensure the best possible outcomes. The Early Help Strategy was revised in 2014, which in turn led to the introduction of early intervention locality teams from 1st September 2014. The Lead Professionals Procedures, revised in September 2014, state clearly that "Remember that when you undertake the Lead Professional role you are accountable to your home agency for delivering the Lead Professional functions. You are NOT responsible or accountable for the actions of other practitioners or services. If a Lead Professional encounters problems or barriers with other services, then the HBC Escalation Policy should be referred to and implemented as appropriate." However the Lead Reviewers heard from members of the Review Team - service managers in Halton in 2015 - that although there have been systems changes and investment in all aspects of the Common Assessment Framework, some of the culture remains the same. This was backed up by practitioners in the Case Group who talked about the "big role" of the Lead Professional and the challenges faced by any individual who takes on that role. Even today 'people have different ideas of what a CAF is'. The practitioners suggested that those in the Lead Professional role today still struggle to challenge others in multi-agency networks: "what if you are leading a CAF, what is your capacity to question other people?". Another member of the Case Group with a more supervisory role said: "It's lost in Halton - the idea of Lead Professionals". And Review Team members agreed that another aspect of the role that is " a real tussle", is for the Lead Professional to keep challenging parents. From the Lead Professional procedures, the two most relevant aspects of the role for this Finding are Co-ordinate the delivery of the actions agreed by the practitioners involved, to reduce overlap and inconsistency in the services received Identify where additional services may need to be involved and put processes in place for enabling their involvement Amongst the extensive changes since the Young Person's CAF was closed, CAFs are now all on Care First and an eCAF system is scheduled to start in October 2015. In addition, the Family Support Service now compiles specific chronologies that assist with CAFs. However, despite process and IT changes, it is the cultural change of shifting 30 expectations about the role of other professionals in the CAF process that feels less secure. This in turn links to the issue about the status of the Lead Professional and their confidence to escalate concerns. Lead Professionals have as their starting point "the information we get before a CAF; [and you] can’t test out a hypothesis If you've not got a steady team around you as Lead Professional and you are not the expert". The Review Team was left with questions about not just the support available for Lead Professionals, but also, what levels of oversight exist for the role in Halton, and how such oversight fits with any standards of competence required to take on the role. Using the Young Person's case as a starting point, the Review Team asked about practice now in secondary schools, and what oversight there is. Management information about safeguarding and levels of need amongst pupils in any school is reported by the headteacher to the governing body each term, including figures on CAF, and numbers of children on Plans. The minutes have to be produced for inspections - but there are no minimum standards, which is in line with the revised version of Keeping Children Safe in Education of July 2015. The Safeguarding Children in Education Officer in Halton has supplied schools with standardised material to put in their safeguarding policies and procedures. The material does not, however, include any recommendations for qualitative feedback from Lead Professionals that might highlight the difficulties of escalating concerns about other professionals. Nor does it cover the type and effectiveness of oversight that such a professional receives from their manager within the school. Although schools were chosen as an example, the Review Team thought that the lack of a competence framework for Lead Professionals would have effects in all settings not only in schools. How widespread and prevalent is this issue? In Halton, the Safeguarding Children Board has been scrutinising and trying to understand the issues that lie behind the use of the CAF. November 2015 analysis, reported to the performance subgroup of the Safeguarding Children Board addressed questions about the consistency with which the CAF is used as a tool across all agencies, and what the implications are for other parts of the system. The report stated that: Halton’s Early Intervention Strategy and framework requires all partners across the children and families workforce to take responsibility for supporting children, young people and families and to take the lead responsibility for CAFs when appropriate. Whilst CAF audits show that over a number of years the quality of CAFs has consistently improved, the number of CAFs being completed by, and the proportion of CAFs that are led by, agencies other than some primary schools and Halton Borough Council staff remains at a consistently low level. A high number of cases discussed at Working Together Meetings and/or at CART early intervention level where CAF advised is the outcome, do not seem to progress to a CAF being completed. 31 The implications of this are two-fold "42% of referrals that other agencies/partners are referring in have needs that can be met through signposting and/or referral to a single agency that should be taking place directly from partner agencies or via advice/guidance at the front door "- and this picture was similar for both Widnes and Runcorn teams so there is not wide variation in the two areas of Halton. and " Another area of some concern is the number of CAFs advised that do not result in a CAF being carried out– over the time period looked at 51 CAFs were advised for children in Runcorn and 60 in Widnes, with no evidence of a CAF currently uploaded or sent in to the CAF inbox. Whilst a proportion of these will have been advised recently so not yet underway this is a significant number of CAFs advised that are not leading to a completed CAF." The report to the Safeguarding Children Board concluded with an action plan to address different elements of the concerns that were outlined in the report. Along with a recommendation about the action plan, there was a second recommendation: That all partners take responsibility for ensuring that their workforce understand and take on their responsibility for early intervention, advice guidance and support, and in particular take on lead professional role for CAFs. What are the implications for the wider safeguarding system? The November 2015 analysis that was reported to the Halton Safeguarding Children Board comes in the context of plans for substantial investment in early help across the whole of Cheshire. This makes it more important than ever that the full range of professionals who could potentially carry out CAFs and take the role of Lead Professional do so. If the range of assessors and Lead Professionals increase, the safeguarding system could be working with many more practitioners who are inexperienced and lack confidence in identifying neglect in teenagers. Finding 4: Practitioners within the multi-agency network perceive the role of Lead Professional to be one with limited status, with the consequence that individuals in the role do not feel confident to escalate concerns about colleagues in other agencies - inhibiting multi-agency efforts to provide the right help at the right time. Summary of risks 32 The role of Lead Professional remains one that practitioners are reluctant to undertake. The identification of safeguarding issues at an early point is limited if only some professionals feel able to take on the role of Lead Professional. Agreed oversight arrangements for Lead Professionals in Halton, and minimum standards for the CAF are not in place, but could assist with both skill and confidence of practitioners. Planned investment in early help across the whole of Cheshire in 2016 means that the role of Lead Professional will become even more crucial, as will the training and guidance available to those taking on the role Questions and considerations for the Board Have Board members previously encountered concerns that the role of Lead Professional is not one that all relevant practitioners feel confident to take on? How much of a priority is it for the Board to address this? How does the LSCB ensure that all agencies have an understanding of the Lead Professional role, and what to do if cooperation is an issue? How does the LSCB ensure that all agencies are putting in the right level of support and oversight to Lead Professionals? Can the HSCB consider the value of a supervision process for Lead Professionals? And do board members have any suggestions about the sort of professionals that might provide this oversight? Finding 5 Are professionals in Halton who deliver universal and early help services sufficiently confident to raise questions about family and household members who could pose a risk of harm to the child or young person - with the consequence that they leave these young people vulnerable to abuse and neglect? Category of Finding: Family / professional interaction This Finding is about the importance of creating a culture where professionals are not naive. Serious Case Reviews of recent years have promoted the importance of identifying "hidden men" but this has not extended to the wider members of families and households. How did this feature in the case? The Review Team initially thought that there had been two different adult males in the Young Person's life, as partners of his mother. This was due to a very definite description from professionals at the Young Person's school that his mother had two different partners - one 'good' and one 'bad'. Only on interviewing the social work professionals, 33 and then confirming it through a meeting with the individual in question, was it absolutely clear that one person only was involved. On the day of the incident that triggered this review, the Young Person was staying at the home of a member of the wider family. This was not a one-off, and the Young Person spent time there periodically. One of the paramedics who attended knew, from a previous attendance at the address that there was some reason why children should not be at the property. This was confirmed by the social worker initially allocated to work with the Young Person, who was in fact already involved with children who had been living at that address. How do we know this is not peculiar to the case? The Case Group, the Review Team, and the members of the Halton Safeguarding Children Board all provided information that there is no system in place for supporting professionals with this dilemma. Moreover, practitioners indicated that they are uncertain about when it is appropriate to make enquiries about wider members of the family and household. How widespread and prevalent is this issue? Although there is a growing body of work about "hidden men" (NSPCC 2015), the identification of a wider group of significant adults in a child or young person's life, is less well explored. The NSPCC's analysis of Serious Case Reviews that involved "hidden men" pointed to two categories of ‘hidden’ men: men who posed a risk to the child which resulted in them suffering harm men, for example estranged fathers, who were capable of protecting and nurturing the child but were overlooked by professionals. The same issues probably apply to a wider group of individuals in the lives of children, but the hidden nature of this problem makes it particularly difficult to quantify. In addition, practitioners' lack of clarity about their roles and responsibilities in terms of gathering information and sharing it, means that it remains hidden and that more children may be in vulnerable positions than is recognised. The Review Team acknowledged the question for practitioners of how one would legitimately gain information about these hidden members of a household. What are the implications for the wider safeguarding system? For a safeguarding system to work effectively, professionals need to be equipped to ask questions about every adult who is part of a child or young person's life, and never to be narrow, naive, or make assumptions about who those adults might be. Without this understanding of the significance to the child of family members and associates, professionals cannot assess risk to the child, nor establish who is a source of support or protection for that child or young person. 34 Finding 5: Summary of risks There is a substantial body of work about "hidden men", and the safeguarding implications are likely to be the same for a wider group of extended family members, neighbours and associates who feature in some children's lives. Without professional curiosity and confidence to explore who these individuals might be, and without the support of the HSCB for professionals to exercise this curiosity, the scale and impact of both potential risk and potential support from this extended group cannot be understood or mobilised. Questions for the board How much of an issue is the identification of wider family and household members and associates for early help professionals? Are there any demographic or social changes to complexity in family networks in Halton that might impact on children and young people who need early help? Why does this matter to children and young people and their lived experience? CAFs now have chronologies, would genograms also help professionals in understanding a child's wider networks? What sort of messages might the HSCB want to give about this issue? What sort of measures might the HSCB use to track positive changes in this area? Finding 6: There is not a robust system for multi-agency information sharing during organisational change, with the consequence that information about individual risk to children can be passed on, but does not always receive the analysis of risk that is needed for safeguarding decisions. Category of Finding: Management Systems Findings 6 and 7 move away from direct consideration of adolescent neglect and move on to two distinct issues which came to light during the review, that also have an impact on the safety of children and young people in Halton. As such, the Review Team had questioned whether these two findings might be of relevance to the Children's Trust as well as the Safeguarding Children Board. Finding 6 covers information-sharing risks arising from the scale and continuous nature of organisational change in health and social care. There is not a system for keeping multi-agency networks up to speed with two regular aspects of change - restructure in organisations, and the award of new contracts and ending of existing ones. 35 How did this feature in the case? During the period under review, the commissioning arrangements for School Health services changed. Review Team members felt that this was an example of a situation where service redesign should have included communication to professionals such as the Lead Professional in the Young Person's case, explaining changes in approach - the move to being a public health service, and on a more administrative basis, during the review it was said that information had not been received by School Health because of service changes. How do we know it is not peculiar to the case? Members of the Review Team gave the example of a recent change to the Speech and Language Therapy provision for the area. Briefings on this did not reach professionals who needed to know, and consultation about the changes when they were at the proposal stage could have been further reaching. Review Team members also heard that with the 'lift and shift' of School Health services to Public Health, the Clinical Commissioning Group is trying to monitor the safeguarding aspects of that service in a situation where the contract for the service has not changed- but there has been an internal reorganisation of delivery. Substantial changes to CAF support services form the backdrop for this review, and the Review Team heard that 'people are still getting used to [them]'. Another example was that CAF support workers no longer carry out visits which are more akin to welfare checks in response to concerns from other agencies - instead there is more focused assessment, but balanced with a telephone consultation line to advise on the sort of partner concerns which previously triggered requests for these visits. This has implications for all agencies, in terms of providing information to the Contact and Referrral Team – in 2014 there were 'massive partner briefings' about changes in Children's Social Care and what that meant for other agencies, but this most recent development is another example of change that communication strategies need to keep abreast of. How widespread and prevalent is the issue? The delivery of early help in Halton brings with it organisational change and restructuring. A March 2015 presentation in Halton for the Early Intervention Development day stated: Early Intervention requires effective collaboration and co-ordination at all levels and across services, adopting common service delivery models, tools and processes and the development of multi-agency multi-professional teams. Nationally, What makes change successful in the NHS? (Gifford et al 2012) reviewed 15 systems change programmes - and although the language here is about clinicians, it 36 could be applied to practitioners in early help services, especially as Halton is on the verge of systems change in this area "Change programmes also benefit from a genuinely collaborative process in which clinicians fully engage with diagnosing problems and designing solutions." Finding 6: Summary of risks Extensive changes are planned to the system for delivering early help in Halton in 2016. The information provided to this Serious Case Review suggests that previous changes have not always been communicated to professionals working with children and young people, with the direct consequence that practitioners do not always know where to send information about risk to a child. The forthcoming changes, because of their scale, have the potential to cause similar problems. Questions and considerations for the Board Are Board members aware that some organisational changes of recent years have not been fully understood by practitioners in the period after reorganisation? How much of an issue do Board members think this is? Extensive change to early help systems is planned - has the Board considered its role in the safeguarding implications of this change? Based on the issues that this Serious Case Review has highlighted, how can the Board support communication about organisational change? How will the Board know if communication about the early help systems changes are effective in getting messages across about any new safeguarding processes? How will the Board work with other strategic partnerships, both in Halton, and across Cheshire, on this issue? Finding 7 The whole emergency and urgent care system that includes Halton, is designed to be lean and efficient - and the risk in the system is that exceptionally, when the whole system is under extreme pressure, the efforts of dedicated individuals in the ambulance service cannot compensate for the risk that arises from having such a lean system. Category of Finding: management systems The challenge for an urgent and emergency care system is to provide safe care but also to be lean and efficient. The Review Team heard about changes to the system in Halton to make it as efficient as possible, and were also impressed by the skill and experience of ambulance trust professionals who attended the scene following the 999 call about The Young Person. 37 However it is an intrinsic risk in any lean system that when there is exceptional demand, that demand cannot be met. How did this feature in the case? On the day between Christmas and New Year when The Young Person had a life-threatening asthma attack, local crews and Accident and Emergency departments were on 'Red' alert, with ambulances queuing outside A&E departments in the surrounding area. When an adult dialled 999 stating that the Young Person was not completely alert, having an asthma attack and having difficulty speaking, exhaustive attempts were made by the ambulance service controller to find a crew. Ambulance staff were either engaged or not cleared as they were waiting at hospitals for patients to be admitted to A&E. Eventually professionals who were officially on breaks responded, above and beyond what was expected of them. A rapid response vehicle reached the house 34 minutes after the call was made, followed by an ambulance. This was outside the eight-minute response target for a callout to a child with the severity of asthma exacerbation that the Young Person was experiencing. However the Review Team heard that the pressure which was affecting callout times was due to ambulances being unable to hand over adult patients at the surrounding hospitals and having to queue, with the figures of eleven and twelve ambulances respectively being quoted as waiting at the two nearest hospitals at the most pressured part of that day. How do we know this is not peculiar to the case? A manager from the ambulance trust told the Review Team that in early September, winter pressures start to build – with cardiac and respiratory conditions such as Chronic Obstructive Pulmonary Disease and asthma requiring admission. The manager said that the affected services ‘don’t have a lull any more’. This seasonal increase in demand takes place alongside a growing list of calls in relation to legal highs, cocaine, alcohol, and people 'who don't take their pain relief'. Despite advertising campaigns such as '999 what's your emergency (filming in Warrington during September 2015), the demand on emergency services remains high from members of the public who cannot, or do not wish to, use the range of services set up to deal more appropriately with some of their out-of-hours illnesses. The Review Team also heard about schemes set up by the ambulance trust to address some of the pressures that arise from adult patients, but which then impact on the whole urgent care and emergency system. One of these was the Advanced Visiting Service, where the ambulance trust was in certain situations that met clear criteria, using a GP service to visit patients at home as an alternative to hospital admission. The issue exists for every part of the country. On 3rd September 2015 Polly Toynbee wrote in the Guardian [of a hospital trust in the southeast of England] Every service has targets to hit, waiting times and waiting lists to meet, but they all depend on one another. A week earlier, there had been 14 ambulances lined up outside the emergency department. They had to wait, caring for people inside their vans as they couldn’t offload patients for lack of cubicles and staff inside the hospital. When that happens, the ambulance service misses their target times for 38 answering other calls, damaging their own inspection scores, knocking down the skittles from one service to another. On the day of the incident involving the Young Person - 28th December 2014 - the Review Team heard that the pressure on the service was normal for Christmas. The Young Person was admitted to hospital in the early afternoon but by 9.05 pm, there were still pressures at one of the nearby hospitals, with 9 ambulances outside unable to leave their patients. The agreed plan of action for such a situation was set in motion, and the strategic manager for the ambulance trust sent the operations manager in to work with the hospital. The Review Team heard about the volume of calls to the ambulance service on the day of the Young Person's asthma attack and how this fitted with the pressure on the whole system. There were 72 outstanding calls at the time of the call about the Young Person. The pressure had been relentless all day. At 1.13am there were 25 outstanding calls, 18 of which were life-threatening 'Red' calls (the same priority that was given to the call about the Young Person). The preceding night had seen ambulances queuing at the majority of hospitals in the region. The Review Team questioned whether services were fully staffed, to be told that not only were they fully staffed across the 'east' sector but that services were also supplemented with funding put in by the ambulance trust itself. Practitioners who were usually office based were out in cars as well. How widespread and prevalent is this issue? The Review Team were in no doubt that the issue is one that affects the whole region of north west England and the impact is much the same for Halton as is it for the other authorities in the region. Northwest Ambulance Service's Annual Report for 2014/2015 begins: To say 2014/15 was challenging would be a gross understatement. The NHS found itself under unprecedented pressure and in its nine year history, NWAS dealt with a rise in activity that had never been seen before. Outside the region, the pressures and issues are the same. One of the lead reviewers for this case has recently interviewed ambulance trust staff from another part of the country in the context of an adult safeguarding review, and the issues described were strikingly similar. The Polly Toynbee article quoted in the previous section, illustrates how each part of the urgent care system depends on another - 'knocking down the skittles from one service to another'. In terms of opportunities, from October 2015, NWAS will also be running the non-emergency call centre for the region - the NHS 111 service. The Trust's annual report says: Obtaining the contract gives the Trust a real opportunity to fully integrate the services offered by NHS 111 into NWAS so the advice and help provided to patients, whether they dial 111 or 999, is consistent and tailored to their needs. We are also pleased that this contract offers longer term stability to the NHS 111 staff. 39 For some time now, the Trust has been mindful that we must look at the different ways we can respond to 999 calls as a blue light emergency response and conveyance to hospital is not always in the best interests of the patient or the wider health system. What are the implications for the safety of the multi-agency safeguarding system? A safe system has some slack in it so that children's health emergencies can be responded to. However an efficient system also has to make the best use of resources and strike a balance about the amount of slack that can be available. If members of the community - either families or professionals - remain unable or unwilling to use emergency and urgent care services in different ways, and to respond to national and local messages about alternative points of access - then the pressure on the urgent and emergency care system will continue to follow its upward trend, meaning that on exceptional days such as the one between Christmas and New Year in 2014, there is a risk that response times for children will not be met. Finding 7:Summary of risks A safe system has some slack in it so that children's health emergencies can be responded to. However an efficient system also has to make the best use of resources and strike a balance about the amount of slack that can be available. Pressures on the system are rising and are usually managed, but a period of exceptional demand may occasionally mean that agreed response times for children cannot be met. Questions and considerations for the Board How much of an issue does the Board consider this risk to be? Where does the Board think the oversight for this risk should sit? (For example with the Children's Trust Board, and / or the Health and Wellbeing Board?) Does the Board have any existing concerns about the impact of ambulance response times as a safeguarding issue? The ambulance service is one part of a complex urgent and emergency care system - would the Board want updates from North West Ambulance Service about safeguarding issues identified once NWAS takes on the contract for the 111 number? Conclusions 40 This Serious Case Review was commissioned in response to events that are uncommon. First of all it, involved a young person and an exploration of neglect that had affected the whole of that young person's life. Neglect cases and referrals much more typically involve younger children. Secondly and thankfully, the young person had survived the incident that triggered this Serious Case Review and was able to contribute to the review process. Most of the Findings from this review reflect these distinctive factors, and address the research question: To what extent is Early Intervention in Halton child-focused in addressing adolescent neglect? The events that triggered this Serious Case Review, and the period when the Review was being carried out, occurred at a time of significant planned change for the Early Help services in Halton. The systems challenge, now that the change is being implemented, is to create an environment where professionals are not so pressured that they work in isolation as a response to that pressure - but instead to use the frameworks, training, and the data from Halton Safeguarding Board's audits of early help, to embed multi-agency safeguarding practice that is accountable, but is not measured solely in terms of figures that are easier to capture - such as throughput and timeliness. Instead, it is hoped that the questions for the Board in this report help with a discussion about what it is that a Safeguarding Children Board should have oversight of , and what responsibilities lie with individual agencies that belong to the Board. With the investment and attention being put into early intervention services in Halton, which have already incorporated learning from this review, adolescent neglect should in future get more of a whole-system response than it did in the case of the Young Person. References Brandon, M, Bailey, S, et al. (2013) ‘Neglect and Serious Case Reviews A report from the University of East Anglia’ commissioned by NSPCC University of East Anglia/NSPCC January 2013 Compas, B.E, Jaser S, et al. ‘Coping with Chronic Illness in Childhood and Adolescence’ Annual Review of Clinical Psychology. 2012 April 27; 8: 455–480 Crittenden, P. (1995) ‘Research on Maltreating Families: Implications for intervention’, in J. Briere, L. Berliner and J. Bulkley (eds) The APSAC Handbook on Child Maltreatment Thousand Oaks, CA: Sage, pp.158–74. Davies, C. and Ward, H. (2012) Safeguarding Children Across Services: Messages from Research on Identifying and Responding to Maltreatment, London: Jessica Kingsley. Gifford, J et al (2012) What makes change successful in the NHS? A review of change programmes in NHS South of England 41 HM Government (2015) 'Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children', London: Department for Education. Horwath, J. (2007) The Neglected Child: Identification and assessment London: Palgrave. Horwath, J. (2013) Child Neglect: Planning and Intervention, London, Palgrave McMillan. Nfer, LARC, RIP (2015) ‘We should have been helped from day one: a unique perspective from children, families and practitioners. Key messages about neglect and early intervention for LSCBs’ London: Nfer. NSPCC (2015) Hidden Males: Learning from Serious Case Reviews Ofsted (2014) ‘Early help: whose responsibility?’ Manchester: Ofsted. Ofsted (2015) ‘In the child’s time: professional responses to neglect’ Manchester: Ofsted. Suris, P., Michaud, R, Viner. R. (2004) ‘The adolescent with a chronic condition. Part I: developmental issues’. Archives of Diseases in Childhood 2004; 89:938–942 Woolmore S (2016) The Safeguarding Blindspot, Professional Social Work, June 2016 |
NC52356 | Professional concerns regarding an 11-year-old boy admitted to hospital in April 2020. Liam's presentation at hospital was due to an accidental injury, but his appearance and history of previous medical presentations raised concerns about his care and resulted in the instigation of care proceedings. Learning includes: practitioners should take into account the impact of parental anxiety on a child's overall welfare; practitioners learn strategies for working with parents who are highly anxious; children cannot always easily articulate their day-to-day life experience, particularly when they have no ongoing relationship with an adult outside of the home; the need for practitioners to be professionally curious about information provided by parents and how that impacts upon the care provided; the challenges of working with families where there is partial engagement and disguised compliance. No recommendations, but notes that learning has been incorporated into the local safeguarding partnership's workstreams, including multi-agency training, planned audits and professional guides.
| Title: Learning review report: Liam. LSCB: Hampshire Safeguarding Children Partnership Author: Hampshire Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Learning Review Report Liam This review has been undertaken on behalf of the Hampshire Safeguarding Children Partnership (HSCP) by the Learning and Inquiry Group. The review of Liam’s case is taking place in conjunction with the review a of another child, where some similar characteristics of the case were identified, and it was considered that learning in the two cases were likely to have similarities. A summary of the case: Liam was referred to Childrens Services at the end of April 2020, aged 11, following admission to hospital a fortnight earlier. His initial presentation at hospital was due to an accidental injury, but his appearance (thin and pale), a detailed history of his previous medical presentations and observations of his progress in hospital raised concerns about the care he was receiving at home. A multi-agency assessment of his circumstances resulted in his case being put before the court in public proceedings. History: Liam lives with his mother, father, and older half sibling. There is a history of his parents seeking medical advice from an early age, due to reported concerns about mobility, pain and discomfort and eating difficulties in particular. He was also described as highly anxious, with some social and communication difficulties. Parents were concerned about his health and were anxious about what his reported conditions meant. In particular, they were keen to know if Liam was autistic. At aged 6, Liam’s family decided to home educate him and notified the school and the Local Authority Elective Home Education service of this decision. Liam was seen by various health professionals over the following years during which time he was also waiting to be assessed for autistic spectrum disorder (ASD). Adaptations were carried out in the family home to assist with mobility and Liam was noted to use a wheelchair at times. He was referred to a paediatrician, paediatric orthopaedic surgeon, paediatric physiotherapist, and to the paediatric pain service. A referral was made to Children’s Services via the Multi Agency Safeguarding Hub (MASH) in February 2019, with concerns expressed about his social isolation and the appropriateness of the educational input he was receiving. A Child and Family Assessment was completed which concluded that the family should be offered support at Early Help level, but this was not taken up by the family. Liam was seen and assessed by a commissioned service on behalf of Hampshire Child and Adolescent Mental Health Service (CAMHs) in April 2019, which confirmed his diagnosis of ASD. Matters came to a head in late April 2020 when his family, having sought medical advice and help to treat an injury which seemed not to be healing, took Liam to A&E. It became apparent that Liam 2 was severely underweight and that his diet had become significantly restricted over the previous weeks (particularly since the COVID-19 lockdown on 23 March 2020). Learning points for managers: • Ensure that practitioners take into account the impact of parental anxiety on a child’s overall welfare. • Children will not always easily be able to articulate their day-to-day life experience particularly where they have no ongoing relationship with an adult outside of the home. Practitioners may need to go back to see the child more than once. Learning points for practitioners: • To be 'professionally curious' about information provided by parents and how that impacts upon the care provided. • Copying multiple people into a letter does not guarantee that anyone is acting on the information. Learning points for HSCP: • Help practitioners to engage with parents who are highly anxious. Themes in common with other reviews in Hampshire: • The challenges of working with families where there is partial engagement and disguised compliance. • Children will not always easily be able to articulate their day-to-day life experience, particularly where they have no ongoing relationship with an adult outside of the home. If you do one thing, take the time to…. • Consider the impact of parental anxiety on child development and learn strategies for working with parents who are highly anxious. How was learning achieved: A multi-agency review was commissioned by the Learning and Inquiry Group of Hampshire Safeguarding Children Partnership. Hampshire agencies provided written reports. These were reviewed by two senior managers, independent of the case and where required, additional information sought from professionals involved in the case. HSCP response: The learning in this Learning Review Report has been incorporated into HSCP workstreams. This has included multi-agency training, planned audits, scrutiny work, professional guides, and featured newsletter items. Training and resources: ▪ HSCP Training - HSCP offers training on a variety of safeguarding themes. ▪ HSCP Training 2020/21 ▪ HIPS Procedures ▪ HSCP and IOWSCP Neglect Strategy and Toolkit ▪ HSCP AND IOWSCP Safeguarding Adolescents Toolkit – Strategy Guide on Neglect ▪ Neglect Multi-agency Training ▪ Child and Family Engagement Guidance for Primary Care 3 ▪ Child and Family Engagement Guidance for Secondary and Tertiary Care ▪ Spotlight on Disguised Compliance ▪ Published SCR/LCSPR reports and learning summaries can be found in the Learning and Reviews section of the HSCP website. Published Reviews Publication date: 24 January 2022 |
NC044468 | Death by drowning of a 20-month-old boy in July 2013. Child I was found face down in the bath; mother reported she had left Child I in the bath, informing father she had done so, before leaving the house. Parents were subject to police investigation as alleged perpetrator and witness throughout the case review process. Child I and his two older siblings were subject to child protection plans under the category of neglect at the time of the incident. Parents both had learning difficulties and at times reacted with anger and hostility to professional interventions. The family were receiving support from a wide variety of services, including: health visiting, children's centres, home start, enhanced midwifery support, community outreach, a health early intervention worker and enhanced support from a school. Identifies findings including: lack of intra-agency ownership and accountability for front-line practice; professional emphasis on investigating some physical injuries, at the expense of considering indicators of neglect; hostile parental behaviour distracting professionals from protecting the child; and overreliance on written agreements with parents to support child protection arrangements. Uses the Social Care Institute for Excellence (SCIE) Learning Together model to set out key findings and pose questions to the Lambeth Safeguarding Children Board. Includes a response and action plan from the Board.
| Title: Serious case review: Child I. LSCB: Lambeth Safeguarding Children Board Author: Bridget Griffin and Ghislaine Miller Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Lambeth Safeguarding Children Board Serious Case Review Child I Agreed by the Lambeth Safeguarding Children Board October 2014 Published April 2015 It was not possible to publish the report before April 2015, until the conclusion of Police and Crown Prosecution enquiries. 2 1. Introduction Why this case was chosen to be reviewed Child I died on 23rd July 2013. The circumstances of his death were considered at a meeting of the Lambeth Serious Case Review Subcommittee where it was agreed that the criteria, outlined in statutory guidance1 for undertaking a serious case review, had been met. Lambeth Safeguarding Children Board decided to review this case using The Social Care Institute for Excellence, Learning Together Case Review methodology. Methodology and Process of Review This case has been reviewed using a systems approach, the focus of this approach is on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why – to identify the ‘deeper’, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case and changing them will contribute to improving practice more widely. The data is gathered from a variety of sources, including review of existing documentation alongside data provided by front line practitioners and their managers, who had involvement in the case during the time line under review. Within this report, these professionals are referred to as ‘The Case Group’. The review is completed by a team of senior managers, who did not have line management responsibility for the case, led by two independent lead reviewers2. Together, they make up The Review Team. The data, gathered during the course of this review, the analysis and findings, are the subject of scrutiny by the Review Team. Recurrent cycles of feedback and amendment, by the Case Group and Review Team, are inherent features of case reviews, using this methodology. A critical aspect of a review, using this methodology, is the perspective of family members. The perspectives of both mother and father are reflected within this report. Details of the methodology, data sources and structure of the review process, are outlined in Appendix 1. 1 Working Together to Safeguard Children : HMG 2013 2 Accredited as Lead Reviewers by the Social Care Institute of Excellence (SCIE) 3 Succinct summary of the case3 Child I was born in November 2011 to white British parents living in Lambeth. Child I had two older sisters, a younger brother and a large maternal family, all of whom lived in Lambeth. His childhood was spent living at home with his mother and father and his siblings; he was described as a “happy bonnie” child. Both parents had been known to professionals, from various services, since their childhood. In his teenage years, father had been assessed as having a learning disability. Mother was also thought to have learning difficulties, she had been the subject of a statement of special educational needs (SEN), as a child. Child I, was the 3rd of their 4 children. He was aged 1 year and 8 months when he died. At the time of his death, both parents were in their mid-twenties, his eldest sister was 6, his second sister was 3, and his younger brother was 9 months old. Prior to the birth of the second child in the family (Sibling 2), in April 2010, an assessment using the Common Assessment Framework (CAF) was completed. This led to the allocation of an early intervention social worker. The family were assessed as being vulnerable and isolated and there were concerns about parenting capacity, and domestic violence/anger management. There was regular input from the Early Intervention Multi-Agency Team (MAT) and a number of services were provided to the family during this time. In August 2011, Sibling 1 was found to have an injury to her eye and was referred to Children’s Social Care. A child protection investigation commenced. In November 2011, Child I was born. The child protection investigation, into the injury to Sibling 1, resulted in an initial child protection conference, on 18 November 2011 all three children were made the subject of child protection plans, under the category of neglect. They remained the subject of child protection plans, until July 2013, when I died. A wide variety of services were provided. These services supported the parents in their care of their children. The birth of the fourth child, the youngest child in the family, in September 2012, was a challenging time for the family. On the morning of 23 July 2013, mother left the house to take their eldest child to school. On her return, she found Child I in the bath face down. Attempts made to resuscitate Child I, were not successful. He was pronounced dead on arrival at hospital. Although the exact circumstances of Child I’s death were not clear, and were subject to on-going police investigations, the pathologist concluded that Child I’s death was consistent with drowning. Mother reported that she placed Child I in the bath that morning, advising father that she had done so, before leaving the house to take the eldest child to school. The three remaining siblings were removed using police protection powers, and were placed in foster care. 3 Some of this information precedes the start of the time line for this review, but the Review Team felt it important background information to include in order to assist the reader in giving an understanding of the broader context, and in shedding light on practice within the timeline of this review. 4 Family Composition Family member Age in July 2013 Father 24 Mother 26 Sibling 1 6 Sibling 2 3 Child I Aged 1 year 8 months at time of death. Sibling 3 9 months Ethnic Identity White British Local Context Child I and his family were receiving services from across a wide range of agencies and services in Lambeth, including services provided by the Community and Voluntary Sector. A conservative estimate, of the professionals, staff members and their managers involved, numbered over 40 individuals. During the time line under review, Lambeth was experiencing a significant increase in the demand for services. In April 2010, Lambeth had 210 children with child protection plans. By April 2013, this had risen to 320. A Public Health-commissioned report looked at reasons for the rise and could draw no firm conclusions, but audits showed that these extra children definitely needed statutory protection. This significant increase, in numbers of children requiring statutory protection, had clear resource implications for all services in Lambeth. The increase in numbers of children subject to child protection plans, placed a number of additional pressures on all services and agencies .This included additional demands placed on the administration requirements, inherent within agency systems regarding children who are the subject of child protection plans, and on the increased demands placed on professionals in their day to day work. In terms of the Children and Young Peoples Service, additional capacity was put in place to ensure that caseloads remained appropriate and management was strengthened. However, earlier in 2013, staffing fell away considerably within the Social Work Team providing services to Child I. These issues are discussed in the latter part of this report. 5 2. The Findings What light has this case review shed on the reliability of our systems to keep children safe? A case review plays an important part in efforts to achieve a safer child protection system. Consequently, it is necessary to understand what happened and why in the particular case, and go further to reflect on what this reveals about gaps and inadequacies in the child protection system. Using the Social Care Institute for Excellence (SCIE) Learning Together methodology, the particular case acts as a ‘window on the system’4. For this to happen, the outcome of the review has to say more than what happened in this particular case and needs to provide messages to the Local Safeguarding Children Board (LSCB) about usual practice and normal patterns of working. These messages are presented as ‘findings’, and provide the LSCB with an insight into the underlying patterns that influence professional practice, and outcomes for children. By responding positively to the findings, the LSCB has the opportunity to change how the child protection system operates, and to make it safer. It makes sense, therefore, to prioritise the findings to identify those that need to be tackled most urgently, for the benefit of children and families, even though these may not be the issues that appeared most critical in the context of this particular case. In order to help with the identification and prioritisation of findings, the systems model that SCIE has developed includes six broad categories of these underlying patterns. The ordering of these is not fixed and will change according to which issues are felt to be most fundamental for systemic change. The categorisation of findings is as follows: Tools Family-professional interactions Management systems Patterns of multi-agency working in response to incidents/crises Patterns of multi-agency working in longer-term work Innate human biases (cognitive and emotional biases) The findings from each category convey a message to the LSCB about how that element of the child protection system was working, at the time of Child I’s death. They state succinctly what is, or was problematic, about the system, and are therefore helpful to the reader. It is not uncommon for there to be overlap between the categories of findings. 4 C. Vincent : Analysis of clinical incidents: a window on the system not a search for root causes 2004 6 In what way does this case provide a useful window into our systems? At the start of this Serious Case Review (SCR), Lambeth Safeguarding Children Board (LSCB) identified that this tragic case held the potential to shed light on particular areas of practice, and asked the Review Team to examine the following issues, within the course of the review: How effectively do local agencies work with families where the parents have learning difficulties and there is evidence of neglectful parenting? How do we equip practitioners to work with neglectful parents? How can we effectively monitor children subject to a CP plan for neglect? How can we link safeguarding risks to children from neglect to key stages in their development? How can we effectively support parents with young children where there is evidence of neglect? What is the availability of specialist workers/advisers? If available, are they well used? How is professional challenge raised and resolved? How are written agreements used to protect children? How were the needs of the children individually assessed, and their voices reflected? What was the nature of the neglect? Was it neglect by omission or commission? We have aimed to address these issues in the remainder of this report. A definitive answer to the final question is not provided, as this remained the subject of criminal investigation throughout the review. The result of those enquiries, which have now concluded, is that no one has been charged with any offence as a result of I’s death. . Taken as a whole, this case illustrates the complexities that professionals face in their efforts to safeguard children in situations where the parents of young children have learning difficulties, and there is evidence of neglectful parenting. Many of the issues highlighted here, in relation to neglect, are not new. There is a significant body of research5 about the difficulties faced by professionals in supporting families and safeguarding children in cases of neglect, where change is not easily achievable, and support needs to continue over a prolonged period. However, as identified by Gardner6, integration of this literature, and research findings, into front line services remains patchy. 5 Brandon et al : Neglect and Serious Case Reviews 2013 6 Ruth Gardner et al : Developing an effective response to neglect and emotional harm to children 2008 7 This case also has the potential to highlight the effectiveness of the local response to parents with learning difficulties, which can present additional challenges to the multi-agency group. Evidence of these challenges can also be found in the research literature. For example, Cleaver and Nicholson note: “While there is no association between learning difficulties and willful neglect there is considerable evidence to suggest children suffer neglect by omission as a result of a lack of parental education combined with the unavailability of supportive services”. Children’s needs: parenting capacity: Cleaver & Nicholson et al 2011 Specifically, this case involves a number of challenges which safeguarding agencies, working in Lambeth and nationally, encounter regularly, in the following common areas of practice: Assessing and intervening in cases of neglect Working with parents who have learning difficulties Multi-agency safeguarding work when children are the subject of a child protection plan Multi-agency ownership, accountability, debate and challenge, and the pivotal roles of supervision and management oversight Working with families where care givers are openly hostile and intimidating towards profession Appraisal of professional practice in this case – a synopsis This appraisal of practice sets out the view of the Review Team about how timely and effective the interventions with Child I and his family were, including where practice fell below expected standards. Where possible, it provides explanations for this practice, or indicates where this will be discussed more fully in the findings. Overview The parents in this family had been known to services since childhood. This appraisal of practice is focused on the period under review (May 2010 - July 2013). In a number of ways, this case illustrates the impressive range of services that are available to children and families in Lambeth. Practitioners made use of the resources available, and a number of services provided were of a good quality. Many practitioners, across these services, demonstrated a heartfelt desire to improve the outcomes for the children in this family, and provided services where tangible improvements for each child was evidenced. Practitioners also clearly cared for, and wanted to support, two young vulnerable parents. 8 There were also a number of instances of good practice in this case that were identified during the course of this review. Examples included: Good initial core assessment and child protection medicals. Persistent attempts to appreciate the emotional needs of the parents. Valiant efforts by practitioners to communicate with family members, who were at times hostile and aggressive. High levels of intervention by agencies/service providers to respond to, and manage, the high levels of need in the family. Commitment to engage the parents, with particular reference to the work of a youth worker in providing advocacy at the point early intervention services were involved. However, when taken as a whole, it can be seen that practitioners were, at times, working in isolation- working hard to improve outcomes for each separate part of the family system. Practitioners struggled to balance their support for the parents, with a focus on the needs of the children. Over the period under review, there were few changes in the parenting received by the children, or the neglect they suffered. The remainder of this section explores in detail the response of professionals to the family, falling into a number of distinct areas of practice over a total period of three years and three months. Phase 1 – Early intervention: May 2010-November 2011. Prior to the birth of Sibling 1 in 2007, services were provided to mother and father, including services provided by the CYPS Leaving Care Team and services provided by Youth Support Services. Following Sibling 1’s birth a number of multi-agency services were involved with the family. In May 2010,after a decision was made that the family required services at a higher threshold if intervention, additional services were provided through the Multi-Agency Team (MAT)7.These services were aimed at addressing parental isolation, assisting with parenting, providing assistance with daily living tasks/household management and managing paternal anger. Both parents were recognised as having learning difficulties. Father was known to have experienced a troubled childhood, characterised by loss, separation, abuse, and a troubled life in the care of the Local Authority. The behaviour of both mother and father frequently evidenced their feelings of anger and hostility. In this early period, whilst there were early signs of co-operation from mother, father was openly hostile and resistant to interventions. 7 MAT meetings previously known as Team Around the Child Meetings are the main vehicle in the Early intervention phase for a range of professionals working with the family to come together to share information in the CAF and in other assessments, assess risks, identify interventions to support the family and draw together an action plan. 9 This period of early intervention provided a pivotal opportunity to understand parenting capacity, and to make a judgement of future capacity. The Common Assessment Framework (CAF) was used as the main assessment tool, and as the referral tool to the Multi-Agency Early Intervention Team (MAT), to access ‘family support’ services. An early intervention social worker was appropriately allocated to the family. A number of services were provided and meetings were held. However, these meetings were inconsistent and did not include all the services working with the family. This inhibited both information sharing, and discussion of risk. An emphasis on unmet needs, rather than risks, in these interventions and meetings, resulted in assessments characterised by narrative accounts of family functioning, and meetings that focussed on the provision of more services, not on the risks posed to the children. The reason for this focus was not entirely clear, although from data gathered it appeared these services fulfilled what they regarded to be their remit: of identifying unmet needs, and providing services to meet these needs. Their role in relation to the assessment of risk, was less clear. The childhood history of the parents, and their resulting unmet emotional needs, the lack of sustained change in the parenting of the children, and the evidence of risks to the children, were not sufficiently recognised as indicators of harm, or potential areas of harm. This appears to have been partly due to the difficulty that professionals had in gathering, and articulating, the cumulative impact of the children’s experiences, and ‘naming’ this as neglect. This was compounded by the limited membership of the MAT meeting. This restricted membership limited the amount of information shared, and led to opportunities for multi-agency challenge being missed – this resulted in an overly optimistic view about the parent’s ability to provide care to the children in the future. This is explored further in Finding 1 Two weeks prior to the injury to Sibling 1 in August 2011, the Early Intervention Social Worker from the Multi-Agency Team (MAT) was preparing to close the case. There was no plan for future involvement, by the multi-agency team (MAT) or from specialist services, at this point. These decisions were made on the basis that the family did not meet the threshold for intervention at either the MAT threshold, or at a higher level of service provision. The decision was not challenged by managers, within this service, or by multi-agency partners. The issue of multi-agency ownership is explored further in Finding 2. Phase 2- Professional response following injury to Sibling 1: August 2011 - November 2011 In August 2011, Sibling 1 was observed to have bruising to her eye and this was referred to the Children and Young People’s Service. The initial investigation and core assessment were good. There was good partnership working between the respective agencies. A child protection medical was held promptly and the core assessment, completed by the Social Worker, was of a high standard. There was a delay in the timing of the Initial Child Protection Case Conference (ICPCC). It is unclear what led to this delay. Delaying child protection conferences increases risks to children and is contrary to procedural guidance8. It is the view of the Review Team that information, shared at the ICPCC, suggested that the short and long term risks to the children were sufficient to progress to a more robust level of intervention, and that a decision should have been taken to seek legal advice. Pursuing this course of action would have set a clearer framework, and timeframe, within in which services could have been provided. In the event, legal advice did not form part of the child protection plan- this falls below best practice standards. The Review Team explored the reasons why legal advice was not sought, either when the social work 8 The London Child Protection Procedures: 2010 10 manager signed off the core assessment, or at the ICPCC. It was not possible to ascertain a definitive reason for this. This is discussed further in Finding 2. Phase 3 – Longer term work with the family November 2011-December 2012 Functioning of child protection conferences and core groups.9 The children in the family were the subject of child protection plans from Child I’s birth, in November 2011, until Child I’s death, in July 2013. Although child protection conferences and core group meetings were generally held within required timeframes, there were no separate pre-birth assessments, or conferences, held on the new infants. Instead, discussions about risk to Child I and Sibling 3 took place alongside the discussions on risk to the other children in the family. This had a detrimental impact on the planning for all the children – the specific needs of the new infants were not considered, nor the critical nature of the increased risks posed by the growth of the family – this was contrary to procedures. The plans and the membership of the conferences and core group meetings remained largely constant from the Initial Child Protection Case Conference (ICPCC), and throughout the period the children were the subject of child protection plans. This was despite the changing circumstances in the family that included the birth of a fourth child (Sibling 3), and a number of incidents of harm to the children. Multi-agency staff, providing services to Child I and to siblings 2 and 3, were largely unrepresented. Key professionals, who could have provided first-hand accounts of their work with the family, either did not attend, sent a substitute or were not invited. This restricted the range and quality of information shared, and led to plans that did not respond adequately to changes within the family. The reasons for this are discussed further in Finding 4. Professionals involved at this time felt Mother was doing her best to care for the children. She was noted to make efforts to keep the house in a reasonable state of cleanliness and order, to have sufficient food in the house, to ensure the children attended school and children’s centres, and kept various appointments. Professionals noted many occasions, when both mother and father showed their love and affection for their children. However, the onus of professional intervention was disproportionately slanted towards the provision of more and more support services. Critical aspects of plans, made at the child protection conferences aimed at protecting the children from harm, were not implemented in a number of areas. For example, child protection conferences repeatedly made recommendations for a specialist parenting assessment, and there appeared to be a view within the group that an adequate response could not be provided to the family until this assessment had been conducted. Requests to fund this assessment were declined. In the absence of this assessment, the multi-agency team became ‘stuck’. There were opportunities to challenge the position that had been reached, but these opportunities were not utilized. The conference chair, the multi-agency team and their respective managers, neither effectively challenged this lack of ‘specialist assessment’, nor made a decision to move on without it. A state of 9 Core Groups are the multi-agency team who have responsibility for implementing the child protection plan. The Case Group, referred to in this report, is made up of all front line practitioners who had involvement with the family, only a small number of these professionals were members of the Core Group. 11 ‘stalemate’ persisted for a significant period of time. The functioning of core groups and child protection conferences, and the lack of challenge of decisions, is explored further in Findings 2 and 4. Assessment of neglect and response During the review period, difficulties in understanding the concept of neglect manifested in a number of ways, across the multi-agency network. This included difficulties in: - Understanding what neglect meant to professionals representing different expertise/specialisms. - Articulating and framing professional observations/concerns, in a way that supported the assessment of risk. - Little consideration of the cumulative impact of neglect. - Lack of decisive action in response to concerns. - A tolerance of drift. The children’s delayed development was indicative of neglect, there was evidence of: - Unmet emotional needs in the eldest children. - Lack of supervision of all the children, leading to a number of injuries. - Lack of proper care of the children’s medical needs. - Developmental delay seen in all the children. - A home environment where conflict and anger was present. Overall, professional interventions were characterised by a superficial response to the presenting issues. The needs of the parents and the children were viewed in isolation, and services were provided to address each of the presenting needs. These presenting issues/needs were symptomatic of neglect, yet whilst many of the interventions dealt with the symptoms, the whole picture was not brought together by any of the agencies, either individually or collectively. None of the services effectively dealt with what was driving the neglect, or put another way, the causes of neglect. Judgments about progress were predicated on mother’s ability to access the services offered, and the children’s response to the services. These judgments were made on the basis of the ‘here and now’ evidence, not on the overall picture. This resulted in a pattern of interventions and service provision which lacked an overall coherence. This had a direct impact on the way in which the parents understood what they needed to do, to bring about meaningful change in the parenting of the children. In cases of neglect, where children are suffering significant harm, the assessment of risk is highly complex. To address this, the cumulative picture must be viewed, the drivers and causes of the neglect must be identified and the impact on the individual children scrutinized. Only when this happens, can effective decisions be made. It was the view of the Review Team that, had information been effectively shared and analyzed within a suitable neglect framework, there was sufficient knowledge within the multi-agency group, to obtain a clear picture of parenting capacity, and of the consequent need to place the case within legal proceedings. The absence of support provided through the use of appropriate assessment frameworks/guidance/tools inhibited professionals in their work. The underlying difficulties in conceptualizing and assessing neglect are explored further in Finding 1. 12 Ownership The data gathered in this review suggested that various professionals rarely offered an opinion, in a way that influenced how risk was assessed or how safeguarding decisions were made. Interagency work was marked by an absence of professionals taking responsibility to ensure their professional observations, and opinions, were given due weight in influencing the safeguarding of the children. During the course of this SCR professionals spoke about the risks to the children, but there were inconsistencies in how this was recorded in the case records, and in discussions at the child protection conferences, core group meetings and in the child protection (s47) investigations. It was the view of the Review Team, this indicated a reluctance to take full ownership of the decision making in relation to risk. This led to risk assessment, and decisions made in response to evidence of risk, being incident driven and left largely in the hands of the social worker and case conference chair. This is explored further in Findings 2 and 5. Supervision and challenge The workings of the multi-agency team lacked effective management, leadership and supervision. This was replicated across each of the agencies represented. There was little data to suggest that a significant number of key professionals, from across the multi-agency group, received effective supervision. There was no evidence found to suggest that an overview of the work was provided, within or across the different agencies. Instead, each agency proceeded along their own individual path. Opportunities to take an overview are provided within existing processes, such as through supervision and multi-agency meetings. Case conferences are chaired by a members of staff who do not provide line management to the multi-agency group. They are well placed to facilitate how the multi-agency group view the ‘bigger picture’, but this did not happen in this case. Managers in the Children and Young People’s Service were noted to provide comment on the case, but provided no challenge to the status quo. An existing multi-agency Lambeth Safeguarding Children Board protocol that outlines the need to work jointly with adult services to safeguard children, where parents have learning difficulties, was not followed. The lack of compliance, with this protocol, was not questioned. There was no evidence to suggest that any system or process had been put in place, to facilitate compliance with this protocol. A protocol in place in the CYPS, which ensures senior management review of children who are the subject of child protection plans for eighteen months, was initiated but was not concluded. Hence, an opportunity for senior management overview, at this critical juncture, was missed. The Review Team established the reason this protocol was not followed was due to a decision to change this protocol, at the time this case was referred for senior management review. This resulted in a vacuum, in which no additional oversight of the case was provided. There was a persistent absence of effective challenge by safeguarding partners. This absence of respective multi-agency systems fulfilling their responsibilities, to provide intra and inter-agency scrutiny and challenge, played a significant part in the way in which the case drifted. This is explored further in Findings 2, 4 and 5. 13 Provision of services There is an excellent range of family support services available in Lambeth. The wide range of services provided to the family included specialist health visiting, a community outreach worker, home start, a number of services from two children’s centers, enhanced midwifery support, a health early intervention worker, and enhanced support from a school. Many of these services were excellent in addressing the individual developmental needs of the children. It was clear to the Review Team that, overall, the quality of many services is of a high standard. In addition, there were many examples of excellent professional practice, and a clear dedication to meeting the children’s needs. However, viewed holistically, and with the benefit of hindsight, it was clear to the Review Team that, overall, the multi-agency provision was confused. Many services did not know that another service was involved, and a number of services were duplicated. There were assumptions made about the nature of the services being provided- this left gaps in service provision. This was particularly noted in relation to the absence of any coherent multi-agency plan/action to prevent accidents within the home. This is explored further in Finding 2. Balancing the needs of the parents with risks to the children Throughout the period under review, both parents were frequently observed to be hostile and aggressive, and, in a number of areas, resistant to change. Many professionals worked very hard to engage the parents, in order to access the family home, or to ensure the children received services outside the family home. Observations of parental behaviour were described, but not analysed or articulated explicitly in a way that contributed to a professional opinion of risk. The emotional needs of the parents dominated much of the work of the multi-agency group. Parental behavior frequently disrupted the functioning of meetings and the implementation of plans. When challenged, father would often become verbally abusive and threatening, particularly to a number of social workers. This meant that social workers often felt unable to challenge his behaviour for fear of reprisal, and worked hard to engage with father and to avert his rage. These emotional needs of the parents eclipsed the needs of the children- this was not sufficiently recognised or acted upon. This is discussed further in Finding 6 Hearing the voice of the child During the course of this review it was difficult to gain a picture of Child I and his siblings. Their personalities, their likes and dislikes and their relationships, were largely unrepresented in the data gathered. There were good attempts by social workers to work directly with Sibling 1, in order to elicit her voice. However, during this work, Sibling 1 was found to be reticent. There was information available to suggest that Sibling 1 was silenced by the actions and words of her parents, but this was given insufficient attention. Due to the age, and communication needs, of the other children in the family, direct work to elicit their voices through the spoken word was not possible. There was a range of information available that should have enabled professionals to interpret the children’s voices. Observations, detailed in social work reports, revealed the children would seem ‘oblivious’ to the anger and hostility of the parents, and 14 maternal family members, and to exist ‘as if they were in their own bubble’. These were good examples of the children being observed at home that provided opportunities to gain important insights into their worlds. Other professionals noted their observations during parent-child interaction, or through what they saw displayed in the children’s behaviour, but few saw the world through the child’s eyes. This left the voices of the children unrepresented in the evaluation of risk, and in the provision of services. This is explored further in findings 3 and 6. Compliance with procedures The four children in the family were suffering from harm associated with neglectful parenting. However, professional practice showed a seemingly contradictory pattern in which professionals placed significant emphasis on investigating and ‘proving’ some physical injuries, at the expense of considering numerous other indicators of neglect. There were a number of bruises observed on the children, and a number of concerns were identified that provided medical evidence of neglect. There were two occasions when concerns were investigated (under s47 of the Children Act 1989), triggered by concerns about physical injury to the children. However, there were also occasions when concerns were not the subject of multi-agency investigation under the required procedural framework10. These concerns included the significant weight loss experienced by Sibling 3, a significant finger injury to Sibling 3, a burn on Sibling 1, and bruises seen on Sibling 2 and Child I. The lack of investigation of these concerns meant that information about the injuries either was not shared, or, when it was shared, it was not given sufficient weight in the consideration of risk. This is discussed further in findings 2 and 5. Balancing risks and strengths The child protection conferences, and the assessments of the family, identified the strengths in the family. This is expected safeguarding practice. However, in this case perceived strengths were given undue weight in comparison to risks. Considerable emphasis was placed on the support provided by members of the extended (maternal) family, and this support was cited as a strength throughout the period of time the children were the subject of child protection plans. There was sufficient information available to suggest these strengths offered false reassurances, and posed additional risks to the children. This was not fully acknowledged, or understood, by the multi-agency group. This is explored further in the additional learning. Parental learning difficulties The learning difficulties of the parents were “obvious” to the multi-agency group. These difficulties were not sufficiently understood in order to inform risk assessment and service provision. Father had been assessed by the Children’s Looked after Mental Health Service (CLAMHS) as a teenager, when it was concluded he was functioning at half his chronological age. In terms of his future, the assessment concluded: “we would not expect him to ever manage his daily tasks fully independently”. Mother’s presentation suggested to professionals that she had a learning difficulty, and it was understood that 10 The London Child Protection Procedures 2010 15 she had been the subject of a statement of special educational needs (SEN), when at school. On many occasions, father was observed to be in the sole care of the children at home. Practitioners believed, and on occasions observed that, whilst they were in his care, he did not provide adequate supervision to the children. He was often pre-occupied with loud and violent video games, and seemed ‘oblivious’ to the children’s emotional needs. Father rarely engaged with the services provided to the children, he did not adequately feature in assessments, aimed at understanding parental roles, or in plans and services put in place to improve parental capacity. When assessing the care the children were being provided with, and when targeting interventions, the assumed learning difficulties of the parents were responded to sympathetically. However, the way in which these difficulties impacted on the parenting of the children was not given sufficient attention. There was no consideration given to obtaining learning disability support services for the parents in their own right. The existing Lambeth Safeguarding Children Board protocol (September 2010), is very clear about the joint work that is required between adults and children’s services. Namely, that individuals who have a learning difficulty and are parents are entitled to a services from Adult Social Care learning disability services, and should be referred by children’s services. This protocol was not followed, and the need to make a referral to, and work with, adults’ services was not identified by any members of the multi-agency group, or their managers. Failure to follow the required protocol had the effect of silencing the voices of both the parents and the children. Written agreements, minutes and assessments, neither took proper account of parental learning difficulties, nor provided this documentation in a form that would have permitted parental understanding. The experiences of the parents, in being involved in the complexities of the child protection processes, were not understood, and as a result the support provided to the parents in these processes, whilst well-meaning, was ill-informed. The needs and experiences of the children, living with parents who had learning difficulties, were unknown. This is explored further in Finding 3. Written agreements Written agreements were used in response to safeguarding concerns, to supplement the protection planning. These written agreements were put in place in order to provide the Local Authority with parental assurances that the maternal grandfather would be supervised in his contact with the children, and that the maternal grandmother would stay with the family to support the early care of Child I. These agreements were not shared with a significant number of multi-agency group members. Both agreements were immediately, and consistently, breached by the parents. There was no action taken in response to these breaches, and the written agreements remained unchanged. At best these agreements were benign: they provided no added protection to the children. At worst, they served to undermine the protection of the children by providing a false sense of security. This is explored further in Finding 7. 16 Phase 4- Professional response to Sibling 3’s ‘failure to thrive’: December 2012 - May 2013 Minutes from the child protection conferences, recordings on file, and reports from the Case Group, suggested there were a number of assumptions made by the multi-agency group. These assumptions were not adequately articulated or assessed. A number of these were held onto, regardless of information available to suggest the assumptions were based on a false premise. This included an assumption that the children’s basic care needs were being met. There were times when the parents were not able to meet the children’s basic care needs. When Sibling 3 was seen by the family GP for his 8 week developmental check, he was found to have lost weight and was below his birth weight. The GP, and members of the child protection conference, assumed that his weight was being measured, and plotted, by health professionals in the community. This was a reasonable, but incorrect, assumption. Proper management of Sibling 3’s weight did not happen, and fell short of expected standards.11 Medical investigation concluded there was no medical reason for this loss of weight. Implicit in this conclusion, and in the actions taken by the GP, was that Sibling 3 was not being fed an adequate amount of milk. The loss of weight was reported to Children’s Social Care (CSC), but there was no multi-agency child protection response to this incident. Members of the Review Team expressed significant concern about this loss of weight, and the potential dangers to Sibling 3. It was the view of the Review Team this was evidence that the neglectful parenting, Sibling 3 was receiving, could have serious consequences. This critical safeguarding incident should have led to an immediate investigation under s47, a strategy meeting and, in the view of the Review Team, Sibling 3 should have been the subject of urgent paediatric review in hospital. This would have allowed a more thorough health assessment to identify underlying causes, and a more robust multiagency review of the neglect threshold. Instead, there was no s47 investigation and no strategy meeting. The child protection plan remained unchanged. This is explored further in Finding 5. At a Review Child Protection Case Conference (RCPCC), in May 2013, a recommendation was made to seek legal advice, with the view to place the case within legal proceedings. This recommendation was not made in response to Sibling 3’s failure to thrive, it was made in order to achieve funding for a specialist assessment. The recommendation was not acted upon with sufficient speed, and the case continued along the same path. This is explored further in Finding 2 and in the Additional Learning. Family Perspectives The perspectives of Child I’s parents were gained during a meeting involving the Lead Reviewers, both mother and father were present. The purpose of the meeting was to gain an understanding of parental experiences. This was not an investigatory interview, in that it was not an opportunity to establish fact or to challenge parental perspectives. The meeting was held in an attempt to understand how mother and father experienced the services that were provided, and to see this period of time through their eyes. The following is a summary of this meeting: 11 The Review Team attempted to understand what lay behind the reason Sibling 3’s weight was not the subject of required monitoring standards. A definitive reason could not be established. 17 At the start of the meeting, both Mother and Father reported that they did not understand what they needed to do to change the way in which they provided care to their children. Mother: “I just did not know what I was supposed to be doing”. This remained a theme throughout the meeting. When Mother was asked how professionals viewed father’s role in the family, she replied: “Social Services wanted me to leave father with the kids more often…….. That was their solution to make him do more”. Mother went on to describe the parenting routines within the household that included the different responsibilities for bathing the children: “(Name of father) would bath the boys and I would bath the girls….. (Name of father) would help the girls to put on their pyjamas after their bath”. The range of information, provided by the parents, suggested that the role of father, in the parenting of the children, had been critical in a family where there were 4 small children. The parents spoke about not getting the help they needed and of feeling let down by the agencies, and a number of professionals, providing support to them. When asked what support they felt they had needed, mother talked about needing help with the children’s routines and with parenting skills. She spoke about waiting for support from an organization (which she named), but said that this had not been provided. She spoke about the kind of support she would have received at home, had the funding for this help been agreed. Whilst the parents were positive about a number of professionals, they felt angered and frustrated by others. When mother was asked about the things she would have wanted to change, about the services she received, she answered: “Don’t talk down to me, talk to me as an adult instead of talking to me as if I am a child (I hated them for that)”.When speaking about the meetings she attended (core groups and child protection conferences), she talked about how difficult she had found these meetings. “I felt ambushed …I never saw any of the reports before the conference……people said things at the meeting that they had not told me about before…….I could not read the reports or the minutes. It was observed by the Lead Reviewers that during these discussions mother appeared to be demonstrating her frustrations in being within a process that she experienced as on one hand patronising, and on the other as showing a disregard for her needs. The Lead Reviewers noted mother seemed to have a slight speech impediment. Mother was asked if she had any difficulties with her hearing. She stated that she had, and described receiving treatment as a young child for “a hole in my ear drum”. The Lead Reviewers subsequently confirmed that mother had a glue ear and repair of a ruptured ear drum in childhood, and wondered whether this had affected her speech development. Mother described problems with her hearing, particularly in hearing someone who is placed some distance from her. She demonstrated the distance at which she found it difficult to hear, and showed how near somebody would need to be in order to hear them. The Review Team were left wondering whether this would have had an impact on her engagement in meetings, particularly case conferences, where members sit some distance away from each other in a formal setting. It was concluded that the problems mother identified with her hearing, combined with her learning difficulties, would have placed additional strain on mother, in attending these meetings. Summary of Findings The Review Team has prioritised 7 findings for the LSCB to consider. They relate to five categories of underlying patterns. The reader will observe many of the findings are interlinked, this is the nature of the systemic patterning found within interacting/overlapping systems. 18 Findings Category Finding 1: There is an insufficient understanding across the multi-agency professionals of the concept of neglect, and how to understand and articulate the cumulative impact this has on the health and development of individual children. This results in children continuing to experience neglect, despite input from professionals from across all agencies. Multi-agency working in longer term work Finding 2: The lack of full multi-agency ownership of how children are safeguarded means that there is insufficient professional challenge and debate, compromising the quality of safeguarding work. Multi-agency working in longer term work Finding 3: The confused professional response to families where parents have learning difficulties has a detrimental impact on safeguarding work. Tools Finding 4: There is a lack of rigour in ensuring that child protection conferences and core group meetings are functioning effectively. Management Systems Finding 5: When children are already on a child protection plan, there is a tendency for additional concerns not to be investigated through the correct child protection process. The assumption is that this will be addressed at the next child protection conference or core group. Multi-agency working in response to incidents/crises Finding 6: Despite clear procedural guidance for working with families who are hostile and aggressive, such behaviour still tends to disrupt the effective functioning of the child protection process. The result is an adult focus that distracts professionals from identifying and responding to the risks to individual children. Family-Professional interactions Finding 7: There is a tendency to use written agreements to support child protection arrangements. The effectiveness of written agreements, as a tool to ensure parents do what is required of them, is questionable. Tools Additional learning is detailed in the final part of this section. Findings in detail This section represents the main learning from this case review for the LSCB and partner agencies. Each finding is set out in a way that illustrates: How does the issue feature in this particular case? How do we know it is not peculiar to this case? What can the Case Group and Review Team tell us about how this issue plays out in other similar cases/scenarios and/or ways that the pattern is embedded in usual practice? How prevalent is the pattern? What evidence have we gathered about how many cases are actually or potentially affected by the pattern? How widespread is the pattern? Is it found in a specific team, local area, district, county, region, national? What are the implications for the reliability of the multi-agency child protection system? 19 The evidence for the different ‘layers’ of the findings comes from the knowledge and experience of the Review Team and the Case Group, from the records relating to this case, and other relevant documentation and from relevant research evidence. Seven priority findings were chosen because they represented areas of practice which were significant in how this case was managed, but which also reflected wider patterns of practice and the systems which underpin that practice. The remainder of this section explores the 7 Findings. The Findings Finding 1: There is an insufficient understanding of the concept of neglect and how to understand and articulate the cumulative impact this has on the health and development of individual children. This results in children continuing to experience neglect, despite input from professionals from across all agencies. Placing this finding as the first finding of this serious case review reflects the important systemic implications of this issue in how children are safeguarded, both locally and nationally. The term ‘concept’, used in this finding, has been intentionally chosen by the Review Team to reflect the complex considerations required in safeguarding children from neglect. To a greater and lesser extent, this finding is echoed in a number of significant features detailed in other findings presented in this report, demonstrating the complexity of this safeguarding issue. How did this feature in this case? Throughout this case, it seemed that professionals struggled to articulate a professional opinion in a way that contributed to the assessment of risk. Professionals appeared to struggle to synthesize and make sense of knowledge, from across services and over time, to form a holistic picture of the neglect the children were experiencing. Each of the incidents/concerns were responded to separately, and considered in isolation, by different parts of the professional network, but their longer term cumulative impact was not assessed. Child I, and Siblings 1 and 2 were all observed to have developmental delay, both in terms of their motor development and their speech and language. This was believed to be as a result of the poor stimulation the children received at home. The package of intensive services, provided to each child, allowed these developmental needs to be progressed from what services unanimously agreed was a ‘low base’. There was little evidence to suggest these needs were met at home. The fact that progress was predicated on individual service provision, not on the parenting received by the children, was not given sufficient weight in the assessment of risk. Concern about the ability of parents to be aware of, and to meet, the emotional and behavioural needs of all the children, was identified by a wide range of professionals. Recordings of these observations were characterised by descriptive, episodic accounts. There were various observations, noted in the case records across agencies that questioned parental ability to provide adequate supervision in the home, to ensure the children were protected from 20 household hazards. A number of bruises were seen on the three youngest children and a burn was observed on Sibling 1, all of which were regarded as being caused by a lack of supervision at home. The home environment, and the injuries noted on the children, suggested that the parents did not understand the risks posed within a home where there are young children. This was illustrated in a home visit made by a SW, when a large mattress fell onto Sibling 2, parents did not attempt to remove the mattress and showed no concern about the dangers to the children. When professionals visited the family home, and observed potential hazards, these were largely brought to the attention of the parents. However, there was no effective overview of the ongoing risks or of the parents’ ability to anticipate them. On a number of occasions mother and father were noted to handle the children ‘roughly’. There were a number of incidents that were suggestive of poor hygiene, and there was a pattern of inconsistent administration of prescribed medical treatments. These incidents were either simply recorded, or dealt with as they arose, by separate parts of the multi-agency team. The meaning of these, in the context of neglect, was overlooked. When Sibling 2 was seen by the GP for a review of her eczema, the GP noted a number of bruises. She was concerned about these bruises and made a referral to the SW. The SW arranged a child protection medical. This medical concluded the bruising was likely to be accidental. However, the Paediatrician noted her concern about neglect of Sibling 2’s nappy rash and eczema, and expressed concerns about the supervision of Sibling 2. Information shared, by the GP and Paediatrician, also included concerns about mother’s ‘rough handling’ of Sibling 2 and questioned mother’s ability to adequately respond to Sibling 2’s emotional needs. The strategy discussion that followed, concluded the ‘concerns were not substantiated’, the basis of this decision was that the bruising was thought to be accidental. No further action was taken. These examples illustrate the way in which the whole picture was not brought together by the multi-agency network. Whilst there were core group meetings and case conferences these were marked by, what appeared to be, a lack of a framework about how to conceptualize what was being witnessed in the family. The use of concept is necessary to cognitive processes such as categorization, memory, decision making, learning and influence - all of which are necessary if neglect is to be understood. How do we know it is not peculiar to this case? When exploring with the Case Group how professionals assess and intervene in cases of neglect, it was apparent there was a lack of clarity and understanding about how neglect can be successfully assessed and measured, and a lack of awareness of the tools that are available in the assessment of neglect. It was equally unclear what menu of services are needed to make a difference to the experiences of children who are neglected. Case group members used the terminology of “neglect”, and gave examples of occasions when they observed evidence of how neglect can manifest. However, it was clear there existed no framework in which professionals were enabled to conceptualize this neglect. The Review Team explored whether, in Lambeth, there was access to specialist advisors. It was clear, there are no such advisors in relation to neglect. Case group members gave other case examples of children who are subject to a child protection plan under the category of neglect, where they are unclear how to work with the family in order to achieve required changes. They spoke of the high numbers of children who are the subject of a child protection 21 plan as a result of neglect, and of the length of time these children often spend subject to a child protection plan. Members of the Review Team and Case Group shared their experiences of working with neglect. Case group members spoke of how difficult it can be to articulate the evidence of neglect. They spoke of their frustrations in seeing the neglect of children, but of feeling ill equipped to know how to make the desired changes. There was a lack of clarity about when a case had met a threshold, requiring escalation to a higher level of intervention (such as a referral to Children’s Social Care), or in order for legal intervention to be achieved. Staff representing the CYPS spoke about the legal threshold for neglect being high and of this possibly influencing the thinking/mindset of front- line staff, when working with neglect. Members of the Review Team, with experience of providing supervision/management guidance in cases of neglect, spoke about these cases often not being prioritised for discussion by front-line staff during supervision. Overall, the response of the case group was characterised by both confusion and despondency. How prevalent/widespread is the pattern? Being able to respond effectively to cases of neglect is particularly important given the high frequency of these cases, both locally and nationally. Local data shows that, in June 2012, there were 320 children who were the subject of a child protection plan in Lambeth. Of these, 252 (78.75%) were the subject of a plan under the category of neglect. In June 2013, there were 334 children subject of a plan, of these 220 (65.87%) were the subject of a child protection plan for neglect. Data regarding duration shows that, in June 2012,102 children were the subject of a child protection plan for over 18 months. The available data does not break down these figures into category. However, based on the numbers of children subject to a plan as a result of neglect in June 2012, this data would suggest that the majority of these cases were the subject of a plan, under the category of neglect, for over 18 months. This data supports the views of the Review Team and Case Group that neglect cases form a significant proportion of child protection cases in Lambeth. This pattern is also borne out nationally. National figures for England (DfE 2012- 2013) show that the number of children subject to child protection plans under the category of neglect, far outnumber the numbers of children categorized as suffering from other forms of abuse. At the end of March 2013, of the 52,680 children subject to a plan, 21,600(41%) were the subject of a plan as a result of neglect. The difficulty in maintaining a focus on risk, in neglect cases, has also been shown to be a national, as well as a local issue. Recent evidence from SCR’s highlights the risks to children, who are the subject of a child protection plans, under the category of neglect: For 59 children, a CP neglect plan was in place at the time of their death or serious harm, for the other 42 children the plan had been discontinued. This shows that some children living with substantiated neglect may be at risk of death, not just long-term developmental damage….Neglect was therefore by far the most frequent category of child protection plan in our serious case review sample, as it is nationally”. This research goes on to identify the correlation between neglect cases and drift, and the difficulties presented to professionals in assessing and effectively intervening in such cases. 22 “The possibility that in a very small minority of cases neglect will be fatal, or cause grave harm, should be part of a practitioner’s mind-set. This is not to be alarmist, nor to suggest predicting or presuming that where neglect is found the child is at risk of death. Rather, practitioners, managers, policy makers and decision makers should be discouraged from minimizing or downgrading the harm that can come from neglect and discouraged from allowing neglect cases to drift”.12 What are the implications for the reliability of the multi-agency child protection system? This finding raises important questions about how children are safeguarded from neglect, and the challenges presented by the complex and cumulative nature of neglect. The experiences of practitioners in this case suggest that additional support is required to help professionals to keep track of, and make sense of, the ‘whole picture’ emerging in neglect cases – often over long periods of time, and across a range of different agencies. If professionals are not equipped with the necessary knowledge, tools, guidance, framework and support, they will struggle to achieve the required changes in families and the safeguarding of children will be compromised. It is therefore vital that multi-agency safeguarding partners are sufficiently equipped to safeguard children in this complex area of work. Finding 1: There is an insufficient understanding of the concept of neglect and how to understand and articulate the cumulative impact this has on the health and development of individual children. This results in children continuing to experience neglect, despite input from professionals from across all agencies. Neglect is a complex safeguarding issue that requires a complex response. Unlike other forms of abuse neglect may not be easily observable in a single incident. Rather, numerous pieces of evidence must be pieced together over time, and across agencies, in order to gain a holistic picture. This case has suggested that practitioners in Lambeth do not currently have access to the tools and support that would facilitate this way of working. Issues for the Board and member agencies to consider: What are the ways in which the children’s workforce can be supported in identifying, assessing and intervening in cases of neglect including how the cumulative impact is assessed and measured? What tools can be used to promote the conceptualisation of, and work with, neglect? How will LSCB sufficiently equip practitioners and services in working with neglect in line with their role, remit and responsibilities? What services are available that can promote sustained change in parenting and successfully safeguard children? 12 Brandon et al 2013: Neglect and Serious Case Reviews 23 How are complex cases, where children have been the subject of a child protection plan for a prolonged period of time for neglect, effectively reviewed and monitored by multi-agency partners? How will LSCB know there have been improvements in these areas? Finding 2: The lack of full multi-agency ownership of how children are safeguarded means that there is insufficient professional challenge and debate, compromising the quality of safeguarding work. “Safeguarding is everyone’s responsibility” lies at the heart of statutory guidance, and practice, dictating how children are safeguarded. Working Together 2013, The Munro Review of Child Protection13, and various SCRs, research and associated literature, repeat the mantra that children can only be safeguarded within a multi-agency partnership characterised by shared responsibility. The term ‘ownership’ is not used within relevant statutory guidance. It is used in this finding to define the collective responsibilities of the whole safeguarding partnership. If ownership is present, this is characterised by shared responsibility for assessments, analysis, plans and outcomes, and features professional challenge and debate across multi-agency partners, across systems and processes, and across management hierarchies. The mechanisms by which such shared ownership is exercised in practice is through the interventions made by agencies, multi-agency meetings (such as child protection conferences, core groups and strategy meetings), internal agency meetings, through information sharing, through guidance provided by senior members of an organisation, and through supervision. “Safeguarding is everyone’s responsibility: for services to be effective each professional and organization should play their full part”. 14 This case has suggested that the lead role of Local Authorities, as defined in statutory guidance to co-ordinate the protection of children, has been interpreted to mean that, in practice, the Local Authority owns the responsibility to protect children from harm, rather than this being a shared responsibility. How did this feature in this case? Inherent within all the findings presented in this report is a question that relates to how multi-agency ‘ownership’ is played out in practice. There are a number of examples in this case, across multi-agency partners and within the multi-agency group, illustrating the absence of the defining features of ownership. 13 Professor Eileen Munro 2011: The Munro Review of child protection: Final Report A child- centred system 14 Working Together to Safeguard Children: HMG 2013 24 In addition, there was data found suggesting that, in practice, the assessment of risk, analysis of the risks and decision making, was believed to rest solely with the Children and Young People’s Service (CYPS), in the form of the allocated social worker, rather than a shared responsibility. Intra and interagency ownership. Inter-agency ownership, and intra-agency ownership, is critical, if children are to be protected from harm. Inter-agency ownership is characterised by multi-agency teams working together to jointly share information, assess risk, co-ordinate and provide services, within a partnership that demonstrates joint ownership and accountability for a child’s safety and their outcomes. Intra-agency ownership is characterised by how individual members and teams, within organisations, work internally to prioritise, work in unison, and share accountability, to ensure children are protected from harm and achieve positive outcomes. Intra- agency ownership: In the child protection plans made for the children, the need for a specialist assessment formed a central part of the plans. This recommendation was made at the Initial Child Protection Case Conference (ICPCC) in November 2011. This recommendation was discussed at each subsequent case conference and core group meeting, and carried through the child protection plans for all the children under the timeline under review. This recommendation was never implemented. On a number of occasions, the Social Worker (SW) approached her line manager (deputy team manager), spoke to the conference chair, and to a variety of senior officers up the management line in the CYPS (including the team manager, head of service, and relevant assistant directors), to request funding for this assessment. These discussions persisted throughout the period of time the children were subject to child protection plans. No agreement was ever given, to fund this assessment. At the last case conference, in May 2013, a recommendation was made to seek legal advice. The reason given for this recommendation was that, if the case was in legal proceedings, funding for an assessment would then be released. In reality, the issue about a specialist assessment was secondary to the need to place this case in a legal framework. There is an existing CYPS protocol that details how services provided to children in need, who have been the subject of child protection plans for eighteen months, will be reviewed by senior managers. Close to the critical eighteen month point, in line with this protocol, the case was referred by senior managers to the next senior management level. Due to a proposed, but unresolved, proposal to change this protocol, the case was not the subject of senior management review. As a result, no guidance was provided to either the social worker or the chair. These examples illustrate the lack of intra-agency ownership, and accountability, for the front line practice in this case. Despite the involvement of the independent chair, and a significant number of managers within the CYPS, no management guidance or constructive challenge was provided to the SW or to the chair, to unlock the stalemate that persisted. The case drifted in this stalemate for one year and eight months. Interagency ownership: There were six child protection conferences and thirteen core group meetings during the period under review. These multi-agency forums provided a further opportunity to challenge the drift in this case. No effective challenge was raised by the multi-agency group and no escalation processes were used. 25 Opportunities to challenge were presented through the supervision provided to the multi- agency front line practitioners, by their line managers/specialist child protection leads. There was no evidence found to indicate these practitioners were being provided with supervisory guidance that effectively challenged the way in which the children were being safeguarded. A further example, of how the lack of ownership featured in this case, relates to the contribution of professional opinion in assessment, analysis and decision making. The lack of ownership, demonstrated in how professionals shared their opinions about risk, is illustrated in the examples given in Findings 1 and 5, where professional opinions, in relation to evidence of neglect found during the medical of Sibling 2 and inherent within the concerns about Sibling 3’s failure to thrive, were not the subject of sufficient focus, analysis, scrutiny and debate. The absence of effective challenge by the respective medical professionals led to the gravity of these matters, and the importance they had in contributing to an assessment of risk, being lost. These examples illustrate how the multi-agency safeguarding practice, including inter-agency and intra-agency challenge, the sharing of information and professional opinion, and in the provision of timely services, was marked by an absence of inter-agency ownership, and accountability, for how the children were safeguarded. How do we know it is not peculiar to this case? The view of a significant number of case group members, from agencies other than children’s social care, was that the assessment of risk and decision making in safeguarding children was not something they were party to or had influence over. Case group members were confident about the assessment of risk within the confines of their own agency/area of specialism, but not when it came to how children are safeguarded by the multi-agency team. “…..It is left to CSC to decide (because in a way the buck stops with them)”.Case Group Member During individual conversations with case group members, and during the wider discussions with the Case Group at case group meetings, frequent references were made to the assumption that “as Children’s Social Care are the lead agency, then responsibility for children subject to CP plans rests with them” and further that: “if a child is the subject of a child protection plan, we all (other safeguarding partners) will stand back and breathe a sigh of relief.” Members spoke of reporting concerns about children to Children’s Social Care and, in effect, leaving the decision about next steps in hands of the Social Worker. Members of the Case Group spoke about the child protection process, and the position of the Case Conference Chair, citing the Chair as the person with responsibility and authority to offer challenge. In describing this, case group members were not able to see how they themselves possessed the responsibility, and necessary authority, to offer challenge themselves. On further discussion about this aspect, for a number of case group members, it was clear they had not been given a previous opportunity to consider this issue, both in terms of how they might assume the responsibility for challenging others, or to reflect on how this might be done, including through escalation. Members of the Case Group spoke about the supervision they received in their safeguarding work. It was clear, from their contributions, that for some there was no formal structure within which they could access such supervision. For others, they were unclear who would be providing this supervision, and how they could access this. Case group members, who had a formal supervision structure in place, were invited to discuss the supervision they received. These case group members spoke about the lack 26 of frequency in this supervision. Some experienced an inconsistency in professional/practice supervision/supervisors. A number spoke about the absence of reflective supervision, in their current safeguarding work, and demonstrated a desire to receive this kind of management support. Concern, both about the supervision provided to staff within the CYPS, and the lack of effective inter and intra-agency challenge and debate, has been identified in a recent SCR in Lambeth. How widespread is the pattern? There are many examples in serious case reviews, research and associated literature, of how the lack of effective checks and balances, within multi-agency safeguarding systems and mechanisms, allow for individual and group fallibility to affect judgement and decision making in how children are safeguarded. The absence of challenge, reflective supervision and effective sharing of professional opinion, inhibits multi-agency risk assessment, decision making and action. It is the view of the Review Team that this occurs within a landscape where shared ownership of how children are safeguarded is not put into practice. Research and serious case reviews often provide examples of how this lack of ownership plays out in practice. “A lack of an effectual response, particularly in those cases where the child had a child protection plan, may well have actually increased the risk to these children, since other agencies made their concerns known under the assumption that they would be dealt with, when in reality there was a lack of liaison between agencies, and no clear plan.” 15 “Findings from the Analysis of Serious Case Reviews also demonstrate that the problem of joint responsibility has not yet been fully resolved. For example, the ‘silo’ working mentality continues to be a repeated feature of cases which go seriously wrong. Achieving cultural change and getting agencies to work together is extremely challenging and requires cross-sector commitment.” 16 What are the implications for the reliability of the multi-agency child protection system? Statutory guidance and relevant procedures outline the responsibilities of safeguarding partners in the safeguarding of children, as detailed above. Responsibilities are overarching and apply to all safeguarding partners. Ensuring the correct balance between the leadership role of the local authority, compared to the shared responsibility by partners, is a challenge for every local authority. This case has suggested that, in Lambeth, despite the existence of multi-agency processes and procedures, there is a strong emphasis amongst partner agencies on the fact that the final responsibility for safeguarding lies with children’s social care. This appears to lead to a lack of ownership by other agencies, evident in a lack of multi-agency challenge of social care decisions, and a lack of contribution of professional opinion in assessment, analysis and decision-making. 15 Brandon et al: Neglect and Serious Case Reviews 2013 16 Professor Eileen Munro: The Munro Review of child protection: Final Report A child- centred system 2011 27 Shared ownership and responsibility between agencies and professionals that have different roles and expertise, and at different stages of intervention (including universal, targeted and specialist services), is required if children are to be protected from harm and their welfare promoted. To invest in one service the sole responsibility for owning how children are safeguarded, is unsafe. No one system, process, agency, individual or team can possibly create safety. “Children are best protected when professionals are clear about what is required of them individually, and how they need to work together. Ultimately, effective safeguarding of children can only be achieved by putting children at the centre of the system, and by every individual and agency playing their full part, working together to meet the needs of our most vulnerable children”.17 Finding 2: The lack of full multi-agency ownership of how children are safeguarded means that there is insufficient professional challenge and debate, compromising the quality of safeguarding work. “Safeguarding is everyone’s responsibility” is a rhetorical statement unless it is evidenced in the ownership of how children are safeguarded at the front line, and through management hierarchies. The challenge of safeguarding children is, as this report has demonstrated, multi-faceted. It presents challenges to individuals, professionals, multi-agency teams, processes, systems and governance arrangements. In this landscape, a safe system is predicated on partnerships characterised by ownership, reflective supervision, professional challenge and debate across and within the safeguarding partnerships. It is essential that these critical features become a reality in how children are safeguarded. In order to achieve this, there must be constructive relationships between individual practitioners, and their respective agencies, characterised by an open dialogue about how to ensure the correct balance is struck between the leadership role of the local authority, compared to the shared responsibility by partners in safeguarding work. Unless this takes place, front line practice, demonstrating this shared ownership and responsibility, will continue to be compromised. Issues for the Board and member agencies to consider: Does LSCB recognise this lack of shared ownership in any other safeguarding areas/arenas? How effective is LSCB in modelling shared ownership? How are partnerships defined and advanced at a senior level, and how are such partnerships echoed throughout organisations and seen in the services provided at the front line? How can the LSCB promote dialogue and debate about what shared responsibility for safeguarding, led by the local authority, looks like in practice, to ensure that ownership is 17 Professor Eileen Munro: The Munro Review of child protection: Final Report A child- centred system 2011 28 shared as fully as possible? How does LSCB evaluate how the shared responsibility to safeguard children is put into practice? How will LSCB nurture a safeguarding culture where professionals express their opinions in a way that contributes to an assessment of risk? What steps can be taken to cultivate healthy challenge and debate across management hierarchies, teams, services and systems? How will LSCB satisfy itself that sufficient rigour is being applied to reviewing children who are the subject of child protection plans for over 18 months? How will LSCB know that there have been improvements in these areas? Finding 3: The confused professional response to families where parents have learning difficulties, has a detrimental impact on safeguarding work. Parents with a learning disability may face particular challenges in the task of parenting. When there are concerns about children, and protective services are involved, adults with a learning disability may also need additional support to engage with these services. Lambeth Safeguarding Children Board recognised the need to guide adults’ and children’s services in this complex area of work and in response a protocol was put in place to govern the work. This was published on the LSCB website in September 201018. This protocol provides clear guidance to practitioners providing services to children and families on the process for referring to, and working with, Adult Learning Disability Services. There is an emphasis placed on referring adults, when additional support may be required for an adult whose children are involved in a child protection process. This case has suggested that this protocol is not followed, even when there is consensus amongst the professional group that a parent has a learning disability. This weakens the support provided to parents, and children, and contributes to a confused multi-agency response. How did this feature in this case? There were many professionals, from across a range of agencies, involved with this family over a period of many years. Throughout the involvement of professionals and services, it was widely assumed that both parents had a learning disability. In our conversations with the case group, frequent reference was made to parental learning disability, and examples given of the difficulties the parents appeared to have in comprehending what professionals were asking of them. 18 Safeguarding children of parents/carers with learning disabilities (LD). Protocol between learning disability services and children’s services: Lambeth Safeguarding Children Board Sept 2010 29 However, despite this widespread assumption, the extent of the parents’ difficulties, and how these difficulties impacted on their parenting capacity and response to service provision, was not assessed, or fully understood during the review period. No referral was made to Adult Learning Disability Services on behalf of either parent, and it did not appear that this option was considered by the multi-agency group at any stage. It is unclear why a referral was not considered. Father had been assessed by Adults’ Social Care Learning Disability services prior to the period under review, but found not to be eligible for services. However, this does not appear to have influenced practitioners’ thinking – indeed most of the practitioners involved with the family were not aware of this previous referral. Furthermore, a new referral was required, given that he was now a parent. It was unclear why the LSCB protocol was not known about or followed. It seemed that additional support to understand the parents’ learning disabilities, and tailor support accordingly, would have been beneficial both to the parents and the children in this family. Our conversations, both with the case group and parents, suggested that the family sometimes struggled to understand what was expected of them by professionals. “No one told us why the children were on a plan……. they said we were neglecting their needs but I did not know what this meant”. Mother This understandably led to distress and frustration for the parents, and a feeling that they were being criticised by professionals. For example, when we asked Mother if professionals had discussed accident prevention with her or Father she responded: “No they never did… they just kept criticising….. They told me that … (name of Sibling 3) needed to be allowed to crawl around the floor, as he was in a walker a lot, but when I let him do that and he had a bruise on his head, they criticized me for that”. Neither parent was able to read, but this did not seem to be taken in to account by professionals working with them. Mother expressed her frustration at being sent written conference reports, which she could not understand. There was also significant use of written agreements – this is discussed further in Finding 7. Having additional support from a specialist learning disability service could have supported professionals in understanding the needs of, and communicating with, the parents more effectively. The high level of vulnerability of the parents in their own right also meant that, at times, professional input and energy focused on them, to the exclusion of a focus on the children. The lack of an informed response to parental difficulty led to misunderstandings and confusions. Although a range of services were provided, a number of services were duplicated, such as parenting support. This was provided by three different agencies, at the same time, under the time line under review. None of the individuals, providing these services, knew what the other service was providing. There were assumptions made about the nature of the services being provided, as demonstrated in the assumptions made about how accident prevention was being discussed and effectively managed within the home. Again, the review team questioned whether seeking help from Adult Social Care services for the parents in their own right could have left the children’s services freer to focus on the needs of the children and led to a greater unity in the service provision. 30 How do we know it is not peculiar to this case? Discussions with members of the Review Team, and the Case Group, endorsed the view that these issues are not confined to this case alone. The LSCB protocol19 was published at a time when the early intervention teams were providing a service to the family, and remained in place during the timeline under review. It was clear in the discussions with the Case Group, and the Review Team, that this protocol was not known about, nor used as it was intended, across a range of families where parental learning difficulties are thought to be present. Case Group, and Review Team, members spoke about the ongoing and pervasive difficulties in achieving joined up working between adult and children’s services, across multi- agency partners. As a consequence, it was clear that members of the case group resigned themselves ‘to going it alone’, when working with parents who were believed to have learning difficulties and, other than securing funding for an external assessment of learning difficulties, they could not identify any other way in which they, or family members, could be supported. The Review Team learnt that, in response to these difficulties, a new process of case referral had been recently set up between children’s and adult services. It is early days in the planning and implementation of this process, hence at this point, the impact of this new process on this critical area of work is unknown. How widespread is the pattern? The difficulties encountered, in achieving joined up adult and children services, and the impact this has on safeguarding children, is detailed in a plethora of research and serious case reviews. There is also much written about parents with learning difficulties, and the overrepresentation of these parents in child protection processes: “Parents with learning disabilities are at a higher risk of becoming subject to child safeguarding procedures and are an overrepresented group in child protection conferences and court proceedings; it is estimated that between 15 to 22 per cent of parents involved in child protection conferences and care proceedings have a learning disability” Brandon et al. 2009 And the obstacles they face within these processes: “Parents with learning disabilities are a group affected by multiple disadvantages and experience a higher risk of not receiving the support they need”.20 “Parental learning disabilities are rarely highlighted in serious case reviews although our analysis of these reviews has shown that there are often indications that parents had learning problems which were not assessed or addressed”.21 19 Safeguarding children of parents/carers with learning disabilities (LD). Protocol between learning disability services and children’s services: Lambeth Safeguarding Children Board Sept 2010 20 Bauer: Investing in Advocacy Interventions for Parents with Learning Disabilities 2013 21 Brandon et al : New Learning from serious case reviews: a two year report for 2009-2011 31 The challenges faced by multi-agency practitioners, in providing services, is detailed in research and literature. This research suggests that service provision is often characterised by “a confused multi-agency response”22. What are the implications for the reliability of the multi-agency child protection system? Parents with a learning disability can face particular challenges in parenting and, where there are concerns about children, engaging with family support and child protective services. This is recognised in the LSCB’s protocol on safeguarding children of parents with learning disabilities. This protocol outlines as a key purpose: “To enable practitioners to provide joined up service responses to families where the needs of adults can impact upon the welfare of children”. A protocol alone will not support front-line practitioners to safeguard children, or ensure parents with learning difficulties are provided the support they require. However good a protocol, in the absence of a robust strategy of implementation, protocols alone have no value in the protection of children. This case has suggested that, when parents are thought to have a learning disability, family support and child protection services do not consider referring to adult learning disability services as a way of securing a better understanding of their needs, and obtaining additional support in order the strengthen the safeguarding of children. This means that parents are not benefiting from services which might be available to them in their own right, and to support them through the child protection process. It also means that children’s services are trying to ‘do it all’, potentially meaning that focus on the children is lost. Finding 3: The confused professional response to families where parents have learning difficulties, has a detrimental impact on safeguarding work. Lambeth SCB’s protocol on safeguarding children of parents with learning disabilities aims to promote referrals, as appropriate, from children’s services to the Learning Disability Team, and joined-up working thereafter. This case has suggested that there is a lack of awareness of this protocol, and a lack of mechanisms in place to facilitate this protocol being followed. This means that parents can lose out on support, the safeguarding of children is at risk of being compromised, and the existing multi-agency network does not benefit from the expertise and support provided by specialist learning disability teams. Issues for the Board and member agencies to consider: What actions have been taken by the Board to support how the LSCB Learning Disability protocol is implemented on the ground? What actions have LSCB taken to review the protocol and to evaluate impact on the lives of children and families? What more needs to be done to support implementation? 22 Mc Graw: What Works for Parents with learning difficulties?2000 32 How will the Board know that multi-agency early intervention services and specialist services are working in line with this protocol? Do LSCB know how many children, who are the subject of child protection plans, are living with parents who have learning difficulties? How will this be reviewed to ensure these families are receiving services in line with the existing protocol? How will the new process of case referral to the adults learning difficulties team be evaluated? Finding 4: There is a lack of rigour in ensuring child protection conferences and core group meetings are functioning effectively. Statutory guidance, contained within Working Together 2010 (and in the later edition in 2013), and The London Child Protection Procedures, outline the process and purpose of child protection case conferences, and core group meetings. The purpose of child protection conferences is; “to bring together and analyse relevant information and plan how best to safeguard and promote the welfare of the child and to make recommendations on how agencies work together to safeguard the child in the future”. Core groups have a responsibility to share information and to develop, and implement, the child protection plan. Child protection conferences provide an opportunity to scrutinise membership of the case conference and core group, and to examine how core groups are implementing the child protection plan. Decisions, about membership, rests with the chair of the case conference. In line with statutory guidance and procedure, decisions about attendance should be based on the need to ensure that the conference is in a position to fully consider, and understand, the individual needs of the children. Therefore membership should reflect the changing needs of the child, as the child grows and develops, and the changes in family circumstances. The stated ‘Reason for the Conference’, serves the purpose of succinctly outlining the risks that are present. It is referred to at the beginning of each child protection conference, thereby framing the subsequent conference discussions. It is recorded at the front of the child protection conference minutes, these minutes are distributed to the multi-agency group. This section of the conference minutes provides critical information, on which professionals often rely to inform their knowledge of the safeguarding risks, in the lives of children with whom they are having contact, in their day to day work. The London Child Protection Procedures provide guidance on holding pre-birth child protection conferences: “A pre-birth conference should be held where a child is to be born into a family or household that already has children who are subject of a child protection plan and should take place as soon as practical and at least ten weeks before the due date of delivery, so as to allow as much time as possible for planning support for the baby and family”. 33 This review has identified several issues that are impairing the effective functioning of child protection conferences and core groups: The lack of separate or parallel pre-birth conferences and the implications of this. Membership and attendance of multi-agency practitioners at child protection conferences and core group meetings. Lack of clarity in plans on the changes needed in the parenting of the children. The lack of importance placed on ‘The Reason for the Conference’. How did this feature in this case? The children were all subject to child protection plans from Child I’s birth, in November 2011, until Child I’s death, in July 2013. Child protection conferences, and core group meetings, were largely held within required timeframes. However, in a number of respects, the way in which the core groups and conferences operated was less than optimal. Pre-birth child protection conferences: During the investigation of the injury to Sibling 1, mother was known to be pregnant with Child I. Child I was born nine days before the Initial Child Protection Conference. There had been no pre-birth assessment and no pre-birth conference. Sibling 3 was born sometime later, and again there was no pre-birth assessment, the Child Protection Review Conference, on the other children, was brought forward. Discussions, about the new infants, were integrated into these conferences. Hence, discussions about risk and plans were ‘rolled up’ into the existing child protection conferences for the other siblings. This had a detrimental impact on the planning for all the children – the specific needs of the new siblings were not given sufficient consideration, nor the impact of increasing family size on the needs of the individual children or on their safety. Information sharing and membership at child protection conferences and core group meetings: Throughout the period the children were the subject of a child protection plan the plans, and the membership of the conferences and core group meetings, remained largely the same. This was despite the changing circumstances in the family that included the birth of a fourth child, and a number of incidents of harm to the children. The core groups were all held at Sibling 1’s school. They were either chaired by the social worker, or by a representative from the school. Multi-agency staff, providing services to Child I and siblings 2 and 3, were largely unrepresented at both the core group meetings, and child protection conferences. Key professionals, who had direct contact with Child I and siblings 2 and 3 and with their parents, either did not attend, sent a substitute, or were not invited. This was illustrated in the lack of attendance of health professionals, and staff from a children’s centre, who were seeing Sibling 2 on a daily basis. In the case of the latter, children’s centre staff were unaware Sibling 2 was the subject of a child protection plan. In the case of the former, professionals, across a range of health services including A&E, GP’s, midwifery, paediatricians and specialist services, were largely unrepresented, or where they were represented, this was through the health visitor, or occasionally through a representative from the service. Agencies did not question or challenge the absence of their multi-disciplinary partners. As a result, the conferences and core groups were not attended by the range of professionals, who could provide a first-hand account of their involvement with the family. This was particularly relevant when health information was discussed. During these times the chair, or other members of the core 34 group or conference, were left to interpret the meaning of the information. This resulted in the dilution of information, and important nuances that are so essential in cases of neglect being missed. The impact was illustrated in how father’s role in the family was considered. Father did not attend child protection conferences, or core group meetings, and was rarely seen outside the family home in a parenting capacity. He was seen on various occasions at home, providing care to Child I and to siblings 2 and 3. He was often seen by staff at the Children’s Centre, when he took and collected Sibling 2 from the Centre. At home, father was observed to be unable to pre-empt the needs of the children, or to show an awareness of the potential household hazards. The perspective of staff from the Children’s Centre, was that father took the responsibilities of taking and collecting Sibling 2 seriously. He was normally always on time, and showed kindness to Sibling 2. It was also evident, to these professionals, that he had limited ability to follow guidance, or instruction. He was described by a number of professionals, who visited the family home, as being ‘the fifth child in the family’. These voices were not reflected in the child protection conferences, or core group meetings. This had an impact on the range of information shared, this information was critical in understanding father’s role and in informing the plans. Implementation of Child Protection Plans: Case conference recommendations made, in relation to parenting capacity, included father as part of the child protection plan. This included the need for the core group to be clear about what needed to change in order for the children’s needs to be met. In the absence of information, or understanding, about father’s role and capacity, the core groups focused on the parenting capacity of mother, specifically in relation to Sibling 1. The discussions that followed, focused on the provision of services. Core group meetings did not adequately detail the changes required in mother’s or father’s parenting capacity, father’s role was largely absent from the plans detailed at both child protection conferences, and core group meetings. Reason for the child protection conference: The stated ‘reason for the child protection conference’, gave a full account of the original injury to Sibling 1, and referred to an assortment of other concerns. The way in which the information was presented, was characterised by a narrative account of family functioning. These accounts focused on the adults within the family. Neglect was not named, and there was little reference to the impact of this neglect on the individual children. This was repeated throughout the child protection conferences, on all the children, and was recorded within the minutes distributed. How do we know it is not peculiar to this case? Input from the Case Group, and Review Team, highlighted that a number of the practices observed, were common in Lambeth. For example, it is not unusual for pre-birth conferences to be integrated into a review case conference, held in respect to other children in the family. “It is common for discussions on the risks to children pre-birth to be included in a conference on the other children in the family and it is not clear that this is a separate pre-birth conference ……either in the conference itself or in the minutes”. Case Group Member. There was a divergence of opinion within the Review Team about whether this was typical in Lambeth. Holding pre-birth chid protection conferences in parallel to existing review child protection conferences was identified as ‘common practice’, although whether these were held as specifically delineated pre- 35 birth child protection conferences, or whether they were integrated into an existing child protection conference for other children in the family, was unclear. The experience of members of the Review Team, and Case Group, showed that scrutiny of case conference membership, and core group meetings, was not common practice. There was an assumption that whoever was named on the list of professionals to be invited, were the right professionals to be there. A member Case Group commented; “It can be the case that the membership of the child protection conference and core groups has not been thought through”. Members of the Review Team, and Case Group, recognised the absence of key health professionals, particularly GPs and those representing specialist services, such as consultant paediatricians, as a common feature of child protection conferences. They regarded the sending of a substitute or a report, in place of attending personally as a common, but necessary, solution to the demands of their busy working life. The LSCB Child Protection Report (‘Local Authority Data from Framework’) examined child protection data between October 2012 and December 2012, including attendance at child protection conferences. This showed that, of the GP’s invited to attend child protection conferences, 26.32% of GP’s either attended or sent a report and 50% of Consultant Paediatricians. Members stated that the minutes of the case conference kept them updated regarding the risks and plans made for children. They acknowledged that it was often difficult to read the whole report, before seeing a child, and so were largely reliant on the category used and the section that detailed ‘The Reason for the Conference’. Members recognised that ‘The Reason for the Conference’, is commonly ‘cut and pasted’, from one conference to the next This appears as the reason for all the children in the family being the subject of a child protection plan, regardless of their age and development, or regardless of changes in the family. This was identified as happening ‘routinely’ across a number of cases in Lambeth. “In case conference minutes, it is common to see what seems to be cut and pasting sections from one conference to another” (Case Group member). Members spoke about their experiences of core group meetings in Lambeth. There was information provided to suggest that core group meetings are normally always chaired by the social worker allocated to the case, or by a representative from another agency. It was the view, of a number of Case Group members, this led to a lack of seniority/ authority in the meetings. In addition, it was clear that, for a number of agencies, there was a confusion about their specific role and remit, in being a member of this group. Case Group members made the following comments: “There is a lack of buy in by members at core group meetings”. “The remit and conduct of the core group should be clearer” “The chairing needs to be more robust” “There is a common lack of clarity about the role of core group members, this needs to be explicit” Concern was raised about the quality of the case conference minutes and the length of time it can take to receive a copy of these minutes. Members spoke about inaccuracies and typing errors. There has not been a recent audit in Lambeth in relation to the functioning of core group meetings/child protection conferences, hence hard data on this issue was not possible to locate. 36 How widespread is the pattern? The Review Team shared their experiences of working in other local authorities /county councils, this experience suggests that ‘The Reason for the Conference’, is often ‘cut and pasted’ from the Initial Child Protection Conference, into subsequent conference minutes. This appears as the primary reason for the child protection conference, on the case conference records for all the children, regardless of how long the children are subject to a plan, or whether information is available to suggest that the risks to the children have changed. They also identified a pattern where core groups are often chaired by the social worker, or other members of the core group. Available literature and relevant SCRs, examining pre-birth conferences, membership of core groups, child protection conferences and information sharing during key meetings, within the child protection process, reveals these to be critical components in child protection planning. Whilst it is widely accepted that any weaknesses, in these areas, poses a threat to the effective functioning of these meetings, there is no national or local research examining these issues. There have been a number of Serious Case Reviews that have identified the risks, posed to children, when these weaknesses are present. What are the implications for the reliability of the multi-agency child protection system? When children are made the subject of a child protection plan, their names are added to a list that is circulated as an alert to services/establishments. A formalised process of information sharing through a meeting chaired by an independent case conference chair, then follows. To assume that, once activated, this process provides the necessary safeguards, within which a child is protected, is an unsafe assumption. This process does not, per se, protect children from harm. A safe child protection system is predicated on the contribution of the Interagency Group. Core groups, and child protection conferences, are key forums that facilitate this interagency protection of children. This case has suggested that there are a number of ways, in which these are not working optimally in Lambeth, including the timing of pre-birth child protection conferences, the practice of integrating discussion of risk to unborn children into review child protection conferences, insufficient membership, gaps in information sharing and a lack of focus on the individual needs of the children. These gaps inhibit multi-agency partners in providing protection to children. On the surface, the repetitive use of the ‘Reason for the Conference’, may seem of little significance. However, in practice this frames professional discussion at child protection conferences and, if professionals are in any way reliant on this section of the case conference minutes, copying over this reason from one conference to the next, can skew a full understanding of the risks to the child. 37 Finding 4: There is a lack of rigour in ensuring case conferences and core group meetings are functioning effectively. Statutory guidance and procedure sets out the responsibilities of core groups, and child protection conferences. This includes the need to ensure full membership, of these meetings, and the need to effectively plan for the protection of children. “The core group should develop an outline of the child protection plan, set out what needs to change by how much and by when in order for the child to be safe and have their needs met.... Core groups must implement and refine the child protection plan.” 23 Responsibility for monitoring the effectiveness of the core group, rests with the child protection conference. Case conferences, and core groups, provide a framework and structure that enables the multi-agency protection of children. If this is not working as it should, the protection of children is compromised. Issues for the Board and member agencies to consider: How does the LSCB undertake their statutory responsibilities to maintain an overview of how the child protection conference and core group process is operating in Lambeth? Is the LSCB satisfied that the agencies are clear of their role and remit in core group meetings and arrangements have sufficient authority to allow required tasks to be completed? How will LSCB consider what arrangements need to be in place that allows for full participation of the multi-agency group in child protection meetings? What are the constraints in trying to improve practice in the areas identified? How will these be overcome? How will LSCB know there have been improvements in this area? 23 The London Child Protection Procedures 2010 38 Finding 5: When children are already on a child protection plan, there is a tendency for additional concerns not to be investigated through the correct child protection process. The assumption is that this will be addressed at the next child protection conference or core group. The London Child Protection Procedures detail the requirement for all incidents of harm to children, where abuse or neglect is believed to be a factor, to be investigated under section 47 of The Children Act 1989. This section of the Act states the local authority has a duty to investigate when; “they have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm.” And further that “the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare” The London Child Protection Procedures state that strategy meetings/discussions, should always be held; “whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm”. These requirements apply to all children. If a child is the subject of a child protection plan, due to the inherent complexities of these cases, there is added emphasis on the need to hold a strategy meeting. This case has suggested that on a number of occasions, when responding to an incident of suspected harm, these procedures are not followed. How did this feature in this case? In this case, there were a number of bruises seen on the children and a number of incidents that, in the view of the Review Team, should have triggered s47 investigations, and strategy meetings. On two occasions, relating to explicit concerns that the children had been the subject of physical abuse, s47 investigations were initiated. On a number of other occasions, when concerns were noted by multi-agency professionals, and reported to the Children and Young People’s Service (CYPS), the response was to note the concerns in the case file, and to consider what outcome was required. On some occasions, action was taken in the form of a home visit and/or a call to a member of the multi-agency network. On other occasions, the concern was simply noted on the case file. A number of these concerns were recounted within reports to case conferences. These concerns were not the subject of s47 investigation and so concerns, decision making and action, were not the subject of timely multi-agency decision making and scrutiny. This was demonstrated when Sibling 3 was seen by the family GP for his eight week check. On this occasion, Sibling 3 was brought by his maternal grandfather to the GP Practice for his routine check. On weighing Sibling 3, the GP identified that Sibling 3 had lost weight from his original birth weight; he was found to weigh 3.87 kg. The GP was very concerned by this loss of weight. A feeding chart and high formula milk were given, and an appointment scheduled for the following week. The GP referred Sibling 3 to the ‘Rapid Access Team’, based in a local hospital. She reported her concerns, that Sibling 3 was ‘failing to thrive’, to the health visitor and social worker. Sibling 3’s failure to thrive was discussed at the next core group meeting two days later. The information from the GP was noted by the core group, the Health Visitor reported ‘no concerns’, and no 39 other action was taken. The SW visited the family home two days after the Core Group Meeting; the concerns were not discussed with the parents. The GP continued to monitor Sibling 3 at the surgery. A month later, the health visitor discussed the feeding of Sibling 3 with the parents. Data reveals that no other action was taken, by the multi-agency team, over this critical period of time. After a period of prescribing high formula feeding, review and monitoring by the GP, Sibling 3’s weight sporadically increased. Some five months later, in May 2013, there was a review child protection case conference (RCPCC). By this time, Sibling 3 had gained satisfactory weight. The GP did not attend the child protection conference, but detailed her concerns in a report to the conference. Included in this report was the outcome of the medical investigation by the Rapid Access Team, that Sibling 3’s failure to thrive did not have a medical cause. The case conference noted these concerns, but the gravity of the information was lost. The GP presumed that the SW and multi-agency group understood that this failure to thrive was as a result of neglect. This presumption was not correct, and the conclusion that this was evidence of neglectful parenting, was not given sufficient weight and meaning by the multi-agency group. Whilst the child protection plan, made at this conference, included a new recommendation to seek legal advice, this was not in response to this critical incident. This recommendation was made, in order to achieve funding for a specialist assessment. Overall, it was the view of the review team that not investigating the concerns about Sibling 3’s weight within a s47 framework contributed to the confusion amongst the multi-agency group about the cause and significance of this failure to thrive. How do we know it is not peculiar to this case? The Review Team were struck by the importance of this issue, and attempted to uncover data to explain what may lie beneath this finding. It was not possible to source any hard data on this matter. However, members of the Review Team and Case Group identified this was not unique to this case. Examples were provided of cases involving children, who were the subject of child protection plans, where either a core group, or a case conference, were brought forward, in order to discuss incidents of harm, rather than initiating a s47 process. Experience of the Case Group suggested that this was most likely in cases of neglect. The Case Group gave examples of cases where a concern about a child, who was subject to a child protection plan for neglect, were reported but did not result in a s47 investigation or an earlier child protection conference, or review by a child protection chair. Information from the Children and Young Peoples Services, confirmed there is no system for auditing or reviewing this practice, apart from through the established case conference process. At such times, chairs may make recommendations, in respect to an incident, and may remind participants of the need to instigate s47 investigations, as indeed the chair did in this case, but this does not guarantee compliance. A recent Serious Case Review in Lambeth questioned: “Whether the ineffective management of the Section 47 investigation represented a pattern of working in the individual FSCP Team, and possibly more widely”. During the course of this previous SCR, the Review Team were provided with evidence to suggest this was not a widespread pattern. Data from this review suggests this issue is more widespread than previously thought. 40 How widespread is the pattern? The experiences of the Review Team and the Case Group, in other local authorities/county councils, suggests that if a child is the subject of a child protection plan, there can be an assumption that this process is sufficient to provide for necessary information sharing and multi-agency decision making. Case Group members recognised this to be particularly relevant when working with families who are known well, or when neglect is present. There is no available research to suggest this is common practice, in relation to the generic population of children who are the subject of child protection plans. However, there is a wide range of available research24 concerning how critical incidents are responded to, when children are living in households where neglect is present. Within this research, and associated literature, a repetitive pattern, characterised by a lack of assertive response to incidents, is identified. “Social work practitioners frequently postponed taking decisive action pending further assessments of parenting capacity and parental progress”.25 “There was drift and lack of a sense of urgency among professionals, even when the risks of harm through poor supervision had been highlighted by a CP plan in the category of neglect.” “Practitioners and managers should recognize how easily the harm that can come from neglect can be minimized, downgraded or allowed to drift.” Brandon et al: Neglect and Serious Case Reviews 2013 What are the implications for the reliability of the multi-agency child protection system? Investigations under s47 of the Children Act 1989 are, by their very nature, investigations that confer upon the multi-agency teams a clear structure, timeframe, and decision making process. Equally, strategy meetings place child protection decision making within a clear structure and format that allows for clear, and accountable, information sharing, decision making, and action. The reason for clear, and unequivocal, information sharing, and accountable decision making, does not have to be repeated here. It is an essential component of the safeguarding system. Whilst the Local Authority are the lead agency, they are dependent on the vital contribution and attendance of safeguarding partners, both in sharing information, in receiving the opinions of other professionals, and in collectively making safe and effective decisions to safeguard children from harm. The s47 process provides the framework within which this happens. It is unsafe to assume the same scrutiny, timeliness and accountability, of decision making, in response to critical incidents, are inherent within other parts of the child protection process, or that such detail can be part of a child protection conference. 24 See among others :Cleaver & Nicholson, Brandon et al, Farmer & Lutman, Tanner & Tuney etc 25 Brown & Ward: Decision making within a child’s timeframe 2013 41 Finding 5: When children are already on a child protection plan, there is a tendency for additional concerns not to be investigated through the correct child protection process. The assumption is that this will be addressed at the next child protection conference or core group. This case has suggested that when a child is the subject of a child protection plan, particularly in cases of neglect, concerns are less likely to be investigated under the s47 framework. Investigations under s47 of the Children Act 1989 and strategy meetings are critical if children are to be safeguarded from harm. Such processes allow for full information sharing, and for this information to be the subject of necessary scrutiny and analysis. To assume that incidents of harm to children, who are already subject to a child protection plan, will be adequately scrutinised, and receive a timely response, through the core group/case conference process, is a flawed assumption. It is an assumption that weakens the protection provided to children, and has the potential of creating unsafe loopholes in the multi-agency safeguarding system. Issues for the Board and member agencies to consider: How will LSCB review the extent to which this is a feature of practice in cases of children subject to child protection plans? How will LSCB satisfy itself that this does not feature in cases where children are the subject of significant harm as a result of neglect? How will this be the subject of quality assurance activity in the future? How will LSCB exercise their governance responsibilities in this area? How will the decision making, in relation to decision making about when to commence s47 investigations, be strengthened, to facilitate the involvement of multi-agency safeguarding professionals? How will LSCB review and evaluate the action they take? 42 Finding 6: Despite clear procedural guidance for working with families who are hostile and aggressive, such behaviour still disrupts the effective functioning of the child protection process. The result is an adult focus that distracts professionals from identifying and responding to the risks to individual children. The child protection process is a system of intervention that involves a multi-agency team, and includes child protection conferences, core group meetings, and interventions dictated by the child protection plan. The attendance of family members, at both child protection conferences and core group meetings, is positively encouraged, and the London Child Protection Procedures (2010) provides helpful guidance, about the steps that need to be taken in these circumstances. Balancing the rights and needs of care givers, alongside the need to operate a safe and effective safeguarding system, can be challenging. It is widely recognised that, for many families, the child protection process presents a time that invokes a number of difficult emotions, the process itself can feel overwhelming, and can lead to a sense of powerlessness and/or anger. This case has suggested that, despite the available guidance, involving families effectively in the child protection process remains difficult. Where difficulties are not effectively addressed, practitioners’ focus can be distracted from the needs of, and risks to, children. How did this feature in this case? The unmet emotional needs of the parents, were evident to practitioners. These emotional needs were expressed in their expressions of anger, aggression, and hostility. Father was known to feel angry towards social workers who, it was believed, he saw as representing his difficult childhood in care. He was often described as responding in an aggressive, and hostile, manner when social workers visited the family home. This behaviour was characterised by aggressive shouting, expressing verbal threats, and using threatening body language. When social workers attempted to speak with him, he would turn the volume up on the violent games he was playing in the front room. A number of social worker’s spoke of feeling ‘afraid’, when visiting the family home. Mother’s behaviour was, on occasions, observed to be hostile and angry, she was described by core group members as often reacting like ‘an angry teenager’. In the presence of maternal grandmother, who also consistently showed a level of hostility to professionals, her hostility intensified. As a result, a number of professionals avoided visiting the family home. If contact could be made with the mother outside this environment, this was pursued. It equally affected the way in which child protection conferences, core group meetings, and visits to the family home, were managed. Professionals worked hard to negotiate access to the family home, and to ensure core group meetings and child protection conferences ‘functioned’. Overall, challenge was avoided, and concerns were framed in a way that averted parental aggression. This resulted in an adult focus, where the time and energy of professional input was concentrated on managing, and negotiating around, the needs of the adults. An additional consideration was the presence of the children. The hostility and aggression, from the mother, father and maternal grandmother, was shown, regardless as to whether the children were 43 present or not. Professionals were mindful of the effects of such behaviour on children, as a result they either refrained from challenging the parents, or made a decision to deviate from a normal course of action, such as speaking to the children after an injury had been noted, fearing the aggression of the parents, and impact on the children. The outcome was that plans could not be sufficiently discussed, or implemented, and the children’s voices were lost within the chaotic emotional world of their care givers. There was a difference of perspective, about the aggression shown by the parents to professionals. For a minority, this aggression was not present. When the Review Team sought data, to examine what lay beneath this issue, it was found that if challenge was avoided, parental hostility was averted. However, if challenge was raised, this typically resulted in an escalation of parental response. This was exemplified in the visit, made by the community midwife, when she visited the home after the birth of Sibling 3. At the start of the visit, father appeared amicable. When he was challenged about his care of Sibling 3’s umbilical cord, father’s aggression and hostility rapidly escalated. The history, and patterning, of this behaviour was not understood. There was an assumption made that, beneath this hostility, were the unmet, and unresolved, emotional needs of the parents. This was a correct, but benign, interpretation. It was an interpretation that did not consider the impact of this behaviour, on the children, or sufficiently frame this behaviour, to provide insight into the way in which this behaviour was having a significant impact on the implementation of plans. The possibility that parental hostility could be attributable to the disempowerment, and frustration, felt by parents, in being in a process that, due to their learning difficulties, was overwhelming and incomprehensible, was not the subject of sufficient consideration. How do we know it is not peculiar to this case? Case Group members spoke with passion about the frequent difficulties they have in working with parents who are aggressive, and hostile. They spoke of the barriers this creates in their working relationships, and in the implementation of child protection plans. Case Group members talked about the presence of family members at core group meetings, describing their membership and attendance as a ‘prerequisite’ of the group. They spoke about this being upheld, regardless of whether their behaviour disrupts the functioning of the group. There was no data provided by the Case Group to suggest they were equipped to understand the possible underlying reasons for parental hostility, or parental disruption of meetings, that they encountered in their day to day work. It did not seem that they were supported to view the patterning of this behaviour within a framework, to allow the possible reasons and consequences to be unearthed. Case group members spoke about this aspect of their working life with a sense of resignation, and described dealing with these circumstances as and when they arose in their day to day working life. Practitioners spoke about their frustration about this issue, and the way in which this can significantly inhibit the workings of core group meetings and child protection conferences. The London Child Protection Procedures (LCPP’s) are clear about the steps that should be taken in these circumstances. The Review Team learnt there has been a recent policy put in place in the CYPS in Lambeth, this policy provides guidance and structure for dealing with families who disrupt the workings of child protection processes. The Case Group did not show any awareness of the guidance, provided by the London Child Protection Procedures, or about what they could do in such circumstances. The existence of the guidance within 44 the LCPP’s, and the recently published Lambeth policy, provides additional information to suggest this issue is not peculiar to this case. Case Group and Review Team members spoke at length about how the child’s experiences, and voice, are lost in such circumstances. They strongly identified with children, who are living in households where such adult hostility features, and where the children are silenced within this environment. A number of Case Group members spoke about the need to improve the practice of interpreting a child’s unspoken words: “Not enough is made of a child’s silence, what is the child saying in this silence?” How widespread is the pattern? There are various pieces of research26 highlighting the problems faced by multi-agency safeguarding practitioners, in working with parents who are hostile and aggressive. Such behaviour is referred to in a variety of ways, such as ‘uncooperative behaviour’, ‘ambivalence’, ‘non-compliance’, or ‘highly resistant’, and can present itself in a number of different ways. Research has shown that, whilst intimidation and hostility is acknowledged as presenting overt difficulties to practitioners, there is less acknowledgment of how a collection of behaviours, patterning over time, suggests that some families are in fact ‘resistant’ to interventions. “Although used in practice, the term ‘highly resistant’ families is rarely used in the research literature. Families are sometimes characterised as having ‘multiple’ or ‘complex’ problems and data are available on maltreatment recurrence, but none of these sources necessarily indicates that a family is ‘resistant.”27 Research, examining these types of behaviours, is unanimous; what all these behaviours have in common, are the effects they have on the functioning of the child protection processes, on the implementation of the child protection plans, and on the child. “Working with aggressive and resistant parents in child protection is one of the most difficult and risky enterprises in social work for children, workers and agencies. It is also one of the most neglected”.28 As the Review Team uncovered the data in this case, they were frequently struck by the complex nature of the work with this family, and how the challenges faced by the practitioners has national resonance. A Community Care/Reconstruct survey29, of nearly 600 social work and social care staff, discovered that parents, who exhibit such behaviour, can pose a real threat to their children, through the effects this has on the ability of staff to carry out their assessments, and interventions, effectively and adequately. 26 See amoung others: Calder, 2008; Farmer and Owen, 1998; Littlechild, 2005, 2008a, 2008b; Ferguson, 2011. 27 Fauth et al: Effective practice to protect children living in ‘highly resistant’ families’ 2010 C4EO. 28 Littlechild: Working with Resistant Parents 2013 29 Community Care 2011 45 “91% of respondents stated that their caseload includes parents who are hostile or intimidating”. “Respondents reported that they had found they experienced loss of confidence in carrying out their work, with their ability to protect children compromised as a result of such behaviour. Some staff reported consequent fear of confronting parents appropriately”. There is no doubt that the formalised meetings, and processes, inherent within the child protection process, is a time of additional stress for families. The Family Rights Group have run a long, and continuing, campaign, highlighting how child protection meetings are not conducive to parental engagement, and identifies the barriers encountered by parents in this process. In terms of parents with learning difficulties, the issues become more complex: Research by Booth and Booth30 reported that parents, with learning difficulties, found child protection conferences ‘harrowing and lonely meetings’ where they often did not know what was happening, or who the large numbers of professionals involved were. “Parents felt they were not listened to and disempowered in the formal atmosphere of over-long child protection conferences where inaccurate statements were often made about their parenting and they were often unable to follow the discussion”. What are the implications for the reliability of the multi-agency child protection system? Parents, who have their own unresolved emotional needs, are commonplace within families who are the subject of child protection processes. The challenging behaviour of caregivers, has become an accepted part of the safeguarding arena, for all multi-agency practitioners. Within this context, ‘seeing it from both sides’ is imperative: acknowledging the needs of parents, whilst naming what impact this has on the functioning of the safeguarding system, is the vital balance that needs to be struck. If it is not, the needs of the adults can overshadow the needs of the child, and detract from the safe and effective implementation of the multi-agency child protection process. 30 Parents with learning difficulties in the child protection system: Experiences and perspectives Booth &Booth 2004 46 Finding 6: Despite clear procedural guidance for working with families who are hostile and aggressive, such behaviour still tends to disrupt the effective functioning of the child protection process. The result is an adult focus that distracts professionals from identifying and responding to the risks to individual children. The effective functioning of the child protection process, is an unequivocal fundamental requirement for protecting children from significant harm. Yet caregivers’ experience of this process can be difficult, giving rise to behaviours such as threats, verbal abuse, hostility and physical violence. It can also include the lesser recognised features of ambivalence, or detraction. The impact of such behaviour, on individual staff, will vary, but in effect this behaviour constitutes resistance to the involvement of safeguarding professionals. It averts the gaze of professionals away from the children in the family, and impacts on judgements, interpretation and intervention. This has significant implications for the effective functioning of the multi-agency child protection system. Whilst professionals are spending a significant amount of their valuable time negotiating around such resistance, this can avert professionals from the safeguarding action that is required, and can leave the voices of the parents and children unheard. It has the additional implications of posing a threat to the physical and emotional wellbeing of professionals, and can lead to professional fatigue. Issues for the Board and member agencies to consider: Is the impact of caregivers’ emotional distress, hostility and anger on the child protection process recognised by LSCB? How effective is the current policy in providing assistance to professionals in identifying and working with families in this context? How are the London Child Protection Procedures understood, and guidance implemented, in this area of work? What else is in place to assist multiagency professionals in working with families where these issues feature? What is in place to enable parents with learning difficulties to engage in child protection meetings and processes? How is supervision used to help professionals consider the impact of hostility both on their work to safeguard children and on their own wellbeing? How are children, whose emotional needs are overshadowed by those of the caregiver, identified and provided with a means of expressing their voice? What else may be needed to assist professionals in eliciting the voices of children and their parents in these circumstances? How will LSCB know whether there have been improvements in this area? 47 Finding 7: There is a tendency to use written agreements to support child protection arrangements. The effectiveness of written agreements, as a tool to ensure parents do what is required of them, is questionable. The use of written agreements has become custom and practice in safeguarding children and can be found in frequent use when a child is the subject of a child protection plan. Yet legislation, statutory guidance procedure and policy, make no mention of the use of written agreements in the safeguarding of children. The purpose, and value, of such written agreements is unclear. Their use appears to have originated from cases where legal proceedings are anticipated, or are in progress, with the intention of building up a picture of evidence for court. However, the use of these agreements is highly questionable, particularly when a case is outside of legal proceedings. They are being increasingly used in a mechanistic way as if they can create safety for the child, when this expectation is unrealistic. How did this feature in this case? Whilst the children were the subject of child protection plans, the parents were asked to sign two written agreements. The purpose of these agreements, was to give certain assurances about how the children would be protected from harm. Written agreements were a repetitive recommendation from all the child protection conferences, and formed part of all the child protection plans. Data was found to suggest that two written agreements, were signed within the same month, in November 2011. The first was signed by mother, whilst she was still in hospital, after the birth of Child I. This written agreement, was prompted by two specific areas of concern. Firstly, there was a police investigation into a serious allegation, made against maternal grandfather. Secondly, there were concerns the parents would not be able to cope with the care of all the children, after mother and Child I were discharged from hospital. Hence, this written agreement stipulated a number of requirements, including securing a commitment, from mother, that the maternal grandmother would stay at the family home for the forthcoming 4 days, to assist in the care of the children, and securing a commitment, that the children would not stay in the home of maternal grandparents. Other requirements, included a commitment from the parents, that they would work in an ‘open and honest manner with Lambeth C&YPS’, and finally, that ‘possible action would be taken by the LA’, if the written agreement was breached. The signatures of mother, and the allocated social worker, appear on this written agreement. Information from the case record, and from the allocated social worker, show that this written agreement was signed by mother, on the day she was due to be discharged from hospital with Child I. Signing this agreement, was a prerequisite to discharge. Two days later, the community midwife visited the family home. She was not aware of the written agreement. On her visit to the family home, she met with the father and maternal grandfather. Maternal grandmother and mother were not at home. All 3 siblings were present in the family home, the house was described as being occupied by a number of adult men, who were playing video games in the front 48 room. The maternal grandfather was caring for the children, and was keen to let the midwife know that he thought Sibling 2, had a ‘neurological problem’; ‘as she was often falling and bruising herself’. He took the midwife into a separate room, and showed her a bruise on Sibling 2. When the midwife questioned the maternal grandfather about the bruise, he became hostile. The midwife felt concerned for sibling 2, and for her own safety. She left the house, and reported her concerns. The second written agreement was signed, by the mother at a core group meeting. This written agreement, had been a recommendation of the case conference. This agreement outlined details of the child protection plan. The agreement included the requirement that the children would not be cared for by the maternal grandfather, and would not stay at the home of the maternal grandparents. Sometime later, Sibling 3 was presented to A&E, by the maternal grandfather. His finger nail had been torn out, and was infected. Maternal grandfather explained, to A&E staff, that whilst Sibling 3 and Child I were in his care overnight, Sibling 3 had been injured by Child I. This explanation was accepted as a plausible explanation for the injury. A&E staff were not aware that the children should not be in the care of maternal grandfather. Had they been aware, this may have prompted greater curiosity about this injury. Father was not asked to sign either of the written agreements. The written agreements were breached by the parents, however, there was no action taken to address these breaches. There was no data found, to suggest these written agreements were the subject of monitoring or review. Given that both parents were thought to have a learning difficulty, and both were identified in core assessments as being ‘unable to read or write’, it is unclear how much of these written agreements the parents understood. In a conversation with mother and father, as part of this SCR, mother confirmed that neither she, nor father, were able to read. There were limits, to how the content of these written agreements were shared with the multi-agency group. The first written agreement was shared, with the mother, and placed on the case file, held within Children’s Social Care. It was not shared with the midwives, or any other professional within the multi-agency group. The second written agreement was shared with core group members, but due to the restricted membership of this group, a number of key professionals were not aware of this agreement. The implications were that the full multi- agency professionals, who were responsible for safeguarding the children, were not aware of the agreements, or of the concerns that led to a number of terms outlined within these agreements. How do we know it is not peculiar to this case? Information shared by members of the Case Group, and Review Team, identified that the practice of using written agreements, to supplement or to add weight to a child protection plan, was “routine” in Lambeth. Case Group members identified, that written agreements are; ‘often a recommendation of a case conference’. Members highlighted their concerns about occasions when the details, in the written agreements, are inaccurate, suggesting the wording has been “cut and pasted”, from agreements used with other families. They raised concern that the wording can be “lengthy” and “difficult to understand”, and highlighted that the system, for monitoring compliance and taking action when there was a breach of the agreement, was “ineffective”. 49 How widespread is the pattern? The collective experiences of the Review Team members, indicated that the use of written agreements was a long standing, established practice, in safeguarding children. This experience suggested their use was widespread, was often included as a requirement within legal advice, had become a routine recommendation of child protection child protection conferences, and was often referred to under the banner of ‘best practice’, within ‘safeguarding’ training. In an article about written agreements31 J. Nicolas states the following: “Partnership agreements between social care authorities and parents have been in use for many years, but it is not possible to trace their origins as there is no reference to them in legislation or statutory guidance. I can also find no mention of them in local safeguarding children boards' policies or procedures. Partnership agreements are seen by professionals as one of the tools that can be used to help keep a child safe, yet there is no evidence that they do. In fact, the opposite can be true as they can give a false sense of assurance that the child is safer, because the agreement has been signed by the parent or carer.” Attempts to uncover relevant research, returned nothing of significance. In the review of the literature, an article, by the BBC, makes powerful reference to their use: “Swansea Council has been condemned for "naive" informal agreements to protect children from abuse, according to a leaked report seen by BBC Wales. A critical report from 200732 demanded that the council stop the practice of non-binding written agreements with parents to protect children”. What are the implications for the reliability of the multi-agency child protection system? The use of written agreements, have become part and parcel of the child protection system, particularly for children who are suffering significant harm. Written agreements can be found in use, when legal proceedings are being initiated, or when the case is in legal proceedings. In these circumstances, there is a clear and present process, for both monitoring compliance and gaining evidence, the consequences of breaching these agreements are clear. There is no evidence from research to indicate that use of these agreements provide added safety to children, who are the subject of a child protection plan. At best, the use of these agreements serve a purpose of providing a level of assurance to safeguarding partners, that children will be protected from a specific area of harm. However, this carries with it the inherent risk that, once the agreement is signed, the focus on the specific issue is lost. In addition, using written agreements as part of core group meetings, and gaining the signature of multi-agencies to these agreements, is questionable. The failure to provide copies of these agreements, to the multi-agency group, and the absence of robust mechanisms to enable compliance, monitoring and review, places the multi-agency team in an untenable position. 31 ‘The Guardian Social Care Network’ (April 2014) J Nicolas 32 The Care and Social Services Inspectorate Wales (CSSIW) 50 A written outline, spelling out some basic requirements of parents who require prompts and reminders in parenting the children, can be useful. However, to detail expectations that are unrealistic of parents, or to assume this provides reassurances that the child will be safeguarded, is a false and unsafe assumption. The use of written agreements becomes additionally complicated, and highly questionable, when they are used with parents who have a learning difficulty. Finding 7: There is a tendency to use written agreements to support child protection arrangements. The effectiveness of written agreements, as a tool to ensure parents do what is required of them, is questionable. The origins of written agreements or partnership agreements are unknown. It is believed they may have evolved from the ‘Task Centred’ social work practice model, advocated by Epstein and Reid in the 1970s/80s. It is certainly true that legal advice commonly includes a recommendation that written agreements are signed by parents, when legal action is being taken/is being considered. The merits of written agreements, as a mechanism to protect children from harm, is questionable. These agreements can often be found in use when a child is the subject of a child protection plan. But the setting of unrealistic expectations, the lack of any real consequences when breach occurs, and the lack of a reliable system for monitoring and review, renders these agreements worthless. In their current form and use, written agreements pose a threat to the reliability of the multi-agency safeguarding system. Issues for the Board and member agencies to consider: Are Board members aware of how written agreements are used in safeguarding children? What steps need to be taken by LSCB in order to explore how written agreements are used in Lambeth? Is this an area of practice that is addressed in any current training/ policy procedure/practice guidance? If so is this guidance/policy procedure fit for purpose? What kind of information do LSCB need to identify whether the use of written agreements have a future value in the protection of children? How will LSCB know this matter has been progressed, and there are improvements in this area? 51 Additional Learning Additional learning points are outlined in the following section of this report. It is the view of the Review Team that due to their potential local and national significance, these are important matters to highlight to the Board. Additional Learning 1: Is there a pattern in Lambeth of routinely identifying protective factors and strengths in families, as part of the child protection process that results in false re-assurances when the strengths are named but not fully assessed or are given undue weight? On researching the prevalence of this issue, the Review Team were not completely convinced there was sufficient data to present this as a key finding of this SCR. However, based on the information gathered and in the knowledge that, in line with other LA’s/CC’s, Lambeth are in the process of embedding a strengths based model into child protection case conferences, the Review Team felt this to be an important matter to be brought to the attention of LSCB. Hence the issue is presented as a question posed to LSCB, with the view to prompt further exploration and debate. “Historically, when it comes to assessment, direct service providers have largely been trained to identify deficits and pathologies for specialized services. Problem focused assessment often leads to a laundry list of the things that are considered to be "wrong" or dysfunctional with children and their families. Unfortunately, practitioners can become stuck in their view of the child and family because they have too much information about the problem and not enough information about strengths and solutions”.33 In response to the growing body of research, reflecting the position characterised in the quote above, there was a national move to better identify strengths in work with individuals and families. This has resulted in various assessment models being adopted throughout the country that provide a framework to facilitate a strengths-based approach to working with children and families. Statutory guidance, contained within Working Together 2013, states the requirement that ‘child protection plans should reflect the positive aspects of the family situation as well as the weaknesses’. This case has suggested that whilst there was no a formal model, procedure or policy, to frame this approach in Lambeth, there is information to suggest that the principles of the strengths based approach were adopted. Whilst in line with statutory guidance, this approach can have the unintended consequence of over-estimating the strengths and resilience in families, thus providing a false reassurance to the professional network. In this case, information from the core assessments, child protection reports, and from case group members, identified the maternal family as a ‘strength’. It was clear, the maternal grandparents were active in the care of the children, and they assisted the parents in ensuring the children attended required appointments. Maternal grandmother was often present at core group meetings, and both were often present during professional visits to the family home. 33 Rudolph, S.M., & Epstein, M.H. (2000). Empowering children and families through strength-based assessment. Reclaiming Children and Youth. 52 There was other information, about the maternal family, suggesting that, rather than a strength, the maternal grandparents posed a risk to the children. There was a serious allegation made against maternal grandfather that was not resolved during the time line under review. A cousin of the children, who was living in the home of maternal grandparents, was the subject of a child protection plan, under the category of emotional abuse. He was removed from this home after being subjected to a physical assault. Maternal grandmother was frequently observed to demonstrate hostility towards professionals. It was clear, from case group members, there was, what seemed to be, a received wisdom, about the maternal family providing a ‘safety net’ for the children. It was also clear, there were some who held a different opinion about the ability of the maternal family to offer protection to the children. This opinion was expressed during conversations with case group members, but was not sufficiently represented, in the child protection conferences or core group meetings, in a way that informed an assessment of risk. It was evident, from the contributions of case group members, there was limited knowledge about the concerns held about the maternal family. Each member of the Case Group held different pieces of information, about the maternal family. No complete picture seemed to be available, on which to make a judgement about whether the maternal family strengthened, or weakened, the protection of the children. When safeguarding children, who are the subject of a child protection plan, it has become expected best practice to clearly articulate the strengths, and protective factors, alongside the risks, in families. This allows for a more balanced view of the family to be taken, and for these strengths to be built upon, to maximise the current and future protection of the children. This approach is based on extensive research34.This research concludes that, when working with children, young people and families, using this approach leads to improved outcomes. However, caution is advised in relation to how strengths are assessed, in working with children where harm to a child is known or suspected. 35 The National and Local Picture As stated, a number of models structuring this approach, and proving guidance to practitioners in their work in this area, have been introduced across the country. The move, to introduce a strengths based model in the child protection process, specifically within the context of child protection child protection conferences, has been a relatively recent development. A number of county councils and local authorities, have now adopted a strengths based model in child protection case conferences (these models are termed, and known, interchangeably as the ‘Strengthening Families’ approach or ‘Signs of Safety’36).During the time line under review, Lambeth had not adopted such a model. It is early days in national implementation, and there is limited research about the long term benefits of such a model, particularly when it is used to safeguard children who are the subject of significant harm. Early experience suggests that, whilst the model can bring some clear benefits, there is a need to ensure the strengths do not overshadow the emphasis placed on risks, and further to ensure that, where strengths are identified, these are subject to the same scrutiny and analysis as the risks. Assessments and plans, that adopt a view of strengths that is overly optimistic, carry an inherent danger of leading to services that replicate this optimism, thus weakening the protection of children. 34 See among others: Feeley, Russo, Early etc 35 Signs of Safety in England NSPCC 2013 36 Turnell et al. 53 Is there a pattern in Lambeth of routinely identifying protective factors and strengths in families, as part of the child protection process that results in false re-assurances when the strengths are named but not fully assessed or are given undue weight ? Lambeth commenced piloting the ‘Signs of Safety’ approach, to child protection conferences, in April 2014. There has been a recent change in the way assessments, child protection conferences and reports to conferences, are structured and formulated. These changes reflect this ‘strengths based’ approach. It is early days in the implementation of this approach, for children subject to child protection plans, both locally and nationally. It is unclear, at this point, whether the changes, already made in Lambeth, will address the potential vulnerabilities this case has revealed. As LSCB continue to review the merits of this approach, it will be important for LSCB to consider the possible implications of this issue within the context of child protection conferences, and more broadly, in examining how targeted and specialist services work with families using a strengths based approach. Additional Learning 2: The tragic death of another child had a significant impact on the multi-agency team and had a detrimental effect on the work in this case. In March 2013, the social work team, responsible for Child I and his siblings, had learnt of the death of a child, with whom they were also working. This had a significant impact on the Social Work Team. Whilst contending with the very practical and emotional implications of this death, they were continuing to provide support to this family, and to all the families on their case loads. Due to sickness and staff moving on, by July 2013 the team had only half its capacity. The Team Manager had left and a brand-new Deputy Team Manager was in place, who had previously worked this case. Whilst the team attempted to recover, various agency staff were brought in, who were variable in quality. This meant that permanent members of the team carried more than their share of statutory cases for a while, until the team could be stabilised. It is the view of the Review Team, this would have undoubtedly had an impact on the services this team were able to offer over this time. In addition, there are very real emotional implications to the work of safeguarding professionals. Hearing of the death of a child and, in addition, working with children who are abused and with adults, who exhibit unresolved emotional needs often stemming from their own traumatic childhood, can be both a professional and personal ‘challenge’. Little is written about the impact, on the workforce, of this day to day work, nor on the implications of dealing with the death of a child in a family, with whom they have had regular contact. As previously identified, there was a wide range of professionals, providing services to this family. A number of professionals, had known the parents for many years. Many of the professionals had known, and worked with the children, from the time the children were born. The death of Child I, was shocking. 54 Professionals were deeply saddened by the tragedy, and felt a deep sympathy for all members of the family. During this case review, members of the Case Group demonstrated their anger, frustration, and sadness, in a number of ways. The Review Team witnessed the way in which professionals questioned their professional worth, and how, during their own reflections on practice, they ruminated on critical internal scrutiny of their own actions. This is a natural human response to the death of a child, and indeed can be a necessary part of professional development. However it is unhelpful, and potentially both personally and professionally damaging, if staff are not provided with the right levels and the right type, of support in order to helpfully process the impact of such a tragic event. When a child dies, who has been in receipt of services from any agency, the experience of the Case Group and Review Team revealed that the first response, is to look to find something, or someone, to blame. This frequently seen natural human response to tragedy, is replicated in the wider societal response. What gets lost in this process, is an evaluation, and informed response, to the human cost, and the implication this has on the safeguarding of children. Members of the Case Group spoke with feeling, about the emotional impact of the work they do in safeguarding children. Some talked about receiving a level of support, in their day to day work, and in response to learning about Child I’s death, although most referred to the limited support they normally receive, and had received, in dealing with the news of Child I’s death. They spoke about, and demonstrated, the resultant impact this had on their internal emotional worlds. They were keen for this issue to be brought to the attention of LSCB, in order for LSCB to give thought to how a duty of care can be offered to professionals now and in the future. The tragic death of another child had a significant impact on the multi-agency team and had a detrimental effect on the work in this case. The effective safeguarding of children, is predicated on the work completed by staff in their day to day working life. A healthy workforce, is a prerequisite to this work. Whilst it is recognised, that professionals are expected to work in situations where trauma is present, and indeed professionals acknowledge and accept this as part of their working life, the professional and personal costs of trauma, particularly when a child dies, are underestimated and so unacknowledged. These feelings often remain unresolved. This has an enduring impact on the work of safeguarding professionals, and can lead to sustained personal distress that persists over time. LSCB are encouraged to examine the ways in which member agencies’ duty of care, owed to the safeguarding workforce, is exercised, to ensure professionals are supported in dealing with the emotional impact of the work they undertake, not just in response to the death of a child, but also in their day to day work. It is the view of the Lead Reviewers, members of the Case Group and the Review Team, that taking steps to address this impact, will allow the safeguarding of children to be strengthened. 55 Appendix 1: Methodology Introduction The case review used the systems methodology developed by the Social Care Institute of Excellence (SCIE) called Learning Together37.The focus of a case review using a systems approach is on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why – to identify the ‘deeper’, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case and changing them will contribute to improving practice more widely. The methodological heart of the Learning Together model has three main components: Reconstructing what happened – unearthing the ‘view from the tunnel’ and understanding the ‘local rationality’. Appraising practice and explaining why it happened through the analysis of Key Practice Episodes (KPE’s). Assessing relevance and understanding what the implications are for wider practice – using the particular case as a ‘window on the system’. Using this approach for studying a system in which people and the context interact, requires the use of qualitative research methods to achieve transparency and rigour. The key tasks are data collection and analysis. Data comes from structured conversations with involved professionals, case files and contextual documentation from organisations. Review Team The review has been carried out by a Review Team led by Accredited Learning Together Lead Reviewers Bridget Griffin and Ghislaine Miller. The Review Team received support throughout the process by the Quality Assurance Officer & SCR Project Support, and the Chair of the Serious Case Review Subcommittee, who took on the role of champion for this review. Collectively, the role of the Review Team is to undertake the data collection and analysis and author the final report. Ownership of the final report lies with the LSCB as a commissioner of this Serious Case Review (SCR). The Review Team was made up of nine senior representatives from the different agencies that had been directly involved with Child I. The role of the Review Team Member is to provide expert knowledge in relation to the practice of their individual agency, to contribute to the analysis of practice and to the development of the findings from the review. 37 Fish, Munro & Bairstow 2009 56 Review Team Members Andrew Wyatt Assistant Director, Multi-Agency Assessment, Family Support and Child Protection (CYPS) Avis Williams-McKoy Nurse Consultant, Designated Nurse LCCG Davina Mackenzie Consultant Community Paediatrician Lambeth Community Health GSTT Debbie Saunders Named Nurse Safeguarding Children, Guy’s and St Thomas' NHS Foundation Trust Frances Wedgewood Named GP for Safeguarding, NHS Lambeth Geraldine Abrahams Head of MAT 2 Service. Early Intervention and Targeted Services LBL Graham Griffin Senior Safeguarding Adviser (Schools), CYPS (QA) Malcolm Ward Independent Chair, Lambeth Serious Case Review Panel Rosalinda James Head of Nursing/Named Nurse Safeguarding Children King’s College Hospital NHS Foundation Trust Rupinder Virdee Quality Assurance Officer & SCR Project Support CYPS LBL Russell Pearson Specialist Crime Review Group, Met Police Support from SCIE was provided in the form of case consultation, supervision and quality assurance. Specialist Advice The Review Team received specialist input, about adults with learning difficulties, to support an understanding of systems and the interpretation of professional practice in this case. The Acting Head of Adult Learning Disabilities Team, was invited to join a meeting of the Review Team. This input provided an extremely useful insight into how adults with learning difficulties are assessed and provided with services and assisted the Review Team in understanding the kind of difficulties the parents in this family may have faced. It also helped in bringing sensitivity to how professional practice was appraised. For example, it gave an insight into how the parents may have made sense of the guidance provided by practitioners. 57 Structure of the Review Process The SCIE model uses a process of iterative learning, gathering and making sense of information about a case that is a gradual and cumulative process. Over the course of this review there have been a series of meetings between the Lead Reviewers, Champion, Review Team and Case Group members. Initially there was a meeting between the Lead Reviewers and the Review Team to explain the SCIE Learning Together model and the role of the Review Team in the process. The Review Team then decided the membership of the Case Group based on their individual involvement in the case. An introductory meeting took place with the Case Group at which the Review Team was also present. At this meeting the SCIE model was explained to the Case Group and their role in the review process was clarified. Case Group members were informed they would be involved in individual conversations with Review Team members and the Lead Reviewers and given the opportunity to reflect on and explain their involvement with the case. During the course of the review the Review Team met on ten occasions. The Case Group met on three occasions: one for the introductory session and then for two full day follow-on meetings, where the emerging analysis was discussed and challenged. The Review Team were present in these meetings. The review followed the process, and meeting structures, as outlined by SCIE with additional governance meetings arranged over the course of the review. These meetings involved the Lead Reviewers, SCR Champion, the Independent Chair of Lambeth Safeguarding Children Board (LSCB), and senior managers representing key agencies. Timeframe and Mandate In line with qualitative research principles, reviewers endeavour to start with an open mind in order that the focus is led by what they actually discover through the review process. This replaces the terms of reference (that have a specific focus of analysis before the review process has begun) which are a fundamental feature of traditional Serious Case Reviews. The timeframe for the review was set at the initial meeting between the Lead Reviewers and the Review Team on 8th November 2013. A number of Review Team members were subsequently made aware of a significant history of early intervention services with the parents, this timeframe was later amended to allow a period of this early intervention to be included. The timeframe covered by this SCR is between May 2010 and July 2013. Within the period under review, seven key practice episodes were identified (covering the period from May 2010 until 23rd July 2013). These KPE’s were then analysed in detail to provide insight into not only what happened with Child I but also why things happened as they did. It was from this process of detailed analysis that the learning from the review (presented as findings) was generated. Sources of Data The systems approach requires the Review Team to avoid hindsight bias and to learn how people saw things at the time – the ‘view from the tunnel’. Identifying and examining Key Practice Episodes allows the Review Team to understand the way that things happened and explore the contributory factors that were influencing the Case Group’s working practice. This is known as the ‘local rationality’. It requires those who had direct involvement in the case to play a major part in the review in analysing how and why practice unfolded the way it did and highlighting the broader organisational context. 58 Data from Family Members At an early stage, in this SCR, the parents were contacted and invited to contribute to this review. They expressed their desire to engage in a conversation, to provide their perspectives. However, police advised that the status of the parents, as alleged perpetrator and witness in possible criminal proceedings, ruled out the possibility of their participation in this SCR. These proceedings remained ongoing throughout the review. After a long period of negotiation, with the police leading the criminal investigation by members of the Review Team, agreement was reached for the parents to contribute to this SCR. Both Mother and Father met the Lead Reviewers, and a conversation was held about the services they received under the timeline under review. In this conversation, both Mother and Father were supported by a targeted youth worker, who had known the parents since their childhood. The perspectives of the parents are reflected within this SCR. A transcript of the conversation will be provided to members of LSCB, to further support the learning from this SCR. On behalf of LSCB, the Lead Reviewers wish to express their gratitude to the parents for engaging in this process with grace and humility. In addition, thanks are owed to the targeted youth worker who has continued to provide support to the parents in a time of indescribable loss and grief, and continues to provide support to the parents in looking to the future. Child I’s three remaining siblings are too young to make it feasible to gain their perspectives or experiences. Data from Practitioners Information was provided by members of the Case Group who were directly involved with the family through a process of individual conversations. They were invited to share their experiences of working with Child I and his family in the context of their knowledge, systems and practice at that time. A total of twenty four conversations were held with individual practitioners, who together formed the Case Group for the review. A lead reviewer and a members of the Review Team were involved in each conversation. The Case Group attended two multi-agency meetings, to contribute to the analysis and findings and to share their knowledge of the systems as a whole to help understand whether practice in this case had local resonance. Data from Documentation In the course of the review the Review Team members had access to the following documentation: Integrated chronology Data from agency records Various correspondence across agencies Witten agreements with parents Initial and core assessments Minutes of child protection conferences Child Protection Medicals CLAMHS Assessment (Father) CYPS Leaving Care Pathway Plan (Father) 59 CAF ( Common assessment Framework ) Methodological comment Participation of Professionals The death of a child is a sad and tragic loss. The practitioners in this case knew this family well and many had been in direct contact with Child I and his siblings. This has both personal and professional implications for the practitioners. Naturally, there are feelings of grief for the child and the family. In addition, all the practitioners in this case demonstrated their heart felt desire to improve outcomes for children, and so with this as their mantra, to be involved in a family where a child has died, can bring about complex feelings about their professional worth. This is perfectly understandable and indeed natural. However, the impact of this should not be underestimated. Throughout the process the willingness of practitioners to be involved, and make themselves available for conversations and meetings, has been impressive. At the first Case Group meeting over 40 practitioners and their line managers were present. At each stage of the process, Case Group members have repeatedly shown their commitment to engage in the learning, both in terms of systems and in terms of reflecting on their own of practice. Representation from staff in the Children and Young People’s Service in Lambeth, at Case Group meetings, was limited. This had an inevitable impact on how the voice of this service was represented in the Case Group meetings. Fortunately, there was active participation by a senior manager from this service in the Review Team meetings, this provided a vital link to this service area. After meeting with the parents, the Lead Reviewers were struck by the absence of housing services, both within the Case Group and the Review Team. It was concluded that this lack of representation, from housing services, resulted in a potential gap in the lessons learnt. The Lead Reviewers and the Review Team have been impressed throughout by the professionalism, knowledge and experience the Case Group have contributed to the review, and their capacity to reflect on their own work so openly and thoughtfully. Several have remarked that it has been a positive experience to contribute to learning from the tragedy, for others the process has been more difficult. All this has given the Review Team a deeper and richer understanding of what happened with this family and within the safeguarding network and why, and has allowed us to capture the learning that is presented in this report. Endorsed by LSCB, October 2014 Lambeth Safeguarding Children Board International House Canterbury Crescent London SW9 Published, April 2015 Serious Case Review Child I LSCB Response and Action Plan Agreed October 2014 Published April 2015 Lambeth Safeguarding Children Board 2 The Lambeth Safeguarding Children Board received the Serious Case Review (SCR) at a Special LSCB Meeting on 14 October 2014 and endorsed the findings of the Review Team. It was not possible to publish the SCR at that time, as a criminal investigation into Child I’s tragic death was still ongoing. That investigation is now complete. No one has been charged with any offence in relation to Child I’s death. Lambeth Safeguarding Children Board and its Partners have sought to learn from Child I’s death. This Response should be read alongside the Serious Case Review which gives greater detail of the background to I’s death, the methodology of the SCR and its findings. This Response is not a substitute for the SCR. Child I’s death was an accident. No one could have predicted that he would die in such a way. Child I was 20 months when he died, having been left unsupervised in the bath. He and his siblings were known to local agencies and were subject of a child protection plan. Child I had been subject of a plan since birth, shortly after birth. The SCR shows the need for professionals to work closely with each other and with parents. It also shows that the parents’ own needs and their ambivalence towards professionals can hamper professionals seeing when parenting is not good enough in longer term chronic situations, where there is little change. For this family to parent four young children was a challenge. In a busy environment with organisational change and changes of personnel or roles within the case opportunities were missed for all partner agencies to work together and recognise that there was limited parental capacity or motivation for change and that the child protection plan was not working effectively. The serious case review involved as many of the practitioners and their managers as possible, through individual conversations and workshops to gain a sense of whether the findings were unique to this case or could be used as a ‘window’ on the local child protection system. The Lambeth Safeguarding Children Board is grateful to the practitioners for their openness in the review process, given the sadness caused by Child I’s death. Practitioners worked hard to support the family and develop helping relationships with them. At the end of the review process it became possible to speak with the parents about their experiences of help. What they said has been summarised in the report at face value rather than challenged; it was the parents’ perception – even if the professionals involved believed that the reasons for concern and what had to be different were made clear. The SCR identified seven findings and two additional possible lessons. They are reported below in detail in the Action Plan. They cover: the complexity of recognising cumulative neglect; the need for the whole multi-agency network to take responsibility; Lambeth Safeguarding Children Board 3 the complexity of understanding the abilities and any limitations of parents who may have a learning disability and how to work with them; the importance of the whole system ensuring effective child protection conferences and core groups; the need to thoroughly assess any new incident or concern separately; the need to focus on the individual children and not be distracted by parents, who may be reluctant to engage; and the need to understand the evidence of the value of written agreements, especially with parents who may not understand them: and what will happen when they are not adhered to. The two additional lessons cannot be shown to be systemic beyond this case but were included as the Review Team believed that they were important considerations for wider multi-disciplinary case management. One is in the form of a question rather than found to have been evidenced, querying how judgement is used to fully balance strengths and challenges in families and to ensure that risks to children are fully assessed and understood. In this case it appeared that the positives were seen but not, necessarily, the possible full impact of the gaps or inconsistencies in parenting. The other lesson may be unique. The Review Team believed that the impact of another, contemporaneous and tragic case was negative; adversely affecting some of the key practitioners and, as a result, the timely management of this case. The LSCB has agreed and has been implementing an Action Plan to address these findings. The Action Plan will be kept under review by the LSCB. It is summarised below. Lambeth Safeguarding Children Board April 2015 Lambeth Safeguarding Children Board 4 Serious Case Review Child I Action Plan Actions Lead Person/ Agency Expected outcome SCR Finding One: There is an insufficient understanding across the multi-agency professionals of the concept of neglect, and how to understand and articulate the cumulative impact this has on the health and development of individual children. This results in children continuing to experience neglect, despite input from professionals from across all agencies. 1.1 The LSCB will re-distribute the 2011 publication/s Safeguarding children across services (The DfE Messages from Research into the incidence of neglect and evidence-based responses) to all partners. Partners will be asked to inform the LSCB how the research has been implemented and of any future action plans. Agencies will also be asked to ensure that the research continues to be cascaded to staff and to advise the LSCB of any additional multi-agency safeguarding training needed. LSCB All agencies Learning and Improvement Sub Group Frontline practitioners, their line managers and partner agencies will be reminded of the key research messages relating to neglect. As a result there will be greater awareness and recognition of chronic or longer term neglect and its impact. This will ensure more effective and timely intervention plans. LSCB Multi-Agency Training will have been reviewed to ensure that the messages continue to be delivered to frontline practitioners. 1.2 The LSCB will seek a report on the implementation to-date of the Signs of Safety model for assessment and intervention. The report should cover the impact of the model, It should also assess the model’s effectiveness in addressing longer-term neglect. LSCB CYPS Greater awareness of how the model has been introduced across Lambeth agencies and of the impact it is having in cases, particularly where there is longer term neglect. This will lead to better recognition of children at risk from neglect and more effective intervention and child protection plans. SCR Finding Two: The lack of full multi-agency ownership of how children are safeguarded means that there is insufficient professional challenge and debate, compromising the quality of safeguarding work Lambeth Safeguarding Children Board 5 Actions Lead Person/ Agency Expected outcome And SCR Finding Four: There is a lack of rigour in ensuring that child protection conferences and core group meetings are functioning effectively. 2.1 Children’s Social Care will undertake a review of the operation of Child Protection Plans, Written Agreements and Core Groups and report this to the LSCB. This will include any recommendations for action to the LSCB and Partners. See also 5.1 below CYPS Children’s Social Care A clearer understanding by the LSCB of the operation of CP Plans and Core Groups and what action, if any needs to be taken. The result will be better leadership and understanding by core group members of the role of CP Plans and Written Agreements, greater focus on actions to be taken in cases, avoidance of drift and clarity for families on what must change and how they will be supported. 2.2 The Review at 2.1 should ensure that each CP Plan should contains a clear contingency plan to be used if there is insufficient progress in reducing risk of significant harm and when and how it will be initiated. CYPS Children’s Social Care The Parents and Core Group will have a clear trigger for when to initiate a contingency plan if there is an increase in risk of significant harm or insufficient progress. 2.3 Agencies should inform the LSCB how they will prioritise attendance at Child Protection Conferences and Core Groups. The LSCB should receive quarterly data on agency attendance at CP Conferences and Core groups. All Agencies LSCB CP Conferences and Core Groups will be well-attended by the core agencies and as a result CP Plans will be implemented and monitored more effectively. The LSCB will have a clear understanding of the operation and effectiveness of these two key multi-agency processes. 2.4 Agencies should remind all child protection practitioners and first line case managers/ supervisors of the need to escalate concern where there is insufficient progress of a CP All agencies Practitioners will have the confidence to professionally support and challenge each other for the benefit of children. Where there is insufficient Lambeth Safeguarding Children Board 6 Actions Lead Person/ Agency Expected outcome Plan or lack of adherence to a CP Plan, including lack of adherence to agreed multi-agency process and decision-making. The procedure for this is in the London Child Protection Procedures Part B Practice Guidance: Professional Conflict Resolution In addition to the London CP Procedures, when there is insufficient progress on a child protection plan it should be escalated to the CP Conference Chair for consideration for early review. (See also Finding 5 and Actions below) Agencies should ensure that practitioners have the ability and confidence to challenge partners within the multi-disciplinary team. progress in a CP Plan or where there are increased or new causes for concern CP Plans will be reviewed earlier and revised as necessary to ensure adequate protection. 2.5 The LSCB should satisfy itself that the process for closer monitoring of longer term child protection cases is robust. The LSCB Learning and Improvement Sub Group should be notified when a child has been the subject of a CP Plan for 18 months; or where it is a repeat CP Plan after 12 months. An alert system should be devised. There should be a quarterly report on any such cases to the LSCB and how they have been resolved. Learning & Improvement Sub Group CYPS CYPS Better understanding of cases where there has been insufficient progress over time to enable consideration of alternative actions. Better scrutiny of the overall CP process and its effectiveness. 2.6 In progressing actions under Finding Two the LSCB and Partners should also note the Action agreed in the Child H Short Term Project Group, including members of the Better understanding of cases where there has been insufficient progress over time to enable consideration of alternative Lambeth Safeguarding Children Board 7 Actions Lead Person/ Agency Expected outcome SCR Action Plan (June 2014): The LSCB should review the Quality Assurance procedures for over-seeing cases where children have been made subject of child protection plans … and where there has been no apparent process. Safer Lambeth Partnership and the DV Co-Ordinator. actions. SCR Finding Three: The confused professional response to families where parents have learning difficulties has a detrimental impact on safeguarding work. 3.1 Children’s Social Care should lead a multi-agency review of the Joint Policy for Working with parents who have learning difficulties / disabilities and revise or re-implement it. This review should also consider the use of the Parenting Assessment Manual* and Checklists. The review should be undertaken alongside the review of CP Plans and Core Groups at 2.1 above. (*devised by Dr Sue McGraw) Children’s Social Care All agencies Practitioners’ knowledge and understanding of the impact of parental learning disability will be improved and will provide a better assessment of the capacity of the parent/s to change to meet the child’s needs within the child’s timescale as part of the CP Plan and progress monitoring. 3.2 The LSCB should work with the Safeguarding Adults Board to share the learning from this case review and ensure joint responsibility for assessment pathways, where a parent may have a learning disability, as part of 3.1. LSCB Chair & SCR Sub Group Chair Better access to advice to children’s services practitioners to increase understanding of parents’ learning disability and parental capacity. Realistic CP Plans. Clearer timescales for children Access to specialist resources. SCR Finding Four: There is a lack of rigour in ensuring that child protection conferences and core group meetings are functioning effectively. See Actions for Finding 2 above Lambeth Safeguarding Children Board 8 Actions Lead Person/ Agency Expected outcome SCR Finding Five: When children are already on a child protection plan, there is a tendency for additional concerns not to be investigated through the correct child protection process. The assumption is that this will be addressed at the next child protection conference or core group. 5.1 The review of the operation of CP Plans and Core groups at 2.1 above will include a review of the use of multi-agency section 47 strategy discussions and enquiries for children already subject of CP Plans CYPS Children’s Social Care New concerns, incidents, examples of neglect will be investigated according to the agreed multi-agency guidance. 5.2 Child Protection Conferences and Core Groups will formally note any additional incidents or concerns and the actions taken as a result in all review meetings. See also 2.4 above Child Protection Conference Chairs Core Group Chairs Cumulative assessments will be updated to take account of all new concerns and give a fuller picture of any significant harm. 5.3 All agencies should remind practitioners that any new incident of suspected harm of neglect should be assessed as a section 47 enquiry, under the Child Protection Procedures. See also 2.4 above All Agencies As 5.1 and 5.2 SCR Finding Six: Despite clear procedural guidance for working with families who are hostile and aggressive, such behaviour still tends to disrupt the effective functioning of the child protection process. The result is an adult focus that distracts professionals from identifying and responding to the risks to individual children. 6.1 The LSCB will take steps to strengthen the voice of the child by monitoring that all CP Conferences consider the experience and voice of the child. The LSCB will receive a quarterly report to demonstrate that CP conferences have considered each child’s view and experience. Children’s Social Care CP Conferences will have formally considered the child’s experiences and wishes. The LSCB will have scrutiny that the child’s view is being taken into consideration. Lambeth Safeguarding Children Board 9 Actions Lead Person/ Agency Expected outcome 6.2 All agencies will ensure that practitioners are aware of the London Child Protection Procerdures Supplementatry Guidance B6: Managing work with Families where there are obstacles and resistance As a result of this action All Agencies will advise the Learning and Improvment Sub Group if additional multi-agency training is required to assist practitioners in developing skills in managing hostile or aggressive adults including de-escalation techniques. All Agencies All Agencies Learning and Improvement Sub Group Practitioners will be reminded of the guidance, will consider techniques for managing hostile behaviour in parents and further develop skills. The LSCB will have commissioned training if it is required. SCR Finding Seven: There is a tendency to use written agreements to support child protection arrangements. The effectiveness of written agreements, as a tool to ensure parents do what is required of them, is questionable. 7.1 As part of 2.1 above the LSCB will review the use of Written Agreements and contingency plans; and sanctions when agreements are not adhered to. See also London Child Protection Procedures: Each Local Safeguarding Children Board should ensure that standard arrangements for the recording of the written agreement are in place. (London CP Procedures 5.3.5 – 5.3.13) See also 1.2 above – review of the use of the Signs of Safety methodology and its implementation in Lambeth. CYPS Children’s Social Care Key workers and core group members will be better able to use written agreements to ensure clarity of actions in CP Plans to ensure protection of children and will also include sanctions for failure to comply with the agreed actions. Parents/carers will be clearer about what actions they must take to safeguard their children and what support they will be given; and what agencies will do if children are not protected as agreed. 7.2 The LSCB should audit a sample of written agreements to ensure that there is understanding of the expectations and that the agreements in use are effective Learning and Improvement Sub Group The LSCB will have assessed and assured itself of the use of written agreements and their efficacy in child protection work. Lambeth Safeguarding Children Board 10 Actions Lead Person/ Agency Expected outcome in protecting children. 8. SCR Additional Learning One: Is there a pattern in Lambeth of routinely identifying protective factors and strengths in families, as part of the child protection process that results in false re-assurances when the strengths are named but not fully assessed or are given undue weight? 8 See Action 1.2 above 9. SCR Additional Learning Two: The tragic death of another child had a significant impact on the multi-agency team and had a detrimental effect on the work in this case. 9 A contingency protocol to be agreed in advance to ensure the ongoing quality work in other cases; for implementation when a team experiences a serious critical incident which has a temporary impact on the work of the practitioners and supervisors and hence the management of other child protection cases. 10. Dissemination of the lessons from the SCR 10.1 The LSCB will provide leadership by producing a summary of key lessons in a briefing and through multi-agency dissemination workshops which can be used by agencies and in other relevant professional meetings and local training. These will draw attention to the SCR itself. The LSCB will also include the findings in all LSCB training for next 12 months by providing a key 15 minute briefing. LSCB Training and Development Managers Learning and Improvment Sub Group Practitioners, first line managers and supervisors with case responsibility and specialist safeguarding advisers will be aware of the lessons from this review and will use them in ongoing their work. Practitioners, first line managers and supervisors with case responsibility and specialist safeguarding advisers will be aware of the lessons from this review and will use them in 10.2 Lambeth Partner Agencies will take the responsibility to disseminate the key lessons and briefing to all relevant front line practitioners and to report to the LSCB that they have done this. The agency reports will include the numbers and All LSCB Agencies Lambeth Safeguarding Children Board 11 Actions Lead Person/ Agency Expected outcome percentage of staff who have received the briefings. ongoing their work. 10.4 LSCB Training will be reviewed to ensure that it includes these local lessons. Learning and Improvment Sub Group 10.5 The SCR and findings will be shared with neighbouring LSCBs and the London Safeguarding Children Board LSCB Chair and LSCB Manager Improved Learning wider than Lambeth 10.6 The key lessons from the review will be included in the LSCB Annual Report LSCB Chair and LSCB Manager Improved Learning wider than Lambeth 11. Quality Assurance 11.1 The LSCB will audit a sample of cases subject to child protection plans to ensure itself that the actions above are in place and are having an impact. Learning and Improvement Sub Group Lambeth Partner Agencies will be held to account for implementing the actions and ensuring that direct work with children and families takes account of the risks from parental violence, and works to reduce these or to take alternative actions in order to safeguard children. 11.2 Agencies will be asked to ensure that their internal Quality Assurance and Auditing activity from January 2015 includes reviews of cases where there is chronic neglect, parental learning disability or parental hostility using these lessons and any standards arising from these actions. All agencies Learning and Improvement Sub Group Agencies will report to the LSCB on their audits. 11.3 Monitoring of the Actions Above The SCR Sub Group Chair will report to the LSCB Chair and LSCB at least quarterly on progress of this Action Plan, LSCB Manager & SCR Sub Group Chair The LSCB and Partner Agencies will monitor the improvement as a result of the learning from this SCR. Lambeth Safeguarding Children Board 12 Actions Lead Person/ Agency Expected outcome highlighting any exceptions. Action Plan Agreed December 2014 |
NC52223 | Review of the support received by Child G in the period 2014-2019 including her allegation of sexual abuse in August 2018. In 2018. Child G lived with Mr A, her maternal great uncle, and his wife, who were Child Gs Special Guardians. Child G alleged she was sexually abused by Mr A. A police investigation concluded there was not sufficient evidence to proceed with a prosecution. Mr A had historical allegations of sexual abuse made against him. Child G was born in 2011; parents separated during the pregnancy. She has two older and one younger half siblings. Child Gs mother had mental health needs and was inconsistent in engaging with professionals. Evidence of incidents of domestic abuse. Childrens social care were involved with the family since 1995. In October 2015 Child G was subject to a Child Protection Plan under the category of neglect before moving to live with special guardians in February 2018. Subsequent evidence of distressing and sexualised behaviour led to an urgent GP referral to Child and Adolescent Mental Health Services (CAMHS) in August 2018. Family is White British. Learning includes: communication challenges across partnerships working with a family with multi-faceted needs; the Special Guardianship Order report and recommendation was not subject to sufficient scrutiny; the need for professionals to be aware of the possibility of trauma and current abuse, in children presenting with distress and high levels of disturbance; and delays to accessing of therapeutic support. Recommendations include: ensure that family support is consistently applied and not stepped back due to resource pressures; ensure there are mechanisms to review caseload size, and social work shortages; review of processes for undertaking Special Guardianship assessments; review training on trauma informed practice and sexual abuse.
| Title: Report of the serious case review regarding Child G. LSCB: Surrey Safeguarding Children Board Author: Rhian Taylor Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 36 Surrey Safeguarding Children Board Report of the Serious Case Review regarding Child G Author Rhian Taylor BA (hons) MSc, DipSw, PGCHE, FHEA, Lead Reviewer Associate, In-Trac Training and Consultancy Page 2 of 36 Contents INTRODUCTION ................................................................................................. 3 CASE BACKGROUND ....................................................................................... 5 CASE NARRATIVE AND EVALUATION OF AGENCY PRACTICE .................. 7 SUMMARY OF FINDINGS & RECOMMENDATIONS ...................................... 19 APPENDIX 1 – Terms of Reference ................................................................ 34 APPENDIX 2 – The Review Process ............................................................... 35 Page 3 of 36 INTRODUCTION 1.1 This Serious Case Review (SCR) was commissioned by Surrey Safeguarding Children Board to review and learn from the practice which related to Child G. Child G was placed under Special Guardianship Order1 (SGO) with her maternal great aunt and uncle (referred to in the report as Mr and Ms A). During the latter period when she was living with Mr and Mrs A, Child G was observed to be demonstrating behaviours that could indicate that she had been sexually abused. In November 2018, Child G made allegations of sexual abuse by Mr A and a full ABE (Achieving Best Evidence)2 interview was completed. There had been a previous allegation against Mr A of indecent assault on a minor. There had been sufficient evidence to charge Mr A of this offence, however, he was found not guilty at court. The police investigation which occurred regarding Child G’s allegations concluded that there was not sufficient evidence to proceed with a prosecution. 1.2 In light of this, a referral to Surrey Safeguarding Children’s Board occurred on 13th December 2018. A rapid review took place on the 21st December 2018 and a decision was made that the criteria for a Serious Case Review had been met as abuse of a child was known or suspected and the child was seriously harmed; and there are concerns about how organisations or professionals worked together to safeguard the child3. In April 2019 Rhian Taylor was appointed as an independent lead reviewer and is completely independent of all agencies involved in the review. Rhian’s experience is set out in Appendix two. 1.3 Surrey Safeguarding Children Board appointed a chair and Review Panel to oversee the review. The membership is outlined below. Agency Representative Surrey Clinical Commissioning Group Chair of the Panel: Designated Nurse Looked After Children. Deputy Designated Nurse Safeguarding Children Safeguarding Nurse Advisor for Children and Adults 1 Special Guardianship is an order made by the Family Court under the Adoption and Children Act 2002 that places a child or young person to live with someone other than their parent(s) on a long-term basis. http://www.legislation.gov.uk/ukpga/2002/38/section/115 2 An A.B.E. interview refers to the guidance for interviewing children specified in ‘Achieving Best Evidence (ABE) in Criminal Proceedings: Guidance for Vulnerable or Intimidated Witnesses’ (2011) available at https://www.cps.gov.uk/sites/default/files/documents/legal_guidance/best_evidence_in_criminal_proceedings.pdf 3 H.M. Government (2015) Working Together to Safeguard Children, Online, Available from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf Working together to Safeguard Children is the government’s overarching guidance on safeguarding. Page 4 of 36 Rhian Taylor Independent Overview report author Surrey County Council Children’s Social Care Team Manager Surrey County Council Legal Services Principal Solicitor Surrey and Boarders Partnership Consultant Nurse Safeguarding Children and Families Courts and Advisory Support Services (CAFCASS) Service Manager Surrey Police Force Advisor Child Exploitation and Abuse Surrey County Council Education Authority Area Schools Officer 1.4 There were a number of delays to completing this Serious Case Review, primarily as a result of restructuring in the safeguarding partnership, which caused a delay in organising panel meetings and making sure that chronologies were completed. 1.5 In September 2019, the new requirements for multi-agency safeguarding arrangements outlined in Working Together to Safeguard Children (2018)4 meant that the Surrey Safeguarding Children Partnership replaced Surrey Safeguarding Children Board. The panel, therefore, transitioned to reporting to the Partnership. 1.6 The methodology of the review was designed to focus on not only what happened, but also why practice decisions were made, and to use this understanding to make recommendations for practice improvements. The following agencies were asked to submit a detailed chronology in line with the dates identified in the Terms of Reference (Appendix one), 1st February 2014 to 28th February 2019. They were also asked to comment on their practice alongside the identified timescales in the chronology. During a series of panel meetings, agency representatives were able to analyse these reports in their consideration of learning and recommendations. 1.7 Organisations who supplied information included: • Ashford and St Peters Hospitals • Cafcass (Child and Family Court Advisory and Support Service) • Children and Family Health Surrey • General Practitioner • Independent Social Work Agency • National Probation Service and Kent, Surrey and Sussex CRC (Community Rehabilitation Company) 4 H.M. Government (2018) Working Together to Safeguard Children, Online, Available from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf Working together to Safeguard Children is the government’s overarching guidance on safeguarding. Page 5 of 36 • Surrey and Borders Partnership • Surrey Children’s Social Care • Surrey Police • Surrey Schools and Learning. 1.8 The panel has had access to a number of relevant court reports and statements from the care proceedings made available with judicial permission in order to provide fuller material and balance of opinion within the Serious Case Review process. 1.9 Practitioners contributed to the learning and analysis of practice through a group event early in the process, individual discussions, and a later event that allowed practitioners to comment on a draft version of the final report. 1.10 In line with Working Together to Safeguard Children (2015) guidelines, family members were advised that the review was underway. Child G’s mother was informed about the Serious Case Review process but stated she did not want involvement. Child G’s father was informed and chose to be involved. He was visited by the lead reviewer and a panel member so that his perspectives could be ascertained. His views are included in the report. Mr and Mrs A were notified the review was taking place and invited to participate. They chose to be involved and met with the lead reviewer and a panel member. Their views and perspectives are included in the report. Due to Child G’s age, she was not interviewed as part of the report process. Although the panel has focussed on her lived experience and considered her perspective where possible, without direct contact there are limits to the ability of the report to capture Child G’s voice and individual experience. CASE BACKGROUND 2.1 Family Composition – Names Year of birth Gender Relationship Ethnic origin Child G 2011 F Subject White British Mother F Mother White British Father M Father White British Older sibling - known in the report as Sibling 1. M Half Brother on Mother’s side White British Older sibling- known in the report as Sibling 2. F Half-sister on mother’s side White British Page 6 of 36 Younger sibling – known in the report as Sibling 3. F Half-sister on Mother’s side White British 2.2 Other significant adults: Mr and Mrs A are Child G’s great aunt and uncle on the maternal side. They became Special Guardians for Child G. Child G’s grandmother on the maternal side had an important role in caring for Child G and is currently the carer for Sibling 3. 2.3 In terms of early history, Child G’s mother and father split up during the pregnancy of Child G. Her father has been in contact at various points during her childhood but in interview he explained his involvement had been limited due to serving several prison sentences. He expressed sadness about this limited contact and stated that in retrospect he would have sought to have been more involved with his daughter. He said he always felt confident Child G’s mother would provide adequate care for Child G. Child G’s father has two other children from a previous relationship. They live with their mother and have limited contact with their father. 2.4 Sibling 1 did not live with the family during the main period of this chronology, although visited the family home and occasionally stayed with the family. Until Child G became subject to an Interim Care Order in August 2017, Child G lived with her mother, Sibling 2, and Sibling 3. 2.5 Records indicate that Child G’s mother had ongoing and significant mental health needs. The police chronology reports a number of incidents of domestic abuse within the home. Children’s Social Care have been involved with the family since 1995 with regard to Child G’s older siblings as well as Child G and Sibling 3. The identified concerns were in relation to neglect and parental failure to protect the children from harm and meet their basic needs. Child G’s mother had an inconsistent history of engaging with professionals. Although there was some engagement, the concerns regarding the family were significant, ongoing and are outlined in greater detail below. Page 7 of 36 CASE NARRATIVE AND EVALUATION OF AGENCY PRACTICE Early intervention with the family (February 2014 - October 2015) 3.1 During the period February 2014 - November 2014 there were ongoing concerns about neglect within the family and referrals to Children’s Social Care from the police and the school. There was a particular focus on the needs of Sibling 2. In March 2014 there was a Children and Families Assessment with a recommendation for case closure. In November 2014 there was a Section 47 enquiry5 regarding allegations of physical abuse on Sibling 1 by mother. The younger children were not seen or spoken to. There was no health visitor involvement despite the family having a number of identified needs. This would have been available if Mother had requested it, but as a universal service it was reliant on Mother requesting health visitor input. 3.2 In March 2015 there was a referral from the school regarding the attendance of Sibling 2. The referral highlighted the impact of mother’s poor mental health on the children. There was a Children and Families Assessment, but the children were not spoken to or seen in a home visit. The case was then closed. 3.3 In June 2015 a social worker was allocated due to concerns of neglect. A Child in Need (CIN) plan was put in place but there was a lack of follow up on recommended actions. Mother was not attending her own health appointments. Summary evaluation: Early intervention with the family During this phase of intervention with the family, there was evidence of a lack of listening to, and hearing the lived experience of the younger children in the family, who were often not seen. Their needs were not being made visible, nor were there sufficient links being made between the experience of the older sibling and the likely parallels for the younger children. The children were not receiving the support of a health visitor, as Mother had not requested involvement. However, this could have been a beneficial service in terms of the children’s needs and raises the issue of children missing out on services if parents are struggling to engage or reluctant to ask for support. Whilst different agencies were working with the family and offering some intervention, there was a lack of joined up support and the wider picture of issues that the family was facing, was not addressed. 5 A section 47 enquiry occurs when Children’s Social Care have reasonable cause to suspect that a child in their area ‘is suffering or is likely to suffer, significant harm.’ The aim of the assessment is whether any action should be taken to safeguard the child. HM Government (1989) Children Act, (Online), Available from: https://www.legislation.gov.uk/ukpga/1989/41/data.pdf, Page 8 of 36 The Child in Need plan was not sufficiently effective in bringing together multi-agency involvement. The context for this practice extends beyond this specific case, with similar issues relating to concerns about cases being closed prematurely and poor multi-agency planning, particularly in relation to neglect, being highlighted in the 2015 Ofsted report 6. Ofsted questioned the effectiveness of the system of early help (page 48) and the service has since been restructured. With the benefit of hindsight, it seems that a more effective early intervention would have been useful in addressing the family’s needs as they presented during this period. Child G subject to Child Protection Plan (October 2015 - July 2017) 3.4 In October 2015 a further Section 47 enquiry occurred following an incident of domestic abuse, and the threshold was met for an Initial Child Protection Conference (ICPC). The conference made Child G, Sibling 2 and Sibling 3 subject to a Child Protection Plan under the category of neglect. The Initial Child Protection Conference report outlined numerous concerns regarding Child G, including reports of iron burns to her face and body whilst under her mother’s care. There was a recommendation for parallel legal planning. 3.5 Between November 2015 and January 2016, the subsequent core group met and included the health visitor, who began to build a relationship with the family. There was ongoing difficulty in engaging Mother, who was struggling with her mental health. Records indicated a change of social worker. There was positive engagement with a family support worker who was helping Mother attend appointments. 3.6 In January, the chronology identified Mr and Mrs A as involved in supporting Mother with the children. During February, it was indicated that Child G was staying over with Mr and Mrs A. No risk assessment or further checks were made regarding this. 3.7 On 2nd February 2016, Child G’s primary school informed Children’s Services that a parent had come to see them informing them that Mr A, who was supporting Child G with school attendance, had historical allegations of sexual abuse made against him. This was noted in the subsequent Review Child Protection Conference minutes, indicating a discussion with a family member who had said that he had been found not guilty, but there was no indication that this information was pursued by Children’s Services following the conference. The outcome of the conference was that all three children remained on a Child Protection Plan under the category of neglect, with the chair highlighting that due to the lack of progress there needed to be parallel legal proceedings. This had not been progressed following the first conference. 6 Ofsted (2015) Surrey County Council: Inspection of services for children in need of help and protection, children looked after and care leavers. https://files.api.ofsted.gov.uk/v1/file/50004296 Page 9 of 36 3.8 Child G made an allegation of her mum hurting her. This was not addressed until over a month later. Child G was visited at school by her social worker where she told the social worker different ways she was being hurt, including her older sister holding her face under water. Records indicate that this was seen by the social worker as over chastisement rather than harm. 3.9 In May 2016, Mrs A asked if her and her husband could be considered as carers for Child G. Child G was spending an increasing amount of time with Mr and Mrs A, and they were positive about their relationship with her and their ability to offer support. 3.10 During the June to October 2016 period there was no legal planning despite the earlier direction. The suggested Family Group Conference did not take place. Mother was cancelling appointments with professionals and despite numerous attempts the health visitor did not see Child G for several months. Child G was handed over to the school nursing team. Mother was also not attending her own health appointments. 3.11 The subsequent Review Child Protection Conference highlighted the lack of progress regarding the Child Protection Plan. As a consequence of this, the local authority initiated the pre-proceedings Public Law Outline process. There was no follow up on the noted concerns of sexual abuse allegations regarding Mr A. 3.12 A further Review Child Protection Conference was held in January 2017 with Child G remaining on a Child Protection Plan under the category of neglect. At the conference, the school expressed concern about Child G’s ongoing behaviour deterioration. It was noted that Mrs A was bringing Child G to school on a regular basis. 3.13 In March 2017 there are records of incidents of domestic abuse, and Mother’s mental health was deteriorating to the point it was agreed she would not be on her own with the children. Her mother stayed with the family to assist in supporting the family. Support to Child G was being offered through one to one support at school. There continued to be consistent support and involvement from the family support worker. 3.14 An audit of the case by Children’s Social Care occurred which identified issues of drift and delay. The chronology does not indicate the response to the audit, and whether the tasks set by the audit were completed within the identified timescales. Page 10 of 36 3.15 In May 2017, Child G’s father was released from prison and began to stay with the family. The social worker identified the need for a risk assessment but there was no follow up on this. From discussion with Child’s G’s Father, he describes himself as being keen to get know Child G within this period, although he felt he could not be consistent because of instability in his life and police involvement. 3.16 In June 2017 Child G and Sibling 3 were found almost naked at the local shops. Child G had climbed out of a first-floor window. A single agency Section 47 enquiry was initiated leading to a safety plan. 3.17 At the Review Child Protection Conference, the accumulation of incidents and the lack of progress in meeting the children’s needs for safety and stability was identified. Following the review conference, Children’s Social Care made the decision to initiate care proceedings. Summary evaluation: Child G subject to a Child Protection Plan There was evidence of delays and drift during this period. Allegations made by Child G were not followed up promptly and there were missed opportunities to consider whether Child G was experiencing harm. Records indicate that supervision was still focussing on the older children. The school were passing on allegations but there was not a feedback loop in them knowing how these issues were progressed. Discussion at the practitioner event highlighted confusing messages over what information they were entitled to request following the passing on of allegations, and the school did not feel confident in asking about the outcome of the information they had referred. This lack of information contributed to their ability to effectively use the escalation procedures. There were a number of changes in the professionals working with the family during this period. One of these was that health responsibility for Child G moved from the health visitor to the school nursing team. Whilst these professionals work closely together and shared information effectively, this was still a change in worker for Child G at a point when she had developed a good relationship with the health visitor. Within the service specification there is flexibility in the age children are transferred to the school nursing service (they can be maintained by health visitors until the age of 7). This flexibility in case transfer is important in promoting the building of trust and sustained professional relationships. This is particularly important when parents are engaging inconsistently as Mother was during this period. There was also a change in social worker during this time. Mother was frequently cancelling appointments, leading to the children not being seen. It is likely that frequent changes in professionals made eluding ongoing engagement (if this was what the Mother was doing) more feasible, as if a professional has a sustained relationship with a parent they are in a better Page 11 of 36 position to challenge their behaviour and understand patterns of compliance and disengagement. Professionals with sustained relationships are also in a better position to note and respond to indications of trauma in children. This should be prioritised by agencies and noted as an important part of developing trauma-informed practice in organisations. The social worker was not completing actions and procedural requirements within the correct timescales and the proposed Family Group Conference was not held. Feedback from practitioners indicates that this was a time of high caseloads in the team. There was also a lack of supervision and management oversight to pick up on uncompleted actions and planning. There were no records of audits during this period, which would have provided an organisational oversight of uncompleted tasks. The Ofsted report (2015) highlighted the issues of drift7 (page 15, point 54) and the length of time children were subject to Child Protection Plans, over a year before this point in the chronology. It is concerning that there was still evidence in Children’s Social Care of this issue despite it being highlighted by Ofsted. Despite the deterioration in Mother’s mental health there was a lack of a co-ordinated response. Responses seemed to be crisis driven without sufficient attention to the accumulating concerns. There was not adequate risk assessment on a range of issues, including Child G’s contact with Mr and Mrs A. There was a lack of challenge in the system. The tasks identified by the audit were not followed up and there was insufficient evidence of curiosity and challenge in terms of the children’s experience and their safety. Care planning processes and assessment for Special Guardianship Order (August 2017 - February 2018) 3.18 In August 2017, Mr and Mrs A contacted Children’s Social Care to put themselves forward as carers for Child G, who had been staying with them for the previous three weeks and with whom they felt they had a strong connection. The child’s mother was not aware of this request. In the social worker’s initial meeting Mr A disclosed previous police involvement from 2006 and 2007 where he was arrested and taken to court for an offence of indecent assault on a minor, his ex-partner’s teenage daughter. There was sufficient evidence to charge, however Mr A was found not guilty at court. Criminal courts use ‘Beyond all reasonable doubt’ as their legal standard of proof. A referral for a Regulation 24 assessment8 was sent to the fostering team. 7 Ofsted (2015) Surrey County Council: Inspection of services for children in need of help and protection, children looked after and care leavers. https://files.api.ofsted.gov.uk/v1/file/50004296 8 A Regulation 24 assessment occurs when a relative, friend or other connected person is being considered as a carer for a Looked After Child. The carers are assessed as temporary foster carers under the Care Planning, Placement and Case Review (England) Regulations 2010. Page 12 of 36 3.19 On 31st August 2017 an Interim Care Order was made. Child G and Sibling 3 were placed together out of county, in a foster placement. 3.20 A Regulation 24 assessment was completed stating that the social worker was unable to recommend Mr and Mrs A for a temporary Connected Persons fostering placement. Records in the chronology state that the social worker was unable to recommend Mr and Mrs A due to a number of concerns. Mr A had disclosed mental health issues which could have affected his emotional availability to care for a child. Mrs A had physical health difficulties which could have impacted on her ability to deal with the emotional challenges of caring for a young child and meet their needs. The social worker also stated that bearing in mind the historical accusations of abuse, they were not able to sufficiently assess the risk in the timescale provided, so could not eliminate potential risks relating to this. A Police National Computer (PNC) check was completed but this came back clear with no trace for either applicant. Having discussed this assessment with Mr and Mrs A, they disagreed with the social workers response to their health concerns and told the lead reviewer that these were past problems and would not have affected their care of Child G. 3.21 In September 2017, when at a contact meeting, Child G made an allegation of physical harm by her mother when she was in her mother’s care. She also made an allegation of possible sexual abuse by her mother’s ex-partner. The record of this supervised contact was not responded to, and there was no indication in the chronology of these concerns being followed up. 3.22 During this period, Child G was showing distressed behaviour in foster care, hitting animals and becoming destructive and aggressive in the home. She was subsequently moved to a new foster placement. A handwritten note attached to the Looked After Children (LAC) review in September identified concerns around Child G demonstrating behaviour which had a sexual content. The Independent Reviewing Officer confirmed that whilst this note is no longer available, there was discussion about Child G’s sexualised behaviour at this review. 3.23 A referral for an assessment of Mr and Mrs A as potential alternative carers (Special Guardians) was sent to the Fostering (Friends and Families) Team. The referral did not provide information about the historic allegations, nor the other concerns that led to the negative Regulation 24 assessment. There is mention of a positive viability assessment, but this cannot be sourced from the records. There is no indication in the records or chronology that information was sought from historic Children’s Social Care records of the Section 47 enquiry that would have related to the historic allegations made against Mr A. Children’s services records could have provided relevant information regarding background information on Mr A, and the alleged incident. This social services check should have been completed and would have assisted in Page 13 of 36 providing more evidence for decision making. In the management discussion regarding the referral for the Special Guardianship assessment for Mr and Mrs A, there is no record of consideration of the issues raised in the negative Regulation 24 assessment or the historic allegations. 3.24 Due to capacity issues in the Family and Friends Fostering Team, the Special Guardianship Order (SGO) assessment was outsourced to an Independent Social Work agency. 3.25 In November 2017 the completed SGO assessment was returned. It identified positives in Mr and Mrs A’s relationship and said that the child’s mother supported this prospective placement. The social worker identified vulnerabilities in Mr and Mrs A’s lack of knowledge of attachment and children’s difficulties, Mr A’s mental health and the proximity of the family home to Child G’s Mother. In her report, the assessor acknowledged there were gaps in the information at the time of finalising her report and making her recommendation, stating she had not had sight of the either carers’ Disclosure and Barring Service checks, the medicals, the written references or any other background checks. She had not spoken to Mr A’s previous partner, or Mr A’s daughter or stepdaughter. In the report she acknowledged she only had Mr and Mrs A’s account of the historical allegations. The recorded discussion with Mr A in the SGO report regarding the offence was not supplemented by Police or Crown Prosecution Service documents, and therefore relied on Mr A’s narrative of what happened. In discussions with the reviewer, the report writer said that she only had Mr A’s account of what happened and didn’t have alternative information which could have potentially allowed her to provide a challenge to this narrative. With the benefit of hindsight this was an inadequate response to making a risk assessment which was critical for Child G’s ongoing safety. The report author also identified that access to past Children’s Social Care records and past files would assist Independent Social Workers in having further information and evidence to draw on, enabling a more thorough assessment. This happens in some independent social work agencies but was not a requirement in this particular agency. The SGO report author recommended that a Special Guardianship Order should be made in respect of one child, Child G, given her pre-existing relationship to the family. 3.26 The local authority supported the recommendation of the SGO author for Child G to be placed with Mr and Mrs A. Although questions were raised about the deficits of information during the care planning processes, there seemed to be limited scrutiny regarding the report recommendation. The Independent Reviewing Officer also supported the recommendation. The local authority did not recommend a Supervision Order as it was thought that the support Child G required could be given under a Child in Need Plan. However, Child in Need plans, whilst effective in lots of situations, do not have strong statutory duties. Page 14 of 36 3.27 The Children’s Guardian met with Mr and Mrs A. It is recorded that she was aware of the historical allegations. She noted that Mr and Mrs A wanted a Supervision Order as they thought it would provide an increased level of support. The Guardian raised the issue of the lack of returned Disclosure and Barring Service (DBS) check and contact with Mr A’s daughter in her report, and she clarified that CAFCASS could not recommend an SGO without these being in place. However, she continued to support the care plan, subject to these issues. 3.28 On 30th January 2018, a Special Guardianship Order was granted for Child G to Mr and Mrs A. Sibling 3 was placed separately with her maternal grandparents. A 12-month Supervision Order was also granted. The Court, in making the SGO, made directions in respect of the outstanding DBS checks and the need for the matter to be returned to the Court should there be concerns arising upon receipt. The medical reports had been returned by the time of the court hearing, but the delay meant that they had not been returned in time for consideration within the SGO report recommendation. Child G was moved to live with Mr and Mrs A under the Special Guardianship Order. Summary evaluation: Care planning processes and Special Guardianship Order assessment There were a number of opportunities during this period of practice to recognise potential concerns and provide a more robust approach to assessing the risks that Child G might be subject to. The local authority failed to seek potentially significant information from their own records, and from the Police and Crown Prosecution Service. The SGO assessment was completed and a recommendation made without key checks and significant information. In discussions with the lead reviewer, the SGO report writer said that with the benefit of hindsight, she should have delayed making the recommendation until she had access to the checks and could more fully consider the issues in her recommendation. There was a lack of oversight of this report within the independent social work agency, and by Surrey Children’s Social Care who received the report. There is no evidence of management oversight regarding the quality of this report and the significance of the missing checks. The now adult children of Mr A were not successfully contacted, and the recommendations were made without sight of the DBS check or medical checks. There was a lack of forensic scrutiny regarding the narrative of the allegations of historical abuse told by Mr and Mrs A. This should have been a particular focus, as research indicates that sexual offenders can frequently minimise their offences. Hypothetically, if Mr A had been a perpetrator of sexual abuse, it is possible that he would minimise the seriousness of what happened. No past agency records were sought on Children’s Social Care’s involvement with Mr A at the time of the historic in Page 15 of 36 2006, and no requests were made to the Police or CPS for further allegations information and documentation. Having acknowledged the above lack of scrutiny it is also important to note that Mr A was found not guilty of the allegations in a court of law. The recommendation for an SGO was made and supported without important information, and professionals should have had a more cautious approach in ensuring they had the required information before making care plan recommendations to ensure they have fully analysed every aspect of a situation. The Independent Reviewing Officer supported the recommendation, and whilst the Children’s Guardian raised the issue of the lack of checks, she supported the care plan. Child G is moved to live with special guardians and is subject to a supervision order. (February 2018 - October 2018) 3.29 During the early period when living with her carers, Child G was reported to be demonstrating challenging behaviour at school and at home. There were delays in accessing services, exacerbated by the fact that health services were not informed for two months that Child G had moved back to Surrey. The school reported they were not prepared for the level of need demonstrated by Child G, and in the practitioner event, educational professionals said that they thought insufficient information was shared. Mr and Mrs A reported in interview that the responsibility for sharing information was left to them rather than Children’s Social Care. 3.30 In June 2018, Mr and Mrs A moved to a new home, and it was at this point that they reported that Child G’s behaviour dramatically deteriorated. Child G was excluded from school due to physical outbursts and aggression. She was given a place at a special support unit, whilst staying on role at her current school. Mrs A described G’s behaviour as unmanageable. 3.31 With regard to the Supervision Order in place, an initial Child in Need meeting was held, however there was no health and school involvement in the meeting, and there is no record of minutes being shared with colleagues. The case holding social worker was not visiting Child G regularly, and most support was being given by the family support worker. The family support worker had a very good relationship with Child G, which is a strength, however the lack of recorded visits by her allocated social workers indicate that practice requirements were not met and the lack of qualified worker means that there was an increased risk of safeguarding concerns not being addressed. Page 16 of 36 3.32 In July 2018 a Child in Need meeting identified the urgent need for therapeutic support for Child G, as well as support for Mr and Mrs A as the Special Guardians. Education staff report that support was being offered to Mr and Mrs A from the school and wasn’t always taken up. Mr and Mrs A stated in interview that they would have benefitted from a worker from the Friends and Families service in Children’s Social Care who would have had a specific role in providing independent support for them as carers, and was not directly involved in supporting Child G. 3.33 In August 2018, the GP made an urgent CAMHS (Child and Adolescent Mental Health Services)9 referral, due to Child G demonstrating extremely distressed behaviour, including biting and hitting. The chronology reports increasing sexualised behaviour. Child G was also reported to be having visual and auditory disturbances. Child G was assessed by CAMHS, but not seen as high risk as Child G had adults involved who were perceived as supportive. In discussion with the lead reviewer, the CAMHS worker explained she had referred Child G to an art therapist, however the art therapist had said that the placement needed to stabilise before work could begin. CAMHS therefore felt that working with the carers and professionals involved would be the best way of supporting Child G. This is common practice for children under ten, as parents/carers are key people in the child’s life and therefore providing support for them indirectly works to improve the situation for the child. A meeting was suggested with Mr and Mrs A and Child G’s social worker, and the CAMHS workers wrote to the social worker requesting attendance at the meeting. The social worker didn’t respond, and despite CAMHS leaving messages for the worker and asking for a response by a particular date, the social worker failed to get in contact. She received no response and it was decided to close the case. The CAMHS worker felt that without the social worker’s involvement she couldn’t meaningfully continue with the plan to support the carers. With the benefit of hindsight, the CAMHS worker felt that she should have used escalation procedures to make sure she got a response from Children’s Social Care, rather than closing the case. 3.34 In terms of education provision, during this period Mr and Mrs A report that Child G settled well at the alternative provision she was offered. They feel she found it more difficult when she was returned to mainstream schooling as she was on a restricted timetable, which limited her opportunities her opportunities to be involved in class activities. Education colleagues report that this strategy was agreed by those involved including her carers, to help Child G with the process of settling back in school. 9 CAMHS is the Child and Adolescent Mental Health Services. Page 17 of 36 Summary evaluation - Child G is moved to live with special guardians and is subject to a supervision order. In terms of support and monitoring for Child G, the Child in Need plans did not provide a comprehensive multi-agency response to Child G’s needs and there was unreliability in social worker visits. Consequently, the Supervision Order was not being effectively implemented, as the Child in Need plans were the processes through which the Supervision Order was intended to have effect. The levels of support for Special Guardians is also of note and has been identified nationally as a concern. As children are no longer ‘Looked After’, statutory responsibilities are reduced, however children have often experienced similar issues to those who remain looked after and the support needs of carers can be equivalent. There were a number of delays to Child G accessing therapeutic support. An example of this is the art therapist only taking referrals once the home situation had been stabilised. It seems it is difficult for children who are in a current state of distress to access therapy. This raises the concern of how these children are not getting specialist support and restricts how effectively their voice is being heard. This is a particular concern as these distressed children might be experiencing current harm, as well as past trauma. There was a lack of response from the social worker by a set deadline, which led to CAMHS closing the case, despite Child G still having significant needs. This raises the issue of the impact of poor multi-agency communication from Children’s Social Care. There was a change of social worker during this key period and it was thought that this inconsistency contributed to the lack of response. Children’s Social Care should ensure that worker transitions are managed smoothly without affecting the child. Use of escalation procedures from CAMHS could have meant that a response from Children’s Services was achieved and the case kept open. Child G makes allegations of sexual abuse (November 2018 - February 2019) 3.35 In November 2018, Child G made allegations about Mrs A hitting her with a hairbrush and with her hand, and a joint section 47 enquiry was initiated. Child G was observed by the family support worker to be demonstrating sexualised behaviour. There was an increasingly robust social services response to the support needs, but no revisiting of the allegations within Mr A’s history and the overall placement safety. Page 18 of 36 On 19th November 2018, Child G alleged sexual abuse by Mr A and was moved to a new foster placement under Section 20 of the Children Act 198910. In interview with the lead reviewer, Mr and Mrs A reported that the reason for Child G’s move was not made clear to them. They stated that they were asked to sign the Section 20 consent for Child G to be accommodated but were told there was not time to explain what it meant. 3.36 Child G did not make any disclosures in the first Achieving Best Evidence interview.11 As soon as this finished, Child G then made disclosures and was re-interviewed under ABE conditions. In this second interview Child G made clear allegations of sexual abuse by Mr A. 3.37 Mr A was interviewed and denied sexually abusing Child G. He said that the explanation for Child G’s allegations and her sexualised behaviour was that Child G had witnessed sexual activity whilst living with her mother. 3.38 In January 2019 Child G was moved to a new foster placement. A Child Protection medical occurred at the Sexual Abuse Referral Centre. No injuries were identified in the medical, nor were there physical indications of sexual abuse. The medical did not provide any additional evidence of abuse, however, this would be consistent with Child G’s allegations that the abuse that took place involved ‘touching’ and therefore would be unlikely to result in physical indications of harm. 3.39 Professionals were seeking therapy for Child G during this period. A referral was made to Surrey Sexual Trauma Recovery and Support Service (STARS) on January 17th 2019, and a professionals meetings was held on February 1st, with Child G being offered immediate individual emotional support from the Surrey 3 C’s service (CAMHS Children in Care), alongside support to her foster carers. More specific therapeutic services were then to be offered when her placement needs were clearer. Children’s Social Care, however, decided to seek another provider, and notified 3 C’s that they would not be requiring the services specified. Children’s Social Care then pursued therapeutic services for Child G with the organisation Family Futures. 3.40 Following two further foster placement disruptions a positive Regulation 24 assessment was made on Child G’s Great Aunt. Child G moved to live with this great aunt in a new area on 15th February 2019, being subject to an Interim Care Order. 10 Section 20 is a section of the Children Act 1989, where the local authority can provide accommodation for a Child In Need in their area. If the child is not abandoned or lost, consent from those with parental responsibility is necessary for Section 20 accommodation. 11 An A.B.E. interview refers to the guidance for interviewing children specified in ‘Achieving Best Evidence (ABE) in Criminal Proceedings: Guidance for Vulnerable or Intimidated Witnesses’ (2011) available at https://www.cps.gov.uk/sites/default/files/documents/legal_guidance/best_evidence_in_criminal_proceedings.pdf Page 19 of 36 3.41 There was a review of the police case and it was decided there was not enough evidence to support a prosecution. The investigation was closed on 27th February 2019. Summary evaluation. Child G makes allegations of sexual abuse. The panel considered the police intervention and practice and identified that an area that could have been improved was the preparation for the interview process with Child G. There is little evidence of planning and preparation for the interview and in particular, no consideration was given to whether Child G should have had an intermediary. Given Child G’s vulnerability and the distress she was presenting with, consideration should have been given to the use of an intermediary. Whilst acknowledging how difficult it is to find emergency placements for a child in clear distress, and with the behaviours Child G was demonstrating, Child G had three placements that broke down, following her move from Mr and Mrs A. Although a professionals meeting took place and individual emotional support was offered, this was not pursued by Children’s Social Care and Child G did not receive specific therapeutic support during this period. Whilst not suggesting there are easy solutions to the issue of accessing therapeutic support for children in crisis and experiencing placement breakdowns, it is important to acknowledge the highly destabilising and distressing impact of such instability on a child, who has already been through a high level of trauma and has potentially experienced ongoing sexual abuse. SUMMARY OF FINDINGS & RECOMMENDATIONS Finding One Despite evidence of much good practice within the individual agencies there were challenges in communicating across the multi-agency partnership when working with a complex family with multi-faceted needs. When communication does not work well, the provision of services may not be effective. 4.1 The early periods within this chronology indicate that despite concerns from the school and the police and several referrals being made, Children’s Services closed the case on a number of occasions. There was a long history of trauma and mental health problems from Mother, but there was not a coordinated response from social services and health with regard to how that was likely to affect Mother’s parenting and consequently the needs of the children. As identified in the 2015 Ofsted inspection, Page 20 of 36 the Surrey restructure that led to the establishment of RAIS (Referral Assessment and Intervention Service) teams had contributed to a situation where Children in Need cases were not receiving an adequate service, with the impact of potential risk to their safety not being properly considered’ (p. 39)12. 4.2 This situation has now changed in the county as since the Ofsted report, there has been a significant restructure to a Family Resilience and Safeguarding model, based on the Family Safeguarding Model pioneered by Hertfordshire since 2015. The Hertfordshire model received a positive evaluation in a 2017 government commissioned evaluation of the service13. The aim of this model is to recognise that adult problems cause children to be in need or at risk, and Children’s Social Care practitioners work alongside adult-focussed professions in a joint team. The Surrey implementation of this model has not been evaluated, however the implementation documentation indicated that each pair of family safeguarding teams (there are 22 across the country) will share an adult mental health worker, two domestic abuse workers and a substance abuse worker14. The Early Help provision, will co-locate both CAMHS and SEND (Special Educational Needs and Disability) in a multi-agency hub. These are promising moves and could work to address the lack of a joined-up approach to need identified in this report, whilst acknowledging that the early stages of this chronology are now over five years ago. What is key, however, is ensuring that services are sufficiently resourced so that threshold levels can be consistently maintained and that families are not stepped down to lower tiers of support, if this is not in line with their needs. Surrey Children’s Social Care should make certain that there is clarity over the threshold levels, and provide ongoing monitoring to consider whether there is consistency of interpretation across the county. They need to ensure the thresholds are not reduced in periods where demand for services rises, or funding is reduced. 4.3 In terms of multi-agency communication, practitioners from outside of Children’s Social Care identified that they felt it was difficult to be heard by social workers. When concerns were passed on, they did not receive feedback on what had happened regarding their concerns. There was a sense that when referrals were made, they had to trust that it was being pursued appropriately, but as in this case, this did not always happen. With regard to the initial referral that the school made of the information they had received regarding the allegations of Mr A’s historic sexual offending, the school 12 Ofsted (2015) Surrey County Council : Inspection of services for children in need of help and protection, children looked after and care leavers. https://files.api.ofsted.gov.uk/v1/file/50004296 page 13 and page 39 13 Forrester et al. (2017) Family Safeguarding Hertfordshire. Department for Education. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/625400/Family_Safeguarding_Hertfordshire.pdf 14 Surrey Safeguarding Children Partnership (2019) Surrey Family Resilience and Safeguarding . How our approach is changing. https://www.surreyscp.org.uk/wp-content/uploads/2019/05/How-our-approach-is-changing-May-2019.pdf Page 21 of 36 made a referral and raised it at the Initial Child Protection Conference. Yet this information was not pursued by Children’s Social Care. In discussion about this with education practitioners at the practitioner’s event, they identified a hierarchy with regards to safeguarding, where they perceive education professionals’ views to be considered as less important than social workers. This leads to lack of confidence in asking for follow up information and challenging social workers. Children’s Social Care should ensure they listen to their education colleagues and provide feedback to referring professionals. Education professionals at the practitioner event expressed a lack of confidence in the escalation procedures. Surrey Safeguarding Children Partnership needs to ensure that escalation procedures are widely circulated and known, with professionals having clear and regularly updated contact information. The system for recording alerts, challenge, difference of opinions and the resolution of differences should also be clear to staff across the Partnership. 4.4 With regard to the issues of professional confidence, it is important that all practitioners involved with children feel listened to and their significance is valued with regard to safeguarding. Educational professionals are of key importance here as they are often the people closest to the child and often are the people to whom children disclose child sexual abuse15. Practitioners also raised the importance of strong relationships between police and health workers with social workers. In terms of addressing this, multi-agency training, which stresses the value of all participants in safeguarding would be of value, for information-giving as well as for network building and professional liaison. Joint A.B.E. training was additionally identified as an important potential mechanism in building police and social worker relationships. 4.5 Practitioners raised the issue of school staff not receiving safeguarding supervision. Reflection on practice can occur in a number of different ways, and it was positive to hear that educational professionals have a number of spaces they use for reflection. However, supervision has a particular role in providing emotional support for staff, and a place for professional challenge and feedback. New Ofsted guidance for safeguarding recommends that all Designated Safeguarding Leads have regular supervision16. Supervision provides a context where staff are assisted in following up safeguarding concerns with the local authority and challenged to use escalation processes if necessary. 15 Allnock, D (2019) Key messages from research on identifying and responding to disclosures of child sexual abuse Child Centre for Expertise on Sexual Abuse. 16 Ofsted (2019) Guidance for Inspectors carrying out inspections under the education inspection framework. https://www.gov.uk/government/publications/education-inspection-framework Page 22 of 36 Recommendations 1. Surrey Safeguarding Children Partnership (SSCP) needs to be reassured that the identified threshold levels of the Family Resilience and Safeguarding Model are being consistently applied across the county and families are not being stepped back to lower tiers of support due to resource pressures. 2. For the SSCP to review the effectiveness of escalation procedures ensuring it is fit for purpose and being effectively used. 3. For partner agencies to expedite the implementation of supervision for Designated Safeguarding Leads in line with Ofsted guidance. Finding Two Maintaining expected practice standards is a fundamental aspect of safeguarding practice, and management systems should provide the necessary supervision and oversight. 4.6 Earlier sections of the report detail how practice standards were not met within Children’s Social Care. Plans were not sufficiently robust and targets remained unmet. Some safeguarding concerns were not followed up, as in the case of the first reports of Mr A’s historic abuse. The proposed Family Group Conference did not occur. This is of particular note as the family member with whom Child G is now settled well with had not been considered as a potential carer at an early stage in the proceedings. During the Supervision Order the qualified social worker’s visits were irregular and not recorded. Multi-agency communication was not always effective. There was a lack of effective management and oversight. In considering these issues the reviewer is mindful of the importance of looking through a systemic lens and considering organisational issues. 4.7 In reflecting on the overall themes, it seems that there is a reactive rather than pro-active response to events, leading to a lack of focus on the child and her lived experience. There was a lack of analysis regarding the reasons for Child G’s behaviour and what might be happening to her in the present. Child G had a number of social workers and these trends were present in the work of a number of the qualified social workers who were responsible for her case. In discussing the reasons for these responses with practitioners, it is clear that capacity issues were pertinent. Social workers were described as having caseloads of 28 when the recommended number was 15. Whilst acknowledging there are national issues regarding the social care workforce and the increase in care proceedings which was occurring during a key part of this chronology, contextual information highlights particular workforce issues in this area due to its proximity to London, and some geographical issues Page 23 of 36 regarding travelling. In practitioner discussions the reviewer has been told that during the period of the chronology the area struggled to recruit staff, leading to high turnover of social workers and a shortage of permanent workers. Managers were described as having to ‘act down’ to fill the gaps caused by a lack of staff, which would have restricted their ability to provide adequate oversight. 4.8 Being extremely busy is known to impact on social worker’s critical thinking skills and the work of Ferguson (2017)17 on ‘Invisible Children’ in the child protection system, highlights how social workers are often overwhelmed by the emotional intensity of the work and the complex interaction with often resistant parents. He cites time, insufficient support, and organisational pressures as contributing to anxiety for social workers and the lack of ability to think clearly and ‘hold’ an individual child in their mind. When people are experiencing active anxiety, it is very difficult to ‘think straight’. To address these issues, it is important to look systemically at the organisation, and Ferguson highlights the need for an organisational culture where staff receive opportunities to critically reflect on their experience (p 1021). Supervision is part of an ongoing suite of reflective abilities within a local authority which can provide space for critical thinking, and consideration should be given to providing a culture within teams which supports this. For this critical thinking to occur supervision needs to be more than a bureaucratic exercise in case management, but to have a genuinely reflective content. It is of note that during the most recent months in the chronology there was a significant improvement in the overall standard of practice, so it is likely that progress has been made in these areas during the last year, however an overall picture of staff wellbeing needs is important to ascertain how current these issues are, and for the Surrey Safeguarding Children Partnership to reduce future risks. 4.9 As well as supervision, management audits are also an important part of practice oversight. There was a lack of effective audits in the early part of this chronology. Where issues were picked up by auditors there was not follow up and therefore no feedback loop to ensure identified actions were completed. More recent audits indicate a better system of feedback. It is understood from practitioner conversations that historically the management structure lacked capacity and the more recently configured management structure has delivered more managers at Area Director level based in the different quadrants. This increase in management numbers and capacity should mean that a more robust approach to quality assurance can be maintained. 4.10 Tracking systems also provide monitoring that children are being visited and having their cases reviewed at the appropriate intervals. Whilst tracking systems have limitations in terms of quality of practice, an effective monitoring system would have 17 Ferguson, H. ( 2017) How Children Become Invisible in Child Protection Work: Findings from Research into Day-to-Day Social Work Practice, The British Journal of Social Work, Volume 47, Issue 4, June 2017, Pages 1007–1023, https://doi.org/10.1093/bjsw/bcw065 Page 24 of 36 picked up that Child G was not being visited at the appropriate intervals by her social worker. It is understood that a tracking and monitoring system is now in place in Children’s Social Care. However, it is important that the alerts from this system are appropriately monitored by managers so there can be a swift response when deficits are identified. 4.11 There is a consistent theme across the professional groups that everyone was working at capacity. Practitioners described how people were doing their jobs and passing on relevant concerns when necessary, but they had little extra space to reflect on issues and provide extra follow up. A number of professionals in the practitioner event said that in retrospect there were some instances when they should have followed up on issues but did not have time. It seems that across the professional networks there is an issue of people working at full capacity, which leaves very limited space for critical questioning and ‘holding a child in mind’. It is worth noting that these are concerns across the public sector workforce and are not necessarily specific to Surrey. However, if each agency is working at full capacity this impacts the whole system, meaning it is entirely overstretched. In terms of safeguarding in Surrey, this creates a level of risk in the system and agencies and SSCP needs to reflect on this and its implications for keeping children safe. Recommendations 4. A new supervision policy is in place in Surrey Children’s Social Care, however, this should be evaluated to ensure that the case management elements of supervision are not so dominant that there is no space for reflective analysis and critical thinking. Surrey should promote a high challenge/high support approach to supervision so that there is time in supervision for professional curiosity and challenge over decision making and problem solving. 5. Surrey Safeguarding Children Partnership needs to ensure that there are mechanisms to regularly review caseload size, and social work shortages. This should include reviewing staffing at the managerial level, so that quality assurance processes, including audit feedback follow up, are completed. 6. Surrey Safeguarding Children’s Partnership should ensure the effective implementation of the plans for Family Group Conferences so that the whole range of family networks can be considered in the care planning process. The Board (now Partnership) should review that Family Group Conferences are occurring under the new structure. Page 25 of 36 7. With regard to the finding of a lack of capacity across the partner agencies, Surrey Children’s Safeguarding Partnership should seek assurance from partners that practitioners are not so overloaded that they are unable to focus on the experience of the child, due to issues of workload. If the ability to effectively safeguard children is being compromised because of resource limitations in the agencies, then the Partnership should name this situation and work with partners to mitigate risks. Page 26 of 36 Finding Three The Special Guardianship Order report and recommendation was not subject to sufficient scrutiny within the care planning processes. There is a risk that reports commissioned by independent agencies may fall through the quality assurance net. There is a need for clear expectations to be identified at the point of commissioning independent agencies and relevant information sharing. There should be ongoing challenge within the professional network, and the quality of practice monitored throughout the care planning process. 4.12 The Special Guardianship Order report request was commissioned by Surrey Children’s Social Care to an independent social work agency. This is not current practice but was occurring frequently at the point in time due to the high volume of care proceedings being dealt with in the department and internal capacity issues. The referral to the independent agency lacked vital details. The section on the Police National Computer check was not filled in, and whilst there was reference to the negative Regulation 24 assessment, no details were provided as to the reasons for this. There was no information provided about the historical allegations re Mr A. 4.13 The Special Guardianship Report (SGO) was not sufficiently thorough in assessing potential risks to Child G. In particular, more information should have been sought with regard to the historic allegations of abuse, so this information could have been analysed more thoroughly. The SGO report recommendation was made without the writer having sight of the Disclosure and Barring Service report. The recommendation for the SGO was also made without reference to the medical checks or without speaking to Mr A’s daughter and stepdaughter. These were necessary checks as part of the Special Guardianship Order assessment process. 4.14 The 2015 ADCS/Cafcass guidance on the assessment of Special Guardians as the preferred permanence option for children in care proceedings applications, state that ‘No child should be placed in the case of a Special Guardian without DBS and other necessary checks being carried out.’ The recommendations for the SGO were made without the DBS check being returned. When the DBS check was returned it came back as clear, as did the earlier PNC check. This raises the issue of what is included in PNC and DBS checks regarding police investigations that have not progressed, or not guilty verdicts. This has been raised as a learning point in Lewisham and Harrow Serious Case Review Child LH18, which highlighted that DBS staff have to make complex decisions about the threshold for including so called ‘soft information’ or unproven allegations. This report concludes that there are lessons for agencies and practitioners on an over reliance on DBS checks and, if relevant, it is important that 18 Lewisham Safeguarding Children Partnership (2019) Joint Serious Case Review Lewisham Safeguarding Children’s Partnership and Harrow Safeguarding Children’s Board: Child LH. https://www.safeguardinglewisham.org.uk/assets/1/harrow_and_lewisham_scr_overview_report_in_respect_of_child_lh.pdf Page 27 of 36 practitioners request specific information from the police from the Police National Database (PND) and the Crown Prosecution Service (CPS). In this case, practitioners were aware of the historic allegations regarding Mr A, and he brought them up early in the SGO assessment process. Therefore, in relation to this review the ‘no trace’ checks did not mean that the allegations did not come to light. However, it is significant to note that if professionals were relying on the PNC and DBS checks the historic allegations regarding Mr A would not have been identified. It is also of note that medical checks were not returned prior to the recommendation being made. Both Mr and Mrs A identified medical issues, which could have impacted on their ability to care for a child with emotional and behaviour needs. Medical checks should have been seen as an important part of the assessment process. 4.15 With regard to the allegations of sexual abuse, further information from the police and CPS regarding the allegations of historic abuse should have been sought so that a robust assessment of risk could have occurred. The lack of a robust risk assessment was highlighted in my discussions with Child G’s Father who found this aspect of practice, and how it put his child at risk, particularly concerning. Mr A’s account of what happened could have been discussed in a comparative way alongside considering police information, Crown Prosecution Service documentation and historic social care records which could have been accessed. Comments from practitioner conversations noted that the lack of robustness came from professionals being convinced by an overall narrative that living with Mr and Mrs A was the best course of action for Child G, and a way of keeping her with family members. The fact that ‘everyone’ seemed to support this course of action, meant there was little questioning of it as the preferred course action. It also seems that there was little consideration to the fact that if Mr A was a perpetrator of sexual abuse, and this is being considered hypothetically as we are considering allegations about Mr A rather than convictions, then he might have adept strategies of convincing others of his point of view. Whilst recognising that this review is looking at events with hindsight, it is clear that this lack of analysis was a key factor in the failure to properly asses the risk of Child G experiencing sexual abuse. During the process of writing the review, the independent agency has confirmed that they have produced new guidance for the writing of Special Guardianship Reports to respond to the learning from this review. They have confirmed that Independent Social Workers will not be able to make recommendations until outstanding issues are resolved, and these issues will be clearly listed in the report. Where there has been a prior criminal court case, report writers will be required to assess and investigate factual records, where available, and clarify any missing information as a caveat to the report. 4.16 The deficits of information in the Special Guardianship Order assessment report were not identified when the quality assurance of the report occurred with the independent agency, nor was it questioned by the commissioning Local Authority on receipt of the report. This raises significant issues around the processes for quality assurance in the Page 28 of 36 independent agency and the Local Authority. It is understood from practitioner comments that the procedure in the independent agency is that the report is quality assured by a case manager and this process is separate from any regular supervisory relationship. When Children’s Social Care received the report there was insufficient questioning of the recommendation. Comments from the practitioner event highlight that there was confusion over the route for quality assurance within the local authority and whether the referring team, or the Friends and Family fostering team held responsibility for this. This line of accountability has since been clarified and all reports are now quality assured by the Friends and Family team. 4.17 Surrey Children’s Social Care has informed this review that it no longer uses this independent agency and is now completing SGO assessments internally. Whilst this finding does not necessarily mean that the use of independent agencies is by nature problematic, it does highlight how contracting to independent agencies creates a risk in that the Local Authority does not have control over their quality assurance process, supervisory arrangements and ensuring that the appointed worker has appropriate training. Although the social work regulator19 requires social workers to maintain their continued professional development, there are no specified requirements regarding independent social workers’ supervision and professional support. Therefore, there is likely to be significant variation in supervisory arrangements and quality assurance. In view of this it seems that in order to reduce risks, the Local Authority should view the use of independent social workers as a less favourable option than using internal staff, for whom they can exercise control over supervisory and quality assurance processes. If contracting out to independent agencies on future occasions, Surrey should request information regarding supervision and quality assurance, considering the quality of these in their contracting decisions. 4.18 In comments from the practitioner events as to the reasons why the report was submitted without reference to Mr A’s daughter and stepdaughter and completed checks, one of the issues raised was the pressure of timescales. It seems that independent agencies feel these particularly acutely, as they are commissioned due to capacity issues on the understanding that the assessment can be completed to time. This could mean that independent workers feel less confident in asking for extra time. Local Authorities need to ensure that they support independent report writers with requests for extra time if it is required to complete a full assessment and analyse fully the potential risks to a child. Recent interim guidance from the Family Justice Council20 states that an extension to the timetable should be considered by the court when necessary to ensure the stability of the placement. 19 At the time this practice took place, the social work regulator was the Health and Care Professionals Council (HCPC). On 2nd December 2019, Social Work England took over the role of regulating social workers. 20 Family Justice Council (2019) Interim Guidance on Special Guardians. Available at https://www.judiciary.uk/wp-content/uploads/2019/05/fjc-sg-interim-guidance-pfd-approved-draft-21-may-2019-1.pdf Page 29 of 36 4.19 There was a lack of effective challenge within the professional network during the care planning process. Although the lack of DBS check was identified and questioned by a number of professionals, there didn’t seem to be challenge over the recommendation itself. When discussed at the practitioner event, explanations about this referred to workers ‘overlooking’ things which with the benefit of hindsight seem more significant. Practitioners from Cafcass as well as Children’s social care were reporting issues with workload and staff retention. It was thought that this was likely to have affected the ability to have the time to analyse decisions and follow up on issues. Recommendations 8. Surrey’s Safeguarding Children’s Partnership should ask Children’s Social Care to review its processes for undertaking Special Guardianship assessments, considering how the results of checks are logged and conveyed, clarifying the accountability structures, and how the care planning processes ensure sufficient scrutiny and quality assurance of decision making. 9. Surrey Safeguarding Children Partnership should write to the new regulator, Social Work England, bringing to their attention the finding of this review regarding the lack of regulation of independent social workers in relation to their supervision and the quality assurance of their work. Finding Four It is important that all professionals are attuned to the possibility of present trauma and current abuse, including sexual abuse, in children presenting distress and high levels of disturbance. As part of this process, Supervision Orders should be actively worked by qualified workers, and should monitor the child’s wellbeing, ensuring that any risks are identified and responded to. 4.20 In the period after which Child G had moved to live with her Special Guardians her behaviour changed. Child G’s behaviour displayed considerable anger and aggression, and she also demonstrated sexualised behaviour. She was very difficult to manage both in the home and the school setting and both her Special Guardians and the school were raising how concerned they were and how difficult it was for them to manage her behaviour. This is not to say that there were no earlier incidents of aggression and sexualised behaviour, but there was an increase in them during this period. 4.21 In terms of the professional response there was a lot of concern for Child G, but potentially a misinterpretation of the behaviour she was presenting. The chronology indicates she was often described as aggressive and difficult to manage, and the family thought that she might have had Attention Deficit and Hyperactivity Disorder Page 30 of 36 (ADHD). Without excluding the possibility that this could have been a possibility, it is worth noting that there is increasing interest and research into how ADHD and the consequences of neglect and trauma in children might have similar external symptoms and signs.21 Whilst acknowledging that children’s behaviour is often very difficult to unpick and information is often ambiguous, there should have been greater curiosity as to what Child G might have been trying to communicate via her behaviour about her life in the present. It seems there was an assumption that Child G’s behaviour was a result of past trauma due to her previous experiences of neglect, rather than professionals considering the possibility that this was a child currently being harmed. Education professionals are often the people in the professional network who know the child best and whom they are most likely to talk to22. It is therefore very important that professionals in the partner agencies, particularly schools, have enough training in sexual abuse and the different signs and ways children might communicate over this. At the practitioner’s event professionals from a range of partner agencies said that they would benefit from training on the signs, symptoms and effects of sexual abuse. This is a national issue and a 2015 report by the Children’s Commissioner23 found that professionals often lacked knowledge and confidence in identifying child sexual abuse and in supporting children where there are concerns but no clear disclosure. In terms of the SSCP’s response, it would be important to offer training across the partnership, not just for staff within Children’s Social Care. 4.22 In terms of intervention from Children’s Social Care during this period, despite the Supervision Order and Child in Need plan, visits by Child G’s qualified social worker were irregular. This did not meet procedural guidelines and limited the opportunity for Child G to have talked to her social worker and potentially disclosed her allegations at an earlier stage. The Child in Need plan associated with the Supervision Order was not reviewed according to timescales, nor did it provide the kind of coordinated response which facilitated good multi-agency communication and support during this critical period in Child G’s life. Child G’s school was extremely concerned about her and in the practitioner event said that did not feel they got an adequate response to their escalating concerns. Mr and Mrs A were also asking for support as they felt G’s behaviour was unmanageable. As identified earlier in this report Special Guardians frequently report a lack of support, despite caring for children with very significant needs. 21 An example of this research can be found at: Brown, N et al. (2017), 'Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity', Academic Paediatrics, vol. 17, no. 4, pp. 349-355. https://doi.org/10.1016/j.acap.2016.08.013 22 Allnock, D (2019) Key messages from research on identifying and responding to disclosures of child sexual abuse Child Centre for Expertise on Sexual Abuse. https://www.csacentre.org.uk/index.cfm/_api/render/file/?method=inline&fileID=7C7BB562-DB13-4C7E-B8C21D04920D6AEF 23 Children’s Commissioner (2015) Protecting children from harm: A critical assessment of child sexual abuse in the family network in England and priorities for action. https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/06/Protecting-children-from-harm-full-report.pdf Page 31 of 36 4.23 During this period Child G’s case was closed to CAMHS due to the fact that the social worker did not respond to the CAMHS worker’s offer of support and request for a meeting. In finding 2 of this report, consideration has already been given to why some Children’s Social Care staff were not meeting procedural requirements or exercising sufficient professional curiosity about their caseload. An additional comment was made at the practitioner event which said that workers were asked to ‘prioritise the more urgent cases’, and the Supervision Order and it’s ensuing Child in Need plan was seen as ‘low priority’. This reinforces the identified learning that social workers should have appropriate caseload sizes but it also raises the issue of the potential for Supervision Orders not to be given the weight and significance intended by the court when the Order is granted. 4.24 When Child G made the allegations of sexual abuse by Mr A, she made this disclosure to the family support worker who had worked with the family for some years. This worker had been a regular and long-term visitor to the family and a consistent figure for Child G and was someone she trusted. This is a positive and an important reminder of the importance of continuity of professional relationships, as this worker had been with the family much longer than the qualified workers who changed on a number of occasions throughout the period of the chronology. This effect of this lack of consistency of social workers on children is well documented and this is a reminder of how children are more likely to disclose if there is a context of trust. Comments at the practitioner event indicate that staff who are not in qualified roles often feel that they are not listened to even though they know families best, yet this review highlights their importance in facilitating children speaking about their experience, and consequently in overall safeguarding. Surrey Children’s Social Care is engaged in training staff on trauma informed approaches. Trust is central to responding to children’s trauma as it is recognised that relational disruption and trauma require relational healing. It is therefore important that trauma informed practice training within Children’s Social Care is completed alongside supporting practitioners to develop trusting and consistent relationships. Recommendations 10. For Surrey Safeguarding Children Partnership to review its training on both trauma informed practice and sexual abuse. The review should ensure that training is available to staff across the agencies, and that training on child sexual abuse should include indicators of sexual abuse and how this might impact on children’s behaviour. Page 32 of 36 11. For Surrey Safeguarding Children Partnership to seek reassurance from Children’s Social Care that supervision orders are being actively worked by qualified workers and that the tracking systems now in place would identify gaps in visits to children and lapses in reviewing of Child in Need plans. Finding Five There were significant delays to the accessing of therapeutic support for Child G, during the time when her emotional distress and needs seemed most urgent. 4.25 Chronology reports from Child G’s schools, family members and subsequent foster carers describe Child G’s distressed behaviour. As part of the post-Order support available to Child G on the conclusion of the care proceedings where the Special Guardianship Order was granted, funding was allocated from the Adoption Support Fund so that Child G could receive play therapy. There were a number of delays that affected the play therapy starting. A CAMHS referral for art therapy was also postponed as the therapist thought the home situation should be stabilised before therapy could begin. There was a plan to start the therapy during November 2018, which was then affected by the breakdown in the placement. 4.26 As documented earlier in the report, a referral was made to Surrey STARS service and a multi-professionals meeting swiftly held. Whilst relevant services were offered Children’s Social Care pursued an alternative provider. At the end of February 2019, records indicate that Family Futures would be visiting Child G in her new home to agree ongoing support. Although it is positive that this Family Futures support was initiated, the lead reviewer is concerned by the number of delays to the processes here and the lack of therapeutic support for Child G during such a critical period. 4.27 The reasons for these delays to therapeutic support to child G are multi-faceted and they come from understandable clinical positions. It is difficult to provide a safe therapeutic space when there is instability in a child’s placement, and offering support to the carers is often the most effective option. However, if a child is trying to communicate distress about their placement, then the lack of therapy could restrict their ability to voice what is happening for them. This raises questions over whether a better multi-agency response could be developed. In particular this review highlights the importance of services that can respond to the needs of children who are in crisis in the present. When discussing multi-agency responses to Child G’s therapeutic needs, comments from practitioners included expressions of concern from schools that they are left having to deal with very serious emotional and behavioural difficulties, without adequate support. In addition, Children’s Social Care staff who were experienced, but not specifically therapeutically trained, were often dealing with very complicated needs. Ideas from practitioners as to how things could be done differently included the possibility of drop in CAMHS support. This occurs in Surrey for children aged 10 and above, but at present this is not available to children under ten. Page 33 of 36 A further suggestion was making the Hope service available to children under eleven. The Hope Service is a Surrey multi-agency service for children experiencing mental health, emotional, social or behavioural needs and works with children when there is potential placement breakdown or hospital admission. This is currently only available to children over eleven, however this review highlights the needs of younger children in crisis. Practitioners also thought that embedding CAMHS practitioners in the early help local hubs, as is proposed in the Surrey Family Resilience and Safeguarding structure, would assist in providing a faster response to children. In conclusion, practitioners expressed the view that Trauma Informed Practice training, if complemented by supervision and ongoing training updates, could assist in equipping carers and professionals to respond more effectively to a child’s presenting distress. Recommendations 12. For Surrey Safeguarding Children Partnership to review the therapeutic support available to children under eleven who are displaying significant emotional distress or are in crisis. This review should include consideration of how effectively information about available services is disseminated to multi-agency professionals, parents and carers. Page 34 of 36 APPENDIX 1 – Terms of Reference 5.1 Initial considerations of case materials identified that it would be most appropriate to focus on the period 1st February 2014 to 28th February 2019. Agencies who had been involved with Child G were asked to provide a chronology as well as a narrative record of their involvement which highlighted any emerging practice issues. The terms of reference which were considered during the review process were: 1. How effective was the assessment and Early Help response to emerging concerns of neglect? How effectively had the long-term issues of neglect affecting the family been addressed? 2. Given the significant history of domestic abuse over a protracted number of years involving the mother and a number of associates males / fathers of siblings and concerns about mother’s mental wellbeing: How did agencies work together to understand the lived experience of Child G and her siblings? What steps were taken to protect them from significant harm and what more should have been done to safeguard them? Consider how delays and drift affected safeguarding process. 3. Explore at what point which people knew of the allegations of sexual abuse against Mr A. How far did professionals work together to share information and consider the previous allegations of sexual abuse made against Mr A as part of the assessment process? How robust was the investigation in the Regulation 24 assessment? 4. The SGO assessment was outsourced to an independent agency. Consider the effectiveness of outsourcing of SGO assessments. Who retained ultimate authority? Was there appropriate management oversight and quality assurance? 5. Explore the LA’s thought process that led to the decision to recommend an SGO for Child G to Mr & Mrs A given the concerns raised? Expanding on how professionals worked together and the process of querying the decision making based on information available? 6. When Child G was showing indicators of increasingly sexualised behaviours – what steps did agencies take to explore and address these increasingly concerning behaviours? 7. Consider the effectiveness of the Supervision Order? What steps did agencies take to safeguard Child G? Who was monitoring her wellbeing and safety? What missed opportunities were there to protect and safeguard Child G from harm and abuse? 8. What evidence is there that professionals that knew Child G well, listened to her and took her concerns seriously? Were professionals curious to understand her lived experience and the presenting risks following the ABE in 2018? Explore further the police’s activity in response to Child G’s allegation 9. What level of management oversight took place and was there effective communication with other agencies? What organisational QA processes were in place to pick up that management oversight was not taking place frequently enough? Page 35 of 36 APPENDIX 2 – The Review Process 6.1 In considering the process for this review, account was taken of the principles set out within Working Together to Safeguard Children (2015)24 which specifies that: • There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works to promote good practice. • The approach taken to reviews should be proportionate to the scale and complexity of the issues being examined. • Reviews should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed. • Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. • Families including surviving children should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring the child is at the centre of the process. • The final report must be published, including the LSCBs response to the review findings. • Improvement must be sustained through regular monitoring and follow up. 6.2 Rhian Taylor was appointed lead reviewer. Rhian trained in social work at the London School of Economics qualifying in 1996. She has an MSc in Social Policy and Research and the Post Qualifying Child Care Award. She has over twenty years’ experience as a social worker and manager in statutory children’s services. She is currently an academic at the University of Kent as well as an Associate for In-Trac Training and Consultancy. She writes about, and researches social work supervision. 6.3 Further information was gathered through discussions with practitioners who had worked with the family in order to confirm the detail of what had happened and explore the context within which practice took place and reasons for the decisions that had been made. Practitioners from the following agencies contributed to the review either through group discussion or individual conversations: 24 H.M. Government (2015) Working Together to Safeguard Children, Online, Available from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf Working together to Safeguard Children is the government’s overarching guidance on safeguarding. Page 36 of 36 • Surrey Children’s Social Care • Independent Reviewing Officer • CAFCASS • Surrey - Community Health Services • Surrey and Borders Partnership • Surrey Police • The Independent Social Work agency • Surrey Primary Schools • Lumen Learning Trust • Probation (Kent, Surrey and Sussex Community Rehabilitation Company). |
NC52839 | Young person Child G experienced trauma and instability at an early age, including emotional and sexual abuse, and a lack of certainty about who was there to look after her. As a teenager this manifested in mental health issues and substance misuse, leading to her becoming care experienced and subject to sexual exploitation. Learning points include: practitioners to develop an understanding of trauma-informed practice to identify the emotional abuse of adolescents and recognise the impact of fractured attachments; a move from what is wrong with you? to what has happened to you? in responding to children and young people who have experienced abuse and neglect; awareness of the damaging effect of victim blaming and pathologising language; ensure definitions and advice clearly outline the unacceptability of children being physically punished, with practitioners challenging parents who suggest this is an appropriate disciplinary approach; recognise the importance of a child or young persons relationship with one or two trusted professionals; where child sexual exploitation is suspected, assessments should consider risks which emerge from vulnerabilities arising from past abuse, loss and trauma; schools to ensure that any decision to exclude a pupil (subject to a child in need plan or protection plan) is only done after a discussion with the multi-agency team; consider what practitioners and managers can do to support help seeking behaviour in children and young people; and professionals to maintain a questioning and curious response to what they are told or see. Recommendations are embedded in the learning points.
| Title: Learning from the child safeguarding practice review published 23.5.23: moving from ‘what is wrong with you?’ to ‘what has happened to you?’ [Child G]. LSCB: Oxfordshire Safeguarding Children Board Author: Oxfordshire Safeguarding Children Board Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Learning from the Child Safeguarding Practice Review published 23.5.23: Moving from ‘what is wrong with you?’ to ‘what has happened to you?’ Background to review This summary highlights the key learning points from the review for a young person, who experienced trauma and instability at an early age, including experiences of emotional and sexual abuse, and a lack of certainty about who was there to look after or care for her. As a teenager this manifested in feelings of low self-esteem, mental ill health, self-harm, running away, struggling to manage her emotions at home and at school, and some substance misuse. This led to her becoming care experienced and subject to sexual exploitation and harm in the community. She is described by the professionals that knew her as a warm, caring, mischievous, challenging and funny young person, liked by all those she met. The findings highlight the need for a trauma informed approach characterised by an understanding of the importance of good quality attachments and relationships, where professionals move beyond, “what is wrong with you?” to “what has happened to you?” Key findings In summary the main issues found in this review were: • The importance of relationships which are kind and caring • Recognition of emotional abuse and emotional neglect and the role that child blaming plays within this • The importance of challenging and addressing victim blaming language in professional practice • Promoting help seeking behaviour in children and young people • Taking physical harm to children and young people seriously Themes in common with national reviews • The importance of understanding and considering the impact of adverse childhood experiences and fractured attachments on children and adolescents Themes in common with other Oxfordshire reviews: •Early identification of neglect, abuse and exploitation •Understanding behaviour as a means of communicating emotional distress •The need for a trauma informed approach •The importance of a questioning and curious response to what parents tell us •Children are safer when in education •Understanding the potential impact of transitions 2 • Where child sexual exploitation is suspected, assessments need to consider risks which emerge from vulnerabilities arising from past abuse, loss and trauma • Professionals need to maintain a questioning and curious response to what they are told or what they see • Understanding help seeking behaviour Strengths in practice • The young person wanted to thank those professionals who worked directly with her, for the care and attention they gave her, for speaking positively about her, and seeing the good in her. She remembers their positivity, and how it made her feel valued and cared for • School sought specialist support for her when she reported feeling unhappy and self-harming Learning Points for practitioners • Develop an understanding of what is meant by ‘trauma informed practice’ and the skills needed to take a trauma informed approach • When working with children and young people where there have been fractured family relationships, consider the impact of poor attachment on the emotional wellbeing and development of the child or young person and how this may present • Listen to what children are telling you directly and indirectly, to better understand the child’s perspective and what their life is like for them • Focus on what can be done to address children and young people’s concerns, as opposed to what cannot be done because of procedural limitations • Reports and records should be written to the child or young person, and written in plain English in a way that the child or young person can understand • Although the law suggests it is acceptable to physically punish children, practitioners should consider the impact of physical abuse on a child’s development, and sense of wellbeing, and the message this gives that it is okay to use physical force and aggression against others. Practitioners should challenge parents who suggest this is an appropriate disciplinary approach Learning points for managers • Schools to ensure that any decision to exclude a pupil (who is subject to a child in need plan or child protection plan) is only done after a discussion with the multi-agency team around the child • Promoting, and improving practice, to support help seeking behaviour in children and young people needs to be a routine part of planning and a focus on feedback and debrief when children and young people tell us about harm and abuse Key messages for the safeguarding system • Ensure that all practitioners are equipped in the context of a trauma informed response: o To identify the emotional abuse of adolescents o Recognise the impact of fractured attachments on children and adolescents 3 o Have the appropriate tools and frameworks to support their practice • Rethink our response to children and young people who have experienced abuse and neglect, to move from “what is wrong with you?” to what has happened to you?” • Raise awareness of dissociative seizures amongst staff, and that they are a well-recognised unconscious response or coping mechanism to emotional trauma • Practitioners and managers to be aware of the damaging effect of victim blaming and pathologising language, that victim blaming should always be challenged, and records and reports reflect this • Consider what practitioners and managers can do to support help seeking behaviour in children and young people • OSCB to ensure current definitions and advice clearly outline the unacceptability of children being physically punished, and a challenge to parents who suggest this is an appropriate disciplinary approach • Recognise the importance of a child or young person’s relationship with one or two trusted professionals, particularly where there have been poor attachments and parental-child relationships. Prioritise continuity of those relationships wherever possible Did you know? The following links offer useful further information and guidance: ✓ Communicating with children: A guide for those working with children who have or may have been sexually abused - Centre for expertise on child sexual abuse ✓ Signs and indicators: A template for identifying and recording concerns of child sexual abuse – Centre for expertise on child sexual abuse ✓ Appropriate Language, Child Sexual and/or Criminal Exploitation guidance for professionals – Children’s Society, Victim Support and the NPCC ✓ Getting help: What children tell us about accessing services after sexual abuse – NSPCC ✓ Neglect guidance, tools and resources – OSCB website ✓ Guidance on suspensions and permanent exclusion – Oxfordshire County Council ✓ Overview of permanent exclusion process – Oxfordshire County Council ✓ Trauma informed approaches: What they are and how to introduce them – Margery Infield and Katie Boswell, September 2020 If you do one thing…… Think “what has happened to you?” rather than “what is wrong with you?” Listen to children when they tell you what has happened to them, both directly through verbal communication, and indirectly through help-seeking behaviour. Take a trauma informed approach that: • recognises the impact, signs and symptoms of trauma in children and young people and that resists re-traumatising them • Focus on what can be done to empower and support recovery in children and young people who have adverse childhood experiences |
NC52177 | Death of a 7-year-old boy in December 2016. Emergency services found Child X and Mother deceased at Mother's home address. Inquest concluded Child X was unlawfully killed, and Mother died by suicide. Family moved to England in 2011 for work. Mother worked as a nurse; history of alcohol dependency and mental health problems. Had contact with Police following a rape allegation in 2015. Mother's hospital employment terminated in 2015. School concerned about Child X's appearance and attendance; referrals made by family and school about Mother's wellbeing. Mother reported to cousin that she was going to take her own life and that of Child X. Father reported Child X as missing after he did not attend school, and being unable to contact Mother. Family are Irish. Learning includes: information sharing within police did not always work well and information about Mother and Child X was lost; information held by friends and family should be taken seriously and support given to help them share information; lack of focus on the potential impact of Mother's alcohol use and mental health on her role as a parent and a nurse. Recommendations include: guidance from the College of Policing should be unambiguous that, in cases of sexual assault, a victim care plan should be delivered by the police force where the victim resides; GPs should always ask patients whether they have any dependants when alcohol misuse is a problem; consider with national organisations whether a helpline for families concerned that a child is at risk could be developed.
| Title: Serious case review: Child X. LSCB: Hillingdon Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Hillingdon Safeguarding Children Board Serious Case Review Child X Report Author Jane Wonnacott MSc MPhil CQSW AASW Director, Jane Wonnacott Safeguarding Consultancy Ltd Final Report 17.12.19 Page 2 of 39 Contents 1 INTRODUCTION ........................................................................................................... 3 2 DECISION TO CARRY OUT A SERIOUS CASE REVIEW .......................................... 3 3 THE SERIOUS CASE REVIEW PROCESS ................................................................. 4 4 CASE BACKGROUND ................................................................................................. 5 5 SUMMARY OF AGENCY INVOLVEMENT ................................................................... 6 6 REVIEW FINDINGS AND RECOMMENDATIONS ..................................................... 24 7 SUMMARY OF RECOMMENDATIONS ..................................................................... 33 8 APPENDIX ONE: TERMS OF REFERENCE ............................................................. 36 Final Report 17.12.19 Page 3 of 39 1 INTRODUCTION 1.1 In December 2016, emergency services were called to an address in Hillingdon and found a seven-year-old child and his mother deceased. Subsequent investigations concluded that both the Mother and child’s death had been caused by an overdose of insulin. A suicide note, written by Mother was found at the scene. The initial conclusions of police investigations were that this was a case of murder/suicide. 1.2 A coroner’s inquest in June 2018 concluded that the child was unlawfully killed, and the Mother then died by suicide. 1.3 A review of information known to statutory agencies revealed that Mother had worked as a nurse, the child’s parents had been involved in an acrimonious separation and that Mother had contact with agencies as a result of alcohol and mental health problems. Mother had also had contact with the Metropolitan Police and Thames Valley Police following a rape allegation. Another allegation that she had been harassing her ex-partner via text messages was investigated by the Thames Valley police force. There had also been some contact with Hillingdon Children’s Social Care and limited contact with mental health services. 2 DECISION TO CARRY OUT A SERIOUS CASE REVIEW 2.1 At the time of the deaths the Chair of the LSCB and the then assistant director children’s safeguarding decided that the threshold had not been met for a serious case review or a safeguarding adult review. The (then) national panel whose role was to have an overview of children’s serious case reviews were notified and did not disagree with Hillingdon’s decision. Hillingdon were however informed that Thames Valley Police had decided that the case met their criteria for an individual management review and that this would be carried out by their serious case and domestic homicide review team. 2.2 It is the view of the author of this report that statutory guidance in place at that time1 should have led to a decision to commission a children’s serious case review in early 2017. New national safeguarding arrangements for children would mean that a local rapid review of available information would be carried out and shared with the new national child safeguarding practice review panel2 who would be able to review the circumstances and provide appropriate challenge regarding any decisions made. 2.3 The case was reviewed by the Hillingdon Child Death Overview Panel in May 2018 which recommended that the decision not to conduct a review should be re-considered. Following a consideration meeting on 9th August 2018, a decision was made to commission a local serious case review with consideration of any specific 1 Department for Education (2015) Working Together to Safeguard Children 2https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/793253/Practice_guidance_v_2.1.pdf Final Report 17.12.19 Page 4 of 39 learning in relation to adult safeguarding and this decision was ratified by the new national panel. 2.4 During the process of this review the new national safeguarding arrangements for children came into force and as a consequence although this report was commissioned by the (then) Hillingdon Safeguarding Children Board, this Board no longer exists. The responsibility for overseeing local learning and practice development as a result of this review will therefore sit with the newly formed Hillingdon Safeguarding Children Partnership. As the mother of Child X died and the review has identified lessons relevant to her circumstances, learning and recommendations relevant to work with adults will be overseen by the Hillingdon Safeguarding Adults Board. 3 THE SERIOUS CASE REVIEW PROCESS 3.1 An independent lead reviewer, Jane Wonnacott was appointed to carry out the review and write this report. Jane is a qualified social worker with over twenty years’ experience of conducting Serious Case Reviews and is the author of over one hundred reports. She is independent of all organisations in Hillingdon. 3.2 A review team made up of senior professionals from Hillingdon was appointed to work with the lead reviewer. Members of the review team were: Designated Nurse Safeguarding Children, Hillingdon CCG Named Nurse Safeguarding Children, The Hillingdon Hospital Foundation Trust Deputy Borough Director, Central and North West London NHS Foundation Trust Detective Sergeant Specialist Crime Review Group, Met Police Head of Partnership & Quality Assurance, London Borough Hillingdon Lead CP Advisor for Schools LSCB/SAB Business Manager Named Nurse, Safeguarding Children, Central and North West London NHS Foundation Trust Community Health Service Manager CAFCASS 3.3 The terms of reference for the review are attached at Appendix One. 3.4 Written chronologies of professional involvement with Mother, Child X and his family were requested and analysed by the review team. Organisations who contributed information at this stage were: Cafcass CCG 1 (GP practice) Central and North West London NHS Foundation Trust (mental health, health visiting and school nursing Services) Hillingdon Children’s Social Care Final Report 17.12.19 Page 5 of 39 Metropolitan Police Primary School attended by Child X Thames Valley Police (chronology and individual management review). 3.5 The Metropolitan Police submitted additional information from their report to the coroner following the deaths. This was seen by the lead reviewer only and where relevant, information has been included within this report. 3.6 Verbal information was obtained from a nursing agency to try and confirm Mother’s sequence of employment during the review period. 3.7 Inquiries were made of a private residential substance misuse rehabilitation centre attended by Mother, but it was impossible to obtain any information as the centre has closed. 3.8 The review team are very grateful for the contribution made by Child X’s father who, despite the very painful circumstances was able to help the lead reviewer and the team develop the questions for the review and understand more fully the circumstances leading up to the death of Child X and his mother. 3.9 Practitioners from organisations who had direct involvement with the family or were involved in significant decision making were invited to meet with the lead reviewer and a member of the review team in order to explore the factors influencing practice and lessons for the future. 3.10 The lead reviewer worked with the review team to agree a draft report and this was shared with Child X’s father and practitioners who had contributed to the review. 3.11 It was after this stage of the review that it became possible to identify a private hospital where Mother had worked during the period under review. Information within the chronology indicated that there may be information relevant to the review process and the hospital submitted a chronology. A meeting was also held with senior staff at the hospital and this helped to identify further lines of inquiry which contributed to the learning within this report. 3.12 An updated report was agreed by the review team and shared with Father before being accepted by both Hillingdon Safeguarding Children Partnership and the Safeguarding Adults Board prior to publication. 4 CASE BACKGROUND 4.1 All members of the family were Irish nationals and moved to the UK from Ireland in 2011 to pursue professional careers. 4.2 Mother had previously lived in England where she had trained as a nurse. During this period, in 2003 (and prior to her relationship with Father) she reported to police that she was being harassed by her landlord. In 2005 there is a police record of contact Final Report 17.12.19 Page 6 of 39 from Mother following an argument with her previous partner and the partner told police that Mother had assaulted him. She was arrested on suspicion of assault and this resulted in no further police action. In 2006 Mother called police to report that her previous partner and his new flatmate had been threatening her and in 2007 reported the theft of a mobile phone. 4.3 Child X was born in Ireland in October 2009. Mother and Father came to England for employment reasons in 2011 and rented houses in the London Borough of Harrow and then Hillingdon. At the time of the incident Mother and Child X were living in the London Borough of Hillingdon and Father lived nearby. 4.4 Mother worked as a nurse but was also wishing to train as a lawyer as she had completed a law degree in Ireland. 5 SUMMARY OF AGENCY INVOLVEMENT 5.1 Mother was seen by GP in October 2011 and was diagnosed with alcohol dependence syndrome. She admitted to drinking excessively (in excess of 60 units per week) in the evenings once Child X had gone to bed. She said that this had started after she gave up work when Child X was born. Mother was starting a new job and the alcohol was causing severe anxiety. The GP requested medical investigations and gave advice about support but did not take any further action to investigate any impact her alcohol use might have had on her parenting. As Child X was only two years old a discussion with the health visitor would have been prudent at this stage. The GP concerned has retired and it has not been possible to explore this episode any further. 5.2 In 2012, Mother had several visits to the GP with minor ailments and was referred to an Ear Nose and Throat (ENT) specialist. This referral noted alcohol dependence syndrome. 5.3 The health visitor made a home visit in March 2013 but would have been unaware of the concerns relating to alcohol use. All was noted to be well and Mother was taking Child X to routine appointments (for example for immunisations) and consulting appropriately for any other childhood ailments. 5.4 ENT investigations could not find any cause for Mother’s symptoms and Mother wrote to the GP complaining about the ENT treatment saying that her symptoms were causing her to be “stressed out”. She also reported feeling anxious and depressed. Medical records for this period show several missed appointments. 5.5 It is thought that during 20143, Maternal Grandmother paid for Mother to attend a residential substance misuse rehabilitation centre in Kent. There is no requirement 3 Some records date this as 2015 Final Report 17.12.19 Page 7 of 39 for private facilities to notify the registered GP and there is no record that Mother’s GP was aware of this treatment episode. The facility is now closed. The last inspection report for the facility by the Care Quality Commission, (prior to its closure), notes that patients were not asked any questions about children during the assessment process and it is therefore reasonable to assume that little if any consideration was given to the impact of Mother’s alcohol use on Child X. Mother subsequently told professionals that this facility treated her for PTSD and it was only due to the diligence of the Cafcass practitioner in 2015, who checked the name of the facility on the internet (see paragraph 5.63) that this was challenged. The isolation of private treatment facilities from mainstream health care is an area for consideration which is explored in Finding Five. 5.6 Medical records do show that in September 2014 Mother was prescribed anti-depressants by her GP citing depression caused by the recent death of her father. In January 2015 her GP wrote a letter at her request to the university where she was registered for her law course. This explained she had been unable to attend due to a bereavement reaction and the ending of a long-term relationship. At this stage the GP referred to IAPT Talking Therapies4 but Mother did not take this service up. 5.7 A child minder looked after Child X for a very short time between September and November 2014. She was supposed to have him prior to school and after school but before school sessions did not happen as Mother was running late and took him to school herself. Collection was at 6pm but quite often there was confusion and miscommunication between the parents so sometimes he was collected at 7pm or the childminder would drop him back at home. The childminder has told the review that Father was always chatty and sociable, but she felt Mother was possibly depressed. There was however no specific safeguarding concern that would have warranted contact with Children’s Social Care. The arrangement ended when the childminder needed to reduce the number of children she was caring for. 5.8 From April 2014 through to August 2015 Mother worked as an accident and emergency agency nurse in two hospitals. Both hospitals asked the agency not to send her again. Complaints related to conduct issues including poor relationships with colleagues and inconsistent work practices such as being missing from her workstation and using her mobile phone on duty. Alongside this Mother obtained a permanent role as a nurse in the urgent care department of a private hospital in December 2014. The private hospital obtained two refences, one of them clinical reference. Both references were good. 4 IAPT stands for Improving Access to Psychological Therapy and is an NHS service designed to offer short-term psychological therapies to people suffering from anxiety, depression and stress. Final Report 17.12.19 Page 8 of 39 5.9 On 7th February 2015 Mother reported being a victim of rape to the Metropolitan Police who began the investigation by immediately dispatching officers to her home address. Whilst at the home, evidence was taken including a urine sample. Mother had met the alleged offender on social media and the Metropolitan Police immediately informed Thames Valley Police as the alleged offence was in their area. Thames Valley officers took steps to secure and manage the crime scene. At this stage there is evidence of good liaison between Thames Valley and Metropolitan Police officers. 5.10 The Metropolitan Police alerted their serious sexual assault team and arrangements were made to take Mother to the appropriate venue for a full forensic medical examination. Whilst at this venue officers asked Mother various questions including about her child. She disclosed that she had been drinking alcohol and it is the view of the officers that the questions about her child, and a concern about how her drinking would be viewed in court, prompted her to refuse to be examined and ask for the urine sample taken at the centre to be destroyed. (She had originally agreed to the sample in order to ascertain whether her drinks had been spiked). Three days later Mother again told a Metropolitan Police officer who was involved in the investigation that she was “a drinker”. 5.11 There is nothing in the police records to indicate that any consideration was given to Child X’s welfare in the light of Mother’s alcohol consumption and whether a “child coming to the notice of the police” (MERLIN) should have been completed and sent to relevant agencies. Mother was advised to see her GP. 5.12 Two days after the rape allegation Mother was suspended from work at the private hospital pending an investigation into an allegation that she had reported for work smelling of alcohol and, having explained the recent rape allegation, was referred to occupational health with the offer of counselling. Mother told the occupational health department that she only drank socially and denied drinking excessively. After three weeks leave Mother was passed as fit to return to work by occupational health 5.13 Eight days after the rape allegation Mother had a telephone consultation with the GP and mentioned rape, a new partner and that she had been “drinking alcohol ++”. She also said the police were aware. The GP records note she was to go to HAGAM 5 and to be referred for primary counselling. GP referred to Hillingdon Primary Care Psychological Therapies Services and Counselling and IAPT Talking Therapies6 service. Medication to help sleep was prescribed. At this point there had been opportunities to consider in more depth the impact of Mother’s alcohol use on Child X and her own wellbeing and circumstances. 5 Hillingdon Action Group for Addiction Management – a voluntary organisation 6 IAPT stands for Improving Access to Psychological Therapy and is an NHS service designed to offer short-term psychological therapies (CBT) to people suffering from anxiety, depression and stress Final Report 17.12.19 Page 9 of 39 Neither the GP in 2011 nor the police officers in 2015 alerted children’s social care. Although her employer had noted concerns these were believed to be a “one off” due to stress and did not compromise the safety of patients. February 2015 was the second occasion when the GP was aware of Mother’s alcohol use but did not consider any impact this might be having on either her parenting or her role as a nurse. The GP consultation was over the telephone (as is now increasingly common practice) and Mother’s demeanour and nonverbal cues would not have been apparent. In addition, from discussion with the GP, it is not routine for questions to be asked about dependents when discussing alcohol use. The need for all professionals to think more carefully about their response to known alcohol use is explored further in Finding Two. 5.14 Mother prevaricated as to whether she wished for a prosecution to go ahead but eventually decided that she did wish to proceed, and a video recorded interview took place in the presence of both Metropolitan Police and Thames Valley officers. Two days prior to the interview the suspect in the rape case handed himself in and was arrested by Thames Valley Police. 5.15 At the point of the video interview, there seems to have been a misunderstanding between Thames Valley and Metropolitan Police officers about the provision of victim care. Thames Valley Officers noted that this would be provided by the Metropolitan Police as Mother lived in their area, but this was not the understanding of Metropolitan police officers. This is explored further in Finding One. 5.16 In March 2015 a telephone assessment was completed by IAPT Talking Therapies and Mother declined any further input from them. Following discussion with a supervisor, a letter was sent to the GP informing them that Mother would be discharged from the service. 5.17 Around this time, Child X’s school became concerned about his poor attendance and frequent lateness and asked to meet with Mother to discuss this. Mother met with the head teacher and informed them that her relationship with Father had ended and this was stressful. She also said she would be returning to work as a nurse, had no family nearby and felt isolated. 5.18 In fact Mother was working as a nurse and in April 2015 her probation period (as a new employee) was extended due to continuing concerns about her relationship difficulties with other staff, poor work practices such as using a mobile phone whilst patients were waiting to be seen, being late for work and trying to order an anti-viral medication which was not on the inventory because she thought it should be kept in stock. These issues were considered alongside other reports that she was a capable and caring nurse. Final Report 17.12.19 Page 10 of 39 5.19 Thames Valley Police reviewed the rape case in April 2015 and ascertained that victim liaison had not been provided by the Metropolitan Police and that they had no further contact with Mother after the video interview. There was then repeated attempts (documented in the records) by Thames Valley officers to seek further clarification about victim care arrangements. Although communication between the two police forces had worked well in respect of the rape investigation there remained a misunderstanding about the provision of victim care. This meant that Mother did not receive any ongoing support from several months from the time of the video interview. There are different processes within each force which were not appreciated by front line officers and this is discussed further in Finding One. 5.20 On 28th April 2015, a nursing agency received a reference from a nursing sister at the private hospital as Mother had applied to resume work with them; the reference was completed on the template supplied by the nursing agency and was understood by them to be a professional reference. There is no record of this reference in the hospital’s HR records. In fact, it was not until July 2015 that Mother asked the employer if she could be provided with a reference and was told that any request should be sent to the HR department of the hospital from the requesting employer. No such requests were received. 5.21 On 6th May 2015 Mother’s employment at the private hospital was terminated. She became very distressed and phoned a colleague at home that evening telling them that she was going to take her own life. When this was discussed with a hospital manager the next day, the Metropolitan Police were called and asked to carry out a welfare check, which they did. 5.22 Mother submitted an appeal against her termination of employment, but her appeal was not upheld. Mother went to obtain further work via a nursing agency. 5.23 In June 2015 a Detective Constable from Thames Valley Police contacted Mother to update her on the forensic results which showed enough alcohol use to produce marked drunkenness, drowsiness impaired coordination, reduced inhibitions and memory impairment. The police record notes that Mother requested that the police officer accompany her to an Employment Tribunal as she had been dismissed from her job as a nurse. Information obtained for this review indicates that this may have related to Mother failing to pass her probationary period at a hospital where she had obtained employment. This kind of support was not a role for the police, but the officer concerned made an urgent referral to victim support to request support for Mother. Mother was supported by a colleague at the dismissal appeal meeting. 5.24 The rape investigation was then signed off and sent to the Crown Prosecution Service. Final Report 17.12.19 Page 11 of 39 5.25 Mother had a telephone consultation with the GP on 6th July 2015 and the records note that she wanted it documented that she had not had alcohol for nearly five months. As well as reporting further ENT symptoms she told the GP that she had ongoing depression and did not want this documented in her notes. As a result of this consultation the GP made a second referral to IAPT Talking Therapies. 5.26 Following a telephone assessment by IAPT, it was noted that Mother was unhappy about confidentiality procedures and did not want to continue with the assessment. The therapist discussed this with the supervisor within the team who called Mother back to clarify her concerns about confidentiality. As a result, Mother was referred to secondary care (Community Mental Health Team) as it was agreed that she needed longer therapy and more support. The notes of this call refer to Child X as being a “protective factor”. The term “protective factor” has a specific meaning within mental health assessments and is widely used. Rutter (1985)7 for example defined protective factors as “those factors that modify, ameliorate or alter a person's response to some environmental hazard that predisposes to a maladaptive outcome.” Protective factors can be biological, psychological or within the family and community. In this case Mother’s close relationship with her child would have been understood as a factor reducing the risk of a deterioration in her mental state or likelihood of self-harm. However, this analysis needs to include a second step which questions what this means for the lived experience of the child and whether there is any impact on the care being given. This is discussed further in Finding Two. 5.27 The Community Mental Health Team discussed the case at an urgent referral meeting and decided that the psychology service should complete a risk review. Mother was contacted and was happy to accept this service and was placed on the waiting list. 5.28 On 30th July, Mother was contacted by a specially trained officer8 from Thames Valley Police. The delay in making contact was due to the discussions that had taken place with the Metropolitan Police Service as to who would be responsible. 5.29 Mother told the specially trained officer that she found it hard to go out, was suffering from Post-Traumatic Stress Disorder and had seen her GP about counselling. She told the officer that this was affecting her ability to work as an accident and emergency nurse. With her consent a referral was made to the Independent Sexual Advisor Service. (Mother did not take this up) 5.30 Late in August 2015, Mother was notified by Thames Valley Police that the Crown Prosecution Service were taking no further action following police investigation into 7Rutter, M. (1985. b) Resilience in the face of adversity: Protective factors and resistance to psychiatric disorder. British Journal of Psychiatry; 147: 598–611. 8 A specially trained officer is an officer trained to support victims of sexual crime. Final Report 17.12.19 Page 12 of 39 the rape. The decision was not to charge due to conflicting evidence. Mother was visited at home by the officer in charge from Thames Valley Police to discuss this and was very angry and upset and said she intended to dispute the decision. 5.31 Three days later the police officer was concerned that Mother was at a crisis point and contacted the Metropolitan Police to request a “child safeguarding referral”. The Metropolitan Police call taker suggested that it would be preferable for this to be made directly by Thames Valley Police and provided the number for Hillingdon Children’s Social Care. As it was a bank holiday there was no answer and the Thames Valley Police officer contacted another department within the Metropolitan Police and subsequently recorded that she had agreed with them that the Metropolitan Police were to make a referral the same day. 5.32 Metropolitan Police records for that day note concerns from Thames Valley Police about Mother’s vulnerability and an “Adult Coming to Notice” MERLIN was created and shared with “Hillingdon Adult Social Care”. It seems that at this point there was a disconnect between the phone call which mentioned a child safeguarding referral and the information which was received via e-mail from Thames Valley Police which focused on Mother’s needs as a vulnerable adult. 5.33 The Community Mental Health Team note a MERLIN report received by the police which noted the no further action decision by the Crown Prosecution Service, the death of her father, that she had become a single parent and had lost her job. Mother was contacted and asked to call the duty team and the plan was also to discuss the police notification with the psychiatrist in the urgent referrals meeting. Following this a letter was sent asking Mother to contact the assessment and grief therapy duty worker. A copy of the letter was sent to the GP. 5.34 Mother appealed the decision on her case with the Crown Prosecution Service. 5.35 In September 2015 a parent contacted the school concerned that Mother appeared to have been drinking alcohol when dropping off Child X. The head teacher left a message for Mother to phone back and later met with Mother who said that her GP had prescribed sleeping tablets and she was going to receive therapy after a court case in relation to an assault. Mother stated, ‘she used to have a drink to help her out’. The head teacher offered support through a Team Around the Family (TAF) meeting and allocation of a key worker. Mother declined this offer. 5.36 In October 2015, Mother had not contacted mental health services and a decision was made to discharge her back to the GP to review. A fax was sent to the GP. 5.37 In November 2015 there was an issue regarding pick up of Child X from school as Paternal Grandmother and Mother arrived on same day. Father visited school next day apologising and shared concerns about Child X’s well-being and fear Mother was taking Child X to Ireland and not returning. The head teacher wrote to both parents requesting a meeting to clarify future collection arrangements of Child X. Final Report 17.12.19 Page 13 of 39 The following sequence of events is set out in detail as it is important in understanding how information that Mother had said she would kill herself and her child was communicated and assessed through the system. 5.38 On 26th November 2015, Father contacted Thames Valley Police reporting harassment by Mother who was sending excessive abusive messages to him. Father expressed concern for the welfare of his son and made the police aware of information given to him by Maternal Grandmother that Mother had said “I will kill myself and take the child with me’. This resulted in a domestic harassment and an adult protection report on the police recording system. The domestic harassment report was linked to the rape allegation. 5.39 Later in the day on 27th November, the Thames Valley Police officer in charge placed an update in the adult protection report outlining Mother had told the officer. “Told her mother she feels like killing herself although she has made threats since 2012 and no indication of carrying out the threats, but I feel with the rape appeal, stress of being a nurse and single mother and her partner asking for full custody that there needs to be safeguarding for Mother’s mental state.” The police sergeant emailed the specially trained officer from the rape case to advise of the domestic incident so that safeguarding of Mother could be discussed. The report that was uploaded to the police system noted that the case was assessed as medium risk due to “suspect stress over the rape case appeal and a child being caught in the middle”. 5.40 There were therefore two police reports; a domestic incident report and an adult protection report. The domestic incident report did not initially have the child protection flag ticked and Child X was not listed on the report. This lack of flag was picked up within six days by the Force Crime Registrar. The adult protection report also did not have the child protection flag ticked and this omission was not picked up. This may have been because the statement that Mother had made about killing herself and her child was not copied over verbatim into the adult protection report. The emphasis in the report was on the threat she has told her mother she feels like killing herself. The emphasis was therefore on the adult rather than the child who, although mentioned, was not recorded in such a way that it prompted a child protection referral. When the adult protection report was reviewed the decision was that no referral was needed as there is no record of consent to share personal information or indication that the person lacks capacity to make decisions. The decision not to make an adult safeguarding referral was influenced by police understanding that family members were trying to arrange a home visit from a GP and Mother had attended a private rehabilitation centre for alcohol misuse. 5.41 On 27th November Mother contacted the school to say she would not attend a meeting and that Child X would not be in school as he was unwell. The head teacher contacted the education safeguarding lead in the Local Authority for advice. They advised that the previous allegations by a parent regarding Mother’s drinking could be malicious, the school should keep monitoring and the parents should seek legal advice about contact. Final Report 17.12.19 Page 14 of 39 5.42 Father also contacted the school and met with the head teacher on 27th November. He was told that the education safeguarding lead had been consulted and the situation did not reach the threshold for involvement by Children’s Social Care. The school were informed by Father that the police would be making a MASH referral. More appropriate advice from the education safeguarding lead would have been for the school to make a direct referral to Hillingdon Children’s Social Care. However, the school were reassured by Father saying that police were referring to MASH but at this stage they were not aware that this was Thames Valley Police referring to Buckinghamshire MASH (their local MASH team). 5.43 On 3rd December, Father told Thames Valley Police that Mother had sent further concerning messages. The police officer confirmed that the adult protection report that had been created would be sent to the Metropolitan Police. There was also communication with the specially trained officer regarding the messages to alert her to examples of Mother’s state of mind. Many of the messages sent by Mother referred to Child X who featured in many of the disagreements. 5.44 On Saturday 5th December 2015, Father made an urgent application for a Child Arrangements Order and Prohibited Steps due to his concern that Mother was planning to permanently remove Child X to Ireland. Within the application several ‘harm boxes’ were ticked, and Father raised concerns about Mother’s mental health and alcohol dependency. He also noted her threat to kill herself and their child. He sought a full transfer of Child X’s living arrangements to him. 5.45 Also, on Saturday 5th December the Thames Valley Police MASH risk assessor reviewed the domestic incident report and classified it as standard on the basis that Mother did not pose risk of serious harm to Father. The risk assessor reiterated that one of the concerns was that Mother stated that she would kill herself and “take the child with me” and a task was set for Bucks MASH adult protection to review on Monday 7th December, but this task was closed incorrectly due to the officer’s inexperience with the police recording system. Because it was filed it was not reviewed by a MASH supervisor. 5.46 Despite this, further discussion took place between uniformed officers and the specially trained officer and on 8th December it was recommended that the referral to the Metropolitan Police should go ahead with flagging to notify Children’s Social Care and maybe the education officer. 5.47 On 10th December 2015 Mother was notified that her appeal regarding the Crown Prosecution Service’s decision in the rape case had not been successful. 5.48 On 11th December Mother reported to the GP that her partner was subjecting her to psychological damage. She denied depression or suicidal ideation and refused medication. She told the GP she had had some private counselling. Final Report 17.12.19 Page 15 of 39 5.49 On 11th December Father’s court application was passed to the Cafcass central intake team whose role is to screen for immediate safeguarding concerns within 24 hours. This was done and a referral sent to Hillingdon Children’s Social Care. This referral did not include the information about Mother’s threats to kill herself and her child. Within Cafcass, the case then transferred to a family court advisor in the early intervention team whose role is to prepare a standard safeguarding letter for the court which sets out the outcome of lateral checks and any welfare or safeguarding concerns. At this stage the Cafcass worker noted that no further safeguarding steps were needed as a referral had been sent to Children’s Social Care and completed checks by sending out standard letters to all agencies. 5.50 One of these checks was with Buckinghamshire MASH who did not note any involvement with the family; one reason for this might be that the checks were requested in the child’s name and contact with MASH had been in respect of police contact with Mother. Also, police checks were “level 1” checks which check any known convictions, cautions and arrests but would not give details of any other police involvement. Even if level 2 checks had been carried out these are force specific and if sent to the Metropolitan Police would not have revealed information known to Thames Valley. Cafcass were therefore not aware of the details of current involvement by Thames Valley Police. 5.51 On 14th December, the specially trained officer in Thames Valley Police asked the officer in charge of the harassment case to transfer both the domestic incident and the adult protection reports to the Metropolitan Police. This was done via OBRT9 and information passed over included a string of background e-mails. No crime reference number was requested from the Metropolitan Police as would be usual practice and there is no record as to these being received and any action taken. In this case it would have been better practice within Thames Valley Police for the information to have been managed and passed over via MASH. 5.52 The next day the specially trained officer was informed by the Independent Sexual Violence Advisor (ISVA) that Mother did not wish to engage with their service and that she had been verbally abusive over the phone. The sequence of events in December 2015 shows a series of individual errors and misunderstandings across a complex system. The cumulative effect meant that Mother’s threats to kill herself and her child were not properly assessed. In summary: 1. Within Thames Valley Police, the threat to kill herself and her child was recorded in the domestic incident report but not the adult protection report. As a result of an administrative error the request for Buckinghamshire MASH adult protection assessor to review the domestic incident report was not actioned. 2. This error could have been rectified by the plan of Thames Valley officers to send 9 OBRT is a unit who deal with low level bulk crime reports and the transfer of certain reports between other forces and outside agencies. Final Report 17.12.19 Page 16 of 39 both domestic incident and adult protection reports to the Metropolitan Police with supporting e-mails asking for a child protection referral. However, the transfer of information did not go via MASH (which would have been best practice) but via a general information transfer system and there is no record of this having been received by the Metropolitan Police. 3. The school were reassured by information from Father that MASH had been informed but did not understand that this was not a referral to the local MASH team where Child X lived. 4. As the Metropolitan Police had not received any referral naming Child X this would not have shown in any checks carried out by Cafcass. 5. Although Cafcass had received information from Father about Mother’s threats this was not passed in the referral to Hillingdon Children’s Social Care who could not take this into account in their subsequent assessment. 5.53 On the morning of 16th December 2015 Father contacted the school to enquire about school holidays and if Mother had advised them if she would be taking Child X out of school early. Later that afternoon Mother contacted school to advise she would be taking Child X to Ireland for her brother’s wedding. 5.54 The Cafcass family court advisor made contact with Father over the telephone. He reiterated concerns about Mother and advised that Police were also concerned due to messages Mother had sent. Father also updated them on the arrangements made in court the previous day at an urgent hearing regarding Mother’s undertaking to return from Ireland and arrangements made for him to speak on the phone to Child X. 5.55 Following the referral from Cafcass, a social worker from Hillingdon MASH spoke to Mother over the telephone and she said that she believed that Father had made the allegations as he wanted custody of Child X. She described looking after Child X alone and also referred to the loss of her father, being raped and resulting anxiety and panic attacks. She said she had asked her mother to come from Ireland to support her, whilst she went to a treatment centre for the anxiety and panic attacks and Father thought this related to treatment for alcohol. She said that Father had taken out a non-molestation order against her and he knew it would affect her registration as a nurse. She confirmed that she had sent the text messages after receiving a letter from his solicitors containing false information. She agreed to agency checks being conducted. 5.56 MASH received information from the school and the education participation team regarding Child X’s attendance as being only 80% and concerns regarding Mother’s alcohol use. Child X was noted to be doing well at school. There is no record of any other information being gathered from the GP or police records and no record of any discussion directly with Father. The decision was to close the case as there were “no child protection concerns”. Final Report 17.12.19 Page 17 of 39 This decision highlights the problem with decisions made simply on the basis of self-report and minimal consultation with other agencies. The original concerns in the referral were worrying and warranted a more in-depth investigation which was possible as Mother had given consent for agency checks. Had these checks been completed, information from the GP about Mother’s mental health could have informed the decision although, because of the series of errors outlined above, it is possible that the information held within Thames Valley Police would not have been available unless they had been directly approached. 5.57 Information from the family indicates that during Christmas 2015 Mother was in Ireland, drinking heavily and her relationships with her family deteriorated. 5.58 In January 2016, Mother was contacted by the Cafcass family court advisor from the central intake team. Mother felt Father’s “coercive control” had turned the extended family against her. She denied any alcohol or drug issues affecting her or Father but did admit to stress caused by the court proceedings and having panic attacks, which she was getting treatment for. The family court advisor then filed the safeguarding letter to the court which advised that no further action would be taken by Hillingdon Children’s Social Care in relation to the referral by Cafcass. The court was asked to give further consideration to the alleged safeguarding concerns and require Mother to file a letter from her GP regarding her alcohol use and state of her mental health. 5.59 Four days later in January 2016 a Detective Sergeant from Thames Valley Police contacted Mother to discuss the fact that her criminal injuries compensation claim appeared to have been rejected due to an administrative error. The officer noted that Mother was “quite intoxicated…confused and rambling in her responses” and requested an urgent welfare check of Mother by Metropolitan Police officers. The Thames Valley officer was reassured by the information received from the Metropolitan Police which was that Mother had been seen and said she was fine and during a subsequent conversation with Mother had the impression from Mother that she was in contact with Children’s Social Care. It is important to note that there is no reference in any police record to the welfare of Child X. 5.60 In February 2016 both parents attended court as Father wanted an order to regulate Child X’s living arrangements. He felt these were erratic due to Mother’s shifts as a nurse. He was pursuing a shared care arrangement but ideally wanted Child X to live with him full time and for Mother to get help. Mother opposed this. The court ordered section 7 report10 from Cafcass and case was allocated to a family court advisor to prepare this. 5.61 The Cafcass family court advisor saw Child X alone and found him to be quietly spoken, reserved and to have a balanced view regarding both parents. The family 10 A section 7 report is ordered by the family court and in accordance with The Children Act 1989 requires either Cafcass or the local authority to investigate all the circumstances of the family including the wishes and feelings of a child or young person and send a report to the court. Final Report 17.12.19 Page 18 of 39 court advisor had also intended to interview Mother that same day, but she wasn’t able to talk with Mother in private as she was not able to bring anyone to sit with Child X. The family court advisor therefore arranged to interview Mother by phone. 5.62 A face to face interview did take place with Father which raised no concerns about his parenting capacity. He did not raise specific concerns about Mother’s parenting but said that he wanted her to get help and for there to be some stability in when he could have contact with Child X. 5.63 During the telephone interview with Mother, she said she had been “labelled with alcohol dependency”, denied ever having suicidal thoughts and said she had “no history of mental ill health”. Mother also said she had received treatment for Post-Traumatic Stress Disorder and had been on medication for this. Mother was not honest about her treatment at the private clinic being related to alcohol use and when confronted about this was very defensive. She also said she was an ad hoc agency nurse and would not disclose the name of her employer. 5.64 Due to inconsistencies in Mother’s responses and potential impact of Mother’s alcohol use on Child X a further safeguarding referral was made by Cafcass to Hillingdon Children’s Social Care on 17th March 2016. 5.65 Meanwhile on 14th March the school welfare officer reported to the head teacher that Mother smelt of stale alcohol when dropping off Child X at school. On the same day a parent told the head teacher that she had received abusive texts from Mother. 5.66 Following the Cafcass referral to Children’s Social Care, Hillingdon MASH telephoned Mother and she denied having alcohol issues or feeling suicidal but did say that she did drink occasionally when Child X was in Father’s care. She did not feel that she had mental health issues. She added that the relationship ended because of emotional and domestic violence. 5.67 MASH telephoned the head teacher who said that school did have concerns about Mother’s ability to look after Child X. His attendance at this point was 84.71%. He could look dishevelled when brought in by Mother and he could be late. When Father brought him he was never late. Father had expressed concerns that Mother could self-harm or harm Child X. This conversation was recorded in the social care records with the comment that the school had “nothing concrete to report”. 5.68 Enquiries were made by Children’s Social Care to drug and alcohol services and the Domestic Violence Advocacy Service who advised Mother was not known to them. Mental health services advised Mother was known to them, was feeling low with suicidal thoughts and was waiting for assessment to start therapy. 5.69 The decision by MASH was to close the case as “no safeguarding issues had been identified”. It was felt that the referral related to contact issues. The heath practitioner within MASH informed the school nurse of the referral, citing Father’s concerns about Mother’s alcohol use, but there is no record of any further action by the school Final Report 17.12.19 Page 19 of 39 nursing service. During the serious case review process CNWL health staff have responded to this identified lack of response by the school nurse and the MASH pathway is being updated to include a pathway for CNWL community children’s teams including expectation of how referrals should be managed. A more appropriate decision at this point would have been to pass the case for a full social work assessment. It is hard to equate the concerns of the school with the comment in the records that they had “nothing concrete” to report. The information that they gave regarding concerns about her alcohol use and worries that she would self-harm or harm the child should have prompted further assessment. No direct contact was made with Father and it seems that too much weight was given to the fact that Cafcass were preparing a section 7 report and the limitations of this process were not understood. In private law proceedings Cafcass only has automatic consent to carry out checks with the police and local authorities in respect of safeguarding concerns and have to seek consent to carry out checks with schools and other professionals such as GPs. It seems that social workers were not aware of this and did not alert Cafcass to the school’s concerns. The focus of the work of Cafcass is on the private law application and this is why they refer to Children’s Social Care for assessment if there are any wider safeguarding concerns. This is discussed further in Finding Three. 5.70 On 21st March 2016, the Section 7 report filed by Cafcass concluded that Mother’s allegations of domestic violence were vague and did not reflect a pattern of power and control. There was concern about level of animosity towards Father by Mother, and Mother’s inconsistent accounts of her alcohol use. The in-patient facility Mother attended for treatment of post-traumatic stress disorder turned out to be a facility for those who suffer with alcohol dependency and substance misuse. The family court advisor concluded that Child X would receive good enough parenting with Mother accessing help through the local authority, but with generous shared care arrangements with Father. The family court advisor had not been content with the decision of MASH to close the case and requested that the court asked for GP information to be shared before any order was made. 5.71 Mother responded to the Section 7 report advising she wanted the family court advisor to attend court and she did not feel her concerns had been adequately investigated. 5.72 At a dispute resolution appointment held in court, Mother was directed to provide a letter from her GP setting out her medical history with regard to alcohol use and mental health. Mother had a telephone consultation with the GP to ask for this information to be provided to the court. She spoke of the stress from the court case and asked the GP to sign her off sick from her university course. The information provided by the GP to the court was based solely on Mother’s self-report which was Final Report 17.12.19 Page 20 of 39 that she had not drunk alcohol for five months rather than the GP records which noted a previous history of alcohol dependence syndrome. 5.73 In April 2016 Child X was absent from school on three occasions. On two occasions Mother did not contact the school and was aggressive when contacted. 5.74 On 17th June a referral was made by Child X’s school to Children’s Social Care following a parent reporting that she had spent the weekend away with Mother and Child X and Mother was unable to care for Child X as she was under the influence of alcohol both day and night. This had been witnessed by Child X. Child X was not in school that day. The school had not informed Mother of the referral as “due to her emotional state I believe I could put the child at further risk by informing at this stage”. The school had also not informed Father as they were concerned about how the information could impact on the court hearing. “This has been reported to me by a third party and not witnessed by a member of staff, if dad informs mum that I am making a referral it could escalate the situation with mum and make the child more vulnerable”. The referral from the school went on to say that they were unaware of the outcome from the MASH referral in March. 5.75 The police report prepared after Mother and Child X’s death indicates that Mother spoke to at least one friend in Ireland about her plan to kill herself and her child to get back at Father. The advice to her friend from the Good Samaritans in Ireland was that the only course of action was to consider calling the UK police, but this could put her in danger. They said they could not reach out unless Mother contacted them first. 5.76 Around this time the MASH team called the school to discuss the referral and advised the head teacher that as there were no new concerns apart from third hand information no further action would be taken, and courts were involved. Both parents were contacted by MASH team to advise a referral had been made and the case would be closed. Mother contacted the school the following day upset about the referral made ‘behind her back’. It was not an appropriate decision to close the case. Although the information from the school might be considered to be third party, the information was detailed and consistent with other known information and previous concerns. It seems that the only health information that was sought was from the alcohol treatment service which confirmed that Mother was not known. A thorough, forensic and more questioning approach at this stage which sought information from a wide range of sources could have challenged Mother’s portrayal of her alcohol use and allowed consideration of its potential impact on parenting, her role as a nurse and her own wellbeing. Final Report 17.12.19 Page 21 of 39 5.77 A referral was received by Children’s Social Care from Maternal Grandmother on 24th June 2016. Maternal Grandmother stated that she had visited Child X the day before and saw her daughter drinking heavily. She had started drinking at 10:00am and Child X found her asleep on the sofa at 2:00pm. Child X had said that he found his mother passed out on the sofa and that when she does this in the evening he goes to bed. Maternal Grandmother said that her daughter was an alcoholic in denial, had bad health and appears fragile. She felt that Child X was being neglected and not fed properly as there was no food in the fridge. She was keeping Child X away from family members was denying Father 50/50 custody. She also referred to Mother as being a serial liar. This information prompted a child and family assessment. 5.78 On the same day Mother contacted school to advise she would be collecting Child X early after a class trip. Father arrived to collect Child X later and was informed Child X had left with Mother. The school asked to be informed of any Child Arrangement Order so they had information on who would be collecting Child X on which days. 5.79 Also, on 24th June Mother called the Metropolitan Police following an argument with Father. Father had also contacted the police as he had been unable to collect his son for contact. A risk assessment was completed (in respect of the domestic incident) and recorded as “standard”. Information was shared with Hillingdon Children’s Social Care three days later because of the concerns about the impact on Child X of being in the middle of a relationship breakdown. 5.80 The school received a request from a social worker to visit Child X at school for a child and family assessment. The following day the deputy headteacher contacted the social worker to ask if Father had been made aware of the referral and if he was aware that Child X had been spoken to at school. The social worker advised the school that Father had not been informed but would be contacted. 5.81 The Final Judgement at the court hearing on 4th July 2016 was for a Child Arrangement order for shared care. This was influenced by the GP letter which stated that Mother reported to having been abstinent from alcohol for five months. 5.82 The child and family assessment concluded that Child X was not at risk and there was no need for further social work involvement. Additional support could be provided via the school and a Team around the Family (TAF) service. The assessment also recommended that Mother should self-refer to the alcohol treatment service. Advice was sought from the LADO regarding any implications of Mother’s alcohol use for her employment as a nurse but there is no note of any response on file. Following the assessment Mother declined to engage with the Team around the Family and there is no evidence of any self-referral to the alcohol treatment service. This assessment focused primarily on discord between the parents and its impact on Child X’s emotional wellbeing taking account of information from the GP that there were no concerns about Child X. The analysis in relation to alcohol use relied once more on self- Final Report 17.12.19 Page 22 of 39 report and although it was recorded in the assessment as a danger, Mother’s assertion that she did not abuse alcohol was noted to contribute to keeping Child X safe. Her comment that she had been treated at a private facility for anxiety and depression (rather than alcohol use) was not challenged or checked. Her comment that she had never felt suicidal could not be cross referenced with the threats she had made as these remained within the records of Thames Valley Police and the original documents Father completed when making the application to court. There was no contingency as to what the approach should be if she did not receive help with her alcohol use. One significant gap in this assessment is that Father was not seen face to face and was only spoken to via a telephone conversation. A more detailed discussion with Father may have assisted the social worker in obtaining a more balanced view as to the information given by Mother during the assessment process. 5.83 On 19th October 2016, Father contacted MASH about suspicions about Mother’s drinking, sending threatening text messages and ‘messing him around’ with contact. He wished this to be treated as an anonymous referral but after further discussions decided to withdraw it as he was concerned that Mother would assume it was a member of the family who had made the referral and “things will become uglier”. He said that he had not seen Child X being neglected or at risk. Father recalls that he was told by the MASH worker that if there were problems he would need to go back to court. 5.84 The management decision at this point was to speak to Mother and the school. After contact with Mother no contact was made with the school as Mother did not give her consent for further checks. The decision was that there should be no further action as Mother had provided assurance that she did not have alcohol problems and that the referral was malicious and linked to family tensions. 5.85 On 7th November Mother was seen by her GP for a medical complaint; this was the last appointment before her death. 5.86 On 18th November Child X was absent from school and Mother advised the school that he was unwell with sore throat and upset tummy. He was again absent with a sore throat and a cold on 28th November and Mother told the school Child X had told her he had been upset at playtime the previous day. This was confirmed by the school who explained that there had been a problem in the playground, but Child X had settled and returned to class. 5.87 On Saturday 10th December 2016 Mother refused Father access to Child X due to arriving late, having slept through his alarm. The following day Father arrived to take Child X out, but Mother told him he would not be seeing Child X that day. 5.88 Later that evening Mother left a message on the voicemail of the school to advise that Child X would not be attending school the following day (Monday) due to Child X having a bad chest and cold. Final Report 17.12.19 Page 23 of 39 5.89 On Monday 12th December as Father had not seen Child X that weekend, he telephoned the school and was advised that Child X was off school due to sickness. Police records show that Mother’s mobile phone records indicate that she read a text message at 9.20 that morning. 5.90 Father arrived later that evening to collect Child X as per the court order, however there was no reply and the house was in darkness. Father tried calling Mother, but the phone diverted to voicemail. 5.91 Father called police and 19.24 hours requesting that officers conduct a welfare check in relation to Mother and Child X. He told the police that Child X hadn’t attended school that day. He had made repeated efforts to make contact with Mother by calling her mobile and attending her home address. He had received no response. Father told officers that Mother’s mental health was deteriorating, and she was misusing alcohol. He was concerned she may be drunk. 5.92 Police officers were unable to attend immediately but attended Mother’s address at 20.37 hours and could see a downstairs light on but no response or signs of movement. Intelligence checks were completed, and neighbours were spoken to who said they had not seen Mother. Officers returned again at 01.09 hrs with no signs of change from the previous visit. They spoke at length with Father who explained that this had happened before, but not often and he was concerned this may be malicious. 5.93 As Child X had not attended school on the 13th December, Father visited the school to relay concerns about not being able to contact Mother. The same day Father called the Police twice. The first call was to inform the police that Child X had not been in school and to ask when he could report him missing. He was advised that he could do so at any point. At 12.27 he called the police to make the missing report. 5.94 On the same day Children’s Social Care received a telephone call from Maternal Grandmother requesting a home visit and disclosing that two weeks previously Mother had told her cousin that she was going to commit suicide and take Child X with her. She said that Mother was always drinking, and Child X had not been in school that week. This call should have prompted an immediate call to the police; although it must be stressed that in this case even had this happened the sad outcome would have been the same. 5.95 A MERLIN (child coming to the notice of the police) report was completed and circulated. The initial risk assessment by the police was MEDIUM as it was believed that Child X was with his mother and it was felt there was no intelligence to support forced entry. 5.96 An internal Metropolitan Police review of the police response to the missing child report found that the risk assessment as MEDIUM was proportionate but although it is apparent that supervisors were made aware of the case neither the Duty Officer’s risk assessment entry not the supervision of the MERLIN report were completed Final Report 17.12.19 Page 24 of 39 within the time periods laid down in the risk review protocol. The review also noted that there was no investigation plan or further actions until the case was reviewed by the Sergeant in the MISPER (missing persons) unit at 07.12 in 14th December.11 5.97 On 14th Children’s Social Care started to make enquiries following the referral by Maternal Grandmother the previous day. Conversations took place with Maternal Grandmother, Father, the head teacher at the school and the Metropolitan Police missing persons unit. 5.98 On 14th December 2016 at 10.11 hours officers attend Mother’s address and forced entry where Mother and Child X were found lying in bed deceased. The sequence of events leading up to Child X and his Mother being found deceased show that both police and Children’s Social Care could have responded with more urgency on 13th December. There has been a thorough review within the Metropolitan Police which found there had been no professional misconduct but both organisations will need to continue to reflect on whether their responses in such situations can be improved. However, it should be stressed that there is no evidence that this would have made any difference to the sad outcome in this case. 6 REVIEW FINDINGS AND RECOMMENDATIONS Finding 1 Information sharing within police systems and across police boundaries did not always work well and resulted in information about support for Mother and risks to Child X becoming lost in the system. 6.1 Thames Valley police carried out a thorough individual management review of police practice in this case and identified where individual administrative errors prevented proper sharing of information within their own systems and would have affected information that was shared with other agencies (see para 5.96 above). Specifically, recording lacked precision and as a result potential risk to Child X was not flagged in the adult protection report. The importance of ensuring that all relevant information is copied onto a child protection or adult protection report is subject of an internal recommendation within Thames Valley Police. 6.2 Considering the Thames Valley Police information alongside that given to the review by the Metropolitan Police, there are two specific points where cross border working 11 The eventual outcome of the police review was that the case did not meet the criteria for referral to the Independent police Complaints Commission but individual learning should take place at a local level. Final Report 17.12.19 Page 25 of 39 between police forces needs to be improved in order to make sure that vulnerabilities of both adults and their children are properly identified and managed. 6.3 The first area relates to victim care. Thames Valley Police victim care arrangements are guided by the Home Office circular12 which refers to the expectation that the police force where the victim lives is best suited to offer appropriate victim care in cases of child abuse. The Thames Valley Police individual management review comments that this circular is commonly applied to other serious crimes such as Serious Sexual Assault (SSA) and that the Detective Sergeant quoted this policy in an e-mail to the Sergeant in the Metropolitan Police sexual offences investigation team. Metropolitan Police records seen for this review do not acknowledge this e-mail and in any event, the force do not use the guidance in this circular to direct their work with adult victims. Their expectation would have been that they would have been updated every 30 days about the investigation by Thames Valley Police. Each force assumed the other was arranging support for Mother and the outcome of this misunderstanding was that there was no victim care plan for Mother for several months and opportunities were lost to understand her mental state during this crucial period. This situation was rectified and after Thames Valley Police took over victim care there was an excellent standard of service. 6.4 The second area is information flow between the two forces. In relation to the initial rape investigation this worked well but following the investigation of domestic harassment allegations the totality of the concerns about Mother’s mental state and risks to Child X were not passed via the most appropriate method to the Metropolitan Police. These should have been passed from one MASH team to another, but instead the OBRT system13 was used and there was no follow up to make sure that the information had been received and acted upon. This was important information which included Mother’s threats to kill herself and her child and had this been received by police officers in Hillingdon MASH it could have influenced the subsequent assessments within Children’s Social Care, Cafcass and mental health services. Recommendation 1a The Metropolitan Police and Thames Valley Police forces should review the points in this case where information exchange did not work effectively and ensure that officers involved have been debriefed and relevant learning has taken place across the local system. Recommendation 1b National guidance from the College of Policing should be unambiguous regarding the expectation that, in cases of sexual assault, a victim care plan should be delivered by the police force where the victim resides. 12 Home Office Circular 36/2002 13 See paragraph 5.45 above Final Report 17.12.19 Page 26 of 39 Finding 2 Assessments of Mother’s wellbeing were too often based on self-reported information and there was a lack of focus on the potential impact of Mother’s alcohol use and mental health on her role as a parent and a nurse. 6.5 Mother’s alcohol use is a theme throughout her contact with all practitioners but on most occasions, she was able to convince people that this was either in the past or it did not interfere with her care of Child X. This is what lay behind the positive report by the GP to the family court and was likely to be a factor in the police officers not notifying Children’s Social Care at the time of the rape allegation. Mother was a nurse and although there is no concrete evidence that this influenced responses this cannot be ruled out. There needed to be far more curiosity by practitioners regarding the impact of alcohol on her life, taking account of the possibility that she was minimising described alcohol intake. Several factors seem to have prevented this happening. 6.6 Generally, practitioners lacked confidence in probing in more detail when Mother made reference to her use of alcohol and there is no evidence of any standardised tools being used to understand the extent of the problem. For example, she told police officers that she was “a drinker” but there was no follow up as to what this meant and GP records in February 2015 noted she had been “drinking alcohol ++”. There is no further detail, although the GP did suggest a referral to alcohol treatment services (which Mother did not take up). 6.7 When she had a telephone assessment by IAPT Talking Therapies this also did not refer to any specific analysis of the interaction between mental wellbeing and alcohol intake and the telephone assessment would not have allowed for consideration of any non-verbal cues. Although Mother’s mental health did reach a threshold for consideration by the mental health team, they were not aware of the full extent of her threats to kill herself and her child and could not therefore carry out a detailed assessment that would be expected in these circumstances. 6.8 Within mental health practice an understanding of protective factors is an important aspect of assessment. However, where a child is named as a protective factor more thought needs to be given as to what this means for the child. Although a child may give a parent a reason to engage with therapy, or make them a low risk of completed suicide, there must be next stage of assessment which considers both the needs of the child and any potential risk. The voice of the child was missing from the assessment and there was no attempt in this case to use any framework or tool to assess the needs of the child independently from the needs of the parent. 6.9 A study of common factors in parents who kill their children commented that traditional risk factors for violence are different from commonly occurring factors in Final Report 17.12.19 Page 27 of 39 cases where parents kill themselves and their child.14 Where children are deemed to be a protective factor there needs to be a proactive approach to considering risks. More work is needed to support practitioners with evidence-based tools. A UK study of parents who have killed their child 15 concluded that understanding risk factors for filicide (parents killing their children) is far from complete and more work is needed to support the development of effective intervention strategies. 6.10 From the perspective of GPs, they will rely on self-reported information and within a standard seven-minute appointment may not routinely ask for more detail including whether the patient has caring responsibilities. This is an area of practice that could change with an expectation that when a patient is known to misuse alcohol, consideration should always be given to the impact on those they are caring for. A referral can be made to alcohol treatment services, but it is up to the adult whether or not they wish to engage. Their response to offered treatment needs to be understood from the perspective of others in their family, particularly children. 6.11 Mother did attend a private treatment facility for substance misuse but there is no record that this facility considered her role as a mother or liaised at all with her registered GP. There is no requirement for such facilities to do so and this is a gap in the system. If the GP had received information about this treatment episode this could have been taken account of in subsequent appointments. 6.12 Information obtained for this review indicates that Mother was asked to leave a permanent job as a nurse at the end of her probationary period. On at least two occasions whilst working for an agency the hospitals concerned did not wish to use her again. 6.13 There is no indication that professionals questioned whether any steps should be taken to refer Mother to the professional regulator when they became aware of her alcohol use alongside her role as a nurse. The one exception was a social worker who considered discussing the issue with the LADO16, but this did not result in any further action as it would not have reached a threshold for LADO intervention as Child X was not understood to be at risk of significant harm. Her work practices as a nurse are of relevance since the method by which Mother obtained the insulin used to kill both herself and Child X also remains unclear. 6.14 The problem seems to be that referral to the regulator is felt to be too draconian for fellow professionals, such as GPs, to consider this course of action although there would be no reason why a referral to the Nursing and Midwifery Council could not be made if it was considered that patient safety could be compromised. When Mother 14 Friedman et al (2005) ‘Filicide-Suicide: Common Factors in Parents Who Kill their Children and Themselves’ The Journal of the American Academy of Psychiatry and the Law Online 33(4) 496-504 15 https://www.manchester.ac.uk/discover/news/findings-from-most-in-depth-study-into-uk-parents-who-kill-their-children/ 16 The Local Authority Designated Officer is the term commonly used to describe the requirement within government guidance for the local authority to have designated officer responsible for overseeing investigations into abuse in organisations. Final Report 17.12.19 Page 28 of 39 failed her probationary period in a hospital the concerns were believed to relate to conduct rather than safeguarding issues and arriving at work smelling of alcohol was only reported on one occasion with no further instances after her return to work following the period of suspension. Additionally, work as an agency nurse meant that it was harder to pick up patterns of problematic behaviour, although the agency in question does have a policy of reviewing situations where three separate employers have asked for a nurse not to return. With hindsight, problems with colleague relationships and work practices which did not always put the needs of patients first were a pattern that could have been considered as not meeting professional standards17 18. Expectations on agencies to review situations where complaints have been made should be reviewed to make sure that they are fit for purpose. 6.15 Employment references are an important part of the safeguarding system and in this case it seems that the nursing agency received a positive reference from a member of staff at the private hospital during a period where there were conduct issues being monitored and these had resulted in an extension to Mother’s probationary period. Although this professional reference was written on the template supplied by the nursing agency it had not been obtained via the hospitals HR department who would have been able to give a more objective assessment of Mother’s practice. Recommendation 2a All partner agencies must work together to develop an approach to working with adults who misuse alcohol which assesses level of risk, both to the person concerned and their dependents. Specifically, GPs should always ask patients whether they have any dependents when alcohol misuse is a presenting problem and consider discussing any child under school age with the health visitor. Recommendation 2b The local safeguarding partnership should work with mental health professionals to reinforce the need to use evidence-based tools routinely and systematically where a parent has a mental illness in order to identify any impact on children in their care. Recommendation 2c The Department of Health should require nursing agencies to have in place a process for reviewing the performance of staff registered with them and undertake a formal review when more than one employer has asked that they do not return. Recommendation 2d Safer employment guidance for health organisations should make it clear that organisations should only request and accept professional references directly from the HR department of the organisation who previously employed the professional concerned. 17 https://www.nmc.org.uk/globalassets/sitedocuments/education-standards/future-nurse-proficiencies.pdf 18 https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf Final Report 17.12.19 Page 29 of 39 Finding 3 The involvement of the family in private law proceedings diverted attention away from the role of Children’s Social Care in carrying out assessments where there are concerns that a child may be at risk of harm. 6.16 It is noticeable that the family court advisor was the one professional who moved beyond Mother’s self-reported information and questioned the impact of her alcohol use and mental health issues on her capacity to parent. The problem arose because although Cafcass made referrals to Children’s Social Care and expected safeguarding concerns to be fully assessed, social workers were falsely reassured by the fact that Cafcass were involved and carrying out their own assessment for the private law proceedings. There was a fundamental misunderstanding about the limitations of the Cafcass role in private proceedings and the information that was being considered during a section 7 assessment. This information was gathered with Mother’s consent and did not include information from Child X’s school. 6.17 The misunderstanding about the role of Cafcass within Children’s Social Care is further evidenced by the comment made to Father that if he had concerns about Child X he should “go back to court”. 6.18 Cafcass now recognises that it is good practice to ask parents for consent to contact the child’s school and this is an important element in allowing schools to understand all the various factors that might be impacting on a child’s life. In this case the concerns that had been accumulating within the school could also have been considered by the family court advisor. Asking for information from schools should become embedded in Cafcass policy and practice guidance. 6.19 The family court advisor had expected Children’s Social Care to carry out a full assessment and was not happy with the response. This should have led to professional challenge and debate. If differences of opinion could not be resolved, the escalation process19 should have been used. 6.20 There are some similarities between this case and the findings of a serious case review in Croydon20 (February 2018), indicating that misunderstandings about Cafcass’s role and the need to further develop knowledge and skills in assessing risks in situations of parental disputes applies beyond Hillingdon. Social workers need evidence informed frameworks to help them make sound professional judgements in these complex situations. Recommendation 3a Cafcass should embed into policy its current practice of asking for information from schools in private proceedings. 19 https://hillingdonlscb.org.uk/wp-content/uploads/2018/03/Escalation-Policy-January-2018.pdf 20 http://croydonlcsb.org.uk/wp-content/uploads/2018/02/SCR-Child-J-and-Child-K-publication.pdf Final Report 17.12.19 Page 30 of 39 Recommendation 3b Cafcass should encourage family court advisors in family proceedings to be familiar with the escalation protocol in the area where they work and be proactive in bringing to the attention of Children’s Social Care concerns if they are not satisfied with the response following a referral. Recommendation 3c Hillingdon Children’s Social Care should work with Cafcass to inform social workers about the Cafcass role in family court proceedings and clarify boundaries and best practice in communication between practitioners and assessing potential risks to children in such circumstances. Finding 4 Information held by friends and family needs to be taken seriously and support given to help them share information relevant to the safety of a child. 6.21 Although the extended family and social network may hold important information that could help identify where children may be at risk of harm, this might not be available to practitioners or, where it is known, there may be uncertainty how to use the information provided. 6.22 There is, for example, information within police records suggesting that Mother did have more than one conversation with a friend or family member during which she stated that she had a plan to kill herself and Child X. This information only came to light after the deaths. It is also apparent that what friends and family can do with such information is not clear; they may not know who to talk to and/or be fearful that telling the authorities will result in a child being removed. A confidential helpline for friends and family along the lines of Childline may be one way forward. 6.23 Referring to information from family and friends as “third party”, although accurate, seems to have the effect of minimising the concerns within the content of the information. In this case information from Maternal Grandmother was important and not properly analysed within the context of all the other accumulating concerns. 6.24 The issue of consent to share information is important but professionals do not need consent to listen to the concerns of another and to record the information to help in further assessment. Assessment practice needs to encourage reflection on all types of information and steps taken to confirm or refute information that cannot yet be seen as fact. 6.25 There are several factors evident in this case that challenge our safeguarding system to develop ways to work with families and friends to protect children, whilst working ethically and within the boundaries of confidentiality. 6.26 Balancing information from all parties who know the child is not easy. In this case Father was in a difficult position as he did not want to antagonise Mother to such an Final Report 17.12.19 Page 31 of 39 extent that he caused Child X distress, or his contact with his son became more contentious. He was therefore understandably careful in the amount of information given to Children’s Social Care. When Children’s Social Care did receive information from the family this was treated as third party information and the decision was no further action, as Mother’s account contradicted that of the family member and reassured the practitioner. Recommendation 4a Hillingdon Children and Adults safeguarding partnerships should consider with relevant national organisations whether a helpline for families concerned that a child is at risk could be developed and publicised. Recommendation 4b Assessments should always actively consider the meaning of information labelled “third party” and develop the skills of practitioners in listening, recording and exploring any such information further, in order to use family and friends as a positive resource. Finding 5 Although the notion of “Think Family” has been promoted over several years there continues to be a divergence between the intellectual acceptance that the needs of children are intimately linked with the needs of adults in their lives, and the way in which services respond. 6.27 In this case Mother was known to have problems with alcohol, was described as emotionally vulnerable and referred to mental health services. This information did not sufficiently permeate the system designed to meet the needs of her child. A number of reasons for this have been explored above including; GPs not routinely asking about carers and mental health professionals noting children as protective factors rather than moving to the next step of making sure that the lived experience of the child is understood. 6.28 An additional factor in this case was that Mother accessed a private treatment facility which did not communicate with her GP and seems not to have considered Mother within the context of her family and role as a parent. There is no requirement for private facilities to communicate with GPs. This is a potential gap in the system which prevents a holistic understanding of a patient’s health and care needs. 6.29 Information systems also provide further challenges to a whole family approach with records for children being separate from those of their parents and practitioners needing to take active steps to make connections. This can be challenging in a busy GP surgery and police teams need to make sure that issues for children are actively flagged on any records for adults. Final Report 17.12.19 Page 32 of 39 6.30 Involving fathers in assessments has been frequently written about in child protection literature, but this case illustrates that this is still an issue that needs active thought. Cafcass, by the very nature of their work in the family court, are compelled to talk to both parents, but other social work assessments may not be proactive enough in giving fathers the opportunity to contribute on the same terms as mothers. In this case in July 2016 Mother and Child X had been seen in the family home but Father was spoken to over the phone with no opportunity to understand where Child X spent 50% of his time. 6.31 The review team has considered carefully the possibility that approaches were influenced by an unconscious bias towards Mothers and presumption that they will not harm their child, even when making threats to do so. It is not possible to say unequivocally that this is the case and indeed the Cafcass worker took a balanced approach. However, there are also other indications that there may have been an unconscious gender bias, in approaches within this case. Even when Mother made threats to kill herself and her child these were not viewed with the urgency and depth of assessment that they deserved. 6.32 In relation to the allegations that Mother had harassed Father, the team considered whether these would have been viewed differently had these been made by a female against a male. Mother showed many of the indicators which show increased risk to the child within in the tool, developed by Barnardo’s and set out in the London Child Protection Procedures,21 to assess the impact of domestic violence on children. For example, she made threats to kill, she tried to control Father’s contact with Chid X, there was evidence of harassment via text, mental health issues, alcohol abuse and suicidal ideation. This tool was developed to assess risk to children in situations of male violence towards females and although the London procedures ask practitioners to apply the guidance to all situations of domestic abuse they also acknowledge that the procedures have been written in a context of most domestic abuse being perpetrated by men against women. There is a need for more research and guidance to assist practitioners in working in this complex area. Recommendation 5a Hillingdon Children’s Social Care should expect practitioners to gather information from all relevant adults in the family and make sure that a balanced approach to assessment results in the voice of both parents being properly included. Recommendation 5b Organisations working with adults with substance misuse and/or mental health problems should ensure that care plans for parents always address the care of any children in the family. Recommendation 5c The Department for Health should ask the relevant health bodies to ensure that when a patient attends a private facility due consideration is given to liaising with the patient’s GP. 21 https://www.londoncp.co.uk/files/supp_sg_dv_app1_riskmat.pdf Final Report 17.12.19 Page 33 of 39 Recommendation 5d Hillingdon Local Safeguarding Children and Adult Boards should work with partner agencies to promote a whole family approach and, through supervision and staff development opportunities, develop the confidence and skills of the children and adult’s workforce in working with whole families in order to address the inter-relationship between the needs of adults and their children. Recommendation 5e The gap in evidenced based assessment tools where there are allegations of harassment perpetrated by a mother against a father should be brought to the attention of the Department for Education and this limitation be made clear within the London Child Protection Procedures. 7 SUMMARY OF RECOMMENDATIONS Recommendation 1a The Metropolitan Police and Thames Valley Police forces should review the points in this case where information exchange did not work effectively and ensure that officers involved have been debriefed and relevant learning has taken place across the local system. Recommendation 1b National guidance from the College of Policing should be unambiguous regarding the expectation that, in cases of sexual assault, a victim care plan should be delivered by the police force where the victim resides. Recommendation 2a All partner agencies must work together to develop an approach to working with adults who misuse alcohol which assesses level of risk, both to the person concerned and their dependents. Specifically, GPs should always ask patients whether they have any dependents when alcohol misuse is a presenting problem. Recommendation 2b The local safeguarding partnership should work with mental health professionals (locally and national) to develop evidence based tools to ensure that where children are referred to as a “protective factor” there is always consideration of what this means for the lived experience of the child. Recommendation 2c The Department of Health should require nursing agencies to have in place a process for reviewing the performance of staff registered with them and undertake a formal review when more than one employer has asked that they do not return. Final Report 17.12.19 Page 34 of 39 Recommendation 2d Safer employment guidance for health organisations should make it clear that organisations should only request and accept professional references directly from the HR department of the organisation who previously employed the professional concerned. Recommendation 3a Cafcass should embed into policy its current practice of asking for information from schools in private proceedings and, with appropriate permissions, make sure that schools receive information that can help them to offer the best possible support to a child. Recommendation 3b Cafcass should encourage family court advisors in family proceedings to be familiar with the escalation protocol in the area where they work and be proactive in bringing to the attention of Children’s Social Care concerns if they are not satisfied with the response following a referral. Recommendation 3c Hillingdon Children’s Social Care should work with Cafcass to inform social workers about the Cafcass role in family court proceedings and clarify boundaries and best practice in communication between practitioners and assessing potential risks to children in such circumstances. Recommendation 4a Hillingdon Children and Adults safeguarding partnerships should consider with relevant national organisations whether a helpline for families concerned that a child is at risk could be developed and publicised. Recommendation 4b Assessments should always actively consider the meaning of information labelled “third party” and develop the skills of practitioners in listening, recording and exploring any such information further, in order to use family and friends as a positive resource. Recommendation 5a Hillingdon Children’s Social Care should expect practitioners to gather information from all relevant adults in the family and make sure that a balanced approach to assessment results in the voice of both parents being properly included. Recommendation 5b Organisations working with adults with substance misuse and/or mental health problems should ensure that care plans for parents always address the care of any children in the family. Recommendation 5c Final Report 17.12.19 Page 35 of 39 The Department for Health should ask the relevant health bodies to ensure that when a patient attends a private facility due consideration is given to liaising with the patient’s GP. Recommendation 5d Hillingdon Local Safeguarding Children Board should work with partner agencies to promote a whole family approach and, through supervision and staff development opportunities, develop the confidence and skills of the children’s workforce in working with whole families in order to address the inter-relationship between the needs of adults and their children. Recommendation 5e The gap in evidenced based assessment tools where there are allegations of harassment perpetrated by a mother against a father should be brought to the attention of the Department for Education and this limitation be made clear within the London Child Protection Procedures. Final Report 17.12.19 Page 36 of 39 8 APPENDIX ONE: TERMS OF REFERENCE This is a serious case review into the murder of a seven-year-old child by their Mother who then died by suicide. The review has been commissioned as a serious case review but will also consider any learning for Adult’s Services due to Mother’s previous involvement. Background to the review On 14th December 2016, emergency services were called to an address in Ruislip and found a seven-year-old child and his mother deceased. Subsequent investigations concluded that both the Mother and child’s death had been caused by an overdose of insulin. A suicide note, written by Mother was found at the scene. The initial conclusions of police investigations were that this was a case of murder/suicide. A coroner’s inquest in June 2018 concluded that the child was unlawfully killed, and the Mother died by suicide. A review of information known to statutory agencies revealed that Mother had worked as an agency nurse, the child’s parents had been involved in an acrimonious separation and that Mother had contact with agencies as a result of alcohol and mental health problems. Mother had also had contact with the Metropolitan Police following a rape allegation and some limited contact with Hillingdon Children’s Social Care. Decision to carry out a serious case review At the time of the deaths the Chair of the LSCB and the then assistant director children’s social care did not feel that the threshold had been met for a serious case review or a safeguarding adult review. The national panel were notified and did not disagree. The case was reviewed by CDOP in May 2018 and there was a recommendation that the decision not to conduct a review should be re-considered. Following a consideration meeting on 9th August 2018, a decision was made to commission a local serious case review with consideration of any adult safeguarding issues and this decision was ratified by the new national panel. Purpose of the review The purpose of the review is to improve services and assist in preventing similar events. Final Report 17.12.19 Page 37 of 39 SCOPE OF THE REVIEW The time period for individual agency chronologies is from the start of the individual agency’s involvement until the 14th December 2016. All relevant information should be made available to the lead reviewer. The following agencies should be asked submit a chronology of involvement. Primary School GP for the child and Mother CAFCASS Central and North West London Community Health Metropolitan Police Hillingdon Hospital Children’s Social Care Adult Mental Health Private alcohol rehabilitation facility Issues to be examined Were services effective in recognising and responding to any potential risks associated with Mother’s alcohol use and mental health? Were there any barriers to an effective multi-agency response to the child’s emotional wellbeing including the way in which GPs recorded contact with children’s social care and the integration of information from the private health facility? Did the use of telephone consultations by GPs impact on an accurate assessment of Mother’s mental state? Final Report 17.12.19 Page 38 of 39 Was the impact of parental disputes on the child properly considered and safeguarding concerns identified? Were there any issues that hampered safeguarding as a result of communication between Thames Valley and the Metropolitan Police? What is the process for raising any concerns about the professional practice of agency nursing staff and did this work effectively in this case? To what extent did the professional background of the parents in this case influence professional responses? It is expected that other themes will emerge during the process of review and these will be addressed by the lead reviewer in the overview report. Methodology The review process is designed to ensure an open and collaborative approach which includes the perspectives and views of practitioners and family members. That there is a focus on what happened and why practice decisions were made. The review seeks to move beyond a focus on individual practice to an understanding of lessons for the safeguarding system the as a whole. The process of the review will be: 1. Gathering and analysing written information via chronologies and other relevant reports. 2. Agreeing key practitioners who should be offered an opportunity to contribute. 3. Meeting with practitioners either individually or in small groups. These meetings will be led by the lead reviewer along with a panel representative with professional expertise in the area bring discussed. 4. Meeting with family members. 5. Key themes and earning to be agreed with the panel. 6. Production of a draft report to be agreed by the panel. 7. Sharing of the final draft with all those who have contributed. 8. Production of final report agreed with the panel and presented to LSCB. A statement of good practice The approach taken within this review should be proportionate: led by individuals who are independent of the case; with relevant professionals fully involved and able to contribute their perspectives without fear of blame; family (and others) invited to contribute. Final Report 17.12.19 Page 39 of 39 Criminal (and other) proceedings There are no criminal proceedings regarding this case as the perpetrator of the murder committed suicide. There will be reference to civil proceedings regarding custody and access to the deceased, as these are relevant to the review. Timescale The decision to conduct a review was taken on the 20th September 2018. It is proposed that a draft report will be presented to the panel six months from this date. |
NC52209 | Death of a 3-year-old boy in February 2018 in Croydon. George had been in the rear passenger foot well of a car when the front passenger (Mother's partner, 'A') pushed his seat back twice and crushed George. 'A' was imprisoned for manslaughter, perverting the course of justice and witness intimidation, and George's Mother received a custodial sentence for child cruelty, perverting the course of justice and assault. Actions by Children's services for George and Mother included: supported accommodation; a child protection plan on grounds of neglect; a child in need plan and child and family assessments. Mother was considered vulnerable to abuse and exploitation due to adverse childhood experiences, and there were concerns about her cognitive ability. Mother was involved with two men, 'A' and 'B', both of whom were involved in multiple incidents of domestic abuse and criminal activity. When George was 18-months-old he was taken to hospital twice with head injuries, which Mother claimed to be accidental. Mother and George moved address several times. George was White British. Learning includes: the impact on George of witnessing domestic abuse and unpredictable changes of residence was underestimated; George's presence was not adequately recorded during some incidents; the need for professionals to record and assess incidents considering information on all individuals present; the need for professionals to define demonstrable change in the situation of a child at risk or vulnerable adult before concluding sufficient improvement. Recommendations include: Medway agencies to improve methods of reporting and responding to incidents involving safeguarding issues and vulnerable adults.
| Title: Serious case review ‘George’. LSCB: Medway Safeguarding Children Board Author: Fergus Smith Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. MEDWAY SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW ‘GEORGE’ INDEPENDENT REVIEWER: FERGUS SMITH MARCH 2020 1 1 INTRODUCTION 1.1 TRIGGER EVENT & RESPONSES OF RELEVANT LOCAL SAFEGUARDING CHILDREN BOARDS 1.1.1 On 01.02.18 the London Ambulance Service (LAS) was called to a street in Croydon where George (a White British male nearing his 4th birthday) was found unresponsive. The child, having suffered a cardiac arrest, was resuscitated, taken to hospital and given intensive care. George subsequently developed multi-organ failure and ischemic brain injury and died 3 days after the incident. 1.1.2 Following a criminal investigation, it was established that George had been alive and well when he entered the car and had been in the rear passenger foot well when the front passenger (his mother’s partner ‘A’) twice pushed his seat back and crushed him. Post mortem examination recorded the cause of death as ‘ischaemic brain injury and compression asphyxia’. George’s mother subsequently received a custodial sentence for child cruelty, perverting the course of Justice and assault and ‘A’ was more recently found guilty and imprisoned for manslaughter, perverting the course of Justice and witness intimidation. 1.1.3 It was established that mother and child had moved to Croydon only 2 days before the trigger incident and that George remained registered with Medway health services (GP and health visiting). Medway’s designated doctor for child deaths subsequently chaired a ‘multi-agency rapid review’ and Croydon completed the required ‘serious incident notification’ to the regulatory body Ofsted. 1.1.4 In March 2018 the Metropolitan Police Service (MPS) proposed to the Croydon Safeguarding Children Board (CSCB) that it commission a serious case review (SCR)1. It declined to do so citing insufficient evidence that George was ordinarily resident in that borough. On the advice of its ‘screening panel’, the independent chairperson of Medway Safeguarding Children Board (MSCB) agreed that Medway would commission this SCR. 1.1.5 The prime purpose of this review has been to identify learning opportunities and to enable agencies and professionals to improve the way in which they work individually and collectively to safeguard and promote the welfare of children. 1 Regulation 5 Local Safeguarding Children Boards Regulations 2006 required Local Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with Working Together to Safeguard Children HM Government 2015 (since replaced by a 2018 equivalent) . A ‘serious case’ is one in which, with respect to a child in its area, ‘abuse or neglect is known or suspected and the child has died’ [including cases of suicide] or been ‘seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard her/him’. 2 1.1.6 An independent report was commissioned from CAE Ltd (www.caeuk.org) and Fergus Smith was asked to: • Collate and evaluate material supplied • Draft for consideration by the SCR panel and subsequent publication, an overview report identifying opportunities for organisational and individual learning • Formulate any justifiable recommendations for the Safeguarding Children Boards (or member agencies) in any of the involved local authorities 1.1.7 In February and April 2019 letters had been sent to mother and the man assumed to be George’s father (‘B’) to inform them that the SCR was being undertaken and to invite them to contribute to it. No response was received. By November, relevant criminal proceedings had been completed and further invitations were sent. Personal encouragement and support was also provided by the probation officer working with her and a meeting with the author of this report subsequently held at mother’s current location. 1.1.8 In spite of her ongoing distress at the loss of her son, mother was able to confirm the accuracy of much of the narrative that had been drafted and on occasions to add her own perspectives. The author and panel members are grateful that George’s mother contributed in the hope that the learning emerging from this review might better safeguard other vulnerable children. 1.1.9 This SCR has addressed the following: • Family History: Mother’s background and relationship with George’s maternal grandmother (MGM); understanding of mother as victim of domestic abuse including coercive control; agencies’ knowledge of father’s background including offending history, domestic abuse and substance misuse and level of interaction; knowledge of mother’s partner, their relationship and his contact with George • Quality of Assessments: How was family history taken into account? What assessments were made of mother’s parenting and cognitive ability? Were assessments made in an informed and timely way? Were assessments child-focused? What was the quality of analysis of risk and protective factors? Did assessments appropriately consider mother and George’s housing needs and moves? Was he identified as a missing / invisible child? Did recommendations reflect the levels of perceived risk to George? How well understood and managed was the mental health of mother and father and what was its impact? What was the role of management oversight and supervision in assessments ? 3 • Child Protection and Pre-birth Planning: Was the pre-birth child protection timely, effective, robust and compliant with procedures? Did the child protection plan appropriately reflect known risks within the family? Was the plan child-focused? How well were agencies engaged in the child protection process; Quality of managerial oversight / supervision? Opportunity for reflection? Was the agency’s supervision policy adhered to ?; Effectiveness of the core group process? • Multi-agency Working and Information Sharing: Did agencies communicate effectively and share information? Opportunities for agencies to safeguard and promote welfare of George? Any opportunities missed? Was the ‘challenge and escalation process’ considered or used ? GEORGE’S ‘SIGNIFICANT OTHERS’ Ages at time of trigger incident SCR PANEL, MATERIAL EVALUATED & REPORT STRUCTURE 1.1.10 The panel overseeing the SCR met on 8 occasions over 12 months from December 2018 and comprised senior representatives of relevant national and local agencies (Health Services, Children’s Social Care, and Police). The SCR drew on information in ‘individual management reviews’ (IMRs) from involved agencies and some brief reports from those with a less significant contribution. 1.1.11 George’s life had been rendered more complex by the several men with whom his mother became involved and many moves of home. No complete record exists of the overlapping personal relationships and a ‘calculation’ of a dozen changes of home / location may be an under-estimate. By way of highlighting the risk ‘A’ and ‘B’ posed to vulnerable others, ‘domestic incidents’ triggering Police attendance have been counted (a minimum of 12 for ‘A’ and 7 relating to ‘B’). 1.1.12 Section 2 offers a narrative of events and agency contacts during the review period (October 2013 to George’s death in February 2018). It is interspersed with emboldened comments on the quality of responses or issues emerging. Section 3 addresses the terms of reference and section 4 provides recommendations for improved service design and/or delivery. ‘A’ (George’s killer) (25) ‘B’ (presumed father) (40) MOTHER (23) GEORGE 3.75 years old 4 DEVELOPMENTAL INFLUENCES IN PRE-REVIEW PERIOD 1.1.13 A good deal of collated detail associated with mother’s earlier experiences may be summarised by stating that she had experienced a troubled childhood leaving her vulnerable to abuse and exploitation by others. ‘B’, who is assumed (though not proven to be) George’s father has an extensive criminal record of dishonesty, domestic violence, arson and drugs-related offences. 1.1.14 Mother’s reported partner at the time of the trigger incident (‘A’) had, been adopted as a young child. Having attained the age of criminal responsibility, ‘A’ went on to acquire an extensive juvenile criminal record, some relating to sexual offending with younger females and as a teenager, he was re-accommodated by a local authority. In adulthood, ‘A’ has accrued an extensive criminal record of domestic and other forms of violence. 1.1.15 Both ‘A’ and ‘B’ are known to have significant mental health difficulties, agency responses to which have been addressed within this published report only to the limited extent that they did, or might reasonably have been seen to impact on the safeguarding or development of George or any other child with whom either individual might be associated. 5 2 PERIOD UNDER REVIEW 2.1 EVENTS DURING MOTHER’S PREGNANCY WITH GEORGE IN MEDWAY (2013/14) 2.1.1 In Summer 2013 George’s mother (then aged 18) booked (slightly late) and went on to make good use of available ante-natal care in Medway. No significant medical or social concerns were identified. The identity of the baby’s father was not established. At her meeting with the author, mother spoke positively of the service provided. 2.1.2 During this period ‘A’ (then 20) was arrested in the Midlands in connection with an indecent assault. There was insufficient evidence to pursue the case. In the same week the Metropolitan Police Service (MPS) received an allegation of domestic abuse from his Croydon-based partner (‘R’) - the mother of their son. Enquiries made by Croydon’s Children’s Social Care resulted in his child being deemed a ‘child in need’ and a support plan formulated. 2.1.3 The first indication of a link between mother and ‘B’ was in early January 2014 when Kent Police attended a street-based altercation between them. Mother reported being 6 months pregnant and that ‘B’ was not the father. Medway Children’s Social Care was appropriately notified via a ‘domestic abuse notice’ (DAN). A pre-birth assessment of need was attempted though thwarted by mother’s disinclination to co-operate (which she does not now recall) and eventually dropped. George’s birth & Probation Referral to Children’s Social Care 2.1.4 Records of George’s birth in mid-May 2014 provide no indication of the presence of a partner. On the ward, mother needed to be advised about the basic care of George (feeding / maintaining adequate body warmth etc) but no concern about their relationship was recorded. George was discharged to the home of his paternal grandmother (‘B’s mother). 2.1.5 In late May Medway Children’s Social Care received a referral from Probation which was concerned because ‘B’ was not allowed to have unsupervised contact with children. In addition, there were concerns about domestic abuse between mother and ‘B’ and a risk the paternal grandfather was believed to represent. Enquiries under s.47 Children Act 1989 were commenced and Children’s Social Care funded a place for mother and George in local supported accommodation for 16-25 year olds. It was assumed she would supervise contact by ‘B’ (named on George’s birth certificate as his father and by then in daily contact). 2.1.6 A report provided by the Unit for the purpose of this SCR provides a more elaborated, convincing and concerned view of mother’s behaviours than is apparent from the records of statutory agencies. Mother speaks positively about her time in supported accommodation and of her relationship with her key-worker. Children’s Social Care completed no risk assessment of mother’s ability or motivation to safeguard George during visits by ‘B’. 6 2.1.7 Significant concerns being expressed by the Accommodation Provider about mother’s ability to manage (self-care and state of her room) were shared with health visitor HV1. She in turn sought (unsuccessfully) to engage the allocated SW3 in a discussion. The lack of responsivity justified escalation. Informed by the results of an ‘Edinburgh Post Natal Depression Scale’, HV1 put in place (an unspecified) support package and sought to alert the GP by filing a letter in her/his records. Mother did not thereafter consult the GP so the issue was not pursued. 2.1.8 ‘B’ was involved in a further domestic incident on in mid-July 2014 (his 2nd) involving an ex-partner ‘CD’ and their daughter. Mother revealed to HV1 the name of an alternative man whom she thought was the biological father of her child, though later re-confirmed it to be ‘B’. Mother’s genuine, confabulated or mistaken belief / assertion were never further explored or any DNA test contemplated. 2.1.9 The child and family assessment was completed in early August and concluded that mother was not acknowledging the risks that ‘B’ posed toward George. Whilst the above events were playing out in Medway, mother’s future partner ‘A’ was involved in a domestic incident at the flat he was then sharing with a new partner ‘P’ in the Blackpool area. Initial Child Protection Conference (ICPC): George 2.1.10 At the ICPC in late August 2014 George was made subject of a child protection plan on the grounds of neglect with a review due in November. It was also agreed that mother should complete an assessment of her cognitive ability. A ‘core group’ was established. Early observations by HV1 and a newly allocated social worker SW5 were positive. Mother agreed to remain at her accommodation on specified days to enable completion of a parenting assessment. 2.1.11 Mother’s future partner ‘A’ was involved again with the MPS in early October (3rd such episode) in connection to an allegation of his behaviours toward a then girlfriend. The investigation and the relationship ceased soon afterwards. During October, ‘A’ received further convictions for violence and sending offensive / indecent material to an ex-partner. Mother was remaining at her accommodation on agreed days and George’s father ‘B’ was found to be unsuitable for an anticipated domestic abuse programme to which he had agreed. 2.1.12 Initially as a result of the death of her step-father, mother was ‘temporarily’ residing with MGM and still to start the ‘Freedom Programme’2 and counselling. The Accommodation Provider’s report offers examples of controlling / coercive behaviour by ‘B’ and MGM, the impact of which was compounded by mother’s inability to assert her own perspective or to prioritise George’s needs. Records suggest some difficulty in understanding what she had been told or agreed to and reinforce doubts about mother’s cognitive ability. The potential value of 2 further core groups was undermined because SW5 did not attend. 2 The Freedom Programme is a well-established formalised approach to informing and empowering those experiencing domestic abuse to recognise and challenge their situation. 7 2.1.13 Mother actually moved to ‘B’s address in Medway in late January 2015. HV1’s attempt to confirm with the social worker that she had, as asserted by mother, agreed to the early move prompted no response. SW5’s 2nd apparent failure to respond to such a message (and absence from 2 core groups) justified escalation. Meanwhile, mother’s future partner ‘A’ had again been involved in domestic abuse of another partner (5th such example). 2.1.14 In March 2015 the 2nd review conference determined because of co-operation and apparent progress (the parents had been cohabiting for only 1 month), that it was safe to step down to a ‘child in need’ (CIN) plan with monthly social work visits and bi-monthly health visitor contact. The planned cognitive assessment and an evaluation of the impact of the Freedom Programme or counselling had apparently been set aside. 2.1.15 ‘A’ (this time using an alias) was involved in a domestic abuse incident (his 6th) with a different female. The event triggered no additional action by the Community Rehabilitation Company (CRC’s) ‘responsible officer’ nominally monitoring ‘A’s previously imposed Community Order. 2.1.16 By chance, when a newly allocated HV2 made her first home visit to mother and George in early May 2015, SW5 was present and indicated an intention to close the case. No formal CIN plan has been located and no record of any regular CIN reviews found; it appears that SW5 may have ‘re-branded’ this chance encounter with the health visitor as a ‘CIN meeting’. During mid to late May, ‘A’s ‘responsible officer’ continued to make ineffective attempts to trace and encourage him to engage. Arson at home of mother & George 2.1.17 In late May 2015 there had been a further domestic incident involving mother and ‘B’ (his 3rd ). During completion of a risk assessment, mother reported having ended the relationship some 2 weeks earlier, since when ‘B’ had threatened suicide or seriously harming her and George. The situation was assessed as ‘high risk’ and child protection and MARAC3 referrals were initiated. A fire at the Medway home address of mother and George which was empty at the time, had been deliberately started and ‘B’ had been seen running away. He became a suspect for ‘arson with intent to endanger life’. At her meeting with the author, mother asserted that ‘B’ knew neither she nor George were present and that he had never (then or later) shown any aggression toward her son. 1st Multi-agency Risk Assessment Conference (MARAC) meeting: George’s mother 2.1.18 A MARAC meeting in late June 2015 considered the arson and domestic incidents and confirmed additional safety-related steps e.g. referral to Children’s Social Care and a suggestion for mother to consider use of a local domestic abuse charity. 3 MARAC = Multi-agency Risk Assessment Conference 8 2.1.19 MGM reported to the health visitor at this time that she had not seen George or his mother for some weeks and suspected they and ‘B’ had fled the area. The health visitor contacted SW5 who undertook to alert Police though did not do so. It was later reported by mother that following a row with MGM’s partner, she had left though ‘B’ (with whom she denied having resumed a relationship) was nonetheless paying for her to stay with George in a flat. Mother’s ongoing dependence on the controlling and risky individual who had tried to burn the then home down (and whose bail conditions prohibited contact with mother and George) should have been very clear. 2.1.20 HV2 was justifiably dubious about mother’s claims and subsequently emailed SW5 to advocate stepping up the case to ‘child protection’ status. In addition to taking the steps recommended by the health visitor, Police should have been informed of the ongoing relationship and contact between mother and ‘B’. 2.1.21 By late October 2015 mother and George were back with MGM where mother reported further abusive calls from ‘B’. SW5 undertook to enlist an independent domestic abuse adviser (IDVA) though did not do so. Following an allegation to Kent Police that mother was a drug addict, a ‘welfare visit’ did not confirm that (in breach of bail conditions) ongoing contact between the parents. In early November, ‘B’ was admitted to a psychiatric ward at a Kent hospital for ‘suicidal and homicidal thoughts’, an assurance that he had no contact with George was accepted at face value and neither Children’s Social Care or mother alerted to the event. 2.1.22 Meanwhile, ex-partner ‘CD’ reported to the MPS ‘A’s threats to kill her, her children and a brother (his 7th such episode) though subsequently completed a ‘withdrawal statement’. It was learned that ‘A’ had also had a relationship with the sister of ‘CD’ in South London. George’s reported head injuries 2.1.23 George (18 months old) was transported by ambulance to a Medway hospital in November 2015 having reportedly tripped, fallen and banged his head. Routine treatment was provided and overdue immunisations noted. Next day, mother re-presented George saying she had dropped a hammer which had bounced and hit him in the face. Concerned staff appropriately liaised with ‘out of office hours’ Children’s Social Care before agreeing discharge and a discharge letter was emailed to the Health Visiting Service. It has not been possible to confirm receipt of comparable notifications by relevant GPs. The author has been assured current arrangements facilitate such notifications. No evidence has been found that a planned follow-up by Children’s Social Care occurred. 2.1.24 In mid-January 2016 a 3rd party reported an incident which ex-partner ‘CD’ later confirmed as ‘B’, attending her home drunk, though not making threats (his 4th such episode). Police, on the basis of known history, assessed the risk as ‘medium’ and Children’s Social Care was notified. 9 2.1.25 Soon afterwards, ex-partner ‘CE’ attended a South London Police station and reported further harassment and stalking by ‘A’ since November 2015 (‘A’s 8th such episode). Allegations included a report of texting a threat to use a firearm he possessed. 2.1.26 By late January 2016 SW5 reported an ‘improvement’ in the case and a decision was made to close it. There had been no sustained improvement in mother’s ability / motivation to protect George from the emotional and potentially physical consequences of a wholly dependent relationship with disturbed controlling men and associated rapidity of residence changes. 2.1.27 In late March 2016 ‘A’ (thought to be living in South East London) was arrested as a result of ex-partner ‘CE’s allegation that he had called her in November 2015 and threatened to shoot her brother. 2.2 MOTHER & GEORGE IN BLACKPOOL (APRIL- MAY 2016) 2nd consideration by MARAC 2.2.1 In early April 2016 Lancashire Police contacted Kent colleagues and relayed what it described a ‘medium risk’ event involving mother and ‘B’ (his 5th). It was upgraded to ‘high risk’ by Kent on the basis of the previous offence for which ‘B’ remained bailed and a MARAC referral and child protection notification initiated. Mother and George had been having a ‘short break in Blackpool’. In her explanation to attending officers, mother acknowledged engaging in consensual sexual intercourse with ‘B’ following his arrival at the address but argued with him when he became intoxicated in front of George. In contrast to many of the other moves, mother described to the author that the move to Blackpool had been her idea. 2.2.2 A very comprehensive MARAC to MARAC transfer between Medway and Blackpool was completed on the basis that mother had indicated she would not be returning to Medway and had been allocated a permanent address in Blackpool. MGM left a message with Children’s Social Care soon after the above indicating that mother and George were ‘missing’. After 2 further reminders, SW5 called back and suggested MGM contact Blackpool. In late May, Blackpool Children’s Social Care was notified via the police officer of its MASH4 that ex-partner ‘B’ continued to be in contact with mother, contrary to defined bail conditions. A management decision was made to undertake what became the 3rd child and family assessment. 2.2.3 In early June, mother reported being back in Medway as a result of the hospitalisation of her own mother (MGM), though reported that she would be returning to Blackpool. She claimed that she would not be reconciling with ‘B’, accepted a referral to Women’s Aid and provision of advice about obtaining a ‘Child Arrangements Order’ to define with whom and where George should live. 4 MASH = A ‘Multi-agency Safeguarding Hub’ in which co-located professionals from Health, Social Care and Police filter incoming notifications and requests for service. 10 2.3 RETURN OF MOTHER & GEORGE TO MEDWAY, SUTTON & CROYDON (JUNE 2016 - JANUARY 2018) 2.3.1 Toward the end of June 2016 mother and George returned to MGM in Medway. Before her return, mother had informed a social worker that she and a ‘new partner’ (‘A’) had argued over a bank card (‘A’s 9th such episode). Blackpool’s HV3 also confirmed the move back to the local area in a phone call to a colleague in Medway. 2.3.2 Kent Police dealt with his 6th such episode in late June when a verbal argument between ‘B’ and his ‘ex-partner’ ‘CD’ centred on access to their child. A fortnight later Kent Police attended a further altercation in a Gravesend street involving mother and ‘B’ (his 7th such episode). He admitted ongoing contact in spite of bail conditions. An initial assessment of ‘high risk’ was later lowered by a sergeant to ‘medium’. The incident of April 2016 remained relevant and the initial ‘high risk’ had been a proportionate evaluation. 2.3.3 At the end of September 2016 during a visit to MGM, SW5 accepted a reassurance that ‘B’ (reported to be living in mid-Kent) was not in contact. SW5 consequently recommended case closure (enacted in early November by a ‘step-down’ to ‘Early Help’). Health Visiting Services remained un-informed of the decision. Little account was taken of historic information especially the repeated (false) reassurances about a genuine separation from ‘B’. Hence the risk to George in consequence of mother’s choice of associates and inability to safeguard him was unchanged. 2.3.4 In late December 2016, a newly allocated HV4 arranged a home visit and on contacting Children’s Social Care, was informed of the case closure. A challenge of case closure made would have been justified. In mid-February 2017 Kent Police were told of an assault by ‘A’ on MGM (10th such episode for ‘A’). Subsequent attempts to trace him failed and mother (nominally still a partner) revealed only that he was ‘in the North of England’ and claimed an inability to contact him. Though circulated as ‘wanted’ on the Police National Computer (PNC) and later arrested twice by the MPS for other matters, he was never dealt with for the alleged assault of MGM. Mother & George coming to attention of Kent Police 2.3.5 HV4 learned in late February 2017 of an altercation at a friend’s house following a move from MGM’s by mother and George. Attending police officers has been sufficiently concerned about the lack of a stable environment to submit a ‘child protection referral’ including the following …’ there is concern over George being present during regular arguments and volatile situations as was the case during this incident. Mother appeared scared and uncertain. It is a concern that she does not have stable accommodation with George as it appears her mother kicks them out after getting intoxicated and arguing with mother.’ 2.3.6 Medway Children’s Social Care’s response was limited to a letter which, in spite of the knowledge she had left there, was sent to MGM’s home. 11 Imprisonment of ‘B’ / further contact with Police by or about ‘A’ 2.3.7 In late April 2017, ‘B’ was sentenced for the arson attack to 3 years imprisonment with supervision in the community after release. Case management was allocated to a National Probation Service (NPS) officer PO1. At about this time, the MPS responded promptly to a request for information from Bromley Children’s Social Care which was gathering information to inform its response to an attempt by ‘A’ to gain access to his 5 year old daughter. 2.3.8 In early May 2017 ‘A’ (using an alias and an address in Sutton) reported to Police an assault by 10 men said to have been witnessed by George’s mother. The investigation was closed due to insufficient evidence. 2 weeks later Kent Police were informed by the MPS of a report that mother was carrying a gun in her purse for potential use by partner ‘A’. This prompted a standardised response on the records of both parties. The safeguarding implications of the possible possession of a gun were insufficiently recognised. 2.3.9 Significantly, information communicated from the prison to PO1 refers to ‘Restraining Orders’ on 2 females not previously linked to George and a prohibition on entering a named road and area. This information suggests that ‘B’s behaviours had been impacting on more than just those known to the agencies involved in this SCR. Arrest of ‘A’ on suspicion of drug-related offences 2.3.10 In early June 2017 ‘A’ and 4 others were arrested on suspicion of ‘possession of drugs with intent to supply’ and possession of an imitation firearm. Records suggest without making explicit, a child/ren at home (same Sutton address again). It was later determined that there existed no realistic chance of prosecution and no charges were preferred. The circumstances recorded indicate an under-estimated risk to associated children. ‘A’ remained ‘wanted’ by Kent Police for common assault of MGM. As a result of an oversight, Kent Police Service was not notified. Allegation of risk to life 2.3.11 While at a cousin’s address in Kent, mother (who reported being 4 weeks pregnant with ‘A’s child) alleged that he had issued a threat to kill her, the baby and himself (his 11th domestic episode). ‘A’ subsequently ran away from officers. The incident was assessed as ‘medium risk’ and Children’s Social Care formally notified. That evaluation was later raised to reflect known history including the recent issue of possible possession of a firearm and subsequently downgraded again by a Public Protection Unit supervisor to ‘medium’. Mother subsequently claimed to have spoken with ‘A’ but to be unaware of his whereabouts. She anyway withdrew her co-operation; the investigation was closed off and ‘A’ was never spoken to in relation to the incident. There was scope for a more thorough investigation and potentially, the arrest of ‘A’. 12 2.3.12 A complex explanation offered by Kent County Council of the arrangements then in place includes a reassurance that current responses to such notifications would ensure that all children present are considered (the significance of George who was present had been overlooked) by what is referred to now as its ‘Front Door’ Service; 2.3.13 A week later, ‘A’ became a suspect for criminal damage to the car of a male with whom he was familiar, though the case was dropped for lack of evidence. Kent Police received a call in late June 2017 about screaming at the well-known address of mother’s cousin in Gravesend (the same address as the ‘threats to kill’ incident). George was present and the address was noted to be ‘cramped, dirty and smelly’. A report was submitted to the Public Protection Unit though Police records do not confirm that Children’s Social Care was also alerted. Insofar as officers were often alerted to noise at this address and one person present acknowledged having a social worker, an alert to Children’s Social Care would have been justified. Allegation of George’s ‘kidnap’ by ‘A’ 2.3.14 Kent Police received a call from a female at MGM’s address on a date in early August. The caller claimed to be a friend of George’s mother and that a male described as an ‘ex-partner ‘A’ had abducted the child. Efforts to locate ‘A’, mother or George failed. Next day both (appearing well) presented to Bromley Police Station. Mother said she had willingly stayed overnight with ‘A’ and George at a Travelodge. Though closed off as a potential hoax by an officer within the Public Protection Unit, this incident should have been investigated more thoroughly and relevant extracts retained for future intelligence-related purposes. Alleged rape / fraud: ‘A’ 2.3.15 Although not reported to Lancashire Police until late March 2018, it appears that ‘A’ was suspected of raping a named female in September 2017. His home address was reported to be Croydon. Days after the above incident, ‘A’, accompanied by George’s mother again defrauded a Travelodge by means of a previously used technique. 2.3.16 Within 2 weeks of his daughter’s birth, ‘A’ was reported by ‘ex-partner’ ‘CE’ to have assaulted her by pulling her hair, sticking his fingers down her throat and throwing her to the floor (his 12th domestic episode). The allegations were later withdrawn and, following arrest and denial, the case dropped. A notification to Sutton’s MASH was completed and 7 days later Children’s Social Care contacted Police because it had not proved possible to make contact and neither of the older siblings had attended school. 2.3.17 A search by Police of the unoccupied premises failed to locate the family, which was at this time an open case to Sutton Children’s Social Care. More extensive enquiries established that the family were staying with the maternal grandparents of ‘A’s daughter in Mitcham. 13 2.3.18 The last occasion on which Kent Police was involved and noted the presence of a child thought to be George was in mid-September when a community support officer (PCSO) attended MGM’s address, only (she believed) in support of a local ‘enforcement officer’ pursuing an un-related matter. Having established the presence of a responsible adult, the officer did not record details of those present. Had the ‘Force Control Room’ been clearer about the reason for her deployment (the enforcement officer’s earlier reported concern about a ‘confused 3 year old answering the door’) she would probably have been more inclined to establish more precisely the names and circumstances of all present. Initial child protection conference: child of ex-partner ‘CE’ 2.3.19 An ICPC was convened in late October 2017 by Sutton Children’s Social Care and addressed concerns about the domestic abuse that characterised the relationship of ‘A’ and ex-partner ‘CE’. All the involved children were made subject of child protection plans under the category of ‘neglect’ and the case scheduled for review in mid-January 2018. 2.3.20 In early November ‘A’ was arrested for the alleged assault in September, which he denied. The Crown Prosecution Service (CPS) advised ‘no further action’ by Police. In accordance with standard procedures, the MPS responding to a ‘locate and trace’ request on the Police National Computer (PNC) and emailed Kent Police. On 12.11.17 ‘A’ initiated contact with the MPS and alleged that his daughter should (in accordance with a court order) be at her maternal grandparents’ home. Officers attended and the child’s mother explained that a Sutton social worker had agreed her move and that she and ‘A’ were ‘no longer partners’. There were no concerns about the home or children and a Merlin was shared via the MASH. Anonymous referral to Sutton’s Children’s Social Care 2.3.21 On 05.01.18 a caller who wished to remain anonymous had alerted Sutton’s Children’s Social Care to her concern about an unnamed child (‘child X’ aged 1) staying at a house previously shared by ‘CE’ and ‘A’. The caller was worried about the risk ‘A’ posed to ‘child X’ and her/his mother. In addition the caller referred to the criminal history of an unnamed ‘adult 4’. It would seem that the caller was unaware that George was / might also be present. Review child protection conference (RCPC) / contacts with George’s last known location 2.3.22 ‘A’ had not attended a RCPC on 15.01.18 which determined that the protection plan for his child remained necessary and the case would be further reviewed in June 2018. 2 days later it was learned that these children, ‘A’ and his brother were all living in a flat. Following a strategy discussion by phone next day a meeting was scheduled for 24.01.18. Police welfare visits prior to that meeting found that the property appeared empty and had elicited no response. The delay in convening a formal strategy meeting was unfortunate but welfare checks by police officers offered a robust interim safety plan. 14 2.3.23 The strategy meeting on 24.01.18 was well attended and informed the planning of a joint visit next day under s.47 Children Act 1989. At the visit next day by a senior and a newly qualified social worker, supported by MPS officers, mother and son (only later identified as George and his mother) were noted to be ‘happy and well’. As in earlier examples, there would have been real advantage in establishing identities and significance of all those with whom professionals have contact; had George’s identity been established, a referral via MASH could have been progressed. 2.3.24 Upon their return to the office, the assistant team manager of the MASH asked for mother and George to be invited for an office meeting at which details could be derived and a MASH referral initiated. Next day ‘A’ informed his daughter’s social worker and offered an explanation about the various adults and children at the address, some of whom (he said) would be returning to Blackpool. The other unnamed ‘adult’ also attended the office that day and amongst other matters, confirmed that ‘A’ and George’s mother were in a relationship. A further (unannounced) home visit on 30.01.18 prompted no response though there were people present. George’s mother and unnamed friend failed to attend on 31.01.18 as requested. At interview with the author, mother could not recall agreeing to that arrangement. 2.4 TRIGGER INCIDENT IN CROYDON 2.4.1 Following the trigger incident described in para. 1.1.1, hospital staff became suspicious of the varying versions of events and differing addresses offered by mother and initiated a safeguarding referral. 2.4.2 George was transferred for paediatric intensive care to St. Thomas’ Hospital and Croydon Health Services (CHS) Safeguarding Team and its ‘named nurse’ notified. The latter’s contact with Croydon Children’s Social Care revealed no knowledge of the child / family but confirmed they were known by Medway Children’s Social Care). 2.4.3 Though there was some initial uncertainty about which local authority was primarily responsible, the safeguarding lead nurse at the Paediatric Intensive Care Unit usefully drew attention to the ‘London Child Protection Procedures’ which made it clear that the responsibility rested with Croydon until a ‘home authority’ agreed to accept responsibility. 2.4.4 An initial strategy meeting agreed the need for enquiries under s.47 Children Act 1989. There was a full exchange of known information between local authorities, and varying explanations by mother of events and relationships. The outcome of the enquiries was that concerns could not be substantiated. Following George’s death on 05.02.18, a 2nd strategy meeting was convened and Sutton Children’s Social Care acknowledged that it had visited a property in its borough in January 2018 at which mother, George and ‘A’ has been staying. 15 2.4.5 Sutton staff also visited on 05.02.18 (just before being notified of George’s serious injuries) and formed the view that the property had been vacated. George was confirmed as having being present on 25.01.18. On the day before, ‘A’ had been present so as to participate in a parenting assessment with respect to daughter and her half-siblings, though the house appeared vacated. It remains uncertain whether George was present during the unsuccessful visit on 30.01.18. 2.4.6 Given continuing uncertainty about cause of death and confirmation that the last known connection was Medway, the case was closed to Croydon’s Children’s Social Care the rationale being that the child was ‘ordinarily resident’ in Medway. 2.4.7 Reported service improvements since the trigger event e.g. co-location of Police within the borough’s ‘Single Point of Contact’ (SPOC) and completed audits of case notes (with a requirement of sufficient evidence of reflection) render recommendations for Sutton Children’s Social Care (which might otherwise have been justified) unnecessary. 16 3 RESPONSES TO TERMS OF REFERENCE & OVERALL FINDINGS 3.1 FAMILY HISTORY 3.1.1 The significance of mother’s personal history in terms of her heightened risk of domestic abuse, as well as that of her various partners with respect to the physical and emotional risk they posed toward a partner and/or a child was under-estimated to a greater or lesser degree across most involved agencies. 3.1.2 The Midwifery Service focused entirely on medical matters and seems to have had no interest in George’s paternity or the circumstances into which he was to be born. Attempts by Medway Children’s Social Care to complete a pre-birth assessment were frustrated by mother’s reluctance to co-operate and it would seem that, although the response had been triggered by the first of what would be many domestic incidents, that there was little if any enquiry about her partner. 3.1.3 Whilst the 2nd (and completed) assessment in August 2014 was denied some (unknown) information reportedly held by Kent County Council, it was anyway limited in its exploration of the ongoing impact of mother’s relationship with MGM and her partner. 3.1.4 Enquiries by midwives and health visitors about potential for domestic abuse had also been less explicit than would have been helpful. Staff of the Accommodation Provider were more attuned to and witnessed directly, coercive and controlling conduct from ‘B’ as well as MGM some 2 months into placement. Though staff there liaised effectively with the health visitor, the latter appeared to lack the confidence to challenge more formally the unduly optimistic view being developed by SW4 and her successor SW5 (neither of whom, according to records and mother’s own recollection shared with the author) appeared to spend much time in direct contact with mother or George). 3.1.5 Following HV1’s recognition of mother’s lowered mood state, the absence of further engagement with the GP Practice meant that its potential value for mother or child remained unrealised. 3.1.6 Given that the law with respect to ‘coercive control’ changed only in late 2015, the links initiated by officers in Kent and Metropolitan Police Services prior to that date suggest a welcome awareness of the relevance of the abusive behaviours of ‘B’ and ‘A’. 3.1.7 Blackpool’s brief involvement with mother and George lacked exploration of personal history and showed minimal recognition of the relevance of male partners, existence of a Non-Molestation Order etc. 17 3.1.8 During George’s final weeks (some of it at a Sutton address) the focus of that borough’s Children’s Social Care had been on ‘A’s daughter and other adults within the household in question. Similarly, the initial referral of the hospitalised George in February 2018 included no reference to his father ‘B’ and it only emerged subsequently that ‘A’ had been known to the agency during the period 2013 -2015. 3.2 QUALITY OF ASSESSMENTS 3.2.1 According to Medway’s records, a request had been made to Kent County Council for background information that could inform the ICPC report in 2014 but none was received. Assessments completed by Medway Children’ Social Care were insufficiently informed by collation and analysis (with respect to implications for George) of mother’s developmental experiences, cognitive ability, latest relationship or unresolved issue of paternity. 3.2.2 Descriptions provided by the Accommodation Provider offered a well evidenced account of examples of dishonesty of mother, ‘B’, and MGM as well as mother’s inability / unwillingness to challenge ‘B’. The value of the material provided in terms of the implication for future care of George were under-estimated by Children’ Social Care. 3.2.3 The risk that ‘B represented to George and his mother was under-estimated by several agencies: • Medway’s Midwifery and Children’s Social Care’s ongoing acceptance of mother providing sufficient monitoring of ‘B’s near-daily visits to George when he and his mother were in the accommodation provided (late 2014) • The Kent hospital and SW5 in November 2015 when the former accepted without question ‘B’s assurance of no contact with George and the latter accepted mother’s admitted contact with ‘B’ 3.2.4 Sutton’s responses to the other children present at George’s last known address are beyond the scope of this SCR. It had though, no basis on which to formally assess the well-being of George and/or his mother. 3.3 PRE-BIRTH PLANNING & CHILD PROTECTION 3.3.1 Pre-birth planning was inevitably limited by the combination of few observed grounds for concern amongst the professionals (chiefly midwives) from whom mother accepted involvement and those (Children’s Social Care) from whom she refused it. Because the pre-birth assessment was resisted and delayed, the potential for addressing the significance of ‘B’ and the risk he represented and mother’s level of vulnerability in forming intimate relationships was lost. 18 3.3.2 Following George’s birth, protection efforts were undermined by: • No (recorded) conclusion of the cognitive assessment of mother agreed as needed at the ICPC in August 2014 • A failure by Children’s Social Care to ensure that all parties e.g. Health Visiting Service, GP were sent copies of child protection or CIN plans or made clear about the reason for an ongoing protection plan at the RCPC in November 2014 • Relatively limited contact by SW5 with her client or her colleagues • Insufficient recognition of the well-articulated and more cautious concern being expressed by the Accommodation Provider who had spent most time with, were trusted by and (above all) knew mother best 3.3.3 The decision to ‘step-down’ from child protection to a CIN status in March 2015 seems in hindsight, to have been less an evidence-based plan and more a passive acceptance of the status quo. With weeks of the decision to ‘step-down’, case closure was being contemplated. The arson at the home of mother and George (confirmed by mother as being also ‘B’s home) did not appear to have significantly amended the level of risk that he was seen to represent (though the incident could by definition have proved fatal). 3.3.4 An incident of domestic abuse whilst mother and George were with MGM and her partner was withheld from SW5 when she visited. Even after formal notification by Police, it did not prompt a re-evaluation of mother’s intrinsic vulnerability to victimisation and a consequent diminished capacity to prioritise George’s needs. 3.4 MULTI-AGENCY WORKING & INFORMATION SHARING 3.4.1 An early (and possibly only) example of an unjustified refusal to share information was reported by the Accommodation Provider. ‘Sure Start’ reportedly declined to report on mother’s progress at its local Centre. The position it is said to have adopted may have reflected insufficient briefing or preparation by the commissioners. Children’s Social Care could and should have explicitly sought mother’s consent for those she trusted at her accommodation or the allocated social worker to seek such feedback in the context of a voluntary acceptance of family support under s.17 Children Act 1989. 3.4.2 The Accommodation Provider’s report makes it clear such feedback could have been of relevance to mother’s everyday ‘one to one’ responses to her son e.g. she was sufficiently manipulative to ensure toys were made available to George before (and only before) a visit by the health visitor. It is very disappointing that the insights gained by those working directly with mother e.g. lack of cleanliness with respect to the care of George or self, were diluted by the time they appear in the records of Children’s Social Care. The report provided also indicates their clear and valuable evidence was latterly excluded when it was not invited to the final ‘core meeting’ held in January 2015. 19 3.4.3 It would appear that the GP Practice at which mother and George were registered had not been informed of their circumstances prior to or following his birth e.g. her placement. As described in section 2.1.7, though its potential value remained unrealised, the effort made by the health visitor to inform the GP of mother’s lowered mood state represented good practice. 3.4.4 Later when George became subject of a ‘child protection’ plan and later still a ‘child in need’ plan, there is no confirmation that the relevant GP Practice was informed or sent a copy of the relevant plans. These omissions represented missed opportunities to share relevant information and in so doing, strengthen support of the vulnerable mother and child. 3.4.5 Whilst acknowledging that they were operating in an agency formally evaluated at the time by regulator Ofsted as ‘inadequate’, the following examples of individuals’ lack of reliability or responsivity and poor multi-agency collaboration would have justified challenge or escalation by professionals in other agencies: • SW3’s failure to respond in July 2014 to the expressed concerns about mother’s behaviours in placement in 2014 • SW5’s unexplained absence from the core group of December 2014 (and apparent failure to respond to the health visitor’s questions in January 2015 about discharge or to attend CIN meeting 1) • Failure to alert Police when mother and George were reported ‘missing’ in July 2015 • Only after repeated messages about the reportedly ‘missing’ mother and George in 2016, initiating a phone call to MGM though not liaising with Blackpool Children’s Social Care, where it was thought mother and child could be located and/or contacting Police • An unjustified Children’s Social Care case closure decision in December 2016 20 3.4.6 The response to the 2 successive presentations of George to A&E in November 2015 were sufficiently well-managed (albeit poorly recorded) by hospital and Medway Children’s Social Care. The formal child protection and child in need processes appear to have been efficient in terms of timing and with the following exceptions reflect what appears to have been a professional consensus: • The category under which George remained subject of a plan at the RCPC of November 2014 is unclear • Records of the final RCPC in March 2015 have been described as confused and omitted any recorded requirement of change of the behaviour of ‘B’ • The conclusion of CIN meeting 5 in February 2016 that sufficient progress had been made and the risk to George diminished (which rapidly led on to case closure) was at odds with the evidence of ongoing and uncontrolled risk from George’s father and other partners 3.4.7 Case closure by Medway’s Children’s Social Care in late February 2016 was completed without any formal record of its (ill-informed) decision (and the later September 2016 case closure without any notification of the Health Visiting Service). 3.4.8 The communication by Blackpool Children’s Social Care of the return of mother and George in Summer 2016 was well-informed, and a delay that ensued before the recommended re-assessment was completed was beyond its control. In its admittedly very time-limited involvement, that agency offers a further example of an unmet need to factor-in recorded history when assessing needs or risk. 3.4.9 The resumed contact between mother and ‘B’ (still on bail for arson and with a condition of ‘no contact’ with mother) at this time represented a greater level of risk that was evaluated at the time by the more senior of the Kent police officers who dealt with domestic episodes 6 and 7. 3.4.10 The notification by Kent Police of the assault of mother by the maternal grandmother’s partner in June 2015 had been slow. Its response to the disturbance in February 2017 at the house of a friend of mother was though, a sensitive and efficient one. The response of Medway Children’s Social Care (a letter sent to MGM’s home even when it was known that mother and George had left there) was wholly inadequate. 3.4.11 The significance of the presence of George was overlooked by Kent Children’s Social Care when in mid-June 2017, Police notified it of officers’ attendance at a Gravesend address in response to an allegation by then pregnant mother that ‘A’ had threatened to kill her and her baby. 3.4.12 An opportunity may have been missed when Kent police officers’ alert of the Public Protection Unit following their attendance at the ‘cramped, smelly and dirty’ flat in June 2017 may not have been relayed to Children’s Social Care. 21 3.4.13 Though their immediate safety was assured, there was scope for more investigation of the alleged kidnap of George in August 2017. 3.4.14 The response of Sutton Children’s Social Care to the anonymous referral of January 2018 was well planned and reasonably executed. The presence of mother and George was unknown to the informant and became apparent only after some elapse of time and effort. Though there existed some uncertainty about which borough would become case-accountable, the immediate responses of medical, Social Care and MPS to the extraordinary trigger incident on 01.02.18 appear to have been of a good standard. 3.4.15 The panel recognised that the responsible decision by Medway LSCB to complete a SCR rendered its agencies more visible and vulnerable to criticism than the many other that had been involved in George’s life. The following additional question was subsequently formulated by the panel: • To what extent could and should other agencies with which George and/or ‘A’ or ‘B’ had contact have recognised and responded to the risk those individuals represented ? 3.4.16 A summary of the most obvious missed or insufficiently exploited of such opportunities is provided below. Opportunities to better recognise risk to George / other children presented by ‘B’? 3.4.17 ‘B’ was predominantly visible and more effective responses could have been made: • Following a welfare visit by Kent Police in November 2015 when (contrary to bail conditions imposed after the arson attack) it was apparent that there was ongoing contact with mother and George • By a Kent Hospital in November 2015 when ‘B’s assurance that he had no contact with George was accepted at face value • Had the attempted assessment in May 2016 by Blackpool Children’s Social Care been more prompt, it might have achieved contact in advance of mother and George returning to the Medway area • By the involved GP when in January 2017 an angry ‘B’ walked out of a consultation 22 Opportunities to better recognise risk presented by ‘A’ 3.4.18 ‘A’ went to greater efforts than ‘B’ to hide his location or identity but more robust responses would have been desirable: • By Cumbria and Lancashire CRC in 2016 when terminating anyway inadequate involvement without checks with other relevant agencies (‘re-nationalisation’ of Probation Services by Government render it unnecessary to formulate recommendations for this agency) • When a Blackpool social worker failed to follow up mother’s account of a domestic episode with ‘A’ • ‘A’s reported threat to kill (an apparently pregnant) mother in June 2017 • When in Summer 2017, Kent and MPS respectively were involved in reports of mother keeping a gun for ‘A’, and subsequent discovery of an imitation firearm • By Kent Police in response to a reported (concluded to be hoax) kidnapping of George by ‘A’ in August 2017 • By Kent Police in September 2017 when George’s (probable) presence at the address attended by a community support officer went un-recorded 3.5 OVERALL FINDINGS CASE-RELATED 3.5.1 In addition to the emotional vulnerability generated by mother’s past experiences, her cognitive ability appears to have remained un-tested i.e. to what extent was she able to understand the expectations of professionals in the agencies with which she had contact ? 3.5.2 The high level of mobility and significant levels of dishonesty of mother, ‘B’ and ‘A’ rendered it difficult for involved agencies to form, retain and as necessary share, accurate estimates of risks. The Parent / Child placement had been appropriate though potential value reduced in consequence of insufficient attention paid its observations. It is uncertain whether SW5’s practice reflected agency weaknesses and/or insufficient supervision or management (there was significantly more evidence of supervision of involved health visitors than social workers). 3.5.3 The ongoing risk ‘B’ represented to George and mother was clear from initial Probation / Children’s Social Care liaison. There is little evidence behaviours improved e.g. ‘B’ was assessed as ‘unsuitable’ for a domestic violence group; nor any that mother’s ability or willingness to be protective grew - completing a domestic abuse course or some ‘counselling’ does not equate to effectiveness. That mother’s physical care of George was (when observed) ‘good enough’ should not have diminished concern about the immediate and longer-term impact of witnessing domestic abuse and experiencing constant unpredictable changes of residence, routines and familial or wider contacts. 23 3.5.4 With the advantage of hindsight, ‘B’s typical behaviour toward agencies was controlling (at times coercively so) and mirrored that toward George’s mother and other partners. In spite of a plan agreed with mother and the professional network in late 2014 that she would remain in the accommodation provided, ‘B’ manipulated his way back into (from early 2015) sharing an unsupervised cohabitation with mother and child. Even after being bailed for arson on condition of ‘no contact’, the relationship continued and episodically involved cohabitation. 3.5.5 Whilst nobody could have predicted the fatal trigger incident, George had until then endured and survived the consequences of a succession of domestic crises involving his mother and her associates. Aggregated evidence from participating agencies suggests there would have continued to be damaging events sufficient in number and magnitude to justify a reasonable suspicion that ‘he was suffering or was likely to suffer significant harm’5. 3.5.6 The rapidly changing locations of mother and son (still below compulsory school age when attendance rates would have had the value of rendering him more ‘visible’) made it possible for a chronic risk of harm to be rendered insufficiently apparent to professionals in any one agency and location. Whilst it might have been difficult to establish grounds for Care Proceedings, it would have been prudent to seek advice from the Legal Service as to other potential responses to deal with ‘B’s ongoing breach of bail conditions and mother’s clear collusion and prioritisation of her relationship/s over safety of George. 3.5.7 Mother’s first partnership with ‘A’ (a volatile and potentially dangerous individual if one aggregates available evidence) may have begun in mid-Summer 2016 and lasted up to a year. By August 2017 ‘A’ seems to have resumed a relationship with ‘CE’, though was probably (with or without their knowledge or agreement) maintaining this and other intimate relationships. The limited involvement of Kent Police constrained its opportunities for evaluating the risk to mother, George and any other children. The occasional liaison with colleagues in the MPS offered opportunities that could have been better exploited to assess the risks to which George was being exposed. 3.5.8 Throughout the period of review there has been approaching a dozen contacts or referrals (the majority from professional sources as well as, some anonymous and arguably malicious). 3 family assessments were completed though only the 2nd was thorough enough to inform the child protection conference and justify its conclusion. 3.5.9 In essence, the focus of Health and Social Care agencies was on mother and child with insufficient recognition that the dangerous men with whom mother associated inevitably represented a significant risk to any dependent child. 5 If a local authority is informed that a child who lives, or is found, in its area (i) is the subject of an Emergency Protection Order; or (ii) is in police protection or (iii) has reasonable cause to suspect that s/he is suffering, or is likely to suffer, significant harm, the authority shall make, or cause to be made, such enquiries as they consider necessary to enable it to decide whether it should take any action to safeguard or promote the child’s welfare. 24 CONTEXT-RELATED 3.5.10 Several reports supplied to the SCR describe structures, policies, systems and expectations within the relevant agency across the period of review. Some seek to make a connection between these contextual variables and the performance of the agency or individual. For Medway’s Children’s Social Care, the period has been characterised by a high rate of change of leadership, approach to social work, levels of supervision as well as within the systems supporting the agency. Successive inspections by regulator Ofsted found services to be ‘inadequate’. Consideration of current functionality has also been provided in other agency reports supplied. Whilst welcoming several reports of improved performance, this report has, in its identification of potential improvements, avoided reliance on any current structure, policy or leadership. It offers in section 4 pragmatic recommendations that transcend such variables and should be of more lasting value. LEARNING POINTS 3.5.11 It is apparent that the ‘lived experience’ of George was insufficiently recognised or captured in the records of most involved agencies (with the exception of the Accommodation Provider). The ongoing succession of dramatic / traumatic events experienced by his mother dominated professional responses and left little scope for recognising how emotionally damaging the constant changes of associated adult / parent figures, locations and absence of peer relationships must have been. Those who pose a danger to more vulnerable adults almost inevitably represent a risk to children . 3.5.12 On the following occasions, responses to observed or reported situations rendered George partially to wholly ‘invisible’: • Medway’s (anyway misdirected) response to an alert by Kent Police in February 2017 • The response of Kent Children’s Social Care in June 2017 to notification of a threat to kill mother by ‘A’ • The visit by social workers supported by Police to the Sutton flat at which George was present in January 2018 3.5.13 To be effective, the recording, interpretation and assessment of an incident or situation by any professional needs to reflect all available information e.g. identity and significance of all present and avoid capturing only ‘presenting circumstances’. Reflecting their respective sources of anxiety (being re-victimised or held to account for their conduct) the account offered by a victim or a perpetrator of domestic abuse may be partial, confused or inaccurate. If the account is at odds with other available information, it should be explored / challenged. 3.5.14 Those assessing and seeking to mitigate risk to a child or vulnerable parent must define explicitly and within a time-frame, demonstrable change before concluding sufficient improvement. Reflective supervision in all involved agencies is of central importance to that accurate and reliable identification and management of risk. 25 4 RECOMMENDATIONS MEDWAY SAFEGUARDING CHILDREN BOARD (MSCB) 4.1.1 MSCB should: • Seek confirmation from Kent Children’s Social Care that in circumstances when it receives Police notification of an incident involving a child, it reliably captures and responds to all relevant information • Monitor progress made in implementing all recommendations in agencies’ submitted reports or which were identified during the course of this SCR • Seek confirmation that all members agencies’ training and development programmes address current lawful definitions and required understanding of ‘coercive and controlling conduct’ MEDWAY CHILDREN’S SOCIAL CARE 4.1.2 Any service commissioned by Children’s Social Care needs to be recognised as a source of potentially valuable information and its views and must be routinely and reliably required to submit written and/or oral contributions at all relevant formal planning forums. 4.1.3 Children’s Social Care should offer MSCB a written assurance that social work staff in comparable roles to those involved with George: • Receive reliable and timely reflective supervision • Are monitored with respect to completion of allocated tasks and decisive management action taken if under-performance is apparent MEDWAY NHS FOUNDATION TRUST 4.1.4 Staff training programmes should emphasise the value and necessity in of exploring any indication of additional ‘vulnerability’ e.g. acknowledged involvement with Children’s Social Care / experience of domestic abuse MEDWAY COMMUNITY HEALTHCARE 4.1.5 The internal safeguarding policy should be reviewed to ensure it includes a requirement for staff to escalate unresolved concerns / professional disagreements to a manager and ‘Safeguarding Team’. 4.1.6 Awareness levels of the above revised policy should be increased via briefing / training events and awareness levels audited within the following year. 26 KENT POLICE 4.1.7 Officers and staff should be reminded of: • The necessity of considering all known information when dealing with potentially vulnerable children or adults • Requirement to submit referrals relating to children and vulnerable adults where risk is identified 4.1.8 Force Control Room dispatchers should be reminded to highlight any potential vulnerabilities linked to calls to which officers are dispatched. MEDWAY CLINICAL COMMISSIONING GROUP (CCG) 4.1.9 The CCG should • Remind all GP Practice Safeguarding Leads that of the need for post-natal checks and mental health reviews for this group of vulnerable patients. • Take steps to ensure that patients with signs of post-natal depression have a risk assessment within their records |
NC50665 | Death of a 13-week-old baby in March 2017 as the result of acute traumatic brain injury due to abusive head trauma. Father had called emergency services as baby BZ was unresponsive and not breathing. BZ admitted to hospital and injuries found to be consistent with abusive head trauma. BZ died two days later. Father was arrested for BZs murder and was found guilty in March 2018. Mother had longstanding mental health problems, learning difficulties and a diagnosis of schizoaffective disorder. Father had a history of domestic abuse in a previous relationship. BZ was subject of a Child Protection plan at birth for emotional harm. Sibling had been the subject of Child Protection plan for neglect and physical abuse. Mother was detained under the Mental Health Act and Father became the sole carer for BZ. Ethnicity or nationality of the family is not stated. Key areas of learning include: historical information and understanding its importance and relevance to on-going work should be recognised to safeguard unborn and new-born babies; the practice of waiting until mothers are 30 weeks pregnant before a multi-agency approach is adopted in cases that meet the threshold for child protection may leave unborn babies and new-born babies at unnecessary risk. Case review uses the Welsh concise model. Recommendations to the Local Safeguarding Children Board include: review the arrangement around parenting assessments to ensure they are robust; seek assurance from Children's Social Care (CSC) that all assessments are subject to oversight, challenge and scrutiny by managers within CSC; seek assurance from CSC and adult mental health services that analysis of the effects of parents behaviours on their children forms part of assessments and is evident within CP plans.
| Title: Child BZ: serious case review: final report. LSCB: Blackpool Safeguarding Children Board Author: Nicki Walker-Hall Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child BZ Serious Case Review Final Report BSCB Child BZ SCR FINAL 2 1 INTRODUCTION Initiation of Serious Case Review The interim Head of Safeguarding and Principal Social Worker referred this case to the case review sub group the day before BZ’s death in March 2017. The chair of the case review sub group determined there was prima facie evidence that the case met the criteria for a Serious Case Review and called for all involved agencies to provide further information. The chair of Blackpool Safeguarding Children Board supported the Case Review subgroup’s determination that the case met the criteria for a serious case review, on the basis that abuse and neglect were clearly evident in the period prior to the incident and BZ had died. The known facts in relation to this case met the statutory requirement, in accordance with Working Together to Safeguard Children 20151: Abuse or neglect of a child is known or suspected and Either a child has died; or the child has been seriously harmed and there is cause for concerns as to the way in which the authority, the board partners or other relevant persons have worked together to safeguard the child The Department for Education and the National Serious Case Review Panel were informed. Family Composition 1.1.1 BZ was the only child of Mother and Father. Below are tables to demonstrate household composition and significant family members of BZ, Mother and Father. TABLE 1: Household composition TABLE 2: Significant others referred to in the report 1 Working Together to Safeguard Children, 2015 Chapter 4 Term used in report Relationships Age in March 2017 BZ Subject of the review 13 weeks Mother Mother of BZ 24 Father Father of BZ and Half sibling 35 Term used in report Relationships Age in March 2017 Sibling Half sibling 13 Ex-partner Half sibling’s mother MGM Maternal grandmother MGF Maternal grandfather MU Maternal uncle PGM Paternal grandmother PA Paternal aunt BSCB Child BZ SCR FINAL 3 Methodology 1.1.2 This review adopted the Welsh2 concise model. This formal process allows practitioners to reflect on case in an informed and supportive way. The review sought to understand: precisely who did what through development of agency chronologies and review of relevant documentation the underlying reasons that led individuals and organisations to act as they did through conversations with practitioners involved in the case. Where practitioners were no longer in post, managers of the services provided organisational and service context 1.1.3 A panel consisting of senior managers of the involved agencies, working with an experienced lead reviewer Nicki Walker-Hall from a health background and the independent chair of the panel the Head of Safeguarding for Blackpool Teaching Hospitals, managed the review. 1.1.4 The review looks in depth at the period from March 2016 until the death of BZ in March 2017. Agency involvement 1.1.5 The following is a list of the agencies involved with the family and the services they offered. Where abbreviations have been identified these will be used throughout the report to denote the organisation the author is referring to: Blackpool Teaching Hospital NHS Foundation Trust Blackpool Council (Children’s Social Care (CSC), Early Help, Adult Mental Health service, Children’s Centre, Safeguarding, Quality and Review Service) Lancashire Constabulary NSPCC Blackpool Service Centre Lancashire Care NHS Foundation Trust North West Ambulance Service Wythenshawe Mother and Baby Unit, Greater Manchester Mental Health NHS Foundation Trust (GMMH) previously part of University Hospital of South Manchester NHS Foundation Trust Blackpool Clinical Commissioning Group (CCG) GP practice NHS England The process 1.1.6 The process included: Chronologies from all involved agencies. A practitioner’s event to gather first-hand the experiences of the practitioners involved with BZ at the time and maximise the learning opportunity whilst informing the review process. 2 Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012 BSCB Child BZ SCR FINAL 4 The lead reviewer was given access to key documents and assessment. The panel met on four occasions to discuss and progress the review. Timeframe 1.1.7 The timeframe for this review has not met with statutory timescales. The parallel process, please see section below, lead to considerable delay. Parallel Processes 1.1.8 There were two parallel processes. This case has been subject to Coroner’s Inquest and criminal proceedings. BZ’s Father was arrested for BZ’s murder. Many of the professionals crucial to complete the review gave evidence in the trial. A decision was made in September 2017 to halt the process pending the outcome of Father’s trial. Father was tried and found guilty of murder in March 2018. Family participation 1.1.9 Mother was contacted via her Adult Social Worker and Father was contacted via his probation officer, firstly to inform them of the review and then to invite them to be part of the review process. Both agreed to be interviewed however, Mother was initially too unwell and Father, having agreed, later declined to meet the lead reviewer and chair. The lead reviewer and chair of the SCR made further efforts to engage the parents in the process, through their respective workers and via MGM, prior to completion of the final report, but without success. Limitations 1.1.12 This review has been affected by the lack of discussion with mother and father. The lead reviewer would have welcomed an opportunity to explore Mother and Fathers perspectives on the support and services offered and how practitioners and agencies worked together to support the family. Key focus points 1.1.10 The Serious Case Review panel decided upon the key focus points for the review and highlighted the lines of enquiry for consideration. These can be found at Appendix 1. BSCB Child BZ SCR FINAL 5 2 CONTEXT Parental background 2.1.1 Mother had longstanding fluctuating mental health problems and a diagnosis of schizoaffective disorder3. Mother had been under a consultant psychiatrist for a number of years having regular reviews of her care and management. Mother had at times needed acute in-patient treatment. Staff reported Mother could be very aggressive when unwell. Mother also had learning difficulties. 2.1.2 Father had a history of perpetrating domestic abuse in a previous relationship. In 2004, there had been child protection concerns regarding sibling; Father had been the only adult present when sibling sustained injuries at a young age. The Child 2.1.3 BZ was born three weeks earlier than the due date. BZ required some initial assistance at birth requiring oxygen and had a brief stay on the special care baby unit (SCBU) for intra-venous antibiotics due to maternal infection. BZ had a relatively disrupted life; BZ spent the first weeks of life living in a Mother and Baby Unit. Mother was acutely emotionally unwell at times so much of BZ’s care was delivered by hospital staff or by Father when he was visiting. In the weeks before his death, BZ moved into the full time care of Father. Father’s Mother (PGM) and Paternal Aunt (PA) offered their support, caring for BZ whilst Father tended to his affairs. BZ was meeting expected developmental milestones. Family Dynamics 2.1.4 Mother lived with MGM, MGF and MU. MGM was a carer for MGF and Mother, both of whom had serious mental health difficulties and for MU who had learning disabilities. MGM was under her GP for low-level anxiety. This was a family who, to professionals, seemed to “muddle along”. There was a history of MGM declining support. Whilst MGM took the lead for Mother, she could be inconsistent herself. Where Mother was living became less clear nearer to the birth of BZ. Health workers believed MGM’s address was Mother’s main address, CSC viewed Father’s address as the main address. Professionals reported it was not unusual for service users to move between addresses however, this was more problematic in this case, as Mother did not have her own telephone so there was greater reliance on MGM and Father to pass on messages. 2.1.5 Father’s family dynamics were complex. Father was brought up in his younger years by extended family members and due to bereavement facts about his parentage came to light which impacted on his relationship with his biological parents and caused him some distress. Father was known to be receiving medication for depression from his GP. In February 2015, father was indicating a number of longstanding family issues, including difficulties in his relationship with MGM, which detracted from his mental wellness and that he had recently been using alcohol to 3 Schizoaffective disorder is a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania BSCB Child BZ SCR FINAL 6 try and help with his symptoms and sleep (four – five cans a night). Father, according to family, had been a recluse for a number of years having difficulty leaving his home; this was not evident to professionals. Father had a nocturnal lifestyle playing computer games for many hours. Background prior to period under review 2003 2.1.6 During 2003, at the age of two months, Father’s first child (sibling) was taken to A&E. Father was hostile and aggressive to his partner and nurses screaming in partners face. Sibling was oblivious and slept through causing staff to wonder if Father was exhibiting his normal behaviour. Father ran off before the Police arrived. The incident was referred to children’s social care (CSC). The couple separated. 2.1.7 The following month partner alleged Father became aggressive refusing to leave contact. Partner locked herself and sibling in the bathroom. Father was kicking the bathroom door in when Police arrived. Father was removed and the case referred once more to CSC. 2.1.8 Within weeks, there was a further domestic abuse (DA) incident at a bus stop. Father was drunk and partner was arguing with him whilst sibling was present. The incident was referred to CSC. 2004 2.1.9 At the beginning of 2004, there was a DA incident where a female lunged at Father who was holding sibling. This was once again referred to CSC. 2.1.10 The following month Father was physically and verbally aggressive during an argument over sibling and slapped and kicked partner. A further referral was made to CSC. CSC carried out an assessment; partner and her family reported Father kept partner and sibling hostage for three days, Father was reported to be verbally and physically abusive. Father was thought to be more believable. 2.1.12 In April, sibling sustained a physical injury whilst in Father’s care. The injury was not consistent with the history. The case went to initial child protection conference (ICPC). Father stated sibling fell down three steps trying to follow him, sibling had bruising to eye and cheeks. The injuries were not consistent with the explanation however, the CPS concluded there was insufficient evidence to charge based on the Paediatrician’s report. 2.1.13 In July sibling was made the subject of a Child Protection (CP) plan under the categories of neglect and physical abuse; a core assessment commenced. 2.1.14 By the end of the year partner and Father were no longer together. The CP plan ended, it was a unanimous decision. 2005-2016 2.1.15 Between February 2006 and December 2013 Father had five attendances to A&E with alcohol related issues. Whilst this would not be seen as overly significant, it may indicate an underlying alcohol problem. BSCB Child BZ SCR FINAL 7 2.1.16 In August 2013, Mother had an argument with her then boyfriend who punched her in the face; he was jealous mother had been in contact with MGM. The attending police officer was aware Mother had a mental health diagnosis; it is incorrectly recorded that mother had schizophrenia. BSCB Child BZ SCR FINAL 8 3. NARRATIVE, APPRAISAL OF PRACTICE AND ANALYSIS OF THE KEY LINES OF ENQUIRY 3.1 Introduction 3.1.1 This section will provide the narrative, appraisal of practice, analysis of the key lines of enquiry and the findings of this serious case review, with associated recommendations for BSCB and its partners. The findings relate to what has been learnt about the strengths and weaknesses in the multi-agency systems. 3.2 Events and activities prior to mother becoming pregnant 3.2.1 In the six months prior to Mother’s pregnancy being confirmed Mother had a prolonged admission (over two months) in hospital, having been detained under the Mental Health Act (MHA). Mother had not been taking her prescribed medication and this was thought to be the reason for her relapse. 3.2.2 On discharge there were difficulties getting the dosage of Mother’s medication to a point where her symptoms were reduced without her being overly medicated. Mother and Father were already a couple having met five months earlier, however Mother continued living with her family with MGM as her Carer. Mother once again became low in mood with reduced self-caring. MGM was advised to seek advice earlier. This decline in Mother’s mental health was followed up with a call by the Mental Health Social Worker (MHSW), however whilst the call was to Mother the MHSW spoke to Father, who reported Mother feeling better, eating ok and no unusual thoughts. Comment: This is the start of a re-occurring theme of professionals making attempts at telephone contact with Mother and not speaking directly to her. Insufficient consideration was given to the role of partners. Father’s suitability as a Carer was, at this point, unassessed and Mother was choosing not to live with him. 3.2.3 Mother was subsequently offered a support worker to try to provide some structure to her days, as she had no meaningful activities; this was declined. There remained non-compliance with taking medication and Mother’s mental health was a concern. Father was offered a support worker and declined. An outpatient appointment (OPA) was cancelled by Mother, this was followed up, rearranged and attended; Mother was once again offered, but declined a support worker. Comment: Health professionals were clearly identifying Mother needed and likely, would benefit from support worker involvement. Mother and Father’s declining of additional support was their right. 3.2.4 Mother was involved in an incident in a pub where she was asked to leave because of her behaviours; she had spat in the pub managers’ face. Alcohol was believed to have exacerbated the situation. Mother received a community resolution for common assault. The police officer dealing with the incident was unaware of Mother’s mental health disorder; she was seen as violent and aggressive. Comment: There is a reliance on frontline police officers having the skills to assess whether violent and aggressive behaviour has a mental health component. Officers can now ring to check if a person has a mental health disorder, but it is down to BSCB Child BZ SCR FINAL 9 the judgement of the attending officer as to whether behaviour relates to alcohol or mental illness. 3.3 Actions and activities during Mother’ pregnancy 3.3.1 Mother was very open with the health professional’s involved in her care at the point she found out she was pregnant. MGM was proactive in requesting information from the GP as to whether Mother’s medications may be harmful or potentially dangerous to BZ. An outpatient appointment (OPA) and Pharmacist review were booked. MGM, Mother and Father attended the pharmacist meeting. Mother was on the correct medications for her condition in pregnancy. Mother failed to attend (FTA) her OPA the following week. Comment: The pharmacist’s review was good practice. Mother was reliant on MGM or father to remind her of appointments. 3.3.2 In referring to midwifery the GP wrote and shared Mother’s past history including her mental health and her medication. All professionals involved during the pregnancy were therefore aware of Mother’s mental health condition. Two weeks post referral Mother and Father attended a booking in appointment. The community midwife (MW) was concerned by Father’s controlling behaviour; Mother was asked about domestic abuse, but denied any abuse. Mother’s PHQ94 showed moderate depression; Mother was referred for consultant care and to the specialist MW for complex social needs and to Baby Steps 5. Father disclosed previous CSC involvement with his now 13-year-old child and seemed very keen for Mother to move in with him. Comment: There is much to explore at a booking in appointment, so whilst Father’s disclosures and behaviours could have been explored further, it becomes understandable that they were not. A follow-up appointment should have been arranged the following week to discuss these further. Father’s disclosures and behaviours should have formed part of the onward referral. 3.3.3 The community MW with additional input from the mental health specialist midwife (MHSM) provided Mother’s care. The MHSM believed mother to be 16 weeks pregnant. Mother disclosed the injury to Father’s previous child to the specialist MW, Father did not. Father gave varying accounts of his level of contact with sibling, which ranged from seeing sibling at weekends to none; this discrepancy was not highlighted in discussions between professionals. 3.3.4 Other professionals learned of the incident where sibling sustained an injury in Father’s care, largely through Father’s self-report. This self-report made Father appear open and truthful to professionals. The incident was not known to any of the health professionals currently involved, nor had the paediatrician’s child protection medical report been seen. The difficulty for health professionals is often how the transfer of relevant information flows when parents have children with multiple 4 PHQ9 – A patient health questionnaire, used by health professionals to assess mood. 5 Baby Steps is an educational programme designed to support Mums and Dads to be able to manage the emotional and physical transition into parenthood. BSCB Child BZ SCR FINAL 10 partners. The information about a child remains with the child and therefore with the household in which the child is living, in this case Father’s ex-partner and is not readily available. This means that health professionals have to actively seek that information and, unless it was known that there was a safeguarding issue would have to request permissions in order to do so. The same is not the case for the police and CSC who can access the required information readily from their systems. There was recording of the incident on police and CSC IT systems and CSC records. 3.3.5 Father disclosed his own mental health issues to the MHSM and indicated he was taking anti-depressant medication. The MHSM sought further information regarding Father via the Adult MASH. 3.3.6 Mother was managed through a joint clinic and joint work between the MHSM and Mother’s mental health Adult Social Worker. The midwives and psychiatrists met every Wednesday to discuss pregnant women with mental health conditions and Mother was part of those discussions. Mother had an antenatal scan and all seemed well; Mother was deemed to be 21/40 weeks pregnant by obstetrics (later believed 17). Comment: This was good practice. It was felt by those attending these meetings that the discussions could have been enhanced further by the attendance of the obstetrician. 3.3.7 A mental health management plan was developed and the fact that Mother did not recognise when her illness was in decline was included in the plan. 3.3.8 At a Multi-Disciplinary Team (MDT) meeting, there was discussion that Mother was at high risk of relapse; thus, a referral should be made to CSC. Blackpool SCB policies and procedures indicates referrals should be made 16 weeks into the pregnancy, Mother was either 17 or 21 weeks into her pregnancy, as she was thought to be further along in the pregnancy, when a Getting It Right referral (Level Three) was submitted. The referral noted that MGM, Mother’s carer, was also caring for her son with learning disabilities and husband with mental health issues. 3.3.9 The referral contains all pertinent information and the CSC SW was advised to progress the referral and arrange a visit prior to going on leave; this did not happen. A week later the MHSM contacted CSC raising concerns in respect of Mother’s mental health, indicating the need to approach the assessment with care as Mother was at high risk of relapse, and suggested a joint visit. The MHSM was advised that the CSC SW was on leave and a visit was arranged for three weeks’ time. The MHSM suggested the case should be reallocated given concerns around Mother’s mental health and the need for her to build a relationship with the CSC SW; this was good practice however, it did not happen. Indeed, the planned visit was delayed by a further two weeks. The lead reviewer learned that pan Lancashire procedures indicate 30 weeks is the latest time for a conference to be held. Practitioners reported that, because of the pressures of work, there is a practice of waiting until 30 weeks to start preparations for conference, however, there is nothing to prevent multi-agency meetings taking place. Some CSC SW’s start preparation for conference prior to 30 weeks, but that is up to individual CSC SW’s and results in an inconsistent approach. Perinatal team meetings were happening although they were multi-disciplinary in nature they were single agency with health staff only in attendance. BSCB Child BZ SCR FINAL 11 Finding: The practice of delaying holding multi-agency meetings, in cases where safeguarding concerns have been identified, until the pre-birth conference is not making the best use of a pregnancy when mothers are most receptive to change6. Recommendation 1: BSCB and its partners to review the current policies, processes and practices around unborn babies to ensure professionals are clear about the need to proactively progress referrals, build relationships between social workers and parents, and request information to complete assessments wherever possible prior to the birth of the child. Compliance must be subject to monitoring and audit. 3.3.10 At 20 weeks’ gestation, the care co-ordinator and specialist midwife start joint visiting. Mother’s mood was flat; she reported her family were accusing Father of taking Mother’s money. At the visit Father was speaking for Mother; practitioners in recognition of this told Father to leave, but he kept returning. Mother indicated she did not feel ready to move in with Father, was having difficulty coming to terms with pregnancy, struggling with going out and managing finances. Father was buying baby items without Mother. Comment: It is clear that there were a number of issues at this point and it would have been useful to have a multi-agency approach however, the first CSC assessment session was planned for a month hence; the timing being somewhat impacted by SW annual leave; the specialist midwife challenged this delay suggesting the case be reallocated given mother’s mental health and the need for her to build a relationship with the social worker – no change of plan was made within CSC. 3.3.11 During this period, health disciplines continued to work well together with a shared care approach. When Mother cancelled a psychiatrist appointment, this was discussed at Perinatal MDT and a further appointment made for psychiatric review. On attendance, Mother was reported worried, not talkative and it was difficult to access her thoughts. Medication was discussed with liaison with Mother’s GP for review of medication a few weeks later. 3.3.12 Joint visiting continued with the care co-ordinator and specialist midwife visiting MGM’s when Mother was 24 weeks pregnant. Father was once again speaking for Mother and asked to leave. The Adult Social Worker was going on maternity leave so a new MHSW was to be introduced. There was no DA enquiry. 3.3.13 At the GP review, Mother requested a change of medication. The GP agreed to discuss this with the CMHT. Mother was seen by the consultant psychiatrist and reported erratic use of one of her medications. Mother was reluctant to take it so it was discontinued and her other medication increased. Mother indicated she was not keen to go to the mother and baby unit, post birth, as it was out of area. Practitioners report Father appeared to be influencing Mother, as he did not want his relationship with baby to stall. Perinatal mental health problems are very common, affecting up to 20% of women during pregnancy or the first year after childbirth. Since this case, there has been a proposed change to services to women in Cumbria and Lancashire experiencing perinatal mental health problems. A new 6 Olander, E., Smith, D. & Darwin, Z. (2018) Health behaviour and pregnancy: a time for change. Journal of Reproductive and Infant Psychology. 36:1, 1-3, DOI:10.1080/02646838.2018.1408965 BSCB Child BZ SCR FINAL 12 local specialist Perinatal Mental Health Unit is due to open in 2018; it is hoped this will lead to women receiving care locally alongside their babies. 3.3.14 Professionals report having seen MGM and Father together and there being no evidence of hostility between them. MGM tended to let Father do the talking, but affirmed the information he was sharing. MGM had indicated to professionals that she hoped Mother and Baby would come home to her. MGM was described as a quiet, timid woman. Father had expressed that he did not want baby to go to MGM’s because it was smoky. As time went on the relationship seemed fractured. 3.3.15 During this time, MGM had taken an overdose and was in hospital; not all the professionals involved knew this information. 3.3.16 A family engagement worker from the NSPCC received the referral for the Baby Steps programme and contacted Father to speak to Mother. Mother was overheard to say she did not want to speak to the FSW directly and they were not sure they wanted to participate. However, the couple indicated they would attend. The referral contained limited information regarding the incident with sibling and the mental health issues. A decision was made for no lone working until further information regarding risks had been received. The case was discussed with the manager and Framework i (IT case management system) was checked and further information on the system regarding the previous child and planned pre-birth assessment was gleaned. There was an issue regarding date recording on the NSPCC system at that time, which makes it appear that case was closed before a visit took place, this has since been resolved. Finding: Referrers are not recognising the importance of providing full information on referral forms. A poorly completed referral can lead to, poor decisions on the acceptance and advancement of referrals for appropriate services, delay and can place workers in risky situations. Recommendation 2: Partner agencies of the BSCB to review all its referral forms to ensure they include a prompt to the referrer to provide full and accurate information and an assessment of risk when referring to another service or agency. Where referrals are of a particularly complex nature this should be indicated with a request for contact. 3.3.17 When Mother was 25 weeks pregnant a home visit was conducted by the family engagement worker at Father’s address. Mother indicated she was not living with Father; they had only been in a relationship a year and she was not ready. Mother was quiet and needed assistance to complete the forms. Father raised a concern regarding Mother possibly not bonding with the unborn. From the information gleaned, the worker concluded the couple had good supportive families, but with little evidence other than self-report. The ‘Baby Steps’ programme was to be delivered at a children’s centre location which Father identified was too near his ex-partner’s house so this was changed. The family engagement worker attempted contact with the MW and CSC SW for further information and got no reply from one and the other was off sick. Because Mother and Father wanted to access the programme at an alternate venue, they would come under a different family engagement worker so plans were made to transfer the case therefore no further BSCB Child BZ SCR FINAL 13 entries were made on the file and the case was closed in that group and for that worker. 3.3.18 Before the case had been reallocated to another Baby Steps worker and group, Mother contacted the service advising she and Father did not want to take part in the Baby Steps programme. Mother was reported not well enough. The midwife was informed who indicated Mother was very poorly at present and should not be pushed. The family engagement worker’s team manager signed off the episode concluding it was a shame Mother had chosen not to participate. Comment: The Baby Steps programme is somewhat isolated from other services. The practitioners indicated they are almost fully reliant on the quality of information in the referral; inclusion in multi-agency meetings would have helped. Adult mental health workers were unaware that the service had been involved. The negative effect on the unborn was not given sufficient consideration and whilst mother might have been too poorly to attend groups, further exploration of how the programme might have been delivered did not happen. 3.3.19 Over the next few weeks, there was a flurry of activity by professionals as Mother’s mood fluctuated, however agencies were initially working in silos; there remained no meetings where all professionals were present. 3.3.20 Commencing at 27 weeks’ gestation Mother and Father engaged in a pre-birth assessment carried out by a CSC SW over three sessions. Although there is little recorded, it is clear relevant information had been gleaned as when the case was discussed in CSC SW supervision, the incident with sibling featured and, the CSC SW requested Mother be put on the list for a Parenting Assessment Manuel (PAMS) assessment. The CSC SW also discussed that Father took medication for anxiety, depression and agitation and sometimes had difficulties leaving the house. What is less clear is analysis of the information. 3.3.21 Following the third assessment session a request is made for sibling’s case file; it is not clear why this occurred so late in the assessment. The plan at this point was for: a PAMs assessment in respect of Mother, to clarify Father’s MH issues with his GP, for Mother to continue to engage with MH services, a Carer’s assessment to be completed of Father, further information required re sibling and for legal advice to be sought. 3.3.22 What is missing from the documented assessment is MGM and the wider family, and an assessment of the risks to and the impact on, the unborn of parental mental health. It is clear the assessment was discussed in CSC SW supervision on one occasion, but there appears to have been a lack of managerial oversight and lack of challenge as to why actions required had not been completed. 3.3.23 One explanation could be that the time for booking an initial conference was close, the assessment would have gone out of timescale if this information was needed, and the assessment started very late. Later the SW confirmed that multi-agency BSCB Child BZ SCR FINAL 14 plans were completed, but were not specific in the assessment and that agencies were consulted as part of the assessment. MGM was spoken to as part of the assessment, but this again was not specifically recorded in the assessment. It was reported that MGM also had mental health difficulties, which would have resulted in her being in a poor position to support Father and Mother with the baby. Wider consideration of how MGM was fulfilling her Carer role and what this meant was not evidenced. The risks identified in the assessment process were primarily around the impact on baby due to Mother's poor mental health and the concern that this would become more difficult when she gave birth. The planning was around this. Mother had had angry outbursts and this was of concern. Mother could manage day to day, but concern was her health would deteriorate and Father would become sole or main carer for baby. At this time, the thinking was no significant concerns had been raised about Father's ability to parent other than requiring support as any new parent may require. The risks identified in respect of Father's flat, that is was not suitable for a new-born baby as the flat was deemed for single tenancy only, prompted a plan be put in place to address this. The CSC SW recognised that Mother might disengage and Father might not be compliant with his medication. There was suggestion that if Father did not comply, questions would be asked and, an assessment made. All this was considered, but not fully incorporated in the assessment; this was not scrutinised nor challenged by managers. Finding: This case highlights the importance of accurately interpreting historical child protection information so it can be used to plan actions to safeguard unborn and new-born babies. Insufficient credence is currently being paid to historic information to complete informed risk assessments. The focus of the Pre-birth assessment was on the here and now rather than a full assessment including the historical information. The danger of considering an assessment as complete before all relevant information has been gleaned is that, as in this case, any risk assessment can easily become skewed. Assessments are not a single event rather a continuum; they should be revisited as new information is received and reassessment of risk and adjustments made to the plan. In an NSPCC review7 it concluded that professional optimism could lead to risks being underestimated and there being a tendency to see the birth of a new baby as an opportunity for a fresh start. This sometimes hindered professionals from recognising pre-existing patterns in parents’ behaviour, which posed a risk to the baby. Recommendation 3: The BSCB to seek assurance from CSC that all assessments and plans of children subject to CIN, CP and Pre-birth, show evidence of the gathering and appropriate use of historical information. Finding: There is no evidence that the assessment was driving the planned actions to improve outcomes for BZ. Recommendation 4: BSCB to seek assurance from CSC that all assessments and plans are subject to managerial oversight, that there is evidence of thorough scrutiny and challenge by managers. 7 NSPCC (2017) Infants: Learning from case reviews BSCB Child BZ SCR FINAL 15 3.3.24 Health held a series of MDT meetings with the MW, psychiatrist, perinatal MH nurse and specialist HV perinatal and infant mental health. Best practice would have been for either the CSC SW to have been present too or the health plan to have fed into the CSC SW assessment. 3.3.25 Mother was alternately being reported to be more engaged with the pregnancy, but worried regarding coping; or low in mood. On occasion Mother ran out of medication. 3.3.26 During this period, Mother attended a GP antenatal clinic, she was 29 weeks pregnant and all was said to be well with the pregnancy. Learning point: There was a general lack of routine enquiry regarding domestic abuse by health professionals throughout the pregnancy. Whilst a meta-analysis8 did not detect improved outcomes for women screened for intimate partner violence, there was insufficient evidence within the meta-analysis for screening in healthcare settings and current NICE guidance advocates routine enquiry around domestic violence and abuse.9 3.3.27 In early December, a strategy discussion took place between the SW and the police; there was no health input, which appears an oversight however, the lead reviewer learned, strategy discussions in cases that clearly need to go to pre-birth ICPC had become a formality and thus no in depth discussion took place. This was outside of expected practice. Coincidentally a scheduled audit identified the same issue and as a result a clear message was sent to the CSC SW’s that this was not acceptable. Current process means there has to be a strategy discussion for a case to advance to conference. A PVP was created at a medium risk with recommendation of progression to ICPC. The PVP identifies partial information; Mother and Father plan to reside in the same block of flats, Mother is untested on her own, Father was not involved in his first child’s upbringing, both have parental support. Much of the factual information of the case is missing. Finding: Adopting a stance where strategy discussions are treated as a formality is unacceptable. This approach is fuelling a lax attitude where cases that should lead to strategy meetings are remaining as discussions between police and CSC. Health should have been part of any strategy, be it discussion or meeting. The danger of discussing such a complex case in a discussion rather than a meeting is the risks to the unborn are not sufficiently recognised and the information advanced to ICPC from this forum is scant. This was a missed opportunity to assess risk and for a multi-agency approach to begin. Recommendation 5: BSCB and its partners to audit the practice around strategy meetings for unborn babies, to ensure that meetings are being held in accordance with procedures. The audit should seek evidence that discussions within the meeting form part of the analysis of risk from the start of the child protection process. 8 BMJ 2014;348:g2913Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis 9 NICE (2014) Public Health guideline (PH50) Domestic violence and abuse: multi-agency working BSCB Child BZ SCR FINAL 16 3.3.28 The ICPC was not scheduled to take place for a further nineteen days, which at this stage in the pregnancy 33 weeks was significant. In between times: Mother missed a psychiatry appointment Father declined a referral to Single Point of Access (SPA). The CSC SW sought legal advice and was advised further work was required; the decision was not to issue care proceedings. The family engagement worker declined an invite to conference, but agreed telephone contact. The MW was increasingly concerned regarding both Mother and Father’s MH and non-engagement. The SW visited, but Father denied any MH issues, but his sister was present. There was a failed visit by the HV to complete an antenatal 26-28/40 visit. The case was allocated for Family Group Conference (FGC). Mother attended the Delivery Suite having Phoned 111 with abdominal pain. The ambulance staff noted no safeguarding concerns at home on their records, however documented that ‘the family arguing and tensions high. Strong smell of cannabis and Father refused request to stop smoking whilst paramedics there. Mother not prepared, no bag packed unsure of dates and no credit on her phone’. There was no referral form or information sharing from the crew, but the information was passed to the allocated SW via the hospital. No evidence the SW takes any immediate action. A Carer’s assessment in respect of Father was carried out. Father was advised by LCFT to engage with carer service, but was unwilling to do so. 3.3.29 It is not clear whether the family engagement worker’s decision not to attend or provide any written information was discussed with and agreed by the Team Manager. However, it is evident that there was information and observations made during the initial contact with the family that would have been useful to have shared with CSC in order for them to have had a fully informed picture of risk, need and capacity. Blackpool NSPCC has subsequently addressed the matter, as this has been a reoccurring issue. Learning point: Any request for attendance at CP conference should be complied with in accordance with Policies and Procedures. If attendance is not possible a written report, including all relevant information must be provided. 3.3.30 Preparation for conference commenced. The Health Visitor (HV) was unaware of the conference. Practitioners reported that Health Visitors were not always invited to pre-birth conferences; this missed an opportunity for the HV to become involved earlier. In addition, neither Mother nor Father’s GP were made aware of or invited to the ICPC or RCPC. Finding: Current practice of not inviting all health professionals to conferences is potentially limiting the effectiveness of safeguarding meetings. As pre-birth conferences do not occur until after 30 weeks it is likely HV’s will have conducted BSCB Child BZ SCR FINAL 17 an initial visit between 28 and 32 weeks into the pregnancy and will therefore have relevant, recent information regarding the client to share. GP’s are in receipt of all NHS health information regarding their patient. At the time of Mother’s pregnancy, the SW provided the list of who she knew needed to attend; however, where the unborn was a first child or the mother’s children were over five the SW did not always know which HV to invite. The current revised system dictates where there is only an unborn (no other siblings) the Quality Assurance (QA) team at the LA will send the invite to the safeguarding email inbox for the midwives and also send to the correct email inbox for the HV team. The SW should also be able to identify the HV as part of the pre-birth assessment by either asking the midwife or checking with the mother’s GP and linking to the correct HV team. Both parents’ GP’s must be invited to pre-birth conferences. Recommendation 6: The BSCB to seek assurance from CSC that systems for inviting health professionals to conference are now effective. The LA Quality Assurance team to monitor attendance and provision of reports to conference and report to the BSCB. 3.3.31 The case went to conference. Absent were the HV, GP and the family engagement worker. The risks identified were Mother’s mental health and its’ manifestation when unwell, Mother’s learning difficulty in relation to how this might affect care of the baby, the injury to sibling – when CPS took no further action, and Father’s depression. What was missing was DA in Father’s previous relationship, Father’s coercive and controlling behaviours in relation to Mother witnessed by professionals, details of the family arguing and the high tensions noted by the ambulance crew, historic alcohol use and current cannabis use also noted by the ambulance crew. 3.3.32 The challenge when chairing a conference of a complex case, as in this case, is how to share all the relevant information in a relatively short period of time. Attendees’ and non-attendees’ reports need to be of a high quality and contain all relevant information; they then must be read in order the information is shared effectively. In this case, the police report contained relevant information about the incident to sibling although no conclusion as to whether the injuries were accidental or non-accidental. Police information did not include information about the incident with Mother at the pub. The MW report did not contain information from Mother’s attendance with abdominal pain, the SW report also had gaps in information, including the ambulance service information. Finding: Professionals did not include all relevant information in their reports to conference. The importance of information sharing has been an on-going issue identified within numerous national Serious Case Reviews and Inquiries for decades. Information sharing guidance has been produced for professionals.10 Recommendation 7: BSCB and its partners to assure themselves that reports for conference contain all relevant information and are compliant with best practice. 10 DFE (2015) INFORMATION SHARING ADVICE FOR SAFEGUARDING PRACTITIONERS BSCB Child BZ SCR FINAL 18 3.3.33 The SW had accessed sibling’s IT record and concluded that there was no evidence that Father caused the injuries despite the inconsistent account. This becomes understandable when you explore what was recorded on the IT system, which differed from what was recorded in the paediatrician’s report. What was absent was the impression recorded by the paediatrician that the injuries were not consistent with the history and it was difficult to explain the injuries secondary to a fall from the stairs. 3.3.34 Professionals agreed this incident made them feel uneasy and cautious as there was, they believed, at the very least, misreporting. Professionals indicated they were also conscious not to stigmatise Father and to take a balanced and proportionate approach. Professionals were informed Father was allowed contact with sibling from a CSC perspective, which served to reassure them, however, there was a lack of clarity surrounding the real situation around contact. Professionals were made aware that there was information around ten DA incidents between Father and a previous partner, one incident were Mother was the subject of domestic abuse in a previous relationship, an alcohol related incident for Mother and cannabis for Father but had failed to recognise that this was a case where the indicators for ‘toxic trio’11 were present. Finding: The incomplete representation of the contents of the historic medical report coupled with the CPS decision not to prosecute, the lack of focus on Father in terms of behaviours appears to have reduced professionals’ thinking around the risk Father might pose to BZ. No one with a health background reviewed the child protection medical report as part of the ICPC to give a health perspective on the findings of the paediatrician at that time. Recommendation 8: A system should be developed to ensure that in cases where there have been historic concerns, including previous child protection medicals regarding siblings of the subject of a Child Protection/Child in Need Conference/meeting, all agencies should review the source record and the most appropriate health person should review the information included in the child protection medical report and provide their view to the Child Protection conference. 3.3.35 The detail of the mental health management plan was shared so all professionals had an opportunity to know this. However, practitioners reported that at conference, there was a lot of information to go through and this would have been easy for them to miss. This was disputed by the panel who suggested that perhaps the practitioners were limited by their lack of mental health knowledge. 3.3.36 Parenting assessments were considered within the conference. The suggestion being that mother would be put forward for a PAMs assessment. This specialist assessment, done by social workers who are trained assessors and with approval by a CSC manager, was meant to be progressed onto the PAMs assessment list following supervision between the SW and manager when the case was first referred, but was not . A PAMs assessment is a 12-week assessment for parents with 11 Toxic Trio – has been used to describe the issues of domestic abuse, substance abuse and mental ill-health issues which have been identified as common features of familieswhere harm to children has occurred. They are viewed as indicators of increased risk of harm to children and young people. BSCB Child BZ SCR FINAL 19 learning difficulties. The lead reviewer learned that prior to a PAMs assessment a cognitive assessment of ability has to be completed; this can lead to delay. The system is not easy to navigate with the potential for much delay. For Mother there should have been no need for a cognitive assessment as she had numerous assessments as a child resulting in education within a special school that demonstrated impaired cognitive ability. Although Father was quite open with professionals that he was suffering from and being treated for depression by his GP; this was not openly discussed within the conference. Father was also believed to have some level of learning disability however, there was no suggestion he might also have been eligible for a PAMs assessment. Assessment of Father’s parenting ability did not commence until after BZ was born. The lead reviewer learned there is currently a shortage of trained assessors and a backlog of assessments meaning assessments are often not started and are rarely complete before a parent has full care responsibilities for their child. Finding: If a decision and/or taking action on a decision, that a parenting assessment is required, is left until conference at 30+ weeks into a pregnancy, this must be considered in terms of what this means for care and safety of a child post-delivery and pre completion of the parenting assessment. This issue has the potential to leave the most vulnerable children in Blackpool in the care of parents who lack ability to care for them. Recommendation 9: BSCB and its partners to review the arrangement around parenting assessments, both routine and specialist, to ensure they are robust. 3.3.37 There was consideration of further referral to Baby Steps for parenting, but this was not pursued on the advice of the midwife due to Mother’s mental health and an understanding that Mother would not manage in a group setting. Baby Steps practitioners indicated that some elements of the programme could be delivered on a 1:1 basis by HV’s or Baby Steps workers; however, there is no evidence this was explored further. It was recognised that the service would not have had the capacity to do this at that time. Baby Steps do not have access to health records and are reliant on a comprehensive referral. Baby Steps were not present at the Child Protection conference; it was thought multi-agency meetings pre-birth would be useful. 3.3.38 A decision was made that BZ would be placed on a CP plan under emotional harm at birth. A pre-birth plan was developed and known to attending professionals. The plan included contingencies for if Mother’s mental health deteriorated. The mental health plan sat alongside the CP plan. The midwifery plan was for Mother and baby to remain on the ward and Father to stay too; this was outside of normal practice, but believed to be in the best interests of Mother and BZ. There had been discussion with legal services as to whether the case met the threshold for care proceedings whereby the child could be taken into care; it was deemed it did not, but suggested further work was needed and to return to a legal planning meeting if there were further concerns about the arrangements for and care of the baby when born. The first core group took place immediately post conference. BSCB Child BZ SCR FINAL 20 3.3.39 Three weeks later the HV contacted the CSC SW to share information from a multi-disciplinary team meeting and request information on the plan and the date for core group. 3.3.40 The midwife informed the CSC SW in an email of MGM’s concerns that Father would not call anyone if Mother’s mood were to relapse, due to actions that could be taken by CSC e.g. taking the child into care. A CSC Social Work Assistant (SWA) was allocated to assess Father’s parenting and an initial meeting took place. 3.3.41 An adult MH worker visited. Issues on this visit related to the flat being cold; it transpired the gas had been disconnected. The CSC SW believed Mother was staying at MGM’s because of the cold, but the adult MH worker records tensions between Mother and Father as the reason Mother went to stay with her parents for support. Comment: Parental tensions were not shared appropriately with the core group. A professionals’ meeting could have been held; the quality of information sharing was identified internally and measures put in place to address this. 3.4 Events and activities after the birth of BZ 3.4.1 BZ was born at 37 weeks into the pregnancy, five weeks after being placed on a CP plan. BZ required some initial assistance at birth including oxygen. There was an added complication as Mother had a Strep B infection and needed antibiotic treatment and BZ needed a blood test and monitoring to establish whether BZ also had Strep B; results proved negative. There was some confusion as to whether BZ may need scoring for drug withdrawal from Mother’s prescribed medication; although it was agreed that this was not necessary. 3.4.2 The mental health plan had been for the Crisis Home Treatment Team (CHTT) to assess Mother’s mental health on a daily basis, however the rapid deterioration in Mother’s mental health coupled with her now expressing a wish to go to the Mother and Baby Unit (MBU) meant this never happened. The plan developed at pre-birth conference to obtain missing information, complete a PAMs parenting assessment on Mother, look at parenting support and consider accommodating BZ had not been advanced. The second core group meeting took place on the day BZ had been born. The CSC SW, MH SW, Children’s Centre, MW and adult MH worker attended the core group; although there is record of the meeting taking place on Mosaic (CSC IT system), there is no associated recording of the meeting. Additional information that Mother had a history of being in relationships that had been abusive came to light. Staff documented concerns that Father was controlling of Mother and questioned Mother’s ability to care for BZ. 3.4.3 Within 14 hours of the birth of BZ’s Mother was agitated and hearing voices. Mother indicated she would not be able to cope and regretted passing up on the out of area Mother and Baby unit placement, there was an urgent review of her care, this did not include discussing the possibility of BZ going into care. Father’s family were concerned as Father was indicating he would kill himself if he had to choose between Mother and the baby. Mother’s medication dose was increased and Mother and BZ were referred to a mother and baby unit. BSCB Child BZ SCR FINAL 21 3.4.4 There is evidence of good information sharing from the MW to the HV and CSC SW with preparation made for a discharge planning meeting. 3.4.5 The CSC SW carried out a CP visit to Mother and BZ the following day. Mother and BZ were fit for discharge. Father was upset and was supported to get BZ and Mother’s belongings. Father was struggling to feed BZ; staff offered support. The CSC SW was concerned about Mother’s interactions with BZ and Father’s irritation when he was challenged, however, made positive observations of Father’s interaction with BZ. There were concerns that Father would be separated from BZ however, stringent efforts were made to keep Mother and baby together demonstrating good practice. 3.4.6 The discharge planning meeting took place swiftly and Mother and BZ were transferred on Day two to the Mother and Baby Unit, Mother was placed on constant observation. Community midwifery from the Mother and Baby Unit visited Mother the following day completing physical health checks on Mother and BZ. 3.4.7 Mother’s MH nurse maintained contact with Father and steered him towards additional help from the Carers Centre. The adult mental health worker had a no access visit to Father; he was staying with MGM for support. 3.4.8 Over the first week Mother’s MH deteriorated and she was detained under the MHA. 3.4.9 Mother continued to be monitored by the community MW who requested maternal blood pressure monitoring as this was high. BZ had a small blister like mark on a knuckle, BZ’s weight was increasing. 3.4.10 Adult Mental Health and CCTT services were trying to contact Father in the first two weeks with no response; this was not shared with CSC. 3.4.11 By Day 14, staff reported Mother was doing little to care for BZ. It was felt Mother needed acute ward care. 3.4.12 Assessment of Father’s parenting ability took place within the out of area Mother and Baby Unit, the assessment found that BZ’s basic needs were being fully met. However, the assessment concluded ‘it is unclear if this can be sustainable when BZ returns home’. Father showed that he welcomed guidance and advice and was starting to be able to recognise and pre-empt BZ’s needs. 3.4.13 Throughout the assessment, Father reflected on his own parenting practice concerning sibling and agreed that he needed the support of professionals and family as his knowledge and experience were poor. The assessor noted ‘Father displays a willingness to learn and confidence in handling BZ that comes from the natural bond between them.’ ‘Father appears to be able to put BZ’s needs before his own and to those of Mother. Putting this into practice on a daily basis will be hard work, but achievable. I think Father embraces the commitment necessary to succeed.’ ‘I do not doubt that Father truly loves BZ and is prepared to do whatever it takes. I have to question whether the long-term commitment needed to manage BZ as BZ grows and develops is a realistic option for Father alone. Father’s family provides the confidence and experience Father needs; I am unsure Father could manage this without support.’ BSCB Child BZ SCR FINAL 22 3.4.14 Within the Child and Family Assessment there is a section entitled parental/child factors at assessment indicating the assessor should tick any child and parent risk factors, the only factor ticked was learning disability. The author believes an opportunity to reflect on all the risks present in this case was missed. Finding: The tools within the assessment designed to hone a practitioner to consider risk had not been completed in this case. There was no evidence that this had been recognised or challenged by managers. Recommendation 10: BSCB to seek assurance from CSC that all assessments are subject to oversight, challenge and scrutiny by managers within CSC. 3.4.15 The HV at the mother and baby unit shared information with the local HV, which was expected practice. 3.4.16 Mother’s condition deteriorated and she had an altercation with staff leading to a transfer of care to an acute ward. No strategy meeting was held. Following transfer LCFT completed a risk assessment and updated the care plan. The electronic safeguarding record was updated however, the information was incomplete regarding BZ’s details and potential safeguarding concerns and the information was not shared further. Finding: This case had identified gaps in information sharing between Adult MH services and CSC with a lack of proactive response by both services. The deterioration in Mothers MH was an opportunity for a multi-agency meeting to be held. Recommendation 11: CSC and Adult Mental Health services to review their information sharing processes and ensure policies clearly state sharing of and flow of information between adult MH services and CSC must be routine in cases where children are in the safeguarding arena. 3.4.17 This transfer meant CSC had 48 hours to make a decision as to where BZ should be placed. Whilst recognising this did not afford much time for the CSC SW to make plans, the decision was made very swiftly and as a single agency, allowing BZ to go home into care of Father the following day. Father’s parenting assessment had been completed and whilst it questioned Father’s ability to care for BZ alone, regular updates obtained by the CSC SW from staff at the mother and baby unit identified no concerns. 3.4.18 It could be argued that placing BZ in the care of Father did not constitute a change to the CP plan as the plan was always for BZ to go home into the care of Mother and Father, with Father being the main carer. Promotion of keeping BZ in the care of birth family was always the thinking. However, there does not appear to have been sufficient consideration of the findings in the parenting assessment, further information that emerged regarding Father; the conference chair was not aware of the changes to the plan. CSC SW workload impeded at that time. Practitioners indicated that the concentration was on the number of cases allocated to each worker rather than the complexity of the cases; the CSC SW identified workload at that time was heavy. Practitioners report an improvement in workload and in performance monitoring and management since that time. Conference chairs now automatically review cases at the midpoint between conferences. If that had been BSCB Child BZ SCR FINAL 23 the process at that time, the chair would have been aware that BZ and Mother had entered the Mother and Baby Unit. 3.4.19 There was no consideration to holding a discharge planning meeting or a multi-agency meeting at this time; nor was the conference chair consulted. There was insufficient thought and analysis as to whether the couple’s change in circumstances warranted a multi-agency meeting or a core group to take a multi-agency decision on the best course of action to meet BZ’s needs. There was no consideration of foster care as an option. 3.4.20 If the SW had taken the full 48 hours open to her a core group, already scheduled to take place the following day, could have taken place with advice or attendance of the conference chair or a SW manager, a multi-agency decision taken and plan made. The core group was postponed to the following week. Finding: Decisions regarding unplanned changes in living arrangements for children subject to CP plans must, wherever possible, be made on a multi-agency basis, with the child as the focus. Recommendation 12: BSCB to amend its procedures to advise that any changes to the living arrangements of a child subject to a CP plan should be made with the knowledge and agreement of involved multi-agency partners. 3.4.21 In the days following BZ’s transfer of care to Father there was a flurry of activity: the SWA conducted a home visit the resource panel agreed Families in Need (FIN) service involvement, four weekdays and Saturday and Sunday to increase monitoring and support. A date for the review child protection conference (RCPC) was arranged that was in line with usual timescales. There was no discussion regarding the need to bring forward the dates for this conference. Financial and housing issues become apparent. Father attended the citizen’s advice bureau (CAB) with PGM. The CSC SW conducted a home visit the following day and noted Father was accessing appropriate support. BZ was yet to be registered with a GP. Father declined carer support, as he was staying with PGM and too busy. CSC re-referred for family group conferencing (FGC) as an earlier referral had not been progressed; FGC open case. Mother remained unwell in hospital. Father indicated he did not think it would be beneficial for MGM to be involved as she had her own issues so invites to FGC went to PGM and PA. Mother was noted to be verbally aggressive to Father over the phone. Mother was found to have an infected Caesarean wound four weeks post-delivery. The core group was cancelled leading to a five day delay. 3.4.22 During these first days, there were some positive visits to BZ and Father. PGM was supporting both Father and BZ, PGM was police checked to allow PGM to have BZ overnight. 3.4.23 The HV had a failed access visit. The core group took place, the HV was unaware of this meeting and had not been invited, the only record of the core group is by the FIN worker and CC engagement worker and no minutes exist for this meeting. BSCB Child BZ SCR FINAL 24 Practitioners recalled there was discussion within core groups regarding Father’s coercive behaviours. 3.4.24 In the ten days prior to BZ’s admission FIN visited regularly; there were no concerns regarding Father’s parenting of BZ. The Health Visitor conducted a home visit. Father was interacting well with BZ although a little nervous. BZ’s birth had not yet been registered. During the visit Father asked the HV what he should do if he was worried about something; he raised concerns about identifying bruising in babies and what to do if he was worried about something. Father shared the events of sibling. This provided the HV with an opportunity to discuss the foundation for Father’s concerns at that time; Father related this to his supervising Mother with BZ. It could be speculated that this might be Father indicating he was struggling. 3.4.25 The HV attempted, but was unable to, discuss this with the SW until the RCPC, 36 hours before the incident and Child BZ’s admittance to hospital. 3.4.26 FIN continued their visits, Father was offered and accepted a Carer assessment, MGM was also offered a Carer assessment, but declined it. The plan was that both MGM and Father would be carers for Mother on discharge. 3.4.27 Mother’s MH started to improve and she became an informal patient; there were plans to move her closer to home and register BZ’s birth. There remained some incidents of aggression. 3.4.28 LCFT completed a risk assessment, there was no suggestion that the relationship between Mother and Father was abusive/ problematic; there was no account of colleagues concerns about Father’s coercive behaviours. 3.4.29 At this time Father was trying to address the fact he had not received electric and gas payment. Father also rang EDT to ask if, PGM could look after BZ overnight, which was agreed. 3.4.30 FIN conduct a visit during which Father became hostile; as he did not wish to discuss Mother. This was the first evidence of hostility witnessed since the birth of BZ. This was not shared or challenged at RCPC. 3.4.31 The CP conference chair and SW discussed progression of the plan however risk was discussed in terms of Mother, but not Father. 3.4.32 Father appears to be starting to disengage with a no access visit for FIN, the Carer assessment worker and the Complex Care and Treatment Team (CCTT) support worker. It should be noted that there is no evidence of joint visiting as there had been pre-birth, this might have assisted Father. 3.4.33 Escorted leave visit for Mother was facilitated in order to register the birth of BZ; Mother fed and changed BZ. 3.4.34 Mother was transferred nearer to home; Father and BZ visit until 2300 hours. This was discussed with EDT. 3.4.35 All professionals except the GP, who was not invited, attended the RCPC. Father was challenged about his conversation with the HV; he gave the same explanation. There was no mention of Father’s hostility to the FIN worker, or the late night visiting, and the focus of the meeting moved to Mother and the safety of Mother going home. BSCB Child BZ SCR FINAL 25 The IRO indicated she would have been concerned if legal advice and senior management advice had not been sought prior to the ICPC. 3.4.36 Discussion at RCPC included whether Father was able to care for both Mother and BZ and it was felt that it was less onerous whilst Mother remained in hospital. What was never explored was the impact on Father of the couple’s exchanges during visits and in between visits over the telephone. Mother had been noted to be verbally aggressive towards Father and make multiple telephone contacts to Father. Finding: Assessing the likely positive and negative impact of the relationship of parents on children needs to be constantly updated in cases where one or both parents are experiencing fluctuating mental health problems and changes in their levels of aggression. Recommendation 13: The BSCB to seek assurance from CSC and adult mental health services that analysis of the effects of parents’ behaviours on their children, forms part of assessments and is evident within CP plans. 3.4.37 There was recognition Father needed to make some lifestyle changes in order to meet BZ’s needs, as Father was nocturnal in his habits and reliant on energy drinks. What was not fully considered was whether Father was willing or able to make those changes nor how his lifestyle might be adversely affecting BZ. 3.4.38 All practitioners agreed that at the end of the conference they knew what was happening and who had responsibility for each part of the plan. 3.4.39 Physical abuse was added to categories of harm in view of Mother’s aggression. The plan was for FIN input to decrease; the rationale being there had been no concerns regarding Father’s care and he was supported by his extended family. What was also not fully explored was whether Father was finding it easier or harder to care for BZ as time was progressing, nor the extent of the support Father was receiving from his family in order to be able to care effectively for BZ. Witness statements indicate Father was receiving extensive support from his extended family to an extent that he was only partially caring for BZ. The lead reviewer believes that had this been fully explored the decision to reduce FIN input would not have been made. Not all invitees received minutes. 3.4.40 As a consequence of a deterioration in Mother’s mental health, her behaviour deteriorated post transfer. She became hostile to staff and was on the phone to Father much of the time. Family requested a planned visit, the evening before BZ was admitted, went ahead. The visit took place in two parts as Mother left part way through. 3.4.41 Unbeknown to the professionals PGM was going to care for BZ that night, however as PGM was unwell, BZ remained in Father’s care. High levels of support by Father’s family potentially masked that Father was struggling to care for BZ. 3.4.42 The next day in the early hours of the morning there was a 999 call as BZ was unresponsive and not breathing. Father had called his sister to go around prior to making the call. Father was noted to have an injury to his hand – he indicated he had punched a wall. Police launched an investigation and Father was arrested on suspicion of Assault and Child Neglect. Father stated BZ had been unwell for two BSCB Child BZ SCR FINAL 26 days; there was no mention of this to any professionals who had contact in that time. BZ was admitted to hospital at 04.16 BZ’s injuries were found to be consistent with abusive head trauma. A strategy meeting was held same day, which considered the impact on Mother. BZ was ventilated and tests commenced to ascertain if BZ’s injuries were incompatible with life. 3.4.43 BZ’s ventilator support was removed two days later and within twenty minutes BZ passed away; both parents were present. The cause of death was Acute Traumatic Brain Injury due to abusive head trauma. Father was charged with murder. BSCB Child BZ SCR FINAL 27 4 CONCLUSION 4.1.1 The death of any child is a tragedy, but the death of a child, well-known to professionals brings with it questions that warrant scrutiny so lessons that can be learned. In this case, there is evidence of some extremely good practice; of particular note is the effective joint working between midwifery and mental health services during mother’s pregnancy. There are five key areas of learning for the BSCB and its partners. 4.1.2 The first pertains to historical information and understanding its importance and relevance to on-going work. This case highlights the importance of accurately interpreting historical child protection information so it can be used to plan actions to safeguard unborn and new-born babies. Insufficient credence is currently being paid to historic information to complete informed risk assessments. 4.1.3 The second and of greatest importance, pertains to the practice of waiting until mothers are 30 weeks pregnant before a multi-agency approach is adopted in cases that meet the threshold for child protection. In complex cases, such as this, this means time that could be being used to request information, commence assessing parent’s abilities to care for a child safely and establish working relationships with families, is being lost. The lack of activity within CSC following referral of mother’s pregnancy with BZ, until a few weeks prior to the birth, meant assessments were not complete and decisions were being made on partial information. The decision to place BZ at home with Father was made before full information had been obtained on the injury to sibling. Father’s parenting assessment was overly optimistic given what was knowable about domestic abuse, the injury sustained by sibling, cannabis use and his own depression and lifestyle. The lead reviewer believes this practice is leaving unborn babies and new-born babies at unnecessary risk. 4.1.4 The third pertains to when there are significant changes to a child’s circumstances whilst they are on a CP plan. Decisions are being taken outside of the child protection arena, without core group members’ knowledge. The plan was for BZ to go home with Mother and Father, however when Mother agreed, post birth of BZ, to go to the Mother and Baby Unit much of the CP plan became null and void. The core group needed to come back together and revisit the plan. 4.1.5 The fourth element is around assessment of risk. Not all the information required to make a full and effective assessment of the risks to BZ was either recognised or available for all professionals. Significant information regarding parents’ behaviours, including domestic abuse and cannabis use were not routinely explored or shared, incidents of hostility to professionals were not seen as sufficiently concerning so as to be discussed at review conference. As a result, Father was viewed as someone who presented less of a risk to BZ than Mother; this may have been correct however, less risk is not the same as no risk. In short, indicators of the toxic trio were present in this case, but this was not recognised within conferences and plans. 4.1.6 Of significance in the later stages of the review period is the fifth element, managerial oversight and escalation. Whilst managerial oversight occurred in the early stage of assessment, at the pre-birth conference and in the third trimester of pregnancy, there was a lack of managerial oversight post birth. In addition, there is a lack of evidence that the case was discussed in supervision following BZ’s birth. BSCB Child BZ SCR FINAL 28 Appendix 1 Lines of enquiry 1. How was the historical information used? Did the 2003 incident involving Father unduly influence decisions/ actions taken? 2. Were practitioners aware of Mother’s mental health condition and her non-recognition of her illness when in decline? 3. Was there any pre-birth planning and was the expectations of the parents discussed? 4. What were the dynamics of the relationship between MGM and Father? 5. Was Father’s controlling and coercive behaviour explored? 6. Was there any evidence that Father suffered from mental health issues? 7. What risks to Child BZ were identified by agencies and did this change over time? 8. Were parenting assessments for both Mother and Father considered? 9. What was the non-specialist mental health practitioners’ level of understanding of Mother’s mental health and what impact did the different recording of her diagnosis have? 10. At the Strategy Discussion on 2 December 2016, who was involved, what was the purpose and what was the process? 11. How did the strategy discussion interface with the child and family assessment and initial child protection conference? 12. How was information from the incident in which Mother attended the Delivery Suite on 17 December 2016 shared? 13. Were the housing and debt issues identified in December 2016/ January 2017 new or had they previously been missed? 14. Did the core groups act as a forum for emerging issues, or were these addressed in different forums? 15. How was the decision to place Child BZ in Father’s care made and was Father living with PGM part of this? 16. What was known about the family’s financial circumstances and carers status? 17. Was the use of cannabis explored and the associated impact on the home? 18. Was safer sleep advice given and were any questions asked about where Child BZ was sleeping? 19. How were reports that Father was concerned about bruising etc. assessed and acted upon? 20. Were concerns about multi-agency working escalated appropriately? 21. How effective was management oversight (including the sign off of assessments)? |
NC043841 | Death of a 22-month-old baby boy from a serious head injury in November 2010. Mother and father were arrested; father later pleaded guilty to child neglect and received a 15-month custodial sentence. Maternal history of: troubled upbringing; behavioural issues at school; alcohol and drug misuse; depression; housing and debt problems; and one known suicide attempt. Children's services received several referrals in relation to Child Y, including one in 2009, when a nurse practitioner noticed bruising to his cheek and forehead during a routine vaccination visit. The paediatrician who examined Child Y accepted the parents' explanations for his injuries and no further action was taken. Issues identified include: missed opportunities for assessment and insufficient communication and coordination between agencies; impact of emotional and mental ill health on parenting capacity; impact of persistent housing concerns and debt on mother's wellbeing; lack of professional curiosity and challenge; and allegations from mother deflecting agencies' attention away from children. Makes various interagency and single agency recommendations covering health services, children's services and police.
| Title: Serious case review: executive summary of overview report concerning the death of Child Y. LSCB: Oxfordshire Safeguarding Children Board Author: Malcolm Ross Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 1 OXFORD SAFEGUARDING CHILDREN BOARD Serious Case review Executive Summary of Overview Report Concerning the death of Child Y Nov 2013 Introduction Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 2 This Serious Case Review was initiated following the death of a 22 month-old boy on in November 2010. He was admitted to hospital in November 2010 with serious head injuries and died a week later. The father has since been charged with, and pleaded guilty to child neglect. The child’s older half-sister (same mother, different father) is placed with her father. The child’s full sister (same mother and father) is placed in the care of foster parents. Legislation and statutory guidance require Local Safeguarding Children Boards to carry out a Serious Case Review in circumstances in which it appears that a child has died and abuse or neglect is known or suspected to be a factor in the death. After consultation with Ofsted, the Chair of Oxfordshire Safeguarding Children Board (OSCB) decided that a Serious Case Review should be carried out in accordance with statutory guidance and protocols adopted by the Board. A Serious Case Review’s aim is to examine the circumstances of the events leading to a child’s injury or death, and to ascertain whether lessons can be learnt by agencies to make less likely their reoccurrence in other children’s cases. Independent Overview Report The Overview report brings together and analyses the findings of the various reports from agencies and others, and makes recommendations for future action.The Overview report has been written by Independent Author Malcolm Ross. The role of Independent Panel Chair was then taken by Andrea Hickman, who is Independent Chair of the Oxfordshire Safeguarding Children Board. This is an executive summary of the Overview report, which has been compiled by Malcolm Ross in conjunction with the Serious Case Review Panel. It makes three recommendations along with one reminder of practice; these are listed at the end of this summary. Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 3 The Individual Management Review Reports The following agencies had involvement with Child Y and his family, and carried out Individual Management Reviews and produced reports of their involvement with the family: Oxfordshire County Council – Children, Education and Families Directorate (previously Children, Young People and Families) Cherwell District Council Connection Floating Support Thames Valley Police South Central Ambulance Service Oxford University Hospitals NHS Trust (previously Oxford Radcliffe NHS Trust) Oxford Health NHS Foundation Trust (previously Community Health Oxfordshire NHS Trust and Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust ) Oxfordshire Clinical Commissioning Group (previously Oxfordshire PCT) The recommendations in the Individual Management Review reports were accepted and adopted by the agencies that commissioned the reports and supported by the Overview report. Serious Case Review Panel Agencies nominated a Serious Case Review Panel of professionals to carry out the Serious Case Review, discuss the reports and consider the issues that arose. They were; Mr Malcolm Ross, Independent Consultant Mrs Andrea Hickman, Independent Chair of the Panel Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 4 In addition, the other professional members of the Panel were: Deputy Director, Children’s Social Care, Oxfordshire County Council Designated Nurse, NHS Oxfordshire Designated Doctor, NHS Oxfordshire Detective Chief Inspector, Thames Valley Police Head of Legal and Governor Services, Oxfordshire County Council Safeguarding Manager, Oxfordshire County Council Business Manager, Oxfordshire Safeguarding Children Board All meetings of the Panel were conducted in an open, honest and thorough manner; the Review was carried out in accordance with statutory guidance. Purpose, Scope and Terms of Reference The purpose of the Serious Case Review was to identify steps that might be taken to prevent a similar death and in so doing to (a) Establish what lessons should be learned (b) Establish how lessons should be acted upon, and what should change (c) Improve inter agency working to better safeguard children (d) Identify examples of good practice. All agencies carried out Individual Management Reviews and produced reports of their involvement with the family. They each completed a chronology of involvement from February 2005 (first pregnancy of mother) to November 2010. The chronologies outlined when Child Y, the older sibling or the parents had been seen, or when there had been communication relating to each child. The chronologies contained a summary of any observations, actions taken or services offered. Independence The government guidance requires that those conducting agency reviews of services should not have been directly concerned with the child or family, given professional advice on the case, or be the immediate line manager of any practitioners involved. The Overview report author confirms that this requirement was met. Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 5 Family Involvement Government guidance requires that consideration be given to how members of Child Y’s family might be involved in the Review. Both mother and father were arrested by the police shortly after Child Y died and were subject to police bail for a considerable period of time. The father was charged with the offence of neglecting Child Y and received a custodial sentence. The mother has since moved to the Republic of Ireland. They have not been seen by the author or chair of this review - this was a decision made by the Panel based on the family circumstances. Summary of Information The Review considered a summary of background information as set out in the scoping and term of reference: Child Y’s older sibling was born in early 2006. Child Y was born in early 2009 and died in November 2010, aged 22 months. Mother of Child Y had a troubled upbringing. She had behavioural issues at school that led to suspension, and became involved with alcohol and drugs. She became pregnant at the age of 18 and was living with her partner, Father 1, who was aged 21. Child Y’s elder sibling (Child X) was born in early 2006 and the family were seen routinely by the health visitor following the birth. In October 2006 the family moved to another part of the England where the father’s family resided. Health records were requested from this area as part of the SCR process and since none were found it is likely transfer of records did not take place. The 8 month development check and the Edinburgh Post Natal Depression assessment, due at this time, could not be evidenced as having taken place. By February 2007 mother and father had separated and mother returned to Oxfordshire with Child X to the maternal grandmother’s house, which proved to be wholly unsuitable. Later that month, mother reported to her GP that she was having difficulty coping with her work and housing problems. The GP recommended the assistance of a health visitor. Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 6 The Local Housing Officer attempted to assist Mother with alternative accommodation and provided a two-bedroomed tenancy. However she immediately hit financial problems. She reported that she was feeling depressed. At this time mother was 20 years of age and Child X was 15 months old. In September 2007 mother reported that her house had been broken into and property stolen. She blamed her former partner for this, who was arrested and interviewed but no further action was taken due to inconclusive evidence. Mother was in a relationship with a man who was to later become Child Y’s father. During the early hours of New Year’s Day 2008 Police were called to mother’s house as she had taken an overdose and had cut her wrists. She was taken by ambulance to hospital and was seen in the accident and emergency department and referred to the liaison mental health nurse. This practitioner contacted the GP to say that mother had been encouraged to self-refer to the Complex Needs service (within adult mental health) and contact the Citizen’s Advice Bureau regarding her debts. There followed several visits to her GP. Although mother did discuss personal problems with her GP she reported that she was coping well with her child. Problems for mother continued with rent arrears and debt. The new partner (referred to now as father 2) also had debt problems. This was followed by a short period of depression for mother and she received medication from her GP. By May 2008 mother was pregnant by father 2. This put extra strain on the housing situation. In October 2008 mother reported that she was having problems with her ex-partner pestering and harassing her. She contacted the police who looked into the matter and issued her ex-partner with a Harassment Warning Notice preventing him from continuing to approach her. This resulted in no further harassment. In early 2009, Child Y was born. At the Primary birth visit by the health visitor mother reported to feeling well but was concerned about the poor quality of her flat and the possibility of eviction. Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 7 In September 2009 Child Y was taken for a routine vaccination at the GP’s, when a nurse practitioner noticed that he had bruising to his cheek and forehead and a graze on his nose. This was appropriately referred to social care by the practice nurse. Later the same day police and social care visited the family home and persuaded mother and father 2 that Child Y required examination at hospital. Mother and father 2 said that Child Y had fallen asleep with his head against cot bars and he had also been on the floor and banged his head on a metal dividing strip between rooms, causing the facial injuries. The paediatrician who examined the child found their explanation credible and accepted it. The judgement of the paediatrician was not challenged and his decision was made with only an explanation from the parents and without due consideration of all of the facts known to the police, the nurse practitioner and social care. There is no record of a review strategy meeting where all of the facts could have been shared and an informed assessment made about the injuries and the likelihood of abuse or neglect. There was a two month delay before the paediatrician’s report was completed and shared with social care. In June 2010 social care received an anonymous referral reporting that Child Y had developmental delay and possible bruising from falling over. This incident was not recorded properly or investigated fully by social care and only came to light during the period after Child Y’s death. Appropriate disciplinary action has been taken by social care. In November 2010, mother and father 2 took Child Y to the A&E of the local hospital. He was found to have extensive serious injuries to his head which included a fractured skull. He had bruising to his abdomen and his skull which doctors suggested were quite fresh. He was transferred to another hospital where his condition remained critical until he passed away a week later. Explanations given to the doctors and the police from the parents were inconsistent with the injuries caused. Both parents were on police bail for many months while forensic tests were completed on Child Y. Eventually father 2 was charged with the offence of neglect. Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 8 Commentary Each agency submitted a report of their involvement with the child and family, and from those reports the Independent Author identified these areas which necessitate comment: Assessment of mother during the ante-natal period – Child Y’s older sibling Communication between the health visitor and midwife was not evidenced in the review. The health overview report highlights the missed opportunity to complete an ante-natal assessment, but it also reports that current practice is that a formal ante-natal pathway is in place. Had this been in place at the time, additional vulnerability factors for mother, such as periods of abuse from an ex-boyfriend may have been identified. Assessment of emotional and mental health and impact on parenting There is no record of documentation of the Edinburgh Post Natal Score (EPNS) being conducted after the birth of sibling in 2006, either in the new area when mother moved out of Oxfordshire, or on her return to Oxfordshire. There is guidance in place regarding the completion of a depression assessment following birth, and the Community Health Oxford Individual Management report reminds professionals that, ‘When a family moves to another area all practitioners in Community Health should ensure that professionals in the new area are contacted and all outstanding medical issues are pursued in that new area.’ When mother took an overdose and cut her wrists in early 2008 she was taken by ambulance and was treated at the A&E of the local hospital. The significance of this episode in terms of mother’s emotional/ mental health and of the older sibling’s welfare was not fully considered by all agencies and there was no effective information sharing. There was no direct referral from the liaison mental health nurse or the hospital to the health visitor. The health visitor remained unaware of the full information in the Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 9 mental health assessment carried out by the liaison mental health nurse, including a previous abusive relationship mother had suffered from between the ages of 14 and 17 years, her low self-esteem, work problems, and a recent burglary she had been a victim of. Recommendation (1) All agencies to be reminded that when dealing with adults who have identified mental health needs, consideration must be given to the wellbeing and safety of any children and to the potential impact on parenting capacity of the parent/carer, and information is to be shared to prevent a child being at risk of significant harm. Housing There were times when mother was desperate for alternative accommodation. Mother’s concerns and difficulties about housing had persisted between 2005 and 2009, even though she was provided with a two-bedroomed tenancy in 2007. Debt was a constant feature and source of stress. Harassment – Risk assessment and classification In October 2008 there were several alleged incidents of harassment by her ex-partner, the father of the older sibling. On the first occasion the police assessed the risk from the ex-partner as a standard risk. The review of the police action towards this harassment incident was that it should have been dealt with as a full offence of harassment and thereby rendering the ex-partner liable to arrest. Harassment from the ex-partner continued and resulted in him being served with a Harassment Warning Notice, but there is nothing to indicate that the effect these episodes of harassment were having on mother and the children, was ever escalated for consideration by any agency. Lack of professional curiosity and challenge In September 2009, Child Y was taken to his GP’s surgery to see the nurse practitioner for a routine vaccination appointment. It was noticed that the child had Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 10 bruising across his forehead and cheek as well as a graze down his nose. Mother gave the explanation that Child Y had banged his head on the carpet and the bruising to his cheek had been caused by him falling asleep against the side of the cot bars. Child Y was 8 months old. The nurse practitioner was concerned and she raised the issue with a health visitor who confirmed that she should make a referral to social care which she did. Within two hours of the referral a strategy discussion and a joint police and social care visit had taken place to the family home. The officer noted the injuries on a body map and despite reluctance from father 2, the parents were persuaded to take the child to hospital to be seen by a paediatrician. There followed a medical examination by the paediatrician which assessed the injuries to have a plausible explanation. The paediatrician concluded that the injuries were consistent with the explanation given by the parents. The paediatrician did not compare the accounts that had been given by the parents to the police officer, the nurse practitioner and the social worker. There was no review strategy meeting which would have entailed a multi-agency risk assessment and an effective challenge of the paediatrician’s decisions. There was a lack of professional curiosity by those involved, influenced by their perception of the doctor’s seniority and experience. As indicated in the Overview report a new Oxfordshire Safeguarding Children Board guidance introduced in March 2012 now stresses the proper processes to be adopted in these circumstances. Recommendation (2) OSCB to require all agencies involved in Section 47 investigations to jointly review and re-assess new information as it emerges throughout the investigation and have the ability to escalate concerns if necessary. Missed opportunity In June 2010 an anonymous referral was received by social care that Child Y had been seen with developmental delay and possibly bruising from falling over in the Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 11 recent past. The referral was not dealt with in accordance with procedures and the child was not seen. A referral was made to the health visitor and a telephone call was made to mother, but there was no consideration for a full assessment and no written record of a referral. It appears the senior practitioner decided that the allegation did not require further social care assessment but there is no explanation of how he arrived at this conclusion. The Children’s Social Care service reported that at the time there were staffing issues within the department, which may have contributed towards this missed opportunity. The Overview report includes a reminder of practice for the agencies involved to ensure that anonymous referrals are taken as seriously as named referrals. Signed agreement instigated by the police Following the injuries of Child Y, an interagency strategy meeting was held at which the police requested to be informed of any intended communication amongst professionals about the case to ensure that the criminal investigation was not compromised. Those in attendance were asked to sign a document, which was outside of the safeguarding procedures and had unintended consequences. Social care staff members present were prevented from speaking to the parents of Child Y or anyone concerning the case. On examination of the signed document, it is clear that any restriction related to speaking about the events surrounding Child Y’s death and not about generic care, support and other child protection issues. However the police’s actions led to an unacceptable delay on the social worker’s assessment of the protection and care of Child Y’s sibling and a missed opportunity to follow up on an overheard remark by a friend of father 2 that could have contained incriminating evidence. The Independent Overview author has made the final generic recommendation: Recommendation (3) ‘The OSCB should ensure that a monitoring framework is in place to evidence and report on the progress of to the implementation of the recommendations Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 12 in this report; to monitor how Board agencies will evidence the impact of lessons learned from this Serious Case Review’ Finally, the Overview Report includes some history of the mother making allegations and complaints which had the effect of deflecting professional’s focus from Child Y. Mention has been made in previous OSCB Serious Case Review Recommendations about dealing with parents who attempt to deflect attention away from the child(ren) which creates a risk of professionals losing sight of the child in the centre of the review. Identified areas of good practice The Independent Overview author recognised areas of good practice, namely the local Housing Authority assisting the mother to re-locate and to have improvements to her accommodation; Citizen’s Advice Bureau and Floating Support assisting mother with her financial worries and tenancy issues. And finally in September 2009 the nurse practitioner appropriately referred Child Y to social care about her concerns regarding the bruising to Child Y. Social care instigated promptly a Section 47 joint investigation and used considerable skill to ensure Child Y was taken to hospital for a medical examination. Conclusions This is a tragic case of a 22 month old child dying from the most serious and horrific injuries. The mother was a vulnerable woman who suffered from harassment, had financial issues, and had at one time felt so low as to attempt suicide. Not all agencies were aware of all of these issues and as a result the impact on her capacity to parent her two young children, in conjunction with the father of the younger child, was not fully understood or used to lever in additional support. There are common problems with this case in that communication and coordination between agencies could have been improved. This learning is reflected in the Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 13 thematic report published by Ofsted in 20111 on lessons from serious case reviews’. The main messages are the importance of: carrying out assessments effectively ensuring that the necessary action takes place using all sources of information valuing challenge, supervision and scrutiny implementing effective multi-agency working focusing on good practice This review has identified the following: Carrying out assessments effectively: Quality of assessments Identifying the vulnerability of a mother with two children. She had previously attempted suicide and was struggling to cope with her own life, including financial, housing and harassment problems from her ex-partner. Carrying out assessments effectively: Missed opportunities Mother’s self-harming episode was a missed opportunity for a more coordinated response and improved information sharing between services, and for the welfare of the older sibling to be considered at the point of the emergency ambulance call out and subsequent A&E attendance. There was no assessment of the difficulties or strengths brought to the family by Child Y’s father. Carrying out assessments effectively: Keeping the focus on the child Mother had a history of making allegations and complaints which had the effect of deflecting professionals’ focus from Child Y. Using all sources of information: Thinking outside the box 1 26 October 2011 Ofsted published a thematic report covering evaluations of 482 Serious Case Reviews carried out between by the inspection agency in England between 2007 and 2011 ‘Ages of concern: learning lessons from serious case reviews’ Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 14 There was a lack of ‘thinking outside the box’ and of taking the wider picture into account. There was an opportunity for professionals to assess more fully the impact of mother’s previous history, relationship difficulties, housing, finance problems and emotional health on her parenting of the older sibling. This lack of a holistic view meant that there were missed opportunities to provide additional support to Mother, to both Mother and Father 2 together or to the children through early help services. Ensuring that all necessary actions take place. In September 2009, there was a failure to hold a review strategy meeting, undertake a multi-agency risk assessment and take protective action of Child Y. Valuing challenge: A lack of professional curiosity. In September 2009 there was a lack of professional curiosity by those involved in the assessment of injuries to Child Y. The paediatrician assessed the injuries to have a plausible explanation. The paediatrician did not compare the accounts that had been given by the parents to the police officer, the nurse practitioner and the social worker. There was no effective challenge of the paediatrician’s decision. Implementing effective multi agency working. The signed agreement instigated by the police was outside Oxfordshire Inter-agency Safeguarding Procedures. The actions of the police in this case deviated from the usual procedures of the Child Abuse Investigation Unit and affected the smooth implementation of the joint working following Child Y’s final injuries. If interagency enquiries and assessments had been more thorough at an earlier stage of family life when problems were first emerging it is likely that practice would have provided effective preventative support to Mother. Similarly if judgments had been more soundly reached and plans reviewed Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 15 against objectives it is likely that interagency arrangements and processes could have better fulfilled their purposes. In conclusion, taking all of the circumstances into account and looking at the whole history as presented by the IMRs of the agencies involved, whilst there are issues of concern, there is nothing to indicate that at any time either of the children should have been removed from their family. There were occasions however when Child Y should have been the subject of a multi-agency strategy meeting when bruising was seen or developmental delay reported. ’ If the inter-agency safeguarding procedures in existence at the time had been followed after the first incident, it may have led to the child being placed on a child protection plan, which in turn, may have prevented the death of Child Y. The cause of Child Y’s injuries remains clouded with suspicion despite what the father has said. The fatal injuries suffered by Child Y were most likely to have been caused by trauma and more than likely intentionally caused; however the criminal investigation could not obtain sufficient criminal evidence for a prosecution other than that of neglect. At a ‘Finding of Fact’ hearing it was found that father was the most likely perpetrator of the injuries as the Judge did not believe the father’s given reasons for the injuries to be a truthful account. In May 2013 the father was prosecuted for a criminal charge of child neglect to which he pleaded guilty and received a fifteen month custodial sentence. Oxford Safeguarding Children Board, Final update to the report Nov 2013 Oxfordshire Safeguarding Children Board – Serious Case Review – Child Y 16 Recommendation (1) All agencies to be reminded that when dealing with adults who have identified mental health needs, consideration must be given to the wellbeing and safety of any children and to the potential impact on parenting capacity of the parent/carer, and information is to be shared to prevent a child being at risk of significant harm. Recommendation (2) OSCB to require all agencies involved in Section 47 investigations to jointly review and re-assess new information as it emerges throughout the investigation and have the ability to escalate concerns if necessary. Recommendation (3) The OSCB should ensure that a monitoring framework is in place to evidence and report on the progress of to the implementation of the recommendations in this report; to monitor how Board agencies will evidence the impact of lessons learned from this Serious Case Review. Reminder of Practice Children’s Social Care to be reminded of the importance of recording details of anonymous referrals in accordance with existing procedures and ensuring the child is seen. |
NC046623 | Injuries to a 3.5-year-old (A) sustained between February and August 2014. Child A and Child B were subject to child protection plans at the time, under the category of neglect. Charges of neglect and physical assault against mother and maternal grandmother were dropped. A and her 2.5-year-old sibling were placed in foster care. Children were living with their mother and grandmother, who was also known to authorities as she was caring for mother's sister's child. Mother was widowed and suffering from depression. Concerns around neglect included missed medical appointments and a dirty home environment. Issues discussed include a tendency to focus on the parent's perspective and not from the child's experience, leading to children at risk of neglect being seen as at less immediate risk than other forms of abuse; a pattern of telephone strategy discussions which excluded health professionals; confusion around reporting arrangements when an allocated social worker is unavailable; and confusion amongst partner agencies following a children's services reorganisation. Uses the Social Care Institute for Excellence (SCIE) Learning Together model to highlight issues for consideration by the safeguarding children board and partner agencies.
| Title: Serious case review: regarding Children A and B: overview report. LSCB: Shropshire Safeguarding Children Board Author: Fiona Johnson, Claire Porter, Lisa Charles Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Shropshire Safeguarding Children Board Report of the Serious Case Review Regarding Children A & B Authors: Fiona Johnson, Claire Porter, Lisa Charles 2 Index Title Page 1.1 Why this case was chosen to be reviewed 3 1.2 Succinct summary of case 3 1.3 Family composition 3 1.4 Time frame 3 1.5 Organisational learning and improvement 3 2.1 Methodology 4 2.2 Reviewing expertise and independence 5 2.3 Acronyms and terminology 5 2.4 Methodological comment and limitations 5 2.4.2 Participation of professionals 5 2.4.3 Perspectives of the parents 5 2.5 Structure of report 5 3 Professional practice appraisal 7 4 The Findings 13 4.1 Introduction 13 4.2 What light has this case review shed on the reliability of our systems to keep children safe? 13 4.3 Summary of findings 14 4.4 Findings in detail 15 6 Conclusion 33 Appendix 1: The SCR Process in detail 34 Appendix 2: Glossary 40 Appendix 3: Bibliography 41 3 1 Introduction 1.1 Why this case was chosen to be reviewed The Shropshire Local Safeguarding Children Board determined to conduct a Serious Case Review (SCR) because the circumstances of this case met the following criteria: (a) abuse or neglect of a child is known or suspected; and (b) (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. (Working Together to Safeguard Children, 2015:75)1 1.2 Summary of case 1.2.1 This review concerns the services provided by Shropshire agencies, over a period of six months, to two children who were cared for by their widowed mother who had recently returned to live in Shropshire. The children were the subject of ‘child protection plans’2 because of her neglectful parenting. During the review period the older child experienced two separate injuries. The investigations into these injuries were problematic and there were delays and insufficient follow-up on concerns. The second investigation resulted in the children becoming accommodated and care proceedings were instigated. The children are currently in foster-care and will not be returning to live with their mother. 1.3 Family composition Family member Age during review period Child A 3½ years Child B 2½ years Mother 33 years Father deceased Maternal Grandmother 63 Maternal step Grandfather 64 Aunt 25 Cousin 10 1.4 Timeframe The review period is from 18th February 2014, when the family first moved back to Shropshire until 5th August 2014 when the children were placed in foster-care. 1.5 Organisational learning and improvement Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews states that: ‘Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and 1 Working Together 2015 https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 2 Where there are concerns about the well-being of a child an initial child protection conference brings together family members (and the child where appropriate), with the supporters, advocates and professionals most involved with the child and family, to make decisions about the child’s future safety, health and development it is the responsibility of all involved agencies To plan how best to safeguard and promote the welfare of the child. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 4 why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children.’ (Working Together 2015:72) and ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.’ (Working Together 2015:73) Shropshire Local Safeguarding Children Board (LSCB) identified that a review of this case held the potential to shed light on particular areas of practice including addressing the following questions: How effective is agency input and involvement in the child protection planning process? How effective are professionals at recognising and responding to non-accidental injuries to children? Once the review was started and it became apparent that neglect was a key feature it was also agreed that the review would explore the extent to which the SSCB Neglect Strategy had impacted on frontline practice. 2. Methodology 2.1 Statutory guidance requires reviews to be conducted in such in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. (Working Together 2015: 74) It is also required that the following principles should be applied by LSCBs and their partner organisations to all reviews: there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process (Working Together 2015: 72-73) In order to comply with these requirements the Shropshire LSCB has used a review methodology based on the SCIE Learning Together systems model (Fish, Munro & 5 Bairstow 2010). Detail of what this has entailed is contained in the Appendix 1 of this report. 2.2 Reviewing expertise and independence The review has been led by Fiona Johnson, an independent social work consultant accredited to carry out SCIE reviews with extensive experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework; and, Claire Porter and Lisa Charles, who are employed by Shropshire Council and are also SCIE accredited. All reviewers have had no significant previous direct involvement with the case under review. 2.3 Acronyms used and terminology explained Statutory guidance requires that SCR reports be written in plain English and in a way that can be easily understood by professionals and the public alike (Working Together 2015: 79) Writing for multiple audiences is always challenging. Throughout the report footnotes are provided to explain relevant aspects of professional practice. In the Appendix 2 we provide a section on terminology which aims to support readers who are not familiar with the processes and language of the safeguarding and child protection work. Shropshire LSCB is keen to improve the accessibility of SCR reports and welcomes feedback and suggestions for how this might be improved. 2.4 Methodological comment and limitations 2.4.1 This review was undertaken using the SCIE methodology but did not have supervision from SCIE and is therefore not a SCIE review. A key aspect of the methodology is the direct involvement of the frontline professionals who knew the family in the review process, assisting in developing the findings from the review. For more information regarding the methodology see appendix 1. 2.4.2 Participation of professionals The lead reviewers and the review team have been impressed throughout by the professionalism, knowledge and experience that the case group (the professionals involved with the family, from all agencies) have contributed to the review; and their capacity to reflect on their own work so openly and thoughtfully in the review process. This has given the review team a deeper and richer understanding of what happened with this family and within the safeguarding network and why, and has allowed us to capture the learning that is presented in this report. There were two groups of professionals who were less involved in the review process. The hospital staff could not attend any of the case group meetings however review team members did meet with them at the hospital and gained their perspective. Similarly there was limited involvement by the GPs and practice staff. As their involvement in this case was greater than the hospital staff this was felt by the review team to be a significant limitation. The review team was very pleased that the Practice Nurse was able to attend the second case group meeting and found her input to the review process of assistance in developing the findings further. 2.4.3 Perspectives of the family The lead reviewers wished to involve the mother and grandmother in the review but this was not possible. The mother was invited to contribute on a number of occasions both by direct contact and via her solicitor. Most of these invitations were ignored and the only response was asking for a visit on the same day which was not possible as none of the reviewers were available. Since then the review team has received no response from the mother. This was regretted by the review team who wished to better understand what might have assisted the mother further in her care of the children. 6 2.5 Structure of the report Section 1 of the report provides background information and Section 2 describes the methodology used to undertake the review. Section 3 is an overview of ‘what’ happened in this case and ‘why’ - providing an appraisal of professional practice and including the review team’s judgements about the timeliness and effectiveness of interventions. This leads on to Section 4 which is a presentation of the priority findings about what needs to happen in the multi-agency safeguarding system to reduce the risks of recurrence. Each finding concludes with some key questions for LSCB member agencies. It is the responsibility of the LSCB to decide how best to respond to the findings, with the aim or reducing the recurrence of poor practice. The questions are intended to support their considerations. Appendix 1 provides more detail about the methodology used in the review, Appendix 2 is a glossary of terms and abbreviations used in the report and Appendix 3 is a bibliography. 7 3. Professional practice appraisal 3.1. This section provides an overview of ‘what’ happened in this case and ‘why’. The purpose of this section is to provide an appraisal of the practice that is specific to the case and it therefore includes the review team’s judgements about the timeliness and effectiveness of practice including where practice was below expected standards. Such judgments are made in the light of what was known and was knowable at that point in time. 3.1.2 For some aspects of the case the explanation for ‘why’ will be further examined in the findings in section 4 and a cross reference will be provided that is highlighted in bold. There are also other issues that are underlined and italicised which the review team agreed were aspects of practice in which the LSCB might have an interest but were not prioritised to be findings. 3.1.3 The time period for the review is from 18th February 2014, when the family first moved back to Shropshire until 5th August 2014 when the children were placed in foster-care. This review has been undertaken because of concerns about the agency response to the injuries experienced by Child A whilst she was the subject of a child protection plan. These concerns focussed both on the joint agency investigation of the injuries and the multi-agency work in support of the child protection plan. 3.2 Initial Contact 3.2.1 The first significant agency contact with the family was when there was a ‘transfer-in’ review child protection conference3 to consider whether the child protection plan needed to be continued following mother’s move from Wales to Shropshire. This meeting was challenging because mother was distressed and still grieving the death of her husband. It was however, chaired effectively and was attended by the relevant agencies. The decision reached was that the child protection plan should continue and the main focus of concern was seen as mother’s neglectful parenting in particular that the home she provided for the children had been dirty and that she had not taken the children to medical appointments. This behaviour was considered in the context of mother’s depression following the death of her husband and it was identified that she should be provided with additional support to help her care for the children more effectively. At the conference it was noted that mother would be staying with the maternal grandmother who was known to most agencies because she was caring for mother’s sister’s child. This information was not provided to professionals attending the conference prior to the meeting which meant they were not able to check their records for details of their contact with the wider family. This was relevant as although maternal grandmother was generally viewed by conference participants as a support for mother, all agencies had historic information that could have provided a fuller context about the wider family dynamic. 3.3 Fractured Clavicle 3.3.1 Within three weeks of the child protection conference mother took Child A to the GP concerned that she was in pain. The GP examined the child and could not identify any concern so told mother to give her some Calpol. The next day mother contacted the out of hours GP because she remained concerned and was advised to return to her own GP the next day. She did so but the GP remained unable to find a cause for the pain and so arranged for the child to be seen that day at the local hospital for an expert opinion. The GP did not check with mother whether she was able to take the child to the hospital 3 When a child and family have moved permanently to another local authority area. In such cases, the receiving local authority should convene a child protection conference within 15 working days of being notified of the move. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 8 which was some distance from mother’s home address. Mother did not take the child to the hospital and later that evening hospital staff contacted the Emergency Duty Team (EDT) because they were concerned that a child with an injury who was the subject of a child protection plan had failed to attend an arranged appointment. This was an alert response by the hospital and is to be commended. 3.3.2 The Emergency Duty worker was unable to visit mother because there is only one worker covering Shropshire in the evening during the week and, although they have access to on-call cover workers, they chose not to use this resource. Instead they contacted the Police and asked if they could visit. There are known issues about the EDT which are being reviewed by the Local Authority, the LSCB may wish to consider the outcome of this review at some point. The police sent a uniformed officer to visit and he met with mother who explained that she had not been able to take the child to hospital because she had not been able to arrange a lift and could not afford public transport. The police officer saw the children, who were both asleep but seemed settled and well, and advised mother to await contact from her social worker the next day. The police officer then advised EDT of his actions. This was good practice by the police officer. The review panel was impressed by this co-operative work by the police service, although it is accepted that it would not be usual practice for the police to conduct the check. The EDT worker, in accordance with local practice, made a record on the case file and alerted the social worker by email that there had been activity overnight. 3.3.3 There is no record as to whether this email was received however the social worker (who no longer works for Shropshire Council) made no contact with mother the next day. Instead the day after a member of the family rang the GP and asked if the child should still be taken to the hospital and was told to take the child to casualty. It is noteworthy that there was no contact with the GP about the missed appointment and at the time of the review the GP was still unaware that mother had not taken the child immediately to hospital. Child A was seen in hospital and was found to have a fractured clavicle (broken collar-bone). The medical staff were surprised that mother could not provide an explanation for the injury which would have required significant force and were also concerned about her delay in bringing the child to hospital and so contacted the social work team asking for a section 47 assessment.4 This was in accordance with local procedures and professional practice. The social work manager decided to send a senior social worker to the hospital, with the allocated worker, because she was inexperienced in child protection investigations, this was good practice. The manager did not contact the police or formally initiate a child protection investigation via a ‘strategy discussion’5 and as this worker has left the council it was not possible to fully ascertain her reasons. The senior social worker understood that there had been a telephone ‘strategy discussion’ and that it had been agreed that the social work team would undertake single-agency inquiries. The role of ‘strategy discussions’ in Shropshire and their effectiveness is discussed further in Finding 1. 3.3.4 The social workers attended the hospital and were present when Child A had a child protection medical. Maternal grandmother was also present (having brought Child B to mother at the hospital) and suggested that the injury could have been caused playing on the swing. Hospital staff were concerned that the explanations being given by the mother did not adequately explain the injury. They were not clear if the injury was accidental or non-accidental, but were concerned at the lack of proper explanation and 4 A section 47 enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 5 A ‘strategy discussion’ is a process to determine the child’s welfare and plan rapid future action whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. As a minimum it should involve professionals from Children’s Social Care, Health and Police and may be a telephone conversation or a meeting. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 9 agreed that Child A should return home with mother. The senior social worker’s explanation for this decision is that they did not consider that the medical staff were clear in their view in terms of definitely saying that the injury was or likely to be non-accidental and considered it was probably a result of mother being neglectful and that this meant she would not harm Child A. They were also concerned that it was getting late and felt that the children needed to go to bed. The perception that neglectful parenting is less risky for children than other forms of abuse is examined further in finding 2. The medical staff considered that by advising the social workers of the injury they had fulfilled their responsibilities and that the social workers were therefore responsible for any further decision-making. There was no consultation with the manager about this decision as the decision-making responsibility was delegated to the senior social worker. 3.3.5 Early the next day the maternal grandmother contacted the social worker saying that the explanation for the injury was not right. She discussed this with her manager who telephoned the police and agreed that there should be a joint visit by police and social workers later that morning. The social work manager did not record this conversation as a ‘strategy discussion’ 6 or start a section 47 inquiry however the police officer did record it as a ‘strategy discussion’. The issue of recording of ‘strategy discussions’ is considered later in finding 3. 3.3.6 The social workers and a police officer attempted a visit to mother who was unavailable as she had taken Child A to a follow-up appointment at the hospital. They then visited maternal grandmother who suggested that the injury to Child A had been caused when a heavy curtain pole had fallen on the child the previous weekend. The social worker and the police then went to the local GP and discussed with them mother’s presentation at the surgery and confirmed that she had voluntarily taken Child A twice to the surgery because of she was concerned that she was in pain. When mother returned from the hospital they visited the family home. Mother explained that while she was on the lavatory Child A climbed up the curtain and pulled the pole away from the wall. She said that she did not see it happen but that she found Child A and the curtain pole on the floor. The social workers and the police officer considered that mother’s explanation was credible and jointly agreed that the paediatrician should be informed of the outcome of their visit and consulted about whether the injuries could have been caused in the manner described by mother. This joint visit by the police and social workers was thorough and comprehensive, in accordance with procedures and best practice. 3.3.7 Following this visit there was no further inter-agency discussion of this injury until the review child protection conference in May. Neither the social workers nor the police contacted the paediatricians and provided them with the alternate explanation for the injury. There was no follow-up strategy discussion meeting involving health professionals. The role and function of ‘strategy discussions’ within Shropshire is considered further in finding 1. The paediatrician’s report of the child protection medical was not received by the social worker until mid-May, despite it having been written in March, this is thought to be an administrative failure as a copy of the report was received by the named nurse within the hospital. This was a known problem at this time but the case group confirmed that following changes in the hospital administrative systems this has now improved. It was not clear why the allocated social worker did not contact the paediatrician and discuss the outcome of the joint visit. The senior social worker advised her to do so but did not take any responsibility for ensuring that this had happened. This was because he had moved to another job as a result of the 6 Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a ‘strategy discussion’ involving local authority children’s social care https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 10 reorganisation of Children’s Services and also he understood that this was a task for the social worker’s manager. It is clear that at this time there was a lack of clarity about the responsibilities of senior social workers and that this could have led to confusion. Since then the role has been reviewed and clearer guidance provided about relative roles and responsibilities. This role and function of senior social workers is an issue about which the LSCB may wish to receive a report from the Director of Children’s Services. The fractured clavicle was reported to the child protection review conference in May but there was minimal discussion as it was reported as an accident and the only significant issue noted was the delay in taking Child A to hospital. The police investigation into the fractured clavicle was closed at the end of May 2014 when they received a copy of the child protection medical. 3.4 Routine Monitoring 3.4.1 Between April and July 2014 Child A remained the subject of a child protection plan. There was a review conference and three core group meetings but the allocated social worker was only present at one core group meeting. This lack of attendance led to a lack of continuity in case planning and placed pressure on other agencies to provide the continuity of care. The health visitor and family centre worker continued to work with mother around potty training and helping improve Child A’s speech and development. A new social worker became the key worker in early June but was told that it was a temporary allocation pending a permanent worker being identified. With hindsight it is clear that during this period there was drift in child protection planning with limited implementation and oversight of the child protection plan. One reason for this may be that the allocated key worker was temporary and therefore unlikely to be as focussed on the longer term goals. Core Group members were aware of the reorganisation and therefore accepted that this would result in some discontinuity of social workers. The review team were concerned that despite the evident absence of a consistent key worker there was no challenge from other members of the core group nor any attempt to escalate concerns about this situation. The issue of how effective core groups are in challenging and ensuring that there is a good enough service for children is considered further in finding 4. 3.5 Burn to arm 3.5.1 In mid-July Child A came into school (after having had two days off) and was noted by teaching staff to have a mark on the arm that they thought was a burn. This was discussed with mother who was not communicative and could not provide an explanation for the injury. The teaching staff immediately had concerns as they felt that mother’s responses were different from usual (she was normally quite chatty) they also were concerned that Child A had nappy rash and was wearing a nappy that was too small for her. It was the last day of term and they decided that their concerns should be passed to the social worker. They contacted the social work team but the allocated social worker was unavailable so they sent her an email informing her of the mark and that they thought it was a burn and also advising her of the nappy rash and that she had missed two days of school. The school response in identifying the burn and discussing it with mother and then deciding to report the injury to the social worker was exemplary practice and showed a school that had a good understanding of its responsibilities with regards to safeguarding children. The decision to send the social worker an email was more problematic as although it ensured that the information was provided to the key worker there was no guarantee that this information would be accessed immediately. A more appropriate response in the absence of the allocated social worker may have been for them to have contacted the Initial Contact Team (ICT) who could have ensured that their concerns received a speedy response. The local procedure however is for professionals to attempt to contact the allocated worker and if that person is not available speak to their manager and in their absence they would be directed to a local duty worker separate from the ICT. The lack of clarity about actions to be taken 11 when there are concerns about a child and the allocated social worker is absent is discussed further in Finding 5. 3.5.2 The allocated social worker did not view the email until the next day and was unable to immediately respond to the concerns. At this time she was providing cover for her line manager, who was on leave, and was also in court. As a result she arranged for another social worker to visit the family; to see the burn in order to consider whether any further action was needed. There was no discussion with the police about the injury. This social worker visited, by arrangement with the family, the maternal grandmother’s house, early evening on a Friday. When the Social worker saw the mark on Child A’s arm she believed the injury to be a cigarette burn due to its presentation. Mother told her that the injury had been caused by a toy but the social worker did not think that this was a coherent explanation. The social worker advised the mother to take the child to the GP on the Monday but did not arrange for the child to be seen by a medical practitioner that night, this was not good practice. That evening the Social Worker updated the allocated social worker (who was also her manager) of the course of action she had taken and she agreed that the social worker had taken the correct course of action and that she would follow this up on the Monday. The rationale for this decision was linked to a belief by both workers that the mother would not deliberately harm her child and associated with that a perception that because the mother was mainly seen as a neglectful parent she did not pose a risk of significant harm to the child. The influence on professionals of the belief that a neglectful parent does not pose harm to a child is discussed in finding 2. That neither worker considered at any point consulting with the police, via a strategy discussion, about the need for a joint investigation reflects the attitude towards strategy discussions described in Finding 1. 3.5.3 It appears that the social work team at this time was under significant pressure following the social work restructuring, with vacancies and temporary staff, which may have meant that good practice was undermined. There had been a period of significant change within the children’s social work service with all staff having experienced and adapting to changes in teams and roles. The effect of change on staff and the risks this may pose in safeguarding children are discussed further in finding 6. It was also clear that a factor that was influencing the workers was that at this time it was usual practice to make all requests for medicals initially to the GP rather than asking for child protection medicals directly. This practice was partly a result of known difficulties in accessing child protection medicals, which were under-resourced. Social work practice has now changed and child protection medicals will now be directly requested however the service remains under pressure. It is reported that these difficulties are being addressed via a re-commissioning of the child protection medicals service. The LSCB should request a report as to the progress of the re-commissioning of child protection medicals and may wish to audit whether the service has improved. 3.5.4 On the Monday the Social Worker phoned mother to see if she has taken child A to the GP, mother had not, so the social worker again asked her to do so. The social worker phoned mother again on the Tuesday when she confirmed that she had been to the GP and gave a different explanation for the injury saying that Child A had brushed past a cigarette. The social worker tried to arrange a visit over the next two days but mother said she was unavailable. It was not good practice that the social worker did not visit the child at this time or confirm with the GP practice that the child had been seen. It is not known why this did not happen but it is known that at this time the worker was very busy and was covering for the line manager who was on leave. Child A was seen at the GPs surgery on two occasions: first on the Tuesday by the Practice Nurse who dressed the wound and was told by the mother that the injury was not a burn. The Practice Nurse told mother to bring Child A back in a week for the dressing to be changed. The next day Grandmother telephoned the surgery and said that the dressing had fallen off the burn. 12 She was told to bring Child A to the surgery. Child A was seen by the GP and was told by the mother that the burn was caused by Child A brushing against her grandmother’s cigarette when they were in the garden. The GP took a photograph of the injury. Both the GP and Practice Nurse were sceptical about mother’s explanation for the injury but did not feel that mother would deliberately harm her child and that therefore accepted her explanation that the injury was accidental. The reasons for professionals failing to challenge mother are discussed in finding 7 3.5.5 The following Tuesday the social worker rang the GP surgery to check if mother had taken Child A to the surgery, she spoke to the Practice Nurse who confirmed that the child had been seen and told the social worker about mother’s conflicting explanations for the burn. Two days later mother failed to bring Child A in to have the burn dressing changed and the Practice Nurse discussed with the health visitor for Child A’s cousin her concerns about the injury and that mother had failed to bring the child in for the dressing to be changed. The health visitor looked at the photograph of the burn and considered that it was a cigarette burn and that its shape suggested that it was unlikely to have been caused accidentally. The health visitor noted the Practice Nurse’s concerns on Child A’s records and agreed to raise them with the relevant health visitor on her return from leave after the weekend. Whilst it is good practice that the health visitor was available to the Practice Nurse to provide professional support and evidenced good multi-agency working, the review team was concerned that the Practice Nurse did not seem to be aware of the appropriate process for escalating concerns and felt that the health visitor should have advised her to raise the issues with the designated professional within the GP Practice. The difficulties in this service are being addressed with the GP Practice by the CCG and the LSCB may wish to ask for an update report regarding progress. 3.5.6 The following Monday the health visitor attended a meeting about the cousin of Child A and discussed with his social worker the concerns raised by the Practice Nurse the previous week. This social worker agreed to talk with Child A’s social worker when she returned to the office. As a result of this conversation Child A’s social worker phoned the police to request a strategy discussion to plan a joint investigation into the injury almost three weeks after the school had sent her the information about the burn. At this point the social worker spoke to the Development Officer in the Police Harm Assessment Unit (HAU) saying that she felt there was a need to hold a Strategy discussion to plan a Section 47 assessment and investigation. The HAU was newly established and the Development Officer had some difficulties in conducting checks with external forces however it was rapidly agreed that there needed to be a joint investigation. The HAU worker then attempted to contact the Detective Sergeant, who was not immediately available, as she was attending another strategy discussion. The information was however emailed to her, and she responded by agreeing that there should be a joint visit the next day, and passed the information onto a Detective Constable to arrange the visit. This officer was the same one who had been involved in the joint investigation of the fractured clavicle and based on his recollection of that investigation, he proposed that the visit and necessary medical assessment should not be postponed and the visit then took place the same day. It was good that this officer was alert and identified the need to prioritise the visit however the review team was concerned that all the relevant information was not considered as part of a strategy discussion involving the Detective Sergeant. There are deep-rooted issues associated with the understanding of police and social workers about the relative roles of the HAU and the police officers with regards to responsibilities for strategy discussions. These are explore more fully in Findings 1 and 3. 3.5.7 Later that day the social worker and the police visited the family and arranged for Child A to be medically examined. The paediatrician examined the burn and did not feel that it 13 was consistent with the explanation given by the mother that it was caused by brushing against a cigarette. As a result it was decided that the children should not return to mother’s care and they were accommodated on a voluntary basis and placed in foster-care. The next day the mother and maternal grandmother were arrested on suspicion of neglect and child assault. These charges were later dropped, however, care proceedings were initiated with regards to the children and they are now living permanently away from their mother. 14 4 The findings 4.1 Introduction Statutory guidance requires that serious case review reports provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence. Section 3 provides the analysis of what happened and why, whilst section 4 provides the findings about what needs to happen in the multi-agency safeguarding systems to reduce the risks of recurrence. The SCIE Learning Together systems approach uses the learning from an individual case to provide a ‘window on the system’7 into how well the local multi-agency safeguarding systems are operating. 4.2 What light has this case review shed on the reliability of our systems to keep children safe? 4.2.1 This case provided the LSCB with the opportunity to examine how effective professionals in Shropshire are at recognising and responding to non-accidental injuries to children and the strength of agency input and involvement in the child protection planning process. The review has highlighted some difficulties regarding strategy discussions and planning and concluding child protection investigations. It has also shown that professionals working with children who are perceived to be at risk of neglect do not identify the same level of immediate risk as with other forms of abuse. It is also thought that they may be too concerned with the parent’s perspective and therefore fail to focus on the child’s experience. The review has also identified a lack of clarity amongst professionals about referral routes on cases open to children’s social care and a possible lack of assertiveness by core group members. Finally it has also shown the negative effect that organisational change can have on safeguarding systems. 4.2.2 In order to help with identification and prioritisation, the systems model that SCIE has developed includes 6 broad categories of these underlying patterns. The ordering of these in any analysis is not set in stone and will shift according to which is felt to be most fundamental for systemic change:- Innate human biases (cognitive and emotional) Family-professional interaction Responses to incidents Longer term work Tools Management systems There is, of course, overlap between categories. The precise nature of each Finding, expressed in its headline, forms a sub-category within each pattern. 4.2.3 The task in developing each finding is to present a clear example of how the issue manifests itself in the case, and then to: identify in what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case; highlight any information gleaned about how general a problem this is perceived to be locally, or data about its prevalence more widely; be clear about why it matters; and state how the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. 7 C A Vincent Analysis of clinical incidents: a window on the system not a search for root causes Downloaded from http://qualitysafety.bmj.com/ on July 3, 2015 - Published by group.bmj.com 15 4.3 Summary of findings 4.3.1 This section contains 7 priority findings that have emerged from the learning review. The findings explain how professional practice could be improved. It does this by considering patterns that are supportive of good quality work and patterns that introduce or increase risk to the reliability with which we can expect professionals to achieve good quality work. 4.3.2 Each finding also lays out the evidence identified by the review team that indicates that these are not one-off issues. Evidence is provided to show how each finding is indicative of potential risks to other children and families in future cases, because they undermine the reliability with which professionals can do their jobs. Findings for which there is only initial or emerging evidence of prevalence outside this case have been presented as questions. 4.3.3 The review team have prioritised 7 findings for the LSCB to consider listed below: - Finding Category 1 Are strategy discussions in Shropshire seen as a one-off events for social care and police to plan short-term responses rather than an ongoing process involving all agencies for planning and concluding a child protection investigation? Responses to incidents 2 In Shropshire, where a child is seen to be at risk of neglect, professionals find it harder to assess the degree of risk, regardless of the impact on the child, because they do not consider that the harm would have been deliberately caused by the parent. Longer term work 3 In Shropshire the records of telephone strategy discussions are separately recorded by Police and Children’s Social Care meaning that there is no joint record of the decisions reached leading to the possibility of misunderstanding about their content. Human–tool operation 4 Is there a pattern whereby members of core groups don’t understand their responsibilities for ensuring the effectiveness of the child protection plan and delegate responsibility to the social worker? Longer term work 5 In Shropshire agencies are unclear about who to contact when there are urgent concerns on open cases and the allocated social worker is unavailable. Longer term work 6 In Shropshire re-organisations of services by individual agencies are not planned in a multi-agency way, which means that there may be unintended consequences that can lead to confusion amongst partner agencies, resulting in poor accountability and decision making, which ultimately does not safeguard children. Management systems 7 In cases of neglect is there a tendency to assess risk from the parent’s perspective and not to focus on the child’s experience, meaning that neglectful parenting is tolerated? Longer term work 16 4.4 Findings in detail 4.4.1 Finding 1: Are ‘strategy discussions’ in Shropshire seen as a one-off events for social care and police to plan short-term responses rather than an ongoing process involving all agencies for planning and concluding a child protection investigation? (communication and collaboration in response to incidents) Working Together 2015 states that the local authority Children’s Social Care Services should convene a ‘strategy discussion’ to determine the child’s welfare and plan rapid future action whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. This might take the form of a multi-agency meeting or a telephone call. Working Together 2015 recommends that a local authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the ‘strategy discussion’. This case has suggested that the tendency to use brief, telephone ‘strategy discussions’ is precluding involvement of all relevant professionals, as recommended in the guidance. 4.4.2 How did the issue feature in this particular case? During the assessment of Child A when she had the fractured clavicle there was not a ‘strategy discussion’ meeting that involved a local authority social worker and their manager, health professionals and a police representative. There was one brief telephone conversation between the social work manager and the police that resulted in the joint visit to mother but this was only recorded by the police as a ‘strategy discussion’. It is clear that if there had been a follow-up ‘strategy discussion’ meeting following the visit to mother this could have involved the paediatrician and would have enabled a discussion about whether the curtain pole could have caused the injury or not. Such a discussion would also have alerted the other members of the core group to the outcome of this investigation. 4.4.3 How do we know it is an underlying issue and not something unique to this case? Discussion with the review team and case group identified that the most recent Ofsted inspection of Shropshire, in 2012, had identified that there were too few ‘strategy discussion’ meetings and that the use of telephone ‘strategy discussions’ was excluding health professionals. As a result there had been an increase in the proportion of ‘strategy discussion’ meetings as opposed to telephone ‘strategy discussions’. It was acknowledged however that generally ‘strategy discussions’ were initiated at the beginning of assessments/investigations and that it was less usual for there to be review meetings/discussions to confirm the outcomes. Clearly many ‘strategy discussions’ result in child protection conferences however there are a significant number where this does not happen. Prior to April 2014 there was no separate method for recording telephone ‘strategy discussions’ as opposed to ‘strategy discussion’ meetings in Children’s Social Care (CSC). In April 2014 a new form was introduced requiring that they be recorded separately. Analysis of CSC statistics concerning all ‘strategy discussions’ showed that of 891 ‘strategy discussions’, only 67 were reviewed or followed up with a further ‘strategy discussion’. Police recording of ‘strategy discussions’ (telephone and meetings) would indicate that there are more ‘strategy discussions’ in Shropshire than Telford and Wrekin and that this is placing pressure on their resources. As a result the Police Harm Assessment Unit was established to attempt to rationalise and possibly reduce the number of ‘strategy discussions’ being held. 4.4.4 How common and widespread is the pattern? CSC quarterly statistics about ‘strategy discussions’ in Shropshire indicates that there are approximately 200-220 per quarter and that in the first two quarters there were twice as many ‘strategy discussion’ meetings as telephone ‘strategy discussions’. The second 17 two quarters however show that these proportions were changing and by the fourth quarter there were equal numbers of telephone ‘strategy discussion’s as ‘strategy discussion’ meetings. In part this may reflect a decision by the police to try and reduce the time spent by CPU officers in ‘strategy discussion’ meetings and is associated with the change in roles as introduced by the establishment of the HAU. It is relevant to note that of 891 ‘strategy discussions’ held under a quarter 181 resulted in a joint investigation by Police and CSC, 490 resulted in a single agency assessment by CSC and 220, over a quarter, resulted in no action by either agency. CSC records of Strategy Discussions by Type and Quarter (2014/2015) Type Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total 2014/15 Telephone Strategy Discussion 64 80 87 102 333 Strategy Discussion Meeting 137 191 125 105 558 Total 201 271 212 207 891 Police statistics about ‘strategy discussions’ (telephone or meeting) are not available for this period. Discussion with frontline practitioners has indicated that the police may not have recorded all telephone ‘strategy discussions’ with social work staff as ‘strategy discussions’. This is because of a confusion within the police service about who makes a decision about when and whether a ‘strategy discussion’ should be held. 4.4.5 What are the implications for the reliability of the multi-agency child protection system? The lack of involvement of agencies other than police or CSC in ‘strategy discussions’ and in assessments may lead to a gap in understanding of what is known about the needs of a particular child. This is particularly problematic with very young children where often the only agencies to have had significant contact will have been Health. To be effective such information sharing has to be a two-way process so that all professionals fully understand each other’s concerns. Research has shown that effective communication requires an openness to detail, a willingness to engage with referrers and an avoidance of hasty categorisation. The facts are rarely out there simply to be passed on; rather, a case formulation emerges through discussion and interaction.8 The ‘strategy discussion’ meeting is a key opportunity for joint working enabling better planning of the investigation and subsequent work with families. However, brief and/or telephone-based ‘strategy discussions’ may not provide the best environment to effective information processing and decision-making. 8 Ten pitfalls and how to avoid them What research tells us Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln September 2010 www.nspcc.org.uk/inform 18 Finding 1: Are ‘strategy discussions’ in Shropshire seen as a one-off events for social care and police to plan short-term responses rather than an ongoing process involving all agencies for planning and concluding a child protection investigation? This review has identified a pattern whereby the use of telephone ‘strategy discussions’ between CSC and police to plan short term responses rather than longer term planning leads to an absence of multi-agency involvement in investigation and assessment. It raised the question whether the right balance had been achieved focusing on timely investigations and assessments with ensuring the right professionals are contributing effectively to improve the outcomes for children. Considerations for the Board and partner agencies Is the Board confident that there is a common understanding about the purpose and function of ‘strategy discussions’ across all agencies? Does the Board think that resources are a limiting factor for ‘strategy discussion’ meetings? Since the revisions made in Working Together (2013), can the Board be assured that there is an appropriate balance between the focus on timeliness of investigations and assessments with ensuring involvement and engagement with other agencies? Are there technological solutions that can facilitate greater involvement of agencies in telephone ‘strategy discussions’ separate from face to face ‘strategy discussion’ meetings? Does the Board think the MASH will make a difference? Does the Board think there is a need for further clarity about the role of review ‘strategy discussions’? 19 4.5.1 Finding 2: In Shropshire, where a child is seen to be at risk of neglect, professionals find it harder to assess the degree of risk, regardless of the impact on the child, because they do not consider that the harm would have been deliberately caused by the parent. (Communication and collaboration in long term working.) Neglect is a multi-faceted issue, which can include dimensions such as emotional, supervisory and medical neglect, as well as neglect of physical care (Horwath, 2007)9. Neglect is notoriously difficult to define as there are no clear, cross-cultural standards for desirable or minimally adequate child-rearing practices. While neglect generally refers to the absence of parental care and the chronic failure to meet children’s basic needs, defining those needs is not straightforward. Working Together 2015 defines neglect as: ‘the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development.’ It includes in the description ‘a parent or carer failing to provide adequate food, clothing and shelter’ and a failure to ‘ensure access to appropriate medical care or treatment’.10 4.5.2 How did the issue feature in this particular case? Child A was on a child protection plan for neglect and all the professional involved with the family saw this as the major child protection risk. In March 2014 the hospital contacted the allocated social worker because they were concerned about Child A who had been seen at the hospital with a fractured clavicle. The paediatrician did not think that the nature of the injury matched the explanation given by the mother and furthermore was concerned that she had failed to bring Child A to the hospital for an appointment arranged by her GP. The Social Work Manager did not commence a section 47 inquiry but sent two social workers to the hospital to gain further information about the injury. At the hospital the social workers were unable to clarify whether the injury was accidental or non-accidental but considered it to be a neglect issue and so were content for the children to go home. They thought that the injury was possibly accidental and there was probably a lack of supervision as it was not clear who was looking after the children at the time. They did not consider that mother posed a risk to the children and so made the decision that they could go home with mother. The medical staff were not clear if the injury was accidental or non-accidental, but were concerned at the lack of proper explanation, however, as there was no medical need for the child to be admitted to hospital, they also agreed to the child going home with mother. 4.5.3 How do we know it is an underlying issue and not something unique to this case? During individual conversations with case group members a number of them reported that their immediate thinking was that any injury sustained was likely to be due to neglect or lack of supervision, as this was a family where a need for parenting support had been identified. There was a firmly held belief amongst practitioners that mother would not harm her child. Professionals did not seem to recognise at the time that the impact on the child was the same regardless of how the injury had occurred. The child’s lived experience did not seem to be considered and the risk to the child from physical harm and neglect was minimised and downgraded. There were a number of occasions where the threshold for a Section 47 investigation was met but the response from Children’s Social Care was to gather more information before deciding if a strategy meeting/discussion was needed. When social workers were sent to gather more information they were pre-disposed by the ‘label of neglect’ to 9 Horwath, J (2007) Child Neglect: Identification and Assessment, Basingstoke, Hampshire: Palgrave Macmillan 10 Working Together 2013, DfE 20 assume that the injuries were accidental and this affected the outcome of the investigations. As this was the mind-set of a number of practitioners and not something that they recognised as being unique to this case it would suggest that it is an underlying pattern There was no evidence from any members of the case group that they had used the SSCB Neglect Strategy in this case. There was a misunderstanding of the application of the strategy with a number of case group members thinking that it was only to be used to identify neglect in the first instance and that as neglect had already been identified in this case the practitioner toolkit was not viewed as something which could be applied to monitor concerns over time. This would imply that practitioners are not making use of any specific tools to neglect assessment tools or recording their concerns over time in order to consider the history of the family and inform sound decision-making. Therefore this pattern could well apply to all children who are already on a child protection plan for neglect. SSCB undertook a practitioner survey in early 2014 to understand how well the SSCB Neglect Strategy was being used, if it was fit for purpose and if it was helping professionals and families in achieving better outcomes for children and young people. The showed the following: 57% of the 132 practitioners from a range of agencies that completed the survey reported that they had never used the strategy, with 34% of the respondents having only used it 1 to 5 times in the last 12 months. 20% of respondents identified barriers to using the strategy. One of these being not having the confidence to challenge parents - however the majority of practitioners who had used the strategy felt that it had helped to increase their confidence generally in dealing with issues of neglect. Only 22 of the 55 practitioners that had used the strategy made use of the Home & Circumstances Checklist tool. Discussions with the case group also identified that at the time there was limited awareness of the SSCB Neglect Strategy and little understanding of its intended application to assist practitioners in working with neglectful parents over time 4.5.4 How common and widespread is the pattern? Neglect is the most common reason for someone to contact the NSPCC (NSPCC, 2012). Neglect has been described as the "most serious type of child maltreatment and the least understood" (Dubowitz, 1999 p.67). It is the most common reason for a child having a child protection plan in the UK. In the year ending 31 March 2011(or 31 July 2011 in Scotland), 44 per cent of child protection registrations in the UK related to children considered to be at risk of neglect. 11 In March 2014 the rate of children in Shropshire that were on a child protection plan under the category of neglect was 20.9 per 10,000 of the children and young people population, rising to 21.3 by the end of March 2015, (the latter figure equates to 128 children).National research has also highlighted the difficulties professionals face in ascertaining whether certain behaviours constitute neglect (Gardner, 200812; Rees et al. 201113). It is noteworthy that although neglect is a factor in determining many children to be either ‘vulnerable’ or ‘in need’ there is currently limited data collection about this matter. Recent summary research commissioned by the Department for Education identified seven mind-sets that could 11 Neglect NSPCC research briefing August 2012 12 Gardner, R. (2008) Developing an effective response to neglect and emotional harm to children. London: NSPCC 13 Rees, G. et al. (2011) Adolescent neglect: research, policy and practice. London: Jessica Kingsley 21 hamper professional confidence and limit their actions, many of which the review team thought were evident in this case: Fears about being considered judgemental, A focus on the parent rather than the child, Failure to consider the child’s lived experience or understand the child’s world, A fixed view of the family, Parents’ superficial or false compliance, Not my area of expertise, Reluctance to refer. 14 4.5.5 What are the implications for the reliability of the multi-agency child protection system? For children to be effectively protected professionals need to be confident in their understanding of all aspects of neglectful parenting. Over-emphasis on one aspect of neglect will result in a failure to identify children at risk and could result in other risk factors not being fully understood. In Shropshire, where a child is seen to be at risk of neglect, professionals find it harder to assess the degree of risk, regardless of the impact on the child, because they do not consider that the injury would have been deliberately caused by the parent. This review has identified that professionals working with children where neglect has been identified as a risk factor are less likely to identify physical injuries as non-accidental because they explain the injuries as accidents resulting from poor oversight by the parent. Considerations for the Board and partner agencies Does the Board consider that the multi-agency neglect training and strategy has been effective? Does the Board think the current Neglect Toolkit and Strategy are fit for purpose? Does the Board think that training initiatives are an effective way of addressing professional mind-set? Does the Board think that supervision arrangements are sufficiently robust in enabling the child’s experience to be understood? 14 Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report https://www.gov.uk/government/publications/indicators-of-neglect-missed-opportunities 22 4.6.1 Finding 3: In Shropshire the records of telephone strategy discussions are separately recorded by Police and Children’s Social Care meaning that there is no joint record of the decisions reached leading to the possibility of misunderstanding about their content. (Patterns in human–tool operation) Working Together 2015 states that the local authority Children’s Social Care Services should convene a strategy discussion to determine the child’s welfare and plan rapid future action whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. This might take the form of a multi-agency meeting or a telephone call. Where the strategy discussion is a meeting, Children’s Social Care Services minute the meeting and circulate the record to all attendees however where it is a telephone conversation each professional makes their own record which are not shared and which are not available to professionals not involved in the telephone conversation. 4.6.2 How did the issue feature in this particular case? In March when Child A suffered a fractured clavicle and maternal grandmother contacted Children’s Social Care (CSC) saying that mother’s explanation of the injury was inaccurate the Team Manager contacted the police to arrange a joint visit. This was not recorded on the CSC system as a strategy discussion but was recorded as such by the police. There was no record sent to any other agency so the health visitor, who was aware that Child A was in hospital, did not know that a joint police investigation had started. 4.6.3 How do we know it is an underlying issue and not something unique to this case? Discussions with the case group identified a lack of consistency & clarity around who was responsible both within and across agencies for making key decisions, and how those decisions are recorded internally & between agencies. The case group identified that following the Police restructure there was a lack of clarity felt around who decision makers in the Police were, and who was responsible for conducting Strategy discussions, once CSC made contact with the Police HAU. Further investigation by the Review Team has shown that there has continued to be confusion in this respect with Police HAU staff believing they were responsible for conducting the telephone ‘strategy discussions’, rather than information sharing for the Detective Sergeants to then conduct the ‘strategy discussion’. CSC have been under the impression that they were holding a ‘strategy discussion’ with HAU and have recorded these discussions as such. The fact that the record of the content of telephone ‘strategy discussions’ is not shared across agencies has allowed this misconception to continue until recent weeks. 4.6.4 How common and widespread is the pattern? According to CSC records, of the 891 ‘strategy discussions’ held in Shropshire in 2014/15 333, over a third, were telephone ‘strategy discussions’ where the recording was not shared. It is not known what proportion of these records would not tally or how significant the discrepancies are. 4.6.5 What are the implications for the reliability of the multi-agency child protection system? Joint understanding of agreed actions are a fundamental tenet of joint investigations as outlined in Working Together 2015. If there is the potential for miscommunication of agreed actions this could place children at risk. 23 Finding 3: In Shropshire the records of telephone ‘strategy discussions’ are separately recorded by Police and Children’s Social Care meaning that there is no joint record of the decisions reached leading to the possibility of misunderstanding about their content. This review has identified that the recording systems for telephone ‘strategy discussions’ do not allow for all agencies to know and understand the actions taken to protect children as part of section 47 investigations. Considerations for the Board and partner agencies Does the Board think the current recording arrangements for ‘strategy discussions’ are adequate? Will the introduction of a MASH make a difference? Do current procedures need changing/amending? 24 4.7.1 FINDING 4: Is there a pattern whereby members of core groups don’t understand their responsibilities for ensuring the effectiveness of the child protection plan and delegate responsibility to the social worker? (Communication and collaboration in longer-term work) Working Together to Safeguard Children 2015 states that a responsibility of core groups is to “implement the child protection plan and take joint responsibility for carrying out the agreed tasks, monitoring progress and outcomes, and refining the plan as needed.” 4.7.2 How did the issue manifest in this case? In May 2014 there was a review child protection conference with a different chair for the conference because the allocated chair was off sick. The police did not attend the meeting having not been invited; the GP did not attend or send a report. The allocated social worker was absent so her manager and a duty social worker attended instead. There was little mention in the conference about the investigation into the clavicle injury and there was no consideration whether the category for the child protection plan should change from neglect to physical harm. In June 2014 an advanced practitioner social worker became the child’s social worker with a brief to hold the case temporarily until it was allocated elsewhere. During the three month period (April to June) there were three core groups and a review child protection conference and the allocated social worker was only present at one core group meeting. This lack of attendance lead to a lack of continuity in case planning. Despite the lack of clear direction from the key worker none of the other agencies involved challenged CSC about the inconsistencies or escalated concerns through other routes. 4.7.3 How do we know it is an underlying issue and not something unique to this case? Discussion amongst the Case Group highlighted that core group members felt that the child protection plan provided a safety net as there was an allocated social worker, and that this reduced their levels of concern. Similarly both hospital staff and health staff at the GP practice assumed that because there was an allocated key worker and there was a child protection plan that the child would be safe. This assumption continued even when those workers agreed actions, such as allowing the child to return home with mother that contradicted their understanding of the risks to the child. An SSCB Multi-agency Case Audit in September 2014 focussed on children subject to a second child protection plan within two years, which included cases of neglect, identified that: Core groups could be strengthened as there was evidence that the meetings need to be more effective in monitoring the child protection plan. Professionals should provide appropriate challenge in core groups and child protection conference to ensure that they are clear about next steps. An SSCB SCIE pilot Learning Review that concluded in May 2014 identified that professionals with the Case Group had different understandings of the purpose of meetings and therefore the role that they should play in the meeting. This resulted in a lack of effective multi-agency working to safeguard the young person. Evaluations of SSCB multi-agency training on Case Conferences and Core Groups demonstrate that the learning is effective. Practitioners leave the course understanding their role in the process and feeling more confident to make contributions in the meetings. When evaluating the transfer of learning in to practice one example given by a delegate suggests that this training is crucial for those professionals attending case 25 conference and core groups in order to understand the role that they play and to be able to actively contribute to the monitoring of the child protection plan. “I am currently supporting two clients through case conference and core group meetings. The training has provided me with the skills to be able to prepare and support my clients with what to expect at conference and core meetings. It has given me more knowledge and confidence when attending these meetings” 4.7.4 How common and widespread is this pattern? The quality assurance of child protection conferences process identified that there has been a steady percentage of agencies that attended and contributed meaningfully to the core groups. Year % All agencies attended and contributed meaningfully to the core groups 2012-2013 92% 2013-2014 93% 2014-2015 91% The figures above give a general indication of how prevalent this issue may be, but only really inform us of a lack of contribution when agencies are not represented at core groups. This performance indicator does not measure the quality of the contributions made in multi-agency working nor does it measure the impact of those contributions on monitoring the effectiveness of the child protection plan. The SSCB Multi-agency Case Audit in September 2014 that identified the need for core groups to be strengthened and for professionals to provide challenge was undertaken on five cases of children subject to a second child protection plan in two years. These findings featured across all five of those cases. SSCB multi-agency training figures show that there has been a decrease in the number of professionals attending the Case Conference and Core Groups training, (52 delegates in 2013-2014 and only 19 delegates in 2014-2015). This is due to courses being cancelled as they have not been promoted by agencies A national report which analysed over 800 serious case reviews from 2003-201115 where neglect was a feature found the following: ‘Undue professional optimism can mean the impact of medical neglect and the danger for the child is missed and thus no referral is ever made to children’s social care. Health professionals sometimes appear to shield parents from children’s social care.’ and ‘There was drift and a lack of a sense of urgency among professionals, even when the risk of harm through poor supervision had been highlighted by a CP Plan in the category of neglect.’ 15 Neglect and serious case reviews: a report from the University of East Anglia commissioned by NSPCC, January 2013, Marian Brandon et al. http://www.nspcc.org.uk/globalassets/documents/research-reports/neglect-serious-case-reviews-summary.pdf 26 4.7.5 What are the implications for the reliability of the multi-agency child protection system? A robust effective safeguarding system requires all professionals to take responsibility for child protection which means that they need to have the confidence to provide challenge to professional colleagues where there are concerns that children’s well-being are not being best met. Finding 4: Is there a pattern whereby members of core groups don’t understand their responsibilities for ensuring the effectiveness of the child protection plan and delegate responsibility to the social worker? This review has highlighted that when there was sub-optimal leadership from the allocated key worker professionals within the core group did not question this practice or raise concerns within their own service system. Throughout the case history there were assumptions made by professionals that the child protection plan would safeguard the child even when the actions of the involved social workers did not support that premise. QUESTIONS FOR THE BOARD TO CONSIDER Does the Board recognise this issue? Does the Board think that the current data collection about core groups is effective? Does the Board know whether the right professionals have received core group training? Are there are other barriers to effective multi-agency working within core groups? 27 4.8.1 Finding 5: In Shropshire agencies are unclear about who to contact when there are urgent concerns on open cases and the allocated social worker is unavailable. (Communication and collaboration in long term working.) When professionals have concerns about a child their responsibility is to raise those concerns with Children’s Social Care by making a referral. If those concerns are about a child who has a known allocated social worker they would pass the concerns directly to that worker. If the worker and their manager are unavailable these concerns can be raised with a duty worker either from the team or from the team responsible for receiving referrals, which in Shropshire is ICT. 4.8.2 How did the issue feature in this particular case? When the school identified the burn injury on Child A and were unhappy with mother’s response they immediately tried to contact the allocated social worker but she was unavailable and her line manager was on leave. They did not consider that they should pass the information on to the Initial Contact Team (ICT) as they felt this was for new referrals’ They decided instead to pass the information to the allocated social worker via email. This meant that there was no guarantee that the allocated social worker would access the information in a timely way and it is thought that the email was not read until late in the following day. 4.8.3 How do we know it is an underlying issue and not something unique to this case? The West Mercia Consortium Child Protection procedures16 direct agencies to report concerns to the relevant social worker or their manager and in their absence to the duty worker from that team. Discussion with the review team and case group showed that there was a lack of knowledge of the procedures and some concern that administrative staff may be protective of duty workers and not advise other agencies where to address their concerns when the allocated social worker was unavailable. The case group also confirmed that the guidance and flow-chart provided to agencies regarding the use of the ICT service did not include any detail about how agencies should act where there were concerns about children who had an allocated social worker who was unavailable. 4.8.4 How common and widespread is the pattern? Potentially this is a relevant issue for all children who are open to Children’s Social Care and have a social worker. In May 2015 there were 313 Looked After Children and 250 children with child protection plans about whom there could be concerns raised by professionals that need an urgent response. A Review Team member involved in a recent internal file audit (not related to this review) identified one case file where child protection concerns has been e-mailed to a case manager and recorded on the file under observations. It is not clear whether there was any delay in the key worker receiving and acting on those concerns in that case. 4.8.5 What are the implications for the reliability of the multi-agency child protection system? In order to safeguard children it is necessary that there are clear communication systems in place that accommodate the absence of key workers. These arrangements need to be trusted and accessible to all agencies otherwise it is possible that information will not be shared and children will not be protected effectively. 16 www.westmerciaconsortium.proceduresonline.com/ 28 Finding 5: In Shropshire agencies are unclear about who to contact when there are urgent concerns on open cases and the allocated social worker is unavailable. This case has highlighted confusion about reporting arrangements for agencies when there are concerns about children with an allocated social worker who is unavailable particularly when their manager is also absent. Considerations for the Board and partner agencies Does the Board have a view about how this issue should be resolved? Are the current arrangements with duty workers in individual teams the most effective way of covering this work? Does the Board have a view as to why agencies are unaware of the local procedure? Is the current procedure easily understood by professionals from external agencies? Would it be more appropriate for the ICT to cover this work? Does the Board know if the ICT is sufficiently resourced to undertake this work? 29 4.9.1 Finding 6: In Shropshire re-organisations of services by individual agencies are not planned in a multi-agency way, which means that there may be unintended consequences that can lead to confusion amongst partner agencies, resulting in poor accountability and decision making, which ultimately does not safeguard children. (Patterns in human-management systems operation) Within Shropshire between April and July 2014 there were two major re-organisations of services intended to improve outcomes for children and to ensure best use of limited resources. Children’s Services were restructured into a different configuration in order to reduce the number of social workers a child would have through their journey within the service. The Police created Harm Assessment Units (HAUs) with the intention of streamlining services by providing a single 'gateway' into policing services. There was also a re-organisation of Women’s and Children’s Hospital Services that led to a reduction of in-patient beds and overall resources. 4.9.2 How did the issue feature in this particular case? In April 2014 there was a major restructure within Children’s Social Care which meant that many social workers and managers were moved into different teams. When the temporary social worker, who had case responsibility for Child A, left in May 2014 it was not possible to permanently re-allocate case responsibility and so the case was allocated temporarily to a social worker who already had a high case load. This meant she was unable to prioritise attending meetings associated with this child and although there was always social work representation at the meetings there was a lack of continuity and some drift. During the six month period of the review Child A had three allocated key workers which did not provide good continuity of care. It is noteworthy that in the six months following the end of the review period there has been one allocated worker who has been able to provide focussed care planning and has achieved good permanence outcomes for Child A and the sibling. 4.9.3 How do we know it is an underlying issue and not something unique to this case? The case group members reported that the major restructure within Children’s Social Care meant that many social workers and managers were moved into different teams and all staff involved in this case were anxious about their personal position. Following these changes there was a period when individual workers were holding high caseloads and there was increasing turnover of staff. This resulted in some cases being held temporarily by workers whilst the problems were resolved. At the same time as the CSC restructure the Police restructure their service and created the HAU intending to streamline the way that police received referrals and optimising the use of their professionally qualified police officers. The case group identified that following the Police restructure there was a lack of clarity felt around who decision makers were, and which staff were responsible for conducting Strategy discussions, once CSC made contact with the Police HAU. Further investigation by the Review Team has shown that there has continued to be confusion in this respect. It is also noteworthy that the CSC restructure of teams was driven by the need to reduce the number of social workers a child would have through their journey with the service. Despite this the case group reported that high workloads, absence of line managers & seasonal increases in reporting continued to cause issues in this case and in general over the July 2014 period, thereby preventing the key social worker to have the degree of involvement required. 30 The SSCB Annual report 2013/14 summarises in point 8.7 ‘At an organisational level, there have again been considerable changes and developments, driven by a combination of national requirements (in the case of the NHS and Probation, for example) and local responses to financial constraints (e.g., Shropshire Council, West Mercia Police), which brings risk in relation to service quality and consistency and also has an impact on the LSCB itself. Partners have worked hard to maintain continuity despite all this, and have usually ensured that the LSCB has been kept well informed of developments.’ 4.9.4 How common and widespread is the pattern? National research on neglect has identified that a factor that can lead to poor outcomes for children when there is ‘ … a systemic problem when drift and confusion is prompted by overwhelming workloads, high staff turnover and high vacancy rates alongside numerous unallocated cases’17. During Autumn 2013 five serious case reviews (SCRs) were published which attracted considerable media attention, Daniel Pelka (Coventry), Keanu Williams (Birmingham), Child T (Haringey), Child D (Portsmouth) and Maisie Harrison (Northamptonshire)’. While each case has unique features the accounts given by the SCRs have much in common with each other and with the conclusions of research by Marion Brandon et al who says that ‘In nearly all cases there was evidence of resource and organisational, capacity and capability problems in key social care, police and NHS agencies’. In her conclusions Marion Brandon states: ‘It was notable that resource issues were rarely mentioned in any of these reviews. This seems surprising in a time of austerity and widespread cuts in welfare budgets. It is possible that both the professionals involved and those conducting the serious case review are blind to the impact of resource, staffing and finance on working practices, that they accept this as the status quo and an issue that cannot be changed, or that, in the absence of a direct link with the outcomes, they do not make a connection between the two’.18 4.9.5 What are the implications for the reliability of the multi-agency child protection system? It is generally accepted that at times of restructures of services children and young people are at greatest risk because professionals may be distracted by the change process and the changes themselves may have unknown consequences that affect service delivery to children. An effective safeguarding system will ensure that there is the opportunity for the fullest discussions between agencies about the proposed changes in order to minimise the risks posed by the changes. 17 Neglect and serious case reviews: a report from the University of East Anglia commissioned by NSPCC, January 2013, Marian Brandon et al. http://www.nspcc.org.uk/globalassets/documents/research-reports/neglect-serious-case-reviews-summary.pdf 18 New learning from serious case reviews: a two year report for 2009-2011. Brandon et al Research Report DFE-RR226. 31 Finding 6: In Shropshire re-organisations of services by individual agencies are not planned in a multi-agency way, which means that there may be unintended consequences that can lead to confusion amongst partner agencies, resulting in poor accountability and decision making, which ultimately does not safeguard children. Considerations for the Board and partner agencies Is the Board aware of this issue? Is the Board assured that there is sufficient focus on safeguarding children when planning re-organisations Does the Board think there should be more multi-agency consultation prior to re-organisations? Is the Board fulfilling its functions ‘to coordinate local safeguarding work and ensure the effectiveness of local activity to keep children safe’ with regards to re-organisations of services? 32 4.10.1 Finding 7: In cases of neglect is there a tendency to assess risk from the parent’s perspective and not to focus on the child’s experience, meaning that neglectful parenting is tolerated? (Communication and collaboration in long term working.) Working Together 2015 emphasises the importance of child-centred safeguarding systems, and the risks posed to practice when professionals lose sight of the needs and views of children, or place the interests of adults ahead of the needs of the children.19 This case highlighted a tendency for professionals to assess the seriousness of the situation in terms of the intentions and motivations of the parent, rather than the impact on the child. 4.10.2 How did the issue feature in this particular case? Repeatedly throughout the brief history of agency involvement professionals considered that the injuries experienced by Child A could not have been done deliberately by the mother who was seen as a loving parents who was experiencing difficulties because of her recent bereavement and difficult childhood. As Child A had very poor speech it was difficult for professionals to get the child’s views and few professionals spent enough time with Child A to develop the trust and engagement that was required to understand her world. This was compounded by the tendency by professionals to focus on mother’s motivation, which meant that insufficient attention was paid to the child’s experience. Professionals were asked about this during the review, and their replies suggested that they saw the mother as loving and caring. In other words, it seemed that practitioners based their judgement of ‘safeguarding’ from the perspective of the parent. Because practitioners felt that the mother’s inability to care for her child was unintentional, and based on her poor mental health, this did not constitute a safeguarding concern. This led to a view that the mother was doing her best in the face of adversity and should be supported and encouraged, not penalised. 4.10.3 How do we know it is an underlying issue and not something unique to this case? Discussions with the Review Team and Case Group identified that mother’s situation did lead to professionals over-empathising with her resulting in a lack of focus on the risk to Child A. They also confirmed that this was not uncommon when working with parents with personal problems who are also neglectful parents. Such adults often have their own difficulties and genuinely want to be good parents which makes it hard for professionals to be critical when this is not achieved because of the parent’s personal problems. Research into neglect would support this approach with the emphasis being placed on the responsibility for the act of omission and the intention behind it. Some researchers argue for the importance of distinguishing deliberate harm, which is defined as abuse, from instances of harm that occur as a result of carer ignorance or competing carer priorities, which they define as neglect. Others consider carer or parental acts to be neglectful irrespective of the reason why they occurred and warn against a pre-occupation with determining carer intention as it may over-shadow concern about the impact on the child and also hinder working with parents. 4.10.4 How common and widespread is the pattern? The ‘rule of optimism’ that can affect assessment and decision-making in child protection work was first identified by Dingwall Ekeelaar and Murray (1983) who identified that the key concern was that child protection professionals would wish to ‘see 19 Working Together 2015 p9 33 the best’ in people, and have hope and optimism that their interventions can help the safety and well-being of the child. They identified however that these attitudes could, however, also leave children at risk of being abused and neglected. (Laming, 2009; Marshall, 2011).20 Similarly research by Marion Brandon et al identified that empathy and established relationship skills were necessary when working with resistant families but that they need to be balanced with an eyes-wide-open, boundaried, authoritative approach aimed at containing anxiety and ensuring that the child’s needs stayed in sharp focus. They identified that the complexities of the adults’ problems often eclipsed children’s immediate needs. All practitioners need to be ever vigilant to children’s needs for protection in the short and long term.21 4.10.5 What are the implications for the reliability of the multi-agency child protection system? A safe multi-agency child protection system is one where professionals are able to assess and evaluate risk from the perspective of the child and are not unduly influenced by sympathy for adults’ experiences. The focus of professional intervention needs to be on the child’s experience regardless of the causal factors Finding 7: A tendency to assess risk from the parent’s perspective, and not to focus on the child’s experience, means that neglectful parenting is not viewed seriously. (Communication and collaboration in long term working.) This review has shown that professionals may fail to acknowledge the effect of neglectful parenting on children because they judge risk from the perspective of the intention and motivations of the parent, rather than the experience of the child. Considerations for the Board and partner agencies What does the Board know about what enables professionals to be able to assess risk from the point of view of the child? How can the Board ensure that multi-agency risk assessment of neglect is sufficiently robust? What does the Board know about multi-agency consideration of neglect factors and how professionals work together with neglectful families? 20 https://swscmedia.wordpress.com/2012/05/23/%E2%80%A8avoiding-avoidance-recognising-and-responding-to-the-risks-of-resistant-and-uncooperative-parents-in-child-protection-swscmedia-debate/ 21 http://www.ncb.org.uk/media/60156/safeguarding_knowledge_review.pdf 34 6 Conclusion 6.1 At the start of the review it was agreed that the focus would be on understanding how well agencies worked together when children were the subject of a child protection plan. There was also a desire to understand how effective professionals were at working together to investigate injuries to children. Finally the LSCB was interested to know if the SSCB Neglect Strategy was embedded in professional practice and was being used by frontline practitioners. 6.2 The review has shown that there were a number of areas of individual good practice at the front line: the health visitor input was exemplary, and there was evidence of good joint investigative working in the joint visit by police and social worker to investigate the clavicle injury: and effective partnership working, as witnessed by the response by the hospital and police when mother failed to take Child A to hospital after the clavicle injury. 6.3 The review has also identified some significant issues regarding the functioning of ‘strategy discussions’. In particular the creation of the HAU has led to confusion within the Police Service as to who is responsible for convening and recording these processes which impacts on other agencies. This matter has been able to continue because of the absence of a joint record between agencies where the ‘strategy discussions’ are by telephone. This poses a risk that there is a lack of joint understanding of agreed actions. There are also concerns about whether all agencies are appropriately involved in strategy discussions and whether the discussions focus too heavily on immediate issues and fail to consider longer term goals and outcomes. 6.4 Conversations with Case group members confirmed that the SSCB Neglect Strategy is generally viewed as an assessment tool and front line practitioners are not sufficiently aware that it can be used to work with families where neglect is an identified problem. The difficulties that professionals have in maintaining focus on the child’s experience when working with a neglectful parent was also evident. 6.5 There is a lack of clarity amongst agencies about who to contact when allocated social workers are unavailable and a concern that whilst core groups are meeting their effectiveness is less obviously visible. Finally the review highlighted the risks associated with significant changes in structure and organisation of services and queried whether there was sufficient inter-agency planning and scrutiny of these changes prior to their introduction. 35 Appendix 1 – Methodology 1. This SCR has used an approach based on the SCIE Learning Together model for case reviews. This is a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, in order to identify effective supports and solutions that go beyond a single case. Initially used as a method for conducting accident investigations in other high risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009). National guidance in the 2013 revision of Working Together to Safeguard Children (2013) now requires all SCRs to adopt a systems methodology. 2 The model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. 3 Learning Together is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working. However, some systems findings can and do emerge which relate to an individual agency. Where this is the case, the finding makes that explicit. 4 The basic principles – the ‘methodological heart’ – of the Learning Together model are described in summary form below: a. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’). What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency Child Protection system. d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums. e. Analytical rigour: use of qualitative research techniques to underpin rigour and reliability. 5 Typology of underlying patterns 5.1 To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local child protection systems are functioning. Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively? They are presented in six broad categories of underlying issues: 1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems 36 Each finding is listed under the appropriate category, although some could potentially fit under more than one category. 6 Anatomy of a finding For each finding, the report is structured to present a clear account of: - How the issue manifests itself in the particular case In what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case? What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally? How the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. This is illustrated in the Anatomy of a Learning Together Finding (below). 7 Review Team and Case Group 7.1 The review team comprises senior managers from the agencies involved in the case, who have had no direct part in the conduct of the case. Led by two independent lead reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They are also a source of data about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints and changes in structure. The review team members also have responsibility for supporting and enabling members of their agency to take part in the case review. 37 Review Team Members Fiona Johnson, Independent Lead reviewer Claire Porter, Shropshire Council Lisa Charles, Shropshire LSCB Steve Ladd, Local Authority Social Care, Helen Kinrade, West Mercia Police, Dr Ganesh, Designated Doctor, Julie Harris, Named Nurse Safeguarding Children, SCHT Sarah Wilkins, Children Centre’s, Local Authority Social Care 7.2 The Case Group are the professionals who were directly involved with the family. The Learning Together model offers a high level of inclusion and collaboration with these workers/managers, who are asked to describe their ‘view from the tunnel’ – about their work with the family at the time and what was affecting this. In this case review, the Review Team carried out individual conversations with 19 case group professionals, and up to 25 professionals were invited to attend the case group meetings which discussed the practice in this case and agreed the findings. 7.3 Structure of the review process A Learning Together case review reflects the fact that this is an iterative process of information-gathering, analysis, checking and re-checking, to ensure that the accumulating evidence and interpretation of data are correct and reasonable. The review team form the ‘engine’ of the process, working in collaboration with case group members who are involved singly in conversations, and then in multi-agency ‘Follow-on’ meetings. The sequence of events in this review is shown below: Date Event 6th February 2015 Introductory meeting for the Review Team 6th February 2015 Introductory meeting for the Case Group – to explain the Learning Together model/method, and the case review process which they will be part of. 9th to 10th February 2015 30th & 31st March Four days’ conversations with members of the Case Group – these were all initially set up for February but some had to be delayed till the end of March because of possible criminal charges. (individual sessions of about 1.5 hours with each member of the Case Group; normally conducted by two members of the Review Team) 8th April 2015 First Review Team analysis meeting 24th April 2015 Second Review Team analysis meeting 38 12th May 2015 First Follow-on meeting (Review Team and Case Group) In this meeting, the group works together on identifying Key Practice Episodes (KPEs) in the case which affected how the case was handled and/or the outcome of the case appraising the practice in these KPEs considering what was affecting the work/workers at the time (the ‘view from the tunnel’) 13th May 2015 Third Review Team analysis meeting 1st June 2015 Fourth Review Team analysis meeting 2nd June 2015 Second Follow-on meeting (Review Team and Case Group) At this meeting, the group were provided with a draft report which sets out the emerging underlying patterns and findings, and were asked to consider whether these are specific to this individual case or pertain more widely and form a pattern. 29th June 2015 Fifth Review Team meeting – to consider the draft final report 10th July 2015 Learning & Improvement Sub-Group meeting – to consider the draft final report 14th July 2015 LSCB Executive meeting – to consider the draft final report 17th September 2015 LSCB Meeting to endorse the final report and action plan 12th November 2015 Final report, fit for publication, to be submitted to Department for Education (DfE) 7.4 Scope and terms of reference Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference, such as in a traditional SCR. This enables the data to lead to the key issues to be explored. 7.5 Sources of data 7.5.1 Data from practitioners Conversations, as described above, with members of the Case Group; these were recorded and discussed by the whole Review Team. Members of the Case Group have also helpfully responded to follow-up queries and requests from the Lead Reviewers and the Review Team for clarification or further information, where this has been needed. 7.5.2 View from the Tunnel and Contributory Factors The data from the conversations with the Case Group translates into their ‘view from the tunnel’ which enabled us as reviewers to capture the optimum learning from the case. Case Group members are also an invaluable source of information about the why questions – an exploration of the Contributory Factors which were affecting their practice and decisions at the time. 7.5.3 Participation The Lead Reviewers and the Review Team are grateful for the willingness of the professionals to reflect on their own work, and to engage so openly and thoughtfully in 39 this SCR. Everyone has contributed very fully in the process. Individual practitioners all have participated responsively in conversations, which have recalled their role in this story, and in group discussions which have at times been very difficult and challenging. All this has given the Review Team a deeper and richer understanding of what happened with this family and within the safeguarding network, and has allowed us to capture the learning which is presented in this report. 7.5.4 Data from documentation The Lead Reviewers and members of the Review Team reviewed the following documentation: CSC records, Police records, Hospital records, GP records, Health Visiting records, Child Protection conference Minutes, Core group records, Strategy Discussion records. 7.5.5 Data from family, friends and community As in traditional SCRs, the Learning Together model aims to include the views and perspectives of family members as a valuable element in understanding the case and the work of agencies. 40 Appendix 2 GLOSSARY OF TERMS AND ABBREVIATIONS CAIU Child Abuse Investigation Unit (Police) CSC Children’s Social Care EDT Emergency Duty Team providing emergency out of hours social work service to Shropshire HAU Police Harm Assessment Unit the staff who respond to all initial contacts regarding child protection within the police ICT Initial Contact Team the team who respond to all initial contacts with Children’s Social Care GP General Practitioner LSCB Local Safeguarding Children Board MASH Multi-Agency Safeguarding Hub S.47 enquiry / Section 47 enquiry /child protection enquiry S.47 enquiry refers to section 47 of the Children Act 1989 which gives local authorities the duty to ‘make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare’ when they have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm Strategy Discussion Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving local authority children’s social care (including the fostering service, if the child is looked after), the police, health and other bodies such as the referring agency. This might take the form of a multi-agency meeting or phone calls and more than one discussion may be necessary. A strategy discussion can take place following a referral or at any other time, including during the assessment process SCR Serious case review SSCB Shropshire Safeguarding Children Board TM Team manager 41 Appendix 3 Bibliography Marian Brandon et al. Neglect and serious case reviews: a report from the University of East Anglia commissioned by NSPCC, January 2013 http://www.nspcc.org.uk/globalassets/documents/research-reports/neglect-serious-case-reviews-summary.pdf Brandon, M. Glaser, D. Maguire, S. McCrory, E. Lushey, C. & Ward, H. – Childhood Wellbeing Research Centre. (2014) Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report Department for Education: London https://www.gov.uk/government/publications/indicators-of-neglect-missed-opportunities Marion Brandon et al. New learning from serious case reviews: a two year report for 2009-2011. Brandon et al Research Report DFE-RR226 Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln, Ten pitfalls and how to avoid them - What research tells us, September 2010. www.nspcc.org.uk/inform Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 Gardner, R. (2008) Developing an effective response to neglect and emotional harm to children. London: NSPCC HM Government, Children Act 1989, HM Government, Working Together (2015) https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 Horwath, J (2007) Child Neglect: Identification and Assessment, Basingstoke, Hampshire: Palgrave Macmillan Munro, Prof. E., ‘A systems approach to investigation child abuse deaths’, British Journal of Social Work, 35 (4), pp. 531-546, 2005 (also LSE Research Online) Neglect, NSPCC research briefing August 2012 Rees, G. et al. (2011) Adolescent neglect: research, policy and practice. London: Jessica Kingsley Vincent, C, A, (2004) Analysis of clinical incidents: a window on the system not a search for root causes Downloaded from http://qualitysafety.bmj.com/ on July 3, 2015 - Published by group.bmj.com |
NC043840 | Death of a 5-week-6-day-old baby girl in October 2012 as the result of a severe skull fracture. Mother admitted to a charge of infanticide due to post natal depression and received a community order with a supervision requirement for three years. Family were known to universal services only. Identifies learning lessons in relation to Child L's death and her family's journey and contact with services, including: need for universal service practitioners' to recognise their role in safeguarding children; and consideration of the role of fathers and men in households in service provision and assessment. Makes recommendations for health services, midwives and ambulance services.
| Title: Serious case review overview report: in respect of: Child L LSCB: Hull Safeguarding Children Board Author: Pat Cantrill Date of publication: [2014] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Overview Report In respect of: Child L Produced by Professor Pat Cantrill May 2013 CONTENTS Page SECTION ONE – INTRODUCTION AND BACKGROUND 1 1.1 Reason for conduction the review 1 1.2 Scope and process 1 1.3 Subject 2 1.4 Time period 2 1.5 Terms of reference 2 1.6 Process 4 1.7 Membership of SCR panel 5 1.8 Involvement of the family 6 1.9 Family composition and background 6 1.10 Family Genogram 7 1.11 A Childs Journey 7 SECTION TWO - ANALYSIS OF INDIVIDUAL MANAGEMENT REVIEWS 9 2.1 General Practice 9 2.2 Hull and East Yorkshire Hospitals NHS Trust 13 2.3 City Healthcare Partnership CIC 19 2.4 Yorkshire Ambulance Service 26 2.5 Health - General Issues 30 2.6 Hull City Council 32 2.7 Humberside Police 34 SECTION THREE – LEARNING LESSONS, IMPROVING SERVICES 37 3.1 Lessons to be learned 37 3.2 Terms of Reference 42 SECTION FOUR – RECOMMENDATIONS 48 Appendix 1 - Ofsted and Care Quality Commission inspection 49 - 1 - SECTION ONE – INTRODUCTION AND BACKGROUND 1.0 Introduction This Serious Case Review looks at the circumstances surrounding the sudden unexpected death on 8th October 2012 of Child L aged 5 weeks 6 days. Child L was pronounced dead shortly after arrival at Hull Royal Infirmary. The initial post mortem found the cause of death to be a severe skull fracture with no known explanation. Child L's death was considered by the Police to be suspicious. Adult N (Child L’s mother) was arrested on suspicion of causing the death of Child L. On 11th November 2013, at the commencement of her trial for murder, Adult N admitted to, and the court accepted, a lesser charge of infanticide due to post natal depression. Adult N received a Community Order with a supervision requirement for three years. 1.1 Reasons for Conducting the Review Chapter 8 Regulation 5 of ‘Working Together to Safeguard Children’ 20101 and Regulation 5 of ‘The Local Safeguarding Children Boards Regulations 2006’ requires that a Local Safeguarding Children Board considers undertaking a Serious Case Review in cases where there has been a death or serious impairment to the health and development of a child and abuse or neglect is known or suspected. The circumstances surrounding the death of Child L were considered consistent with these criteria and a Serious Case Review was commissioned. The purpose of this Serious Case Review is to establish the role of services and their effectiveness in the care of Child L, whether information was fully shared by the professionals involved and that procedures were appropriately followed, so that any deficiencies in services can be identified and lessons learned to minimise the risk for another child. This should also reassure the public and prevent the need or demand for further external inquiries. 1.2 Scope and process of the review and terms of reference A Serious Case Review was recommended by the Hull Serious Case Review Sub-Committee; which is a sub group of the Hull Safeguarding Children Board (HSCB) on 23rd November 2012. A Serious Case Review (SCR) was commissioned by the Independent Chair of the Hull Safeguarding Children Board on 23rd November 2012, in line with the requirements and expectations of Working Together 20102. A specific Serious Case Review Panel met on 22nd January 2013 to consider the circumstances surrounding the sudden unexpected death of Child L. Child L was known to universal services only. 1 Working together to safeguard children - a guide to interagency working to safeguard and promote the welfare of children, DCSF 2010 2 The process was initiated and completed in accordance with the statutory guidance (Working together to safeguard children, 2010) which was in place at the time of the commencement of the SCR rather than that identified in the new guidance Working together to safeguard children, 2013. - 2 - In line with 8.26 Chapter 8 of ‘Working Together to Safeguard Children’ 2010 the Chair of the LSCB sought advice from police and partner agencies about progressing the SCR during criminal investigations and determined that this should not delay the review. Parallel investigations: Criminal/Civil Humberside Police kept the HSCB informed of the ongoing criminal investigation and provided regular updates through the HSCB SCR sub-committee. Conduct/Professional Practice It was agreed that should any conduct/professional practice issues arise, in respect of an individual member of staff during this review, they would immediately be dealt with in accordance with agency procedures and the outcome relayed to the HSCB. Any other professional practice issue that may arise must be dealt with immediately and the HSCB informed of any immediate training issue or change needed to processes/procedures. 1.3 Subjects The subjects of the review were identified by the Serious Case Review Panel on 23rd November 2012 as Child L and Family M. 1.4 Time Period The time period under review is from 15th February 2012 which is the date that Adult N ‘booked in’ with midwifery services, to 8th October 2012, the date that Child L died. The time period applies to each of the family members within Family M as specified within the terms of reference detailed by the HSCB. 1.5 Terms of Reference It was agreed that the review should cover the above time period. Under Chapter 8 of Working Together 2010 the purpose of this review is to: 1. establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; 2. identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and; 3. improve intra- and inter-agency working and better safeguard and promote the welfare of children. - 3 - In addition, the following areas will be addressed in the Individual Management Reviews and the Overview Report: Each agency is asked to: 1. Examine whether or not Child L’s death could have been anticipated or prevented. 2. Construct a comprehensive chronology of involvement with the named family members. 3. Examine the agency’s involvement with the individual members of the family particularly in respect of any: 3.1. concern for Child L’s welfare which arose from services provided to the family ante and post-natally; 3.2. identified causes of stress in family life which might have affected the care provided to Child L; 3.3. referral or request for service (including self-referral). By analysing in detail any concerns that arose in respect of Child L, her mother or father, or other people living in the family home at the time, and, in particular; 3.3.1. how the concern was dealt with; 3.3.2. the quality of assessment and decision making and how that was recorded; 3.3.3. the quality and relevance of any service provided; 3.3.4. the quality of the agency’s child protection procedures and whether or not they were followed; 3.3.5. how Child L’s needs and welfare were considered; 3.3.6. how information was shared between agencies. 4. Examine specifically what was known about mother (Adult N) and if there was any evidence to suggest that she might pose a risk to Child L. 5. Examine considerations around ethnicity, religion, diversity or cultural issues that may require special attention. 6. Consider the impact of the social, cultural and economic environment in which the family were living and in which the professionals operated. 7. Consider the context in which local professionals work and the extent to which their actions are influenced by the organisations and systems in which they are working. 8. Take account of any relevant lessons learned from research and from biennial overview reports of serious case reviews and describe how these lessons have been applied to the analysis of this case. 9. Examine whether or not there were opportunities for agency intervention that were missed. - 4 - 10. Identify any recommendations for action: 10.1. within the agency; 10.2. in respect of local child protection guidelines and procedures; 10.3. of national significance. 1.6 Process The specific Serious Case Review Panel requested that the following agencies/bodies secured their records and identified and commissioned an independent author of sufficient experience and seniority to undertake an Individual Management Review. Individual Management reviews were requested from the following agencies: • Humberside Police • Health: - City Healthcare Partnership - Hull and East Yorkshire Hospitals NHS Trust - NHS Hull Clinical Commissioning Group - Primary Care (GP) The Designated Nurse (NHS Hull CCG) also prepared a health overview report. • Yorkshire Ambulance Service • Hull City Council (incorporating Adult, Children and Family, Services, and Neighbourhoods and Housing Directorates) Hull City Council Adult, Children and Family Services Directorate had no contact with Adult N and Child L, or any relevant involvement with any other member of Family M during the period under review and therefore did not produce an IMR. Senior representatives from the Council’s Safeguarding and Learning and Localities service areas remained as members of the panel to provide any required information, to contribute to the review process and to ensure that the learning from the review could be captured for both agencies. An IMR was produced by the Hull City Council Neighbourhoods and Housing Directorate. Additionally, all HSCB partners were asked whether any family members were known to them and the nature of their involvement, to consider whether IMRs were required from any other agency. Hull Youth Justice Service, Humberside Probation Trust, Children and Family Court Advisory Support Service (CAFCASS), Adult Mental Health, Adult Substance Misuse and Domestic Abuse Partnership confirmed that no family members were known to their service. The author of the overview report, Professor Pat Cantrill, is a Registered Nurse and health visitor and was a senior civil servant at the Department of Health. Pat has led a number of high profile serious incident and domestic homicide reviews. Professor Cantrill attended panel meetings from 22nd January 2013 as the overview author to observe but was not a formal member of the panel. Her appointment is in accordance with the guidance at 8.20 in ‘Working Together to Safeguard Children’ 2010 which states that: ‘the overview author should be independent of the local agencies, professionals involved and the LSCB. And that the person should not be the chair of the LSCB or the SCR subcommittee / panel’. - 5 - 1.7 Membership of the Serious Case Review Panel: Independent Chair IMR Authors Named Nurse for Safeguarding Children City Health Care Partnership (CHCP) Named Nurse for Safeguarding Children Hull and East Yorkshire Hospitals NHS Trust (HEYHT) Head of Safeguarding Yorkshire Ambulance Service NHS Trust (YAS) Named GP NHS Hull Clinical Commissioning Group Designated Nurse - Health overview report NHS Hull Clinical Commissioning Group Practice Manager Hull City Council - Neighbourhoods & Housing Detective Inspector, Lead for Child Protection and FLC, Policy Unit Humberside Police Other Panel/SCR Sub-Committee members Lay member Hull Safeguarding Children Board Manager Safeguarding Adults Partnership Board City Learning & Skills Manager Hull City Council Adult, Children & Family Services Designated Nurse NHS Hull Clinical Commissioning Group City Children Safeguarding Manager Hull City Council Adult, Children & Family Services Chief Superintendent Humberside Police Project Manager, The Difference Engine North Bank Forum for Voluntary Organisations Designated Doctor NHS Hull Clinical Commissioning Group Assistant Head of Service Hull City Council - Adult, Children & Family Services - Safeguarding Children directorate Safeguarding Children Officer for schools Hull City Council - Adult, Children & Family Services - Learning & Skills directorate Hull Safeguarding Children Board advisors Manager Professional Practice Officer Child Death Review Co-ordinator (administration) The objective of the Individual Management Reviews (IMRs) that form the basis for the SCR, is to give as accurate an account as possible of the effectiveness of services provided to help and support Child L and her family, to evaluate it fairly, and if necessary to identify any improvements for future practice. IMRs also propose specific solutions which are likely to provide a more effective response to a similar situation in the future. The authors of the Individual Management Reviews are independent in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children’ 2010. This states that: “Those conducting management reviews of individual services should not have been directly concerned with the child or family, or the immediate line manager of the practitioner(s) involved”. The IMR authors and the overview author have provided a valid analysis and cross referenced information to complete gaps. Where possible, triangulation of sources of evidence has been used - 6 - to increase confidence in the findings. All of the agencies involved in this review have provided frank accounts of their involvement in order to establish if there are any lessons to be learned. The report’s conclusions represent the collective view of the Serious Case Review Panel, which has the responsibility, through its representative agencies, for fully implementing the recommendations that arise from the review. There has been full and frank discussion of all the significant issues arising from the review. In addition, a comprehensive integrated family chronology of agency involvement and significant events from the period 15th February 2012 to 8th October 2012 has been compiled and analysed by the Serious Case Review panel. The Overview Report will be made public and the recommendations will be acted upon by all agencies, in order to ensure that the lessons of the review are learned. An action plan has been developed and is being implemented. The implementation and impact will continue to be monitored by the HSCB SCR sub-committee. 1.8 Involvement of the family ‘Working together to safeguard children 2010’ recommends that Serious Case Review panels should consider ‘how family members should contribute to the review and who should be responsible for facilitating their involvement’. In reporting the views of individuals who received services, the Review Panel is not endorsing those views as accurate or as a fair assessment of the services they were given. They are the subjective views of the service user and should be considered with respect, in that they may offer lessons for the service providers. The report author and the HSCB Manager met with Adult N - (Mother), Adult P - (Father) and Adult R - (Maternal Grandmother) and the HSCB Manager with Adult P's mother and father (Paternal Grandmother and Grandfather). They were interviewed to discuss their views about the involvement and effectiveness of agencies and to enable them to contribute to the review. The content of the report has been discussed with them and their contribution approved. 1.9 Family composition and background Subject: Child L Family Members: Adult N - (Mother) Adult P - (Father) Adult R - (Maternal Grandmother) Child S - (Uncle - Mother’s sibling) Adult N's older sibling, Adult T, is identified by some agencies as being a member of the household. The review has established however that Adult T, whilst registered at the address, did not live as a member of the household during the significant time period and has therefore not been included as part of the review. 1.10 Family Genogram Maternal Grandfather Adult P Child L Adult N Child S Adult R 1.11 A Child's Journey In her second interim report called ‘The Child’s Journey’, Professor Munro identifies the importance of analysis of the child’s journey from needing to receive effective help for problems arising from family and social circumstances. In the case of Child L that journey was extremely brief as she was only six weeks old when she died. Child L was born on the 28th August 2012 to Adult N aged 20 and her partner Adult P aged 25 years. Adult N lives with Adult P, Adult R (her mother) and Child S (her sibling). Adult N experienced an uneventful pregnancy. Adult N and Child L remained in hospital until discharged on 29th August 2012. There were no recorded clinical or other concerns. Child L had a full physical examination before discharge from hospital by a Paediatrician. It is recorded that there were no abnormalities and no risk factors warranting further investigation. Child L was seen by community midwives and by a health visitor and was progressing well. On 8th October 2012, Yorkshire Ambulance Service (YAS) received a 999 emergency call from Adult P, about Child L. She was said to have stopped breathing. - 7 - - 8 - Support was offered to Adult P by the Emergency Operations Centre (EOC) to initiate Basic Life Support until the ambulance arrived. When the Ambulance crew, a Paramedic and Ambulance Practitioner arrived Child L was in cardio-respiratory arrest and she was taken immediately to the Hull Royal Infirmary Emergency Department. Child L was pronounced dead ten minutes after arrival at hospital. Child L had a severe skull fracture and the Police and Children’s Social Care were informed. No family members accompanied Child L on the transfer to the hospital. It became apparent that Adult N had been brought to the same hospital in a different ambulance following what was stated to be a fall. The Police arrested Adult N on suspicion of causing the death of Child L. On the 11th November 2013 Adult N admitted to the infanticide of Child L caused by hitting her head against a hard surface, causing fractures. She was given a three year Community Order with a Supervision Requirement. - 9 - SECTION TWO - ANALYSIS OF INDIVIDUAL MANAGEMENT REVIEWS The focus for this section of the report will be an analysis of the response of services involved with Child L and Adult N, why decisions were made and actions taken or not taken. Service Involvement with Family M Review and analysis of records for Family M ,who lived with Adult N and Child L, has established that there are no significant factors regarding services with Adult R or Child S that had any direct or indirect impact on the death of Child L and therefore reference to them is limited in the report. The format of the analysis sections varies to reflect the requirements of each agency. In order to manage an account of agencies’ involvement with Child L and Adult N the author has described separately the involvement of each agency. Health Services This part of the report contains analysis from the Health IMRs and the Health Overview report. At the end general cross service comments are addressed. At the time the incident occurred, the structure of the NHS consisted of the Yorkshire and Humber Strategic Health Authority (SHA) and Hull Teaching Primary Care Trust, who had responsibilities for performance management and commissioning of the healthcare in the area. Since 1st April 2013 the NHS within the area has been transferred to the structures as detailed within the Health and Social Care Act (2012). The commissioning architecture now consists of NHS England with Regional and Local Area Teams and Clinical Commissioning Groups (CCGs). For the purpose of this report this now encompasses NHS England, North Yorkshire and Humber Area Team and NHS Hull Clinical Commissioning Group. At the time of the review, the health care that Adult N and Child L received was provided by City Health Care Partnership, and acute care and some community paediatric services by Hull and East Yorkshire Hospitals NHS Trust. In September 2013 there was a transfer of community paediatric services from Hull and East Yorkshire Hospitals NHS Trust to City Health Care Partnership 2.1 General Practice General Practice is the main point of contact for all primary healthcare services. It is expected that General Practitioners will have a holistic overview of their patients and their needs. However, General Practice has changed significantly in the last decade. The traditional practice where one or two practitioners know all their patients, and their extended families, is disappearing. Moves towards larger practices with part-time and/or salaried clinicians, a range of service providers (e.g. GP Out of Hours Services, Walk-in Centres, and GP-led Health Centres) has tended to fragment this knowledge base and continuity of care. It is therefore critical that communication and record-keeping is robust and meticulous. This IMR considers the involvement of the GP Practices and their staff in relation to Child L and Adult N. Adult N and Child L were registered with one general practice. Adult P was registered with - 10 - a different practice during the period of this review. A detailed examination of his records has taken place. There were no significant issues identified from Adult P’s records. Service Involvement with Child L and Adult N There were four episodes of contact during this period which included: • In February 2012 Adult N received care from the Out of Hours GP Services. At the time she was 13-14 weeks pregnant and was admitted to the local maternity hospital. This episode did not raise any child protection issues surrounding Adult N's unborn child. • In September 2012, when Child L was four weeks old, Adult N saw the GP accompanied by Adult R. Adult N was complaining of feeling low and tearful, not able to cope. The entry in the record states that she was "happy with baby, lives with mum and gets good support, poor appetite, no other triggers, happy with boyfriend, goes out with baby whenever he is free, denied any crisis, also feeling exhausted ...". The GP noted that Adult N has "good rapport but tearful, normal speech, Insightful." Adult N was given a prescription for an antidepressant. The GP also recommended a blood test which identified that Adult N had anaemia and medication was given. This was the only occasion when information about Adult P was referred to in any consultations with Adult N or Child L. There is nothing in the GP records related to concerns that would or should have triggered the initiation of child protection procedures. • On 2nd October 2012, Child L was seen by the nurse at the GP surgery for oral thrush which was said to have been identified by the health visitor the previous day (this was in fact by the nursery nurse who saw Child L at the clinic). Adult N informed the nurse that she had been advised to "get treatment." It was also documented that Child L was feeding well and gaining weight, but was having difficulties defecating. Examination of Child L by the nurse identified that, except for oral thrush which the nurse treated with the appropriate medication, there were no other problems. • The GP was notified of Child L's death on 8th October 2012 by the HEYHT Safeguarding Children Team. The practice was also notified that Adult N presented to A&E twice on 8th October 2012, once at 08.52 hours and then again at 19.10 hours. The information provided about Adult N was limited. Analysis of Involvement Child L and Adult N Firstly, the conclusion based on the information held in the electronic GP record system (SystmOne), is that Child L's death could not have been anticipated or prevented, but there were factors present that pointed to there being potential safeguarding issues associated with Child L but no child protection issues. Section 2 of the GMC‘s ‘Protecting children and young people: The responsibilities of all doctors’3 identifies the importance of Doctors considering whether a patient poses a risk to children. 3 Protecting children and young people: The responsibilities of all doctors. General Medical Council. September 2012. - 11 - When Adult N attended the GP practice in September 2012 she identified she felt stressed, struggling to cope with her new baby (Child L) and at the time was diagnosed with depression. The GP did explore the relationship between mother and baby as well as what kind of support the mother was getting from relatives. The GP identified that Adult N's mood was low, that she felt she could not cope and prescribed appropriate medication. Adult N reported good support from her own mother and was asked about the input from Adult P. Whilst overall, there were no factors indicating that the child was at increased risk of violence or other forms of child abuse or neglect there were safeguarding issues associated with low mood, having a new baby and post natal depression. It would have been good practice for the GP to have discussed Adult N with the community midwife or health visitor to enable them to contribute to the assessment of Adult N and to provide her with additional support. There also appears to have been a lack of curiosity about the role of Adult P. Adult P's role within the family unit is only recorded on one entry in the GP notes when the mother presented to the GP in the September 2012. Reference to his role within the family is limited to, "happy with bf (boyfriend)”, “goes out with baby whenever he is free". There is no reference to his level of involvement within the family unit or the extent to which he was able to contribute to the care of Child L. The next contact with Adult N and Child L was on the 2nd October 2012, six days before the death of Child L. The consultation did not give rise to any concerns regarding the welfare of Child L. The care provided by the practice nurse is in line with that expected and is documented clearly. The practice nurse identifies that Adult N did not appear to be distressed or tearful and if that had been the case, she would have documented it and would have taken appropriate action/s. Multiagency Information Sharing The review of documentation and recorded information sharing identifies mixed performance. GP records had references to various members of the family having had contact with health professionals at Child Health Unit at Hull and East Riding CHS information systems but there is no specific detail about this contact. GPs and nurses at the Family M practice have access to entries made by health visitors and child health provided that they are recorded on the computer system being used in that surgery, but don't have access to the information recorded on the CHCP electronic system. The capacity of professionals to be able to view each other's records would significantly improve child safety and is in the process of being reviewed as part of the implementation of SystmOne. Individual practitioners or agencies may have a low suspicion of concerns about a child's safety that would not reach the threshold for activating child protection procedures but trans-agency record sharing may escalate concerns and elicit appropriate action. This may require the patient to actively consent to the sharing of information. There are issues identified by this case in enabling different branches of the organisation and agencies to view each other's records such as Child Health team, GP surgery and A&E. City Health Care Partnership (CHCP) is committed to introducing the electronic record SystmOne (S1) for Adult Services, and Children and Young Peoples Services, to complement approximately 80% of GP Practices in Hull which currently use S1 as their patient record. The S1 electronic - 12 - record essentially provides a single electronic patient record to which professionals working with the patient can contribute. A new sharing model is being introduced in early 2014 within the Yorkshire and Humber area which will enhance the sharing ability of the S1 electronic patient record. Religion, Diversity or Cultural Issues The GP records do not contain any information about the family’s religion, diversity or cultural issues. The records, however, do specify ethnicity in registration details but do not mention them anywhere else in the record during the time interval investigated. Ethnicity is specified in the GP record. According to the GP records Child L had the ethnic origin "British or mixed British-ethnic category 2001 census" and Adult N has the ethnic origin "White and Black Caribbean-ethnic category 2001 census". This is the first and only reference to Adult N being “White and Black Caribbean” and is believed to have been a recording error. All have English recorded as the main spoken language recorded although Child L would not have been old enough to be in command of any language. The ethnic status or main language of adult P is not recorded in the documents. Training and Supervision The GP practices which Family M are registered with have in place a Safeguarding Children Policy dated 22nd May 2012. All doctors and nurses are up-to-date in their Safeguarding Children and Child Protection Training and three core members of the administrative staff also completed the training. Further practice- wide training sessions are being held and will ensure that all staff are trained in the subject and also to meet CQC best practise baselines. Both practices have supervision arrangements in place and a GP identified to take the lead in matters of safeguarding children. GPs will also discuss cases of concerns amongst each other. As no concerns regarding child L's safety had been raised, this case had not been discussed amongst the healthcare professionals of the practice at the time. - 13 - 2.2 Hull and East Yorkshire Hospitals NHS Trust (HEYHT) Hull and East Yorkshire Hospitals NHS Trust (HEYHT) was established in October 1999 through the merger of the Royal Hull Hospitals NHS Trust and East Yorkshire Hospitals NHS Trust. The Trust operates from two main sites: Castle Hill Hospital and Hull Royal Infirmary (including the local Emergency Department and Women and Children’s Hospital/maternity hospital), as well as other locations within the geographical area served by the Trust. The Trust provides medical and surgical services, both acute and planned, for approximately 600,000 people who live in the Hull and East Riding of Yorkshire area, in addition to a range of more specialist services to a much wider population, and employs over 8,000 staff. Service involvement with Child L, Adult N, and Family M HEYHT’s knowledge of the children and family health history during the time period of the review is summarised below by family member: • Child L was known to the Trust as an unborn child from the initial antenatal contact with the midwife, and as an individual from birth, until death. • Adult N received services from HEYHT prior to the commencement of this review, and which are unrelated to this review. During the period of this review Adult N received maternity services input and two contacts with urgent care services. • Adult P has not received a service from HEYHT during the period of this review however he has accompanied other family members during their contacts with the organisation. HEYHT's contact with Adult N and Child L is divided into three episodes of care: antenatal care, postnatal care and the 8th October 2012, the date of Child L's death. Service Involvement with Adult N Antenatal Care Adult N attended the first appointment with the midwife in February 2012 accessing maternity services via the Direct Access to Midwifery Service self-referral system prior to her 12th week of pregnancy, as recommended by the Royal College of Obstetricians and Gynaecologists (2008)4. A comprehensive midwifery led assessment took place and was recorded in Adult N’s hand held maternity records, and electronically recorded to enable the Community Midwifery Service access to the assessment. Adult N disclosed a family history on both maternal and paternal sides of various medical conditions. Adult N was asked the “routine enquiry for domestic abuse” question and answered “no, never”. It is clear from the maternity records, that Adult N lived at the same address as Adult R. It is documented that Adult N’s partner is Adult P; however, it is not made clear if Adult P lived at the same address as Adult N. 4 Royal College of Obstetricians and Gynaecologists (2008) Standards for Maternity Care: Report of a Working Party. - 14 - Midwife X referred Adult N to a Consultant Paediatrician and Consultant Obstetrician (Dr U) in accordance with HEYHT Guidance (2010). Both of these outpatient appointments took place. Adult N was assessed as not requiring further intervention. A referral to the “smoke free team” was generated at the initial call to the Direct Access to Midwifery Service. Adult N was returned to “midwifery led care” at 21 weeks gestation. In line with expected practice Adult N was asked questions in relation to her mental health and it is documented that following this assessment of mental health, no further action was taken; this decision complies with NICE Guidance. Following a viable pregnancy and expected due date being confirmed, a summary of the antenatal booking was sent to Adult N’s GP and the Health Visiting Service, in accordance with HEYHT guidance (2011). Both Consultant Obstetrician U and midwife Z discussed smoking cessation with Adult N during the pregnancy. Service Involvement with Adult N Postnatal Care On 28th August 2012 Adult N attended hospital and Child L was born. Child L was assessed by the midwife and no anomalies or abnormalities were detected. Adult N and Child L remained in hospital until discharged on the following day. There were no recorded clinical or other concerns. Child L had a full physical examination by a Paediatrician prior to discharge. This is standard practice and meets with the postnatal requirements documented within the National Screening Committee Guidelines. It is recorded that there were no abnormalities and no risk factors which would warrant further investigation. The midwives caring for Adult N and Child L in the postnatal period did not express concerns about their progress. Midwife U has documented that a routine informative discussion occurred with Adult N, prior to her care being transferred to the community midwives. Each postnatal visit to Adult N and Child L at home comments on Child L’s progress. Child L’s birth weight was 2790 grams and on the 6th postnatal day Child L was weighed and had lost 4%5 of birth weight, which is classed as within normal limits. On 10th September 2012 Child L was seen in the postnatal clinic at the Children’s Centre by midwife Z with Adult N, Adult P, and Adult R. Child L's progress was again assessed and she weighed 2900 (6 pounds and 6 ½ ounces). The weight gain made by Child L was within normal limits. A holistic examination of Adult N was undertaken at the postnatal appointment which concluded that there was no cause for concern regarding her general health and wellbeing. Adult N and Child L were discharged by the midwifery service with contact numbers and information regarding how Adult N could access the midwifery service for up to 28 days in the postnatal period, if she had any concerns or required advice, and information that Adult N could access other health professionals such as the health visitor or GP for appropriate advice and support as required. The postnatal care received by Adult N and Child L was “routine”. No concerns in relation to child protection or child welfare had been identified during this period. Analysis of Service Involvement 5 4% weight loss in between birth and post natal day 6 is considered to be a normal weight loss. If an infant were to lose more than 10% of their birth weight, action would be taken. - 15 - Midwives are the lead professional for healthy pregnant women. They have the expertise to refer to and coordinate between specialist services when required (Department of Health 2007 and 2010)6. This is clearly demonstrated with the appropriate referrals for consultant opinion and subsequent agreement that Adult N could continue under Midwifery Led Care. Adult N’s referral to another service following a concern about her health was the only issue documented in the antenatal period. She was referred promptly and appropriately to the correct service for medical investigation. Information regarding this referral was shared appropriately with the Primary Care Service, and documented in the HEYHT Maternity records. Adult N received routine antenatal care in accordance with the National Institute of Health and Clinical Excellence (NICE) Guidance (2008)7, which states “in an uncomplicated pregnancy, there should be 10 appointments for nulliparous8 women”. This translates into practice as 9 appointments in the antenatal period and 1 appointment if the woman goes past her due date. Adult N had nine appointments in the antenatal period however Child L was born the day before the due date. Therefore Adult N received the correct amount of antenatal appointments. Smoking cessation was discussed with Adult N in accordance with National Institute for Health and Clinical Excellence (NICE) guidance (2008) and The Department of Health (DoH) Child Health Promotion Programme (2008), for the benefit of the unborn child. It is evident from the midwifery records that a discussion was held with Adult N and information leaflets given regarding: postnatal care and home visiting; jaundice in babies; preventing cot death; postnatal exercises for new mothers; family planning and sexual health; baby feeding information; smoking cessation and passive smoking; and new-born blood spot tests. Adult N was given information regarding how to access the midwifery service if she had any concerns or if advice was required and contact numbers were given in writing and transferred to the care of the community midwife from hospital following childbirth. There are two relevant issues related to Adult N's contact with services during the post natal period: • The Department of Health (2005)9 recommend health professionals routinely enquire about domestic abuse. HEYHT and CHCP (Health Visiting Service) use the same codes for Routine Enquiry responses, following a recommendation from a previous SCR, to enhance communication between partner agencies. This does not appear to have been effective in this case because of changes to IT systems which resulted in the interpretation of codes not being consistent across partner organisations. • The pre-printed records for the first assessment or “booking in” appointment with a midwife, do not facilitate easy documentation of who else lives in the family home. This point of 6 Department of Health (2010) Midwifery 2020: Delivering expectations. Department of Health (2007) Maternity Matters: Choice, access and continuity of care in a safe service. 7 National Institute for Health and Clinical Excellence (2008) Antenatal Care: Routine care for the healthy pregnant woman. 8 Nulliparous is the medical term for a woman who has never given birth to a viable, or live, infant. 9 Department of Health (2005) Responding to domestic abuse. A handbook for health professionals. - 16 - learning is being added in reference to the research on adult males: 10Ofsted (2011) and Brandon et al (2010)11. Service Involvement with Child L and Adult N on 8th October 2012 A pre-alert call was received from the Ambulance to inform the local hospital (Hull Royal Infirmary) Emergency Department that Child L was being transferred to them requiring resuscitation and that cardio-pulmonary resuscitation had been commenced in the community. Area E1 of the Emergency Department was prepared for the emergency and specialist staff were in attendance when Child L arrived. No family members accompanied Child L on transfer to the hospital. It is unusual for a parent not to accompany a child under these circumstances. It became apparent the Adult N had been brought to the same hospital in a different ambulance following a fall. Parents are normally asked if they would like to be present during the resuscitation. In this case, because the parents did not arrive with Child L, they were unable to observe the resuscitation and be verbally prepared by staff for the death of their child which is the usual practice prior to the cessation of resuscitation. As the parents did not accompany Child L to hospital in the ambulance, on arrival in area E1 Dr Z took a history of events from the paramedics and examined Child L. Later, when Adult P attended area E1, Dr Z took a detailed history of events prior to the discovery of the child’s collapse, to inform assessment of Child L. Child L arrived at A&E at 08.22. Paediatric resuscitation continued until Child L was pronounced dead at 08.40. Dr Z informed Adult P of the death of Child L, accompanied by nurse Z, as Adult N was in area E2 of the Emergency Department at this point in time, awaiting assessment. Adult P informed Adult N of the death of Child L. Adult N, Adult P and Adult R were all able to hold Child L, whilst nurse Z maintained a discreet presence. Consultant Paediatrician Dr W was also present during this time. Working Together to Safeguarding Children (2010) and The Foundation for the Study of Infants Deaths (2005)12 recommends that parents and other family members are allowed the time to hold the baby. The staff in area E1 enabled this to take place. Dr W examined Child L within 1 hour of confirmation of death, and a full history was taken from both Adult P and Adult N to inform this assessment. Dr Z was concerned about Child L's skull fracture and the Police and Children’s Social Care team were notified of the unexpected child death, the definition of which is taken from Working Together (2010: page 212: para 7.21). The Sudden Unexpected Death in Infancy (SUDI) box was completed13. A Rapid Response Meeting was convened promptly, including the relevant staff identified at that time, and chaired by the Designated Paediatrician for Deaths in Childhood, in accordance with Working Together to Safeguard Children (2010). Adult N 10 Ofsted (2011) Ages of Concern: learning lessons from serious case reviews London: Ofsted 11 Brandon, M. Sidebotham, P. Bailey, S. Belderson, P. (2011) A study of recommendations arising from serious case reviews 2009-2010 University of East Anglia: Department for Education, DFE-RR157 12 Foundation for the Study of Infant Deaths (2005) Sudden and Unexpected Deaths in Infancy: Guidelines for Accident and Emergency Workers 13 This is a briefcase containing a contacts list and checklist of all the necessary tests, samples and forms required for the pathologist looking into the cause of death, which has been agreed with the local Coroner. - 17 - Adult N was brought to hospital area E2 by ambulance. After the death of Child L, Adult N returned to area E2 with Adult P and Adult R. Dr Z attended area E2 to assess and plan the care for Adult N’s injuries. This is good practice as this provided continuity of care for Family M, and offered Family M additional opportunity to ask questions of Dr Z. There was a difference in the history of events given between Adult N and Adult P. Adult N reported her collapse and hitting her head on the floor. Adult R reported that Adult N had “hit her head on a door jamb”. There are no recorded safeguarding adult concerns around the injury to Adult N. Following examination Dr Z diagnosed that Adult N had a “minor head injury and facial injury”. Adult N was discharged with advice regarding the management of the head injury. She was arrested by the police and taken into custody. Adult N returned to HEYHT area E2 that evening accompanied by the police, who had been concerned about her behaviour whilst in custody. Following triage, Adult N and the accompanying police personnel were escorted to wait in a separate room. Adult N was seen by Dr Y promptly due to the clinical concern regarding her head injury. She was discharged following investigations and a period of observation, without follow up care being required. Analysis of Services Provided on 8th October 2012 Management accountability for decision making was taken by the Consultants on the date of Child L’s death, which is appropriate and adheres to the HEYHT Policy for situations where abuse or neglect is suspected, and the guidance within Working Together (2010). The child death checklist was completed by nurse Z. This checklist is a HEYHT form which prompts the nursing staff to action, date, and sign when procedures/offers of support/contacts were actioned. The HEYHT Safeguarding Children Team were notified of Child L by area E1 staff whilst she was being resuscitated. A member of the Safeguarding Children Team contacted a senior police officer and the children’s social care team manager to alert them of the likely referral. This effective communication enabled suitably qualified police and social care personnel to attend HEYHT in a timely manner. The Designated Paediatrician for Deaths in Childhood convened a rapid response meeting which occurred the same day. The reporting of unexpected child deaths to the Police and Children’s Social Care followed the Guidance in “Working Together to Safeguard Children” (2010). Training and Supervision There were no outstanding issues identified for HEYHT in respect of staffing, and no escalation policies activated in respect of staffing numbers in the work areas which Adult N and Child L accessed. Therefore the issue of staffing has not been highlighted as an area of concern. Current HSCB Guidelines and Procedures are available on the HEYHT Safeguarding Children intranet site. The review of information within HEYHT illustrates that where the threshold of need for intervention was met, appropriate referrals were made in a timely manner to the appropriate agencies, following the HEYHT Safeguarding Policy and HSCB (2011) ‘Thresholds of need guidance’. - 18 - HEYHT has a target set by the Primary Care Trust, of 80% staff trained at Intercollegiate (2010) Level 2 Safeguarding Children Training. HEYHT’s performance against this target on 1st September 2012 was 82%. 5 of the 6 midwifery staff caring for Adult N and Child L are up to date with their Intercollegiate Level 2 Safeguarding Children training. None of the 6 midwifery staff were up to date with their Intercollegiate Level 3 Safeguarding Children Training at the time. However they could have sought advice from the Safeguarding Children Team if there had been any concerns of a safeguarding nature. Supervision arrangements for staff are described in the HEYHT Child Protection Supervision Guidance (2012). Staff that are not identified caseload holders have access to ad-hoc safeguarding supervision with a member of the Safeguarding Children Team who are based on the Acute Hospital site, on weekdays. Out of hours support can be sought from line managers and safeguarding children advice can be sought from the Consultant Paediatrician on call. No safeguarding supervision had been sought in respect of Family M as no risk factors or concerns had been identified prior to the death of Child L. Conclusion Adult N had in total nine antenatal appointments. She was seen by midwife Z for six of these appointments. During this period Adult N had ten contacts in the hospital and three postnatal contacts in the community. Midwife Z attended Adult N at two of these appointments. The midwifery service delivered to Adult N, Adult P, and Child L is an example of good continuity of care. The care delivered to Adult N during the period of this review was appropriate and timely, and met the HEYHT standards and guidelines. There were no safeguarding concerns identified and none were missed. When Child L died, an appropriate and timely referral was made to the Police and Children’s Social Care team. - 19 - 2.3 City Health Care Partnership Community Interest Company (CHCP) City Health Care Partnership CIC (CHCP) provides community health services to the City of Kingston upon Hull and surrounding areas. City Health Care Partnership CIC (CHCP), previously NHS Hull provider services, officially formed on 1st June 2010 as an independent health services provider separate to the commissioning organisation, NHS Hull. Amongst other services, CHCP provides community paediatric nursing, health visitors, school nurses, dentistry, public health and GP practices in a community setting. During the time period of the review, the north locality Health Visiting team consisted of 9.6 Whole Time Equivalent (WTE) staff and had one vacancy. The Health Visiting team covered both the Northern and Wyke boundary areas. Health Visiting teams use a corporate approach to the pro rata allocation of families to a named health visitor. It is regularly reviewed by the team with the clinical manager to ensure equity in terms of number of children, families and levels of need within each practitioner’s caseload. Health visitor caseloads are typically 400 per WTE14 which is consistent with other health visitor services nationally. Service involvement with Child L, Adult N and Family M Contact with Adult N The health visiting service’s contact with Adult N commenced when she was 34 weeks pregnant and included: • February 2012 - The first communication regarding Adult N was from Community Midwifery Services following Adult N’s attendance at the local maternity hospital. The Health Visiting Service was notified that Adult N had booked for care during her pregnancy and had been assessed by a midwife. The Antenatal Booking Summary provided the Health Visiting Service with information about Adult N’s family status, which was “single two parent”, her ethnic group, her occupation, family history and personal health history, including Adult N’s gynaecological and surgical history. No problems were identified; either related to Adult N's pregnancy or welfare issues. There is no record of the Routine Enquiry question about domestic violence being asked (the midwife did ask and Adult N said “no”). This would have provided information for the health visiting service about whether Adult N considered herself a victim of Domestic Violence either currently or in the past. It would have enabled a risk assessment to be made. As identified in section 2.2 there is no specific place on the midwifery booking form to record this. The only public health issue identified which could have impacted on the health and well being of Child L was that Adult N was a smoker. It was clear that the midwife had addressed this during her assessment but it was not clear if the advice given had been followed by Adult N. In the absence of other information relating to risk, this issue would not have led to Adult N being assessed as needing a service above the universal provision being offered. It is not clear if Adult P was present at the ‘booking in appointment’ but there is some limited information about his ethnicity and employment on the antenatal booking summary. 14 Why Health Visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. (Department of Health Policy Research Programme, ref. 016 0058) - 20 - • In March 2012, as there was no other liaison from midwifery services an assessment was made that Adult N should be allocated to the Universal/Corporate antenatal Health Visiting caseload. Based on the information held by Health Visiting services at this time this decision followed CHCP organisational practice. Following this assessment, Adult N was sent and attended an appointment at the antenatal clinic at her local health centre in July 2012. It is recorded that Adult N attended with Adult P and Adult R. The record details information about Adult P and refers to Adult R and Child S. Adult R’s first name is written in the record but the full name and date of birth of Adult R and Child S, as significant others in the same household, were not recorded within the generic health record. The Whooley15 questions have also been addressed. The framework covers areas of potential health concern and safeguarding risk including smoking, alcohol/substance misuse, support from fathers and safe sleeping. Specific discussion or information gathered is documented in more detail. Adult N declined a referral for smoking cessation. The records confirm that Sudden Infant Death, co-sleeping and shaken baby (“handle with care”) were discussed. It is also recorded that Adult N’s emotional health was assessed. The records identify that Adult N had no history or current signs of depression. The records also indicate that the Routine Enquiry question about domestic violence was not asked, the box was not ticked. This is confirmed by a written entry in the record stating that Routine Enquiry was not asked but without an explanation why it was not. • In August 2012 Adult N was seen again for a screening following a referral from the GP. Contact with Adult N and Child L • On the 31st August 2012 Child L's birth pack was received by the Health Visiting Team from Child Health Services. On receipt of this Adult N and Child L’s care was reassigned to Health Visitor #2’s caseload. The birth pack was then made available for Health Visitor #2 to review and to arrange the birth visit. Due to annual leave the health visitor did not return to work until 3rd September 2012. It was noted during the review that the letter to Adult N was not generated by the administration team until Monday 10th September 2012. The letter was to arrange an appointment for 13th September 2012 which was outside of the recommended birth visit by 2 days (Healthy Child Programme 2010). The short delay was due to the impact of annual leave. • On 13th September 2012 the primary birth visit was completed as planned by Health Visitor #2. Child L was 16 days old. The review of the records indicated that the assessment, which includes revisiting all the issues relating to health and potential safeguarding risk, was completed. This includes repeating the Routine Enquiry question for domestic violence. There is no record of a response to this enquiry. Health Visitor #2 has no recollection of asking the question therefore it has not been possible to establish if the Routine Enquiry question was asked. Health Visitor #2 did state that she would as routine revisit the Routine 15 The NICE Antenatal and Postnatal Mental Health Guideline (2007) recommend use of the Whooley questions in the antenatal and postnatal periods. During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things? Is this something you feel you need or want help with? - 21 - Enquiry questions if Adult N was alone at the follow up visit. The CHCP guidance for health visitors is that the Routine Enquiry questions should be considered at each contact. The assessment undertaken during the visit identified no unmet health needs or safeguarding concerns. This review has highlighted, however, that there was an opportunity for establishing if there was any domestic violence in the family home. The service level of need was assessed at Universal and Health Visitor #2 therefore booked the follow up visit for the 8th October 2012 with Adult N, when Child L would be almost 6 weeks old (5 weeks 6 days). A follow up visit between 6-8 weeks follows the universal core visiting programme (National Healthy Child Programme, 2010). • On 1st October 2012 Child L attended the Child Health Clinic and was seen by the nursery nurse which is standard practice. Child L's weight was recorded as 3560 grms which was an appropriate increase. The documentation suggests that Adult N had concerns about Child L's bowel movement and that Child L had oral thrush. The family were advised to see the GP. The nursery nurse assessed that the relationship between family members was appropriate and no health or safeguarding concerns were identified. • On 8th October 2012 Child L died. This was the same date that an appointment had been arranged with Adult N by Health Visitor #2 to complete the follow up visit. On 8th October 2012 following Child L’s death, the established operational Rapid Response process was instigated by the Hull and East Yorkshire Hospitals NHS Trust staff. This resulted in information being shared with Health Visitor #2 via the CHCP Safeguarding Children Team in a timely manner which prevented Health Visitor #2 visiting the property of Family M for a planned, routine review and prevented causing unnecessary distress to Family M and Health Visitor #2. Analysis of Involvement There was no information available to Health Visiting services during any contact with Adult N, Adult P, Adult R and Child L which raised any unmet or unaddressed health needs or safeguarding concerns. The care provided to Child L and Family M was generally compliant with CHCP standards in relation to service delivery, with the exception of the use of Routine Enquiry and of establishing significant others in the family. Adult N, Adult P and Adult R engaged with arranged appointments at the antenatal clinic and, following the birth of Child L, Adult N engaged with services at the birth visit. When Adult N, Adult P, and Adult R had concerns about Child L they actively sought support and guidance from Health Visiting services at a child health clinic. During the 2 post natal contacts, observation of the interactions with Child L, Adult N and Adult P appeared to demonstrate that Child L was being cared for appropriately by her parents and significant other. There were no emotional health issues identified in relation to Adult N. The protective factors in place were that Child L had both parents involved in her care and she was recorded as living in a two parent family. However, it is unclear from the records if her parents were living together following her birth. Adult N, Adult P and Child L appeared to be well supported by family members. They proactively - 22 - engaged with services, seeking support and guidance when necessary and appeared receptive to the advice given. There were no missed opportunities for intervention identified. Antenatal care New antenatal referrals to Health Visiting services are triaged on their receipt by the duty health visitor and are allocated according to clinical requirements. Triaging the antenatal booking form takes into consideration the information available to the service i.e. previously identified health needs or areas of concern. This means that those women assessed as having no additional needs are offered an antenatal clinic contact and those women identified as having additional needs are allocated to a named Health Visitor and a home visit is offered. A full health needs assessment is completed at this contact. Reviewing the care of Adult N during this period there are no significant areas of practice that would have influenced the outcome for Child L and no identifiable missed opportunities. Antenatal contact with Adult N took place when she was 34 weeks pregnant which is outside of the Healthy Child programme of best practice guidance of a contact at 20 to 28 weeks gestation. This was as a result of a capacity issue at this particular time which was identified by staff and service managers and extra clinics were arranged to address the delay. This review has highlighted the lack of clarity regarding the meaning of the term “single, two parent”, which appears to have been open to interpretation by health professionals. This reflects the importance of establishing significant others within family units. Taking into consideration information shared by midwifery services and Adult N’s response to issues discussed during the contact, the assessment of Adult N raised no un-addressed health needs or safeguarding concerns. There are, however, two issues that have been raised which might be more significant in other cases. Information About Significant Others The guidance on recording significant others in the family household was not followed as the information obtained was incomplete. Adult R and Child S were not identified, and detail of Adult P was not complete. Health Visitor #1 recorded that Adult N lived with Adult R and Child S but did not record their details as significant others. She did record the name, relationship and date of birth of Adult P. Significant others in families includes other family members. Recommendations made from a previous Serious Case Review (SCR. Family F 2011) stresses the importance of recording significant others in the child’s records. Health Visitor #1 had attended the training implemented following the last SCR in Hull. It appears she had taken this into consideration in her assessment in terms of Adult P but had not extended it to include Adult R and Child S. Review of the antenatal booking form has highlighted uncertainty regarding the use of the terminology regarding the family, in particular use of the term “single, two parent” and its definition. This illustrates the need for clarity and consistency across health partners with regards to language and communications. This review has highlighted the need to ensure that there is a process to systematically record significant others in the health care record. This requires addressing both in terms of the individual - 23 - practitioners concerned, to establish the quality of the practice of each, as well as across the service to ascertain the scale of this issue. Organisations will undertake an audit of records to establish if this is an isolated occurrence or if it is prevalent within the service. The findings of the audit will be addressed. Routine Enquiry About Domestic Violence The antenatal booking form has no specific place to record if the Routine Enquiry questions about domestic violence have been asked by a midwife and what the response to that enquiry was. Health Visitor #1 did not ask the routine question at the antenatal meeting she had with Adult N. Health Visitor #1 identified that she would not ask the questions when others were present due to the potential to escalate risk if the perpetrator of any domestic violence was present. She explained that she would leave the tick box empty to highlight to health visitors at future contact that Routine Enquiry had not been asked. The documentation was incomplete as the proforma within the generic health record used to evidence that Routine Enquiry had been considered or questions have been asked, was not completed. This proforma does include an option of a tick box to indicate that the questions were not asked because others were present. Health Visitor #1 did record more detail in her assessment of Adult N and her emotional health which, as identified earlier, did not identify any concerns and also that Adult P was a smoker and that they didn’t live together at that time. There was no alcohol or substance misuse reported. She recorded that she had not asked the Routine Enquiry question but did not record why she made that decision. On questioning she feels she didn’t ask it because others were present, but because the record is incomplete this is not conclusive. Not asking the Routine Enquiry question when others are present is within CHCP practice guidance due to the potential to increase risk to the mother and unborn/child if a perpetrator is present. The response, or the reason why the question was not asked, should be recorded, however, to inform future assessment and intervention. At the primary birth visit, the health visitor is expected to revisit all the issues relating to health and potential safeguarding risk. This includes repeating the Routine Enquiry question for domestic violence. There is no record in the primary birth visit of a response to this enquiry. The documentation is incomplete in terms of Routine Enquiry. Health Visitor #2 has no recollection of asking the question therefore it has not been possible to establish if the Routine Enquiry question was asked. It was not significant in this case as there is no indication of domestic abuse but it may be significant in other situations. Healthy Child Programme Health visiting services are delivered in line with the national Healthy Child Programme 2010. This follows a model of a universal core programme of service delivery to all antenatal mothers and fathers progressing to a programme of care and service that meets different levels of need and risk (progressive universalism). The Assessment takes place at each contact with the service user. It takes into consideration identified current need and future risks which inform the level of service provided. - 24 - The three service levels of need are; Universal which, as stated, is a core programme of care; Universal Plus, where a short time-limited increase in service is provided in response to an assessment of additional need, for example support with breast feeding; and Universal Partnership Plus programme of care which is provided where an assessment of health need has identified a child or their carer as having an additional health need, physical need and/or where there are safeguarding concerns around an unborn child or a young person. (Health Visitor Implementation Plan, DoH 2011) It is recorded that Adult N's antenatal assessment took place when she was 34 weeks pregnant which is outside the recommended best practice guidance of contact between 20-28 weeks gestation (Healthy Child Programme 2010). The reason for this was explored and during the summer months of 2012, including July, it was identified by the service that the regular clinics did not have the capacity to offer appointments within timescale to the number of antenatal mothers requiring an appointment. In response to this, extra clinics had to be arranged to ensure antenatal contact was offered to all antenatal mothers registered with the Health Visitor Services. The birth visit took place at 16 days which was outside the guidance of taking place ‘by 14 days’, and therefore identified as not being best practice. This was attributed to the health visitor being on annual leave at the time. Assessment at the birth visit did not identify any concern or risk in relation to the care of Child L. The service level of provision offered was therefore Universal which, based on the review of the information, was appropriate and in line with national guidance (The Healthy Child Programme, DH, 2010). The performance of CHCP in relation to meeting the targets set in the Healthy Child programme is assessed against an indicator set by NHS Hull CCG. Whilst the visits made to Adult N, both antenatal and for the birth visit, were outside the standard by 6 and 2 days respectively, this is not significant in this case. Training and Supervision The focus of the review of training is in three areas; Handle with Care, Routine Enquiry and the recording of significant others. In relation to this review, the injury Child L sustained raises issues about the health visitors’ knowledge of working with parents to enable them to develop the appropriate skills of handling vulnerable babies. Handle with Care training and information shared with antenatal/postnatal mothers was explored as part of this review. The last Handle with Care training session for staff from training records was February 2008. A new ‘Vulnerability of Babies’ training package was piloted in January 2012 which evaluated well. Health Visitor #1 has not had the Handle with Care training as she was not in post when the training occurred. Health Visitor #2 and the nursery nurse have had the training as they were in post when the training was available. Training on Routine Enquiry is provided by the organisation but is not systematic. The training records of the staff concerned with this family indicate that, whilst training has been accessed in the past, it pre-dated the current record keeping process. The training therefore is likely to have been provided a minimum of four years ago. Training on Routine Enquiry needs to be systematic and monitored by the management team as with other safeguarding training. - 25 - Training on the recording of significant others in families has been incorporated into the Record Keeping Training since 2010 following a previous local SCR recommendation. All staff working within Children and Young People’s Services were provided with access to training and three training sessions are provided annually to address new staff. It is noted however that Health Visitor #2 did not attend this training. This training also includes identifying and supporting male victims of domestic violence. All staff have access to supervision provided by the Safeguarding Children Team. The health visitors who are caseload holders receive regular safeguarding supervision at a minimum every three months. Health Visitor #1 and Health Visitor #2 were compliant with this requirement. Health visitors are also able to access the safeguarding team whenever they have concerns. The performance of CHCP relating to clinical and managerial supervision is assessed against an indicator set by NHS Hull. There were no safeguarding concerns identified in this case which would have indicated a need for discussion in supervision with a supervisor. - 26 - 2.4 Yorkshire Ambulance Service NHS Trust Yorkshire Ambulance Service (YAS) NHS Trust was established on 1st July 2006 when the county’s three former services merged. Currently, YAS employs 4,358 staff, who, together with over 3,000 volunteers, provides a 24-hour emergency service to more than five million people; approximately 1.2 million of those are under 18 years of age. YAS currently attends on average 3 unexpected child deaths a week, and consistently makes over 250 referrals to Children’s Social Care for vulnerable children a month. The Safeguarding Team within YAS consists of 2 Named Professionals for Adults, 1 Named Professional for Children and the Head of Safeguarding. Service Involvement with Child L and Adult N Incident 1 There is no record of YAS contact with Family M outside the timescales of the review. The first contact was on 8th October 2012 when YAS received a 999 emergency call regarding a 6 week old child who was stated by the caller, Adult P, to have stopped breathing. The YAS member of staff from the Emergency Operations Centre (EOC) confirmed details with the caller and provided directions to initiate Basic Life Support (BLS) until the ambulance arrived. A Double Crew Ambulance (DCA) was sent to the incident and Paramedic1 (Para1) and Advanced Practitioner1 established that Child L was in cardio-respiratory arrest. The attending YAS staff made the decision to remove Child L to the Emergency Department (ED) at Hull Royal Infirmary (HRI). The adults in the home were asked who would travel with the child but as there was no response Para1 made the decision to convey Child L to hospital as quickly as possible for treatment and left without any adults to accompany her. The DCA left the incident with a turnaround time of 2 minutes. AP1 made a pre-alert call to request that HRI ED staff were made aware of an impending paediatric cardiac arrest. Six minutes later the DCA arrived at the ED. BLS was continued throughout the journey. On arrival the patient was taken to the paediatric resuscitation area and handed over to the awaiting staff. There was no handover signature obtained from ED staff by Para 1. YAS EOC informed the local Clinical Supervisor of the incident, who went to the ED to offer immediate support for the staff. Para 1 and AP1 completed a referral to Children’s Social Care via the YAS Clinical Hub in line with policy and procedure following the event. The Clinical Supervisor remained at the ED with the staff and returned to the ambulance station with the crew to complete a Post Incident Care report. This process also informs the YAS Safeguarding Team of an unexpected child death and was only recently launched following lessons learnt from another child serious case review. Incident 2 - 27 - YAS received another 999 emergency call to attend the address of the previous incident 3 minutes after the DCA had left the address on 8th October 2012. The adult female caller indicated that her daughter’s baby had just been taken by an ambulance to hospital and that she needed help for Adult N. On arrival, Para 2 was shown to the patient, Adult N, who was still on the bed. The supporting DCA arrived at the incident two minutes later. Para 3 and AP 2 entered the house. Para 2, Para 3 and AP 2 were informed that Child L had just been conveyed to Hospital #1. A set of primary clinical observations were recorded for Adult N and some bruising, swelling and abrasions to her left eyebrow and left shoulder noted. Adult N was conveyed to HRI. Adult R travelled with Adult N to hospital as they thought this necessary due to the situation. Adult N was described as being in a highly distressed state throughout the journey, but only required basic care with no further clinical interventions. On arrival at HRI Para 3 provided a clinical handover to staff, and a signature was obtained on the Patient Report Forms (PRF) as per procedure. Para 3 escorted Adult N to the resuscitation area where Child L was being treated. Analysis of service involvement The appropriate service was provided by YAS during both incidents. The 999 calls were handled and graded appropriately. The attending YAS practitioners during incident 1 were faced with a critically ill child. Staff recognised the significance of the cardiac arrest Child L had suffered and transferred her to hospital. Practitioners acted appropriately in transferring Child L to the nearest children’s Emergency Department (ED) as recommended in Joint Royal College Ambulance Liaison Committee (JRCALC) guidelines (2006) for children under 18 years of age. The crew recognised the child was critically ill and made the right decision to request a full resuscitation team to attend at the ED. This decisive action followed YAS Policy. Their initial clinical assessment and management of Child L highlighted two areas of concern regarding treatment of Child L and PRF completion standards. The IMR author identifies that the incident with Child L focussed on resuscitative efforts and at the time gaining further information about the incident would have been very difficult. It is noted that no adults travelled in the ambulance whilst Child L was being resuscitated. Had this been the case, then there may have been opportunity to obtain more information about the incident and issues regarding family functioning during the journey and on immediate arrival at hospital. YAS provided emergency assessment, treatment and transport to an ED for Child L and Adult N. The emphasis on dealing with 999 emergency calls is dictated by the requirement for a rapid telephone assessment, response and dispatch of appropriate resources. National response targets require ambulance services to reach 75% of Red Calls within 8 minutes. This target was achieved during incident 1. During Incident 1 YAS practitioners appear to have made the correct assessments and decisions during the initial management of the incident. A total of 2 minutes was spent at the address assessing the patient. Unexpected child death procedures in YAS were followed and the decision - 28 - to convey Child L to hospital for further assessment and treatment was the correct action to take. A Clinical Supervisor was informed of the incident by the EOC and immediately attended the ED to support the staff. This support enabled assistance with completion of a referral to Children’s Social Care and completion of Post Incident Care documents and for provision of support to the attending staff. The Safeguarding Team were also notified of the incident and discussed the case with the Clinical Supervisor the same morning. This should be highlighted as the expected level of support for emergency service staff that are faced with such demanding incidents. It must be acknowledged that the post incident care (PIC) process in YAS is a new and innovative process amongst UK ambulance services and appears to have worked well during and immediately following incident 1. A review of YAS staff support in 2012 was completed as a result of another child serious case review in Yorkshire. It was identified that YAS had numerous policies and procedures in place relating to the health and well-being of staff, but no method of capturing and collating the data across the Trust. The PIC process was introduced in August 2012. The system is intranet based and whenever staff receive care and support following a traumatic or distressing event, this is captured following completion of the document. If the event relates to child protection or an unexpected child death, then the system also generates an immediate e-mail to all members of the YAS Safeguarding Team. This serves numerous purposes of notification, but just as importantly, delivers early help and support to frontline practitioners dealing with distressing incidents. A PIC interview was also completed for the EOC call handler who dealt with the 999 call for incident 1. Members of staff disclosed that incident 1 was their first paediatric cardiac arrest and that they had found the event extremely distressing. Children’s Social Care was appropriately and promptly informed the same day, which is expected practice in this situation. The YAS staff recognised the potential indicators of abuse/neglect and acted appropriately in line with YAS ‘Safeguarding Children and Young People Policy and Procedure’ (March 2011) when there are concerns raised about a child(ren) at an incident or attendance at a child death. The Safeguarding Team requested that the Patient Report Forms (PRF) for the incident were secured and forwarded for immediate attention for subsequent CDOP processes. Whilst not contributing to the death of Child L the review of the PRF identified that the quality of completion was below standard and that some elements of the resuscitation were also below standard for incident 1. The YAS Head of Safeguarding consulted the locality Clinical Manager and Clinical Development Manager and it was agreed that a Clinical Case Review (CCR) would be convened to address the identified areas. The Clinical Case Review was completed on 9th November 2012 and Para 1 and AP 1 received actions as a result of the review. These actions are: • Complete two reflective accounts based on medical document completion and paediatric resuscitation. • Attend a Paediatric Advanced Life Support Course. - 29 - • Attend the Hull and East Riding Child Death Rapid Response Training Para 1 and AP 1 accepted that some of their judgements may have been rushed and affected by the distressing nature of the event. This issue was discussed during the CCR and further help and support was offered by the panel. The YAS EOC constantly audit 1% of 999 emergency calls for compliance against national standards. Both calls were audited at 100% compliance in respect of asking the correct questions, providing the correct advice and customer care elements. The attending staff (Para1) during incident 1 did not follow YAS guidance for PRF completion in relation to these issues during the event. Para 3, however, did complete these areas on the PRF during incident 2. There were different demands placed on Para 1 and Para 3 in the separate incidents. Incident 2 appears to have been a more controlled environment, whilst still physically and mentally challenging for the attending staff. It is normal working practice for ambulance personnel to work as autonomous professionals when responding to emergency and urgent cases, following calls for help. The evidence relating to staff in this case clearly demonstrates that first line supervisors and staff in managerial positions were informed about both incidents at relevant points during and after the event. YAS provides safeguarding children and child protection training for frontline practitioners which is compliant with the Royal College of Paediatrics and Child Health (RCPCH) 2010 inter-collegiate guidelines. A review of safeguarding training status of the members of staff involved in the two incidents demonstrates that 4 of the 5 staff who attended the incidents were compliant at the time. The review of training reports indicate that Para 2 had dropped from compliance at the time of incident 2. A subsequent check of all staff from YAS Workforce Information reports, demonstrates that all 5 staff are currently compliant with training requirements for level 2. Conclusions The incidents identified during this review are typical of demands in pre-hospital emergency care. The nature of care in this field dictates that all elements are conducted with swift responses in mind. A quick triage through the EOC, rapid deployment of resources and a quick assessment and transport of patients were required. All of these elements were compliant within this sequence of events on the 8th October 2012. YAS EOC staff and frontline practitioners usually have no knowledge of the child and family functioning or background. This does present particular problems for ambulance services when entering homes and houses particularly regarding information sharing and accessing background knowledge that other professionals and agencies have. This issue is compounded by the time spent with service users as in incident 1, when the YAS staff spent only 2 minutes at the home address. 2.5 Health Organisations - General Issues Child death review processes - 30 - Following the death of Child L, child death review processes were instigated and organisations secured their records in line with the national guidance (’Working Together’ Chapter 7, March 2010). The case was reported through the NHS critical incident reporting system to the Yorkshire and Humber Strategic Health Authority. The NHS Mental Health Service provider for Hull and East Yorkshire was asked to screen their records which revealed no contact with Adult N or Adult P. On 7th January 2013 and 14th January 2013 meetings were co-ordinated by the Designated Nurse and Doctor for Safeguarding Children with the HEYHT, CHCP and Primary Care (GP) IMR authors in order to discuss initial findings collectively and identify any immediate actions to be taken. It is positively acknowledged that, where possible, provider organisations have already taken action in regard to some findings. In addition, individual authors have been given support and guidance regarding the process by the designated leads. Guidelines and Procedures All three organisations involved in the provision of health services to Family M have safeguarding children guidelines and procedures relevant to their organisations which are regularly reviewed and are accessible to staff. Procedures are in line with HSCB Guidelines and Procedures. The HSCB has a Guidelines and Procedures Sub-Committee on which the Designated Nurse sits in addition to the Named Nurses for the key health provider organisations. Therefore, there is an effective route to disseminate any changes and updates to the HSCB guidelines and procedures within health organisations. There are no issues identified in this review in relation to an absence or inadequacy of safeguarding children policies and procedures. Training and Supervision In July 2009 the Care Quality Commission published a report16 following a review of safeguarding arrangements in the NHS. It identified areas for improvement including safeguarding children training levels. Therefore, all Trusts were required to review their services to ensure the necessary improvements were being made and publish a declaration of compliance prior to registration with the CQC in April 2010. NHS North of England Area Team have continued to monitor compliance on a quarterly basis. Currently the Hull CCG and all local Trusts are compliant. GP practices are also now required to be registered with the CQC and to have training arrangements in place. Both HEYHT and CHCP have current safeguarding children training strategies. Training uptake is monitored by HEYHT and CHCP internally and via the NHS Hull CCG Safeguarding Assurance Board. GP and practice staff training uptake is also monitored by the NHS Hull Safeguarding Assurance Board. Training issues are monitored by the HSCB safeguarding training sub-committee. Level 1 and 2 safeguarding children training (Intercollegiate Document 2010)17 is delivered as single agency training within the ‘family’ of health providers. It is recommended in the Intercollegiate Document 2010 and in Working Together to Safeguard Children 2010 that midwives receive inter-agency training. IMRs identified that the majority of staff 16 Care Quality Commission (July 2009) Review of Arrangements to Safeguard Children in the NHS CQC 17 Intercollegiate Document (2010) Safeguarding Children and Young people: roles and competences for health care staff. Royal College of Paediatrics and Child Health - 31 - who had contact with Adult N and Child L had received the required level of training. However, although trained to Intercollegiate Level 2 none of the 6 midwives involved in the care of Adult N and Child L have received inter-agency safeguarding children training. This is not considered to have had an impact on the outcome for Child L in this case. The HSCB is aware of the historical difficulties of some agencies in accessing multi-agency safeguarding children training and this is being addressed through the Training sub-committee. A revised HSCB training strategy has now been ratified (January 2013). Its implementation should be prioritised. A process of case supervision is in place on an ad hoc basis in GP surgeries to enable GPs to discuss cases of concern. It is also a local requirement that each GP practice has an identified child protection lead. This requirement is in place in the GP practices offering services to Family M. Additionally, there is a Named GP and a Designated Doctor for Safeguarding Children as well as other safeguarding children professionals to whom GPs have access for advice and support. It was not necessary to seek safeguarding advice or supervision from those professionals in the case of Family M. Both CHCP and HEYHT have adequate supervision processes in place although it is less clear what arrangements are in place for community midwives. Nursery nurses receive supervision from the health visitor who is the caseload holder for the child and family. Practice Most of the practice evidenced within the three IMRs was of the expected and required standard. Additionally, there is some evidence of good practice. In general, decision making was appropriate and recording of decisions was clear although there are some areas that need further consideration: • There was no consideration by the GP of communicating with the health visitor in relation to Adult N presenting with low mood in the postnatal period. • Documentation was not rigorous in recording Routine Enquiry or the significant members of a household. • The role of Adult P as a significant partner was not well understood or documented. - 32 - 2.6 Hull City Council Hull City Council Adult, Children & Family Services Directorate Safeguarding Children Service Area Children’s Social Care services had no involvement with Child L or any other members of the Family M during the time period under review. For this reason no IMR was produced by Children’s Social Care. Learning & Skills Service Area During the period under review no concerns or reports were raised in relation to any member of Family M. For this reason no IMR was produced by Learning Services. Hull City Council Neighbourhoods and Housing Directorate IMR Neighbourhoods and Housing is an integrated housing service which involves the Housing and Wellbeing Team, the Housing Investment Team, the Housing Strategy and Renewal teams and the Area Teams working together to deliver a full range of housing and regeneration activity and services within the city and across housing tenure. Service Involvement Adult N submitted an application for council accommodation for her and Child L in June 2012. She was pregnant and stated in her application that she had been asked to leave her family home. Adult N was sent information advising her that she should contact the Options Team for further advice. However she did not make any subsequent contact with any department in Neighbourhoods and Housing in connection with her application and she did not place any bids for properties that were advertised. During the review period, contact with the household in connection with tenancy management was in the course of carrying out repairs to the property. Routine repairs resulted in several members of staff attending the property during the period between Child L’s birth and death. Child L was seen on at least one occasion. None of the staff who attended the property identified any issues or concerns. Analysis of Involvement The service provided to Adult N in connection with her application for accommodation was standard and in accordance with internal procedures. There were no safeguarding issues or concerns identified. The tenancy management service provided in connection with the tenancy held by Adult R was standard and in accordance with internal procedures. There were no safeguarding issues or concerns identified. Adult N’s only contact with Neighbourhoods and Housing was the application for accommodation which she submitted in June 2012. It appears that the application form was completed by Adult N and she declared just herself and Child L as wanting rehousing. - 33 - Adult N stated in her application that she had been asked to leave her current accommodation and she stated that there was “too much animosity in the house. Not enough room for me when baby arrives, myself and teenage brother always arguing. My mum is disabled and sick of the atmosphere”. She also stated that she needed to be rehoused close to her family to provide support stating that “my mum is disabled and needs me to help dress and wash her, go to shops etc”. Adult N was sent a letter advising her that she should contact the Options Team at the Centre for further advice. Adult N did not make any subsequent contact with Neighbourhoods and Housing in connection with her application and she did not place any bids for properties that were advertised. This limited information suggests that there may have been pressure in the household prior to the birth of Child L. However there was no further contact from Adult N, or any other member of the household, in connection with the application and there were no incidents or information that staff in Neighbourhoods and Housing were aware of that raised any concerns in respect of Child L either prior to or after her birth. Safeguarding procedures are in place throughout Neighbourhoods and Housing. Safeguarding Children procedures were formally reviewed and updated during 2012. These were endorsed by the HSCB in May 2012 then disseminated to all members of staff within Neighbourhoods and Housing. A 3 year training schedule delivered via HSCB is in place to ensure that staff have appropriate up to date awareness training. Repairs and Maintenance Contracts have reference to a Corporate Social Responsibility including safeguarding. Conclusion During the review period the only contact with the household by Neighbourhoods and Housing was in connection with repairs to the property and the application form submitted by Adult N for rehousing. In all instances standard procedures were followed, there were no concerns identified and consequently no actions taken. Based on a thorough investigation of the limited involvement the service had with the household it is the overall conclusion of this IMR that there were no opportunities for intervention that were missed and that Child L’s death could not have been anticipated or prevented by Housing staff. - 34 - 2.7 Humberside Police Humberside Police Force covers the unitary local authorities of North East Lincolnshire, North Lincolnshire, East Riding of Yorkshire and Kingston-upon-Hull. Humberside Police employs 1,829 police officers and 1,956 police staff. In 2005 Humberside Police formed Major Investigation Teams (MIT’s) with the key aim of enhancing performance and following national best practice within major investigations. There is one MIT for the Force, with bases within each of the three Force Divisions. The MIT is managed by a Detective Superintendent who reports to the Head of CID. The Public Protection Team in Hull is a dedicated team which has the responsibility for, 1. Protecting children 2. Tackling domestic abuse 3. Protecting vulnerable adults 4. Tackling honour-based violence 5. Managing sex and violent offenders (and other potentially dangerous people) 6. Dealing with missing people 7. Assessing rape investigations for inclusion within public protection arrangements 8. Tackling prostitution The Team are overseen by a Detective Chief Inspector and have an establishment of 2 Detective Inspectors, 7 Detective Sergeants, 44 Detective Constables, 7 Investigating Officers (at scale 5 ) and 12.5 support staff which includes a Juvenile Liaison Officer. The total establishment is 76.5 staff. Service involvement Humberside Police did not have contact with either Adult N or P during the timescales of this review, until the admission of Child L to Hull Royal Infirmary on the 8th October 2012. The criminal investigation initiated in response to Child L’s death resulted in Humberside Police having contact with all family members involved in this review on 8th October 2012 and beyond. The initial report of Child L’s attendance at Accident and Emergency was made to Humberside Police by nurse #1 directly to police officer #1, a Dedicated Decision Maker who works within a co-located team with Children’s Social Care. A joint decision was made by police officer #1 and social services manager #1 about the required response and an agreement was made for the case to be investigated jointly between Humberside Police and Children’s Social Care in accordance with Section 47 Children Act 1989. Police officer #1 immediately brought the situation regarding the death of Child L to the attention of police officer #5, a Detective Inspector in the Public Protection Unit who attended the hospital with staff to obtain further information and assessment of the case. Following an initial assessment of information and evidence available to police officer #5, the case was referred to police officer #7, a Senior Investigating Officer within the Major Incident Team, who took overall responsibility for the criminal investigation. - 35 - Adult N and Adult P were arrested at HRI on suspicion of the murder of Child L. The decision to arrest Adult N and Adult P was based on early enquiries and information received from hospital staff that the injuries sustained to Child L were potentially non-accidental, and that Child L had been in the care of both Adults prior to her admission to hospital. As the death of Child L was being treated as suspicious, arrangements were made for a Home Office post mortem to be undertaken at a hospital out of area . It is National and Humberside Force Policy for police to deploy Family Liaison Officers to families when an investigation is being undertaken into an unexplained death. Family Liaison Officers were deployed to Adult R and to the paternal grandparents of Child L. Following their arrest, Adult N and Adult P were interviewed by officers from within the Major Investigation Team. Adult P was subsequently released unconditionally from police custody. Adult N was released on police bail. Analysis of service involvement This case demonstrates good working relationships between Humberside Police and partner agencies, in particular with Children’s Social Care. Both agencies have a lengthy history of working together on investigating child abuse allegations jointly. The co-location of Humberside Police with Children’s Social Care allowed for immediate information sharing taking place between the agencies, which directly informed the decision making. There was good communication between HRI, Humberside Police and Children’s Social Care and decisions made between agencies were in accordance with HSCB Guidelines and Procedures. Detailed records were maintained by Humberside Police in respect of key information sharing during the earlier stages of the criminal investigation. There were no organisational difficulties experienced either within Humberside Police or with external partners. This allowed for initial attendance at the hospital to be undertaken by Specialist staff and Supervisors from within the Public Protection Unit, who identified and undertook immediate lines of enquiry and information gathering in order to secure the existence of forensic and medical evidence to support the criminal investigation. From the point of referral, the criminal investigation was directed and managed by a Supervisor from within the Public Protection Unit, with overall responsibility for the case being undertaken by a Senior Investigating Officer from the Major Incident Team The investigation into the death of Child L was undertaken in accordance with Force, National and HSCB Guidelines and Procedures. All staff involved in the case were working in the fields of Public Protection and Major Incident Teams, therefore conversant with the investigation of Serious and Complex Crimes. Appropriate Supervision for the case was in place. Initial attendance at the hospital was undertaken by a police officer #5 who is a Detective Inspector from the Public Protection Unit. - 36 - This officer has worked in the field of public protection for a number of years, has been trained at a National level on the Investigation of Sudden Deaths in Childhood and has previous experience of investigating childhood deaths. Police officer #5 also represents Humberside Police on a number of groups within HSCB , including the Child Death Overview Panel (CDOP). The criminal investigation was managed and overseen by police officer #7 who is a Detective Chief Inspector within the Major Incident Team and a Senior Investigating Officer. This officer is highly trained in the investigation of childhood deaths, having attended a National Senior Investigating Officer course and undertaken the National training from the NPIA on the Investigation of Sudden Deaths in Childhood. Police officer #7 delivers training with two Local Safeguarding Children Boards on Rapid Response Procedures to child deaths and has done so for the last five years. This officer has also previously worked within the field of Public Protection and investigated previous deaths of children. The conduct of the criminal investigation was sensitive to the racial, cultural, linguistic and religious identity of Family M. There is no record of any issues identified regarding communication, or the social or economic environment in which Family M resided. Humberside Police has in place policies and procedures in respect of safeguarding and promoting the welfare of children. The Force has a practice direction entitled – ‘Unexplained Child Deaths – Police Action,’ which was last updated in June 2012. This document supports national police guidance contained within a number of documents including – ‘The Murder Investigation Manual,’ NPIA (National Police Improvement Agency) – ‘Guidance on Investigating Child Abuse and Safeguarding Children 2009,’ ‘Chapter 7 Working Together to Safeguard Children 2010’ and Local Safeguarding Children Boards Guidelines and Procedures. Access to Force policies, National guidance and HSCB Guidelines and Procedures is available to all staff via the Force Intranet, which is accessible 24 hours per day. Humberside Police are in the process of ensuring all Detective Supervisors and Senior Investigating Officers, within Public Protection Units and Major Incident Teams receive training on the National Police Improvement Agency course on ‘Investigating Sudden Childhood Death.’ This is a specialist accredited course aimed at Supervisors investigating unexplained childhood deaths, particularly in relation to babies and young children. Conclusion As Humberside Police had no contact with Family M prior to Child L’s death there is no evidence from this review which identifies that the death of Child L could have been prevented or anticipated. There were no missed opportunities for intervention by Humberside Police or information known around any potential risks posed to Child L. What is apparent from the review is that the police applied policies, National guidance and HSCB Guidelines and Procedures and that there was effective multiagency working in response to Child L’s death. SECTION THREE - LEARNING LESSONS. IMPROVING SERVICES. - 37 - The specific Working Together18 terms of reference (a) to (c) (8.5) required in every SCR are reflected throughout the lessons to be learned. Specific terms of reference are identified at the end of the section: • establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children. This section of the report identifies conclusions that have arisen from this detailed review of the services provided to Child L, Adult N and Family M. Some of the issues identified do not relate directly to Child L's death but provide an assessment of her and her family’s journey and contact with services. Overall Conclusion Adult N and Child L were known to universal services only and therefore there was no history of involvement of Children's Social Care services. The social, cultural, and economic environment in which the family were living had no impact on this case or on the way in which professionals operated. Adult N's post natal depression and the GP's knowledge of the history of Adult N, Child L and family health problems should have resulted in Adult N being referred to the midwife or health visitor who could have provided additional support which may have assisted in safeguarding Child L. However if this action had been taken it is unlikely to have either anticipated or prevented the death of Child L. 3.1 LEARNING LESSONS 1. What is obvious from reviewing the IMRs from the different agencies that provided services for Child L and Adult N is that there are areas of notable practice. This included: • Adult N had a total of nine antenatal appointments and saw the same midwife for six of these. Adult N received two postnatal contacts and saw the same midwife on both occasions. The author considers this indicates a high level of provision of continuity of care. 8 out of 11 of the community midwifery contacts with Adult N were carried out by the same midwife which provides a high standard of continuity of care within community midwifery. • Where an applicant states on their housing application that they have been asked to leave their current accommodation, for example as a result of relationship breakdown, the applicant is sent information advising that they should contact the Housing Options Team for further advice and support. Although in this instance Adult N did not seek further advice or support, this practice demonstrates a joined up approach which helps to raise awareness of the service provided by the Housing Options Team in providing advice and support for people in housing need. 18 Working Together to safeguard children 2010 DCSF - 38 - • The pre-alert call made by the Ambulance staff to the HEYHT which facilitated the arrival of key members of staff in the resuscitation room prior to the arrival of Child L. • The referral to the police being made directly to the Detective Inspector of the Public Protection Unit rather than a 999 call. This is an example of good inter-agency activity. • There is evidence of good information sharing and inter-agency working with partner agencies and Humberside Police following the admission of Child L to hospital, as well as good communication and working within the police service between Public Protection Unit and Major Incident Team. • The report highlights the demands placed on professionals in cases of the unexpected death of babies and children. Having identified from a previous SCR the potential emotional impact of pre hospital care from both the YAS EOC and front line staff perspective, YAS have developed their Clinical Supervision Policy and Procedure to ensure that in such cases, general clinical supervision is provided at local level to all operational and front-line staff via locality Clinical Supervisors (CS) and Clinical Managers (CM). • The co-location of Humberside Police with Children’s Social Care allowed for immediate information sharing taking place between the agencies, which directly informed the decision making between both agencies, the joint investigation and commencement of a criminal investigation • The referral to Children’s Social Care being made directly to the team manager. This is an example of good inter-agency activity. • The same senior Dr examined both Child L and Adult N, which is an example of consideration for the needs of Family M. • The care of Child L and attention to the parent’s cultural and religious views in respect of Child L. There is evidence of sensitive practice in relation to arranging a blessing for Child L by the hospital chaplain and ensuring the privacy and dignity of Adult N whilst in the A&E department under police escort. • Enabling Family M time with Child L in a quiet environment following her death. 2. There has been a considerable amount of work undertaken in Hull with agencies and individual practitioners to increase their knowledge and understanding of child protection and also thresholds of need. What this Review identifies is that there remain issues with some practitioners recognising their role in safeguarding children. Safeguarding children and young people has been defined as: All agencies working with children young people and their families taking all reasonable measures to ensure that the risk of harm to children are minimised and where there are concerns about children and young people’s welfare all agencies taking appropriate action to address those concerns working to agreed local policies and procedures in full partnership with other local agencies 19 Child protection is a part of safeguarding and promoting welfare. It refers to the activity that is undertaken to protect specific children who are experiencing, or are likely to suffer, significant harm. Effective child protection is essential as part of wider work to safeguard and promote the 19 The 2nd Joint Chief Inspectors’ report on arrangements to safeguard children 2005 - 39 - welfare of children. All agencies and individuals are expected to proactively safeguard and promote the welfare of children so that the need for action to protect children from harm is reduced. Early intervention is crucial to ensuring the best outcomes for children and young people where their safety is an issue. Universal services, like GPs, have to play a key role in the identification of safeguarding issues, early intervention and appropriate referral to other agencies. The GP did not consider a possibility of safeguarding issues related to Adult N's depression. This should have resulted in the GP making contact with other professionals to establish if there were issues related to safeguarding. 3. Multi/trans-agency working is key to ensuring the effective provision of safeguarding services. Reder and Duncan20 identify the danger of professionals failing to share discrete pieces of information. The knowledge held by an individual agency may not, on its own, appear worrying but, when collated, the overall picture may indicate a more significant level of concern and risk. Effective intervention will draw on a range of professional perspectives and will require a coordinated response from all professionals and services involved. Clear co-ordination is also necessary to avoid overwhelming the family or individual and to prevent confusion in the professional network. Intervention strategies need to be congruent with the findings of the assessment. This requires a flexible approach and the ability to match intervention to identified needs. A wide range of formal and informal responses may be needed in any one case to increase the family’s ability to offer appropriate care to children. Within the IMRs from CHCP and the GP there is no evidence of communication between the GP and the health visitor or midwife regarding an attendance at the GP surgery by Adult N. It has been a recommendation of a previous local Serious Case Review (Child F 2011) that communication between health visitors and GPs is improved. Information sharing systems are integral to competent safeguarding practice but this not only requires robust systems and protocols, it requires practitioners to simply communicate across organisational and service boundaries. Communication between key health professionals (GP and health visitor) was not evidenced in this review. There remain issues associated with health professionals gaining access to information across agencies and with GP Practices and being sufficiently aware to share it with each other. 4. The previous local SCR completed on Child F in 2011 identified the importance of all agencies working with children and their families to demonstrate how the role of fathers and men in households are considered in service provision and assessments. Ofsted (2010)21 identified gaps in serious case reviews where “information from or about fathers, whether living at home or elsewhere, and other adults living in the home” might have contributed to a better understanding of the children and their families. A previous local serious case review in 2011 recommends “All agencies working with children and their families will demonstrate how the role of fathers and men in households are considered in service provision and assessments. All staff working with children and families should assess the status and role of males and new partners living in the same household”. 20 Reder, P. and Duncan, S. (1999) Lost innocents: a follow-up study of fatal child abuse, London: Routledge 21 Ofsted (2010) Learning Lessons from serious case reviews 2009-2010, London: Ofsted. www.ofsted.gov.uk/publications/100087 - 40 - High quality assessments based on a holistic picture of a family are important in order to adequately safeguard children. This case illustrates that, on occasion, assessments made particularly by the GP, midwives, hospital staff and health visitors were not based on full, in-depth information; for example, there was a lack of curiosity about the exact role of Adult P, the extent the health needs of Adult R impacted on her supportive role and the level of attachment between Adult N and Child L. The issue is not just one of recording but also that the appropriate safeguarding culture is in place to ensure that professionals are committed to identifying significant others in a child's life. This is not just a local issue. The Ofsted report (2010) identifies descriptive evidence of the mother’s (or female carer’s) current parenting capacity was available at respectable levels (high or medium) in 83% of cases. A lower figure of 52% was achieved for information about father’s (or male partner’s) parenting capacity. However, in 55% of cases in which there was a mother/female carer and 69% of cases in which there was a father/male present, there was little, if any, information about the carer’s own developmental and relationship history. 5. Perinatal depression and anxiety affects 15% of women in the antenatal period and 10-20% in the postnatal period22. Perinatal depression is a spectrum, with Puerperal psychosis at one end, and mild "baby blues” at the other. But in the middle of these two extremes, many, if not most, new mothers experience profound lows as they struggle to adjust or cope with their changing lifestyle. The true incidence is probably far higher, for postnatal depression is often missed or misdiagnosed. The symptoms of feeling low and despondent, tired and lethargic, inadequate, irritable, tearful and unable to cope, as well as loss of appetite, insomnia and physical symptoms such as headaches and stomach pains are easily explained away by common postpartum experiences such as broken sleep, changes in marital relations and impaired health as a result of the physiological stresses of pregnancy and childbirth. Women are often reluctant or simply too tired to consult doctors, particularly if they expect having a baby to be nothing but a source of joy. Adult N presented to the GP, with Adult R, complaining of feeling “low, tearful and unable to cope”. Anti depressants were prescribed by the GP and a blood sample taken which identified borderline anaemia. There is also some description in the record to indicate an unsettled baby. Although the symptoms exhibited by Child L are relatively common and mild, the effects on an individual’s coping skills in the early postnatal period should not be under-estimated and should be a trigger factor for the offer of additional support. It is noted that the GP did ascertain some potentially supportive, protective factors; one key support being Adult R. The GP had a full history of family health problems which could have been used to inform an assessment of the overall support mechanisms within Family M. This information was not considered as part of a holistic picture. There is no evidence that this had an impact in this case. However, there was an opportunity to share this information with the health visitor or midwife to provide a more holistic overview, further assessment and potentially provide additional support. Adult N feels that she received limited support from her GP during pregnancy and following Child L's birth and that she was not depressed when she saw the GP and only took one of the prescribed antidepressants. She would have valued more support. 22 Routine postnatal care for women and their babies. NCCPC 2006 - 41 - locally. The Government have recently announced that to help identify and support women who may be at risk of postnatal depression every maternity unit in England will have a dedicated mental-health midwife by 2017. 6. The NHS often provides the one setting where adults or children feel able to disclose, and it is, therefore, imperative that the services are aware of the need to provide safe spaces for early identification and prevention of domestic abuse. This Review has highlighted the need to review the use of Routine Enquiry and the recording of significant others. Whilst not an issue in this case, it does identify a gap in service provision which should be addressed. The DoH announced the introduction of Routine Enquiry regarding domestic violence in all health settings within an agreed framework in 2005 (DoH)23, suggesting all services should now be working towards this goal. Many professional and governmental bodies recommend Routine Enquiry about domestic violence for all women; for example, the British Medical Association, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists, and the Royal College of Psychiatrists (National Collaborating Centre for Women’s and Children’s Health, 2008). Screening would be likely to increase the number of women identified as experiencing domestic violence and appropriate support and advice provided or signposted. Current Department of Health guidelines state that the successful implementation of policy and guidelines for domestic abuse relies on a comprehensive education and training programme. All staff who have contact with patients should be trained in domestic abuse issues, this includes administrative and reception staff 26. The Home Office, in its guidance for health professionals, suggests that given the importance of domestic violence as a factor impacting on health, training about enquiry should be part of pre-registration curricula and post registration on-the-job training for all health professionals (Taket, 2004) 24. There is evidence to suggest that the importance and value of Routine Enquiry needs to be reemphasised 23 Responding to domestic abuse: a handbook for health professionals. Department of Health. December 2005 24 Should Health Professionals Screen All Women for Domestic Violence? Ann Taket, C. Nadine Wathen, Harriet MacMillan 2004 - 42 - 3.2 TERMS OF REFERENCE The main source of the evidence in response to the terms of reference is drawn from the IMRs of the health services that had the most relevant contact with Child L, Adult N and Family M during the time period of the review. The section also draws heavily on the conclusions reached in the health overview report. The terms of reference have been combined to reduce repetition of responses. The involvement of the police and ambulance service was after the collapse and/or death of Child L and therefore has less relevance. 1. Examine whether or not Child L’s death could have been anticipated or prevented. 9. Examine whether or not there were opportunities for agency intervention that were missed. There was the potential to promote safeguarding of Child L by providing Adult N with appropriate additional support. The GP had a full history of Adult N, Child L and family health problems which could have been used to inform a holistic assessment of the overall support mechanisms within Family M. This information should have been shared and discussed with other health professionals to inform a more holistic assessment of Adult N and Family M, including the need, if any, for additional support. 3. Examine the agency’s involvement with the individual members of the family particularly in respect of any: 3.1. concern for Child L’s welfare which arose from services provided to the family ante and post-natally; 3.2. identified causes of stress in family life which might have affected the care provided to Child L; 3.3. referral or request for service (including self-referral); by analysing in detail any concerns that arose in respect of Child L, her mother or father, or other people living in the family home at the time, and, in particular: 3.3.1 how the concern was dealt with; 3.3.2 the quality of assessment and decision making and how that was recorded; 3.3.3 the quality and relevance of any service provided; 3.3.4 the quality of the agency’s child protection procedures and whether or not they were followed; 3.3.5 how Child L’s needs and welfare were considered; 3.3.6 how information was shared between agencies. 4. Examine specifically what was known about mother (Adult N) and if there was any evidence to suggest that she might pose a risk to Child L. Most of the practice evidenced within the IMRs was of the expected and required standard. During the antenatal and postnatal period all the expected health services which are directly responsible for providing care to children and families were involved. There was no concern about Child L's welfare during the antenatal or post natal period. There is no evidence in any chronology to indicate non-compliance by Adult N and Family M to planned intervention or of “disguised compliance” (Reder and Duncan 1993)25. 25 Reder P, Duncan S (1993) Beyond Blame: Child Abuse Tragedies Revisited Routledge: London - 43 - The fact that there were no concerns or indicators for future concern about Adult N or Child L is supported by the information that she was assessed to receive the core contacts required within the Healthy Child Programme where increased risk factors are not present and many recognised protective factors were present. The Healthy Child Programme (Department of Health 2010) is the early intervention public health programme that is at the heart of universal services for children and families. It is part of the Government’s Child Health Strategy which has a strong focus on prevention in the first years of life and provides an opportunity to identify families that are in need of additional support and children who are at risk of poor outcomes. The Healthy Child Programme outlines a universal service that is offered to all families, with additional services for those with specific needs and risks. There were some potential causes of stress in family life which might have affected the care provided to Child L. Some of the issues were known to some professionals involved with the family. Others are difficult to evaluate because of the lack of comment and assessment recorded in records. These include: • High quality assessments based on a holistic picture of a family are important in order to adequately safeguard children. This case illustrates that on occasion assessments were not based on full, in-depth information, for example, the exact role of Adult P, the extent the health needs of Adult R impacted on her supportive role and the level of attachment between Adult N and Child L. • The importance of attachment and ensuring that professional contact with the family routinely involves and supports fathers, including non-resident fathers, is noted within the Healthy Child Programme. There was a lack of information and curiosity about Adult P, his relationship with Adult N and involvement with Child L and Family M. • The assessment of parental–infant attachment is essential as part of the assessment of needs and subsequent intervention for any infant (Howe 2005)26. It is of positive note that the emotional health of Adult N was assessed in the antenatal period by both a midwife and health visitor. It is recognised that for some professionals in the postnatal period, parent-child attachment is difficult to assess in a brief snapshot of time. Child L lived for only five weeks so there were relatively few opportunities for assessment. Midwife Z discussed the birth experience with Adult N and Adult P at the first postnatal visit. • The GP notes in the consultation when Adult N describes feeling tearful and low that she is also “happy with baby”. However, within the 9 documented postnatal contacts there is no explicit reference to assessment of the attachment of Adult N and Child L. • The first three months after the birth of a baby pose the greatest lifetime risk for new mothers in developing mental health difficulties. Management of post natal depression may require more urgent intervention because of its negative effect on the baby, on the woman’s physical health 26 Howe D (2005) Child Abuse and Neglect, Attachment, Development and Intervention Palgrave McMillan New York - 44 - and her ability to function and care for her family (NICE 2007)27. The NSPCC report 'Prevention in mind ‘, Hogg 2013, identifies that Post partum psychosis affects 2 in 1,000 new mothers which would equate to approximately 10 women in Hull (each year). The report identifies the need for early intervention to reduce the risk of deterioration in the woman's mental health. On 20th September 2012 Adult N presented to the GP, was assessed as having post natal depression and was prescribed anti depressants. There is also some description in the record to indicate that Child L was an unsettled baby. Although the symptoms exhibited by Child L are relatively common and mild, the effects on an individual’s coping skills in the early postnatal period should not be underestimated and should be a trigger factor for the offer of additional support. It is noted that the GP identified some potentially supportive, protective factors. However, consideration was not given to sharing this information with the health visitor and no arrangement was made to follow up Adult N. The Court at Adult N's trial heard that she was experiencing postnatal depression, had gone to see her GP and was given antidepressants. However, due to the stigma she and her family felt about them she had only taken one tablet. As the GP did not ask Adult N to return to assess the impact of the antidepressants or contact the health visitor to request that she contacted Adult N the GP was not aware that Adult N had not taken the prescribed medication. • Whilst there is no evidence of domestic violence in this case there are issues associated with professionals providing an opportunity for Adult N to disclose if there had been. Routine Enquiry into domestic abuse was asked by the midwife in the ante natal period though not by the health visitor. • The Housing IMR identifies that Adult N submitted an application for council accommodation on 11th June 2012. At this point Adult N was pregnant and stated in her application that she had been asked to leave her family home. • The care of Adult N and Child L on the 8th October 2012 after the cardio-respiratory arrest of Child L evidenced within the YAS, Humberside Police and HEYHT IMRs was of the expected and required standard and in many instances provided examples of best practice. There is evidence of multi agency working focused not only on the care of Child L but also on meeting the needs of Adult N, P and family M in difficult circumstances. 5. Examine considerations around ethnicity, religion, diversity or cultural issues that may require special attention. In their analysis of Serious Case Reviews from 2009-2010, Ofsted found consideration of race, language, religion and culture to be patchy (Ofsted 2010). The IMRs for each organisation identify that issues related to ethnicity, religion, diversity or cultural issues were considered. There is only one issue related to the recording of ethnicity in the patient record at GP registration which is confusing as descriptions of the family include White and Black Caribbean which is not 27 National Institute for Health and Clinical Excellence (2007) Antenatal and postnatal mental health. Clinical management and service guidance - 45 - included in other records. It has not been possible to establish if this resulted from a recording error which, whilst not significant in this case, in others could influence the care provided. Organisations involved in this case identify that they give high priority to the equality and diversity agenda and there is evidence to support this. It forms a component of mandatory training programmes for employees of NHS Hull CCG, HEYHT and CHCP. It is also positive that the HEYHT IMR highlights the sensitivity with which staff attended to the religious needs of Family M after the death of Child L. Discussions with paternal Grandparents identified however their concerns and distress that they were not allowed to see Child L or to witness the blessing given by the Chaplain that they had requested. The Paternal Grandparents stated that they were told that this was because it was a 'crime scene.' The Paternal Grandparents understood that they would not be allowed to touch/hold Child L. This denied them the opportunity to say 'goodbye' which was clearly very distressing to both of them. Subsequently Police Officers have met with the Paternal Grandparents to discuss their contact with them during the period that Child L was at HRI. The meeting identified some learning outcomes for Humberside Police which have been incorporated into a number of training programmes including Rapid Response Procedures and Family Liaison Training. 6. Consider the impact of the social, cultural and economic environment in which the family were living and in which the professionals operated. There is some description of family composition and employment history in records but it is not always accurate or clear and does not appear to form the basis of a comprehensive understanding of the social, cultural and economic environment of the family. There is no documented area within the GP records to note social issues including economic or employment circumstances. Overall, the information contained in all the IMRs in relation to Family M would appear to indicate a greater focus on the assessment of clinical and medical needs with a more limited focus on social circumstances and needs. It is not uncommon within the city for extended family to live with or in close proximity to each other. Thus, it may be easy for health professionals to assume this circumstance denotes a necessary level of support, rather than questioning it further 7. Consider the context in which local professionals work and the extent to which their actions are influenced by the organisations and systems in which they are working. There is no evidence in the Police, Hull City Council or YAS IMRs of any organisational issues that adversely influenced the care given. There is however evidence that systems in place supported professionals to undertake their roles in difficult circumstances. In June/July 2011, Ofsted and CQC conducted an unannounced inspection of Hull’s safeguarding and looked after children’s services. The inspection provides an independent assessment of the performance of children’s services and the context in which partnership organisations and practitioners were working. The overall effectiveness of services in Hull in safeguarding and promoting the welfare of children and young people was assessed as adequate. The Director of Children’s Services was found to - 46 - provide effective leadership. HSCB was assessed to be well established, fulfilling its statutory duties with the engagement of partners and with good processes in place for consultation with children and young people. Partnerships with the voluntary and community sector were found to be particularly positive and productive. Partner agencies were found to have a clear commitment to securing the safety and well-being of children and to maintaining, within a challenging financial context, sufficient levels of resourcing for front line safeguarding services. (See appendix 1) The HSCB has a Guidelines and Procedures Sub- Committee on which the Designated Nurse sits in addition to the Named Nurses for the key health provider organisations. Therefore, there is an effective route to disseminate any changes and updates to the HSCB guidelines and procedures within health organisations. There are no issues identified in this review in relation to an absence or inadequacy of safeguarding children policies and procedures. The HSCB has a training policy in place focussing on multi-agency training as recommended in Working Together to Safeguard Children 2010. All three organisations involved in the provision of health services to Family M have safeguarding children guidelines and procedures relevant to their organisations which are regularly reviewed and are accessible to staff. Procedures are in line with HSCB Guidelines and Procedures. Information sharing systems are integral to competent safeguarding practice but this not only requires robust systems and protocols. It requires practitioners to simply communicate across organisational and service boundaries. There is evidence of effective communication between professionals but there were issues associated with the GP communicating with the health visitor and midwife. Consistent findings from studies have shown that tragedies often occur at times of major service re-organisation, staff shortages or lack of resources with practitioners feeling “overwhelmed” (Brandon et al 2010). The NHS and provider health organisations have, over the last three years and continue to undergo, a series of major changes. This does not appear to have had a major impact on organisational capacity in this case although the CHCP IMR does indicate that the two key contacts with Adult N and Child L took place late owing to capacity issues on the first occasion and the impact of annual leave on the second. It is of positive note that CHCP is implementing the NHS Yorkshire and Humber Health Visiting Plan 2011-15 in line with the NHS Operating Framework 2011/12. A four year education commissioning plan is underway which has taken into account numbers of health visitors currently in training, the increase in commissions required to meet the regional four year health visitor target, and the number of potential retirees. The GP IMR hypothesises that the ten minute consultation period allocated GPs and practice nurses can at times be inadequate and therefore, consultation times overrun. There is no indication that this affected the care given to Family M in this case. There are some issues related to the provision of training and supervision and auditing outcomes; for example training on Routine Enquiry is provided by CHCP but is not systematic. The training records of the staff concerned with this family indicate that, whilst training has been accessed in the past, it pre-dated the current record keeping process. As such the training is likely to have been provided a minimum of four years ago. Training on Routine Enquiry needs to be systematic and monitored by the management team as with other safeguarding training. Training on the recording of significant others in families has been incorporated into the Record Keeping Training since 2010 and following an SCR. All staff working within CHCP, Children and - 47 - Young People’s Services were provided with access to training and three training sessions are provided annually to address new staff. It is noted however that Health Visitor #2 did not attend this training as requested and this has been addressed with her. An audit of the recording of significant others within the clinical records has not been undertaken by the organisation to date. This requires addressing both in terms of the individual practitioners concerned to establish the quality of the practice of each, as well as across the service to ascertain the scale of this issue. The findings of the audit will be addressed. An audit of significant others will be incorporated into the clinical audit programme to ensure regular review. 8. Take account of any relevant lessons learned from research and from biennial overview reports of serious case reviews and describe how these lessons have been applied to the analysis of this case. Also, any similarities with previous local Serious Case Reviews or national themes, their recommendations and subsequent actions. In Learning lessons, taking action Ofsted identifies that although there have been developments since Every Child Matters28 there remains a challenge to ensure that effective learning and action results from every serious case review and that all services fully appreciate the role they play in ensuring this happens. This case has been reviewed by IMR authors, overview author and panel by applying the lessons that have been identified in other SCRs by desk top review and by utilising professional knowledge and experience. There are issues identified in this review regarding: • The role of universal services in safeguarding children and early intervention. • The impact of perinatal depression on the effectiveness of parenting. • The role of fathers and significant others in parenting. • Early detection and intervention in domestic violence. There is one recent local SCR that is pertinent to this case. This was the SCR undertaken following the death of Child F (2011). This SCR highlighted the need for those working with children and their families to demonstrate how the role of fathers and men in households is considered in service provision and assessments. This appears to still be an issue and requires further review. SECTION FOUR - RECOMMENDATIONS The following recommendations derive from the learning from this review. The recommendations have been agreed by the Hull Safeguarding Children Board Serious Case Review Overview Panel. The recommendations are supported by a detailed action plan which is being implemented by agencies and monitored by the Board’s Serious Case Review Sub-Committee. 1. Health practitioners should apply recognised evidence in the recording and information sharing in relation to: 28 www.everychildmatters.gov.uk/ - 48 - • The role of significant others within a family and household membership • The response to Routine Enquiry for Domestic Abuse Agency with lead responsibility: NHS Hull Clinical Commissioning Group Impact: There will be effective communication and information sharing between health professionals providing health care and interventions to children and their families to enable appropriate early help to children. 2. Local commissioners and the Local Safeguarding Children Board should work together to ensure that health professionals have access to and receive the appropriate level of safeguarding children training, including wherever practical, inter-agency training. Agencies with lead responsibility: NHS Hull Clinical Commissioning Group and Hull Safeguarding Children Board Impact: Health professionals will be able to recognise indicators of safeguarding and child protection issues and take appropriate action. 3. The Named Midwife for safeguarding children will ensure arrangements are in place for midwives to receive child protection supervision Agency with lead responsibility: Hull & East Yorkshire Hospitals Trust Impact: Midwives will receive safeguarding supervision that will support them to safeguard children, young people and vulnerable adults. 4. YAS will implement the recommendations resulting from the internal Clinical Case Review within six months. Agency with lead responsibility: Yorkshire Ambulance Service Impact: YAS staff involved in responding to the paediatric incident will have increased knowledge of paediatric resuscitation and advanced life support skills, and raised awareness of the process of clinical handover. Appendix 1 - Ofsted and Care Quality Commission inspection The Ofsted and Care Quality Commission inspection of Safeguarding services in 2011 identified the benefit from independent leadership and scrutiny brought about by the appointment of an independent chair. The HSCB has supported change by monitoring the effective implementation of plans to improve services like e-safety and domestic violence. HSCB was also advised by inspectors to: - 49 - • Review and strengthen the current HSCB business plan, including arrangements for monitoring core safeguarding activities and the implementation of a multi-agency auditing process. • Ensure core groups adhere to HSCB Guidelines and Procedures so that individual child protection plans are developed into detailed working tools and that they are meeting sufficiently regularly to monitor actions and outcomes against the child protection plan. • Introduce annual reporting on the operation and activity of the Local Authority Designated Officer (LADO) to HSCB • Ensure the evaluation of safeguarding training across children’s services monitors the impact of training on service delivery The inspection recommended that partner agencies should address: threshold issues, timescale compliance, risk assessment, targets and audit, written agreements, strengthening supervision, assessment and analysis and capturing parents’ views. A ‘safeguarding improvement plan’ was drawn up to reflect the requirements arising from the inspection. Implementation of the plan was overseen by the City Council’s Cabinet and the HSCB. Significant progress has been made on these issues (for example, a revised Children’s Social Care ‘case audit’ process, revised safeguarding supervision policies and monitoring arrangements across the ‘health provider’ family and new guidance for social workers on the use of written agreements Since the inspection in July 2011, the following work has been undertaken to progress these issues: • The thresholds guidance has been approved and widely disseminated by HSCB. The dissemination has been supported by a major multi-agency training programme. Both the training and the impact of the guidance on practice and referral outcomes have been evaluated by the HSCB. ‘NFA’ referral rates have decreased significantly over the period. • A refreshed HSCB business plan was produced and published in November 2011. Multi-agency ‘learning from practice’ (auditing) processes have been implemented and HSCB’s monitoring framework continues to be strengthened. • The LADO presented an annual report to the HSCB in January 2012 (and subsequently again in March 2013) • All HSCB safeguarding training is rigorously evaluated. The HSCB continues to develop more effective mechanisms for evaluating the longer-term impact. One example of this is the work undertaken to evaluate the impact of thresholds training. |
NC52174 | Death of a 20-day-old infant in 2018. Baby Darryll was admitted to hospital and died five days later. Mother was a care leaver, had experienced a difficult childhood, and was known to Children's Social Care from the age of nine-years-old due to domestic abuse between her parents. Mother moved into care at 13-years-old, and had episodes of going missing, child sexual exploitation, and drug and alcohol use. Concerns about Mother entering abusive relationships. Pre-birth risk assessment highlighted concerns over housing arrangements and Mother's cannabis use. Coroner's Court concluded an outcome of death by misadventure, with the post-mortem stating cause of death as hypoxia. Ethnicity and nationality not stated. Learning includes: recognising adverse events that have happened in a person's earlier life can provide important context to understanding their current circumstances and behaviours; in cases where an adult is judged to have their own vulnerabilities, and they already have a named worker to support these needs it is important that for any child living in the same household there is consideration to them having their own allocated worker. Recommendations include: inform the Family Nurse Partnership National Unit to allow them to consider the learning; promote learning, as a public health message to the wider population, about the importance of avoiding co-sleeping and unsafe sleeping arrangements with babies; seek assurance about the quality and effectiveness of joint working arrangements for those services who work with care leavers who are pregnant and who require housing support.
| Serious Case Review No: 2020/C8534 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. CLASSIFIED INFORMATION – FINAL REPORT Official Local Authority A Local Safeguarding Children Board Serious Case Review Baby Darryll Anonymised -Review report This report is strictly confidential and must not be disclosed to third parties without prior discussion and agreement with Local Authority A Safeguarding Children Partnership. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved. Independent Reviewer: Kevin Ball Anonymised version Page 1 of 22 Final Report Submitted 21st October 2019Anonymised Report 20th August 2020CLASSIFIED INFORMATION – FINAL REPORT Official CONTENTS Area Page 1.Introduction to the case review 1 2. Process for conducting this review 1 3. Family structure & contribution to the review 2 4. Relevant case history - Relevant background information prior to the timeframe under review - Relevant information during the timeframe under review 3 - 5 5. Findings & analysis - The quality of pre-birth assessment including the use of information about known risk factors - Thresholds for intervention across services & discharge planning - The impact of transitions across Boroughs & the quality & effectiveness of support offered - Local knowledge & understanding about vulnerabilities of young babies - The quality & effectiveness of services provided to the mother as a care leaver 5 - 19 6.Good practice 19 7. Conclusion 19 8. Recommendations 20 Anonymised version Page 2 of 22 CLASSIFIED INFORMATION – FINAL REPORT 1 Official Introduction to the case review 1.1. Following the death of a 20-day old infant in 2018 Local Authority A Safeguarding Children Board considered it appropriate to conduct a Serious Case Review, as required by statutory guidance1. For the purposes of this review, the infant will be known as Baby Darryll. In summary, the circumstance of the case concerns a young mother who had 1.2. The following findings have been made as a result of this review; - No causative link between the Mother’s cannabis usage and Baby Darryll’s death has been found; the circumstances in which the child was found may indicate unsafe sleeping arrangements. - The Mother’s parenting capacity was untested, and assumptions were made that she would be able to manage without specific support being offered. - Information sharing across agencies was disjointed and did not happen in a timely way, resulting in delays to assessments and decision making. Had information been shared effectively, and in a timely way, it may have resulted in a more coordinated offer to support to the Mother and baby, and more timely assessments and decision making. - The impact of cannabis use on parenting capacity were not fully recognised, and bias thinking influenced professional decision making. 2. Process for conducting this review 2.1. The approach taken has adhered with the principles as set out in statutory guidance2. As such, the process has been able to capture and identify opportunities for professionals and organisations to reflect, learn and improve safeguarding practices from a whole safeguarding system perspective. 2.2. Following the decision by the Independent Chair of the Board in October 2018 to commission this Review the following steps were taken; - The Board commissioned Kevin Ball as the Independent Reviewer3. - Single agency reports and chronology were requested and submitted by those agencies and professionals who had contact with Baby Darryll and family4. This process provided each agency with the opportunity to reflect on 1 Working together to safeguard children, 2015, HM Government 2 Working together to safeguard children, 2015, HM Government. 3 Kevin Ball is an experienced & independent consultant and Scrutineer, with specific experience of chairing & authoring case reviews & with a background of working in children’s services. 4 The following agencies and bodies have contributed to this Review: - Hospital C - GP Practice via the CCG - Local Authority A Borough Children’s Social Care - Metropolitan Police Service - Local Housing Trust - Hospital C experienced a difficult childhood but was positive and looking forward to her role of being a mother. The Mother was in receipt of antenatal services for a period of time and was receiving support from other professionals during the pregnancy however due to changes in her housing arrangements complications arose. Notwithstanding those complications, following birth, Baby Darryll was discharged from hospital without concern. During the pregnancy a pre-birth risk assessment was conducted highlighting a number of concerns; specifically relating to the impact on the Mother should her housing arrangements alter, but also the extent of her cannabis use. The significance of these risk factors was not fully recognised by the professional network. In the summer of 2019, the Coroner’s Court concluded an outcome of death by misadventure. As a result of this finding, and the fact that drug toxicology testing was negative, the Police will not be taking any further action. The post-mortem has concluded the cause of death as hypoxia. CLASSIFIED INFORMATION – FINAL REPORT 2 Official their involvement by examining their records but also seeking the contributions and views of those practitioners that came into contact with the Baby Darryll and family. As a result, agencies have been able to consider actions required of themselves in order to make improvements to practice, - Review Panel meetings have interrogated information submitted and sought clarity when necessary, thereby enabling a robust and thorough examination of practice in context. - The Independent Reviewer met with Baby Darryll’s mother to gain her perspective. 2.3. The timeframe under review was from February to October 2018. Any relevant historical information prior to this timeframe is included. 3. Family structure & contribution to the review 3.1. For the purpose of conducting this review the following individuals are relevant; 3.2. Seeking the Mother’s contribution to this review has been an important consideration in helping shape some aspects of the learning from this review. The Independent Reviewer met with the Mother on two separate occasions. Firstly, to gain her perspective about service that came into contact with her during her pregnancy and post birth of Baby Darryll, and then again to discuss the findings of the review and recommendations. 3.3. The Mother was able to express her frustrations about her contact with services and professionals whilst also balancing this was positive aspects of contact with them. Her frustrations and perceptions centred mostly on two issues; firstly the difficulties of securing housing and having to move back into Local Authority A when she had been settled in another London Borough, and secondly; the need for professionals to constantly ‘assess’ her and her situation when she had been already ‘assessed’. The Mother acknowledged that she had worked with professionals for many years, had expectations about how she should be treated as a care leaver, and conveyed greater hopes for how she might be supported when pregnant and with a new baby. When this failed to materialise, this came as a disappointment and frustration. The Mother’s perception of constant assessment and referral activity by professionals was that she was being pulled back into a system that had failed her as a child and that her hopes for what to expect with her own baby were greater than was actually on offer. She described this process as ‘… fighting the system and having to come out of a struggle with the system …’. The Mother accepted her role and responsibility in the way in which she worked with some professionals and conveyed a hope that the review would lead to improvements and better services offered to care leavers who become young parents. 3.4. Positively, the Mother commented on the antenatal appointments being helpful and reassuring acknowledging that early in the pregnancy the Midwives had clearly alerted her to the risks of using cannabis during pregnancy, and that they took time to listen to her anxieties about the pregnancy. Despite the advice, the Mother acknowledged that she continued to use cannabis throughout the pregnancy as a way of managing anxiety. The Mother also described her Personal Adviser as being helpful and supportive, particularly in respect of getting information to her about housing related issues. - Hospital D - South London Maternity Service - Local Authority A Adult Social Services: Substance Misuse Team - Other London Local Authority Children’s Services - Hospital E - Family Nurse Partnership National Unit Individual: Identified as: Subject child Baby Darryll Mother to Baby Darryll Mother Maternal Grandmother to Baby Darryll Maternal Grandmother Maternal Aunt to Baby Darryll Maternal Aunt CLASSIFIED INFORMATION – FINAL REPORT 3 Official 4. Relevant case history 4.1. Relevant background information prior to the timeframe under review 4.1.1. Baby Darryll’s Mother had been known to Local Authority A Children’s Social Care from the age of nine years due to domestic abuse between her parents. Her own mother, the Maternal Grandmother, was dependent on alcohol and there was often physical and verbal conflict between the adults in the house. As a result of living in this home environment the Mother was accommodated5 at 13 years old. Whilst growing through adolescence the Mother would frequently go missing, experience sexual exploitation, and use drugs and alcohol, with cannabis use beginning at around 10 years old. Additionally, there were concerns about the Mother entering abusive relationships and being at risk from gang associations. Given these particular risks the Mother was intentionally placed by Local Authority A Borough Council in another London Borough in a residential unit away from the known risks in the Local Authority A area. Given the length of time the Mother was in the care of the local authority this meant that she became a relevant child6, and as a care leaver benefitted from continued support from the local authority. The Mother described being very excited to be pregnant with Baby Darryll and although not involved with the Father of the child was positive about the future. 4.2. Relevant information during the timeframe under review 4.2.1. The Mother registered her pregnancy with the GP at the end of January 2018 and was appropriately referred for antenatal care. In early February she was referred to a South London Maternity Specialist Midwifery Team due to a history of anxiety and depression; referrals were also made to the other London Borough MASH7, the Borough Perinatal Mental Health Team and the Borough Antenatal Drug Service given the Mother’s known cannabis use. Additionally, a referral was made to the Borough’s Family Nurse Partnership8. 4.2.2. During this time the Mother had submitted an application to both her current London Borough and Local Authority A Councils Housing Services to be re-housed, requesting to remain in the other London Borough. The outcome of the housing application was that the Mother was offered accommodation back in Local Authority A in July 2018 by Local Authority A Housing. The offer was reluctantly accepted by the Mother who was worried about returning to an area where there were known risks. Prior to this, and with the support of the Local Authority A Leaving Care Team and an Advocate the Mother made a complaint in May 2018 about the level of support she had been given around her housing needs. The outcome of this complaint clarified the support offered as well as finding that no further action was needed given the accommodation had been accepted in Local Authority A. 5 Section 20, Children Act 1989: the provision of accommodation for a child by the local authority, who is deemed in need (even though a person who has parental responsibility for that child is able to do so) if the local authority considers that to do so would safeguard or promote the child’s welfare. 6 Relevant child: A ‘relevant child’ is a child who is not being looked after by any local authority, but was, before last ceasing to be looked after, an eligible child, and is aged 16 or 17. It is the duty of each local authority to take reasonable steps to keep in touch with a relevant child for whom it is the responsible authority, whether he is within their area or not to appoint a personal adviser for each relevant child. An ‘eligible child’ is one aged 16 or 17, who has been looked after by a local authority for a period (13 weeks), or periods amounting in all to that period, which began after he/she reached 14 years of age and ended after he/she reached the age of 16. It is the duty of the local authority looking after an eligible child to advise, assist and befriend him/her with a view to promoting his/her welfare when they have ceased to look after him/her. For each eligible child, the local authority shall carry out an assessment of his/her needs with a view to determining what advice, assistance and support it would be appropriate for them to provide while they are still looking after him, and after they cease to look after him/her, and shall then prepare a pathway plan for him/her, Children Act 1989 & Children (Leaving Care) Act 2000. 7 MASH – Other London Borough Multi-Agency Safeguarding Hub. 8 The Family Nurse Partnership (FNP) provides a home visiting service to support young first-time mothers (aged 22 years and under) from early pregnancy until their child is two years old. CLASSIFIED INFORMATION – FINAL REPORT 4 Official 4.2.3. Also, during this period, as a result of the earlier MASH referral the other London Borough’s Children’s Social Care completed a pre-birth assessment to explore risks to the unborn child. This concluded towards the end of June 2018, identified a number of risk factors but resulted in a decision that the Borough’s Children’s Social Care did not have a role and that the South London Specialist Midwifery Service, the Borough’s Family Nurse Partnership, and Local Authority A Leaving Care Team would be best placed to support the Mother and new baby. At this time, the involvement of the other Borough’s Family Nurse Partnership had not been secured and confirmed. Risks and concerns identified during this pre-birth assessment included current cannabis misuse, risk of postnatal depression and an insecure housing situation; with a recommendation from the other Borough’s Children’s Social Care to Local Authority A Council that they do not rehouse the Mother in Local Authority A due to the known risks. 4.2.4. Due to the Mother being rehoused back into Local Authority A in July 2018 the Mother never met anyone from the other Borough’s Family Nurse Partnership. Following assessment, the Mother had declined support from the other Borough’s Perinatal Mental Health Team as she felt she had enough support around her. 4.2.5. The Mother was seen at 29 weeks pregnancy by the South London Specialist Midwifery Service. This was their last contact with the Mother before her care being transferred out of their area. 4.2.6. During the above timeframe the Maternal Grandmother had come to the attention of Local Authority A MARAC9 due to allegations of domestic violence by her adult children. The Maternal Grandmother was also briefly known to Local Authority A Adult Social Care Substance Misuse Service. 4.2.7. Once rehoused in July back in Local Authority A the Mother was advised to transfer her maternity care to a more local hospital. Initially the Mother wanted this to be Hospital A and the South London Specialist Midwifery Team contacted this hospital to ensure the appropriate handover arrangements were made. The Mother then changed her mind and instead wanted to transfer her care to the Hospital B. The South London Specialist Midwifery Service appropriately contacted the Named Midwife for safeguarding children at the Hospital B to advise of the Mother’s background and the transfer of antenatal care. As a result of these complications the Mother was next seen at 38 weeks pregnancy at the Hospital B in August; accounting for a nine-week gap in antenatal care being available to the Mother. Given the history and concerns shared by the South London Specialist Midwifery Service, the Hospital made a referral to Local Authority A Children’s Social Care Front Door Service. This referral was processed resulting in the Hospital Social Work Team receiving information two days before Baby Darryll was born. A discharge planning meeting was then held in September three days after the birth and the day before Baby Darryll was discharged from Hospital. Local Authority A Health Visiting Service were not invited to this meeting, nor made aware of the Mother’s history or the involvement of either the other Borough or Local Authority A Children’s Social Care. 4.2.8. Three days after discharge Hospital C’s Community Midwifery Service attempted a home visit however entry was denied because the Mother had not been expecting a Midwifery visit. This refusal was communicated back to the Hospital Social Work Team. The following day the Community Midwifery Service attempted an unannounced home visit, but again access was declined as the Mother was not expecting the visit and instead was expecting a scheduled visit from the Health Visitor the next day. The following day, the Health Visitor made a successful home visit and found no concerns, stating that the Mother and Baby Darryll appeared to be doing well. Local Authority A Leaving Care Team also conducted a successful home visit and were not concerned. 4.2.9. The Mother then attended a Hospital clinic as scheduled and the assessment was that both Mother and Baby Darryll were doing well resulting in them being discharged from Midwifery care to the care of the Health Visiting Service. The Mother was reported as feeling positive but was concerned about her own mother’s health. The day after 9 MARAC – Multi Agency Risk Assessment Conference – a forum which shares information about risks due to domestic abuse and harm. CLASSIFIED INFORMATION – FINAL REPORT 5 Official the Mother attended this clinic the Maternal Grandmother died in hospital from natural causes. Two days after this Baby Darryll was admitted to hospital and died five days later. 5. Findings & analysis 1. The following section provides a commentary and analysis of professional practice. Having mapped the professional and agency contact with Baby Darryll over the timeframe under review, there are a number of features that stand out that help us understand what happened, and why events occurred as they did. These features are relevant from a multi-agency safeguarding system and practice perspective and, as such, provide us with the greatest insight into the quality and effectiveness of the response to Baby Darryll and Mother. Where possible, an explanation of why events occurred as they did, has been provided. Learning points for use by all professionals and trainers have been emphasised. The following themes are explored; - The quality of pre-birth assessment including the use of information about known risk factors - Thresholds for intervention across services & discharge planning - The impact of transitions across Boroughs and the quality & effectiveness of support offered - Local knowledge & understanding about vulnerabilities of young babies - The quality & effectiveness of services provided to the mother as a care leaver 2. By way of a summary, the findings from the analysis highlight the following issues as relevant to learning; - The circumstances in which Baby Darryll was found may indicate unsafe sleeping arrangements, with toxicology testing showing no drug use and drugs not being a contributory factor to Baby Darryll’s death. - The Mother’s use of cannabis was known about by a range of professionals and whilst acknowledged as a risk factor, had not been assessed to be at a level to compromise the Mother’s caring abilities. Her parenting capacity had not been tested and the extent of the impact of cannabis use on parenting skills was unknown. Curiosity about these issues was lacking, and potentially contributed to be a minimisation of the impact of cannabis. - Risk and vulnerability factors, both pre-disposing and situational, were not consistently acknowledged across all partner agencies who came into contact with the Mother. In turn, the risks to Baby Darryll’s welfare and the support needs for the Mother were not fully recognised during the final stage of pregnancy and into early parenthood. - There was insufficient weight attached to the transfer of housing accommodation for the Mother, placing her at increased risk from known associates. - Information sharing was somewhat fragmented, and not achieved in a timely manner – which inhibited timely assessment and decision making about which services could offer support to the Mother and baby. - There were elements of professional bias by Local Authority A Children’s Social Care when assessing the Mother, complicated by case management processes, which had the effect of minimising risks to the baby. 5.1. The quality of pre-birth risk assessment including the use of information about known risks factors 5.1.1. Statutory guidance 10 states ‘… no system can fully eliminate risk. Understanding risk involves judgement and balance. To manage risks, social workers and other professionals should make decisions with the best interests of the child in mind, informed by evidence available …’ .When assessing risk from a safeguarding and child protection perspective, risk can be categorised into those factors that are currently presenting themselves as a concern, for which it may be possible to manage i.e. situational risks, and those where there is less likelihood of effecting change and which occurred prior to the current circumstances i.e. pre-disposing risks. 10 Working together to safeguard children, 2018, HM Government CLASSIFIED INFORMATION – FINAL REPORT 6 Official 5.1.2. In this case there were a number of known pre-disposing risk factors that formed part of the Mother’s history, and which the professional network had no control or influence over; these included, - The Mother’s own childhood experiences of living with domestic abuse between her parents and witnessing parental alcohol misuse. - The Mother’s reported use of cannabis from the age of 10 years, being in abusive relationships as an adolescent and being at risk from gang associations. - The need for the Mother to be taken into the care of the local authority aged 13 years and placed in a residential home, as opposed to foster care, which was out of the local area due to the extent of risks faced. 5.1.3. These factors are significant from a safeguarding perspective and highlight the Mother had experienced considerable adversity, abuse and neglect herself. There is a body of research evidence that supports the view that such experiences may go on to compromise their own parenting capacity and abilities11. Research12 about childhood adversity and trauma highlight maltreatment, violence, household adversity, and needing to adjust to relationships as contributory factors that can impact negatively on development and later life chances. These factors are relevant in helping us understand the likely support needs of the Mother and pathways to protection or pathways to harm for Baby Darryll. Much of the information outlined above was known, or knowable, by all professionals involved with the Mother. Learning point: Recognising, and exploring, adverse events that have happened in a person’s earlier life can provide important context to understanding their current circumstances and behaviours. Where the safety and welfare of an unborn child is of concern it is imperative to gather information about the parents own experiences in order to inform safety planning. 5.1.4. In addition to the pre-disposing risk factors highlighted above, the Mother was experiencing a number of situational risk factors which, either singularly or combined, had a real potential to increase risk to Baby Darryll during pregnancy and when born; these included, - The Mother’s continued use of cannabis. - The challenges faced by the Mother in securing safe and stable accommodation in the run up to, and following, the birth. - The Maternal Grandmother’s illness and death resulting in additional stress being placed on the Mother. - The risk of the Mother experiencing postnatal depression. - The Mother’s untested abilities as a first time and young parent, given her known history and vulnerabilities. 5.1.5. The South London Maternity Services have confirmed that the procedural pathway for mothers who disclose using cannabis during pregnancy was not completely followed in this case during antenatal appointments; there was no recorded curiosity about the frequency, amounts and circumstances of cannabis usage shown nor information leaflets given to the Mother about the risks to her and the unborn baby. This reflects a mind-set that normalises the use of cannabis without considering the potential risks to children13. As a result of this review the pathway and guidance will be amended to strengthen practice but also reflective supervision, encouraging greater professional curiosity. 11 i) Does the past predict the future? Reder, P., in Studies in the Assessment of Parenting, Reder, P., Duncan, S., & Lucey, C., Routledge, 2007 and ii) Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2003 – 2005, HM Government. 12 Young Minds & NHS Health Education England: Addressing childhood adversity and trauma 13 NHS - Cannabis: the facts & NSPCC Parental substance misuse CLASSIFIED INFORMATION – FINAL REPORT 7 Official 5.1.6. The procedural pathway was followed when a urine sample was taken for toxicology testing; the results were positive for cannabis prompting a maternity safeguarding notification being completed and smoking cessation service referral offered, although this referral was declined by the Mother. Opportunities to discuss risk minimisation with the Mother were therefore not taken. This may have helped the Mother think about the risks of using cannabis and safe sleeping arrangements. The Trust is undertaking a review of this procedural guidance and plan to issue a revised pathway. 5.1.7. The other London Borough’s Perinatal Mental Health Service have reflected on their involvement and assessment, concluding that that whilst the Mother was stable and would not be eligible for their services at this stage of the pregnancy, there could have been greater curiosity about her housing situation and the impact this might have had on her. Additionally, the need to consider crisis plans at the point of discharge from their Service, and sharing these with partner agencies, is a learning point that has been highlighted; in this case, as the Mother moved through her pregnancy this may have been a useful addition to her overall ante-natal care package. 5.1.8. Evidence submitted to this review shows that the other Borough’s Children’s Social Care conducted a focused pre-birth assessment that was concluded in a timely manner. Information relating to the pre-disposing vulnerabilities and risks outlined above is mentioned, as is an assessment of the positive move for the Mother out of Local Authority A into their own Borough three years previously to create distance for her from gang associations and an abusive partner. The following positive features are also evident; - The purpose of the pre-birth assessment was clearly defined and explained to the Mother. - It included known vulnerabilities which might impact on the Mother’s care of her baby, both currently as a care leaver and those arising from her historical experiences as a child. - The assessment was informed by contributions from all the relevant agencies involved with the Mother and in relation to her pregnancy; this included her Personal Adviser in Local Authority A; the Specialist Midwifery Team; the other Borough’s Antenatal Drug Service; Change Grow Live (drug and alcohol services); and the Borough’s GP Practice. - The reports provided by other agencies verified the veracity of the Mother’s own account to the Social Worker (of her family history, relationships, challenges and vulnerabilities) reflective of the Mother being open and honest in the assessment and being prepared to work with professionals. - The assessment included discussions with the Mother’s sister, who also appeared open and honest about her contact with a Children’s Social Care department. The accounts by the sister were followed up by the other Borough’s Social Worker, again demonstrating good practice in triangulating information rather than relying on first accounts. - The assessment evidences curiosity by the other Borough’s Social Worker with the Mother about who the baby’s father might be; but without success in identifying him. - The assessment explored the quality of the relationship between the Mother and the Maternal Grandmother. 5.1.9. The assessment concluded by identifying the current main concerns as: continued cannabis misuse; a risk of post-natal depression; and the insecure housing situation and anxiety this was causing the Mother and that she should not be rehoused back in Local Authority A. The assessment of risk in relation to the Mother’s continued use of cannabis was considered. Discussion between the South London Specialist Midwifery Team Manager and Social Worker confirmed that given the other positive aspects to the Mother’s circumstances, it was agreed that on balance the risks were not high, and they could be managed within a general support plan. In this context the pre-birth assessment recommended that the Mother work towards stopping her cannabis due to the potential adverse impact it could have on her baby’s development. On the basis of information submitted and known at the time this professional practice is judged as positive and reasonable given the circumstances. The pre-birth assessment closing letter was however not shared with the Health Visiting Service or Hospital C Midwifery Service by the other Borough’s Children’s Social CLASSIFIED INFORMATION – FINAL REPORT 8 Official Care; the full assessment was also not sought by Local Authority A Children’s Social Care. The reasons given for this point to the final part of the process simply not being completed. This had led to a single agency learning point to amend procedural guidance to ensure it is a stage that is not missed in future. 5.1.10. However, there are two areas of learning from this episode. Firstly, the other Borough’s Social Worker encountered problems in getting chronological information, recent assessment work and a genogram from the Mother’s Local Authority A Personal Adviser, despite a number of attempts. Full information was not provided by the time the other Borough’s assessment was completed and the case had been closed to the other Borough’s Children’s Social Care. Sharing information in a timely manner with professionals is a core task in safeguarding work. 5.1.11. Secondly, it was felt that although there was no role for the other Borough’s Children’s Social Care, those best placed to support the Mother included the South London Specialist Midwifery Service, the South London Family Nurse Partnership, and Local Authority A Leaving Care Team. The Midwifery Service would have offered very short-term support and then transferred support over to the Family Nurse Partnership. This would have worked had the Mother remained in the other Borough and can be seen as an appropriate protective pathway for Baby Darryll. The support offered by Local Authority A Leaving Care Team would have been focused on the Mother, not Baby Darryll. Relying on this as a source of support for both mother and baby was flawed and would have placed the Local Authority A Personal Adviser in a double bind situation; conflicting priorities which may have resulted in a loss of focus on each placing the worker in a no-win situation in terms of their responsibilities. The baby, once born, would have warranted a separate worker in order to offer an objective opinion about safety and care arrangements. Learning point: In cases where an adult is judged to have their own vulnerabilities, and they already have a named worker to support these needs it is important that for any child, or children, living in the same household there is consideration to them having their own allocated worker. This may help avoid conflicts of interest and biased thinking in assessment and decision making. 5.1.12. Hospital B have confirmed that information was shared with them about the Mother’s vulnerabilities or risk factors despite her transferring to their care late during the pregnancy (at 38 weeks). They were aware of the other Borough’s Perinatal Mental Health Team assessment of the Mother being stable and that other Borough’s Children’s Social Care had conducted a pre-birth assessment and had consequently closed their involvement with the Mother. They were also aware that the Mother had engaged well with the South London Hospital Specialist Midwifery Service, and that the Mother appeared to be prepared for the arrival of her baby. Despite the information being given that assessments had been carried out and the case had been closed by the other Borough’s Children’s Social Care, the Midwifery Service at the Hospital B still made a referral to Local Authority A Children’s Social Care (although not obtaining consent from Mum who said that everyone already knew about her). This was good practice due to the Mother’s previous history and highlights recognition of the Mother’s vulnerability and risks to the baby. 5.1.13. Local Authority A Children’s Social Care have highlighted that when their Front Door Service received the Early Help referral from the Midwifery Service at Hospital B it was processed immediately for further enquiries. Importantly, the referral did not provide any detail about the most worrying features of the case or the reasons for referral. Information about cannabis use was only included in the summary section and was described as a complicating factor rather than a risk to the baby in its own right. It is noted that ‘ … there was no detail in the referral about the possible effects or consequences of using cannabis either in pregnancy or with a new born baby and it would appear that the main reason for the referral was the previous concerns of the threat of domestic abuse and gang affiliation now that Mother was back in Local Authority A …14’. Further detail was provided in the summary section including a reference to there already being a pre-birth assessment conducted in the other Borough. 14 Local Authority A Children’s Social Care submission to the review. CLASSIFIED INFORMATION – FINAL REPORT 9 Official Learning point: For those professionals making a referral it is important to think about how the information you submit will be read and interpreted by the person reading it. You are taking the time to make a referral because you are worried. It is therefore worth investing time into making the referral clear and evidence based; and then placing yourself in the seat of the person receiving it re-reading it to ensure it is as helpful as it can be. 5.1.15. From a system thinking perspective this episode can be described as a trade-off15. Trade-offs are a system thinking concept. Work in complex systems is impossible to assign, predict and prescribe completely. Demand fluctuates, resources are often limited and goals often conflict. Frequently, the choices available to us are not ideal and we are forced to make trade-offs and choose sub-optimal courses of action. Trade-offs such as these help us understand system behaviour and system outcomes. The trade-off in this situation was that the Front Door Service practitioner experienced competing demands on their time and made a decision to not interrogate the database to see if there was further relevant information to inform the assessment of current circumstances. Learning point: From a safeguarding system perspective, when practitioners work under pressure and struggle to manage the demand of the throughput of work, there may be value to gaining an understanding about the likely trade-offs that will be used by workers and managers to cope e.g. partial assessments, keeping records up to date, not involving all relevant partner agencies. Some trade-offs may be tolerable; others not as they compromise the welfare of children. 5.2. Thresholds for intervention across services & discharge planning 5.2.1. As stated, the other Borough’s Children’s Social Care conducted a thorough and proportionate pre-birth assessment. It concluded with a plan for protection and support which, as outlined above, was dependent on the South London Specialist Midwifery Service, South London Family Nurse Partnership and Local Authority A Leaving Care Team. Given the positive aspects noted by the assessment the decision by the other Borough’s Children’s Social Care to step down their involvement seemed rational. There was no information to warrant a step up of intervention. 5.2.2. The single complicating factor in the whole support and safety plan was that the Mother had made housing applications to two Boroughs. The advice and recommendations of the pre-birth assessment were dependent on the Mother remaining in the other Borough and receiving support from services in this area. The assessment and closing letter to Local Authority A Children’s Social Care, clearly stated that if the Mother returned to live in Local Authority A – where it was known she had previously faced risks – the situation would need re-evaluating. Practice in the other Borough’s Children’s Social Care is that a copy of the assessment is provided to family members and a letter summarising the assessment and its outcomes is sent to all the professionals involved. The Mother confirmed that she had been given a copy of the assessment, although found it difficult to fully understand. 15 Trade-off - as cited a) Learning into Practice: improving the quality and use of serious case reviews, Masterclass 2: Systems thinking, SCIE & NSPCC, 2016 and b) Systems thinking for safety: Ten principles – A White Paper, Eurocontrol, 2014. 5.1.14. The Front Door practitioner made appropriate enquiries including speaking to Mother; the initial assessment contained all the relevant risk factors and emphasised the concerns about cannabis use. However, critically the practitioner overlooked the fact that there had been a pre-birth assessment in June 2018 in the other Borough. Having sight of this would have added considerable weight to the quality and depth of assessment completed. The closing summary from the other Borough Children’s Social Care was logged on the database case notes for the Mother, because it had been sent to Mother’s Personal Adviser, but it was not accessed at the time of the Front Door Service assessment. The reason given for this oversight has been due to work pressures to undertake tasks in a very short timeframe. CLASSIFIED INFORMATION – FINAL REPORT 10 Official 5.2.3. At the end of June 2018, the other Borough’s Children’s Social Care closed their involvement with the Mother believing there was a sufficient support and safety plan in place. This was a reasonable course of action however the formulated plan subsequently became invalidated due to the Mother being rehoused in Local Authority A in early July. This meant in practice the other Borough’s Children’s Social Care had no reason to track and monitor arrangements once they had closed the case. It also meant that the Midwifery care transferred to Hospital B (although there was a nine week gap in handover as outlined above) and because the Mother would no longer be eligible for the services of the other Borough’s Family Nurse Partnership and any postnatal specialist care would be picked up by the D London Community Healthcare NHS Trust Health Visiting Service. The Family Nurse Partnership service in Local Authority A has different eligibility criteria to that of its counterpart in the other Borough. 5.2.4. Family Nurse Partnership (FNPs) works ‘… with parents aged 24 and under, partnering them with a specially trained family nurse who visits them regularly, from early pregnancy until their child is two …’16. To be eligible the young parent has to be living in the authority and be up to 28 weeks gestation, and the emphasis is offering a personalised model of care for each young parent. The service is not available in every local authority and capacity is limited especially when needing to prioritise the most vulnerable and complex young women. The eligibility criteria for other Borough’s FNP17 is for women aged 22 years and under with complexities and vulnerabilities. The Mother fitted this criterion, being under 22 years of age at the time and was offered the service at 29 weeks pregnancy (some discretion was applied given the stage of gestation as the other Borough’s FNP is part of the ADAPT testing programme18). In contrast Local Authority A FNP19 offer the programme to young women aged 20 years and under (although care leavers aged 20 – 24 years are eligible). This highlights a difference in age criteria across the two Boroughs. The South London Specialist Midwifery Service ‘… did not inform Local Authority A FNP because their professional opinion was that the Local Authority A team would face limitations in regard to any action they could take because the Mother was outside of their criteria of intervention …’20 (due to her being later on in gestation). The criteria, although different across the two Boroughs, does allow some flex; the criteria in Local Authority A FNP does explicitly permit care leavers to be eligible. On this basis it was worth making an application. Learning point: One Service cannot make a decision or assumption on behalf of another Service about whether someone in need of support will, or will not, be eligible. This is especially so where the eligibility criteria may be similar but there are grey areas that require local interpretation and local decision making. 5.2.5. From a system thinking perspective this episode highlights a misalignment of FNP service provision across local authority areas which had the potential to create a pathway to failure21. The pathway was one that created a mismatch with Local Authority duties for care leavers potentially up to the age of 25 years. Whilst it is recognised that local delivery mechanisms need to consider funding, capacity and resource implications there is a certain logic to ensuring that offers by innovative initiatives such as the Family Nurse Partnership align with the expectations placed on other agencies targeting the most vulnerable cohort of young parents. The review has benefitted from the contribution of 16 Family Nurse Partnerships - Programme information 17 South London Family Nurse Partnership 18 Family Nurse Partnership - ADAPT 19 Local Authority A Family Nurse Partnership 20 South London Hospital Maternity Services submission to the review. 21 a) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 24, University of Warwick & University of East Anglia, May 2016 & b) Learning into Practice: improving the quality and use of serious case reviews: Masterclass 2 Systems thinking, SCIE & NSPCC, 2016. CLASSIFIED INFORMATION – FINAL REPORT 11 Official the National Unit for the FNP programme, who have confirmed that all FNP arrangements now have the flexibility and choice to offer support to young women up to the age of 25 years, and have done so since April 2016, making it more aligned to Local Authority duties. There is also a national evaluation underway which is looking at whether changing the gestation period criteria is viable. 5.2.6. The South London NHS Trust Maternity Services have also highlighted that there is ‘… no evidence of consideration by the [Specialist Midwifery Service] prior to transferring maternity care of the increase in risks following mother being placed back in Local Authority A … It would be expected that when the mother was moved back to Local Authority A a MASH referral to Local Authority A would be made by the Midwife as the risks to the unborn baby had increased ...’22. Current Antenatal Care guidelines do not provide guidance on the transfer of care during pregnancy; as a result of this review it has prompted an action to amend and update the guidelines. 5.2.7. The South London NHS Trust has also confirmed that there is no evidence that safeguarding supervision was sought by those practitioners involved with the Mother. Having access to objective and skilled supervision which allows an opportunity to explore the more complex and vulnerable cases a practitioner may be responsible for is an important and healthy aspect of safeguarding work; it increases the likelihood that good decisions will be made about thresholds and case management. The use of safeguarding supervision is an area that is known to be of concern and there is ongoing work to remedy this, with there being an expectation that practitioners should receive supervision every 12 weeks. 5.2.8. The Hospital Social Work Team, which is part of the front-door referral & assessment service of Local Authority A Children’s Social Care, acknowledge that the ‘contact’ from the Front Door Service was not dealt with in a timely manner remaining as a ‘contact’ until after Baby Darryll had been injured and taken to hospital. This delay is confirmed by Hospital B who have reported having no response to the referral they made in September. In practice this resulted in a two-week gap of there being no action to either allocate to a worker for assessment or step down to another service. Local Authority A Children’s Social Care have noted that ‘… this practice falls short of the required standard to review the contact and make a decision in a timely way …’23. This two-week window of time would have allowed ample time to convene a meaningful multi-agency discharge planning meeting which could have been informed by an updated assessment from the one conducted by the other Borough’s Children’s Social Care. As a consequence of this inaction, the discharge planning meeting was not sufficiently robust resulting in a limited safety plan being in place. 5.2.9. A number of risk factors are noted to have been discussed at the discharge planning meeting in September. The Mother did not think it necessary for there to be another assessment and consequently did not give her consent to one taking place. This reflects the Mother’s frustration with ‘the system’, which she felt should have known enough about her circumstances already and not need further assessments. Records examined highlight an optimistic tone concerning risks for the baby but with the Mother giving different information about her cannabis use than is contained in the original information from the Midwives i.e. she stated that she had ceased her cannabis use one month prior to the baby’s birth but in the referral the cannabis use was said to be on going. The outcome of this meeting for the Hospital Social Work Team was that a worker would not be allocated to undertake a further assessment. Those managers involved at the time have reflected on their involvement and decisions and revealed some uncertainty about the best course of action. The Mother had not agreed to an assessment, creating a dilemma for the managers who were mindful that the decision made by Local Authority A Front Door service was that the case should proceed to an assessment. The following factors influenced the Hospital Team’s decision making; - The concerns were historical rather than current. 22 South London Hospital Maternity Services submission to the review. 23 Local Authority A Children’s Social Care submission to the review. CLASSIFIED INFORMATION – FINAL REPORT 12 Official - Mother had said that she had stopped smoking cannabis a month before the baby was born. - The Personal Adviser supporting Mother did not have any concerns about her ability to care for the baby. - A risk assessment conducted by the Leaving Care Team was in place in relation to the risk of gangs and domestic abuse; the Leaving Care Team were monitoring this and working with Mother to keep her safe. - The closing summary letter from the other Borough’s Children’s Social Care did not raise current safeguarding concerns. - Mother had support from close family and had been back in the Local Authority A area for three months with no problem to date. 5.2.10. There are a number of factors which counter the criteria used by the Hospital Team to make their decision. These include; - The extent of the Mother’s cannabis use was uncertain at this time. Despite the Mother stating that she had stopped smoking a month before the Baby Darryll’s birth, she gave no undertaking to stop using it when she went home. Her cannabis use was a long-standing habit and one which was likely to prove very difficult to stop altogether. The Mother advised that she did not want support in stopping and that she used it to control her anxiety and to help her sleep – highlighting a self-medicating purpose rather than as a recreational drug. - There are two accounts of the discharge planning meeting which place a different emphasis on the risks to Baby Darryll – one from the attending Social Worker who did not know the case and one from the Personal Adviser. Differing accounts from a meeting may reflect on the quality of chairing and recording arrangements. This has prompted the creation of a report format to more accurately capture the discussion and decisions from discharge planning meetings. - The full pre-birth assessment from the other Borough’s Children’s Social Care had not been considered at this time despite it being known about and available. One of the recommendations from the other Borough’s assessment was that child protection procedures should be considered in the event that Mother moved back to Local Authority A. Not using this assessment was a missed opportunity to build on work completed and consider next steps. This would have played into the Mother’s sense of professionals continually re-assessing her circumstances. - The Mother had reported receiving support from extended family members. This was viewed as a positive feature however the extent of these support networks had not been fully explored and assessed; there had been a reliance on the Mother’s account of what she felt was available for her. Had this been explored it would have revealed some concerns about the extended family’s care of children and their involvement with Children’s Social Care. 5.2.11. This episode reveals a persisting challenge and dilemma for frontline practitioners who are required to form judgements about thresholds, especially those where there is a need to balance safety with, or sometimes alongside, offering support. The Hospital Team’s balancing of risk factors might be viewed as reasonable given the presenting information, however decisions were made in the absence of important information. This approach or style of thinking and decision making reflects what Munro24 refers to as an intuitive form of reasoning ‘… a cognitive process that somehow produces an answer, solution or idea without the use of a conscious, logically defensible, step-by-step process …’. In the absence of the knowable additional information a best fit decision was taken. The other style of reasoning is analytic which is characterised as ‘… a step-by-step, conscious, logically defensible process …’. Both forms have their own merits and can be used effectively to complement decision making. In this case however, a further assessment would have been the step-by-step pathway to offering greater protections to Baby Darryll and allowing an opportunity 24 Munro, E., Common errors of reasoning in child protection work, 1999, LSE Research Articles Online. CLASSIFIED INFORMATION – FINAL REPORT 13 Official to prove or disprove a hypothesis that the Mother was capable and coping25. Calder26 notes of intuitive reasoning that it can be heavily relied on in child protection work citing research27 which describes this form of reasoning as ‘…a hazard, a process not to be trusted … because it is … flawed by biases …’. 5.2.12. This view has been reflected by Local Authority A Children’s Social Care ‘… in reviewing the additional information … that was not considered, the threshold becomes clearer. All indications are that although Mother was upset about the possibility of another assessment, she was generally co-operative. Efforts to persuade her … might have been fruitful. … an assessment of mother and baby in situ would have been advisable, as no social worker from a child protection perspective had assessed mother’s current circumstances. In the absence of consent, s47 enquiries would have been the option available …’ Learning point: When faced with needing to make a pivotal decision about case management and there is any question about which is the best course of action to take, there will always be benefit in seeking a fresh and impartial perspective. Seeking peer or management supervision or specialist opinion is the best option when presented with a dilemma about the safety and welfare of very young children. 5.2.13. Examination of this episode has revealed at that time there was no system for dealing with differences in opinion between Local Authority A Front Door service and the Assessment Teams when recommendations about progressing to assessments were not accepted. Therefore, there was no requirement to either follow the Front Door Service’s recommendation or follow a process that would require further exploration of the situation. As a result of this finding, changes have been introduced to greater scrutiny of disagreements or discrepancy about threshold decisions. 5.2.14. The Housing Trust have considered their response in terms of thresholds for intervention. At the time of the six week visit the Housing Trust were not aware that the Mother was a cannabis user nor was it evident that she was smoking cannabis in her property. Signs of cannabis use at this visit would have triggered the Trust’s child safeguarding procedures. Information contained within the Local Authority A Council’s nomination form and the Mother’s application form set out that the Mother was a care leaver, was heavily pregnant and had a history of anxiety and depression. This should have prompted a vulnerability alert being placed on the Trust’s electronic case management system in accordance with procedural guidelines. As a result, an earlier three weeks visit and check as opposed to the six week check, could have been completed. When exploring with the housing practitioner whether they recognised the vulnerability indicators it was acknowledged that with the benefit of hindsight this should have happened, but as there were no immediate presenting concerns and the Mother was receiving support from Local Authority A Leaving Care Team, the Midwifery Service and her GP, it provided a level of assurance that satisfied the practitioner that a vulnerability alert was not necessary. Learning point: When there is a known network of professionals involved with a young parent there can be no harm done by making contact with the primary lead professional for the young parent (in this case the Personal Adviser) to advise them of your role and whether there is anything they should remain alert to. 5.2.15. A challenge for the Housing Trust, as with many housing providers is the need for them to be aware of, and interpret, threshold guidance across a large number of local authority areas. Given the high likelihood of housing staff 25 Local Authority A Children’s Social Care submission to the review. 26 Calder, M., Risk in child protection: Assessment challenges & frameworks for practice, p 112, 2016, Jessica Kingsley. 27 Hammond, C., Human Judgement and social policy: irreducible uncertainty, inevitable error, unavoidable injustice, 1996, Oxford University Press. CLASSIFIED INFORMATION – FINAL REPORT 14 Official working with vulnerable adults and families it is worthwhile gaining this familiarity with local procedures and expectations. Learning point: Strategic partnerships in local authority areas have a responsibility in ensuring all local services are familiar with safeguarding guidance, thresholds information and procedures. 5.2.16. The Housing Trust had no knowledge that a pre-birth assessment had been undertaken and were not invited to, or made aware of, the hospital discharge planning meeting. D London Community NHS Trust responsible for Health Visiting were also not notified or invited to the discharge planning meeting. Consequently, the Health Visitor was not aware of the historical information and current concerns. 5.2.17. Hospital B were advised that there were no immediate concerns that should prevent the Mother from being discharged. As the Safeguarding Midwife was absent at the time there was no one to challenge this decision. The Hospital Midwife attempted to make contact with the Community Midwifery Service but did not get an answer resulting in the postnatal discharge documents being sent via email but requesting a verbal handover. The specific mention of a verbal handover suggests a level of concern sufficient to request a conversation rather than just an electronic notification. Learning point: A safeguarding system cannot rely on one person; it is the responsibility of the agency or service to ensure that there is adequate contingency planning to cover annual leave, sickness or other unexpected staff absences and that suitably qualified cover arrangements are available. 5.2.18. From the Health Visiting perspective D London Community NHS Trust has highlighted that the Health Visitor was not invited to the discharge planning meeting and as a result of this was not aware of the Mother’s vulnerabilities as no information had been shared with them previously. On review of the records it has been noted that the discharge summary birth notification had been received the same day as the new birth visit had taken place and that it had no information about the risk factors and concerns. Although the Mother was open and forthcoming about her background at the new birth visit which was completed within procedural timeframes, it meant that the Health Visitor relied on the first account from the Mother. This must have been somewhat disempowering for the Health Visitor as it prevented her from undertaking any checks beforehand by way of preparation for the visit. The established pathway for this information exchange about cases should take place during the monthly Vulnerable Women’s Forum Meetings, where all vulnerable antenatal clients are discussed and logged on an electronic reporting system and then shared with the allocated Health Visitor. Due to the late notification this did not happen. 5.2.19. During the new birth visit the Health Visitor had queried the smell of cannabis and cigarettes in the property; this was on the back of the Mother stating that she continued to smoke cannabis outside of the home. Although the Health Visitor discussed the risks of sudden infant death, safe sleeping and other health related information, it appears that there was little enquiry about cannabis use, again reflecting a mind-set which normalises cannabis use. The conclusion of the new birth visit was positive with the Mother assessed as being calm (although tired due to visiting her own mother in hospital), confident and receptive to advice given. No concerns were observed, and the home environment was reported to be clean and tidy and very appropriate. The Health Visitor did however make contact with Local Authority A Children’s Social Care following the visit and was informed that the case was closed. 5.3. The impact of transitions across Boroughs & the quality & effectiveness of support offered 5.3.1. There are two transitions of note in this case; firstly, the transition around the Mother being re-housed from another Borough to Local Authority A, and secondly, as a result of the first handover the transition of antenatal care between different maternity services. CLASSIFIED INFORMATION – FINAL REPORT 15 Official 5.3.2. Service transitions and handovers create vulnerability in system processes; introducing new workers, differences in thresholds and procedures, have resourcing implication, and differing safety net mechanisms. When coupled with situations in which children face risk and there is a level of inherent uncertainty about case management it creates fertile ground for miscommunication and failures to occur. These are unintentional but are a key feature for professionals to be mindful of when working in complex systems, such as multi-agency partnership arrangements. It is of note that, in this case, had the Mother remained in one Borough she still would have needed to navigate three different health Trusts from the point of receiving antenatal care through to receiving community Health Visiting (Hospital B, Hospital C and D London Community Healthcare NHS Trust). Due to the transition across Boroughs this increased to five health Trusts. Such arrangements provide fertile ground for errors to occur due to organisational boundaries, different recording and databases being used, and multiple professionals requiring handovers. 5.3.3. Before considering these two key transitions, the review has highlighted some short delays in information exchange between the South London Specialist Midwifery Service, the other Borough’s Children’s Social Care and Local Authority A Leaving Care Team at the time of the referral being made to the other Borough’s MASH and the subsequent pre-birth assessment. Whilst these delays did not have a negative impact on the next steps undertaken by the other Borough’s Children’s Social Care it does highlight added complications when working across geographical boundaries and working with multiple agencies. Delays in information sharing create further delays in decision making. Transitions and housing provision 5.3.4. Review of this episode shows that the Mother submitted applications to two Borough Housing Services at the same time. The other Borough Housing accepted a preventative duty towards the Mother and would have offered her accommodation if she had become homeless. The Mother chose not to accept the accommodation offer, perceiving it to be an offer of shared accommodation as, at around the same time, an offer from Local Authority A Housing was forthcoming. Not wanting to be made homeless, the Mother reluctantly accepted the Local Authority A Housing offer of her own flat as this was a more attractive option. 5.3.5. The impact of the decision by Local Authority A Children’s Social Care to place the Mother in another Borough some years earlier was evidently a good one. It appears to have resulted in no further domestic abuse or gang associations for three years. The decision to then provide the Mother with housing in June 2018 is therefore at odds with the earlier decision and suggests a lack of joined up thinking from within Local Authority A Council. The safety and support plan for the Mother, and by association Baby Darryll, revolved around the Mother remaining outside of Local Authority A. By all accounts the Mother was settled in the other Borough, engaged with services, and received continuity of care from her local GP Practice who knew about her alcohol and drug use and were supporting her. The closure letter from the other Borough’s Children’s Services to all involved clearly recommended that ‘… Local Authority A continue to find appropriate accommodation as a duty to her as a care leaver within an alternative Borough to Local Authority A due to the risks …’28. 5.3.5. The Housing Trust have reflected that no contact was made by any agencies working with the Mother once she had moved back into Local Authority A accommodation. As stated in section 5.2, the Trust were not made aware of the full extent of the Mother’s background or support needs during the first six weeks of her tenancy. Care Leavers are acknowledged as a vulnerable client group by the Trust and are offered 1:1 support. This offer of support was made by the Trust at the six-week welcome visit but was declined by the Mother who felt she had a sufficient support network already. 28 Other Borough’s Children’s Social Care submission to the review. CLASSIFIED INFORMATION – FINAL REPORT 16 Official Transitions and antenatal care 5.3.6. The second transition to be examined concerns the handover of antenatal care between maternity services. As highlighted the Mother changed her mind about where she wished to receive antenatal care. Women are able to choose where they wish to access antenatal care and the South London Specialist Midwifery Service were consistent in their practice of sharing information with both Hospital A’s and then Hospital B. This is good practice and clearly demonstrates a focus on the needs and wishes of the Mother but also consideration of the needs of the unborn child. From this aspect, the South London Specialist Midwifery Service made attempts to support a protective pathway. There is however a possible learning point from this episode. In order to support better practice the South London Specialist Midwifery Service might have also considered making a referral to Local Authority A MASH at the point they became aware that the Mother was going to be rehoused in Local Authority A. At the time (June 2018) they were the only Midwifery Service that had had contact with the Mother and their insights into the Mother’s situation could have added a useful perspective to any further assessment work undertaken. This referral would however need to be balanced with gaining the consent from the Mother and given the Mother’s view about not needing additional support this would likely have prompted a threshold dilemma for the Specialist Midwifery Service. A consultation with the Maternity Safeguarding Team might have given the Midwife an opportunity to reflect on, and take action in regard to the increase in risks for the unborn baby, by mother moving back to Local Authority A. The Mother’s Personal Adviser and the Midwifery Service were the only two consistent professionals working with the Mother. 5.3.7. As highlighted in section 5.1. Hospital B were provided with background information from the South London Specialist Midwifery Service, although had not had sight of the pre-birth assessment from the other Borough’s Children’s Social Care. They appropriately made a referral to Local Authority A Children’s Social Care because from their perspective there was no current social care involvement. This impacted on the quality of the discharge planning meeting. Learning point: Sharing pre-birth assessments, which have been conducted due to likely risks to the infant, with all relevant health care professionals is an important, and necessary, task. Failure to share this assessment disadvantages those professionals making their best decisions, reduces the impact of conducting a pre-birth assessment and potentially places the infant at risk. 5.4. Local knowledge & understanding about the vulnerabilities of young babies 5.4.1. Research29 into other Serious Case Reviews highlights the largest proportion of cases subject to review relate to children under one year of age with a significant percentage being children under three months. Given this knowledge it is helpful for this review to explore the extent of professional knowledge and understanding about this particularly vulnerable group of children, especially in the context of known information about both pre-disposing and situational risk factors in this case. 5.4.2. From the other Borough’s Children’s Social Care perspective, the pre-birth assessment was conducted by a Social Worker in their assessed and support year of employment (ASYE) and supported by an experienced Manager. Additional support was also available from an experienced Senior Social Worker. Relevant guidance about conducting pre-birth assessments was accessed. Records indicate just one supervision session taking place. An awareness of the risks to the unborn child are clearly evident. 5.4.3. Local Authority A Leaving Care Team and the Personal Adviser for the Mother had a key role in bridging services and acting as a facilitator to promote joined up working arrangements, especially given the transitions discussed above in section 5.3. They were aware of the Mother’s history, had worked with her a long time and had regular contact with 29 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 35, University of Warwick & University of East Anglia, May 2016. CLASSIFIED INFORMATION – FINAL REPORT 17 Official her supporting her through the pregnancy. They were well placed to assess the strengths and difficulties of the situation, although as articulated in section 5.1., it is arguable they were placed in a double bind situation during the pregnancy due to a potential conflict of interest. Records and discussions confirm that they were mindful of the baby’s needs, in its own rights, and conversations took place between the Manager and Personal Adviser about whether they should make a referral to the MASH. A decision was reached that they should make such a referral, and this was also a recorded action in the Mother’s Pathway Plan in August 2018, only a few weeks before the birth. However, a referral was not then made for the following reasons: - The pre-birth assessment by the other Borough’s Children’s Social Care was relatively positive. - The risks associated with gangs were considered to be negligible because the Mother had ceased contact with these individuals. The Mother had confirmed that she was actively avoiding them and had a contingency plan in place should she meet them. - Risks associated with domestic incidents were considered; although a legal intervention via a Non-Molestation Order was an option, on balance it was felt best not to alert the perpetrator about her return to the area. - An evaluation that the Mother had matured in recent months, was in control of her alcohol and cannabis use and generally she appeared to be having a positive outlook on life. This was supported by the fact that the Mother was also seeing a counsellor, and this was seen as a positive relationship. 5.4.4. Whilst the above list of situational factors is positive, there is little recognition about; - The weight of the Mother’s earlier life experiences and how this may impact on her parenting capacity. - The fact that she was not disclosing to anyone who the baby’s father was; something that ordinarily may be a cause for considerable curiosity but also concern. - The extent and reliance on her cannabis use as a self-medicating habit rather than recreational usage; which is likely to have some impact on parenting capacity. - The possibility of the decision to not make a referral being overly optimistic in terms of the pathway for the Mother and baby once born, and the likelihood of additional support being needed sooner rather than later. 5.4.5. It is arguable that the revised decision by the Local Authority A Leaving Care Team to not make a referral to the MASH further reflects an intuitive form of reasoning, as discussed in section 5.2, highlighting a possible bias that was favourable towards the Mother, and which left Baby Darryll vulnerable. Learning point: It is important to remain open and receptive to having to re-evaluate your assessment and relationship with the parents you work with, being mindful of any undue bias or influence about someone’s character or situation or convincing information. 5.4.6. From the perspective of the Housing Trust staff have completed training with a specific focus on the vulnerability of both young and unborn babies where there are known risks and vulnerability factors and the importance of reporting concerns, early intervention and inter-agency working. 5.4.7. The Midwife who saw the Mother and Baby Darryll at home had attended the appropriate level of safeguarding training, where a session is devoted to the vulnerability of babies even without extra risk factors. The Midwife was aware of the mother’s cannabis smoking and asked for reassurance that the mother would try to give up. 5.4.8. The South London Specialist Midwifery Services have reflected that there is room for improvement in terms of their specialist service evidencing in recording understanding and curiosity about the vulnerabilities of young babies, especially where there are known risk and vulnerability factors. These risks and vulnerabilities include known cannabis use and the impact on parenting plus the transfer of housing back to an area where there were known risks. This expectation will form part of the revised pathway referred to in section 5.1. CLASSIFIED INFORMATION – FINAL REPORT 18 Official 5.4.9. The D London Community NHS Healthcare Trust responsible for Health Visiting Services in the Local Authority A area have confirmed that the allocated Health Visitor had completed the appropriate level of safeguarding training, in line with expectations30, which included risk and vulnerabilities for young babies when known vulnerability factors. 5.4.10. The practitioner involved with the Mother and Baby Darryll from Hospital B took appropriate actions thereby demonstrating knowledge and understanding about the risks to Baby Darryll in the circumstances. 5.4.11. There is learning for Local Authority A Adult Substance Misuse Service who were involved briefly with the Maternal Grandmother. Their initial assessment of her provided them with an opportunity to be more curious about the disclosure by the Maternal Grandmother about her daughter’s pregnancy. She had shared some concern about the father of the unborn child and that he was ‘… involved with people with guns …’. This information was correctly shared via email in early September with the Leaving Care Team. As the worker was on annual leave an out of office message was received but the information was not followed up with a phone call. It was only on the Leaving Care practitioners return from leave some 10 days later was the information received. Although this information may not have been critical to the assessment and case management at the time, it could have added useful contextual detail to the knowledge held by the Personal Adviser and the Midwifery Services. Learning point: Safeguarding children is everyone’s responsibility. When information emerges from your interactions with service users, irrespective of your role and agency remit, that indicates someone has a worry about a child it is important to be curious with the service user about the information being shared. This may then require you to seek advice about whether it is appropriate to share this information with either the Police or Children’s Social Care. 5.5. The quality & effectiveness of services provided to the mother as a care leaver 5.5.1. Local Authority A Children’s Social Care have confirmed that the Mother had benefited from a Personal Adviser for over three years having been allocated a worker when she became 18 years old. Reports indicate the relationship was positive and that other members of the team knew the Mother and she genuinely found their support helpful. The team in which the Personal Advisers work is multi-disciplinary. The Mother was also engaged with a counsellor. The Mother had a Pathway Plan, and this has been judged as of a good standard and relevant to her circumstances, having been reviewed just prior to Baby Darryll’s birth. There are two areas of interest in terms of the quality and effectiveness of services provided to the mother as a care leaver. When care leavers become parents: 5.5.2. The review has considered areas for learning and improvements in relation to the work that Personal Advisers and the Leaving Care Team undertake with care leavers who then become parents. These areas include; - The Leaving Care Team primary purpose is to support care leavers and as such this is their focus; not that of any children of the individual care leaver. In this case, there are some signs that the focus on the mother as a care leaver obscured a shift in attention, or equal attention, on to Baby Darryll. - The Pathway Plan does not contain a section to assess the needs of care leavers who are, or about to become, parents. In this case, the Mother’s Plan contained information about a range of practical tasks such as preparing her accommodation for the baby, liaising with housing about access with a pushchair, and exploring the correct State benefits. Whilst the focus on practical tasks is entirely appropriate and necessary there is little mention about the need and capacity to develop parenting skills. Reflections by the Leaving Care Team, and with the benefit of hindsight highlight that there were services such as playgroups and young parenting groups that were available but were not considered for the Mother or Baby Darryll. Similarly, a referral to Local Authority A Family Nurse Partnership would have been an entirely appropriate step to take, however this was not considered. 30 Royal College of Nursing - Safeguarding children & young people: Roles & competencies for healthcare staff CLASSIFIED INFORMATION – FINAL REPORT 19 Official 5.5.3. It is possible that other professionals involved with the Mother once back in Local Authority A, for example the Midwifery Services, saw the Personal Adviser as the conduit to action in respect of Baby Darryll’s welfare. Records indicate liaison between these services may have resulted in unwittingly blurring the boundaries between the Leaving Care Team meeting the support needs of the Mother against meeting the safety and welfare needs of Baby Darryll. This issue has also been touched on in section 5.1. Learning point: When there is a significant event or change in a young person’s life as a care leaver, such as becoming a parent or a very close bereavement, and there is a professional network involved it will important for the network to reflect on their roles and responsibilities and whether changes are needed to the support being offered. Supporting care leavers with accommodation and housing: 5.5.4. The Mother’s hope was to continue living in the other London Borough as she felt safe and had developed local connections e.g. friends and college. It would appear that her application was treated as a general homeless application rather than considering her as a care leaver and assessing her other vulnerabilities. Under the Homelessness Reduction Act (2018) Care Leaver’s should be able to apply to any local authority where they have a local connection and to be assessed for housing; multiple applications can also be made to different housing authorities. The involvement of advocacy support with the Mother’s case did not result in any change in decision. The weight and level of support provided to the Mother during this process may be an area that Local Authority A Children’s Social Care may wish to examine in greater detail to ensure that the offer of advocacy and support to care leavers is in line with expectations and promotes good outcomes. 6. Good practice 6.1. This Review has identified a number of areas which can be highlighted as good practice. It is important that good practice is recognised and shared. Examples include; - The pre-birth assessment and closing summary conducted by the other Borough’s Children’s Social Care is a well thought through and proportionate piece of work. - The Community Midwifery Service from Hospital C acted appropriately in contacting Local Authority A Children’s Social Care to escalate their concerns about the Mother’s refusal to grant entry to them when they visited. - The Community Midwifery Service from Hospital C achieved meaningful engagement with the Mother in a postnatal clinic resulting in the Mother being open about her difficulties and family issues. - The South London Specialist Midwifery Service applied professional judgement in ensuring antenatal care was transferred despite there being no guidelines to do so. - Hospital B Midwifery Service made a referral to Local Authority A Children’s Social Care despite being told that the previous social work department had closed the case. - The support offered by the Mother’s Personal Adviser following Baby Darryll being admitted to hospital and after the death has been commended. 7. Conclusion 7.1. This case review has examined the circumstances around the death of a 20-day old infant in October 2018. It has examined multi-agency contact and involvement with the Mother during the pregnancy and benefitted from the contribution of some of the professionals involved at the time. The review has also captured the views and perspective of the Mother. 7.2. The review has highlighted that there were a number of pre-disposing and situational risk factors identified, but which were assessed to not be at a level that justified statutory intervention. Investigations and enquiries by the Police and Coroner have concluded that the cause of Baby Darryll’s death is a case of misadventure. The circumstances may indicate unsafe sleeping arrangements. CLASSIFIED INFORMATION – FINAL REPORT 20 Official 7.3. A number of factors contributed to the multi-agency response not being as effective as they might have been; these include a minimisation of risk from parental cannabis use, biased professional judgements informing decision making, disjointed information sharing that was not timely, and untested assumptions about the Mother’s parenting capacity. The review has highlighted points for learning and improvement within single agencies but also across safeguarding partnerships. The review concludes with recommendations. 8. Recommendations Those agencies that have contributed to the review have submitted action plans to make improvements alongside the reports submitted at the beginning of this review process. As such, agencies have been able to progress learning and improvement activity without the need to wait for the overview process to conclude. Much of the learning identified in this review has been captured as areas for improvement by those agencies represented and is reflected in their action plans. The following recommendations are for the Local Authority A Safeguarding Partnership to take forward. 1. To ensure the learning from this review is disseminated across the multi-agency safeguarding partnership to practitioners and managers. 2. To seek assurance that the actions identified by each partner agency, as a result of this review, have been managed, implemented and embedded in a timely manner. 3. To inform the Family Nurse Partnership National Unit of the findings of this review to allow them to consider the learning and shared with local partnership arrangements and supervisors. 4. To promote learning, as a public health message to the wider population, about the importance of avoiding co-sleeping and unsafe sleeping arrangements with babies. 5. To seek assurance about the quality and effectiveness of joint working arrangements for those services who work with care leavers who are pregnant and who require housing support. 6. To review the information sharing protocol and practice around sharing of pre-birth assessments (closing summaries and full assessments) to confirm that they are provided to the relevant professionals and agencies that are involved with the mother/father; consent to share by mothers/fathers should not be seen as a barrier to the professional network and guidance should include advice about how to overcome any barriers which may arise as a result of consent issues. 7. All organisations across the partnership to ensure all agencies use of the threshold document is proactively considered, especially when consent is withheld and there may be a need to re-evaluate decisions taken on individual cases. 8. To seek assurance that all multi-agency safeguarding training courses and relevant resources relating to risk assessment include explicit reference to the risks associated with cannabis use and the potential impact during the antenatal period and on parenting capacity. |
NC049016 | Multiple non-accidental injuries to a 16-week-old boy in December 2014. Baby M was admitted to A&E twice in two days: presenting with a fractured skull, multiple bruises and torn frenulum; unresponsive and found to have rib fractures of different ages. Father stated he fell whilst holding Baby M after tripping on his trousers. Both parents had learning disabilities. Mother known to multiple agencies and subject to a child protection plan in 2004. Referred to CAMHS for self-harming behaviours. Father had been in care, was known to Youth Offending Team and had a history of criminal behaviour including armed robbery. Family is of White British heritage. Learning includes: where more than one unit is involved with children, in one family, ensure the needs and risks of all the children are jointly assessed and evaluated; where a child is subject of a Child In Need (CIN) or Child Protection (CP) plan agreement to the discharge from hospital without a strategy meeting to be sought by the social worker or Practice Improvement Manager (PIM); formulate and carry out a plan to ensure that social workers routinely consider and incorporate family history as part of Child and Family Assessments. Recommendations include: ensure there is a robust identification and tracking of unborn children, with multi-agency information sharing and working; ensure that all identified tracked vulnerable unborn children have an agreed birth plan in place prior to delivery to ensure that agencies are aware of the plan at birth and alerted when they have been born.
| Title: Serious case review: Baby M. LSCB: Buckinghamshire Safeguarding Children Board Author: Sharon Hawkins Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. April 2016Serious Case Review Baby M SHARON HAWKINS INDEPENDENT REVIEWER Confidential – not to be photocopied or distributed Serious Case Review Baby M 1 CONTENTS Chapter Page Number Introduction – The Child’s Journey 2 Publication 3 Reason for the Review 3 Specific Terms of Reference 4 Timescale 7 Family Involvement 7 Parallel Processes 7 Independent Reviewer and Panel 8 Process and Methodology 9 Ethnicity, Diversity and Cultural Issues 9 Background Narrative as Known to Agencies 10 Chronology of Significant Events Identified in the Individual IMRs 14 Critical Analysis of Concerns 30 Responses From the Key Lines of Enquiry 37 Confidential – not to be photocopied or distributed Serious Case Review Baby M 2 Organisational Context Issues 40 Good Practice 42 Findings and Recommendations 43 Confidential – not to be photocopied or distributed Serious Case Review Baby M 3 Serious Case Review Baby M INTRODUCTION 1 BACKGROUND - The Child’s Journey 1.1 In her second interim report entitled ‘The Child’s Journey’1, Professor Munro identified the importance of analysis of the ‘child’s journey’ through services and for families to receive effective help at the earliest point for problems arising from family and social circumstances. In the case of Baby M that journey started from the date that agencies were first informed that his Mother was pregnant on the 10/01/2014 until the date of the Emergency Protection Order on the 10/12/2014. 1.2 Baby M, a 16 week old baby, was admitted to A&E at 3.45am on the 27th November 2014 following an incident during which his Father was alleged to have fallen whilst holding him after tripping over his trousers. The Father stated that he had fallen, landing on Baby M. Baby M was admitted to hospital and following medical investigations he was discovered to have a linear fracture to the left parietal of his skull. This injury was indicative of a single trauma. In addition he had multiple bruises and a torn frenulum. The explanation provided by the Father was accepted by hospital staff and Baby M was discharged home initially staying with his maternal grandmother then returning to the care of his parents on the 4th December 2014. 1.3 Baby M was readmitted to hospital in the early hours of the 5th December 2014 following a call to the emergency services as he was floppy and unresponsive. Baby M was discovered to have numerous bruises and rib fractures of different ages in addition to the skull fracture, bruising and torn frenulum of his previous admission. A Finding of Fact hearing during subsequent Care Proceedings found that the rib fractures had occurred during two separate incidents with the first occasion prior to Baby M’s first admission to hospital with the skull fracture. 1 The Child’s Journey- 2nd Interim report -https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/206993/DFE-00010-2011.pdf. Confidential – not to be photocopied or distributed Serious Case Review Baby M 4 2 PUBLICATION 2.1 In line with publication requirements for Serious Case Reviews this report has been anonymised to protect the identity of the child involved, he shall be known as Baby M and his date of birth will not be included in the report. REASON FOR THIS SERIOUS CASE REVIEW 3.1 Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases in accordance with procedures as set out in ‘Working Together to Safeguard Children’ (HM Government 2015). 3.2 A serious case is one where: • abuse or neglect of a child is known or suspected; and • Either the child has died or the child has been seriously harmed. 3.3 In these circumstances the LSCB should conduct a Serious Case Review (SCR) into the involvement that organisations and professionals had with that child and their family. 3.4 Working Together 2015 says SCRs should: • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; • recommend actions which result in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and • be transparent about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final reports of SCRs with the public. Confidential – not to be photocopied or distributed Serious Case Review Baby M 5 3.5 The Buckinghamshire Safeguarding Children Board (BSCB) Chair decided on 17th December 2014 to hold a Serious Case Review because the child in this case had suffered serious injuries and abuse was suspected. 3 SPECIFIC TERMS OF REFERENCE Assessments 4.1 To establish what assessments were undertaken of the Father and Mother, and the quality of those assessments. This should include assessments relating to mental health and substance misuse. 4.2 To establish what risk factors were identified in relation to the baby pre-birth, and whether appropriate procedures were followed. 4.3 To establish what risk factors and needs were identified in relation to the baby after the birth. 4.4 To establish to what extent the parenting capacity and the needs of the parents were considered and addressed. 4.5 To establish if plans were implemented for the Mother, Father or baby, and to what extent the plans addressed any risk factors identified in the assessments. 4.6 To establish whether practitioners understood the thresholds for intervention - from Early Help through to Child Protection. Service provision 4.7 To establish if there were factors which enhanced or impeded working relationships with the parents. 4.8 To establish if there were any capacity issues within agencies which impacted on the quality of services provided. 4.9 To take account of whether lessons learned from relevant previous Serious Case Reviews have been embedded. Confidential – not to be photocopied or distributed Serious Case Review Baby M 6 Professional practice 4.10 To establish if the staff involved had the skills, knowledge and experience to address the issues within the family. 4.11 To establish if the diversity needs within the family were identified and addressed. 4.12 To establish if staff within agencies co-operated to achieve the best outcomes for the child. Management oversight 4.13 To establish if agencies shared information appropriately and involved other professionals or agencies as necessary, including adult services. 4.14 To establish to what extent individual agency and multi-agency policies were adhered to and comment on the adequacy of those policies. 4.15 To establish if staff directly involved had appropriate supervision and managerial guidance. Other 4.16 Individual Management Review Report writers to identify any additional issues for consideration by the Overview Report writer, including those which fall outside of the active period of the review. 5 TIMESCALE 5.1 The timescale for the active period of the review is from the 21/01/2014 to the date of the Emergency Protection Order for Baby M on the 10/12/2014. Confidential – not to be photocopied or distributed Serious Case Review Baby M 7 6 FAMILY INVOLVEMENT 6. 1 It is important that family members are involved in the review process and that they have the opportunity to understand why a Serious Case Review is being conducted. Family members should be consulted and given the opportunity to provide information about their contact with professionals and the quality of services that have been provided. 6. 2 It has not been possible to interview Baby M’s parents due to ongoing criminal investigations. The family were notified that a Serious Case Review would be taking place. 7 PARALLEL PROCESSES 7. 1 During the process of this review there have been ongoing criminal investigations and care proceedings in respect of Baby M. Care proceedings have now concluded and Baby M is the subject of a Placement Order2. Expert medical reports and those of the Finding of Fact hearing relating to those proceedings have been released by the court to be considered within this review. 8 INDEPENDENT REVIEWER AND PANEL 8.1 An Independent Reviewer, Sharon Hawkins, was commissioned to undertake this Serious Case Review. Sharon qualified as a Social Worker in 1994 and after 18 years of being employed in Local Authorities in the North West of England she became an Independent Safeguarding Consultant in 2012. Sharon has 21 years of experience of both social work and management at various levels in frontline children’s services. She is experienced in completing Serious Case Reviews and reflective learning reviews and completed the national training programme for Serious Case Review authors in 2013. 2 A Placement Order, made under section 21 of the Adoption and Children Act 2002, gives authority to a local authority to place a child with prospective adopters. It can only be made in relation to a child who is the subject of a Care Order or where the Threshold Criteria for a Care Order are satisfied or where there is no parent or guardian. Confidential – not to be photocopied or distributed Serious Case Review Baby M 8 8.2 Short reports and Individual Management Reviews were requested from the following agencies: Buckinghamshire County Council’s Children’s Social Care Service IMR Youth Offending Service IMR Wycombe District Council IMR Buckinghamshire Healthcare NHS Trust - Maternity IMR Buckinghamshire Healthcare NHS Trust - Acute Services IMR Buckinghamshire Healthcare NHS Trust - Health Visitors IMR Thames Valley Police IMR General Practitioners (GPs) IMR Oakhill Secure Training Centre Short report Ambulance Service Short report Buckinghamshire County Council’s Adult & Family Wellbeing Service Short report Buckinghamshire Law Plus Short Report Oxford Health – CAMHS (Children & Adolescent Mental Health Services) Short report CAFCASS (Children and Family Court Advisory and Support Service) Short Report Organisation providing support for young people aged 16 – 18 yrs Short report Special Needs School Short Report Organisation providing support for young homeless people aged 16 – 20 yrs) Short Report Connexions Short Report Addaction Short Report Young Addaction Short Report Confidential – not to be photocopied or distributed Serious Case Review Baby M 9 8.3 The members of the Serious Case Review panel for Baby M comprised of senior managers from the key statutory agencies who have had no direct involvement with the case. The panel members identified authors within their own agencies to complete the Individual Management Review reports. The role of the panel was to actively manage the review and to provide oversight and scrutiny through all aspects of the process. An Independent Chair, Malcolm Ross, was appointed to chair the Serious Case Review Panel. 8.4 The following agencies were represented on the panel alongside the Buckinghamshire Safeguarding Children Board: • Buckinghamshire Healthcare NHS Trust • Youth Offending Service • Buckinghamshire County Council Social Care • Thames Valley Police • Buckinghamshire Clinical Commissioning Groups 9 PROCESS AND METHODOLOGY 9.1 On the 17/02/2015, the Serious Case Review Panel met to consider the timeframe and terms of reference for the SCR. 9.2 Working Together 20153 requires serious case reviews to be conducted in such a way which; • recognises the complex circumstances in which professionals work together to safeguard children 3https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf Confidential – not to be photocopied or distributed Serious Case Review Baby M 10 • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight • is transparent about the way data is collected and analysed • make use of relevant research and case evidence to inform the findings. 9.3 The Serious Case Review Panel in this case requested that agencies completed chronologies and Individual Management Reviews of their involvement with Baby M and his parents. A composite chronology was completed and made available to the Independent Reviewer. 10 ETHNICITY, DIVERSITY AND CULTURAL ISSUES 10.1 Buckinghamshire is a relatively affluent county with good transport links to London. It has shown increasing population growth rates with increases of 5.7% between 2001 and 2011, a population rise from 479,024 to 506,550. Reflecting the national picture there has been a large increase in older people age 65+ at 21%. However, there has also been an increase in population for children and young people (age 0-19) and adults (age 20-64) of 3.3% and 2.9% respectively. The future population predictions have indicated that growth will continue to increase to 547,022 by 20214. 10.2 Buckinghamshire has a predominately White British population; the second largest ethnic group is people from Asian British heritage5. 10.3 Baby M and his parents are of White British heritage and identified with the local culture where they lived. 10.4 Both parents had learning disabilities and attended special needs schools. Very few agencies recorded any information in respect of disability. 4 http://www.buckscc.gov.uk/media/2906128/Buckinghamshire-Population-Projections-Dec2014-.pdf 5 https://docs.google.com/spreadsheets/d/1yc8W1SiCbWd9V4I9KmTlY_Rk_qullL828Qxbsvth93w/edit?hl=en&pli=1#gid=0 Confidential – not to be photocopied or distributed Serious Case Review Baby M 11 10.5 The Father of Baby M is a former Looked After Child and received After Care Services. 11 BACKGROUND NARRATIVE AS KNOWN TO AGENCIES Family Composition Relationship Acronym Subject Child Baby M Mother Baby M’s Mother Father Baby M’s Father Maternal Grandmother to Subject Child MGM Maternal Grandfather to Subject Child MGF Paternal Grandmother to Subject Child PGM Paternal Grandfather to Subject Child PGF Maternal Great Grandmother to Subject Child MGGM Maternal Great Grandfather to Subject Child MGGF Confidential – not to be photocopied or distributed Serious Case Review Baby M 12 Genogram Mother 11.1 There is a long history of service involvement with the Mother of Baby M, dating back to her early childhood. The first recorded referral in respect of Baby M’s Mother was in August 2004 when she was aged 8 years. Prior to this referral the maternal family had been known to Children’s Services and Baby M’s Mother had been subject to a child protection plan in 2004 along with her siblings. Information identifies that she grew up in a household where there was a considerable level of domestic abuse and concerns regarding compromised parenting. 11.2 Concerns continued throughout Baby M’s Mother’s childhood and at aged 15 she was referred to CAMHS due to concerns regarding self-harming behaviours. Baby M’s Mother had special needs and attended a Special Needs School as a boarding pupil from Monday to Friday, spending weekends at home with her Mother Father Maternal Great Grandmother Maternal Grandmother Mother Maternal Great Grandfather Baby M Paternal Grandfather Paternal Grandmother Maternal Grandfather Confidential – not to be photocopied or distributed Serious Case Review Baby M 13 and siblings. She was one of the more able students at the school but her behavioural difficulties held her back. As well as Baby M’s Mother attending a special needs school her Mother, the MGM, was also a pupil at the same school when she was younger. Agencies continued to have concerns about the parenting Baby M’s Mother and her siblings received during this period, including a joint Section 47 investigation being carried out following allegations that the maternal grandmother had punched Baby M’s Mother’s brother in the stomach. 11.3 Baby M’s Mother was seen by CAMHS in January 2012 following an overdose. When she was 17 the relationship between her and her Mother deteriorated and Baby M’s Mother left the family home initially staying with an aunt before this broke down; she was referred to Connexions due to homelessness risk. In 2013 she was part of an enquiry into Sexual Exploitation. Baby M’s Mother was one of a number of female victims in this investigation. The offender pleaded guilty to a number of the charges, but the one relating to Baby M’s Mother was not proceeded with. It has not been clear throughout the review as to why this happened and the Police IMR author has been unable to identify a reason other than Baby M’s Mother was living in supported lodgings at this time and had declined to cooperate with any Police investigations. The case was closed to Children’s Services on 18th Nov 2013 as Baby M’s Mother was no longer deemed in need of services. Father 11.4 Baby M’s Father first became known to Children’s Services in July 2008 when he was 12 years of age. The referral was made by the probation officer who had been working with his Mother due to benefit fraud. During meetings with the Probation Officer she had disclosed that Baby M’s Father had been violent towards her, she also disclosed that her relationship with his Father (PGF) had been one of regular violence resulting in him leaving the family home when Baby M’s Father was aged 3. 11.5 A further referral was received in 2011 by Children’s Social Care when Baby M’s Father was aged 16; concerns were in respect of him regularly featuring as a Confidential – not to be photocopied or distributed Serious Case Review Baby M 14 missing person. His Mother said she was struggling to cope with him and requested that he was accommodated under S206. 11.6 Baby M’s Father had a diagnosis of ADHD and had been prescribed medication for this. He attended a school for children with emotional and behavioural difficulties. He had involvement from CAMHS between May 2011 and January 2012 and again in November 2013 to December 2013. 11.7 In September 2012 Baby M’s Father was remanded into Local Authority care following his involvement in an attempted robbery7. He was placed at home with his Mother and received services as a Looked after Child. 11.8 Baby M’s Father was known to the Youth Offending Team; he had a history of criminal behaviour including armed robbery for which he received a 18 month Detention and Training Order of which he served 7 months in custody and the remainder in the community on licence. He was subject to MAPPA8 and classified as a category 29 offender. He was released from Custody in January 2013 and had been an exemplary prisoner. Risk assessments of him indicated he was a medium risk of serious harm to others. 11.9 In November 2013 Baby M’s Father was detained by the Police under section 136 of the Mental Health Act following an attempt to hang himself in the family home. He ran away and was found in the woods by Police with a scarf, cable tie and 6 Section 20 of the Children Act 1989 relates to the Local Authority’s duty to provide accommodation for any child in their area who needs somewhere to live. 7 Attempted Robbery’ and ‘Possession of a Firearm or Imitation Firearm at the time of Committing or being Arrested for an Offence’ 8 Multi-agency public protection arrangements are in place to ensure the successful management of violent and sexual offenders. The Criminal Justice Act 2003 (“CJA 2003”) provides for the establishment of Multi-Agency Public Protection Arrangements (“MAPPA”) in each of the 42 criminal justice areas in England and Wales. These are designed to protect the public, including previous victims of crime, from serious harm by sexual and violent offenders. They require the local criminal justice agencies and other bodies dealing with offenders to work together in partnership in dealing with these offenders. 9 People convicted of a violent or other sexual offence (even if nobody was actually hurt), who are not registerable sexual offenders, with a 12 month or more prison sentence or hospital order, for a schedule 15 offence (Category 2). Confidential – not to be photocopied or distributed Serious Case Review Baby M 15 a penknife. He was detained and taken to a place of safety and following assessment he was discharged to the care of his aunt. 11.10 Between 2008 and 2014 Baby M’s Father was reported as a missing person on 51 occasions, as a victim and suspect in robberies, reported to have assaulted a female with a bat, to have himself been a victim of assault and involved in domestic incidents. 11.11 Information known to agencies in respect of Baby M’s Father included him being a young man with learning difficulties who displayed aggressive and violent behaviour, was involved in risky behaviour including going missing and staying out overnight, cannabis misuse and offending behaviour involving violence. 12 CHRONOLOGY OF SIGNIFICANT EVENTS IDENTIFIED IN THE INDIVIDUAL IMRs 12.1 This section is designed to summarise the key relevant information that was known to the agencies and professionals involved with the parents, who were both very young first time parents with known learning difficulties, and the circumstances of Baby M both pre and post birth. The Review is concerned with Baby M and the events which may have impacted on the adults caring for him. Pre-birth Period 12.2 On the 21/01/2014 the Community Midwife had her first contact with Baby M’s Mother at the GP surgery; she was seven and half weeks pregnant and living in supported accommodation. The estimated date of delivery was in late summer of 2014. The Father of Baby M was not recorded as being present at the booking appointment but was identified as her emergency contact. 12.3 She disclosed a history of depression, learning difficulties, family problems and occasional cannabis misuse. She advised the Midwife that the baby’s Father was a care leaver, had ADHD and was a daily cannabis user. The Midwife undertook the routine enquiry for domestic abuse but no disclosure was made. Confidential – not to be photocopied or distributed Serious Case Review Baby M 16 12.4 The Midwife had access to the Mother’s GP notes and had noted the previous history of self-harm. Following the booking appointment a referral was made to the Teenage Pregnancy Liaison Midwife. The issues identified in the referral form were in respect of accommodation; however it was noted about the previous self-harm, cannabis and mental health issues. 12.5 On the 08/02/2014 Baby M’s Father was reported as missing by a member of staff at his supported accommodation. The member of staff telephoned Thames Valley Police and advised them that this had not happened before. Baby M’s Father had told staff about a ‘punch up’ he had been involved in the night before following accusations that his girlfriend was pregnant with another man’s child. Baby M’s Father’s girlfriend is recorded as being less than three months pregnant. The member of staff gave a list of Father’s vulnerabilities: these included having a small build like a ten year old, having ADHD, alcohol/ drug misuse including legal highs and self-harm. 12.6 The member of staff also advised the Police that Baby M’s Father liked to fight and might carry a weapon to make up for his small size. He had telephoned his Mother (PGM) who lived locally but she had told him not to visit her as she was poorly. The member of staff thought that he was out on his bike somewhere possibly trying to seek retribution for the events of the night before. He turned up later the following day but would not say where he had been or with whom. 12.7 Baby M’s Father appeared in court on the 21/2/2014 for Possession of Cannabis and he received a six month Referral Order. An assessment took place by the Youth Offending Service which risk assessed him as medium risk of re-offending, high risk of vulnerability and low risk of serious harm to others. This resulted in a Vulnerability Management Plan being put in place. He was re-referred to CAMHS by the Youth Offending Service following email and telephone discussions between the two services. 12.8 During this same time period Baby M’s Father was presenting with increasingly difficult behaviours at his supportive lodgings placement, he was failing to engage Confidential – not to be photocopied or distributed Serious Case Review Baby M 17 with staff and not adhering to the house rules, he also had fallen out with other young people over money. 12.9 The Community Midwife met with the Children in Care Social Worker at her request to discuss Baby M’s Father who had been a Looked After Child. The Children in Care Social Worker advised the Community Midwife that she would liaise with the social work team once initial referral had been received from the Community Midwife in respect of Baby M. 12.10 An incident occurred outside of the Connexions building between Baby M’s Father and another young person on the 19/03/2014, which resulted in Baby M’s Father being assaulted. This was as a result of the other young person believing Baby M’s Father was responsible for getting the assailant’s cousin (Baby M’s Mother) pregnant. 12.11 On the 20/03/2014 a referral was received by Children’s Social Care, the referrer was the Community Midwife and the referral was received by the First Response Team. The referral identified that Baby M’s Mother was 16 weeks pregnant and living in temporary accommodation. She had engaged in ante-natal support and was open to support from other agencies. The referrer identified that Baby M’s Mother required support around her housing need and did not identify any other vulnerabilities. The same day the Children in Care Social Worker for Baby M’s Father was contacted by his placement due to concerns that he had been smoking cannabis on site, had been constantly presenting with disruptive behaviour and had taken another vulnerable resident off site and persuaded him to take MKAT10. 12.12 A Child and Family Assessment was commenced on the 20/03/2014 following on from the referral from the Community Midwife. Baby M’s Mother also contacted the First Response Team on the 27/03/2014 to inform them she was pregnant and that she needed support with accommodation. The records for unborn Baby M commenced this day. 10 Mephadrone, also known as 4-methylmethcathinone is a synthetic stimulant drug of the amphetamine and cathinone classes. Slang names include M.CAT, White Magic and meow meow. Confidential – not to be photocopied or distributed Serious Case Review Baby M 18 12.13 As well as referring Baby M’s Mother to Children’s Social Care the Community Midwife also made a referral to the Family Nurse Partnership11. The Family Nurse Partnership is a national programme which is designed to improve the health, wellbeing and capacity of young first time parents. The programme offers support for up to two years to first time mothers under the age of 19. Support is available through the stages of pregnancy until a child is two years of age. The evidence base around Family Nurse Partnership has shown that the programme provides positive outcomes in the short and long-term. The service has limited capacity and once practitioners are at caseload capacity there is limited opportunity for new families to be picked up. This was the situation with Baby M’s Mother; at the point of referral there was no capacity and she did not receive a service. 12.14 The assessment for the unborn child continued and on the 23/04/2014 as part of the process the First Response Social Worker spoke to the Community Midwife and asked about her view and prognosis of Baby M’s Mother as a mother; he also spoke to Baby M’s Father’s Children in Care Social Worker. Following the discussion with the Children In Care Social Worker it was noted in the case record for Baby M by the First Response Social Worker that: “we have a discussion. He (Baby M’s Father) does not present with any concerns as a potential Father in regards to safeguarding. By nature of his status he will be vulnerable”. On the basis of this recording it appears to the IMR author that the First Response Social Worker accepted that Baby M’s Father posed no risk to the unborn child. 12.15 Between March and June 2014 concerns continued to be raised from the placement provider for Baby M’s Father to his Children in Care Social Worker in the Children in Care Unit. The concerns involved unauthorised absences, drug use and behaviour toward other tenants. On the 02/06/2014 the Children in Care Social Worker visited the placement due to continued concerns regarding Baby M’s Father taking food and money off other young people and being critical about the state of the bathroom. When challenged about this behaviour in the unit he had smashed a 11 Fnp.nhs.uk Confidential – not to be photocopied or distributed Serious Case Review Baby M 19 table to pieces. The Children In Care Social Worker shared this information with the First Response Team as she was concerned about the incident and the risks Baby M’s Father could pose to Baby M’s Mother and the unborn Baby M. Baby M’s Father expressed unhappiness at this and agreed to stay within the boundaries set by the placement. 12.16 According to the Thames Valley Police IMR, during the time period from confirmation of the pregnancy to Baby M’s birth there were four separate occasions when Thames Valley Police had receipt of information and intelligence which should have been shared with Children’s Social Care. The Police IMR author noted that with the knowledge held in respect ‘of Father’s previous violent offending behaviour, cannabis use, and recent suicide attempt, news that he was going to become a Father would be of interest to Children’s Social Care and would have met the threshold for information sharing’12. 12.17 On the 12/5/2014 a referral was made by the First Response Social Worker to Family Nurse Partnership (FNP). He was advised that Baby M’s Mother had already been referred in by the Community Midwife but that there was no capacity to take the referral at this time. During May the First Response Social Worker made a number of referrals for Baby M’s Mother regarding accommodation needs, Adult Services for a capacity assessment due to her ‘additional needs’ and also referred the family to the Junior Catch Team13 for a pre-birth assessment. He advised the manager of Junior Catch that although the Child and Family assessment was still ongoing it was likely that the outcome would be for the unborn baby to receive services as a Child In Need. The team manager at Junior Catch advised the First Response Social Worker that she would be unable to allocate immediately due to service pressures and demand. 12 The threshold is met when someone believes a child may be suffering or at risk of suffering significant harm. (NPIA Investigating Child Abuse 2009, 1.9.1) 13 Junior CATCH focuses on supporting the units in providing an intensive, flexible service for children and families, including a rapid response service. The Junior CATCH Teams will consist of staff with a range of skills suitable for working with families who are in crisis or where chronic problems have become acute. Confidential – not to be photocopied or distributed Serious Case Review Baby M 20 12.18 On the 18/06/2014 Baby M’s Father was seen by CAMHS for his appointment following on from the referral from the Youth Offending Service. He advised CAMHS that he was feeling well emotionally and mentally and did not require a service from them. He informed the Psychologist that he was going to be a Father. A letter was sent to the Youth Offending Service from CAMHS advising that he was not in need of services at this point. 12.19 As a young person in care Baby M’s Father had regular statutory visits14 undertaken by the Children in Care Social Worker to his supported lodgings. During a statutory visit his key worker raised concerns with the Children in Care Social Worker regarding his anger and the high risk this may pose for a baby. The Children in Care Social Worker agreed she would be informing the unborn Baby M’s Social Worker of this information. Baby M’s Father was unhappy about this being shared but the Children In Care Social Worker explained to him that she was very concerned for his girlfriend’s safety and more so for the baby’s safety. He agreed to comply with the placement boundaries. 12.20 During June Baby M’s Father spent less and less time in the placement, often staying with Baby M’s Mother. There was regular email communication between the Social Worker for Baby M, the Children in Care Social Worker and the Youth Offending worker. During these email exchanges reference is made to the anger issues displayed by Baby M’s Father and also his use of drugs including Cannabis and MKAT. There is also reference to his diagnosis of ADHD. • Baby M’s Father was discussed at the Risk Management and Vulnerability Panel15 in June. The Children in Care Social Worker attended the panel and discussed the concerns she had in respect of his behaviour and drug misuse. 14 www.proceduresonline.com/buckinghamshire.chservices/chapters/p_sw_visits.html 15 RMVP’s are held on all young people who are assessed as high or very high risk of serious harm to others or vulnerability. This ensures that the Case Manager is given support in devising and delivering interventions for high risk cases and that these are subject to relevant management team support and scrutiny. This is a formal meeting chaired by an Operational Manager. Relevant partner agencies attend which ensures the risk is managed in a co-ordinated way. Confidential – not to be photocopied or distributed Serious Case Review Baby M 21 CAMHS were contacted following the panel to confirm whether or not he was still being prescribed medication for his ADHD. His Risk Management Plan was updated following this panel and his risk was assessed as Medium risk of Serious Harm to others. It is noted in the Risk of Serious Harm ASSET16 that “if this behaviour continues in front of a child this could cause harm in terms of emotional and unintentional harm as it would be intimidating and feeling of security and safety would be affected.17” 12.21 The YOS worker shared by e-mail details of a session with Baby M’s Father on 01/07/2014 in which she discussed anger management issues with him. In this session he told her that the staff at the placement "lie" about his anger issues. He denied that he had broken the table alleging that this was already broken. He described dealing with anger towards Baby M’s Mother by walking away and that a baby would be a different type of stress. 12.22 On 01/07/2014 the Junior Catch Social Worker emailed Baby M’s allocated Child In Need (CIN) Social Worker giving a summary of her background reading and concerns about the family situation and she requested a network meeting in 3 weeks. It is unclear to the reviewer why this timeframe was suggested considering the delay in the pre-birth assessment commencing and the birth being now only a couple of months away. The purpose of the network meeting would be to plan the work with Junior Catch, and the allocated Social Worker from the CIN unit would lead this planning process and bring together the relevant agencies to share information. The Junior Catch Social Worker also asks in the e-mail, "Is this case going to CP?" There is no indication in the records throughout the period of the review that child protection procedures were considered by either the First Response Social Worker or the CIN Social Worker. 16 ASSET is a structured assessment tool that is used by Youth Offending Teams(YOTs) in England and Wales with young people who come into contact with the criminal justice system. It aims to look at the young person’s offence or offences and identify a multitude of factors or circumstances – ranging from lack of educational attainment to mental health problems – which may have contributed to such behaviour. 17 YOS IMR Confidential – not to be photocopied or distributed Serious Case Review Baby M 22 12.23 Concerns regarding anti-social behaviour in respect of Baby M’s Father continued in July and these were discussed during a case management discussion in the Child In Need Unit on the 27/07/2014. The Children’s Social Care IMR identified that both parents are recorded as having been difficult to get hold of during this time. The planned network meeting took place on the 01/08/2014 and six sessions were planned with the parents for the pre-birth assessment. 12.24 Three of the planned pre-birth sessions took place before Baby M was born in August 2014. There is evidence in one of the sessions of Baby M’s Father controlling the agenda regarding what needed to be covered. He advised the Junior Catch Social Worker that he had experience of babies due to looking after an electronic one previously for 24 hours. He stated that he had managed well, therefore this did not need covering in the session. Baby M’s Mother also identified that she knew how to care for a baby due to caring for her sister’s child. Baby M’s Father identified that drug issues did not apply as he no longer used these and he had also not been involved in any violent or aggressive behaviour therefore the worker did not need to assess this area. 12.25 During this pre-birth period, as well as the work which arose in respect of Baby M, Baby M’s Father continued to receive services as a young person who had been in care and was eligible for after care services. He therefore had an allocated Social Worker, from the Children in Care unit. This Social Worker continued working with him until the 11/8/2014 when he was allocated a Personal Advisor from the After Care Service. Post Birth Period 12.26 Baby M was born in August at 37 weeks gestation in hospital. Baby M’s Mother was accompanied by her grandparents when she presented and labour and delivery progressed normally. Baby M was born in good condition weighing 2720g. 12.27 Mother and baby were discharged home and visits continued by the Community Midwife until the 26/08/2014 when the baby was discharged into the care of the Heath Visitor. The Community Midwife did not have any clinical concerns about Confidential – not to be photocopied or distributed Serious Case Review Baby M 23 either Mother or baby; any clinical concerns would have resulted in a delayed discharge. 12.28 Baby M’s arrival did not trigger any contact between the Midwifery Service and Children’s Social Care. The first notification that Baby M was born came after Baby M’s Mother attended a planned pre-birth assessment session at Junior Catch on 22nd August and arrived with Baby M. Social Care records indicate that the baby was born prematurely but the birth date is within the expected range of the possible delivery date of a full term baby. Baby M’s Mother advised the Junior Catch Social Worker that she was living with her Mother (MGM) with Baby M and that she was due to move to her own flat the following week. 12.29 Baby M was seen on a regular basis from his birth onwards by a range of agencies and throughout September 2014 home visits and observations of him in the care of both his parents were undertaken by the Health Visitor and the CIN Social Worker for Baby M. The Health Visitor noted Father feeding and cuddling Baby M during one of her visits. During the CIN Social Worker’s visit the parents advised that Baby M’s Father was visiting daily and staying over two nights each week. Baby M’s Mother described him as a good support and helpful with the baby. 12.30 On the 22/09/2014 the emergency services were contacted by a female, who was suspected to be Baby M’s Mother, via the 999 service. The female mentioned her boyfriend to the operator and then the phone was disconnected before the call was connected to Thames Valley Police. A further call was received by Thames Valley Police indicating that a dispute had been heard outside the flat occupied by Baby M’s Mother. The caller alleged that Baby M’s Mother had thrown a scooter down the stairs outside of the flat and that smashing was also heard. The caller knew that there was a young baby (Baby M) at the address and that the Father had left the property. When the Police attended, Baby M’s Mother advised them she had “kicked Father out” as he was lazy and he had ADHD and didn’t take medication. Baby M was seen by officers who stated he ‘seemed happy’18. Baby M’s Mother 18 TVP IMR Section 4.156 Confidential – not to be photocopied or distributed Serious Case Review Baby M 24 stated that he had been lying on the bed during the domestic incident. Children’s Social Care and the Health Visitor were notified about this incident; the Health Visitor visited the following week and discussed the domestic abuse incident and the impact this could have on Baby M. 12.31 There is no indication that Children’s Social Care responded to the domestic abuse notification or reassessed any risks to Baby M on the basis of this information. Universal health services continued to be offered during this time; Baby M was seen by both the Health Visitor and the GP and was seen to be developing well. 12.32 Child In Need (CIN) meetings did not take place despite Baby M being subject to a CIN plan and this being a recommendation in supervision notes for the CIN Social Worker in both September and October 2014. 12.33 A unit case management meeting on 21/11/2014 describes the situation positively regarding the family and suggests that initial concerns had been allayed by how well Baby M is developing and meeting his milestones. The flat was described as clean and furnished and Baby M’s Father was staying over a few nights per week with a view to moving into his own flat. Despite being referred to a children’s centre the parents had not accessed any services. First Hospital Admission 27/11/2014 12.34 Baby M was admitted to the hospital Accident & Emergency department on 27th November, 2014 at 03:45 am. He was brought to the hospital by his Mother and Father following a fall. 19Baby M was seen in the Paediatric Decision Unit (PDU), and an assessment was carried out by the Triage Nurse at 03:47. The Triage Nurse took a history regarding the incident from the parents. Father reported to the nurse that he had been giving the night feed, and whilst holding Baby M, he tripped and fell onto Baby M. The parents reported that Baby M had not lost consciousness and had not vomited following the fall. During this initial assessment, the Triage Nurse noted there were marks around Baby M’s face, particularly around his nose and 19 BHT Acute Services IMR Confidential – not to be photocopied or distributed Serious Case Review Baby M 25 mouth, as well as bruising under Baby M’s right eye. Parents informed the nurse that this had been caused by a scratch from the previous day. 12.35 Baby M was seen by two doctors in A&E and reviewed by the Consultant Paediatrician. The Father maintained his story of tripping over his trousers and falling with the baby in his arms and he was consistent in the telling of this to all three doctors and to the Triage Nurse. The hospital completed a referral form to Children’s Social Care but this was sent for information only and not because they were requesting a service. During the telling of the sequence of events the parents did give two different versions of how they got to hospital. Initially they stated that they had called 111 immediately after the incident and an ambulance attended and took them to hospital. Later when Baby M was reassessed in PDU by the A&E doctor the parents informed him that they tried to call for an ambulance, but were advised to get their own transport, so Baby M’s Father called his Father (PGF) who provided them with transport to the hospital. 12.36 The assessments undertaken in A&E included social and medical history and a genogram being completed. It was during this process that the A&E Doctor discovered that Mother had a Social Worker and that Father had been in care. An examination of Baby M was completed, and it was noted that Baby M had long dirty nails and a range of marks and bruises. The A&E Doctor completed a body map, documenting all of Baby M’s injuries and discussed the case with the on call Paediatric Consultant. Following this discussion it was agreed that the case would be discussed with Children’s Social Care and the Health Visitor during daytime hours and that the child protection pro forma20 was not necessary. The agreed plan also stated that a CT scan and ophthalmology review were required: depending on the outcome of these two investigations, a skeletal survey may be completed. The A&E Doctor was unable to reach the radiologist despite ringing and bleeping. At 07:50, Baby M was reviewed by a Paediatric Consultant. The Paediatric Consultant went over the history of the incident with the parents, and in the consultant’s opinion 20 The Buckinghamshire Healthcare NHS Trust Child Protection pro forma was introduced in August 2007. The proforma was introduced as a link document to the Child Protection policy Confidential – not to be photocopied or distributed Serious Case Review Baby M 26 the story given was consistent, and the parents had sought immediate help. The Paediatric Consultant was aware that Baby M was on a Child in Need Plan, however details of the plan were not known. Following this review, the Paediatric Consultant felt that this injury was accidental. The plan was to complete a CT scan, observe the pain relief and for the case to be discussed with the CIN Social Worker to get details of the Child In Need Plan. 12.37 During the remainder of the 27/11/2014 Baby M had a range of tests and consultations, including a consultation with the Plastics Team regarding his facial injury. The Specialist Registrar who saw Baby M noted that the bruise was likely to be less than 24 hours old. He also examined the small tear to the frenulum and concluded that no medical intervention was required. 12.38 A CT scan was undertaken which confirmed that the initial diagnosis regarding a skull fracture was correct and Baby M had a linear fracture to the left parietal. Following this diagnosis a decision was made to admit Baby M to the ward for 48 hrs for observation. There was consultation between the hospital and Children’s Social Care during this time. The CIN Social Worker advised the ward that she would no longer be working for Children’s Social Care and that the case would be reallocated. She also informed the Ward Nurse that the case was due to be ‘downgraded’ but that the decision was likely to be reviewed in light of the injuries. The CIN Social Worker did not suggest a strategy meeting take place nor did the nurse request that consideration be given to this. During the conversation the CIN Social Worker advised the nurse that she would be speaking to the parents the following day. 12.39 Following her visit a second call was received from the CIN Social Worker to the hospital ward advising them that she was leaving her employment with immediate effect and she provided alternative contact details for the hospital. The Ward Nurse was informed by the CIN Social Worker that Baby M’s Father was not supposed to be staying overnight and the nurse requested that this information should be confirmed the following day. There is no mention in the IMRs as to whether this happened or not. Confidential – not to be photocopied or distributed Serious Case Review Baby M 27 12.40 Baby M was discharged from hospital on the 30/11/2014 into his parent’s care. The explanation provided by the Father was accepted by hospital staff and Baby M went home with both parents. He stayed with his maternal grandmother on the night of the 03/12/2014 then returned to the care of his parents on the 04/12/2014. The CIN Social Worker spoke to the hospital but did not challenge the decision regarding the injuries being accidental. A strategy meeting did not take place whilst Baby M was on the ward or prior to discharge however there is record of a telephone strategy discussion21 between Children’s Social Care and Thames Valley Police on the 3/12/2014. The outcome of this strategy discussion was that the case did not hit the threshold for S47 investigation and the agreement was that Children’s Social Care would continue with their involvement as a ‘single agency case22’. There is no explanation as to why this strategy discussion was so delayed or why there were only the two agencies involved. 12.41 Children’s Social Care continued with the plan to work the case under Child In Need procedures despite the lack of joined up working in the previous three months and risk never really being considered. There was a view that the care given to the baby by both parents was of a good standard. A file audit took place and it is recorded in the Children’s Social Care IMR that the auditor noted: “this case has not been worked properly by the allocated Social Worker in the previous three months since Baby M’s birth therefore it is not considered appropriate to step up to child protection” . 12.42 Baby M was seen at home by the Social Work Team Manager on the 01/12/2014. He was at home with his Mother and MGM and there is little of note recorded about this visit other than it took place. This in itself is of concern given the events of the 27/11/2014. 21 Working Together 2015 states there should be a strategy discussion involving Children’s Social Care, Health, Police and other agencies whenever there is reasonable cause to suspect that a child is suffering or likely to suffer significant harm. 22 Thames Valley Police IMR 4.201 Confidential – not to be photocopied or distributed Serious Case Review Baby M 28 12.43 Baby M was readmitted to hospital by ambulance in the early hours of the 05/12/2014. He presented as floppy and unresponsive with intermittent twitching of all four limbs. A full physical examination on admission noted significant bruising and marks to the body and head. Second Hospital Admission - Friday 5th December 2014 12.44 On the 04/12/2014 Baby M had been presenting as unwell. At about 11.30pm his parents reported that he had stopped breathing momentarily and was floppy and unresponsive. His parents did not call an ambulance until approx. 4.30 am on the 05/12/2014 some five hours after this incident. At 4.37am on the 05/12/2014 an ambulance was dispatched from South Central Ambulance Service to the home of Baby M after a 999 call was received. Ambulance staff on arrival noted that Baby M was shaky, jittery and cool to the touch. The ambulance staff took Baby M straight to A&E and he was taken into resuscitation. 12.45 The Paediatric Registrar23 took the history from Baby M’s Mother and she reported that Baby M was “grizzly” in the morning when he returned from his maternal grand-mothers home. However he fed through the day, but became fussy with his evening feed, he went to bed but awakened at 11pm and refused to take his night feed. Mother reported that Baby M’s Father gave Baby M 2.5ml of paracetamol, and then Baby M became floppy and stopped breathing momentarily. Mother stated Father didn’t have time to do anything because Baby M was back to normal quickly. However shortly after midnight his parents reported that Baby M was pale and had begun shaking. Baby M’s parents put him skin to skin in bed, but eventually called an ambulance. 12.46 The Paediatric Registrar noted the delay in mother bringing Baby M to A&E. Mother stated she was reluctant to call an ambulance because she said they hadn’t attended previously when Baby M fractured his skull. A full physical examination was undertaken of Baby M and a detailed history and body map was completed. The 23 IMR BHT Acute Sector Confidential – not to be photocopied or distributed Serious Case Review Baby M 29 Mother could offer no explanation for the injuries seen and rather than appearing concerned about Baby M she spent her time texting on the phone. It was noted she did not attend to his needs; she did not talk to or try to reassure him. The Paediatric Registrar felt that there was a significant indication of non-accidental injury and therefore planned for a CT scan, skeletal survey, bloods, ophthalmology assessment, medical photography, and, to rule out any possible medical conditions, a lumbar puncture was also undertaken. During this process Baby M’s Mother was kept fully informed of what was happening. 12.47 Discussions took place between Children’s Social Care and the hospital during the morning of the 05/12/2014 and the decision was made that Baby M should not be discharged from hospital without a strategy meeting taking place. Examinations and tests continued in the hospital during the day including medical photography seeing Baby M and taking photographs of multiple sites of injury. The Children’s Social Care Practice Improvement Manager (PIM) contacted Thames Valley Police requesting a strategy discussion and Referral Manager 38 at Thames Valley Police rang her back at noon. The PIM shared the information regarding the injuries noted on Baby M’s back, leg and forehead and the delay there had been in getting him treatment. Referral Manager 38 confirmed that the Police would attend a strategy meeting on the 08/12/2014. It is not clear from the Police IMR or the Children’s Social Care IMR as to whether this ‘discussion’ was viewed as a strategy discussion, however what did not happen was an agreed plan to safeguard Baby M over the coming weekend nor was a decision taken to instigate a S47 investigation. 12.48 There was consultation also on the Friday 05/12/2014 between the Children’s Social Care PIM and Buckinghamshire Law Plus regarding the arrangements for Baby M. It has become clear during the review that full information sharing did occur and that the information received by Buckinghamshire Law Plus was limited .The Buckinghamshire Healthcare NHS Trust (BHT) Acute Services’ IMR and subsequent clarification received from them states that the information shared with Children’s Social Care regarding Baby M’s presentation indicated that infection was only one of two possible reasons for Baby Confidential – not to be photocopied or distributed Serious Case Review Baby M 30 M’s presentation at hospital with the other reason being NAI, however there was still concern about the delay taking Baby M to hospital of some five plus hours despite the mother stating that Baby M had momentarily stopped breathing. This alone is a cause for grave concern. What is clear in the responses and recording of all three of these agencies is that on the Friday the hospital were in the process of completing full child protection medical procedures including a skeletal survey, eye examination and that the decision had been made to call a strategy meeting for the Monday 8/12/14. 12.49 A further issue for the hospital on this Friday was how to manage the parents on the ward as they had informed Children’s Social Care that they couldn’t have staff with Baby M all of the time he was an inpatient. The Consultant explained that the hospital could not keep an eye on Baby M at all times when the parents were around. Following this call the Children’s Social Care PIM discussed this case with the legal team. It is recorded in the medical notes that the advice was that there were not enough grounds to ask for supervised visits, therefore ward staff were just to observe the interaction of parents with Baby M. Due to the previous CIN Social Worker for Baby M leaving the case had been reallocated to a new CIN Social Worker and she visited the ward late afternoon and met with the parents. An agreement was made with the parents for Baby M to stay on the ward over the weekend but no restrictions were in place regarding Mother or Father visiting. Saturday and Sunday 6th & 7th December 2014 12.50 Baby M remained on the ward over the weekend; his scans were reviewed by the Neurosurgical Registrar at a tertiary hospital and concerns were noted about the low density observed around the temporal lobe. The registrar was unsure whether it showed encephalitis and as a result a lumber puncture was carried out. Test results identified that Baby M did not have sepsis or any other medical reason for his injuries. Further reviews of Baby M’s condition continued over the weekend and no new concerns were noted. Monday 8th December 2014 Confidential – not to be photocopied or distributed Serious Case Review Baby M 31 12.51 Baby M was reviewed medically on the Monday and continued to present with no new concerns. An assessment was undertaken by the Ophthalmologist later that day. During this examination they noted that Baby M had bruising/ petechial and haemorrhages present in his right eye. Later that day a strategy meeting took place at the hospital and was attended by the Consultant Paediatrician, Named Nurse, Acting Detective Sergeant 39 from the Child Abuse Investigation Unit, Baby M’s CIN Social Worker, the Practice Improvement Manager and a Solicitor from Buckinghamshire Law Plus. During the meeting concern was raised regarding the parents’ lack of attachment to Baby M, an issue that had not previously been raised by professionals working with the family. The outcome of the strategy meeting was that the injuries to Baby M were non accidental and a section 4724 investigation was to be instigated. The CIN Social Worker intended to speak to the parents to seek agreement to Section 20 accommodation.25However, there is some confusion between the Police and Children’s Social Care recording regarding this matter. The Police recorded following the strategy meeting, that the parents had signed a Section 20 agreement; however in the Children’s Social Care records this was not the case and no agreement to S20 was achieved. The plan following the strategy meeting was for Baby M to remain in hospital and from this point onwards contact was to be supervised by a CIN Social Worker. The solicitor from Buckinghamshire Law Plus was in attendance at the strategy meeting and it was an outcome of the meeting that legal proceedings would be initiated and Baby M would be discharged into foster care. A flag was added to the hospital’s address on Thames Valley Police’s Command & Control database which advised any officers attending following a call from the ward of the situation re Baby M and advising them to consider using their Police Protection Powers26 if required. 24 Section 47 of the Children Act 1989 is a Children’s Social Care led assessment of a child which also involves other agencies when there is reasonable cause to suspect that a child is suffering or likely to suffer significant harm in the form of physical, sexual, emotional abuse or neglect 25 Section 20 of the Children Act 1989 relates to the Local Authority’s duty to provide accommodation for any child in their area who needs somewhere to live. 26 Section 46 Children Act 1989 allows the police to safeguard a child in an emergency if they are at immediate risk of significant harm. Confidential – not to be photocopied or distributed Serious Case Review Baby M 32 12.52 The CIN Social Worker for Baby M spoke to Baby M’s maternal grandmother following the strategy meeting and the grandmother questioned whether Baby M’s Mother had understood the information she had been given, making reference to her having a ‘learning disability’. She also advised the CIN Social Worker that she was concerned that the parents were hiding something. Tuesday 9th December 2014 12.53 On 9th December Baby M’s Mother and Father were interviewed under caution at Aylesbury Police Station. They voluntarily gave Police their mobile phones for examination and allowed access to their address for photographs to be taken. That morning the Police photographer had also attended at the hospital to take photographs of Baby M’s injuries. Baby M’s CIN Social Worker also arrived at the Police station to see the parents and she served them papers for a court hearing the following day. The Social Worker returned Baby M’s Mother home. Baby M’s Father was to be returned home later that day by the Police who had identified him as vulnerable. When the Social Worker saw both parents at the Police station they had been asked to agree to Baby M being accommodated under Section 20 of the Children Act. Despite taking Baby M’s Mother home the CIN Social Worker did not go through the paperwork and ask Mother to sign the forms but left them with her. Later attempts to contact the parents to sign the Section 20 agreement were unsuccessful and on the 10/12/2014 an application was made to the courts for an Emergency Protection Order. 12.54 A skeletal survey was carried out on the 10/12/2014 and Baby M was found to have numerous rib fractures identified at different stages of healing. From the admittance of Baby M on the 05/12/14 five days passed before Baby M had a full skeletal survey. It has not been possible to ascertain what the delay regarding this was. It is possible that Baby M being admitted just prior to the weekend may have had an impact however the IMR author for BHT Acute Services identified that there is always an on call Radiologist available and the service should have been available. Confidential – not to be photocopied or distributed Serious Case Review Baby M 33 13 CRITICAL ANALYSIS OF CONCERNS Assessments 13.1 A range of assessments were undertaken by agencies including Children’s Social Care, Youth Offending Service, BHT Acute and the Children & Adolescent Mental Health Services (CAMHS) however there was no holistic assessment undertaken which looked at the needs of unborn Baby M and collated together all of the information from the many agencies involved with the family. As the lead agency for safeguarding, Children’s Social Care should have undertaken this role. The Child and Family Assessment in respect of Baby M highlights significant areas of risk and concern which required further action however it was not identified how those risks were to be managed or further assessed. There was delay in the assessment starting; the referral from the Community Midwife was made on 20/03/2014 however the Social Worker in the First Response Team did not commence work actively on the assessment until 27/04/2014. It is of concern that the First Response Social Worker was able to make a judgement in a very short space of time that the case was to be managed under a Child In Need Plan despite the assessment being incomplete. 13.2 The IMR author notes that had this assessment been completed in a more timely way it would have provided the basis for further action. What is of concern in this assessment is that the First Response Social Worker has focussed on the housing need for Mother and also attempted to access a range of services for her vulnerabilities but this has taken the focus off the risks that were evident and present and noted in the assessment for Baby M. The analysis of the Child and Family Assessment concluded that further work was to be undertaken and the case was to transfer to the Child In Need Unit. A referral was made for a pre-birth assessment but no other support was in place and the assessment recommended continued liaison between Baby M’s Father’s Children in Care Social Worker and the CIN Social Worker for unborn Baby M. Confidential – not to be photocopied or distributed Serious Case Review Baby M 34 13.3 The pre-birth assessment undertaken by the Junior Catch Team was totally inadequate and did not grasp the issues relating to the family at all. Rather than a risk assessment being undertaken the assessment focussed on the parents’ ability to undertake basic care tasks. The Child and Family Assessment had highlighted considerable risk yet upon transfer the Social Worker in the Child In Need Unit did not guide the pre-birth assessment being undertaken by Junior Catch but rather it appears has disengaged from the process. The delay in the pre-birth assessment starting resulted in Baby M being born before the assessment was half way through. The IMR author27 noted that the assessment had ‘limited value’ and was not an adequate assessment upon which to base an assessment of risk and capability of the parents and the provision of services. 13.4 The parents of Baby M were well known to a range of agencies including Children’s Social Care, Thames Valley Police, Youth Offending Service, CAMHS and Connexions. The information held by the various agencies highlighted concern about the high vulnerabilities of both of the parents and the risks associated with Baby M’s Father in respect of violence and drug misuse. Upon receipt of the referral for Baby M Children’s Social Care did not routinely make checks with other agencies, despite these agencies holding a wealth of information which would have informed decision making and assessments outcomes. The decisions in this case were made prematurely and without sufficient investigation. Children’s Social Care did not take on a coordinating role to ensure that all agencies working with the family contributed to the assessment. There was no co-ordinated multi-agency response to those identified risk factors which would have formulated a meaningful plan of intervention. 13.5 There was a failure by all agencies to take a holistic view of the family, with incidents and concerns being treated in isolation. The exchange of information and communication between all agencies was inconsistent and agencies did not always follow up on concerns once they had referred the matter through to Children’s Social 27 Children’s Social Care IMR Confidential – not to be photocopied or distributed Serious Case Review Baby M 35 Care. There were a number of occasions when the use of escalation would have been appropriate. An example of this is with the first injury there was no challenge from CSC regarding the mechanism around how the bruises and torn frenulum had occurred. Also in respect of this first presentation at hospital the Paediatric registrar had documented the injuries to Baby M in detail and had recommended amongst other tests a skeletal survey and was clearly considering a non-accidental injury. This decision was over ruled by the consultant who was on duty during the day and believed that the parent’s explanation fitted the injuries observed. 13.6 Despite evidence to the contrary professionals displayed optimism about the parent’s ability to provide appropriate care for Baby M. The range of risk factors known regarding both parents were not investigated or interrogated in a meaningful way. The First Response Social Worker makes reference to having concerns about Mother’s capability; there were concerns about her learning and vulnerabilities. This vulnerable young mother had limited family support and a partner who in his own right was extremely vulnerable and displayed a range of behaviours and volatility which should have alerted professionals to the potential risk to the baby. Yet despite these concerns it is evidenced several times in this case that there was an overly optimistic view rather than a robust analysis about how these parental vulnerabilities impacted on their parenting capacity. (e.g. ‘However my gut instinct is that the risk is minimal’28….. “He does not present with concerns as a potential Father. By nature of his status he will be vulnerable”29). It is possible that in some of these instances the “rule of optimism”30 resulted in an unrealistically positive interpretation being put on the behaviour of the parents. 13.7 Baby M’s Father had a number of assessments completed during the review period. Due to the concerns regarding his previous offence in respect of a firearm the Risk of Serious Harm ASSET was undertaken when he was on a Referral Order. The information regarding his risks are clearly documented in this assessment and 28 Youth Offending Service IMR 29 Social Care IMR 4.2.28 30 Blom-Cooper L, et al. A child in trust. The report of the panel of inquiry into the circumstances surrounding the death of Jasmine Beckford. London Borough of Brent: Kingswood Press, 1985. Confidential – not to be photocopied or distributed Serious Case Review Baby M 36 the Children In Care Social Worker attended the Risk and Vulnerability panel where the concerns regarding Baby M’s Father were discussed and he was identified as being a medium risk of harm to others. However this assessment does not appear to have been considered by Baby M’s CIN Social Worker or managers to have influenced any decisions around risk. 13.8 When Baby M presented at hospital on the 27th November 2014 at the point of presentation he had suffered significant harm either intentionally or unintentionally whilst in the care of his parents. Information gathered during the triage process identified two separate incidents which resulted in injuries to Baby M. The first injury which was a bruise to the area below the right eye area happened the day before his presentation on the 27/11/2014 and this issue was not picked up following the initial consultation with the Triage Nurse. The Registrar does not appear sighted on the fact that there were two separate injuries. Neither the Triage Nurse nor the Registrar questioned why a non-mobile baby would have two separate injuries within such a small timescale. The A&E Doctor was unable to reach the radiologist despite ringing and bleeping and as a result a skeletal survey did not take place. There was no healthy scepticism or challenge to the story that parents were telling and staff at the hospital accepted what they were being told by Baby M’s Father. There was no forensic analysis of the injuries Baby M presented with to establish if they could have happened in the way Baby M’s Father stated. The Specialist Registrar from the plastics team did not query the mechanism for the injuries despite the bruise observed and the torn frenulum. This was compounded by the CIN Social Worker who also accepted wholeheartedly that this was an accidental injury despite having a considerable understanding of some of the risks factors surrounding Baby M’s Father. 13.9 Despite Baby M suffering significant harm there was no multi-agency strategy meeting31 on the 27th or 28th November 2014 to share information, to make 31 Strategy meeting is held to determine whether there are grounds for a Section 47 investigation and should involve the key individuals from the relevant agencies. Confidential – not to be photocopied or distributed Serious Case Review Baby M 37 decisions about what the next steps should be, or to decide if a S47 investigation should have been initiated. Working Together 2015 makes it clear that a Section 47 enquiry should be initiated to decide if and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. Without a strategy meeting full information sharing did not take place. 13.10 The second presentation at the hospital and the subsequent management and failure to safeguard him is extremely concerning and action needs to be taken by BSCB to ensure that procedures are immediately adhered to. There was a systemic failure by Thames Valley Police, Children’s Social Care, Buckinghamshire Law Plus and BHT Acute Services to safeguard Baby M from when he was admitted in the early hours of Friday 05/12/2014 with an initial presentation, which was highly suggestive of a non-accidental injury, to the date of the Emergency Protection Order some five days later. A full physical examination on admission noted significant bruising to the head and body for which Baby M’s Mother could offer no explanation. The injuries noted on the body maps and in the detailed notes taken include bruises of red/purple colour to the cheek, left wrist, right lower leg/ankle, mandible and back. There was also swelling to the entire right cheek and petechiae over the forehead, bridge of the nose, upper back and eyelids. Child Protection procedures designed to protect him were not followed. On the 5/12/2014 there should have been an immediate strategy meeting with at least the Police, A&E Doctor, Legal representative and Children’s Social Care in attendance and from this meeting a plan should have been put in place to safeguard Baby M. The weekend was approaching and this vulnerable baby was on a ward with both his parents in attendance. What was known on this Friday was that Baby M had been admitted a few days previously and presented with two separate incidents which had resulted in multiple injuries which he could not have inflicted himself. 13.11 The quality of information sharing and subsequent advice given, due to inaccurate and incomplete information sharing between Children’s Social Care, BHT Acute Services, Thames Valley Police and Buckinghamshire Law Plus on the Confidential – not to be photocopied or distributed Serious Case Review Baby M 38 5/12/2014was extremely poor. Buckinghamshire Law Plus could have challenged more robustly Children’s Social Care, BHT Acute Services and Thames Valley Police regarding the decision not to hold an immediate strategy meeting to ensure that they were fully informed about Baby M’s injuries and able to influence a plan to safeguard him. Buckinghamshire Law Plus have a wider professional duty and could have more strongly challenged poor working together by these other agencies. In the Fact Finding hearing for the Care Proceedings the Consultant reported a high index of suspicion of inflicted injury. A full physical examination on admission noted significant bruising and marks to the body and head for which there was no plausible explanation. On the 5/12/14 Baby M was considered by all agencies to have either suffered a non- accidental injury (NAI) which resulted in his multiple bruising or there was an underlying medical condition which at that stage could not be ruled out due to his extremely poor medical condition. There were a number of multiple factors which should have alerted Children’s Social Care, Thames Valley Police and Buckinghamshire Law Plus to view the injuries with scepticism and to have taken a more robust stance: • There had been a delay in Baby M’s presentation at hospital in excess of five hours – this was despite him appearing to have stopped breathing. This was reported by the parents to ambulance staff. • He had been floppy and unresponsive when paramedics attended him at home and needed immediate medical support. He was noted to be covered in multiple bruising and was extremely poorly on admittance at hospital. • Parents could offer no plausible explanation for Baby M’s bruises. • Baby M had only days earlier presented at hospital with bruising to his face, eye, had a fractured skull and a torn frenulum. • Mother did not appear overly concerned whilst Baby M was being attended to in A&E and spent her time texting on her mobile phone. Confidential – not to be photocopied or distributed Serious Case Review Baby M 39 13.12 The above factors should have ensured that Thames Valley Police, Children’s Social Care and BHT Acute Services were alerted to the high possibility of NAI and Baby M and this information should have been communicated to Buckinghamshie Law Plus to ensure that there was a robust safeguarding plan in place. The parent should have been invited to leave and not stay at the hospital. Had they refused against this background then they would have given the grounds for the Emergency Protection Order (EPO). Nationally there is often a reluctance to take matters before the court for an Emergency Protection Order32 because of the very draconian nature of this order and the threshold for removal of a child from his parent’s care being rightly very high. Courts have to balance the rights of a child to be safeguarded and protected and the human rights of both child and parent to a family life. The local authority has to evidence compelling reasons why such an order would be necessary and proportionate. 13.13 It is the opinion of the Independent Reviewer that the advice given by Buckinghamshire Law Plus was made without the full knowledge of all of the information available and thus the actions taken by Children’s Social Care not to agree a safeguarding plan or to issue immediate legal proceedings was flawed and failed to ensure Baby M was safeguarded. He was left in hospital on a busy ward with his parents caring for him when it was highly probable that one or both of them had been responsible for his injuries. The hospital was carrying out its normal procedure where a child has unexplained injuries and ensuring that there was not an underlying medical reason for the injuries as well as maintaining that outside of this explanation the injuries were highly suspicious of a non-accidental mechanism. The strategy meeting on the 08/12/2014 agreed that the threshold for legal proceedings had been met and a safeguarding plan was put in place until the 10/12/2014 when a legal order was secured. The Fact Finding hearing in the Care proceedings indicted that the date of some of Baby M’s fractures to the anterior right 8th, 10th and 1st rib 32 http://www.proceduresonline.com/buckinghamshire/chservices/chapters/p_app_emer_prot_ord.html An Emergency Protection Order (EPO) enables a child to be removed from where s/he is, or to be kept where s/he is, if this is necessary to provide immediate short-term protection. The EPO will grant the local authority Parental Responsibility for the child which will enable the child to be removed to other accommodation or to remain in a place where he/she is being accommodated (e.g. a hospital or foster placement). Confidential – not to be photocopied or distributed Serious Case Review Baby M 40 occurred between the 29/11/2014 and the 10/12/2014. Five of these days fall within the timeframe for when Baby M was left on a busy ward in the care of his parents. While it is not suggested that these injuries occurred on the ward the lack of action on the 05/12/2014 regarding a robust safeguarding plan raised the risk that he could have potentially suffered further injuries. 13.14 Management oversight in general was limited in the Children’s Social Care records and it appears that the case was not on the radar of first line managers as being significant. Therefore it would not have been flagged up to senior managers for advice or guidance. 13.15 Child In Need processes were not followed, there were no active planning and review processes built into this. There was no multi-agency mechanism which enabled agencies to share information and concerns in a co-ordinated way to ensure assessment and subsequent plans of intervention were based on the evidenced risks. Child in Need processes were not embedded on a multi-agency level across the partnership and there is little mention of how these cases should be managed. The Buckinghamshire Safeguarding Children Board’s Individual Case Management Procedures, which are available on the BSCB website, had not been updated since 2010 and there were no links to the more detailed Social Care procedures relating to Children in Need. In February 2015 Children’s Social Care moved to an online procedures manual which is now linked to the BSCB website. However, the Safeguarding Board’s Individual Case Management Procedure has not yet been updated in line with this resulting in a lack of clear and easily accessible to guidance for professionals on case management. 13.16 There was also a distinct lack of professional curiosity displayed in this case and this was particularly apparent in relation to the first admittance to hospital with the two separate injuries which occurred to Baby M. There was an acceptance by professionals and little challenge to the information provided by the parents. The transfer of the case from the Triage Nurse to the Registrar resulted in there not being sufficient rigour given to the mechanism surrounding a non-mobile baby Confidential – not to be photocopied or distributed Serious Case Review Baby M 41 receiving two separate injuries accidently. There is no evidence of challenge by professionals who received this information. 13.17 There are several instances of poor recording and information not being clear in records and there was no Child In Need Plan in place which agencies involved appeared to be working towards or monitoring. Where there are safeguarding issues identified the multi-agency mechanisms of a Child Protection Conference was not given consideration by agencies; therefore the formal processes for multi-agency review and planning are not implemented. There is the same expectation that similar process around planning and reviewing in relation to Child In Need cases should take place but it does not appear to be embedded as practice amongst agencies. 14 RESPONSES FROM THE KEY LINES OF ENQUIRY 14.1 The Children’s Social Care records indicated that there was limited management oversight in relation to this case. The Child and Family Assessment took from March to June 2014 to be completed which is outside of timescale and, although risk factors were identified, it does not appear that the Team Manager or the Social Worker formulated a plan of how to manage this risk or move the case forward. The IMR author identifies that the vulnerabilities of Baby M’s Mother in respect of her learning difficulties were highlighted in the assessment and the First Response Social Worker was concerned that the housing options for her were inappropriate and would take her away from her current sources of support and could place her “at the mercy of some exploitative individuals”. The IMR author identified that workers for both young people had commented to her that whilst presenting with difficulties both Baby M’s Father and Mother could also be insightful and appeared to support each other and work well together. 14.2 The Children’s Social Care records identify some evidence of disguised compliance with Baby M’s Father and Mother giving different information to different professionals and because agencies were not working actively together this Confidential – not to be photocopied or distributed Serious Case Review Baby M 42 information was not triangulated in a meaningful way. An example of this was identified by the Children’s Social Care IMR: ‘For example in September 2014 Baby M’s Father was asking his PA about sharing the tenancy with Baby M’s Mother but the ICS records says he is bidding for his own tenancy. Children in Care Social Worker said he told her he had saved £400 for the baby but at the time he was stealing food.’33 Baby M’s parents gave agencies fragmented information which if triangulated may have indicated concerns. The Biennial Review of SCR’s 2005-2007 34identified that 75% of parents do not engage with services despite appearing to do so. Baby M’s parents also managed to persuade medical staff on the 27/11/2014 that the injuries to Baby M had a totally accidental mechanism and the BHT Acute IMR Author commented that (NICE) 2009 guidance on when to suspect child maltreatment indicates that maltreatment may have occurred if bruising is found in a child who is not independently mobile35. Baby M had a significant head injury, torn frenulum and bruising under his eye yet although non accidental injury was considered by the Registrar this was then dismissed by the Paediatric Consultant. Some medical staff did not consider that “they should think the unthinkable”36. Lord Laming (2003) commented following the death of Victoria Climbie about the need for “healthy scepticism” and respectful uncertainty in their dealings with families”37 and the need to verify information from other sources while listening to what parents have to say. “One of the most problematic tendencies in human cognition….is our failure to review judgement and plans-once we have formed a view on what is going on , we often fail to notice or dismiss evidence that challenges that picture”38 14.3 Positive outcomes were assumed despite clear indicators that the opposite was to be a more likely outcome. The IMR author for Children’s Social Care has 33 Children Social Care IMR 34 The Biennial Review of SCR’s 2005-2007 35 The National Institute for Health and care Excellence 36 http://www.coventry.gov.uk/downloads/file/17081/daniel_pelka_-_serious_case_review_overview_report 37 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf 38 Fish S, Munro E and Bairstow S(2008) Learning together to safeguard children pg 9 Confidential – not to be photocopied or distributed Serious Case Review Baby M 43 identified that at the very least the outcome of the assessments and information known about both parents should have led to a Child Protection Case Conference. It is the view of the Independent Reviewer that had all of the information been shared when the referral first came into Children’s Social Care in March 2014 and a robust assessment undertaken based on multi-agency information then this matter should have progressed into the Public Law Outline process39. If this had occurred and assessments had been completed before Baby M was born then it is likely that different decisions would have been made for him. Assessment does not seem to have been an ongoing process that evolved with the case but a one off event, and the past histories that both these young people had experienced did not inform the assessments undertaken. 14.4 The assessments undertaken in A&E during the first admission were in line with local protocol, however information in the social history taken was sketchy and a recommended ophthalmology assessment did not take place. It was accepted by the Consultants who reviewed Baby M that the injuries had an accidental mechanism. It was not considered that he could have been shaken or whether there would be other injuries that were not so obvious. The Paediatric Consultant stated to the IMR author that it was his role to question “was the injury possible?” The IMR comments that using the same logic it can equally be assumed “that it is not possible”. 14.5 A skeletal survey was not undertaken during the first admission on the 27/11/2014. During the second admission the skeletal survey was delayed until the 10/12/2014 and revealed the following injuries for Baby M: • Healing fractures to the right 3rd,6th,7th,8th and 9th ribs at the costovertebral junctions with new bone evident • Further incomplete fractures on the anterior 8th, 9th and 10th ribs on the right showing no healing by new bone formation. 39 https://www.justice.gov.uk/courts/procedure-rules/family/practice_directions/pd_part_12a Confidential – not to be photocopied or distributed Serious Case Review Baby M 44 • Healing fractures to the left 4th, 5th, 6th, 7th, 8th, 9th, and 10th in the postero lateral position with early new bone formation evident. • Fracture of the 1st rib on the left showing distraction (separation) at the ends of the fracture with no healing bone formation The judgement in the Finding of Fact hearing found, based on expert testimony that the skull fracture and the first rib fractures occurred during a single incident on the 27/11/2014. The lack of a skeletal survey during this first admission meant that the scale of injuries Baby M had suffered were not fully realised and conclusions were reached that the injuries had been accidental. Had this skeletal survey taken place then he would have been unlikely to have returned home with his parents where he received further injuries. 14.6 The Thames Valley Police IMR author identified a number of occasions when information sharing from the Police was not effective. In general, information exchange and communication between the agencies was inconsistent and at times poor. 14.7 From the date of the notification of the pregnancy the family came into contact with a range of agencies and received many services. Few services and interventions had a positive impact on either parent or Baby M. Family Nurse Partnership (FNP) is a service that may have had a positive impact and would have provided high levels of support to these very young parents in both the pre and post birth periods. FNP can help safeguard some of the most vulnerable and costly families as they take a whole family approach as well as working with mothers. A report by The Centre for Social Justice identified that at least one in ten care leavers are parents who have had a child taken into care in the last twelve months40. FNP does not operate a waiting list and they are required to take a prescriptive approach 40 Finding their Feet, Centre for Social Justice Confidential – not to be photocopied or distributed Serious Case Review Baby M 45 to their interventions. A recommendation of the report was that the NHS should make Family Nurse Partnership a default position for all Looked After Children and care leavers and the Independent Reviewer of this review would echo that recommendation. In October 2015 the responsibility to commission and extend the coverage of Family Nurse Partnership will rest with the Local Authority due to the transfer of public health arrangements to Local Authorities and consideration should be given to how this service can be targeted at those young parents most in need. 15 ORGANISATIONAL CONTEXT ISSUES 15.1 The period covered by this Serious Case Review includes the period leading up to the inspection of Children's Services by Ofsted in June 2014 and the period following the inspection when the Improvement Plan was in place and many of the findings of this review were known during and after the inspection. The Ofsted report indicates that it was recognised by senior managers and political leaders that there were serious problems within the system and that despite injections of funding changes had not been effective. Further, Ofsted commented that the “failures by Buckinghamshire’s safeguarding services are widespread and serious. The result is that children are not being effectively protected. Children and young people do not always receive help when they need it”41. Within this case there is clear evidence of what was being experienced within the organisation. Social work caseloads were high and records often poor. A reorganisation of the service into Units had impacted and the social work units introduced functioned with a smaller number of staff using a method of work called "systemic practice”. The problem was exacerbated by difficulties in recruitment and retention as there had been significant movement of staff when the new structure was introduced. 41 reports.ofsted.gov.uk/sites/default/files/documents/local_authority_reports/buckinghamshire/051_Single%20inspection%20of%20LA%20children%27s%20services%20and%20review%20of%20the%20LSCB%20as%20pdf.pdf Confidential – not to be photocopied or distributed Serious Case Review Baby M 46 15.2 The IMR for Thames Valley Police did not identify any significant contextual information which had an adverse impact upon their practice. 15.3 The IMR completed for the Health Visiting Service identified that there were a number of factors which could have impacted upon practice during the period of the review. The Team Leader was new to the team and the IMR author identified that challenging the existing CIN Social Worker, who had a strong personality, was a possible issue. The Team Leader also described pressure within the organisation for staff to perform and achieve Key Performance Indicators (KPI) targets. This created conflict and also a lack of understanding around how to prioritise workload. 15.4 The IMR for BHT Acute services identified that there were no specific issues of capacity identified within A&E and Ward 3, which were felt to impact the quality of services provided for Baby M. The IMR author interviewed both Consultants who were involved in Baby M’s admission on 27/11/14 and they both agreed that there were no unusual issues, apart from Baby M being an inpatient during the weekend, which is generally a busier time. The Ward Nurse stated that the Paediatric Day Unit (PDU) is always extremely busy in October and November as it is the start of the season where there is an increase in admissions due to respiratory issues and, although staff in PDU always feel more staff are needed, she felt on this date there were ample staff available and a good skill mix on duty. 15.5 The GP IMR has identified that there were no capacity issues in the surgery which would have impacted on the care given to Baby M’s Mother or Baby M. What is noted is that Baby M’s Mother booked ‘on the day’ appointments with GPs and this resulted in a lack of continuity of care as she would have not been seen by the same GP. Had she booked routine appointments she would likely be under the care of the same GP. Positively each booked ante-natal appointment was with the same Community Midwife Confidential – not to be photocopied or distributed Serious Case Review Baby M 47 15.6 The Youth Offending Service IMR has not identified any organisational difficulties that were experienced within or between agencies in relation to this review period. Staffing levels were adequate and there was no impact of annual or sick leave during that time. 15.7 The BHT Maternity IMR has not identified any adverse organisational issues which impacted on service delivery. The IMR author however has commented that there were capacity issues in respect of the Teenage Pregnancy Liaison Midwife who had reduced her working hours and the team were in the process of recruiting a job-share partner for her. 15.8 Family Nurse Partnership received the notification about mother’s pregnancy in February 2014. The service was in its first year at this time and caseloads were at capacity. They had met their commissioned contract but were in the process of building a business case for increased capacity. This was agreed and they are now able to offer the service to approximately 50% of the eligible population at any one time. The service is now established and has grown, clients are graduating the programme every month (they stay in the programme 2 ½ years). This means that they now have a constant flow of clients in and out of the programme, which was not the case in early 2014. They have also made a commitment to prioritising those clients according to geography and need and agreed that all LAC clients will be offered FNP in Buckinghamshire. 16 GOOD PRACTICE 16.1 An area of good practice was observed during Baby M's second admission, when the assessments completed were thorough and considered all risks for Baby M. The Paediatric Registrar acted promptly and informed Children’s Social Care of her concerns immediately. 16.2 The completion of the Risk of Serious Harm ASSET would not be normal practice for the Youth Offending Service to complete for a young person with an offence of Confidential – not to be photocopied or distributed Serious Case Review Baby M 48 Possession of Cannabis. However, due to Baby M’s Father’s previous offending history, this was completed and identified the’ risk of harm to others ‘status for him as being medium. 16.3 There were no other examples of good practice above and beyond what was the normal expectation of agencies and individual workers. 17 LEARNING EVENT 17.1 A Learning event took place with practitioners using appreciative inquiry42 was held and was attended by agency representatives, a total of twenty practitioners and police attended. The learning event had previously been scheduled to take place at an earlier date but concerns from Thames Valley regarding the ongoing police enquiries had resulted in this being postponed and ultimately a delay in the completion of this Serious Case Review. This was despite reassurances that ACPO43 guidelines would be followed and that officers could be in attendance on the day. Prior to the event a brief summary was shared with practitioners and themes explored through appreciative inquiry and group discussion and workshops. Practitioners who attended the event were honest and candid in their responses and many of the hypothesis were able to be tested out and triangulated. 18 FINDINGS AND RECOMMENDATIONS 18.1 A question that this review has to answer is whether or not Baby M could have been protected earlier. This review does conclude that Baby M could have been 42 Appreciative Inquiry is a theory and applied practice as a model for analysis that is co-operative and asks questions to strengthen the understanding of systems and organisations. 43 http://www.baspcan.org.uk/files/120614%20SCR%20and%20Criminal%20Proceedings%20Guidance%20Document%20June%202014%20Final.pdf Confidential – not to be photocopied or distributed Serious Case Review Baby M 49 protected at an earlier stage. In the pre-birth period there were enough indicators of risk to predict potential harm and the systemic failures following the first admission to hospital ensured that Baby M was returned home with his parents to be further abused. 18.2 There is recognition that the poor planning in the pre-birth period was a missed opportunity in this case and in another Serious Case Review that has taken place in Buckinghamshire. The 2015 Baby K SCR44 makes reference to an “inadequate pre-birth assessment…which did not lead to a robust plan”. The Healthy Child Programme45 highlights the importance of recognising risk factors in both pre and post birth periods. In this case the pre-natal risks were not considered or analysed. Whilst there are meetings in place between BHT Midwifery and Children’s Social Care to try to identify vulnerable babies these lack structure and do not adequately track unborn children through the system. The SCR for Baby D, another Buckinghamshire baby, carried out in 2012, identified that the risks in that pregnancy were deemed as low therefore the case was not referred to Children’s Social Care. As in this case the baby’s mother presented at hospital on a number of occasions with vague symptoms which may have been indicative of Domestic Abuse. When she did inform the GP that she was experiencing Domestic Abuse assumptions were made about the Police dealing with the matter resulting in the GP not following this up. 44 www.bucks-lscb.org.uk/wp-content/uploads/Serious_Case_Reviews/Baby_K 45 Department of Health (2009) - Healthy Child Programme. London RECOMMENDATION 1: BSCB to ensure that there is a robust identification and tracking of unborn children. This will require current arrangements to be strengthened and will require multi-agency information sharing and working to ensure that risk is identified early and planning is robust. RECOMMENDATION 2: The BSCB should ensure that all identified tracked vulnerable unborn children have an agreed birth plan in place prior to delivery to ensure that agencies are aware of the plan at birth and alerted when they have been born. Confidential – not to be photocopied or distributed Serious Case Review Baby M 50 Family Nurse Partnership 18.3 This Serious Case Review, and another review this author is undertaking, has highlighted the lack of service provision available nationally for young parents who have high needs. It is inconceivable that nationally provision such as the Family Nurse Partnership is not targeted at those young people who most need intensive support in the short, medium and long-term. In particular care-leavers who are to become parents should automatically fall within a target group for this provision, given they are likely to have experienced compromised parenting themselves. The responsibility for commissioning Public Health Services for Children aged 0-5 will transfer to Local Authorities from NHS England which brings opportunities to look at how the service is commissioned nationally. It is positive that locally in Buckinghamshire FNP will now be offered to all LAC and care leavers who are to become parents. However there is still a requirement for the mother to be referred to the service by 19 weeks and work will need to be undertaken across the partnership to ensure all practitioners who work with young and vulnerable parents are sighted on this. RECOMMENDATION 3: NATIONAL RECOMMENDATION That consideration is given to commissioning arrangements for the Family Nurse Partnership programme to be targeted at all young parents who are or have been Looked After Children / Care Leavers. This will ensure they receive the support required in the short, medium and long-term to enable them to develop the skills to successfully parent. Commissioning arrangements would need to consider local demographics and need. Confidential – not to be photocopied or distributed Serious Case Review Baby M 51 Threshold Decisions 18.4 This case has identified that threshold decisions in the whole are not understood across the partnership. The case clearly had dimensions of risk and early indicators of harm or potential harm yet did not progress into the child protection arena. Confusion is evident between the Police and Children’s Social Care as to whether a strategy meeting had taken place or not. Following the first admission to hospital the ‘discussion’ between the Police and Children’s Social Care did not take place until three days post-discharge. The second admission to hospital left Baby M at risk and on the ward unprotected until five days after admission as the strategy meeting and S47 investigation decision were delayed. The response from Buckinghamshire Law Plus was wholly inadequate. The case of Baby M lacks effective management, oversight and challenge. The Ofsted inspection of June 2014 identified a range of failures, in particular responding to young people in need of help and protection. The findings of this report are in line with these findings. Confidential – not to be photocopied or distributed Serious Case Review Baby M 52 RECOMMENDATION 5: BSCB to assure itself that Strategy Meetings and S47 investigations are being carried out in line with policy. RECOMMENDATION 4: For BSCB to urgently satisfy itself that current arrangements and understanding regarding threshold decisions are safe and robustly adhered to. RECOMMENDATION 7: BSCB should require agencies to review and provide evidence that staff are aware and have received training regarding the use of the escalation process and that there are systems in place which will support this. Regular audits to be undertaken to monitor the arrangements. RECOMMENDATION 6: BSCB to arrange a workshop comprising of representatives from key partner agencies to look at the systemic issues in respect of professional challenge which are particularly evident in this case, with a view to understanding how to ensure, in future cases, that professionals in individual agencies are able to challenge and escalate appropriately and that the current barriers which are impeding challenge are removed and partnership working strengthened. RECOMMENDATION 8: BSCB should ensure that up to date core procedures are easily accessible via the BSCB website. Confidential – not to be photocopied or distributed Serious Case Review Baby M 53 19 Individual Agency Recommendations As part of the methodology of this review it was agreed that each agency which provided an Individual Management Review would also provide a set of recommendations for improving services and practice within their agency. Each of the individual agency recommendations below are therefore directly drawn from the Individual Management Reviews and have already been agreed by senior managers within those agencies. 19.1 Children’s Social Care 19.1.1 Develop a system for measuring, reporting and evaluating operational risk factors in units - This action has already been progressed as part of the SCR for Baby K 19.1.2 Carry out an Audit of the quality of recording for unit meetings in CIN units, including an evaluation of the quality of management decisions made during the meeting - This action is already being progressed as part of the Ofsted improvement plan 19.1.3 Monitoring systems for CIN cases - This action is being taken forward as part of the Ofsted improvement plan 19.1.4 Monitoring systems for supervision - This action is being taken forward as part of the Ofsted improvement plan 19.1.5 Where more than one unit is involved with children and young people, in one family, ensure the needs and risks of all the children and young people are jointly assessed and evaluated 19.1.6 Where a child is subject of a Child In Need (CIN) or Child Protection (CP) plan agreement to the discharge from hospital without a strategy meeting to be sought by the social worker from CSWM or Practice Improvement Manager (PIM) Confidential – not to be photocopied or distributed Serious Case Review Baby M 54 19.1.7 Review the scope and remit of Junior Catch to ensure there is a protocol for prioritising allocation of cases (according to need and assessed risk / vulnerability rather than case type) and the role of Junior CATCH role in assessment is clearly defined. 19.1.8 Formulate and carry out a plan to ensure that social workers routinely consider and incorporate family history as part of Child & Family Assessments 19.2 Thames Valley Police 19.2.1 Thames Valley Police to remind officers that everyday policing decisions, including risk assessments, should be made using the National Decision Model and provide an example of how this should look when recording rationales in URNs/NICHE occurrences 19.2.2 Thames Valley Police to ensure their front line staff (including intelligence staff) are competent in their role in identifying the needs of children and any risk factors at an early stage and sharing this information in a timely and effective manner. This should include reference to the 2015 advice issued to the police by the Home Office and College of Policing entitled ‘Early Intervention: a guide for frontline police officers and PCSOs 19.2.3 Thames Valley Police to ensure staff are routinely conducting research into parents, children and unborn children in order to provide a full picture in relation to any risk factors. Where there are concerns then a ‘Child Protection – non-crime incident’ should be created for referral to the Multi-Agency Safeguarding Hub 19.2.4 Thames Valley Police to ensure PEC Operator understanding of question 6 within the missing/absent risk assessment. This question relates to the absent person as the victim of crime and not the perpetrator Confidential – not to be photocopied or distributed Serious Case Review Baby M 55 19.2.5 Thames Valley Police to remind staff that, in the event of a strategy meeting being delayed, investigative considerations must be documented and action must be taken to expedite evidence gathering. If the investigation is not commenced immediately, the rationale must be recorded within the Niche OEL or policy log 19.2.6 Thames Valley Police to consult with relevant practitioners within the MASH and Referral Centres to ascertain the general status attributed to the initial discussion between police and social care following a new referral. Is this considered to be a strategy discussion? If so, how is this formally recorded? The end result of this consultation should provide practitioners with clear guidance in this area 19.3 Buckinghamshire Healthcare NHS Trust (Acute Services) 19.3.1 Accident and Emergency department and the Radiology department to review the Trusts Non Accidental Injury ( NAI) imaging policy with the current national legislation and research to determine whether a skeletal survey should routinely to be completed on all children under 1year old who attend with a skull fracture. 19.3.2 The Safeguarding Lead and Lead Named Nurse to review the safeguarding children’s training and compliance ensuring all staff have the correct level of training expected of them. To review the quality of the training packages, ensuring that staff are given effective training on documentation. 19.3.3 Lead Nurse for Paediatric services to review the Hospital’s Nursing Policy for discharge of children 19.3.4 Safeguarding Lead and Lead Named Nurse for Safeguarding Children to review the child protection policy. To be reviewed and updated to reflect current practice and legislation. This policy must then be disseminated to all Trust staff 19.3.5 A Task and Finish group in conjunction with BSCB on updating and developing a policy on Bruising in any Child not independently mobile Confidential – not to be photocopied or distributed Serious Case Review Baby M 56 19.4 Buckinghamshire Healthcare NHS Trust (Maternity) 19.4.1 The importance of documenting 28 week maternity assessments will be highlighted to all midwives 19.4.2 Information concerning support agencies to be circulated to all community midwives 19.4.3 All postnatal care plans are to be available following discharge from community midwifery team 19.5 Buckinghamshire Healthcare NHS Trust (Health Visiting) 19.5.1 Operational Lead for School Nursing to give clarity in terms of what service School Nurses offer to young people/children who are not accessing education but are deemed to be vulnerable 19.5.2 Named Nurses for child protection to ensure that all health visiting staff and school nurses are updated or trained to use the DASH tool 19.6 Youth Offending Service 19.6.1 Devise a standard template for all young people who are going to become a parent, who are already a parent, or who have caring responsibilities for young children. This will include: • An assessment of parenting capacity taking into account a young person’s risk and vulnerabilities • A list of agencies that are working with the young person and how they communicate Confidential – not to be photocopied or distributed Serious Case Review Baby M 57 • A plan of how and when information is shared • A section for management oversight 19.7 General Practitioners (GPs) 19.7.1 GPs to do some routine antenatal care as per the local guidelines 19.7.2 Pro-active follow up of domestic incident reports. CCG good practice guideline to be reviewed 19.7.3 Vulnerable family meetings to be held in surgeries 19.7.4 Improve knowledge of GPs about the importance of early help for vulnerable families 19.7.5 Surgery 1 will discuss this case in depth at a learning event |
NC52402 | Death of a 13-year-old girl as a result of multiple stab wounds. Clare and her siblings had all been subject to child protection plans. A man staying with the family was convicted of Clare's murder and is serving a life sentence. Learning includes: the impact of parental discord and domestic abuse on the emotional health and wellbeing of children must be recognised and given sufficient importance by professionals involved in safeguarding children; parents can be intimidating and aggressive to professionals but this must not be allowed to detract from keeping the best interests of children and their safety at the centre of all professional practice; the need to listen to children, whether they speak directly to professionals or indicate concerns indirectly by their actions and behaviour is an important lesson. Recommendations include: undertake an independent audit of Public Law Outline cases to ensure that required procedures and timescales are adhered to and cases are not subject to drift; remind agencies of the impact of domestic abuse on the health and emotional wellbeing of children; and support professionals to adopt a trauma-informed approach.
| Title: Child Clare learning report. LSCB: Southampton Safeguarding Children Partnership Author: Moira Murray Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child Clare Learning Report Lead Reviewer Moira Murray 2 Contents Page No 1 Reasons for the review and synopsis of the case 3 2 Key Themes Arising from the review 3 3 Learning Arising for the Safeguarding Children Partnership 7 4 Good Practice 8 5 Conclusion 8 6 Recommendations 8 3 1. Reasons for the review and synopsis of the case 1.1 On the recommendation of the Southampton Serious Case Review Group, a decision was taken by the Independent Chair of the Southampton Local Safeguarding Children Board in July 2018 to commission a Serious Case Review into the death of a child (hereafter referred to as Clare). The recommendation was based on the decision that the circumstances of Clare’s death met the criteria for a Serious Case Review under Chapter 4 Section 17 of Working Together to Safeguard Children (2015)1. 1.2 Clare was 13 years old when she died as a result of multiple stab wounds. A man was convicted of her murder and is serving a life sentence. Prior to Clare’s death, the perpetrator had been staying with the family intermittently for almost twelve months. 1.3 Clare lived with her mother, her mother’s partner, and her three siblings, two of whom were half siblings. The family had been known to statutory agencies because of past incidents of domestic abuse. Throughout her short life, Clare and her siblings witnessed frequent arguments and incidents of domestic abuse between her parents and subsequently between her mother and her partners. 1.4 Following a private court hearing, mother was given care and control of the children, with their father allowed regular contact. The ruling was against the recommendation of Children’s Social Care and after the hearing their father had little contact with the children. Concerns about the care and emotional wellbeing of Clare and her siblings began to emerge when they started school, resulting in the children being made subject to Child Protection Plans. Clare and one of her siblings were referred to Children and Adolescent Mental Health Services (CAMHS). The Local Authority considered removing the children from mother’s care, however the proceedings were delayed and did not progress further than the Public Law Outline (PLO) stage. 1.5 Concerns were raised with Children’s Social Care by teachers at both secondary schools, which Clare attended, that she had an older boyfriend whom it was believed could be sexually exploiting her. The referrals were investigated, however, because of assurances given by Clare’s mother that there was no foundation to these concerns, no action was considered necessary. Information subsequently emerged that Clare had been sexually abused by the perpetrator since the age of 12, when he began to stay with her family. 2. Key Themes arising from the Review 2.1 A number of key themes have emerged from this review, which are important to the improvement of practice. Parental discord, domestic abuse and the emotional impact on children 2.2 There is growing evidence that children who live in families where there is domestic abuse can suffer serious long-term emotional effects. A child's fear and anxiety will affect their self- 1 Working Together to Safeguard Children (2015) - NB this guidance was updated in 2018, however this Serious Case Review was commissioned prior to the update. The update to the guidance included the fact that Local Safeguarding Children Boards should become Local Safeguarding Children Partnerships. 4 confidence and often make them depressed, withdrawn or violent.2 Research by The Children’s Society found that children experiencing domestic violence and abuse could see a negative impact on their mental health and wellbeing, school attendance and achievement, emotional development and physical safety.3 2.3 Clare and her siblings witnessed ferocious verbal arguments and violence between their parents and between mother and another partner throughout their childhood. The impact of exposure to prolonged periods of parental discord, which was prevalent during Clare’s short lifetime was manifest in her exhibiting insecurity, anxiety and vulnerability, particularly whilst at primary school. The children were at the very centre of parental arguments which resulted in them experiencing significant emotional harm, and at times physical abuse. 2.4 As a consequence, the children were subject to Child Protection Plans and the PLO process was initiated. Despite these measures, outcomes for the children were inconsistent in ensuring their safety and emotional wellbeing. There was a well-intentioned belief, on the part of those professionals involved that the situation would improve, however, this resulted in a lack of focus on the needs of the children. Disguised compliance and hostility towards professionals 2.5 The engagement of parents with safeguarding professionals is key to the assessment of risk to children. From information provided to the review, by multiple agencies, Mother was described as being at times ‘defensive’, ‘controlling’, ‘aggressive’ and ‘intimidating’. She was able to influence professional judgement in her engagement with health, school and Children’s Social Care, and indeed the court, in ways similar to those she affected with the fathers of her children. For example, Mother was determined that Clare and her siblings remained in her care, and on succeeding in an application to the court for care and control, ensured that it would prove difficult for Father to maintain contact with his children and they with him. 2.6 It is apparent that Mother was largely able to manage situations involving the children on her terms in her involvement with all agencies, which proved to be detrimental to the well-being of the children. The review recognises the difficulties faced by professionals in attempting to engage with parents presenting in this way. However, such behaviour should not be allowed to detract from the need to focus on the safety and wellbeing of children. Thus, professionals need to be aware of disguised compliance, be resilient when faced with hostility, and confident in understanding when to escalate their concerns. The role of CAMHS and diagnosis of children with ADHD 2.7 Mother believed that both Clare and one of her siblings had Attention Deficit Hyperactivity Disorder (ADHD). She was persistent in this belief when meeting with teachers, Primary Care clinicians and with CAMHS practitioners. However, in respect of Clare both the school and the GP considered that she did not present as a child with ADHD. On receipt of referrals assessments were undertaken, which resulted in both Clare and her sibling being assessed by CAMHS clinicians as requiring medication to ameliorate their behaviour. 2.8 The review found that the standard pathway for ADHD assessment in respect of Clare was not followed. A number of screening tools and assessments which were part of the usual 2 Barnardo’s https://www.barnardos.org.uk/what-we-do/helping-families/domestic-abuse 3 The Children’s Societyhttps://www.childrenssociety.org.uk/mental-health-advice-for-children-and-young-people/domestic-violence 5 procedures were largely bypassed, the reason being that the family was known, Clare’s sibling already having been assessed as having ADHD, and the insistency by mother that Clare’s behaviour at home and at school was indicative that she had the condition. 2.9 The review has been informed that a clearly defined pathway for ADHD is now in place, consisting of four appointments and completion of various screening tools. Solent NHS Trust has confirmed to the review that this ADHD pathway document has been disseminated. Male partners in the family environment 2.10 The importance of agencies sharing known information concerning the background of males who become involved with children and families cannot be underestimated. Clare and her siblings had experienced different male partners coming to live in their home, after father had left. This resulted in the children witnessing the distress of parental discord, argument and violence and led to them being made subject to child protection plans because of the risk of emotional harm. The arrival of a male who was allowed to stay as a semi-lodger with the family, however presented a different risk of harm. 2.11 Mother informed the review that she was unaware of this man’s history of violence and if she had, she would never have allowed him into her home. He was well known and appeared to be well liked and trusted in the local community. This man was however, also well known to Police and Children’s Social Care did have knowledge of elements of his background. Before being sentenced to life imprisonment for Clare’s murder the perpetrator had numerous previous convictions, which included theft, battery, criminal damage, domestic violence and possession of cannabis. 2.12 Agencies, including Children’s Social Care, were aware of the perpetrator’s criminal history. The referrals by Clare’s secondary schools detailing concerns about Clare’s involvement with this man did not progress further than the ‘Front Door’ to the Multi Agency Safeguarding Hub (MASH), which resulted in no multi-agency sharing of information held by Police, the School and Children’s Social Care. The referrals needed to be treated as one of child protection. If this had happened, a Strategy Discussion under Section 47 of the Children Act, 1989 could have been convened concerning the risk this man posed to Clare and her family. This did not happen and was a missed opportunity. The importance of the Public Law Outline & the need for robustness in the Child Protection Process 2.13 Concerns about the welfare and safeguarding risk posed to the children resulted in Children’s Care appropriately requesting that a legal planning meeting being convened. This resulted in a decision that the children were suffering from emotional harm, which met the threshold for a PLO. 2.14 The PLO process should not take any longer than 16 weeks from the time of commencement. In this case, it continued for fifteen months after the decision was taken to commence the process. During this time, Capacity to Care Assessments were undertaken on mother, father, and the father of one of Clare’s half-siblings. Clare and her sibling also underwent therapeutic assessments. There is no documentation available to the review as to the outcome of those assessments informing any decisions made about the future of the children. 6 2.15 The PLO had been in place for ten months, when a solicitor in the Local Authority Legal Services Department questioned why the process was taking so long. A decision was then taken that as the process had been going on for many months and the prospect of care proceedings being successful was remote, the PLO should be withdrawn. The PLO was not however withdrawn for a further five months. During this period Legal Services sought instructions on several occasions from Children’s Social Care as to how to proceed. However, the lack of timely decision making which would have ensured that the PLO process progressed appropriately and efficiently, meant that this process was allowed to drift. This can only be described as poor practice, which resulted in the court not being given the opportunity to decide what was in the best interests of the children. 2.16 In response to questions raised as to why this case was allowed to drift, the Lead Reviewer has been informed that there was no designated business support for Children’s Services to support the Legal Gateway process, as such services are shared across departments in Southampton City Council. Given the demands on Children’s Social Care to fulfil their statutory duty to care and safeguard children, it is seriously concerning that such support was not in place. It is recognised that business support provide administrative assistance in this process, and not the management of cases which remains the responsibility of Children’s Services. It can be said that the welfare and best interests of Clare and her siblings were compromised by the system for review of PLO processes, and has resulted in a recommendation arising from this review. (Recommendation 2). 2.17 The children remained subject to Child Protection Planning until February 2016 when a Review Child Protection Conference decided that the case be stepped down to one of Child in Need. This was a split decision and the outcome to proceed to Child in Need plans was one endorsed by the chair of the review conference. Within months of the Child in Need planning being closed the perpetrator moved into/began to stay in the family home. 2.18 The importance of clear, comprehensive child protection planning, and child focused decision making, is a finding of many Serious Case Reviews. Unfortunately, this case is not an exception. The children were subject to Child Protection Plans on two occasions over a three year period. They remained on Child Protection Plans for almost another three years thereafter, and for a year on Child in Need plans. The question needs to be asked, not only why the children were subject to Child Protection Plans for so long, but also whether by the time the decision was taken to remove them from plans, full consideration had been given that the risk to their wellbeing had diminished and that they were no longer considered to be at risk of significant harm. The decision, at a Review Conference, to remove them from child protection planning was not a unanimous one and would indicate that there were concerns amongst some agency representatives that the children remained at risk. The crucial importance of comprehensive information being available at Child Protection Conferences, the need to challenge decisions which are not unanimous and the recognition of safeguarding risk by professionals from all agencies cannot be underestimated and is a finding of this review. Lack of Professional Curiosity 2.19 Lack of professional curiosity is a frequent theme emerging from Serious Case Reviews. It has been illustrated in this report that there was lack of further investigation by Police into the perpetrator’s background when he came to their attention, prior to Clare’s death, not least when it became known he was tattooing under-age young people. Similarly, there should have 7 been an escalation from the Front Door to the MASH of the concerns raised by the schools about Clare’s involvement with an older man. 2.20 Whilst it is acknowledged that as a male, known in the community and to mother and her partner, the perpetrator was able to inveigle himself into the family home; the significance of recognising what constitutes a safeguarding concern and seeking additional information when a safeguarding referral is made to statutory agencies is a fundamental requirement of professional practice. By not following up on the concerns expressed about this man, an opportunity was missed to consider the risks he presented to Clare and other young people. Listening to Children 2.21 Whilst Clare did not share that she was being abused by the perpetrator with her mother, she did disclose to friends at school that she had an older boyfriend. The two secondary schools she attended took appropriate action and referred this information to the Front Door of the MASH. This showed that both schools had a good understanding of child sexual exploitation and sought to protect Clare from this situation by escalating their concerns. 3 Learning Arising from the Review 3.1 The most significant learning arising from this review can be summarised as follows: 3.2 Parental Discord and domestic abuse: The impact of parental discord and domestic abuse on the emotional health and wellbeing of children must be recognised and given sufficient importance by professionals involved in safeguarding children. 3.3 Disguised compliance and hostility towards professionals: Parents can be intimidating and at times aggressive to health professionals, teachers and social workers. However, such behaviour cannot be allowed to detract from the necessity to keep the best interests of children and their safety at the centre of all professional practice. 3.4 The role of CAMHS and the diagnosis of children with ADHD: The need to recognise that ADHD can arise as a result of attachment disorders and parental relationship difficulties is a learning point arising from this review. Whilst it is often not possible to explore underlying issues such as relationship difficulties until a child has been treated with medication to manage their behaviour and thereby be able to focus on such issues, the need for appropriate assessment and proportionality in the prescribing of medication by clinicians is vital. 3.5 Robustness of the Child Protection Process: the importance of clear, comprehensive child protection decision making, and planning is crucial, if children are to be safeguarded and cases are not allowed to drift. It is of note that in 2015, a new system was implemented within Primary Care in the City of Southampton to support the Initial and Review Child Protection Conference process coordinated by Children’s Social Care. 3.6 Information sharing amongst agencies: as so many statutory reviews into the death and serious abuse of children have found, the importance of information sharing by and within agencies cannot be underestimated. 3.7 Lack of professional curiosity: the significance of recognising what constitutes a safeguarding concern and seeking additional information when a safeguarding referral is made to statutory 8 agencies is a fundament requirement of professional practice. The recognition by the Local Authority that the use of a particular methodology to assess referrals to the MASH, which was in place prior to Clare’s death, was not in the best interests of safeguarding children is a finding of this review. 3.8 Listening to children: the need to listen to children, whether they speak directly to professionals or indicate worries and concerns indirectly by their actions and behaviour is an important lesson arising from this review. 4 Good practice 4.1 The care and concern shown to Clare and her sibling by the staff at their primary school is commended and is an example of good practice, as is their escalation of safeguarding concerns to Children’s Social Care. 4.2 The therapy offered by the Behaviour Resource Service (BRS) to Clare and her sibling positively contributed to their wellbeing and emotional health. It is commended as an example of good practice. 4.3 The referral of concerns about Clare and her involvement with the perpetrator by both secondary schools is also commended as examples of good practice. 5 Conclusion 5.1 As a result of this review a number of partner agencies who have been involved in the process have changed procedures to enhance the way in which children are safeguarded. This includes changes to management responsibility for PLOs, a review of MASH procedures, a clearly defined pathway for ADHD and a new system in Primary Care in the City of Southampton to support Initial and Review Child Protection Conferences. Further learning arising from the review is reflected in single agency action plans and recommendations. This is in addition to the recommendations arising from this Serious Case Review. 6 Recommendations The following recommendations are for the consideration of Southampton Safeguarding Children Partnership: Recommendation 1 (a) When referrals are received into the MASH investigations are undertaken to ensure that all relevant information is gathered from agencies to make an informed decision as to the risk of harm to a child. (b) It is recommended that an independent audit of current MASH procedures is undertaken to reassure the Partnership that referrals are receiving appropriate priority and adequate investigation by appropriate information gathering. Recommendation 2 (a) It is recommended that an independent audit is undertaken of Public Law Outline cases to ensure that required procedures and timescales are adhered to and cases are not subject to drift. 9 (b) The system whereby no designated business support is available to strengthen the legal gateway process requires urgent review. Recommendation 3 (a) All agencies are to be reminded of the impact of domestic abuse on the health and emotional wellbeing of children, and support offered to professionals to adopt a trauma informed approach. (b) Intimidating and aggressive behaviour by parents and carers cannot be allowed to detract from the importance of professionals focusing on the safety and protection of children. The Partnership should seek assurance that the provision of safeguarding training to raise awareness of disguised compliance, and regular, reflective supervision is being delivered and accessed by professionals. If this is not happening, then action should be taken to ensure that the situation is addressed. Recommendation 4 It is recommended that an independent audit is undertaken of CAMHS to ensure that the pathway for children diagnosed with ADHD introduced by Solent NHS is adhered to, and that children are not being medicated unnecessarily to enable them to remain in education. Recommendation 5 It is recommended that a formal procedure is developed to ensure that where siblings attend different schools, information is shared between each individual school to ensure that an overall picture of a child and their family is available to teachers and education professionals. Recommendation 6 It is recommended that Southampton Children’s Safeguarding Partnership gives consideration to launching a campaign to raise awareness amongst parents and carers of the need to be curious about the background of males who are invited into their homes. The toolkit used by Hampshire Safeguarding Children Partnership may assist this recommendation. https://www.hampshirescp.org.uk/toolkits/understanding-unidentified-adults/practical-tools/ |
NC049433 | Extensive injuries of a child inflicted by the mother and her partner in October 2014. Child M, mother and her partner had been known to agencies for a number of years. Maternal history of domestic abuse, mental health problems, and disruptive childhood with allegations of inter-generational sexual abuse. Allegations of sexual abuse of Child M made by mother and maternal grandmother in December 2010; investigation was inconclusive. In January 2014 Child M disclosed sexual abuse by a family member to GP, who made a referral to children's social care; case closed in February 2014. Mother's partner had significant criminal history and was released from prison in June 2014. At the time of Child M's injuries an assessment was underway to assess the risk posed by partner to Child M; mother was pregnant. Ethnicity or nationality not stated. Key findings include: lack of recognition and understanding of the complex family circumstances and the risks to Child M and the unborn child; lack of understanding of Child M's lived experiences; child protection procedures were not adhered to. Recommendations to Dudley Safeguarding Board include: to seek assurance that local interagency child protection procedures are adhered to and that children and young people's views are sought; to share the findings of this case with GPs and Mental Health Services to raise awareness of their safeguarding responsibilities and what action to take when there are concerns about the risk posed by adults living with children.
| Title: Overview report: serious case review: significant incident learning process: Child M: year of birth: 2008. LSCB: Dudley Safeguarding Children Board Author: Adrienne Plunkett Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 OVERVIEW REPORT SERIOUS CASE REVIEW SIGNIFICANT INCIDENT LEARNING PROCESS Child M: Year of birth: 2008 SILP Lead Reviewer and Report Author: Adrienne Plunkett Presented to Dudley Safeguarding Children Board: 21 October 2016 Final Version: March 2017 2 CONTENTS: PAGE 1. Statutory Framework 3 2. Significant Incident Learning Process (SILP) 3 3. Process for this Serious Case Review 3 4. Background to the Serious Case Review 5 5. Engagement with the family 5 6. Pre-Scoping Period 6 7. Scoping Period 7 8. Analysis 14 9. Examples of Good Practice 26 10. Findings 27 11. Recent Developments 28 12. Conclusion 28 13. Recommendations 29 Appendix A: Terms of Reference Appendix B: Key single agency recommendations Appendix C: References Appendix D: Acronyms explained 3 1. Statutory Framework: 1.1. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the functions of LSCBs, including the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: a. abuse or neglect of a child is known or suspected; and b. either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.2. Working Together to Safeguard Children 20151 contains the statutory guidance for undertaking Serious Case Reviews (SCR) and states that LSCB’s should ensure that: • Reviews are conducted regularly, not only on cases which meet statutory criteria, but also on other cases which can provide useful insights into the way organisations are working together to safeguard and protect the welfare of children and that this learning is actively shared with relevant agencies; • Reviews look at what happened in a case, and why, and what action will be taken to learn from the review findings. 2. Significant Learning Incident Process (SILP): 2.1. The SILP methodology reflects on multi-agency work systemically and aims to answer the question why things have happened. The model engages frontline staff and managers in the review of the case, focussing on why those involved acted in a certain way at that time. Importantly, it recognises good practice and strengths that can be built on. 2.2. The SILP model of review adheres to the principles of: • Involvement of families • Active engagement of practitioners and frontline managers • Systems methodology • Proportionality • Learning from good practice 2.3. SILPs are characterised by practitioners, managers and Agency Report Authors coming together for a Learning Event. Agency Reports are shared in advance with participants. The perspectives and views of all those involved are discussed and valued. This same group meets again at a Recall Event to consider the first draft of the Overview Report. 3. Process for Serious Case Review: 3.1. On 4 May 2015 Dudley Safeguarding Children Board’s Independent Chair, following a recommendation from the SCR Sub Group, made the decision that injuries to Child M in October 2014 did not meet the criteria, as set out in Working Together to Safeguard 1 Working Together to Safeguard Children, DFE, 2015. 4 Children 20152, to undertake a SCR. Whilst Child M had suffered extensive injuries, these were not life threatening and had not resulted in long term physical impairment. However, it was agreed, as encouraged by Working Together to Safeguard Children, that a Case Review should be initiated to consider the circumstances leading to Child M’s injuries and identify the learning, for individual agencies and for multi-agency working. 3.2. Furthermore, a decision was taken that this Case Review would be undertaken using the SILP methodology. A Scoping Meeting to discuss the Terms of Reference (Appendix A) was held on 1 October 2015 and the Agency Report Authors’ Briefing on 15 October 2015. 3.3. There was a delay in commencing this Case Review, due to changes in responsibilities within the Board, notably in the Chair of the SCR Sub Group. DSCB’s Chair acknowledged that this should have been avoidable. 3.4. The first draft SILP Overview Report was presented to the Serious Case Review Sub Group on 4 March 2016. 3.5. A new Independent Chair of DSCB took up post on 1 April 2016. The Independent Chair requested that the SCR Sub Group reconsider the decision that the criteria had not been met to undertake a SCR. This was undertaken and the Sub Group unanimously recommended that the criteria were met. Therefore, the status of the Review changed and in response the SILP process has been reviewed to ensure that it has been rigorous and the Overview Report received further scrutiny by the SCR Sub Group. 3.6. The Scoping Period for this SCR was agreed to be from August 2012, when Dudley Children Social Care (CSC) received the referral from another local authority CSC team in respect of the sexual abuse of Child M, to October 2014, when Child M received non-accidental injuries. 3.7. Agencies were also asked to provide brief details of any significant events and safeguarding issues prior to the Scoping Period, e.g. domestic abuse episodes, substance misuse. This material would be used to provide the background context. 3.8. Agency reports were commissioned and received from: • West Midlands Police (WMP) • Children's Social Care services, those known to have been involved with child M • Education (School) • Black Country Partnership NHS Foundation Trust: Health Visiting and School Health Services • The Dudley Group NHS Foundation Trust (Acute Hospital) • Clinical Commissioning Group: General Practitioner 3.9. The SILP Learning Event was held on 7 January 2016 and the Recall Day on 11 February 2016. All the Agency Reports were shared with the participants prior to the Learning Event, so that they had a wider understanding of agencies’ involvement. The draft Overview Report was circulated to participants prior to the Recall Day, in order that it could be checked for accuracy and the findings and recommendations fully discussed on the Day. The Overview Report was amended following this discussion. 3.10. The Learning Event was attended by practitioners, managers and Agency Report Authors from the Police, the NHS Foundation Trusts, the Clinical Commissioning Group and 2 Working Together 2015, DOE 5 Children’s Social Care. It was positive that the Lead GP from the family’s Practice and the Named GP attended, as well as the Deputy Head and Head Teacher. The LSCB Business Manager and Child Death Overview Panel (CDOP) Co-ordinator were also in attendance. Representation at the Recall Event included the Police, the Clinical Commissioning Group (CCG), the NHS Foundation Trusts, the GP Surgery, the School and staff from the DSCB Business Unit. 3.11. CSC was unable to provide representation at the Recall Day. This was significant as CSC could not contribute to the multi-agency discussions in respect of the learning and recommendations from the SCR. 3.12. The Lead Reviewer for this Serious Case Review was Adrienne Plunkett; a qualified Social Worker, with a MA in Child Studies. Ms Plunkett has substantial experience working in the area of CSC, including as a Senior Manager, and has managed a LSCB. Ms Plunkett is a trained SILP Lead Reviewer. 3.13. In the Overview Report the names of family members have been anonimised 4. Background to the Serious Case Review: 4.1. This SCR concerns Child M, who as a child suffered serious physical injuries, inflicted by Mother and her partner, who were both convicted of criminal offences in relation to this assault. Child M did not sustain any long term physical or mental impairment as a result of the assault, although she has suffered emotional harm. 4.2. Child M and mother had been known to a range of agencies during Child M’s life and were first referred to Dudley CSC in July 2012, following the alleged sexual abuse of Child M by a family member. AM has a significant criminal history and had been released from prison in June 2014, having served a three-year sentence for supplying Class A drugs. At the time of Child M’s injuries an assessment was underway by Children’s Social Care into the risk posed to Child M by AM joining the family. 4.3. Child M is described as a bright and lively child, who has good communication skills, and progress at school is good. 5. Engagement with the family: 5.1. The aim of meeting with family members is to ascertain their views of the services offered and whether there are any lessons to be learnt. Contact with Child M’s Mother and Father was facilitated by the Dudley CSC Social Worker. 5.2. Mother agreed to meet with the Lead Reviewer in January 2016, however, subsequently cancelled this. A follow up letter was sent, suggesting that she could write or phone the Lead Reviewer or speak to her Social Worker, who could then pass on the information to the Reviewer. No response was received. 5.3. Father also agreed to the Lead Reviewer making contact with him. Attempts were made to contact him by phone, which were unsuccessful. A follow up letter was sent asking him to make contact with the Lead Reviewer, but no response was received. 5.4. Both parents were again contacted following the decision to change the status of the review to a SCR and offered the opportunity to meet with the Independent Reviewer. No response was received. 6 5.5. During the Review process consideration was given as to whether the views of Child M should be directly sought. The view of the practitioners working with Child M at the time was that this would be emotionally difficult and could well be confusing for Child M to comprehend. Therefore, a decision was taken not to approach Child M directly, but to ensure that the Overview Report provided full information about what Child M was telling the multi-agency network, both directly and through presentation and behaviour about life, so Child M’s voice would be heard through this. 6. Pre-Scoping Period: 6.1. Child M, Mother, and AM, had been known to a range of agencies for many years prior to the Scoping Period of this SCR. 6.2. Child M’s Mother had a disruptive childhood, with parental alcohol and mental health difficulties and allegations of inter-generational sexual abuse. Mother’s younger siblings were the subjects of Child Protection Plans. As a child, Mother was referred to Child and Adolescent Mental Health Services (CAMHS). 6.3. Mother has a history of difficulties in her personal relationships, which are characterised by domestic abuse. Medical information indicates that she had emotional/mental health problems, with low mood and depression. In November 2010, the Health Visitor noted that Mother’s score on the Edinburgh Post Natal Depression Scale was indicative of depression. A year later Mother attended the GP. She presented as depressed and agoraphobic and was commenced on an antidepressant. 6.4. Health Visiting records indicate that Mother bonded well with Child M after birth. However, in June 2011, whilst Child M and Mother were living in outside of Dudley, the Maternal Gran Mother (MGM) expressed concern to the Health Visitor about Mother’s care of Child M and alleged physical and verbal abuse. The Health Visitor referred the matter to Children’s Social Care and a Strategy Discussion was held between the Police and CSC in the area. However, the outcome is not known, despite several requests for the information. 6.5. Allegations of sexual abuse of Child M were made by Mother and MGM in December 2010. This was investigated, but no evidence was identified and the investigation proved inconclusive. At the time, Mother reported Child M had a poor appetite, difficulty sleeping, and was wary of male figures. 6.6. Mother’s partner, AM, also had a disruptive childhood and was the subject of a Child Protection Conference as a teenager. He has a substantial criminal record, many of the crimes being drug related. In June 2014, AM was released from Prison, having served a 3-year sentence for the distribution of Class A drugs. He had been released earlier on licence, but was recalled to Prison due to breaching his conditions, and a release planned for November 2013 was withdrawn due to a deterioration in his behaviour. 6.7. In 2005 AM, had been charged with Abstracting Electricity and Assaults on his then partner and her 3-year old child. At Court, he pleaded guilty to Abstracting Electricity. The CPS view was that it was not in the public interest to pursue the assault charges and offered no evidence. The letter to the victim explained that, as AM had been sentenced to two and a half years’ imprisonment for Abstracting Electricity, and the maximum period of imprisonment in relation to the assault charges would be six months, it was not in the public interest to pursue the assault charges as any additional sentence would run concurrently with the already imposed sentence. 7 7. Scoping Period: Key Episodes 7.1. Referral to Dudley CSC in respect of Child M’s alleged sexual abuse: 7.1.1. The CSC service from another Local Authority area referred Child M and the family to Dudley CSC in August 2012. The referral was made by phone and there is no evidence it was followed up in writing. Child M and mother were living in Dudley and the wider maternal family were in another area. The MGM had reported to the local CSC that Child M had been sexually abused by a family member. It was noted that Child M’s mother ‘wanted to minimise’ the incident. Child M’s relative had been abused by a family member and had emotional and behavioural difficulties. 7.1.2. Attempts were made to obtain further information from the referring CSC, notably to establish whether Section 47 enquiries had been undertaken and, if so, what the outcome was. Further information was provided during telephone calls, but a letter sent to the area CSC by the Team Manager early in September, did not receive a response. The Team Manager also contacted the area Police Protection Unit. They had no further information about the allegation, although they did have information about allegations of domestic abuse made by Mother against Child M’s Father and a subsequent partner. 7.1.3. In mid-August Mother attended the GP. She reported twelve months of low mood and anxiety. She was having occasional thoughts of self-harm and suicide, but would not act on these for the sake of her child. Mother had been prescribed medication previously, but had not taken this. It was agreed she should do so and counselling was discussed. 7.1.4. Three weeks after the out of city referral was received, a decision was taken by Dudley CSC to invite Child M’s mother to the office to assess her ability to safeguard Child M. Having cancelled two appointments, she was seen early in September. Mother explained that she was not happy to visit her family, as she could not supervise Child M adequately. Advice was provided regarding supervising Child M and a referral made to the Children’s Centre for Keep Safe work. 7.1.5. The decision to undertake an Initial Assessment was taken on 5 September, which was allocated on 12 September, with a home visit being undertaken on 21 September. Mother had moved to Dudley to make a ‘fresh start’. She was in a new relationship with a male she had met on Facebook 7 years previously. There had been court proceedings in respect of Child M’s contact with father and this was to be supervised. It was not recorded whether Child M was seen by the Social Worker on this visit. However, it is recorded that Child M was seen a week later (7 weeks after the referral was received) and presented as a ‘happy, chatty and confident child’. The Nursery reported that Child M’s ‘speech and language are excellent and Child M is always well presented.’ 7.1.6. Further information was obtained that an assessment was undertaken by another local authority CSC in November 2011 due to concerns about the relationship between Child M’s Parents. Father had mental health needs and Mother alleged that he had subjected her to domestic abuse and abused Child M. Mother was believed to be agoraphobic and had previously taken anti-depressants. The allegations were investigated, but proved inconclusive, although Child M’s contact with Father was to be supervised. 8 7.1.7. The Initial Assessment was completed by Dudley CSC on 17 October 2012 and the case closed on 9 November 2012. The assessment concluded that Child M and Mother had a positive relationship and Mother was viewed as protective. It was noted that Child M had a good relationship with Mother’s partner, although there is little evidence to support this assertion. Child M had an awareness of the domestic abuse between parents and was due to have supervised contact with father. CSC has no record of the Health Visitor or GP being contacted, although Health Visiting records would indicate that there was contact. The position regarding the investigation undertaken by the other area CSC remained unknown. 7.1.8. At the SILP Recall Day previously unknown information was provided by the GP. Mother had taken Child M to a GP appointment in June 2012, due to symptoms which could be indicative of sexual abuse. Oral antibiotics were prescribed and when Child M was seen a week later there was an improvement. This was a week after Child M had been registered as a new patient with the GP Practice, so when seen, the medical records were not available to the GP. If CSC had contacted the GP whilst undertaking the Initial Assessment, helpful safeguarding information would have been shared by both agencies. 7.1.9. The Health Visitor attempted to visit Child M and Mother through October and November 2012, but was unsuccessful. This was achieved early in December. Child M was observed to be clean and appropriately dressed. Child M was sociable, with good language skills and played with age-appropriate toys. Mother was planning for her current partner to move in, as he provided her main support. The Health Visitor advised regarding Mother’s responsibility to keep Child M safe and to consider this carefully. A plan was made to review Child M in Clinic, but Mother did not attend as arranged. 7.2. A Referral to Dudley CSC from out of area Hospital: 7.2.1. At the end of January 2013 Dudley CSC received information from a hospital in another local area that Child M’s father was in hospital. The Duty Team Manager took the decision that, as there was no evidence that Child M was having contact with her father, no further action would be taken. 7.3. Referral from Child M’s GP to Dudley CSC: 7.3.1. In January 2014 Child M attended the GP Surgery with Mother having complained of abdominal pains for several months, although Child M was eating and drinking well. Child M told the GP about the sexual abuse by a family member. The GP noted that Child M had recounted this ‘slowly and clearly’ and that Child M presented as ‘alert and happy’, apart from when recollecting what had happened. 7.3.2. The same day the GP contacted West Midlands Police to report the allegation of sexual abuse (101) and was advised to inform CSC. The Call Handler recorded this call on ‘E-Notes’, noting that the Public Protection Unit were aware. However, there is no record in PPU, which raises the question as to whether the PPU was notified, but it was not recorded, or the PPU was not notified. The Call Handler should have added a log on Oasis and identified the Officer spoken to and has been advised regarding this matter. The Call Handler phoned the GP, but the Surgery was closed and no further contact was made. 7.3.3. The GP made a referral to CSC by phone, requesting support for Child M 7.3.4. Mother contacted the Police two days later (at 04.03 a.m.), stating that Child M had made a disclosure of sexual assault two years previously. The matter was passed to the Child 9 Abuse Investigation Unit (CAIU) and Detective Constable 1 visited the Mother the same day. She was advised that West Midlands Police would undertake the initial investigation, but overall responsibility was with the Police area where the incident took place. 7.3.5. The GP received no feedback from CSC in respect of the referral and phoned the Duty Team on 20 January, but could not get through, so sent a letter outlining the concerns. The GP also wrote to the Consultant Paediatrician on 20 January outlining that Child M had been seen ‘on multiple occasions with abdominal pain’ and had now disclosed sexual abuse. It was unclear why the GP sent this letter and what, if anything, was being requested, so an Administrator sought clarification from the Police regarding this. 7.3.6. A Strategy Discussion was held on 20 January which agreed that the Police would undertake a single agency investigation. Health agencies were not involved in this discussion. An Achieving Best Evidence interview was undertaken and Child M made the same disclosure to the Police Officers as that made to the GP. Papers were forwarded to the investigating Police Force area. There was consideration of a medical being undertaken, but a decision was taken not to pursue this, without seeking medical advice. 7.3.7. CSC did not open the case for an Initial Assessment and neither Child M, or Mother were seen. Neither the School, Health Visitor, or School Nurse were informed of the referral. In November 2013, Mother had returned the screening questionnaire to the School Health Service detailing that she had concern about Child M following contact with Father. No action was taken in respect of this. 7.3.8. CSC closed the case on 13 February. There is no evidence that the GP’s request for support for Child M was considered or acted upon, or that the GP received any feedback in respect of the referral. In addition, there is no evidence that following the actions on 20 January the GP followed this up with CSC. 7.3.9. Also in January 2014 Mother was seen by the GP regarding depression. She had previously attended the GP in December 2013 as she was feeling low. A Biopsychosocial Assessment had indicated severe depression and she was prescribed anti-depressants. She had been taking these and was feeling a bit better, but experienced social anxiety and was reluctant to go out. Mother was to be referred for counselling and to continue with her medication. This information was not shared with health colleagues or other agencies. 7.4. GP’s referral to CSC in respect of AM living with Child M and her Mother. 7.4.1. AM was released from Prison in June 2014, having served a three-year sentence for supplying Class A drugs. He had been released on licence earlier, but was recalled due to breaching his licence conditions. As he had served the full sentence, he was not on licence on release. Within a few days, Police received intelligence that AM was using heroin and dealing in drugs outside the hostel where he was living. 7.4.2. On 17 July 2014 CSC received a telephone call from the Health Exchange GP (Practice for Homeless) expressing concern that AM had moved in with Child M and her Mother. There were concerns that he was a known drug user and had recently been released from prison, having served a five-year sentence for the distribution of Class A drugs. CSC do not have a record of the GP sharing any information about AM’s mental health history. 7.4.3. The Duty Social Worker pulled together information from CSC’s records, including that in 1999 AM had been the subject of a Child Protection Conference, in 2002 he was convicted of the robbery of two victims aged 16 years and in 2005 had been charged with assault on 10 his partner and her son, aged under 3 years. The Duty Social Worker recommended that an assessment was required due to ‘Child M’s vulnerabilities and concerns in respect of AM’. Four weeks later the case was allocated to Social Worker 2 for an Initial Assessment. 7.4.4. Mother attended a GP appointment on 23 July. She was living alone, without support from her family. She was tearful and had suicidal ideations, but would not act on these because of having Child M. Mother admitted to smoking cannabis, as she could not afford alcohol. Mother had been taking anti-depressant medication intermittently since 2013. This was continued and in addition she was to be referred for counselling. GP records note an earlier attendance in May 2014, when Mother stated she had been intoxicated and had fallen down the stairs, sustaining rib injuries. She was prescribed anti-inflammatory medication and X-rays were arranged. Domestic abuse was not considered and neither incident was discussed with the Safeguarding Lead in the GP Practice or referred to CSC. 7.4.5. Social Worker 2 contacted Probation at the end of July. The Probation Officer expressed ‘extreme concern’ about AM living in a household with children and advised that the Social Worker should not visit alone as he can become aggressive. The Probation Officer also advised that AM had a Police Sex Offender Manager. The same day the Police Offender Manager 1 (POM1) contacted CSC and advised that, as AM had served his entire sentence, he was not supervised by Probation. According to CSC’s records, POM1 confirmed that AM had been convicted of an assault on an under 3-year old. This was not correct, as AM had been charged but not convicted, so either inaccurate information was provided by the Police or it had been misunderstood, or incorrectly recorded. 7.4.6. Social Worker 2 and a colleague undertook a home visit, but no one was at home. This was followed by another home visit, two weeks later, when Child M and Mother were seen. Mother was defensive, denied that AM was living at the address, despite AM telling his GP that he was, and stated that he should be allowed to move on with his life. Child M was seen alone by the Social Workers and showed them drawings, included one drawn of Mum and Dad. Mother confirmed that Child M referred to AM as ‘Dad’ and this was allowed as Child M often became upset that other children at school had a Daddy and Child M did not. It was recorded that there was no physical evidence that AM was living in the home, but clearly the information provided by Child M meant that Mother’s assurance that AM was not living in the family home was open to challenge. 7.4.7. There is a note in Police records on 1 August 2014 that AM was being managed by WMP Offender Managers as a Prolific Priority Offender (PPO). He was not required to meet any conditions and co-operation was on a voluntary basis. Police were monitoring intelligence. 7.4.8. Mother failed to attend the rearranged counselling appointment early in August and on 18 August she saw the GP again. She was feeling low in mood and requested a further referral for counselling. 7.4.9. AM registered with the same GP as Mother and Child M on 14 August. (Same day as the Social Workers’ visit to the home.) He gave his home address as that of Child M and Mother, and gave Mother as his next-of-kin. The next day he phoned and requested medication for his ‘personality disorder’, which he stated led to aggression. He was advised that he should make an appointment to discuss his mental health needs and was seen by a GP on 18 August. It was agreed that he would be referred to mental health services and mood stabilising medication was prescribed by the GP. The referral was not made by the GP until 4 weeks later. This stated that AM had an anti-social personality 11 disorder and had been known to the Mental Health Team whilst in prison. There had been no recent incidents, but AM was requesting mental health follow up. 7.4.10. On 19 August, the Police received a 999 call from a neighbour, reporting a disorder at the family’s address. Some people had arrived, there was ‘shouting and swearing’ and it sounded like ‘they are smashing the house to bits’. The neighbour noted that there was a child and puppy in the home. Uniformed Police Officers attended and Mother was found to have a head injury. She stated she had fallen over the puppy and hit her head on the corner of a wall, and was taken to hospital for treatment. Mother’s explanation was accepted and no further inquiries were made, e.g. with neighbours. There appears to have been no consideration of the possibility of domestic abuse or of a referral to the Domestic Abuse Referral Team (DART). Police records do not indicate whether AM was in the home or whether Child M was seen. Children’s Social Care was not informed of this incident. 7.4.11. Unrelated to the above incident, the following day Social Worker 2 contacted Police Offender Manager 1 (POM1) regarding the concerns about Mother’s partner. Information was shared about AM’s criminal history. This telephone call is recorded in the Police records, but not in Children’s Social Care’s records. There was a further discussion between Social Worker 2 and Police Offender Manager 2 (POM2) on 21 August, when POM2 agreed to undertake checks and conduct a home visit. POM2 recorded that the information shared by CSC would suggest that the relationship between Mother and AM was more than she was declaring it to be. 7.4.12. On 29 August POM2 checked with the Hostel where AM had been living following his release and was informed he had left just days after his release. POM2 also contacted his Drug Worker and was informed that AM had failed to attend appointments and was not in receipt of a methadone script, despite being on a drug rehabilitation programme. 7.4.13. On the same day, the Police received two phone calls. The first caller alleged that AM and another male were trying to gain access to a flat. Police attended, but there was no trace of the men. The second caller alleged that AM and Child M’s Mother were selling drugs on the High Street. Again, Police attended but there was no trace. No further action was taken. 7.4.14. POM 2 and 3 visited the family home early in September, but no-one was at home. A card was left, asking AM to make contact, which he did. He confirmed he was living with his new partner who was pregnant. He was drug free and did not require support. 7.4.15. AM was discussed at the One Day One Conversation (ODOC) meeting, involving Probation and Police, on 8 September. Police reported that AM was living with a new partner, who was pregnant. As AM had not accessed, and was not requesting, any support it was agreed to begin the process of deregistering him from the Prolific and Priority Offenders scheme. He would then be managed by the WMP’s High Offender Management Team. There is no evidence that a risk assessment was undertaken. 7.4.16. Mother failed to attend the second counselling appointment on 9 September. 7.4.17. On 11 September, a week after AM’s telephone call, POM2 confirmed with CSC that AM was living with Mother, who was pregnant, and that his case was being closed as he did not want any support from the Unit. Social Worker 2 was on leave and this information was passed to the Assistant Team Manager. There is no record of what action was then taken. 12 7.4.18. Child M was absent from school on Friday, 12 September. No reason was given for this, which was unusual. 7.4.19. On 13 September, at 10.34 p.m., the Police received a phone call from AM, who reported that a drunken male had attacked his pregnant girlfriend. Police attended and this involved an incident with a relative of Mother’s previous partner, who AM alleged had chased them with a knife. Subsequently the Police tried several times to obtain statements, but were unsuccessful and the case was closed. As this incident involved the family of an ex-intimate partner, a referral should have been made to the Domestic Abuse Referral Team (DART), but was not. It is understood that Child M was present during the incident, but there is no reference to Child M’s wellbeing in Police records. CSC was not informed. 7.4.20. AM attended an appointment with his GP on 17 September. He was feeling stressed, as ‘his life was not going according to plan’, although he said his relationship was okay. 7.4.21. On 23 September, 5 weeks after the last contact, CSC sent Mother and Step-father (AM) a letter inviting them to the office on 30 September. On the same day, Social Worker 2 informed Police Offender Manager 3 that a child protection investigation was being initiated, with a view to convening an Initial Child Protection Conference. Mother and AM did not attend the appointment with CSC. 7.4.22. AM again attended an appointment with his GP (same GP) on 24 September. He was wanting to be seen by Mental Health Services and was very anxious about having to wait. 7.4.23. Child M was unwell at school on 25 September and there were difficulties contacting Mother. School staff had become increasingly concerned about Child M’s care this term, including not always in the correct uniform nor regularly bring a book bag and, Child M’s hair was not always brushed and the clothes worn were creased. In addition, staff and parents were ‘not comfortable’ with Mother’s new partner, who sometimes came to collect Child M. This was ‘a professional hunch’. Child M’s class teacher was ‘monitoring’ the situation. 7.4.24. On 30 September CSC contacted Child M’s school to inform them of the concerns regarding Mother’s new partner. CSC’s records note that the school were already aware of AM. Child M was looking dishevelled at school, and there were incidents of unexplained absence. Child M appeared to be concerned about the family’s puppy. The school had concerns about AM, he was seen as intimidating and had been aggressive to other parents. He was taking and collecting Child M from school. 7.4.25. Social Worker 2 and the Assistant Team Manager undertook an unannounced visit early in October. AM was present and stated he had moved in three weeks earlier. He presented as polite and compliant, wanting to work with CSC. Child M’s Mother was 10 weeks pregnant. This visit, and the subsequent discussion between Social Worker 2 and the Assistant Team Manager, was not recorded until 28 October (3 weeks following the visit and after the assault on Child M) and is not detailed. It notes that there was a subsequent discussion between Social Worker 2 and the Assistant Team Manager as to whether AM should be asked to leave the family home whilst an assessment was undertaken. The Assistant Team Manager was to discuss this further with the Team Manager, however, there is no evidence that such a discussion took place 13 7.4.26. Mother and AM presented at DMBC as homeless on 7 October. They were facing eviction due to rent arrears. Housing advice was given, followed by a further interview to collect information. 7.4.27. AM was assessed by the Consultant Psychiatrist (locum) on 13 October, two months after the initial GP appointment. The Consultant’s outcome letter was received by the GP Surgery one month later. It did not contain a risk assessment. 7.4.28. AM had informed the Consultant Psychiatrist that he had been in and out of prison for 13 years, his offences included burglary and armed robbery and many were drug related. He had been using drugs for many years and was currently using heroin. He stated he had previously consumed large quantities of alcohol, but was currently not drinking. As a child, he had been referred to CAMHS due to family problems. AM said he was happy, but became irritable over trivial issues and often got into fights. He spoke about a ‘red line’ which if crossed led him to become violent. AM currently had a partner, who had a young child and was 15 weeks pregnant. This baby would be AM’s fourth child. He wanted help to amend his ways, so that he could be a good father. 7.4.29. In the assessment letter to the GP, the Consultant Psychiatrist identified no evidence of psychosis or depression. There was no clinical evidence of a deterioration in AM’s mental state, with mood assessed as stable and no evidence of any risk in relation to his mental health. As AM did not have a treatable illness, requiring mental health services, the Consultant discharged him to the care of his GP and recommended counselling. There is no evidence that the welfare and safety of Child M or the unborn child were considered by the Consultant Psychiatrist, nor that the Trust’s Safeguarding Lead was contacted for advice or CSC informed. 7.4.30. On the same day, Child M was not collected from school on time. A message was sent to Mother, but no response received. Child M was placed in Out of School Care and collected at 5.33 p.m. The reason for the late collection is not known. Also, in October the School Site Manager had reason to speak to Mother and AM about smoking and bringing a puppy on to the school site and this was being monitored. The puppy subsequently disappeared. Child M worried about the puppy and school staff felt this played on Child M’s mind. 7.4.31. The Team Manager recorded the decision to proceed to Section 47 enquiries on 14 October and on 15 October a referral was made to the Public Protection Unit via email. In response, the Tactical Co-ordination Group undertook intelligence checks, which identified that AM had a significant crime record and had previously been charged with an assault a three-year old child, but was not convicted. Subsequently on 16, 17 and 20 October the Police phoned and left messages for the Team Manager about arranging the Strategy Discussion. The Team Manager did not return the calls and on 20 October, the Detective Sergeant recorded that staff ‘do not have the capacity or time to continually chase up partners’ and that the matter ‘will be filed until such time as the matter is followed up by them (CSC)’. 7.4.32. Mother and AM attended an antenatal appointment in mid-October. AM disclosed that he had a ‘violent personality disorder’. The Midwife was highly experienced, but felt worried by his behaviour. She referred the family to the Duty Team, CSC, on the same day, following this up with a written referral. The Midwife also informed the GP that the family were known to CSC and the GP added a safeguarding alert to Child M’s records. 14 7.4.33. The Duty Social Worker contacted Social Worker 2 who advised that the information should be passed to the Team Manager, who was arranging a Strategy Discussion. There is no evidence that this information was acted upon. 7.4.34. AM attended an appointment with his GP on 20 October, the day of the assault of Child M. He reported feeling stressed and extremely anxious and felt that he was ‘spiralling out of control’. He was worried about the threat of eviction; a letter of support to Housing was provided and he was advised to contact the Citizens Advice Bureau (CAB). There is no evidence that consideration was given to the impact of his mental health on the family or that this information was shared with any other health practitioners or agencies. 7.4.35. The school reported to the Duty Social Worker that there had been further late collections of Child M and requested that these were logged. 7.4.36. Later on 20 October, at 21.05 p.m., the family’s neighbour attended the local Police Station. He was extremely upset, refused to speak to the Officer on the front desk and demanded to speak to an Officer from the Child Abuse Investigation Unit. He reported that, between 19.30 and 20.00 p.m., he had heard a child being shouted and sworn at and physically assaulted. He had recorded this on his phone. The neighbour stated that this was not the first time he had heard such things. He was concerned for his own safety, but felt that he could not ignore what was going on. Uniformed Officers were dispatched immediately and attended the home at 22.29 p.m. 7.4.37. The Officers found Child M sleeping on a bare mattress in a sparsely furnished room and had extensive bruising. Police Powers of Protection were assumed and Child M was taken by ambulance to hospital. 7.4.38. On examination Child M had multiple bruises and scratches. Child M told the Consultant Paediatrician of being woken by Mum and Dad and made to go into the shower due to being naughty at school. Some of the injuries were thought to be caused by the forceful impact from a hard object, such as a shower head. Prior to the photography of the injuries, Child M expressed fear of getting in to trouble if Dad saw the photos. 7.4.39. Mother and partner were arrested and charged with the ill-treatment of a child. They were convicted and received custodial sentences. Child M and the unborn baby became the subject of Care Proceedings by the Local Authority. Mother has served her sentence and been released from custody. AM was released in March 2016 and will be supervised by the Probation Service, with certain licence conditions, until April 2017. 7.4.40. Subsequent information provided by Child M indicates that there had been a physically and emotionally abusive ‘punishment regime’ in place in the family home. Previously when Social Workers had visited, Child M had a bedroom that was appropriate for Child M’s age. At the time of the injuries Child M was sleeping in another bedroom and all toys had been removed. 8. ANALYSIS: Terms of Reference: The Analysis section of the Serious Case Review is shaped by the Terms of Reference, but includes further issues identified through the Learning and Recall Events. It will consider the information above, gained from the Agency Reports and discussions at the Events. The Analysis leads to the lessons from this Review and recommendations for Dudley 15 Safeguarding Children Board. It is important to guard against hindsight in drawing conclusions and to bear in mind the context that practitioners were working in at this time. 8.1. Quality of information sharing, including the making of referrals: 8.1.1. The Information Sharing guidance for practitioners (DCSF, 2008)3 highlighted that Information sharing is ‘vital to safeguarding and promoting the welfare of children and young people’. It encouraged practitioners, from all agencies, to remember that ‘there can be significant consequences to not sharing information, as there can be to sharing information’. The guidance made it clear that practitioners must use professional judgement to decide whether to share or not, and what information was appropriate to share. The Government’s revised advice for practitioners on information sharing4 highlighted that a key factor identified in many serious case reviews (SCRs) has been a failure by practitioners to record information, share it, understand its significance and then take appropriate action 8.1.2. Evidence submitted for the Serious Case Review indicates that in the main this case is characterised by poor information sharing between agencies and the significance of information was not always understood and acted upon. 8.1.3. There are some examples of timely information sharing, but also examples of when agencies should have contacted Children’s Social Care to alert the agency to their concerns. Dudley CSC did not appropriately seek information in a timely way and agencies did not proactively share information. A number of agencies had highly relevant information, but this was never pulled together to give a full picture of the family history and current circumstances, and of the immediate and significant risks to Child M. 8.1.4. There are three examples of timely information sharing: • The GP promptly contacted both the Police and CSC in January 2014 following her discussion with Child M in respect of the alleged sexual abuse. • In July 2014, when the GP learnt that AM had joined the family, he/she applied ‘think family’ principles, recognised the potential risk to Child M and informed CSC. • When AM attended the ante-natal appointment in October 2014, the Midwife was concerned by his presentation, and the potential risk to Child M and the unborn baby, and referred the matter to CSC on the same day 8.1.5. An Initial Assessment was undertaken by Dudley CSC in 2012 following the referral from the CSC team from another local authority are concerning the alleged sexual abuse of Child M. The referral lacked crucial information, e.g. regarding Section 47 enquiries, and the Social Worker and Team Manager tried hard to obtain this, but were unable to do so. The Assessment was completed and the case closed without contacting the family’s GP. 8.1.6. Following the referral from the GP in July 2014, informing CSC that AM had moved in with the family, there was a delay in undertaking the assessment and it was not completed by the time of the injuries to Child M in October, i.e. three months later. The information received from the Police on 11 September confirmed that AM was living with Child M and Mother and this should have triggered an immediate Strategy Meeting. However, it was not until 14 October that a decision was made to initiate child protection procedures and 3 Information Sharing: Pocket Guide, Department for Children, Schools and Families, 2008 4 Information Sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers, HM Government, March 2015. 16 convene a Strategy Meeting. This did not take place, despite a further referral from the Midwife on 15 October. Therefore, at no point did agencies come together to pool information and gain a full picture of the family’s circumstances and of the risks and protective factors. 8.1.7. The Police attended various domestic incidents concerning Mother and AM in August and September, but none of these incidents were referred to CSC. It is known that on 19 August the Police had been informed that there was a young child in the household, however, it is not apparent on the other two occasions whether Officers were aware that there was a child in the home. There is no evidence that Officers sought to ascertain Child M’s welfare on any of the occasions, nor that they accessed information available in the Police records, which would have alerted them to wider issues in the family and to AM’s criminal history. 8.1.8. Discussion at the Recall Day highlighted the significance of the superficial approach taken by the Police Officers in August and the distinct lack of professional curiosity. Mother’s explanation that her injury was caused when she tripped over the dog was taken at face value by Officers, without consideration of the nature of the report from the neighbour or further discussion with the neighbour. If this had been recognised as a potential incident of domestic abuse, then a referral would have been made to the Domestic Abuse Referral Team (DART), which would have triggered notifications to CSC and the GP Practice, where a safeguarding alert would have been added to the records of Mother, Child M and AM. This would have alerted the agency network to the potential risk posed by AM. A further opportunity to trigger a referral to DART was missed following the incident in September. 8.1.9. Both Mother and AM had a history of mental health difficulties and egularly attending their GP in respect of these. In May and July Mother disclosed concerning information about her low moods and use of alcohol and drugs. Similarly, through September and October, AM was raising concerns about his level of anxiety and on 20 October reported that his mental health was ‘spiralling out of control’. There is no evidence that the GPs considered the fact that there was a child in the family home and Mother was pregnant. The CCG Report Author notes ‘There is evidence that mother’s needs were put before those of Child M and her mental health issues were deemed to be the focus rather than the impact that these issues could have had on her ability to safely parent Child M’. There was no discussion with the Safeguarding Lead or with other health practitioners involved with the family, e.g. School Health. There is no evidence that the GPs accessed past information about the adults and it seems likely that each presentation was viewed in isolation. 8.1.10. When AM was assessed by the Consultant Psychiatrist on 14 October, he talked openly about his history of drug and alcohol issues and the time he had spent in prison. He shared his irritation over trivial matters and the ‘red line’, beyond which he became violent. The assessment letter was not sent to the GP until November and it appears no consideration was given to the immediate risk AM might pose to himself and others. 8.1.11. The General Medical Council’s short guide, Protecting children and young people5, highlights that ‘all doctors have a duty to act if they think a child or young person is at risk of abuse or neglect, even if they don’t routinely see them as patients.’ Further that ‘Doctors who treat adults must be alert to the possibility that their patient poses a risk to a child or young person, and know how to act on such concerns. There is no evidence that 5 Protecting children and young people, short guide for doctor who treat adult patients, GMC, 2012 17 the doctors in Dudley who dealt with Child M’s Mother and AM were working to this guidance. 8.1.12. The School became concerned about Child M’s presentation after the summer holidays in the Autumn Term 2014. Staff were also concerned by the presentation of Mother’s new partner and they were ‘monitoring the situation closely’. There is a question for the school about how long they would have monitored the situation before seeking advice from the Education Safeguarding Lead or contacting CSC. At the Learning Event school staff expressed the view that their concerns would not have been considered sufficiently serious by CSC. However, it is important to be mindful of the fact that each agency will have certain information and it is only when the information from all agencies is pulled together that the full picture is obtained. Also ‘monitoring’ on its own does not safeguard children. An agency must be very clear what they are monitoring and why and what action they intend to take and when. 8.1.13. The Government’s information sharing advice makes it clear that ‘No practitioner should assume that someone else will pass on information which may be critical to keeping a child safe. If a practitioner has concerns about a child’s welfare, or believes they are at risk of harm, they should share the information with the local authority children’s social care,6 8.1.14. Lord Laming emphasised that the safety and welfare of children is of paramount importance and highlighted the importance of practitioners feeling confident about when and how information can be legally shared. He recommended that all staff in every service, from frontline practitioners to managers in statutory services and the voluntary sector should understand the circumstances in which they may lawfully share information, and that it is in the public interest to prioritise the safety and welfare of children. 7 8.1.15. As outlined above, a number of agencies, including the GP, Consultant Psychiatrist and Police, had information which should have been shared urgently with CSC but was not. This indicates a failure by agencies to fulfil their safeguarding responsibilities and a lack of focus on Child M’s welfare and safety. Child M was invisible. Practitioners failed to demonstrate professional curiosity. Additionally, when CSC was provided with information, they failed to respond to this in a timely way and to seek further information from agencies. 8.2. How well did practitioners recognise and understand the complexity of factors contributing to the risk to the child, including the family history and neglect, substance misuse and sexual and domestic abuse (Mental Health)? ‘Assessment should be a dynamic process, which analyses and responds to the changing nature and level of need and/or risk faced by the child.’8 8.2.1. The importance of timely, good quality, robust risk assessments cannot be overstated. Assessments should inform the planning and interventions with a family. Working Together to Safeguard Children, 2015,9 states that the aims of assessment are ‘to use all the information to identify difficulties and risk factors as well as developing a picture of strengths and protective factors’. It is apparent through Agency Reports and discussion at 6 Information Sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers. HM Government, March 2015 7 The protection of children in England: A progress report. DCSF March 2009. 8 Working Together to Safeguard Children, DFE, 2015 9 Working Together to Safeguard Children, DFE, 2015 18 the Learning Event that there was a paucity of timely and good quality assessments in this case, which considered the significant changes in the family’s circumstances. 8.2.2. CSC completed an Initial Assessment following the referral in July 2012. However, the CSC Report Author considers that this ‘lacks depth and is adult focused. It pays little attention to the impact issues of domestic abuse, sexual abuse, parental mental health and parental instability will have had on Child M. There is no attempt to contact Child M’s father, who has parental responsibility, to seek his views.’ 8.2.3. CSC did not undertake an assessment following the referral from the GP in January 2014 which requested support for Child M, who was displaying distress in relation to the sexual abuse. Child M and Mother were not seen. There was no assessment of Child M’s emotional and developmental needs and there was no consideration toward the need of support or counselling, despite the request from the GP. 8.2.4. Following the referral from the GP in July 2014, informing CSC that AM had moved in with the family, there was a delay in undertaking the assessment and it was not completed by the time of the injuries to Child M in October, i.e. three months later. A decision was made on 14 October to initiate child protection procedures and convene a Strategy Discussion/Meeting, but this did not take place. Hence, an Initial Child Protection Conference was not triggered. Therefore, at no point did agencies come together to pool information and pull together a full picture of the family’s circumstances and hence the risks to Child M and any protective factors. A chronology was not compiled, which would have assisted in identifying any patterns, e.g. with Mother’s partners. Actions are characterised by a lack of urgency and timeliness. 8.2.5. There is no evidence that the Police (and Probation) undertook risk assessments. When Police Officers attended the domestic incident in August they accepted Mother’s account of how she sustained her injury, displaying no professional curiosity. There was no consideration of whether this could be an incident of domestic abuse and hence a referral was not made to the Domestic Abuse Referral Team, which would have undertaken an assessment of risk. 8.2.6. At the One Day One Conversation Meeting, attended by Police and Probation, the decision was taken to begin the process to deregister AM from the Prolific and Priority Officers scheme. Officers were aware of AM’s family circumstances, however, there was no consideration of the risk he posed to Child M and the unborn baby and no follow up action agreed in terms of liaison with CSC regarding this. 8.2.7. Both Mother and AM were regularly attending appointments with their GP and expressing concerns about their mental health. It is understood that AM saw the same GP on four or five occasions, including on the day of the injuries to Child M. However, it does not appear that consideration was given to the impact of the adults’ difficulties on their parenting capacity. The local GPs did not ‘think family’. Similarly, there is no evidence that the Consultant Psychiatrist undertook an assessment of the risk AM posed to himself or others. 8.2.8. In the course of the Serious Case Review a number of historical and current factors have been identified which contributed to the risk to Child M, as well as to the unborn child. Risks were heightened by the combination of risk factors present. There is no evidence that practitioners fully recognised the serious risks or acted upon them. 8.2.9. The risks identified include: 19 • Mother’s dysfunctional family background, including intergenerational sexual abuse. • Mother’s long-standing history of emotional/mental health difficulties. • Mother’s pattern of abusive relationships. • Allegation by MGM that Mother had behaved in an abusive manner to Child M. • Child M’s abuse by a family member. • AM’s childhood history. • AM’s criminal history, including drug offences. • AM’s mental health – anti-social personality disorder. • AM’s charge of assault on the three-year old child of a previous partner. • Probation Officer expressed extreme concern about AM living in a family with children • Mother’s lack of compliance and lack of honesty about her relationship with AM. • Deterioration in Child M’s care observed by School in the Autumn Term 2014. • Police attended three incidents between August and October 2014, in two there were indications of domestic abuse. • Deterioration in the mental health of Mother and AM. • Mother’s use of alcohol and drugs (cannabis). • AM’s continued use of heroin. • Threat of eviction, due to rent arrears. 8.2.10. Cleaver, Unell and Aldgate10 stress that ‘while caution is needed in making assumptions about the impact on children of parental mental illness, problem alcohol or drug use or domestic abuse, if the issues coexist the risk to the children increases considerably. There is substantial independent evidence from research into both parental mental illness and problem alcohol or drug use, that the combination of issues, particularly the link with domestic violence, is potentially dangerous for children.’ Evidence provided for this Serious Case Review shows that such issues coexisted in the family. 8.2.11. Records indicate that Mother was seen as protective towards Child M. However, there is minimal evidence to support this assertion. It appears that Mother had a neglectful childhood and there were attachment difficulties in her relationship with her own Mother (MGM). She had a history of emotional and mental health difficulties, with low moods and suicidal idealisation. Her intimate relationships were characterised by domestic abuse and she failed to access support offered to her in this respect. The MGM had raised concerns about Mother’s behaviour towards Child M, indicating there may have been some underlying ambivalence. Therefore, there are grounds to question whether Mother had the mental strength, and determination, to safeguard and prioritise the needs of Child M or indeed to protect herself. 8.2.12. A stark element of this Review is that Mother and AM did not conceal their difficulties. Between them they provided significant information to the GPs and Consultant Psychiatrist, which indicated that their mental health difficulties were worsening. AM commented to the Consultant Psychiatrist that there was a ‘red line’, beyond which he became violent and to the GP that he was ‘spiralling out of control’. This last comment could well be viewed as a ‘cry for help’. The Dudley CCG Agency Report Author commented that ‘The care for both Child M’s mother and AM was adult focused and did not consider that the risks to Child M’s safety were escalating with the carers deteriorating mental health’. ‘Men with antisocial 10 Children Needs – Parenting Capacity, The Impact of parental mental illness, problem alcohol and drug use and domestic violence of children’s development. Department of Health. 1999 20 personality disorder have been found to be three to five times more likely to misuse alcohol and drugs. This in itself should have led professionals to consider that Child M may be at risk of harm, particularly from someone who struggles to control his anger.’ 8.2.13. In the Beyond Blame study, Duncan and Reder 11 identified that a number of families had provided a ‘covert warning’ to practitioners. They had ‘approached professionals and communicated what was, in retrospect, a disguised admission that abuse was critically escalating’. Such warnings require professionals to translate the presentation into the risk of child abuse. Whether AM’s comments were covert warnings is worthy of consideration. 8.2.14. Duncan and Reder 12also highlighted that parents who kill children usually come from depriving, hostile or abusive backgrounds, leaving them with ‘unresolved care and control conflicts’. Care conflicts show in later life as excessive reliance on others and fear of being left by them. Control conflicts were enacted through violence, low frustration tolerance, attempts to exert control over others or intolerance of others perceived as controlling. Evidence would suggest that AM is someone with control conflict. 8.2.15. In summary, there were no single or multi-agency assessments of the family circumstances, of the parenting capacity, the child’s needs and the wider family, and practitioners did not fully recognise or understand the complexity of the factors which presented serious risks to Child M. It is true to say that there was no greater understanding of the risks and any protective factors at the point of Child M’s injuries in October, than there was at the time of the referral in July 2014, i.e. after three months. The lack of assessment and analysis of the available information by agencies, contributed to this failure. 8.3. Was the voice of the child heard, including an understanding of the child’s lived experience? ‘Seeing the world from the child’s point of view and understanding the risks of harm he or she faces, is dependent on front line staff getting to know the child.’13 8.3.1. Child M is a bright child, who was, and still is, achieving academically at an age appropriate level. There is evidence that Child M is well able to articulate what has happened and how this feels. In January 2014 Child M provided a very clear account to the GP of the abuse by a relative. This was dealt with sensitively by GP, who took appropriate action leading to the Achieving Best Evidence interview. The CAIU Officers built a rapport and understanding with which allowed Child M to disclose details of the abuse experienced. In October 2014, Child M gave a full account to the Consultant Paediatrician of what had occurred on 20 October, including expressing some anxiety about what would happen if ‘Dad’ saw the photographs of the injuries. However, in general agencies did not promote Child M’s voice or gain an understanding of the day to day lived experiences for this Child. 8.3.2. There were ways in which Child M’s presentation was giving clues to what had been happening/was happening. The anxiety about sexual abuse being repeated was manifested in abdominal pains and difficulty sleeping. Following AM joining the family Child M’s presentation at school had deteriorated and there was anxiety about the 11 Beyond Blame, Reder et al, 1993 12 Predicting Fatal Child Abuse and neglect, Reder and Duncan. Early Prediction and Prevention of Child Abuse, A Handbook. Wiley 2002. 13 Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews 2005 – 07, DCSF, 2009 21 disappearance of the family’s puppy. Child M shared drawing with the Social Worker, which included a picture drawn of Mum and Dad. This provided clear evidence that AM was spending considerable time with the family. It is highly likely that time spent alone with Child M would have provided a good picture of the day to day life, including the worries and fears and how life had changed since AM had joined the family. 8.3.3. Whilst the family were residing in Dudley, Social Workers visited the family home on just three occasions, Child M was seen and spoken to alone on two of these visits. It was not recorded whether Child M he was present on the third. No attempts were made to visit Child M at school, i.e. in a neutral environment. There is no evidence that a relationship was developed between the Social Worker and Child M. The Biennial Review of SCRs 2005 – 200714 stresses the importance of building a relationship with a child and suggests that the ‘starting point is to have a sound understanding of the children’s day to day experience of life at home, but this is not possible without first seeking to discover what the infant, child or adolescent thinks and feels, as a person, not just someone potentially at risk of harm.’ ‘Seeing the world from the child’s point of view and understanding the risks of harm he or she faces, is dependent on front line staff getting to know the child.’ 8.3.4. To some agencies, Child M appeared to be invisible, as was the unborn baby. This invisibility of children has been highlighted in many SCRs and The Biennial Analysis of SCRs 15 noted that ‘The way that children of all ages were able to slip from view was a powerful theme of this report.’ Following AM’s release from Prison, the Police were called to several incidents involving Mother and AM in August and September. There is no record as to whether Child M was seen and spoken to on these occasions and none of the incidents were referred to CSC. As described earlier the safety of Child M was not considered by the Police and Probation at the One Day One Conversation Meeting. 8.3.5. Both Mother and AM had a history of mental health difficulties and were regularly attending their GP in respect of these. In May and July, Mother disclosed concerning information about her low moods and use of alcohol and drugs. Similarly, through September and October, AM was raising concerns about his level of anxiety and on 20 October reported that his mental health was ‘spiralling out of control’. There is no evidence that the GPs considered the fact that there was a young child in the family home and Mother was pregnant. It is not difficult to picture what Child M’s lived experience would have been like living in a family with adults with such complex difficulties. 8.3.6. Ofsted’s thematic review, The Voice of the Child16, which analysed 67 SCRs undertaken between April and September 2010, found that children were not seen frequently enough by the professionals involved, were not asked about their views and feelings, and practitioners focussed too much on the needs of the parents, especially on vulnerable parents, and overlooked the implications for the child. In addition, agencies did not interpret their findings well enough to protect the child. 8.3.7. There is clear evidence that Ofsted’s findings were mirrored in this Serious Case Review. Whilst there were occasions when Child M was seen and spoken to by practitioners, this was not frequent enough, including being seen alone. Child M’s views and feelings were not obtained nor was Child M’s voice heard. The agencies which worked with the adults, 14 Understanding Serious Case Reviews and their Impact, DCSF, 2009 15 Understanding Serious Case Reviews and their Impact, DCSF, 2009. 16 The voice of the child: learning lessons from serious case reviews, 1 April to 30 September 2010. Ofsted, April 2011. 22 i.e. Police, Consultant Psychiatrist, GP, focussed very much on the adults’ difficulties, without any consideration of the implications for the welfare and safety of the child and unborn baby. In effect Child M was invisible to these agencies and the Needs of Child M were not prioritised by practitioners. 8.4. To what extent did practitioners Think Fathers? 8.4.1. The Biennial Analysis of SCRs 2005 - 200717 highlighted the ‘urgent need to consider in what ways the mother’s husband or boyfriend or partner, or lodgers or other adults living in the family, might pose a risk to the child’s safety or, conversely, act as a protective presence’. ‘Assessment and support plans tended to focus on the mother’s problems in caring for her children and paid little attention to the men in the household and the risks of harm they might pose to the children given the histories of domestic violence or allegations of or convictions for sexual abuse.’ Following on from this, Working Together 2013, Chapter 10,18 highlighted the need for agencies to ‘Think Fathers’, noting that Fathers can have a significant impact on outcomes for children and that Children’s Services can often be ‘Mother focussed’, without giving due regard to the role of the Father. 8.4.2. The Agency Reports and discussions at the Learning and Recall Events would indicate that in this case the risks posed by Mother’s partner(s) were not recognised or assessed by agencies, or acted upon. Mother had four partner during Child M’s life and these relationships were characterised by domestic abuse. However, despite Mother being seen as protective by practitioners, she did not recognise the potential risks that a new relationship posed to herself and Child M. When CSC tried to alert her to the concerns in respect of AM, Mother was keen to minimise them, and denied he was living in the family home. Mother failed to prioritise Child M’s needs and safety. 8.4.3. Natalie Valios’s article in Community Care in 200919 pulled together research into the risks posed to children by stepfathers. Overall evidence would indicate that there is ‘considerable excess risk at the hands of stepfathers’. Further that deaths caused by stepfathers tend to be rage driven, ’impulsive acts motivated by hostility towards the child and characterised by violently beating or shaking them’. Stepfathers have no genetic stake in the child and can see them as competition for attention and time and their own offspring. David Finkelhor, Director of the Crimes against Children Research Centre, concluded that these men ‘do not feel a natural affinity or protectiveness about the child of the women they are involved with. These are not men who are nurturing’. 8.4.4. Cavanagh, Dobash and Dobash 20 found that the risk was increased when stepfathers had disrupted, disadvantaged and problematic childhoods, a history of drug or alcohol abuse and offending. There was a reluctance to invest in other men’s children and they viewed the child as a nuisance. This profile would fit with AM, who is known to have had a difficult childhood, with a history of drug and alcohol abuse and persistent offending. Daly and Wilson21 compared step-fathers and genetic fathers who had killed children and concluded that they kill in a different way and for different reasons. Stepfathers were often motivated by resentment of the victim and the cause of death likely to be by beating. The 17 Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews 2005 – 07, DCSF, 2009. 18 Working Together to Safeguard Children, DFE, 2013 19 Natalie Valios, Lurking in the Shadows. Community Care, 9 April 2009 20 The Murder of Children in the Context of Child Abuse, Cavanagh, Dobash and Dobash. 2006 21 Some Differential Attributes of Lethal Assaults on Small Children by Stepfathers versus Genetic Fathers, Daly and Wilson, 1994. 23 picture of AM’s negative attitude and approach towards Child M, for example the imposition of a punishment regime, indicates that he had developed a sense of resentment towards her, which culminated in the serious physical assault. 8.4.5. Mother and AM were seen together by the Social Worker and Team Manager just once, early in October at the family home. They confirmed that AM had moved into the home and he appeared to be compliant and co-operative. Evidence would indicate that the Workers were falsely reassured by this visit, without given due consideration to the complex background information. 8.4.6. Whilst neither the Police or Probation had a supervisory role in respect of AM, as he had served his custodial sentence in full, he was well known to both these agencies. He was managed on a voluntary basis by the Police Offender Managers as a Prolific Priority Offender. However, as he was not accessing any support it was agreed at the One Day One Conversation meeting between the Police and Probation early in September that the process should commence of deregistering him from the scheme. The Police were aware that AM was living with the family and his partner was pregnant, but at this meeting there appeared to be a complete lack of consideration of the potential risks that AM could pose to Child M and the unborn baby. 8.4.7. The role of mothers in such cases has been considered by Kennedy, Consultant in Clinical and Forensic Psychology. He found these mothers tended to be depressed, overwhelmed or so distracted by their own difficulties that they do not feel able to protect their child. They were usually highly vulnerable women, who have a confused understanding of relationships. Their backgrounds were characterised by abuse and they were highly dependent on being in a relationship, even if it was dysfunctional because it provided them with security.22 Child M’s Mother’s history very much reflects this picture, a difficult childhood, abusive relationships, and a history of low moods and depression, with a failure to protect Child M, which had gone unrecognised. 8.4.8. Therefore, the evidence presented to this SCR indicates that agencies did not ‘Think Fathers’. The Daniel Pelka SCR23 highlighted the lack of understanding of ‘the role of the fathers and of other significant males in the home’ and this finding is mirrored in this Serious Case Review. Overall, there was insufficient consideration of the impact of AM spending time with the family and no recognition of the risks he was likely to pose to Child M and the unborn baby. There was no sense of urgency of the need to assess the impact of AM’s presence in the family home and to take any action deemed necessary. 8.5. How did practitioners approach challenge and/or escalation and what was their level of knowledge around the processes for these? 8.5.1. There is little evidence of challenge or the use of escalation in this Serious Case Review, though there are examples of when this should have occurred. The GP made a referral to CSC for support for Child M who was showing signs of anxiety following the alleged sexual abuse, however, this was not acted upon and the GP did not follow up with CSC or raise as an issue with the GP’s Safeguarding Lead. 8.5.2. The Police had difficulty in getting hold of the Team Manager to arrange the Strategy Discussion, though phone calls were made and messages left on three occasions in October. After the third attempt the Officer added a note to the records to the effect that 22 Valios. Community Care, 9 April 2009 23 Overview Report, Serious Case Review, Daniel Pelka, Coventry Safeguarding Children Board, Sept 2012 24 no further attempts would be made, there was not the time to do so and Police would wait for contact from CSC. Given the Police’s knowledge of AM’s history and the risks he posed to Child M, this clearly should have been escalated internally as a matter of urgency to a Manager. It is understood that the Officer has been advised regarding this matter. 8.5.3. Another area where challenge would have been appropriate was Mother’s assertion to Social Workers in August 2014 that AM was not living with the family, despite Child M showing the workers drawings of Mum and Dad, who Mother agreed was AM. There appears to have been too great a focus on whether there was physical evidence of AM living in the family home, when Workers had clear evidence from Child M that he (AM) was now a significant person and they were spending time together. Mother should have been challenged by Social Workers regarding this. 8.5.4. There is no evidence of challenge within Children’s Social Care. The Assistant Team Manager (ATM) does not appear to have challenged the Social Worker about the delay in progressing the assessment and there was no challenge by the ATM of the Team Manager about the delay in arranging the Strategy Meeting. 8.5.5. Overall, there is no evidence of challenge and escalation in this case. This may well indicate an underlying lack of recognition of the immediate and serious risks to which Child M was exposed daily. In addition, there may be a lack of awareness in agencies about when and how to challenge and escalate concerns, both within agencies through Safeguarding Leads and via DSCB’s multi-agency processes. 8.6. Provide some analysis of the quality of management oversight and decision making. Was there evidence of understanding of the complexity of the family/the use of a genogram? Effective professional supervision can play a critical role in ensuring a clear focus on a child’s welfare. 24 8.6.1. Overall the Agency Reports and discussion at the Learning and Recall Events demonstrate a lack of timely and evidence based decision-making, both single and multi-agency. Additionally, they demonstrate a lack of supervision and management oversight in most agencies, as well as a lack of use of agency Safeguarding Leads, e.g. Education, GP, Police. 8.6.2. The Social Worker, Assistant Team Manager and Team Manager have advised CSC’s Report Author that the concerns about Child M were frequently discussed in formal and informal supervision sessions. However, there is a lack of recorded evidence of management oversight, timely decision-making or supervision in CSC’s records. The first record of supervision taking place is on 30 October 2014, i.e. after the injuries to Child M. Certainly, there is no evidence that the complexity of the family situation and the inherent risks to Child M were understood or acted upon. Significantly, there is a lack of evidence of managerial action following the visit on 3 October when AM confirmed that he was now living with the family. The visit was not written up until 28 October, after Child M’s injuries. 8.6.3. There was a delay in the Team Manager making the decision to convene a Strategy Discussion/Meeting. This should have taken place immediately after the confirmation that AM was living with the family, which was received from the Police on 11 September 2014, if not before. 24 Working Together to Safeguard Children, DFE, 2013. 25 8.6.4. The CSC Report Author suggested that the case lacked direction and that staff in CSC were unsure which direction to go in, notably whether to request that AM leave the family home whilst the assessment was undertaken. The lack of supervision undoubtedly contributed to the lack of direction, sense of urgency and adherence to timescales. There were no opportunities for reflection and analysis to aid decision making. 8.6.5. The CSC Report Author referred to Working Together 2013 25 which states that ‘Effective professional supervision can play a critical role in ensuring a clear focus on a child’s welfare………The Social Worker and their manager should review the plan for the child and together they should ask whether the help given is leading to a significant positive change for the child.’ It was the author’s view that there was a lack of clear focus on Child M’s welfare and no record of supervision to suggest otherwise. 8.6.6. It is understood that the Strategy Discussion in January 2014 decided to undertake a single agency investigation, as it related to an ‘out of Borough’ allegation. This meant that CSC took a back seat and did not meet with Child M and Mother before closing the case. The issue of support for Child M was not addressed. The rationale for this decision is open to challenge as it is contrary to the guidance contained in Working Together to Safeguard Children, 2013 26, which was in force at that time and states that CSC should be the lead agency in undertaking child protection enquiries. Health were not involved in the discussion and advice was not sought regarding the appropriateness of undertaking a medical. 8.6.7. The Learning Event discussed the decision of the Crown Prosecution Service in 2005 not to proceed with the charge against AM in respect of the assault on the three-year old son of his partner. The reasoning behind this appears to have been that, if convicted he would receive a lesser sentence for the assault than for a conviction for Abstracting Electricity, so this was the charge that should be proceeded with. This may have seemed expedient at the time, but did not address the long-term risks that AM would pose to children. If he had been convicted of the assault on a child, he would then have been managed as a Person Posing a Risk to Children, which would have helped to ensure the safeguarding of any child that AM subsequently had contact with. 8.6.8. It has been difficult to evidence the course of decision-making in this case, there is lack of evidence of consistent management oversight and of timely and effective decision-making. Within CSC there is a paucity of evidence of supervision, which undoubtedly reflects the lack of momentum in the management of the case. 8.7. What were the barriers to providing an adequate response? 8.7.1. It is important to understand why there was not a more proactive, timely and robust multi-agency response in this case. Some potential barriers have been identified through the Serious Case Review process, including: • Child M’s voice was not promoted and made the child invisible to some agencies. • Lack of assessment, and analysis, of the risks and protective factors, which was regularly updated to reflect the changes in the family’s circumstances, and of recognition, and understanding, of the complexity of risk factors. • Lack of an assessment of Mother’s parenting capacity, 25 Working Together to Safeguard Children, DFE, 2013. 26 Working Together to Safeguard Children, 2013, DFE. 26 • Lack of understanding across agencies of the principles of effective information sharing. • Lack of recognition and understanding of safeguarding responsibilities by some agencies (GP/Mental Health Services/Police). • Too greater focus on trying to establish whether AM was actually ‘living with the family’, so that the lack of physical evidence of his presence in the home reassured the Social Workers. The key factor in terms of risk to Child M was whether AM was spending significant amounts of time with the family and this information was graphically provided by Child M and would have been provided by the school if contacted sooner. • Mother’s lack of honesty with professionals regarding her relationship with AM. • Mother and AM were co-operative and AM appeared ‘compliant’ when the Social Worker and Assistant Team Manager visited. This may well have given them a false sense of reassurance about Child M’s safety. • Each incident was seen in isolation by some agencies, without reference to previous occurrences or family history (Police/GP). • The incident in August when Mother had sustained a head injury was not investigated robustly and Mother’s ‘superficially plausible account’ (Police Agency Report) was ‘unequivocally accepted’ without question, i.e. without professional curiosity. WMP domestic abuse procedures were not implemented which meant that the matter was not referred to the Domestic Abuse Team and other agencies were not alerted to the potential risk of domestic abuse, i.e. GP, CSC. • Culture of delay in Dudley CSC led to a serious delay in responding to the referral in July 2014 in respect of AM being in the family home. There was no sense of urgency in dealing with the referral, despite its serious nature and the early recognition of risk by the Duty Social Worker. Were timescales for response to referrals/completion of assessments monitored and reported on at this time? • Lack of effective supervision, management oversight and direction which led to a lack of clear planning and challenge when actions were not completed within timescales. • Lack of evidence of the use of agency Safeguarding Leads. • Perceived high thresholds for agencies raising concerns with CSC. (School) • School were concerned about making a judgement about AM based on his attitude and appearance, though he made staff and parents feel ‘uncomfortable’. It was a ‘professional hunch’. Need to be mindful that if AM made staff feel this way, then what would be the day to day impact on the life of a young, and vulnerable, child. • Referral made/Information shared by CSC to the Police in August 2014 was not made through the designated gateway, i.e. Central Referral Unit, in line with procedures. This delayed the Police response. 9. Examples of Good Practice: • The out of area Hospital identified that Father was linked to Child M and alerted Dudley CSC to concerns. • The Health Visitor was persistent in her attempts to see Mother and Child M when they moved to the Dudley area. 27 • The Team Manager make several attempts to seek greater clarification from another local area CSC, including following this up in writing. • The Police responded on the same day to Mother’s report of the sexual abuse. • The GP’s discussion with Child M regarding the alleged sexual abuse was sensitive and is well recorded, not only noting exactly what Child M said, but also noted the child’s demeanour. • The GP at the Health Exchange recognised safeguarding concerns about AM moving in with Mother and Child M and notified CSC. • The Midwife recognised the risks AM presented to the unborn baby and referred these concerns to CSC. • The Consultant Paediatrician who undertook the child protection medical spent time talking to Child M about what had happened and this is fully recorded. • Post the incident, the school have provided excellent support to Child M. In addition, the role of the neighbour in safeguarding Child M should be fully recognised. He had been concerned about his own safety, but fortunately his concerns regarding Child M took priority. 10. Findings: • Local LSCB procedures were not adhered to. Following the referral in July 2014, there was a lack of timeliness in reaching the decision to convene a Strategy Discussion, compounded by a further delay in arranging this. If a Strategy Meeting had been held, and Section 47 enquiries undertaken, it is likely an Initial Child Protection Conference would have been convened. This would have ensured that all the available information was shared in order to build a more holistic picture of the family circumstances, and of the serious risks to Child M. In addition, agencies, e.g. GP, School, would be informed of the potential risks to Child M. (Recommendation One) • Lack of an assessment, chronology or genogram being completed, which should have fully analysed the risks and protective factors. • Practitioners failed to gain an understanding of Child M’s lived experiences and to promote the voice of the child. Child M was invisible to some agencies and the clear ability to provide a picture of what life was like through the ‘child’s eyes’ was not harnessed. (Recommendation Two) • Social Workers failed to spend sufficient time with Child M in order to establish a trusting relationship to enable Child M to feel able to confide and share any worries. • Practitioners did not fulfil their safeguarding responsibilities and apply a ‘Think Family’ approach. There was a lack of recognition by agencies of the immediate risks posed to Child M by the adults’ difficulties, and of the increased risk due to the complexity of factors present, i.e. parental mental health needs, drug and alcohol misuse, criminality and domestic abuse. This led to a delay in a risk assessment being undertaken and action taken to safeguard Child M. (Recommendation Seven) • Police Officers did not recognise potential domestic abuse, or follow WMP procedures, i.e. referral to DART, which would have alerted other agencies, e.g. GP, CSC, to the risks of domestic abuse. The GP Practice would have added a safeguarding flag to the patient records. (Recommendation Five) 28 • The Police treated each contact with the family as a single occurrence, without reference to previous history or contacts. Child M was invisible to the Police and there was a serious lack of attention to the wellbeing or safety of Child M, e.g. One Day One Conversation meeting. (Recommendation Six) • Lack of understanding by GPs, and the Consultant Psychiatrist, of their safeguarding responsibilities, leading to important safeguarding information not being shared with CSC or discussed with Safeguarding Leads within their organisations. Lack of a ‘think family’ approach. (Recommendations Seven, Eight, Nine and Ten) • Effective management oversight and supervision was lacking, notably in Children’s Social Care which contributed to the lack of direction, delay and challenge. (Recommendation Four) • The decision by the CPS in 2005 not to proceed with the assault charges against AM was short sighted, and did not consider the long-term implications in respect of safeguarding children with whom AM would come into contact in the future. (Recommendation Eleven) 11. Recent Developments: • Regular meetings are now held in some GP Practices in Dudley between GPs and Health Visitors to discuss children where there are safeguarding concerns. • Child M’s GP Practice now routinely check members of the household at a mother’s post-natal check and a baby’s 6 weeks’ check. • Child M’s GP Practice ensures that notes of all new patients under the age of 18 years are reviewed within 24 hours, so that safeguarding issues can be identified and safeguarding flags triggered when necessary. • Child M’s GP Practice is looking at putting in place a system for the Safeguarding Lead to monitor and ‘progress check’ referrals that have been made to Children’s Social Care. • Dudley Safeguarding Children Board has revised its Threshold Guidance and multi-agency events have been held to raise awareness of this. Participants at the Learning Event were of the view that there was now less of a ‘block on referrals’. • Dudley CSC now has a Single Point of Access (SPA) and a Multi-Agency Safeguarding Hub (MASH) went live in May 2016. • Health agencies in Dudley have developed a strategy to enhance communication and the sharing of information between GPs, Health Visitors and School Nurses. • Dudley and Walsall Mental Health Partnership Trust has provided Level 3 safeguarding training to all doctors, including Consultants, and invested in additional resources to ensure safeguarding alerts are actioned appropriately. • Police have a rolling programme of Child Protection Training for all staff, not just those working in child protection, this includes recognising and responding to domestic abuse. • DSCB’s Resolution and Escalation Protocol was relaunched in April 2016. 12. Conclusion: 29 12.1. It is a sad reality that Child M was no safer at the time of the physical assault in October 2014 than when the GP made the referral to CSC raising concerns about AM’s presence in the household in July 2014, three months earlier. The multi-agency safeguarding system, which should have offered protection to Child M, did not operate effectively and appropriate action was not taken to safeguard the child. 12.2. There was a lack of recognition and understanding of the complex family circumstances and of the considerable risks to Child M, and to the unborn child. The deteriorating family situation was not recognised, despite the worrying presentation by Mother and AM to various agencies, e.g. GP, Consultant Psychiatrist. 12.3. Child M, and the unborn baby, were invisible to some agencies and insufficient time was spent talking to Child M in order to gain an understanding of what life was like, despite Child M being known to be a bright and articulate child. If more time had been spent talking to Child M, it is likely that there would have been some indication of the changes in the family circumstances and in the safety and emotional wellbeing of Child M. 12.4. Child protection procedures were not adhered to. A Strategy Meeting was not convened, nor were Section 47 enquiries undertaken. Hence, an Initial Child Protection Conference (ICPC) was not triggered. If procedures had been followed, and an ICPC had been convened, then information would have been shared, and analysed, in a multi-agency setting. It is highly likely that a decision would have been made that Child M was at risk of significant harm and required a Child Protection Plan to safeguard Child M. This would have enabled the safeguarding network to operate more effectively together, with a Core Group and multi-agency plan in place. 12.5. Additionally, West Midlands Police procedures were not followed. Referrals to the Domestic Abuse Referral Team (DART) were not triggered following the incidents in August and September. If they had been then agencies, i.e. GP, School Nurse, CSC, would have been alerted to concerns about potential domestic abuse in the family and action taken, e.g. a safeguarding flag would have been added to the GP records. 12.6. Despite clear evidence of the presence of a range of significant risk factors to Child M, notably parental mental health needs, criminality, drug and alcohol abuse and domestic abuse, safeguarding action was not taken. Crucial information had not been shared with, or sought by, CSC. This meant that health agencies, notably the GP Practice, were not party to significant information. A risk assessment had not been undertaken by any agency and there is no evidence that advice was sought from Safeguarding Leads within health organisations or Education. 12.7. Overall, the safeguarding system, which should have been working together to keep Child M safe, was not well informed or co-ordinated. Agencies were working independently, rather than together, which is recognised to be the most effective way of keeping children safe. 12.8. If local procedures had been followed steps would have been taken to safeguard Child M, and the unborn baby, and it is reasonable to conclude that Child M’s injuries could potentially have been prevented. 13. Recommendations: Individual agencies have made recommendations (See Appendix B), which have been implemented. These recommendations, together with the ones below from the Serious Case 30 Review, have been incorporated into an Action Plan by Dudley Safeguarding Children Board, the progress to completion has been monitored by the Serious Case Review Sub-Group. 13.1. Single agency: • The Dudley Group NHS Foundation Trust should consider the feasibility of informing GPs when a child protection referral is made to CSC. 13.2. Dudley Safeguarding Children Board 1. Dudley SCB should seek assurance that the local Inter-Agency Child Protection Procedures, e.g. timescales for Strategy Meetings and assessments, are adhered to, through Multi-Agency Case File Audits and an Audit of contact, referral and assessment services. (DSCB’s Quality Assurance Sub Group) 2. Dudley SCB should seek assurance that children and young people’s views are sought and that these inform assessments and decision making through Multi-Agency Case File Audits. (DSCB’s Quality Assurance Sub Group) 3. Consideration should be given to arranging Strategy Meetings, rather than telephone Strategy Discussions, whenever possible, ensuring that key agencies, including health, education and Probation, are invited and full information shared. DSCB’s Inter-Agency Child Protection Procedures should be amended to reflect this and an Aide Memoire developed for practitioners. (DSCB Policy and Procedures Sub Group) 4. DSCB should seek assurance that CSC has a robust Supervision Policy in place and that this is adhered to. This should be monitored through the Performance Information presented to the Board. (DSCB’s Quality Assurance Sub Group) 5. DSCB should seek assurance from West Midlands Police that the Domestic Abuse procedures are being followed in Dudley and a process is in place to provide schools and GPs with information following the Domestic Abuse Referral Team (DART) meetings. (DSCB’s Quality Assurance Sub Group) 6. DSCB should seek assurance from West Midlands Police that where ‘One Day One Conversation’ meetings are held, full consider should be given to any safeguarding concerns in relation to children and young people to include taking appropriate action to ensure children are safeguarded. 7. DSCB should promote the importance of the role of agency Safeguarding Leads in advising staff and facilitating communication between agencies, and individual agencies should raise awareness of their role and responsibilities, notably within health. (Designated Nurse and Named GP) 8. DSCB should promote a ‘Think Family’ approach in their communications and guidance. Safeguarding Leads should play a key role in this promotion. (DSCB Policy Group) 31 9. DSCB should seek assurance that the system for GPs to ‘flag’ adults and children where there are safeguarding concerns is being implemented, through an audit of patient records. (Named GP). 10. The findings of this case should be shared widely with GPs and the Mental Health Services, and the General Medical Council’s guidance; Protecting Children and Young people promoted, to raise awareness of their safeguarding responsibilities and what action to take when there are concerns about the risk posed by adults living with children. (Designated Nurse) 11. The Chair of DSCB should write to the Crown Prosecution Service to request that there is a review of the decision-making in 2005, which led to the charges of assault against AM being dropped and the charge of abstracting electricity continuing. (DSCB Chair) 12. Discussion should be held between DSCB and the Caldecott Guardian to ensure that there is a common understanding of the principles of information sharing when there are child protection concerns, and when the LSCB is fulfilling its statutory responsibility to undertake a Serious Case Review or Case Review. (Designated Nurse) 32 Appendix A DUDLEY SAFEGUARDING CHILDREN BOARD SIGNIFICANT INCIDENT LEARNING PROCESS SUBJECT: Child M Year of birth. 2008 33 1. SCOPE: The subject child, Child M is in scope Time period: August 2012 (when the case came to the attention of Children’s Social Care) to October 2014 (Child M was made subject to Police Powers of Protection) 2. FRAMEWORK: Serious Case Reviews and other case reviews should be conducted in a way in which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings (Working Together to Safeguard Children, para 10, March 2015) 3. AGENCY REPORTS TO BE COMMISSIONED: 1. Children’s Social Care 2. School (and Nursery) 3. Police 4. Police Offender Managers 5. Probation 6. GP 7. Children’s Centre 8. Health Dudley Group NHS Foundation Trust 9. BCPFT School Health Adviser An anonymisation key will be used to anonymise family members. 4. TERMS OF REFERENCE: 1. How well did practitioners recognise and understand the complexity of factors contributing to the risk to the children including neglect, substance misuse and sexual and domestic abuse? 2. What were the barriers to providing an adequate response? 3. Was the voice of the child heard (including an understanding of the child’s lived experience)? 34 4. How was the family history incorporated into assessments? 5. To what extent did practitioners Think Fathers? 6. How did practitioners approach challenge and/or escalation and what was their level of knowledge around the processes for these? 7. Comment on the quality of information sharing including the making of referrals? 8. Provide some analysis of the quality of decision making. Was there evidence of use of genogram/understanding of the complexity of the family? 5. A TEMPLATE FOR AGENCY REPORTS: Attached 6. AGREED TIMETABLE BEFORE THE REVISED STATUS OF THE REPORT: Scoping/Terms of Reference 1 October 2015 Commissioning letters 12 October Agency Report Authors’ Briefing 15 October Agency Reports Submitted 14 December Distribution of material to Learning Event attendees 21 December SILP Learning Event 7 January 2016 Drafting Overview Report and distribution 3 February 2016 SILP Recall Day 11 February 2016 Revising Report 25 February 2016 Presentation to DSCB SCR Sub Group 3 March 2016 7. Meetings with Family/Significant Others Explanation of Process 15 October 2015 Feedback re: experience of services 6 January 2016 Discussion of final report 25 February 2016 35 Key single agency recommendations: Appendix B Children’s Social Care: • All referrals must be allocated within 24 hours of the decision for an assessment. • Where a Child in Need referral has been accepted, the child must be seen within five working days of the referral. • Assessments must be child centred, include the views of a child, holistic, focused on action and outcomes and informed by evidence. • Assessments must be completed and authorised within the timescales as per the Practice Standards. • Management direction and decision making should be clearly recorded on the child’s electronic care file from allocation to closure. • Supervision must take place on a monthly basis as stated in Dudley’s Supervision Policy. • Practitioners must capture the voice of the child throughout all interventions and ensure this is recorded and evidenced. West Midlands Police: • Offender Management training to ensure staff and supervisors are aware of the importance of identifying potential child abuse matter from both contact with managed offenders and with partner agencies. Clinical Commissioning Group: • Reiterate the ‘Think Family’ approach, particularly with those working with adults. NHS Foundation Trust 1: • When information is shared and there are concerns that correct procedures have not been followed the support and advice from Named and Designated Professionals should be requested. NHS Foundation Trust 2: • School Health Nurses to ensure all school health questionnaires/assessments are reviewed, health issues actioned appropriately and documented. • Health Visitors and School Health Nurses to ensure that the voice of the child is heard, including directly asking the child their views/feelings when seen. 36 Education: • Review the ways in which records are transferred and ways in which absent records are pursued on transition, including statutory guidelines. • Review with Social Services’ colleagues the sharing of key information and needs of troubled families with schools. • Review with social Services colleagues the sharing of information on identified ‘risky adults’ with school. 37 References Appendix C • Working Together to Safeguard Children, DFE 2015. • Information Sharing: Pocket Guide, Department for Children, Schools and Families, 2008 • Information Sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers, HM Government, March 2015. • The protection of children in England: A progress report. DCSF March 2009. • Children Needs – Parenting Capacity, The Impact of parental mental illness, problem alcohol and drug use and domestic violence of children’s development. Department of Health. 1999 • Beyond Blame, Reder et al, 1993 • Predicting Fatal Child Abuse and neglect, Reder and Duncan. Early Prediction and Prevention of Child Abuse, A Handbook. Wiley 2002. • Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews 2005 – 07, DCSF, 2009. • The voice of the child: learning lessons from serious case reviews, 1 April to 30 September 2010. Ofsted, April 2011. • Working Together to Safeguard Children, DFE, 2013 • Overview Report, Serious Case Review, Daniel Pelka, Coventry Safeguarding Children Board, Sept 2012 • Natalie Valios, Lurking in the Shadows. Community Care, 9 April 2009 • The Murder of Children in the Context of Child Abuse, Cavanagh, Dobash and Dobash, 2006 • Some Differential Attributes of Lethal Assaults on Small Children by Stepfathers versus Genetic Fathers, Daly and Wilson, 1994. • Protecting children and young people, short guide for doctor who treat adult patients, GMC, 2012 |
NC042528 | Review by Rochdale Borough Safeguarding Children Board into child sexual exploitation in the borough. It looks at how agencies such as the council, police, and NHS worked to safeguard children at risk of exploitation between 2007 and 2012. The review found many missed opportunities to safeguard children. It makes several recommendations for improving practice, including development of a local strategy for responding to child sexual exploitation in Rochdale; more training for professionals; better inter-agency working; and effective use of referrals to ensure children are provided with good services, specific to their needs.
| Title: Review of multi-agency responses to the sexual exploitation of children. LSCB: Rochdale Borough Safeguarding Children Board Author: Rochdale Borough Safeguarding Children Board Date of publication: 2012 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 0 THIS REPORT IS CONFIDENTIAL IS NOT FOR DISTRIBUTION AND MUST NOT BE SHARED WITHOUT THE EXPRESSED PERMISSION OF THE CHAIR of ROCHDALE BOROUGH SAFEGUARDING CHILDREN BOARD Review of Multi-agency Responses to the Sexual Exploitation of Children RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 1 Contents 1. Introduction ....................................................................................................................................2 2. Methodology...................................................................................................................................4 3. Participants .....................................................................................................................................4 4. The case study.................................................................................................................................6 5. How did agencies judge their practice?..........................................................................................8 Chronology......................................................................................................................................8 Analysis .........................................................................................................................................19 6. What were the key lessons and associated recommendations?..................................................21 7. Summary of review recommendations ........................................................................................26 8. Addendum RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 2 1. Introduction This purpose of this report is to review how agencies in Rochdale Metropolitan Borough Council, hereafter known as Rochdale, worked together from 2007 until 2012 to safeguard children and young people who were at risk of sexual exploitation. This review was commissioned by Rochdale Borough Safeguarding Children Board (RBSCB) in line with its statutory reviewing and investigative functions as defined in ‘Working Together to Safeguard Children: A guide to inter‐agency working to safeguard and promote the welfare of children’ (2010). In December 2010, Greater Manchester Police (GMP) launched Operation Span to investigate a large group of men who were suspected of sexually exploiting children and young people in Rochdale. The Serious Case Review Screening Panel (SCRSP) considered, in depth and over the following year, the information provided by the police, the local authority and other agencies and organisations, about the work they had undertaken with young people affected by sexual exploitation. In December 2011, the SCRSP concluded that there were grounds to consider undertaking serious case reviews. The Panel felt strongly, for a wide range of reasons, that the serious case review model, as described in Working Together, was not the most suitable vehicle for effectively extracting the lessons in relation to multi‐agency working with sexually exploited young people, in a timely way. The Panel recognised that an initial alternative approach would need to be just as robust and transparent as the serious case review process and should be measured by the extent to which it would make a difference and eradicate any poor practice which still existed. In January 2012, The Chair of the RBSCB received the recommendations of the SCRSP and agreed that the threshold for undertaking serious case reviews had been met, while acknowledging the views of the SCRCP in respect of the methodology. Consequently, the RBSCB determined that it would: conduct a preliminary review of how agencies had worked together; identify any additional learning from the criminal trial; and aggregate lessons from individual organisational reviews. When those tasks were completed, the Board would determine whether a Serious Case Review was RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 3 required to ensure that all the lessons are learned and that there is a comprehensive plan for improvement in place. On 1 February 2012, therefore, while the criminal process was current, the Board undertook its preliminary review of how partner agencies had responded to the allegations made by the young people. The review process culminated in a facilitated learning event which involved senior officers from the local authority, the police and its partner agencies. The stated aim of the review was to ensure that agencies were best placed in future to: a. identify sexually exploitative activity locally; b. engage with affected and vulnerable young people; c. disrupt any such activity in a timely manner; and d. prosecute alleged perpetrators. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 4 2. Methodology The learning event was designed and led by Clare Hyde, independent facilitator, from The Foundation for Families, a not for profit Community Interest Company established in July 2010. Over a period of four days, Ms Hyde worked with a small group of Board members to develop a model that would enable participants both to consider the events and circumstances in one child’s life while, at the same time, to take into account contemporary national and local policies and practice developments. In this way, the child’s story was to be both personal and representative. The results of this dynamic exercise informed the second part of the review which focused on identifying actions for RBSCB’s strategy to counteract and manage child sexual exploitation, including actions specific to the specialist multi‐agency child sexual exploitation team (Sunrise). It was agreed that the learning from this event would inform a review report which would be published to ensure transparency. 3. Participants In addition to the facilitator, the participants in the review day were: Independent Chair Rochdale Borough Safeguarding Children Board Executive Director Children’s Services Rochdale Metropolitan Borough Council Chief Superintendent Greater Manchester Police Chief Inspector Greater Manchester Police Chief Inspector Greater Manchester Police Detective Inspector Greater Manchester Police Operational Manager Children’s Service Pennine Care NHS Foundation Trust and Heywood, Middleton and Rochdale Community Healthcare Designated Nurse Safeguarding Pennine Care NHS Foundation Trust and Heywood, Middleton and Rochdale Community Healthcare Safeguarding Nurse Pennine Care NHS Foundation Trust and Heywood, Middleton and Rochdale Community Healthcare Team Manager, Crisis Intervention Team Pennine Care NHS Foundation Trust and Heywood, Middleton and Rochdale Community Healthcare Service Director, Targeted Services Rochdale Metropolitan Borough Council Service Manager, Duty and Assessment, Targeted Services Rochdale Metropolitan Borough Council Service Manager, Safeguarding, Targeted Services Rochdale Metropolitan Borough Council Youth Offending Team Manager, Targeted Services Rochdale Metropolitan Borough Council RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 5 Senior Practitioner, Sunrise Team Rochdale Metropolitan Borough Council Coordinator, Sunrise Team Rochdale Metropolitan Borough Council Business Manager Rochdale Borough Safeguarding Children Board Local Authority Designated Officer Rochdale Borough Safeguarding Children Board Independent Chair, Serious Case Review Panel Rochdale Borough Safeguarding Children Board Team Leader, Licensing Authority Rochdale Metropolitan Borough Council Head Teacher Brownhill School, Rochdale Director Early Break, Rochdale Operational Manager Early Break, Rochdale Neither the private providers of care for looked after children nor the Crown Prosecution Service (CPS) were represented in the review meeting: this is an acknowledged gap. However the Chair of the Board and the Boards Business Manager subsequently met with the managers of the care home which had supported one of the young people involved in Operation Span and the subsequent trial to review the service offered and latterly the provider forum which agreed to conduct a review of safeguarding in the children’s care home sector in Rochdale. This review is expected to be completed towards the end of the year. Additionally, the RBSCB Chair has discussed with the Chief Crown Prosecutor from CPS North West how alleged sexual exploitation cases are managed within the criminal justice system. It is noted that Chief Crown Prosecutor is to share the learning from the internal review of CPS practice in relation to sexual offences with the Board. Due to the timing of the learning event, prior to the trial, it was agreed that the voice of the young people would be sought at a later date. The issues raised by them are to be found in the Addendum to the report. The Board would like to thank the young people for agreeing to share their experiences with us and for the courageous offers of support from them to help us make the improvements necessary to safeguard other young people who may find themselves in similar circumstances. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 6 The case study Suzie is the subject of the case study on which the review focussed. Suzie was a real victim of sexual exploitation, although this is not her real name and some details of her circumstances have been omitted to preserve her anonymity. When Suzie turned 15, there were already signs that she was a troubled and vulnerable young person. In the course of that year Suzie disclosed on two separate occasions and to two different agencies that she had been the victim of serious sexual assaults by a number of adults who were linked to takeaway premises in the area. Although police investigations were carried out, to begin with the possibility that she was being sexually exploited was not recognised. At that time, professional focus was on providing individual support services for Suzie and on assisting her parents to set boundaries to keep her safe. It seems, however, that these actions had little impact on Suzie’s circumstances: she remained at risk of sexual harm, compounded by her abuse of alcohol and possibly drugs. Whilst still a teenager Suzie became pregnant. At the beginning of 2009, Suzie made a detailed complaint to the police about the abuse she had experienced during the previous six months. As a result, a number of men were arrested in connection with offences against her and against other young people. Suzie reported that she was being threatened, both by the offenders and by other victims. Suzie stated that she did not feel confident that agencies could protect her. In the months which followed, Suzie continued to have the support of specialist sexual health and alcohol services. However, children’s social care ended their involvement with Suzie as a ‘child in need’, while at the same time an initial assessment was made of her capacity to provide care for her child. In the same month, the men whom Suzie and others had accused were ‘refused charge’ by the Crown Prosecution Service (CPS). Some months later Suzie disclosed further abuse to the police. Again, referrals were made to children’s social care for support to Suzie. However, children’s social care took no action in relation to these referrals. The agency was, however, concerned for the safety of Suzie’s baby. Their concerns were specifically, the risk that was posed to the baby by Suzie’s alcohol misuse and by male visitors to the family home. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 7 At this point, it appears that Suzie felt both under pressure from professionals about her parenting and frightened by the offenders who were using other young victims to gain access to her and to threaten, intimidate and coerce her. In November 2010, a man was arrested as a result of Suzie’s evidence and the following month GMP launched Operation Span. In the weeks that followed it was evident that Suzie’s mental health was deteriorating: she was self‐harming, using alcohol excessively and going missing for periods of time. Child protection processes were instigated in respect of Suzie’s baby. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 8 4. How did agencies judge their practice? It is acknowledged that the case study raises potentially a large number of practice issues, both for individual agencies and for the RBSCB, not all of which are related to issues of child sexual exploitation. However, as noted above, the purpose of the review was to consider and improve practice relating particular to this area. This means that, inevitably, other issues have not received the same level of attention. Chronology The review attempted to identify national as well as local factors which influenced how agencies and organisations responded to child sexual exploitation in Rochdale. It found that only some factors related directly to practice in this area. Other factors had an associated impact on practice which was sometimes consequential and sometimes unintended. This report concentrates on those developments which are specific to child sexual exploitation, although reference is made to significant external events where these are considered to be particularly pertinent. The chronology includes the reflections of review participants on events and developments. 2007 By 2007, local and national awareness of child sexual exploitation was growing, but the scale of the problem and the way in which victims were targeted was only just becoming clear. Just as was the case nationally, it is evident that professionals in Rochdale were not skilled at recognising and responding to child sexual exploitation. However within the borough there were two distinctive developments. These were: • the formation of a Sexual Exploitation Working Group (SEWG), whose remit included gathering and analysing information about the incidence of the sexual exploitation of children resident or placed in the borough; and • the subsequent formation, under the auspices of the RBSCB, of a Sexual Exploitation Steering Group (SESG) to provide guidance and direction to the SEWG; to report the findings of the survey to the Board; and to make recommendations for improvements. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 9 Between January and December 2007, the SEWG identified 50 children and young people who were considered to be affected by, or to be at risk of, sexual exploitation. The children in this group were overwhelmingly girls; they were aged between 10 and 17 years old; just over half were in education; and 15 were looked after children. No distinction was made in the survey between those children who were looked after by Rochdale Borough Council and those who had been placed in Rochdale by other local authorities. Clear links were identified to take‐away businesses in an area of the town and to associated taxi companies. Three individual perpetrators were reported to have been convicted as a result of police investigations. Reflecting on practice at that time, the review group acknowledged that children at risk of sexual exploitation were being provided with support by agencies such as Early Break, the young people’s drug and alcohol advisory service, and the Crisis Intervention Team, which provides one‐to‐one advice to vulnerable young people in respect of their sexual health. However, for those children who came into contact with children’s social care, it often appeared that ‘no further action’ would be taken. Case files state that the children were often considered to be ‘making their own choices’ and to be ‘engaging in consensual sexual activity’. The poor response by children’s social care to cases where children were at risk of sexual exploitation was aggravated by the fact that professionals did not make consistent reference to the procedures for dealing with vulnerable young people or to guidance about working with young people engaging in underage sexual activity. As noted above, professional focus generally, at this time, was on individual cases rather than on the wider picture. As a result, there was little evidence either of disruptive action, such as the involvement of the Licensing Authority, or the use of Civil Orders which might have curtailed the activities of actual and potential offenders. 2008 In the early months of 2008, national consultation took place in relation to issues of child sexual exploitation, prior to the publication of guidance the following year. This consultation document established the definition of child sexual exploitation and proposed protocols for working with children and young people. In response to that initiative, RBCSB developed its own multi‐agency Child Sexual Exploitation Protocols. However, the impact of these protocols was unknown as no arrangements were put in place to support or monitor how they were used by local agencies. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 10 Then, in June 2008, the SESG reported to the Board. Its report analysed the SEWG data and concluded that the incidence of child sexual exploitation locally was similar to that found in other North West local authority areas. However, it also identified a number of weaknesses in the local safeguarding response to young people at risk of sexual exploitation: one of which was ‘uncoordinated multi‐agency working’. For those reasons, the SESG recommended that a dedicated multi‐agency team, based on models which existed elsewhere, should be established in Rochdale as a matter of urgency. From August 2008, a small working group was set up to develop the specialist team proposal, looking at the role of such a team, its funding and management, and the relationship to the wider network of services. However, strategic progress to develop the specialist team was slow and, on occasion, halted completely. Review participants identified a range of problems in setting up the specialist team. These problems included: a. there was no agreement for sustainable funding; b. governance arrangements of the team were uncertain; c. there was no business plan; d. a performance framework had not been created; and, crucially, e. no support and supervision were in place for team members. At the same time, the RBSCB provided training and awareness‐raising sessions to agencies across the Borough1. In addition, individual agencies, such as Early Break, and a number of discrete groups of professionals from within the health service undertook agency‐specific training in relation to child sexual exploitation. As a result, Early Break and the Crisis Intervention Team developed their own practice in this area and put in place more effective joint working arrangements. These two agencies in particular began to recognise and to respond to children and young people as victims of abuse and exploitation, rather than as consenting young adults. At the same time, the Crisis Intervention Team made a number of referrals to children’s social care, expressing concerns about children’s welfare or safety. 1 Between 2007 and 2011, the Board provided 3 sets of 2 day training ‘Sexually Active under 18s and Sexual Exploitation’ and 7 half‐day seminars on Child Sexual Exploitation. Total No. staff trained = 207 RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 11 At that time, however, knowledge gained from work with children was not systematically passed to the police as intelligence and this hindered the development of the larger picture. Although areas of improved practice were developing, this was by no means universal. Crucially, front line practitioners and managers in children’s social care did not consistently recognise or understand the nature of the sexual exploitation of children and young people. Review participants considered that a number of factors were significant in this. Primarily, there were difficulties specifically related to identifying and managing cases where child sexual exploitation was a feature. These difficulties included: a. No specific assessment tool existed, which meant that behaviours indicative of sexual exploitation were seen rather as problematic, and essentially wilful, behaviours on the part of the child; a. Older children were considered to have capacity to make their own decisions and were not perceived to be as ‘at risk’ of harm as younger children; b. Professional focus was more frequently on the perceived ability of parents to manage the child’s behaviour, rather than on the child’s vulnerability to abuse outside the home. Less directly, it was also the case that the most significant safeguarding issue at this time was the response at a national and local level to the Serious Case Review of the death of Peter Connelly (Baby P). This saw increasing numbers of referrals to children’s social care; more children becoming the subjects of child protection plans; and a rise in the number of children being taken into local authority care. As a result, professional safeguarding priority was to ensure that the danger to younger children at risk of neglect and physical harm were assessed and reduced. However, even taking these contributory factors into account, review participants acknowledged that there were clear deficiencies in the way that children’s social care responded to Suzie’s needs. In December 2008, agencies identified funding for a social worker and health worker to be allocated to the Sunrise Team. It was anticipated that the team would be formally ‘launched’ in April 2009. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 12 2009 In January 2009, Suzie made further disclosures to the Crisis Intervention Team. In her statement, Suzie ‘catalogued’ her experience of abuse and exploitation. As a result, Suzie was interviewed by the police. GMP acknowledges, however, that the investigation of Suzie’s detailed complaint was poor. At the same time, a further referral in respect of Suzie was made to children’s social care but again no action resulted. Suzie, at 16 years old, was considered to be ‘making her own choices’. This sequence of events confirms the review participants’ beliefs that while, within certain agencies, improvements were being seen in skills, confidence and response to issues of child sexual exploitation; this was not consistent across agencies. When it was reported that Suzie was pregnant, children’s social care’s focus shifted to the welfare of her unborn child. At a tactical level, focus on the suspected perpetrators of sexual exploitation began to intensify and the local authority licensing department provided essential intelligence to the police, so that the alleged perpetrators’ activities could be disrupted. However, progress in developing the specialist child sexual exploitation team continued to be slow. Recruitment and staffing issues continued and the absence of key managers at relevant planning meetings impeded the development of the team’s role and functions. Nevertheless, work went on to produce multi‐agency information‐sharing protocols for the team and to begin to tackle the issues of record keeping and intelligence systems. However, by June 2009, two months after the original target date for the team launch, only a health worker and a police officer were established in post: no social worker had yet been recruited. The potential prosecution of the perpetrators suffered a serious setback, when the men were refused charge by the Crown Prosecution Service. Review participants identified several factors which led to this. These included: a. issues with forensic evidence; b. cost; RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 13 c. officer workload which led to delay; and, significantly, d. a view that Suzie would be an unreliable witness. Also in 2009, the government published, ‘Safeguarding Children and Young People from Sexual Exploitation: Supplementary guidance to Working Together to Safeguard Children’. This guidance provided local safeguarding children boards and their partners with a strong framework for developing strategic and frontline responses to child sexual exploitation. Importantly, it also changed the language of what had previously been referred to as ‘child prostitution’ to ‘sexual abuse’ and ‘exploitation’. 2010 In January 2010, the Sunrise Team became fully operational, albeit with a different structure from the team that had been envisaged. In its first progress report in May 2010, the team identified 79 children and young people in Rochdale who had been experiencing, or who were at risk of, sexual exploitation. All 79 children and young people had been worked with by at least one member of the four person team. However, although the team was functioning, difficulties existed in relation to how the team operated. This meant that their first progress report also contained 14 separate recommendations for change. Key issues for the team included: a. strengthening team relationships; b. accessing and sharing information, c. supervision, d. ‘fast‐tracking’ social care involvement; and, e. improving the team’s ‘physical space’. In May 2010, a coalition government was formed, following the UK general elections. In June 2010, the government commissioned Professor Eileen Munro to conduct a review to improve child protection. In addition, a number of white papers were published which were significant for the Board and for individual agencies. These included changing arrangements for commissioning within the NHS, plans to abolish Police Authorities and changes to the role and function of Children’s Trusts. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 14 Locally, in June 2010, Ofsted inspected the local authority’s safeguarding and looked after children services. The inspection report acknowledged that for the Sunrise team, early signs and levels of engagement were encouraging: however, it recognised it was too early to report on the success of this team. In September 2010, the RBSCB appointed a Local Authority Designated Officer (LADO). The role of the LADO was to act as the single point of contact for all allegations that a person who works with children had‘harmed, or might have harmed a child; had possibly committed a criminal offence against a child or who, in other ways, might be unsuitable to work with children’. The terms of their licence meant that allegations against taxi‐drivers fell within these procedures. Strategy meetings and allegations management meetings, therefore, offered opportunities to share information between the police, the licensing authority, children’s social care, schools, local authority solicitors, voluntary agencies and private child care providers. Also in September 2010, Suzie disclosed further abuse to the police and a number of arrests were made. Although no charges were brought the perpetrators who worked as taxi‐drivers were arrested, their licences were suspended and discussions with proprietors continued. The Sunrise Team health practitioner continued to provide support to Suzie, but her fear of her abusers was escalating. At the same time, from a children’s social care perspective Suzie’s potential to abuse or neglect her own child was coming under increasing scrutiny. In October 2010, the government presented its public spending review which, among other measures, indicated that there would be reducing budgets for local authorities, police, probation and social housing over the next four years. The extent to which these reductions would impact on the functioning of the Board and its partner agencies was unknown. In the last quarter of 2010, a number of events, with implications for the investigation of child sexual exploitation, took place within GMP. These included: a. A review by the police modernisation team that changed the way that investigations were managed; b. Clarification of the role of Public Protection Division in investigating child sexual exploitation; RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 15 c. Investment of resources across the force, leading to identification of other child sexual exploitation activity within the GMP area; and d. The launch of ‘Operation Span’. In November2010, RBSCB appointed a new Independent Chair. It was determined that the Board would be reconstituted and that there would be a separation of the strategic and executive functions. Within children’s social care, a restructuring of looked after children services was taking place and the death of Peter Connelly continued to have an impact. 2011 In January 2011, Suzie’s circumstances were considered by the Serious Case Review Screening Group of RBSCB. In the same month, a child sexual exploitation strategy meeting was held at which information about Suzie was considered. Children’s social care undertook an initial assessment, which identified a number of concerns about Suzie’s welfare, including alcohol misuse; self‐harming behaviours; and being ‘missing’. However, no further action was taken in respect of Suzie who was, by this time, almost 18 years old. A core assessment was completed in respect of Suzie’s child. Also in January 2011, Barnardo’s published ‘Puppet on a String: the urgent need to cut children free from sexual exploitation’. This report acknowledged that recent high‐profile cases had meant that child protection had been firmly focused on babies suffering abuse and neglect at the hands of their parents, relatives or carers in the family home. The report found that despite new national guidance, in most local authorities, child sexual exploitation was not recognised as a mainstream child protection issue. This report called on the Secretary of State for Education to take the lead in ensuring a fundamental shift in policy, practice and service delivery in England. Shortly afterwards, CEOP announced it would carry out a thematic assessment of the phenomenon known as ‘localised grooming’ following the prosecutions of adult males for the grooming and sexual exploitation of children in various towns and cities in the UK. Locally, in the early months of 2011, premises in Rochdale suspected to be associated with the sexual exploitation of children were identified through regular meetings held between the licensing RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 16 authority, the police and the Sunrise Team. In addition, checks were carried out around local schools, with taxi drivers being questioned and their legitimacy verified. Around the same time, information and awareness raising activities were carried out at local mosques and RBSCB formed a multi‐agency Child Sexual Exploitation Strategic Group with a police lead and a significant focus on managing communications with the media and local communities as interest in this subject was growing within the wider public. Effective Multi‐agency planning ensured a quiet response to an English Defence League march in Rochdale in March 2011. RBSCB also subscribed to ECPAT UK (End Child Prostitution, Child Pornography and the Trafficking of Children for Sexual Purposes) at this time. In May 2011, the Munro Review of Child Protection was published: this did not, however, explicitly address issues of child sexual exploitation. In the summer of 2011, CEOP published ‘Out of Mind, Out of Sight’; the report of its findings following the thematic assessment carried out earlier in the year. However, the report acknowledged that the data was significantly weighted towards the relatively limited number of areas which had provided a comprehensive response: areas which generally already had stronger partnership arrangements to address child sexual exploitation. The assessment could not be seen, therefore, as fully representative of the nature and scale of child sexual exploitation in the U.K., or, indeed, of the ‘localised grooming’ model. CEOP noted that ‘agencies which did not proactively look for child sexual exploitation would as a result fail to identify it’. Nevertheless, the report provided a specific definition of ‘localised grooming’ as a discrete aspect of child sexual exploitation. The findings suggested that both the victim experience in Rochdale and the multi‐agency responses to this kind of child sexual exploitation were similar in many ways to the picture across much of the country. Planning meetings took place amongst a wide range of professionals to co‐ordinate support to meet all Suzie’s needs. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 17 The Sunrise Team continued its work, although recruitment to the social care senior practitioner post remained problematic. The Crisis Intervention Team supported 20 young people during interviews with police and a Sunrise Team worker, with health practitioner background, was trained in Achieving Best Evidence interview techniques. The CPS overturned its decision not to bring charges against alleged perpetrators identified by Suzie. In October 2011, the University of Bedfordshire published ‘What’s Going On?’ a research project which explored the extent and nature of the response of LSCBs to the 2009 government guidance on safeguarding children and young people from sexual exploitation. This found that where the guidance had been followed, there were examples of developing and innovative practice to protect and support young people and their families and to investigate and prosecute their abusers. However, the researchers found that the delivery of that dual approach to child sexual exploitation was far from the norm. This document and the CEOP survey served as references to undertake analyses of two cases and underpinned a development day, focussing on the Sunrise Team. As a result of this development day, a revised structure for the Sunrise Team was proposed: this included increasing the size of the team and having a co‐located team coordinator. A Child Sexual Exploitation Strategy Group was established and the children’s social care Service Director took the lead in developing the strategy for the Board. This group incorporated the former police‐led strategic group. In November 2011, a proposal to secure funding for the revised Sunrise Team was put to the RBSCB. Also in November 2011, Rochdale Community Safety Partnership made the formal link between child sexual exploitation and serious crime, reflecting national developments and the publication the Association of Chief Police Officers (ACPO), ‘Strategy for Policing Prostitution and Sexual Exploitation’. This report confirmed that: ‘In the case of children and young people, the emphasis is always on safeguarding the young person and on the proactive disruption and prosecution of their abusers’. Generally, review participants found that around this time partnership work between the licensing authority and the police was providing an effective vehicle for making connections between RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 18 individuals and premises and for disrupting the activities of perpetrators. They also noted that Criminal Records Bureau (CRB) checks began to confirm that applicants had been investigated in relation to allegations of child sexual exploitation. Again in November 2011, the national action plan for tackling child sexual exploitation was published and brought together, for the first time, actions by the Government and a range of national and local partners to protect children from this form of child abuse. The action plan considers sexual exploitation from the perspective of the child. It highlights areas where more needs to be done and sets out specific actions which government, local agencies and voluntary and community sector partners need to take. Towards the end of 2011, partnership working to disrupt activities associated with child sexual exploitation was thwarted, as multi‐agency recommendations to rescind licences were not endorsed by the Licensing Authority. This outcome was not communicated to partner agencies at this time. 2012 In January 2012, the RBSCB endorsed a recommendation that Suzie’s case, and others, had met the criteria for serious case review. Also in January 2012, the Sunrise Team recruited a social work senior practitioner and team co‐ordinator. The local Residential Care Provider Forum agreed to send letters to placing local authorities providing a ‘position statement’ about child sexual exploitation in the borough. This same group also developed inter‐home protocols for sharing information and for managing the care of children and young people who go missing. The forum continues to meet monthly to discuss issues affecting the market and local providers, but specifically also now discusses safeguarding, to establish protocols to ensure safety. At the point that the review learning event was held, a number of very serious incidents of alleged child sexual exploitation were being addressed by Strategic and Operational Managers from a wide range of agencies. GMP were reviewing how investigations of child sexual exploitation has been managed and investigated across the city and liaising with the Independent Police Complaints RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 19 Commission. A number of alleged offenders were being brought to trial and a second investigation was underway. Analysis There is no doubt that Suzie was suffering significant harm from 2008 onwards: indeed, Suzie told several professionals, on several occasions, that she was being sexually abused and exploited by a number of men. The nature of the harm and of the ‘relationship’ between Suzie and the offenders was understood by members of the Crisis Intervention Team and the Early Break Service, however their referrals were generally not acted on by children’s social care. Social work practitioners and managers wholly over estimated the extent to which Suzie could legally or psychologically consent to the sexual violence being perpetrated against her. This was frustrating for referring practitioners. However, there was no escalation of agency concerns that the needs of this group of young people were not being adequately assessed and dealt with by the local authority. The absence of knowledge in respect of the appropriate response to child sexual exploitation was a significant feature of practice. However, it was not the whole story: participants in the review acknowledged that, had existing legal processes and safeguarding processes been used effectively in all other aspects, the harm that Suzie was suffering could have been mitigated and her risk of suffering harm in the future could have been reduced. The review found, therefore, that, while some organisations were consistently supportive in their response to Suzie, overall, child welfare organisations missed opportunities to provide a comprehensive, co‐ordinated and timely response to her as a child in need and, in addition, the criminal justice system missed opportunities to bring the perpetrators to justice and so to protect Suzie and other young people from their criminal behaviours. It was not until 2011, that a comprehensive assessment of Suzie’s needs was carried out and a support plan put in place; and, it was 2012 before the alleged offenders were brought to trial. More generally, agencies and organisations in Rochdale made faltering early progress in developing a satisfactory framework for managing allegations of child sexual exploitation. The need for a specialist resource was identified in 2008, but its development was inadequately co‐ordinated and supported. Specific training to frontline practitioners in the borough was patchy and lessons were absorbed inconsistently. Efforts were made to identify the extent of the problem locally, but RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 20 responses to individual children, although evident in some instances, were not sufficiently comprehensive. In children’s social care, as in similar organisations across the country, the focus was on younger children at risk of abuse from family and household members, rather than on vulnerable adolescents. Activity to disrupt alleged offenders was developing on the ground, but this was not always followed through at a more senior level. The early investigations of crimes and the prosecution of alleged offenders were flawed. Although between 2009 and 2012, some improvements had been consolidated; overall, the review group acknowledged that there were many missed opportunities, over the last five years, to safeguard children and young people who have been affected by sexual exploitation. It also recognised that there is still much to be done to ensure that children and young people are better protected in future. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 21 5. What were the key lessons and associated recommendations? LESSON 1 Without a single multi‐agency strategy, it is impossible to develop a shared understanding of the problem of sexual exploitation; progress is likely to be piecemeal and uncoordinated; and agencies cannot be held to account for their actions or failures to act. The leadership of the RBSCB is crucial to this task. Associated recommendation RBSCB should develop an effective local strategy, ensuring there is a co‐ordinated multi‐agency response to child sexual exploitation, based on the knowledge which already exists about the extent and nature of child exploitation locally. This should include: • Revising Terms of Reference for the RBSCB Child Sexual Exploitation Implementation Group and ensuring effective reporting arrangements; • Ensuring that formal structures are in place to deal with ‘cross‐border issues’; • Ensuring that commissioning is well planned, informed, and effective; • Ensuring involvement of non‐statutory agency partners at all levels; • Conducting a self‐assessment of current arrangements; and • Clarifying governance arrangements for the Sunrise Team and how the Strategy Group links to other bodies such as the Children’s Trust. LESSON 2 Children and young people are more likely to be protected from child sexual abuse if professionals, young people, parents and the wider community have a better understanding of the problem, can recognise key signs and know how to respond. Associated recommendations 1. Awareness‐raising briefings should be held as a matter of urgency at high schools across the borough; 2. ‘Train the trainer’ sessions should be provided for professionals working with children and young people at risk of sexual exploitation as a basis for effective training of the wider workforce; RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 22 3. The RBSCB strategy should identify and ensure that appropriate levels of training/ awareness‐raising/ information is provided for: • those professionals for whom training in respect of child sexual exploitation should be mandatory; • those professionals where ‘awareness‐raising’ activities are required; • those community groups where ‘awareness‐raising’ activities are indicated, and • parents and carers. LESSON 3 Children are more likely to be protected from sexual exploitation if professionals engage actively with the local community Associated recommendations 1. Partner agencies, particularly the local authority and the police, should review how they work with local communities and consider how communications and opportunities for representation can be further developed. This should include using third sector partners to gain access and build trust. LESSON 4 For those children who are identified as being at risk of, or suffering harm through child sexual exploitation, it is essential that their needs are comprehensively assessed and that they are provided with good services, specific to their needs. This requires clear single and multi‐agency policies and procedures and good practice guidance. Associated recommendations 1. RBSCB should ensure that policies and procedures in place for managing referrals in relation to children at risk of, or suffering harm through child sexual exploitation are used effectively. 2. RBSCB should provide good practice guidance for practitioners and managers to build their knowledge and support their work with children and young people at risk of sexual exploitation. LESSON 5 Once perpetrators have been identified, it is crucial that police build the case against them and that prosecutions are secured. If this does not happen, children and young people will continue to suffer abuse and violence and lack confidence that agencies can protect them. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 23 Associated recommendations 1. GMP should ensure that all their staff are aware of appropriate legal compliance in evidence gathering requirements and that, when arrests have been made, that there are appropriate bail conditions in place to protect the victim/s. 2. Criminal justice organisations locally should work together to ensure that support is provided for sexually exploited young people throughout the whole process of reporting the crime, making a statement, pre‐trial preparation, going to court and after the trial. LESSON 6 Disrupting the activity of perpetrators can reduce the incidence of abuse and sends a very valuable message to young people, their families and their carers. It is crucial therefore, that the RBSCB strategy requires both early preventative measures to be put in place, as well endorsing the use of more intrusive interventions. Associated recommendations 1. The RBSCB should ensure that the use of disruption tactics permeates the work with young people; work in particular locations; work with local businesses; and targeting offenders. 2. GMP and a representative of the Sunrise Team should attend Licensing Panels to assist the Chief Officer in determining applications where applicants have been interviewed about the sexual exploitation of children. LESSON 7 The effectiveness of multi‐agency work to safeguard children and young people from sexual exploitation needs to be measured by evaluating progress against a set of key indicators Associated recommendations 1. RBSCB should establish a specific performance management framework to evaluate progress made by agencies in preventing child sexual exploitation; in diverting those at risk; in responding to the needs of those young people who are being sexually exploited; and in reducing the overall incidence of this type of abuse. RBSCB should provide challenge to agencies against that framework. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 24 LESSON 8 Although review participants considered that there was currently a good understanding of the local prevalence of child sexual abuse, they recognised that this knowledge needed to continue to be updated, if prevention, disruption and intervention strategies are to be effective. It is important, therefore, that regular ‘scoping’ takes place to establish target potential offender and victim populations and to identify changing ‘hotspot’ locations. Associated recommendation 1. The RBSCB should establish multi‐agency information‐sharing meetings. 2. The RBSCB should ensure that these meetings collate and analyse information about offender and victim profiles and identify changing hotspot locations, so that disruptive action can be planned and taken. LESSON 9 The review participants recognised the centrality of the Sunrise Team in safeguarding children and young people from sexual exploitation. However, the group concluded that there specific actions were required to develop and support the team. Associated recommendation The RBSCB should ensure that agreed actions to develop and support the Sunrise Team are implemented. Agreed actions include: • Oversight and governance of the team should be co‐ordinated by RBSCB to ensure an effective multi‐agency approach; • Commissioning arrangements should be formally agreed and integrated into a service level agreement with clear outcome and other performance measures; • Consistent, high quality staff supervision and professional support is essential to enable practitioners to deal with complex and difficult safeguarding issues. This supervision and support should be provided within the team structure; • The role and responsibilities of the Sunrise Team should be communicated to all agencies/ professionals who work or come into contact with children and young people; • The referral pathway into the Sunrise Team must be clearly communicated to all agencies and potential referral sources: the referral pathway should be simple and accessible; RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 25 • The Sunrise Team’s should be supported to provide physical, psychological, social and emotional assessments, plus immediate and ongoing assessments of risk, witness protection measures, support for the family and a key worker system. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 26 6. Summary of review recommendations 1. RBSCB should develop an effective local strategy, ensuring there is a co‐ordinated multi‐agency response to child sexual exploitation, based on the knowledge which already exists about the extent and nature of child exploitation locally. 2. Awareness‐raising briefings should be held as a matter of urgency at high schools across the borough. 3. ‘Train the trainer’ sessions should be provided for professionals working with children and young people at risk of sexual exploitation as a basis for effective training of the wider workforce. 4. The RBSCB strategy should identify and ensure that appropriate levels of training/ awareness‐raising/ information for: a. those professionals for whom training in respect of child sexual exploitation should be mandatory; b. those professionals where ‘awareness‐raising’ activities are required; c. those community groups where ‘awareness‐raising’ activities are indicated and, d. parents and carers. 5. Partner agencies, particularly the local authority and the police, should review how they work with local communities and consider how communications and opportunities for representation can be further developed. This should include using third sector partners to gain access and build trust. 6. RBSCB should ensure that there are clear policies and procedures in place for managing referrals in relation to children at risk of, or suffering harm through child sexual exploitation. 7. RBSCB should provide good practice guidance for practitioners and managers to build their knowledge and support their work with children and young people at risk of sexual exploitation. 8. GMP should ensure that all staff are aware of the appropriate and legally compliant evidence gaining requirements and that, when arrests have been made, that there are appropriate bail conditions in place to protect the victim/s. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 27 9. Criminal justice organisations locally should work together to ensure that support is provided for sexually exploited young people throughout the whole process of reporting the crime, making a statement, the pre‐trial preparation, going to court and after the trial. 10. The RBSCB should ensure that the use of disruption tactics permeates the work with young people; work in particular locations; work with local businesses; and targeting offenders. 11. GMP and a representative of the Sunrise Team should attend Licensing Panels to assist the Chief Officer in determining applications where drivers have been interviewed about the sexual exploitation of children. 12. RBSCB should establish a specific performance management framework to evaluate progress made by agencies in preventing child sexual exploitation; in diverting those at risk; in responding to the needs of those young people who are being sexually exploited; and in reducing the overall incidence of this type of abuse. 13. The RBSCB should establish multi‐agency information‐sharing meetings. 14. The RBSCB should ensure that these meetings collate and analyse information about offender and victim profiles and identify changing hotspot locations, so that disruptive action can be planned and taken. 15. The RBSCB should ensure that agreed actions to develop and support the Sunrise Team are implemented. Agreed actions include: a. Oversight and governance of the team should be co‐ordinated by RBSCB to ensure an effective multi‐agency approach; b. Commissioning arrangements should be formally agreed and integrated into a service level agreement with clear outcome and other performance measures; c. Consistent, high quality staff supervision and professional support is essential to enable practitioners to deal with complex and difficult safeguarding issues. This supervision and support should be provided within the team structure; d. The role and responsibilities of the Sunrise Team should be communicated to all agencies/ professionals who work or come into contact with children and young people; e. The referral pathway into the Sunrise Team must be clearly communicated to all agencies and potential referral sources: the referral pathway should be simple and accessible; f. The Sunrise Team’s approach should include physical, psychological, social and emotional assessments, plus immediate and ongoing assessments of risk, witness protection measures, support for the family and a key worker system. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 28 Addendum Meeting with the victims and witnesses When the CSE review was planned, it was the RBSCB’s intention to meet with the young people who were victims and witnesses to the abuse that had occurred. Their voices and opinions would be of the utmost importance when considering what lessons needed to be learnt and to help plan and inform future service interventions. Officers from GM Police and Children’s Social Care (CSC) that were still in with contact and offering services to the young people made initial contact. An independent worker facilitated and conducted the interviews with the young people and their families. Not all of the victims of the Court case were willing to take part in this part of the learning process. Suzie did take part in this process. The following highlights the key themes raised by the young people and the parents who took part in interviews. 1. Assessments and interventions by agencies All of the victims clearly identified agencies which they considered helped them and those agencies that had not been supportive. They expressed frustration with the initial response from CSC and the police and described these services as ‘not listening’ to them. They felt that they had cooperated fully with police processes and given sufficient information for the agencies to help protect them but nothing changed and the abuse carried on. CIT and Early Break were identified by two of the victims as being particularly helpful and acting as advocates on their behalf. CIT identified which services could help them and tried to get CSC and the police to do something. One of the victim’s parents reported that the police and CSC did not tell them what was happening and said that their 16‐year‐old daughter was just hanging out with a ‘bad crowd’ and was making choices about relationships and sexual partners. He informed that no one told him that these choices involved his daughter having contact with such men. 2. Power of the perpetrator All the victims described in detail the control the perpetrators had over every element of their lives. The threat of and in some cases the use of violence to control the victims was evident. These threats often included proposed violence against the victims’ families. This intimidation was given as one of the reasons the young people did not tell their parents what was happening and why they did not engage with services earlier. The victims explained that the perpetrators told them that they had committed the crime that they were prostitutes and that no one would believe them. RBSCB/Child Sexual Exploitation Themed Review/ Final September 2012 Page 29 3. Isolation The victims describe being trapped with no hope of escape from the abuse. They felt unable to tell their parents or friends what was happening as they felt they would not be believed. A common disclosure by the young people was that even when they cooperated with agencies, nothing changed, the abuse continued. The interviewer would like to comment on the engagement of the young people in this process. They were open, honest and engaged fully during what must have been an ordeal in reliving past events. The bravery shown by these young people was a humbling experience. |
NC52473 | Death of a 2-day-old girl in May 2020 from sustained injuries after mother appears to have fallen asleep while caring for the child. Learning is embedded in the recommendations. Recommendations include: share the learning from this case review, and the changes made to policy and practice as a result of Child W's death, with safeguarding children partnerships in England; obtain assurance that GP practices play an appropriate part in pre-birth planning; monitor the effectiveness of the action taken to increase professional awareness of the risks from co-sleeping; consider conducting a safe sleeping assessment when appropriate; obtain assurance that the pre-birth procedures and the integrated care pathway for pre-birth assessments are well understood and followed by professionals; obtain assurance that the 0-19 service, which commissions health visitors and school nurses, for public health services for children aged 0 to 19, has systems in place to ensure that antenatal visits are conducted; seek assurance of improvements made to risk assessment and pre-birth planning for expectant mothers with epilepsy; and work with partner agencies that may make home visits prior to full information sharing, in an effort to devise an approach for risk assessment for professionals, particularly when lone working.
| Title: Local child safeguarding practice review: Child W. LSCB: Barnsley Safeguarding Children Partnership Author: David Mellor Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Strictly Confidential 1 Barnsley Safeguarding Children Partnership Local Child Safeguarding Practice Review – Child W Contents Page Number Introduction 2 Terms of Reference 2-3 Glossary 3-4 Synopsis 4-14 Family contribution 14 Analysis 14-25 Findings and Recommendations 25-32 References 32 Appendix Strictly Confidential 2 1.0 Introduction 1.1 During May 2020, two days old child W sustained injuries from which she subsequently died after apparently being overlaid by her mother who appears to have fallen asleep whilst caring for the child. At the time of the incident mother and child W were receiving postnatal care in hospital. It had been necessary for child W to remain in hospital for 3-5 days following birth to enable monitoring of withdrawal symptoms, given mother’s long term use of prescribed morphine. 1.2 Antenatally, children’s social care had decided to remove child W from the care of her parents at birth. All mother and father’s previous children had been removed from their care and they had made determined efforts to conceal the birth of a previous child from the authorities. Children’s social care had applied for an Interim Care Order which was granted on the first working day after the incident in which child W was severely injured. 1.3 Barnsley Safeguarding Children Partnership decided to conduct a Local Child Safeguarding Practice Review (LCSPR). David Mellor was appointed as the independent reviewer. He is a retired police chief officer who has nine years’ experience as an independent reviewer of LCSPRs have and other statutory reviews. He has no connection to services in Barnsley. A description of the process by which the review was conducted is set out in Appendix A. 1.4 An inquest into the death of child W may be held in due course. 1.5 Barnsley Safeguarding Children Partnership wishes to express sincere condolences to child W’s family. 2.0 Terms of Reference 2.1 The period on which this review has primarily focussed is from October 2019 when agencies became aware of mother’s pregnancy with child W, until 16th May 2020 when the new born child W suffered injuries which later ended her life. There are a number of significant events which took place prior to October 2019 which have also been considered. 2.2 The key lines of enquiry addressed by the review are as follows: • How effective were the actions taken to safeguard child W following her birth? • How comprehensive was the assessment of mother, father and the unborn child W? • How effective was the Child Protection Plan for child W? • How effective was the Birth Plan for child W? Did the Birth Plan address any interval between birth and the removal of the child from her parents? • Did the earlier than anticipated delivery of child W impact upon the implementation of the Birth Plan in any way? • Given that Care Proceedings could not be heard until 4 days after the birth of child W at the earliest, should more urgent action to remove child W have been considered? Strictly Confidential 3 • How effectively were any risks mother may present to child W assessed and managed, including the risks associated with co-sleeping? • Was safe sleeping advice given to mother? • How effective was the supervision of mother and child W on the postnatal ward, including: • ‘specialing’ (enhanced observation of a patient) • how health care workers perceive risk and act on this • the risk assessment documentation • the handover between shifts • the role and input of the BHNFT safeguarding team • Was the prescribing of oral morphine to mother by her GP in accordance with expected policy and practice? • Was the dispensing of oral morphine to mother by the hospital pharmacy in accordance with expected hospital policy and practice? Should there have been any communication between the hospital pharmacy, the postnatal ward and the GP? • How effectively were any risks father presented to child W, directly or indirectly, managed? Did the fact that Covid-19 restrictions largely precluded his presence in hospital affect practitioner’s appreciation of the risks he may present to child W? • Did practitioners consider the possibility that father could exercise coercive control over mother by telephone or other means? • Did restrictions imposed as a result of Covid-19 impact in any way on measures necessary to safeguard child W? • Is the learning from this LSCPR consistent with the learning from the National Panel Review of Sudden Unexpected Death in Infancy? 3.0 Glossary Domestic violence and abuse is any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, psychological, physical, sexual, financial and emotional abuse. Emergency Protection Order is an order which enables a child to be removed from where they are, or be kept where they are, if this is necessary to provide immediate short term protection. An application for an EPO is regarded as a very serious step, and the Court to which the Local Authority applies must be satisfied that it is necessary and proportionate and there is no more appropriate order which could be sought. Interim Care Order is an order made by the Family Court under which a child can be looked after by the Local Authority on a temporary basis until the Court can make a final decision about the future of the child. Strictly Confidential 4 SafeLives DASH (Domestic Abuse, Stalking and 'Honour'-based violence) is a commonly accepted tool which was designed to help front line practitioners identify high risk cases of domestic abuse, stalking and ‘honour’-based violence and to decide which cases should be referred to the Multi-Agency Risk Assessment Conference (MARAC) and what other support might be required. Section 47 Enquiry is required when children’s social care have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. The enquiry will involve an assessment of the child’s needs and the ability of those caring for the child to meet them. The aim is to decide whether any action should be taken to safeguard the child. A Strategy Discussion must be held whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. The purpose of the Strategy Discussion is to decide whether a Section 47 Enquiry under the Children Act 1989 is required and if so, to develop a plan of action for the Section 47 Enquiry. 4.0 Synopsis 4.1 Mother and father are well known to services and first came to notice in Barnsley in 2013 when midwifery services noted that mother, who was pregnant, and father were the subject of a National Alert instigated by Durham children’s social care having left that area without notice. On that occasion the new born baby was removed into care at two days of age and subsequently adopted. 4.2 Both parents have a number of previous children, none of which are in their care. Mother has given birth to five previous children, all taken into care, and father is reported to have fathered eleven children, none of whom are in his care. 4.3 Locally, there was a history of domestic abuse in father and mother’s relationship. The first reported incident took place in October 2013 when father punched mother following a verbal argument. Father was charged and later convicted of assault. The sentence included a ‘programme requirement’, the details of which are not known. Over the following years the police were called to seven verbal arguments between mother and father. The arguments often related to the large number of dogs they kept on the premises and financial issues. In September 2017 mother disclosed that father had punched her on the torso but declined to answer the DASH (Domestic Abuse, Stalking and ‘Honour’ Based Violence) risk assessment questions nor would she support a prosecution. 4.4 On 6th April 2019 the police were called to an incident of domestic abuse involving father and mother which was assessed as ‘medium’ risk. Father was arrested for common assault although the Crown Prosecution Service (CPS) decided to take no further action. Mother’s responses to the DASH questions indicated longstanding coercive and controlling behaviour by father. A ‘helpline referral’ was agreed. Mother was noted to be five weeks pregnant at the time. It is not known what the outcome of this pregnancy was. (GP records indicate that mother had 9 pregnancies, 5 of which led to live births) There is no indication that the pregnancy generated any concern in the light of mother and father’s prior history (Paragraph 4.1) 4.5 A further domestic abuse incident was reported to the police on 19th May 2019. This was a verbal dispute between mother and father which was assessed as a ‘standard’ risk. Mother declined domestic abuse support and father was said to be returning to live with his Strictly Confidential 5 parents in Durham. There is no reference to mother being pregnant at the time of this incident. 4.6 On 3rd October 2019 mother was discharged from the specialist epilepsy service – provided by South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) - following a consultation with a neurologist during which dosages and titration of her epilepsy medication were explained. 4.7 On 13th November 2019 mother telephoned the specialist epilepsy service to say that she had not had any epilepsy medication for the past ten weeks and that her seizures had increased. She also said that she had recently changed her GP practice. The specialist epilepsy team contacted mother’s GP practice which advised that she had declined appointments in respect of her medication but that prescriptions had been issued for some epileptic medications and sent to her pharmacy. 4.8 The following day (14th November 2019) the specialist epilepsy service had further telephone contact with mother. The service checked mother’s electronic record and noted that on 30th October 2019 the GP Out of Hours service documented that mother was pregnant after taking a home pregnancy test two days previously. (This initial notification of mother’s pregnancy is recorded only in the SWYPFT chronology submitted to this CSPR). The epilepsy specialist discussed mother’s pregnancy with her because some anti-epilepsy medications are contra-indicated in pregnancy. Mother said that she had become pregnant after her implant failed and that, at her request, her GP had arranged an appointment on 20th November 2019 for termination of the pregnancy. Later the same day the epilepsy specialist spoke to mother’s GP practice to discuss her epilepsy medication. The GP said that mother had been advised to self-refer to a British Pregnancy Advisory Service (BPAS) clinic for a termination two weeks previously but mother did not appear to have done this. 4.9 The consultant neurologist subsequently advised mother’s GP that her epilepsy medication could continue if the termination was taking place. Mother was invited to an appointment with the specialist epilepsy service on 13th December 2019 to discuss her medication and establish whether or not she was still pregnant. 4.10 On 26th November 2019 mother phoned the specialist epilepsy service to say that her GP practice would not issue any medication to her because her patient records from the previous GP practice had not been transferred. She confirmed that she was going ahead with her termination although she had no date for this as yet. The epilepsy specialist contacted mother’s GP practice which advised that mother, accompanied by father, had visited the surgery that day to request ‘pain medication’ which the GP had been reluctant to prescribe as mother had already been prescribed ‘two lots of painkillers’ that week. The GP added that mother had not requested epilepsy medication which the practice was reluctant to prescribe due to her pregnancy. The GP was asked to check whether the letter from the consultant neurologist (see previous paragraph) had been received. The GP said that ‘an alert had been utilised’ during the consultation with mother and father as the GP had felt threatened. The GP documented that during the consultation mother had started crying and father had entered the room at some point and begun ‘speaking loudly’. 4.11 On 5th December 2019 mother contacted the specialist epilepsy service wishing to re-start her epilepsy medication as she reported having more seizures. She said that she had a dating scan arranged for 11th December 2019 and the termination – in Newcastle - was also booked in. The epilepsy service phoned mother’s GP practice which said that they were confident that the termination was going ahead and, as such, they were happy to Strictly Confidential 6 recommence mother’s epilepsy medication. Mother later confirmed that she had re-started her epilepsy medication and had had no further seizures. 4.12 On 2nd January 2020 the epilepsy team phoned mother who said that because she had been depressed she had not attended the scan appointment and the termination had not yet taken place. Mother said that she was still planning to have a termination and was advised to continue with the epilepsy medication. It was planned to review the situation the following week but several calls to mother’s mobile phone between 8th and 17th January 2020 received no reply. 4.13 On 17th January 2020 the epilepsy team phoned mother’s GP practice which said that mother had not been seen by them since 5th December 2019. The GP practice had been contacted by BPAS on 19th December 2019 to advise that mother had not attended for the scheduled scan. The GP practice went on to advise that mother had previously had five children removed from her care and adopted for ‘safeguarding reasons’, although mother was said to be hopeful that she could keep the baby from the current pregnancy. 4.14 The epilepsy team offered mother an appointment for 27th January 2020 which she did not attend. 4.15 On 12th February 2020 BPAS Safeguarding Admin contacted children’s social care to advise that mother was around twenty four weeks pregnant with an estimated delivery date (EDD) of 1st June 2020. BPAS added that mother had initially attended the service in November 2019 stating she wanted to have a termination but had not attended further appointments and the service had been unable to contact her for some time. It was understood that mother had arranged her own scan after missing a BPAS scan appointment. BPAS went on to say that mother had re-contacted them on 8th February 2020, at which time she was still requesting a termination but had been advised that it was now too late for a termination and that she needed to book in for antenatal care. 4.16 Children’s social care phoned mother the same day. She confirmed that she had been advised that it was now too late for her to have a termination. She explained that she had sought a termination because of her health conditions, including epilepsy. She said that she had not yet booked in for antenatal care but planned to discuss this with her GP on 25th February 2020. She added that she felt that she should have stopped taking her epilepsy medication whilst pregnant and was to contact the epilepsy service for advice. Children’s social care advised mother that a pre-birth assessment would need to be carried out due to the service’s past involvement, which mother said she understood. 4.17 On 17th February 2020, the social worker to whom the pre-birth assessment had been allocated made initial telephone contact with mother and also notified midwifery, advising them that mother was 24 weeks pregnant and had not yet received antenatal care. 4.18 On 20th February 2020 mother’s GP practice contacted midwifery to advise of mother’s pregnancy and highlight that all her previous five children had been removed. The GP practice said that they had ‘minimal information’ as to why the children had been removed, adding that mother had told them it was because of father’s previous involvement with the police. Mother was prescribed medication for epilepsy, asthma and morphine and mirtazapine for stomach pains. 4.19 On 23rd February 2020 mother was seen by midwife 1 at her home address for booking in. Mother was noted to be 25 weeks pregnant. Health concerns were noted in Strictly Confidential 7 respect of smoking and opioid use. Personality disorder was also recorded although this was later confirmed with her GP to be self-diagnosed. Mother disclosed sexual abuse by her father. She also disclosed that she had previously tried to conceal a pregnancy by moving to Barnsley and using her sister’s name in order to take the baby home. Nineteen animals were noted to be present at the home. 4.20 On 28th February 2020 mother and father did not attend the scheduled pre-birth assessment meeting with the social worker. 4.21 On 3rd March 2020 mother did not attend her first antenatal appointment and a new appointment was given. It had been planned that mother would also be seen by the substance misuse midwife at this appointment because of her long-term morphine use. 4.22 On 4th March and 6th March 2020 mother and father did not attend scheduled pre-birth assessment meetings with the social worker. 4.23 On 9th March 2020 children’s social care discussed progressing the case to a strategy meeting and a Section 47 assessment in the light of the lack of engagement from the parents in the pre-birth assessment. It was decided to persist in attempting to engage them in the pre-birth assessment for a further short period. 4.24 On 10th March 2020 safeguarding midwife 1 phoned the social worker to inform her that mother had not attended her first antenatal clinic appointment and had been sent another appointment for 25th March 2020. 4.25 On 13th March 2020 mother did not attend a further scheduled pre-birth assessment meeting with the social worker which prompted a phone call to father who said that mother’s ill health – severe migraines, vomiting, diarrhoea and stomach cramps – had prevented her attending appointments. However, father attended that day. 4.26 On 24th March 2020 mother phoned the antenatal clinic lead to say that she would not be attending the 27th March antenatal clinic as she was asthmatic and had therefore chosen to self-isolate as a result of Covid-19 risks. Mother was offered antenatal care which would involve minimal contact with staff and other patients including being placed last on the list for clinic appointments. 4.27 On 25th March 2020 the case was reviewed by the substance misuse midwife who, in addition to the information previously noted in this case summary, documented that mother had previously self-harmed and father had six children who were not in his care. The plan arrived at as a result of the review was for the substance misuse midwife to contact mother to provide reassurance around hospital care and to request a telephone strategy meeting as soon as possible. 4.28 On 26th March 2020 the social worker contacted mother’s epilepsy specialist who said that she had not been engaging with the service and appeared to have not taken any epilepsy medication since she became pregnant, despite continuing to take tramadol and morphine. (The epilepsy service had recently had further contact with mother’s GP practice which had confirmed that mother had not collected epilepsy medication since October 2019 which contradicted mother’s assertion that she had recommenced taking the medication). The epilepsy specialist explained that as mother suffered with tonic-clonic seizures in which she was likely to fall to the floor and convulse, continuing taking epilepsy medication was usually recommended as falls represented as much, or more, danger to the baby as the Strictly Confidential 8 medication. Mother’s engagement with the epilepsy service continued to be ‘poor and inconsistent’ 4.29 On 30th March 2020 midwife 1 rang and texted mother who texted a reply the following day to say that she would ring midwife 1 on Wednesday 1st April 2020 but did not do so. On Thursday 2nd April 2020 midwife 1 again rang and texted mother and received no reply. 4.30 On Thursday 2nd April 2020 mother and father did not attend telephone appointments for the pre-birth assessment. Mother later sent a text saying that as she had been self-isolating her sleeping routine was ‘all over the place’. 4.31 On Wednesday 8th April 2020 the social worker and a colleague made home visits. After initially not being admitted, father answered the door to say that mother was in bed with abdominal pain and that the social worker needed to ring in advance of any visit. 4.32 On Thursday 9th April 2020 the social worker made a home visit and saw mother and father. Mother appeared small for the stage of her pregnancy and she commented that she was usually larger by this stage of previous pregnancies. She said that she had been having a minimum of three seizures a week and all had resulted in unconsciousness for several minutes. She confirmed that she was not taking epilepsy medication which prompted a ‘long conversation’. Mother told the social worker that her friend had advised her to deliver the baby at home so that no-one would know about it, allowing her to keep her baby. Mother added that she had no intentions of doing this and the social worker strongly advised against it. Father was said to ‘look different’ during the visit. When the social worker questioned his appearance, he said that he had taken two tramadol’s that morning. 4.33 Following the home visit, the social worker updated midwifery and the epilepsy team. The social worker said that mother had agreed to attend an antenatal appointment but was refusing to attend an appointment with the epilepsy team. The social worker said that she was writing a pre-birth assessment although mother had not attended any formal assessment sessions whilst father had engaged in only two sessions. 4.34 On Friday 10th April 2020 midwife 1 scanned a private scan mother had had on 8th January 2020 into mother’s patient record. The EDD had previously been calculated to be 18th June 2020 but on the basis of the private scan was then documented to be 4th June 2020. 4.35 On Monday 13th April 2020 mother texted social worker to say that ‘legal proceedings were not what they wanted’ and that they would do anything to keep their baby and ‘be a family’ and prove that they were good parents. She described the prospect of the baby being removed at birth as ‘devastating’. 4.36 On Wednesday 15th April 2020 mother was seen by midwife 1 who referred her to the epilepsy nurse and transferred her to the care of a different obstetric consultant who specialised in epilepsy. Mother reported historic cannabis use. She said she was on anti-depressants but described her mood as ‘good’. The EDD was documented as 18th June 2020 at this point which did not reflect the amended date of 4th June 2020 (see Paragraph 4.34). Mother was advised of the need to remain in hospital for between 3 and 5 days following the birth due to the baby’s possible withdrawal from mother’s prescribed morphine medication. A Medical Paediatric Alert referral form was completed relating to concerns with Strictly Confidential 9 Group B Streptococcus - which is the UK's most common cause of life-threatening infection in new born babies – and morphine use, which was sent to the paediatrician. 4.37 On Thursday 16th April 2020 a safeguarding midwife contacted children’ social care to request a birth plan as the due date had been altered to 4th June 2020. On the same day the safeguarding midwife also spoke to mother about creating a ‘memory box’ and ‘life journal’ following the removal of child W. 4.38 On the same date (Thursday 16th April 2020) the epilepsy specialist advised social worker that she had spoken to mother and planned to support her to re-start her epilepsy medication. The relevant prescription was sent to mother’s GP on 21st April 2020. The epilepsy specialist also appears to have suggested a multi-disciplinary team (MDT) meeting, although there is no indication that this was actioned. 4.39 On Monday 20th April 2020 the pre-birth assessment was completed which recommended that Section 47 enquiries should commence and in parallel, legal advice should be sought. On the same date the Head of Service for children’s social care consulted with Legal Services following which it was decided to issue Public Law proceedings at birth in respect of the unborn child W. When mother and father were advised of the pre-birth assessment recommendations, they requested a change of social worker and that further communication be sent to their ‘legal team’. 4.40 On Wednesday 22nd April 2020 mother did not attend an antenatal clinic appointment. On the same date health visiting were notified of the late booking pregnancy by midwifery. 4.41 On Monday 27th April 2020 the police were called to a verbal argument between mother and father over their 16 dogs. The incident was assessed as a ‘standard’ risk. It was noted that there had been previous ‘low-level’ incidents between father and mother. Referrals to Independent Domestic Abuse Services (IDAS) were offered to both parties and apparently declined. No referral to children’s social care appeared to be considered in view of mother’s pregnancy. 4.42 On Tuesday 28th April 2020 the health visitor contacted the social worker to ask about the outcome of the pre-birth assessment. Having been advised that the outcome was a decision to issue Public Law proceedings on the birth of child W, the health visitor advised that she would not be making antenatal contact with the parents. The social worker responded by saying that professionals should complete scheduled interventions. 4.43 On Wednesday 29th April 2020 mother did not attend an antenatal clinic appointment and the following day the antenatal midwife tried to ring mother and left her a message. 4.44 On Thursday 30th April 2020 a strategy meeting took place. The meeting took place virtually due to Covid-19 restrictions. A number of concerns were shared including: • Mother and father had been known to children’s social care and the police in South Yorkshire and elsewhere for a number of years. • A number of children had previously been removed from their care and neither mother nor father had any of their children in their own care. Strictly Confidential 10 • Attempts had been made to conceal previous pregnancies and the couple were known to abscond which made timely reporting of concerns to children’s social care ‘paramount’. • Father was known to the police for sexual and physical abuse of children, arson, possession of offensive weapons, fraud and harassment. Mother was known for threats to kill, harassment and drugs. It was also noted that the couple ran a dog breeding business from their home address which had attracted enforcement activity and complaints. • Both mother and father had failed to meaningfully engage with services or with the pre-birth assessment in respect of the unborn child W. • Mother’s medical history was compounded by prescribed morphine. 4.45 It was also documented that mother wanted to leave father and needed help to do this. She had texted the social worker that day saying that she needed to be assessed alone as her relationship with father had broken down. She added that she ‘needed a house’ which she was ‘having difficulty with’. The reported incidents of domestic abuse were discussed, including indications of coercion and control by father. 4.46 The outcome of the strategy discussion was that the unborn child W was at risk of suffering significant harm, that single agency Section 47 enquiries should be commenced by children’s social care and an Initial Child Protection Conference (ICPC) should be convened. It was also documented that children’s social care had decided to seek an Interim Care Order and remove the child from mother. Additionally, midwifery were to assess mother’s mental health, screen her urine and she was to be referred to IDAS. A planned antenatal telephone contact by the health visitor with mother was also agreed at the meeting. 4.47 On the same date (30th April 2020) duty social workers attempted to make a home visit but did not receive an answer. 4.48 On Friday 1st May 2020 duty social workers made a home visit. Mother was present but not father. Mother declined a referral to IDAS as she said there was no domestic abuse, although there had been in the past. She added that father was ‘fine’ but ‘distant’ because of the involvement of children’s social care. The social workers documented concerns about mother’s presentation which was described as ‘erratic’ throughout. 4.49 On Sunday 3rd May 2020 mother did not attend an antenatal appointment. 4.50 On Monday 4th May 2020 mother sent the following text to social worker, ‘Out of curiosity, what would your position be if I went at this alone?’ The social worker responded by saying that she needed to speak with both mother and father. 4.51 On Tuesday 5th May 2020 Section 47 enquiries concluded that an ICPC should be convened in light of the concerns. 4.52 On Wednesday 6th May 2020 mother attended an antenatal appointment where she was reviewed by a consultant. Mother reported that she had begun to take epilepsy medication although she was not engaging with the epilepsy service. She continued with anti-depressants, morphine and used nicotine patches. A scan was completed. Reduced Strictly Confidential 11 amniotic fluid was noted. A drug test was performed and mother tested positive for opiates as expected given the morphine she was prescribed. 4.53 On the same day (6th May 2020) children’s social care sent the birth plan to midwifery who noted that the plan stated that children’s social care were to be informed of the birth by midwifery; mother would have full time care of the baby whilst in hospital until the Interim Care Order was granted; assessment of care of the baby was required whilst on the ward; there were no restrictions on who could visit the baby although mother and father would need to be supervised closely given ‘father’s history and mother’s health’; the baby would be discharged from the hospital to foster carers and police and children’s social care were to be contacted at the point of discharge. 4.54 On Thursday 7th May 2020 safeguarding midwife 1 contacted the social worker to request the birth plan to be amended to reflect the current Covid-19 restrictions in that no visitors were allowed to visit, father could be present during the birth but would be asked to leave shortly afterwards. Additionally, ward staff would not be able to provide 24-hour supervision of mother and baby but would provide routine postnatal care to mother and baby and endeavour to provide additional support when necessary. The ‘additional support’ contemplated appeared to be for mother and child W to be in a room next to the nurse’s station with the door open so staff could have more oversight. 4.55 Also on Thursday 7th May 2020 the social worker made a home visit to share the outcome of the pre-birth assessment with mother and father. Mother had rearranged the visit from the previous day and later sought to defer the 7th May visit but the social worker made the visit and spoke to mother. Father was absent. Mother’s presentation during the visit was documented to be concerning and erratic. 4.56 On Monday 11th May 2020 child W was allocated to a health visitor. 4.57 On Tuesday 12th May 2020 the social worker made a planned home visit but received no answer. Wednesday 13th May 2020 4.58 Safeguarding midwife 1 contacted children’s social care to advise that mother was in hospital and the birth was to be induced following concerns about reduced foetal movement which had arisen during her appointment with the consultant earlier that day. She requested a copy of the birth plan which was to have been amended following the discussions which took place on 7th May 2020. The birth plan was then sent to midwifery. It had not been amended to reflect the feedback made by midwifery on 7th May 2020 (Paragraph 4.54). 4.59 Prior to going into hospital, it is understood that mother visited her GP practice in an effort to obtain her weekly morphine prescription in advance of the date on which it was due. Her request for the early prescription was refused. It is understood that she informed the GP practice that she was to be admitted to hospital for the birth of child W. However, maternity records indicate that the decision to induce the birth was taken after mother attended hospital for a scan so it is unclear how mother could have communicated the impending arrival of child W to her GP practice with any degree of certainty. Thursday 14th May 2020 Strictly Confidential 12 4.60 Mother gave birth to child W during the early hours of the morning. Her friend supported her as father was documented to be ‘unwell’. The baby was fit and well and she and mother were transferred to the antenatal postnatal ward. At this point the clinical recommendations were for increased observation from once per day to twice per day for mother as she had had a raised white cell count therefore the observations were initially hourly, then two hourly observations for child W for feeds and for review of neonatal abstinence syndrome (NAS). Maternity advised children’s social care of the birth of child W. 4.61 At 8am mother was reviewed by the substance misuse midwife, who discussed her current medications. It was explained to mother that she must only take the medication prescribed by the hospital and that any medication she had brought with her should be handed to staff for safe storage and dispensing. Mother said that she had only brought her Keppra (epilepsy treatment) and inhalers (asthma treatment) into hospital. The inhalers were left with mother to self-medicate as required. At this time, child W was appropriately dressed and nursed in the cot, where she was settled post feed. Safe sleep was discussed with mother as per Lullaby Trust guidelines (The Lullaby Trust raises awareness of sudden infant death syndrome (SIDS), provides expert advice on safer sleep for babies and offers emotional support for bereaved families). 4.62 Later in the morning mother left the ward in her nightwear and took a taxi to her GP practice and collected her morphine prescription which she then took to the community pharmacy for dispensing before travelling back to the hospital by taxi. The GP practice is 4 minutes’ drive from the hospital. The collection of the prescription from her GP practice was timed at 9.47am. Hospital staff were unaware that mother had left the ward for this purpose. The hospital had assumed responsibility for prescribing mother’s medication for the period of her admission meaning that she was later also prescribed morphine from the hospital pharmacy which was unaware that her community prescription had been dispensed. 4.63 From 2pm NAS monitoring of child W was adjusted to four hourly. However, maternity records state that child W was seen every two hours at a minimum. 4.64 As neither parent would be able to attend – mother was in hospital with child W and father was unwell – and the Local Authority planned to make an application for an Interim Care Order, it was decided not to proceed with the scheduled ICPC that day. The ICPC would be reconvened as a matter of urgency should the Court not support the Local Authority’s application. 4.65 During the day the social worker spoke with mother who said that child W was of lower birth weight than her previous children and that she was having some difficulty feeding her. She said that whilst she did not agree with the Local Authority’s decision, she did not intend to ‘jeopardise anything’. She also reported a lack of communication with father, adding that he had told her that he did not want to go through the process of supervised contact with the child and ‘all the emotional stuff’ again. The social worker attempted to phone father but did not get a reply to her call. 4.66 Ward staff noted that mother appeared to be in a ‘good mood’ and was regularly engaging with staff to ask for assistance with baby cares or to talk to them in general conversation. She was noted to frequently leave the ward, reportedly to speak to friends on the ‘landing’ who wanted to see the baby. Ward staff informed her that she should not be doing this due to Covid-19 restrictions. Child W was fitted with an ankle bracelet, as is routine for all new born babies on the ward, which allowed for monitoring of where the child was. Ward staff, who had been advised to be ‘hyper vigilant’ in case mother attempted to Strictly Confidential 13 remove the baby from the hospital, offered mother the opportunity to video call her friends so that they could see the baby. The possibility of calling security appeared to be under consideration. Friday 15th May 2020 4.67 Midwifery advised children’s social care that mother and baby were doing well. The midwife had been caring for the baby whilst mother went to have an implant fitted (contraception) but usually mother was undertaking all care of child W independently and there were documented to be no concerns. Child W was showing no signs of withdrawal but the plan was for the baby to remain under observations for 5 days. 4.68 During the morning the substance misuse midwife reviewed mother and noted that she presented well and was not in a sedative state. The substance misuse midwife again discussed mother’s medication with her and she confirmed she only had her inhalers and the Keppra. Mother was advised to give the Keppra to the midwife providing care to her. Mother questioned her morphine prescription stating that the dose had changed. The specialist Midwife reviewed the prescription as there was a discrepancy between what mother was saying and what was to be prescribed. The substance misuse midwife paused the morphine until the dose was confirmed by the GP practice. Mother consented to the substance misuse midwife calling her GP practice to seek clarity in respect of her prescribed medication. At this point it was again reiterated to mother that she must only take the medication the Hospital prescribed. The GP practice was informed that mother had given birth and was currently an in-patient. This contact with mother’s GP was also prompted in part by her request for codeine in addition to her prescribed morphine which was considered unusual given that she had had a normal vaginal delivery and was taking morphine. 4.69 The social worker phoned mother who requested support to find alternative housing away from father because their relationship was ‘over’. She said that she had lost her children and twelve years of her life because of father and insinuated he had been unfaithful to her earlier in the year. She added that he had shown no interest in this pregnancy and she was also worried about him neglecting their dogs whilst she was away from home. She said that she planned to stay with a friend following her discharge from hospital. (This appears to have been the same friend who was present during the birth of child W). 4.70 Following the phone call with mother, the social worker emailed safeguarding midwife 1 to advise that the Court paperwork had been completed which was with management for approval, and carers for child W had been identified. The social worker added that she had spoken to mother by telephone and she had been very tearful and asked hospital staff to ‘check in’ with mother over the weekend as she seemed isolated. The social worker also advised that mother had told her that she didn’t want father to have contact with the baby after the Interim Care Order had been secured. 4.71 The social worker submitted her statement and the care plan for child W to Legal Services and this was then transmitted to the Court. 4.72 During the afternoon ward staff noted that child W had been left in their room alone by mother and had begun to cry. Mother was noted to be off the ward for an hour. Saturday 16th May 2020 Strictly Confidential 14 4.73 During the night (Friday/Saturday) ward staff noted mother to be tearful. She said she had had an argument with father and that she had been ‘thrown out’ of the house she shared. She was also worried about their 16 dogs. However, she was noted to be caring for child W independently and asking questions ‘relevant’ to the care of the child. 4.74 At approximately 7.45pm mother ran out of the side room saying the baby was unresponsive. She said that she had fallen asleep with the baby at approximately 6.30pm and woke to find the baby unresponsive although this was not witnessed by staff. Extensive neonatal resuscitation commenced but child W was found to be critically ill after apparently being over laid by mother. Sunday 17th May 2020 4.75 A virtual strategy discussion took place and a Police Protection Order was taken out as an interim measure in advance of the Interim Care Order, which was granted by the Court the following day. 4.76 Child W died on 14th September 2020 following a High Court judgement that she be transferred to palliative care. 5.0 Family contribution to the review 5.1 At the time of writing both mother and father were subject to a criminal investigation which precluded offering them the opportunity to contribute to the review at this time. 6.0 Analysis History of concealed pregnancies 6.1 Both mother and father have a number of children – mother has five and father has eleven -none of whom are in their care. They also have a history of attempting to conceal pregnancies from the authorities in order to prevent new born children being taken into care, including travelling from Durham to Barnsley in 2013 to enable mother to give birth in an area in which the couple were not known to services. 6.2 Given this history, and the high risks which mother and father may present to children conceived by mother, local agencies could have responded to initial information that mother was pregnant with child W with more alacrity. Additionally, an earlier pregnancy, which it is assumed did not progress to full term, did not generate any curiosity by the police or consideration of a referral (Paragraph 4.4). 6.3 Mother’s pregnancy with child W was first noted by I-HEART Barnsley - which provides out of hours GP services - on 30th October 2019, when it is estimated that she would have been around two months pregnant. It is not known whether I-HEART had access to any information which could have generated concern about the pregnancy, but this pregnancy was recorded in mother’s patient record which was picked up both by her GP and the epilepsy service (Paragraph 4.8). Although the epilepsy service were not aware of the fact that all mother’s previous children had been removed from her care at that stage, the GP practice was aware of this fact (Paragraph 4.18) although the fact that mother’s stated intention was to have a termination seems likely to have diminished the GP’s perception of safeguarding concerns for the unborn child. Strictly Confidential 15 6.4 However, the GP practice could have considered a safeguarding referral, or at least initiated a conversation with children’s social care, when doubts about mother’s intention to follow through with the termination arose from 19th December 2019 (Paragraph 4.13). The epilepsy team could also have considered a discussion with SWYPFT’s safeguarding team, a safeguarding referral, or contact with children’s social care, when mother’s GP advised them that her previous five children had been removed from her care for ‘safeguarding reasons’ (Paragraph 4.13). 6.5 Given the compressed time period subsequently available to partner agencies to safeguard the unborn child W - from 12th February until 14th May 2020 – it would have been helpful for children’s social care and partner agencies to have been given the earliest possible notification of mother’s pregnancy. How comprehensive was the assessment of mother, father and the unborn child W? 6.6 As stated above, there was not an abundance of time for children’s social care to conduct a pre-birth assessment and then address the concerns arising from that assessment prior to the birth of child W. The time available was reduced when mother’s estimated date of delivery was re-calculated from 18th June to 4th June 2020 and when child W was actually delivered even earlier on 14th May 2020. 6.7 The lack of time available to partner agencies was compounded by what appears to have been deliberate efforts by mother and father to evade contact with children’s social care and maternity services. Mother and father failed to attend the first four in-person pre-birth assessment appointments with the social worker and when telephone appointments took place as a result of Covid-19 restrictions, they were equally elusive. Additionally there was no answer to three out of four home visits made by the social worker. Nor did mother attend the five antenatal clinic appointments maternity offered to her during March and April 2020, although she was under no legal obligation to attend these. 6.8 Maternity offered mother support in an effort to encourage her to attend the antenatal clinic appointments, including funding a taxi, placing her last on the list for clinic appointments so that she could have as little contact with staff and other patients as possible, given her concerns that her asthma put her at increased risk should she contract Covid-19. She was also assured that the enhanced personal protective equipment was being used. Additionally, midwife 2 attempted to contact mother to provide reassurance around the care offered to her by the hospital. 6.9 The social worker escalated the case to management on 9th March 2020 when it was decided to persist in attempting to engage with the parents rather than progress to a strategy meeting and a Section 47 assessment at that time. Whilst it was not unreasonable to allow a little more time for the parents to engage, it was a further 7 weeks before the strategy meeting took place. From the outset it seemed unlikely that mother and father would be able to demonstrate that meaningful change had taken place since the previous attempt to deceive agencies about the birth of a child in 2013, albeit 7 years had elapsed. As such, there was a growing inevitability about the need for a strategy meeting and it would have been more appropriate to progress to a strategy meeting at the earliest opportunity. The case was also escalated by maternity services and following a review by the substance misuse midwife on 25th March 2020, she decided to request a telephone strategy discussion as soon as possible. Strictly Confidential 16 6.10 Despite the very limited engagement from mother and father, the pre-birth assessment was completed by 20th April 2020 which led to decisions to commence Section 47 enquiries and to issue Public Law proceedings upon the birth of child W. 6.11 In their contribution to this review, children’s social care state that the very limited engagement of mother and father adversely affected the pre-birth assessment. In particular the service’s understanding of the relationship between mother and father was largely based on historical information and there were a number of ‘unknowns’. It is concluded that this is a balanced view of the comprehensiveness of the assessment of mother, father and the unborn child W. How effectively were any risks mother may present to child W assessed and managed, including the risks associated with co-sleeping? 6.12 A virtual strategy meeting took place on 30th April 2020 which appears to have been the first time that all risk information was shared because during the meeting the social worker noted that she had previously been unaware of the risk that father had previously carried weapons and had been attempting home visits unaccompanied. 6.13 The minutes of the strategy meeting document that a very substantial amount of risk information was shared. For example the police said that their researcher had compiled a 30 page document detailing incidents involving father and mother. The risk information was eventually distilled down into the following concerns: • ‘Historic criminality’ • ‘Domestic violence’ • ‘Historical children removed from parents’ care’ • ‘VISOR – encouraging sexual act of 13 year old boy’ • ‘Not engaged epilepsy, social care, antenatal services’ • ‘Substance use’ • ‘Concern for health of baby’ • ‘Concerns regarding health of mother’ 6.14 With the benefit of hindsight, the specific area of risk which led most directly to child W’s death was mother’s use of opiates and possible dependence and the history of what appears to have been ‘drug seeking behaviour’ by herself and father. The primary source of information about this area of risk was mother’s GP practice, which was not represented at the strategy meeting. However, midwifery highlighted ‘historical’ records from mother’s GP practice, which were said to ‘possibly’ relate to her last pregnancy, which indicated that she had been extremely abusive when not able to obtain morphine based drugs from the GP practice. Additionally the police informed the meeting that an unknown female (who may, or may not have been mother) in company with father altered a prescription and attempted to get it dispensed in Sheffield in August 2019. The police also described father as a cocaine user. 6.15 During the meeting the social worker said that father appeared to have a glazed expression when she saw him which prompted a discussion of whether he could also be using mother’s pain relief medication, which she was noted to be prescribed ‘a lot of’. Concerns about both father and mother’s presentation – on the rare occasions on which it had been possible for them to be observed by professionals – (Paragraphs 4.32, 4.48 and 4.55) was thought to be a possible indicator of substance misuse. Strictly Confidential 17 6.16 The only risk that mother’s use of morphine was considered to present to child W was the risk to the child of withdrawal symptoms from the drug. One of the many actions arising from the strategy meeting was for midwifery to conduct urine screening of mother. Mother’s opioid use had been noted as a ‘health concern’ at her maternity booking-in appointment and it had been planned for her to be seen by the substance misuse midwife earlier (Paragraph 4.21), but this was finally accomplished when mother attended an antenatal clinic appointment on 6th May 2020 and tested positive for opiates (Paragraph 4.52). 6.17 Arguably more weight could have been given to mother’s use of painkillers, including morphine and her and father’s drug seeking behaviours but in fairness to the professionals who attended the strategy meeting, there was an unusually substantial risk history to consider in this case. In attempting to make sense of this substantial risk history, it may have been helpful to have a clearer focus on the risks to child W during the periods prior to, and following, her birth. During the period prior to her birth, there were a wide array of risks such as the risk of the parents absconding, mother’s compliance with her epilepsy medication which increased her risk of seizures, the risk of domestic violence and abuse by father on mother, and their lack of engagement with both health and social care professionals. Following the birth, the range of risks to child W narrowed somewhat. For example the risk of mother absconding with the child was mitigated by the oversight of medical professionals on the ward and the fact that the ankle bracelet worn by child W would trigger an alarm if mother attempted to remove her from the ward. 6.18 The review has received no information to indicate mother’s use of painkillers including morphine and her drug seeking behaviour informed any safe sleeping risk assessment for the period in which mother would be caring for child W in hospital. There is no indication that a safe sleeping risk assessment was carried out. Normally such a risk assessment would have been carried out as part of the new birth visit by the health visitor. No such postnatal visit was scheduled to mother as it was understood by all professionals involved in the case that, assuming the Interim Care Order was granted, mother would not be taking child W home with her. As previously stated safe sleeping advice was provided (Paragraph 4.61). 6.19 It seems likely that no safe sleeping risk assessment was considered because it was anticipated that child W would be in the care of mother for only a short period and this brief period of maternal care would take place within the maternity ward of a hospital where mother and baby would be regularly observed and cared for by medical professionals. Many of the factors known to increase risk of sudden unexpected death in infancy from co-sleeping would not be present in a maternity ward environment such as parental smoking, sleeping on a sofa or armchair, sharing a bed with the baby or overcrowding. However, parental substance use is a factor known to increase the risk of death from co-sleeping and although the hospital assumed responsibility for the prescription and administration of drugs to mother, a hospital is not a secure environment and there was nothing to stop mother leaving the ward from time to time, nor was there any means of exerting control over who she made contact with when absent from the ward, nor was there any means of monitoring of any substances she obtained whilst absent from the ward. 6.20 SWYPFT has advised this review that from the discussions which took place at the strategy meeting, it was the perception of the epilepsy team that mother would not be involved in the care of child W post-delivery. Had it been understood that mother would be caring for child W for a time, a risk assessment should have been completed by the epilepsy team. This normally takes place at 32 weeks, although mother was not engaging with the epilepsy team at that time. Strictly Confidential 18 6.21 It is worthy of note that the nationally mandated antenatal visit by the health visitor (1) did not take place in this case. There had been some discussion between professionals as to whether the antenatal visit was necessary given that child W was to be removed from mother’s care shortly after birth, but ultimately it was decided that all scheduled interventions should be completed (Paragraphs 4.42 and 4.46). In the event, no antenatal visit to mother was completed, possibly because of the compressed time period during which professionals were aware of mother’s pregnancy. 6.22 Whilst some of the issues expected to be addressed during the health visitor antenatal visit would not have been relevant to mother and father, such as the explanation of the health visitor offer; a family needs health assessment, emotional support and infant feeding would have been relevant and could have informed oversight of the care of child W by mother in hospital. 6.23 It is worthy of note that this is the third Barnsley LCSPR completed by this independent reviewer in which the antenatal visit was not completed including two cases in which very young babies died. 6.24 It is concluded that the risks arising from mother’s use of morphine and possible dependence and the history of what appears to have been ‘drug seeking behaviour’ by herself and father were insufficiently articulated and explored. This risk was overshadowed by other risks mother and father were considered to present to child W. Whilst clarifying risks was made more challenging by the limited engagement of mother and father in the pre-birth assessment and the compressed time window available to professionals, it may have been helpful to have a clearer focus on the risks to child W during the periods prior to, and following, her birth. A safe sleeping assessment should have been carried out for the period in which mother cared for child W in hospital. How effective was the Birth Plan for child W? Did the Birth Plan address any interval between birth and the removal of the child from her parents? 6.25 The birth plan documented a number of concerns from father and mother’s history but did not always specify which concerns related to which parent and those which applied to both parents. For example ‘being a perpetrator of domestic abuse/violence’ and ‘domestic abuse within the couple’s relationship’ were included in the documented concerns but it was not stated which parent was perceived to be the perpetrator and which the victim. Additionally ‘substance misuse history’ was documented but no further details were provided. Looking back, children’s social care and BHNFT both feel that the birth plan should have specifically addressed mother’s capacity to parent child W safely and any risks mother may have presented to child W. 6.26 The birth plan went on to state that ‘the couple need to be supervised closely given father’s history and mother’s health needs’. ‘Supervised closely’ was not defined. 6.27 An opportunity to clarify the level of supervision required arose when safeguarding midwife 1 requested the amendment of the birth plan to reflect the impact of Covid-19 restrictions – which would limit father’s presence in the hospital to the delivery only – and pointed out that 24 hour supervision of mother and baby would not be possible. Safeguarding midwife 1 went on to state that routine postnatal care would be provided to mother and child W and that ward staff would endeavour to provide ‘additional support’, which appeared to consist of locating mother and child in a room next to the nurse’s bay with the door open which would facilitate more oversight (Paragraph 4.54). Strictly Confidential 19 6.28 Four working days after safeguarding midwife 1 requested the amendment of the birth plan, mother was admitted to hospital for the birth of child W. The birth plan had not been amended as requested by safeguarding midwife 1 and there is no indication that any discussion took place to further consider the level of supervision required during the period in which mother would be caring for child W in hospital. This meant that the birth plan was not fully fit for purpose and provided insufficient clarity to the staff likely to come into contact with mother and child W during their 3-5 day stay on the postnatal/antenatal ward. 6.29 It would have been beneficial to formally document the level of supervision required of mother and the new born child W. If the level of supervision could not be provided by the hospital, then this would have necessitated consideration of how mother and child W were to be supervised whilst in hospital. 6.30 Father’s exclusion from the hospital - except for the period of the birth - appeared to reduce some of the risks documented in the birth plan but the plan was not revised to document how his absence from the ward affected the risks he could present to child W, mother and professionals. Had this been done it could have led to consideration of the risks he could continue to present remotely. 6.31 It is concluded that the birth plan did not sufficiently define the level of supervision required for mother and child W and was not revised to reflect the changes to father’s contact with mother and the new born baby. Did the earlier than anticipated delivery of child W impact upon the implementation of the Birth Plan in any way? 6.32 The earlier than anticipated delivery of child W further compressed the time professionals had to engage with mother and father and take the action necessary to safeguard child W. As stated above, the earlier delivery reduced the time available for the birth plan to be revised to reflect the points made by safeguarding midwife 1 on 7th May 2020 (Paragraph 4.54). 6.33 The recalculation of the EDD does not appear to have had any effect on pre-birth planning as the revised EDD of 4th June 2020 was communicated by midwifery to children’s social care on 16th April 2020 (Paragraph 4.37) which was well in advance of the strategy meeting. How effective were the actions taken to safeguard Child W following her birth? 6.34 In parallel with the birth plan, observations were made to check on medical matters such as neonatal abstinence syndrome (NAS) which afforded regular opportunities to interact with mother and child W. The observations provided on the ward went above and beyond what would be expected on a busy antenatal/postnatal ward. For example, when the need for NAS monitoring was reduced to four hourly checks, midwifery continued to check on child W every two hours. 6.35 Father was not present for the birth and so maternity staff were not required to manage any implications arising from his physical presence on the ward. However, there did not appear to be any consideration of the risks he could present through remote contact with mother, either by phone, text or physical contact during mother’s frequent absences from the ward. Strictly Confidential 20 6.36 The identity of the friend who supported mother during the birth has not been shared with this review but it is understood that she may have been the friend who advised mother to deliver the baby at home ‘so that no-one would know about it’ (Paragraph 4.32). If this friend was also one of the friends mother frequently left the ward to speak to following the birth of child W, it is conceivable that the presence of the friend could have increased the risk that mother would attempt to abscond from the ward with the baby. Any risks associated with the friend do not appear to have been considered. 6.37 Ward staff noted no issues with mother’s personal care of child W, although concerns arose over an apparent deterioration in her relationship with father, the amount of time she was spending off the ward during which she left child W alone for an hour on one occasion and her periodic tearfulness which was linked to relationship problems with father but may also have been connected to the imminent removal of child W from her care which may have triggered memories of past removals of children from her care. 6.38 It is concluded that efforts to safeguard child W following her birth were compromised by a birth plan which was insufficiently specific about risks and the level of supervision required and an assumption that the maternity ward of a hospital was an unequivocally safe place for child W. How effective was the Child Protection Plan for child W? 6.39 There was insufficient time to complete a child protection plan for child W. On 30th April 2020 it was decided that an ICPC would be convened following the completion of Section 47 enquiries. The latter enquiries were completed in three working days and these confirmed the need for an ICPC. 6.40 The ICPC was scheduled for 14th May 2020 which was over two weeks before mother’s EDD. However, as she gave birth in the early hours of the same day and was therefore not available to attend the ICPC, and father was said to be unwell, it was decided not to proceed with the ICPC on the understanding that it would be reconvened as a matter of urgency should the Court not support the local authority’s pending application for an Interim Care Order. 6.41 Deferring the ICPC denied professionals the opportunity to further discuss the case which could have been beneficial given the fact that only one multi-agency meeting had taken place – the strategy meeting held on 30th April 2020. 6.42 Whether or not the ICPC went ahead there would have been benefit in following the strategy meeting with a further multi-agency meeting to ensure the actions arising from the strategy meeting had been completed, further clarify risks and the action necessary to mitigate those risks. In their contribution to this CSPR, the police state that they contacted children’s social care to suggest referring father to the Multi-Agency Public Protection Arrangements (MAPPA) to further consider his risk of violence and coercive control, but that this was not progressed. The police also felt that there could have been benefit in having a ‘trigger plan’ should it become necessary to consider taking more urgent steps to protection child W, through a Police Protection Order (PPO) for example. Given that Care Proceedings could not be heard until 4 days after the birth of child W at the earliest, should more urgent action to remove child W have been considered? Strictly Confidential 21 6.43 Child W was born on Thursday 14th May 2020, the application for an Interim Care Order was made the following day and heard by the Court on the next working day – Monday 18th May 2020. 6.44 Children’s social care have advised this CSPR that, had imminent and immediate risks to child W been identified, an application could have been made for an Emergency Protection Order. They added that as no immediate safeguarding risks had been identified in respect of maternal care of the child, such as previous deliberate harm to children, or concerns regarding mother’s basic care of the child which would put her at risk, the threshold for this Order was not met. Discussion between children’s social care and the local authority’s legal services confirmed this position at the time. However, the difficulties experienced in completing a sufficiently thorough pre-birth assessment left children’s social care in a position where they could not take a well-informed view on ‘imminent and immediate’ risks. 6.45 Given the hospital’s plan was for child W to remain in hospital for 3-5 days to monitor withdrawal of the baby from mother’s opioid use, children’s social care decided that it was appropriate for the child to remain in mother’s care on the antenatal/postnatal ward for this period which would allow the Interim Care Order to be obtained and the child then to be placed with foster carers. 6.46 At the practitioner learning event arranged to inform this LCSPR it was said that arrangements such as this were fairly common prior to the death of child W and that there would often be negotiation between children’s social care and the hospital to enable the new born baby to remain in the care of their mother in the hospital until the Interim Care Order had been obtained. In child W’s case there was an entirely legitimate medical reason for the baby to remain in hospital for 3-5 days (observation of NAS), but in other cases the hospital was previously usually prepared to accommodate a request for the mother and the child to remain on the ward until the Interim Care Order had been obtained – providing there was no immediate risk to the baby. Often the parent’s solicitor would have been consulted and it was usually felt to be in the interests of all parties for the mother and baby to remain on the ward whilst the Interim Care Order was sought as opposed to making application for an Emergency Protection Order or the use of police powers. In their contribution to this LCSPR children’s social care state that it would have been very rare for the local authority to provide supervision to a mother and baby whilst on the ward unless there was a direct risk to the baby. In child W’s case this was not considered at any point but the service accepts that, on reflection, it should have been in this case. 6.47 The practitioner learning event was advised that since the death of child W an entirely different approach is taken and that 1:1 supervision of mother and baby on the ward is now arranged until the Interim Care Order is obtained. It is understood that 1:1 supervision is provided by the hospital - from the NHS Staff Bank from which temporary staffing is drawn for increases in demand or staff shortages – and funded by the local authority. This arrangement is agreed prior to the birth for the baby to ensure a quick and robust plan of care to ensure the baby is safeguarded. 6.48 It is difficult to escape the conclusion that prior to the death of child W ‘custom and practice’ was that a new born baby would remain in hospital with their mother until such time as an Interim Care Order had been obtained and that was generally perceived to be in the best interests of all parties. No application could be made to the Court until the birth of the baby which conferred a legal existence on the child and the hospital was perceived as a Strictly Confidential 22 place of safety and the time the mother spent with the new born baby on the ward had the potential to alleviate the trauma associated with removal to an extent. Was safe sleeping advice given to mother? 6.49 Whilst mother was in hospital following the birth of child W safe sleeping was discussed with her on the day on which the baby was born and on subsequent occasions and there appeared to be no reason to doubt mother’s ability to understand this information. Normal practice would be for safe sleep to be discussed again prior to discharge. 6.50 The hospital records indicate that child W was in her cot, the incubator or in mother’s care at all times. When mother was off the ward, the baby was always found in safe sleeping positions. How effective was the supervision of mother and child W on the postnatal ward, including: • ‘specialing’ (enhanced observation of a patient) • how health care workers perceive risk and act on this • the risk assessment documentation • the handover between shifts • the role and input of the BHNFT safeguarding team 6.51 Mother’s care of child W was continually assessed and documented within records, and no specific concerns raised. Nor were there any concerns about mother’s presentation when she was on the ward, appearing attentive, coherent and alert. She appeared to be meeting the baby’s needs. 6.52 There were clear verbal and written handovers. Observation times were clearly documented within the records and also included when the next observations were due. 6.53 Staff attempted to record when mother was off the ward for long periods – as requested by children’s social care – but as she was not observed 24 hours per day, it was difficult for staff to always be aware of mother’s whereabouts in a busy ward environment. Mother did not always advise staff when she was leaving the ward. Additionally, staff did not always record whether mother was present when they observed the baby. 6.54 The BHNFT Safeguarding Team were involved with the care and assessment of mother and baby and provided advice to staff on issues such as the impact of mother’s opioid use on the unborn child and possible withdrawal symptoms following birth. However, they did not become aware of any substance misuse by mother. This was an issue which was discussed with her at those antenatal appointments which she attended. As previously stated, the BHNFT Safeguarding Team raised questions in respect of the Birth Plan although these had not been resolved prior to the birth of child W. Was the prescribing of oral morphine to mother by her GP in accordance with expected policy and practice? Was the dispensing of oral morphine to mother by the hospital pharmacy in accordance with expected hospital policy and practice? Should there have been any communication between the hospital pharmacy, the postnatal ward and the GP? Strictly Confidential 23 6.55 The chronology submitted to this review by mother and father’s GP practice was extremely limited. Further information was provided by the CCG at the practitioner learning event and it has been possible to piece together mother and father’s contact with their GP practice by using information from chronologies from partner agencies where that agency had been in contact with the GP practice. A number of questions were submitted to the GP practice following the practitioner learning event and the responses to these questions have informed this report. 6.56 It is understood that mother had been prescribed morphine for abdominal pain since 2015 and that her GP became concerned about mother developing an opiate dependency and discussed a referral to specialist support which she declined. She collected morphine weekly and would regularly attempt to collect it early as she appears to have done just prior to her admission to hospital to give birth to child W (Paragraph 4.59). When her requests to collect morphine early were declined, mother could be verbally aggressive to reception staff at the GP practice. As previously stated, there is further evidence of drug seeking behaviour by mother and father which on one occasion was accompanied by threatening behaviour towards the GP (Paragraph 4.10). 6.57 Having been admitted to hospital, administrative responsibility for prescribing and administering the morphine was assumed by BHNFT, which was explained to mother (Paragraphs 4.60 and 4.68). 6.58 Mother’s appearance at both her GP practice and then her pharmacy (it had initially been thought that mother collected the morphine prescription from her GP practice and then returned with it to the hospital where it was dispensed by the hospital pharmacy but it has since been confirmed that the morphine prescription was dispensed by her community pharmacy) in her nightwear and possibly displaying evident signs that she was a hospital patient could have caused questions to be asked by the staff who came into contact with her at the GP practice and the pharmacy. Mother’s GP practice has advised this review that when she collected her prescription on 14th May 2020 this was her regular weekly prescription day. Reception staff did recall the event as mother was well known to them because of aggressive behaviour when previously attempting to obtain prescriptions early. Reception staff noted that she was wearing nightwear but this was not considered particularly unusual because some patients attend the GP practice wearing dressing gowns for example. 6.59 The hospital was unaware that mother had travelled from the hospital to her GP practice and pharmacy to obtain her morphine prescription. This CSPR has been advised that there is no process for pausing GP prescriptions whilst a patient of that GP practice is admitted to hospital. The CSPR has also been advised that pausing GP prescriptions for women admitted for child birth would not be a realistic aspiration given the short period of time women usually spend in hospital to give birth. 6.60 In this case, midwifery telephoned mother’s GP to check on the correct dose of morphine mother required. This contact was prompted in part by mother’s request for additional pain relief which was considered unusual given the fact that had experienced a normal vaginal delivery (Paragraph 4.68). This telephone contact presented a potential opportunity for mother’s GP practice to have noticed that mother had collected her morphine prescription the day before and also to have discussed her previous drug seeking behaviour. The GP practice advise that mother’s medical notes contain no record of the call from midwifery. However, the GP practice has advised this review that it is not common Strictly Confidential 24 practice to check a patient’s medical collection history when informed of their hospital admission. 6.61 Following this contact with her GP, midwifery explained the risk of taking non-prescribed medication to mother (Paragraph 4.68) although it is not known whether this explanation explicitly linked the risk of taking non-prescribed medication with increasing the risk of death of an infant from co-sleeping. 6.62 Overall, mother’s presentation whilst in hospital caring for baby W appears to have been largely accepted at face value by maternity staff. There appears to have been little or no weight given to her previous attempts to manipulate and deceive professionals. In their contribution to this CSPR, BHNFT have stated that their staff were unaware of mother’s dishonesty and were unduly trusting of what she reported. Mother was not documented to appear sedated at any stage and false reassurance was provided by the fact that mother did not fully take all of the morphine prescribed by the hospital pharmacy. How effectively were any risks father presented to child W, directly or indirectly, managed? Did the fact that Covid-19 restrictions largely precluded his presence in hospital affect practitioner’s appreciation of the risk he may present to child W? 6.63 As previously stated, father was not present for the birth and so maternity staff were not required to manage any implications arising from his physical presence on the ward. As previously stated, there did not appear to be any consideration of the risks he could present through remote contact with mother, either by phone, text; or possibly through physical contact during mother’s frequent absences from the ward. Nor were the risks father presented reviewed in the Birth Plan once children’s social care was advised that he would only be allowed to be present on the ward for the birth. Did practitioners consider the possibility that father could exercise coercive control over mother by telephone or other means? 6.64 There was a history of domestic abuse in the relationship between father and mother. Locally, the police had been called out to domestic abuse incidents since 2013. The incidents frequently consisted of verbal arguments but also involved violence by father (Paragraphs 4.3 and 4.4). Additionally, a DASH risk assessment completed in the year prior to the birth of child W indicated longstanding coercive and controlling behaviour by father (Paragraph 4.4). 6.65 Mother declined referrals to IDAS (Paragraphs 4.41 and 4.48) but just prior to the birth of child W (Paragraph 4.45) and immediately following the birth (Paragraph 4.69), she disclosed to the social worker that her relationship with father had broken down and she needed support to move away from him. However, mother had also asked the social worker whether she might be allowed to keep child W if she was no longer in a relationship with father (Paragraph 4.50) which suggested that mother may have had an ulterior motive in presenting as someone who wished to leave an abusive relationship. 6.66 However, father’s ability to coerce or control mother by phone, social media or by meeting her during her frequent absences from the antenatal/postnatal ward could have been given greater consideration. It would certainly have been prudent for hospital security to have been briefed to look out for his presence on the hospital site and for mother to have been asked about any contact from father. Strictly Confidential 25 Did restrictions imposed as a result of Covid-19 impact in any way on measures necessary to safeguard Child W? 6.67 The first Covid-19 lockdown in England commenced on 23rd March 2020 which was six weeks after children’s social care and maternity services became aware of mother’s pregnancy with child W. The lockdown restrictions remained in place throughout the period during which child W was born and then sustained the injuries which later ended her life. 6.68 Although the Covid-19 restrictions had significant implications for the manner in which all agencies in contact with mother, father and child W delivered their services, there is no indication that the restrictions had an adverse effect on efforts to safeguard child W, other than the aforementioned possibility that the physical absence of father from the hospital ward, in compliance with Covid-19 restrictions, may have provided agencies with a false sense of assurance that he was not in a position to influence mother’s behaviour or harm child W. 6.69 Mother’s stated fears of Covid-19 as a pregnant woman who suffered with asthma were accepted at face value and maternity services offered appropriate adjustments to her antenatal clinic appointments in an effort to assuage her concerns. Is the learning from this LSCPR consistent with the learning from the National Panel Review of Sudden Unexpected Death in Infancy? 6.70 The National Child Safeguarding Practice Review Panel oversaw a review entitled ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm’ (2), hereinafter referred to as ‘the SUDI review’. SUDI cases represented one of the largest groups of cases notified to the National Panel and involved parents co-sleeping in unsafe sleep environments with infants, often when the parent had consumed alcohol or drugs. Additionally, there were wider safeguarding concerns in these cases – often involving cumulative neglect, domestic violence, parental mental health concerns and substance misuse. 6.71 Whilst the case of Child W has many of the features of the cases considered by the SUDI review, the key difference is that the child’s death arose as a result of co-sleeping with her mother in an environment which would not be considered unsafe i.e. on a maternity ward whilst being monitored closely by maternity staff. 6.72 As in the case of a recent Barnsley CSPR in respect of child X, the indications of mother’s substance use are more evident in hindsight than they were to professionals at the time. Taken together, the cases of child W and child X strongly indicate that a much greater emphasis should be placed on the thorough exploration of maternal substance use and the risk of death to any infant the mother intentionally or inadvertently co-sleeps with. In child W’s case there were indications of opiate dependence, drug seeking behaviour accompanied by dishonesty, manipulation and threats and a long track record of engaging with services only on her terms. Unfortunately, much of the information about substance use and drug seeking behaviour was held by mother’s GP practice which was only indirectly involved in the multi-agency efforts to safeguard child W and the information available to professionals about mother’s substance use was distinctly overshadowed by other more obvious risks. 6.73 The SUDI review arrived at the following three conclusions: Strictly Confidential 26 • Professionals needed to obtain a better understanding of parental perspectives in order to develop a supportive yet challenging relationship which facilitates more effective safer sleep conversations. • Work to reduce SUDI needs to be embedded in multi-agency working and not just seen as the responsibility of health professionals. • The use of behavioural insights and models of behaviour change to support interventions to promote safe sleeping need to be explored. 6.74 Applying these conclusions to the case of child W, mother - and father’s - marked reluctance to engage with professionals severely limited any understanding of their perspective, which could not be taken at face value in any event. This case also indicates that there is further work to be done to embed work to reduce SUDI in multi-agency working. For example, mother did not receive safe sleeping advice from the social worker who conducted the pre-birth assessment. Achieving behaviour change was not a professional focus in this case given the decision to remove child W from the care of her parents. Good practice 6.75 There was much good practice in this case. 6.76 During November and December 2019 the epilepsy team was very proactive in contacting mother and her GP practice in an effort to ensure her epilepsy was appropriately managed at a time when it was unclear whether she intended to go ahead with a termination of her pregnancy (Paragraphs 4.11 and 4.12). 6.77 BPAS made appropriate contact with children’s social care when it became clear that terminating her pregnancy with child W was no longer possible for mother (Paragraph 4.15). 6.78 Children’s social care responded promptly to the referral from BPAS by contacting mother and notifying midwifery (Paragraph 4.16). 6.79 The social worker made very diligent, tenacious and persistent attempts to engage mother and father in the pre-birth assessment. 6.80 Maternity services were flexible in making a home visit to mother for the booking-in appointment and offering mother support, reassurance and a more personalised service in an effort to engage with her and address her stated fears in respect of Covid-19. 7.0 Findings and Recommendations 7.1 The death of new born child W was a truly shocking event. She sustained the injuries from which she later died whilst within a hospital maternity ward in which she was being cared for by her mother for a short period whilst an interim Care Order was obtained to enable the removal of the child from her parents. Partner agencies had recognised that child W was at risk of significant harm and had worked together for the express purpose of safeguarding the child. 7.2 The death of a baby in such circumstances also appears to be a very rare event. The independent reviewer has been unable to find a similar case in the NSPCC CSPR repository. The death of child W prompted urgent review activity locally and a number of policies and practices have been strengthened in advance of this LCSPR report being concluded, Strictly Confidential 27 including the provision of 1:1 support to mothers and new born children in hospital where it has been decided to remove the child as soon after birth as logistically possible. 7.3 Notwithstanding the changes already made, there is considerable additional learning from this case which is reflected in the recommendations set out below. The assumption that a hospital environment is unequivocally a place of safety for a new born infant has been challenged. Until the death of child W, it was ‘custom and practice’ for a baby it was intended to remove at birth to remain in the care of the mother on the maternity ward until such time as an Interim Care Order could be obtained. It seems likely that this remains the approach taken elsewhere, given the lack of any nationally agreed standards. Therefore the first recommendation is that the learning from this CSPR and the changes already made to policy and practice locally are shared with Safeguarding Children Partnerships across England. Recommendation 1 That Barnsley Safeguarding Children Partnership share the learning from this LCSPR and the changes already made to policy and practice as a result of the death of child W with Safeguarding Children Partnerships in England. ‘Early Warning’ Systems 7.4 There was little doubt that the parents of child W could present a significant risk of harm to any child conceived by mother. None of their children are in their care and they had previously attempted to conceal pregnancies from the authorities in order to prevent the removal of children. Despite this, the agencies which initially became aware of mother’s pregnancy with child W – mother’s GP practice, the Out of Hours GP service and the epilepsy service – did not alert either children’s social care or the police. The years which had elapsed since the most recent attempt to conceal a pregnancy and the belief that mother intended to terminate her pregnancy with child W were mitigating factors. Additionally, the police became aware of an earlier pregnancy, which is assumed not to have progressed to full term and did not appear to appreciate the significance of this. 7.5 Mother and father remain a potential risk to any children they conceive – in this relationship or possibly in any other intimate relationship they may initiate. The risk they present to children should be clearly flagged up on the records of all agencies they are in contact with or may come into contact with locally and should either or both of them relocate, then the risk information should be shared with the area to which they move. 7.6 It is therefore recommended that the Safeguarding Children Partnership obtain assurance that all relevant local agencies are made aware of the risk which mother and father present to any children they may conceive and that this information is conspicuously flagged on their records together with advice on action to take should they become aware of mother becoming pregnant. Recommendation 2 That Barnsley Safeguarding Children Partnership obtains assurance that all relevant local agencies are made aware of the risk which mother and father present to any children they may conceive and that this information is conspicuously flagged on their records together with advice on action to take should they become aware of any further pregnancy. Strictly Confidential 28 The role of GP practices in pre-birth planning 7.7 Barnsley’s Pre-Birth procedures state that the antenatal period provides a window of opportunity for practitioners and families to work together to understand the impact of risk to the unborn baby (3). In this case the GP practice could have considered a safeguarding referral or a conversation with children’s social care when doubts began to emerge about mother’s intention to terminate her pregnancy with child W from 19th December 2019. This would have expanded the period available to partner agencies to work together to safeguard the unborn child W from 13 to 21 weeks. 7.8 The GP practice also held much relevant information about mother’s long-term use of morphine, concerns about dependency and drug seeking behaviour. This information was only partially shared as part of pre-birth planning. The GP practice was not involved in the one multi-agency meeting which took place. 7.9 It is therefore recommended that the Safeguarding Children Partnership obtain assurance that GP practices play an appropriate part in pre-birth planning and as a minimum, are either invited to attend or send a report to any multi-agency pre-birth planning meetings. Recommendation 3 That Barnsley Safeguarding Children Partnership obtains assurance that GP practices play an appropriate part in pre-birth planning and as a minimum, are either invited to attend or send a report to any multi-agency pre-birth planning meetings. Parental substance use and co-sleeping 7.10 There were an unusually large number of risk factors present in this case. However, the risk which led directly to the death of child W – mother’s morphine use/possible dependence and drug seeking behaviour - did not receive sufficient attention, was never fully articulated and was insufficiently explored. 7.11 This is the first of two local deaths of infants in quick succession in which the substance use of the mother increased the risk of sudden infant death arising from co-sleeping but where the risks to the child arising from maternal substance use had been under-estimated and insufficiently explored by professionals. This review has been advised that work on raising professional awareness of the risks arising from unsafe sleeping commenced in 2020, when a task and finish group was established led by Public Health. Key actions included undertaking a local review of cases and identifying learning themes from the local review and the national thematic review. Multi-agency training has been established and single agency training has been promoted. This is available as a virtual offer or e learning package. Multi-agency guidance is currently being developed which will include a risk assessment tool. Pathways for transfer of care and the highlighting of risks are under development. Work is underway to improve the postnatal offer around smoking cessation support. A public heath campaign is being run periodically through the year which includes a radio and social media campaign and promotional activities. Engagement of all agencies which have contact with children and families has been key to progressing this work and widening the scope from the traditional workforce (health visiting and maternity). Training has been delivered to social care staff and is now included as part of their risk assessment. In addition, a task group has been established to lead work on the ICON (I – Infant crying is normal; C –Comforting methods can help; O – It’s OK to walk away; N – Strictly Confidential 29 Never, ever shake a baby) programme which was introduced in January 2021. This has included multiagency training, pathways and again awareness raising via social media and a radio campaign. 7.12 It is therefore recommended that the Safeguarding Children Partnership monitors the effectiveness of the considerable action taken to increase professional awareness of the risks from co-sleeping, in particular the increase in the risk of sudden infant death from co-sleeping arising from substance use by parents or carers. Recommendation 4 That Barnsley Safeguarding Children Partnership monitors the effectiveness of the action taken to increase professional awareness of the risks from co-sleeping, in particular the increase in the risk of death to children from co-sleeping arising from substance use by parents or carers. Safe Sleeping assessment 7.13 There is no indication that mother’s use of painkillers including morphine and her drug seeking behaviour informed any safe sleeping risk assessment for the period in which mother would be caring for child W in hospital. Indeed, there is no indication that a safe sleeping risk assessment was carried out. It seems likely that a safe sleeping assessment was not considered because it was anticipated that child W would be in the care of mother for only a short period (3-5 days) and this brief period of maternal care would take place within the maternity ward of a hospital where mother and baby would be regularly observed and cared for by medical professionals. Despite the fact that many of the factors known to increase risk of sudden unexpected death in infancy from co-sleeping would not be present in a maternity ward environment, it would have been of benefit to carry out a safe sleeping assessment in this case. 7.14 It is therefore recommended that the Safeguarding Children Partnership seeks assurance from the Barnsley Hospital NHS Foundation Trust that they will consider conducting a safe sleeping assessment when appropriate. It is accepted that this is only likely to be necessary for a small minority of hospital births. Recommendation 5 That Barnsley Safeguarding Children Partnership seeks assurance from the Barnsley Hospital NHS Foundation Trust that they will consider conducting a safe sleeping assessment when appropriate. Assessment of risk of significant harm to the unborn child 7.15 In the case of child W, the risks arising from maternal substance use were overshadowed by other risks mother and father may present to child W. Clarifying risks was made more challenging by the limited engagement of mother and father in the pre-birth assessment. 7.16 There is much to be learned from this complex case about clarifying risks, seeking out further information about risks where it is available and being really clear about the action necessary to mitigate risks. It would therefore be of value when the learning from this case is disseminated for approaches to assessing and managing risk to be highlighted. Strictly Confidential 30 Recommendation 6 When Barnsley Safeguarding Children Partnership disseminates the learning from this case, approaches to assessing and managing risk are highlighted. Multi-Agency Working in the Pre-Birth Period 7.17 Barnsley’s Pre-Birth Procedures – which appear to have been revised to reflect the early learning from this case - and the Integrated Care Pathway for Pre-Birth Assessments (April 2020) set out in detail the process to be followed when there are concerns that an unborn child may be likely to suffer significant harm. The procedures and the pathway also set out at which stage of the pregnancy specific actions should be taken. 7.18 However, the case of child W did not fit neatly into any pathway or procedures. Timescales were compressed and then tightened further and it was clear from the parent’s current and historic behaviour that they were highly unlikely to co-operate with partner agencies and may attempt to obstruct or mislead them. 7.19 Only one multi-agency meeting took place, which was the strategy discussion on 30th April 2020. This meeting could have been held much earlier which would have allowed more time for a subsequent Pre-Birth Conference and/or a Pre-Birth Planning meeting as envisaged by Barnsley’s Pre-Birth Procedures. This would have been of great value in this case as, whilst the strategy meeting was a very helpful forum for sharing the large number of concerns in this case, it needed to be followed up by at least one further multi-agency meeting to ensure that the wide range of concerns had been translated into a clear plan with contingencies. 7.20 Whilst it is important for the Safeguarding Partners to obtain assurance that the Pre-Birth Procedures and the Integrated Care Pathway are well understood and followed by professionals, this case also highlights the importance of having the ability to apply the principles of the Procedures and the Pathway to cases where greater urgency is required, and/or where the case is particularly complex or presents unusual features or risks. Recommendation 7 That Barnsley Safeguarding Children Partnership obtains assurance that the Pre-Birth Procedures and the Integrated Care Pathway for Pre-Birth Assessments are well understood and followed by professionals. Recommendations 8 That Barnsley Safeguarding Children Partnership requests partner agencies to reflect on the particular challenges of this case and articulate how the principles of the Pre-Birth Procedures and Integrated Care Pathway could have been applied flexibly in order to safeguard child W from the risk of significant harm. Birth Plans – defining supervision required by hospital 7.21 The Birth Plan did not define the level of supervision required for mother and child W whilst in hospital following the birth. This remains an important issue despite the amended practice of providing 1:1 support to mothers and new born children it is intended to remove. Strictly Confidential 31 The Integrated Care Pathway for Pre-Birth Assessments does not make explicit the importance of defining the level of supervision required and so it is recommended that the Pathway document is amended accordingly and that professionals are reminded of the need to define the level of supervision required. (BHNFT advise that since this incident they have a developed a policy which sets out responsibilities with regards to the supervision of children and parents, which has been shared with partner agencies). Recommendation 9 That Barnsley Safeguarding Children Partnership arranges for the Integrated Care Pathway for Pre-Birth Assessments document to be amended to make the need to define the level of supervision required explicit and that professionals are reminded of the importance of defining the level of supervision required. In addition, BHNFT propose the adoption of a memorandum of understanding stating which agency will be responsible for the provision of supervision. Since this incident the Trust have a developed a policy which has been shared with other agencies setting out responsibilities with regards to the supervision of children and parents. Mother’s contact with father and others whilst in hospital 7.22 Father’s absence from the hospital ward – primarily because of Covid 19 restrictions- largely removed the risks he could present to mother and child W from further consideration by professionals. The risk that he could continue to exert influence, possibly through coercion or control, over mother remotely or through in-person contact when she was absent from the ward was overlooked. Additionally, mother was frequently absent from the ward, including the occasion on which she was able to obtain a prescription of morphine from her GP. Whilst the hospital had no power to prevent mother leaving the ward, insufficient weight was given to the long history of manipulative and dishonest behaviour displayed by mother and father towards professionals. However, ‘Dishonesty’ and ‘lack of meaningful engagement with services’ were documented as concerns in the Birth Plan. 7.23 In their contribution to this review, mother’s GP practice has advised that patients attending in nightwear is not unusual. Reception staff knew mother well because of her aggressive behaviour when her previous attempts to obtain prescriptions early were declined and recalled her attendance on the morning after giving birth to child W. However, they did not notice any indication that mother was a hospital patient. The GP practice has conducted a ‘significant event analysis’ which decided that if a patient attends in nightwear, reception staff are to: • visually check for hospital wristbands • enquire of the patient if they are an inpatient at the hospital • contact admissions desk at the hospital to directly enquire if the person has been admitted to hospital • record ALL unusual occurrences in the medical notes • inform the lead on-call GP of any ‘unusual events’ 7.24 Mother’s GP practice also stated that reception staff may not have considered the possibility that mother was a hospital inpatient because ‘primary care has every confidence that hospital systems would prevent an in-patient from leaving an obstetric ward in her nightwear after giving birth’. This level of confidence is misplaced as hospitals can only prevent a patient leaving the hospital in very specific circumstances. Strictly Confidential 32 7.25 There does not appear to be an obvious ‘systems’ solution to the administration of morphine by both the GP practice and the hospital in this case. However, it would be of value for the learning from this review, including the actions taken by mother’s GP practice following their ‘significant event analysis’ to be circulated to all Barnsley GP practices and it is therefore recommended that the Safeguarding Children Partnership ensures that this is done. Recommendation 10 That Barnsley Safeguarding Children Partnership requests NHS Barnsley Clinical Commissioning Group to ensure that the learning from this case, including the measures taken by mother’s GP practice, are disseminated to all GP practices in Barnsley. 7.26 The outcome of the criminal investigation is ongoing which is examining contact between mother and father following the birth of child W in detail. Further learning for the hospital may emerge once the criminal investigation is completed and so it is recommended that the Safeguarding Children Partnership requests South Yorkshire Police to advise them of any further learning when the criminal proceedings are completed. Recommendation 11 That Barnsley Safeguarding Children Partnership requests that South Yorkshire Police advise them of any further learning from this case arising from the criminal investigation. Antenatal visits by health visitor 7.27 It is worthy of note that this is the third Barnsley CSPR completed by this independent reviewer in which the parents did not receive the nationally mandated antenatal health visitor visit, including two cases in which very young babies have died. Whilst it was clear that child W was to be removed at birth, partner agencies had agreed that all scheduled interventions should be completed. 7.28 It is therefore recommended that the Safeguarding Children Partnership seeks further assurance that the 0-19 service has systems in place to ensure that antenatal visits are conducted. Recommendation 12 That Barnsley Safeguarding Children Partnership obtains further assurance that the 0-19 service has systems in place to ensure that antenatal visits are conducted. Antenatal and postnatal risk of maternal epilepsy 7.29 It is clear that there were considerable antenatal risks to mother and child W arising from mother’s epilepsy and her risk of seizures arising from the management of her condition. In their contribution to this CSPR, BHNFT has advised that, given these antenatal risks and increased risk to mothers and infants in the postnatal period (4) there is a requirement for better risk assessment for all expectant mothers with epilepsy and a multi-disciplinary plan for the birth. SWYPFT has advised this review that currently, the epilepsy specialist nurse offers a face to face appointment with the pregnant woman to go through a checklist and risk assessment in relation to their pregnancy and treatment. This is done in Strictly Confidential 33 liaison with the epilepsy midwife, who also monitors the pregnancy. The pregnant woman also receives written information in relation to epilepsy and the management of epilepsy. SWYPFT add that historically, there was an epilepsy specialist midwife in the hospital and there would be a joint clinic for women to attend. This service was discontinued due to staffing and resource issues. 7.30 It is therefore recommended that the Safeguarding Children Partnership seek assurance from BHNFT and SWYPFT in respect of improvements made to risk assessment and pre-birth planning for expectant mothers with epilepsy. Recommendation 13 That Barnsley Safeguarding Children Partnership seeks assurance from BHNFT and SWYPFT in respect of improvements made to risk assessment and pre-birth planning for expectant mothers with epilepsy. Safety of professionals 7.31 Both the midwife and the social worker made unaccompanied home visits to mother and father without the knowledge that father could present a risk to them until information was shared at the strategy meeting that there was a police warning about him carrying weapons. Additionally, the GP practice had utilised an alert after feeling threatened by mother and father earlier in the pregnancy with child W. There is no indication that this information about risk to professionals was shared as part of multi-agency pre-birth planning. 7.32 In this particular case the risk to professionals could be included in the ‘early warning’ information which it is recommended should be recorded by partner agencies (Recommendation 2). However, the late sharing of information about risk to professionals may also apply to other cases. 7.33 It is therefore recommended that the police work with those partner agencies which may make home visits in advance of full information sharing - such as children’s social care, midwifery and health visiting - in an effort to devise an approach to earlier information sharing about risks to professionals, particularly when lone working. Recommendation 14 That Barnsley Safeguarding Children Partnership requests South Yorkshire Police to work with those partner agencies which may make home visits in advance of full information sharing - such as children’s social care, midwifery and health visiting - in an effort to devise an approach to earlier information sharing about risks to professionals, particularly when lone working. The National Panel’s SUDI Review 7.34 Whilst the case of child W has many of the features of the cases considered by the SUDI review, the key difference is that the child’s death arose as a result of co-sleeping with her mother in an environment which would not normally be considered unsafe i.e. on a maternity ward whilst being monitored closely by maternity staff than would normally be the case. Strictly Confidential 34 7.35 The SUDI review arrived at the following three conclusions: • Professionals needed to obtain a better understanding of parental perspectives in order to develop a supportive yet challenging relationship which facilitates more effective safer sleep conversations. • Work to reduce SUDI needs to be embedded in multi-agency working and not just seen as the responsibility of health professionals. • The use of behavioural insights and models of behaviour change to support interventions to promote safe sleeping need to be explored. 7.36 Applying these conclusions to the case of child W, mother and father’s marked reluctance to engage with professionals severely limited an understanding of their perspective, which could not be taken at face value in any event. This case also indicates that there is further work to be done to embed work to reduce SUDI in multi-agency working. Mother did not receive safe sleeping advice from the social worker who conducted the pre-birth assessment, although this review has been advised that social workers now routinely speak to mothers about safe sleeping and this is recorded on case files. Achieving behaviour change was not a professional focus in this case given the decision to remove child W from the care of her parents. References: (1) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/464880/Universal_health_visitor_reviews_toolkit.pdf (2) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf (3) Retrieved from https://www.proceduresonline.com/barnsley/scb/p_pre_birth.html (4) Retrieved from https://epilepsysociety.org.uk/pregnancy-and-parenting Appendix A Process by which the CSPR was conducted It was decided to adopt a broadly systems approach to conducting this CSPR. The systems approach helps identify which factors in the work environment support good practice, and which create unsafe conditions in which unsatisfactory safeguarding practice is more likely. This approach supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative approach to case reviews in that those directly involved in the case are centrally and actively involved in the analysis and development of recommendations. Agency reports and chronologies which described and analysed relevant contacts with child W and her family were completed by the following agencies: • Barnsley Children’s Services Strictly Confidential 35 • Barnsley Clinical Commissioning Group • Barnsley Hospital NHS Foundation Trust (BHNFT) • Barnsley Public Health Nursing Service • South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) • South Yorkshire Police The independent reviewer analysed the chronologies and identified issues to explore with practitioners and managers at a learning event facilitated by the independent reviewer. At the time of writing it had not been possible to offer child W’s family the opportunity to contribute to the review as a result of the ongoing criminal investigation into the circumstances of child W’s death. The independent reviewer then developed a draft report to reflect the agency reports, chronologies and the contributions of practitioners and managers who attended the learning event. The report was further developed into a final version and presented to Barnsley Safeguarding Children Partnership. |
NC046921 | Death of "Rose", a 9-week-old baby girl, in January 2015. Rose's mother pleaded guilty to manslaughter by diminished responsibility. The plea was accepted following psychiatric reports and she was sentenced to remain in a mental health facility with an unlimited restriction order. Rose's body has never been found. Mother received antenatal services from her GP and Chelsea and Westminster Hospital (C&WH) maternity services until the 29th week of her pregnancy. GP also referred mother to the perinatal psychiatry service but she returned to her home country to give birth before they could see her. Mother came back to the UK with Rose shortly before her death. Risks identified include: mother's anxiety and low mood related to her pregnancy; previous request to terminate the pregnancy; isolation from her family; low income; and separation from Rose's father. Findings include: communication across and between health services and professionals was fragmented. Professionals did not fully understand procedures for making referrals and the geographical areas covered by the C&WH midwifery service. Recommendations include: the perinatal and maternity services must audit referrals to ensure the new system is robust and vulnerable women are identified and followed up; health services should work together to develop a communication pathway locally to improve outcomes for service users.
| Title: Serious case review in relation to Baby Rose: overview report. LSCB: Hammersmith and Fulham, Kensington and Chelsea, Westminster Local Safeguarding Children Board Author: Ann Duncan Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. LOCAL SAFEGUARDING CHILDREN BOARD Serious Case Review in relation to Baby Rose Overview Report July 2016 Published: 28th September 2016 Independent Author: Ann Duncan 2 CONTENTS The Circumstances that led to Undertaking this Review 3 Family Composition 3 Brief Summary of the Case 4 Methodology 4 A Succinct Summary of the Case 6 Key Issues and Analysis: Terms of Reference to be Addressed 8 Conclusions and Findings 13 Bibliography 14 Appendix 1: Acronyms and Terminology 15 3 1.1. The Circumstances that led to Undertaking this Review 1.1.1. The mother, a European National, returned home in September 2014 to have her baby; the baby (Rose) was born in November. The mother returned to the UK in late January 2015 with Rose and checked into an hotel that she had pre-booked. Three days after her arrival in the UK she informed the grandparents that Rose had been taken into care by Social Services. The grandparents travelled to the UK the following day and the mother then informed them that Rose had been abducted from her hotel room. The grandparents took the mother to the local police station to report the abduction, initially the mother was treated as a significant witness but her account of events was inconsistent and she was subsequently charged with the murder of Rose. 1.1.2. The LSCB Case Review (SCR) Sub-Group recommended to the Chair of the Safeguarding Children Board that the case had met the criteria for undertaking a Serious Case Review (SCR) under Working Together To Safeguard Children 20151, in that there was information that: (b) (I ) the child has died. The Independent Chair of the Board accepted and endorsed the recommendation for a proportionate review and commissioned this SCR. 1.1.3. The mother pleaded guilty to killing Rose and entered a plea of manslaughter by diminished responsibility. The plea was accepted in light of three psychiatric reports. 1.1.4. The mother received a Section 37 Mental Health Act (MHA 1983) Hospital Order with a Section 41(MHA1983) Restriction Order attached, for appropriate treatment. The s41 Order has no time limits. 1.1.5. The mother was described as a complex person who still carries a high risk of offending which cannot be confined to just infants, be it her own or others and or future infants. She carries a high risk of violence and has difficulties with interpersonal relationships. 1.2. Family Composition 1 Working Together: HM Government 2015 4 1.2.1. The family members relevant to this review will be referred as follows: Family member Anonymisation Subject Rose Mother of Rose Mother Father of Rose Father Maternal grandparents of Rose Grandparents 1.3. Brief Summary of the Case 1.3.1. The mother came to the UK seeking work in the summer of 2013. The mother met the father via an online dating service, they had six dates during which Rose was conceived, the father was unsupportive of the pregnancy and the relationship ended. Although the mother was initially ambivalent about whether to continue with the pregnancy, she went ahead and returned to her own country to give birth. 1.3.2. When Rose was approximately nine weeks old the mother returned to the UK with Rose and booked them both into an hotel. At this point the grandparents were unaware that the mother had left the country with Rose. 1.3.3. Three days later she telephoned the grandparents telling them that Rose had been taken into care by Children’s Social Services. The grandparents travelled to the UK, as they were very concerned. The mother then told the grandparents that Rose had been abducted. 1.3.4. The grandparents took her to a local police station. Following review of closed circuit television (CCTV) footage the account that the mother gave was inconsistent and the mother was arrested on suspicion of the murder of Rose and later charged. 1.3.5. The body of Rose has not been found. 2. Methodology 2.1.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards (LSCB) to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows: Reviews are not ends in themselves. The purpose of these is to identify improvements, which are needed, and to consolidate good practice. LSCBs and their partner organisations should translate the 5 findings from reviews into programmes of action, which lead to sustainable improvements, and the prevention of death, serious injury or harm to children. (Working Together, 2015) 2.1.2. The statutory guidance requires reviews to consider: “what happened in the case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as the did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings. 2.1.3. Management Reviews (IMRs). The following agencies submitted IMRs: Metropolitan Police Service (MPS) Chelsea and Westminster NHS Foundation Trust (C&WH) General Practice for mother. (GP) This was followed up with an interview with Head of Midwifery for C&WH and the Service Manager for perinatal services Central and North West London NHS Foundation Trust (CNWL) 2.1.4 The timeframe for the review is from the end of March 2014- end of January 2015. 2.1.5. The Review directed the author to follow a number of lines of enquiry, with a view to reaching conclusions and making recommendations to the LSCB: Information sharing/ referral pathways between health organisations, including mental health, to evaluate the effectiveness and the timeliness of the information sharing with the relevant European services. Review the action and involvement of each agency involved with mother in the antenatal period to identify any learning to prevent this situation reoccurring. The effectiveness of patient held maternity records in safeguarding vulnerable women. 2.1.6. Family involvement. The involvement of key family members in the Review can provide particularly helpful insights into the experience of receiving or seeking services. The author of the review met with 6 the mother to explain the purpose of the SCR and inviting her to comment on how services could be improved. The mother felt that the GP was very kind and supportive and gave her time to talk. She also praised the midwife who undertook her ‘booking appointment’ but felt that the subsequent antenatal appointments were too short and felt that staff did not explore her feelings or why she was tearful. By the time the perinatal appointment was offered she had already decided to return home as she had recently lost her job and felt very low and isolated. 3. A Succinct Summary of the Case. 3.1. The mother attended her GP in late March 2014 as she thought that she was pregnant, this was confirmed and she was referred to the Chelsea and Westminster Hospital (C&WH) for antenatal care. At this time the mother felt happy about the pregnancy but reported that her boyfriend was not so happy about it. At the booking clinic at the hospital she disclosed that she was no longer with the father but didn’t require any additional support at this time. 3.2. On the 21/04/14 the mother emailed the GP following an appointment at the hospital the previous day ‘to discuss the interruption of her pregnancy’ and needed to see the GP urgently as she was already 14 weeks pregnant. The GP saw the mother four days later, she felt unable to continue with the pregnancy. A referral was made and an appointment made to discuss the termination of the pregnancy. The mother did not keep the appointment and continued with the pregnancy. 3.3. The mother attended seven antenatal appointments at C&WH between May and August. The mother was referred to the maternal medicine clinic as it was noted that she had protein C deficiency.2 3.4. Early in July she attended a routine antenatal appointment with her GP, she was 22 weeks pregnant. At this consultation she reported that she was anxious and low in mood about how she was going to cope. All her family lived abroad. The GP questioned the mother about any thoughts of deliberate self-harm (DSH) or suicide, which she denied. The mother was going on holiday to see her parents. The GP gave her a sick certificate and arranged to telephone the mother on her return to the UK. The GP also referred the mother to the perinatal psychiatry service (this service is provided by CNWL NHS Foundation Trust) The referral was received by the perinatal service and discussed at a team meeting on the 14/07/14; the decision was made to invite the mother for an assessment and contact the GP to complete the service specific referral form (this doesn’t appear to have happened). 2 Protein C deficiency is a rare genetic trait that predisposes to thrombotic disease, it was first described in 1981. 7 3.5. On the 23/07/14 the GP attempted to call the mother as arranged without success but saw the mother five days later at the surgery. The mother was noted to have anxiety and low mood related to her pregnancy and was given a sick certificate for a further four weeks. The mother had not heard from the perinatal service. A letter was sent from the perinatal service on 25/07/14 asking the mother to contact the service to arrange a date to be seen. Following receipt of the letter the mother contacted the perinatal service and requested that her assessment was postponed until after her trip home. 3.6. On the 13/08/14 the mother attended the GP for review of mood at 26 weeks pregnant. It was noted that the mother seemed stronger and had heard from the perinatal services, she was due to seen in 4-6 weeks. The mother had no thoughts of suicide or DSH. The mother was considering going back home to have her baby as she had good family support there. (This was the last visit to the GP). 3.7. The mother attended an appointment with the midwife on the 28/08/14, she was 28 weeks pregnant, and she made no further antenatal appointments. 3.8. On the 29/09/14 the GP received a phone call from the perinatal service requesting that their specific referral form was filled in and returned to the service, as the referral letter was not adequate. (This was supposed to have happened in July following the referral letter and discussion at the team meeting) 3.9. On the 24/01/15 the mother and Rose returned to the UK and travelled to a pre-booked hotel by taxi. The mother had no baby equipment with her. 3.10. A friend visited the mother the following evening and the friend reported that she spent a couple of hours in the bedroom with mother and Rose. 3.11. On the morning of the 26/01/15 the mother left the hotel alone and returned approximately an hour later having bought cleaning products and bin liners. She later left the hotel for a second time that day and returned with a pink suitcase. The mother then went to another hotel and booked a room and returned to the original hotel a few times to move her belongings. 3.12. The following day 27/01/15 the mother called the grandparents and told them that Rose had been taken into care by Social Services. On the same day she was seen to leave the second hotel with a suitcase and later returned without it. 8 3.13. The grandparents flew to the UK on 28/01/15 and the mother told them that someone had abducted Rose from the hotel room. Her parents took her immediately to the local police station to report the abduction. 3.14. The mother was arrested on suspicion of the murder of Rose and later charged, the body of Rose has not been found. 4. Key Issues and Analysis: Terms of Reference to be Addressed. 4.1. Introduction. This section of the Review assesses the quality of multi-agency practice at those key points, which were considered to provide the most significant learning. In doing so, it takes into account both the contemporary required standards and also the information that was known, or could have been known at the time of the events. Where there is information about why practice may not have met the required standards these are explained. By understanding why things have happened in the way that they did, rather than simply what happened, the Review is seeking to achieve a greater depth of learning. 4.1.1. The body of Rose has not been found but the mother allegedly has admitted that she suffocated Rose on the 26.01.15 and disposed of the body, the mother has not confirmed where. 4.1.2. It is difficult to know whether there would have been a different outcome had the mother been seen and assessed by the perinatal service during the antenatal period. The mother didn’t tell the midwife in August, on what would turn out to be her last appointment, about her plans to return home to give birth. The mother’s view is that she did inform the midwife at this visit as she had also been made redundant from her job. As a consequence of this, the antenatal records were not copied and given to the mother to take with her and there is no copy on file of the hand held Maternity records at C&WH. The midwifery service was unaware of the referral to the perinatal service and mother was not identified as being vulnerable. 4.1.3. There is no information available to the author about the birth and the subsequent post-natal period and it would therefore be wrong to speculate. 4.1.4. The mother arrived back in the UK with Rose over a weekend. The mother had booked an appointment with the GP on the 30.01.15. Sadly events overtook this and the appointment was missed. 4.1.5. The author is of the view that the death of Rose was neither predictable nor preventable. However, the independent author agrees that there are areas of practice that could have been improved and lessons to be learnt that will further strengthen the safeguarding system. 9 4.2. Information sharing/ referral pathways between health organisations, including mental health, to evaluate the effectiveness and the timeliness of the information sharing and whether there was appropriate sharing with the relevant European services. 4.2.1. The mother was registered with a GP close to where she lived; she elected to have her baby at the C&WH. Although the practice is only about two miles from the hospital, the practice falls outside the community boundaries for C&WH and there is therefore no allocated community midwife/team for this practice. This is likely to happen frequently in the future where pregnant women travel greater distances due to closure of local midwifery services and patient choice. 4.2.2. The GP made a referral to C&WH when the mother was eight weeks pregnant, this was her first pregnancy and was reported to feel happy about the pregnancy but her boyfriend was not so happy about it. Three weeks after her ‘booking appointment”3 she contacted the GP asking for an urgent referral, as she wanted to have the pregnancy terminated. The GP made the appropriate referral but the mother didn’t keep the appointment and continued with the pregnancy. 4.2.3. Following a consultation with the GP early in July 2014 it became evident that the mother was struggling with low mood and anxiety related to her pregnancy. The GP identified that there were other factors increasing her risk such as isolation from family; low income; no longer with the father of the baby; previous request for termination and first pregnancy. The mother was referred the same day to the perinatal service for urgent assessment. The GP made a timely and appropriate referral to secondary mental health services, however the referral was not shared with the Midwifery service and she was not considered as a vulnerable woman. There is an expectation that the referrer should follow up the referral; liaison with the midwifery team would have been beneficial. 4.2.4. Referral often involves a transfer of clinical responsibilities between professionals. A good referral should contain the following elements: Necessity-patients are referred as and when necessary, without delay Destination-patients are referred to the most appropriate Process-referral letters contain the necessary information, in an accessible format and patients are involved in decision making around the referral4 3 Booking appointment, this appointment books you in for maternity care provided by your local health trust or hospital 4 The quality of GP diagnosis and referral, The Kings Fund 2010 10 4.2.5. It would appear that the GP made good and timely referrals but feedback from the other professionals involved could have been better. However, given the fact that the GP made a referral to the perinatal service good practice would be that the GP contacted the perinatal service directly to find out what the delay was. 4.2.6. The referral was received by the perinatal service and the case discussed at the Multi-disciplinary Team (MDT) meeting on the 14.07.14. The decision of the meeting was to offer an assessment to the mother and to contact the GP to complete a referral form. According to the internal investigation by CNWL there is no record of the telephone request to the GP. The perinatal service was under pressure at the time with vacancies within the clinical team, coupled with higher than average sickness levels. A letter was sent to the mother on the 25.07.14 inviting her to contact the service; this had not been received when she was reviewed by the GP on the 28.07.14. 4.2.7. Whilst the mother was waiting for an appointment she was seen regularly by a consistent GP. After each appointment she was safety netted5 and made aware of emergency services provided by the GP practice and mental health services. There was always a follow-up appointment booked and telephone consultations were carried out. The care provided was of a good standard. 4.2.8. The GP was contacted on the 29.09.14 by the perinatal service requesting that the referral form was completed; this was the only communication as far as the practice is concerned from the perinatal service. The mother by this time had already left the country and was never seen by the service. 4.2.9. There was no referral pathway in place at the time but following an internal investigation by CNWL to learn lessons a more robust way of managing referrals is now in place. The perinatal service now sends an appointment directly to the patient and has an internal tracking system to ensure that patients are not lost within the system. There is closer working with the midwifery service; The Antenatal Care (ANC) lead now attends the perinatal referral meeting (MDT) on a weekly basis and cross references all women with their midwifery team to make sure that they are identified as vulnerable women. Further work needs to be done on how to communicate effectively with GPs by the perinatal service and other antenatal services particularly when there is no allocated community midwife because of catchment areas. 4.2.10. Normal practice would be that when mothers have elected to return to their home country to give birth, the hand held maternity records are photocopied and a copy placed on file and the mother is given a copy of the maternity records to take with her. This did not occur, as the mother had not told anyone that she was going home, she had spoken 5 The term ‘safety-netting’ was introduced to general practice by Roger Neighbour who considered it a core component of the general practice consultation.2 11 informally about the possibility with her GP. C&WH are used to a high number of European Nationals electing to return to their home country for the birth of the baby. 4.2.11. Unfortunately the hand held maternity records have not been available so it is difficult to know what was recorded, this will be further discussed under patient held records in safeguarding vulnerable women. 4.2.12.Both the perinatal service and maternity services have made changes to the way referrals are processed and information shared. There is still a gap between how information is shared with general practice. It might be helpful to explore further what the expectations and standards from the perinatal service are, in how to communicate effectively with GPs and other antenatal teams. Recommendation 1: The perinatal and maternity services must audit referrals made to the service to provide assurance to the Board that the new system is robust and vulnerable women are identified and followed up. 4.3. Review the action and involvement of each agency involved with mother in the antenatal period to identify any learning to prevent this situation reoccurring. 4.3.1. The two agencies involved with the mother during the antenatal period were the GP and the C&WH Maternity Services. It would appear that the care provided within general practice was of a very high standard. I have already commented on the one area where the GP could have improved the care, which was to follow up on the referral that was made to the perinatal service. 4.3.2. The maternity services at the hospital provided antenatal care up until the 29th week of the pregnancy. 4.4. The effectiveness of patient held maternity records in safeguarding vulnerable women. 4.4.1. Pregnant women are given their own personal held maternity records at the booking appointment. They are responsible for keeping then safe and presenting them to professionals during the pregnancy. As has been previously stated the patient held maternity records for this case have not been available and it is therefore difficult to assess what information was shared on the records. 4.4.2. The maternity services were unaware of the referral that the GP made to the perinatal services and the mother was not identified as a vulnerable woman, which meant that no additional records were opened. 12 4.4.3. The maternity services keep an electronic record of all women booked to have their baby at the hospital. If there are concerns or risks identified then the normal practice would be to write a line in the patient held records such as “special consideration and management plan” which would direct professionals to review the electronic record. The pages where this information is written are half pages and therefore stand out. The electronic record is available for the professionals working within the hospital setting. Currently there is no robust platform for all healthcare practitioners to communicate via. 4.4.4. Whilst it is recognised that the hand held maternity record is a good method for transmitting information between health care professionals, the maternity service should ensure that there is a centrally held copy (backup) of all clinical contacts with pregnant woman. This is especially important for vulnerable women with chaotic lifestyles. Recommendation 2: The midwifery service must demonstrate to the Board that there is a plan in place to implement the centrally held electronic record system including a completion date in place. 4.5. Was the practice sensitive to issues of racial, cultural, linguistic and religious identity and any issues of disability of the child and family? Were any such issues appropriately explored and recorded? 4.5.1. The mother came to the UK to seek employment and worked as a receptionist, there are no recorded issues regarding her ability to communicate effectively in English given that this was not her first language. 4.5.2. There were no issues of conflict raised in this case. The practice was sensitive to the patient’s needs with no religious conflicts surrounding abortion. 4.6 Evaluate the impact of any organisational change over the period covered by the review or any systems issues that you consider to be relevant. 4.6.1. General practice identified that the Information Technology (IT) system used for recording patient notes and information was changed during this period. This change however, did not affect the referrals, patient management or communication between the services. 4.6.2. The Chelsea and Westminster Hospital have amended the ‘Did Not Attend’ (DNA) policy to ensure that women who do not make a follow up appointment are followed up. 13 4.6.3. The Antenatal Clinic Lead now attends the perinatal referral meeting and cross references all women with their midwifery team to make sure that they are identified as vulnerable women and appropriate referrals are made. 4.6.4. The perinatal service identified that they did not have a pathway in place at the time of this review and that there was a higher than average sickness rate within the administration team combined with low levels of clinical staffing due to vacancies and sickness. Work has been undertaken and changes made to the referral process. There is now more robust internal tracking of referrals received by the service. 4.6.5. Whilst undertaking this review it became evident that communication across and between services and professionals was fragmented. Information about changes to service provision, how to refer to services using the correct form and the geographical areas covered by the midwifery service at C&WH were not fully understood. Recommendation 3: Health services should work together to develop a communication pathway locally to improve outcomes for service users. 5. Conclusion and Findings 5.1. This is a review about the death of a nine-week-old baby who was reportedly suffocated by her mother having returned to the UK without the knowledge of the grandparents who thought mother and baby were visiting friends at home. The review sought to try and understand whether there were any lessons to be learned from the case in terms of professional practice, early intervention and safeguarding. 5.2. The mother appeared to be ambivalent about the pregnancy and asked for a referral for a termination. She then changed her mind and continued with the pregnancy despite no support either emotionally or financially from the father of the baby. The mother presented to the family GP with low mood and anxiety associated with the pregnancy and was referred to the perinatal services. Unfortunately the mother was not seen by this service and returned to her own country for the birth of her baby where she reportedly had strong family support. There is no information available to the author about the birth, the postnatal period or her mental state. 5.3. The management and care given by the GP was of a good standard. 5.4. It is difficult to say whether there would have been a different outcome to this case if the mother had been assessed by the perinatal service and her antenatal care shared with the clinicians in her home country. What is clear is that the review has identified areas of practice that can be strengthened and improved; some changes have already taken place within the services that have been involved. 14 5.5. The LSCB is invited to consider the review and findings, as a way forward to strengthen and develop the multi-agency safeguarding network across the three boroughs of Hammersmith and Fulham, Kensington and Chelsea and Westminster. 5.6. Recommendation 1:The perinatal and maternity services must audit referrals made to the service to provide assurance to the Board that the new system is robust and vulnerable women are identified and followed up. 5.7. Recommendation 2: The midwifery service must demonstrate to the Board that there is a plan in place to implement the centrally held electronic record system including a completion date in place. 5.8. Recommendation 3: Health services should work together to develop a communication pathway locally to improve outcomes for service users. Bibliography Working Together to Safeguard Children, A guide to inter-agency working to Safeguard and promote the welfare of children, HM Government, 2015. London Child Protection Procedure 2014(Edition 5) The Quality of GP Diagnosis and Referral, The Kings Fund 2010. 15 Appendix 1: ACRONYMS AND TERMINOLOGY ANC Ante Natal Care CCTV Closed circuit television CNWL Central and North West London NHS Foundation Trust C&WH Chelsea and Westminster NHS Foundation Trust DNA Did Not Attend DSH Deliberate Self Harm GP General Practice, family doctor IMR’s Individual Management Review LSCB Local Safeguarding Children Board MPS Metropolitan Police Service MDT Multi- disciplinary Team |
NC050348 | Death of an infant under 3 months in December 2016. Baby D lived with his mother and older sibling. Father had lived in the family home but was deported from the UK before Baby D was born. Mother started a new relationship with a man a few weeks prior to Baby D's death; both were in the home on the day of his death. The ambulance service received a call from the mother saying that she had found Baby D 'not breathing'. A post mortem concluded that Baby D had injuries consistent with death resulting from co-sleeping. After a police investigation into the death the Crown Prosecution Service advised there was no criminal case to pursue. Learning includes: NICE guidance in relation to management of mental health issues in pregnancy should be followed by practitioners in all settings; professionals require ongoing training in relation to the effects and impact of cannabis on mental health and parenting; professionals need support in making enquiries about existing and new relationships; professionals should have access to support to address any concerns regarding resistant parents and unwillingness to change risk behaviours. Recommendations include: ensure that GPs receive advice in relation to specific concerns regarding safe sleeping and that they take opportunities to reinforce safe sleeping advice; all relevant practitioners should have access to good quality drug and alcohol training and be aware of the services provided by local drug and alcohol services.
| Title: Serious case review: Baby D. LSCB: Bolton Safeguarding Children Board Author: Maureen Noble Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 BOLTON SAFEGUARDING CHILDREN BOARD Serious Case Review Baby D Lead Reviewer: Maureen Noble Published April 2018 2 CONTENTS 1. Introduction To The Review 2. Background To Baby D And Professional Narrative 3. Significant Agency Contacts And Key Events 4. Analysis Of Professional Practice 5. Learning from the Review 6. Recommendations 7. BSCB Response to Recommendations 8. Appendix 1; Abbreviations and Key 3 1. INTRODUCTION AND METHODOLOGY The review offers condolences to the family of Baby D on his tragic death. 1.1 Key People This Serious Case Review (SCR) relates to the death of Baby D, who sadly died in December 2016. Baby D lived with his mother (MD) and his older sibling (SD). He was below 3 months of age at the time of his death. During the period under review MD had two consecutive relationships, MDP1 and MDP2. MDP1 was Baby D’s father and lived at the family home with MD and SD. SD is said to have thought of MDP1 as his father. MDP1 was deported from the UK before Baby D was born. MD’s relationship with MDP2 appears to have begun a few weeks prior to Baby D’s death. MDP2 was present in the family home when the incident leading to Baby D’s death took place and was questioned under police caution following Baby D’s death. APPENDIX 1 – FAMILY GENOGRAM 1.2 Incident Leading to the SCR On the date of Baby D’s death the North West Ambulance Service (NWAS) received an emergency telephone call from MD saying that she had found Baby D ‘not breathing’. MD said that Baby D had been unwell the day before and that she had taken him to see the GP. Hospital staff informed police of Baby D’s death. The SUDC (Sudden Unexpected Death of a Child) Paediatrician, Duty Social Worker and the Bereavement Team were also contacted in line with the local protocol.1 At mother’s request they also informed MDP1 by telephone. At this time MDP1 had been deported and was residing in another country. Following notification police began a criminal investigation into Baby D’s death. It was established that both MD and MDP2 were present in the home at the time of the incident. Both MD and MDP2 were voluntarily interviewed by police under caution. 1 http://greatermanchesterscb.proceduresonline.com/pdfs/pr_gm_sudc.pdf MD Baby D MDP1 MDP2 Unborn Sibling SD FSD 4 A post mortem was conducted following Baby D’s death which established that he had injuries consistent with death resulting from overlay.2 This was confirmed by a Home Office pathologist. 1.3 Review Process A referral for consideration of a Case Review was received by the Bolton Safeguarding Children Board (BSCB) in February 2017. The Learning and Improvement Group recommended that a SCR take place in March 2017 and this was approved by the Chair of the BSCB. An Independent Reviewer was sought and, following a commissioning process, Maureen Noble was appointed to undertake the review. The BSCB commissioned a concise SCR using a blend of the SCIE Learning Together SCR Methodology3 and the ‘Welsh Model’ for Serious Case Reviews.4 The time period considered for the review was agreed as twelve months prior to the death; this is in accordance with recommendations from systems methodologies. A combined chronology/timeline was compiled from agency records and individual conversations were held with practitioners; these resources were used to identify significant episodes of practice for analysis and learning. A panel of professionals from relevant agencies was established as the review team and met on four occasions to oversee the review. Details of panel members are set out below: Designation Agency Associate Director of Safeguarding / Interim Associate Director of Safeguarding NHS Bolton Clinical Commissioning Group Designated Doctor Bolton NHS Foundation Trust Named Nurse Safeguarding Children Bolton NHS Foundation Trust Detective Constable, SCR Team Greater Manchester Police Safeguarding Children Board Officer Bolton Safeguarding Children Board 1.4 Research Questions to be addressed by the Review The review team agreed the following areas for discussion with professionals involved in the case: Did agencies identify and respond to specific vulnerabilities and risks in relation to substance misuse and other ‘lifestyle’ factors? 2 file:///C:/Users/noble/Downloads/Sudden%20unexpected%20death%20in%20infancy%20and%20childhood%20(2e).pdf 3 https://www.scie.org.uk/publications/ataglance/ataglance01.asp 4 http://www.sewsc.org.uk/fileadmin/sewsc/documents/Published_SCR_CPR/Child_Practice_Review_Guidance_-_Welsh_Government.pdf 5 Did professionals demonstrate an understanding of the daily lived experience of Baby D (and his older sibling)? Did professionals respond appropriately to MD’s current and historical mental health issues? Did professionals discuss safe sleeping with MD? Are local policies, procedures and practice in relation to safe-sleeping robust and up to date; are there modifications that can be made to improve understanding and compliance? Has the review identified good practice? Has the review identified practice that could be modified to strengthen safeguarding? Has any additional learning been identified by the review? The Lead Reviewer held one to one conversations with the following practitioners: Family GP Health Visitor Nursery Nurse A statement of involvement was received from Midwifery Services. A learning event was held with professionals who were directly involved in the case prior to presentation of the report to the BSCB. A wider learning event was also held to share the learning from the case, promote good practice and discuss modifications to future policy and practice. 1.5 Criminal Proceedings A police investigation into the death of Baby D took place. A police file was submitted to CPS in relation to prosecution. In December 2017 the review was informed that the Crown Prosecution Service advice was that there was no criminal case to pursue. 1.6 Coroner’s Inquest HM Coroner was informed in writing at the commencement of the SCR. A Coroner’s Inquest was pended until the completion of criminal proceedings. The Coroner’s Inquest took place towards the end of 2017. The Lead Reviewer of the SCR was instructed to attend the inquest. The Coroner’s findings were that the cause of Baby D’s death was overlay; an open verdict was recorded5. 1.7 Family Involvement in the Review MD was informed of the Serious Case Review by her allocated social worker and confirmed in writing by the SCR Panel. MD was invited to participate in the review following completion of the criminal investigation. Prior to the Coroner’s Inquest, a member of the review panel and the Independent Chair of Bolton Safeguarding Children Board met with 5 There is not enough evidence to return a verdict. This is a rare verdict. 6 MD. The purpose of the meeting was to share the final draft of this report and to seek MD’s views. MD’s comments on the report and her views are included throughout the report and are shown in italics for ease of identification. 2. BACKGROUND TO BABY D AND PROFESSIONAL NARRATIVE 2.1 Background to Baby D In February 2016 MD consulted her GP as she thought she may be pregnant with Baby D and ‘booked’ into maternity and midwifery services at around 8 weeks pregnant. She was said to be happy about the pregnancy and looking forward to a new baby. MD had a history of anxiety and depression. In 2011 she had taken what she described as an impulsive overdose and was referred to Community Mental Health Services. She received ongoing treatment with anti-depressant medication from her GP. MDP1, the father of Baby D, was deported in May 2016. This was difficult for MD although she remained positive about the relationship and had plans to visit father when Baby D was born. Following father’s deportation MD lived as a lone parent with SD (Baby D’s older sibling). SD was a toddler during the period under review and attended a local nursery. During her pregnancy with Baby D, MD had noticed that SD’s behaviour had become difficult; she said that he was demanding and naughty. She discussed this with the Health Visitor (HV) and sought support in helping with his behaviour. HV requested that a nursery nurse offer assessment and support. MD received ante-natal services as set out in clinical guidance. Midwifery services were aware of MD’s history and that she smoked cannabis. A discussion was held as to whether MD should be referred to the Outreach Midwife service (a service targeted to families with vulnerabilities) however this was discussed with MD and she said that she had stopped smoking cannabis so she didn’t need the service.6 MD attended her ante-natal appointments and, other than physical symptoms, the pregnancy was uneventful. MD consulted her GP appropriately during pregnancy. When she was first booked as pregnant her GP decided to stop prescribing anti-depressants for the duration of the pregnancy. MD told professionals that she wanted to go back onto anti-depressants after Baby D was born as they helped her to manage daily life. Baby D was born at full term with no complications and returned home with MD following discharge. Baby D lived at home with MD and SD. He received care in line with expected practice from universal services under the national Healthy Child Programme7. The Community Midwife handed over care to a Health Visitor who conducted the first birth visit and Baby D’s 8-10 6 The local policy is that the Outreach Midwife and Community Team would continue to work closely together so that any emerging issues could be picked up and a re-referral made. 7 https://www.england.nhs.uk/wp-content/uploads/2014/12/hv-serv-spec-dec14-fin.pdf 7 week check (conducted at 8 weeks). HV also saw MD in the mother and baby clinic and opportunistically in the local area. Baby D was healthy other than minor health conditions for which he was taken to the GP. He was taken for all vaccinations and MD both welcomed professionals into the family home and attended appointments, although it was noted that she was sometimes reluctant to take on board the advice given to her by professionals who felt that MD had the view that she ‘knew best’. In line with Bolton Safeguarding Children Board protocols both the Community Midwife and Health Visitor provided detailed information about safe sleeping on several occasions8. SD was seen by professionals and no concerns were noted. However, MD did state that since Baby D’s birth, SD had become difficult to manage and naughty. The HV delegated a Nursery Nurse (NN) to see MD and SD at home to support with behaviour management. NN found the visit to be difficult and observed that the relationship between MD and SD felt more like an adult to adult than parent to child interaction. NN did not observe any inappropriate behaviour from SD, however she did talk to MD about the support that could be offered and said that she would call again. She arranged to do this when SD was at nursery so that she could have a more open conversation with MD about her concerns regarding SD’s behaviour. Following the second visit MD said that she did not want to take up the offer of behaviour support for SD. The day before Baby D’s death MD had presented with him to the GP practice. He was examined by the GP who noted MD’s reports of vomiting after feeds. The GP advised MD regarding feeds and oral hydration, and that if vomiting persisted or became worse, MD should come back to the see the GP. 2.2 Professional Narrative MD was described as being well known to local health agencies. She had been registered with a local General Practitioner for many years and had frequent contact with the practice. Practitioners who met MD described her as an outgoing character who stood out as being gregarious. She was described as approachable, willing to contact services, capable as a parent although perceived by some ‘not to be in control of her own behaviours’. MD appeared to professionals to be honest and open about her lifestyle choices; she admitted that she used cannabis although she said at various times that she had stopped using or had cut down her use considerably. She was asked about alcohol use but said that she did not really drink alcohol. In May 2016 her long term partner and father of Baby D had been deported due to a failed residency application. MD found this a stressful time; she did not want to separate from her partner and professionals were of the view that they were both looking forward to the birth of Baby D. Following deportation MD continued to have contact with the father and was hoping to arrange to visit him with Baby D for an extended stay after the birth. 8 http://boltonsafeguardingchildren.org.uk/sleep-safe/ 8 Professionals were aware of MD’s historic and current mental health issues. She told professionals that she needed medication to manage her mental health and volunteered this information to all the professionals she had involvement with. MD was perceived as a forceful character who was able to look after herself and SD. Professionals who visited MD at home observed home conditions that were acceptable and they had no safeguarding concerns about SD or Baby D until the event in August 2016 when MD told HV that she had resumed her cannabis use, was drinking alcohol and was sleeping with both children in bed with her. This was in addition to prescribed medication. For the most part professionals did not perceive MD as a parent who was not meeting the needs of her children. There were no issues of neglect (although the review will highlight the professional view of the use of drugs and alcohol in this context). There was no historic or current involvement of Social Care and there had been no referrals made by any professional in relation to child protection concerns. The professional mind-set in relation to MD was that she was capable of looking after SD and Baby D but that she did not always take on board the advice given to her by professionals. It was recognised by professionals that there were times at which MD needed additional support, particularly when she reported low mood and depression; when this happened she was offered ‘listening visits’. On one occasion her GP gave her contact details for a local counselling service. Professionals were aware that MD did not appear to have a supportive network of family and or/friends. 3. SIGNIFICANT CONTACTS AND PRACTICE LEARNING EVENTS The combined multi-agency chronology shows 30 separate contacts with MD during the period under review, these include face-to-face (clinics, hospital, surgery and home visits); contacts by telephone and opportunistic contacts in the local area). The review panel has analysed all contacts and extracted those from which significant learning can be gained both in relation to good and modifiable practice. These are referred to below as significant practice learning events (SPLE). In January 2016 MD presented to her GP saying that she felt depressed and suicidal and that, despite being prescribed anti-depressant medication, she was feeling worse. The GP enquired about MD’s reference to suicide and assured himself that she had no plans to harm herself. MD said she did not feel she would actually ‘do anything’; she was experiencing stress at home. The GP doubled the dose of anti-depressant medication and gave MD a contact number for the counselling service (it is a self-referral service). SPLE Note: On reading the final draft report MD contested that she had told the GP that she was suicidal. However she did agree that she was depressed at this time. The GP record contains information that MD had reported she was suicidal; on that basis this information is included in the report. 9 The GP made enquiries about suicidal thinking to be assured that MD did not have plans to take her own life. The GP offered information regarding counselling services (the service is self-referral). The GP had considered a safety plan for MD. The GP did not explore in any depth the reasons why MD was feeling in this way. Opportunities to discuss social issues were not taken nor was there discussion regarding the safety of SD. MD had been prescribed the anti-depressant medication for some time; this would therefore have been a good opportunity to talk to MD about the effectiveness of prescribing given that she was feeling in low mood. Reviewing MD’s general situation and well-being, as well as her medication, may have resulted in a better understanding of factors contributing to low mood and therefore better informed the treatment plan. In mid-February MD presented to her GP and said she thought she was pregnant (she would have been around 7 weeks pregnant at this time). The GP recommended stopping the anti-depressant medication MD was taking. SPLE This was a missed opportunity for the GP to make enquiries about home life, particularly given the earlier presentation about low mood and suicidal feelings. The recommendation to stop prescribing does not appear to take into account the long-term nature of prescribing or the impact of sudden cessation. In early April MD booked for ante-natal care at 13 weeks pregnant. She told the midwife that she used Cannabis (up to five times a day) which MD said had helped her to manage extreme morning sickness in her last pregnancy. A referral was made to the Outreach Midwife (OM) as a potential high risk in pregnancy. MD had a number of other risk factors in her previous pregnancy including smoking and history of mental ill health. The midwife advised regarding the health risks of cannabis use and also the risks in terms of safe sleeping. MD declined referral to the smoking cessation or substance misuse service. SPLE Note: MD disputes that she was offered advice in relation to potential risk to Baby D resulting from her use of cannabis. MD disclosed several risk factors to the Midwife which raised the Midwife’s cause for concern. The midwife demonstrated good practice by discussing each risk factor with MD and offered practical interventions such as referral to smoking cessation and substance misuse services, although these were declined. The midwife also made a referral to the outreach midwife. In early May when she was 18 weeks pregnant MD asked her GP to re-start the anti-depressant medication which they did.9 This was an opportunity to further explore MD’s reasons for requesting to re-start anti-depressant medication. 9 https://www.nice.org.uk/guidance/cg192/chapter/1-recommendations 10 In late May at an ante-natal clinic appointment MD informed the midwife that her partner was due to be deported. The midwife enquired about cannabis and MD said she no longer used it. SPLE In June MD was admitted briefly to hospital. A few days after discharge she visited her GP and enquired about travel to another country as her partner had been deported there. It was noted that she would be unable to travel due to pregnancy. At an antenatal visit in August MD reported that she had a history of depression and self-harm, the last episode being in 2014. She said her mood was low at present due to the deportation of her partner and that she was smoking five cigarettes per day. She was offered support to stop smoking but declined this. MD was offered listening visits. SPLE In October Baby D was born at a local hospital with no complications. MD and Baby D were discharged to home five days later. On the seventh day after discharge HV conducted a new birth home visit at which MD, Baby D and SD were present. Baby D was noted to be feeding well and gaining weight. No concerns were noted regarding Baby D. MD reported that her partner was still in another country due to a failed residency application. MD said she was coping ‘OK’ but wanted to increase the anti-depressant medication and would contact the GP. She reported little family support. MD declined the Edinburgh Postnatal Depression check and listening visits, she was given open access to HV. SPLE MD reported at the visit that she was struggling with SD’s behaviour and HV arranged a visit to be undertaken by a Nursery Nurse with a view to putting in place a six week behaviour management support intervention. In November the NN made a home visit to discuss behaviour management support for SD. She found MD to be welcoming but noted that she did not appear to want advice or support in relation to managing SD’s behaviour. NN observed that MD and SD’s relationship was not like that of a parent/child but that MD treated SD as a companion and involved him in adult conversation and tasks; indeed NN observed SD holding and feeding Baby D, she also noted that MD used bad language in front of SD and advised her not to do this. NN left the home with some concerns around the family dynamic and with reservations about MD’s willingness to put in place actions to change her behaviour in relation to managing SD. When NN returned to her office she spoke to a colleague about her concerns regarding the dynamic within the family. She did however observe that she had not witnessed any inappropriate behaviour on the part of SD. NN checked with the SD’s nursery who said they had no concerns about him. This was good practice. SPLE She made a note to review and return to visit at home again in two weeks’ time when SD was at nursery. At the end of November HV visited the family home to conduct the 6-8 week review of Baby D. HV administered the ages and stages questionnaire and noted that Baby D was not using both arms equally, this was noted for review in one month. There were no other concerns about Baby D’s physical health. 11 MD told HV that she had ended her relationship with Baby D’s father who was still in another country. She disclosed to HV that she had been sleeping in the same bed with SD and Baby D, that she was using cannabis and that she had started to consume alcohol before going to bed. HV talked to MD about safe sleeping and reinforced the messages about the safety of the environment and also the risks associated with using drugs and alcohol. HV offered to refer MD to the substance misuse service however this was declined. HV made a note to keep risk factors under review and planned to discuss with the GP. SPLE The following day HV opportunistically encountered MD at the GP surgery. That same morning HV had left a message with reception staff at the surgery to share her concerns about MD’s cannabis and alcohol use. HV spoke again to MD about drugs and alcohol and reinforced the messages regarding safe sleeping. She asked MD where the baby had slept last night and MD assured her that he had slept in his ‘Moses’ basket. HV was reassured by MD’s response. SPLE Six days later HV opportunistically encountered MD again at the Well Baby Clinic. HV took the opportunity to speak to MD and to remind her about safe sleeping. MD said that HV had ‘scared her into’ placing Baby D in his Moses basket to sleep, she also said that she had stopped drinking alcohol. SPLE Two days later NN returned to the family home to speak to MD about SD’s behaviour management. MD and Baby D were present in the home. MD welcomed NN into the home but made it clear that she had no intention of following her advice in relation to behaviour support and that she would not attend a ‘drop in’ session. NN noticed that Baby D was asleep in a pushchair and was wearing outdoor clothing. NN advised MD to remove the clothing and take care that Baby D did not overheat however MD did not act on this advice. Note: MD said that she did unbutton Baby D’s coat but that he was asleep and she did not want to disturb him by removing his clothing. NN noted that there was a faint smell of cannabis in the house, however she did not raise this with MD. NN reported back to HV that MD had said she did not require any support with managing SD’s behaviour and that she would not be taking up the offer of a six week programme. HV told the review she was surprised at this as MD had seemed keen. SPLE. Note: MD commented that she believed that the appointment that had been made was for SD and not for her. She said she declined the appointment because it was in ‘school time’ and that she heard nothing from the service after that. Two weeks later MD presented to the GP. The GP prescribed contraceptives for medical reasons; MD said she was not currently in a relationship. SPLE The following day HV had a third opportunistic meeting with MD in the local area. HV was driving past and saw MD with Baby D. She enquired again whether Baby D was sleeping in his Moses basket and MD assured her that he was. Two days after this, MD presented to the GP complaining of pain and was prescribed a higher dose of codeine based medication. SPLE 12 On the day before his death MD presented to the GP with Baby D complaining of a rash that had been present for 24 hours accompanied by vomiting. The GP thoroughly examined Baby D and advised re feeding and hydration. The GP asked MD to note if symptoms worsened and to contact the GP again. The following day the events leading to Baby’s D’s death took place. 4. ANALYSIS OF PROFESSIONAL PRACTICE The review analysed professional practice in relation to the research questions (set out in Section 1 of this report) and to the key practice episodes identified by the review. This forms the basis of the recommendations set out in Section 5 of the report. The review has also gathered wider learning which will strengthen safeguarding practice which is set out in Section 5. 4.1 Good Practice Identified by the Review The review has seen several examples of good practice particularly with regard to professional’s efforts to engage MD. The Health Visitor built a good relationship with MD and maintained MD’s confidence whilst also being tenacious and taking every opportunity to remind MD about safe sleeping. With hindsight MD was not always truthful with HV about aspects of her life but she did disclose to HV that she was using cannabis and that she had been sleeping with Baby D and SD in her bed. The GP had also built up a good rapport with MD and knew her history well. He felt that she was open and honest. It appears that MD felt comfortable discussing a range of health issues with the GP; she also presented early in her pregnancy with Baby D suggesting that MD had confidence in engaging with the service. When MD presented to the GP in January 2016 she indicated low mood and suicidal feelings. The GP demonstrated good practice in exploring her current mood and intent. The GP also recommended to MD that she contact a counselling service and gave her details of a local service; the local service is self-referral only. With hindsight it is clear that MD did not always discuss aspects of her life with her GP. At 13 weeks pregnant MD booked with Midwifery Services and a history was taken. MD disclosed that she was a regular user of cannabis and that she had a history of mental ill health. The midwife demonstrated good practice in speaking to MD about the risks associated with cannabis use (as well as smoking) in pregnancy and suggested support services however these were declined by MD. The Community Midwife (CM) raised vulnerabilities and risk factors with MD and consulted with the Outreach Midwife. They communicated well in relation to MD’s care, needs and vulnerabilities. Both practitioners continued to review MD’s needs and had an arrangement whereby MD could be quickly referred back to the Outreach Midwife should a need be identified. The Nursery Nurse had some concerns after her first home visit and raised these immediately with a colleague on return to the office. The Nursery Nurse also arranged a second home visit at a time when SD would not be present to assess the home situation and 13 to more freely discuss any difficulties that MD was having with SD. NN also observed the bond and relationship between MD and SD from SD’s perspective; had MD agreed to behaviour support interventions NN planned to work with the family to establish boundaries. She observed that MD appeared to treat SD as an adult and as a friend. Note: MD commented that this was the nature of her relationship with SD; that it was her style of parenting and that no professional ever raised this as a concern. 4.2 Modifiable Practice Identified by the Review There are a number of areas in which practice could be modified to strengthen safeguarding as set out below. These will be explored in further detail in the learning section of this report. The review concludes that there were a number of occasions when the GP could have taken the opportunity to further explore the reasons for MD’s low mood. She disclosed that she was having problems in her relationship but these were not explored further. A proactive review of MD’s treatment plan would be good practice, rather than reactive responses to requests for increased medication without further exploration of underlying factors. MD presented to the GP in February saying that she thought she was pregnant. The GP’s response was to refer MD for booking and to suggest that she cease taking the anti-depressant medication during pregnancy. During this consultation there is no indication of discussion regarding either the impact of ceasing anti-depressant medication or of any discussion regarding alternative medication or interventions. This would have been good practice. When MD attended an antenatal appointment in August she disclosed that she had experienced low mood and depression and that she was currently experiencing low mood. She was offered listening visits however there is no indication that attempts were made to understand more about the disclosures. Professionals were aware that Baby D’s father had been deported and that SD had developed a close bond with him (it was reported to the review that SD thought of MDP1 as his father). The impact of the loss of MDP1 in such circumstances on both MD and SD does not appear to have been addressed by professionals. Following the birth of Baby D MD received a home visit from HV to conduct the new birth visit. At this visit MD told HV that her partner had been deported and that this resulted in her feeling low. MD said she wanted to increase her anti-depressant medication. She also reported that she was struggling with SD’s behaviour. At the second home visit conducted at 8 weeks, MD also disclosed to HV that she had resumed her use of cannabis, that she was drinking alcohol before bed and that she had been sleeping in the same bed with SD and Baby D. HV spoke to MD about dangers and risks. She also reflected on whether or not she should make a referral to Children’s Social Care however the following morning she saw MD opportunistically at the GP surgery and was reassured when MD told her that she had taken on board what HV had said and would 14 not put SD and Baby D into bed with her again. The review has concluded that professionals currently have options to discuss concerns through informal team working and with team leaders at weekly or monthly work allocation meetings. There are more formal options available to seek advice and guidance from other agencies (e.g. duty social worker) which is what HV intended to do at the next review which would have taken place at 12 weeks, sadly Baby D died at 11 weeks. With regard to the disclosures of risk factors relating to drugs, alcohol and safe sleeping HV was sure that she had made the right decision in reminding MD about risks and that this would be effective. It appears that HV erred on the side of optimism with regard to MD’s intentions or ability to change her behaviour in relation to cannabis use. It would have been good practice to revisit the issues with MD and to seek a peer or multi-agency discussion regarding risk factors. At the birth visit HV introduced and offered the Edinburgh Postnatal Depression Scale (EPNDS); however MD said she did not want to complete it. HV might have considered following up with the GP at this stage although MD had previously completed the assessment following SD’s birth and HV would have introduced it again at future visits as the opportunity arose. When NN visited the family home for the first time she felt uncomfortable with the dynamic between MD and SD and expressed her concerns to a colleague. When she returned for the second visit NN noticed that Baby D was wrapped in outdoor clothing. She spoke to MD about the possibility of Baby D overheating but felt that this advice was not taken on board or acted on. NN also noticed a smell of cannabis in the room however she did not raise this with MD. NN did not feel that her concerns warranted referral for early help; however it would have been good practice for NN and HV to have held a detailed discussion about NN’s observations and concerns and for them to have agreed a plan to re-engage MD in relation to SD’s behaviour management. In the two weeks prior to Baby D’s death it appears that MD had met a new partner (MDP2) and that he was staying at the family home. Professionals were not aware of this and MD did not disclose it to either the GP or HV. There were two further occasions on which MD consulted her GP prior to Baby D’s death. The GP could have taken the opportunity to discuss MD’s day to day life at these consultations. The GP did ask about the need for contraception and was informed by MD that she was not sexually active. The GP could have explored this further with MD. 15 5. LEARNING FROM THE REVIEW – FINDINGS AND RECOMMENDATIONS 5.1 Findings The review has concluded that the death of Baby D was neither predictable nor preventable by any of the agencies involved in his care. The review has identified good practice and practice that can be modified to improve safeguarding as set out in the analysis of professional practice set out above. Specific learning is summarised below and grouped under thematic headings linked to the research questions and key practice episodes. 5.1.1. Theme 1 – Responding to Current and Historic Mental Health NICE guidance in relation to management of mental health issues in pregnancy should be followed by practitioners in all settings. A multi-agency discussion in this case would have facilitated the sharing of historic and current information and enable joint care planning. 5.1.2. Theme 2 - Responses to Maternal Substance Misuse Professionals recognise the prevalence of cannabis use and require ongoing training in relation to its effects and impact on mental health and parenting. The offer from drug services in supporting long term cannabis users should be made widely available to all practitioners.10 A brief assessment questionnaire similar to the one used some years ago developed by the Standing Conference on Drug Abuse (SCODA) would help professionals to assess levels of use and identify concerns.11 Alcohol may have been used as a short term coping strategy by MD. Professionals should make routine enquiries into increased alcohol consumption alongside other lifestyle factors 5.1.3. Theme 3 - Disrupted relationships and hidden men The deportation of MD’s partner was difficult for her and would have impacted on the lives of both SD and Baby D. Whilst the deportation is recorded by professionals there is no indication of this being seen as a significant event in MD’s life. MD did not share information about her new partner with professionals. The review recognises that the daily lives of Baby D and SD would have been impacted by the introduction of a new partner to the household and identifies that support is needed for professionals in making enquiries about existing and new relationships.12 10 https://www.boltondrinkanddrugs.org/about/services-menu/ 11 http://www.socialworkerstoolbox.com/scoda-risk-assessment-of-parental-drug-use-and-its-impact-on-childrentool/ 12 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men/ 16 Note: MD disagreed that professionals should ask about personal relationships. Her view is that health visitors and other professionals are there for the child, not the adult. 5.1.4. Theme 4 - Understanding Baby D’s Daily Lived Experience (and that of SD) Professionals were focused on the children and there are examples of professionals taking the opportunity to speak to SD. Although only a small number of agencies were involved at this time, a conversation triggered by MD’s disclosures in August 2016 would have raised awareness regarding MD’s vulnerabilities and risks and given a clearer picture of the daily lived experience of Baby D (who was unborn at this time) and SD The impact of MPD1’s deportation could have been further explored by professionals in terms of impact on the day to day lives of Baby D and SD 5.1.5. Theme 5 - Safe sleeping Guidance in relation to safe-sleeping appears to be woven into the professional mind-set and professionals take every opportunity to give safe sleeping messages to new parents A professional consultation undertaken as part of this review has highlighted areas in which the current safe sleeping policy can be updated and strengthened. 5.1.6. Theme 6 - Resistant Parents With hindsight it is apparent that MD was not open and honest with all professionals about aspects of her life (although MD’s GP felt that MD was open with him). On some occasions professionals observed an unwillingness to take professional advice although at the time this wasn’t seen as being a cause for concern or reaching the threshold for further interventions. Note: MD’s view is that she would take professional advice if necessary but that she would also use her own judgment in making decisions regarding her children. Professionals should have access to ongoing training, support and supervision to address their concerns regarding resistance and unwillingness to change risk behaviours. Note: MD contests that she was not open and honest with professionals. MD said that she told professionals about cannabis and alcohol use, but that she was not asked for any detailed information about her cannabis use or offered support to stop using cannabis. 5.1.7 Wider Learning The panel noted that information sharing between health agencies is hampered by the lack of a single system for recording, storing and sharing information across agencies. This is reflective of a national problem with regard to health information systems. 17 6. Recommendations The panel makes the following recommendations to the BSCB. A multi-agency action plan is attached at Appendix 2 setting out the BSCB’s response to the recommendations and a plan for implementation. Recommendation 1 The BSCB should be assured that the management of anxiety and depression in primary care settings complies with NICE guidance (both general guidance and guidance for managing mental health conditions in pregnancy). Recommendation 2 The BSCB should be assured that all single agency early help assessment tools are aligned to ensure that:- there is no duplication of effort there is no disincentive to the completion of early help in relation to referral into social care services by any agency Recommendation 3 BSCB should be assured that those practitioners who work directly with children and/or their parents/carers have access to the appropriate level of awareness raising and training in relation to working with parents who are resistant to change. Recommendation 4 The BSCB should support the further development of local Safe Sleeping guidance based on the learning from this case. At the request of HM Coroner specific action is required to ensure that GPs receive advice in relation to specific concerns regarding safe sleeping and that they take opportunities to reinforce safe sleeping advice. Recommendation 5 The BSCB should be assured that all relevant practitioners have access to good quality drug and alcohol training and are aware of the service offer from local drug and alcohol services. 18 7. BSCB RESPONSE TO RECOMMENDATIONS SCR RECOMMENDATION BSCB RESPONSE 2017-2018 The BSCB should be assured that the management of anxiety and depression in primary care settings complies with NICE guidance (both general guidance and guidance for managing mental health conditions in pregnancy). Currently CCG governance and safety committee working with primary care directorate to perform initial audit of GP practice compliance with key outcome measures of NICE guidance; in particular frequency of reviews for patients with anxiety and depression and medication reviews for anti-depressants with enquiries made re: psychosocial factors impacting on these mental health conditions. The findings will be reported to Bolton Safeguarding Children Board Provide summary to GPs around NICE guidance, and also run an education session regarding best practice when treating a patient with anxiety and depression in primary care aligned to NICE guidance. Compliance will be re-audited to establish practice improvement and any areas for further development The BSCB should be assured that all single agency early help assessment tools are aligned to ensure that:- there is no duplication of effort there is no disincentive to the completion of early help in relation to referral into social care services by any agency Early Help processes have been part of Bolton’s model to safeguard and promote the welfare of children for a significant number of years, and were most recently relaunched in 2014 in response to findings from an evaluation by Lancaster University; in that time there have been significant improvements in the number of Early Help Assessments and plans developed for children as well as an increase in the range of services using the process. During 2017-2018 the Early Help Strategy was redeveloped and the SCR recommendation is being addressed through the ‘Embedding Early Help and Tackling the Barriers’ strategic workstreams. The progress and implementation is being tracked through the Early Help Steering Group, which reports to BSCB. An annual assessment of effectiveness made in BSCB’s annual report. A review of current referral processes to social care is planned for January to May 2018 – a multi-agency task and finish group is leading this and a report will be provided to BSCB on strengths and areas for development 19 SCR RECOMMENDATION BSCB RESPONSE 2017-2018 BSCB should be assured that those practitioners who work directly with children and/or their parents/carers have access to the appropriate level of awareness raising and training in relation to working with parents who are resistant to change. BSCB has previously published a learning brief on ‘Recognising and Responding to Resistance’ and this has been recirculated. BSCB has re-commissioned a revised training programme on this topic and it will be rolled out from January 2018 and impact evaluated during this period. Board members have been requested to provide assurance to BSCB on the their ‘Resistant Parents/Families’ offer The BSCB should support the further development of local Safe Sleeping guidance based on the learning from this case. At the request of HM Coroner specific action is required to ensure that GPs receive advice in relation to specific concerns regarding safe sleeping and that they take opportunities to reinforce safe sleeping advice. A task and finish group is currently reviewing local Sleep Safe guidance, publicity materials etc.; the group are also exploring a range of options for promoting sleep safe messages BSCB’s Sleep Safe Guidance has been reviewed by the Regional Lead for the Lullaby Trust. The Regional Lead commented A multi-agency seminar was facilitated by the Lullaby Trust Regional Lead to share current sleep safe research and best practice. GPs have been reminded of the importance of safe sleeping guidance via GP practice bulletin. If the GP has or receives information giving rise to concerns about safe sleeping practices from other sources including the family of a 0-12 month old baby then reinforce the guidance at that contact and/or at subsequent contacts. Where concerned about sleeping practices within a family the GP will share this information with the health visitor. The recommendation will be further emphasised in a refresh of the current health visitor/GP communication pathway The BSCB should be assured that all relevant practitioners have access to good quality drug and alcohol training and are aware of the service offer from local drug and alcohol services. There is a multi-agency training programme on substance misuse delivered in Bolton and accessible by all partners. In 2018-2019 specific ‘Cannabis And Its Impact’ Workshops’ are planned; these will be open to all partners working with children and adults. The impact of these sessions will be evaluated and reported to BSCB 20 Appendix 1 8. Abbreviation and Key Abbreviations Meaning BSCB Bolton Safeguarding Children Board SCR Serious Case Review MD Mother of Baby D SD Sibling of Baby D MDP1 Mother of Baby D Partner 1 MDP2 Mother of Baby D Partner 2 SUDC Sudden Unexpected Death of Children GP General Practitioner HV Health Visitor NN Nursery Nurse SPLE Significant Practice Learning Event |
NC048228 | Child 1 witnessed mother's death in the family home in 2014 from multiple stab wounds caused by father. Child 1 sustained stab wounds including the partial amputation of finger during the incident. Child 1 was the eldest of three siblings, one of whom was also present in the home at the time of the incident. The children were not known to child protection agencies; they attended school and had no additional health needs. Father and mother were married for 16 years prior to the incident, but were experiencing marriage difficulties. The parents were attending marriage counselling both together and separately. Mother admitted to suffering domestic abuse and disclosed that she thought father bugged the house, her phone and computer and that she was frightened for her safety and that of her children. Both parents had been in contact with police with issues around domestic difficulties. The criminal investigation revealed that the family home was dominated by father's controlling behaviour. Issues identified include: a point of separation represents increased risk of harm to a victim of domestic abuse as well as children within the relationship; stalking behaviour in the context of domestic abuse is an indicator of high risk and is significantly associate with dangerous acts; the sharing of information between professional agencies is critical. Recommendations include: development of early help initiatives to help children talk about domestic abuse; publicising and promoting the role for independent domestic violence advocates; the use of public information notices to maximise the impact of warnings in cases of stalking.
| Title: Child 1 LSCB: Warrington Safeguarding Children Board Author: Colleen Murphy Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Child 1 Author: Colleen Murphy 1st March 2017 WARRINGTON SAFEGUARDING CHILDREN BOARD This report is written for publication in line with statutory guidance. In order to preserve the anonymity as far as is possible, the author has: used numbers to reflect each child and generic “mother” and “father” terms to denote adults made limited reference to the gender of person, other than where not to do so would compromise the reader’s understanding of the report avoided the use of exact dates 2 1. The circumstances which led to a Serious Case Review 1.1 Child 1 is the first born child within the marriage of mother, referred to as mother throughout the report and father, referred to as father throughout the report. Two younger siblings followed the birth of Child 1, eighteen months and three years later. Both parents were employed, and the family lived together in a large mortgaged home in an affluent area. 1.2 Father had two children born within previous relationships. His first child was born within a former marriage and second child within a relatively short relationship. Father maintained a relationship with his first born child until that child’s adolescent years, but never had any relationship with his second child. 1.3 Father and mother were married for sixteen years prior to the incident which gave rise to this this Serious Case Review. Although to the outside world family life was presented as idyllic, in reality, the marriage was characterised by paternal dominance and both parents had had a relationship outside of the marriage. 1.4 Other than through the provision of standard universal child health and education services, the children of the family were little known to agencies with additional safeguarding responsibilities for children. 1.5 In November 2014, the lives of the children changed immeasurably when their father killed their mother in the family home in an act fully witnessed by Child 1, and whilst Child 3 was present in the family home. During the same incident, father caused Child 1’s hand to be injured by partial amputation of the middle finger and deep cuts across the finger and thumb area. 1.6 Quite remarkably, in the midst of the most traumatic experience imaginable for Child 1, Child 1 was able to use a mobile telephone to make a 999 telephone call to the police. Although not in a position to speak directly to the Police, Child 1 placed the telephone call on loudspeaker leaving the line open so that without father’s knowledge, and the call handler was able to hear father apologising to mother with the sound of children screaming in the 3 background. A second call in the same manner enabled the call handler to ascertain that mother had been stabbed. 1.7 An emergency response resulted in police officers and paramedics arriving at the family home within minutes. They discovered that mother had multiple stab wounds and attempted resuscitation unsuccessfully. The scene before them revealed that mother had been killed by father and that Child 1 had serious physical injuries that required urgent hospital treatment. Child 3 was present but not physically injured. 1.8 Father was arrested from a field at the back of the family home. He was subsequently charged with the murder of mother and attempted murder of Child 1. 2. Decision to undertake a Serious Case Review 2.1 Three weeks after this fatal incident, a Criteria Panel was convened jointly between the Warrington Local Safeguarding Children Board, the Warrington Safeguarding Adult Board and the Warrington Community Safety Partnership to consider whether the grounds for both a Serious Case Review and a Domestic Homicide Review were met. 2.2 In reviewing the information available to the Panel, it was clear that a homicide had taken place that fell within the definition of the circumstances within which a Domestic Homicide Review should be convened, within Section 9 of the Domestic Violence, Crime and Victims Act 2004, and paragraph 5 of the Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (August 2013) and a recommendation was made to the Chair of the Warrington Community Safety Partnership that a Domestic Homicide Review should be held. 2.3 The Panel also gave consideration to the statutory guidance in respect of Serious Case Reviews as outlined in Working Together 2013. The Panel considered that the injury to Child 1, the potential additional harm caused to Child 1 and Child 3 through being present at their mother’s death, alongside the severe psychological damage to all three children warranted consideration under a child led review as to whether there is learning for 4 local safeguarding partners that would help protect children exposed to harm through domestic abuse. A recommendation was therefore made for this to the Chair of the Warrington Safeguarding Children Board that an SCR should be held. 2.4 The Chairs of the Warrington Community Safety Partnership and the Warrington Safeguarding Children Board agreed that both Reviews were necessitated. The National Panel, the Department for Education and the Home Office were advised and informed of the decisions taken. 2.5 From the outset, an agreement was made that both Reviews would be run through a collaborative but not inter-dependent process. The Criteria Panel identified the need to minimise the impact of two statutory reviews on a grieving and vulnerable family, maximise efficiency of engagement with contributory agencies and ensure that learning was shared across adult and child facing safeguarding systems. 2.6 Accordingly collaboration and integration has been a guiding principle in how the two reviews have been conducted. 3. Methodology 3.1 The Local Safeguarding Children Board commissioned an Independent Chair and an Independent Author, both of whom have substantial experience in undertaking Serious Case Reviews. The Community Safety Partnership appointed an Independent Chair to facilitate and author the Domestic Homicide Review (subsequently referred to the Chair of the Domestic Homicide Review). 3.2 A Review Panel of senior officers from agencies contributing to the Review was established as follows: Manager, Warrington Community Safety Partnership Designated Nurse, Safeguarding Children and Children in Care, Warrington CCG Designated Nurse, Safeguarding Adults, Warrington CCG 5 Named Nurse, Safeguarding Children, Bridgewater Community Health Care NHS Foundation Trust Detective Constable, Cheshire Constabulary Major Crime Review team Senior Operation Manager, Refuge Manager, Citizens Advice Bureau Warrington Head of Service, Quality Assurance and Safeguarding, Families and Wellbeing Directorate, Warrington Borough Council Assistant Director, Children and Young People’s Targeted Services, Families and Wellbeing Directorate, Warrington Borough Council Legal Services Team Manager, Warrington Borough Council Head of Adult Safeguarding and Quality Assurance Division, Families and Wellbeing Directorate, Warrington Borough Council Operational Director, Adult Social Services, Families and Wellbeing Directorate, Warrington Borough Council Relate Strategic Partnerships Officer, Warrington Borough Council Business Manager, Warrington Local Safeguarding Children Board The Panel provided support and oversight to the review and co-ordinated the involvement of the various agencies. The diversity of the Panel, which included voluntary sector representation to increase objectivity and a representative from a specialist national domestic abuse charity to increase challenge, led to genuinely challenging debate and consideration of the wider implications for local strategy and practice with regard to domestic abuse and child safeguarding. 3.3 The Panel sought a written contribution through an Individual Management Review from those agencies that had direct contact with either parent or the children in the months leading up to the precipitating incident, this included: Cheshire Constabulary Relate Warrington Borough Council Children’s Social Care Services Warrington Borough Council Adult Social Care Services 6 Ofsted Primary and Secondary Schools attended by Child 1, 2 and 3 Warrington Clinical Commissioning Group Bridgewater Community Healthcare NHS Foundation Trust Warrington and Halton Hospitals NHS Foundation Trust 3.4 In addition each agency provided the Review with a chronology of contacts and interventions which was collated together in order to establish who knew what and when. 3.5 Working Together 2013 requires that Serious Case Reviews are conducted in such a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way that data is collected and analysed, and makes use of relevant research and case evidence to inform the findings. 3.6 Although the Domestic Homicide Review sought information from a much wider range of sources, the Serious Case Review confined its activities to consulting directly with a small number of agencies. The only professionals who knew the children well were their respective schools and both willingly met with the Author of the Serious Case Review as did Cheshire Constabulary. Although it was initially agreed that the Author of the Serious Case Review and Chair of the Domestic Homicide Review would meet with Relate, the organisation subsequently expressed that they did not wish to meet with the Authors, requesting written communication only. From a Serious Case Review perspective, this was a disappointing response, and one which impacted upon the Authors’ ability to engage in a reflective discussion to gain a better understanding of the practitioner’s perspective. 7 3.7 In order to make sense of what happened on the day that mother was killed by father, Cheshire Constabulary provided the Author of the Serious Case Review with access to the statements gathered for the purposes of the criminal investigation and prosecution of the father, as well as the video interviews of Child 1, 2 and 3 under achieving best evidence conditions. 4. Terms of reference and Timescales for Review 4.1 The first Panel meeting was essentially used to place a framework around both reviews, taking into account the statutory guidance for each and determining the areas of commonality and divergence. 4.2 The timeframe the review would cover was agreed as 1st September 2013 to 9th November 2014. This was agreed in order to consider the children’s full school year, which in essence meant three and half school terms, leading up to the precipitating incident and immediate actions. It was considered that this timeframe would facilitate agencies to consider any identifiable issues that may, albeit in hindsight, be significant to the build-up to the precipitating incident and the immediate actions that were taken afterwards. The Terms of Reference further requested that any historical agency records of incidents relating to safeguarding or domestic abuse should also be included in order to consider the historical context of the more recent events. 4.3 The relevant agencies were asked, through the Individual Management Reports, to consider the following issues: What appear to be the most important issues to address in identifying the learning in these matters? Are local policies and procedures in place, and to what extent do they assist professionals in protecting children and/or those at risk of domestic abuse? Are there any barriers to professionals complying with national and local policy guidance? Were there any predictable risks of serious harm to the victims? If so, were they appropriately identified and acted upon? Were any 8 opportunities missed to safeguard the victims? What factors either promoted or detracted from protective practice? Was there an appropriate exchange of inter- and intra-agency communication as required to protect children and/ or those at risk of domestic abuse? Were staff supervised appropriately and were sufficient resources available to undertake the work required? Additional Specific Key issues for the Serious Case Review: What advice is available in the community for families, friends or neighbours who have suspicions that children are experiencing neglect or exposed to domestic abuse? Were there opportunities for the child’s voice to be heard amongst relevant agencies? To what extent did relevant agencies have an understanding of the child’s day to day life? 4.4 For both reviews, there was the will and desire to complete within an anticipated six month timescale in order that any learning could be embedded quickly for the purpose of enhancing the protection of children and vulnerable adults. 4.5 Although early progress was made in a timely fashion, significant delay occurred because of the impact of protracted criminal proceedings (as referenced in Section 5). The delay in father’s criminal trial impacted upon the appropriateness of access to evidence gathered for criminal proceedings both in terms of statements and the potential risk of contamination of witness evidence by discussing matters necessary for the purposes of the Review prior to the giving of witness testimony at trial. 4.6 Following consultation with the Senior Investigating Officer from Cheshire Constabulary, a pro-active decision was made, through discussions that took place between the Chair of the Serious Case Review and the Chair of the Safeguarding Children Board, that the Reviews should be suspended until 9 after the criminal trial. The suspending of the Review did incur a greater delay than initially anticipated for reasons set out in Section 5 of this report. 5. Parallel Processes The Serious Case Review was mindful of five parallel processes: 5.1 Criminal Proceedings Father was charged with the murder of mother and attempted murder (later changed to Grievous Bodily Harm) of Child 1 in November 2014. As the review commenced, it was anticipated that the criminal trial would be concluded by the spring of 2015. However, a series of judicial delays ensued related to the unexpected unavailability of the trial judge scheduled to hear the case, and a late decision, post-trial, by father to dismiss his legal advocates and seek application to vacate his original guilty plea, prevented this from being achieved. The legal matters were finally resolved in November 2015 at which point father was sentenced to life imprisonment for the murder of mother, with a minimum period of 27 years before he can be considered for parole and a concurrent 12 years imprisonment for the assault to Child 1. In passing sentence, the Judge identified three central features which justified a lengthy prison sentence: “One, you killed your wife in front of her and your own children in their home. The bloody savagery of your murderous violence provided an appalling spectacle liable to seriously scar their lives forever. Two, not only were Child 1 and 3 made to witness the murder of their mother but they were put in sustained and wholly realistic fear that they too might be killed. Three, your onslaught was protracted and punctuated by pauses which prolonged your wife’s agony”. 5.2 Family Law Proceedings The children’s maternal family wished to quickly secure legal permanence for the children after the death of their mother at the hands of the only person who subsequently held Parental Responsibility. This necessitated private family law proceedings and an enormous adjustment for the children and their 10 extended family members. The Review Panel was ever mindful of the trauma and depth of adjustment facing this family, and that this could only have been exacerbated through the unexpected turn of events related to the criminal proceedings. Contact was maintained throughout by the Chair of the Domestic Homicide Review on behalf of both reviews, and the family were approached and agreed to meet following the Christmas period of 2015. 5.3 Domestic Homicide Review The two reviews have worked together which has provided both additional support and challenge. The final Reviews will be presented within the same month to the relevant governance Boards and will be shared together with the family members. 5.4 Police Due to the fact that Cheshire Constabulary had had five contacts with family members prior to the fatal incident, the case was referred to the Independent Police Complaints Commission (IPCC). The Commission considered the circumstances of the case and made a decision that the case should be reviewed at a local level without further involvement from the IPCC. This resulted in a very detailed local investigation, the analysis of which informed the Individual Management Review. 5.5 Coroner A coroner’s inquest into the death of mother was formally opened and adjourned within a week of the death and given fathers conviction for murder was not re-opened. 6. Engagement with Family Members 6.1 The Review Panel agreed that it was important to involve the members of the maternal family who have care of the children as well as the father. The Chair of the Serious Case Review and the Chair/Author of the Domestic Homicide Review met with family members to seek their contribution and questions. Very careful consideration was given to offering the children the opportunity to make a direct contribution to the Review, particularly Child 1. Ultimately it was 11 agreed that this decision was best placed with the maternal family members who had care of the children. The children have experienced trauma and are having to make major adjustments to their lives, they have lived with the uncertainty and unpredictability of criminal proceedings and only following this has any sense of respite from the dominance of this event been achieved. Ultimately, maternal family members believed that involving the children in a further process which looked back over what happened in this family could re-traumatise and trigger the depth of feelings they are beginning to manage and as such it was too risky to their emotional welfare. 6.2 Father was seen in prison post sentencing. He said that he is a man of strong principles, and that he was profoundly affected by his ex-wife stopping his contact with his first born child. He stated that he is exceptionally risk averse and felt that the fear of potential loss of his children was the single biggest factor that resulted in him killing mother, describing himself as going ‘ into an instant spiral of mental breakdown’. 6.3 Father stated that he became paranoid and, although he does not recognise other people’s general description of him as a controlling person, he does accept that he became ultra-controlling in some ways after he found out about mother’s affair. Father agreed that he did control spending and kept spreadsheets depicting intimate aspects of his life with the mother, but saw this as necessary to keep control or prove a point. Father stated that in the days leading up to the murder he was sleep deprived for up to eight days and lost a lot of weight. 6.4 Father said that as parents to Children 1, 2 and 3 out of himself and the mother he was the disciplinarian and that the mother had a more permissive approach. Father reflected that he would “give them [the children] a forfeit” when they needed this; most of the which involved sitting down and discussing with the children what they had done wrong and how to make amends. On other occasions he agreed he would give them an actual forfeit such as taking their iPad off them, undertaking a domestic task or physical exercise or give them lines or a story to complete. 12 6.5 Father stated that his relationship with Child 1 had changed in the preceding two years, noting that Child 1 had become grumpier with him and apparently getting on much better with the mother. On occasions, as on the day of the murder, father found Child 1 to be disinterested in and dismissive towards him. 6.6 Father stated that if the Courts had not favoured his ex-wife’s custody of his first born child, then he believed that he would not have reacted as he did to the thought of losing his children and that mother would therefore still be alive today. It should be noted that although residence was granted to the mother of his first child, the testimony of his ex-wife would suggest that contact between father and child continued but that the relationship deteriorated over time during adolescent years when the child found the father to be rigid and inflexible. In addition, father was dismissive about his role in the life of his second born child, simply stating that the mother of that child was solely responsible for that child. 6.7 The maternal family members described mother as a devoted mother, a warm and gentle person who could light up a room by her very presence. This sentiment is echoed by all who knew her. The family members were aware that the marriage was in crisis and that mother was having an extra-marital affair, and although they perceived father as ‘odd’ at times, socially inept and ‘hard’ on the children, they never envisaged the real danger that he posed to mother and the children. A family member had accompanied and supported mother to seek legal advice some weeks before the murder, as father had stated that he would get a low paid job and sell the house undervalue to ensure that mother was cut off from financial support and security. They also believed that father had approached a solicitor with a view to cutting mother and the children from his will. 6.8 The maternal family posed two specific questions that they wished the review to consider; firstly, why did the police officer advise them to stay away for one night and then not follow them up following a return the following day, and secondly, whether the counsellor from Relate could have been more pro-active in referring mother and the children directly to safeguarding services. 13 6.9 Words cannot express the trauma and devastation endured by this family, and the courage and determination that have they had to find to try to help the children rebuild their lives. They have co-operated in totality with all that has been asked of them whilst grieving and helping the children to cope day to day. 7. Overview of significant information known to Agencies between September 2013 and 2014. Information known to agencies but significant to understanding how events unfolded is identified by italic script. 7.1 All three children attended school routinely and had no additional health needs beyond the common range of childhood illnesses. Each child was considered to be settled in school and content in their day to day life. In October 2013, the family faced an emotional crisis when the children’s maternal grandmother died unexpectedly. This came as a great shock and greatly affected mother who was particularly close to her mother. In order to ensure the children were well supported mother advised each school of what had occurred so they could be additionally vigilant with the children. 7.2 Mother worked in the home in a role that involved caring for children. Through this employment, mother was connected into a network of support and on occasions attended training and support meetings. 7.3 In March 2014 mother accidentally bumped into a man with whom, prior to her marriage to father, she had had a close and positive relationship. In the following weeks and months, they rekindled a friendship which then became an intimate relationship. 7.4 Shortly after the family returned from a family holiday, father presented at a Cheshire Constabulary Police Station some ten miles from his home town and and requested to speak to a police officer. Father told the police officer that he believed his wife was having an affair and that her new partner was planning to harm or kill him in order that his wife could inherit his assets. Father stated that he had lodged a ‘suspicion notice’ to this effect at his 14 solicitors and had notified his sister of his concerns, but that he had not spoken to the mother about his suspicions at this time. 7.5 The police officer established that father lived with the mother and their children Child 1, 2 and 3. It was noted that father and mother had been married for approximately 16 years and that the couple’s wedding anniversary was a few days later. The Police Officer recorded that father spoke highly of his family and stated that he thought they had been happily married up until recently and that he wished for the marriage to work. Although father stated that he was in fear for his personal safety, the police officer established that he did not have any evidence of this and had not at any time been assaulted, threatened or approached in any way which could be construed as a threat to his safety. 7.6 Father told the police officer that he had installed a ‘spyware’ tracking device on mother’s mobile phone that had captured her in a compromising position. He also stated that he believed his wife was lying to him because her movements did not match up to the CCTV installed in the house. The police officer offered advice and stated that he would make a contact call to father over the next few days. 7.7 Two days later, at 4:37am, Greater Manchester Police (GMP) contacted the Cheshire Police Force Control Room to advise that father had attended at a (different) Police Station within their Force area, and a concern for his safety was raised as a result of what he said. Checks were completed by Cheshire Constabulary and it was established that there were no current incidents at the family home address, however, the presentation at a different Police Station two days earlier was noted and shared with GMP. An officer from GMP forwarded an email to the police officer who responded to father two days earlier outlining the circumstances of this second visit by father. GMP told Cheshire Constabulary that father had stated that he was scared to go to his home address because he believed that mother was having an affair and that her new partner was planning to kill him. GMP had contacted mother and she reported that she was concerned that father was having a breakdown and that she was concerned for the welfare of herself and Child 1, 2 and 3. The 15 GMP officer reported that father had left the police station as they had no powers to keep him there and a welfare visit was requested at the home address in light of both father and mother stating they were concerned for their safety. GMP advised mother to contact Cheshire Constabulary if and when father returned home and there were concerns regarding her safety or his welfare. 7.8 At 8:21 a.m. a Cheshire police officer attended the home address and spoke to both father and mother. The officer obtained details of all the people resident at the address, including the children’s maternal grandfather who was visiting. Father requested to speak with the police officer in private, and took the officer to the bottom of the garden out of sight of the CCTV attached to the outside of a summer house. Father informed the officer that he believed the mother was having an affair and that he feared that her new partner was going to kill him. Father told the officer that he had been out the previous evening and had seen a suspicious vehicle but nothing had happened after he had left mother alone in a public house some distance from their home because she had gone to the toilet and used her mobile phone. Mother was collected by her father, after father had rung his father-in-law to say that mother was having an affair. During this journey, mother confided to her father that she was having an affair. 7.9 Father told the police officer that he had installed a tracking device to mother’s mobile phone which was capable of recording video footage. He said that the device had been in place for approximately one week and for that period of time father had been able to monitor mother’s movements and had on one occasion recorded an intimate occurrence. Father confirmed to the police officer that no other person had been seen or heard in the footage and that he was now unable to view it because he believed that mother had deleted it from his phone. The police officer established from father that he had not received any physical threats to his wellbeing and that he had no substantial evidence of the suspected affair. 7.10 After concluding the conversation with father, the police officer spoke with mother who confirmed that she was engaging in an affair but was not 16 prepared to tell father who that was with. Mother stated that no threats had been made to father and that she was not frightened of him. After leaving the home the police officer submitted a Vulnerable Person Assessment (VPA) and Domestic Abuse Stalking and Harassment (DASH) Risk Assessment, in relation to father, graded as standard/low risk. 7.11 The police officer subsequently reflected on the fact that mother was not aware of the tracking device and sought further supervisory advice on this matter. The police officer made a second visit to the family home the following day and informed mother of the tracking device. Mother did not seem surprised by the actions of father and did not want to make a formal complaint. Mother said that she had not felt harassed but wished for the device be removed from her phone. The device was removed by father in the presence of the police officer. Mother said she did not wish for any further support from the police. 7.12 Nineteen days later the VPA and DASH Risk Assessment were reviewed by the Public Protection Referral Unit (PPRU) in Cheshire Constabulary who agreed with the standard/low risk assessment. 7.13 Four days after the police officer had attended the family home, father attended a GP consultation, and mother was present for the first half of the consultation. Father stated that he had confronted the mother the previous week about his suspicion that she was having an affair; he described how until the confrontation he had not been sleeping due to his worry that the person that the mother was having an affair with would assault him. Father reported that he had not been sleeping since the confrontation and wanted to work on the marriage. He told the GP that he had no concerns about work and no suicidal ideations. The GP noted that Father was coherent, had normal speech, good eye contact and no evidence of psychosis. The GP advised father to contact Relate to seek marriage guidance. 7.14 Eleven days later, father sought and attended a further GP appointment. The GP noted that father was under much stress, had marital problems and was not sleeping. Father reported that he has lost one stone in weight and was 17 finding it difficult to concentrate, requesting a sick note for one week; he was advised to self-refer for counselling and was given a sleeping medication. 7.15 Eight days later, father did not attend a scheduled GP appointment. The GP contacted father who said that the medication to aid him to sleep was not helping for the full night. He was advised to double the dose and re-book the missed appointment. 7.16 That same day, father telephoned Relate to enquire about relationship counselling and booked and paid for an initial consultation session with a counsellor for himself and the mother the following day. Father and mother attended the counselling session together; they told the counsellor that mother had had an affair and also disclosed some contact with the police. Father stated he wished to know who the affair was with and mother said she would not give him a name, fearing what he would do to the person as he had already told lies to the police. It was agreed that the couple would each attend a further individual session, although father expressed a desire for counselling as a couple only. Three days later father contacted Relate and booked and paid for an individual appointment for himself the following day and one for mother two days later. 7.17 Father attended the individual counselling session at Relate. During the session he disclosed that he had put a spy camera on the mother’s telephone and a microphone in her iPad. He also advised that he had been to the Police to ask them to record his fear that he would be killed by the man that mother was having an affair with. Father said that he had told the Police about the spying equipment he was using, and that they told him that this amounted to stalking and to remove it. He stated that the Police had asked mother if she wanted to press charges which she declined. Father told the counsellor that he was not sure that he could trust her (the counsellor) and the counsellor recorded that she felt genuinely frightened of him. 7.18 When mother attended the individual session with the counsellor she asked, on arrival, if she could leave her telephone at reception. Mother told the counsellor that she thought father had bugged the house, her phone, the 18 computer, and possibly her father’s house as well. Mother told the counsellor that she was frightened for her own safety and that of the children, as father had threatened to “self-combust” and had told her that she would never see the children again. Mother was not clear what father had meant by the term “self-combust” but said that she did not think that he would actually harm the children. Mother described an incident that had occurred on the night of their wedding anniversary approximately one month earlier when father had driven erratically because he believed a car full of men was following them. Mother shared with the counsellor examples of father’s controlling behaviours which included: Control over the family computer to such an extent that, if typing an email, a message would pop up from father stating ‘I can see what you are doing’ and this was disturbing to the children; That father controlled all the family finances and she was concerned he would leave her without money for the children That he had started filming her going about her job That she had been scared to refuse intimacy The counsellor encouraged mother to prioritise her safety and that of the children, urging her to contact the Police for further support; advising that she had been in a controlling relationship for years and that as she had started to challenge and move away from the relationship, there were risks to her safety and she could be in danger. The counsellor indicated that father was unpredictable and she feared his reactions when she told him that counselling could not as he hoped save the marriage. The counsellor gave mother information about the domestic violence service provided in Warrington, the Refuge Warrington Independent Domestic Violence and Abuse Service and encouraged her to talk to her father and the police again. The counsellor asked mother for a telephone number for one of her trusted friends and she provided one. 7.19 The following day, the counsellor sought consultation with her supervisor about the case via e-mail copying in the Chief Executive. The decision was taken not to offer any counselling on the grounds of safety and it was agreed 19 that this would be explained to the clients at a short session to be attended by father and mother the following day. The counsellor delivered a short session to the couple to close the case. Mother was advised to seek counselling over the loss of her mother, and father was advised to consult his GP about possible mental health issues. 7.20 During this first half term period of the new school year, neither school noted any issues of concern with the children. On one occasion Child 2 was noted as distracted and talking in class by a history teacher which prompted an email to the Head of Year. 7.21 Two days later, mother contacted Cheshire Constabulary and informed them that she and father had been to Relate and that their counsellor had advised her to make further contact with the police. Mother stated that the counsellor had advised against a police visit, for fear that it might inflame the situation, but had given mother the contact details of an agency which could support her to get away from father as soon as possible. Mother stated that her father was staying with them, and that she would attend at Warrington Police Station at 22.00 that evening. The call handler obtained the following information from mother ; that the counsellor had informed her that she was not in immediate danger but was more concerned about father’s mental health; that the counsellor had said that mother was in a mentally abusive relationship; that the counsellor wouldn’t see them again until they both sought help with father’s paranoia and mother’s grief at the death of her mother; that father had been to see his doctor who had allegedly said he was ‘fine’ but he had not been sleeping well since finding out about the affair; that mother and father had decided to end their relationship that day. The previous Police records were reviewed and it was further noted that: 20 mother had refused to make a formal complaint about the tracking device installed on her mobile phone; mother was reported to have said on more than one occasion that she was not scared of father but wanted the information noted. The call handler noted that whilst on the phone to mother, father was constantly calling her mobile phone. 7.22 The Inspector acting as Force Incident Manager reviewed the information and made the decision that in light of the differing accounts provided by mother and father, a low key welfare check at the address should be undertaken by a specialist department such as the CID or Public Protection Unit (PPU). The requested departments were unable to attend due to other policing commitments. Less than two hours later, at 19:02pm, a uniformed sergeant and a police constable attended the family home. Father was not present when they arrived and the officers spoke with mother who was surprised and shocked by the police attendance at her home. She presented as embarrassed by the situation and informed the officers that she had entered into an affair and it had had a profound impact on father. Mother was compassionate towards father but pragmatic and assertive in her decision making process that she did not want a reconciliation. Mother is recorded as repeatedly stating that she was not in fear of father and is reported to have almost laughed at the suggestion that father would be violent towards her. 7.23 Mother spoke at length with the sergeant about what had occurred within the marriage and confided that father had told the children about the affair in an attempt to embarrass her, but in fact Child 1 had been very supportive of her. Father had called mother derogatory names in front of Child 1. Mother advised that she was very worried though about leaving, partly because of the financial issues and the fact that the house was only in her husband’s name, and partly because of her commitment to her business which she ran from home. Whilst the conversation between the sergeant and mother was taking place, the police constable spoke with Child 1. Child 1 was observed to be at ease and confident, and talked to the officer indicating that mother’s affair was 21 known within the family but that it was not her fault because father was not nice to mother. Child 1 said that father was unpredictable and that Child 1 did not trust him; he had never been violent to them but would shout and get frustrated. Child 1 believed that father had hidden cameras in the house and thought that he was spying on them. Child 1 did not indicate fear of father, and was accepting that a parental separation was appropriate. The Officer found Child 1 to be mature and intuitive. 7.24 Just as mother and the children were leaving the home address, father arrived home. He appeared shocked by the presence of the police at the home, asking what was going on and what was happening with his family. Father continually requested to speak to mother on her own, stating to the officers that he had not done anything wrong and that it was mother who had entered into an affair with a ‘gangster’ and had refused to tell him the person’s name. He acknowledged that he had said some things regarding the children which he deeply regretted, but did not wish the marriage to end. The officers calmed father; he stated that he was at ‘rock bottom’ due to lack of sleep but did not have any suicidal thoughts. He also stated that he did not believe that mother was trying to harm or kill him and appeared embarrassed by having alleged such a thing. 7.25 The sergeant requested that mother notify Cheshire Constabulary of where she was staying that night and advised that there may be further contact from the PPU at a later date. Father was given advice to see his doctor and that it would be better if he went to his sister’s address so that he was not on his own. 7.26 In total, the police officers were at the family home for nearly two and a half hours. They submitted a VPA and DASH risk assessment graded as medium risk. It was also requested that a critical marker be placed on the address to provide information to other police officers who may have cause to attend. Intelligence checks and review of the VPA and DASH Risk Assessment was undertaken by the PPU sergeant. The sergeant agreed with the medium risk assessment and made a referral to New Directions Adult Mental Health Service in connection with father’s mental health. 22 7.27 That same day the referral from the PPU was received by Adult Social Care Reception. The VPA was also sent onto Children’s Social Care when the screening revealed that three children were referenced in the household. The VPA was received by Children’s Social Care on the same day. It was misplaced into an information only folder prior to a decision being made about what action was required. It was subsequently discovered the day after the incident. 7.28 That same day, mother returned to the family home with the children, having changed her mind about leaving the home, because she remained concerned that she was letting down her clients and that the children needed to be back in school. Later that day mother rang the GP to request bereavement counselling and was given information about how to refer herself to the local Improving Access to Psychological Therapies Service. Mother also rang Relate and spoke to an administrator, asking to see the counsellor again because she was confused about her feelings. She told the administrator that, acting on the counsellor’s advice, she had contacted the police and had left the family home overnight; however father was persuading her to give the relationship another go. Concerned that her phone might be bugged the counsellor determined that it was unsafe to speak with mother, and consequently, the administrator was asked to briefly contact mother’s father and give him the details of the IDVA service. This took place thirteen days before mother was murdered. 7.29 The following day, father had a telephone consultation with the GP surgery. Father discussed only a concern about his prostate and it was agreed that he would provide a urine sample and have a blood test to test for levels of prostate cells within the patient’s blood. Three days later, father had a face to face consultation with the GP. He told the GP that the counsellor from Relate had recommended individual counselling and he was given self-referral details. He stated that he was not sleeping but did not want anti-depressant medication and a repeat prescription for night sedation was given. The GP noted father was coherent with good eye contact. Father indicated that he had noticed a spot of blood in his motion and the doctor discussed carrying out a 23 blood test. Between the two consultations, the referral to New Directions was processed within Adult Social Care Services, and, in accordance with standard practice, a letter was sent to father, inviting him to make contact. 7.30 Five days after mother returned to the family home, father, mother and the children went away for the weekend on a planned trip with another family. Following this, mother, her father and the children went to stay with maternal family members for the children’s half term break. Upon returning home, mother and father spoke about their relationship. Those close to mother indicate that mother had concluded that the relationship was ending, whilst father states he remained hopeful that the marriage would survive. 7.31 The fatal incident occurred the following day, the day before the children were due back at school. 8. Analysis 8.1 Through the evidence exposed through a criminal investigation for the murder of mother, it is now know that Child 1, 2, and 3 lived in a family home that was dominated by father’s controlling behaviour, which impacted greatly on the mother and his relationship with the children. Having read many of the statements gathered by the police during the investigation, it is clear that mother was a very warm and optimistic person who sheltered the children as far as possible from the excessive traits of her husband’s behaviour. It is apparent that father used the strength of mother’s relationship with the children as a tool against her, evidenced by a family member recalling that on an occasion when mother asked to go out with friends, father responded by saying that if she did he would cut the children’s food allowance. 8.2 There is evidence that father was controlling and rigid in his style of parenting, and this was likely to have been a significant factor in why his relationship with his adolescent children became so difficult. His first born child found his attitudes and behaviour hard to tolerate and Child 1 indicated that he was ‘weird’, recognising his behaviour as different to that of other parents including mother. His need to exercise control resulted in the children experiencing 24 punitive punishments, such as writing lines and essays, physical exercise drills and withdrawal of communication. 8.3 The Domestic Homicide Review has identified that father had had a long history of controlling behaviour as evident in his first marriage and more recently history suggests that mother had become accustomed to behaviours that were indicative of his need to control. They lived in an affluent area, where high expectations of family life are considered to be the norm, according to professionals who work there. The area would not be typically targeted by community or welfare services, and potentially in an area where economic and employment status is significant, it may be highly stigmatising to seek outside help or support. 8.4 In conversations with the children’s schools, it is evident that the school knew the children and had regular contacts with mother. The children were perceived as happily settled in school and took advantage of school life with no obvious barriers to learning. Most parental contact was with mother who was noted to be a very attentive and warm parent. The contacts with father tended to be on more formal occasions such as parents’ meetings where he was considered to be a ‘pushy parent’ who apportioned blame to the school if the children were not top of the class. The school never had occasion to be concerned about the children from a safeguarding perspective and had not known of the parents’ marital conflict. The children had friendship groups and were popular amongst peers. One can only conclude that the children’s resilience, given the stress of living with father, was a testament to the skilful parenting of mother and the quality of the relationships with their extended maternal family. 8.5 It is evident from Child 1’s statement to police that the child’s relationship with father had not been easy but had become much more strained during adolescence. Child 1 perceived father as nagging, irritating and overly controlling of mother. Child 1 considered that father restricted mother’s freedom and that she missed out on life because of this. As Child 1’s relationship deteriorated with father, it strengthened with mother so that when father told the children about their mother’s affair, expecting a sympathetic 25 reaction to him, Child 1 was supportive of mother and accepted and understood the context in which this had happened. 8.6 During the last few months of mother’s life, she appeared to have developed a dawning realisation that she was a victim of her husband’s controlling behaviour and that domestic abuse had a wider context than only acts of violence, which was reinforced by her contact with the counsellor from Relate. In the last months of her life, mother, in common with many women in her situation, was struggling to make sense of what this meant for her and her children and trying to overcome the barriers to changing her circumstances. Commonly, women are highly vulnerable, feel a sense of shame and embarrassment believing themselves to be responsible for their husband’s behaviour, alongside a range of conflicting emotions and practical dilemmas. The overwhelming effect of all of these issues should never be overlooked by professionals, who need to take a supportive and empowering approach with a woman, but also have a responsibility to act independently if there is a belief that a woman or child is at risk of significant harm. The paragraphs below consider the single and multi-agency approach to three significant episodes of practice and what can be learnt from this to enhance safeguarding practice. 8.7 Response to father’s presentation at two Police Stations 8.7.1 Father presented at two separate police stations over a period of two days and on each occasion indicated that he believed himself to be at risk of harm from a person with whom his wife was having an affair. It is now known that one week prior to the first visit, suspicious that she was having an affair, Father had installed a spyware device on Mother’s mobile phone so that he could track her movements. The officer that spoke with father recalled that he was worked up about his concern that his wife was having an affair. The officer made intelligence checks which revealed no concerns about domestic abuse within the family home and having established that there was no evidential basis to his claims, concluded that he would undertake a follow up contact within one week. This officer did not complete a VPA because he considered this was not a report of a domestic incident, that father did not present as vulnerable and there were no identifiable child protection concerns. 26 In essence, the officer considered that father was seeking some ‘common sense’ advice to put things into perspective. The officer spent one and half hours with father and subsequently recorded the contact, tasking himself with a follow up contact. 8.7.2 The Police Management Report questions whether any offences had been committed at that time in relation to the reference to spyware device and whether reasonable consideration was given to the issue of stalking at this point. Ultimately, the report concluded that although there was no evidence of an actual offence and indeed no indication as to whether mother knew of this, the officer could have investigated further the circumstances surrounding the spyware device and the CCTV at the family home and issued a harassment notice in the form of a Police Information Notice (PIN). The reason this did not happen was because this officer did not consider an offence had been committed, indicating that tracking devices are not uncommonly used in such situations and that CCTV is a growing feature of many family homes. 8.7.3 Amendments were made to the Protection from Harassment Act 1996 in 2012 which introduced a new offence of stalking whereby ‘a person pursues a course of conduct in breach of S1 (1) of the 1997 Act (i.e. a course of conduct which amounts to harassment) and the course of conduct amounts to stalking’. There are a number of types of stalking including ‘monitoring the use by a person of the internet, email or any other form of electronic communication’ and ‘watching or spying on a person’. The Police note it is pertinent that an offence of stalking can only be committed where an offence of harassment has occurred, and this would mean having an understanding of whether the victim had been caused any alarm or distress, in this instance, this was not known or pursued. The officer did make a decision to follow up on father’s situation, however this did not happen before father presented at a second police station two days later. 8.7.4 The second presentation was at a Police station within the jurisdiction of a different Police force, Greater Manchester Police, and the information was shared across the Forces in an efficient and timely way. It is now known that prior to presenting at this station father had confronted mother about his belief 27 that she was having an affair, loudly and publicly, in a restaurant. Father left the restaurant and mother called her father to collect her (see paragraph 7.8). The response by Cheshire Constabulary to undertake a visit to the home demonstrated an appropriate response to a second such presentation and was intended to check out the facts of the situation and establish that all was lawful. The police officer who attended recalled that father presented as lucid and coherent in his conversation but displayed a paranoia regarding his marriage. He spoke at length with father and mother, established that mother had as father suggested been having an affair and advised that father saw the GP about his lack of sleep. 8.7.5 The Police Officer reflected on the fact that father had told him he had used a tracking device and his discomfort that mother did not know this. The officer sought advice from a senior officer on the matter before making a second visit to address this information with both father and mother. Mother asked that the device was removed but stated that she did not wish to make a complaint about it; she was concerned for father and indicated that she did not feel harassed by him. The police officer warned father about the use of such a device, he explained that stalking was a criminal offence that he could be arrested for. The police officer could have issued a Police Information Notice (PIN). A PIN does not constitute any form of legal action, but is used to demonstrate that a suspect was aware that their behavior could count as harassment. This can be important because the offence of harassment occurs when ‘there has been a course of conduct (not a single event) and the perpetrator knows that their conduct amounts to harassment’. The use of a PIN would have been appropriate in the circumstances, however, because the police officer noted that mother was not fearful of father, this was not considered. 8.7.6 The evidence gathered for the criminal trial revealed that despite the verbal warning by the police officer, father continued to purchase and use covert surveillance such as a car tracker device and a tracing company to establish the whereabouts of the man with whom mother was involved. Whilst speculative, it is possible that the formality of a notice may have deterred 28 father from further use of technology for the purpose of stalking but this Review does demonstrate the challenges of predicting risk for a crime that has a higher rate of repeat victimization than any other crime. 8.7.7 The officer recalled that in speaking with mother, father and maternal grandfather all were calm and the atmosphere was comfortable. The officer did however complete a VPA and a DASH risk assessment in relation to father, but not in respect of mother. This was because father had stated he was at risk of harm, whilst mother had indicated that she was not in fear of her husband. This omission indicates that controlling/stalking behaviour is not being responded to as would be physically abusive behavior. 8.8 Mother and father contacts with Relate 8.8.1 Five days after the visits from the police father attended the GP accompanied by mother with presentation of similar issues, that being father’s reaction to mother’s affair. The family was living in a state of crisis. The GP suggested that Relate would be an organisation that could help them address their issues as a couple. 8.8.2 Relate charity is the parent organisation for a service that provides a counselling approach to support healthy relationships, which is delivered by local and individual Relate charities, each with its own Board of Trustees. It is the national body which develops the policies and procedures, including those for domestic abuse and child safeguarding, which are then used by the local services. The client group is self-referral and commonly this would occur when there is a problem or crisis in a relationship between a couple. The couple were allocated a counsellor who is a qualified practitioner who had completed organisational training in domestic abuse in 2007 and Child Safeguarding in 2015 post the injury to Child 1. The organisation is supported by a Domestic Violence/Abuse Policy and a Child Protection and Safeguarding Policy both written in 2013 and reviewed in 2016. The first session was attended by the couple together; this is a standard approach to assessment with the aim of establishing whether relationship counselling would be appropriate for the couple. Given the information that father had contacted the police because he believed himself to be at risk, the counsellor made a decision to undertake 29 Individual Structured Interviews (ISI), again a standardised approach to making a more detailed assessment as to whether counselling as a couple can be offered safely. The information gathered from the ISIs was discussed with a clinical supervisor and a decision was made and imparted to mother and father that counselling was not appropriate. 8.8.3 The Individual Management Report provided from Relate suggests that there are no lessons to be learnt from involvement with this Review, that all policies and procedures were provided appropriately, and that mother acted on advice to remove herself from potential harm. The Report cites as evidence of this that mother contacted Relate to inform them that she had successfully left the family home with police assistance. This is however contradicted by the police statement taken from the counsellor which indicates that mother contacted the Relate office asking to speak to the counsellor because although she had left the family home the previous night, father was persuading her to give the relationship another chance. Mother was not offered the opportunity to speak to the counsellor or a professional member of staff at Relate because it was considered too risky given that father had previously bugged her telephone. This was a very significant call from mother; she may have been seeking affirmation, reassurance, and a reminder of the reasons why this was necessary to enable her to carry through the action she had commenced. Instead her father was contacted with a telephone number of the IDVA service. Whilst there clearly was some risk present, arguably there was greater risk in not responding directly to her needs at that point in time and arranging a safe manner of contact. The Domestic Violence/Abuse Policy states at 8.2: ‘The victimised partner can also be invited to attend a short number of sessions to help them consider their own and their children’s safety and to access suitable external support’. 8.8.4 The counsellor at Relate had a firm understanding that mother was exposed to risk of harm and gave very specific advice that father was unpredictable and that mother and the children needed to be removed from that risk. The counsellor understood that a point of separation represents a hugely 30 increased risk in respect of domestic abuse and that this posed a threat to mother and the children. When mother saw the counsellor individually, she reflected and articulated that she was a victim of domestic abuse, she shared how this manifested itself and the impact it had on her. Most significantly mother disclosed marital sexual violence. The counsellor was rightly extremely concerned by all that she heard, and advised mother to seek police assistance in moving out of the home. Whilst understanding that the counsellor wanted to support and empower mother to take control of her situation, I am firmly of the view, that because the counsellor did appreciate the risks for the children, that when mother indicated that she was vacillating in her decision a referral should have been made directly to the police and/or Children’s Social Care in respect of the children. The action of not seeing or speaking with her again, left her, as a victim, taking responsibility for her own protection and that of the children. Mother, in common with many victims, was not best placed to objectively assess the risk she and her children faced; professionals were. 8.8.5 Mother wanted to separate from father. She was, however, struggling to reconcile how she would practically manage this: what would happen to their home, how she would access financial resources, and how would she earn a living given that her job operated from home and that she would be letting down her clients. There are many emotional barriers that prevent women from leaving abusive relationships, and this can be particularly so when a woman has been a victim of psychological abuse because it can be very hard to take back control. Varying research suggests that women will attempt to leave an abusive relationship between five and seven times before successfully doing so. 8.8.6 The Relate Domestic Violence/Abuse Policy makes the following connection with the safeguarding of children: “5.1 In view of the interconnection between domestic abuse and child abuse, whenever Relate staff or volunteers receive information that gives cause for concern about an adult’s safety, they will bear in mind the increased possibility that there may also be a child at risk of direct abuse and they will 31 always ask for details about children and will make sensitive enquiry as to their safety.” “5.2 If there is cause for concern about a child they will act in accordance with Relates Child Protection & Safeguarding Policy” “5.3 When responding to either of the situations in 5.1 or 5.2 above, Relate will seek to safeguard the vulnerable parent as an essential and integral part of safeguarding a child at risk.” There was no reason for the counsellor to believe that mother would intentionally place the children at risk. However, the counsellor, more than mother, understood that a decision to remain with father did place the children at risk of harm, and for this reason, I consider that a referral to Children’s Social Care was an appropriate course of action and should have been discussed with mother. It is also significant that mother cared for other children in her home and there was an additional responsibility to consider whether these children were also at risk. 8.8.7 The Child Protection and Safeguarding Policy is explicit that: “Paid and volunteer staff need to be aware of their responsibilities for safeguarding and promoting the welfare of children, how they should respond to child protection concerns and make a referral to local authority children’s social care or the police if necessary”. The Individual Management Review does not indicate that specific consideration was given to whether there was a risk of harm to the children despite a view that father was unpredictable and presented a risk to mother. 8.8.8 There is considerable reflection and learning for Relate; the agency identified risk well, and did take steps to advise and encourage mother to achieve a safer environment for herself and the children. There was however limitation in the approach to safeguarding by not sharing information directly with those agencies that have a duty to assess and potentially act upon the risk identified. Relate’s course of action placed all safeguarding responsibility with mother, which missed a key opportunity to share the very sound knowledge of the counsellor with key professionals going forward. 32 8.9 Mother’s contact to Police 8.9.1 Mother’s contact to the Police was two days after the last meeting with Relate. Mother stated that she was following the advice of the counsellor that she needed support of Police to safely achieve a separation from father. When this contact was evaluated, in light of the previous contacts, a decision was made for an officer to visit the family home, the sergeant requested that a police constable accompany him in the knowledge that there were the children in the home, and they were briefed that the previous contact had been in relation to a marriage breakdown and the previous use of a tracking device. 8.9.2 The officers found mother to be an articulate and honest woman devoted to her children. She indicated that she did not really want the police involved as she thought the situation had been ‘blown out of all proportion’. On reflection, both officers recalled that mother was embarrassed by their presence and worried about what the children would think and also how it would appear to the neighbours. Mother did not indicate that she was in fear of father; she was assertive in stating that their marriage was over, whilst at the same time showing concern and care for father. The Sergeant spoke with maternal grandfather who was staying with the family and the police constable spoke in some depth with Child 1, and briefly with Child 2 and 3. Child 1 spoke disparagingly of father, how he controlled mother and that if they left the address they would ‘lose everything’. Child 1 did say [the child] was scared of ‘what he’ll do to mum’, this was understood to be in the context of making her life difficult through refusing an amicable separation. Child 1 questioned whether father was also tracking their movements. 8.9.3 The officers did not identify any child protection concerns, other than a strained relationship between father and Child 1, and concluded that mother was not fearful of father, more that this was a couple and family struggling to achieve an amicable way forward when mother wanted a separation and father did not. The sergeant understood that marital breakdown is a high risk factor in domestic abuse and this, coupled with the tracking device and the information that mother shared from Relate, led him to make a judgement that a safeguarding approach should be taken and he suggested and reached agreement that mother would leave the family home with the children and her 33 father that evening. This action was intended to negate any flashpoint which could potentially occur once father returned to the family home and to provide mother with an opportunity to make a clean split, giving mother the independence to go where she wanted without the knowledge of father. The Sergeant asked mother to let them know where she went later that evening, this was in order to complete the task of helping her to leave safely and to demonstrate concern for their welfare as they made this move. 8.9.4 In the event, father returned to the family home as the family were preparing to leave. The officers remained throughout and suggested to father that he consider staying with a family member that night as he was clearly distressed by the turn of events. The officers assessed that father was upset but at no time unpredictable or volatile. He was advised to see his GP because of concerns that he was not eating and sleeping. 8.9.5 The officers completed and submitted a VPA and DASH risk assessment. The DASH risk assessment was completed with mother and she answered no to most of the standard questions, which led to the following results in respect of father: He had never been violent or tried to hurt her or the children He had never hurt a family pet He had never threatened to hurt her or the children He had never stated that he was going to harm himself He was not addicted to alcohol or drugs He had never tried to suffocate or drown her He had never said anything of a sexual nature which made her feel bad about herself He had only ever used lawful chastisement on the children and this was never excessive What is less apparent from this assessment is the extent to which he used psychological measures to control mother and that he had a high level understanding of technology to aid this. Additionally, it is now known that mother did disclose sexual violence to the counsellor, however, this did not appear to be specifically identified as a very specific matter for concern. The 34 level of risk was assessed as medium and this was appropriate to the application of the tool. The officers attending that night took a robust approach and met the objective of helping mother safely achieve a physical separation from father. 8.9.5 The VPA and DASH risk assessment were screened by the PPRU the following day. As stated, the risk assessment was appropriate to the information known; however, this also raises one very pertinent question, that being why it was that the counsellor had indicated that mother needed to place herself out of danger swiftly. Inherent in the limitations of understanding the whole picture of risk for mother was the fact that there was no communication between the counsellor and the Police. Had this occurred, then the likelihood is that the much more concerning information shared by mother in a one to one situation with the counsellor would have been shared with the police. I am of the opinion that this would have elevated the risk assessment for mother and the children. The PPRU officer did consider forwarding the information through to the Independent Domestic Violence Advocacy (IDVA) service but she did not do so because she believed that Relate were already providing a service. Significantly, Relate had provided mother with a contact number for the IDVA service but had made no direct referral. The absence of direct communication between the Police and Relate had an impact on the quality of information known to the Police, which in turn impacted on the risk assessment which did not refer the mother or the children to further services. 8.9.6 Mother’s decision to return to the family home did not appear to have been considered as a possibility. It was a very significant decision, and one commonly taken by women struggling to separate from men who have long standing power over them. Had this possibility had been considered, a follow up response from PPRU or indeed the counsellor following mother’s request could have helped mother to maintain the separation until she was in a stronger position emotionally. The value of information sharing across professionals directly is a consistent theme in Serious Case Reviews. Although mother was an articulate woman and capable parent, indeed 35 descriptions of her murder reflect that she was focussed on protecting Child 1 until her dying breath, she was also the victim of long standing psychological abuse who needed significant support to keep herself and her children safe. The IDVA service was the most appropriate service to offer the level of support that mother needed and had referrals been made directly by professionals, this service would have been best placed to respond appropriately. 8.9.7 The PPRU officer in reviewing the VPA noted that this was a second referral surrounding the situation, which now raises concern about father’s mental health and accordingly made a referral to New Directions through Adult Services in relation to father. The standard response to such a referral was to write to the person inviting a contact; father did not respond to this. The screening in adult services resulted in the referral also being shared with Children’s Social Care, as stated this was misplaced and not screened prior to the incident. The Individual Management Report from Children’s Social Care indicates that had this contact been screened, it is likely it would have been progressed to a referral and that checks with other agencies would have been completed. Standard checks with school and health services would not have revealed any issues of concern for the children and in all likelihood that would have led to a letter advising of support services being sent to the family. 8.9.10 The significant points of missed opportunity for communication lay between Relate and the Police, and the absence of either agency making and initiating a contact with the other, specifically in relation to mother’s need for support and protection led to additional vulnerability for the children. 9. Learning Outcomes 9.1 The children of this family have experienced trauma beyond what is imaginable. Two of the children witnessed the horrific murder of their mother by their father, and all three children have lost both parental figures. The effects on their lives are profound and lifelong. The maternal family, themselves grief stricken, have followed the lead of the mother and care for 36 the children with stability, love and nurture to help them to continue their lives. This is a tragedy that no family should have to endure. The appraisal of professional practice in no way seeks to apportion blame to professionals who were responding to an unfolding series of events. It is the father alone who is responsible for what happened and the impact on the children. The outcomes do however seek to understand what can be learnt in order to better assist the future safeguarding of children. 9.2 Children who live with Domestic Abuse in the home may face challenges and risks that can be life - long and should be considered as Children in Need under the Children Act 1989. Children are often described as the hidden victims of domestic abuse. The last fifteen years has seen a growing recognition and understanding that living in a home where there is domestic abuse is harmful to children. Whilst there is the obvious risk of becoming physically hurt in a violent relationship, children also suffer long-term emotional effects as a result of living with domestic abuse. The Adoption and Children Act 2002 extended the definition of significant harm from The Children Act 1989 to include ‘impairment suffered from seeing or hearing the ill-treatment of another’. When there is a known risk of harm, it is appropriate for professionals to make referrals to Children’s Social Care who have a primary duty to undertake an assessment of a child’s needs in accordance with Section 17 and 47 Children Act 1989. To this end, the Relate Child Protection and Safeguarding Policy should be reviewed, using the case as an instructive case scenario, to ensure that clear local advice and guidance is available to practitioners to support the need for referral about risk to children. This guidance should be consistent with the local area threshold criteria for access to children’s services. 9.3 A point of separation represents increased risk harm to a victim of domestic abuse as well as any children within that relationship. Successive enquiries and research have shown that there is a strong relationship between victims who attempt to end an abusive relationship and partner homicide. The ending of an abusive relationship must serve as an 37 indicator to professionals supporting victims and assessing risk that additional services should be accessed for both support and expertise. It is professionally naive to consider that separation will be achieved on the first attempt or that it is the end a problem when in reality it is simply the beginning of the next chapter. 9.4 Stalking behaviour in the context of Domestic Abuse is an indicator of high risk and is significantly associated with dangerous acts. Although there is no UK comparable data, studies an America reveal that 76% of women murdered by an ex-partner were stalked in the lead up to their death. It is a fact that with relative ease and limited knowledge, a perpetrator can use technology to track their victim’s whereabouts through tracking/locators on mobile telephones and cars. It is believed that the father, who had a high level of knowledge of technology, was able to record mother’s private conversations and observe her movements through remote access to the household CCTV. From 2012, two criminal offences specifically relating to stalking have been introduced, the Suzy Lamplugh Trust points out that stalking differs from harassment because of the ‘obsessive fixation’ of the stalker, and the element of fixation which means that stalking that can escalate very quickly and dangerously. The use of PIN notices, whilst having no legal status in itself, serves as an indisputable warning to the perpetrator, the naming of the behaviour, and an indicator of concern for the victim. Given the undoubted risk of stalking, their use should be firm and consistent. 9.5 The sharing of good quality information directly between professional agencies is critical to ensuring robust risk assessments and responses are achieved. A key limiting factor in assessing risk to children is poor quality of information and for this reason structures that support good quality information sharing are critical to safeguarding children. The point is already made that review of guidance by Relate would benefit practitioners seeking guidance about how and when to share information, and it equally important for Officer in Public 38 Protection undertaking quality assurance to be wholly satisfied that they have relevant source information and have made no assumptions that other agencies are providing services. The Domestic Homicide Report considers in some detail the model of the DASH risk assessment. It notes that national research recognises that it is easier for police officers to recognise Domestic Violence than wider issues of coercion and control within relationships and the current DASH risk assessment was not felt to support officers to develop this approach. A revision of the model, with a greater focus in issues of coercion and control, is to be piloted in a small number of police force areas with the intention of rolling it out nationally once it has been fully evaluated. This is a positive development; however, there remains a local need to ensure immediate learning and refocus. The police officer attending the Panel meeting clearly articulated the need to be mindful that DASH is a tool that should never be used to replace professional judgement and intuition. 9.6 IDVA services play a critical role in supporting victims of domestic abuse and co-ordinating multi-agency risk assessment for victims and children and rely on partner agencies to facilitate contacts with this that need help. The Independent Domestic Violence Advocacy service is provided by Refuge in Warrington. It is structured in such a way to be responsive to crisis and readily available to victims in need. It provides an expertise of the legal systems that victims are often intimidated by, and safety planning as well as access and support to find practical solutions to the very real issues faced by victims leaving a partner. Although mother was provided with the contact details for this service by the counsellor, the service was never made aware of the mother and the risks presented to her family. Given the mother’s wish to separate, but confusion that she felt in being able to achieve this, the IDVA service would have been ideally placed to offer the support that was needed. 39 9.7 For some children, Domestic Abuse is causing hidden harm. Systems that help children be aware of, and talk about Domestic Abuse, will help to identify and support children to remain safe. The children of the family, in particular Child 1 as the eldest, were all aware that their father used controlling behaviour toward them and their mother. There is no indication that, other than when asked by the police officer, Child 1 spoke about this outside of the family. The children’s schools had no knowledge of the police visits to the children’s home, and no evident reason to be concerned for their welfare. The school attended by Child 1 is currently taking part in Operation Encompass, an initiative between the Local Safeguarding Children Board, school and Cheshire Police. This operation aims to ensure that schools are made aware in a timely fashion of all police responses to domestic abuse where a child is present and attends their school. This will enable school staff to offer support to ensure that children feel consulted and safe and promote the awareness of the all parents that domestic abuse impacts on children. The Domestic Homicide Review has given particular consideration to the accessibility of information about domestic abuse within the profile of the community where this family lived and has made recommendations to the Community Safety Partnership about how this can be enhanced. 10. Recommendations 1. That WSCB publicises and promotes the role for Independent Domestic Violence Advocates amongst professionals within constituent agencies; 2. The WSCB seeks assurance from Relate that their Child Protection and Safeguarding Policy specifically direct practitioners and manager to the action that should be taken when there is a known risk of harm to a child in accordance with local threshold criteria; 3. The WSCB seeks assurance from Cheshire Constabulary that Public Information Notices are utilised to maximise the impact of warnings in cases of stalking, and that the issuing of such notices in matters of 40 domestic abuse where is a child is present is shared with Children’s Social Care colleagues through the Multi Agency Safeguarding Hub; 4. That the WSCB supports and develops early help initiatives to help children talk about domestic abuse. |
NC52561 | A 16-year-old girl in local authority care detained under the Mental Health Act in November 2019, following an incident where she stated she intended to take her own life. Learning includes: professional bias must be acknowledged and managed when working with a child who appears capable and articulate; supervision, including inter-disciplinary group supervision, is important for professionals working with highly complex families; when a child does not want to share allegations with the police or withdraws them, consideration should still be given as to whether a criminal investigation is required and whether there is a need to safeguard the child through other proceedings; professionals need to be clear about the law regarding child sexual exploitation, particularly relating to 16-17-year-olds; face to face meetings can help to ensure optimum information sharing when a child is living outside of their home area; it is important for a child who is placed in another area to keep as many key professional relationships as possible. Recommendations include: ensure professionals in partner agencies have an awareness of mental health systems and understand how vulnerable children can access support; consider how professionals in partner agencies are supported to work with families who resist offers of support; use the direct words of Child A (including in the report) when training professionals and in supervision, to help provide an understanding of the impact of systems and practice on children who have mental health concerns and those at risk of exploitation.
| Serious Case Review No: 2023/C9795 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 14.12.20 Local Child Safeguarding Practice Review (LCSPR) Child A Agreed by the Local Authority Safeguarding Board 21st January 2021 Independent reviewer: Nicki Petitt 2 Contents 1. Introduction page 1 2. The process page 2 3. Case information page 2 4. Analysis and learning page 2 5. Recommendations and questions page 13 1 Introduction 1.1.1 The Local Authority Safeguarding Board agreed to undertake a Local Child Safeguarding Practice Review (LCSPR) by considering the case of a 16-year-old girl to be known as Child A. They recognised the potential that lessons could be learned from this case about the way that agencies work together to safeguard children in the Local Authority. 1.1.2 Child A was detained under section 2 of the mental health act1 in November 2019 following an incident where she stated she intended to jump from a bridge. She had been the subject of a child protection plan2 and was a child in care3 at the time. Child A was well known to mental health services and was at risk of sexual abuse through exploitation both online and in the community. 1.1.3 Learning has been identified in this review regarding: • Assessing and planning when needing to respond to crises. • Consideration of the trauma a child has experienced and ongoing risk, however they present. • Working with families who are hard to engage, including fathers/male partners. • Respectful professional challenge. • The importance of reflective supervision. • The need to build relationships. • The law in relation to CSE, particularly the relevance to children aged 16 and 17. • Providing services to a child living outside of their home area. • Accessing a mental health assessment. 2 Process 2.1.1 An independent lead reviewer was commissioned4 to work alongside a panel of local professionals who met on a regular basis to undertake the review, despite the impact of COVID 19. Chronologies and an analysis of partner agencies involvement and the effectiveness of their 1 Mental Health Act 1983 2 Category emotional harm 3 S20 voluntary care Children Act 1989 4 Nicki Pettitt is an independent social work manager and safeguarding consultant. She is an experienced chair and author of Serious Case Reviews and LCSPRs and is entirely independent of the Local Authority 3 practice were requested from all those involved, and professionals involved at the time were meaningfully involved in discussions about the case.5 2.1.2 The lead reviewer has spoken to Child A.6 Engagement was also planned with Child A’s parents in order to identify any learning regarding systems and practice from their point of view. They chose not to meet with the lead reviewer. 2.1.3 This report has been written with the intention that it will be published, and only contains the information about Child A and her family that is required to identify the learning from this case. The review will be published anonymously on the NSPCC library, in order to protect the identity of Child A and her family as the area where they live is a small unitary authority. 3 Case Information 3.1.1 Child A lived with her family prior to coming into the care7 of the Local Authority early in November 2019. No concerns had been shared with partner agencies until February 2019 when advice was sought by the family about Child A and her self-harm. 3.1.2 Over the next nine months concerns for Child A increased. There were a number of reports of self harm and behaviours perceived by her family and professionals as attempts to take her life. Child A spent six weeks in an inpatient mental health unit for young people during 2019. Whilst an in-patient Child A made disclosures suggesting she had been a victim of sexual exploitation (CSE) by older men. Concerns of this type escalated over the coming months. 3.1.3 Child A was made the subject of a Child Protection Plan (CPP) following her discharge from the mental health unit due to concerns about her mental health, the risk of CSE and the fraught relationships at home which appear to have predated the professional concerns about Child A. This was followed by the commencement of pre-proceedings work under the Public Law Outline (PLO) in September 2019. 3.1.4 Late in October 2019 Child A went missing and was found in another area with a man who was arrested for sexually assaulting her. A temporary placement was found in that local authority area and she was accommodated under S20, which her parents agreed to. Having spent just over two weeks in the placement, Child A went missing and a suicide note was found in her room. She was subsequently found some 50 miles away voicing her intention to kill herself. She was taken to hospital, assessed and sectioned under S2 of the Mental Health Act 1983. Child A then spent a significant amount of time in a specialist mental health hospital and is continuing to receive support. 4 Analysis and learning 4.1 Due to the response to Covid-19 practitioner participation sessions8 were held in July 2020 using video technology. From the information shared during the Rapid Review, in the information 5 It was originally planned to hold a large consultation event with all of the professionals involved. The impact of the Covid-19 pandemic led to a change of plan and smaller consultation sessions were held with those involved via virtual meetings 6 This was by telephone at Child A’s request. 7 S20 Children Act 1989 4 provided by agencies, during the consultations with professionals involved at the time and when speaking to Child A, the review has identified the following areas for analysis: 4.2 Assessments and planning 4.2.1 The manner in which Child A’s needs became known to services was untypical in the experience of those working with older children with complex needs, in that she was not known to any professional other than those providing universal services until she was in year 11 of school. The serious concerns for her mental health, the significant risk of exploitation, the concerns about the difficult relationships at home and the allegations she made about her care from her parents emerged over a relatively short period. Those involved described the amount of time they spent working with Child A in order to build the required relationships, assess her needs and the risk, and to keep her safe. The impact on professionals of a child going missing and being at high risk of self-harming and CSE should not be underestimated. Having to react to the emerging risks from different forms of serious harm made planned work very difficult, and required the needs of Child A to be managed alongside concerns for her sibling and their existing caseloads. 4.2.2 The focus on Child A’s mental health and then the identified risk of sexual exploitation dominated the work undertaken by professionals as they potentially posed an immediate risk and were regularly of most concern. There were a number of incidents during the period reviewed requiring urgent responses, which made planned work difficult on occasion. For example, within days of her discharge from the mental health unit in the summer of 2019 Child A took an overdose and went missing from home. The review considered a hypothesis that the concerns about care in the home for Child A and her sibling were not given adequate focus due to the amount of work required in responding to the frequency of urgent events on the case. As stated within the agencies analysis of practice ‘responding to multiple, serious crises in the present, arguably left little space to do the gentle work of gradually uncovering the past.’ While this was indeed to a certain extent the reality, it has been found that those involved managed, on most occasions, to balance responding to crises with the need for planned and child focused work. 4.2.3 As well as the frequent need to respond to unexpected crises, there were difficulties in engaging the family. The family were undoubtedly reluctant to work with professionals, and most reported finding the parents difficult to engage with a pattern of appointments being cancelled, a refusal to allow professionals into the home unless it was planned in advance, and reluctance by the parents to reflect on their roles as parents in their daughter’s difficulties, preferring to see the issue as hers and not theirs. Mother was said to be a strong influence in meetings. Professionals recognised the need to meet with Father alone and made attempts to do so. They were largely unsuccessful in achieving this. 4.2.4 The family had very little contact with professionals before Child A engaged in self harm and suicidal behaviour and it is also possible that an assumption was made that there had been no 8 Four groups were organised chronologically. Each group considered a period of professional involvement with the Child A and her family. Some professionals attended more than one session. 5 reason for any concern relating to any past events. This lack of a known family history of abuse or neglect, the families relative affluence, the children’s academic achievements and the parent’s articulate arguments about why Child A was having the problems she had (initially blaming the stress of her upcoming GCSEs) meant that initially the suggested response was the provision of support for her from CAMHS. When it emerged that Child A was actually very unhappy at home and that her relationships with her parents were fractured, it made engaging with the family challenging for professionals and there was a lack of meaningful compliance. The decision to step up the case from a child in need plan to a child protection plan in the summer of 2019 (not long after her discharge from the mental health unit) then the step up to using the Public Law Outline later in 2019 was not just due to the increasing concerns about Child A’s risk of being exploited or her self-harm, it was also due to the limits enforced by the parents when it came to meaningful engagement with family therapy, assessments, a family group conference and other attempts to progress the matter. 4.2.5 Child A was not able to consistently communicate her views about being at home and how she felt about her parents. She used a diary as a way of communicating with professionals and took opportunities to share this with professionals including her support worker, the social worker and nursing staff in the accident and emergency department. Those who saw the diaries told the review about the heartfelt prose that Child A produced as a way of expressing her serious distress and concerns, and demonstrated another form by which she attempted to communicate with professionals. Those working with Child A considered that such communications rarely went as far as making specific allegations about her home life that would enable the police or CSC to pursue specific enquiries, however enough was known about Child A’s life to assess that she was suffering significant emotional harm. These concerns could have led to a meaningful exploration about whether an investigation and child protection response was required using the evidence that was available around three months prior to the ICPC9. 4.2.6 The need for family therapy was identified in the initial assessment by CAMHS in early 2019. When Child A later had a period as an inpatient in 2019 there was reportedly an attempt to hold family sessions, but the parents did not engage. It appeared that the period while Child A was an inpatient would have been a good opportunity for professionals both in the unit and in the community to work with the family on the concerns that had been identified at the time. However, when a child is an inpatient within a mental health hospital, community CAMHS does not work with the child or family, only taking on responsibility again when the patient is discharged. Resources and systems mean that community CAMHS need to prioritise those in the community. This is a 9 In 2019 there was a Joint Targeted Area Inspection of the multi-agency response to sexual abuse in the family in a number of different local authority areas, including the Local Authority. It found that ‘in some instances, decision-making is overly influenced by children’s views and police investigations are not taken further as the child did not wish this. Although this shows appropriate consideration of children’s wishes and feelings, in a small number of cases this means any wider potential risk from perpetrators to other children is not fully explored. 6 systemic issue which has an impact on the consistency of important therapeutic relationships for children who have regular inpatient stays. 4.2.7 As the parents did not engage with what was offered in the unit, and it was not offered when Child A was at home, family therapy remained an unmet need throughout the timeframe being considered by the review. Child A and her sibling had been assessed as children in need and plans commenced early in 2020. The family worker who was initially allocated the case and the social worker who became involved as a co-worker around this time tried to engage with the family prior to Child A’s discharge from hospital. There were obstacles when it came to engagement which included a lack of insight into the impact of their behaviour on the children, a refusal to discuss their own childhoods or mental health and the parent’s view that they did not require support from children’s social care. 4.2.8 Professionals working with the family reported that they sometimes found the parents intimidating. While the professionals supported each other and were able to recognise that this was a way of the family avoiding scrutiny and professional persistence, it remained difficult for those involved to be transparent about their views regarding the parent’s own issues in the face of denial. For professionals it is a difficult balance between trying to ensure the on-going engagement of parents in order to support and protect children, with the need to challenge them and address concerns and potential parenting deficits. In this case there was a need to keep the parents engaged in order to try and facilitate improvements for Child A and her sibling, but resulted in professionals not always being as forthright as they wanted to be. There was also concern about what the alternative might be for Child A and if she would actually be any safer in foster or residential care, along with the view that further evidence was likely to be required in order to take any assertive legal action. 4.2.9 Extended family members were concerned about Child A and her sibling, and shared information with the social worker. They were seen as potential support system for Child A and possible alternative carers if this was required on a short-term basis. A family group conference (FGC) was arranged but significantly delayed due to the time Child A spent in the mental health unit and then due to the parent’s ambivalence about the benefits of the process. By the time it was convened an initial child protection conference had been arranged for the following week and the FGC was not therefore considered to be as helpful as professionals had first hoped. The meeting did provide a helpful insight into the family dynamics and level of family dispute at that point in time however. 4.2.10 Learning • When there is a constant need to respond to urgent matters, it is essential to ensure that opportunities to assess, plan and reflect are not lost. • Professional bias must be acknowledged and managed when working with a child who appears capable and articulate, ensuring that the level of trauma and risk is assessed, 7 informs an understanding of the child’s capacity and that plans are made which address the risks. • Working with parents who can be challenging and intimidating is difficult for professionals. • Professionals need to identify when parents blame their child for difficulties, and provide support but also respectful challenge. • Reflective supervision is important for all professionals working with highly complex families; this should include inter-disciplinary group supervision if there are a number of professionals providing services. • Every effort should be made to engage with fathers or male partners as equal parents. • When a child does not want to share their allegations with the police or withdraws them, consideration should still be given to whether a criminal investigation is required and whether there is a need to safeguard the child through other proceedings10. 4.3 Responding to missing episodes and concerns about the risk of exploitation 4.3.1 It was not until Child A was an inpatient in the mental health unit in July 2019 that it emerged she was at risk of CSE. It was during this period of hospitalisation she began to partially disclose historic incidents that appeared to be sexually abusive from peers and adults unknown to the family. Her disclosures were historic and prior to the timeframe being considered by the review. She also admitted to currently contacting men on-line. It was unknown if this abuse could be a cause of her self-harming and suicidal ideation, or if it was her existing vulnerability that led to her being at risk of such harm. Understanding the impact of the trauma associated with these factors remained a constant challenge for professionals working with Child A. 4.3.2 The 2016 Triennial Review of SCRs identified a number of risk factors that increase young people’s vulnerability to CSE. “Experience of neglect, parental failure to protect, and time spent in care feature strongly, as do emotional and behavioural difficulties, school disruption, going missing from home, school and care, substance misuse, low levels of self-esteem and seeking affection and approval often in risky places.”11 These common vulnerabilities to CSE were well known to the professionals involved with Child A and it is clear that despite the concerns about her mental health and low self-esteem, most of the suggested vulnerabilities did not appear to feature in her case. This accounts for why the risk of such harm was not assessed or identified before she made her first disclosures. 10 In 2019 there was a Joint Targeted Area Inspection of the multi-agency response to sexual abuse in the family in a number of different local authority areas, including the Local Authority. It found that ‘in some instances, decision-making is overly influenced by children’s views and police investigations are not taken further as the child did not wish this. Although this shows appropriate consideration of children’s wishes and feelings, in a small number of cases this means any wider potential risk from perpetrators to other children is not fully explored. 11 Sidebotham P et al (2016) Pathways to protection a triennial analysis of Serious Case Review 2011-14 DfE. Pg 119 8 4.3.3 Once the risk of CSE was identified, Child A’s vulnerability to exploitation dominated the contact with her by professionals in the community. She was allocated a worker in the Child Exploitation12 team who worked closely with Child A and with her social worker and CAMHS worker in order to prevent an escalation of the known risk of exploitation. The Child exploitation worker was a particularly significant professional relationship for Child A. This specialist CSE provision supported the social worker to work with the wider family and undertake assessments and child protection planning. The Child exploitation worker also worked with the CAMHS worker to provide support regarding Child A’s mental health difficulties, which continued at this time, and with the school to concentrate on supporting Child A with the transition to sixth form and A levels. There was evidence of a strong multi-agency team around Child A and good communication. Over the course of the next few months the system determined that there needed to be a large number of meetings, including strategy meetings and MACE (multi-agency child exploitation) meetings around specific CSE concerns and allegations. Child A told her allocated workers about her plans to meet men and this enabled a certain amount of preventative and disruptive work to be undertaken by the police and CSC including the Child Exploitation team. As a result, Child A was the subject of an effective CSE assessment and a comprehensive safety plan was devised. She told the review that her vulnerability to exploitation during the period being considered by the review was in large part due to her perceived unmet mental health needs, her feelings of hopelessness and the thought that she was not being taken seriously. 4.3.4 As Child A was over 16 years old it was not possible to use a number of the possible CSE disruption tactics such as Child Abduction Warning Notices or criminal charges relating to underage sex, even if Child A had provided details of those she was planning to meet. Largely however, her age did not impact on the professional view of the risk to Child A. It has been identified that there was some confusion in advice provided by the police regarding consent and the legislation for 16 and 17 years old children. The law13 is clear that it is illegal to pay for sexual services or to incite the sexual exploitation of a child under 18, and was therefore relevant to Child A at that time. A recommendation has been made in the Thames Valley Police IMR that aims for sexual exploitation to be more robustly recorded as a crime when the circumstances of the offence are met, and for needs to be better awareness that children aged 16 and 17 are vulnerable to CSE and of the legislation regarding this. 4.3.5 The review has found that an understanding of contextual safeguarding was developing in the Local Authority at the time being considered. In 2017 the University of Bedford and the Contextual Safeguarding Network published an overview of the operational, strategic and contextual framework of Contextual Safeguarding14 which is an approach to ‘understanding and responding to young people’s experiences of significant harm outside of their families’. Traditionally child protection services and systems are focused on risk from and within families, but contextual 12 The Local Authority’s child exploitation team is within children’s social care and works closely with the police to provide a service to children who are at risk of or a victim of exploitation. 13 Sexual Offences Act 2003 14 https://contextualsafeguarding.org.uk/assets/documents/Contextual-Safeguarding-Briefing.pdf 9 safeguarding stresses that professionals need to consider not just safeguarding issues within the home but also abuse within the child’s social contexts. As children subjected to CSE are not necessarily abused by those who raise them, there have been a number of calls for systems to reflect this. 4.3.6 The review asked if those involved at the time considered whether the treatment of Child A from her parents, such as not allowing her age appropriate independence, was due to their concerns about keeping her safe from exploitation and whether professionals adequately understood and considered contextual safeguarding. It was found that contextual safeguarding was considered by those involved at the time and there is evidence that those working with Child A understood the impact of external factors when it came to considering Child A’s risk from CSE. However it was also rightly identified that the issues at home could in part account for Child A’s distress and increased vulnerability to CSE. 4.3.7 The case has raised issues about strategy discussion systems and practice in the Local Authority. The actions agreed at strategy discussions/meetings were not always SMART15 in this case and were often not completed. This appears to be due to the strategy meeting process and forms completed being incident led, due to the high number of meetings in this case because of new concerning incidents, and due to the time required to complete tasks, such as seeking information about potential adult perpetrators. Those informing the review believe this is an issue more generally when it comes to strategy meetings held in the area. A need has been identified for actions from strategy meetings to be reviewed either as a specific review or as part of a core group meeting if the child is already subject to a child protection plan. An action has commenced to ensure that in future S47 investigations will not be signed off until all tasks from the strategy meeting are completed. In this case it has also been noted that the record/decisions of the meetings are not consistently shared with attendees, and this will also be addressed by the plan for improvement described above. 4.3.8 Good practice has been identified regarding the preventative work undertaken with Child A in regard to the risk of CSE. There is no doubt she was made aware of both the general risks and her own vulnerability to this type of abuse. The CSE screening tool was completed with Child A and her Social Worker as a joint discussion, which gave Child A significant opportunity to share her views and describe her lived experience, and for her to consider the risk indicators. There was particularly good practice from the Child Exploitation team. The allocated worker knew Child A well and had undertaken a number of return interviews following missing periods. She recognised patterns of behaviour and identified increasing risks over the period of her involvement. This led to effective joint work with the police and the allocated social worker. Child A told the review that her most significant professional relationship at the time was with the Child Exploitation worker who provided her with the time and opportunity to speak about what was worrying her and who had the skills to facilitate meaningful engagement. 15 Specific, measurable, attainable, realistic and time bound. 10 4.3.9 Learning: • The time and opportunity to build relationships is vital to enable professionals to work in a meaningful way with children who are at risk of exploitation. • Professionals need to be clear about the law in relation to CSE, particularly its relevance to children aged 16 and 17. • Relationships and good communication between professionals helps to prevent and disrupt CSE. 4.4 Communication and information sharing across areas 4.4.1 There were a number of examples of good practice when it came to professionals sharing information, communicating well and developing good relationships in this case. This is often a challenge when a child moves to another part of the country, as was the case for Child A in later in 2019. Child A had travelled independently a distance of 80 miles to meet an older man. Following a joint agency response, she was located and found with the man. She subsequently reported he had raped her and he was arrested. Child A stated she did not want to move back to her home area and it was decided that a short-term placement be provided within the local authority area in which she was found. This was also considered to be a good choice due to the significant concerns about the risks posed to Child A from an adult man nearer to home. Staff were aware of the difficulties in finding somewhere for children of Child A’s age to live, which reflects wider issues about the general shortage of placements for 16 and 17 year old and for Child A. The process of being safeguarded resulted in her spending many hours at a police station while decisions were made and a placement found. 4.4.2 Before Child A was transported to her placement, she spent all day with a number of professionals, including police and nurses at the SARC (sexual assault referral centre). During this period there was a strategy discussion held jointly with professionals responsible for Child A in the Local Authority and a plan was made to investigate the allegations and keep Child A safe. CAMHS in the Local Authority advised that she should be accommodated in a Tier 4 mental health unit, and the nurses at the SARC agreed that a mental health assessment was required. The nurse who spent much of the day with Child A was extremely concerned about her mental health and risk of serious self-harm, believing she intended to take her own life that day. The police officer in attendance however thought that while Child A was nervous and very upset, they did not consider she was a risk to herself or others and did not meet the criteria for S13616 of the Mental Health Act, a provision available to the police if they have serious concerns. There appeared to be some confusion on the day about whether Child A needed an assessment of her mental health or a Mental Health Act17 assessment. The process being followed on the day was for an assessment by CAMHS for a child with a mental health crisis (of the type which would happen in A&E) rather than 16 Section 136 of the Mental Health Act 1983 allows you to be taken to a place of safety, if a police officer is concerned that you may have a mental disorder and should be seen by a mental health professional. 17 The Mental Health Act 1983 is the main piece of legislation that covers the assessment, treatment and rights of people with a mental health disorder. 11 an assessment under the Mental Health Act which would consider if Child A needed to be detained in hospital for urgent assessment and treatment for a mental health disorder and whether she was at risk of harm to herself or others. It appears that no one involved on that day in the Local Authority (via telephone) or within the area where she had been found clarified the exact nature of the required assessment. It is not known if Child A should in fact have had a MHA assessment that day, as this was not pursued at the time. The focus was on getting a CAMHS assessment, which was not successful due to there being no capacity to attend the SARC to undertake an assessment. Child A told the review that she feels that she did require a MHA assessment and that she was actively and seriously planning to take her own life on that day and in the weeks that followed. 4.4.3 No mental health assessment of any type was completed until a week later. It was thought inappropriate for Child A to be taken to A&E as requested, because there was a chance Child A would abscond and because she required the sensitive support being provided to her at the SARC. The CAMHS Initial Core Assessment (ICA) undertaken the following week followed a request from the social worker in the Local Authority and was undertaken by the CAMHS Intensive Support Service and community team local to her placement. The social worker has told the review that there were significant difficulties in being able to arrange this assessment, including basic challenges such as being able to obtain the correct telephone number to call. 4.4.4 Child A was not thought to be in a mental health crisis by the time the assessment took place. The assessment found Child A to be a medium risk. The IMR completed for this review has stated that a number of high-risk areas were identified at that time and were evident in her recent history, and that the assessment may not have been fully trauma informed. At that time there was no communication between those who assessed her and professionals in the Local Authority which would have limited any understanding of her case history. The IMR provided by CAMHS in that area has identified learning in relation to this and a recommendation has been made. 4.4.5 Planning in regard to the risk of CSE continued while Child A was in this placement. This proved challenging as there are positive relationships between the Make Safe team and the neighbourhood and central police teams covering the Local Authority that were not in place with the relevant agencies in the locality of her placement. Staff caring for Child A were briefed regarding what to do if Child A went missing and they were part of the updated and detailed ‘missing trigger plan’. On the day of the serious incident there was a concerted effort by all of those involved to find Child A and to ensure her safety, which was aided by the plan. 4.4.6 Her care in the placement was good and there was effective communication with professionals in the Local Authority. It was complex to ensure she had appropriate educational provision, but efforts were made to ensure she continued to receive educational input. The review was told that Child A’s school provided her with work and there was a plan to get Child A a tutor to help her to keep up with her A level subjects, although when speaking to the lead reviewer Child A disputed this, stating she does not recall having any contact from her school. There is no doubt that Child A 12 missed a significant amount of academic work during her first term of year 12 due to the on-going concerns about her mental health, the missing episodes and then the move to another area. The school had previously shown their commitment to Child A including admitting her to the sixth form and adapting her timetable so that she could attend part-time. They also provided coordinated support following the incident that led to this review when Child A was in hospital. Child A had a personal education plan (PEP) put in place following her initial looked after review. 4.4.7 Learning: • There are difficulties in providing timely services to a child who is living outside of their home area, due to the lack of local information and contacts. Face to face meetings should be held as often as is practicable to ensure optimum information sharing, ownership and governance. • All professionals need to be aware of the options available when a child is in need of an urgent mental health assessment. This should include knowledge of when a Mental Health Act assessment might be suitable and how to access such an assessment. • It is important for a child who is placed in another area to keep as many of the key professional relationships from their home area as possible, while ensuring their needs are also being met in the placement area. 4.5 Voice of the child 4.5.1 Children need to be provided with different ways to enable their voice to be heard, and professionals need to critically reflect on what is said and what children may be trying to communicate by their behaviour. Understanding the lived experience of the child is central to protective safeguarding work. Child A had contact with professionals on an almost daily basis throughout the timeframe considered by the review. Some developed a close and meaningful relationship with a child who appeared in need of adult time and attention. Child A was always encouraged to share her views and was regularly given the opportunity to communicate with professionals who knew her well. She had a voice and it was sought. These relationships had a significant impact on the day of the serious incident when Child A was in contact with a professional she knew and trusted. 4.5.2 Child A’s views were considered (including through access to her diary) when undertaking assessments, when building a relationship with Child A and when providing support and therapeutic interventions. She was regularly offered the support of an advocate. Her behaviour was considered to reflect her situation and professionals worked hard to understand her world and lived experience. For example she was observed to be very quiet when her mother was around. There was an understanding that her behaviour was likely to be linked to past trauma, but Child A was always very guarded with what she shared. Professionals faced a dilemma when Child A stated she did not want her parents to be told her views and wishes and when she retracted or minimised previous allegations. The period of 6 weeks in the mental health unit in the summer of 2019 was not enough time for Child A to build trust with the staff and very little was achieved in 13 terms of understanding her lived experience. Child A told the review that she felt that her needs were not met and that she did not feel safe or listened to while in the unit. The detail of this has been fed back to the appropriate partner agency. 4.5.3 Child A was on the CAMHS central waiting list for individual and family therapy from early 2019 and she remained there at the time of the incident 10 months later, with no identified therapist assigned. However, the CAMHS duty lead took a holding role in the interim and showed a clear commitment to Child A. They were an active member of the team supporting her and they knew Child A and her family well. The CAMHS worker responded to crises and provided direct work to Child A, often tailoring his approach to meet her needs. The system, while not ideal, enabled an on-going relationship to develop between the duty CAMHS worker and the family. At the initial child protection conference (ICPC) there was a concern that Child A’s mental health needs had not been assessed and responded to sufficiently and in a timely way, despite the involvement of CAMHS and her time as an inpatient. Child A told the review that she was aware that the CAMHS worker was temporary and that she interpreted this as the organisation not caring about her enough for her to be given a permanent worker. She said that she did not feel able to share this view at the time, and mainly sat in silence during sessions. 4.5.4 Those who do not work in mental health services told the review that they did not fully understand the processes, systems and thresholds for CAMHS services, and that they had a general lack of confidence regarding working with mental health issues. Capacity and demand is a known issue for all CAMHS services. Increasing numbers of children require support to address their mental health.18 The Office for National Statistics reported in September 2018 that growing numbers of teenagers in England and Wales are killing themselves. Fifty-six girls and women aged between 15 and 19 killed themselves in 2017, the highest number since records began in 1981. The suicide rate among that group, 3.5 per 100,000 people, was also the highest on record, having been 2.1 per 100,000 in 2010. The school that Child A attends has emotional wellbeing support for children, but they have a waiting list and can only provide a fixed period of support for up to 6 weeks. 4.5.5 There were many professionals in the Local Authority who tried hard to get to know Child A and who did much to meet her needs. While looked after, Child A was placed out of the area and was provided with care and support at the unit where she lived. She had been well supported at the SARC in that area following the disclosure she made. By considering the records kept at the time and from speaking to those involved, it is clear that Child A wanted support and received services as soon as the extent of her difficulties emerged. Capacity and demand had an impact, and there were issues with some of the services provided, but on the whole the response to Child A’s needs and the risks she faced was good. With hindsight Child A has said that she was unable to be honest about her feelings and the extent of her illness. It was only following the incident and her spending a significant amount of time in a mental health setting that the seriousness of Child A’s 18 9.7% in 1999. 11.2% in 2018 14 mental health difficulties became evident. She told the review that the inpatient care and support provided following the incident was exceptionally good. 4.5.6 Learning • Under-pressure systems, like community CAMHS and children’s social care, need to ensure that the right people are in the right place to build relationships with children and to understand their needs and the risks to which they are exposed. They need the requisite skills and experience to do this complex work and to be well supported. They can then respond to the needs of children with complex needs. 4.6 Learning from Child A herself 4.6.1 As part of this review the lead reviewer spoke to Child A. As described by the professionals who know her, she is bright, articulate and sensitive. She was keen to share her views and has given permission for the following statements to be included in this report. They should be considered by all professionals working with young people. • There is always a reason for a child’s behaviour • It is hard for a child to find the words. Be patient and give them your time • If a child withdraws allegations it doesn’t mean they are not true, it probably means they are scared • If a child says they want to die, don’t say ‘you don’t’, as they will probably want to prove you wrong. 5 Conclusion and recommendations 5.1.1 At the time of the serious incident, Child A was found by police some distance away from her placement and it was the view of those who assessed her that she intended to take her life. She was extremely vulnerable and unhappy. Despite the good relationships she had with a number of the professionals involved and how hard they worked to keep her safe, Child A remained at risk of suicide, self-harm and exploitation. While it was impossible not to focus on and respond to the immediate risks that occurred on a frequent basis, those involved recognised the impact of Child A’s history and worked with the hypothesis that the family environment was the primary causal factor in Child A’s behavioural presentation. Engaging with the family to address this was a constant challenge, but those involved were persistent and tenacious, showing the family they were not going to go away while Child A was at risk. 5.1.2 The Child Safeguarding Practice Review Panel stated in their annual report 2018-19 that the ‘complexity of practice requires sophisticated conversation, hard wired into the DNA of our child protection practitioners’. It asks, ‘how do we help people talk to each other within a context of high-risk, high-volume and limited resource, often when practitioners are fearful of reprisals from families, employers and society at large?’ This case shows that good information sharing, open communication between professionals and embedded relationships between the professionals working with a child can make a positive difference, but it also exposes the vulnerabilities when 15 recourses are limited, when there is limited understanding of some parts of the system, and when a child moves to another area. 5.1.3 Single agency learning has been identified during the review and a number of recommendations have been agreed to address these, including single agency SMART action plans. 5.1.4 There has been excellent cooperation with this review from the partner agencies in both areas, which was essential in establishing the learning from this case. 5.1.5 Having considered the learning from this review that has not been addressed in the single agency actions, the following additional recommendations are made to ensure improvements. Recommendation 1: That this report is shared with the Children’s Safeguarding Partnership in the area in which Child A was placed and that they provide feedback on the progress of any recommendations from their partner agencies that have contributed to this review. Recommendation 2: The Local Authority Safeguarding Board should ensure that professionals in its partner agencies have an understanding of mental health systems, in order that non-mental health staff are confident regarding what is required on a case by case basis and how vulnerable children can access the correct support. Recommendation 3: The Local Authority Safeguarding Board to consider how professionals in the specific relevant partner agencies are supported to work with families who resist offers of help and support, including when the appropriate use of authority is necessary to safeguard children. Recommendation 4: That the Local Authority Safeguarding Board asks its partner agencies to use the direct words of Child A when training professionals and in supervision in order to provide an understanding of the impact of systems and practice on children who have mental health concerns and who are at risk of exploitation. |
NC52435 | Long-standing chronic neglect suffered by a child whilst in the care of her mother. She was removed from her home under police protection and admitted to hospital due to the impact of severe physical and emotional neglect in August 2020. Learning includes: the need for professionals to collate and consider information which raises concerns about the safety of a child being home educated; when a child has a history of non-school attendance professionals need to recognise this as a serious safeguarding issue; the necessity for professional challenge when there is indecisiveness and or inappropriate decisions being made during the course of child protection conferences; use of resources available to assess neglect is vital if professional practice is to be improved and children protected. Recommendations for the Department for Education include: consider amending statutory guidance so that when a parent gives notice of their intention to electively home educate their child, information should be collated from safeguarding partner agencies prior to the child being removed from mainstream education; consider amending statutory guidance so that local authorities have authorisation to seek assurance that the parent has the intellectual capability and appropriate resources to provide suitable home education to the child, and decide whether it is in the child's best interest. Recommendation to the Safeguarding Review Panel: consider including a section on children who are electively home educated in any future revision of Working Together to Safeguard Children. Makes a number of recommendations to the Safeguarding Children Partnership.
| Title: Child safeguarding practice review: executive summary: Child A. LSCB: Hounslow Safeguarding Children Partnership Author: Moira Murray Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 15 Hounslow Safeguarding Children Partnership Child Safeguarding Practice Review Executive Summary Child A Lead Reviewer Moira Murray April 2022 Page 2 of 15 Contents Page Introduction: Background Summary 3 Terms of Reference Timeline for the review 5 Involvement of the family in the review 5 Learning Arising from the Review 5 – 8 Good Practice 8 Conclusions Recommendations 9 10 -11 Appendix 1: Terms of Reference Methodology Agencies involved Lead Reviewer 12 Page 3 of 15 1. Introduction: Background Summary 1.1.1 Child A first came to the attention of Children’s Social Care in 2005 when she was two and a half years old. At the time there were concerns about Mother’s mental health and domestic abuse. Mother refused to engage with Children’s Social Care, maintaining that Child A was not present at the time of the domestic abuse incident and that she could protect her daughter. The case was closed. 1.1.2 Child A’s father ceased to be involved with the family when Child A was four, and it seems from then onwards there was no contact with him. By this time, Child A was attending nursery, where speech and language difficulties were first identified. Concerns about Child A’s presentation, behaviour and learning difficulties were also identified, which continued when she started Primary School. Child A’s school attendance was poor and continued to deteriorate throughout her school aged years. 1.1.3 Mother and her extended family suggested that Child A needed to attend a Special Educational Needs School. An assessment by an Educational Psychologist found that Child A’s cognitive ability was low, that she had high levels of anxiety and poor self-esteem. A referral was made to the Early Intervention Team however Mother did not engage. 1.1.4 In 2014, Child A transferred to a mainstream Secondary School. By this stage her attendance had further deteriorated, and she had become selectively mute. Concerns about Mother’s mental health increased, and it became evident that this was impacting on Child A’s wellbeing. Secondary School staff did their utmost to maintain a relationship with Child A and Mother to ensure that Child A remained in mainstream education. 1.1.5 In April 2015, because of Child A’s poor attendance, the Secondary School made a request for intervention by the Education Welfare Service, and also raised concerns that Mother’s mental health was resulting in Child A being at risk of physical and emotional neglect. In June 2015, the Secondary School was informed by the Local Authority that Mother had elected to home educate Child A and in September she was taken off the school roll. 1.1.6 Following concerns that there was no evidence of home education taking place as well as the home conditions, the Elective home Education Team made a referral to Children’s Social Care in January 2016. An Initial Assessment commenced in February 2016 and in August 2016, Child A was made subject to a Child Protection Plan under the category of neglect. By this time Child A was 14 years old. Page 4 of 15 1.1.7 The Elective Home Education Team ceased involvement and Child A was referred to the Continuing Access to Education (CATE) School. A referral was made to CAMHS, but Mother refused to engage with the service, nor did she engage with CATE. 1.1.8 During 2016 – 2017 attempts were made by Children’s Social Care to gain access to Child A, at times requesting Police assistance, however, Child A remained in Mother’s care. In October 2018, following a Review Child Protection Conference and Legal Planning Meeting, pre-proceedings were initiated with the intention of applying for a Child Assessment Order. This was not pursued, despite Mother’s lack of cooperation. Although consideration was given to applying for an Interim Care Order, it was decided that as Child A was now 16 years old there was little chance of success. 1.1.9 Child A remained on a Child Protection Plan until March 2019 when a Review Child Protection Conference decided it should end. Following concerns raised with the Community Risk Panel, a Strategy Discussion took place in February 2020. A joint home visit with Police and Children’s Social Care discovered that Child A and Mother had vacated their flat and had moved in with Maternal Grandmother and Maternal Uncle, who was a convicted sex offender. 1.1.10 In May 2020, Police and CAMHS practitioners took Child A to hospital under a s135 Mental Health Act warrant. Following an assessment in A&E, Child A was discharged home into her mother’s care. 1.1.11 It was not until August 2020, that Police called at Maternal Grandmother’s home in the early hours of the morning, having received an urgent call from a member of the public in the USA, with whom Child A had been in contact via social media. Child A was removed by Police Officers and having spent a significant period of time at the Police Station, was eventually placed with an emergency foster carer. The next day Child A was seen by the Community Paediatrician for a Child Protection Medical and was assessed as requiring immediate medical attention. Child A was taken to A&E and subsequently admitted to a paediatric ward, where she remained for four weeks. 1.1.12 On her discharge from hospital, Child A was placed with long term foster carers, where she remains. As she is now adult, Child A’s care has transferred to Adult Social Care. After Child A’s removal from her mother’s care, Mother was sectioned under the Mental Health Act, 1983 and was diagnosed with paranoid schizophrenia. No criminal charges have been brought against Mother or members of the extended family. 1.1.13 Given that that Child A had been neglected for the majority of her childhood, the involvement of agencies with the family, Child A being subject to a Child Protection Plan and Elective Home Education, consideration was given by Hounslow Children Safeguarding Partnership as to whether the case met the criteria for a Child Safeguarding Practice Review under Working Together to Safeguard Children, 2018. Page 5 of 15 It was decided on 12 October 2020 that the case did meet the criteria for a Local Review to be commissioned. The Child Safeguarding Practice Review National Panel has indicated that the review is of particular interest nationally, given that Elective Home Education was a feature of the case, as well as the effectiveness of certain agencies in Child A’s life (see below). Terms of Reference, Methodology and Scope 1.2.1 Full details of the terms of reference and methodology for the review can be found in Appendix 1, as can details of the agencies involved, and the Lead Reviewer. 1.2.2 A multi-disciplinary Learning Event for practitioners was held on 1 July 2021. Because of the Covid 19 Pandemic, the event took place virtually. The event proved to be worthwhile, with practitioners providing important information, engaging in helpful discussions and insightful suggestions for improvement of practice. Discussions arising from the event have informed the learning and recommendations arising from this review. The Lead Reviewer would like to thank all those who attended and the Safeguarding Children Partnership Team for arranging and facilitating the event. Time Period under Review: 1.2.3 The review will explore the support and services working with the family from January 2011 – August 2020. 1.2.4 The review will seek to understand and evaluate responses in key areas of enquiry identified through the Rapid Review process and recommendations made by the National Panel. Involvement of family members in the review 1.2.5 Mother was informed on 28 July 2021 that a Child Safeguarding Practice Review had been commissioned. Mother has not engaged with the review. Father’s whereabouts are not known. 2 On 28 October 2021 the HSCP Service Manager and on 1 November 2021, the Lead Reviewer spoke with Child A’s foster carer. Child A did not feel able to speak directly with the Lead Reviewer, however she was in agreement for her views on her past and current experiences to be relayed to the Lead Reviewer by her foster carer. 3 Learning arising from this Child Safeguarding Practice Review 3.1.1 The following learning for Partner agencies has arisen from this review. 3.1.2 Whilst it may be a parent’s right to electively home educate their child, professionals need to consider whether there is a safeguarding risk posed to a child when they are removed from mainstream education. This involves ensuring that the parent has the Page 6 of 15 intellectual capability and resources to provide a suitable standard of education. Most importantly, the child themselves should be asked their view as to whether they agree to be home educated. There is no evidence that Child A was asked if she was happy and agreed to the proposal that she should be removed from her Secondary School. 3.1.3 The importance of collating information from agencies who know the child, especially the school they are attending, to ascertain whether there are any concerns about a child being removed from mainstream education is vital if children are to be safeguarded and their wellbeing promoted. In this case the Secondary School raised immediate concerns when Mother said she was going to home educate Child A. These concerns were made known to the Local Authority, and it is to the school’s credit that they had made previous referrals to the Education Welfare Service and Children’s Social Care about Child A’s lack of attendance and Mother’s mental health. This information was available to the Elective Home Education Team prior to the authorisation for Child A to be removed from the school roll. The need for professionals to collate and take account of information which raises concerns about the safety of a child being home educated is a lesson learned from this review. Recommendation 1 3.1.4 It is acknowledged that the Elective Home Education Team is insufficiently resourced and over stretched. However, when a member of the Team is concerned about the home environment and does not consider the work programme set by a parent for their child to be appropriate for their needs, such concerns need to be brought to the immediate attention of their line manager. This is a lesson learned from this review. Recommendation 4 3.1.5 When a child has a history of non-school attendance, as was the case for Child A, professionals need to recognise this as a serious safeguarding issue. Child A’s school attendance was of concern from when she was at primary school and deteriorated when she transferred to secondary school. Prior to her being removed from the school roll, Child A had not attended school for five months. For Mother to then inform the Local Authority that she wished to electively home educate her child, should have raised immediate concerns, and provoked a comprehensive assessment as to whether Child A was at risk of significant harm. The fact the Child A continued to be home educated when she was subject to a Child Protection Plan, not least given Mother was refusing to allow professionals to enter her home, is deeply concerning. Such practice is not consistent with statutory guidance, Working Together to Safeguard Children 2018 and is indicative of systemic failure. This is a lesson learned from this review. 3.1.6 The review has highlighted the lack of reference to children who are electively home educated in statutory safeguarding guidance. The need to ensure that consideration is given to include children who are home educated in any future revision of Working Together to Safeguard Children is a lesson arising from this review. Recommendation 3 Page 7 of 15 3.1.7 This report has detailed the deficiency of the Child Protection process in this case. Over a period of almost three years when Child A was subject to a Child Protection Plan, there were numerous opportunities for professionals to intervene to remove her from an increasingly volatile and dangerous environment. The necessity for agency representatives to challenge each other when there is indecisiveness and or inappropriate decisions being made during the course of Child Protection Conferences, including the basis of the legal advice provided, is vital if there are to be positive outcomes for children at risk and is a lesson learned from this review. Recommendation 5 3.1.8 Given that neglect is the most frequent category of abuse for children subject to Child Protection Plans, it could be anticipated that professionals would be knowledgeable of the signs, impact and negative outcomes for children who are neglected. It is apparent however, that there was a lack of recognition of the chronic neglect to which Child A was subjected. The tools to assess neglect are readily accessible to all agencies working in Hounslow and the Safeguarding Children Partnership is to be commended for the range of resources available to professionals. It is of concern that in this case such resources were not fully utilised. If the Quality of Care assessment tool had been used appropriately, the initial assessment undertaken by Children’s Social Care would hopefully have been more robust and would not have taken five months to complete. The need to ensure that partner agencies use the resources available to assess neglect is vital if professional practice is to be improved and children protected. This is a lesson learned, which is reflected in Recommendation 6. 3.1.9 The review has exemplified the impact of a parent’s undiagnosed mental illness on a child’s health and wellbeing. As has been detailed, Mother’s presentation to the GP and to the Mental Health Team was indicative of depression and anxiety. Yet there were indications of underlying paranoia, as evidenced by Child A’s disclosure of Mother speaking of ghosts, keeping the curtains closed, her obsession that a neighbour’s child was continually threatening her and Child A, refusing to allow entry to the home and her withdrawal into an enclosed home environment consisting of herself and Child A. The importance of sharing known information about a parent’s mental health is crucial if children are to be protected. 3.1.10 In this case, the Police, the Secondary School and the GP did make referrals about Mother’s increasingly disturbed behaviour, but it was not until Child A was taken into Police Protection that the full extent of Mother’s mental illness was diagnosed. However, information was known about Mother’s mental health by those involved in the Child Protection process. If such information had been collated into a chronology, then those agencies involved, including Legal Services, would have been provided with evidence-based knowledge of the seriousness of Mother’s mental health and its impact on Child A’s wellbeing. This is a lesson learned from this review. Recommendation 7. Page 8 of 15 3.1.11 Listening to children who are experiencing neglect and or abuse is of the utmost importance if they are to be safeguarded. Child A was provided with some opportunities to disclose what was happening to her, and it is significant that on each occasion she did so, she was in a safe place and Mother was not present. Child A was able to disclose at times, some of the abuse she had experienced by speaking directly to people she trusted. It is however also important that professionals working with children consider children holistically, which involves taking account of what is not said, the conditions in which they live and their physical and emotional presentation. 3.1.12 Appropriately, Child A was taken into Police Protection in the early hours of the morning when she was removed from Maternal Grandmother’s home. However, it was inappropriate for her to be taken to a police station to await the identification of an emergency foster placement, a process which in the event took approximately twelve hours. The reasons why there was such a delay in finding a placement by the local authority have been identified, and the review has recognised the major challenges faced by Children’s Social Care in finding placements for older children. Nevertheless, this situation was detrimental to Child A’s welfare, as it would have been to any child. It is the responsibility of the Initiating Officer to ensure a child’s wellbeing whilst under Police Protection and given the length of time which Child A remained at the Police Station, the situation required intervention and escalation. The review has found that consideration should be given to identifying a Single Point of Contact within Children’s Social Care for the Initiating Officer to be able to discuss, share and if necessary escalate concerns for a child awaiting a foster placement whilst under Police Protection. This is a lesson learned and is reflected in Recommendation 8 4 Good Practice 4.1.1 The review has identified the following good practice: • The action on the part of the Secondary School to take seriously the concerns about Child A’s non-school attendance, the quality of her life at home and Mother’s intention to electively home educate her daughter was good practice and is to be commended. • The concerns raised by Police about Mother’s mental health and the welfare of Child A was good practice. • The questioning of the A&E doctors about Child A being discharged was good practice. • The referrals to the Mental Health Team, CAMHS and to Children’s Social Care by the GPs involved with the family was good practice and showed an effective awareness of safeguarding. Page 9 of 15 4 Conclusions 4.1.1 This review has been complex and of necessity detailed. 4.1.2 Whilst the majority of children who are electively home educated can be considered to have an enjoyable and rewarding experience, this review has highlighted the risks presented to vulnerable children whose wellbeing is compromised by such an arrangement. Therefore, the need to ensure that information is collated about the circumstances under which home education is to be provided, the history of a child’s school attendance and any concerns about a child’s welfare is a pre-requisite for agencies involved. 4.1.3 Child A was a child about whom teachers had sufficient concerns which resulted in referrals being made to the Education Welfare Service and Children’s Social Care. The Secondary School recognised the risk presented to Child A if she was removed from the safe environment of mainstream education and made their concerns known to the Local Authority. Mother’s decision to home educate Child A provided the means for her to remove her daughter from any form of regular monitoring concerning her health and wellbeing. 4.1.4 Child A was essentially lost to systems set up to safeguard and monitor children from February 2015 when she effectively ceased attending secondary school until August 2020 when she was finally removed from the care of her family. For part of this period of five and a half years, Child A was on a Child Protection Plan, and whilst seen on occasions, she remained under the care and control of her mother throughout. This was despite the deteriorating home conditions, no educational provision, isolation, Child A’s significant weight loss, neglectful presentation and Mother’s worsening mental health. 4.1.5 This review has concluded that the means were available through the legislative framework to safeguard children for Child A to have been removed much earlier from Mother’s care. That she was allowed to remain in an unsafe environment for so long resulted in her suffering chronic neglect was due to systemic failure. This resulted in Child A losing years of her childhood and adolescence and may have affected her cognitive and physical development. It is fortuitous that a secure, caring long term placement has been found for Child A which will hopefully enable her to progress safely into adulthood. Page 10 of 15 5 Recommendations The following recommendations are made for consideration: For the Department for Education: Recommendation 1 The Department of Education to consider amending statutory guidance so that when a parent gives notice of their intention to Electively Home Educate their child, information should be collated from safeguarding partner agencies to ensure that there are no known concerns that may place the child at risk of significant harm. These checks should take place prior to the child being removed from mainstream education. For the Department for Education: Recommendation 2 The Department for Education to consider amending statutory guidance so that local authorities have authorisation to seek assurance that the parent has the intellectual capability and appropriate resources to fulfil the requirements to provide suitable home education to the child. Where such assurance is not forthcoming, the local authority can decide whether it is in the child’s best interest to be Electively Home Educated. For the National Panel: Recommendation 3 The National Panel to take into consideration the importance of the need to include a section on children who are Electively Home Educated in any future revision of Working Together to Safeguard Children. commendation 3 For Hounslow Safeguarding Children Partnership: Recommendation 4 If a visiting member of the Elective Home Education Team has concerns about the suitability of the education being provided by a parent, if appropriate and safe, such concerns need to be raised with the parent and also with their line manager. For Hounslow Safeguarding Children Partnership: Recommendation 5 Where there is disagreement about a Child Protection Conference decision or concerns about the way in which a Child Protection Plan is being adhered to, professionals should be confident to challenge each other and the Conference Chair, to ensure that the best interests of the child are at the centre of any decision making. Page 11 of 15 For Hounslow Safeguarding Children Partnership: Recommendation 6 Assurance should be sought that agencies are utilising the tools and resources made available by the Partnership to assess neglect and improve outcomes for children. Where it is evident that such assessment resources are not being sufficiently utilised, agencies need to be held to account. For Hounslow Safeguarding Children Partnership: Recommendation 7: The use of multi-agency chronologies as part of the Child Protection process, especially in cases of chronic neglect, should be promoted as a means of collating information concerning parents and children. For Hounslow Safeguarding Children Partnership: Recommendation 8 When a child is taken into Police Protection: (a) Consideration should be given, as to whether advice is needed (if out of hours from the Consultant Paediatrician on call 24/7 at West Middlesex University Hospital) to decide if a child protection medical and/or immediate medical attention is required. (b) Consideration should be given by Partner Agencies to appointing a Single Point of Contact within children’s Social Care for concerns to be discussed, shared, and escalated when a child is waiting for an appropriate care placement to be found, so as to ensure the welfare of the child is not compromised. Page 12 of 15 Appendix 1 Local Child Safeguarding Practice Review – Child A Terms of Reference 1) Background In September 2020 the Local Authority notified Ofsted of a Serious Incident following recommendation from the Cases Sub-Group of the HSCP, as a result of long-standing chronic neglect suffered by Child A, now 18 years old, whilst in the care of her mother. She was removed from her home under Police Protection and admitted to West Middlesex University Hospital due to the impact of severe physical and emotional neglect. Prior to her removal from her home in August 2020, Child A had previously been subject to protection plans and the risk of significant harm considered within the legal threshold for removal from her mother care. In August 2020, Child A was discharged from hospital into a foster placement. 2) Overall Objectives The overall objective of the review is to review multiagency practice in how the system responded individually and together to address concerns, safeguard and promote the wellbeing of the children. It will understand strengths and any weaknesses in practice and service delivery and will identify organisational learning and improvements and, where relevant, the prevention of the reoccurrence of similar incidents. Individual and organisational accountability is manifest through being open and transparent about any problems identified in the way the case was handled and demonstrating a commitment to seek to learn from and address the causes. Recommendations will be made and translated into an action that will lead to sustainable improvements. The review will be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children. • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. • Is transparent about the way information is collected and analysed. • Makes use of relevant research and case evidence to inform the findings. The review will: Page 13 of 15 • Be proportionate. • Involve the professionals fully and invite them to contribute their perspectives without fear of being blamed for actions they took in good faith. • Involve the family, including the young person, where possible. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process; 3) Review timeline and themed areas of enquiry and wider questions to be addressed The review will explore the support and services working with the family from January 2011 – August 2020. The review will seek to understand and evaluate responses in the following key areas of enquiry identified through the Rapid Review process and recommendations made by the National Panel: • The focus on the child in all assessments and understanding how she became less visible to professionals. (Requested by National Panel) • What opportunities were created for the child to make disclosures. • The assessment and consideration of undiagnosed parental mental health impacting parenting and ability to make and sustain positive changes. • The effectiveness of decision making and assessment of risk, outcomes and impact within the Child Protection Case Conferences and multi-agency safeguarding meetings. • Professional understanding of the reasons for Elective Home Education within the timeline of the child’s life and how well it was explored and understood. (Requested by National Panel) • The understanding and consideration by all agencies of the impact of Elective Home Education on the child and its consideration in assessments of risk. (Requested by National Panel) • Professionals understanding and/or awareness of the indicators of neglect / abuse missed by multi-agency safeguarding system. • De-escalation as a means of engagement and compliance when the family disengaged • The effectiveness of interventions offered by all services throughout the timeline of the review • The effectiveness of professional scrutiny and challenge across the network • How well information was shared across the system and the effectiveness of the pathways to feedback to referrers • The effectiveness of the role of GP, School Nursing Services and CAMHS in the child’s life. (Requested by National Panel) 4) Method of enquiry (steps may overlap and may not occur in this order) LCSPRs are required to be completed within six months and the final overview report and recommendations will be published on the partnership’s website. Page 14 of 15 The methodology being used for this review is systemic seeking to understand the rationale for decisions and actions taken in the context of the agencies in which practitioners were working at the time. The method incorporates: • Oversight by a LCSPR Panel Chaired by the Independent Chair of the HSCP and led by an Independent Reviewer • Each agency involved will provide a chronology created from agency records for the time period of the review. • Single agency Individual Management Reports (IMRs) evaluating their involvement with the family and other agencies, using agency standards and identify any lessons learnt, as a result of this review. The IMR should be completed by an experienced and independent senior officer, able to analyse the quality of the work and decisions, within the context of agency procedures, relevant research and any significant systemic issues which were current in the agency during the time period of the review. The report should be endorsed by a senior manager who is also a HSCP Board member for that organisation and who did not have direct involvement in the management of the case. • Engagement with family members - the family will be informed of the review and invited to share their views about the agencies who worked with them; they will be offered meetings with the Independent Reviewer. • Agencies should involve relevant practitioners in conversations about the work, decisions and actions when analysing the rationale for the work undertaken. The HSCP will invite them to Practitioner Learning Event/s, to seek the views of practitioners about the work and its context. • The Panel may consider how to speak with any practitioners individually where appropriate. • The Independent Reviewer may request specific case documents where they believe it would assist the understanding of the case; and any relevant agency policy or procedural documents. • The review should refer to relevant law, guidance and research • The Panel may seek legal advice if required 5) Areas excluded or limited in scope The focus of the review activity will be on the areas that are considered to be the most important (see section 3 above). Additional items may be added to the terms of reference if significant new information emerges. Page 15 of 15 The Lead Reviewer Moira Murray is a social worker by training and has undertaken numerous SCRs, Learning Reviews and Safeguarding Children Practice Reviews. She has been involved in safeguarding audits for the NHS, the voluntary sector and local authorities. She co-authored HM Government Safeguarding Disabled Children Practice Guidance, 2009 whilst Head of Safeguarding at the Children’s Society. She was a non-executive board member of the Independent Safeguarding Authority for 5 years, was Safeguarding Manager for Children and Vulnerable Adults, London 2012 Olympics and Paralympic Games; has undertaken a review for the Foreign & Commonwealth Office, reviewed the BBC post Jimmy Savile and undertaken safeguarding reviews of Premier League Football. Until recently she was the Senior Casework Manager in the National Safeguarding Team, Church of England. |
NC52364 | Attempted suicide by a 7-year-old child at the family home. Sixteen months prior to this event, Child G had disclosed that they had been sexually abused on two occasions by their stepfather. Learning includes: it is important to continue to communicate with children about their world; professionals need to be reflective in the context of what may be a change in the child's priorities rather than adhere exclusively to an adult assumption of what the child requires; consider a more judicious use of care planning forums when there is lack of clarity about what the options are in reducing risk within families; there should be more effective planning, assessment and recording at all stages of the achieve best evidence (ABE) process. Recommendations include: for agencies to consider the importance of not making assumptions about the source of a child's distress in the absence of speaking to the child directly, and the clarity about a plan to work together concerning how the child's needs are met while awaiting specialist assessment; ensure that procedures for convening multi-agency meetings are followed, to allow for clearer planning and communication between agencies; ABE interviews should be carefully planned and appropriately documented, in line with expected good practice and guidance, and there should always be consideration as to whether a further strategy meeting is required following the ABE interview.
| Serious Case Review No: 2022/C9323 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Child G LCSPR overview report – FINAL 02.11.21 1 Overview 1. The Safeguarding Children Partnership (SCP) decided to undertake a Child Safeguarding Practice Review in the matter of Child G who, age seven, attempted to take their own life at the family home. 2. Sixteen months prior to this event, Child G had disclosed that they had been sexually abused on two occasions by their stepfather. The allegations were investigated by the police and a risk assessment was undertaken by the specialist sexual risk assessment service in the area. Although the stepfather was prohibited from being in the family home while the police investigation was proceeding, and during the time that the sexual risk assessment was in progress, he returned to live there six months later. There was insufficient evidence to take further action on either criminal grounds or welfare concerns. Stepfather was living at home when the attempted suicide took place. Because of the Covid-19 pandemic lockdown, Child G had not been to school for five months in the period immediately preceding this event. 3. Although, thankfully, Child G did not die or suffer serious physical injury as a result of their actions, the view of the police and the ambulance service was that this was ‘a near miss’. One hypothesis is that this behaviour may have been the act of a very distressed child, who had been living in the same household as their possible abuser for over a year, with a mother who was not protective and no one outside the family to turn to. 4. From the time of the disclosure to the attempted suicide there was extensive involvement from Children’s Social Care (CSC), specialist sexual risk services, the police, Child G’s school and specialist educational support services. The purpose of this partnership review is to consider if there are any systemic or underlying reasons why actions were taken or not taken by agencies and to provide a summary of any improvements recommended to the area safeguarding partners and/or other agencies to safeguard and promote the welfare of children. The Process 5. The national Child Safeguarding Practice Review Panel (CSPRP) was notified by the SCP about Child G’s actions as a serious incident. The circumstances surrounding Child G’s attempted suicide qualifies as a ‘serious incident’ because it had implications for the ‘serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development’ of Child G. Working Together recognises that, ‘even if a child Child G LCSPR overview report – FINAL 02.11.21 2 recovers, including from a one-off incident serious harm may still have occurred.’ (pg. 85 para 11)1 6. In keeping with Working Together guidance, ‘rapid review’ reports were requested from all the agencies that knew Child G and their family, or who responded on the day the serious incident occurred. 7. Upon receiving those reports the SCP considered that the criteria were met for a Local Child Safeguarding Practice Review (LCSPR). In a letter dated 26/10/20, the National Child Safeguarding Panel agreed that ‘there is learning to be drawn from this case’ and endorsed the decision to carry out a LCSPR as set out in Working Together (2018). Independent Management Reviews (IMRs) were requested from eight of the agencies who submitted rapid review reports. In addition, the police submitted a second report from the Specialist Crime Operations Crime Review Team (SCOCRT) of an internal review undertaken after the attempted suicide because of concerns about the initial investigation into Child G’s allegations. 8. The author is an independent social worker, trainer, and safeguarding consultant. She has no other affiliation with the Safeguarding Children Partnership. The author has considerable clinical experience of working in the area of intra-familial child sexual abuse and has been involved as both a chair and an overview report writer for serious case reviews in various parts of the country. 9. The author held interviews at least once with 21 of the practitioners who had the most direct involvement. The majority of the interviews were conducted online but Child G’s mother, their social worker and the social worker’s manager were seen face-to-face at the area office. 10. It was decided that the time frame under scrutiny would be from when Child G disclosed the abuse to when the attempted suicide took place. The SCP Case Review Group met regularly during this period to monitor the progress of the review process. 11. A half-day online learning event for practitioners who contributed to the review was held in June 2021. The participants had sight of Draft 2 of this report prior to the event and their comments and the feedback from the discussion groups held on the day are incorporated into this version of the partnership review. Family Engagement 1 Working Together to Safeguard Children (2018) https://www.workingtogetheronline.co.uk Child G LCSPR overview report – FINAL 02.11.21 3 12. The author met with the mother face-to-face on her own for an hour at the area office. Details of the mother’s views can be found in paragraphs 70 - 72 of this report. 13. It was decided not to interview Child G directly in the course of this review. Given her age, and the length of time that had passed since the allegation of abuse and suicide attempt, it was agreed to rely on the impressions of the allocated social worker, who knows Child G and the family well, rather than for Child G to speak to someone they do not know about events that may be retraumatising or confusing for them. The Case 14. Child G lives at home with their mother, elder half-brother, younger half-sister, and younger half-brother, who was born after they made their disclosure. Child G’s stepfather lives with the family. Their birth father lives in another town with his partner, their child and her two children. 15. The family became known to services when Child G was still a baby. At the time of the first referral there was domestic abuse between Child G’s mother and her then partner (not Child G’s father). There were also concerns about mother’s ability to manage the already difficult behaviour of Child G’s older brother, who has since been diagnosed with autism, and about neglect. 16. Early Help became involved with the family because of the problems experienced by mother in managing the behaviour of the older half-brother and his aggression towards Child G. The family also had problems with debt and their overcrowded housing conditions. Mother’s recent difficult pregnancy had just ended in miscarriage, and she was affected by anxiety. The support worker concluded that, although there were difficulties, mother’s ability to manage the three children, her own mental health, and the overcrowded house, with minimal support from her partner, was just about ‘good enough’. The support worker was about to close the case when Child G made their allegations against stepfather. 17. Child G’s mother contacted their school to say that the previous day Child G had clearly described to her an episode of serious sexual assault against Child G by their stepfather. On the same day the stepfather presented himself at the local police station to ask for advice regarding Child G’s allegations. 18. The school submitted a referral to the Single Point of Access (SPOA) the same day. Child G was not in school on the day that mother shared information about Child G’s disclosure. On the following morning, the day they returned to school, Child G wrote a note to their class teacher saying ‘I am telling the truth’. Attached to the note was the teacher’s comment about what Child G had said to them: Child G LCSPR overview report – FINAL 02.11.21 4 (Child G) came up to me and said that they were scared that they would get into trouble when they told the truth. They were worried that Mum would be angry and wouldn’t come to the topic this afternoon. Child G feels sad because Mummy doesn’t believe them, and they are telling the truth. 19. Two days later Child G was spoken to at school by a police officer and duty social worker. They again named their stepfather, Daddy A, as the person who sexually assaulted them. The interviewing police officer contacted their sergeant who went to the family home and arrested the stepfather. He denied the allegations and was subsequently bailed on condition that he did not return to the family home. The arresting officer recorded that the mother was immediately reluctant to believe her child’s allegations. 20. The Achieving Best Evidence (ABE) interview took place four weeks after the initial disclosure. A Registered Intermediary (RI) was appointed three weeks prior to assess Child G’s communication needs and ensure that these were taken account of in the interview. 21. In the period between Child G disclosing the abuse and the ABE interview, the mother contacted the police to inform them that Child G had now told her that it was their birth-father and not their stepfather who had abused them. Child G repeated this change in the identity of the perpetrator in the ABE interview ‘basically I thought it was Daddy A (step-father) who did it, but when I woke up it was Daddy B (birth father)’. 22. An Initial Child Protection Conference (ICPC) regarding the children in the family was held on the same day as Child G’s ABE interview. As part of the protection plan specialist family services were commissioned to undertake a risk assessment concerning the stepfather and the birth-father and a Protective Parenting Intervention (PPI) with the mother. Only after that work was completed could the separate offer of therapeutic work by specialist sexual risk services be considered. 23. Because Child G was now naming their birth-father as the perpetrator rather than their step-father, the birth-father was also interviewed by the police. This interview did not take place until three months after the ABE interview and was on a Voluntary at Station (VAS) basis rather than as a result of an arrest as had been the case with step-father. 24. The step-father’s bail conditions were lifted a month following the ABE interview and no further action was taken although the investigation was not officially concluded for another four months. He returned to live in the family home prior to the completion of the investigation. On the advice of specialist sexual risk services, he was asked to leave again because their risk assessment work with him had not yet begun. He agreed to do this. Child G LCSPR overview report – FINAL 02.11.21 5 25. The specialist sexual risk-assessment concluded that step-father presented an increased risk of sexual abuse towards children at that time and recommended that he did not have unsupervised contact with any of the children in the family and that mother was not sufficiently protective to act as supervisor. Until mother was able to participate in protective parenting work, which she delayed because she was heavily pregnant and feeling overwhelmed with appointments, it was the specialist sexual risk service’s conclusion that it was too dangerous for step-father to return to the family home. Both he and mother disagreed with this conclusion, and he returned to live at the family home regardless but with a safety plan in place that required him never to be alone with the children. This safety plan was developed with the family by the allocated social worker but not agreed by the specialist sexual risk service. Aftermath of the allegations 26. Although step-father ostensibly complied with the requirement to live outside of the family from the time of his arrest until the conclusion of the specialist service risk assessment seven months later, mother still became pregnant with his child during that period. The pregnancy was difficult and fraught with anxiety because of her miscarriage the previous year. 27. The school reported that Child G’s behaviour was becoming increasingly disruptive and aggressive, and this downward spiral was also evident at home. Although the allocated social worker saw Child G regularly as part of the child protection plan, there was no structured emotional support pending the therapeutic work that the specialist sexual risk service was expected to undertake. Eventually, in the absence of work commencing with this specialist service, the school arranged for Child G to have help from Emotional Literacy Support Assistance (ELSA), an initiative that was aimed at supporting children who have emotional barriers to making progress at school. They had regular sessions with a member of staff who was trained in this approach. The school also contacted the Education Support Behaviour and Attendance Service for advice on managing Child G’s behaviour in the classroom. 28. As mother’s due date drew near and there continued to be concern about complications in her pregnancy, the family decided that Child G should go and stay with their aunt in another part of the county until after the baby was born. It was anticipated that they would be there for three months and was enrolled in the local school. In the event Child G only stayed six weeks, with visits home at weekends, because they wanted to return to their mother. During the time that they were living with their aunt, the specialist sexual risk service undertook one session with Child G. It was planned for the sessions to continue once things had settled down at home after the birth of the baby, but mother put these on hold because of the COVID-19 lockdown. It was also felt by the specialist sexual risk service that any subsequent work with Child G would have to be done online from home, where their step-father was still residing, and that this would have been inadvisable in terms of Child G’s safety. Child G LCSPR overview report – FINAL 02.11.21 6 29. There was a Review Child Protection Conference (RCPC) nine months after the Initial Child Protection Conference (ICPC) where, by unanimous decision, the statutory status of the family’s involvement with services was stepped down to child in need. The rationale for this was ‘mother’s openness and honesty throughout the child protection process’, the commencement of the therapeutic work, elder brother’s placement at a more appropriate school and Child G’s settled behaviour both at their new school and in their aunt’s household. 30. The family quickly self-isolated as the pandemic took hold in March 2020, wanting to take no risks with a newborn baby in the household. The family social worker’s last recorded ‘doorstep’ visit was mid-April. The social worker visited again in early summer to deliver a laptop to the family. 31. The school continued to check on the welfare of Child G and their family throughout the first lockdown via weekly phone calls to the parent and they were provided with vouchers for free school meals. The school notified CSC that Child G was not attending school and their name was included in the Vulnerable Children Risk Assessment Group. This was a system established by the local authority during the first lockdown to monitor the welfare of children in the county considered to be vulnerable and was reviewed weekly. Although Child G was no longer on a CP plan and, as a vulnerable child, they could have come to school, their mother decided to keep them at home. The school had no direct contact with Child G from the start of the COVID-19 lockdown until early July, apart from four days in April and again for three days in July. Child G did not engage with Google classrooms during this period, attend lessons or participate in ‘Show and Tell’ sessions at any time. 32. The worker from the specialist sexual risk service who had seen Child G for the initial session contacted mother in April 2020 to ask how Child G was and enquire about resuming their sessions. Mother advised that she was not concerned about Child G now as they were not showing any signs of distress or trauma. Whilst she was happy for the work to continue, she was not sure that it was currently required. The decision was made to pause the work and review the situation when Child G returned to school. 33. In May 2020 the case was closed to the locality with the understanding that the specialist sexual risk service could still offer therapeutic work if requested by the family. 34. In July 2020 the police and an ambulance were summoned when Child G was discovered in their bedroom having attempted to take their own life. There was concern that this was linked to the allegations they had originally made against their step-father concerning sexual abuse. Child G LCSPR overview report – FINAL 02.11.21 7 Analysis and Learning 35. There are five key themes arising from the events leading up to the apparent attempt by Child G to take their own life. Analysis of these themes has implications for reflections on practice and learning These themes include • Meaning of Child G’s behaviour to themself • Practice interface between specialist services and Children’s Social Care • The ABE interview process • The use of power and authority in relationship-based practice • The impact of Covid-19 on practice and outcomes The meaning of Child G’s behaviour 36. Much emphasis in recent years has rightly been placed on the importance of professionals listening to the ‘voice of the child’ in matters concerned with safeguarding. 37. Although the attempt by a seven-year-old to end their own life is extreme and rare it is important that unilateral assumptions are not made about what the behaviour meant to the child. 38. Much of the tenor of the rapid reviews and the IMRs appears to imply a linear relationship between the allegations of sexual abuse made by Child G and their actions some 16 months later in apparently attempting to kill themself. The impression seems to be that they deliberately tried to end their life out of despair that they were not listened to, not protected, and had spent much of the time following the disclosure at risk because they were living in the same house as the originally-named perpetrator, with a mother who was not able to safeguard them. 39. Sixteen months is a very long time in the life of a seven-year-old and there were many events subsequent to the abuse allegations that affected them. In the opinion of the staff at Child G’s school their main concerns during the time that their behaviour was so problematic, in the autumn of 2019, was not worry about having been sexually abused by and resuming contact with their step-father whom they had originally named as the perpetrator. Their view was that Child G was very much pre-occupied with their mother’s health and survival as the date for the birth of the baby drew closer. The head teacher at the school showed the author drawings made by Child G at the time, of their mother bleeding to death. 40. In the autumn of 2019, the specialist sexual risk service was coming under some pressure by the family social worker regarding commencing the therapeutic intervention with Child G. Child G LCSPR overview report – FINAL 02.11.21 8 The practitioner from the specialist service who was to undertake the work with Child G took advice from the manager of the Child Assessment and Treatment Team (CATT) and a child psychiatrist about starting the work with Child G whilst they were living with their mother and step-father. The advice was that it was not possible to offer this safely under these circumstances. What the specialist service practitioner was intending to do with Child G was a specific programme developed for young children who had been traumatised by experiences of sexual abuse. To open up those areas in therapy when they were still living with the perpetrator was thought to be potentially confusing and re-traumatising for Child G. Whilst these reservations are understandable, it assumes that the source of Child G’s distress was the events of March 2019. It was the view of Child G’s school, who knew them well, that this was not currently their main concern. 41 During the autumn of 2019, there appeared to be a feeling of paralysis by other agencies regarding giving Child G an opportunity to talk to someone in depth about what was troubling them because that work was due to be undertaken by the specialist sexual risk service. The specialist service seemed organised around the belief that the problem was still trauma induced by the sexual abuse and the assumed pressure put on Child G by the family to change the identity of the perpetrator and the fact that, despite their disclosure, nothing had changed for Child G and their step-father was still in the family home. By not having any exploratory discussion with Child G about what they were currently worried about, professionals may have imposed on Child G an interpretation of the most important issues in their world that was not consistent with Child G’s own reality. It may be that changing from a position of focus on the sexual abuse to a more holistic presentation of the family, the risk factors and the children’s presentation may have moved the situation on’. Learning Point- It is important to continue to communicate with children about their world. Professionals need to be reflective in the context of what may be a change in the child’s priorities rather than adhere exclusively to an adult assumption of what the child requires. 42 The mother said that on that day of the attempted suicide there had been a disagreement between herself and Child G concerning being told to fold their own clothes, when their younger sister had her clothes folded for her by mother. It was when the mother was momentarily out of the room after that conversation with Child G that the suicide attempt was made. There had been no previous indications that Child G was unusually depressed, upset, or unhappy. The threat to ‘kill myself’ was one that Child G would have heard frequently from their elder brother, but which he appeared not actually to have attempted. The police officer who attended the scene shortly after the event said that Child G told them that the reason for their actions was because ‘nobody loves me, I was feeling left out, and everyone had a dad but me’. Child G told the police officer that no one suggested the idea of harming themselves, ‘the idea was in my head’. They apologised to their mother and to the ambulance personnel and police officers who attended the scene saying ‘I am so sorry I tried Child G LCSPR overview report – FINAL 02.11.21 9 to kill myself’. But whether, at the age of seven, Child G really understood the finality of death and the concept of their life ending would require further exploration, preferably in a therapeutic setting. 43 The police officer asked them directly whether this was anything to do with what they had said about their step-father. Child G originally couldn’t recall the incident but eventually told the police officer that ‘it wasn’t daddy A it was daddy B’ and that nothing had happened since. They were profusely apologetic to everyone for ‘trying to kill myself’ but within about 20 minutes that mood of contrition appeared to have passed with Child G playing happily. 44 The craving that Child G seems to have for their mother’s attention should not be underestimated and their actions could have had tragic, but possibly unintended, consequences. Nevertheless, it is important that the meaning behind this behaviour is not reliant exclusively on an adult-oriented interpretation of events. Practice interface between Specialist Services and Children’s Social Care 45 One of the themes that emerged from the IMRs and the interviews with practitioners was tension in the relationship between the specialist sexual risk service and CSC concerning the management of risk once Child G had disclosed that they had experienced sexual abuse on two occasions. 46 There appeared to be general agreement that there are usually good relations between the specialist sexual risk service and the locality teams and that the expertise that the specialist service brings in their knowledge about the difficult dynamics in intra-familial child sexual abuse is highly regarded. It was to the specialist service that the interviewing social worker turned for support in trying to shift the mother’s denial about the truth of Child G’s allegations. The social worker welcomed the offer from one of the specialist service’s advanced practitioners to accompany them to the family home in an attempt to open her mind to the possibility that step-father could be a risk, but to no avail. 47 There is discussion above about the dissatisfaction expressed by some locality practitioners, by the school and also by Child G’s mother that the therapeutic work with Child G never happened in the way they expected it would; and by the time it was offered the moment had passed. 48 The fact that Child G named a different perpetrator at ABE interview was perceived as diluting the focus of the risk assessment and criminal investigation in having to take what Child G said seriously and put birth-father in the frame as well. There was concern that this rendered the assessment reports ‘ambiguous’ and ‘on the fence’, a description that the specialist service denies. The duty social worker who spoke to Child G at school expressed Child G LCSPR overview report – FINAL 02.11.21 10 their disappointment that they were not invited by the specialist service to discuss with them the social worker’s first-hand experience of Child G’s presentation when interviewed at school. 49 The specialist sexual risk service received a short notice invitation to the RCPC and was not able to attend. It was at this meeting that there was unanimous agreement to step down the case from child protection to child in need. The specialist service subsequently expressed reservations about the decision. In their view the risk to the children had not gone away with step-father still in the family and Child G still without a ‘safe person’ in the family to believe and support them. 50 It was clear from discussions with the front-line practitioners in this case that there was a difference in opinion between the specialist service and the social work team about the appropriateness of the specialist service commencing work with Child G while the original alleged perpetrator was in the family. 51 There is a danger that the frustration with the intractable situation concerning risk within the family was being mirrored in what also appeared to be an intractable situation in the perceptions held within the professional system as well, especially between the police, the specialist sexual risk service and CSC. The sense of ‘stuckness’ at not being able to move forward was frustrating and there was a danger that this frustration could be projected as criticism by each agency for the others. 52 Both the CSC and the specialist sexual risk service IMRs suggest that one way to manage this situation would have been to take this matter to the Care Planning Forum (CPF) for consideration and an airing of the issues. This could have been especially helpful at times in the life of the case when risk was high and the power to do something to reduce that risk was low. The specialist service IMR refers to occasions when such a meeting may have helped to bring people together rather than polarise them, thereby creating a forum for discussion and attempting a mutual understanding of each side’s perspective. The author understands from the specialist service Practice Manager for sexual risk that, currently, there is no expertise in the area of sexual risk represented in the CPF and they are not usually invited to their discussions. Allowing the specialist service a presence on the CPF when the case being considered involves intra-familial sexual abuse may be something to consider as a result of this review. 53 In the author’s experience it is very common for professionals to share a sense of anxiety about the safety of children in situations where there is a high level of concern about likely sexual abuse but very little by way of the firm evidence that is required to reach the threshold for intervention, either in civil or criminal proceedings. Child G LCSPR overview report – FINAL 02.11.21 11 54 The CSC IMR (3.8.9) ‘acknowledges that opportunities were missed to take a structured approach to planning at key points in the progress of the case: following the conclusion of the police investigation; following receipt of the specialist sexual service risk assessment; and when the stepfather was back in the home (in sole care of the children) because mother was in hospital’. 55 The CSC IMR goes on to suggest that ‘whilst professionals felt that the threshold was unlikely to have been met, a formal discussion and consideration of a Meeting Before Action (MBA) might have resulted in a clearer plan’. It was clear from discussion with practitioners across agencies that this would be usual practice and that the case management in Child G was not typical of how cases were usually conducted. Learning Point- More judicious use of Care Planning Forums should be considered when there is lack of clarity about what the options are in reducing risk within families and to form a plan with a clear way forward that can be owned by all the relevant agencies The ABE Interview 56 Following Child G’s allegation of abuse, Child G wrote a note to their teacher to say that they had been telling the truth even though they didn’t think their mother believed them. This is referred to as Note 1 in the discussion below regarding its significance to the subsequent investigation. 57 Child G was spoken to at school by a police officer and duty social worker, the day after the mother had shared the allegations with Child G’s school (Child G was not in school on that day). The social worker felt that Child G’s embarrassment and reluctance to tell them out loud what had happened added to their credibility. Child G agreed to write down the words rather than speak to them. The police officer established with Child G what they understood those words meant. Although they were not specific about when this took place, it was the impression of the duty social worker that the events were recent. This document, made by Child G during the conversation at school, is referred to as Note 2. 58 The mother appeared to disbelieve her child from the start; at first saying they were ‘confused’ and ‘couldn’t work it out’ and then accusing Child G of ‘lying and trying to break up the family’. Despite a visit the following week by the duty social worker and the specialist sexual risk service advanced practitioner to encourage her to consider the possibility that there may be some truth in what Child G had said, the mother maintained her point of view. 59 During the four-week period between the disclosure and ABE interview, the mother phoned the police to say that Child G had now changed their account of what happened and that it was their birth-father (Daddy B) and not their step-father (Daddy A) who had abused them. Child G LCSPR overview report – FINAL 02.11.21 12 This information was shared with the ABE interviewing team who saw Child G two weeks later. 60 The ABE interview took place almost a month after the interview at school. The reason for this delay was complications in the timing for the Registered Intermediary (RI) to see Child G in school to assess their communication needs because of the intervening two-week Easter school holidays. 61 It is usual police practice to provide the services of an RI in ABEs involving children as young as Child G, despite it sometimes involving a delay between allegations being made and the interview being conducted. The risk is that, in the interest of assisting the child’s communication needs, the delay may mean that the child’s memory for details is compromised, and the child may be open to other influences during that time. 62 Child G’s school broke up for the Easter holidays the day the RI was appointed. The RI arranged to see Child G in school for the communication assessment the day that school re-opened two weeks later. The ABE interview took place at the end of that week. Although there were other interview venues available for undertaking the communication assessment which may have reduced the delay, these would have involved a distance to travel and would have been strange to Child G. It was deemed important that proximity and familiarity were the priority in this instance. 63 The RI sent the author the notes of their assessment interview with Child G titled ‘Things to consider when asking (Child G) questions at ABE’. It was very detailed and practical and may have been helpful to those who spoke to Child G subsequently in a non-evidential capacity. 64 The police officer and social worker who interviewed Child G at school were not given Note 1 that Child G had written to their teacher about not being believed by their mother. It is not clear whether they were made aware of its existence at any point during their visit to the school that day. The note was still in the school files when the matter was re-investigated by the Complex Abuse Unit. Because of the mother’s reluctance to believe Child G in her subsequent conversations with professionals and the change in Child G’s account of the identity of the alleged perpetrator between what they said at school and what they said in the ABE, not having access to this note becomes especially significant. It is an unfortunate omission that note 1 was not produced, which the school was unable to account for. During the ABE interview it was only Note 2, which included what Child G wrote down at the time that they were spoken to in school, that was referred to. 65 The ABE interview was also affected by the fact that it was scheduled at the same time as the ICPC which meant that the mother could not attend both. In the event it was the maternal grandfather who accompanied Child G to the interview. Child G LCSPR overview report – FINAL 02.11.21 13 66 Because of mother’s previous phone call to the police, it should not have been a surprise to the interview team that Child G was now naming their birth-father and not their step-father as the perpetrator, but they had now heard this account directly from the child. However there appears to have been no attempt to convene a strategy discussion after the interview to discuss the criminal and welfare implications as a result of this development. 67 The social work interviewer said that their impression was that the matter would only be of interest to the local authority, not the police. 68 Not having a multi-agency post interview strategy meeting, with input from legal services, was a missed opportunity to formulate a more effective plan as to how services should go forward in view of this change of direction. 69 In the matter of the interview with Child G, it was determined by the police that what was said did not reach threshold for submission to the Crown Prosecution Service (CPS), therefore a detailed Record of Taped Interview (ROTI) was not required. Instead, the police interviewer wrote up brief notes of the interview on the police log so that other officers were aware of the salient points of the interview. It was this record that was shared with CSC but not until five months after the ABE interview took place. Learning Point- There should be more effective planning, assessment and recording at all stages of the ABE process. This should involve • deciding whether a strategy discussion would assist future planning for how both the criminal investigation and safeguarding concerns proceed, especially if information shared at interview takes those concerns in a different direction • the summary of the ABE interview report to be made and distributed to all relevant agencies as soon after the interview is conducted as possible Building more effective relationships with the family 70 The powerful presentation of the mother of Child G and the implications of this for professionals in trying to establish a relationship with her has been mentioned at several points throughout the process of this partnership review. The CSC IMR mentions the wide variation in how the mother was experienced by staff who were trying to engage her. She was variously described as ‘lacking in emotional warmth’ (especially toward Child G) and ‘difficult’, ‘aggressive’ and ‘demanding’ in her dealings with practitioners. Others considered that she did well to manage the many demands on her and that she was a vociferous presence in fighting for her children, especially in securing for her eldest son the appropriate services he needed as a child who had significant additional needs associated with his autism spectrum condition. Child G LCSPR overview report – FINAL 02.11.21 14 71 The duty social worker who interviewed Child G said that (the mother) ‘presented as cooperative if you agreed with her but would become oppositional if crossed’. The family social worker agreed that mother could be ‘fiery’ but also said that ‘I have never been denied entry to the house even if she is angry with me’. ‘There was never any disguised compliance’. 72 Child G attended a small village school. There was awareness by the school that at times mother fell out with other families and that this discord sometimes found its way into life at school as well. But the headteacher and deputy headteacher described her as a ‘strong mother’ who had a sense of Child G as a person in their own right, even though much of her energy often went to securing services for the eldest son. They did have concerns that mother sometimes ‘over-shared’ with Child G, particularly when it came to her anxieties about her pregnancy. They did not, however, consider her to be a neglectful mother. 73 Mother said she felt ‘very judged’ by agencies about what had happened to her child (the suicide attempt) and their implication that she was neglectful. 74 She told the author that she felt ‘let down by the specialist sexual risk service’ who she was told were ‘amazing, wonderful’. She said ‘if they can offer me so much why didn’t they?’ In addition to not working with Child G at the time when she was ‘spiralling out of control’, mother felt that the assessment and protective work that the specialist sexual risk service offered was one-way; her perception was that she and step-father were cooperative with what was being asked of them but received little in return from the specialist service. She said she was especially disturbed by the specialist service requiring her to ‘tell everyone who comes into the house that there had been allegations of sexual abuse against (step-father)’ as part of the safety plan to manage his return to the family home. She thought that the specialist service practitioner who did the PPI work with her and the risk assessment of step-father ‘got a lot of the information wrong’…’she wrote down what she thought and took no notice of what it was like for me’. 75 Child G’s mother did have more favourable things to say about other professionals in whom she had trust. When Child G first made their allegations against step-father she went straight to the school to tell them and ask for their advice. On the day of the attempted suicide mother phoned the family social worker to tell them what had happened. ‘If it hadn’t been for (the family social worker) where would the support have been for my family?’. 76 It is the author’s understanding that the mother did not share her intentions to send Child G to live with their aunt with the Local Authority although the children were on CP plans at the time. The school were surprised by the decision for Child G to move to the aunt and were not consulted on this decision or the planning around this. Had they been they could have Child G LCSPR overview report – FINAL 02.11.21 15 proactively supported Child G in this process and undertaken some transition work. The liaison with the receiving school was reported by the temporary school to have been undertaken by the social worker. There was an RCPC at the end of January which unanimously agreed that Child G and their siblings no longer needed CP plans. The fact that Child G was residing with their aunt at the time and was expected to remain there for three months, during which time the therapeutic work with Child G would take place, was a significant factor for the agencies in reaching this decision. The author of the CSC IMR acknowledged that, in hindsight, it would have been better practice to seek more information about the plan for Child G to live with their aunt, perhaps through a viability assessment, rather than basing their decision to step away on an apparently casual plan between the mother and her sister. 77 Another occasion when the family took matters into their own hands without adequate reference to the authorities was when Child G’s mother said that she wanted to have the risk assessment on step-father completed in time for him to come home for the birthday of their youngest child. The response to that by several staff members from both specialist services and CSC was to the effect that mother did not control the terms of the child protection arrangements, and it was not for her to say when he came home and perceived this as an example of the family being oppositional. From the family’s perspective they had waited a long time for the assessment to begin, they had cooperated by agreeing that step-father would leave the family again even after his bail conditions were lifted, they had attended sessions and gone along with safety measures they did not always agree with. The child’s birthday party was an important family event and Child G’s mother felt that this was not recognised by those who set the rules for how their family was to live. In the event, step-father was there for the birthday, but the incident appeared to contribute to the impression of professionals that mother was ‘difficult’ and left mother feeling disempowered ‘who am I, I am only the parent’. 78 The reality is that when state child protection services become involved the family inevitably loses some of their autonomy in making decisions about their family life. Those procedures are there to provide a structure for safeguarding children who are deemed to be at risk but adhering to them is sometimes experienced by the family as oppressive rather than ‘working in partnership’. 79 The significance of relationship-based practice has been identified as an essential component of good practice in child protection (Munro 2011)2. Relationships require give and take and compromise. The importance of taking the perspective of the client into account and really listening to what they have to say reduces the likelihood that the client 2 The Munro Review of Child Protection: final report, a child-centred system (2011) https://assets.publishing.service.gov.uk › uploads › file Child G LCSPR overview report – FINAL 02.11.21 16 will experience their dealings with professionals as oppressive and resort to ‘disguised compliance’. 80 The Child Safeguarding Practice Panel Review: Annual Report 2020 3 lists ‘Six Key Practice Themes that Make a Difference’. The second theme describes ‘Working with families where their engagement is reluctant and sporadic’ and makes the observation that one of the key learning points from safeguarding reviews in the past year includes recognition of ‘the importance of effective relationships and connections between practitioners and families in creating the motivation and opportunity for change’. Understanding by the practitioner of the client’s experiences is a significant component in creating such a relationship. 81 Although there are indicators that the mother was attempting to do the best she could under the difficult circumstances she found herself in there are also examples of emotional neglect by mother that had a negative impact on Child G. They may well have been in receipt of too much information from their mother regarding the difficulties in her pregnancy, rendering Child G very fearful and preoccupied about their mother’s safety. Their mother’s focus on securing services for their older half-brother because of his autism may have made Child G feel overlooked and unprotected during the many times he was aggressive towards them. If mother did question Child G’s reality regarding the identity of their abuser, it may have left Child G feeling confused and unsupported and alienated from their father and their relationship with the children in his household. Whatever her emotional state in the 16 months prior to the attempted suicide, on the day itself Child G told the police officer that they felt ‘unloved’ and that ‘everyone else had a daddy except me’. 82 It is notoriously difficult for practitioners to know how to work with families in which the children are affected by the emotional abuse/neglect of their carers. The quality of the relationship that can be established by professionals with the family can help to create conditions where such challenging work may have a better chance of being effective. Learning Point- To be aware of the importance of emotional intelligence and empathy in strengthening trauma informed practice with clients to improve working relationships and promote the safeguarding of children. The impact of Covid-19 on practice and outcomes 83 The onset of lockdown in mid-March 2020 in response to the developing COVID-19 pandemic occurred at a time for this family when the baby was just weeks old after a difficult pregnancy and complicated birth. The decision of Child G’s mother was to keep all the children home from school for the duration of the lockdown because of the vulnerability 3 https://www.gov.uk/government/publications/child-safeguarding-practice-review-panel-annual-report-2020 Child G LCSPR overview report – FINAL 02.11.21 17 of the baby. This meant there were four children, including a new-born baby, and two adults, one of whom was the originally named perpetrator of sexual abuse against Child G, in a small two-bedroom accommodation. 84 The step-father had completed his risk assessment which concluded that he should not be alone with the children. This requirement had not been complied with during the later stages of the mother’s pregnancy because of her admissions to hospital due to complications in the pregnancy. The mother was assessed as needing to increase her ability to protect the children, especially Child G, through the PPI programme that the specialist sexual risk service was planning to deliver. The terms of this were discussed with her just a few days after delivery and it was decided to put commencement of the work on hold for the moment because of all her commitments to the family. 85 Child G had one session with the specialist service worker who was going to do the therapeutic programme with them. This was while they were staying with their aunt two months earlier because it was thought to be unsafe to commence that work while they were living in the same household as the step-father who they had originally named as the perpetrator. 86 The children came off CP plans at the RCPC because of mother’s ‘open and honest’ relationship with professionals, Child G being more settled at school, elder brother’s placement in a more suitable school and the commencement of therapeutic work for Child G. They were stepped down to child in need status. 87 The combination of these factors meant that Child G and their family entered the social isolation of lockdown with a less than robust safety plan around the children and no possibility of regular, effective contact with anyone outside the family, either friends or family members or professionals. 88 The names of the children in the family were all included in the Vulnerable Children Risk Assessment Group and, as such, were reviewed weekly by CSC. The mother received a weekly phone call from the school to ascertain the welfare of the children who were also in receipt of free school meals. The school kept a notebook with the number and nature of their contacts with the families of all children that weren’t in school, but unfortunately those notebooks were not retained so no record of school’s contact remains. It is unclear how frequently the family social worker undertook doorstep visits. 89 Child G did return to school for a few days after the Easter holidays and for three days in July but did not stay because they said they wanted to wait until they could go to ‘proper school’. Although the family was given a laptop toward the end of the first lockdown, Child G did not take part in any online learning or activities during this time. Child G is a bright child who Child G LCSPR overview report – FINAL 02.11.21 18 usually enjoyed school, apart from the troubled time they had with their behaviour in class during the previous autumn. It is likely that they were quite academically under stimulated during this time and resumed school in September with a lot of learning to catch up on. 90 Although there was a degree of remote contact and monitoring, and some direct doorstep visiting by the family social worker, there was little direct involvement with the family by professionals during the first lockdown. 91 The worker from the specialist sexual risk service contacted mother in April to discuss resumption of therapeutic work with Child G. The mother said that Child G was more settled, and their behaviour had improved. Even though it might be useful at some point for Child G to have sessions, now was not the right time. Additionally, any direct work would have to take place online in cramped accommodation with the step-father being in the household at the time and using equipment and connectivity of indeterminate effectiveness. So, the opportunity for Child G to speak to someone in depth about how they were feeling was postponed again, in part because of the restrictions imposed by lockdown. Conclusions and Recommendations Several learning points were identified in the course of the Partnership Review process. Communicating with the child 92 There was considerable anxiety expressed by those working with Child G that Child G was not offered any focused direct work in the immediate aftermath of the allegations of sexual abuse. This was based on the reluctance by anyone to work with them in depth until the therapeutic work to be undertaken with them was completed. This work never happened as planned, leaving Child G in a distressed state, and displaying increasingly disruptive behaviour. 93 Because Child G received no therapeutic support it is not known whether their disturbed presentation was directly related to their experience of sexual abuse or to other events going on in the family at the time. Convening multi-agency meetings 94 There was concern among the agencies that it was difficult to create conditions of safety for Child G after they changed their account as to the identity of their abuser. There were a number of missed opportunities for practitioners to meet together to discuss their options in the wake of new developments in the life of the case. Child G LCSPR overview report – FINAL 02.11.21 19 95 The three points at which a multi-agency professionals meeting with input from legal services would have been helpful in making clearer plans and reducing tension between agencies by giving opportunities for open communication were • Immediately following the ABE interview when Child G named the perpetrator as their birth-father and not their step-father • Upon the lifting of step-father’s bail conditions, freeing him to return legally to the family and when the police officially decided to close the investigation and take no further action • When the specialist sexual risk assessment was completed, and recommended that step-father remain outside of the family home until the protective parenting work with mother was finished. The couple decided not to adhere to the recommendations but did agree to a safety plan that included step-father not being alone with the children in the house. This soon proved unsustainable when mother had a series of hospital appointments and overnight stays because of complications in her pregnancy Improving practice and quality when undertaking ABE interviews 96 The ABE interview with Child G was a crucial event in determining the direction of this case. There was a four-week interval between Child G being spoken to at school and the ABE interview. It is felt that living in the situation where mother openly did not believe step-father abused Child G for a number of weeks before the interview may have compelled or influenced them to change their account. The delay was mainly because of the need to work around the Easter school holiday which meant there was no opportunity for the Registered Intermediary to assess Child G’s communication needs prior to the ABE until school re-convened after the Easter break, nearly three weeks after the RI had been appointed. 97 During those four weeks mother also learned that the children in Child G’s father’s household were on CP plans. Not only should mother have been told this at an earlier stage because Child G occasionally stayed with their birth father for sleepovers with the other children in his household, but the timing was such that it may have been that learning this information when she did played a part in Child G changing the identity of the person they said had abused them. 98 The ABE interview is important in both safeguarding the child and in the criminal investigation and should be conducted with adequate thought and planning both before and after the interview. Not being able to hear from the police officer who spoke to Child G at school and conducted the ABE interview has made it difficult for the author to gain an accurate impression about the nature of the pre-session planning or the thinking behind not having a post-interview strategy meeting. Although the social work interviewer at the ABE was spoken to by the author, their role was specific to the execution of the interview itself Child G LCSPR overview report – FINAL 02.11.21 20 on the day, and their memory of it was understandably affected by the passage of time. As cited above, not having access to Note 1 about Child G telling the teacher they didn’t think their mother believed them became extremely relevant to both how the investigation unfolded and to the conduct of the risk assessment. 99 Neither was there any post-interview strategy meeting, ideally with advice from legal services, about how to take both the child protection process and the criminal investigation forward now that Child G had changed their account of what happened. Building more effective relationships with the family 100 Child G’s mother reported a very unsatisfactory experience in her contact with some of the agencies she met following her child’s disclosure of sexual abuse. She felt let down that the specialist sexual risk service did not deliver the help for Child G that they had promised. She believed that she had cooperated with them regarding the risk assessment recommendations but they did not appreciate how this affected her. 101 Her motivation to make arrangements in the best interests of Child G and of the family were interpreted by some professionals as a lack of cooperation or disguised compliance. It is the opinion of the author that some of the professionals who worked with mother did not adequately convey to her that they understood the impact on her of this interference in her life by the requirements of the child protection system. There is also evidence of mother feeling understood and supported by some of the professionals she encountered e.g., the allocated social worker and the teachers at school. Recommendation One For agencies to highlight the learning from this review regarding; • the importance of not making assumptions about the source of a child’s distress in the absence of speaking to the child directly. • clarity about a plan to work together concerning how the child’s needs are to be addressed during the time that they are awaiting a specialist assessment Recommendation Two Partnership to ensure that procedures for convening multi-agency meetings are followed, to allow for clearer planning and communication between agencies. All relevant agencies, including specialist services are invited to contribute. Recommendation Three Child G LCSPR overview report – FINAL 02.11.21 21 ABE interviews should be carefully planned and appropriately documented, in line with expected good practice and guidance. All documentation arising from ABE interviews should be shared appropriately and in a timely manner. There should always be consideration as to whether a further Strategy Meeting is required following the ABE interview. Gretchen Precey Independent Social Worker 2 November 2021 |
NC048222 | Death of a 23-month-old infant due to non-accidental injuries whilst in foster care in June 2013. Child T was a looked after child who was placed with foster carers in March 2013 as a result of injuries sustained whilst in his mother's care. In June 2013 Child T died following admission to hospital with non-accidental injuries. The foster mother pleaded guilty to manslaughter and was sentenced to a term of imprisonment. Key learning include: the role of fostering social workers includes considering the needs and wellbeing of the children in foster care from a safeguarding perspective; regular and consistent supervision of foster placements is crucial for safeguarding children; unrealistic expectations and views of foster carers due to lack of knowledge of child development must be challenged and addressed through training; information sharing between teams within a local authority is important. Recommendations include: ensure that partner agencies give sufficient scrutiny and importance to the safeguarding of looked after children; social workers should be made aware of the need to formally register any concerns about the care offered by foster carers as complaints to be investigated; the role of the Family Nurse Practitioner needs to be clarified where children are in foster care.
| Title: Serious case review: Child T LSCB: Warwickshire Safeguarding Children Board Author: Naomi Bentley-Lawson Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Warwickshire Safeguarding Children Board SERIOUS CASE REVIEW CHILD T Redacted report prepared by Naomi Bentley-Lawson based on the full SCR report. 1st March 2017 2 LIST OF CONTENTS Page Introduction and Background to the Review 3 The Review Process 3 Methodology 4 Narrative of Key Events 4 Analysis of Failures in the System Assessment of the Foster Carers Supervision of the Foster Home Information Sharing Placement Procedures Continuity of Professional involvement with T Consideration of Views of Family Members and Connected Others LAC/Child Protection process 14 14 15 19 23 26 30 36 Findings / Lessons Learned Finding 1 The Sharing of information Finding 2: Foster Carers as Perpetrators of Abuse Finding 3a: The Supervision and QA of Fostering Services, and monitoring of placements Finding 3b: Implementation and monitoring of care and placement plans Finding 4: Connected People 37 37 39 41 42 44 Conclusions 44 Recommendations 45 Appendix 1 Summary of Practice Learning Points 48 WSCB Response to the SCR 52 3 INTRODUCTION 1. Background to the Review 1.1 Following his admission to hospital as a result of injuries sustained whilst in his mother’s care, T had been placed with foster carers on 29 March 2013, and he became a looked after child. T tragically died on 30 June 2013. T was 23 months old at the time of his death and had been in the care of foster carers for three months when he was admitted to hospital as an emergency with non-accidental injuries. He was subject to an interim care order at the time of his death. 1.2 The foster mother pleaded guilty to the manslaughter of T and was sentenced in April 2016 to a term of imprisonment. 2. THE REVIEW PROCESS 2.1 The purpose of a Serious Case Review is to: Establish whether there are lessons to be learned from the case about the way individual agencies work individually and together to safeguard and promote the welfare of children; Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result; Improve individual agency working and inter-agency working and communications in order to better safeguard and promote the welfare of children1. 2.2 WSCB appointed two independent consultants to lead the SCR. Their report was accepted in full by the board. WSCB had legal advice that the SCR report could not be published in full, and so an indpendent lawyer was commissioned to prepare this redaction of the report for publication. 2.3 A Panel of Senior Managers from each of the agencies involved was appointed to support the process. The Scope of the Review 2.4 The period under review was from 12/12/2007 when the foster carers first expressed an interest in fostering children to 3/07/2013 when it first became 1 Working Together to Safeguard Children, 2015 4 known that T had died as a result of non-accidental injury. Relevant background information concerning the period of T’s short life, prior to his placement in foster care, was also included to inform the review and to put his death into context. 2.5 Family Composition at time of child’s death: T Mother Father: identity not confirmed, not included in this review Maternal Grandmother Foster Mother Foster Father Parallel Processes 2.6 An inquest into T’s death was opened and adjourned on 12 July 2013, and was discontinued following the conviction of the foster mother. 2.7 The criminal conviction of the foster mother has been set out in paragraph 1.2 3. METHODOLGY 3.1 The methodology used for this Serious Case Review has been a blended approach, incorporating: Independent Lead Reviewers, Chronologies and Individual Management Reports; a commitment to meetings with practitioners and their managers significantly involved with the case. These meetings proved particularly valuable in clarifying issues raised and informing the Serious Case Review process. 3.2 The LSCB in Bossetshire - where the foster carers resided - was invited to contribute to the Serious Case Review. 5 4. SUMMARY NARRATIVE: KEY EVENTS January 2009 Warwickshire County Council approved the couple as foster carers with the approval category of 1 child, 2 if siblings 5-10 years of either gender. Their first placement in October was uneventful, but the second placement of a 9-year old child in November proved difficult and the foster carers requested that he be removed. December 2009 Concerns were raised about the emotional welfare of a child in the couple’s care, raised by the psychologist and supported by the social worker. The local authority put further support into the placement. The placement irretrievably broke down a month later, and the foster carers had given notice to terminate the placement. January 2010 The first annual fostering review noted concerns about the breakdown of this placement, and also recorded that the foster father had been rude to professionals. No action was taken about these concerns, but the couple’s approval category was set at one child, two if siblings, aged 5-10 years, for short term or respite placements. June 2010 The foster carers approval category was amended to cover the age range of 0-12, to reflect the placing of a younger child in January 2010. July – September 2010 Two brief mother and baby placements were made with the foster carers which were outside of the foster carers approval category and extensions were not sought from the Fostering Panel, thus breaching regulations. July 2010 Two children, under 5 were placed with the foster carers. The children’s social worker had a number of concerns about the placement, especially the self-esteem and emotional well-being of the children. These concerns were discussed with the foster carers, particularly the male foster carer, who denied that there was a problem. The concerns raised about the care of the children were not escalated by the social worker, and no ‘disruption of placement’ meeting was convened as in fact the placement was not deemed to have disrupted but to have ended in an unplanned way at the wish of the social worker for the children. January 2011 Two children under 4 were placed for a weekend in the placement. Their mother made a written complaint concerning inappropriate remarks made by the male foster carer about the older child. The complaint was passed to the supervising fostering social worker who went on long term sick leave in November. A fostering social worker to supervise the placement was not appointed until August 2011. Cover arrangements via the fostering duty desk 6 were available. There is no information available as to how/whether this complaint was dealt with. Second annual foster carers review took place. The approval status of the placement changed to one child, two if siblings, 5-10 years, plus one respite child 0-2 years. It was noted that the foster mother had given up her employment to become a full time foster carer and was more relaxed. December 2011 The foster carers moved house to Bossetshire, but remained foster carers for Warwickshire County Council. March 2012 Foster carers annual review, which was presented to the Fostering Panel. Their approval status was changed to one child (two if siblings) aged 0-18. June – September 2012 Complaints raised by children in placement about rough handling by the carers, and a professional raised concerns about the way the children in placement were spoken about by the carers. The family were reported to be experiencing financial difficulty. The Practice Leader and the Fostering Social Worker visited to discuss the complaint with the foster carers. The foster father apologised but denied the alleged language used. November 2012 Complaint by the mother of a child placed with the foster carers that the foster mother had allegedly slapped one of her children. The child subsequently said this had not happened. A Strategy Meeting was convened by Warwickshire children’s social care who were unable to substantiate the allegation and no further action was taken. In late November, the foster mother went on holiday for three weeks, leaving the foster father to care for 4 children under six. Some help was offered by the fostering team to care for the children. No concerns were raised by either the fostering social workers about the appropriateness of this arrangement. November 2012 T was 15 months old at this time, and was taken to Hospital 1, A&E by Mother having sustained a head injury. The injury was considered to be consistent with the explanation given by his mother, but A&E staff were concerned about T’s neglected presentation and a referral was made to the Emergency Duty Team. February 2013 The Operations Manager visited the placement to address the complaints the foster carers had about the lack of fostering social work support they had received. The Manager agreed to take up their concerns with the team, but the foster carers subsequently gave notice to remove two children from the placement. The foster mother was particularly unhappy about the contact arrangements for these children. February 2013 It was noted in supervision between the fostering social 7 worker and her manager that the foster carers “should not take children as young as this again”. However, their approval status remained unchanged and no urgent review was undertaken as to the suitability of the placement for young children. The foster carers annual review took place at the end of the month. Concerns and allegations about recent placements were shared with the Fostering Panel, no further action was taken and their approval status remained at one child of either gender, two if siblings aged 0-18. March 2013 Mother took T to Hospital 1, A&E Department, with Mother’s current partner. On arrival at A&E T, who was 20 months old, was found to have a number of injuries, thought to be non-accidental. During T’s stay in hospital he was observed by the staff to be a lively child, running around the ward, happy and enjoying himself. The same liveliness was witnessed by the social work staff when he came to the Children’s Social Care offices before being collected by the foster mother. An ICO was granted by the Court, and T left hospital and was placed with the foster carers. He was five months younger than their youngest child in placement. The foster mother collected T from the Children’s Social Care office. No social worker accompanied T to the placement. The placement plan was drafted by the duty social worker. April 2013 T was registered with the foster family’s GP, but was never taken to the surgery during his three month placement. During mother’s first contact session with T, T was observed to be pleased to see his mother, played with a balloon and ate some chocolate. Mother was to have 3 contact sessions a week for 1.5 hours at a contact centre. A Looked After Children (LAC) statutory visit took place on the same date. The foster carers raised concerns with the social worker that T was unsteady on his feet and that he ‘seems to struggle to chew on one side of his face’. They were also concerned that he could not use a beaker and was still using a bottle; that he was a ‘fussy eater’. Overall, the social worker concluded that T was settled in the foster home. 4 April 2013 Cafcass appointed a Children’s Guardian for T. Family Nurse (FN) visited T at the foster placement within 10 days of the placement. This was the first time she had met T. FN recorded that T’s weight and height were on the 91st centile and that he ‘presented as quiet, withdrawn and 8 seemed lethargic in his movements.’ The foster mother reiterated that T was still using a bottle, was an unsettled sleeper and was unsteady on his feet. FN arranged to visit in 3-4 weeks’ time. The next day the foster father contacted the Fostering Social Worker 1(FSW 1) seeking advice as to whether he could replace T’s bottle with a cup. FSW 1 informed him that the foster carers needed to be supportive of T and wait for a suitable time to replace his bottle. In mid-April, an Initial Child Protection Conference (ICPC) was convened. The first Looked After Children (LAC) Review was held in conjunction with the ICPC, in accordance with the ‘dual status’ policy. Mother and her solicitor, as well as Maternal Grandmother, were in attendance at both meetings. The foster mother attended. FSW 1 was omitted from the invitation list. The major consideration of the ICPC and the LAC Review was the Police investigation concerning the injuries to T and the parenting assessment of Mother. Maternal Grandmother confirmed that she wished to be assessed as a carer for T. She later attended contact sessions with Mother. The foster mother stated that T had settled in well to the placement, he was now using a drinking cup. He was prone to tantrums, for which he was placed on the ‘time out step’. 22 April 2013 The foster carers had a supervision session with FSW 1. T’s injuries were discussed and the foster carers described how T could not chew his food properly, had a limited vocabulary, that he ‘whines and whinges a lot and seems to constantly seek food.’ They also stated that ‘he falls a lot and has poor balance’ and that……‘he possibly has hearing problems.’ 25 April 2013 The couple with whom Mother had previously lived contacted Children’s Social Care to state that they wish to be considered as carers for T and wished to be part of the care proceedings. They were advised to seek legal advice, but when Mother indicated that she did not want them involved in T’s life, their interest was not pursued by the local authority. 30 April 2013 FN made a second visit to T. She noted that he was reluctant to explore and appeared to be ‘passive, still, very wary and hesitant.’ His Ages and Stages Questionnaire score was below the cut-off point. FN agreed to discuss 9 with Mother the need for a referral to the audiology clinic. The foster carers were advised to make a list of their concerns to be discussed with the Community Paediatrician at T’s LAC Health Assessment. Later the same day FN visited Mother and Maternal Grandmother. Mother agreed to a referral to the audiology clinic and for Speech and Language Therapy. Both Mother and Maternal Grandmother told the Family Nurse that T was an active child before his admission to hospital, climbing on and off furniture. A second LAC visit took place. The foster carers told FSW 1 that they ‘find it difficult to get a response from T’. There was no record of liaison between the FSW 1 and the Children’s Team Social Worker as to T’s progress or whether the placement was meeting his needs. May 2013 6 May T’s Initial LAC Health Assessment took place. Both foster carers attended, but Mother and the Children’s Team Social Worker were not present. The foster carers informed the LAC Community Paediatrician that T had difficulty chewing food and that he choked easily. They reported he was always hungry, had poor eye coordination and difficulty in interacting with other children. They also said his speech and vocabulary were delayed and that he fell over easily and could not run. Community Paediatrician noted that T listened to the male carer more and that he ‘was very watchful.’ T’s height and weight were not taken as part of the assessment. The Community Paediatrician concluded that T might benefit from extra help and made a referral to physiotherapy and portage. 20 May T’s contact with Mother was cancelled after the foster carer contacted the Children’s Social Worker to say that T was unwell, possibly with chicken pox. The next day T attended an audiology appointment with the foster carer. 24 May Mother’s contact with T was cancelled due to the sessional worker responsible for supervising the contact being unwell. 28 May A statutory LAC visit took place. T was described as placid. A referral had been made to Speech and Language Therapy. 31 May The foster carers asked FSW1 if they could have another child placed with them. The request was refused and the FSW1 noted that the foster carers motivation for an additional child was financial. FN2 observed a contact session, where she noted that T’s 10 face ‘lit up’ when he saw Mother. The Children’s Guardian was also present at the session. The FN2 discussed T’s placement with her supervisor and noted he ‘is not thriving in foster care and is losing weight.’ June 2013 11 June The foster carers cancelled the contact with Mother, as they said that T was ill and thought to have chicken pox. At a Directions Hearing the Judge ordered the local authority to use ‘its best endeavours to facilitate additional contact between T and Mother’. Mother expressed her concerns to her solicitor about T’s presentation and said that ‘he is not the boy he was’. 12 June The contact session was cancelled by the foster mother as she said T possibly had chicken pox. This was the third session to be cancelled because of T having suspected chicken pox. T had not seen the GP throughout this period of illness, which had lasted almost a month. 18 June The Court was informed that contact was not going ahead because of T’s suspected chicken pox. Mother agreed for contact to be resumed once he was better.19 June A Family and Professionals meeting took place. Neither Mother nor the foster carers were present and it cannot be ascertained from the record whether they were invited. It was noted that the last four contact sessions had been cancelled. Mother’s solicitor raised concerns with the legal department about T’s presentation and that he was a ‘much quieter’ child since being with the foster carers. This information was shared with Children’s Social Care. 21 June (a Friday) FN2 visited T at the foster home. The foster mother said she thought he had lost weight. T was weighed and was noted to have lost 2kg since being in the placement. The foster mother was told by FN2 to increase T’s portion size at meal times and to take him to the GP if he is unwell. During this visit the FN2 completed an Ages and Stages assessment, and according to FN2 he performed all the tests adequately while sitting on her lap. On returning to her office the FN2 attempted to contact the Community Paediatrician and the Children’s Team SW1, both of whom were unavailable until Tuesday, 25 June. 25 June A contact session between T and Mother took place. 26 June The foster mother contacted FN2 to explain that T’s food intake had increased but that morning he vomited and appeared unwell. FN2 told the foster mother to take T 11 to the GP and agreed to telephone later. The Family Nurse tried to contact the Children’s Team SW1 but she was out of the office. The foster mother did make contact with the Children’s Team SW1 and informed her of T’s weight loss. She also contacted the Fostering Duty Social Worker to request that the contact session was cancelled, as T had been ill and was sleepy. On returning home, the foster father found T unresponsive and called the GP surgery. He was told to call an ambulance. T was taken by emergency ambulance to hospital in a state of unconsciousness. 26 – 30 June 2013 Wednesday 26 June 14.30 T was admitted to Hospital 2. He was in a critical condition and was unresponsive. The history given by the foster carer was that he was seriously abused three months previously and was now in foster care. He had vomited earlier during the day and an hour later was found unresponsive. On initial presentation it was thought that there might be a medical cause for T’s presentation. Consideration was also given to the possibility that T may have sustained a previous head injury, which could be related to his current condition. The most urgent need was to stabilise T and CT scans were required. On admission child protection concerns were not considered. A CT scan showed T had suffered a bleed to his brain, which was described as ‘relatively minor’. A further CT scan was conducted overnight, which revealed that T’s condition was deteriorating. Warwickshire Children’s Social Care Team were aware of T’s admission. Warwickshire Fostering Service were also informed. This was on the basis that T was a Looked After Child. At this time, no consideration was given to NAI. Mother and Maternal Grandmother were allowed to visit under the supervision of the foster carers. The foster carers were allowed to visit unsupervised and to stay overnight with T. Thursday 27 June Warwickshire Police only became aware of T’s admission to hospital in the afternoon of the 27th when Mother contacted them to alter her date for signing on for bail, due to T being in hospital. T had retinal haemorrhaging in both eyes and further medical opinion indicates that this was probably the result of NAI. The Consultant Paediatrician’s opinion that the 12 injury was different to T’s previous hospital admission at Christmas, and that the injury was highly likely non-accidental in nature, the possible cause being shaking of the child. T was seriously ill and his prognosis was poor. That evening, DS1 Bossetshire Police telephoned Hospital 2, Paediatric Intensive Care Unit (PICU) concerning injuries to another child. The doctor who answered the call assumed she was calling about T and informed her that T was on the unit, that he was a looked after child with an acute brain injury and was ventilated. On discovering that DS1 knew nothing of the circumstances of T’s admission the doctor refused to disclose further details. On receipt of this information DS1 telephoned Emergency Duty Team (EDT) in Bossetshire County Council and was informed that they had no knowledge of T. The EDT Social Worker contacted Warwickshire EDT and was informed that T was a Warwickshire looked after child, that Warwickshire Children’s Social Care was aware of his admission and were dealing with the matter. The EDT Social Worker concluded that T was the responsibility of Warwickshire and took no further action. No consideration was given to undertaking any further inquiries by EDT, even though T was a child living in their area, with a query NAI. DS1 then made contact with a staff nurse at Hospital 2 and was told that a ‘Form A Safeguarding Form’ had been sent to Warwickshire Children’s Social Care. DS1 contacted Warwickshire EDT and was told that ‘this was nothing to concern herself with as Warwickshire Children’s Services managers; EDT managers and Nuneaton Police were dealing with it.’ The review has been informed that PICU staff contacted the on-call safeguarding nurse to inform her of T’s condition. It was her responsibility to contact Children’s Social Care, who would then inform the Police. This was the protocol for informing Police of suspected NAI. Having contacted DI 1, CAIU Duty DI, DS1 and DI 1 visited Hospital 2, PICU to seek further information about T’s injuries. They noticed that the foster father was sitting by T’s bedside, but did not make contact with him. Due to a number of emergencies on the unit, the officers were unable to ascertain much additional information about T. DS1 later succeeded in making contact with the 13 Safeguarding Nurse on duty, who informed her that the hospital Safeguarding Team had received a ‘Safeguarding Form A’. DS1 was told that when T arrived at the hospital he showed signs of lacking oxygen, swelling and unequal pupils. He had retinal hemorrhaging and was due for eye tests the following day. Expert medical opinion had confirmed that the likely cause was NAI, possibly by way of shaking. Ophthalmic review. The children’s intensive care registrar rang the on-call hospital safeguarding nurse to explain that following the ophthalmology review a potential diagnosis of NAI was suggested. The nurse said she would inform Children’s Social Care and Police. The registrar advised that the Police were aware because information had already been shared, due to the confusion concerning the two safeguarding cases on PICU. Warwickshire EDT telephoned DS1 to update her on the situation. A Social Worker from the Bossetshire County Council EDT spoke with the on-call Safeguarding Nurse at Hospital 2. The EDT Social Worker explained that “she is happy to do a joint visit to the home with the police that night, but because the child is under Warwickshire Social Care, she can only act at their request” 23.23 Telephone call from Safeguarding Nurse, Hospital 2, to Warwickshire EDT to inform them that the outcome of T’s ophthalmic review indicated that his injuries were the result of NAI. The EDT Social Worker informed her that Children’s Social Care were aware of the circumstances of T’s admission, and there was a social worker allocated to the case. The situation should therefore be left until the next morning. The Safeguarding Nurse expressed concern that there were other children in the foster home, however the EDT Social Worker said he was not aware of this and would liaise with Police. 23.55 A nurse from PICU, Hospital 2, contacted the on-call Safeguarding Nurse to inform her that the foster mother was at home with other children. The Safeguarding Nurse rang Warwickshire EDT and left a message, but there was no call back. Friday 28 June DS1 made a number of enquiries with Hospital 2 about T’s condition, Warwickshire Children’s Social Care and Warwickshire Police. A safeguarding strategy meeting 14 was convened at the hospital. This involved Warwickshire and the Bossetshire Social Care, Warwickshire and Bossetshire Police, Hospital 2 Safeguarding Team and doctors from the PICU. A representative from Bossetshire Police major crime team also attended the meeting with CAIU officers. Warwickshire decided to undertake their own Section 47 investigation in respect of T. Doctors attending the safeguarding meeting were of the view that T’s injury was of a non-accidental nature, but would not commit fully to this conclusion. Police requested that they be kept informed by Hospital 2 as to T’s condition over the weekend and in particular if he died. It was agreed that the foster carers would not be allowed unsupervised contact with T. Following the meeting, Police Officers from Bossetshire CAIU visited the foster home and to take an initial account from the foster carers of events leading to T’s emergency admission to hospital. Sunday 30 June Police received no contact from Hospital 2 as to T’s condition. An officer from the CAIU finally spoke to a PICU doctor, who was reluctant to divulge information. It eventually transpired that T’s condition had deteriorated and that he was ‘brain dead’. The doctor explained that a meeting was taking place with T’s mother and Warwickshire EDT to obtain permission for organ donation. The Officer expressed concern at such action, and explained that if T died, his death could potentially be a murder investigation. The doctor agreed to speak to the Coroner’s office, who stated that organ donation was not appropriate in this case. T was declared dead and medical intervention was withdrawn. Following T’s death, the foster mother pleaded guilty to manslaughter and another offence, and has been sentenced to a term of imprisonment. ANALYSIS OF THE FAILURES IN THE SYSTEM 5. ASSESSMENT OF THE CARERS 5.1 The foster carers were approved by Warwickshire County Council Fostering Panel in January 2009 with the category of one child, two if siblings, aged 5-10 of either gender. During their fostering career they had a total of 23 15 placements, 11 very short term i.e. under 3 weeks, and 12 ranged from 1-7 months duration. 5.2 The Fostering Regulations and National Minimum Standards 2002 were in use during the time relevant to this Review, and were generally adhered to, with the exception of the period when the fostering social worker was on sick leave for a period of ten months. 5.3 The assessment of the foster carers met the key requirements of the Fostering Regulations 2002. The references raised no issues. The only negative comment at this point was from a family friend who felt the foster father might not be as committed to fostering as the foster mother, and that they had not been together as a couple for very long. 5.4 The analysis of the application did not uncover any breaches in the regulations of Warwickshire’s Fostering Service. There is a view from this analysis and from an independent review of the fostering service conducted after the local case review following T’s death, that there were no contraindications emerging for their approval as foster carers. However, it is significant to note that the fostering assessment did not include that the foster mother had experienced postnatal depression and in 2004 had attempted suicide following the breakdown of her marriage. Whilst it is not uncommon for prospective foster carers to have experienced significant emotional difficulties in their past, it is expected that these issues are raised by the prospective carers and fully explored with the fostering social worker in order to determine whether the issues had been resolved, and the carers would be able to manage the challenges of fostering. In this case such disclosure of relevant past information did not happen. 5.5 The lack of honesty and transparency on the part of the foster mother raises serious questions for this review, which continued to reverberate once the couple were approved as foster carers. Practice Learning Points - Assessment 1. There was limited exploration of some aspects of the foster carers’ lives and the effect these may have on their relationship. 6. SUPERVISION OF THE FOSTER HOME Allocated Supervising Social Worker 6.1 Within the Fostering Regulations 2002 there was an expectation that once foster carers were approved they would have their own allocated social worker, and they would be visited by their supervising social worker at regular intervals. For Warwickshire County Council this was set at a minimum of four 16 monthly. In addition to this, unannounced home visits needed to be carried out at least at annual intervals. The purpose of the supervising social worker’s visits was set out as having “a clear purpose and provides the opportunity to supervise the foster carers’ work”. The visits to the couple met requirements, apart from ten months when there was no allocated worker. During this period there is only evidence of a duty service response to the foster carers, and possibly one visit from a manager to carry out the annual review. This meant in practice that either the foster carers were responsible for ‘self-reporting’ incidents and/or concerns, or the children’s social worker ensured that any issues relating to the care provided were escalated appropriately2. This was a clear breach of regulations and did not support continuity of understanding and monitoring of this household. 6.2 Although there had been an absence of an allocated fostering social worker, by the time T was placed, one had been allocated. The review has been informed that one unannounced visit took place in July 2011, but this would have been insufficient to gain an insight as to how the couple were functioning as foster carers. 6.3 Additional information has been provided to the review from direct interviews with Fostering Managers concerning management arrangements for the service at that time. The service was then managed through the locality Social Work Teams. This meant it was difficult to provide cover for absent social workers. The service has since been brought together. This allows for economies of scale and practice has changed to ensure that where a fostering social worker is absent for longer than three months, another worker is allocated to the case. There are also now named Social Care Workers in post, who are not qualified Social Workers, but who maintain contact with carers. Reviews of the Foster Home 6.4 The Regulations also stipulated that annual reviews of a foster home should take place, and more frequently if any issues were raised. It is Warwickshire County Council policy for these reviews to be taken to the Fostering Panel, which is good practice and exceeds the standards. It would be expected that any comments, concerns or complaints raised during the period since the last review were considered, and that there was a full discussion of any training needs or requirements for formal change of status which might arise out of this. The 2002 Regulations stipulate that the fostering service provider when reviewing a foster home should “make such enquiries and obtain such information as it considers necessary in order to review whether the person continues to be suitable to act as a foster parent”. It does appear that the annual reviews took place on time, but there is little evidence of concerns being considered in a cohesive way, thus there was a lack of opportunity to put together the sequence of events and concerns, which with hindsight, can 2 During the period from November 2010 – August 2011 when there was no supervising fostering social worker, no incidents were reported. 17 be seen to be accumulating. Whilst poor performance by the foster carers could not perhaps have been predicted from the assessment, their actual performance was questionable from very early in their placement history. 6.5 Reviews were held on time, (save for one) and recorded, but there was an absence of detailed comment from the social worker as a result of sick leave and the failure to allocate a new worker. Given the limited contact the Fostering Team had with the foster carers during this period it is surprising that there was seemingly no challenge from the Panel as to the accuracy of the information in the review. Information about the concerns which had arisen about the care offered to some children in the placement was not shared with the Panel, as it was not included in the annual reviews. The lack of robustness in the annual reviews was a lost opportunity to begin to collate concerns and alert practitioners. It is however, important to note that the couple were considered to be experienced foster carers. Support that was given, was seemingly on the basis of supporting them as foster carers, rather than consideration being given to the safeguarding needs of children in their care. Absence of fostering social worker 6.6 The independent review of the fostering service in December 2013, assessed the quality of case recording of the Fostering and the Children’s Social Care services. This Review was commissioned by Warwickshire County Council. The conclusion reached was that the recording was broadly within guidelines, in that it was timely and detailed. However, there was a lack of analysis and on several occasions there were discrepancies in the detail. Overall, it can be said that there was a distinct lack of clarity about how concerns raised about the foster carers were followed up. 6.7 The same assessment can be made of the management oversight of the fostering social work practice in this case. There is evidence of managers’ comments and some supervision but the analysis is lacking, and there are few indications of management direction following concerns, apart from the joint visits on a couple of occasions to the foster carers. Training undertaken by foster carers 6.8 There is an expectation in the Regulations that foster carers are offered and will take up training, including additional input if there have been any issues raised. There is evidence of basic training being undertaken by the couple, particularly the initial training sessions for foster carers, and Skill level 1 in August 2008, and later Skill level 2. By September 2010 they had completed the standard Children With Disabilities Care course required at that time. However, there is little record of training after this, only four courses between the two carers, which included the foster father attending a ‘Men in Fostering’ course and an attachment course. There is, however, no indication that given the concerns which had been raised about the lack of understanding, particularly on the part of the foster father, concerning child development and the trauma often experienced by children looked after, of the foster carers 18 requesting, being provided with or attending training in these crucial areas. This is illustrated by the lack of empathy or understanding of T’s needs shown by the foster carers when he was first placed with them. T had suffered non-accidental injuries whilst in his mother’s care, including an injury to his mouth. Within days of T’s placement, the foster father was informing the social worker that T had problems chewing and could not chew out of one side of his mouth (seemingly not equating this difficulty with the injury T had suffered). At the same time the foster father requested that T be trained to use a cup and that his bottle be removed. This was in the context of a 20-month old child who had experienced not only the trauma of physical injury, but who had also spent several days in hospital and had then been placed into a strange environment with people whom he had not previously met. 6.9 The expectations of the foster father that a child who had been as traumatised as T could adapt to behaving in the same way as another child of that age, with whom T was on occasions compared, was not only unrealistic but also showed a complete lack of understanding of the needs of a vulnerable child. It is evident that there was a significant gap in both the foster carers knowledge of the needs of the children they cared for, which should have been recognised by the supervising social workers. Consideration should have been given to put in place increased supervision and for their attendance at additional training. 6.10 It is significant to note additional changes which have taken place in the Fostering Service since T’s death, which include: managers signing off all referrals to fostering; the Fostering Operations manager approving all exemptions to foster carers approval in a timely manner, i.e. where carers exceed the number of children for whom they have been approved; All extensions to approval categories now go to the Fostering Panel for decision, i.e. mother and baby placements and age range changes. Practice Learning Points – Supervision of the Foster Home 1. Whilst there was recording of the fostering assessment, annual reviews and contact with the foster carers, there was a lack of critical appraisal of their skills, and gaps in supervision at key points, by the fostering social worker. It is important to recognise that the role of the fostering social worker is to take into account not only the needs of the foster carers, but most importantly the needs and wellbeing of the child in the placement. 2. The need for regular and consistent supervision of foster placements is crucial for the safeguarding of children, especially nonverbal/pre-school children. In this case the foster carers were without the oversight and support of a Fostering Social Worker for ten months. The onus was on 19 the foster carers to bring any issues to the attention of the Fostering Duty Social Worker or for the Children’s Team Social Worker/s to report any concerns about the care of the children in placement. This was a clear breach of regulations and did not support continuity of understanding and monitoring of this household. 3. There was seemingly no challenge from the Fostering Panel as to the accuracy of the information presented, given the limited contact the Fostering Team had with the foster carers during this period. The overall lack of robustness in the annual reviews was thus a lost opportunity to begin to collect concerns and alert practitioners. Both social workers and the Fostering Panel need to consider and question whether information is missing or unavailable, when reports are prepared and when they are presented. 4. There was a lack of recognition by fostering social workers of the gaps in the knowledge and understanding of child development and attachment theory on the part of the foster carers. This was evident in the unrealistic expectations the foster father clearly expressed about T. The need to robustly challenge such views and to ensure that suitable training is made available to and taken up by foster carers is an important finding of this review. 5. The need to share information between teams within a local authority cannot be overemphasised. The sharing of important information did not happen in this case. There is now in place the means for such information to be readily accessed electronically by all social care practitioners working with looked after children. It is anticipated that the findings of this review will enhance and strengthen the use of this facility. 7. INFORMATION SHARING 7.1 The table of Key Events sets out a number of issues with the performance of the foster carers, which were not appropriately investigated and recorded, which in turn meant that the information was not shared. 7.2 The second Foster Carers Review in January 2011 changed the status of placement to one child, two if siblings, 0-12 years plus one child 0-2 years, short term or respite. This seems to be an acknowledgement that the foster carers were less effective with two children in placement, but there is little evidence that this was complied with in further placements. 7.3 The third annual Fostering Review took place in March 2012. At this point their approval was changed to one placement, two if siblings of either gender, aged 0 to 18, which was in line with the new fostering regulations introduced in 2011. In the case of these foster carers it seems to have 20 been done without adequate reflection on how they managed younger children or what they could offer to older children. There is little evidence of any analysis of the couple’s abilities or skills. 7.4 In June 2012, a 10-year old girl was placed with the foster carers on an eight day respite basis. She complained that the foster carers had roughly handled her and another child in placement. Information contained in Warwickshire records states that the incident was discussed by the Social Worker in Warwickshire with the Allegations Manager (LADO) for Bossetshire, but from information available it seems that no investigation was initiated by either the Bossetshire or the Warwickshire LADO. A decision was reached between Fostering and Children’s Social Care in Warwickshire that the issue should be regarded as one which could be dealt with by the foster carers receiving training. However, no evidence was seen by the Review as to whether this training took place. There is no information available as to whether the allegations were fully investigated, as there was no Strategy Meeting. 7.5 The importance of detailed and timely recording of concerns related to the care of children looked after by foster carers cannot be underestimated. If the issues raised in the career of the foster carers had been appropriately investigated and recorded, it may have possibly made a difference to the future placement of children with these foster carers, including T. 7.6 This Serious Case Review has highlighted the complexities as to which Local Authority Designated Officer, (LADO) undertakes an investigation into allegations against foster carers who are employed by one authority, but reside in another3. It is apparent that the need for LADOs involved in such cases to communicate with each other is crucial, if allegations concerning the care of children are to be appropriately investigated. It is understood that since the tragic death of T, the regional LADO group which includes Bossetshire has discussed cross boundary working practices and have agreed a working protocol of how such cases are dealt with. 7.7 It is recorded that the foster carers had serious financial difficulties, however, these were never analysed by any fostering social worker. Such financial constraints need to be seen as instrumental in the foster carers motivation to have additional children placed with them. 7.8 In August 2012 a professional raised concerns about how the foster carers spoke about a young foster child in their care, in a derogatory manner. 3 Position of Trust procedures are normally overseen by the LADO covering the local authority area in which the adult works. With foster carers there is ambiguity about whether the work address is their home, or if it is the office address of the agency/local authority by whom they are employed. The Serious Case Review has been informed by the Bossetshire LADO that it is their practice to investigate allegations against foster carers from independent agencies if they are resident in their area. In the Bossetshire Region, allegations against local authority foster carers would be investigated by the employing LA regardless of where they are resident. 21 Some of the comments made about this child were to resonate when T was later placed with them. There was some appropriate follow up to these concerns, in that the Practice Leader and the Fostering Social Worker visited together to discuss the complaint. The foster father apologised, although he denied using the precise language as was stated. This was a sign that the foster father did not fully appreciate how inappropriate his comments were and it is of concern that this was not followed up with, for instance, a proposal for training on child development. 7.9 In November 2012 the mother of a child placed with the foster carers notified her solicitor of an allegation made by her child that the foster mother had slapped her. It is evident that the way in which this allegation was investigated by Warwickshire Children’s Social Care and the Fostering Service did not comply with child protection procedures. There was no liaison with the Bossetshire LADO, Children’s Social Care or the Bossetshire Police. When the foster father subsequently told the fostering social worker that the foster child had withdrawn the allegation, this was not followed up with the child. An interview under ABE procedures,4 did not take place. A child protection medical was not undertaken, and neither was a Section 47 investigation instigated. The matter was referred to Warwickshire Police, and a Strategy Meeting was convened by Warwickshire Children’s Social Care at the end of November 2012, however, no other agency attended, including the Police. The outcome was that no further action was deemed necessary. 7.10 An extract from a supervision session in February 2013 between the fostering supervising social worker and her manager notes that the couple “should not take children as young as this again.” The significance of this comment was however not available for the Fostering Panel to consider, as the report presented as part of the foster carers annual review to the Panel on 25 February 2013 had been prepared by the social worker ahead of the meeting. The social worker did not attend the Panel and there was thus no update available. As is procedure in Warwickshire County Council (then and now), the review was presented to the Panel by a Practice Leader. Practice Leaders attend on a rota basis and in this instance, the Practice Leader presenting the report was not the Practice Leader responsible for supervising the case. Although some of the concerns and allegations were shared, crucially the assessment that the couple should not take very young children was not included in the report. No further action was taken and the approval status remained at one child either gender, or two if siblings, aged 0-18 years. There was no urgent review of the foster home, nor was any consideration given to drawing up an action plan to address the concerns and allegations raised, as the Fostering Panel did not have the full updated information about the household. 4 ABE: Achieving Best Evidence in Criminal. Proceedings. Guidance on interviewing victims and witnesses, and guidance on using special measures. March 2011 22 7.11 The lack of questioning by the Fostering Panel of the concerns which had been presented to them, was a missed opportunity for the placement to have been robustly reviewed and for the financial pressures the couple were facing to be explored. In addition, the system in place for presenting reports to the Panel was reliant on the Practice Leader having a grasp of the case, based on the report prepared by the fostering social worker. The concern, expressed by the social worker during supervision was missing from the report to Panel. Although this was an important omission, a system which relies on Practice Leaders presenting reports, rather than the fostering social worker, can only succeed if the report is comprehensive and there is sufficient time for the case to be fully discussed between the presenting Practice Leader and the social worker. This did not happen in this case, which in turn led to T being placed with the couple. It is of concern that given the same procedure for presenting reviews to Panel is currently in place, similar concerns about foster placements may be missed. This is a lesson learnt from this serious case review, resulting in a recommendation being made for the LSCB to consider. Practice Leaders are currently known as Team Managers in Warwickshire Children’s Services. 7.12 The end of placement report for the two children who had moved in January 2013 was completed on 5 February 2013. The report noted that the match was not ideal, and that contact arrangements had caused problems. It is of significant concern that the placement of T, a child of a similar age, who would have required contact with his mother, was placed with the couple so soon after the breakdown of this placement. 7.13 The concerns raised by Mother and Maternal Grandmother with Children’s Social Care about the changes in T’s presentation whilst in the foster placement were noted but not acted upon by the children’s team social worker. Practice Learning Points – Information Sharing 1. There were concerns from very early on in the couple’s fostering career. However, there was a lack of rigorous monitoring of their development skills as carers, and too little communication between those professionals who had knowledge of the household. Essentially these were safeguarding concerns. 2. Concerns were not followed up, as expected by the fostering regulations, and neither were they fully considered in the context of child protection. 3. If concerns about the placement had been reviewed and assessed, it would have revealed that: the foster carers had difficulty meeting the needs of children unless they were very straight forward; they struggled with placements where the child had learning difficulties and where children had attachment issues. Indeed, they showed very little understanding of attachment theory and the link 23 with child development; they found it difficult to work with parents, particularly in relation to contact; at times there were indications the foster carers were under financial stress, but the impact of this on their capabilities as foster carers does not seem to have been understood or explored. 5 Over the four years of fostering children, the foster carers experienced difficulties working with several parents of children placed with them. In all, there were 7 concerns raised about their care of children. In turn, they made complaints about professionals and at times threatened and subsequently gave notice for children in their care to be removed when the placement became too difficult for them to manage. These issues were not viewed from a holistic perspective by professionals supervising the placement, which enabled the foster carers to continue to have vulnerable children placed in their care. 6 Only one of the concerns or allegations raised about the foster carers were escalated to the LADO in either Warwickshire or Bossetshire. Whether this was because there was a lack of awareness of the procedure and criteria for making a referral is not known. However, it is apparent from the practitioners’ meetings set up to inform this review that there continues to be a lack of awareness across agencies in Warwickshire as to the function of the LADO. A number of practitioners attending the meeting were unaware of the LADO’s role or the criteria for making a referral. 7 Where concerns arise about the approval category of a foster carer, i.e. the number and age of children placed, such information needs to be incorporated into fostering reviews. 8 A system which relies on Practice Leaders presenting cases, for which they have no direct responsibility, can lead to important information not being presented to the Fostering Panel. 9 There was little seeming awareness on the part of those professionals working with the foster carers of the requirement to consider the welfare of the children in their care from a safeguarding perspective. 8. PLACEMENT PROCEDURES 8.1 T’s placement with the foster carers was an emergency placement. The review has been informed that there is a requirement for social workers to explore all options for ‘in house’ foster placements to accommodate children before looking at external providers. The foster carers had a vacancy; the request was within their approval category and they had previous experience of young children. Although the Fostering Social 24 Worker was on annual leave when the request for the placement arose, there was a note on the fostering board to discuss any placement with her before a child was placed. There was, however, no indication as to why the social worker should be consulted first or that children should not be placed with these foster carers. The recent note in supervision that children this young should not be placed with the couple was not on the foster carers case record, and this information had not been recorded on the fostering review or passed for consideration to the Fostering Panel. There was no record of complaints on the foster carers record, as the concerns raised were not recorded as formal complaints. Given there was no written information to indicate the placement should not be used, in the absence of the Fostering Social Worker, the placement was discussed with the Fostering Duty Practice Leader, who agreed the placement could be made. 8.2 On her return from leave, however, the Fostering Social Worker did not review the placement, given the concerns expressed to her Practice Leader in supervision. This was a missed opportunity to assess whether the placement met T’s needs, but it perhaps also needs to be seen in the context of Key Performance Indicators in place at the time (and still current) that looked after children should not have more than three placement moves. However, the Review found that it is more likely that this missed opportunity to review T’s needs within the placement arose more from the pressures on the fostering system to focus on new referrals and children coming into the system, rather than reconsidering apparently settled placements which are within approval categories, such as T’s. 8.3 The placement was arranged by the Duty Fostering Social Worker. T was placed in spite of the close age of other children in the placement. He was admitted straight from hospital with no placement meeting, and the Placement Plan was drafted in the Children’s Social Care office and not in the carers’ home with their involvement. No social worker accompanied T to the foster home, as he was taken from hospital to the office by a duty social worker and then collected by the foster mother, who took him home. This did not comply with placement guidelines and was not good practice. When the question was asked of practitioners at the meeting held to inform this review, as to why no social worker accompanied T to the foster placement, no explanation could be provided. 8.4 It is recognised that since T’s death, an improved database is available for placing children by duty social workers, which includes more detailed information about a placement. However, there is no guarantee that sufficient ‘soft’ information, i.e. concerns about foster carers, but which are not formal complaints, are recorded on the system, and it is possible that important information concerning the appropriateness of a placement continues to be missed. This is a lesson learnt and is a recommendation arising from this review. 8.5 Like many other local authorities, Warwickshire County Council struggles at times to find placements for children and there was evidence that the 25 couple were used on a number of occasions to place children outside their approval category. Whilst not an uncommon occurrence, this may be seen as contributing to poor standards of child care within foster placements, and needs to be considered in light of the particular financial pressures the foster carers were facing at the time of T’s placement, which was known to the fostering service, and should have been seen as contributing to stress. The issue was very slow to resolve and there is very little comment in the recording about the implications or the likely impact on the household. Practice Learning Points Placement Procedures 1. The importance of formally recording decisions/recommendations in fostering reviews and with the Fostering Panel about the appropriateness of the placement of children with foster carers is crucial if tragedies such as occurred in this case are to be avoided. Such information needs to be easily accessible to placing social workers and needs to be flagged on the data base of available foster placements. 2. There is a need to take into consideration the closeness in age of children already in a home when placing any child, including when in emergency circumstances. Where such placements cannot be avoided the need to review the appropriateness of the decision made as soon as possible is of the utmost importance to maintain the welfare of the child. No such review took place in this case when the supervising fostering social worker returned from leave and undertook responsibility for the placement. 3. No social worker accompanied T to the foster home, as he was taken from hospital to the office by a duty social worker and then collected by the foster mother, who took him home. This did not comply with placement regulations and was not good practice. 4. When a child is admitted to foster care, it is best practice for a placement meeting to take place, within 5 working days, at the foster home, to draft a placement plan, with the foster carer/s, the child’s social worker, the fostering social worker and the child’s birth parent (if no risk is presented by the birth parent to the placement) to be present. This did not occur in this case, as the placement plan was drafted in the Children’s Social Care office. This was a lost opportunity to compare how T was at that time before he was placed the foster home. 5. There were indicators that the foster carers were under some financial pressure, however, this was not fully explored or monitored by those supervising the placement. Financial difficulties are not necessarily an indicator of a safeguarding concern in a foster placement, however it was of particular significance in this case as their difficult financial 26 circumstances proved to be a key part of the foster carer’s motivation to foster children. Information Sharing for Placement 8.6 The foster carers were aware of the circumstances of T’s admission to hospital and concerns about Mother’s behaviour and actions. The placement occurred at a time when there were minimal numbers of staff working. 8.7 At the time of the placement, the information provided about T on the referral form to the Fostering team was largely concerned with the reasons for his accommodation rather than with his individual needs. This was reasonable, given that it was information gathered from hospital staff and the Emergency Duty Team, including T’s ‘boisterous’ behaviour. No information was gathered from his mother who could have provided helpful information about his behaviours, preferences and personality. This meant that the foster carers did not have a full picture of T’s needs or a detailed care plan when he was placed. However, it is significant that although they made clear on several occasions to the Social Worker, the Fostering Social Worker, Health professionals and the Children’s Guardian their difficulties in meeting T’s needs, and raised concerns about his cognitive ability, there is no evidence to suggest that the foster carers actively sought further information about T’s background. Neither did they seek advice about how best to support and care for a child who had experienced significant trauma prior to his placement. 8.8 Although T was referred to Portage Services5, he was not considered to be a child with disabilities. The health information provided to the Community Paediatrician showed no indication of concerns of a chronic nature of health complaints or conditions. There were no suggestions from medical information that a diagnosis of disability had been given in response to the injuries he sustained. 9. CONTINUITY OF PROFESSIONAL INVOLVEMENT WITH T 9.1 From the time of T’s admission to hospital in late March until his tragic death in June 2013, there were three social workers, as well as social workers from the Emergency Duty Team who were involved with him during his two hospital admissions. In addition, there was the Fostering Social Worker responsible for supervising the placement. Apart perhaps from the sessional worker who supervised contact, it was the Fostering Social Worker, of all the social care professionals, who had the most consistent contact with him during this three-month period. However, the 5 Portage is a home visiting educational service for pre-school children with additional support needs and their families 27 focus of her role was to support and supervise the foster carers rather than to work directly with T. Thus, her main knowledge of him would have been derived from her observations of T when she visited the foster placement and from information supplied by the foster carers. It is evident that she had expressed concerns about the financial motivation of the foster carers for wanting more children to be placed with them, as well as concerns that the foster mother was ‘over medicalising’ the children in her care, particularly T. None of these concerns however appear to have been fully explored or escalated. 9.2 It is concerning that as a result of systems issues, the Fostering Social Worker was not invited to the Looked After Children (LAC) Review, which immediately followed the Initial Child Protection Conference on 12 April 2013. As a result of not being invited to the first LAC Review, she was not on the list of professionals to be part of the Family and Professionals meetings which followed. Had the Fostering Social Worker been present, she would have been provided with the opportunity to gain a fuller understanding of T through such information sharing meetings. The oversight of the Fostering Social Worker not being invited to the LAC Review was seemingly not queried by the Independent Reviewing Officer. 9.3 The social workers from the Children’s Team did not know T well. The first Social Worker (SW1) undertook the initial work which concentrated on the initiation of care proceedings. The second Social Worker (SW2) met T through her visits to him and work with Mother (SW2 was undertaking a Parenting Assessment of Mother). The case was then transferred to a third Social Worker (SW3) on 23 April 2013 who was newly qualified, but who was not receiving supervision in accordance with the requirements for newly qualified social workers. This meant that she did not receive sufficient oversight or support in her dealings with the foster carers. This is especially important given the past history of concerns about the couple as carers, and at times the intimidating behaviour of the foster father. 9.4 The transfer of the case at a number of key practice points, (as part of the organisational structure in place in Children’s Social Care at that time) led to a situation where no one social worker had overall personal knowledge of T. Little information was gathered from Mother or for that matter Maternal Grandmother about T’s needs, his likes/dislikes or his behaviour at the time he was placed in care or at any time thereafter. No one sought to gain information about T from the two people who possibly knew him more than any other carers, namely the friends with whom Mother and T had lived. The lack of consistency of social workers allocated to T, led to a situation where no one, apart from Mother, had an understanding of the changes in his behaviour. When Mother did raise such concerns, they were noted, but no action was taken to investigate what was causing such an obvious change in T’s presentation. 9.5 The structural organisation of Children’s Social Care at the time led to a situation where a vulnerable child did not receive consistent supervision from a social worker who had comprehensive knowledge about him as a 28 child in his own right. This can be seen as a systems failure, which if the same structure is still currently in place could lead to other children being placed at similar risk. The Review learned that there has since been a restructure in Warwickshire’s Children’s Services which has reduced the number of potential transfer points in a child’s case. 9.6 The Community Paediatrician who undertook the LAC health assessment of T had not met him before. Neither Mother nor a Social Worker were present at the medical to provide any information about T. The Review was told that there are challenges in the current system for booking Health Assessments and arranging transport to enable parents and carers to attend6. This is currently under review to ensure a meaningful Health Assessment can be held within timescales with the appropriate people present. Although the Community Paediatrician liaised with Hospital 1 about the extent of his non-accidental injuries, of necessity she had to rely on information provided by the foster carers as to T’s behaviour and perceived health needs. Based on the information provided, the Community Paediatrician assessed that T might be in need of additional support in the form of speech and language therapy, physiotherapy and portage services and made appropriate referrals. It is clear from information provided to the review that there was not a single understanding on the part of professionals about the role and responsibilities of the LAC doctor. 9.7 There was no contact with a GP during T’s placement. T was registered with the foster carers’ GP Practice on 12 April 2013, however he was never seen by a GP. It would seem from information provided that the GP was unaware that this household was fostering children. Neither was the Health Visiting Service involved with him, as he and Mother continued to be part of the Family Nurse Partnership Programme. 9.8 FN saw T on four occasions during the review period. All of these occurred whilst he was a Looked After Child and in fact FN was the last professional to see T before his catastrophic brain injury. Three of the visits were at the foster carers’ home and the other was during a contact session with Mother. It was noted by FN that whilst medically T was felt to be satisfactory he was displaying watchful behaviour and was described as ‘traumatised’. These observations were considered in the context of T being separated from his Mother and being placed in local authority care. Because she had no contact with T whist he was cared for by his mother, she understood that the rationale for his presentation as being ‘withdrawn’ was due to T being separated from his mother. This can be said to be reinforced by her description of T during the contact session with Mother, which FN attended, when she said ‘he lit up’ when Mother was in the room. 6 Warwickshire is a rural county and community paediatricians are based all over the county, as it is not a localised service. Thus, assessments are often held in central locations. 29 9.9 If the description provided by FN of T as a watchful, wary child, who did not move easily, interact or play with others, and who had lost 2 kg in weight over a period of 12 weeks, had been made of him when he was living with Mother, it would have raised serious safeguarding concerns. That T was in the care of trusted foster carers meant that such a presentation was seen in the context of him being separated from Mother. There was a lack of professional curiosity as to whether there might be another underlying cause. It was evident however, that FN was beginning to feel uneasy about T’s dramatic weight loss and just days prior to his death she attempted to raise this issue with SW3 and the Community Paediatrician, but neither was available at the time. 9.10 The Children’s Guardian observed T during two contact sessions with Mother. She did not visit the foster placement from the time she was allocated the case, and relied on telephone conversations with the foster carers to inform her of whether T was settled and how he was progressing in the placement. She thus had no direct knowledge of T’s interaction with the foster carers compared with how he interacted with his mother. This would have been a significant observation for two reasons. Firstly, as a Children’s Guardian she was required to comment upon the child’s relationship with his mother and her ability to meet his needs. Secondly, the Guardian would normally be able to rely upon the foster carers as being approved and skilled carers of children in a way that the mother may not have been. The contrast between the child’s responses to the different quality of care could have provided an insight into T’s needs, development and progress, and enabled the Guardian to comment upon the mother’s concerns about the changes in his presentation and behaviour. These concerns, given the knowledge of what we now know was happening in the foster home, proved to have been prescient. It would have been a reasonable expectation for the Guardian to have taken account of Mother’s views about T’s change in presentation. 9.11 The Children’s Guardian’s role is to comment upon what is in the best interests of the child, and not to just accept that because the foster carers had been assessed as appropriate to care for T, there was no reason to believe this was not the case. Whilst not an explicit part of her duties and responsibilities, as set out in the relevant Practice Direction 16A for Guardians, if the Guardian had visited the foster placement, she would have gained valuable insight into the presentation of T in the placement as opposed to with his mother during contact. The Review considered that it would have been best practice to carry out this visit at an early stage, in order to strengthen the Guardian’s analysis of the child’s needs. Direct observations of T in his home setting might have triggered concerns about the inconsistency in the accounts of his behaviour and development. The Guardian has informed the review that she intended to visit the foster placement as part of her investigations, but would not have anticipated doing so in the early months of T’s placement, preceding his death. The Review accepts that the Guardian was working within the Practice Direction, but considers that the guidance was problematic in the context of a young pre-verbal child. The Practice Direction does not address the 30 needs of these children, where information collection is more complex and requires direct observation of the child. T’s behaviour showed clearly that he was miserable and at times hungry. The fact that the Practice Direction does not stress the value of early visiting to the child in placement meant that an opportunity was lost to question how negative the lived experience of this child was in reality. 31 9.12 Practice Learning Points – Continuity of Professionals Involved with T 1. Information provided about T on the referral form to the Fostering Team was largely concerned with the reasons for his accommodation rather than with his individual needs. No information was gathered from his mother, who could have provided helpful information about his behaviours, preferences and personality. This meant that the foster carers did not have a full picture of T’s needs or a detailed care plan when he was placed. 2. Issues about the care offered by the foster father to children previously placed in the foster home were not explored by social workers, as the foster mother was seen as the main carer. This meant that concerns and complaints from professionals and parents were dealt with on a case by case basis, and not looked at holistically. 3. The structural organisation of Children’s Social Care at the time, resulting in a transfer of the case at a number of key practice points, led to a situation where a vulnerable child did not receive consistent supervision from a social worker who had comprehensive knowledge about him as a child in his own right. This can be seen as a systems failure. 4. The Fostering Social Worker was not invited to the Looked After Children (LAC) Review, which immediately followed the Initial Child Protection Conference. As a result of not being invited to the first LAC Review, she was not on the list of professionals to be part of the Family and Professionals meetings which followed. 5. The lack of continuity of professional involvement meant that the foster carers were relied upon to provide information to health and social care professionals pertaining to T’s needs, behaviour and presentation. Neither Mother nor the Social Worker were present at the Looked After Child medical to provide any information about T. 6. There was not a single understanding on the part of professionals about the role and responsibilities of the LAC doctor, and she was seen as the clinician responsible for his primary health needs, rather than the GP. 7. An earlier visit by the Children’s Guardian to observe T in the foster placement would have enabled direct observation of T’s interaction with the foster carers compared to how he interacted with his mother. Children’s Guardians should not be reassured that because a foster placement has been approved by a local authority it necessarily meets the needs of vulnerable child/ren placed there. 32 10. CONSIDERATION OF VIEWS OF FAMILY MEMBERS AND CONNECTED OTHERS 10.1 Mother first saw T on 2 April 2013 following his placement with the foster carers. This contact was supervised by a sessional worker and lasted for one and a half hours. Mother described how pleased T was to see her. He put his two arms out, but he was also really upset, crying and clinging to her. We were told that T was an active child when with her, running around and jumping on chairs. This was also confirmed by Maternal Grandmother. 10.2 Within a couple of weeks of being with the foster carers, Mother noticed a marked change in T. He would not play with his toys and would scream for chocolate and crisps. At the last contact session Mother was surprised that T put all his toys away. He would often just sit on her lap during contact and Mother said “He just dropped, he wasn’t lively anymore”. Mother explained how he appeared vacant and said “If the Social Worker waved her hand in front of his face he would not react.” She also noted a marked decline in his weight, especially when she changed his nappy. Mother described how at one contact session T had a bruise on his forehead which the foster carers told her had occurred when T had ‘head butted’ the foster father. Mother told us that the foster mother had said that she used to sit T in front of the radiator because he was always cold, especially his hands and feet. A condition, which Mother said T did not have whilst in her care. 10.3 When asked whether there was any problem with T eating or vomiting, Mother said this was not the case. T enjoyed his food and she would make him spaghetti bolognaise, fish fingers and chicken, which she would cut up into pieces for him. 10.4 Mother told the social worker and her solicitor that something was wrong and that T was a different child since he had been in care. Maternal Grandmother explained that both she and Mother told the social workers of their concerns about the change in T. Their concerns were not acted upon. 10.5 Mother spoke movingly of T’s last days and described how she knew something was not right when the foster carer locked herself in another room at the hospital, crying hysterically. Mother told Maternal Grandmother that “I knew she had done something to T”. Mother described how she had to be supervised by the foster carers’ during her visits to T when he was in the PICU, which was the first time she had met them, although she had spoken to the foster mother on the telephone when T was too unwell to attend contact. She described how upset she was when the doctors spoke to the foster carers first instead of her and Maternal Grandmother about T’s condition. She said of the foster carers’ “I just wanted them to go so that I could be with T. I just didn’t realise how serious it was.” 33 10.6 Mother said that she told the social worker that Maternal Grandmother should have T. She went on to say “if they’d just listened he would be here still. Social Services should have done their job properly. They didn’t listen to me and my mum [when informed of their concerns]. We think some foster carers are just in it for the money, when they should be there for the children.” 10.7 The Children’s Social Care IMR makes reference to the fact that because T was an emergency admission to care no specific work was undertaken with T or his family, as would have been the case if an initial or core assessment had taken place. This resulted in a lack of early understanding of T’s needs. The report goes on to state that “during April 2013 the social worker necessarily prioritised work on the accommodation of T but did not subsequently develop a relationship with him.” Whilst it is accepted that this was the case, the local authority had instigated care proceedings in respect of T, a parenting assessment of Mother and Maternal Grandmother was being considered as a potential carer. Such assessments should have provided plenty of opportunity to explore their view of T prior to and during his placement with the foster carers and for any concerns about changes in his character and presentation to be listened to and investigated. This did not happen, Mother’s concerns were recorded, but no action was taken to follow them up, prior to his death. 10.8 Maternal Grandmother was being assessed as a potential carer for T, but as referenced previously in this report, it was her view that the process was taking too long and she was not being taken seriously. 10.9 The Lead Reviewers had the opportunity to meet with one of the people who cared for T when he and his mother lived with her and her then partner. She was one of the few people who was able to provide an insight into what T was like as a child, prior to his placement with the foster carers. The information provided has been helpful and informative to the review. The following is an account of what the friend told the Lead Reviewers of her involvement with Mother and T, and Children’s Social Care. 10.10 The couple had met Mother again in early April 2013 and she told them that T was in foster care. Mother showed them a photograph of T. The Lead Reviewers were told that T was unrecognisable, as he had lost so much weight. On learning that he was in care, the couple decided that they would like to look after him. They contacted Children’s Social Care to discuss their interest. Despite telephoning and visiting Children’s Social Care offices, the couple were not provided with any information about T, nor were they considered as carers for him. They were told that as Mother had stated that she did not want them involved in looking after T, they could not be assessed. 10.11 The couple sought legal advice, applied to the court to be parties to the proceedings, and lodged an application for parental responsibility. They 34 received confirmation from the court that they could be party to the care proceedings on the day T died. 10.12 Because Children’s Social Care decided it was not appropriate to consider this couple as connected people, suitable to care for T, several opportunities to influence the outcome of this case were missed. If the couple had been interviewed by Children’s Social Care, not only could they have been assessed as possible carers for him, but an insight into T’s life could also have been ascertained from two people who knew him very well. In addition, information could have been provided that may have informed the parenting assessment of Mother, which was being undertaken at that time. The decision by the Local Authority not to pursue this couple because Mother opposed their involvement in T’s life, removed the possibility of T being placed in the care of people who had known and loved him. 10.13 It was particularly unfortunate that the couple were not assessed as potential carers. This is especially so given that the review has learnt that the couple were approved respite foster carers for an independent local fostering agency at the time they were asking to be considered as carers for T. The Lead Reviewers were told that they had looked after a number of children on a respite basis, and had informed Children’s Social Care that this was the case when they asked to be assessed as carers for T. There is no record of this information having been documented. 10.14 The review has received information that the duty system in place at the time was such that duty calls were filtered by call handlers, who were administrators, and a Practice Leader then decided what was appropriate to pass on to the duty team. It is possible that the couple’s initial request to be considered as potential carers for T went through to the duty system. The review has been informed that the system has now changed. 10.15 It is concerning that this couple were not interviewed by the Children’s Guardian, who told the review, at the practitioners meeting that it was not her responsibility to make contact with or make an assessment of those wishing to be considered as connected people in care proceedings. Clearly the main responsibility for identifying potential alternative carers for a child lies with the Local Authority, but it can be expected that the Guardian would seek to assure herself that the Local authority had carried out this duty within reasonable timeframes. It is unclear how the Guardian had exercised this part of her responsibilities and may be a learning point in Quality Assurance for CAFCASS. 10.16 The Review accepts that had the couple been identified as potential carers by the local authority or the Court, then the Guardian would have sought to interview them herself, but the local authority failed to follow up the couple’s initial interest. For the Guardian to have interviewed the couple prior to this may well have been seen as inappropriately usurping the role of the local authority. 35 Practice Learning Points – Consideration of Views of Family Members and Connected Others 1. An earlier visit by the Children’s Guardian to observe T in the foster placement would have enabled direct observation of his interaction with the foster carers compared to how he interacted with his mother, although the Review accepts that this is not explicit in Guardian’s Practice Directions. Children’s Guardians should not be reassured that because a foster placement has been approved by a local authority it necessarily meets the needs of vulnerable child/ren placed there. 2. The concerns of parents and family members about significant, ongoing changes of presentation in a looked after child, need to be listened to, taken seriously and investigated by professionals. The Legislative Framework concerning ‘Connected People’ 10.17 Given that Warwickshire County Council decided not to consider Mother’s friends as potential carers for T, seemingly because of her objections, it is important to consider whether there was any basis in law for such a decision. Regulation 24 of the Care Planning, Placement and Case Review (England) Regulations 20107 which became effective from 1 April 2011, replaced Regulation 38 (2) of the Fostering Services Regulations 2002, which related to immediate placements of children with relatives and friends not previously approved as foster carers. 10.18 “Regulation 24(1) provides that where the local authority is satisfied that an immediate placement with a Connected person is the most appropriate placement for the child notwithstanding that the proposed carers are not approved as foster carers, the carers can have temporary approval for a period of up to 16 weeks provided that an assessment of their suitability under Regulation 24(2) has taken place”. It is evident, however, that Children’s Social Care’s interpretation of this regulation was that consideration needed to be given to people connected to the parent, and not to those connected to the child. This view was confirmed at the practitioners meeting, when Children’s Social Care staff commented that they were dependent on the parent to identify the ‘connected person.’ It was recognised, however, by those attending the meeting that there was a need for social workers to be more proactive in identifying who could be considered as ‘connected people’, and that there should not be an over reliance on those put forward by birth parents. 10.19 The review has been informed that Mother’s friends were approved respite foster carers at the time, by a local independent fostering agency. 7 http://www.legislation.gov.uk/uksi/2010/959/pdfs/uksi_20100959_en.pdf 36 Whilst Mother’s view needed to be taken into consideration as to whether she had any objection to this couple becoming carers for T, the legislation does not state that such objections were paramount in deciding what is in the best interest of a child. Given that Warwickshire County Council had an interim care order in respect of T, then the local authority shared parental responsibility with Mother prior to a Care Order being made. However, the local authority can determine the extent to which they exercise their parental responsibility. If, after assessing the couple a decision was reached that T could be placed with them, the local authority had power to do this and, if this was in the best interests of the child, they had a duty so to place him. 10.20 The fact that the couple knew and loved T, that he had lived in their household for almost a year and he knew them, should have been taken into account by the local authority at the earliest opportunity, after they expressed an interest in caring for him. That they had already been approved by a local agency as respite foster carers would have become known to the local authority, and could have been highly significant in that it was a ready reckoner that they were prima facie suitable to care for children. They could have been very quickly assessed under the regulations as most of the requirements that needed to be met as to their suitability would have demonstrably already been met by their existing approval as foster carers. The only real issue was whether it was in the bests interests of T to be placed with this couple. Unfortunately, the option was not given due consideration as the local authority did not provide an opportunity for them to be assessed as possible carers for T. 10.21 The need for Children’s Social Care to take into full consideration, appropriately investigate and assess those who are connected to a child, who come forward as carers, is a paramount finding from this Review. It is a lesson learnt and will no doubt resonate with decisions taken in other cases involving the placement of children both in Warwickshire and other local authorities. Practice Learning Points – Connected People 1. The dismissal of two people who wished to look after T on the basis of Mother stating that she was opposed to their involvement in his care was a misjudged and misinformed decision on the part of the local authority. This was possibly a result of the organisational culture and systems at the time seeing ‘connected people’ as those being connected to the parent, rather than the child. 2. The responsibility of Children’s Social Care to take into full consideration, appropriately investigate and assess those who are connected to a child, who come forward as carers, is a paramount finding from this review. 3. It is the responsibility of the Children’s Guardian to ensure that the Local Authority has considered and assessed people close to the child, 37 and to ensure that all connected people have been appropriately identified. This is a key finding from this Review. It is not the responsibility of the Children’s Guardian to assess connected people, but there is a key role to play in ensuring that the local authority has taken appropriate steps to identify those who may be in a position to offer care and support. 11. LOOKED AFTER CHILDREN REVIEW/CHILD PROTECTION PROCESS 11.1 The purpose of these meetings was to ensure continuity of the care plan for Looked After Children in between reviews when a Child Protection Plan had ended. 11.2 Although the review has been told by IRO1 that the major consideration of the ICPC and the LAC Review was the Police investigation concerning the injuries to T and the parenting assessment of Mother, it is significant that four medical reports concerning T’s injuries were not available to be shared at the ICPC. There was no representative from the GP Surgery and the Consultant Paediatrician from Hospital 1 was unable to attend. This was to lead to a reliance on the foster carers providing information to health professionals and social workers of T’s health and well-being whilst in their care. 11.3 The ‘Analysis of Risk’ on the Child Protection section of the minutes of the ICPC, reiterates that Dual Status means that Child Protection and Care Planning for T should be integrated. Each agency gave a view and all agreed that T was ‘currently safeguarded as he was in Local Authority Care and subject to an Interim Care Order.’ Thus, a specific Child Protection plan was not required. Whilst this seems an appropriate decision, the record of this dual meeting remains unclear in that the two processes are not sufficiently separated. There is repetition of recording and discussion without drawing out strong recommendations in the Looked After Child Review section. Specifically, the care plan does not: receive detailed consideration; there is no record of timescales for the assessments, and there is no consideration of exploring other adults who had been in T’s life as potential carers. 11.4 There is no record that the Looked After Children review considered the lack of a placement meeting, and at that stage, the foster placement was considered to be a place of safety for T. However, the lack of a robust care plan, with clear outcomes for the child, which would have required continuity of social work involvement, meant that a holistic assessment was never made of whether the placement met T’s needs and promoted 38 his well-being. This was particularly important, as T was a child placed out of county, and without notification of his transfer to Bossetshire received no input from the Bossetshire Health Visiting Services, the GP or the Named Nurse for Looked After Children. 11.5 The Designated LAC Nurse for Warwickshire was not notified that T was placed out of county. This was in breach of statutory guidance as it is a legal requirement8 and within local guidance (South Warwickshire NHS Foundation Trust Integrated Care Pathway) for such notification to take place. Information has been provided to the review, following interviews by the South Warwickshire NHS Foundation Trust IMR Author with the Designated Nurse for LAC, that the LAC Health Team are frequently not notified by the local authority when a child is placed into care, despite efforts to obtain the information. Although it is a statutory requirement for relevant professionals to be notified, it would appear as the IMR author comments that “there is professional acceptance that this does not always happen.” The lack of sharing such information is significant in this case, and is as relevant for all looked after children placed outside their local authority. Practice Learning Points – Looked After Children Review/Child Protection Process 1. Arrangements for invitations to dual status meetings are not sufficiently clear and risk missing people who should attend the LAC review. 2. It needs to be clear who is responsible for reviewing the invitation list for review case conferences and statutory reviews so that relevant people are not overlooked because they were not invited to the ICPC. 3. There is a need to ensure that the Designated Nurse for Looked After Children is informed when a child is accommodated, particularly so if the child is placed out of county. 12. FINDINGS/ LESSONS LEARNED Finding 1: The Sharing of Information 12.1 The sharing of information between professionals is crucial if children are to be safeguarded, and features in the findings of the majority of serious case reviews. It is extremely pertinent in this case as not only was information withheld by the foster carers, important information was not shared between professionals within the same agency, nor was it always shared on an interagency basis, as highlighted by the lack of information 8 HM Statutory Guidance 2009, section 9.4.1 39 recorded by the Bossetshire LADO Service of referrals made by Warwickshire Children’s Social Care. 12.2 This, together with a lack of escalation, or indeed proper investigation of the concerns raised by social workers, other professionals, parents, a psychologist and a family court judge, resulted in a missed opportunity to holistically assess the situation as to the safety of this foster placement for vulnerable children. 12.3 It is evident from this Serious Case Review that there was a poor understanding of the purpose of LAC health assessments and the role of the Designated Doctor for Looked After Children, as well as the relationship between these functions and the community health services available to children. 12.4 There was confusion as to the role of FN2 in this case. She was working with Mother, but was also responsible for health visiting services to T, without being the designated health visitor. The need for professionals to be fully informed and aware of their role and responsibilities, with clear boundaries, when working with looked after children is a finding of this review. 12.5 The lack of timely and appropriate information sharing between clinicians and Police when T was admitted to Hospital 2 is a finding of this review. The confusion on the part of the PICU doctor as to which child the CAIU police officer was enquiring about when the unit was contacted has been documented in this report. It is evident from the information provided by Hospital 2 and the Bossetshire Police that by the time T had been admitted to the PICU, non-accidental injury was being considered as a possibility. Whilst definitive scan results and the opinion of expert clinicians were awaited, it was evident that NAI was being taken into account by clinicians. Police should have been informed that this differential diagnosis was being considered earlier on in the process. 12.6 This was further compounded by the failure of the EDT social worker in Bossetshire to inform the Bossetshire Police, because of a misunderstanding as to who had statutory responsibility for investigating the circumstances of T’s hospital admission. This resulted in Police Officers having to make a number of enquires to ascertain why T was admitted to hospital with a catastrophic brain injury. This in turn meant that the foster carers had unsupervised contact with T during a crucial period, during which time they sought to cast suspicion on his mother, suggesting that his current head injury had resulted from when he was in her care. The need for clear procedures/protocols concerning the timely sharing of information with Police when NAI is suspected, and for all professionals to be conversant with such procedures is a finding, and will be a recommendation from this review. 12.7 A further significant finding of the review is that there was a pattern of not sharing information between professionals throughout this case, which sadly contributed to the serious outcome for T. Incidents were seen in isolation 40 and connections not made, which might have led to questioning of what was happening in the placement. For example, it was accepted that T was possibly incubating chicken pox for a period of a month, which resulted in him not being taken to contact sessions with his mother. This meant that he was not seen by his mother, or indeed any other professional during this period of ‘illness’. There was no challenge to the foster carer of why a medical opinion had not been sought, and her word was accepted that T was unwell. It was only Mother who raised the issue of why so many contact sessions were cancelled, which was then brought to the attention of Warwickshire Legal Services and Children’s Social Care. Professional overview of this case was lacking and, the pattern of what was essentially, disguised compliance on the part of the foster carers was missed. Finding 2: Foster Carers as Perpetrators of Abuse 12.8 That there were concerns raised by different social workers, parents and other professionals about the foster carers behaviour towards children in their care, has been fully documented in this report. Although such concerns were raised, they were not escalated through the formal processes related to complaints about foster carers. This resulted in concerns being recorded on individual children’s casefiles, but they were not viewed holistically, until after T’s tragic death. Allegations made by children and parents about the behaviour of the foster carers were strongly denied. Although the allegations were noted, they were not robustly investigated and were prematurely closed, without being referred to or appropriately assessed by the LADO. This was a missed opportunity to review the suitability of these foster carers and is a finding of this review. 12.9 In discussion with the Named Doctor at Hospital 2, the Lead Reviewer was reminded of the findings of Lord Laming into the death of Victoria Climbié in 2003. Whilst Lord Laming was referring to resistant birth parents, the finding also resonates with the actions and behaviour of the foster carers involved in this serious case review. Lord Laming recognised that social workers faced a ‘tough and challenging task’ when working with adults who deliberately exploit the vulnerability of children and who act in devious and menacing ways. “They will often go to great lengths to hide their activities from those concerned for the well-being of the child…….staff have to balance the rights of a parent with that of the protection of the child.”9 12.10 It is apparent, albeit, with the benefit of hindsight that the foster carers were creating a picture of a child with special needs, who was difficult to care for and whose catastrophic collapse was due to the previous injuries received whilst in his mother’s care. 12.11 It is now evident that the foster mother particularly, used the excuse that T may have been incubating chicken pox over a period of a month to ensure 9 The Victoria Climbié Inquiry: Report of an Inquiry by Lord Laming, 2003 41 that contact sessions with his family were cancelled. Neither foster carer sought medical advice or attention for T during this time, yet no social worker questioned whether this was appropriate. The reasons as to why such questions were not asked could be linked to the position of trust in which foster carers are held. FN advised the foster mother to take T to the GP, but she ignored this advice, and no action resulted. When it became apparent that T had lost a very significant amount of weight, the foster carer was advised by FN to increase his food portions, but the reason for his weight loss, i.e. his alleged choking when eating, was not questioned or fully explored. It is clear that T was hungry, as evidenced when he sought food from his mother during contact visits. The Serious Case Review into the death of Daniel Pelka reached a difficult conclusion about the work undertaken by professionals who work in the area of safeguarding children. Given the harm experienced by T, it is worthwhile remembering the following statement from the Daniel Pelka review: “In this case professionals needed to think the unthinkable and to believe and act upon what they saw in front of them, rather than accept parental versions of what was happening at home without robust challenge.”10 12.12 Unfortunately, the professionals who had contact with T, with the exception of Warwickshire EDT Manager 1, had no knowledge of what he was like prior to his placement with the foster carers. His mother and maternal grandmother said on several occasions to social workers (and Mother’s lawyer) that his behaviour had changed and that he was not the same child. Professionals described T as a watchful, quiet, unresponsive and wary child, who had difficulty making eye contact. At the practitioners meeting held as part of this serious case review, SW3 told us that the way he presented was not like anything she had come across before. She was so concerned that she was seeking an expert opinion as to whether his presentation was organic. 12.13 That professionals could be so convinced that there was ‘something wrong’ with T and the problem was with him, is an indication of the level of deviousness to which the foster carers resorted to ensure that their neglect and ill treatment of T remained undiscovered, until it was too late. 12.14 Although the foster mother attempted to medicalise T, her lack of care and concern for T is apparent from the above, but was especially evident on the day he was critically injured. The foster mother deliberately delayed calling the GP or an ambulance for T for several hours after he was injured and left him alone, in a coma, in his bedroom, whilst she attended to the other children. Although it could be said that the foster mother may have panicked after violently shaking T, which resulted in his critical injury, her refusal to call for immediate medical attention cannot be excused and is indicative of a complete lack of compassion or empathy for a small, vulnerable child. 10 Coventry LSCB 2013, Serious Case Review Daniel Pelka 42 12.15 Foster carers are in a position of trust, and the majority of foster carers respect that trust and provide excellent care to children. Professionals do not expect children to be harmed, neglected or ill-treated whilst being looked after by foster carers. It is therefore difficult for professionals to consider the possibility that a child in a foster placement might be deliberately neglected or harmed. It is apparent, however, especially given recent disclosures of historical abuse by children previously looked after, that social workers need to maintain respectful uncertainty where concerns arise about the care offered to a looked after child, or where there is an obvious deterioration in the health, behaviour and presentation of a child. The need to share and act on those concerns is of paramount importance if children are to be protected and is a finding of this review. 12.16 This Serious Case Review has highlighted the importance for all partner agencies to be made aware of the need for respectful uncertainty on the part of professionals in their involvement with foster carers where concerns arise about a child’s presentation, behaviour and health needs. Finding 3a: The supervision and quality assurance systems within Fostering services, and the monitoring of placements 12.17 The importance of consistency of social worker allocation and their supervision cannot be over stated in this case, and was an issue in both the Fostering and Children’s Social Work Teams. In respect of the Fostering Team, historical concerns about the foster carers were not known by the social worker supervising the foster home during T’s placement. The importance of reading and understanding the whole of a child’s file has been particularly highlighted by this case. There was evidence of good and appropriate use of supervision to discuss Fostering SW1’s growing concerns about the foster carers, but no evidence of how this was followed up, and particularly no evidence of this being shared with the child’s social worker. It was apparent from the reports and practitioners’ meetings that the social workers in the Fostering Team did not read the previous records, so although social workers do change and organisationally this can be difficult to address, the impact would have been mitigated if the records had been thoroughly read and the history understood. This applies to both Fostering and Children’s Social Work Teams. 12.18 Organisationally there was little evidence of a culture of information being shared between Children’s and Fostering Teams, including “soft” information where concerns were beginning to mount. This in part supported the organisational culture of workers and managers taking on board comments and views about people and situations made without substantial evidence, and then not re checking back to the source. An example of this is the discrepancy between how the foster carers described T and how his mother described him. The implications for this were not scrutinised. This was particularly apparent during the practitioners meeting, when some people were still clearly struggling to accept the degree of the foster carers’ culpability in T’s ill treatment and death whilst in their care. Views developed early on with little firm evidence were held without professional interrogation 43 or curiosity. This has of course been seen in a number of Serious Case Reviews nationally. 12.19 There is also a finding from this Review about the impact of the quality of information going to the Fostering Panel on the subsequent recommendations, and the lack of follow through of actions when these are recommended by Panels. Panels are only able to make a judgement and recommendations based on the information put in front of them, and the review has found that the Fostering Panel did not have all the information required to make sound recommendations. 12.20 Organisationally there is an issue about the quality assurance of both social work reports and the Panel functioning. The Fostering Assessment provided to the Serious Case Review was procedurally compliant and at that stage there was no evidence that the foster carers would not be able to care safely for young children. The issue here is the lack of consistency in identifying and bringing growing concerns to the Performance Reviews. If the concerns had been reported as complaints, as has been considered earlier, they would have been included in the summary for the fostering reviews. However, there was no scope for discussion about the foster carers overall coping capacity within the system of Practice Leaders taking reviews to the Panel on behalf of social workers, when they did not have personal knowledge and involvement with the foster carers. This is an example of a good idea about saving resources of time, which in fact was not fully thought through. It was functional in processing reviews but the quality was affected. 12.21 It is apparent that there was a significant period where the foster carers received no supervision from the Fostering Service, which was unacceptable, and which could not only have led to children being placed at risk, but also left the foster carers vulnerable and unsupported. It is apparent that the focus of the Fostering Service has been on supporting foster carers rather than scrutinising their day to day practice as carers for children with often complex problems. Thus, these carers who were perceived as being experienced, would not have been seen as a priority for allocation in the absence of their permanent worker. Finding 3b: The implementation and monitoring of care and placement plans 12.22 Consistency of social work involvement in a case is crucial if a comprehensive picture is to be built of a child’s needs. This is particularly relevant to this review, given that three different social workers had responsibility for T at different times during his three-month period in care. This was due to the way in which the system was structured to accommodate the allocation of cases, which resulted in a situation where none of the social workers allocated to T had time to develop a relationship with him and get to know him as a child in his own right. The Lead Reviewers were told by SW3, at the practitioners meeting that her main focus was on the preparation of the case for care proceedings, not on the placement. 44 12.23 The process in place was procedurally correct, in that this social worker was receiving close supervision from an experienced Practice Leader, but the process did not apparently support the Practice Leader in doing anything which allowed her to triangulate the reporting of the worker, for instance by visiting the child herself and familiarising herself with the background. This was not in practice a co-worked case and the social worker was allocated a complex and serious child protection case without the support she needed. At this stage in practice development the worker, like others in this case, was taking reporting from the foster carers at face value and thus formed a view of T based on their reporting. In parallel to this, the Practice Leader also accepted the view of the social worker. There was little evidence of communication between the Children’s Team and the Fostering Team, which might have offered a different view of the placement. The role of the Family Nurse Practitioner as we have already seen, was similarly not fully used to triangulate what was actually happening in the household, as so little information was shared. 12.24 Given the concerns raised by the Fostering SW1 about the placement before T was placed as an emergency, a placement review should have taken place on her immediate return from leave. This did not happen. 12.25 The LAC review raises concerns about whether it sufficiently addressed T’s needs and promoted his wellbeing. The care plan did not receive detailed consideration at the review; there was no record of timescales for assessments and there was no consideration given to exploring other adults in T’s life as potential carers. It is the responsibility of Children’s Social Care to consider whether there were any connected people who might be potential carers. The review accepts that it is not the role of either the Children’s Guardian or the IRO to assess adults in a child’s life as potential carers, but it is part of their responsibilities to ensure that questions are asked to draw out who may be relevant in a child’s life. In this case it is evident this did not happen and it is a failure of Quality Assurance specifically for the Independent Reviewing service that this gap in understanding of the role was not picked up. 12.26 The dual status of the ICPC and LAC review did not appear to support the opportunity of looking in detail at the day to day experience of T in his placement, as the main focus was on the child protection element. A specific LAC review would more likely to have been held in the foster carers home, and would have probably allowed for more reflection on T’s presentation, his medical and developmental needs and his day to day routine. This might well have allowed more free discussion and involvement from Mother and thus a reflection on his changed presentation and demeanour. The focus on risk and forward planning of the dual status review rather than what was happening here and now for T assisted in the foster carers’ manipulation of the view of T. 12.27 This Serious Case Review has found that there was an absence of a constructive care plan which took into account all possible care options for T, 45 his best interests and his wellbeing. The concerns expressed by his mother and maternal grandmother about the deterioration in his presentation and demeanour, (especially given that T was a child with limited vocabulary) were not given appropriate importance. There is a stark contrast between the response to the foster carers providing information to that of Mother reporting changes in T’s presentation. The need for professionals to listen to and take account of the concerns voiced by parents and family members about detrimental changes in a looked after child, is one of the paramount findings of this review. This review has highlighted that the perceived status of an individual communicating information makes a difference as to the way in which professionals respond. The need for LAC plans and reviews to be subject to a process of robust Quality Assurance is a finding and will be a recommendation arising from this review. 12.28 It was apparent that the role of the Community Paediatrician and the function of LAC Health Assessments was not clearly understood by all those involved in this case, and there was an inconsistent view. This led to confusion about who was responsible for following up day to day concerns about T’s health and development, and specifically undermined the role of the local GP and Health Visitor. Too much reliance was placed on the Health Assessment picking up and progressing concerns about this child. There was also no transparent process in place for the distribution of reports before and following a Health Assessment and this had a serious impact in this case. Finding 4: Connected People 12.29 The need for professionals to give serious consideration to connected people, who wish to care for a child is an important finding of this review. Professionals from all agencies need to focus on the connection of people to the child and not their connection to the parent. 13. CONCLUSION 13.1 The first public inquiry into the death of a child in foster care was the Monkton Inquiry which opened in April 1945 following the brutal murder of a 13 year old boy, Dennis O’Neil, by his foster father. The findings of the Inquiry were to lead to the passing of the Children Act 1948, which placed an emphasis on keeping children with birth parents, wherever possible. Although the circumstances of Dennis O’Neil’s murder were different to those leading to the death of T, some of the findings from that Inquiry are pertinent to this Serious Case Review, and to the many other reviews and public inquiries which have followed, namely: “The issues that contributed to his death – poor record-keeping and filing, unsuitable appointments, lack of partnership working, resource concerns, failing to act on warning signs, weak supervision and “a lamentable failure of communication” – were not buried with Dennis O’Neill. These failings were to feature regularly in inquiries held into the death or abuse of children in care 46 for the next 60 years – up to and including that of eight-year-old Victoria Climbié”11. 13.2 It is seriously concerning that the issues which contributed to the death of a child over 70 years ago are still prevalent today. The need for professionals to maintain professional curiosity, and respectful uncertainty where concerns arise about the care offered to children whether by birth parents or foster carers cannot be overemphasised. There were sufficient concerns to question the motivation and the suitability of these foster carers to look after children. If information about such concerns had been appropriately shared and investigated, then questions as to the suitability of the foster carers may have been more robustly considered. Similarly, serious consideration should have been given to others who came forward to care for T. If such scrutiny had occurred, then T’s death may have been prevented. 14. RECOMMENDATIONS FOR CONSIDERATION BY WARWICKSHIRE LSCB 1. The Board should consider whether partner agencies are giving sufficient scrutiny and importance to the safeguarding of children looked after. Specifically, actions need to be in place to ensure that it is well understood that at times children are harmed by carers and other professionals, and this can include foster carers. There cannot be a presumption that all children in placements are safe at all times, and training and briefings on issues arising from this Serious Case Review should address this. 2. It is important that the tensions between the County Council’s responsibilities for ensuring sufficiency of placements and maintaining the quality assurance of fostering placements are well understood and held in balance. Lessons from the process of quality assurance for externally contracted placements may be useful. 3. The Board will want to reassure itself that a review carried out into the Fostering Service has addressed the following issues: • Is information from other services shared and considered by Fostering Panels? • How robustly cases are presented to Panels and by whom? • Has the Fostering Service improved since it has become a countywide service, and have the recommendations of the Fostering Review Action Plan been put into place, including the new role of Quality Assurance Officer? • Is there a robust Quality Assurance system in place for ensuring that professional curiosity and scrutiny are maintained in the process of decision making for approving foster carers, and for the continual supervision of placements? 11 http://www.communitycare.co.uk/2007/01/10/what-have-we-learned-child-death-scandals-since-1944/ 47 • Are concerns/complaints about foster carers being recorded on the fostering file, and appropriate action taken where required? • Are arrangements in place for restricting the type of placements made in individual fostering households, on the basis of professional assessment and review, rather than with emphasis on the carers’ preferences alone? • Are the communication links between Fostering and other teams, including Children’s Social Work Teams sufficiently robust to ensure that concerns from all professionals and people relevant to a child in care are given weight and shared appropriately? • Are appropriate processes in place to ensure that when information is requested from GPs during assessments for fostering the detail needed is clear and transparent? 4. The Board needs to be assured that the role and function of the LADO is understood by all agencies, and that there is a robust system in place to ensure that concerns about those in a position of trust are appropriately managed. 5. Where social workers and partner agencies have concerns about the care offered by foster carers they are made aware of the need to formally register such concerns as complaints to be investigated. Such complaints which concern allegations against foster carers and their position of trust need to be brought to the immediate attention of the LADO. Clarity is required as to cross border LADO arrangements for investigating allegations brought against foster carers employed by one local authority, but who reside in another. 6. Professionals, including medical staff should not wait until a definite diagnosis is in place before making child protection referrals. This recommendation is made in light of the fact that hospital staff appeared to have waited almost 24 hours before raising child protection concerns in respect of T, while investigations as to whether he had an organic illness or had suffered trauma took place. During this time there was confusion about contact and parental responsibility. It is of note that he did receive excellent medical care. Warwickshire and Bossetshire LSCBs need to ensure professionals are reminded that the threshold for making a child protection referral is ‘reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm12’. 7. Multi-agency staff need to be clear about whether they are notifying Social Care colleagues about a looked after child who is in hospital; or whether they are making a child protection referral in respect of a suspicion of non-accidental injury to a child who is also looked after, and a Section 47 investigation is required. 8. When a Looked After Child is placed out of area this adds to the complexity of a case, and will require communication with more than one Local Authority. 12 The Children Act 1989 48 The fact that a child may still be geographically close to their Local Authority of origin must not cloud the issue of the need for careful information sharing across borders. There have been changes to the structure and management of out of hours services for child protection in the area relevant to this review and it is appropriate for the Board to ensure that the lessons from this case are now well understood. 9. The Board needs reassurance that measures are in place to ensure that Children’s Social Care and Health professionals are clear about the function of a Looked After Child (LAC) Health Assessment, and the role of the Community Paediatrician who undertakes such assessments, in comparison to other clinicians and Health Services provided to a child. 10. The role of the Family Nurse Practitioner needs to be clarified specifically where children are in foster care. The support a foster carer may require in caring for a child, needs to be addressed separately from the overview of day to day child health and development, which would normally be monitored by a Health Visitor attached to the child’s registered GP. There appeared to be a disconnect between the FNP and local community health services in this case, which left a child vulnerable, with an overreliance on the account of the foster carers rather than on accurate observation and knowledge of this child. In addition, the FNP programme needs to review their processes to ensure that an effective health provision is in place when an FNP programme is being delivered across a border into an area where it is not provided. 11. The findings of this review are disseminated to all partner agencies, to Bossetshire Safeguarding Children Board and the judiciary involved in the care proceedings case of the foster carers’ children for the promotion of learning and reflection. 49 APPENDIX 1 Summary of Practice Learning 1. There was limited exploration of some aspects of the foster carers’ lives and of the effect these may have on their relationship. 2. Whilst there was recording of the fostering assessment, annual reviews and contact with the foster carers, there was a lack of critical appraisal of their skills, and gaps in supervision at key points, by the fostering social worker. It is important to recognise that the role of the fostering social worker is to take into account not only the needs of the foster carers, but most importantly the needs and wellbeing of the child in the placement. 3. The need for regular and consistent supervision of foster placements is crucial for the safeguarding of children, especially nonverbal/pre-school children. In this case the foster carers were without the oversight and support of a Fostering Social Worker for ten months. The onus was on the foster carers to bring any issues to the attention of the Fostering Duty Social Worker or for the Children’s Team Social Worker/s to report any concerns about the care of the children in placement. This was a clear breach of regulations and did not support continuity of understanding and monitoring of this household. 4. There was seemingly no challenge from the Fostering Panel as to the accuracy of the information presented, given the limited contact the Fostering Team had with the foster carers during this period. The overall lack of robustness in the annual reviews was thus a lost opportunity to begin to collect concerns and alert practitioners. Both social workers and the Fostering Panel need to consider and question whether information is missing or unavailable, when reports are prepared and when they are presented. 5. There was a lack of recognition by fostering social workers of the gaps in the knowledge and understanding of child development and attachment theory on the part of the foster carers. This was evident in the unrealistic expectations the foster father clearly expressed about T. The need to robustly challenge such views and to ensure that suitable training is made available to and taken up by foster carers is an important finding of this review. 6. The need to share information between teams within a local authority cannot be overemphasised. The sharing of important information did not happen in this case. There is now in place the means for such information to be readily accessed electronically by all social care practitioners working with looked after children. It is anticipated that the findings of this review will enhance and strengthen the use of this facility. 7. There were concerns from very early on in the foster carers fostering career. However, there was a lack of rigorous monitoring of their development skills as carers, and too little communication between those professionals who had knowledge of the household. Essentially these were safeguarding concerns. 50 8. Concerns were not followed up, as expected by the fostering regulations, and neither were they fully considered in the context of child protection. 9. If concerns about the placement had been reviewed and assessed, it would have revealed that: a) the foster carers had difficulty meeting the needs of children unless they were very straight forward; b) they struggled with placements where the child had learning difficulties and where children had attachment issues. Indeed, they showed very little understanding of attachment theory and the link between child development; c) they found it difficult to work with parents, particularly in relation to contact; d) at times there were indications the foster carers were under financial stress, but the impact of this on their capabilities as foster carers does not seem to have been understood or explored. 10. Over the four years of fostering children, the couple experienced difficulties working with several parents of children placed with them. In all, there were 7 concerns raised about their care of children. In turn, they made complaints about professionals and at times threatened and subsequently gave notice for children in their care to be removed when the placement became too difficult for them to manage. These issues were not viewed from a holistic perspective by professionals supervising the placement, which enabled the foster carers to continue to have vulnerable children placed in their care. 11. Only one of the concerns or allegations raised about the foster carers were escalated to the LADO in either Warwickshire or Bossetshire. Whether this was because there was a lack of awareness of the procedure and criteria for making a referral is not known. However, it is apparent from the practitioners’ meetings set up to inform this review that there continues to be a lack of awareness across agencies in Warwickshire as to the function of the LADO. A number of practitioners attending the meeting were unaware of the LADO’s role or the criteria for making a referral. 12. Where concerns arise about the approval category of a foster carer, i.e. the number and age of children placed, such information needs to be incorporated into fostering reviews. 13. A system which relies on Practice Leaders presenting cases, for which they have no direct responsibility, can lead to important information not being presented to the Fostering Panel. 14. There was little seeming awareness on the part of those professionals working with the foster carers of the requirement to consider the welfare of the children in their care from a safeguarding perspective. 15. The importance of formally recording decisions/recommendations in fostering reviews and with the Fostering Panel about the appropriateness of the placement of children with foster carers is crucial if tragedies such as occurred in this case are to be avoided. Such information needs to be easily accessible to placing social workers and needs to be flagged on the database of available foster placements. 51 16. There is a need to take into consideration the closeness in age of children already in a home when placing any child, including when in emergency circumstances. Where such placements cannot be avoided the need to review the appropriateness of the decision made as soon as possible is of the utmost importance to maintain the welfare of the child. No such review took place in this case when the supervising fostering social worker returned from leave and undertook responsibility for the placement. 17. No social worker accompanied T to the foster home, as he was taken from hospital to the office by a duty social worker and then collected by the foster mother, who took him home. This did not comply with placement regulations and was not good practice. 18. When a child is admitted to foster care, it is best practice for a placement meeting to take place, within 5 working days, at the foster home, to draft a placement plan, with the foster carer/s, the child’s social worker, the fostering social worker and the child’s birth parent (if no risk is presented by the birth parent to the placement) to be present. This did not occur in this case, as the placement plan was drafted in the Children’s Social Care office. This was a lost opportunity to compare how T was at that time before he was placed the foster home. 19. There were indicators that the foster carers were under some financial pressure, however, this was not fully explored or monitored by those supervising the placement. Financial difficulties are not necessarily an indicator of a safeguarding concern in a foster placement, however it was of particular significance in this case as their difficult financial circumstances proved to be a key part of the couple’s motivation to foster children. Information provided about T on the referral form to the Fostering Team was largely concerned with the reasons for his accommodation rather than with his individual needs. No information was gathered from his mother, who could have provided helpful information about his behaviours, preferences and personality. This meant that the foster carers did not have a full picture of T’s needs or a detailed care plan when he was placed. 20. Issues about the care offered by the foster father to children previously placed in the foster home were not explored by social workers, as the foster mother was seen as the main carer. This meant that concerns and complaints from professionals and parents were dealt with on a case by case basis, and not looked at holistically. 21. The structural organisation of Children’s Social Care at the time, resulting in the transfer of the case at a number of key practice points, led to a situation where a vulnerable child did not receive consistent supervision from a social worker who had comprehensive knowledge about him as a child in his own right. This can be seen as a systems failure. 22. The Fostering Social Worker was not invited to the Looked After Children (LAC) Review, which immediately followed the Initial Child Protection Conference. As a result of not being invited to the first LAC Review, she was not on the list of professionals to be part of the Family and Professionals meetings which followed. 52 23. The lack of continuity of professional involvement meant that the foster carers were relied upon to provide information to health and social care professionals pertaining to T’s needs, behaviour and presentation. Neither Mother nor the Social Worker were present at the Looked After Child medical to provide any information about T. 24. There was not a single understanding on the part of professionals about the role and responsibilities of the LAC doctor, and she was seen as the clinician responsible for his primary health needs, rather the GP. 25. An earlier visit by the Children’s Guardian to observe T in the foster placement would have enabled direct observation of his interaction with the foster carers compared to how he interacted with his mother, although the Review accepts that this is not explicit in Guardian’s Practice Directions. Children’s Guardians should not be reassured that because a foster placement has been approved by a local authority it necessarily meets the needs of vulnerable child/ren placed there. 26. The concerns of parents and family members about significant, ongoing changes of presentation in a looked after child, need to be listened to, taken seriously and investigated by professionals. The dismissal of two people who wished to look after T on the basis of Mother stating that she was opposed to their involvement in his care was a misjudged and misinformed decision on the part of the local authority. This was possibly a result of the organisational culture and systems at the time seeing ‘connected people’ as those being connected to the parent, rather than the child. 27. The responsibility of Children’s Social Care to take into full consideration, appropriately investigate and assess those who are connected to a child, who come forward as carers, is a paramount finding from this review. 28. It is the responsibility of the Children’s Guardian to ensure that the Local Authority has considered and assessed people close to the child, and to ensure that all connected people have been appropriately identified. This is a key finding from this Review. It is not the responsibility of the Children’s Guardian to assess connected people, but there is a key role to play in ensuring that the local authority has taken appropriate steps to identify those who may be in a position to offer care and support. 29. Arrangements for invitations to dual status meetings are not sufficiently clear and risk missing people who should attend the LAC review. 30. It also needs to be clear who is responsible for reviewing the invitation list for review case conferences and statutory reviews so that relevant people are not overlooked because they were not invited to the ICPC. 31. There is a need to ensure that the Designated Nurse for Looked After Children is informed when a child is accommodated, particularly so if the child is placed out of county. 53 |
NC52266 | Near-fatal knife injury to a 17-year-old boy in December 2020. Child V had been subject to a child protection plan until March 2020. Learning includes: the need to view children who are not in school, especially those with Education, Health and Care Plans (EHCP), as high risk and requiring a safety network of agencies to work together; there is a need for professionals to improve their understanding of the impact of cumulative harm on an adolescent who is struggling to find a safe transition into adulthood; there is a need to ensure that the work already undertaken to develop a contextual safeguarding approach is strengthened to include a wider range of agencies; ensure that the child's voice is heard. Recommendations include: EHCP reviews must involve health and social care to ensure that there is a multi-agency approach to addressing the educational needs of the children; ensure that there is an effective multi-agency partnership approach to identify critical indicators of the risk of extrafamilial harm by applying contextual safeguarding principles; ensure that there is a process in place for regularly reviewing children being removed from a child protection plan without the outcomes being achieved; ensure that children who are out of school are given opportunities to voice their views of their situation.
| Title: Child V: child safeguarding practice review. LSCB: Sutton Local Safeguarding Children Partnership Author: Nicola Brownjohn Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child V Child Safeguarding Practice Review August 2021 Author: Nicola Brownjohn 2 1 CONTENTS 2 Introduction by Independent Author ................................................................................ 3 3 Executive summary ........................................................................................................... 4 4 Reason for commissioning the Local Child Safeguarding Practice Review ....................... 6 5 Purpose and scope of review ............................................................................................ 6 6 Involvement of Child V and his mother ............................................................................. 7 Child V ........................................................................................................................ 7 Child V’s Mother ........................................................................................................ 8 7 History and key circumstances of the case ....................................................................... 9 History ....................................................................................................................... 9 Key circumstances of the case ................................................................................. 11 8 Questions raised regarding how agencies worked together........................................... 13 Did agencies consider that Child V at risk of exploitation? ..................................... 13 What could have been done earlier in Child V’s life to change the outcome? ....... 14 How was the EHCP for Child V managed by the Multi-Agency Network? .............. 15 What significance did professionals place on the role of Child V’s access to male role models? ........................................................................................................................ 16 9 Analysis of practice .......................................................................................................... 17 Theme 1: Individual needs of the young person ..................................................... 17 Theme 2: Family history and dynamics ................................................................... 20 Theme 3: Quality of practice ................................................................................... 21 Theme 4: Impact of non-engagement on relationships? ........................................ 24 9.5 Theme 5: Disconnected Systems and Insufficient evidence of harm ........................... 25 10 Learning points ............................................................................................................ 26 School as a place of safety ....................................................................................... 27 Cumulative harm ..................................................................................................... 28 Contextual safeguarding: applying thinking to practice .......................................... 29 Relationship-based practice .................................................................................... 30 Hearing the child’s voice ......................................................................................... 31 Managing organisational or partnership risk .......................................................... 32 11 Key Practice Issues ....................................................................................................... 33 12 Conclusion ................................................................................................................... 34 13 Recommendations for LSCP Statutory Partners and relevant agencies ..................... 34 14 Appendices .................................................................................................................. 36 Methodology ........................................................................................................... 36 Action Plan ............................................................................................................... 38 3 2 INTRODUCTION BY INDEPENDENT AUTHOR I was commissioned to undertake this review in February 2021 by the Local Safeguarding Children Partnership (LSCP). The review focused on the circumstances prior to the incident resulting in a near fatal stabbing of a young person. For Sutton, this was the first incident of this nature to occur in the borough and the LSCP were keen to ensure that learning could be identified to prevent future incidents. As with any learning review, it is crucial that the subject, if still alive, and families are invited to contribute to the review. Unfortunately, both Child V, who is now an adult, and his mother have not responded to the offer to speak to me. Therefore, it is difficult to gain their perspective of what happened, and despite the despite the best efforts of agencies, the full details of the incident have not been discovered. In my view there are three potential reasons for the incident: 1. Child V was in the wrong place at the wrong time: Little is known about how Child V spent his days during that period of time. 2. Child V was involved in violent street crime: He was known to police and the youth justice system 3. This was a dispute between the family and other, unknown, individuals: Following the incident there was a fear of retaliation raised by mother and son. From my research I would consider 2 or 3 as holding the most likely underlying indicators of the risks faced by Child V. Additionally, he was reported to have been taken to the outside of the hospital by the perpetrators. This incident should not have happened. It could have been prevented had the systems of child protection, exploitation, youth offending, and education been able to find a way to work with Child V to facilitate him finding a safe pathway into adulthood. Nevertheless, my conclusion is that practitioners made immense efforts to try to find a way but were impeded by the influence of difficult historical involvement with the family. The National Panel recognise that adolescent reviews tend to focus on the recent past when it is seen to be difficult to make any positive change for the young person1. The Panel note that the major decisions that could have prevented the harm would have been in the adolescent’s early childhood years, but these periods are not considered within the learning of these reviews. 2 Therefore, I have 1 Dickens, J. et al. (2021) Annual Review of LCSPRs and Rapid Reviews. The Child Safeguarding Practice Review Panel. p.21. 2 ibid 4 attempted to pull into the learning ways in which the LSCP can ensure that other high risk adolescents are identified and that there is preventative work undertaken to improve the outcomes for younger children experiencing abuse or neglect. The report provides some contextual background of Child V’s life and then sets out a summary of the key periods within the timeframe of November 2019 and December 2020. Within the conduct of the review, questions were identified to follow through within conversations which then lead into the full analysis of practice. The core practice issues were explored in terms of how they relate to wider practice within Sutton, beyond this case. The report concludes with recommendations for improvement arising from the learning identified. This was a focused review using a brief chronology, documents showing key decisions within Child Protection Conferences and Missing and Child Exploitation Panel (MACE), plus conversations with practitioners, managers, and multi-agency groups. I would like to thank the services and individuals who contributed to the review in a candid and honest way. I know this case has made a significant impact on those involved with the family and there is an ambition to learn from it to improve outcomes for others in similar circumstances. 3 EXECUTIVE SUMMARY Child V was 17 years old when, in December 2020, he was sustained a near fatal knife injury. During the previous year, he had been subject to a Child Protection Plan until March 2020 and on the review list of the MACE until November 2020. Child V was dropped off at the hospital, possibly by the perpetrators, and walked into the Emergency Department alone. He was transferred to a trauma centre for a lifesaving operation. He is reported to have sustained long term damage to his lungs, limiting his work choices due to his breathing being impaired. He is now 18 years old. Prior to the incident, agencies attempted to address Child V’s needs but would be blocked through disengagement, and at times aggression, by the child or mother. Efforts were made to offer support to the mother for her own emotional and mental wellbeing, but she would only engage with the GP. Advocacy was offered for the child protection process, but she refused, assessments for both mother and child were offered but not taken up. This meant that professionals were unable to gain a deep understanding of Child V’s life or to develop stable relationships with him to promote positive outcomes. 5 This review has identified areas of good practice in how agencies recognised how the family could not work with statutory services. There was recognition that a few professionals were able to reach the family. It was agreed within the multi-agency network, at practice and management levels, that these workers could lead the work with the family. However, this was limited and only lasted for the time that the family would engage. Once that stopped then Child V was left again in an unknown world, within the home and outside. The review has identified key areas of learning for practice. Firstly, the need to view children who are not in school, especially those with Education, Health and Care Plans (EHCP), as high risk and requiring a safety network of agencies, not solely education, to work together. Considerable attention has been given to the importance of schools during the Covid-19 Pandemic in the extent to which schools provide a safe place for children3. For Child V, he lived much of his childhood without that safe place, not just a few months of lockdown. Secondly, there is a need for professionals to improve their understanding of the impact of cumulative harm on an adolescent who is struggling to find a safe transition into adulthood. Thirdly, the LSCP needs to ensure that the work already undertaken to develop a Contextual Safeguarding approach is strengthened to include a wider range of agencies. This will support the partnership to fully embed the approach into the safeguarding of children in the borough and embrace a culture of constant vigilance of the most high-risk children. Fourthly, and aligned to the Contextual Safeguarding approach, is the need to strengthen relationship-based practice throughout the multi-agency partnership. This requires all services working with children and families to reflect and review how they adapt their offer to facilitate the engagement of those who need their support, rather than closing the doors to them. Fifthly, as so often in children’s reviews, there is a need to ensure that the child’s voice is heard. For Child V, agencies could not reach him, but the challenge is for professionals to be supported, with time and resources, to persevere in their efforts to reach such young people. Finally, it was evident from this review that there was an ambition by senior managers to support their teams to work in different ways to reach a successful outcome. However, this can be a high risk for organisations and the partnership to manage. Nevertheless, it is important that the systems enable flexible working 3 The Child Safeguarding Practice Review Panel (2020) Supporting Vulnerable Children and Families during Covid-19: Practice Briefing. 6 when professionals are faced with blocks that cannot be broken down by the customary procedures. Child V survived a life-threatening assault. The learning for the LSCP is crucial in preventing this type of incident happening for other adolescents in Sutton. 4 REASON FOR COMMISSIONING THE LOCAL CHILD SAFEGUARDING PRACTICE REVIEW The Local Authority submitted a notification of serious child safeguarding notification, in relation to a knife stabbing, to the national Child Safeguarding Practice Review Panel within the statutory timescale after Child V’s assault was reported. On 08 January 2021, a statutory Local Safeguarding Children Partnership (LSCP) Rapid Review meeting was held to consider whether the criteria for undertaking a Local Child Safeguarding Practice Review (LCSPR) had been met based on the initial chronologies. The grounds for the decision to recommend a LCSPR at this point was that the initial chronologies and analysis of agency involvement by those organisations who had been involved in the case: a) Highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified. b) Highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children. c) Highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children. d) Where the safeguarding partners have cause for concern about the actions of a single agency. On 02 February 2021, the National Panel confirmed the decision that the case met the threshold for undertaking a LCSPR and the LSCP was advised that the learning could be through a local review. 5 PURPOSE AND SCOPE OF REVIEW The purpose of this LCSPR is to independently review the circumstances that led to the serious incident, in order to identify learning for individual agencies and the partnership. The LSCP must also seek assurance that children’s safeguarding needs are effectively responded to by local services and the wider partnership to prevent further serious incidents of this nature. 7 The scope of this Local Child Safeguarding Review is based on the requirements and quality standards set out in the Safeguarding Practice Review Panel: Practice Guidance (2019) and Working Together 2018 and includes: a) To review the circumstances and analyse critical incidents in the care of Child V during the period of November 2019 until 20 December 2020 and provide any other significant relevant information prior to this time. b) To review the professional involvement during Child V and the family’s involvement with services, specifically special educational needs, drug use and offending behaviour. c) To frame questions to explore and seek clarification on whether anything could have been done differently to prevent the serious youth violence incident from occurring. d) To engage directly with the Child V and the mother to explore their experience and perception of the effectiveness and impact of services and professionals. e) To engage directly with frontline practitioners and their managers to examine standards of practice and compliance with procedures and protocols with a view of identifying if there is future learning to improve practice and services. 6 INVOLVEMENT OF CHILD V AND HIS MOTHER Both Child V and his mother were contacted by letter offering them the opportunity to contribute to the review. However, neither responded. Given their relationship with statutory services, perhaps this is not surprising. Nevertheless, it means that the review has a significant gap in not being able to tell Child V’s story from his perspective. Therefore, this section will try to pull together a little of Child V’s life and consider this from his, and his mother’s perspective, by trying to be in their shoes. CHILD V Little is known of Child V’s lived experience, from his own voice. When he was 14, the EHCP noted his views: “I have conduct disorder and emotional and behavioural and social needs and I don’t like speaking to strangers. I don’t like meeting with strangers as I get panicky. I like going out with my friends on my bike. I enjoy playing football. My dream is to be a carpenter or work for Playstation. I think I am good at playstation, technology and fixing things like building my bike. I do not like going to school as it is really far. I find it hard when I have to speak to strangers. I find it hard to sit still and focus on work” 8 Child V is of mixed heritage, unlike his half siblings. Child V witnessed violence in the home at a young age. He has not been in school for four years. He is reported not to mix with peers of his own age but those who are already adults, but some previously known to the care system. One of his half siblings has a job which Child V has shown interest in. As part of the assessment for the initial child protection conference in 2019 there was a home visit by social workers. Child V was reported to be: “Initially frustrated with the social workers and said that he and his mum have been unsupported all this time. However, towards the end of the visit (Child V) indicated he wouldn’t mind working with Integrated Youth Services again. He ended the meeting in a polite manner telling the worker it was nice to meet them” The YOT worker managed to engage him on limited occasions and noted that Child V had aspirations for work and was happy to work with the YOT worker on his cannabis use. “Child V looked and sounded well. He was clean and tidy and made good eye contact with me. This was a massive turnaround from when I last tried to work with him about 18 months ago. At that time, he barely spoke to me and would sit at the top of the stairs, give ‘yes’ or ‘no’ answers and then quickly retreat into his bedroom” However, 3 days later, when Child V attended the centre to meet the YOT worker he did not engage well and did not turn up for the following session. CHILD V’S MOTHER Child V’s mother told the YOT worker that she could not relate to the social worker assigned to Child V for the Child Protection Plan in 2020 due to the social worker: “Being too young, no life experience and not a parent of teenagers” A mother’s perception of a professional at the start of the relationship means that the possibility of any productive work to be undertaken is highly unlikely and sets both up to fail. Child V’s mother did have, apparent, trusting relationships with some services, namely the YOT worker, NEET (Not in Education, Employment or Training) worker and, for a period of over 8 years, the GP practice. She was proactive in seeking help from these services and would contact them about Child V. There was evidence noted within the Child Protection minutes that Child V’s mother wanted him to get a career and employment and she would report to the police if he went missing. Therefore, she did demonstrate that she wanted a positive future for her son. Nevertheless, she did not have the ability to help her 9 son, or the capacity to fully understand the way professional support could only be effective with the family as active participants. In 2019, the social worker noted that: “From my observations and speaking with (Child V) it is clear that he has a strong bond with his mother. I observed her speak to (Child V) in a warm tone. She enquired about his mood, encouraged him to engage with me and paid attention to what (Child V) was saying. (Child v) also appears to worry about his mum and has been observed wanting to support her. (Mother) shared that (Child V) at times offered her money for electric and is able to manage his finances” 7 HISTORY AND KEY CIRCUMSTANCES OF THE CASE HISTORY Child V was the youngest child of a white British mother. His father was black Caribbean, unlike his half-siblings’ fathers. From an early age Child V was known to Children’s Services, in fact the local authority had been working with the family since 1997 in relation to the older children, with Child Protection (CP) Plans in place between 2004 and 2007, and 2008 to 2012. During this time, the focus was on the behaviour of one of Child V’s siblings who was viewed as being beyond parental control, as well as the mother’s parenting style, domestic violence, and alcohol misuse. A series of child protection and court proceedings ended in relation to the older children in July 2012, however concern regarding Child V’s schooling coupled with the lack of CAMHS involvement meant that the court proceedings for Child V continued until October 2012. Since 2011, an Education, Health and Care Plan (EHCP)4 (previously known as Statement of Educational Needs) had been in place for Child V. In June 2016, a referral was received via the National Society for the Prevention of Cruelty to Children (NSPCC). The concerns raised related to, unsubstantiated physical abuse, neglect, emotional abuse, and alcohol & substance misuse. Child V’s mother refused to cooperate with services. However, during this time Child V came to the notice of the Police for anti-social behaviour and assault on a peer. His mother informed the Police that Child V had learning difficulties with a mental age of seven. Child V was 13 years old at the time. Child V was given a youth caution and preventative work was offered by the YOT team however, the family did not engage. Later in 2016, Child V’s mother had an altercation with the Headteacher of his school which led to the mother being banned from the school premises and seems to have been the final issue that led 4 Statutory assessment under Children and Families Act 2014 10 to Child V’s school attendance declining to a point of no return. Child V’s mother refused support and alternative placements. Before November 2016, Child V had deteriorated to a school attendance level of 32.97%. By the end of 2018 he was off roll of any mainstream school. From 2017 until 2021, when he reached 18, he was provided with alternative placements, none of which proved successful. In 2016, it was recognised how vulnerable he would be in not attending school. However, his mother refused to engage with any services and refused entry into the home. In 2016 Police reported that there had been a long history of violence within the family, Child V was involved with a group of youngsters with disturbed behaviour and exposure to violent episodes both at home and outside. It was during this time that Child V was subject of a CP plan for neglect, but his mother refused to engage, and it was not possible for assessments to be completed. Nevertheless, the professional network recognised the risks that had the potential to have a negative impact on Child V’s development, including witnessing violence, non-school attendance, lack of mental health assessment and living in a household where he could be influenced by the behaviour of siblings. It was known that Child V was at high risk, not just from non-attendance at school, but also the violence and possible criminal behaviour of members of his family. However, care proceedings were unsuccessful in achieving his removal from the home. All options had been tried and were unsuccessful. There is a sense that the professional network had to withdraw due to insufficient evidence of harm. In 2018, there was an EHCP review for Child V held at the school where he had remained on roll. Child V was identified as having severe social, emotional, and mental health problems and ADHD. Child V’s mother attended and stated that she “didn’t want everyone to waste any more money on V as this money could be better used with pupils that will use it, as V is not going to”. She reported that Child V would be violent if forced to do something he did not want to do. She also reported her own mental health difficulties and ill-health. The outcome of the review was for a referral to NEET and work with the careers’ adviser rather than taking immediate legal action regarding non-attendance. Child V’s mother reported that he would be able to do some work experience with a family member once he reached 16 years. That was the final review held for Child V. In 2019, he was no longer on roll at the school and was not in a further education setting. Both he and his mother refused to engage. The NEET worker undertook the liaison between the SEND service and the family. In 2020, a review was not held due to waiting for an Educational 11 Psychology Assessment to be undertaken, which was refused by Child V and his mother. KEY CIRCUMSTANCES OF THE CASE There are four key episodes identified during the period in focus for the review. Key Episode 1: November 2019: Safeguarding Referrals During 2019, there were safeguarding referrals and concerns raised with Children’s Services. These culminated in a strategy discussion being held, in November 2019, which concluded that the concerns met the threshold to convene an Initial Child Protection Conference. The concerns included an anonymous referral was received by Children’s Services via the NSPCC. The concerns related to physical abuse, neglect, emotional abuse, alcohol, and substance misuse. The absence of an education placement was noted, and the education officer was tasked with finding one that would be agreeable to Child V. Key Episode 2: December 2019 – March 2020: Child Protection Plan In December 2019, Child V was made subject to a Child Protection Plan (CPP) under the category of emotional abuse. At the Initial Child Protection Conference, mother and Child V were present. Child V’s mother was angry at the conference. The decision was that the YOT social worker would liaise with the family as he was one professional who seemed able to engage the family. However, this was on a voluntary basis and the engagement was not sustained between the initial and review conference. The local authority reported that they had taken the case to the MACE panel which suggested a police welfare check. This was done however the police were unable to get into the family home as the mother would not give them access and Child V was not in the home. The mother did send a picture of Child V to the YOT worker to prove that he was alive. There was recognition by the Conference that Child V had a poor experience of childhood and that there had been a theme throughout his life, and his siblings’ lives, of a lack of boundaries and neglect. Consideration was given to Care Proceedings, however it was deemed unrealistic due to the outcome of previous proceedings in 2012 and 2016. It was acknowledged that both Children’s Services and IYS had made significant attempts to work with the family. However, due to their non-engagement, it was very difficult to decide how best to support the family. Child V’s age was deemed, alongside his childhood experiences, to limit his ability to change. He needed to be able to engage with services to move forward. He was considered to be old enough to advocate for himself and, without the evidence to back up the concerns that professionals had regarding Child V’s welfare, it was 12 decided that he did not meet the threshold for a CPP but needed early help services to continue to try to engage the family. Key Episode 3: March 2020 – October 2020: MACE Panel monitoring Child V was monitored through the MACE Panel from March 2020 due to the indications that he was involved in criminal activity, some of it in association with adults. The incidents included an aggravated vehicle taking and robbery charge, suspected aggravated burglary and several other burglaries, for which there was insufficient evidence of Child V being involved. He was also found in possession of cannabis and, during an unrelated search of the home, was found to have scales and snap bags in his bedroom along with knives and a baseball bat in the home, which the family denied were his. In March 2020, Child V was risk assessed as having low vulnerability to child exploitation, although it was recognised that this was likely to be higher but there were numerous unknown factors about his life. Nevertheless, in March Child V had been arrested, due to robbery charges, which led to a period of being on an electronically monitored curfew between the hours of 7.00pm and 7.00am. He complied with the curfew which allayed concerns slightly and his mother reported that he was easier to manage. He had weekly contact with the Integrated Youth Service (IYS) and was seen to be more engaging than when they had worked with him in 2018. There was limited information regarding his peer group but there seems to have been the suspicion that some of his peers were also known to the Youth Offending Team (YOT). In October 2020, Child V was assessed as being low risk. There was no evidence of current child exploitation concerns, with little being known about what was happening in his life. He was considered as being potentially vulnerable due to: Poor relationship with parents Parents own vulnerabilities History of abuse Poor school attendance Learning Disabilities/ communication problems Alcohol/drug misuse Mental health issues Low self esteem Change in engagement with professionals Engaging in anti-social behaviour 13 Additionally, there was evidence of potential grooming as he had been found in possession of unaccounted for items. The assessment score was 18 and this led to Child V being removed from the list, with no further action.5 Key episode 4: December 2020: Stabbing On 20 December 2020, the Police were called to the Emergency Department, at 1707hours, following a report from the hospital of Child V having walked in with a stab wound to the back, and was in a life-threatening condition and was deteriorating. Child V was transferred, by ambulance, to a trauma unit where he had a lifesaving operation. A strategy discussion was held on 21 December 2020, following which Child V’s mother agreed to her son being voluntarily accommodated under s20 of the Children Act 1989. Although she rescinded this agreement on 23 December 2020 and Child V was discharged home. 8 QUESTIONS RAISED REGARDING HOW AGENCIES WORKED TOGETHER Several questions were identified from the review of the chronology, documents, and discussions with staff. The purpose was to establish whether the incident could have been prevented, and what difference the agencies, either together or alone, could have made. DID AGENCIES CONSIDER THAT CHILD V AT RISK OF EXPLOITATION? It was reported that there was no evidence to show that Child V was being exploited. Nevertheless, he was reviewed at the MACE panels due the assessment that he was at a high risk of being exploited. He was believed to mix with older young people, who had poor life experiences, rather than peers. The understanding of the level of risks that Child V faced was difficult to assimilate with the actions of the MACE to remove him from the panel list. It seemed obvious that the outcomes for Child V would not be positive. Although he was clearly known to services, he was the ‘invisible young person’ as professionals could not reach him to gain his trust and facilitate any possibility of a positive outcome for him. 5 Sutton Exploitation Screening tool: 0-20 = low risk: No evidence of current Child Exploitation concerns. A child is potentially vulnerable to exploitation, but no current concern they are being targeted or groomed. Multi Agency Early Help responses to be considered. 14 The professional networks tried various ways to connect with Child V but ran out of options available to them. It was deemed that there was insufficient evidence to suggest that he was being exploited. Ultimately, although the assessment of risk was scored as low, the ‘gut feeling’ of those professionals who knew Child V, recognized that his risk was higher. The evidence of a ‘checklist’ was given more status than professional opinion. From the perspective of the MACE panel, there needed to be more evidence of the risks faced by Child V. WHAT COULD HAVE BEEN DONE EARLIER IN CHILD V’S LIFE TO CHANGE THE OUTCOME? Child V spent his childhood being neglected in some way. His needs were not prioritized within his family when younger, as he witnessed violence in the home; his education requirements within a school setting were not prioritized by his mother or schools. This led to him being out of the school system for 4 years, although he did have education support. This was a child who was known to have a conduct disorder and had an Education, Health and Care Plan in place. However, there was no therapeutic intervention for the conduct disorder as Child V’s mother had not taken him for the CAMHS assessment. The EHCP included the need for an Educational Psychology assessment which was not achieved due to both mother and child not agreeing to take part. Child V had been subject to a CPP earlier in his life and had been known by Children’s Services throughout his life. However, relationships between professionals and Child V’s mother failed, leading to her pushing services away. Child V was left to grow up with his mother, without the safe space of a school placement. At the end of 2019, when there had been an anonymous referral to the NSPCC regarding neglect of Child V, full consideration was given to the need to protect him. He was made subject of a Child Protection Plan, but the idea of progressing to Care Proceedings was not taken forward due to his age and that previous Proceedings had not achieved the safety that professionals desired for Child V. It is difficult to see a child, aged 16 or 17, left in a potentially unsafe situation due to his age. However, when this was discussed with various professionals, as part of the review, it was very clear that they felt all options had been fully considered. There was a consensus that to have progressed with Care Proceedings would not 15 have helped Child V. If he had been removed from his mother there was an extreme likelihood that he would abscond, return to his mother and his associates in the community. There was a definite sense that the connection between Child V and his mother was strong. There was also evidence that his mother wanted to protect him from the outside world but found it all but impossible to trust professionals to help her to do this. The impact of decisions earlier in Child V’s life had left professionals making assumptions about their ability to progress with meaningful relationships with the family that would make a positive difference his life. HOW WAS THE EHCP FOR CHILD V MANAGED BY THE MULTI-AGENCY NETWORK? It was striking that Child V was reported not to have been in school for 3 or 4 years. This gives the impression that he had no access to education during that time but had an EHCP. However, the Special Educational Needs and Disability (SEND) team explained that he did have access to education during that time and there were immense efforts to provide bespoke packages. It was reported that he was provided with Social, emotional and Mental Health Need (SEMH) placements but the family did not engage with these provisions. Then, once he had reached 16, his mother said her son would not engage, and a home online package was provided, but again was unsuccessful. It needed commitment from the family to follow through with the work. There were other placements offered and Child V did engage for short periods in the Life Centre work, but he did not receive a consistent secondary education, i.e., 2015-2021. However, this was a child who had an Education, Health and Care Plan (Statement of Educational Needs) from 2011. Child V was known to the Not in Education, Employment or Training (NEET) worker who was able to connect with Child V and his mother, intermittently. Efforts, currently, continue to be made to try to engage Child V in education or work experience to enable him to move forward into a positive adult life. At the start of 2020, Child V was subject to a Child Protection Plan. Within the documentation, of the CP conference, seen there was evidence that it was recognised that NEET needed to be involved with Child V. However, there was no representation from education at the conferences. From the evidence found, there was a misunderstanding between social workers and education regarding the process of invites. This meant that the vital contribution of the SEND team was missed. Subsequently, there was a lack of understanding about Child V’s educational needs, the fact that he did have an EHCP, and the reasons behind him not being in a school placement. 16 At this point neither mother nor child were actively engaging in the education opportunities offered. Indeed, there is sparce evidence of how Child V spent his day. It was reported that the mother had told workers that she felt let down by the education system for not providing her son with the right placement. This contradicts what she had told the EHCP review in 2018 that her son would not accept anything. Workers did try to see Child V at home, with little success. His mother warned professionals that Child V would be aggressive if they visited. Meanwhile, there were offers for him to meet workers at outside venues, but this required a commitment from him or his mother to get there. There seemed to be a significant expectation on his mother to address the needs of a child with a conduct disorder who was limited, without intervention, in being able to function within society. WHAT SIGNIFICANCE DID PROFESSIONALS PLACE ON THE ROLE OF CHILD V’S ACCESS TO MALE ROLE MODELS? It is not clear what involvement Child V’s father had in his life. The impression is that he did not feature after the family were moved due to him being violent. Child V’s mother raised concerns at the Initial CP Conference in December 2019 that the father’s details were recorded on the documentation. She informed the professionals that her ex-partner was not permitted to know the family’s location. However, there were suggestions that Child V had been bought an expensive coat by his father. This was not explored by professionals because they could not reach a point of a trusting relationship to discuss this with the family. This highlights the invisibility of a father to professionals and the poor understanding of the impact that of that parent on a child’s life. This has been identified extensively within other reviews, as professionals fail to ask about fathers and men in the lives of the child6. Thus, the need of a child to have positive male role models in their life is missed. Child V had half-brothers who were, at times, involved in Child V’s life. Indeed, Child V reported being interested in the work that one of his brothers did. However, there were varying professional views as to who was living in the home. The male professionals involved during the period reviewed seemed to have the most success, albeit limited, in reaching Child V. This was recognized within the CP Conference with the plan for the YOT worker to engage with him. 6 Dickens, J. et al. (2021) Annual Review of LCSPRs and Rapid Reviews. The Child Safeguarding Practice Review Panel. 17 9 ANALYSIS OF PRACTICE The terms of reference identified three key themes for exploration: Individual needs of the young person; family history and dynamics; Quality of practice. Two further themes were identified during the review. THEME 1: INDIVIDUAL NEEDS OF THE YOUNG PERSON Child V was viewed through his needs and behaviours: Conduct Disorder / Oppositional Defiance Disorder (ODD)/Unsocialised Conduct Disorder Long term absence from school and Learning difficulties Trauma from childhood experiences Offending behaviour Additionally, there is a theme of how his unique identity and ethnicity were not visible within the documents reviewed. Conduct disorder It was noted that Child V had a conduct disorder but there were varying accounts of what actual diagnosis he had. The GP was able to confirm that, in 2013, he was seen by CAMHS and had a diagnosis of Unsocialised Conduct Disorder. However, due to his mother not taking him for appointments, CAMHS closed his case and, therefore, ended the opportunity for a coordinated approach to provide Child V with the high-quality care as defined by NICE.7 This review did not explore what options were offered by CAMHS as their involvement had ended many years ago. However, within the CPP it was recognised that he had a conduct disorder, but any assessment had been refused by his mother. There did not appear to be any consultation with CAMHS to aid the decision making. It was just seen as one of those too difficult things to address because it would have needed mother’s engagement. Given that Child V’s mother had a good relationship with the GP practice, this could have been a route in for agencies to encourage her to take her son to CAMHS appointments. Between the CP Conference and the EHCP reviews there should have been the opportunity for workers to discuss with Child V and his mother the need for assessment and treatment of his disorder to enable him to function safely and transition into adulthood. Although, the EHCP included an educational psychology assessment, this was incomplete due to workers not being able to engage Child V and his mother. 7 https://www.nice.org.uk/guidance/cg158 : accessed 31 May 2021. 18 There remains insufficient knowledge of Child V’s life experience and his insight into how the conduct disorder affects him. Nevertheless, there is sufficient evidence that Child V did not receive the intervention he needed to support his mental and emotional needs. This is deemed to be due the negative response from Child V and his mother to voluntary interventions and assessments. However, there was evidence that mother reported that Child V could become aggressive when asked to do something he did not want to do. This showed that his mother had difficulty in managing him. Therefore, the expectations placed on the mother to get Child V to appointments were unrealistic. It is of note that Child V did access hospital services, when necessary, and the YOT/IYS, when required. Therefore, the potential for a different approach to attempt to reach Child V was available but not addressed by the multi-agency network. School absence and learning difficulties For the scope of this review, Child V was not at school and had not been for years. In fact, in 2016 when he had previously been subject of a CPP and Care Proceedings, the main problem was seen as him not attending school. At that time, he was 12 or 13 years of age. More should have been done at this point, or earlier in primary school, to ensure that he was in a school placement that could meet his needs. The view held within the EHCP was that education was not the main problem for him, yet it was the SEND service that was having to continue to find a solution. Education provision was offered during those years, but this seems to have been isolated from the wider professional network. This diminished the opportunities for a holistic solution focus within MACE, Child Protection Conferences, EHCP meetings and youth offending discussions. There was an incomplete picture of the extent of his learning difficulties. This with the unmanaged conduct disorder meant that Child V did not receive the assessment and treatment set out in the NICE guidance. There was no consultation for professionals with CAMHS or Educational Psychology. There needed to be a collaborative approach to ‘wrap around’ a family to prevent the misdirection of professionals. Child V had a severely limited education. From a history of moving schools, exclusions, and non-attendance at alternative placements. He missed out on the safety of a school, positive role modelling, learning opportunities, management of his conduct disorder, all that would be needed to enable him to function well within society. 19 Given Child V’s emotional behavioural issues and communication difficulties, his needs should have been considered in collaboration between education, child protection and youth justice rather than in isolation of each other, to give him constructive support. There were assumptions made of the authority of each system to enforce change. There were reports of him being interested in a job done by one of his brothers which seemed positive, but this needed Child V to take part in educational activity at a time when he had been out of school for too long and struggled with the concept of a college course. There was also an indication that a male relative was going to get him some work experience, but this was when he was 16, and there was no knowledge of whether that came to fruition. Childhood trauma This family reflected high levels of harm towards the children due to witnessing violence or being subjected to physical harm. In Child V’s early years, his mother was viewed as being able to manage him, although there was evidence of her not managing the older sibling. In 2019, there was another opportunity to address the harm Child V had been subject to during his life, but the professional network was incapacitated from making any impact to improve his life chances. He was about to transition into adulthood on an unsafe pathway. There was a dearth of legal options available to professionals due to his age and these would not have kept Child V any safer than he was with his family. For Child V, he needed a ‘reachable, teachable moment’ which was unlikely to be found until he was within the criminal justice system. Although, he had been seen during 2019-20 within hospital settings, it was not until after the stabbing, that he was seen a trauma centre where he would have had access to youth workers to talk to him. Had he had an opportunity for that moment when he might listen to trusted adults, within the local hospital or urgent care setting, he might have been ‘reached’ before the incident. 9.1.4 Offending behaviour Child V was known to take risks. He was known to Police and to YOT. Over a period of five years, he came to the notice of the Police 175 times. Yet, he managed to keep on the edge of criminal activity and risk taking, thus avoiding any intensive agency intervention, until he became the victim of a violent assault. It is possible that he could have just as easily have been a perpetrator rather than a victim. More should have been done to view him as a child, at risk of exploitation. If this had been done, in alignment with the child protection work and knowledge of his 20 learning difficulties, it might have been possible to find a way to work with him to reduce his risk taking. 9.1.5 Identity and ethnicity It is not known how Child V has found his identity within his family and difficult to make a judgement without speaking to him and his mother. Nevertheless, there was a view from some professionals that Child V’s mother struggled with him being a person of colour. Although this was not found to have been explored by professionals. In the documents reviewed, there was evidence of recording of his ethnicity, but this was not used in any context for the work being undertaken. For example, it was noted in the MACE risk assessment but there was no mention of ethnicity as a factor in the risks of exploitation faced by Child V. In fact, in terms of youth violence, he did not fit the Sutton profile that shows that the majority of victims of knife crime in Sutton are male, over 18 years of age and of White European ethnicity, indeed there has been a substantial reduction in the number of knife crime victims under the age of 258. THEME 2: FAMILY HISTORY AND DYNAMICS This is a family known to services for over 20 years, yet there was limited knowledge of Child V’s life during his teenage years. According to the genogram, Child V has four half-sisters and two half-brothers. The two brothers and one sister seem to have been part of Child V’s home life, although one of the brothers had been in care and in 2016 continued to have a different address. It is not known where the sister is but there were reports of the other brother returning to the home. There have been varying views from professionals as to who else is currently living in the home. This shows that there was information available about Child V which was only reviewed by individual agencies rather than within a multi-agency context. Had it been there would have been the opportunities for more questioning by professionals about how this young person could achieve his full potential and how they could work together to facilitate this. This theme is subdivided into: Dysfunctional families Mother’s influence 8 Sutton Serious Youth Violence Strategy. 21 Dysfunctional families So little is known about the family, although they have been known to services for the whole of Child V’s life, and earlier. Agencies made numerous attempts to get into the home whilst Child V was subject to a CPP during the first part of 2020, but both Child V and his mother blocked this. This meant that there was limited understanding about Child V’s experience in the home and the adults who have been part of his life. Professionals recognised that this was a dysfunctional family over long period of time, through consistently withdrawing from services after short periods, historical violence within the home, difficulties in parenting and boundary setting, indicators of substance misuse and criminal activity. Child V appears to have spent his childhood learning to live in isolation from positive social experiences and professional contact. He has learned to live in a transactional world with others, like him, who struggle to function within mainstream society. Mother’s influence The dominating figure in making decisions about Child V’s life is his mother. From her arguments with schools, mistrust of social workers, refusal to let workers into the home and not taking Child V to appointments, she appears to have dictated the path that Child V has led and continues to lead. Services report that mother has her own, long term, mental health issues, possible, substance misuse, and aggressive responses to professionals. Although she has managed to remain a patient at the same GP Practice for many years. She has a working relationship with the team there, to the extent that, when agencies had not seen Child V, the social worker asked the GP Practice to check with mother. The Practice Manager phoned the mother and she obliged by passing the phone to Child V. This shows that there were ways of working with the mother which could deliver successful responses, even though small. THEME 3: QUALITY OF PRACTICE The initial finding, in relation to the quality of practice, is that Child V was ‘unreachable’ by services. There were numerous proactive attempts to accommodate both his, and his mother’s, wishes. However, when systems were put in place to help Child V, either he would not follow through with taking part in the work, or his mother refused the involvement of the professionals. The impression is that services were not able to move forward with supporting, and protecting, Child V. The focus moved onto him as an offender, but this seems to have been mainly due to the YOT worker being the main person with any chance 22 of engaging Child V. The consequence was that the necessary assessments were not completed as these required other professionals and services to be involved. The systems did not support the individual professionals and services to make a positive difference to Child V’s life chances due to the need for families to ‘engage’ with services. Although there was supervision in place for workers, and line managers were focused on supporting their staff, e.g., at the CP conference, there needed to be more opportunities for bringing together the key agencies to find a solution and to be able to formalise the agreed approach. This needs to be set within a statutory framework to ensure that plans do not drift, due to informal arrangements. In the case of Child V, the CP Plan was the appropriate mechanism to hold the work together, rather than stepping down to early help at the point at which the YOT worker was no longer able to commit to the efforts made to reach the young person. There are three key areas of practice to be considered: Assumptions about historical decision-making Quality of multi-agency meetings: CP Conference and MACE Panel Responding to Risk 9.3.1 The assumptions that professionals make regarding historical decisions and the influence this has on their current concerns In 2012 and 2016 there had been care proceedings which resulted in supervision orders which the mother ignored. There was a sense from the social work team that they had been failed by the judge and guardian ad litem as the request had been for removal of Child V from the care of his mother. However, when this was checked with the legal team, it was found that Children’s Services, certainly in 2016, had not asked for removal. Nevertheless, this seems to have been the view that led to the thinking at the Child Protection Conferences in 2019 and 2020, i.e., not to go for care proceedings. It was clear from the conversations held with the professionals that Care Proceedings would not have worked for Child V due to his age and his strong bond with his mother. Child V was seen to be able to advocate for himself. However, there was no consideration of alternative options which created a mindset of if something did not work then the risks to the child must be low. 9.3.2 Quality of multi-agency meetings: CP Conference and MACE Panel Child V’s mother would not engage with the CPP 2019-2020. Within the initial conference it was clear that she would not work with Children’s Services. As Child V had been engaged with YOT/IYS, it was decided that the worker would lead the interventions with Child V and his mother. This was agreed at senior management 23 level. It was positive in recognising that Child V’s mother was difficult to engage but had a good relationship with the YOT worker. The expectation was that the YOT worker would be the key practitioner if the family would agree to engage. However, Child V chose not to continue to work with the YOT worker who was unable to influence this as there had been no formal arrangement for Child V to be on his caseload. Although it was included within the CP Plan that this would be the way forward, there was no consideration of the potential outcomes. Meanwhile, the MACE panel continued to monitor Child V, but could not establish the evidence of high risk for him, despite the intuition of the IYS worker who was another professional able to have some, limited, engagement with Child V. Subsequently, MACE monitoring came to an end before the incident as well. There was consideration of the risks at the Child Protection Conferences and MACE panels. This was supported by managers who attended the meetings regarding Child V as they recognised the risk to their teams. However, both professional networks did not find the tools to support them to address the risks. Decisions were based on incomplete assessments due to being unable to reach the family. There needed to be formalised work on behalf of the systems. Targeted intervention, using mentoring, needs to be intensive and consistent to enable trusting relationships to be established9. This could have supported Child V, and his mother, to start to trust other workers and agree to further intervention and assessments. However, for this to have been successful it needed to be embedded within the CP Plan, EHCP and MACE plan. Responding to risk Child V was part of a cohort of high-risk adolescents who seem to be ‘unreachable’ by statutory services. Child V met the profile for a wide range of risk factors for both perpetrator and victim of serious violence as set out in the national youth strategy10. It is extremely difficult to manage the risks for this cohort without a coordinated, consistent approach. Otherwise, as in Child V’s case, there can be a tendency for workers and organisations to feel powerless to change the young person’s life chances. 9https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/498493/what-works-in-managing-young-people-who-offend.pdf : accessed 19 June 2021. 10 Home Office (2018) serious Youth Violence Strategy pp32-43 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/698009/serious-violence-strategy.pdf : accessed 19 June 2021. 24 For Child V, during 2019-2020, there were growing indicators of the risks he posed for himself and others, whilst his mother continued to be unable to effectively interact with the professionals who could assist her in keeping her son safe. There were three, somewhat disconnected, systems in place: Child Protection, MACE, and EHCP. These did not work together to pool their information regarding the risks Child V faced. Additionally, there was no inclusion of specific services such as GP and A&E which could have been points for reaching Child V and his mother more effectively. THEME 4: IMPACT OF NON-ENGAGEMENT ON RELATIONSHIPS This family did not engage with services over most of Child V’s lifetime. There was evidence of limited engagement with some services, but actions would not be completed by the family. The lack of ‘engagement’ can be divided into different themes: Not taking a child to appointments leading to a service closing the door to the family Aggressive attitude by a parent leading to a service withdrawing from the family Family members needing to undertake activity to help themselves but not doing so, leading to no improvement and the service withdrawing from the family In Child V’s case, his mother had several poor experiences with professionals over the years of being a parent. Meanwhile, there is no knowledge of her own childhood experience. Child V had a poor experience of school and saw his mother’s difficult relationships with most professionals. Child V lived in a household where the avoidance of statutory agencies was normalised. His mother avoided any service where there were expectations made of her to act, i.e., Children’s Services, CAMHS and education. This meant that Child V was aware that it was possible to avoid any perceived interference. However, this also meant that he had little exposure to potential trusted adults who could help him, and when they did appear he dropped them if he needed to be an active participant in the relationship. Child V connected with the IYS/YOT but only when he chose to, e.g., he attended the centre to meet with the YOT social worker in relation to his use of cannabis. He appeared, initially, to take an interest in the activities to understand the impact of substance misuse but then disengaged. This does not appear to have been an issue of the service not being flexible enough but, rather, that Child V realised that it was voluntary, and he made the choice to not attend. 25 There is a definite sense that the family know how to use services, specifically health services. Child V’s mother used the GP practice and had remained a patient there for many years. The reason for this was that the staff there had also been in place for years and understood Child V’s mother and responded to her needs. Interestingly, Child V was not proactive in using the GP practice. His mother would contact the GP on his behalf. Meanwhile, if Child V needed health care, he would take himself to A&E, and this remains the case. However, what Child V needed was education services and CAMHS intervention to address his conduct disorder and learning difficulties. Yet neither he, or his mother, recognised these in the same way as they did general or urgent health services. The difference being that the latter are available whenever an individual decides they need support, whereas education and CAMHS require active participation and are not immediately available. Non-engagement cannot be a reason to stop statutory work to safeguard a child. There needs to be a united front by professionals with an agreed plan, single lead practitioner, shared purpose and agreed outcomes for change. The impact of non-engagement for the future management of Child V’s disorder and learning difficulties needed to be addressed by the agencies. 9.5 THEME 5: DISCONNECTED SYSTEMS AND INSUFFICIENT EVIDENCE OF HARM At the Initial CP Conference in December 2019, the threshold was considered, unanimously, to have been met. However, at the Review CP Conference in 2020, it was concluded that there was insufficient evidence of harm. Only months later, the MACE concluded that there was insufficient evidence of exploitation. From November 2019 until December 2020 when Child V arrived at the hospital having been stabbed in the chest, there were concerns about Child V but never sufficient for immediate action. There should have been a clear agreement, between the CP Conference members and the MACE panel, on the expected outcomes for him to ensure that he was not left without the safety net of either11. Individual workers, and managers, were concerned for the safety of Child V. Managers attended Child Protection Conferences and decisions were discussed with senior managers. Yet, there was still a mindset of professional powerlessness when Child V or his mother would not engage with services sufficiently to enable evidence to be gathered to fully understand the risks Child V faced. 11 Sheffield Safeguarding Children Board (2020) Serious Case Review: Archie. 26 This has been raised in other reviews of various safeguarding work, under the auspices of professional curiosity. This can be viewed as a ‘cliché’ as a way of not fully exploring the underlying reasons why adolescents might be seen as ‘troublesome’.12 For Child V, professionals knew a great deal about his history, they felt blocked by his mother in their efforts to initiate any up-to-date enquiry into Child V’s behaviour and thought processes. This left him isolated. 10 LEARNING POINTS The criteria for this review included: a) Highlights or may highlight improvements needed to safeguard and promote the welfare of children, including where those improvements have been previously identified. In this case, the practice systems for child protection, criminal exploitation and special educational needs did not support practitioners in coming together to find a way of safeguarding Child V and enabling him to have a successful transition into adulthood. The review shows that improvements are needed in the way the multi-agency networks communicate with each other and in how adolescents are safeguarded within Sutton. b) Highlights or may highlight recurrent themes in the safeguarding and promotion of the welfare of children. The review suggests that there is a recurring theme of how agencies support children who are not in education but have complex needs in relation to their social and emotional wellbeing. c) Highlights or may highlight concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children. The review highlights that there is a disconnect between education services and the child protection system. There are concerns about the absence of CAMHS within the EHCP and child protection systems when families have disengaged with the service. d) Where the safeguarding partners have cause for concern about the actions of a single agency. 12 Dickens, J. et al. (2021) Annual Review of LCSPRs and Rapid Reviews. The Child Safeguarding Practice Review Panel. 27 The focus of this review has been on how agencies have worked together rather than any cause for concern about a single agency. Nevertheless, there does need to be more understanding and consideration of the role of the Police in working with partners to address how to find evidence of criminal exploitation when professionals intuitively know that a child is at risk of harm. Additionally, although not asked to contribute to the review, there should be discussion about how CAMHS can contribute to CP Conferences and EHCP reviews, in a consultative manner, for children who should be under their care. This case shines a light on the Sutton systems in six specific areas: School as a place of safety Cumulative harm Contextual safeguarding Relationship-based practice Hearing the child’s voice Managing organisational risk SCHOOL AS A PLACE OF SAFETY The Covid-19 Pandemic has highlighted the risks to children when they have long term absences from school, as for so many during the first lockdown in spring 202013. However, there were already a cohort of children without access to regular school time, either through parents not taking them to school, children absenting themselves, or schools using permanent exclusions. These children can be invisible to services and wider society. These children have limited ways of making their voices heard. These children are at high risk of exploitation due to their invisibility and exclusion is a definitive indicator for being at risk of significant harm14. The pandemic has emphasised the extent to which a school is a place of safety for children. Taking the Covid-19 lockdown as a benchmark, those who have not been in school for four to six months are at highest risk. Some will remain on the school roll, but this might be placed out of borough. Therefore, there needs to be tighter monitoring of these children to ensure that there is joint working with neighbouring boroughs to find a way of sharing information, thoroughly and timely, for children who are not attending school, particularly those who have behavioural disorders. 13 The Child Safeguarding Practice Review Panel (2020) Supporting vulnerable children and families during COVID-19: Practice Briefing. DFE. 14 The Child Safeguarding Practice Review Panel (2020) It was hard to escape: Safeguarding children at risk from criminal exploitation. DFE. 28 The second aspect of school safety is that of providing special educational needs support, which, again, is a serious problem when a child has been excluded or does not have access to a placement that can meet their needs. This lack of access can be through insufficient supply or parental refusal. This was raised in a previous Sutton review15. It has been shown that much work has been done to improve the SEND offer16 in Sutton, including the development of the ‘Graduated Response to Preventing Exclusions’.17 Nevertheless, there continues to be a need for more, multi-agency, analysis regarding those highest risk children with complex behavioural needs who sit outside of the school system. CUMULATIVE HARM A child growing up in a household where the dominating issues are those of the parents, such as violence or mental health problems, can lead to the child not having their needs adequately addressed. When the child has been diagnosed with a behavioural disorder, any lack of supervision or affection by the parents can exacerbate the child’s risky behaviour. Alongside this, there can be a lack of effective professional intervention due to the parental dynamics, just when robust, creative interventions are needed to enable this child to reach their full potential18. Brandon et al. (2020) highlighted the long-term harm caused to a child when there are parental and environmental risk factors present19. They noted that ‘When there is a focus on parental illness (mental and/or physical) and other difficulties, the voice and lived experience of the child can easily be overlooked’20. Within Sutton, for Child V, there was plenty of historical information available. Within formal networks, the agencies worked together well in their ambition to make a positive difference to the child. However, Brandon et al (2020) suggest that the amount of information held, and the nature of complex families such as Child V’s, can block the sight of the professionals attempts to identify the risks face by the child and opportunities to understand the lived experience of the child.21 Brandon et al (2020) found that: 15 Sutton LSCP (2020) Child Safeguarding Practice Review: Child T. 16 DFE (2015) Special Educational Needs and Disability Code of Practice: 0-25 years; Sutton Local Offer www.sutton.gov.uk : accessed 31 May 2021. 17 Sutton Schools Graduated Response - Preventing Exclusion. https://www.sutton.gov.uk/downloads/file/4260/sutton_schools_graduated_response_-_preventing_exclusion: accessed 31 May 2021. 18 Okuda M et al. (2018). Do parenting behaviors modify the way sensation seeking influences antisocial behaviors? Journal of Child Psychology and Psychiatry, 60, 169-177. doi: 10.1111/jcpp.12954 19 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE. p14. 20 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE.p16. 21 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE.p66. 29 ‘Adolescents were living in situations of neglect may be particularly vulnerable to having their needs, and the risks they face, overlooked. Clear pathways for transition to adult services are important to ensure young people receive the care and support they need.’22 Therefore, the Sutton LSCP needs to gain assurance that adolescents are not left at high risk due to the family living in isolation of societal support. During one of the workshops held as part of this review, there was a decision that the partnership needed to monitor the ‘top 10’ children at risk to find ways of intervening to help them to achieve their full potential. This should be done for those at different, crucial, transition periods of childhood such as ages 4-5, 10-11, 15-16. This was raised at a workshop on 20 May 2021, which led to a discussion as to how the Sutton Vulnerable Pupil Panels could be utilised to initiate multi-agency problem solving work in relation to those children who are deemed to be at highest risk of long-term harm but appear to be ‘unreachable’. CONTEXTUAL SAFEGUARDING: APPLYING THINKING TO PRACTICE The Contextual Safeguarding work underway in Sutton could be used to strengthen the approach towards this age group, in enabling practitioners to be more enquiring about the ‘capacity of contexts to create safety around young people and open-up safer choices.’ 23 This could build on the work done by Children’s Social Care through their restorative practice model. Firmin (2018) found that 33% of young people involved in a study of nine peer on peer cases, had experience of harmful behaviour within their families.24 However, the expectations of programmes to reduce community antisocial behaviour by young people, usually rests with the need for parents to supervise their children25. Yet, for a young person such as Child V, this a way of setting the family up to fail as the parenting capacity is not at a level to provide the supervision he needed. Sutton is currently doing work in the upscaling of Contextual Safeguarding, with a project lead who is facilitating the discussions into whether the concerns are about the individual young person or the community. The workshop held, as part of this review on 20 May 2021, discussed the need to find ways of working with young people whose behaviour is entrenched. Workers need to have the tools to engage 22 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE.p66. 23 Owens, R. et al. (2020) Relationship-based Practice and Contextual Safeguarding: Key messages for practice. p.9. https://www.csnetwork.org.uk/en/resources/briefings/practice-briefings : accessed 19 June 2021. 24 Firmin, C. (2018) Abuse between Young People: A contextual account. Routledge. Oxon. 25 Featherstone, B. et al. (2020) The Social Model and Contextual Safeguarding Key Messages for Practice. The International Centre. 30 with the young people, and their families, without becoming overwhelmed by the complexity of their lives. At the May 2021, workshop it was suggested that young people are asked to name a key person who has made a difference in their life. Anecdotally, where a young person can name a key adult then that young person has managed to find the right path into adulthood. Therefore, the ambition should be that all children and young people are able to identify one adult who has been a protective factor for them. Of note, the local hospital Emergency Department (ED) does not have youth worker provision, due to it not being a trauma centre. Considering the frequency of use by Child V of the ED, it seems to have been a missed opportunity for him to be reached by professionals. The Contextual Safeguarding work provides the opportunity for the LSCP to think about the wider possibilities to reach young people and what measures can be put in place as they transition into adulthood. RELATIONSHIP-BASED PRACTICE This case demonstrates the difficulties that professionals face when parents refuse to engage with the service, be it voluntary or a statutory requirement such as schools or CPPs. The children in these families do not learn how to have a trusting relationship with services designed to help them. The professionals can view these families as not engaging and reduce the level of activity to attempt interventions. Within this case, the ‘non-engagement’ took place throughout Child V’s life, and this had a severe negative impact on his ability to reach adulthood safely and with a positive purpose for life. The term ‘non-engagement’ is used frequently for families who do not attend appointments, because a parent has not taken the child; for parents who refuse to work with social workers, and others, to change their behaviour to enable them to meet the needs of their children; constant changes of individual practitioners mean that parents can lose the willingness to work with professionals. However, this maintains the focus on the adult relationships and allows the child to be lost without a voice. Brandon et al. (2020) placed a vital importance on the need for professionals to develop good relationships with families to enable good understanding of the family context and effectively manage the complex risks over a period of time, which are not impeded by staff changes. 26 This includes the need to have a workforce capable of developing an empathetic relationship with parents. 26 Brandon et al (2020) Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report. DFE.p18. 31 There needs to be clear understanding of the reasons for a family to ‘non-engage’ and what the resulting risks are for the child. Additionally, organisations need to challenge themselves about the level of flexibility their service provides, to ensure that avoids promoting a ‘one size fits all’ approach but recognises the personalised needs of those they are trying to reach. The National Panel (2021) found that a key theme of reviews was that some parents were overwhelmed by the number of professionals they needed to work with.27 The emphasises the need for a single practitioner to take the lead. This does not necessarily need to be a social worker, as in the efforts made within the CP plan within the case of Child V, but this role must be recognised, given the resources and authority to act. Within Contextual Safeguarding, there is a significant focus on the importance of relationships for interventions with children and young people at risk of exploitation. These relationships are seen as having five key features, consistency, reliability, stability, continuity, and authenticity28. This case review shows the need for adolescents to have consistent relationships with professionals, which can set clear expectations. The case demonstrated that not all services did what they said they would do, throughout the child’s life, e.g., following through with options for activities. There needs to be strengthening of how workers gain a good understanding of the impact of a child’s experience of professionals. HEARING THE CHILD’S VOICE Consider how to gain the trust of a child to enable them to be able to disclose, when they are ready. There can be challenges regarding children disclosing abuse or neglect but then there is no improvement in their situation. Professionals need to recognise the strength of relationships between children and their parents even when professionals can see neglect. If a child is in school, there are more opportunities to hear their voice than if they are never in school. Therefore, the voice of the child should be a high priority for professionals trying to work with families where a child has been permanently excluded or absent from school. Additionally, for children with special educational needs, they can be excluded from having their voice heard from an early age, due to the reliance of services on the parents to engage with the interventions. 27 The Child safeguarding Practice Review Panel (2021) Annual report 2020: Patterns in Practice, Key Messages and 2021 work programme. 28 Owens, R. et al. (2020) Relationship-based Practice and Contextual Safeguarding: Key messages for practice. https://www.csnetwork.org.uk/en/resources/briefings/practice-briefings : accessed 19 June 2021. 32 MANAGING ORGANISATIONAL OR PARTNERSHIP RISK Working with adolescents who have complex needs can be challenging for organisations and partnerships to manage. The role of the parents can become a conflict with the growing independence of the young person. This makes it challenging for professionals when undertaking assessments and planning interventions. Under 18 is still a child under the Children’s Act 1989, yet it can be extremely difficult for professionals to take forward legal protective actions due to either the parental obstruction or that of the young person themselves. There is evidence of an approach akin to that of a social model that promotes a way of working that diminishes ‘them and us’ professional to family conversations and encourages thinking about the wider inequalities for a child and family.29 In this case, Sutton made use of the fact that the mother could not work with social workers due to her previous experience. Therefore, the plan was made to utilise a professional who was known to connect with the mother. This posed a high level of risk for Children’s Services to step down from the Child Protection model. However, it was a risk that was held by the senior leaders and is something to build on. If that way of working had been tried at earlier and had the resource and provided the worker with the ‘permission to act’ rather than being seen as an informal approach, this might have helped the young person more. The Contextual Safeguarding scale up work being undertaken in Sutton could be used to strengthen this approach, through a partnership commitment to fund workers who can undertake the intensive interventions with the children and young people most at risk of exploitation30. The Sutton approach to the use of the Vulnerable Pupils Panel (VPP) and Graduated Response provides a good framework for managing the risk for these children and young people. However, within the framework it requires referrals to other services, thus the LSCP needs to be able to gain assurance that all referral pathways enable a quick response to referrals from the VPP. This needs to include a collaborative approach from the three statutory partners: the police need to strengthen their engagement with the Contextual Safeguarding work through sharing data and critically planning how to disrupt the serious youth violence that meets the needs of the distinct Sutton profile; the CCG needs to ensure that CAMHS services are commissioned in a way that enables intervention for those at risk of serious youth violence or isolation from a school community, and to review the profile of under 18s attending local A&E or Urgent Care settings which could provide vital points of diverting the young people; education need to reflect on 29 Featherstone, B., Gupta, A., Morris, K.M. et al. (2016) Let’s stop feeding the risk monster: towards a social model of ‘child protection’. Families, Relationships and Societies. https://doi.org/10.1332/204674316X14552878034622 : accessed 11 May 2021. 30 Owens, R. et al. (2020) Relationship-based Practice and Contextual Safeguarding: Key messages for practice. https://www.csnetwork.org.uk/en/resources/briefings/practice-briefings : accessed 19 June 2021. 33 the impact of no school or home learning on the risks to a child or young person at risk of serious youth violence31. 11 KEY PRACTICE ISSUES From the learning points, there is evidence of the key practice issues that need improvement within Sutton. These will be expanded on within the recommendations, but it is important that these are acknowledged throughout the local safeguarding partners, relevant agencies, and other strategic networks with a role to play in preventing serious youth violence. This table can be used, alongside the recommendations, to promote joint conversations within multi-agency groups. Practice Issue Areas for improvement Role of education within the wider professional network The impact of a child not being in school and having a limited education due to: SEMH needs not met Historical poor attendance at school for a child with an EHCP Education provision not achieved through working together across agencies Professional responses to cumulative harm over a child’s life Repeated child protection plans without progress Multi-agency systems not enabling working together to reduce harm Responding to adolescents in the high-risk cohort Commitment to adopting a Contextual Safeguarding approach Chairs of MACE and CP Conference need to join up to develop safety plans for young people Contextual safeguarding needs to be embedded throughout the partnership Professionals need to come together to apply their knowledge of an individual and community to assess the risks to children Finding out about the adolescent’s identity Practitioners need to find ways of talking to a child to hear their voice 31 Home Office (2021) Serious Violence Duty: Preventing and reducing serious violence. Draft guidance for responsible authorities. pp24-34 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/986086/Draft_Guidance_-_Serious_Violence_Duty.pdf : accessed 19 June 2021. 34 Be more proactive in asking about fathers or male role models Across professional networks, formalise the role of the worker who can act as the key contact to the child, with perseverance and support from others across the agencies Relationship -Based Practice Professionals need to reflect on how they address refusal of assessments by parents Need for multiagency reflective practice, not isolated within single agencies 12 CONCLUSION The case of Child V shows some good relationships across the professional network, at senior levels. Nonetheless, there is a need to strengthen how systems come together to ensure that assumptions are not made that a child is being safeguarded, and their needs met, by another system. The findings from this review correspond to the wider learning, for independent scrutiny, from the London Safeguarding Children Board set out in a workshop in April 2021.32 The findings from the review and the wider London work should be taken forward by the LSCP to take forward to improve practice across all agencies and strategic networks. The LSCP should use these recommendations to seek assurance about the effectiveness of safeguarding for the children resident in Sutton and enable the joint working in the borough to be strengthened. 13 RECOMMENDATIONS FOR LSCP STATUTORY PARTNERS AND RELEVANT AGENCIES Review Finding Recommendations There are risks to children who have social, mental, and emotional health needs whose needs are not met in mainstream schools. 1. EHCP reviews must involve health and social care to ensure that there is a multi-agency approach to addressing the educational needs of the children. Where there are limited options or barriers in place, there should be a multi-agency review of the safeguarding risks to the child. 2. For the LSCP to seek assurance that the SEND Coordinator is routinely included in the invites 32 Ibbotson, K. (2021) Selected learning from reviews of deaths and serious injury due to serious youth violence: Questions for independent scrutiny. London Safeguarding Children Partnership. 35 and attends Child Protection Conferences, as required. Contextual safeguarding is an approach that would help the system in developing more constructive ways of working with those at risk of criminal exploitation and adolescents who have had a neglected childhood. 3. For the LSCP to seek assurance that there is an effective multi-agency partnership approach to identify critical indicators of the risk of extra-familial harm by applying Contextual Safeguarding principles. 4. For the LSCP to seek assurance that there is a clear framework that underpins the rationale for the decision making about removing children and young people from the risk list. 5. For the LSCP to seek assurance that there is a process in place for regularly reviewing children being removed from a child protection plan without the outcomes being achieved. E.g., If there are expectations on Early Help services to work with the family, EHCP or MACE, then this needs to be risk assessed if these do not make sufficient progress. 6. For the LSCP to seek assurance through an independent scrutiny exercise that there are effective problem solving mechanisms in place to address complex adolescent child protection concerns. The Serious Youth Violence Duty will require Sutton partners to review how they address the changing needs of young people in the borough. 7. The LSCP to seek assurance that the Police effectively share data and plans within the multi-agency system that have an impact on disrupting the potential for serious youth violence. 8. The CCG should review the commissioning of CAMHS to ensure that there are arrangements for the service to support those at risk of criminal exploitation. 9. The CCG should review the profile of under 18s attending A&E or Urgent Care settings. Managing organisational and partnership risk: focus on seeing schools as places of safety 10. The LSCP should undertake annual scrutiny of the top 10 children of concern who are approaching transitions e.g., those due to start school, those in year 6 and those approaching 16. 11. For the LSCP to seek assurance that there are effective systems within the Local Authority for sharing data, plans and risks in relation to those children, who are resident in Sutton, who are excluded or missing school for more than four months. This needs to include those children on roll out of borough. Relationship based practice needs to be 12. For the LSCP to seek assurance about how the Local Authority work with parents and 36 strengthened to prevent families withdrawing from the help of services. adolescents who have found it difficult to relate to professionals to find gather their views on what would hinders and what can improve engagement. Partners need to ensure that there are opportunities for all children to have their voice heard by agencies without this being reliant on parental engagement. 13. The LSCP to seek assurance from the Local Authority about how children who are out of school are given opportunities to voice their views of their situation. 14. This should include looking at the options for a youth worker to be placed within the hospital setting to work with adolescents who attend particularly those who are at risk from violence, mental health problems or substance misuse. Contextual Safeguarding needs to be utilised within Child Protection Plans 15. The LSCP should undertake development sessions for those involved in child protection plans for adolescents to: a. Strengthen the use of contextual safeguarding within the plans b. Establish an agreed protocol with the MACE to ensure that there is a discussion between the two systems prior to an adolescent being removed from either’s safety plan. Sutton need a framework for developing transitional safeguarding within the borough to ensure that the work to meet the needs of children does not end when they reach adulthood. 16. The LSCP should arrange to share the learning from this review with the Safeguarding Adult Board to ensure that the needs of those who are 18-25 who have been at risk of being exploited are provided with constructive opportunities for support. 17. For the LSCP and Safeguarding Adult Board to work together to use this case to evaluate the transitional safeguarding work in place within Sutton. This includes ensuring that Child V’s case has been discussed with Adult Social Care, Adult Mental Health, Education, Primary Care, IYS and Police to develop a joint plan for offering support to the young person to keep him safe. 14 APPENDICES METHODOLOGY This methodology was blended with the SCIE ‘systems’ model to observe how much Child V’s case provided a ‘window on the system’ beyond the specific 37 case33. This provided the basis for the learning points but also enabled the acknowledgement of the work already achieved by the agencies in Sutton. The recommendations were suggested by the independent author and then developed in consultation with the Case Review Group to ensure LSCP ownership of the actions to be taken forward from the learning in the case. 33 Social Care Institute for Excellence (2012) Learning together to safeguard children: a ‘systems’ model for case reviews 38 ACTION PLAN No. Recommendation Rationale Action Lead By When Intended Impact 1. EHCP reviews must involve health and social care to ensure that there is a multi-agency approach to addressing the educational needs of the children. Where there are limited options or barriers in place, there should be a multi-agency review of the safeguarding risks to the child. To mobilise the multi-agency network to meet the special education needs to reduce the risk of children being abused and exploited. To develop or update existing multi-agency adolescent safeguarding protocols and children social care practice directive. LSCP 31/01/2022 To ensure that all staff are aware how to utilised SEN specialists to review safeguarding risks. To ensure that special education needs form part of child safeguarding planning. To undertake a multi-agency audit into safeguarding children in education. LSCP 31/01/2022 To ensure that multi-agency planning processes to meet the needs of the child are joined up. 2 For the LSCP to seek assurance that the SEND Coordinator is routinely included in the invites and attends Child Protection Conferences, as required. To ensure that EHC needs are considered alongside child protection planning processes from the perspective that schools protect. To follow up with children’s social care, systems are in place to routinely invite the SEND co-ordinator to a CPC and/or MACE panel for any child who is subject to an EHCP. LSCP 31/01/2022 To ensure that SEND specialism is utilised in safety planning. 3 For the LSCP to seek assurance that there is an effective multi-agency partnership approach to identify critical indicators of the risk of extra-familial harm by applying Contextual Safeguarding principles. Multi-agency planning meetings are informed by a contextual safeguarding approach. To hold a multi-agency learning event and roll out contextual safeguarding training across the multi-agency professional network. LSCP 31/03/2022 To improve responses and safety planning for children who are at risk of extra familial harm. 4 For the LSCP to seek assurance that there is a clear framework that underpins the rationale for the decision making about removing children and young people from the risk list. Children are removed from the MACE risk list because of evidence of reduced risk. To ask the MACE panel to explore whether a decision making criteria for removing children from the MACE risk register can be developed. LSCP 31/01/2022 To ensure that there is a safe rationale for removing children from the MACE panel. 39 No. Recommendation Rationale Action Lead By When Intended Impact 5 For the LSCP to seek assurance that there is a process in place for regularly reviewing children being removed from a child protection plan without the outcomes being achieved. E.g., If there are expectations on Early Help services to work with the family, EHCP or MACE, then this needs to be risk assessed if these do not make sufficient progress. Contextual safeguarding principles refer to services being flexible to respond to the needs of the child; and to take a relationship based approach to ensure that children with complex safeguarding needs are protected. To undertake an audit of children removed from child protection plans and whether the outcomes were met, and if not what action was taken. LSCP 31/01/2022 To ensure that children with complex safeguarding needs are not excluded from services. 6 For the LSCP to seek assurance through an independent scrutiny exercise that there are effective problem solving mechanisms in place to address complex adolescent child protection concerns. To ensure that there are effective multi-agency arrangements to address complex adolescent safeguarding needs. To include problem solving approaches in the multi-agency deep dive audit of safeguarding children who have special education needs. LSCP 31/03/2022 The learning to be used within supervision and training for those working with younger children within the child protection system. 7 The LSCP to seek assurance that the Police effectively share data and plans within the multi-agency system that have an impact on disrupting the potential for serious youth violence. Children who are not in school do not have the same access to professionals who can identify safeguarding risks. To request that the police undertake a review of the intelligence gathering for children who are known to MACE and not in school. LSCP 31/01/2022 To ensure that community risks to children are fully considered for those who are not in school. 8 The CCG should review the commissioning of CAMHS to ensure that there are arrangements for the service to support those at risk of criminal exploitation. To support emotional well being needs and trauma informed responses for children who are at risk of criminal exploitation. To review whether the current commissioning arrangement with CAMHS includes providing professional expertise to the MACE panel and CP Conferences; and to provide services as part of multi-agency safety planning. CCG 31/01/2022 To improve responses and safety planning for children who are at risk of extra familial harm. 40 No. Recommendation Rationale Action Lead By When Intended Impact 9 The CCG should review the profile of under 18s attending A&E or Urgent Care settings. To influence intervention opportunities with the children and young people, without reliance on parents to engage. The CCG to review the profile of under 18s attending A&E or Urgent Care settings and make appropriate recommendations CCG 31/01/2022 To improve responses to children accessing A&E and Urgent Care settings 10 The LSCP should undertake annual scrutiny of the top 10 children of concern who are approaching transitions e.g., those due to start school, those in year 6 and those approaching 16. This work should provide greater understanding of the issues the children are facing and to ensure that interventions are implemented to safeguard these children. The LSCP to undertake annual scrutiny of the top 10 children of concern who are approaching transitions LSCP 31/03/2022 To have an improved understanding of the issues children are facing and to ensure that interventions implemented to safeguard are effective. 11 For the LSCP to seek assurance that there are effective systems within the Local Authority for sharing data, plans and risks in relation to those children, who are resident in Sutton, who are excluded or missing school for more than four months. This needs to include those children on roll out of borough. To ensure that children who are hidden from services due to being out of school are risk assessed and provided with services, as needed. To set up arrangements to provide the data and any other information to assess risks of exploitation and going missing LSCP 31/01/2022 To ensure that children out of school are risk assessed as any other child who attends school, and that plans are put in place to address safeguarding needs. 12 For the LSCP to seek assurance about how the Local Authority work with parents and adolescents who have found it difficult to relate to professionals to find gather their views on what would hinders and what can improve engagement. To listen to those with lived experiences of services to find ways to more effectively engage with young people and their families. To gather the views of people with lived experience who have found it difficult to relate to professionals in the past, but have found a way to progress, to gather their views on what worked for them, or did not. LSCP 31/03/2022 To have an improved understanding of the issues children are facing and to ensure that interventions implemented to safeguard are effective. 13 The LSCP to seek assurance from the Local Authority about how children who are out of school To ensure that the lived experiences of children and their wishes and feelings are recognised. To gather the views of people with lived experience who are out of school. LSCP 31/03/2022 To have an improved understanding of the issues children are facing and to ensure that interventions 41 No. Recommendation Rationale Action Lead By When Intended Impact are given opportunities to voice their views of their situation. implemented to safeguard are effective. 14 This should include looking at the options for a youth worker to be placed within the hospital setting to work with adolescents who attend particularly those who are at risk from violence, mental health problems or substance misuse. To ensure that young people are supported by appropriate services, and to reduce the need to access A&E services. To review A&E attendance of adolescents at risk and the outcome of responses. LSCP 31/03/2022 To improve responses to children accessing A&E and Urgent Care settings 15 The LSCP should undertake development sessions for those involved in child protection plans for adolescents to: a. Strengthen the use of contextual safeguarding within the plans b. Establish an agreed protocol with the MACE to ensure that there is a discussion between the two systems prior to an adolescent being removed from either’s safety plan. To ensure that safety planning processes are joined up across systems (CPC, MACE, EHCP reviews). To revise the multi-agency adolescent safeguarding protocol to reflect the findings from this review. LSCP 31/03/2022 Joined up multi-agency approaches to safeguard children with complex needs. 16 The LSCP should arrange to share the learning from this review with the Safeguarding Adult Board to ensure that the needs of those who are 18-25 who have been at risk of being exploited are provided with constructive opportunities for support. To ensure that the Safeguarding Adult Board is aware of the risks faced by those who are transitioning to adulthood. To present the Child V LCSPR overview report and findings to the Safeguarding Adult Board. LSCP 31/01/2022 To ensure that the Safeguarding Adult Board is aware of the risks faced by those who are transitioning to adulthood. 42 No. Recommendation Rationale Action Lead By When Intended Impact 17 For the LSCP and Safeguarding Adult Board to work together to use this case to evaluate the transitional safeguarding work in place within Sutton. This includes ensuring that Child V’s case has been discussed with Adult Social Care, Adult Mental Health, Education, Primary Care, IYS and Police to develop a joint plan for offering support to the young person to keep him safe. To ensure joined up processes for young people transitioning to adult services. To develop a joint multi-agency transitional safeguarding protocol. LSCP 31/03/2022 Joined up multi-agency approaches to safeguard young people transitioning to adulthood with complex needs. |
NC050436 | Significant abuse, neglect and cruel parenting of two siblings aged 12- and 14-years by their relative carer over a period of ten years. The siblings had been removed from their parents' care in their early years because of abuse and neglect. Both siblings had a diagnosis of mild learning disabilities; Sibling A was assessed as having global developmental delay at age 6 and attended a specialist school; Sibling B attended a mainstream school. The siblings had long term involvement with specialist services from birth. The relative carer reported difficulties with both siblings' behaviour to the GP and CAMHS. There were concerns about the carer's negative and hostile approach to Sibling B; whilst in foster care Sibling B made a number of allegations of previous physical and emotional abuse. Sibling A was subsequently also placed in foster care. Findings: all children and young people deserve to be effectively safeguarded from harm; the additional vulnerability of disabled children to abuse needs to be recognised and addressed; insufficient professional recognition or challenge of the blame of children by parents/parent figures as their defence against harsh, abusive and inconsistent parenting; poor assessments and ineffective Child in Need processes leave children and young people's needs unaddressed and at risk of potential abuse and harm; fixed professional thinking which is not picked up through supervision and reflection has the capacity to undermine the ability of the safeguarding system to keep children and young people safe. Sets out key findings using a hybrid version of a systems process. There were no recommendations.
| Serious Case Review No: 2018/C7357 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Serious Case Review Siblings A and B XXXXXXX 2 1. Introduction to the SCR and review process Why this serious case review (SCR) was undertaken? 1.1 This SCR has been commissioned by XXXXX Safeguarding Children’s Board (SCB) and is about Sibling A & B. When they came into Local Authority care at the ages of 12 and 14 they were found to have experienced significant abuse, neglect and cruel parenting over a 10-year period at the hands of a relative with whom they had been placed at a young age. They were both disabled children, with a diagnosis of mild learning disabilities, and despite the long-term involvement of many professionals they were not effectively safeguarded. The review reflects on the reasons for this and considers what action needs to be taken by the SCB to address this. The Siblings Family Background 1.2 Sibling A & B were removed from their parents care in their early years because of abuse and neglect. They were placed with a relative carer who had three teenage children who remained living at the family home into adulthood. Another relative moved to live with the family in 2012 to provide support1. The whole family is white/British. 1.3 Sibling A was assessed as having Global Developmental Delay at the age of 6 by a paediatrician and attended a specialist school for children and young people with learning disabilities. Sibling B is not assessed as having any disability, but the relative carer told some professionals that Sibling B also had Global Developmental Delay and implied to many others that Sibling B was disabled. Sibling B attended mainstream school and they provided support for what they understood to be the difficulties caused by harsh parenting and a difficult home life. 1.4 There is little available information in the records about the sibling’s day to day life, their personalities, their likes and dislikes or their friendship groups. Much of what is written about them in the assessments and records is reported directly by the relative carer with who they lived and was often negative and derogatory in nature. School reported that Sibling A was doing well at school, was a happy child and was well liked. Sibling A did not have friend’s come to the home and was said to be isolated in the family home but liked being in the bedroom with toys. Sibling B was also doing well at school, liked sports such as 1 No further details about the family are provided to ensure confidentiality for the siblings. 3 Badminton, but was not allowed to go to after school clubs. Sibling B reported wanting to spend more time with friends, but this was not often allowed. Sibling B loved the dogs at home, spent time looking after them and was responsible for cleaning up after them. Sibling B was also isolated in the home, often eating different food with Sibling A, separate from other family members. Process of the Review 1.4 This review has been undertaken using a hybrid version of a systems process. The frame of reference was set during the commissioning process. Chronologies of agency involvement with single agency reflections on practice were commissioned (see appendix 1) and interviews were conducted with most of the professionals involved with the family; it was not possible to interview all as some professionals had left their posts, but this gap was not significant to the review or data gathering process. The records, assessments and reports/email correspondence held by agencies were also reviewed. This SCR was overseen by an independent reviewer (see appendix 2) and her work has been assisted by a panel of multi-agency senior safeguarding professionals (see appendix 3) who helped with the analysis, received draft reports and made comment and revisions. This panel met with all those professionals for a practitioner’s event where core themes were agreed and these are the Findings in Section 3. Family Involvement 1.5 The panel discussed the sibling’s involvement and contribution to the review process. Advice was sought from those professionals currently working with them and their professional view was that the siblings were settling into the foster family and it would be unhelpful for them to talk about the recent past. This view was respected. Given this, it did not seem appropriate to include any other family member because of their continued negativity to the siblings. 4 2. Brief chronology of professional involvement Background information 2.1 The agreed review timescale for review was from November 2014 to the time when Sibling A came into local authority care in May 2016; Sibling B was already placed with a foster family at this time. They were aged 15 and 12. The siblings had long term involvement with specialist services from birth and a summary is provided of this earlier contact. 2.2 Sibling A & B moved to live with relatives at a young age. They had experienced negative and abusive experiences by their parents and it was recognised that they would need support regarding this early trauma. The available evidence suggests that the assessment of these relatives by another Local Authority was superficial and did not give sufficient weight to the type of parenting that traumatised young children might need in the long term. Support from 2011 to 2014 2.3 In the period from 2011 to 2014 the family were provided with considerable support. CAMHS2 provided parenting support and Theraplay3 to help improve the relationship between the siblings and the relative carer. Some progress was noted, but there were concerns about harsh parenting and scapegoating of Sibling B. The school that Sibling attended was also concerned about possible neglect and harsh parenting. 2.4 These concerns were appropriately shared with Children’s Social Care (CSC). Assessments were completed and some family support work and social work support provided. The focus of attention was on the early trauma that both siblings had experienced, and the relative carer diverted professional attention by highlighting how difficult and unmanageable Sibling B’s behaviour was. This ability of the relative carer to blame the children for what was happening to them and recording of the relative carers negative perspective about both 2 CAMHS stands for Child and Adolescent Mental Health Services. CAMHS are the NHS services that assesses and treat young people with emotional, behavioural or mental health difficulties. There are local NHS CAMHS services around the UK, with teams made up of nurses, therapists, psychologists, support workers and social workers, as well as other professionals. 3 Theraplay is an evidence-based child and family therapy for building and enhancing attachment, self-esteem and trust. Theraplay sessions aim to create an active, emotional connection between the child and parent or caregiver, resulting in a changed view of the self as worthy and lovable and of relationships as positive and rewarding. https://theraplay.org/index.php/what-is-theraplay-3 5 children, most of which was not evidenced, was a theme across the whole review period and is discussed in Finding 2. 2.4 The relative carer asked that Sibling B have a period of voluntary care for a period of three months. During this placement Sibling B made progress but returned to the care of the relative carer. 2.5 Sibling B disclosed physical abuse and being hungry to school and in October 2013 an anonymous referral was received regarding Sibling B being physically abused at home. There was also an allegation that an adult family member had physically abused Sibling A. These incidents were investigated by the children and family social work team, but the conclusion was that these incidents were caused by the Sibling’s complex behaviours, reported by the relative carer, and led to parenting support and advice, as opposed to an exploration of possible abuse. A theme that is evident across the period or review and which is addressed in Finding 1. Professional involvement November 2014 to May 2016 2.6 In November 2014 the children and family social work team felt that progress had been made with the parenting support and their involvement ceased. Three weeks later the relative carer made contact with the team requesting support because she could not manage what she described as the siblings difficult and challenging behaviour. This was passed to the disabled children’s team and an assessment was started, focussed on eligibility for respite care4 and support. This was despite Sibling B having no disabilities. 2.7 In January 2015 the relative carer and an adult family member went to the GP to report difficulties with managing what they described as Sibling B’s difficult and destructive behaviour. Support from CAMHS was discussed. 4 Respite care is a form of short-term substitute care provided by someone other than the parents or usual carers for a child. The 1989 Children Act provides a clear framework for the provision of short-term care known as respite care. The act requires children to be consulted about their needs, the services to be provided and if a child is using 'respite care', The Children Act 1989 was amended to include a requirement that social services authorities ‘assist individuals who provide care for such children to continue to do so, or to do so more effectively, by giving them breaks from caring. Children and Young Persons Act 2008 s25, inserting a new para into CA 1989 Sch 2 – namely para 6(1)(c). 6 2.8 In February 2015 Sibling B and the relative carer attended a routine appointment at CAMHS and the relative carer described Sibling B as having behavioural problems, lying and stealing at home and at school. It was agreed that further support could be offered to improve relationships. The relative carer also telephoned CAMHS in the same month to report problems dealing with Sibling A’s behaviour, anger and aggression to family members. 2.9 Whilst the disabled children’s team was undertaking their assessments there were some incidents of concern. In March 2015 Sibling A (aged 13) came to school with a bruise on the nose, which was said to have been caused by an argument with the relative carer who pushed Sibling A into the wall. The relative carer reported that this was as a result of managing complex behaviours and led to no further action. There was a further similar incident a few weeks later and the relative carer reported that Sibling A was violent and aggressive and had been bruised as a result of “being contained”. This incident was again shared with the disabled children’s team who spoke to the relative carer and accepted her explanation. 2.10 There was a school meeting regarding Sibling B in March 2015. The relative carer alleged that Sibling B was stealing at home and school. The school reiterated that they had no evidence that Sibling B (aged 11) was stealing, but the relative carer said that she had asked a family friend in the police force to take Sibling B through a pretend process of being arrested for theft and taken to the cells. The relative carer said this was said to make Sibling B aware of negative actions. This was shared as a concern but led to no action. 2.11 At the beginning of April 2015 there was an anonymous call to the police regarding allegations that Sibling B was stealing at home and at school, was destroying family property and generally being destructive. A home visit by the police was undertaken, and concerns about Sibling B were shared with Children’s Social Care and passed to the disabled children’s team. This information was considered as more evidence that the relative carer was struggling to manage as opposed to concern about possible abuse. 2.12 The assessment by the disabled children’s team was concluded in April 2014. The focus of the assessment was on the relative carers reported difficulties in manging the complex behaviour of both siblings, rather than on the many incidents of possible physical abuse, emotional abuse and neglect and both siblings talking about being unhappy at 7 home. The conclusion was that parenting support would be provided and that both siblings were assessed as being children in need5. No Child in Need plan6 was ever developed and so progress or the lack of it was never monitored and the sibling’s own needs not outlined. The lack of a child focus in the assessment and inadequate child in need processes is discussed in Finding 3. 2.13 In mid-April 2015 the relative carer and another adult family member came into Sibling B’s school to report concerns about Sibling B’s behaviour, the impact of this on the family and “jokes” being made by other adult family members that they would hurt Sibling B. The school were concerned about the family’s negativity and asked them to leave. Sibling B was very upset by this incident and a teacher spent time facilitating to Sibling B be able to talk about what was happening at home and Sibling B disclosed recently being chained to a radiator, being treated harshly and unfairly by all family members and not wanting to go home. This support to Sibling B was good practice. 2.14 This disclosure was shared with the social worker from the disabled children’s team who discussed this with the team manager. The relative carer’s explanation regarding Sibling B being chained to the radiator was that she could not leave Sibling B alone while she had a shower because of the danger to Sibling B and others because of aggressive and out of control behaviour. This explanation was accepted as further evidence that the relative carer was struggling to cope and consequently there was no strategy discussion as would be expected and the police were not informed of this serious incident. Sibling B was not seen until several weeks later. The issue of fixed professional thinking is discussed in Finding 5. 2.15 There was a Child in Need Meeting where the incident of Sibling B being chained to the radiator was discussed. There would be further meetings in May, June and July, no minutes were produced for any of the meetings (except the school’s own record) so it is unclear exactly 5 A child in need is defined in the Children Act 1989. A child shall be taken to be in need if— (a)he is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority; (b)his health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services; or (c)he is disabled. Children’s Services decide if a child is in need by assessing their needs. 6 . Children’s Services decide if a child is in need by assessing their needs. If they decide the child is in need they will normally draw up a plan setting out what extra help they will provide to the child and their family, focussing on how a child or young persons health and developmental outcomes can be improved. http://www.legislation.gov.uk/ukpga/1989/41/section/17 8 what was discussed and there was still no Child in Need Plan formulated (see Finding 3). 2.16 The GP and the disabled children team social worker made a referral to CAMHS for Sibling B and the family received a letter saying they would be offered an appointment in due course. 2.17 Sibling A was seen at CAMHS for the start of the assessment process with the relative carer. Sibling A was described as out of control and exhibiting violence and disruption at home. Sibling A talked about wanting things to be fairer at home. It is unclear why the siblings were to be seen separately. 2.18 In July 2015 the school noticed scratches to Sibling B’s neck and they contacted the disabled children’s team social worker. The school were informed that the relative carer had already explained that the injury was caused accidentally when Sibling B was caught stealing. The Child in Need process was to continue. The school were unhappy with this conclusion and wrote to and called the disabled children team manager. Their concerns were not taken seriously and so school staff considered how best to escalate their concerns and tried to contact the LADO7 as this had been helpful in the these past, but they were unable to make contact; the differences in opinion were not resolved and led to no change. The issue of the importance of dealing effectively with professional disagreements in a child focussed and centred way is discussed in Finding 4. 2.19 The difficulty in getting these differences addressed was in part caused by the fixed professional thinking about the cause of the sibling’s difficulties and distress. Some professionals recognised the abusive nature of the care they were receiving, but others believed that it was the manifestation of early trauma and behavioural difficulties because they were disabled children. This fixed thinking did not change, despite the available evidence; the importance of addressing cognitive biases through supervision, management oversight and opportunities for reflection is discussed in Finding 5. 2.20 In July 2015 there were also further concerns expressed by Sibling A’s school about a bruise which the relative carer had said was caused by trying to manage Sibling A’s behaviour. In August 2015 Sibling A 7 The role of the LADO is set out in Working Together to Safeguard Children (2015) and is governed by the Authorities duties under section 11 of the Children Act 2004 and North Somerset Inter-Agency Policy and Procedures. This LADO role is managing allegations against people who work with children who are paid, unpaid, volunteers, casual, agency or anyone self-employed. 9 attended a further appointment at CAMHS and said that things were more settled at home. The relative carer also went to the GP for help with filling in the Disability Living Allowance form for Sibling B who was described as difficult to manage. In September there was an assessment completed by the disabled children’s team social worker, which contained the same information as the previous assessment. 2.21 Sibling B was seen at CAMHS to start the assessment process in October 2015. An appointment had been offered in August but cancelled by the family because of summer activities and the family had been on holiday in October. At this appointment the relative carer reported that both siblings had Global Developmental Delay8 and that Sibling B’s behaviour was unmanageable with lying and stealing at home and at school. It was agreed that Cognitive Behaviour Therapy(CBT) 9 would be offered to Sibling B to help with impulse control and emotional regulation. 2.22 In November 2015 Sibling A was seen by CAMHS. The relative carer reported a difficult holiday because of the sibling’s behaviour and that she had ensured that both siblings wore special wristbands to indicate that they had special educational needs and they could be supported. CAMHS made contact with Sibling A’s school after this appointment and the school chronology of concerns regarding possible physical abuse, emotional abuse and neglect was shared. It was agreed that there would be further discussion within CAMHS about next steps for Sibling A. 2.23 In January 2016 the school noticed bruising to Sibling A’s face. Sibling A was asked about this and looked uncomfortable. School phoned the relative carer who explained that the injury had been caused by a family member needing to restrain Sibling A because of aggressive and violent behaviour. This family member admitted to slapping Sibling A. A new disabled children team social worker had recently started work with the family and was concerned about this incident and ensured a 8 The term 'developmental delay' or 'global development delay' is used when a child takes longer to reach certain development milestones than other children their age. This might include learning to walk or talk, movement skills, learning new things and interacting with others socially and emotionally. https://www.mencap.org.uk/learning-disability-explained/conditions/global-development-delay 9 Cognitive behavioural therapy (CBT) is a talking therapy that can help young people manage problems by changing the way they think and behave. It's most commonly used to treat anxiety and depression, but can be useful for other mental and physical health problems. https://www.nhs.uk/conditions/cognitive-behavioural-therapy-cbt/ 10 strategy meeting10 was called. This was effective practice from a new social worker who challenged the fixed thinking. The strategy meeting decided that child protection enquiries11 (Sec 47 Children Act 1989) would commence and a police investigation. 2.24 The child protection enquiries were undertaken and both siblings were made subject to Child Protection plans12 for physical abuse. The focus remained, however, on the relative carer and the adult family member’s difficulties in managing the Siblings reported complex behaviours and the impact of early trauma. The fixed thinking that this was an issue of problems with parenting, rather than an issue of harsh and cruel parenting and physical, emotional abuse and neglect continued. See Finding 5. The police investigation regarding this incident was discontinued because it was believed that the possible physical abuse had been provoked by Sibling A’s behaviour and that appropriate support was in place. 2.25 Over the next few weeks (January to February 2016) the social worker became concerned about the relative carers’ increasingly negative and hostile approach to Sibling B. There was a meeting in March 2016 where neglect of Sibling B and a serious incident of self-harm disclosed by Sibling B were discussed. A psychological assessment at this time recommended that Sibling B needed increased level of care and nurturing to prevent an escalation of self-harming behaviours. The relative carer was asked to consent to both siblings being placed voluntarily (Sec 20 Children Act 198913) with a foster family. She would only consent to this for Sibling B. Whilst in foster care Sibling B made a number of allegations of previous physical and emotional abuse and 10 Children’s Social Care must hold a Strategy Discussion/Meeting whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer Significant Harm. This takes place between Children’s Services, the police and possibly other child care agencies at the beginning of child protection enquiries. whether any immediate. Working Together 2015. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 11 Children’s Services have a legal duty to look into a child's situation if they have information that a child may be at risk of significant harm. This is called a child protection enquiry or investigation. Sometimes it is called a “Section 47 investigation” after the section of the Children Act 1989 which sets out this duty. The purpose of the enquires is to gather information about the child and their family so that social workers can decide what action, if any, they need to take to keep a child safe and promote their welfare. http://www.legislation.gov.uk/ukpga/1989/41/section/47 12 A child protection plan is drawn up at the initial child protection conference. It says what support and monitoring will be put in place when a child is considered to be at risk of significant harm because they have suffered, or are likely to suffer physical abuse, emotional abuse or sexual abuse or neglected. When there is a child protection plan, the child will be given a social worker who should meet regularly with the child and the parents to discuss the child's progress. The child's situation and the plan will be reviewed after three months and then every six months. 13 Section 20 of the Children act 1989 says Children’s Services should look after a child when there is no-one with parental responsibility for the child or when the person caring for the child is prevented from caring for them, for whatever reason. This is also called voluntary Accommodation. 11 legal proceedings were commenced and at the beginning of April 2016 an Interim Care Order14 was granted. 2.26 The Children’s Guardian15 met with the Independent Reviewing Officer to discuss plans for Sibling A. It was greed that the circumstances would be closely monitored and individual support be provided by a family support worker. Sibling A had expressed a preference to remain living with the relative carer. 2.27 The individual support started, but the family support worker tasked with this work was immediately concerned about how unhappy Sibling A was and that the care provided by the family was hostile and negative. The Children’s Guardian was also concerned through her contact with both siblings and the chronology of concerns she had developed. The relative carer became more hostile and uncooperative and the plan was for Sibling A to be removed and placed with Sibling B. Initially a voluntary arrangement was discussed but the Children’s Guardian recommended Court Order as the safest and most appropriate option for ensuring security and stability for Sibling A and this was agreed. At this time the relative carer reported to the police that Sibling A had assaulted an adult family member. A police investigation started but led to no further action. 2.28 In June 2016 Final care Orders were granted for both Siblings and they remain living with their foster family where they are making good progress. 14 A Care Order is a court order which places a child in the care of Children’s Services. It lasts until the child is 18 unless the court ends it before then. When there is a care order, Children's Services share parental responsibility for the child with the parents. Children's Services must find out the parents’ wishes about any decision they make about their child, but they always have the final say and can make plans for the child even if the parents don't agree with them. 15 A children’s guardian is an independent and experienced social worker who is an officer of the court. Their job is to make enquiries about the child’s circumstances and make a recommendation about what is best for the child in the future. Children's Guardians are organised by a service known as CAFCASS. The court will automatically appoint a guardian for the child for an Emergency Protection Order or a Care Order. 12 3. The Findings 3.1 The review of these children’s circumstances has highlighted a number of issues or Findings regarding the effectiveness of safeguarding processes for them, with implications for other children. The aim of a serious case review is to use a single case as a ‘window on the system’, to uncover more general strengths and weaknesses in the safeguarding system and to try and understand what was influencing the professional response. At the heart of this review is the importance of a skilled and prepared workforce who are supported to effectively safeguard children and young people, particularly those who are disabled. This is covered in Finding 1, but all the other Findings are connected to this core issue. 3.2 Some professionals in this case developed fixed thinking about the sibling’s circumstances which was not addressed or noticed, these professionals relied too much on the relative carers distorted and biased views and accepted uncritically the blaming of children for the abuse they were experiencing. Disclosures of abuse were not dealt with appropriately and poor assessments and child in need processes meant that the right support was not provided and action not taken. Those professionals in schools that knew the children best advocated for them but were not heard and the struggle to get these professional disagreements addressed meant safeguarding action was not taken. The Findings 1. All children and young people deserve to be effectively safeguarded from harm; the additional vulnerability of disabled children to abuse needs to be recognised and addressed. 2. There is insufficient professional recognition or challenge of the blame of children and young people by parents/parent figures as their defence against harsh, abusive and inconsistent parenting. 3. Poor assessments and ineffective Child in Need processes leave Children and young people’s needs unaddressed and at risk of potential abuse and harm. 4. Addressing intra and inter professional disagreements and disputes is essential to promote the well-being of children and protect them from harm. 5. Fixed professional thinking which is not picked up through supervision and reflection has the capacity to undermine the ability of the safeguarding system to keep children and young people safe. 13 Finding 1: All children and young people deserve to be effectively safeguarded from harm; the additional vulnerability of disabled children to abuse needs to be recognised and addressed. 3.3 There was significant evidence over time of neglect, physical abuse and emotional abuse of Sibling B and Sibling B. Both reported being hungry, and there were fluctuating concerns about them being low weight. They were given different food from the rest of the family. They were both observed to be unkempt. Sibling A was observed to have bruises of concern, which Sibling A confirmed were caused by an adult hitting or restraining. The adult children of the relative carer were said to be resentful of the siblings and discussed causing them harm and bullying them on a number of occasions. 3.4 Child protection processes were instigated on some occasions, but there were incidents where a strategy meeting/discussion should have been held and was not. An example is when Sibling B was chained to radiator where the action was to ask the relative carer not to repeat this or behaviour or when the relative carer admitted slapping Sibling B and parenting support was suggested, but not accepted. It is clear that some professionals made assumptions about these circumstances based on a false understanding of the impact of disabilities and early trauma. 3.5 Sibling A was known to have Global Developmental delay and mild learning disabilities, attended a specialist school and was provided with specialist support at that school. Sibling B had no diagnosed disability but was often represented by the relative carer as having a disability. The relative carer claimed Living Disability Allowance for Sibling B. In December 2014 both siblings were assessed by the Disabled Children’s Team. This perception of the disability being the key issue became an influencing factor in the effective safeguarding of the siblings, where evidence of possible physical abuse was described by the relative carer as difficulties in managing children with complex needs and behaviours. 3.6 Research has found that disabled children are three to four times more likely to be abused and neglected than non-disabled children (Jones et al 2012i; Sullivan & Knutson 2000ii); are more likely to experience multiple types and occurrences of abuse (Sullivan and Knutson 2000) and have a prevalence rate of 20% for experiencing physical violence, 14 % sexual violence, 18% emotional abuse and 9.5% for neglect (Jones et al 2012iii). Disabled children have an equal right to protection, yet 14 researchiv shows that there are a number of barriers to effective practice in this area. There can be reluctance on the part of professionals to believe disabled children, the indicators of abuse can be mistakenly understood to have been caused or exacerbated by their impairments and there has been a reluctance to challenge parents – or to see them as “heroic carers” dealing with children who make demands on them. There was evidence of this for the siblings. 3.7 The circumstances of Sibling A and Sibling B echo that of the national research and concerns emerging from other Serious case reviews. Locally there has been work in this area to address the safeguarding response to disabled children and the Board will need to be satisfied that this is having a positive impact. Finding 2: There is insufficient professional recognition or challenge of the blame of children and young people by parents/parent figures as their defence against harsh, abusive and inconsistent parenting. 3.8 There were a number of occasions where Sibling A & Sibling B made disclosures about abuse and neglect, and when either a member of the family or the relative carer was asked about it, they said the incident had happened, but that the actions had been necessary because of the complex and destructive behaviour of the siblings; in effect the adults blamed the siblings for the harm they had experienced. This constantly sent a message to the siblings that they somehow deserved the neglect and abuse and were actually responsible for it. This had the potential to be extremely damaging for them but was not acknowledged or noticed by the majority of professionals. 3.9 For example, Sibling B reported wanting to eat the same food as everyone else and to be allowed to eat food with the family. The relative carer reported that this could not happen because the siblings were “messy eaters” and it put the rest of the family off their food. 3.10 It is striking the extent to which the negative views of the siblings made by the relative carer and other family members were accepted by most professionals at face value and reported as facts, despite evidence to the contrary. In one of the many assessments completed it is reported that Sibling B was “stealing food” and “being over controlling” (aged 12) and that Sibling A was out of control and waking the whole house up at night. These were the views of the relative carer and there was no evidence to suggest that they were true. They should have been recorded as the views of the adult, which were not supported by any objective evidence. This build up a picture that the 15 children were unmanageable was something that was not evident when professionals interacted with the children. When an allegation of physical abuse and restraint was made by Sibling A, the relative carer provided a picture of her responding calmly and kindly, helping an unmanageable child and the relative carers views are reported verbatim in the assessment report “the relative was speaking in calm voice, asking her to calm down and they would leave her quietly”. 3.11 Professionals must be supported to remain in a position of “respectful uncertainty” and display “healthy scepticism” which in practice means checking the validity of information provided by parents/adults by cross referencing/triangulating with other sources and testing out the level of parental care and concern for children and the extent to which parents feel a sense of responsibility for their children and their well-being. 3.12 If young people are to develop and grow successfully into adulthood they need and deserve sensitive caregiving, where secure and loving attachments are fostered, where love and care is provided and they are enabled to experience empathy and are treated fairly and justly. 3.13 Parental blame has the potential to undermine helpful interventions because of parental denial of their own responsibility to change. It is a self-reinforcing process whereby young people who have already experienced harm and abuse, which has undermined their self-esteem and resilience, are now held responsible for that poor-quality care. This is something like a cognitive “catch 22” or a “no win” situation which has the capacity to cause great emotional damage and impact on moral development. Ultimately the message here is that these young people do not warrant or deserve appropriate and loving care. 3.14 Parental/carer attitudes to young people which are about blame, harsh and critical care and scapegoating must be recognised as a key indicator of emotional abuse and addressed appropriately. Finding 3: Poor assessments and ineffective Child in Need processes leave Children and young people’s needs unaddressed and at risk of potential abuse and harm. 3.15 There were many single assessments completed by Children’s Social Care regarding Sibling A and Sibling B. Some were never written up, and those that were, were largely descriptive, focussed on the views of adults and did not represent the voice or perspective of the children. They lacked any professional analysis or judgement about the needs or circumstances of the children. Commonly the sections on parenting 16 capacity, an essential part of the assessment, were not filled in nor was the social workers summary. 3.16 This lack of analysis meant that the children’s circumstances were not well understood and therefore was a lack of proposals for action to address them. For example, the assessment completed for the child protection conference which took place around the time that Sibling B came into care noted the incident of self-injurious behaviour. The comment about what needs to happened said “Sibling B needs to live a healthy lifestyle” and “ concern…Sibling B stealing at school….Sibling B reports hunger” the comment on what needs to happen was that “ Sibling B needs to attend school”. Overall all the assessments quoted the views of the relative carer without commentary and without expressing a view about the care being provided. 3.17 Good assessment mattersv vi; they are key to effective intervention and to improving outcomes for children. Conversely, research has shown that poor or inadequate assessments are associated with unclear plans to meet children’s needs, poor outcomes and drift. Poor assessments without professional judgement also undermine the ability of professionals to keep children safe and to address their needs and circumstances. 3.18 Between April 2015 and January 2016, the siblings were assessed as being Child in Need. Child in Need meetings were held, but there was never a child need plan developed. This meant there was a lack of clarity regarding what the siblings needs were understood to be, and therefore no goals or objectives were outlined, progress or the lack of it unknown and overall there was a complete lack of clarity regarding what the purpose of this process was. It meant that the children were not safeguarded and core issues remained unaddressed. 3.19 The Children Act 1989vii defines Children in Need (CIN) as those children whose vulnerability is such that they are unlikely to reach or maintain their health and development milestones without the provision of services to them and their families. This is a serious issue for all children. The emphasis placed on good quality assessment to determine the level of need is reflective of the potential risks for a child’s future. Once an assessment is undertaken and needs identified it is expected that a child focused plan is formulated which addresses those needs, there is a clear outline of the outcomes expected, services to be provided and the reviewing mechanisms identified. The reviewing mechanism are important to ensure that the needs of 17 children are being addressed, that there are positive changes to their circumstances and the right support is being provided. The lack of this focussed approach means that children’s needs and outcomes are not improved, and there is a potential waste of resources with services being provided but being ineffective or not creating change. Without a plan, and goals, and reviews this will not be identified. 3.20 It appears that the perception that both siblings were disabled children impacted on the robustness of the response. In 2012, Ofstedviii undertook a thematic inspection on “Protecting Disabled Children Ofsted (2012) found that for disabled children the children in need (CIN) work was not always well co-ordinated; many plans were not detailed or focussed on outcomes. In a small number of cases children had no plans or reviews were not held. In other cases, the reviews did not always include other professionals working with the children. Ofsted concluded that the lack of rigour nationally in the management of children in need work increased the likelihood of child protection concerns not being identified early enough. This was evident for the siblings. 3.21 There is no data about how widespread an issue this is likely to be locally, but the lack of robust child in need plans impacted on the wellbeing of the siblings and the national picture and serious case reviews suggest this is an area around which the safeguarding Board Finding 4: Addressing intra and inter professional disagreements and disputes is essential to promote the well-being of children and protect them from harm. At no time must professional disagreement detract from ensuring that the child is safeguarded. The child's welfare and safety must remain paramount throughout16. 3.22 This Finding is about the way in which professionals are able to manage and resolve professional differences and disagreements in the best interests of children and young people. Professional disagreements and differences are inevitable given the complexity of safeguarding children and young people, the propensity for human bias and fixed thinking. Establishing a culture of openness to change, to constructive challenge and self-criticism is fundamental to addressing these issues. 16 18 3.23 Reder and Duncanix as a result of their review of Serious Case Reviews nearly twenty years ago argue that professionals need to develop ‘a dialectic mindset’ in which there is a constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events. It is not the disagreements that matter, but whether there is a culture and openness in the way in which they are addressed. 3.24 Researchx and Serious Case Reviewsxi highlight that significant professional differences about the needs of children suggest that those needs are not well understood by any one part of the multi-professional network. The safeguarding procedures17 make clear the importance of addressing disagreements at an early stage in the best interests of children, putting professional rivalries and myths about roles and perspectives to one side. This did not happen for Sibling A and Sibling B. 3.25 The schools that the siblings attended became increasingly concerned about their welfare and the attitude of the relative carer to them. They consistently reported those concerns, but their views were dismissed and they were led to believe that they were incorrect in their analysis. This was in part influenced by the relative carer who sought to split professional, complaining of having been treated unfairly by school. The school did try and address these issues with front line managers but they were unsuccessful and were not then clear about what they should do next. As part of this review it became clear that not all professional groups are aware of the existing escalation policy. 3.26 There were also professional disagreements within the disabled children’s team about what needed to happen for these children. These also remained unresolved and were exacerbated by existing pressures on the team and a management style characterised by autocracy. This has changed, but the concern remains that this issue is not just about knowledge and compliance with the escalation process. It raises the point about what do professionals do regarding differences in the analysis of a child’s circumstances; what are the opportunities for debate and reflection in a multi-agency context? There will always be debate about the complex area of safeguarding practice, and parents/carers can make use of these differences to distract attention from their own abusive or neglectful parenting. This happened for 17 19 siblings and is a known danger for future practice locally and nationally. 3.28 There was evidence that professionals did act on disagreements. The Chair of the Review child protection conference challenged the Disabled Children Team Leader about a lack of proactive action for the siblings and the Children’s Guardian appropriately questioned the best options for both siblings when they cam into the care of the Local Authority. 3.29 This review has highlighted the importance of an awareness of existing escalation processes and professionals finding ways to address professional disagreements in the best interests of children and young people. Finding 5: Fixed professional thinking which is not picked up through supervision and reflection has the capacity to undermine the ability of the safeguarding system to keep children and young people safe. “our failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’ (Fish, Munro and Bairstow 2009xii) 3.30 This Finding focusses on the impact of fixed thinking on professional practice. It is linked to the previous finding on professional disputes, but as a concept has been recognised as a significant issue in the ability of professionals to safeguard children effectively. 3.31 There were high levels of fixed thinking by some professionals regarding the circumstances of Sibling A and Sibling B. There was significant and growing evidence that they were being abused, neglected and being subjected to harsh and cruel parenting. However, the narrative remained for some that this was a family/carer who were struggling to cope with difficult and damaged children. The belief was that this behaviour was a manifestation of their early trauma, which had taken place many years earlier. 3.32 There was no objective analysis that the children had been living with the relative carer since they were 17 months and 3 years old, and therefore the likely influence was currant parenting and circumstances. In one report to the case conference it was reported that “Sibling B will damage property, scream, shout, and threatens to run from the house” and that “Sibling A keeps the whole family up by running around at night” yet the children are described as showing the person undertaking the home visit for this report around their bedrooms and 20 their favourite toys. The observation of the children was different to the descriptions provided by the relative carer and family. The school consistently addressed this with the relative carer and other family members. The fixed thinking did not change with challenge from other professionals or the observations that the children often looked nervous. 3.33 Child protection inevitably involves working with uncertainties and making difficult decisions and complex judgements on the basis of incomplete information in rapidly evolving, often hostile and highly stressful contexts. There is a substantial body of research evidence that has clearly identified the unconscious tendency for early evidence bias in human decision making; that is, an initial summing up of a situation strongly influences the analysis of subsequent or new information leading to fixed thinking and faulty conclusionsxiii. 3.34 Serious Case Reviewsxiv have repeatedly found that professionals were either unwilling or slow to revise their judgements in the face of new or contradictory evidence and that this selective interpretation of information, only using that which confirmed their preferred view about a particular case, became a “pervasive belief” which influenced the professional response. These pervasive beliefs were found to remain, even where there was considerable evidence of lack of progress or success in interventions and services offered. As Munro notes, “the single most important factor in minimising errors in safeguarding practice is for professionals to be enabled to admit that they might be wrong”xv. 3.35 Practitioners must be willing, encouraged and supported to challenge, and where necessary revise, their views throughout the period of any intervention. To achieve this, practitioners and their managers should routinely play their own ‘devil’s advocate’ in considering alternative actions, explanations or hypotheses. Supervision should provide a safe but challenging space to oversee and review cases with the help of a fresh, experienced, pair of eyes and to systematically guard against either rigid adherence to a particular view. 21 Appendix 1 Chronologies were sought from and received from: Police Children’s Services CAFCASS GP and Health Trust Community Partnership Schools attended by the siblings 22 Appendix 2: About the Independent Reviewer and overview author: , is accredited in systems learning and the SCIE “Learning Together” model, and is an experienced independent investigator and safeguarding lead who has undertaken many Serious Case Reviews nationally over the last 15 years. has a professional background in social work, training and policy development. has never worked for any agency in and is completely independent. 23 Appendix 3: Review Panel Organisation Title Independent Author Independent Chair Council Assistant Director, Support and Safeguarding Children Council Service Leader, Strategic Safeguarding and Quality Assurance Council Principal Social Worker Council Safeguarding in Education Training Officer Head of Children’s Safeguarding (Designated Nurse) Designated Nurse CCG Designated Doctor for Child Protection Police DCI , Investigations CAFCASS Service Leader 24 References: i Jones, L., Bellis, M.A., Wood, S., Hughes, K., et al. (2012) Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. The Lancet July 2012. ii Sullivan P.M., and Knutson J.F. (2000) Maltreatment and disabilities: a population based epidemiological study. Child Abuse and Neglect 24, 10, 1257–1273 iii Miller, D. and Brown, J. (2014)’We have the right to be safe’: protecting disabled children from abuse NSPCC. https://www.nspcc.org.uk/globalassets/documents/research-reports/right-safe-disabled-children-abuse-report. pdf iv https://www.nspcc.org.uk/services-and-resources/research-and-resources/2014/right-to-be-safe/ v Barlow, J. & Scott, J. (2010) Safeguarding in the 21st Century -Where to Now. Dartington: Research in Practice. vi Turney, D et al (2011) Social work assessment of children in need: what do we know? Messages from research; DfE https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/182302/DFERBX-10-08.pdf vii http://www.legislation.gov.uk/ukpga/1989/41/contents viii Ofsted (2012) Protecting Disabled Children: Thematic Inspection. London: Ofsted. www.ofsted.gov.uk/resources/ protecting-disabled-children-thematic-inspection ix Reder, P and Duncan, S (2003) Understanding communication in child protection networks. Child Abuse Review. Volume12, Issue2 March/April 2003 x Burton S (2009) The Oversight and Review of Cases in the Light of Changing Circumstances and New Information: How do people respond to new (and challenging) information? Safeguarding: Briefing 3. London: Centre for Excellence and Outcomes in Children and Young People’s Services. xi Sidebotham et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014; Department for Education https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/53382 6/Triennial_Analysis_of_SCRs_2011-2014___Pathways_to_harm_and_protection.pdf xii Fish et al (2008) SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews 25 xiii Broadhurst et al ( 2010) Ten pitfalls and how to avoid them What research tells us; NSPCC https://www.nspcc.org.uk/globalassets/documents/research-reports/10pitfalls-initial-assessments-report.pdf xiv Sidebotham et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014; Department for Education https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/53382 6/Triennial_Analysis_of_SCRs_2011-2014___Pathways_to_harm_and_protection.pdf xv Munro, Eileen (2010) Learning to reduce risk in child protection British Journal of Social Work, 40 (4). 1135-1151. ISSN 1468-263X |
NC52327 | Neglect of a 17-year-old boy, who was admitted to hospital in November 2020. Young Person S was presented in a poor physical and mental state, and was transferred to a psychiatric hospital where he was assessed as experiencing first episode psychosis. Learning includes: the importance of multi-agency professionals understanding mental capacity and applying the law in relation to an individual's decision-making; assessing parenting capacity with multi-agency input; understanding parental and adolescent mental health and its impact on the family, and the need for a Think Family approach; understanding domestic abuse across familial relationships; the importance of multi-agency input into assessments and safeguarding strategies prior to case closure; when engagement is not easily achieved, the need for professional curiosity about why a family may not be engaging; the importance of seeing children, including seeing them alone, when there are worries about a child's welfare. Recommendations include: the development of a Think Family protocol; partnership organisations have the necessary processes in place for shared responsibility of child and adult safeguarding, including systems for information sharing; auditing the quality of child and family assessments; case closure processes ensure the rationale for closure is recorded, and outline what is expected practice when there are difficulties engaging with families; government officials consider the impact of legislative restrictions on elective home education, and how these can potentially leave young people more vulnerable.
| Title: Young Person S – local safeguarding practice review. LSCB: Bexley S.H.I.E.L.D. Author: Deborah Angus Stewart Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Young Person S – Local Child Safeguarding Practice Review Bexley S.H.I.E.L.D. Independent Reviewer – Deborah Angus Stewart– November 2021 This final report completed by: Amanda Gillard (Practice Learning and Review Manager, Bexley S.H.I.E.L.D., March 2022) 2 Foreword This report includes the findings and learning as identified by Deborah Angus Stewart (Independent Reviewer) who was commissioned by Bexley S.H.I.E.L.D. to complete an independent Local Child Safeguarding Practice Review (LCSPR). While the focus of the review was primarily on Young Person S, the reviewer considered findings in relation to how services responded to all individuals in the family and how this impacted on Young Person S. This report therefore references professional involvement with other members of the family where relevant. Introduction This LSCPR was conducted in response to concerns about the neglect of a 17-year old young man (Young Person S). There was concern regarding how agencies worked together in the context of Young Person S’s neglect, isolation, mental ill health and poor educational development. At the time of the incident Young Person S lived at home with his parents Mr S and Mrs S and his two sisters Ms T (19) and Ms V (16). The family were known to Police, Education, Primary and Secondary healthcare services, Children’s and Adolescent Mental Health Services (CAMHS), Children’s Social Care, and Adult Mental Health services. At the time of the notifiable incident, Young Person S and his sister Ms V were not open to Children’s Social Care. There had been involvement from CAMHS and Children’s Social Care some months prior to the incident. Young Person S was past compulsory school age at the time of the notifiable incident and contrary to what was understood, was not in education or training (NEET). Young Person S and his sister Ms V (aged 16) were not open to Children’s Social Care at the time of this incident. Ms V was in regular school attendance and receiving pastoral support in school. The family came to the attention of police and the London Ambulance Service in November 2020 due to Ms T reporting that her brother had been acting aggressively toward her and that his mental health was apparently deteriorating. Police and ambulance crew in attendance to the home, observed Young Person S to be in a poor physical state and were concerned about his environment and for his mental health which they decided needed to be assessed at a hospital. Young Person S and his father were escorted to hospital. While waiting for assessment Young Person S left with his father, before a thorough assessment could be completed. 3 Young Person S presented again the following day to hospital A with his father and was noted to be mute, hypertensive and tachycardic. Young Person S was transferred to a psychiatric hospital (Hospital B) for further assessment and was assessed as experiencing a ‘First Episode Psychosis’. Staff were concerned about the physical and mental state in which he arrived and considered that this would not have developed over a short period of time. The hospital therefore questioned what involvement there had been with other agencies, and the level of assessment and monitoring which had been in place. Hospital B referred the matter to Bexley S.H.I.E.L.D., the safeguarding partnership for children and young people. The matter was referred to the Child Safeguarding Practice Review (National) Panel as a notifiable incident due to concerns about multi-agency working in the community. A Rapid Review was convened, and the outcome was to recommend a LCSPR although the Rapid Review also identified learning for Adult Services. Terms of Reference The time period for the review is from March 2017 to November 2020. This was to allow for consideration of Young Person S’s experience of secondary education and to better understand the family’s involvement with other agencies during this period and up to November 2020 when the serious incident was reported. This included an expectation that where relevant additional historical information prior to this would be summarised when this provided context to the analysis and findings of this review. Some of the information in this report includes reference to other members of the family. The Learning from Practice Group met to agree the scope of the review and requested specific information about the following areas: • The identification and response to risk (individually and on a multi-agency basis) for the parents and the children including the following areas: parenting capacity, mental health, parental conflict, domestic abuse, and resistance to engagement. • Assessing the children’s lived experience and the capturing of the voice of the child. • Practitioners’ understanding of policies and procedures and how they support their work – e.g. mental capacity. • The extent to which the current Covid-19 crisis has impacted on the circumstances of Young Person S and his family and on the capacity of the services to respond to their needs. Approach Information was gathered by way of individual management reports, chronology of involvement and via reflective discussions with practitioners as part of a Learning Event. This included representatives from across the partnership who had most 4 recently been involved with the family as well as others who had historical knowledge and involvement. Family Participation The child’s parents and young adult siblings were informed of the decision to carry out a Child Safeguarding Practice Learning Review and were invited to meet with the review author and a member of the review panel. However, neither parent responded. Young Person S did not have capacity to engage at the time. The allocated social worker to Young Person S was kept informed and asked to share any learning. The process was supported by the Learning from Practice Panel members. The siblings to Young Person S were also invited to meet with the reviewer but declined preferring to be kept informed by their social worker and support worker. Both siblings to Young Person S have been written to by the Safeguarding Partnership detailing what changes have been made as a result of the learning from the review. Immediate Steps Taken Following the initial referral into the S.H.I.E.L.D. partnership, a case mapping was completed to provide an opportunity for practitioners and managers from Children’s Social Care to reflect on what was known about the family and to ascertain the needs of the children Ms V aged 16, and Ms T aged 19 who at the time remained living in the family home. The case mapping provided opportunity to signpost Ms T (19 years) to support from housing, and advocacy, and SOLACE (Domestic abuse services) to ensure she had access to the necessary support. A Child and Family Assessment was initiated in respect of Young Person S and Ms V and arrangements made for regular review from senior management. An Initial Child Protection Conference was held and Young Person S and Ms V were both made subject to child protection plans. Following psychiatric assessment, Young Person S was placed under Section 2 of the Mental Health Act. Legal steps were taken to secure his treatment plan beyond the initial 28 days and care proceedings were commenced. Legal planning commenced in respect of Ms V (16 years) and she was made subject to an Interim Care Order in January 2021. Ms V was offered alternative care arrangements, and with support from the allocated social worker and with preparation was agreeable to move to live with foster carers. 5 Mr S was eventually rehoused following ongoing conflict between the parents and Mrs S was offered a treatment plan from adult mental health and monitored closely by her treatment team In February 2021, S.H.I.E.L.D. jointly with the Adult Safeguarding partnership and senior leads in Adult Social Care, Adult Mental Health and Children’s Social Care met to reflect on the immediate learning identified through the Rapid Review process. It was agreed that there was learning for how the multi-agency network had responded to and worked with the family. A recommendation was made to immediately draft and develop a ‘Think Family Protocol’ together with a training schedule to support the implementation of this approach and to highlight the learning across the partnership. The protocol was completed and jointly overseen by the Adult’s and Children’s Safeguarding Partnership Teams and launched in October 2021. This compliments the existing Signs of Safety Practice model adopted by Children’s Social Care. Mental Capacity Training and Care Act training were made readily available and joint Training for Children’s Social Care and Adult Services was scheduled for 2021. This is ongoing. What is ‘Think Family’ workshops took place as part of the Multi-Agency Learning Forum in Spring 2021 and which is responsible for the dissemination of learning and continual review of impact of the learning from reviews. Summary of Professional Involvement Background history The family have come to the attention of Police, Children’s Social Care, and health services in Bexley since 2001 as a result of Parental Mental Health, and conflict in the parental relationship and the impact of this on their capacity to parent. At the time of the review there was limited information about the parents own childhoods and social histories in the assessment reports completed. Mrs S (mother), is diagnosed with Paranoid Schizophrenia. She has experienced periods of instability since 1994, when she was first detained under the Mental Health Act, with further admissions in 2007, 2015, 2016 and 2019. It is known that the mother has accessed in-patient treatment voluntarily on occasion but in the main has required treatment under section in crises as a result of not taking her medication and or refusing to access the recommended help in order to manage her mental health. At the time of the review Mr S (father) engaged consistently with the family GP in managing his medication due to his diagnoses of Schizophrenia and recovery from a history of drug use, although he was not accessing any therapeutic services, to help with his mental health. 6 The family were all registered with the same family GP for the past 16 years. The family have come to police attention historically due to incidents of parental conflict, and in recent times in 2019, and 2020, when the mother has been experiencing mental health crises. Young Person S was subject to a child protection plan in 2004, under the category of neglect and again in 2012 under the category of emotional and physical harm. Young Person S had been known to CAMHS in 2018, 2019 and 2020. Child protection plans were in place for all three children in 2012, with Young Person S and his sibling Ms V moving to live in Essex in 2013 and being placed on Child in Need Plans. Ms T was moved to a Child in Need plan in 2013. All three children had been subject to Child in Need Plans following concerns about the mother’s deteriorating mental health in May 2015, and then closed three months later due to non-engagement. Young Person S had previously attended 4 schools; including one school in Essex and had experienced two periods of Elective Home Education (EHE) and one period of being a ‘child missing education’. Ms T (Sister to Young Person S) at ages 17,18 & 19 independently requested support from health, housing, and Children’s Social Care, and accessed support from Child and Adolescent Mental Health Service. Children’s Social Care have completed six separate child and family assessments between 2014 and 2020, and prior to this reported serious incident. Four assessments had taken place within the scope of this review, in 2018, 2019, and 2020. Each assessment concluded with no further action aside from one referral to the early help service in 2019, but the parents declined any support. The parents to Young Person S, Ms T and Ms V did not accept that any of the concerns raised in any of the assessments warranted Children’s Social Care support and declined offers of support from Children’s Social Care and/ or early help services. During the course of this review and prior to in the practitioner event held in November 2020, Children’s Social Care and other agencies reported that Mrs S experienced difficulties in engaging with professionals and she could be avoidant, hostile on occasion, obstructive, and dismissive of concerns. Mr S did on occasion report concerns, but was reported to be inconsistent in his approach to engagement with Children’s Social Care. This is explored further later in the report. 7 Key Episodes January to May 2017 Mrs S had elected to home educate Young Person S in 2013, while living in Essex, but Young Person S returned to school in Bexley in 2015. Between January and March 2017 Young Person S experienced internal exclusion for defiance; being intimidating; continued rudeness; verbal abuse to staff, and disruptive behaviour. He was at this time however, reported to be working well with his studies. Mrs S was notified on every occasion with regard to Young Person S’s challenging behaviour and according to the school, she responded by wanting to home educate Young Person S, although the school were never sure of her rationale. When Young Person S could communicate and was withdrawn from school by his Mother to be educated at home, it was not evident that he was given the right to choose the location for his education or the nature of any educational provision; or if he expressed his views as part of the process. Young Person S began a second period of home education in Bexley from March 2017. He had also experienced a period of home education in Essex in 2013. There was limited information sharing between Essex and Bexley in relation to Young Person S’s home education, at the point when Young Person S returned to live in Bexley. After an unknown period, he stopped going out and had no independent access to friends or professional agencies, thus his isolation grew, as did the potential for his neglect. The Elective Home Education (EHE) Service in Bexley operates in line with the DfE guidance, April 2019, and has contributed to the recent London Councils submission to the Education Select Committee on EHE. This Review is advised that parents can declare home education at any time, as allowed by legislation and that when the EHE Service become aware that parents are considering home education, a discussion is held to ascertain the reason, and if there are any issues with school attendance; school support or behaviour issues, then the service offer to liaise with relevant professionals to try and overcome any difficulties, usually resulting in the child remaining in school. The EHE service advised the reviewer that when parents first declare EHE, they are provided with information about learning resources, GCSE examination centres, and Youth Advisory Services. Following this, parents are contacted within 3 weeks to discuss provision, followed by an education review. In relation to Young Person S, EHE was confirmed by Education Services on 4th of April 2017. This was within the expected time frame of 3 weeks of when EHE period commenced. In the meantime, Mr S was noted by the GP to be suffering from fatigue, whilst Mrs S was due a mental health review that month. It would appear that EHE, education services or schools were not aware of parental mental ill health, and there is no evidence that any information was shared in relation to mental health at this point. 8 On the 4th May, an EHE Review meeting was held at the family home with the EHE Officer, Young Person S, and his mother. This was within expected time frame of 12 weeks from declaration of EHE. The Officer decided that the home education in place was ‘suitable and in place’. A range of educational resources were shared, and Mrs S advised the officer that Young Person S enjoyed maths and cookery. It is not clear if the officer concerned spoke with Young Person S individually to hear his views. A second visit, in the form of an educational review, was scheduled but did not take place due to human error, but support was offered via letters, which was rejected by the parents. This resulted in a missed opportunity to seek assurance of Young Person S’s education and wellbeing. Parents are encouraged to contact the service should the situation change, or they require support. Neither parent contacted the service, and it is highly unlikely that the mother would have done so given her history of engagement with services overall, and there was a strong possibility that the father would not have gone against Mrs S’s wishes. There was confusion about the length of time Young Person S had experienced EHE, Children’s Social Care believing it to be two years when it transpired to be nearer four years. When Young Person S was moved by his mother into EHE, the School advised the Review that there was a was a lack of awareness that he was a ‘vulnerable’ child, and records did not indicate Children Social Care involvement at the time. However, as acknowledged by EHE Services in Bexley, there was a missed opportunity to monitor any progress and or his developmental or support requirements – which was likely to have contributed to Young Person S’s isolation, his poor educational attainment, and the potential for neglect. This was a systemic error which they have now remedied. In the Spring 2017 Ms T was diagnosed with depression and was receiving support and treatment from the GP and CAMHS, and was discharged in June of 2017. This period coincided with Mrs S’s decision to withdraw Young Person S from Secondary School, and was during the period of disruptive behaviour exhibited by Young Person S. It is not clear what enquiries would have been made when deciding on whether to challenge a request to home educate at this point. It is possible that the GP and Children’s Social Care were not made aware of Young Person S being home educated at this point. Current practice in Bexley does not support home education for children and young people who are open to Children’s Social Care and subject to Child in Need or Child Protection plans. All parents opting to home educate their children are encouraged to access social activities with other families who home educate to ensure young people have the opportunity to meet with their peers, although this is voluntary and dependent on individual choice. 9 It is acknowledged that at the time of a request for home education, there were no apparent and current mental health issues reported in relation to the parents which would have been seen to impact on home education. However, the older sibling had presented with depression, and there had been a long history of instability within the home due to the mother’s poor mental health. There had been conflict in the home and allegations of physical abuse and domestic abuse over many years, and this ought to have been considered in the context of how conducive home education was and how stable this situation would be for Young Person S. As Young Person S was not open to Children’s Social Care at this particular time, there was no expectation it seems from agencies that there should be any multi-agency liaison. There was limited information sharing between agencies about mental health within the household, which resulted in a fragmented understanding of the potential risks and disruption to Young Person S. Key Learning The assessment to determine whether home education was suitable for Young Person S or not would have benefited from information from health services including adult mental health. In the event that there were no grounds to open Young Person S to Children’s Social Care, there would at least have been more awareness across the partnership agencies of his situation, support needs, and potentially the needs of the siblings. Key Episodes 2018 The GP who monitored Ms T, was aware that her low mood remained, and she was re-referred to CAMHS in January 2018. The latter was a missed opportunity to explore why she had a low mood, and or to consider any other referrals. By May 2018, Ms T had reported to the housing department and Children’s Social Care that she was homeless; was unhappy at home; that her mother was aggressive and that she had been a young carer since she was 13, (then aged approximately 17) but the case was closed without further action. This presentation did not prompt a Young Carers assessment which was a missed opportunity to consider Ms T’s needs and possibly Ms V and Young Person S’s roles within the home, and particularly in light of both parents being known to the GP and adult mental health services due to ongoing mental health issues There was limited curiosity into the domestic abuse which may have been occurring within the household, and the physical and emotional impact of this on other children in the home. Ms T was seen by CAMHS in July 2018 and in September 2018, Ms T attended a Local Emergency Department with suicidal ideation; having taken a small overdose of paracetamol tablets and refusing to return home. She was admitted to an Adolescent Mental Health Unit where she stayed for a week. By 1st October 2018 Ms T was receiving weekly support from CAMHS, and a Child and Family Assessment was commenced following Ms T’s admission to hospital. 10 Children’s Social Care identified in this assessment that Young Person S had been out of formal education ‘since 2015’. Therefore, by this time Young Person S had been out of education for a total of nearly 4 years, given he also experienced a period of home education, while living in Essex. Children’s Social Care appropriately recorded in the Child and Family Assessment their concerns about Young Person S not being seen by professionals ‘on a regular basis’, and that his ‘academic level (was) unknown’. The Child and Family assessment noted that ‘If Young Person S does not receive appropriate support regarding his education, he may not achieve his potential’. Ms T and Ms V reported that Young Person S was not receiving education in the home. In November 2018, The Child and Family Assessment was completed, and transfer was made internally to the Family Wellbeing Team, which would be expected practice when families require ongoing support, and do not meet the criteria for statutory intervention. The family did not access any of the support recommended, and the family were noted as not being willing to engage. The case was therefore closed. The family GP was made aware of the referral of the family to Family Well-being. There was no update as to whether the family had engaged or not, so it is possible that the GP had assumed the family were being supported. Key Learning Ms T would have benefited from a referral for support in relation to domestic abuse and a DASH risk assessment being completed. This is current expected practice. (Multi-agency DASH risk assessment training has been rolled out to partnership agencies in Bexley during 2020 and 2021 and is now mandatory training). Decision making regarding next steps at the end of the assessment in 2018 would have benefited from more in-depth reflection in supervision and or via management oversight, as to previous involvement, patterns of engagement and the history of concerns. There was limited multi-agency input in order to determine whether or not statutory services would have been more proportionate at this point. It appeared that Ms V was known to maintain good school attendance and worked well, but there was little curiosity evidenced in relation to how parental mental health, her brother’s difficulties, and the domestic abuse which was occurring maybe affecting her daily experience of living in the household. This raised pertinent questions of how; when and if, her needs were considered sufficiently in 2018 and or in previous assessments Previous assessments did not focus sufficiently on the individual experiences of all the children and adults within the home and or how mental health and conflict would be impacting, particularly in relation to Young Person S’s education and personal development, despite Children’s Social Care identifying his social needs and obvious isolation. 11 The approach to the assessment and limited input from other agencies resulted in what could be considered as premature closure of the case and limited support being provided to the children in the family. Key Episodes 2019 Police, CAMHS, the GP and Children’s Social Care were all involved with the family in 2019. The family came to the attention of police in February 2019 following a family friend reporting that Young Person S had made comments to them about abusive behaviour from Mr S towards his sister and that Mr S had been giving Young Person S medication. A Sec 47 enquiry took place but no offences were deemed to have taken place and the outcome of the enquiry was ‘no further action’. Police have since confirmed that all the young people concerned were interviewed in relation to allegations. At the time of the enquiry it is not clear whether Young Person S and his siblings were seen away from the home and this is not detailed in the records provided. The review considered the potential significance and importance of this in the context of the children feeling able to speak freely within the home due to the fact it was known the children had previously spoke of being actively discouraged from speaking with professionals, and due to the fact that there had been domestic abuse and what is now considered incidents of coercion and control. A Child and Family Assessment followed. Young Person S was not seen during the course of this assessment, and again concerns were raised regarding his isolation and not being in training and or college; him not receiving appropriate education from parents. A Children’s Social Care social work visit took place on 1st March 2019, and concerns were raised about Young Person S being home schooled, as it appeared to the social worker that he was not receiving appropriate education and was isolated. A further home visit was arranged, but no action taken to consider his post 16 education. In April 2019, at a scheduled home visit, Ms T and Ms V disclosed to Children’s Social Care that their brother, was not leaving the house; would not talk to anyone and could be violent and aggressive. It is not evidenced that any referrals were made to SOLACE (domestic abuse support provider) in respect of the siblings reports about Young Person S’s behaviour towards them from Children’s Social Care. In accordance with expected practice, the visiting social worker tried to talk with Young Person S, but he refused to come out of his room. The social worker raised concern about Young Person S with his father at the visit, who advised the social worker that Young Person S could do what he wanted, and it was nothing to do with Children’s Social Care. A joint visit with CAMHS and Children’s Social Care also took place in April 2019, CAMH’s recommended that Children’s Social Care offer support to Young Person S 12 to access social and educational activities. CAMH’s recommended to Children’s Social Care that there needed to be more work completed with the family. They did not consider they were in a position to support Young Person S further without there being input from Children’s Social Care in the first instance. This indicated that there was a need to work with the parents and Young Person S in order to address concerns rather than to just focus on the perceived therapeutic needs of Young Person S. Children’s Social Care closed the case in May 2019 and report that the family were not willing to accept advice or support. This was a further missed opportunity to consider whether in light of the history there was cause for Children’s Social Care to adopt a more assertive approach. Throughout 2019, Mrs S continued to attend GP mental health reviews and receive treatment from the GP, for continued low mood. In early September, Mr S called the ambulance service worried about his wife’s mental health, noting she appeared dazed, and was observed walking up and down the road exhibiting poor mental health. Ambulance services referred the incident to MASH, who undertook various checks, and the outcome was ‘no further action’. This was a further missed opportunity to explore the family situation and to consider what support may have been required by the children and young people in the household. Three weeks later Mrs S was admitted to a mental health hospital with confusion following substance abuse. It is not evident that a referral was made to Children’s Social Care on this occasion in respect of any concerns with regard to Young Person S, Ms T and Ms V. Ms T may also have required support from adult services. Mrs S had been reported to be non-compliant with medication in 2019, largely by her husband. She denied using substances but tested positive for cannabis. On discharge from her hospital admission, professionals were unable to engage with her in the community, (albeit Intensive Care Coordination from Oxleas Mental Health Trust was in place from 3rd October until June 2020 and the Home Treatment team tried to assist in July 2020). The GP and the practice staff engaged in prompt communication via phone and email with Adult Mental Health Services, and with Children’s Social Care and CAMHS, and worked hard to provide the assistance, protection and healthcare required by all of the family members. The GP added notes to all family member’s records, particularly in relation to alleged abuse from Mrs S to Mr S. During late October, Bexley Youth Advice Service made a follow up home visit to Mrs S regarding Young Person S’s September choices, and she advised them that he was at College A, studying sport, which was not the case. An external visit to the doorstep of the home was an opportunity to be professionally curious, and whilst it is not normal 13 practice to doubt a parent’s word, Bexley Youth Advice Service have adjusted their documentation to explicitly prompt community callers to consider if there are any safeguarding concerns. This aligns with the same process as EHE officers and connects to Bexley Youth Advice Service’s regular training around safeguarding matters. Key Learning The events described above highlights learning in relation to creating the right conditions to ensure young people can where possible speak of their own experience, wishes and feelings, and be a part of decision making. It also highlights the importance of the voice of the child and it would be prudent for professionals from across all partnership agencies to reflect on how professionals made sense of the information shared by the siblings during visits, and through individual interviews. Young Person S was deemed to have capacity and to be able to make his own decisions, but it is difficult to understand how this view was reached when he had not been seen by the social worker and or CAMHS for any period of time. The decision by CAMHS to discharge Young Person S, coupled shortly later, with the Children’s Social Care decision to end their involvement, left Young Person S and the family unsupported, albeit parents were offered the chance to call CAMHS, if circumstances changed. Given parental history of a lack of engagement, and what appeared at times to be fear of services (on behalf of Mrs S) and her domination in the family - it would seem unlikely that she would have requested help. Mr S may have been a more reliable source, but given the circumstances, disagreements, and domestic abuse allegations, there could have been more healthy scepticism about the parent’s reporting they needed support. Mr S’s capacity to engage openly and honestly about what was happening in the home was inconsistent. Adult mental health services responsible for the mother’s care while in hospital could have demonstrated more curiosity into who else was in the home and what support might be required upon her discharge. There was no consideration of the children’s needs on this occasion and no action taken to ensure the children would be supported, and or liaison with other services who would have been best placed to assess the home situation. A referral to Children’s Social Care or at the very least sharing of information would have been expected good practice. This would have again flagged the instability in the home and potentially have identified support needs for the children individually and also in respect of Mr S. The role of Mr S in relation to parenting and his capacity to ameliorate stress in the home is not addressed sufficiently in previous assessments, and therefore it remained unclear as to his capacity to safeguard. 14 Referrals were not made to SOLACE by GP and or Children’s Social Care, and or from Adult Mental Health Services. DASH assessments were not completed by Children’s Social Care and or any other agencies following disclosure of violence from Young Person S to his sisters, which was a missed opportunity to better understand the home situation. Key Episode 2020 In early February, Mr S raised concerns with the GP about his son’s behaviours and requested a home visit. The GP made an urgent referral to CAMHS, which was good practice. It was discussed on the day of receipt, which was also good practice, and between the 12th and 14th February four phone calls were made to gather information (three to Mr S and one to MASH). As a referral to CAMHS was in progress it was agreed to await this and no home visit was made. Between the 12th February and 23rd March, CAMHS made twenty-nine contacts to ascertain information about Young Person S (twelve family phone calls; nine social care contacts; three home visits; three texts and response to two crisis line calls). Mr S had contacted Crisis Line on the 18th February reporting Young Person S was being aggressive and urinating on the floor. It is believed that a CAMHS Doctor visited Young Person S the next day, but he refused to engage and consequently, was not seen. Mr and Mrs S gave background history about their 17-year-old son, and expressed current concerns, stating he had been ‘expelled’ from school (which was not true); Parents advised Young Person S was urinating in his room and the garden; had reduced his self-care; had increased anxiety about leaving the house and that he was laughing without explanation. It was also noted that he was increasingly violent to Ms V. Parents noted his big appetite, cooking for himself and enjoying painting and decorating. CAMHS completed a genogram; noted relationships and parental mental health; conducted a risk assessment and considered the risk of exploitation and self-harm as low for Young Person S, and set out a safety plan for him. Following this meeting, CAMHS decided Children’s Social Care support would help the family, and that Young Person S presentation was likely to be linked to social isolation; a lack of meaningful activity and the way in which he was being supported at home. Questions about his access to training and or post 16 education were not explored in detail, and there was no exploration of his aggressive behaviour within the home and towards his sisters At the end of the month CAMHS made a referral to the Family Wellbeing service (with parental consent) and made a follow up call to MASH, to share information and request advice. They also made daily checks with the parents about Young Person S and progressed the referral to Children’s Social Care, all of which was good practice. 15 On the 22nd February Mrs S called police saying Young Person S was throwing glasses down the stairs and urinating, advising she was scared to approach her son. No police action took place, but a (MERLIN) report was shared with Children’s Social Care. Police have advised that a DASH Assessment should have taken place. On 25th February an alert was received by Children’s Social Care, from a neighbour saying that Young Person S was indecently exposing himself. By the 28th February, the police and CAMHS referred Young Person S to Children’s Social Care. Children’s Social Care acknowledged concerns about Young Person S’s behaviour and the difficulties in management of him in the home, his isolation and the fact he was not in any training. On the 5th March, a joint visit between CAMHS and Children’s Social Care took place. CAMHS were by now aware that Young Person S had not started college the previous September; that he had limited support from Youth Advisory Services (mainly letters) and that he was not leaving the house; refusing to meet professionals; had no contact with anyone outside of the family; and had no phone and was extremely isolated and anxious. CAMHS visited Young Person S again on the 28th of February, and again, he did not engage. Both parents were present. CAMHS advise that they did not wish to pressure Young Person S, and accepted his resistance to engage to prevent distress or behavioural escalation. Parents advised of recent improvement, seemingly not urinating in his room; nor laughing to himself at night, sleeping well and having a new bed. They reported speaking positively to him; offering him more reassurance and seemingly saying that they wondered if this had helped. He was seen by the visiting doctor using a downstairs toilet but then returned to his room, and it was thought Young Person S was listening upstairs. A plan was made, with parental agreement to pre-empt crisis: which was for them to encourage Young Person S to join activities; give him feedback for positive behaviours: spend time with him thinking about his future, and to provide gentle encouragement for him to go out. This was accepted and parents also agreed to the joint visit from CAMHS and Children’s Social Care on the 5th of March. A further referral was made to Children’s Social Care due to poor mental health and behaviours, and a Child and Family Assessment commenced. The GP contacted CAMHS to follow up on the original referral, which was good practice, and was advised that Young Person S case was still being assessed. On 5th March the joint visit took place. The CAMHS Doctor was aware of the family history from the NHS RIO system – which was good practice. Young Person S did not engage and remained in his room, was not seen and did not speak, even through the door. 16 The CAMHS Doctor assessed Young Person S as presenting with acute social withdrawal and isolation but did not believe Young Person S to be psychotic. Mr S reported that his son was mugged at 14 and then stopped going out, and that he (Mr S) became paranoid when he went out, and that Young Person S ‘may have picked it up from him’. Mrs S added that she became anxious in large crowds. The CAMHS Doctor noted that Mrs S ’s admission to hospital in September 2019 may have impacted on Young Person S not accessing further education and considered that Young Person S’s social withdrawal and social isolation made sense in context of the information received. The CAMHS Doctor believed that targeting this, and enabling Young Person S to move into education, was the preferred approach. Later, the case was discussed with the CAMHS clinical Lead, and it was decided that Young Person S could be discharged to the care of his GP and that Children’s Social Care could re-refer if necessary and parents also agreed to contact CAMHS, the GP or Children’s Social Care if Young Person S deteriorated. The GP practice had signposted Mr. S to domestic abuse services and were aware that both parents (particularly Mrs S) would raise concerns, and then push help away - and initially, when Mrs S refused to give consent for CAMHS to share information with other services, Mr S had consented. CAMHS advise that professionals rely on those with parental responsibility to seek support and that in the past, Mr S, had done this, and shown he could be proactive by going to his GP. It was acknowledged by them that his efforts were not always consistent). It is positive that the GP referred Mr S to SOLACE for advice and support in relation to being a victim of domestic abuse. It was known at this point that there were three young people in the household also, but there was limited reflection on how domestic abuse may be impacting on them which left all members of the household vulnerable. When Mr S was referred to SOLACE, regarding domestic abuse, there is acknowledgement that a MARAC referral should have been pursued; that children’s details should have been gathered and a MASH referral made for them. On the 6th March, CAMHS held a professional discussion with Children’s Social Care, which was good multi-agency practice. Children’s Social Care offered to write to Young Person S, to arrange to meet him, away from his home, and to consider a referral for mentorship. Children’s Social Care at that point seemed to recognise the need for intervention and to be assertive and planned to complete a Child in Need Plan, aware they could return to CAMHS for assistance, if required. CAMHS closed the case and parents were contacted, and advised of the plan to support Young Person S, which was good practice. Both parents agreed with the proposals, and a discharge summary was sent to the GP, Children’s Social Care. and the family, all of which was good practice. 17 On the 24th April, Mrs S contacted Children’s Social Care, reporting Young Person S had very much improved; stating he was now coming downstairs; cooking; going out in the garden; joining the family for conversations and that there were no current concerns. The social worker asked to talk to Young Person S, but this was refused. Children’s Social Care had previously noted that Young Person S was not engaging; nor accessing appropriate education ‘despite support and encouragement from parents and professionals’ and that he ‘appeared to have capacity and ability to make choices for himself’ and that: ‘his parents demonstrated an understanding of his difficulties and continue to support and encourage while monitoring his health and wellbeing’. On the 29th April 2020 the Child and Family Assessment was complete and the family were sign posted to the Well Being Service, but they refused support. The case was subsequently closed. CAMHS advised that when clinicians were assessing Young Person S they were aware of Young Person S’s own complex social history. Their formulation being that Children’s Social Care input needed to be put in place before any improvement of Young Person S mental state could occur; and that the serious deterioration of Young Person S occurred after their involvement had ended. CAMHS have advised the Review that when Young Person S was discharged, they had confirmation from Children’s Social Care that he would be assessed and provided with appropriate support. Suggestions were made by Children’s Social Care with regard to enabling Young Person S to engage with the community to reduce his isolation, for example. The decision therefore made by Children’s Social Care to close the case, owing to Young Person S parents refusing support, without a discussion with CAMHS, would seem to have been premature and not compliant with what CAMHS believed was going to happen. In October 2019, Mrs S was admitted to mental health services and in June 2020, Mrs S was discharged from mental health services, but she was later readmitted to hospital in July, following contact with Crisis Line and the Ambulance Service advised Children’s Social Care about her mental ill health. Children’s Social Care contacted Mr S to offer support, however he refused, and was unwilling to engage. No further action was taken, and the case was again closed. This was a missed opportunity to review and evaluate the home situation. When Mrs S was discharged a multi-agency, discussion did not take place, and there was no face-to-face contact from the doctor or Care Co-ordinator (this could have been attributed to Covid-19 restrictions). On the 8th August, a Youth Support Advisory Team member visited the home address to discuss Young Person S education plans. Young Person S was again not seen, and Mrs S refused to provide a contact number. 18 On 11th August Mr S reported he was a victim of domestic abuse from his wife. Given Mr S’s mental health issues, he would have been considered as an adult with care and support needs and a referral to adult safeguarding should have been made. This would also have been an opportunity to alert Children’s Social Care to the alleged conflict between the parents, and allegations of abuse towards the father. It was identified that three children aged 15, 17 and 19 were at home, but details only taken for Ms V then aged 15. A risk assessment was set up for the following day and safety advice was given. A risk assessment followed in August 2020. The GP was informed that a police report had been made, but no action would be taken from mental health services. Mrs S had assaulted her eldest daughter, Ms V grabbing her face and scratching her arms, but no referral was made to SOLACE by Police. This was a missed opportunity to consider in more detail all members of the household and what support may be needed. The risk assessment score for Mr S was 13/24 and following a conversation at Service Manager level, a MARAC referral was indicated, and the case was allocated to an IDVA. On the 17th August the IDVA contacted MARAC to see if any other referral had been received. Contact with Mr S was attempted four times on the 17th, without success. On 2nd September MASH were advised about the deterioration in Mrs S’s mental health and a week later, on the on 9th of September the IDVA service closed Mr S’s domestic abuse case. A MARAC referral was never made. This resulted in limited safety planning. Mrs S was arrested for assaulting Ms T, yet it would appear Ms T was not referred to SOLACE by Police or by the GP. Ms V was 15 years old at the time and police would have been aware of her age, and did not follow up with Children’s Social Care. The GP was fully aware of the children in the household having been the family GP for 16 years. SOLACE have acknowledged that their practices warranted improvement, in relation to Think Family; the quality of assessment and the impact of the complexity, on their decision making. They had no knowledge of Young Person S, because they had not asked enough questions to Mr S, with regard to others in the household, or children in the family. SOLACE have advised the review of the changes they will be making in safeguarding training, including a focus on professional curiosity. During October 2020 when Mrs S contacted the GP Practice because Young Person S had a sore throat and antibiotics were issued, Young Person S was not seen, and again in November, she reported he was soiling himself in a telephone consultation and declined to speak to the GP over the phone. It could be argued that a more assertive approach could have been made to see the patient, however this was during the Pandemic, which may have had influence on such decision-making. Police and ambulance were called to the family home by Ms T on the 6th November and which resulted in Young Person S requiring urgent psychiatric treatment. 19 Police and ambulance experienced obstruction from Mrs S in being able to see Young Person S. He was eventually taken to hospital for assessment. When Young Person S was found in a state of neglect, the police priority was to ensure agreement about safety of the children; whether or not there were criminal matters to pursue, and what would be in the best interests of the children. The Police visiting the home on the 6th November had considered Ms T as a protective adult and Ms V and Ms T remained in the home. Police did not explore the vulnerability of Ms T and or Ms V in relation to the mother’s mental health and the history of violence towards Ms T, or complete DASH assessments. Police accepted post Rapid Review that there could have been more awareness demonstrated as to the vulnerability of Ms T and Ms V. SOLACE have advised the Review that multi-agency working could have ‘been stronger’ and that in August 2020, both MARAC and children’s and adult safeguarding referrals should have been made, which were not. It is evident that there could have been greater co-ordination from Children’s Social Care, in pulling together all professionals to share information, share knowledge, and current and historical concerns, with regard to the multiple layers of risk that this family faced, as a whole. The GP Practice has advised the Review of the impact of Young Person S not having the ability to communicate with services, which in their view potentially delayed the awareness of the seriousness of Young Person S state of neglect. They opined that Mrs S ‘played down’ the situation on his behalf. There have also been references made to the Review where Ms T and Ms V were advised by their mother not to talk to others about the state of affairs at home, which again could have served to minimise the risk Young Person S faced. Such requests would also constitute coercion and control. Key Learning The fact that Young Person S was not seen during the scoping period of the Review other than very briefly in passing by any professional, brings into question, how well any professional was able to understand his situation and what he experienced. Findings from the national Voice of the Child Report established that practitioners focused too much on the needs of the parents (especially vulnerable parents), overlooking implications for the child. Mental Capacity assessments are decision and time-specific and a Mental Capacity Assessment could have taken place, by Children’s Social Care, or CAMHS, in order to ascertain if Young Person S had the capacity to take the decision not to be seen by CAMHS personnel. It should be acknowledged that both agencies found themselves working in challenging circumstances, and seemingly did not believe that Young Person S was 20 at risk of significant harm, and without a warrant, a forced entry could not have been made. This is accepted. CAMHS have in hindsight advised the Review that at the time, Young Person S was presenting as ‘at risk’ in relation to his mental state, with early indicators of psychosis. CAMHS are not commissioned to manage the first episode of psychosis service. However, this would not have prevented CAMHS or Children’s Social Care making a referral of concern to the relevant professionals, i.e. that Young Person S was possibly experiencing early psychosis. Both agencies have accepted this. CAMHS have advised the Review that assessing Young Person S was limited by his unwillingness to engage and that at the time reports from his parents did not imply that he did not have mental capacity to make his own decisions. Practitioners and doctors were unable to make observations about the interactions between parents and Young Person S, and were overly reliant on parental reporting. The continuation of Children’s Social Care and CAMHS professionals not seeing Young Person S, diluted joint efforts to assess him fully and comprehensively. There was an over reliance on the credibility of parental reporting; and a lack of challenge from all professionals to the barriers that the parents posed, alongside a clear lack of professional understanding with regard to changing parental mental capacity and inconsistent parenting ability. The parents’ refusal to access support should have prompted more curiosity as to the repeat notifications and what was preventing stability from being achieved. There had been inconsistencies in the information provided to Children’s Social Care and other agencies. The family had experienced a number of interventions in the months prior as a result of Young Person S’s deteriorating behaviour and presentation. A more assertive approach was warranted on completion of the assessments in April 2020 at this point to test out whether stability could be achieved and sustained rather than to close the matter down. Practitioners referred to trying to make contact or offer support to Young Person S and the family, but found the behaviour of Mrs S, frequently aggressive, volatile, and threatening towards them. There is evidence, from national LCSPRs that practitioners failed to make the connection between the difficulties that they themselves experienced in these situations and the likelihood that the children in the family were also experiencing the same stressful, inconsistent and sometimes abusive behaviour. 21 When professionals from any agency have concerns about their own personal safety, they must always consider the implications for children from exposure to the same risk factors. In addition to this, escalation to managers and the effective use of professional supervision should be considered. The practice-related learning themes are summarised in Appendix 1. Findings A Complex family social history, Think Family, assessment, decision making and prevention It is very evident that this case brings a complex social and complex health family history to all professionals involved. This review highlights the importance of early intervention and partnership working across different geographical locations and organisations, and it also highlights the importance of the ‘Think Family’ approach across Adult and Children’s Services in order that needs are met. Given the extensive background regarding parental mental health, substance use and domestic abuse within the home, these are suggestive of a pertinent social history, complexity, and vulnerability, which leads professionals to retrospectively consider the hidden harm which may have been escalating, particularly during the Covid-19 pandemic and subsequent restrictions. The case also highlights the importance of the voice of the child and consideration of the daily lived experiences of the children and young people in this household. All partners who are responsible for deploying Think Family, in their practice, must note that the likelihood of risk and harm to children increases when a child lives with an adult with vulnerability factors such as poor mental health, domestic abuse, and substance use, and that the risk increases when more than one of those factors is present and if more than one parent is affected. Given the complexity of the family in question, the legislative guidance set out within Working Together 2018 and updated in 2020, strongly points to all three children in this case being at increased levels of risk. The approach taken when completing assessments did not always adopt a Think Family Approach, or take account of the family’s longstanding historical issues, such as the domestic conflict between the parents; both parents substance use; the fact that both parents experienced mental illness; that both had issues with consistent 22 parental capacity; the health and well-being of all of three children, and a multi-agency approach to working, was not always evident. Relevant agencies were involved with the family and assessments were regularly made, but working and planning together was sparse, with exception to the joint visit made to assess Young Person S in March 2020, where the outcomes of the psychiatric assessment were made clear, and a CAMHS ‘open door’ offer was made. The findings confirm that not enough consideration or due regard was given to a wide range of historic, but known factors; their interplay, and the thematic trends, that can be seen in relation to prevention of Young Person S deterioration and his poor mental health; family risk assessment and family risk management. The child and family assessments would have benefited from multi-agency input and while there was professional curiosity into the educational and social needs of Young Person S, there was limited follow up and impact once professionals were aware. The voice of the child both in relation to Young Person S and his siblings did not stand out strongly enough and there was over reliance across partnership agencies on parental reporting. The quality of various assessments fell short in ensuring effective intervention to bring about positive and long-term change for Young Person S and his siblings and there were on reflection many missed opportunities to better understand the family situation, but also key points when referrals and other assessments should have been completed, for example DASH assessments, Young carer assessments, referrals to Housing, MARAC, SOLACE, CAMHS and referrals to Adult Mental Health, and Children’s Social Care. Over-reliance on parental reporting, Young Person S not being seen and case closures Review findings have confirmed that there was an over reliance on parental reporting which prevented the voice of the child being heard, by all agencies. It is clear that there was a ‘good will’ based desire for agencies to believe what they were being told by parents, however this information was frequently inaccurate and not always considered in the context of parental mental health diagnoses. Young Person S was not seen by the Elective Home Education (EHE) Service, Children’s Social Care, and or CAMHS sufficiently to make assessments of his needs at key times; the voice of his siblings was not considered as strongly as could have been which may have helped to inform agencies better on the lived experience of all the children including focus on the health, well-being, and safety of all of the children. 23 Lack of professional curiosity; information sharing and multi-agency planning There was a tendency to close down involvement due to reluctant engagement from the parents, resulting in premature closure, and on occasion a poor response to domestic abuse referrals; there was a lack of opportunity created by all agencies to share information and to coordinate a joint response. A Think Family Approach would have allowed for agencies to adopt a more coordinated approach to working with wide ranging difficulties being experienced by the children and their parents, and to draw on expertise from the relevant agencies in agreeing responses. MARAC and domestic abuse referrals were not always made both in respect of Ms T and or Mr S in 2019, and 2020 which increased risk for the family and prevented opportunities for closer working together. Historic academic information was not always gathered leading to the carriage of misinformation and an inaccurate view about the length of time Young Person S was out of mainstream education; his isolation; his lack of contact with professionals or social systems and therefore increasing the risk he faced. There was limited professional curiosity and information about what had happened to Young Person S in his past included or referenced in a number of assessments; limited information in assessments as to why he was being home schooled, and no evidence of escalation to flag worries when the quality of home-schooling was in question. There was little reflection on why Mrs S had left to live in another borough with only two of her three children, and what contact there had been between family members during this period. There was also a lack of professional curiosity with regard to the domestic abuse that was being experienced by Ms T and the psychological impact of this on both her and her sibling Ms V. Overall, there was a lack of shared analytical thinking. There was a high degree of information beset within different agency systems. Individual agency narrative was not passed on, which hindered decisions about possible interventions. Deployment of the Mental Capacity Act: Young Person S unable to communicate with professionals in the context of his neglect and the difficulties presented by the environment It is accepted that Young Person S has experienced neglect and that he was in a poor physical and mental state when admitted to hospital for further assessment in 2020. The review findings raise questions about professional understanding and knowledge of The Mental Capacity Act, and its application in the community. 24 The Act applied to Young Person S from the age of 16, which would have been from March 2019 onwards, and it is of concern that his capacity was not assessed until he was due to be discharged from hospital in Spring 2021. Professionals and services were aware of Young Person S in the community and the various reported issues such as: his isolation; odd behaviours, domestic abuse toward his sister; inappropriate urination; refusing to come out of his bedroom and not being in mainstream education. When home visits were made by services, Mental Capacity Act Assessments were not made, which was a missed opportunity. This was in the context of a difficult environment, and Young Person S’s refusal to be seen and parental preferences. Young Person S had the right to be enabled to make a decision and or be assessed to make it, without due parental influence and without professionals paying heed to that. The difficulties that were presented in the environment in which professionals attempted to assess Young Person S has been acknowledged, however it can be concluded that professional curiosity and healthy scepticism regarding Young Person S needs being met, should have prevailed, in spite of what seemed to have been the fear and anxiety created in some staff with regard to violence in the family; potential and real aggression and expressed anger from Young Person S mother. The fact that Mrs S was regarded as very volatile and potentially violent is likely to have constrained the effectiveness of practice and engagement in this case. On many occasions, various professionals were not allowed into the home, were prevented from seeing mother and the children or were unable to make contact with her or Young Person S’s father. When a parent/parents do not engage for whatever reasons, it is not enough to allow those reasons to cause a service to close a case or to stop trying. The need to respect privacy of parents can lead to an inadequate focus on the child, with too much attention paid to forming a trusting relationship with the adults. Reflective supervision and skilled management oversight is key in addressing such issues. The impact on the family of mental ill health and their children living with hidden harm It is formally recognised in Working Together that children may be at greater risk of harm or need additional help, in a family where parents: have mental health problems; substance or alcohol misuse; have violent relationships; where there are complex needs or if a child/children or adult has a learning disability. All these characteristics featured in the family concerned. It can be concluded that Young Person S and his siblings, experienced a negative impact in relation to his parent’ prevailing mental ill health. Mr S did request help for his son on at least two occasions, but advice was rarely followed up and his acceptance of professional support was inconsistent. It is highly likely that his wife’s mental health issues, and behaviours impacted on his ability to engage amid the likelihood that his support for Young Person S was likely to be opposed. 25 Professionals might have underestimated the children’s experience of living with a father who had schizoaffective disorder and a mother who had paranoid schizophrenia, because on the face of it, Mr S appeared more stable and he engaged well with his medication. However, his ability to protect and prioritise the needs of the children was not sufficiently assessed. It is evident that some professionals with the lawful responsibility to assess, were unaware of the symptoms of these illnesses; how they manifest and the consequent impact this can have on a young person, on their development, and on parental decision-making. The impact of these diagnoses on ability to work with and build trusting relationships with professionals needs also to be considered. The Review concludes that some agencies showed a lack of recognition of the importance for families to be supported, when affected by mental illness and that how any intervention should optimise successful parenting and the importance of considering the impact on the child if parents do not access the support required. Intervention should also assess and recognise that mental illness can impact on both parenting ability, parental insight, and recognition of their children’s needs and this should be considered in assessment for child protection, child and family consideration and care proceedings. Elective Home Education (EHE) was in place for a total of 4 years, in the case of Young Person S. The Review is aware that legislation does not place any obligation on a School to support parents or pupils, in EHE circumstances, unless there are clear safeguarding reasons why this would not be viable. In Bexley, the practice is to not agree home education when children are subject to child protection/child in need plans. Young Person S was not open to Children’s Social Care for long periods when he was home educated. In the most recent assessments dating back to 2018 and 2019 he would have been approaching the end of his compulsory school career. Legal obligations on the Local Authority applied to both Essex County Council and The London Borough of Bexley - where their duty existed on the grounds that Young Person S was observed as not receiving a suitable education. It is not clear how this was followed up at the time and what action was taken to address it. In this case it would appear that Young Person S got lost in the EHE processes. Children’s Social Care and EHE could have been more pro-active in asserting concerns. Safeguards were also unable to be applied to Young Person S as his case was not able to be referred to the School Nursing Service, because he did not have an EHCP; a CP or CIN plan and parental consent was required, which was not given. Young Person S’s father was not approached because he was not on the home/school contact form. In a case such as this, legislative restrictions on information sharing for EHE children restricted safeguarding the child from harm. 26 The findings from this LCSPR have prompted a review of all young people who are home educated to assess whether the education they are receiving is appropriate and being provided (and appropriate action taken where it is deemed unsuitable). A multi-agency audit has been undertaken, sampling cases currently open to EHE, to determine that there are no opportunities missed for cross-agency referrals or working. This process is being embedded into regular quality assurance practices. The Children as Young Carers This Review concludes that the position, circumstance and status as the children of this family being young carers was largely undetected by services, up until November 2020. A Young Carer’s Assessment would have determined more accurately the support needs of the children. Ms T reported to a social worker and a housing officer in 2018, that she had been undertaking a caring role since she was 13 years of age. This would have been an opportunity to explore the roles within the family and to ascertain whether Young Person S and Ms V were also likely to become young carers. There is a duty to consider whether there were any children involved in providing care, and if so, to consider the impact on the child. CAMHS advised that albeit Ms T and Ms V were discussed in one of their assessment sessions, the two girls were ‘not the focus of the assessment’ and consequently, CAMHS explained were not referred for assessment as young carers. Albeit Young Person S was the focus of the assessment, he was also not considered to be a young carer, when he may have been, or previously been. CAMHS have acknowledged that going forward, this ‘could be thought about more explicitly in future,’ in relation to young people, particularly when their parents are known to adult mental health services, or have a known mental health diagnosis, and that their staff will be encouraged to use tools that are currently in place. The secondary school were unaware that there were any young carers in the household and report that Ms V did not present with any significant concerns whilst at school but was offered support from the pastoral team. SOLACE was unaware of the other children, because information about them was not gathered, and SOLACE have acknowledged they did not explore this adequately and or exercise professional curiosity. Impact of Covid-19 on children’s/family circumstances and on capacity of services to respond to needs The Child Safeguarding Practice Review (National) Panel requested that the Rapid Review consider any Covid factors which may have impacted on the family situation and or on service delivery. The Bexley Learning from Practice Panel considered the current situation and past history of involvement with services and considered that 27 concerns relating to multi-agency response and decision making were present prior to Covid and that positively, there was direct contact with agencies during lockdown. From Children’s Social Care’s perspective, Covid did make an impact in so far as not being able to undertake face to face visits to see Young Person S when he was in hospital from November 2020. Video calls were made to stay in touch and help from ward staff was given. Face to face visits were able to take place at a later date with the use of PPE. Police involvement in this case was not affected by the pandemic. There was minimal disruption noted with regard to GP contact with the family. Some consultations were conducted by phone, which was normal pre-Covid practice for them. All CAMHS contact took place before Covid restrictions came into place and home visits were conducted as normal. Ms V’s school-maintained contact with her through lockdown, via regular contact with parents by the school pastoral team and her engagement and online learning was closely monitored. Bromley Healthcare, Bexley 0-19 School Nursing service, commented that the Covid-19 pandemic may have exacerbated the families’ social isolation and capacity to acquire and access help, accentuated by support restrictions, which may have heightened ‘concerning features of mental health’ and possibly increased the potential for family conflict. They have added that: ‘Professional curiosity may encourage us to consider whether school closures due to the pandemic enhanced the opportunity to disengage from formal educational provision’. It is possible that Covid-19 impacted on the mental health of both parents, particularly as there was limited informal support available. The mother displayed heightened anxiety when police and ambulance visited the home in 2020 referencing her fear of Covid. Recommendations Bexley S.H.I.E.L.D. and its associated statutory partners should seek assurance that: 1. A Think Family Protocol is developed which is branded with strong senior leadership and given a high strategic profile and associated practice is coordinated, multi-agency, effective and underpinned by timely information sharing. 2. All partnership organisations have the necessary processes in place to bring about a shared responsibility to child and adult safeguarding. Including systems for information sharing and processes for supporting Think Family approach and monitoring compliance. 3. There is the provision of ongoing training and practice development for relevant staff across the partnership to ensure that they are competent to deliver their 28 lawful responsibilities in accordance with a)Think Family; b) Mental Capacity c) Education; d) Domestic Abuse; e) Young Carers. 4. Multi-agency assessment protocols and practice guidance are reviewed to ensure they support the embedding of a Think Family approach, and incorporate opportunities for multi-agency discussions and review of the effectiveness of plans and decision making. 5. Children’s Social Care service improvement plans to include audit of the quality of Child and Family Assessments. 6. Case closure processes includes ensuring supervision records include the rationale for closure, and what is expected practice when there are difficulties with engaging with families and when concerns are ongoing. 7. National Recommendation - that relevant government leads note the findings from this review and consider the impact of legislative restrictions on Elective Home Education (EHE) and how this can potentially leave young people more vulnerable. Updates since November 2020 Think Family training was initiated in 2019, as part of recommendations from priority work on Parental Mental Health, and has been ongoing since this time. Think Family will remain a focus throughout 2022. The impact of learning on practice is scheduled to be tested out through the multi-agency learning forum, and learning from practice sub group, overseen by Bexley S.H.I.E.L.D. on an ongoing basis. Bexley S.H.I.E.L.D. with funding from the Department for Education completed an evaluation programme between May 2021 and February 2022 including a focus on the impact of Think Family practice, parent participation, and Bexley’s approach to learning in practice. A final evaluation report was submitted to the Department for Education in February 2022 and Bexley S.H.I.E.L.D Executive are monitoring the progression of all future plans identified through the programme. Bexley Safeguarding Adults Board and the Community Safety Partnership remain involved in all learning activities and there is ongoing review of the joint training to support the embedding of learning (for example, in relation to adult mental health, mental capacity, the Care Act, domestic abuse and Think Family practice). Children’s Social Care service plans for 2022 include the monitoring of the quality of assessments and the supervision and management oversight of records. 29 Appendix 1 – Practice-Related Learning Themes • The importance of multi-agency professionals understanding mental capacity and applying the law in relation to an individual’s decision making. • Assessing parenting capacity with a joined-up approach including input from specialist services, CAMHS, Adults and Children’s Social Care, Adult Mental Health, Education. • Understanding parental and adolescent mental health and its impact on the family including siblings and the need for a Think Family approach • Understanding domestic abuse across familial relationships, understanding pathways and referral processes for support, and using intervention skills particularly when support is refused • The importance of multi-agency input into assessments (and their ongoing review and follow-up), safeguarding strategy, and decision-making prior to case closure. • Healthy scepticism and professional curiosity when working with families and the ability and skill to challenge parental views and their narrative. • The importance of assessments and reviews including the reflecting on and impact of family history as well as strengths. A clear analysis of ongoing worries and what needs to change and the skills to deduce capacity for change. • When engagement is not easily achieved, the need for professional curiosity about why a family may not be engaging, for example mental illness, trauma, learning difficulties, fear of loss, being unable to coerce family members, loss of power and control, loss of benefits to fund the household, substance abuse, debt, fear of being found out. • Non-engagement resulting in a young person’s case being closed or ‘no further action’. The importance of including an analysis of the impact on the child/young person if there is no engagement. • The use of tools in assessment / Harm Matrix / clear danger statements and safety planning. • Importance of Family Network meetings in identifying support and who can be involved to support the child/ren and their family. • The importance of seeing children, including alone when there are worries about a child’s welfare. • Understanding consent and when this can be over-ridden. • The ability of staff to deploy Mental Capacity Act law and assessments to 16+ children. |
NC043407 | Serious, life-threatening injuries to two young men, Tom and Vic, in 2012. The incident involved a third person; all three individuals were considered suspects and subsequently arrested. Tom and Vic pleaded guilty in 2012. Both were well known to agencies and had histories of periods of going missing and substance misuse. Both were regularly subjected to stop and search procedures by the police, received convictions for criminal behaviour and were placed in secure accommodation. Tom was looked after by the local authority at the time of the incident and had been absent from formal education for over a year. Issues identified include: agency focus on procedures not outcomes; insufficient direct work with young people; slow pace of service delivery; insufficient consideration of adolescents who offend in groups. Recommendations include: a holistic package of intervention and support to ensure young people involved in criminal activity access education; children's social care to prioritise improved understanding of related issues including racial harassment, gangs, possessing weapons, and anti-social behaviour.
| Title: Redacted overview report on the serious case review relating to Tom and VicLSCB: Kingston Local Safeguarding Children Board Author: Fiona Johnson Date of publication: October 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 STRICTLY CONFIDENTIAL KINGSTON LOCAL SAFEGUARDING CHILDREN BOARD Redacted Overview Report on The SERIOUS CASE REVIEW relating to Tom and Vic Published October 2013 2 1 INTRODUCTION 1.1 Background to the review 1.1.1 The serious case review was held as a result of an incident in information redacted 2012 when Tom sustained potentially life-threatening injuries and Vic was also hurt. The dispute involved a third party information redacted; all three persons involved were considered as suspects and were arrested information redacted and in information redacted 2012 both Vic and Tom pleaded guilty. 1.1.2 The matter was discussed by the Kingston Safeguarding Children Board (KSCB) Serious Case Review Sub-Committee on 8th June 2012 which considered the criteria for a SCR to have been met on the grounds that one of the subjects was Looked After by Kingston Children’s Social Care at the time of the incident, the injuries sustained by both subjects were potentially life-threatening1 , and there had been intensive involvement by a number of agencies with both young men. This recommendation was confirmed by the KSCB Independent Chair on the same day. 1.2 The Terms of Reference 1.2.1 The purpose of a serious case review as set out in 8.5 of Working Together to Safeguard Children 2010 is to: • establish what lessons are to be learned from the case about the way in which local professionals and organisations worked individually and together to safeguard and promote the welfare of children; • identify clearly what those lessons were both within and between agencies, how and within what timescales they would be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children. 1.2.2 The full terms of reference agreed for this review are attached as appendix 1. Each IMR author was particularly asked to address the following issues: - • What was the quality of practice in relation to this case and how effective was the agency’s engagement with the young people? • Were assessments of a sufficiently good quality and did they include multi-agency involvement? • Were the interventions provided appropriate and how effective were they? • To what extent was it appropriate for the agency to take on the Key Worker role? • Was there effective communication with and from other agencies? • What was the impact on practice of issues relating to ethnicity, religion, language and diversity? • What was the impact of any language issues on the young people’s engagement with the agency and did these issues receive an appropriate response? 1 P235 Working Together to Safeguard Children March 2010 3 • How effective was the support provided to new arrivals in the country, including supporting their transition into the education system? • What was the impact or otherwise on the young people of being excluded from school and to what extent were the appropriate services provided? • Was sufficient and effective support provided to the Looked After young person by the foster placement? • To what extent were gangs and gang culture a feature in this case? • What was the quality and impact of case management and supervision in relation to this case? • Did any organisational difficulties or resource issues, e.g. vacant posts or staff on sick leave, impact on practice in this case? 1.2.3 Additionally it was agreed that authors of Individual Management Reviews, SCR Panel members and the author of the overview report should give consideration to the areas identified in W.T. 2010 Page 245 in their analysis of involvement that were not covered by the above specific issues and should bring to the attention of the SCR panel chair any other matters identified which appeared to fall within the scope of the review if they thought that there were lessons to be learnt either for an individual agency or for the KSCB. 1.2.4 It was also expected that authors of Individual Management Reviews who identified other significant issues not falling within the scope of the review should bring them to the attention of a senior manager within the agency. Finally it was expected that consideration would also be given to the findings of recent SCRs both locally and nationally 1.2.5 The time frame of the review was from January 2008 information redacted up until immediately prior to the incident that took place information redacted in 2012 and agencies were asked to provide a detailed chronology for that period. All agencies were also requested to provide a summary of any significant events and relevant family history outside the specific scope and timescale, where this would help to inform the overall analysis. 1.3 Review Process 1.3.1 Individual Management Review (IMR) reports were received from the following sources: • Royal Borough of Kingston, Children’s Social Care, • Your Healthcare • General Practitioners, Kingston • Kingston Hospital Trust • Epsom and St Helier University Hospitals NHS Trust • Metropolitan Police Service • Royal Borough of Kingston, Youth Offending Service • Kingston & Richmond Joint Substance Misuse Service • Royal Borough of Kingston, Learning and School Effectiveness Service, • South West London & St George’s Mental Health Trust 1.3.2 IMR authors were provided with a briefing session and all authors were also asked to attend the serious case review panel in order that feedback could 4 be provided on the reports and the panel could ask questions in order to clarify any issues. 1.3.3 Additionally reports were received from a number of agencies who had limited contact with the family during the relevant period but who had information that would assist the review. Reports were received from: - • The secondary schools attended by Vic and Tom. • The Fostering Agency who managed the placement where Tom was living. • RBK Children’s Centre Family Support Service Information redacted. • RBK Legal Services. • Information redacted. • ASKK information was requested and was then incorporated into the Social Care IMR. 1.3.4 A health overview report was also produced by the Designated Nurse to enable NHS Kingston, as commissioners, to review and evaluate the practice of all involved health professionals (including GPs and providers) commissioned within the PCT area. 1.3.5 Individual Management Reviews (IMRs) and the Health Overview Report were drawn up by officers who had had no previous involvement in the case. 1.4 Family Input to the Review 1.4.1 Consideration was given to involving the parents and the young men in the review process and the independent overview author offered to meet with both young men and separately with their parents. In the event the author met with Vic and Tom’s mothers. Vic did not feel he wished to meet with the author as following discussion with his mother he felt she had provided all relevant information. An appointment was made to meet with Tom, however he went missing information redacted at the time the report was being completed. 1.5 The Review Panel 1.5.1 The review group membership was as follows: - • Paul Kerswell Independent Chair • Metropolitan Police • Education Services, Royal Borough of Kingston • Youth Offending Service • NHS Kingston - Designated Nurse, Child Protection • Children’s Social Care, Royal Borough of Kingston2• School – Deputy Head teacher, • KSCB Business Manager. 2 There was no attendance at early panel meetings by Children’s Social care however after representations were made via the Chair of the LSCB there was attendance from 22nd November 2012 onwards. 5 Additionally Fiona Johnson, the Independent Overview Writer attended Review Panel Meetings. 1.5.2 Dates of review Panel meetings were as follows: - • 28/9/2012 • 12/10/2012 • 22/11/2012 • 4/1/2013 • 18/1/2013 1.5.3 The Chair of the Panel is Paul Kerswell and he has had no direct involvement with any of the professionals’ work being reviewed. He is an independent Children’s Services consultant and qualified in Social Work in 1988. He has 12 years’ experience of operational management of children’s social care services including 7 years at senior management level. Working for the past seven years as an Independent Consultant he has been involved as either Overview Author or Panel Chair in more than 20 Serious Case Reviews. He is Chair of the Pan-London SCR Chairs and Authors Group. 1.5.4 The independent overview writer is Fiona Johnson, an independent social work consultant. Head of Children’s Safeguards & Quality Assurance in East Sussex County Council between 2004 and 2010, Fiona qualified as a social worker in 1982 and has been a senior manager in children’s services since 1997 contributing to the development of strategy and operational services with a particular focus on safeguarding and child protection. She is HCPC registered and has previously written overview reports for East Sussex, Brighton & Hove, Portsmouth, Southampton, Kent, West Sussex, Wandsworth, Surrey, Slough and Bracknell Forest LSCBs. 1.5.5 The overview report was completed based on information provided in the IMRs and the additional reports. The overview author was also provided with executive summaries from previous serious case reviews held in Kingston that were considered to be relevant. 1.5.6 The Panel considered at all stages how early learning could be shared with relevant agencies and staff. The recommendations and action plans will be shared with staff and implemented immediately where possible. Full publication of the findings of the review will follow on from the completion of the serious case review process. 1.6 Parallel Processes 1.6.1 NHS agencies are required to carry out reviews of “Serious Untoward Incidents” (SUIs). For the NHS agencies involved, that requirement was met by the conduct of this Review. There were criminal processes underway at the start of the review and the panel liaised with the relevant police officers to ensure that the legal process was not compromised in any way by the review. 6 2 THE FACTS 2.1 This review is complex because it concerns two young men who have different life histories but who were injured whilst together, having previously engaged, jointly, in significant levels of anti-social behaviour. In the main the services provided to the young men were separate; and, whilst some agencies were aware of the connection between them, prior to the incident there was no significant attempt at working with them together, and no linking of the two families. This report will therefore provide separate accounts of the services provided to the young men but will then identify any joint themes or systemic concerns that the review has identified. Family Structures Information redacted A genogram and a full chronology covering the period are redacted. 2.2 The Family Background - Tom 2.2.1 Tom is a young man of dual heritage. Information redacted. All his older siblings moved away from the family home in their teens information redacted. 2.2.2 Tom was born in England and his first language is English information redacted. There was little reported in IMRs about the socio-economic background for the family however they are reported to have owned their own home information redacted. 2.2.3 Information redacted. 2.3 The Family Background - Vic 2.3.1 Vic is also of dual heritage information redacted. Vic is one of two children living with their mother in England. Information redacted. Although Vic spoke English well he may have had some comprehension issues. 2.3.2 Little is recorded in the IMRs of the socio-economic background of the family information redacted. She was seen by professionals to be supportive of Vic and worked co-operatively with agencies. There was very little professional involvement with Vic and his family apart from core services until the end of 2010. 2.4 Agencies’ Involvement with Tom 2.4.1 Tom returned to England information redacted and started at a local secondary school. There were no immediate problems identified however information redacted he exhibited some behavioural problems in class which were discussed with his mother who felt that Tom’s misbehaviour was because he was not being sufficiently challenged in lessons. That school year showed a slow and steady deterioration in Tom’s behaviour resulting in a further meeting with Tom’s mother in the summer information redacted. At 7 that meeting she again advised school staff that Tom’s behavioural problems were a result of under-stimulation at school. At this point a CAF (Common Assessment Framework) was completed by the school with the aim of getting additional support for Tom however the parents refused to accept this assistance and would not sign the CAF assessment. 2.4.2 Information redacted Tom’s behaviour continued to deteriorate and the school had difficulties engaging with the parents to achieve any change. Information redacted. The parents were very critical of the school and wanted Tom to transfer to another local secondary school however they did not make an application for a transfer. The parents also refused any other offers of support and would not agree to a referral to Children’s Social Care (CSC). 2.4.3 In information redacted Tom and his older sibling attended a local Accident and Emergency Department because they had both sustained injuries information redacted. Hospital staff considered Tom’s injury to be serious and information was shared with the school health service via the liaison health visitor. The school nurse then contacted the Kingston ‘contact centre’, ASKK to see if any other professional was working with the family and was told that no-one was involved. The nurse did not make a referral and ASKK did not pass on the information to CSC. 2.4.4 In information redacted there was an incident after school where Tom and his information redacted brother were involved in a fight with some information redacted youths. Tom and his brother sustained injuries and both attended hospital accompanied by their father. The police were also involved and information redacted the youths were arrested, the matter was investigated and papers were passed to the CPS, however no legal action was taken. After this the hospital referred the family to CSC however the police did not pass on any information. The next day the school were concerned that there could have been a connection with boys at the school and suggested that Tom and his brother remain at home while the risk was assessed. The parents refused to do this and three days later Tom’s mother made a formal complaint to the Local Authority information redacted. This led to a full investigation which fully exonerated the school. 2.4.5 Relations between the parents and the school continued to deteriorate and on information redacted Tom’s mother contacted the Local Authority asking that Tom have a ‘managed move’ to another local secondary school. A ‘managed move’ is a process that can be initiated by the school where they consider that it would be in the child’s interests to have a new start at a different school. This was explained to Tom’s mother and she was encouraged instead to submit a parental application to the school and was advised of other local schools with vacancies. The Local Authority also advised the school of Tom’s mother’s request. 2.4.6 Tom’s behaviour at home was also proving challenging and on information redacted Tom’s mother contacted the Local Authority and requested that he and an older sibling be accommodated information redacted. This request 8 was passed from the ASKK to CSC and an initial assessment was undertaken which was completed on information redacted. The outcome of this assessment was that Tom was to be referred to information redacted (a service provided by the YOT prevention service) and that the parents would be assisted via the Multisystem Therapy Team (MST). It is unclear which agencies were consulted as part of this assessment information redacted. 2.4.7 On information redacted Tom’s mother contacted CSC to say that she had not ‘…seen Tom for two weeks…. [he] has come home covered in faeces and vomit… [CSC] could take them into care’. No action was taken. On information redacted a social worker telephoned Tom’s mother who wanted him removed that day information redacted. Following this the social worker reported Tom to the police as missing. The police contacted Tom’s mother who refused them entry to her house. On information redacted Tom’s father advised the Police that he had returned the previous evening but the parents refused to allow the police access to the house to meet with Tom. They attempted to see him at school but he had been excluded. On information redacted Tom absconded again and as the parents were not willing to report him as missing the social worker again did so. On information redacted the CSC Prevention and Resource Panel determined that a core assessment should be completed before there was any decision to accommodate Tom and that the ‘missing person’s protocol’ should be followed by the social worker. 2.4.8 Tom was returned home by the police on information redacted; he absconded again that night and was reported missing by his father on information redacted. The police returned him home on information redacted but his father was not keen for him to return and the police placed him instead with an older sibling. On information redacted his mother contacted the Emergency Duty Team (EDT) saying ‘her son is out of control and keeps running away…refusing to return home.’ The EDT case note record says ‘it would appear a decision needs to be made by Day Services about an alternative placement…’ there is no evidence that any action was taken. 2.4.9 On information redacted the school contacted the social worker saying that Tom wanted to talk to a social worker because he was homeless. The social worker contacted the parents who denied that they had thrown Tom out. The social worker then told the school to send Tom home and that she would see him at the school on information redacted. When they met the social worker discussed with Tom the possibility of a respite placement however Tom’s father when telephoned refused to agree to this happening. The school were expressing concern about Tom and raised questions about whether he was ‘sleeping rough’. The social worker then visited the parents on information redacted who were not willing to agree to Tom being accommodated on a respite care basis as they felt that it would not achieve anything. Tom was absent from the family home for most of the rest of the week information redacted. On information redacted the social worker agreed with MST to defer discussing foster care until they had been able to engage with the family. On information redacted the MST undertook an initial assessment 9 with the parents; they had no contact with Tom or his older sibling. They followed this by two further visits to the family on information redacted. 2.4.10 During August Tom was often absconding although his parents did not report him missing. Information redacted. The social worker reported Tom missing on information redacted. The social worker again reported him missing two weeks later although it is not clear why. There was no contact with Tom by social care during August although there was telephone contact with his mother. Information redacted. YOT contacted Tom’s mother who declined their services and said that she was unhappy with Social Services and would be making a complaint about them. 2.4.11 On information redacted Tom was found by the police information redacted at 23.15 and was taken home, he refused to answer any questions and stated that he had been wandering the streets and staying with friends. The police passed this information through to Kingston CSC. On information redacted Tom was given financial support by a duty worker for CSC. On information redacted Tom was arrested in connection with an assault on a youth information redacted; Tom admitted the offence and was bailed. On information redacted there was a meeting at the family home attended by YISP/REWIND, MST and the social worker. At the meeting the parents reported that Tom wanted to be in foster-care and that was the reason for his behaviour, they also expressed concern about his school placement. Information redacted. The professionals recommended that Tom move to foster-care and that the family work with the MST team to resolve the problems; this was rejected by the parents. 2.4.12 On information redacted Tom attended school with a bruise on his cheek said to have been caused by his father. There was a strategy discussion with the police and a legal planning meeting. The decisions reached were that there should be no criminal action but that a section 47 assessment should be undertaken on Tom’s younger siblings and he should be placed in foster care. Information redacted. Both parents were contacted and indicated that they did not want Tom to go to foster care however after discussion he was accommodated and placed in a foster home, in a neighbouring borough, with an expected return home within one month. The next day, information redacted, Tom did not return home from school and was reported missing by the foster carer he was found and returned by the police to the placement on information redacted September. At this point he was noted to be looked after but it was not recorded that he was placed out of borough. The police information on the missing person reports from this point forward are passed to a neighbouring borough CSC not Kingston. Tom was reported missing again by the foster carer information redacted and was found by the police and seen at school on information redacted when he advised them that he did not want to return to the foster home after school but preferred to remain with his friends in the local area. Tom did not return home from school on information redacted and so was reported missing again that day he was eventually found by the police on information redacted. There is no evidence that Tom was seen by a social worker in the two weeks after he was 10 accommodated. His parents have almost daily contact at this time with both the social worker and the MST worker information redacted. 2.4.13 On information redacted Tom was arrested for an offence and was also debriefed about going missing; he refused to answer any questions and was returned to the foster home the following day. Tom was then charged information redacted and placed on police bail. On information redacted Tom was seen in the foster home by his social worker. Tom’s demeanour in school deteriorated during information redacted and he was excluded for five days because of poor behaviour. The school tried to refer Tom to the Pupil Referral Unit but the parents opposed this; they also tried to arrange a managed transfer to a local school requested by Tom’s parents, but this was not successful because the school were over numbers in that year group. The parents were encouraged to appeal against this decision however took no action but insisted to the Local Authority that this was the only suitable mainstream school for Tom. Eventually on information redacted Tom was permanently excluded from school because of his ‘poor behaviour and a lack of parental support’. 2.4.14 On information redacted a new social worker took over as key worker. During October a first Looked After Child (LAC) Review was held. This involved three meetings; the first information redacted was a meeting between the Social worker and the IRO; the second information redacted included the social worker, IRO and Team manager; and the third information redacted involved Tom, his parents, information redacted, the foster carer and her support worker, Tom’s social worker; the MST worker and the IRO. At this point there was no Personal Education Plan (PEP) in place. There was no involvement in the review by YOT, the school or the LAC nurse or doctor. 2.4.15 The social worker had arranged for Tom to attend the PRU but his mother was not happy with this temporary arrangement and refused it. Tom then walked out of the review meeting. The plan at the LAC review was that Tom should return home within four weeks providing a school placement could be found. Tom was out of school for three weeks following his exclusion and started at a new secondary school on information redacted. Tom attended the new school for three days and then went missing from the foster placement and stopped attending school. In late November there was some discussion between the school, the LAC Education Achievement Advisor and the Exclusion and Re-integration Officer about the best way to ensure Tom’s attendance at school. It was considered that Tom did not go to school because he wanted to be at home. No other action was taken for the rest of that school term. 2.4.16 During October information redacted there were five meetings between the MST worker and the family, Tom was present at only one of these meetings. Much of the focus of the meetings was on the parents reporting on Tom’s activities and the parents’ unhappiness with the social worker’s actions in placing Tom in foster-care. Information redacted. 11 2.4.17 During October information redacted Tom was reported as missing from the foster placement five times. On a number of occasions he was returned to the placement by the police but sometimes he returned alone, he also visited his parents during this time. In November information redacted Tom continued to go missing regularly and he was reported missing to the police eight times. On many occasions he returned of his own accord within twenty-four hours information redacted. 2.4.18 Tom attended court on information redacted where he pleaded guilty information redacted and was sentenced information redacted. As a result YISP, who had never been able to engage with Tom, because his mother was unwilling to give consent to their involvement, withdrew. 2.4.19 MST continued to work with the family and during November information redacted had three meetings with the parents about Tom as well as another meeting with Tom and his older sibling. Information redacted. 2.4.20 In December information redacted Tom was stopped by British Transport Police at a London mainline station and said he had been sleeping rough with a friend, he was returned to the foster home. On information redacted December Tom was reported missing by the foster carer and the next day he failed to appear at the police station in response to his bail hearing and so he was circulated to the police as ‘wanted’. On information redacted Tom was arrested for an offence on the previous day information redacted. He was charged information redacted the following day and remanded in custody. Tom appeared in court on information redacted and was made the subject of bail conditions requiring him to live at his foster home with a curfew between 20.00 and 06.00 hours to be electronically monitored. Information redacted. For the rest of December Tom broadly co-operated with the requirements of his bail. 2.4.21 On 10th December information redacted a second LAC review was held attended by Tom’s parents information redacted, the social worker, the year head from the school, MST and the foster carer and her supporting social worker. Tom was in police custody so could not attend. There is no evidence that YOT or the LAC nurse or doctor were involved or consulted. At this point Tom was the subject of a referral order, had started at a new school and stopped attending after three days and had not had any health assessment undertaken despite some reports of substance misuse being reported in the sessions with MST. The outcome of this review was a plan that Tom would return to his parents on information redacted. There is no record of any contact between the social worker and Tom except for seeing him at the LAC reviews. 2.4.22 During December information redacted MST continued to work with the parents seeing them at the LAC review and for further meetings on three occasions. The work of the therapist was directed towards Tom returning to his parent’s care but he was not involved directly in many meetings. On information redacted December the therapist advised Tom’s parents that MST involvement might have to end because it was intended to be time- 12 limited and she was concerned that it was not proving to be productive. A further meeting was held in January (not attended by Tom) where Tom’s parents reported that they had seen Tom on Christmas Day and Boxing Day and that he had told them that he wanted to return home. A plan was agreed with the parents of Tom spending increased time at home from mid January onwards with a view to him returning home later in the month. 2.4.23 On 10th January information redacted the social worker and YOT worker visited Tom at the foster placement and he told them he had a good Christmas visit to his parents and that he wanted to return home. Tom was advised to attend the MST meeting arranged for the next day, to go to school and to prepare for his court appearance information redacted. On information redacted Tom was arrested in connection with an offence that he admitted to having observed but denied direct involvement. He was found to have in his possession an item that was thought to be stolen and so was bailed for five weeks. Tom then attended the MST session and talked positively about the electronic tag helping him stick to curfew and said that he had been attending school. 2.4.24 On information redacted Tom attended court and pleaded guilty information redacted. He was sentenced information redacted. Tom spent the weekend at his parent’s house but this did not go well information redacted. At the MST session on information redacted Tom’s parents indicated that they did not think he could return home and confirmed this view at a follow-up meeting information redacted. Tom’s view was that when he was at home he was picked on by his siblings and his parents did not support him. MST ceased active involvement with the family from the end of January although unsuccessful attempts were made in February and April to have closing sessions with both the parents and Tom. 2.4.25 On information redacted Tom was seen by the Substance Misuse Service following a referral being made by the YOT worker. Information redacted. In February Tom was given a harassment warning in the presence of his foster carer. On information redacted January Tom was reported missing from the foster placement and was found by the police very early the next morning and returned to the foster home. Tom was reported missing again on information redacted January when he appears to have been with Vic; he returned voluntarily the next day. On information redacted January the social worker and YOT worker saw Tom together. He advised them he did not want to see his parents and was not going to attend school. 2.4.26 During February Tom attended three sessions out of four at the SMS. On two occasions he engaged well but was ‘under the influence’ at the third session. Information redacted. He saw his YOS worker on information redacted February and spoke positively about relations with his parents and said that he was aiming to ‘stay out of trouble’. The YOT worker spoke to the foster carer on information redacted February who was less positive and admitted that Tom was missing. When Tom met with his YOT worker on information redacted February he admitted that he was ‘under the influence’. On information redacted Tom was reported as missing to the police by the 13 foster carer and returned of his own accord in the late evening on the information redacted. Early in the evening on information redacted there was an attempted robbery information redacted; Tom was identified as one of the assailants and was later charged information redacted. There was no recorded contact between Tom and his social worker during February and his key worker was changed again on the 17th February. Tom did not attend school during February information redacted and there is no evidence that any professional, education or social care attempted to address this with him. 2.4.27 During March information redacted the foster carer reported Tom missing on five occasions; he is also stopped by the police on four occasions. He attended two meetings with an SMS worker. He did not attend school and did not meet with his YOT worker and so was reported for breach of his order on information redacted. On information redacted Tom visited his family home and was verbally aggressive towards his younger brother and had to be removed from the family home. On information redacted there were two incidents involving the use of weapons. Tom was implicated and on information redacted he was arrested (with Vic) information redacted. Following this arrest Tom was charged with the offences information redacted to which he pleaded not guilty. He appeared in court the next day when he was remanded to a Secure Training Centre (STC) information redacted. 2.4.28 Tom remained at the STC until information redacted he was transferred to HM Prison and Young Offender Institution (YOI) because of his aggression towards staff and other young people. The social worker arranged for his foster placement to be kept open whilst he was in custody. A review was held at the STC on information redacted attended by his the YOT worker and Tom but not by his parents who did not visit him; it is not clear if this was a LAC review or secure review. Concern was expressed at this meeting about his parents’ attitude and a recommendation was made to consider whether there should be a legal planning meeting to consider care proceedings. There is no evidence of any action being taken with regard to this recommendation. After Tom was moved to the YOI he was deemed not to be ‘looked after’ and therefore no LAC review meetings were held. There is also no evidence that he was visited by a social worker whilst there. Information redacted. 2.4.29 Tom was discharged from the YOI in June information redacted. He returned to the foster placement where he was seen by the social worker on information redacted. Tom initially co-operated with the requirements of the rehabilitation order; he attended his induction and a behaviour group information redacted and attended a reintegration meeting at the school information redacted. He was reported as missing on information redacted returning of his own accord the following day. He failed YOT appointments information redacted however was not issued with a warning as the foster carer said she had not received the appointments. 14 2.4.30 On information redacted Tom was arrested with regard to a possible offence but no action was taken. He was not attending school and was reported as missing information redacted returning of his own accord the next day. A LAC review was held on 1st July information redacted attended by Tom, the social worker, the YOT worker and the education worker from YOT worker, the foster carer and her support worker; his parents did not attend. At this review it was noted that Tom was attending a Youth Rehabilitation Project, was not attending school and sometimes stayed out overnight without informing his carer. The decisions from this meeting were to work towards a possible return home and to reintegrate him into school. 2.4.31 During July and August information redacted Tom co-operated minimally with the YOT supervision requirements and was close to being breached in information redacted August. He also was reported as missing on a number of occasions usually returning of his own accord. He was stopped by the police on three occasions but was not arrested. In September Tom’s non-compliance with the YOT requirements increased and he was breached in court information redacted when the order was allowed to continue with no separate penalty despite this being a third breach and a clear history of disengagement with statutory orders. 2.4.32 During September information redacted Tom was reported as missing five times; he returned of his own accord on all occasions usually only being missing for one or two days. Information redacted. The LAC review was not attended by Tom’s parents and the professionals involved were the YOT worker and social worker and foster carer. It was clear that Tom had not been in contact with his parents and he was said to have returned to school on a part-time basis. The conclusions of the meeting were that Tom was to stay in placement until information redacted, that a PEP meeting should take place and that he should visit a local lodgings project which was considered a possible future placement. Information redacted. 2.4.33 During October, November and December information redacted there was little change. Tom continued to go missing regularly (he was reported missing by the foster carer on nine occasions) but on most occasions returned of his own accord frequently the same day or early next morning. He was stopped by the police on eight occasions; on one occasion this was because he was involved in a fight at the school with Vic and some other boys and on another occasion he was involved in another fight on a bus, Vic was not present on this occasion. 2.4.34 During this time Tom was not attending school and there were discussions between education staff, the social worker and the YOT worker about this on three occasions. Finally a meeting was held information redacted when it was agreed that alternative provision would be explored for Tom as school was not working at this point it was recorded that he had attended three sessions at the school since September information redacted. During October Tom was failing to co-operate with the YOT worker leading to the breach. Immediately after this court appearance information redacted he again failed to attend however this was then followed by a period of minimal 15 engagement until his order expired information redacted when the case was closed to the YOT. The social worker is recorded as seeing Tom once during this period information redacted however that worker ceased to be the key worker soon after this visit. 2.4.35 Tom had no contact with his family over Christmas spending it with the foster carer. His mother contacted the new social worker on information redacted to say that children’s services were ‘…failing her son…’ Tom was missing from the placement from information redacted however he was not reported missing for the rest of the month. The new social worker visited on information redacted and Tom told her that he wanted to stay at the placement and did not want to see his family. Tom was not in education at this time and was stopped by the police on three occasions in January, twice with Vic. On information redacted Tom was charged with an offence, this related to the incident on information redacted where he was involved in a fight on a bus. 2.4.36 On information redacted Tom was arrested for an offence in a neighbouring county; his co-defendant in this matter was Vic. During February Tom was missing from the placement on three occasions information redacted. He saw his social worker on information redacted when he denied involvement in the offence. He also had a health assessment on information redacted. During February and March Tom was stopped by the police on six occasions, for four of these he was accompanied by Vic. There was a LAC review on information redacted. He did not want to see his parents who had not contacted him for Christmas or his birthday. The conclusion of the review was that Tom was to stay in the foster placement for at least another twelve months so long as he regularly attended college from September information redacted; the social worker was also attempting to arrange some educational input prior to then. Tom saw his social worker on information redacted. The next day his mother contacted the social worker information redacted. During April information redacted the LAC Education Achievement Advisor was negotiating for Tom to attend a Foundation Learning Programme and a referral had been made to an education and employment project for young people; he had been offered a place at a Further Education College from September information redacted. On information redacted the social worker completed a pathway plan assessment with Tom which concluded that he was not yet ready for semi-independence. 2.4.37 On information redacted Tom was arrested with Vic for possessing an offensive weapon. Both young men were charged and remanded to appear in court the next day. In court Tom pleaded guilty and was remanded on conditional bail information redacted. On information redacted Tom was seen at 01.06 hours by the police and escaped information redacted. On information redacted Tom was reported missing by the foster carer but returned home later that night. On information redacted Tom was arrested for breach of his bail and appeared in court the next day after which he was fitted with a tag. During the next two weeks Tom was stopped by the police on a number of occasions but was seen to be observing his curfew times and bail requirements. On information redacted Tom was arrested for breach 16 of his bail conditions as he had been seen with Vic earlier that day, he was kept in custody to appear in court the next day. On information redacted Tom appeared in court and was sentenced to a youth information redacted order information redacted. Later that day both Tom and Vic were involved in the incident with a third party where they were both injured. Information redacted. 2.5 Agencies’ Involvement with Vic 2.5.1 Information redacted Vic attended a local secondary school. He presented few problems for the school in Year 8 but his attitude deteriorated in Year 9. He was disruptive, rude and aggressive which resulted in some fixed term exclusions in October and December information redacted. In January his mother shared with the school that she was also having difficulties managing his behaviour at home. Various members of the pastoral team attempted to assist but were not successful. Vic was a talented sportsman and in information redacted he transferred to a specialist information redacted Academy information redacted. Vic had some difficulties attending the information redacted Academy as the journey was lengthy each day and there were on occasions evening training sessions in information redacted. On information redacted Vic was reported missing by his mother but in fact had fallen asleep on the train information redacted. To alleviate these pressures Vic lodged with a staff member’s family during the week and returned home to his mother at weekends. Vic attended the information redacted Academy until information redacted. The school record details that Vic ceased attending school because he had moved to another country however he did not do this until information redacted. 2.5.2 Between April and December information redacted Vic started to present some challenges to his mother. She reported him missing on four occasions and each time he was spending time with Tom or another young man known to both of them. On information redacted Vic was arrested for an offence. Information redacted. On information redacted he was seen by a community police officer to try and steal an item, this matter was resolved by him being given a warning. 2.5.3 In November Vic’s mother contacted the Substance Misuse Service (SMS) because she had concerns about her son’s drug use. Vic was offered an appointment on the same day which he attended. Information redacted. A risk assessment was undertaken and he was offered a follow-up appointment information redacted. He failed to keep this meeting and a further appointment despite the worker attempting to contact him via letter and text. The case was closed in January. 2.5.4 On information redacted Vic was arrested for an offence; he was interviewed and bailed information redacted. On information redacted January Vic went missing with Tom. His mother reported him missing to the police and he returned of his own accord the following day. On information redacted Vic’s mother approached CSC asking for assistance, she mentioned his contact with Tom as a factor in his difficult behaviour. A social worker was allocated to undertake an initial assessment this was concluded on 16th February and 17 the outcome was referral to another agency, YOT, and the case was closed on 21st February. On information redacted Vic appeared in court and pleaded guilty to the offence; he was sentenced information redacted. Prior to his appearance in court his mother had arranged for his father to take him to another country in an attempt to separate him from his peers. This arrangement was agreed with the YOT case manager, so long as he returned in a month and reported to YOT in accordance with the order. 2.5.5 On information redacted Vic’s mother contacted YOT and the police informed them that Vic, who was due to return to England information redacted, had run away from his father’s care. Vic’s parents had decided that he should not return to England and this was the trigger for him running. Vic was picked up by the police at St Pancras and was returned to his mother’s care. In March Vic attended his first YOT appointment and on information redacted he was arrested with Tom for a criminal offence involving use of a weapon. Both young men were charged and appeared in court information redacted. The outcome was that Vic was returned home on bail, but with curfew conditions and to have no contact with Tom, who was remanded into secure accommodation. 2.5.6 Vic was arrested for theft information redacted and breach of bail in April. He then failed to co-operate with curfew requirements and was arrested for breach of curfew arrangements on information redacted. The YOT worker referred him to MST on 12th April. On information redacted the police started an investigation of a criminal incident involving a weapon in which Vic was named as one of the suspects. As a result Vic was arrested information redacted; he appeared in court on information redacted and was remanded into care to a Secure Unit. As a result the MST work did not start as they do not work with families whilst young people are in custody. 2.5.7 Vic remained in the secure unit until June. Whilst in the unit he was involved in a fight and placed on the bullying log twice information redacted. A LAC review was held on 5th May attended by Vic, the social worker, his mother and a manager. The review identified the need information redacted for dental and optical appointments to be made. Information redacted. On information redacted Vic pleaded guilty to possession of an offensive weapon but not guilty to the other offence. The YOT case manager discussed with Vic his reasons for carrying the weapon and was concerned about his cognitive processing in terms of attitude towards carrying weapons. 2.5.8 Vic was granted bail information redacted and returned to live with his mother. He was subject to a curfew between 1900 and 0700 hours and was electronically monitored as part of bail conditions, there was no requirement regarding contact with Tom. At this point Vic had no school place and there was no obvious activity for him in the day time. He was stopped by the police on two occasions in July. On 6th July Vic’s YOT caseworker had a joint session with him and Tom to try and develop the positive side of their relationship; she was concerned that they both lacked victim empathy. Vic’s social worker also referred the family to the Family Intervention Project on 18 the 6th July. On 14th July Vic’s mother was advised by education to make an application to school admissions for a school place for Vic and the same day contacted the YOT worker saying that she was concerned about Vic’s aggressive behaviour information redacted. This worker contacted the police who visited. Vic had become angry and had thrown property around his bedroom; he agreed to try and control his temper. The next day Vic’s mother contacted YOT repeating her concerns regarding Vic’s temper information redacted. On information redacted Vic cut his curfew tag off and went missing, with Tom. He continued to breach his bail conditions and on information redacted he was taken to court and re-remanded to a Secure Training centre. 2.5.9 Vic remained in the secure training centre until September. Initially Vic’s behaviour was challenging and there were questions as to whether he would be able to stay however this behaviour modified information redacted. 2.5.10 A LAC review meeting was held on 5th August attended by Vic’s mother, YOT, and staff from the secure unit, the social worker was not present. The meeting was attended by Vic information redacted. His mother advised professionals that information redacted she was having phone contact but not visiting. Information redacted. No date was fixed for the next review. There was no evidence that Vic was visited by a social worker prior to his release and most of the supervision records at this time relate to the need to transfer case responsibility to the LAC team. A plan dated 28th September indicated that a core assessment should be undertaken to identify supports for the family to ensure that ‘…he [Vic] does not revert to criminal activity…’ however this was not completed until January. While Vic was in the secure unit his mother applied on his behalf for a place at a community college she was also supported by the FIP Project who became involved in July. 2.5.11 Vic was acquitted of robbery on information redacted and was released from the secure unit on bail with curfew requirements. His social worker was on long term leave and so another worker had been allocated to him. On information redacted Vic was stopped by the police outside his curfew hours and ran away. On 10th October Vic’s mother contacted the YOT and CSC saying that she could not cope with him and would not be attending court with him or taking him to school; furthermore she said that he was breaching his curfew and that she thought he was staying with Tom. On information redacted Vic was arrested with Tom at a fight outside the school, his mother refused to act as a responsible adult and he was detained for court. The next day Vic was involved in a fight information redacted. His mother took him to hospital which meant that he was breaching his curfew; she advised the police of the reasons for the breach. On 16th October Vic’s mother contacted EDT upset and crying saying that she could not cope with having Vic at home as he was beyond her control. The EDT worker recommended an assessment as the family was in crisis. The social worker attempted unsuccessfully to contact the YOT worker and was advised in supervision to undertake a core assessment but that Vic was ‘…not to be received into care…’ 19 2.5.12 Although Vic’s mother had applied for a school placement for him the Individual Pupil Management Meeting in September decided that the option of an additional/alternative placement at the pupil referral unit should be considered given that Vic was in Year 11 and had been out of mainstream school for over six months. By information redacted October this had still not been arranged. 2.5.13 On information redacted Vic was in breach of his curfew; he was arrested for three offences. One offence resulted from Vic intervening to prevent the police from arresting Tom and a friend. On 1st November information redacted Vic and his mother were seen by a social worker. Following this there was negotiation with the YOT regarding the provision of tuition in a local library. On 1st November a referral letter was received by Kingston Family Adolescent and Child Team (FACT) from FIP asking for support because of cognitive clumsiness this referral was declined on 8th November and FIP was advised to approach a psychologist within the YOT. A whole family assessment meeting planned for 9th November was then cancelled as the social worker was unavailable. 2.5.14 On information redacted Vic was arrested for failure to appear in court information redacted. On information redacted he pleaded guilty to one of the offences and was remanded on conditional bail with curfew arrangements and electronic tagging. On information redacted Vic pleaded guilty to a second offence and was sentenced information redacted. The requirements for curfew were lifted at this court hearing. On information redacted Vic was sentenced information redacted for one of the offences. Following this court appearance there was consideration of his educational needs and on 17th November (seven weeks after his discharge from the secure unit) a package of alternative provision at the Pupil Referral unit (PRU) was arranged. A meeting with the tutors was scheduled for the 24th November however Vic and his mother failed to attend it. 2.5.15 On information redacted Vic was arrested with two others for possession of an illegal substance. Vic’s mother spoke to a social worker on 29th November and was very distressed. Vic’s mother was very concerned about the impact of Vic’s behaviour information redacted and was asking for Vic to be removed. As a result an initial assessment was undertaken with regard to his sibling on 12th December. This concluded that there was a strong bond between the sibling and Vic’s mother and that it would not be appropriate for Vic to be placed outside the family home but that ‘... the intensive package of care in place should continue…’ and that his mother should engage in the work with FIP. A planning meeting with FIP took place on 16th December. There was a change of social worker at this point as the previous worker had returned from extended leave. 2.5.16 In January information redacted Vic appeared in court on two occasions; he was stopped by the police on four occasions, on two occasions (with Tom) information redacted and was charged with possession of drugs information redacted, this related to the incident in November when he was found with drugs and street-bailed. On 4th January Vic was contacted by SMS and 20 offered support but he denied any drug problems and declined the service. The social worker had telephone contact with Vic’s mother but no contact with him. A network meeting was held with the FIP worker on the 18th January. On the 30th January the social worker completed a core assessment that recommended no further action on the basis that Vic was not engaging with the social worker and other agencies (YOT and FIP) were involved. At this time Vic was not attending education and on 19th January he and his mother attended a meeting with the education welfare service and YOT education worker. Their preference at this stage was that Vic should be home-educated however they were persuaded by the professionals to consider a NACRO education project. This was arranged to start on 9th February. 2.5.17 On information redacted Vic appeared in court and pleaded guilty to possession of drugs and was sentenced information redacted. The same day Vic’s mother contacted CSC saying that she was very concerned because Vic had started dealing in drugs ‘…suspicious people come to the door..’ and she was concerned about the effect on his younger sibling. The social worker asked for Vic to immediately come to the office and arranged to see his mother on 6th February; she also liaised with the YOT worker who advised her that YOT were considering making help with substance misuse a part of the order but thought it was unlikely. 2.5.18 On information redacted Vic was in custody for an offence; he had gone missing with Tom and another friend on the 4th February. Vic returned home to his mother on 7th February but remained for a short period before leaving because he was angry information redacted. Vic did however start attending the NACRO education project from 9th February and attended regularly throughout the month. Vic was stopped and searched by the police on two occasions in February but there was no contact with other professionals. There was also a meeting with FIP and possibly MST on 20th February. 2.5.19 In March Vic was stopped by the police on two occasions, on both occasions he was with Tom. By 15th March Vic’s attendance on the NACRO programme was at 50% of the sessions and on 29th March the trial placement was not extended due to lack of engagement and Vic started to be home educated for the remaining period of statutory education requirement. Vic appeared in court on information redacted March and was sentenced for three offences and committing an offence whilst a Youth Rehabilitation Order was in force. He received a further Youth Rehabilitation Order information redacted. 2.5.20 MST started work with Vic and his family on 19th March following a request in mid-February from Vic’s mother for further support. MST attended a FIP review on 21st March. MST met with Vic on 26th March at home. There were then sessions with Vic and his mother on 3rd April, 4th April, 11th April, 12th April 16th 17th April 23rd April and 25th April. This work was aimed at developing a behaviour plan and house rules. On 17th April there was a meeting with FIP to work out how to handover case responsibility as it was not considered appropriate for both agencies to be involved. There was no 21 other agency contact during April and Vic was only stopped once by the police in April when he was with Tom. On 1st May information redacted CSC ceased to work with Vic on the basis that YOT, FIP and MST were involved with the family. MST continued to work with the family throughout May having meetings on 2nd May, 8th May (when the FIP worker ceased to be involved), 9th May, 14th May, 16th May and 22nd May. The focus of work was on understanding Vic’s motivation for criminal behaviour and in particular his use of weapons. He reported that he carried them as a defence (as did his peers) because of threats made against him. 2.5.21 On information redacted Vic was arrested with Tom for possessing an offensive weapon. Both young men were charged and remanded to appear in court the next day when Vic pleaded guilty and was remanded on bail with conditions that included a curfew to be electronically monitored, no contact with Tom and to keep all appointments with YOT. On 8th May Vic’s mother contacted the police to report that Vic had received threatening texts from another young man and that this was the reason he had been carrying the offensive weapon. The police visited on 10th May and initially Vic would not speak to the police but was persuaded by his mother. Information redacted. Unfortunately Vic was not able to name the young men who had sent the texts and had not kept the messages. He was also not willing to substantiate any of the allegations and would not disclose the name of another person whose Facebook account had been used to send similar threats. The police therefore could not take any action. On information redacted Vic’s mother called the police after she saw Vic being threatened by another boy with a knife. Vic was annoyed that his mother had called the police and would not speak to the police officer. Vic was visited by the police information redacted but he would not substantiate the allegation and so was given safety advice and was told not to take matters into his own hands. During May Vic was stopped and searched by the police on four occasions, on one occasion (twice in the same day). 2.5.22 On information redacted Vic was arrested for breach of his bail conditions as he had been seen with Tom earlier that day; he was kept in custody to appear in court the next day. On information redacted Vic appeared in court and was sentenced to a youth rehabilitation order with supervision and curfew requirements including electronic tagging. Later that day both Tom and Vic were involved in an incident with a third party where they were both injured. Information redacted. 3. VIEWS OF FAMILY MEMBERS 3.1 Contribution from Tom’s mother based on interview on 18th December 2012. 3.1.1 Tom’s mother was very unhappy with the services that had been provided to her son and family and points out that they have asked for the services to work together to help but have been refused. Tom’s mother claims they only seem to want to help each other avoid having to do anything. Information redacted. She says that ‘the family failed to get the necessary support information redacted that they asked for and instead adult services refused to 22 work with children’s services except to consider them as a problem or at risk.’ Tom’s mother is currently in legal dispute with the Local Authority information redacted and it is for that reason that she was unwilling to give the Serious Case Review Panel access to her medical notes. 3.1.2 Tom’s mother identified her difficulties as starting while Tom was at secondary school and said that when he was there he was bullied by other young men information redacted and she ascribes the incident in April information redacted to this. She also felt that the secondary school was poorly managed and that her sons were unduly punished for poor behaviour. Tom’s mother did say however that she was experiencing difficulties managing Tom information redacted. 3.1.3 Tom’s mother said she did not agree with him moving to a foster-home and described it as the Local Authority ‘snatching him from her care’ whilst he was at school. She said that she agreed reluctantly to him staying short term in the hope that the ‘supported planned re-integration’ offered would help her care for Tom but it never happened and once Tom was in foster care she felt that there were very different rules applied in the two homes despite promises this would not happen and that Tom was not expected to abide by appropriate house rules which meant that he did not want to return home as Tom felt he could do just what he wanted in foster care which he thought was great but could not cope with this ‘freedom’ and went totally overboard. 3.1.4 Tom’s mother felt that he was rewarded for poor behaviour and that this was fundamentally wrong. Tom’s mother did not find the police or social care supportive and said it was not unusual for Police to arrive in the middle of the night to wake the family and demand to search the house because Tom was missing yet again and often they were rude and difficult as well. Also MST said that they were unable to work properly because Tom was in foster-care not at home. Tom’s mother complains that the Local Authority claim Tom is on a section 20 but the family do not consent to him being held by social services who now say they can keep him because he wants to stay. She complains that the family have been totally excluded from all processes involving Tom and his welfare and have no say at all in anything. Their parental rights have been totally removed without any Court hearing or process ever taking place which is illegal. She says she had warned many times of the terrible consequences this would bring but no one would take any notice. 3.1.5 Tom’s mother was very critical about the ways in which Tom’s behaviour was and is being managed by the foster carer and the social workers feeling that it is ineffective and that he should be subject to a stricter regime with clearer consequences for poor behaviour and not given money for drugs or allowed to stay out in unknown places overnight. She says Tom himself claims he is being paid to stay where he is and that he is saving his money and has got what he considers to be a lot. He is now waiting to be housed. She is also very critical of the behaviour of the foster carer who has been given the parents number several times but did not even phone when Tom was in hospital information redacted. She also complained about his family picking Tom up to visit them. 23 3.1.6 Tom’s mother also felt that gangs and drugs use were a significant feature with regard to Tom’s behaviour. She was clear that she felt that Tom and Vic and some other young men were in a ‘gang’ together and that on a number of occasions there had been gang disputes which had resulted in them being hurt. Tom’s mother was very clear that the incident when both young men were injured information redacted was associated with a gang process. 3.1.7 Tom’s mother wanted a recommendation from the serious case review to be that there should be a truly independent body for people to complain to about the local authority with powers to hold the local authority to account and force them to abide by the law and governmental guidance. She says ‘The public must be able to complain about unfair or illegal treatment and enforce their legal rights especially those relating to parental rights in relation to their own children without having to fight to be heard. We did nothing at all to lose our children and our parental rights. Parents should be able to say they have been lied to, deceived or cheated by the Local Authority if they feel this is happening. At the current time Local Authority is pretty much free to do anything wrong they like and the only thing that can happen is that another review will take place. This will not stop abuse of power or bad practice and it will not fix the problems going on so many more disasters will keep happening. Something fundamental has to change and the Local Authority has to accept that they are supposed to provide public services to a paying public not ideological manipulation of families or money and comfortable housing to naughty children who want to take drugs party and behave badly without parental wrath or punishment.’ 3.18 Further comments were made by Tom’s mother. However, these referred to incidents and situations that were outside the agreed timeframe for this review, as set out in its terms of reference, and therefore have not been included in this report. Tom’s mother’s contribution also raised significant concerns about some aspects of services that were provided to Tom. These matters were scrutinised as part of the review but were not considered to be substantiated. 3.2 Contribution from Vic’s mother based on interview on 19th December 2012. 3.2.1 Vic’s mother identified that her problems with Vic started at his first secondary school when he became involved with Tom and started to ‘act out’. Information redacted. 3.2.2 Vic’s mother saw the first major agency involvement stemming from January information redacted when he was arrested for an offence. She felt that at that time she felt very powerless and experienced the police intervention very negatively feeling that it was very punitive with very little scope for prevention. 3.2.3 Overall she felt that she received little help from social care or the police but that FIP and MST were helpful. FIP was particularly supportive and assisted her in caring for Vic’s sibling and ensuring that his behaviour caused as little damage as possible. The MST input was also useful and was progressing 24 well but was interrupted by information redacted Vic’s subsequent move to secure accommodation. 3.2.4 Vic’s mothers criticisms of the police were about the level of usage of stop and search and the fact that on occasions he was late home and in breach of his bail because he was stopped by the police. She felt that the over-use of stop and search meant that Vic had no faith in authority and so undermined others (YOT and MST) attempts to enable Vic to behave more positively. 3.2.5 Vic’s mother felt that YOT did not take sufficient notice of Vic’s substance misuse problems and that they should have asked the court to make him the subject of a drug treatment order that would have forced him to work with the substance misuse services. She also felt that he should have been breached sooner and that the service gave him too much leeway which was not in his best long term interests. Generally Vic’s mother felt that Vic had difficulty building relationship with and trusting in the YOT worker because of the number of changes in his key worker. More recently Vic has had one worker and has built a good rapport and this works better. 3.2.6 Vic’s mother felt that social care rarely provided support unless she was desperate and described being unaware of her key worker and not knowing how to contact them. She contrasted that with the very positive relationship she currently had with Vic’s social worker and said that she felt the service had previously been very disorganised. 3.2.7 Vic’s mother was very unhappy with the educational services provided to Vic and felt that he had been badly let down. Vic’s mother said that she received little guidance on what she should do to enable Vic to access education and felt that there was significant delay in any action being taken. She was critical that Vic had never been the subject of a statement for educational needs with regards to his ‘emotional and behavioural difficulties’ and did not feel that suitable ‘appropriate provision’ was provided for him. In particular she felt that the NACRO education should have been made available immediately after he was first released from secure accommodation, she was also clear that when it was eventually arranged it was because she organised it. Overall Vic’s mother felt that if he had been more fully occupied during the day through education and other activities it is possible that his more difficult behaviour could have been avoided. 4 KEY THEMES IDENTIFIED BY THE REVIEW PROCESS 4.1 Agency focus on procedures not outcomes 4.1.1 A significant feature of this review was that although there were high levels of input by most agencies working with these two young men there was very little evidence of any positive outcomes being achieved. This may be considered to be a facet of working with adolescents who are notoriously difficult to engage with services and often resist all interventions however the question that must be raised is the degree to which there was any review by agencies of the effectiveness of their interventions and any consideration of outcomes achieved. 25 4.1.2 It is clear from the IMRs that most professionals were acting in accordance with their local procedures and were providing services in an appropriate manner. The exception to this would be CSC where it is clear that there were considerable limitations in the social work interventions as described in the IMR. It is interesting then to consider why, if professionals were operating in accordance with procedures and protocols, so little was achieved with the young people. In order to understand this contradiction analysis must go beyond exploring whether procedures were followed to consider whether the procedures were right in the first place. 4.1.3 An example of an intervention that required significant resources but which achieved little in terms of outcomes were the ‘missing persons’ processes’. Major efforts were made by a range of professionals to ensure that these young men were reported missing to the police; which then involved the police in considerable efforts in both tracing the young men, and then undertaking follow-up interviews most of which provided minimal, useful information. As the Police IMR identifies, with the exception of reports being sent to the wrong borough, the police almost always followed procedures and the missing person investigations were completed in accordance with protocols. This however is to ignore the probable purpose of the protocols which surely must be to prevent the recurrence of the young person going missing. When judged by those standards the effectiveness of the intervention is significantly reduced. Research undertaken with young people in care who run away identified three main reasons for children running away; ‘…running somewhere simply to have fun… running to somebody you want to be with… and running away from your placement because you cannot cope with things there…’3 . Young people also said that sometimes young people were reported as missing when they had simply stayed out longer than they should or had gone somewhere without permission but intended to return. Many of Tom’s missing episodes either fit the last category or were simply ‘to have fun’ yet there was no evidence that professionals considered whether this should influence the professional responses made to his actions. Clearly when Tom and Vic were subject to curfew arrangements there was a need for more formal intervention however it is probable that this would have been better dealt with via breach protocol rather than the missing person procedures. 4.1.4 Similarly the YOT IMR also reports that in general the YOT work was in accordance with the National Standards for Youth Justice Services’ minimum requirements and thus was acceptable practice. It is clear however that in terms of reducing criminal activity committed by these two young men the YOT interventions were far from successful. The IMR does suggest that YOT could reflect on whether their interventions with ‘…regards to the balance of engaging him [Vic] compared with the enforcement of further external controls to monitor him…’ and also suggests that with regard to Tom ‘…a systemic team approach may have been beneficial within the integrated offender management system in order to review the plans and directions of the young people’s systemic support. It is relevant that at the time although there was 3 Running away Young people’s views on running away from care Reported by the Children’s Rights Director for England Ofsted 2012 26 appropriate management oversight neither of these things were done. There was also very little attempt to bring together agencies (including police, CSC and education) to see if alternative interventions should be considered. 4.1.5 There were also very high levels of stop and search used by the police; all of which were deemed to be appropriate and in accordance with guidance. It is clear that these young men would generally meet the criteria accorded to the police for use of stop and search as clearly they did present on occasions a threat to the community and the safety of the public. The effectiveness of this intervention to prevent these young men from committing crimes is questionable and it is unclear what positive outcomes it achieved. It probably contributed to these young men having little confidence in the criminal justice system as a positive process that could protect them as well as controlling their actions; as witnessed by Vic’s unwillingness to co-operate when a victim. Research has shown that ‘stop and search’ may have a negative impact on some individuals. “There is no compelling ‘business case’ for the present level of stop and search … it has a deeply damaging effect on society; it impacts negatively on the law abiding population and is cause of a loss of public support for and de-legitimation of the police. It increases the frequency of adversarial encounters – some of which have the potential to trigger public disorder – and contributes to accelerating the flow of young black people disproportionately into the criminal justice system”4 . Information redacted. There was no consideration of using a multi-agency approach to address Vic’s behaviour; in particular the MST could have worked more proactively with him to enable him to manage the situation in a better way if they had been more aware of the problems. 4.1.6 There was no evidence that agencies reviewed their work with these young men in terms of its effectiveness. In fact despite there being systems in place to measure many of these interventions, the level and number of ‘stop and searches’ and ‘missing person incidents’ did not appear to be known prior to this review being undertaken. It was certainly never shared across agencies and there was no attempt to consider across all the agencies working with the young people whether there could be more effective interventions to achieve better outcomes. Despite both young people being ‘looked after’ for periods of time and a range of agencies being involved there was no evidence that there was ever a discussion between the professionals involved about whether there were other ways in which these young men could be helped. In fact there did not seem to be any expectation that this could or should happen. 4.1.7 The issue of greatest concern is that the absence of this was not examined within the IMRs and there was limited consideration within those reports as to whether the expected interventions were useful or effective. Instead these reports are focussed on whether professionals operated in accordance with the procedures. There was ‘A concern with doing things right versus a concern for doing the right thing.’5 4 Race, Crime and Justice Bowling and Philips (2007: 959-60). The challenge for Kingston LSCB is to 5 14 Peter Drucker (1909-2005), writer, management consultant, and ‘social ecologist’ quoted in The Munro Review of Child Protection Part One: A Systems Analysis Professor Eileen Munro DfE 2010 27 consider how agencies can promote and develop a multi-agency professional mind-set that enables consideration of the effectiveness of interventions and uses outcomes not outputs as measures of their success. 4.2 Insufficient direct work with young people 4.2.1 Despite these young people being of an age when they were very capable of expressing their wishes and feelings the chronology shows low levels of direct contact with the young men. Furthermore those professionals that saw them most were possibly the people who had least capacity for achieving a meaningful relationship. The professionals who had most direct contact were the police however their intervention was often in a context that could be adversarial and there was little continuity so did not provide opportunity for building relationships. 4.2.2 The other agency in regular contact with both young men was YOT and these case workers did have some opportunity for developing more meaningful contact. It must be acknowledged however that these workers are in an ambiguous position as they are also holding the young people to account for their criminal activity and are able to breach them if they fail to act in accordance with the orders to which the young people are subject. This probably places some constraints on the trust that will be accorded and for Vic was made more difficult by a lack of continuity of case worker. There was some evidence of a YOT case worker trying to build relationships information redacted when she met with both young men together to try and develop the positive side of the relationship. This was not further developed and soon after Vic was placed in secure accommodation. 4.2.3 MST also did direct work with both young men with different levels of engagement and success. The MST IMR rightly identifies that their intervention with Tom was less successful and concludes that this was because he was in foster care most of the time and did not attend appointments with the MST staff. The work with Vic was more successful but was challenged by his remands into custody. One of the significant differences between these two interventions was the level of direct contact between the MST worker and the young person; Vic attended five sessions compared with Tom attending one, but also Vic was engaged earlier in the process which probably enabled him to feel he had some control and input over the process. A significant feature of positive engagement with young people is a ‘…willingness to listen and show empathy, reliability, taking action, respecting confidences, and viewing the child or young person as a whole person…’6 It is possible that Tom considered the MST intervention was unfairly biased towards his mother as the bulk of the MST worker’s time was spent with her. It is clear that the worker made attempts to understand Tom’s perspective and the worker did meet with him alone however it is also evident that Tom did not consider that his parents were willing to accommodate his needs, which may be why, ultimately, the MST intervention failed. 6 The Munro Review of Child Protection Interim Report: The Child’s Journey Professor Eileen Munro DfE 2011 28 4.2.4 An agency whose professionals should have had positive relationships with the young people was CSC; however it is noteworthy that these professionals had least contact with both young men despite them both being looked after and Tom in particular having been in foster care for almost eighteen months. In reality a lack of continuity in social workers and an absence of direct work being undertaken meant that Tom and Vic had minimal relations with their social workers. This was particularly unfortunate as they should have been the professionals who could have provided the young men with advocacy and support at points of crisis. ‘Elements of frontline practice that children and young people particularly valued were access to consistent help from the same social worker, to respectful treatment and to services which do not get withdrawn as soon as the crisis is passed.’7 The other person who did develop a positive relationship with Tom is his foster carer and it is positive that this placement was maintained which did enable this relationship to continue. The lack of continuity of social worker probably made it difficult for the foster carer to intervene purposefully on Tom’s behalf. 4.2.5 The absence of any truly effective relationship‐based practice with these young men contributed to their increasing alienation from the system of supports supposed to assist them. Whilst it is probable that much of their offending behaviour may still have occurred the chance to positively intervene was absent whilst there was no professional who had fully engaged with them. It may have also contributed to the lack of co-ordination of service delivery which is considered later in this report. 4.3 No timely response to provide services 4.3.1 Another facet of the services provided to these young men was the slow pace of service delivery which meant that often they were no longer willing or able to engage with options that had been discussed with them. It must be noted that some services did respond rapidly most notably the SMS who provided Vic with an appointment on the same day that his mother accessed the service, but also the police who generally visited in a timely manner. 4.3.2 A stark contrast was the provision of education by the Local Authority. There were delays in the provision of educational options and a failure to engage either young man in educational provision meaning that both Vic and Tom effectively did not attend formal education for almost two school years. This was particularly apparent when reviewing the arrangements for Vic’s education. He ceased attending the information redacted Academy in January information redacted and alternative educational provision was not provided for him until November information redacted. Initially his mother had some responsibility as she did not prioritise finding him a new school when he returned from abroad in March. It is unclear, however, why the Local Authority did not refer Vic to the Education Welfare Service when his mother did not identify a new school for him. Vic’s mother did apply for a school place in August information redacted when he was in secure accommodation. In early September, however, a decision was made by the Local Authority that it was unsuitable for him to be placed there. When he was discharged from secure accommodation on information redacted September it was almost six weeks 7 The Munro Review of Child Protection Interim Report: The Child’s Journey Professor Eileen Munro DfE 2011 29 before alternative provision was provided. The lack of structured activity in the daytime was clearly a risk for re-offending yet despite this there was significant delay in provision of service. ‘Poor attendance or exclusion from school, or attendance at a Pupil Referral Unit, have been cited as key risk factors in the development of offending behaviour for young people’.8 This slow response was replicated when Vic failed to attend the PRU provision in November information redacted. Education welfare staff did not meet with Vic and his mother to discuss alternative options until 19th January information redacted and then he could not start at the NACRO project until 9th February information redacted. Vic did engage to some degree with this provision and it is possible if that had been provided immediately following his discharge from secure accommodation that different outcomes could have been achieved. 4.3.3 There were similar deficits with regard to Tom’s access to education. Despite having a school placement, he rarely attended school throughout 2011 and little was done successfully to address this. An example being that a meeting in December information redacted agreed that alternative provision should be explored for him, the options being foundation learning course and Princes Trust. Funding for this was not agreed until 21st February information redacted and the application was made on 21st March information redacted but was delayed initially by the Easter holidays and then by Tom being remanded. In the event an appointment was not made until May by which time his foster carer had referred him to the education and employment programme for young people starting in September information redacted. 4.3.4 The delay in provision of education was most extreme but other agencies were also slow to provide services. After Vic left secure accommodation in September there was no contact with his mother by the social worker for ten days and that contact was only because she contacted them to say that she would no longer be responsible for him. It was only after his mother had contacted EDT on two occasions in October saying that she could no longer look after Vic that the social worker made contact. 4.3.5 Speedy and responsive service provision is essential to intervening positively with families when they are in crisis. This is particularly true of work with adolescents where there are often very limited windows of opportunity for intervention which need an immediate response. 4.4 Working with adolescents who offend in groups 4.4.1 A significant facet of this review was the extent to which Tom and Vic were offending together. It is clear that they were influenced and affected by each other’s actions as well as being involved consistently with at least one other young person. The extent to which this constituted ‘gang’ activity is open to debate. The definition of ‘gang’ activity in the London Safeguarding Children Board procedures is ‘…a relatively durable, predominantly street-based group of children who see themselves (and are seen by others) as a discernible group for whom crime and violence is integral to the group’s identity.’9 8 (Farrington, 1995; Young et al, 2007) quoted in Teenagers at risk The safeguarding needs of young people in gangs and violent peer groups Kate Fitch NSPCC March 2009 9 Safeguarding children affected by gang activity and / or serious youth violence, London Safeguarding Children Board 2009 30 4.4.2 It is possible that the young men were developing a group identity and certainly they refer to other gangs and appear to be in conflict with young people who may be in gangs. Information redacted. Tom’s mother also referred to Tom and his brother being attacked by gangs. Both young men had also been attacked and suffered significant injuries and this is often evidence of gang involvement as young people involved in gangs are more likely to be victims as well as perpetrators of violence. Whether they were directly involved in a ‘gang’ or not it is clear that Tom and Vic were involved in co-offending behaviour that involved ‘serious youth violence’10 . This accelerated during the period of the review and it was significant that both young men were alleged to have undertaken criminal activities using weapons and had been convicted of having offensive weapons on their person. Fear and a need for self-protection is the key motivation for carrying weapons – it affords a young person a feeling of power. Where a young person is involved with a gang or serious youth violence, the risk or potential risk of harm to the young person may be as a victim, a perpetrator or both. 4.4.3 It is clear from all the IMRs that professionals did not consider the issue of ‘gang’ violence prior to the review and none of them had considered using the London Safeguarding Protocol with regard to responding to the particular challenges of working with young people in gangs. They also did not identify the escalation in the levels of violence; a pattern of behaviour which is most common with serious youth violence that leads to serious injury or death. ‘By far the majority of children do not become violent overnight. Their behaviour represents many years of [increasingly] anti-social and aggressive acts, with aggressive habits learned early in life often the foundation for later behaviour. Where a child succeeds at low-level anti-social acts, such as verbal abuse and bullying, violating rules and being disruptive, s/he may feel emboldened to perpetrate increased violence.’11 This description certainly matches the profile of both young men whose activities became increasingly anti-social and involved increasing levels of violence and aggression. 4.4.4 Research into how best to respond to the needs of young people involved in serious offending behaviour identifies that it should ‘… be planned on a multi-agency basis and include provision from schools, youth offending teams, social care, police and youth and leisure services.’12 10 The definition of ‘serious youth violence’ currently in use by the Metropolitan Police Service is ‘any offence of most serious violence or weapon enabled crime, where the victim is aged 1-19…’ This is confirmed by the London Safeguarding Procedures which advise calling a multi-agency meeting informed by advice from the local professional with specialist knowledge about gangs. This review has identified that whilst many professionals were working very hard with these young men much of their work was in isolation and without a clear perspective about how it fitted with other agencies. There was a sense that professionals found the problems presented by the young men’s behaviour too challenging and looked to another agency, usually YOT to resolve the difficulties. In reality no one 11 Safeguarding children affected by gang activity and / or serious youth violence, London Safeguarding Children Board 12 Teenagers at risk The safeguarding needs of young people in gangs and violent peer groups Kate Fitch NSPCC March 2009 31 professional could achieve the change necessary and what was required was a well-resourced timely package of support that would divert the young people and assist them in addressing their problematic offending. The risk of failing to provide that input is that the young people continue to take increasing risks that lead to potentially more dangerous outcomes. ‘The deaths or serious injury of older young people regularly make up a quarter of all serious case reviews. … The tendency for vulnerable “hard to help” adolescents to be neglected by agencies, who give up on these challenging young people because their needs have become too overwhelming, was first identified in the 2003-2005 study’.13 ANALYSIS 5.1 What was the quality of practice in relation to this case and how effective was the agency’s engagement with the young people? 5.1.1 Quality of practice was variable with some agencies delivering good services and others, notably CSC, failing to meet minimum standards. MST provided good quality interventions but these were limited in achieving positive outcomes because of the problems associated with maintaining engagement with young people who were living away from home. The SMS also provided good services but had limited positive outcomes because of the young people’s unwillingness to accept their intervention. FIP was also seen as very supportive by Vic’s mother who described it as providing her much support and also assisted his sibling even if it did not achieve a change in Vic’s offending behaviour. 5.1.2 The police generally provided services in accordance with their procedures and protocols. The YOT also met most of the minimum standards although their use of breach could have been more proactive. The education service practice was in accordance with legal minimum requirements but was slow and cumbersome and it was partly because of this that they failed to engage with the young people. The school health team practice was sound however there was poor quality of practice by the LAC doctor which has already been addressed by that agency. 5.1.3 The quality of practice within CSC was almost universally poor and there was minimal engagement with the young people. The one positive for Tom was that he was provided with a very competent foster carer who maintained links with him and was enabled by CSC to remain his carer even when he was placed in secure accommodation. This good practice is to be commended. 5.2 Were assessments of a sufficiently good quality and did they include multi-agency involvement? 5.2.1 Assessments provided were generally adequate with the exception of the CSC initial and core assessments and the LAC doctor assessment. The latter 13 serious case reviews: A two-year analysis of child protection database notifications 2007-2009 Brandon et al DfE 2011 32 has already been addressed by that agency. The quality of the CSC assessments was extremely poor in that they were undertaken late, did not include appropriate consultation with other agencies, notably health and adult services, and lacked a sound analytical basis. This work seems to be representative of general practice as the recent Ofsted inspection described; ‘The analysis in the majority of assessments seen, including those in Section 47 enquiries, is poor. Assessments are usually descriptive and lack focus on identifying robustly whether a child has suffered significant harm or is likely to in the future.’ 14 It is therefore being addressed as part of the improvement plan in response to that inspection. 5.3 Were the interventions provided appropriate and how effective were they? 5.3.1 As has already been identified in the ‘themes’ many of the interventions were in accordance with procedures but lacked efficacy. This was particularly true of the missing children procedures which were in the main adhered to by the police and foster carer but which achieved little as the motivations and reasons for Tom going missing were not being addressed. 5.3.2 A missed opportunity for earlier involvement was the incident information redacted when both Tom and his brother attended Accident and Emergency with significant injuries information redacted. The school nurse made contact with ASKK but did not make a referral and the ASKK staff failed to identify that these injuries warranted a referral regardless of the actions of the nurse. 5.3.3 The MST interventions were appropriate but did not achieve the goals and one consideration that could be made is whether it is helpful to cease such involvement when young people go into secure accommodation. It is noteworthy that FIP who also became involved whilst Vic was in secure accommodation continued to provide support which was experienced extremely positively by Vic’s mother. 5.3.4 One aspect of all interventions with Tom and Vic was that most of the community based services ceased when they were imprisoned and there were often delays in re-starting services on their return to the community. Given that the young men may have been most accepting of support immediately after discharge from secure accommodation it is unfortunate that the relationships with community based professionals could not be maintained. Most important however was that these young men would have had to be involved in education and activities whilst in the secure environment and so this should have been maintained on their discharge. In reality there was often significant delay before these arrangements were made. 5.4 To what extent was it appropriate for the agency to take on the Key Worker role? 5.4.1 A significant weakness in the inter-agency working was the absence of a single key worker rather there were a number of key workers with different 14 Inspection of safeguarding and looked after children services – Kingston-upon-Thames Ofsted July 2012 33 responsibilities. Thus both Vic and Tom had social workers but also YOT case workers and it was clear that on occasions time was spent between these professionals working out who was responsible for co-ordinating services. There was an absence of a single planning meeting process that all agencies joined and instead there were LAC reviews, FIP reviews, Education reviews and YOT reviews all of which involved some agencies but none of which involved all agencies. This led to some overlap in decisions and delay in sharing information it also added to the confusion for carers who often had to repeat the same information to a number of professionals. There were also some key agencies that were left out of the process particularly the GP who had least knowledge despite being the one agency that would continue to be involved and whose records would follow the young person wherever they went. 5.5 Was there effective communication with and from other agencies? 5.5.1 There were high levels of communication between YOT, CSC, FIP and MST. It is questionable as to its efficacy as there was little evidence of positive outcomes for Vic and Tom as a result of these discussions. There was minimal involvement of health agencies particularly GP and school nurse in these communications and this was particularly notable around LAC reviews and general health assessments. Much of the communication was necessary because there was an absence of a clear case planning process with a key worker co-ordinating services. There was little evidence of the Local Authority education service contributing to the planning process although the YOT education worker did attend some meetings. 5.6 What was the impact on practice of issues relating to ethnicity, religion, language and diversity? 5.6.1 Both young men were of dual heritage and this was generally identified as part of routine recording by agencies. None of the IMRs identified that they considered that issues of ethnicity, religion, language or diversity impacted on the practice of professionals working in their agencies. It is clear that for the young people their ethnic identity and life experience information redacted was a key factor in their relationship with each other and this was acknowledged by the YOT and MST workers. There is little evidence however of this being taken into account in their work with the young men and little consideration of how a better understanding of the young men’s feelings about their ethnic and cultural identity might assist in working with them and influencing their behaviour. 5.6.2 No agency recorded the young men as following any formal religion so it is probable that this was not significant in their lives. There was very little information provided in any IMRs that gave information about either boy’s social economic background and little about their cultural identity except where it related to their racial and ethnic background. 5.7 What was the impact of any language issues on the young people’s engagement with the agency and did these issues receive an appropriate response? 34 5.7.1 Vic was by birth a European language speaker and his mother raised his need for additional language support at a number of meetings and both his schools identified that he needed some additional support for complex work. It was interesting therefore that the LSES IMR reported that there was no language issue that would impact on the young people’s engagement with the agency. It was clear that this aspect of his educational need had not been highlighted within the educational assessment. 5.7.2 Tom was an English speaker from birth and had no specific language needs. 5.8 How effective was the support provided to new arrivals in the country, including supporting their transition into the education system? 5.8.1 Both young men started school in Year 8 having arrived from abroad and presumably having previously experienced very different educational provision. The LSES IMR reported that there was no specific support programme in place for new arrivals in the country and suggested that schools would provide support to pupils based on their individual need. This did appear to be the case in that Vic was provided with additional English support for some lessons. Whilst this will have addressed learning needs it is questionable as to whether it would address any social or identity issues. 5.8.2 Adolescence is a time when young people are extremely egocentric and when they are developing a concept of self which is very linked to ethnic and cultural identity. Where young people experience shifts in culture or migrate from one culture to another there may be challenges which need resolution. These conflicts and challenges may have been relevant in understanding the conflictual behaviour of these young men and possibly some additional support earlier about identity could have been a preventive factor. 5.9 What was the impact or otherwise on the young people of being excluded from school and to what extent were the appropriate services provided? 5.9.1 Tom was formally excluded from school in October information redacted and was rapidly placed at a new school which was the school that his mother wished him to attend. This process was managed effectively and therefore the exclusion did not have a detrimental effect on him. Vic was never formally excluded from school as his mother withdrew him from school and there is no evidence that he was likely to be asked to leave. 5.9.2 In reality however neither Tom nor Vic attended school for most of the last two years of their formal education and the delays in identifying alternative provision that was suitable for their needs was in effect an exclusion from learning. 5.10 Was sufficient and effective support provided to the Looked After young person by the foster placement? 5.10.1 It is clear from all the IMRs that one of the few consistent supports that have been provided to Tom was his foster placement and his foster carer is to be commended for remaining committed to him throughout a difficult period. It was good practice for this placement to be kept open whilst Tom was in secure accommodation. 35 5.11 To what extent were gangs and gang culture a feature in this case? 5.11.1 The issue of gangs has been addressed earlier in the report under section 4.4. It is not clear whether these young men were in a ‘gang’ however they were co-offending and committing serious youth violence and therefore consideration should have been given to using the ‘Safeguarding children affected by gang activity and / or serious youth violence’ protocols developed by the London Safeguarding Children Board. The absence of any agency considering this issue prior to this review being undertaken does suggest that there may be a need for the LSCB to implement some of the recommendations contained within that protocol. 5.12 What was the quality and impact of case management and supervision in relation to this case? 5.12.1 Case management and supervision was generally sound in all agencies except CSC. The quality of supervision described in the CSC IMR was not positive with staff reporting cancelled sessions. The records of supervision were also poor with records being perfunctory and formulaic with little evidence of reflective discussion and challenge to workers. There were ten formal records of supervision in relation to Tom over a period of two years. 5.12.2 There was limited evidence of middle and senior management oversight of casework despite the complex challenges that both young men presented to social workers. The IMR author rightly suggests that the nature of the problems presented by these young men should have involved middle managers escalating concerns to senior staff however there was no evidence of this being considered. Tom was discussed on five occasions by the Prevention and Resource Panel however the records seen do not show clearly what decisions were made. 5.13 Did any organisational difficulties or resource issues, e.g. vacant posts or staff on sick leave, impact on practice in this case? 5.13.1 The police IMR reported that Kingston PPD had some staffing difficulties which affected the distribution of ‘merlins’ to Kingston however they are now fully staffed and a recommendation was made to audit the performance regarding information sharing via ‘merlins’. 5.13.2 The CSC was re-organised in January 2011 when ASKK moved to early Intervention and four safeguarding teams were created that undertook all social work with children from initial assessment through to long term work with looked after children. There were interim management arrangements between 2010 and 2012 and after January 2011 many staff were under new management arrangements. In June 2011 plans to merge Richmond and Kingston services and provide them via a ‘not for profit’ company with reduced costs from reducing management and administrative expenses were announced. Many staff interviewed for the IMR felt that the changes in management and the uncertainty around future structures destabilised the service. The Ofsted inspection in May and June 2012 highlighted problematic practice and since then there have been significant changes in senior and 36 middle management. There is a comprehensive improvement plan in place to address the shortfalls identified by the Ofsted inspection. 5.13.3 The YOT IMR identified that both young men had changes of worker. This resulted from a combination of factors; student placements, maternity leave and the team needing to be supported for a time by an agency worker. 5.14 Relevant Information from previous serious case reviews 5.14.1 The overview author was provided access to a previous serious case review undertaken in 2010. This was concerned with a family of six children who received services over a significant period of time and who experienced sexual abuse within the family. The author also had an oversight of themes identified by the LSCB from other file audits and multiagency reviews. Whilst there were no exact similarities between these previous reviews and the issues raised by this review a relevant similarity was that many of the reviews had highlighted issues regarding joint working between agencies which is also a factor in the work with Tom and Vic. 6 ASSESSMENT OF IMRs and the SCR process This serious case review was commissioned at a time of significant change within Kingston. An Ofsted inspection had just taken place which had deemed the authority inadequate for safeguarding and the DCS had resigned; the LSCB chair also stood down during the period of the review. These events had an inevitable effect on the process which took longer than planned partly because a number of IMRs had to be re-commissioned and some agencies struggled to prioritise the SCR process when there were other more significant competing demands on their time. 6.1.1 Children’s Social Care, Royal Borough of Kingston 6.1.1 This report addresses the key terms of reference and provides an overview of the involvement by CSC. The report author had considerable difficulty accessing the records to undertake this report as the ICS system was complex and many records were incomplete. There were delays in the report being presented to the SCR panel because of health and holiday commitments which meant that the final version was only approved by the panel in January 2013 after the first draft of the overview report had been completed. 6.1.2 The report highlights some significant failings in the services provided to both Vic and Tom particularly with regard to missing children protocols, the quality of assessments, the arrangements around LAC reviews, the development of care plans and the quality of risk assessments both with regard to the two young men but also with regard to younger siblings in both families. 6.1.3 This IMR was reviewed twice by the panel and after some additional work it was considered to fully address the terms of reference. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 37 6.2 Your Healthcare 6.2.1 This IMR reported on the involvement of the school nurse and LAC nurse with Tom, there was no involvement with Vic. The report identifies the limited involvement of the agency and highlights two areas for improvement; firstly with regard to health assessments of young people starting late at secondary schools; and secondly the need for better involvement of health professionals with looked after children, particularly in attending LAC reviews. 6.2.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.3 General Practitioners, Kingston 6.3.1 This IMR was limited in part because Tom’s parents refused consent for their records to be accessed which limited the IMR content. The report covers the minimal involvement of the GP with both Tom and Vic. It identifies the lack of information sharing between agencies and the GP service which meant that little was known by that service of the particular difficulties being presented by the young men. It identifies particular limitations in the first LAC medical undertaken on Tom and some weaknesses in health recording. 6.3.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendation was appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.4 Kingston Hospital Trust 6.4.1 This IMR details the limited involvement of this hospital with Vic who attended on three occasions. The main learning identified was that all of the presentations were because he has been involved in fights and the author noted that within the last two years procedure have been amended to ensure that this information is shared with relevant health professionals. 6.4.2 This IMR was reviewed by the panel who considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.5 Epsom and St Helier University Hospitals NHS Trust 6.5.1 This report details the limited involvement that this hospital had with regard to Tom and his sibling when they presented as a result of being attacked. The IMR identifies that key safeguarding processes were followed and that relevant agencies informed. 6.5.2 This IMR was reviewed by the panel which considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 38 6.6 Metropolitan Police Service 6.6.1 This IMR provided an analysis of police involvement with the family and their interventions with the young men. It identified that generally practice was in accordance with established procedures and highlighted that information on Tom’s missing episodes had been sent to the wrong Local Authority because the police were unaware that he was a Kingston child placed out of borough. The report also concludes there was limited understanding of the boys patterns of offending behaviour but is dubious as to whether greater analysis would have achieved more positive outcomes. 6.6.2 This IMR was reviewed by the panel who did not feel any changes were needed and considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.7 Youth Offending Service 6.7.1 The first IMR presented by this service was deemed inadequate by the SCR panel and the agency identified another author to produce a second report. This report provided an overview of the YOT casework including some information about the FIP service provision. There were delays in the provision of the full chronology for the YOS and the overview author asked for additional information about the FIP input which was provided speedily. 6.7.2 The final report gave a robust analysis of the inputs to the family and identified two areas where the service could be more robust in ensuring compliance with breach protocols and in the agreed responses with regard to missing persons. The report also identified the need for better understanding within the YOS of issues concerning gang activity and / or serious/ youth violence. 6.7.2 This IMR was reviewed by the panel who considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.8 Kingston & Richmond Joint Substance Misuse Service 6.8.1 This report details the limited contact between this service and the two young men. The report identifies that the major issue raised by the review process was the understanding and awareness within the service of gangs and gang culture which is then reflected in the recommendations. 6.8.2 This IMR was reviewed by the panel who considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.9 Learning and School Effectiveness Service, Royal Borough of Kingston 39 6.9.1 This report provides a comprehensive overview of the services provided by the local authority education services clearly stating that all statutory duties were fulfilled. The report suggests that the major reason that the planned outcomes were not achieved was because of the ‘defiant and uncooperative’ nature of the young people. The report does acknowledge that some information was not known by education services but does not comment on the time taken to provide alternative provision for the young men. 6.9.2 This IMR was reviewed by the panel and some amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendation was appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.10 South West London & St George’s Mental Health Trust (MST) 6.10.1 This IMR provided a comprehensive and insightful analysis of the work undertaken by the service with both young men. It highlights the difficulties of working with Tom when he was in foster care and rightly suggests that CSC should have taken the key worker role in managing the interventions between Tom’s parents and the foster home. It also reports on the more positive work with Vic and his family and draws attention to the need for greater inter-agency working particularly around police stop and search. 6.10.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendation was appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.11 Health Overview Report This very comprehensive and detailed report appropriately reviewed the key themes from the health IMRs and identified any relevant matters of concern for commissioners. The key recommendations relate to the need for greater health input to multi-agency working with looked after children and for the MST processes to be better integrated with LAC processes where a young person is in foster care and the care plan is for them to return home. 7 LESSONS LEARNED FROM THE REVIEW 7.1 This review has identified significant limitations in the services being provided by Children’s Social Care. This mirrors the findings of the Inspection of Safeguarding and Looked after Children undertaken by Ofsted between May 2012 and June 2012. This reported “significant failings in the contribution made by the council and partner agencies to child protection” and that “The quality of assessments and subsequent plans are generally of poor quality.” The IMR provided by Children’s Social Care acknowledges the problems and also reported on changes put in place since the Ofsted inspection. There is an Improvement Board in place which is ensuring that the changes recommended by Ofsted are implemented and this is being monitored at every LSCB meeting. For this reason the recommendations from this report focus on multi-agency learning rather than on the significant changes that are required and being implemented in Children’s Social Care. 40 7.2 The key learning across all agencies was about the difficulties of working with adolescents who are involved in criminal behaviour and serious youth violence perpetrated by their peers in gangs, with increasing anti-social behaviour. It was clear that, although Kingston LSCB has adopted the London Safeguarding Children Board protocol ‘Safeguarding children affected by gang activity and / or serious youth violence’, the understanding and knowledge of these issues by all agencies was very limited. 7.3 A significant weakness identified was multi-agency working to ensure that these young men attended educational provision, during the period of this review. The assessments of need and services provided were slow to be implemented and thus there were missed opportunities to improve educational outcomes for them. In particular it was unacceptable that both young men did not attend formal education for over a year. 8 CONCLUSIONS 8.1 It is not clear whether it was possible to prevent these young men from sustaining potentially life-threatening injuries as they were both involved in risky anti-social behaviour and criminal activities and might not have ceased these activities. The review has identified, however, that professionals were insufficiently aware of the implications of this behaviour and specifically did not identify that the escalation of their criminal activities could mean that they were at greater risk of significant harm. The review has also shown there could have been better co-ordination and speedier delivery of services which might have improved outcomes for these two young men. 9 RECOMMENDATIONS Kingston Local Safeguarding Children Board 1.1 Kingston LSCB to require all agencies to work in partnership with Learning and Children’s Services to develop a system of multi-agency risk assessment and management for adolescents who are at risk of involvement in: • Emergent criminality, serious youth violence perpetrated by their peers in gangs, or increasing anti-social behaviour; and • Serious youth violence perpetrated by children acting on their own. 1.2 Kingston LSCB to ensure all agencies address the issues highlighted in this report around the provision of education for adolescents involved in criminal behaviour and to report on how the services have been improved. The expected outcomes to include: • A holistic package of support to ensure; • Immediate access to education for young people on discharge from secure accommodation; • More rapid intervention to provide alternative provision for young people not accessing formal education; • Improved monitoring and intervention regarding young people who are not attending education for long periods. 41 The Director of Children’s Services to report to the LSCB on progress within one year. 1.3 Kingston LSCB to commission a workshop for middle and senior managers from across the partnership to look at the difficulties of working with hard to reach young people. The outcome of the workshop to be: • Greater understanding by all managers of the particular needs of adolescents who may be at risk because of their own behaviour; • Commitment by all managers to implementing changes required to implement the agreed system of multi-agency risk assessment and management; • The development of a clear implementation plan to achieve the required changes. RBK Children’s Social Care 2.1 Children’s Social Care to ensure that assessments address the risks to all children in the family. Risks to younger siblings need to be rigorously examined and be part of the assessment. 2.2 Children’s Social Care in conjunction with CAIT and partner agencies to undertake a review of the current practice in RBK relating to strategy meetings and discussions, including a review of the extent to which these are inter-agency forums. 2.3 Children’s Social Care to ensure that there is a clear supervision policy and protocols in place which will include 3 monthly summaries where families receive on-going work from Learning and Children’s services. 2.4 Children’s Social Care to ensure that training is available for social workers to develop their skills in relation to direct work with children in order to enable social workers to develop relationships with the young people and families they are involved with. 2.5 Children’s Social Care to work with Adult Services to improve communication and the sharing of information, including establishing clear protocols for working with families where there is learning difficulty, physical disability or mental illness. 2.6 Children’s Social Care to review the role of the virtual head teacher in RBK. 2.7 Children’s Social Care to prioritise improved understanding and working about the related issues of racial harassment, gangs and postcode areas, drug use and supply, antisocial behaviour, possession of weapons, children out of secondary education as part of their on-going training plan. 2.8 Children’s Social Care to ensure that there are clear transition protocols in place including manager to manager, face to face meetings to reduce the impact of the transfer process. RBK Youth Offending Service 42 3.1 Youth Offending Service to implement a consistent compliance panel and protocol in regards to the breach process. 3.2 Youth Offending Service to complete a Service Level Agreement with the Police and Children Service’s regarding the agreed response/interventions around safety awareness in relation to Missing children. 3.3 Youth Offending Service to embed gang identification and interventions via the Pan London Safeguarding children affected by gang activity and / or serious / youth violence and Serious Youth Crime protocol, in order to identify those vulnerable to gang /serious youth crime violence and agree the appropriate level of intervention to address the issues i.e. links with SNT wards to target areas for further surveillance. 3.4 Youth Offending Service to provide refresher training on risk management for staff with specific emphasis on external controls. 3.5 Youth Offending Service to explore the use of volunteers within Kingston and develop a volunteering strategy to embed additional resources from the third sector and volunteering opportunities. Examples of these could be compliance mentors and transitional support for LAC. 3.6 Youth Offending Service to address the lack of Education to Employment resources within the borough (this is not a direct recommendation purely for the YOS). Metropolitan Police Service 4.1 Operation Compass to include in their current review of the Standard Operating Procedures in relation to missing children who are in care homes or foster care the need for the initial investigating officer to record which local authority has responsibility for the Looked after Child. 4.2 The Senior Leadership Team at Kingston Borough Operational Command Unit to carry out an audit of MERLIN missing person reports involving children to ensure that the Public Protection Desk have sent the information to the Royal Borough of Kingston Children’s Services. 4.3 The Senior Leadership Team at Kingston Borough Operational Command Unit to ensure that all staff are reminded that after carrying out a debrief of a missing child a MERLIN/PAC is created detailing information gleaned from that interview. 4.4 The Senior Leadership Team at Kingston Borough Operational Command Unit to ensure that all frontline staff are reminded of the requirement to comply with the completion of a MERLIN/PAC in accordance with Standard Operation Procedures (SOPs). 4.5 The Senior Leadership Team at Kingston Borough Operational Command Unit to review the frequency that checks are carried out by the Kingston Public 43 Protection Desk for non-compliance by staff of not completing MERLIN/PAC reports and ensure that the unit is adequately staffed to carry out their duties. Substance Misuse Service, RBK 5.1 The Substance Misuse Service should ensure that a standardised assessment form is used with all young people accessing the service. It should be adapted or developed to include an exploratory question about gang culture, with a view to exploring the potential impact of gang related activity on young people using substances further. 5.2 The Substance Misuse Service should agree a working definition of the term ‘Gang’ for use by the organisation. Guidance is available on the Home Office website www.homeoffice.gov.uk. 5.3 The Substance Misuse Service should identify and participate in specific training based on the guidance ‘Safeguarding young people who may be affected by Gang Activity’ so that a better understanding is developed of what the local problem is and the team is better able to identify and appropriately support young people at risk. This could be provided by the YOT or through Kingston LSCB. Learning and School Effectiveness 6.1 The Director of Children’s Services to ensure that there is sufficient communication about individual children and young people across the statutory bodies within the Local Authority. South West London and St George’s Mental Health Trust 7.1 When a referral is made to the Multi Systemic Therapy Team and the young person is subsequently accommodated, MST with the health service for LAC should support a multi-agency plan for the steps and milestones for the young person to return to the family home within the LAC review process. This should include a collaborative consistent approach to maximise success. 7.2 Multi Systemic Therapy Service in collaboration with the Local Authority to review the referral criteria for cases where the family foster carer is involved in the care of the young person. This should include shared approaches to boundaries and limit setting and limitations of the service. 7.3 The Multi-Systemic Therapy Team to ensure that when presenting at multi agency meetings the MST plans are reviewed in conjunction with the plans of other agencies. 7.4 The Serious Case Review recommendations and their implementation as it affects MST to be considered and monitored by the MST Multi-Agency Strategic Board as part of annual review of the service. Your Healthcare 8.1 Your Healthcare Board Lead for Universal services to discuss with NHS Kingston Commissioners, service redesign to extend the role of the School 44 Health Team to offer health reviews of all children transferring into a Kingston school. 8.2 Your Healthcare to develop a school health transfer in policy in line with commissioning arrangements. 8.3 Your Healthcare to ensure that the LAC Specialist Nurse is aware of all LAC health reviews. Appropriate health professional to be invited to LAC reviews and receive minutes. Epsom and St Helier University Hospitals Trust 9.1 The Hospital Trust should ensure that, as part of the information sharing audit which is currently recorded on the Safeguarding Children Audit Plan 2012/13, an information sharing audit tool should be designed to incorporate a question in relation to whether the ED record and safeguarding documents are filed in a main record when concerns are identified about the safety and welfare of children who attend the ED. 9.2 The Hospital Trust should ensure that the information sharing audit incorporates a question in relation to whether a record of the GP letter is filed electronically and whether the information recorded on the GP letter is relevant and appropriate to the safeguarding concern identified. 9.3 The Hospital Trust should ensure that a further re-audit of the Paediatric DNA Policy is added to the Safeguarding Children Audit Plan 2013/14 and the notes audit must include children who have not attended Outpatient Fracture Clinic appointments. Kingston General Practitioners 10.1 GP practices to review systems in place for ensuring sharing of information with the school health team when requested. 10.2 GP practices to review their system for reading and acting on children’s A+E discharge summaries. 10.3 GP practices to consider sending out a letter to the carers of looked after children to offer the child a medical review. 10.4 GP practices to consider whether in cases where risk factors for child abuse have been identified, there should be a way of cross referencing information between different family member’s notes. 10.5 GP practices to review their system for identifying and documenting ethnicity of patients. NHS Kingston/CCG – Health Overview 11.1 The Designated Nurse, NHS Kingston, to ensure that the Joint Strategic Needs Assessment for LAC includes a recommendation that health practitioners are 45 invited to attend LAC reviews, send a full health report, and receive timely minutes of the meeting. 11.2 NHS Kingston to ensure that the commissioned RIO electronic record system is installed into Moor Lane where the LAC medical team are based. This should be the primary health record for LAC including those children with disabilities who are in respite care. The health assessments can be uploaded onto the RBK electronic system by the LAC coordinator. 11.3 The Designated Nurse, NHS Kingston, to ensure that the Joint Strategic Needs Assessment includes a clear outline of the referral process to the LAC health professionals. This is to include accurate information for all LAC, foster carers, current GP and any other health information to improve the service provision. 11.4 The Designated Doctor for Safeguarding and the Designated Doctor for LAC to ensure that all Paediatric clinicians receive and actively participate in regular supervision and support in relation to specific safeguarding and child protection issues within the context of their role and specific caseload. 11.5 The named nurses for Kingston and Epsom & St Helier hospitals to ensure that A&E documentation is improved to ensure there is detailed information about the history given about the injuries sustained, any child protection concerns or any referral into safeguarding services. Fiona Johnson 46 Appendix 1 TERMS OF REFERENCE 1. Rationale for SCR The Royal Borough of Kingston upon Thames (LSCB) is conducting a new Serious Case Review in respect of V and T because the circumstances associated with the physical injuries they sustained during an incident in information redacted 2012 meet the criteria for conducting such reviews, as set out in “Working Together to Safeguard Children 2010”. Ofsted were notified of the incident under the notification of serious childcare incident procedures information redacted in 2012. The decision to carry out the Serious Case Review was taken by the LSCB SCR Sub-Committee on 8th June 2012. The Sub-Committee considered the criteria for a SCR to have been met on the grounds that one of the subjects was Looked After by Kingston Children’s Social Care at the time of the incident and the injuries sustained by both subjects were potentially life-threatening. 2. Scope of the Review The overall purpose of the SCR will be to: • Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children; • Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result; and • As a consequence, improve inter-agency working and better safeguard and promote the welfare of children. The SCR will commence from January 2008, information redacted, up until immediately prior to the incident that took place information redacted in 2012. The review will examine: • the quality of practice, including multi-agency practice; • the effectiveness of agencies’ engagement with the subjects and the interventions provided; • the quality of assessment, including multi-agency involvement in assessments; • the effectiveness of communication between and across agencies; • the extent to which the appropriate agencies take on the Key Worker role; • the lessons to be learnt to improve safeguarding arrangements and practice within and across agencies. 47 3. SCR Process The Kingston LSCB SCR Sub-Committee has agreed the scope and Terms of Reference for the SCR. The Terms of Reference have been approved by the Independent Chair of the LSCB. Paul Kerswell works as an independent consultant and has been appointed as SCR Panel Chair. Paul has completed a number of Serious Case Reviews, including three for which he has been the SCR Panel Chair. Paul also has considerable experience in the operational management of Children Social Care Services, including at senior management level. The Panel Chair is responsible for ensuring that the SCR is completed in accordance with relevant guidance, as set out in Working Together to Safeguard Children 2010, and the requirements of Kingston LSCB. The SCR Panel will comprise the following members: • Metropolitan Police – DCI, West Region CAIT • Education Services, RBK – Strategic Manager Education Welfare Service, School Safeguarding & LADO • Youth Offending Service - Service Manager Youth Offending Service & Young People’s Substance Misuse Service • NHS Kingston - Designated Nurse, Child Protection • Children’s Social Care, RBK – Independent IMR Author / Service Manager, Professional Standards & Development • School – Deputy Head teacher, Pastoral Care and Guidance In addition Legal Services, RBK will be invited to contribute to the Panel as necessary and neighbouring LSCBs will be formally contacted about this SCR. SCR Panel members have had no direct involvement in the practice or line management of the case and are considered to possess the required knowledge, skills and experience to fulfil this role. To facilitate and support the SCR process, and links with operational staff, the SCR Panel will be supported by: • LSCB Business Manager • CP & LSCB Administrator The SCR Panel has identified the following agencies that will be required to submit Individual Management Reviews as part of the SCR: • Children’s Social Care, RBK • Your Healthcare 48 • General Practitioners, Kingston • Kingston Hospital Trust • Epsom and St Helier University Hospitals NHS Trust • Metropolitan Police Service • Youth Offending Service • Kingston & Richmond Joint Substance Misuse Service • Learning and School Effectiveness Service, RBK • South West London & St George’s Mental Health Trust In addition, information reports will be requested from: • the two secondary schools Tom and Vic attended • the specialist academy Vic attended • CAFCASS • United Kingdom Border Agency. Other agencies may be identified as the review progresses and asked to provide information / reports: • Independent Fostering Agency • Children’s Centres Family Support Service • Information redacted. All agencies formally contributing to the SCR will identify an appropriate officer, who will have had no direct involvement with the family, or the immediate line management of any practitioner(s) involved, to undertake an Individual Management Review / prepare an information report. All identified agencies contributing to the review will complete: • An Individual Management Review. • A tabular chronology of their involvement with the family. • The chronology must be completed on the WORD template attached to these Terms of Reference. They should not be anonymised. 49 All agreed timescales for completion of reports and attendance at meetings must be adhered to and any indication that an agency is unable to meet its commitment must be referred to the independent SCR Panel Chair, Paul Kerswell immediately. Fiona Johnson has been appointed as Independent Overview Author. Fiona works as a consultant and has extensive experience of contributing to SCRs, in particular as Overview Author. The Overview Author will produce the Overview Report and Executive Summary and present these to the SCR Panel and Kingston LSCB. These will be based upon collation and critical analysis of the IMRs, SCR panel discussion and any supplementary interviews with key stakeholders determined to be required. Upon completion, anonymised IMRs, the overview report, integrated chronology and agencies’ respective actions plans will be submitted to the Department for Education. 4. Outputs Key outputs from the SCR will be as follows: • An integrated anonymised chronology • The Overview Report for publication • An Executive Summary for publication • An Action plan. 5. Parallel Review Processes This case is not expected to give rise to other parallel investigations of practice. However, the review process will need to take account of criminal enquiries. The Legal team have been invited to participate in the SCR Panel to liaise with the Police and Crown Prosecution Service as necessary. 6. Production of Individual Management Reviews All agencies’ reports and chronologies should commence from January 2008 until information redacted 2012. All agencies are required to review all records and materials including: • Electronic records • Paper records and files 50 and provide any information that may be relevant outside the agreed timeframe for the SCR. Agencies that identify significant background history pre-dating January 2008 should provide a brief summary account of the significant history. This will be for the SCR Panel in reviewing the agreed scope of the SCR. Where individual staff are interviewed copies of the interview notes should be retained and referenced within the Individual Management Review (IMR). Appropriate agency support should be identified for all staff involved in the IMR process. All agencies should complete their Individual Management Reviews and chronologies in line with the requirements of Working Together to Safeguard Children 2010, and the London Child Protection Procedures 4th Edition 2011. The Individual Management Review should follow the Kingston template and guidance (derived from the pan-London SCR toolkit published by the London Safeguarding Children Board). The aim of the IMRs is to look openly and critically at individual and organisational practice to determine whether the case indicates that changes could and should be made and, if so, to identify how those changes will be brought about. The SCR Sub-Committee at its meeting on 23rd July 2012 identified the following issues to be considered by the SCR: • What was the quality of practice in relation to this case and how effective was the agency’s engagement with the young people? • Were assessments of a sufficiently good quality and did they include multi-agency involvement? • Were the interventions provided appropriate and how effective were they? • To what extent was it appropriate for the agency to take on the Key Worker role? • Was there effective communication with and from other agencies? • What was the impact on practice of issues relating to ethnicity, religion, language and diversity? • What was the impact of any language issues on the young people’s engagement with the agency and did these issues receive an appropriate response? • How effective was the support provided to new arrivals in the country, including supporting their transition into the education system? • What was the impact or otherwise on the young people of being excluded from school and to what extent were the appropriate services provided? • Was sufficient and effective support provided to the Looked After young person by the foster placement? • To what extent were gangs and gang culture a feature in this case? • What was the quality and impact of case management and supervision in relation to this case? • Did any organisational difficulties or resource issues, e.g. vacant posts or staff on sick leave, impact on practice in this case? Each IMR should also consider the relevant issues outlined in Chapter 8 of Working Together to Safeguard Children 2010. Where an issue is not judged relevant to the involvement of an agency, the IMR must clearly indicate that this is the case. 51 Internal Management Reviews should be quality assured and signed off by the most senior officer of the reviewing agency. 7. Involvement of Family Members Contact will be made with the subjects of the SCR and their parents by the Independent Chair of the SCR Panel to invite their participation in the review. 8. Media Enquiries It is possible that this case may attract some media interest. There should be no contact with the media under any circumstances. All media contacts and enquiries should be directed to the LSCB, who will be advised and supported by Kingston Council’s Press Office. 9. Timescales The SCR process is to be concluded by 28th February 2012. Refer to SCR timeline for key milestone dates During the course of the SCR new information may emerge which necessitates amendment or addition to the Terms of Reference. These Terms of Reference may therefore be revised with the agreement of the SCR Panel. The changes will be approved by the Independent Chair of the LSCB. Appendix 2 Genogram – information redacted |
NC52635 | Death of an 8-month-old boy in December 2021. Baby Euan had injuries that were believed to be non-accidental. Learning includes: a need for professionals to understand what the childs daily life was like; working with families where their engagement is reluctant and sporadic; a need to share information in a timely and appropriate way; the need for more learning around themes of culture and ethnicity, including a focus on intersectional analysis into race, disability, and health conditions; and a need for front-line practitioners to be more alert to the signs and symptoms of controlling and coercive behaviours and be able to highlight possible triggers and subtle inferences and make appropriate referrals. Recommendations include: the partnership should seek assurance from all agencies that they always include the voice and lived experience of a child in their actions and assessments; seek assurance from partners to ensure that they are pursuing alternative ways of engaging families when there is resistance to bring a child to a health appointment; ensure that front-line staff can recognise the signs and symptoms of coercive and controlling behaviour as a form of domestic abuse; and ensure partners understand what the meaning of intersectionality is and that they are embedding this into their agencies procedures and actions of their frontline practitioners.
| Title: Child safeguarding practice review: Baby Euan. LSCB: Central Bedfordshire Safeguarding Children Partnership Author: Russell Wate Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page | 1 Final Child Safeguarding Practice Review Baby Euan Independent Author: Dr Russell Wate QPM Page | 2 Final 1.0 Introduction and Background to this Child Safeguarding Practice Review 1.1 Baby Euan died when he was eight months old at the beginning of December 2021. His father called ‘999’ on that morning reporting that Baby Euan appeared to be struggling to breathe. Ambulance crews attended and Baby Euan was transported to hospital. Despite CPR and treatment, he was pronounced dead. On examination, Baby Euan had several unexplained injuries. The post-mortem confirmed injuries that were believed to be non-accidental including broken ribs, fractured skull, torn stomach, and frenulum. Both father and mother were arrested for the murder of Baby Euan and a criminal investigation is currently ongoing. 1.2 An initial information sharing meeting took place and as a result of this it was found that the family, as well as being resident in Central Bedfordshire before, and at the time of death, had also been resident in Enfield and Lewisham and Baby Euan had been born at North Middlesex University Hospital NHS Trust (North Mid). Further information was requested from those two areas following an initial Rapid Review meeting. A second review meeting was held on the 7th March 2022. This case was further discussed at the Central Bedfordshire Safeguarding Children Partnership (CBSCP) Case Review Group on 12th May and with reference to the requirements as set out in Chapter 4 of ‘Working Together to Safeguard Children’ (2018), the group decided that the threshold was met to commission a Local Child Safeguarding Practice Review (LCSPR) in respect of Baby Euan. 1.3 The Partnership appointed a panel of local safeguarding leads and also appointed an independent lead reviewer Dr Russell Wate QPM to assist the panel with the review and to produce a report on behalf of the panel and the CBSCB. 1.4 A timeframe for the review was agreed as September 2020 to December 2021; this period covers confirmation of pregnancy until Baby Euan’s death. 1.5 It was felt that the review should examine this timeframe using four key practice time periods: • Pre-pregnancy timescale with a rationale to examine mother and father’s history. • Known pregnancy period of September 2020-April 2021 in Enfield and Central Bedfordshire. • Time in Central Bedfordshire, January 2021 until October 2021, and in Lewisham October 2021 onwards. • Return to Central Bedfordshire and the death of Baby Euan, November to December 2021. 1.6 The case review group, the panel and discussions with the lead reviewer also established key learning themes for the review to focus on. • Voice and vulnerability of Baby Euan • Transient -reluctant to engage families, including Information sharing • Domestic Abuse- Coercive Control-Invisible Males • ‘Intersectional analysis’ into race, disability, and health conditions. Page | 3 Final 1.7 Individual Management Reviews (IMR) were requested and completed by agencies in all three areas. The IMRs included critical analysis and reflection of engagement with Baby Euan and his family, identifying learning and recommendations both for the review but also in their individual agency. Existing chronologies were reviewed as part of the IMR process and updated in the IMR as required. 1.8 An extremely well attended practitioner event was held with front line practitioners involved in the case. This included practitioners from agencies in the other Local Authority areas and local agencies. The practitioner event was very helpful to the panel and the author in helping them to develop the learning and to compile this report. 2.0 Analysis of Learning Themes Voice and vulnerability of Baby Euan 2.1 This section outlines Baby Euan’s life including whilst he was developing and growing in the womb, and highlights his vulnerabilities as seen through agency and practitioners reports. 2.2 Baby Euan’s mother’s pregnancy is confirmed by North Middlesex University Hospital NHS Trust (North Mid) on the 3rd of September 2020. The mother has Type 2 Diabetes and is clinically obese. 2.3 Due to the diabetes and the high body mass index (BMI) the mother’s antenatal care was delivered mainly by North Mid diabetic team. The pregnancy for Baby Euan was regarded as clinically ‘high risk’ due to the mother’s co-morbidities. The North Mid IMR author’s review of records and discussion with the diabetic midwife states that the mother’s engagement with the diabetic team was not what they would have expected. It is documented that she had poor compliance with medication for her diabetes prior to pregnancy and during pregnancy. Baby Euan’s mother required more than normal antenatal appointments due to her complex medical conditions. 2.4 In January 2021 the diabetic midwife raised her concerns with the safeguarding midwife and made a referral to Enfield social care for non-engagement with antenatal care (as per North Mid hospital child protection policy). The concerns were heightened as the mother had moved out of the local area during her pregnancy. The mother told the diabetic midwife that although she had been living in the Borough of Enfield with a friend at the beginning of the pregnancy, she had now moved in with the father of the baby in Central Bedfordshire. Even though she had moved out of area, she still wanted to deliver at North Mid as she ‘knew the hospital’. 2.5 It was felt though that this would impact on her ability to attend all her appointments. Outcome of this referral was ‘no further action’ as she now resided out of Borough. This ‘no further action’ decision will be commented on in the next section of this report. 2.6 The mother is registered with the same GP practice between 22nd December 2020 and the 15th June 2021; however, they had no record of her pregnancy. This is something that is normal practice in some areas for example Bedfordshire but should happen elsewhere with maternity units informing GP practices. North Mid are already in the process of considering this as learning from this review. The diabetic midwife did believe that the GP was notified of their involvement antenatally. Page | 4 Final 2.7 Baby Euan was born at the beginning of April 2021 by emergency caesarean section at 37 weeks gestation. Baby Euan required resuscitation at birth as he was born in a poor condition. He was transferred firstly to North Mid Neonatal Intensive Care Unit (NICU), Baby Euan was then transferred out to the Homerton hospital NICU on the first day of life for ‘cooling’ (cooling of the head/brain to prevent any further brain injury) as per national guidelines. 2.8 This review is unable to fully evidence that the mother’s poor antenatal care, alongside her own health needs prior to pregnancy, may have impacted on Baby Euan’s growth and development in – utero. However, discussion by the North Mid IMR author with the medical and midwifery team drew a conclusion that due to the high-risk co-morbidities of mother’s own health, that improved compliance with her antenatal care and her own health needs prior to, and during the pregnancy, may have improved the outcome for Baby Euan at the point of delivery. 2.9 An internal rapid review was undertaken by North Mid maternity risk team as per Trust and national guidelines for a neonate baby requiring brain cooling. North Mid declared a Serious Incident (SI). An independent investigation by the Healthcare Safety Investigation Branch (HSIB) was undertaken in September 2021. This investigation was in accordance with the Department of Health and Social Care criteria (Maternity Case Directions, 2018), taken from ‘Each Baby Counts and MBRRACE-UK’. No safeguarding concerns or recommendations were identified by the investigation. 2.10 In 2014, the Court of Appeal ruled that an unborn child could not be considered as a 'person' at the time the injury was caused because they had not been born. The case that brought this ruling was where a seven-year-old girl, known as CP, and her guardians failed in their attempt to sue her mother for the daughter's foetal-alcohol-spectrum disorder caused by her mother's heavy drinking during her pregnancy. The risks are recognised and advice is given against it, but the advice is not enforceable, and the child has to live - if they survive - with the consequences of the mother's irresponsible but not illegal actions. 2.11 Whilst acknowledging this decision by the Court of Appeal, professionals need to be aware the evidence of how a mother cares for herself in pregnancy is an indication of how they might care for their baby following birth. It is fair to say that the quality of Baby Euan’s developing life within the womb was not optimum. Good practice was shown by the diabetes midwives who sought safeguarding advice and made a referral to their local children social services department. There are numerous cases of babies, who at birth are either taken into care, placed on a CP register, or subjected to a CIN plan. These cases are often when the mother is extremely young, a habitual drug user, misuses alcohol or DA is a strong feature. These cases though could be extended to include other health conditions, as is the case for Baby Euan, and a multi-agency safeguarding discussion would be good practice. 2.12 On the 18th April 2021, Baby Euan is discharged home to Central Bedfordshire; North Mid contact Bedford Hospital Trust (BHT) to advise them that the family are living local to Bedford and requesting follow up as Baby Euan and parents living locally to them. No safeguarding concerns are identified in discharge records. GP letters were sent at the point of discharge of the mother and then at point of discharge for Baby Euan. This is the first contact that the Bedford hospital had in relation to Baby Euan. Page | 5 Final 2.13 A verbal handover between the North Mid and Cambridgeshire Community Services (CCS) took place on the 19th of April which included a summary of Baby Euan’s stay in hospital, the reasons for this and the discharge home on mixed feeding (breast and formula). 2.14 The father contacts a midwife on the 23rd April 2021 stating that Baby Euan had been unwell since birth and had a tongue tie but was feeding ok. The CCS Health Visitor and Speech & Language therapist (SALT) at North Mid have a phone conversation about Baby Euan who had been diagnosed with Grade 1 mild neonatal encephalopathy. Due to assertive pressure from the mother and father, Baby Euan had been discharged home before a feeding assessment could take place. The mother had been offered a referral to Bedfordshire SALT Team for a feeding assessment but this had been declined by parents as Baby Euan’s tongue tie was not impacting on breast feeding. The tongue tie release referral is made on 27th April 2021 at the new birth visit. 2.15 On the 27th April 2021, Baby Euan was seen as part of the mandated contacts with families with new babies for the 0-5 service. A planned (arranged) health visitor home visit was undertaken and discussion about the need for Baby Euan’s tongue tie to be released (a minor procedure) was held with the parents. The midwife had completed a referral for this. Father’s name (given wrongly) is recorded on the electronic records, ethnicity is recorded in the parent held Child Health Record (red book). There was a referral following this appointment on the 27th April by the health visitor to the SALT team for the baby to be seen at the Child Development Centre for initial assessment of dysphagia (swallowing function). 2.16 Baby Euan is seen at Bedford Hospital Trust (BHT) for release of tongue tie on the 28th April 2021 by a specialist midwife and discharged from the service. 2.17 An assessment was completed at the new birth visit, but Baby Euan was not then seen again by the health visitor due to the father making a verbal complaint about the health visitor. He stated that the health visitor had not completed the red book correctly. After a number of attempts the Team Leader was able to get in contact with father of Baby Euan by phone. The father stated that the ethnicity of baby and mobile contact details for parents were entered incorrectly. The parents stated that they could weigh Baby Euan themselves and did not require health visitor input. It was agreed between the Team Leader and father that the red book would be collected and errors corrected. Baby Euan was not brought for SALT appointment, the father reported to the follow up made by a SALT professional that Baby Euan was now feeding well with no problems since the tongue tie release. 2.18 During the telephone discussions with father (not with mother) by the Team Leader regarding father’s complaint, and again during a telephone discussion following father’s request for a call back to support with the Sure Start forms, baby’s wellbeing was considered, but there is a lack of focus on the lived experience of Baby Euan as there was no potential for visual interaction, assessment of the parent/child relationship, or their development. All reports were reliant on father’s reporting of his wellbeing. 2.19 The Team manager who is a trained HV offered to carry out a visit but this was refused by the father. 2.20 Baby Euan attended Lister Children’s Emergency Department accompanied by both parents. Mother and father reported that Baby Euan has been projectile vomiting for three days. This was after every feed so they had brought him in for review due to their concerns Page | 6 Final surrounding projectile vomiting. A full clinical assessment and examination took place, no injuries or bruising was noted to Baby Euan. Records state that the parents came across as anxious and pushed for examinations not deemed as necessary. Hospital recorded no safeguarding concerns but noted that it is unusual for parents that pushed, for example for an ultrasound scan, not to return for any follow up appointments, including for the hypoxic-ischemic encephalopathy found at birth. The HV was notified. 2.21 When Baby Euan was not brought to a virtual appointment with a BHT paediatrician a letter was sent to their Central Bedfordshire GP advising them of the missed appointment and plan to offer another. 2.22 Baby Euan is seen when he is 12 weeks old for the 6-8 week GP post birth check by their GP surgery in Central Bedfordshire with his mother. The father joined the appointment later via Mum’s telephone. The GP was concerned about father’s behaviour during this interaction. The GP stated at the practitioner event that it just felt to them that the interaction was unusual, because mother kept the phone close to her ear throughout the rest of the appointment, which covered the parents requesting for individual vaccinations to be given for Baby Euan. It was noted that mother was attentive and Baby Euan’s development was normal, although he had eczema and reflux. 2.23 One of three vaccines were accepted for Baby Euan at this appointment. Mother reported that she wished to spread out the vaccinations as Baby Euan had had a difficult start. The next immunisations were rescheduled, and the father was encouraged to attend to ask questions. Baby Euan was not subsequently brought for his vaccinations. 2.24 The CCS IMR states that vaccine refusal, even when rational reasons are given, may be much more of a red flag than previously suspected and has been reflected on by all team members involved in the process. They are already discussing such cases at safeguarding meetings and will continue to do so. This should be seen as a risk for other agencies to take note of. 2.25 Based on the GP concerns related to lack of immunisations, possible coercive control, the HV Team Leader sought safeguarding supervision and there is documentation that suggests that Baby Euan’s lived experience was considered, as regards to their long- term health needs and reports from father only. In this case a safeguarding chronology was completed but there was a lack of clear analysis which focused on the lived experience of the child following the GP concerns raised at the liaison meetings. 2.26 Whilst Baby Euan was living in Lewisham the family never engaged with the HV there. 2.27 At 4.14am on the 11th November 2021, a neighbour of Baby Euan and his parents in Central Bedfordshire called Bedfordshire Police reporting hearing arguing, thuds and a baby crying. On attendance, both parents were spoken to separately, they both stated there was no argument, they are dealing with a teething baby. They state that the neighbour is intolerant of the noise and has banged on walls previously. There are no signs of concern noted by the officers and the log is closed. Baby Euan was not seen and no PPN was submitted. Further comment will be made in a later section of this report which considers DA. 2.28 In 2011 Ofsted published a thematic report , ‘The voice of the child: Learning from Serious Case Reviews.’ There were five main messages with regard to the voice of the child within this report. Page | 7 Final • In too many cases the child was not seen frequently enough by the professionals involved, or was not asked about their views and feelings • Agencies did not listen to adults who tried to speak on behalf of the child and who had important information to contribute • Parents and carers prevented professionals from seeing and listening to the child • Practitioners focused too much on the needs of the parents, especially on vulnerable parents, and overlooked the implications for the child. • Agencies did not interpret their findings well enough to protect the child1. 2.29 In the case of Baby Euan, the findings from this study are relevant. He was not seen frequently enough. The parents prevented professionals from seeing Baby Euan by not bringing him to health appointments, and following the complaint, the refusal to allow a HV to visit and be actively involved in Baby Euan’s life. Agencies, although rightly highlighting concerns, did not interpret their findings well enough. Transient-hard to engage families including Information sharing 2.30 In this case there is evidence of the transient movement of the mother and then Baby Euan and the father between three different Local Authority areas. Some of these movements were unknown to professionals and agencies in those areas in which the family were now living, or when they had left their area. 2.31 The period between the Enfield Social Care referral and Baby Euan’s birth at North Mid was subject to scrutiny at the Case Review Group meetings because from the information provided to them it was unclear where the parents were living and which services were being accessed. Information provided following the meetings from the mother’s health records identified that North Mid recorded a move to Central Bedfordshire on 24th January 2021 and that mother planned to continue care and deliver at North Mid. As this information was not shared with agencies in Central Bedfordshire at the time of the move, the parents and the then unborn Baby Euan remained unknown to services within Bedfordshire until 18th April 2021, when Baby Euan is then discharged home to Central Bedfordshire. It was also noted that fathers’ details were not recorded on North Mid and Homerton discharge summary paperwork. It was stated at the practitioner event that this was the first time the mother’s GP found out that she had even been pregnant. However, this is not wholly accurate as there had been conversations antenatally by the diabetic midwife with the GP surgery and when the mother was discharged prior to Baby Euan notification had been sent to the GP surgery. When a mother books her pregnancy directly with midwifery services it would be good practice for their GP practice to be informed of this. GP surgeries to ensure their records reflect this. 2.32 When the mother moved out of the Enfield area during the antenatal period, this did not have direct impact on the care North Mid provided as teams made every effort to engage with her. However, discussions have been held by them as part of this review as to whether the referral made to Enfield social care should have been sent to Central Bedfordshire social 1 report OFSTED. (2011). The voice of the child: Learning from Serious Case Reviews. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/526981/The_voice_of_the_child.pdf. Page | 8 Final care given that the mother was now living in that area. It is felt by the review author notification to Central Bedfordshire should have been made by North Mid. 2.33 A mother has a choice as to where she would like to receive antenatal care. The pregnancy was clinically high risk due to the mother’s co-morbidities. When the mother informed staff that they had moved out of area, the diabetic team discussed with her on several occasions about transferring her midwifery care to her local hospital. The mother did not want to do this, stating that she knew North Mid well and wished to deliver her baby at the hospital. 2.34 It was felt by the NUMH IMR author that because there were no high-risk safeguarding concerns identified, apart from poor attendance to appointments, it would not be expected for midwives to notify the local maternity services in Bedfordshire. They will only transfer care if the mother requests it and in this case the midwife did encourage the mother to transfer her care to a local hospital to where she was residing but the mother refused. This non-notification though conflicts with the fact that they submitted a referral to Enfield CSC and as such had safeguarding concerns, so this should have been sent to CSC where the mother was now residing. 2.35 On 10th May 2021, following the call from the father, when he was unhappy about the new birth visit, records show a CCS team leader made six attempts to contact him before they spoke on 13th May. 2.36 This, and other efforts of the CCS health visiting service to build engagement with Baby Euan’s parents was evident. However, a referral to Children’s Services due to the concerns emerging from professionals, including the parents’ decision not to access follow-up health care for Baby Euan following his birth difficulties, being hard to contact, and them declining routine vaccinations may have if a referral deemed to meet threshold supported relevant historical information about the father being secured and support being offered to the family. 2.37 There had been minimal contact with Bedford Hospital prior to Baby Euan’s death. When informed that the family were moving to Lewisham (October 2021), BHT completed a case review for transfer which included a summary of Baby Euan’s birth difficulties, absence of immunisations, concerns about father’s controlling behaviour, and need for the nine- month developmental review. This meant the new GP in Lewisham would have had relevant health and safeguarding information to support practice. 2.38 The challenge around this case was trying to determine where Baby Euan and his parents were living. The family were understood to have moved to Lewisham in October 2021; professionals were unaware of the subsequent return to Central Bedfordshire. This view was supported by the professionals at the practitioner workshop. 2.39 When at the Lister Hospital, appointment requested for an ultrasound scan for Baby Euan. There were discussions between consultant paediatrician and parents regarding this not being necessary in view of the clinical presentation, and there were no clinical surgical concerns or medical concerns which would warrant this. In view of these observations the consultant paediatrician completed an information sharing form detailing that there were no current safeguarding concerns raised during the admission but requested for information to be shared with the health visiting service to offer some follow up support as it was felt there could be some parental anxiety surrounding Baby Euan’s health. It was noted that there was Page | 9 Final an incongruence between this noted parental concern but declined for paediatric assessment for support. An outpatient ultrasound appointment was provided for reassurance to the parents. This was not attended. 2.40 On 10th September 2021 Baby Euan was due to be seen in a virtual outpatient appointment with the paediatrician, however, he was not brought. The paediatrician attempted to make telephone contact with the family but was unsuccessful. 2.41The ‘Not Brought to Appointments’ pathway is currently being reviewed in line with new ways of working following the pandemic. This will pick up children not brought to virtual appointments. This is however generic learning and not just learning identified as a result of this case. 2.42 The sharing of information in respect of mother not attending appointments might have been beneficial for local services to have known, particularly as this resulted in a referral to MASH in London. This information would have then fed into the decision making around Baby Euan when he wasn’t brought to his first appointment with the paediatrician. 2.43 Learning has been identified in relation to the transfer in / out process which needs to be updated and ensure robust verbal information handover between areas. Domestic Abuse- Coercive Control-Invisible Males 2.45 Information shared with the review by the Lewisham MASH identified that the father was known to their services as a child between 2004-2008. 2.46 Further police checks show that the father has a PNC record of arrests between 2012 and 2020. These relate to offences of harassment, stalking and assault, and appear to be domestic related involving his sister and previous partners. All matters were No Further Action, and he has no convictions or cautions. 2.47 Although the following described incident occurred after the death of Baby Euan it is important that it is included in this section as it might be an indication of what occurred within the household whilst Baby Euan was alive. 2.48 On the 22nd February 2022 Baby Euan’s mother attended the hospital emergency department. She had a head injury, nosebleed and injured hand caused by an assault which she states has been perpetrated by her partner (the father of Baby Euan). She asked the ED staff to contact the police for her. The mother then refused to wait to be seen by the medical team or police. Records show no MARAC referral was made by ED staff. Trust wide notification has now been made as a result of this incident, informing staff that they can make referrals to MARAC based on professional judgement, when consent is not gained due to extenuating circumstances. 2.49 On the 9th of March 2022 the mother again made contact again with the hospital requesting her attendance notes to be amended to indicate that she was not the victim of domestic abuse and violence, and that she denied asking anyone to call the police. No records were altered on her behalf. 2.50 When the North Mid IMR author interviewed the midwife who delivered Baby Euan, they discussed in more detail if she had any concerns regarding domestic abuse and coercive controlling behaviour. On specific questioning she said that although she did not have any Page | 10 Final concerns regarding their relationship but that both parents were verbally aggressive and passive aggressive at different points of the labour towards her. The father, at one point, was particularly verbally aggressive towards the midwife when the emergency caesarean section was required as it was evident that Baby Euan was deteriorating clinically. The midwife reports that the situation was very uncomfortable for her. 2.51 On further reflection, the IMR author and the midwife discussed controlling and coercive behaviour and although the midwife felt that there was none in this case during the contact she had, it is something to consider for future practice when families are extremely challenging during labour and delivery. 2.52 On the 27th April 2021 - A planned (arranged) health visitor home visit was undertaken. The HV stated at the practitioner event that the father gave a false name and did not answer her request for his date of birth. Because of this the correct details of father were not known and could not be located on the NHS Spine. The GP was not able to provide this information either. Of note, the name initially given by father was not similar in any way to the name that he is known by, which was disclosed by police at the rapid review meeting. The fact that the service had been given the wrong name was significant and did not allow for health to undertake any assessment of risk, need or support required. 2.53 The father subsequently made the complaint against the HV and thereby took control of not letting the HV into his home. 2.54 At 12 weeks old, Baby Euan was taken to the GP surgery by his mother for the 6-8 week GP post birth check. The father joined the appointment via mother’s phone. The GP felt concern about the father’s behaviour during this interaction as she felt that there were indictors of controlling behaviour to mother. The mother kept the phone close to her ear throughout the later part of the appointment and as a result there was a parental request for individual vaccinations for Baby Euan. He was subsequently not brought for the vaccinations. The GP at the practitioner event stated that although she couldn’t state categorically it was coercive controlling behaviour but the whole situation was one which she felt uneasy with. Hence why she shared this with HV at subsequent meetings. 2.55 This sharing of information took place at a GP liaison meeting and a health visitor was further informed that when the father had asked for forms to be signed by a GP, he was aggressive and accused staff at the GP surgery of being racist. Father had not given his name to the GP. The health visitor took advice from Team Leader following this liaison meeting. Safeguarding supervision was then sought by the Team Leader and a decision was made to begin compiling a chronology, to register the father into the S1 unit and review his records. However, father’s details were not known and therefore GP was tasked to seek this information and add this, if they knew it. The GP did not have, and was not able to obtain this information. 2.56 There was a strong feeling at the practitioner event that more awareness raising needs to take place with frontline staff as to what constitutes coercive and controlling behaviour and how this affects children who live in these households. 2.57 Coercive control is not primarily a crime of violence, but it is firstly and foremost what the acknowledged international expert on the topic, Stark (2007) describes as a liberty crime. Page | 11 Final Stark provides a detailed breakdown of the behaviours that comprise coercive control, some of which perfectly fits the actions and behaviour of the father in this case: ‘Intimidation (including threats, surveillance, stalking, degradation and shaming), Isolation (including from family, friends and the world outside the home); and Control (including control of family resources and ‘micromanagement’ of everyday life’).’2 2.58 In relation to the concerns of coercive control behaviour to mother by father identified by the GP and Health Visitors, along with declined follow up medical visits, the rapid review meeting considered whether there should have been a safeguarding referral at this point. This would have offered an opportunity to view past concerns, the father’s history, and police record, use of aliases, and to explore the lived experience of Baby Euan and whether the use of the Domestic Violence Disclosure Scheme (DVDS)3 should be considered. 2.59 The review author posed to the delegates at the practitioner event the subject of the father being an invisible male. He suggested to them that the father was visible to agencies and although he was at times aggressive and controlling of professionals and the mother, he did engage with professionals. The unanimous feelings of the practitioners at the event was though, that he was invisible, as no correct name or date of birth was known for him and no knowledge of his background was known in order for him to be understood as a risk to Baby Euan and the mother. 2.60 In the early hours of the 11th November 2021, a neighbour of Baby Euan and his parents in Central Bedfordshire calls Bedfordshire Police reporting arguing, thuds and a baby crying. On attendance, both parents are spoken to separately, they both state there is no argument, they are dealing with a teething baby, walking, talking, and watching TV, they state the neighbour is intolerant of the noise and has banged on walls previously. There are no signs of concern noted by the officers and the log is closed. It is not believed that Baby Euan was seen by officers and no contact was made with the neighbour to consider triangulating the information. No PPN or DASH assessment was submitted by officers. The incident log was closed, ‘no domestic, no offences. There was no evidence of a domestic dispute or any other offences. Will be child making noise which the neighbour does not like.’ 2.61 Bedfordshire Police have for this review recognised this is a missed opportunity. Neighbours were not visited, which might have offered further information on the family and insight into Baby Euan’s lived experience. The Case Review Group considered that the neighbours may not have wanted the police to wake them up or provide indicators that they had made a complaint to the police at that time of night. However, it would have been beneficial to make follow up enquiries with the neighbours, either by phone or a visit during the day. At this point, Baby Euan and his family were not known to health services to be back in Central Bedfordshire. Bedfordshire Police are currently developing training around ‘Voice of the Child’ to further develop knowledge and skills. It has been identified within Bedfordshire Police, that officers attending domestic incidents are not checking children, unsure of their powers and how to have difficult conversations with parents. 2.62 Further learning totally relevant to this call from the neighbour is highlighted in the national review into the deaths of Arthur Labinjo-Hughes and Star Hobson- Child Protection 2 Stark, E., Coercive control. The entrapment of women in personal life. (U.S.A: Oxford University Press, 2007). 3 Also known as Clare’s Law Page | 12 Final in England. Within the report it highlights that ‘All Safeguarding Partners should assure themselves that: Referrals are not deemed malicious without a full and thorough multi-agency assessment, including talking with the referrer, and agreement with the appropriate manager. Indeed, the Panel believes that the use of such language has many attendant risks and would therefore discourage its usage as a professional conclusion.’4 2.63 Although Baby Euan was very young it is important to learn from this case and consider the impact on children in homes where there is domestic abuse and/ or coercive control. The Domestic Abuse Act 2021 sets out that children are victims of domestic abuse that is perpetrated against their parent or carer. Katz (2016) in her article about children’s experiences of coercive control states ‘Children in coercive control-based domestic violence contexts may live with narrow space for action, reduced ‘voice’ within the family, disempowerment and erosion of their confidence’ 5. 2.64 The child safeguarding practice review panel briefing (September 2022) on Multi-agency safeguarding and domestic abuse, states that ‘There appeared to be an assumption that simply naming ‘domestic abuse’ as a concern for a child is enough for all practitioners to understand the situation and respond appropriately. This is an overly simplistic, optimistic and, at times, dangerous assumption that leads to potentially avoidable harm to children and non-abusing parents.’ Statutory and voluntary sector services working with children and adults require detailed understanding of abusers’ use of controlling and coercive behaviour.’6 2.65 The attendees at the practitioner event and the review author agrees with this statement that this understanding is needed and required by practitioners. ‘Intersectional analysis’ into race, disability, and health conditions. 2.66 The Child Safeguarding Practice Review Panel guidance for safeguarding partners that was published in September 2022 states that: ‘Intersectionality is the interconnected relationship of social categorisations such as race, gender, and sexual orientation together with individual vulnerability and adversities suffered by the individual. It is important to consider the potential to learn from issues of ‘intersectionality’ at each stage of the process – particularly when considering the usefulness of an LCSPR7.’ 2.67 This Intersectional analysis has been a key part of this CSPR and highlighted as a theme for partners to consider in their IMRs, at the practitioner event and in panel meetings. It was felt that race, disability, and health conditions did play a part in this case. Using this intersectional approach has helped this report to more than simply recognise diversity but to try to understand the characteristics of the three individuals involved. 4 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1078488/ALH_SH_National_Review_26-5-22.pdf 5 Katz E (2016) Beyond the physical incident model: how children living with domestic violence are harmed by and resist regimes of coercive control. Child abuse review volume 25 46-59 (2016) 6 Child Safeguarding Practice Review Panel (CSPRP) (2022) Multi-agency Safeguarding and domestic abuse. https://www.gov.uk/government/publications/multi-agency-safeguarding-and-domestic-abuse-paper 7 Child Safeguarding Practice Review Panel (CSPRP) (2022) Guidance for Safeguarding Partners https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1108887/Child_Safeguarding_Practice_Review_panel_guidance_for_safeguarding_partners.pdf Page | 13 Final 2.68 A panel discussion took place in relation to whether asking parents about their faith which also was relevant in this case was appropriate. It was felt yes if the purpose was to gain better understanding of child’s lived experience. It could be integral to understanding the child’s experience and practitioners should ask is there cultural or religious practices which they need to be aware of that affects the child, so that they are able to work alongside that family better. 2.69 As part of the paediatric assessment for the ED attendance, the father’s details and demographics were taken as part of the social history and understanding who cares for Baby Euan. This is in line with the Hospital procedures and relevant documentation was kept reflecting this. 2.70 What didn’t happen was the collection of data and demographics surrounding Baby Euan’s ethnicity, this was missing from the clinical records. It is an expectation this information would be collected as part of the clinical assessment and booking in process. While this information would not have changed the assessment/outcome of the clinical assessment of Baby Euan, this information should be routinely collected. 2.71 There are improvements being made to the collection of ethnicity information for all children and young people attending E&N Hertfordshire NHS Trust. This involves an action for a meeting to take place with the Equality & Diversity Team & Digital team to explore digital options to supporting improvements. 2.72 The father made a complaint of racism against health visiting staff, he stated that in his view the health visitor had not been culturally sensitive and had made an inaccurate recording of Baby Euan’s ethnicity, gender, and parental contact details. The Team Manager reported in their rapid review interview that they had been struck by father’s emotional account of their child’s birth and their experience of negativity from others. He was reported to have little trust in the National Health Service. The health visitor at the practitioner event stated they had spent two hours at the address on this visit and felt at the time no issues other than the discussion about father’s name and date of birth and a discussion about the BCG vaccine. Father’s verbal complaint included the health visitor approach to the discussion about BCG, in his view, lacked some cultural sensitivity. 2.73 The Rapid Review discussions considered whether this was a tactic to intimidate staff who were curious about missed appointments and baby having no name or whether there was a case to answer. On investigation, the allegation relating to a mistake in recording the child’s ethnicity was followed up by a manager and corrected. This mistake may have reduced the family’s willingness to engage with services. The father was wary about engaging with services which may be down to his ethnicity and must be taken into account by professionals. One of the practitioners at the event suggested as a consideration, did the father himself, due to his race and ethnicity feel marginalised, and the complaints were his way of trying to regain control. 2.74 Parental refusal of universal services (health visiting, vaccinations) is a choice. It is not known if there were related religious or cultural beliefs informing this decision. Equally, a request to spread out vaccines as Baby Euan had a ‘difficult start’ is a reasonable concern from the family. However, practitioners should be encouraged to explore concerns or reluctance with parents and there was no evidence that this occurred. Page | 14 Final 2.75 The allegation of racism could be interpreted as the father putting up barriers to not let the HV in, but as the Rapid Review states that it is important for professionals to understand the negative outcomes and experiences for BAME groups which are evidenced in research and the lived experience of BAME people. An example of trying to do this is in The NHS Long Term plan ‘commits to ensuring that by 2024, three-quarters of pregnant BAME women will receive care from the same midwife before, during and after they give birth. This is proven to help reduce pre-term births, hospital admissions, the need for intervention during labour and to improve women’s experience of care.’ 8 2.76 It is noted that at the mother’s registration for the pregnancy for Baby Euan, the information recorded her ethnicity as Black Caribbean and shared a diagnosis of Type 2 Diabetes. There were no language barriers recorded. Religion is recorded as Christian for both parents. The midwife present during labour reported that she was aware that the father was speaking to their pastor when difficult decisions were needed from the parents. 2.77 Bedfordshire Police identified Ritual Abuse as a line of enquiry for their criminal investigation. This was due to certain items found on their examination of the home address. The Rapid Review reflected on their records; agreeing that this was not predictable within the information held by agencies and is not discussed further within this report. 2.78 In relation to learning from this review for cultural competency and sensitivity, the CCS will be supporting exploration for both internal and external learning and development. The Trust has pledged to become an anti-racist organisation and is actively implementing objectives to work towards and embed. 2.79 Although the fundamental circumstances of the Child Q CSPR are not relevant to this review, there is though, key learning in relation to race that the local partnership should take account of. ‘The full reasons behind why racism continues to feature in professional safeguarding practice are without doubt wide-ranging and complex. The CHSCP should expedite its work on developing an anti-racist charter and practical guides that support the eradicating of racism, discrimination and injustice across its local safeguarding arrangements9.’ 3.0 Conclusion 3.1 In the Child Safeguarding Practice Review panels 2020 Annual report,10 ‘Patterns in practice, key messages and 2021 workplan.’ the report makes the following comments: ‘From our analysis we have highlighted six key practice themes to make a difference in reducing serious harm and preventing child deaths caused by abuse or neglect. These themes are not new, but they are amongst the most urgent, and also the most difficult. Underpinning all of them is the importance of effective leadership and culture – dimensions which are too often left unexplored in the case reviews that we see. We expect 8 https://www.england.nhs.uk/2020/06/nhs-boosts-support-for-pregnant-black-and-ethnic-minority-women/ 9 https://chscp.org.uk/wp-content/uploads/2022/03/Child-Q-PUBLISHED-14-March-22.pdf 10 https://www.gov.uk/government/publications/child-safeguarding-practice-review-panel-annual-report-2020 Page | 15 Final these six themes to be a focus for shared learning with safeguarding partnerships, and nationally, to improve the safeguarding system.’ ‘Six key practice themes to make a difference 1. Understanding what the child’s daily life is like 2. Working with families where their engagement is reluctant and sporadic 3. Critical thinking and challenge 4. Responding to changing risk and need 5. Sharing information in a timely and appropriate way 6. Organisational leadership and culture for good outcomes.’ 3.2 There are three key pieces of learning from this annual report that are clearly evident in this review for Baby Euan and have been explored in the analysis sections of this report. They are for professionals to understand what the child’s daily life was like, working with families where their engagement is reluctant and sporadic, particularly relevant when the family, and father in particular, was stopping health visits or Baby Euan being taken to health visits, and directly related to this point is where this happens sharing information in a timely and appropriate way, this was even more relevant where the family resided in three different local authority areas. 3.3 The other two areas of learning involve the theme of intersectionality, highly relevant in this case due to mother’s health and the families race and ethnicity and finally domestic abuse. The rapid review group also reflected on links to national reviews including ‘Non-Accidental Injury in under 1s’ and ‘The Myth of Invisible Men’ as Baby Euan was eight months old when he died. The father has a police record relating to domestic incidents and a complex history including social care involvement. As a partnership, Central Bedfordshire have completed two Rapid Reviews in relation to the non-accidental Injuries to babies, alongside reviews completed in neighbouring authority areas. Pan Bedfordshire and local work is underway to ensure best practice and service development in respect of safeguarding infants. This is overseen by the Pan Bedfordshire Non-Accidental Injury working group. 3.4 In discussion with Central Bedfordshire neighbouring partnerships, they are considering the impact of parental choice to decline universal health services; whilst it is a parent’s right to make this decision, they will consider what this may mean for unborn/young babies especially where concerns have already been raised. This has been raised at the Pan Bedfordshire Learning, Improvement and Training Group to support practice development. 3.5 Although controlling and coercive behaviour is now embedded within domestic abuse definitions, it appears to be the least understood aspect of the overall domestic abuse and safeguarding legislation and an area where all professionals need to think wider and seek to explore individuals with greater curiosity. Front-line practitioners in particular need to be more alert to the signs and symptoms of these behaviours and be able to highlight possible triggers and subtle inferences and make appropriate referrals. Page | 16 Final 4.0 Recommendations 4.1 This CSPR has identified learning and made some recommendations, as detailed below, and the implementation of these will assist the CBSCP to deal more effectively with similar circumstances in the future, resulting in the improved safety and welfare of children. Recommendation 1 The Central Bedfordshire Safeguarding Children Partnership (CBSCP) should share this review report with the Enfield and Lewisham Safeguarding Children Partnerships for them to consider if there is any learning that they would wish to consider actioning within their area. Recommendation 2 The CBSCP should seek assurance from all agencies that they always include the voice and lived experience of a child in their actions and assessments. This includes children that are babies, who are unable to communicate verbally. This could be widened to include the mothers and fathers voice and their lived experience. Also, voice and views of the wider family who know the child and parents should be considered if possible. Recommendation 3 The CBSCP should seek assurance from partners to ensure that they are pursuing alternative ways of engaging families when there is resistance to bring a child to a health appointment. In particular those families who decline universal services where there are only known low level concerns. (Paradoxically in this case the family did reach out for health care but did not attend follow up appointments, so this should be borne in mind as well.) Recommendation 4 i) The CBSCP should re-issue the Department for Education Information sharing guidance (2018 ). In particular emphasising how important it is for agencies to notify other areas when they have transient and mobile families that transfer to them. ii) a) The CBSCP should seek assurance from maternity services that when mothers book their pregnancy directly with them, that they send notifications with consent to, where known, the mothers and if they know the fathers/male carers details and they consent to their GP practices. b) That maternity services, where a pregnancy is regarded as clinically ‘high risk’ due to the mothers co-morbidities or other risk factors and they fail to manage adequately these risks, that they share their concerns with children social care. iii) The CBSCP should encourage health visiting services to ensure a verbal handover takes place when children and their families move to another area and to seek this verbal handover when these children and families transfer into their area. Recommendation 5 The CBSCP need to raise professionals awareness, knowledge and understanding of: i) the Domestic Violence Disclosure Scheme, Domestic Violence Protection Notices and Domestic Violence Protection Orders. ii) To ensure that front-line staff can recognise the signs and symptoms of coercive and controlling behaviour as a form of domestic abuse. iii) The fact that household domestic abuse is always harmful to children. (Each agency to support this by also delivering agency specific guidance.) Page | 17 Final iv) Seek assurance from Bedfordshire Police that frontline staff are ensuring that children being seen/spoken to when attending domestic incidents. Recommendation 6 The CBSCP to ensure that their partners understand what the meaning of intersectionality is and that they are embedding this into their agencies procedures and actions of their frontline practitioners. Page | 18 Final Appendix A Child Safeguarding Practice Review: Terms of Reference Baby Euan Subject of Review: The subject of this review will be known as Baby Euan. Reason for Review: Euan, aged 8 months old, died in December 2021. The post-mortem confirmed a number of non-accidental injuries. Central Bedfordshire Case Review Group completed a Rapid Review, identifying areas of learning. This Child Safeguarding Practice Review will bring together practitioners to further explore themes of mobile families, culture and ethnicity, domestic abuse and the voice and lived experience of the child. Independent Reviewer: Dr Russell Wate QPM Dr Russell Wate QPM is a retired senior police detective, experienced in the investigation of homicide and in particular child death. He has contributed to a number of national reviews, inspections and inquiries, as well as being nationally experienced in all aspects of safeguarding children. Russell is part of the National Panel’s pool of reviewers and has been involved in a number of their published reviews. He has carried out a large number of Child Safeguarding Practice Reviews and has also been an independent chair and scrutineer for Safeguarding Children Partnerships. Dr Russell Wate is independent of any agency within Central Bedfordshire. Timeframe to be covered by the review: September 2020- December 2021. This period covers confirmation of pregnancy to Euan’s death. Agencies are invited to further consider significant and relevant contacts or events outside of this timeline. Agencies involved: • Central Bedfordshire Children’s Services • Enfield Children’s Services • Lewisham Children’s Services • Cambridgeshire Community Services Page | 19 Final • Bedfordshire Police • Bedford Hospital Trust • North Middlesex University Hospital NHS Trust • Homerton Hospital • Lister Hospital • Lewisham & Greenwich NHS Trust • Bedfordshire, Luton & Milton Keynes Integrated Care Board (BLMK ICB) • South East London Clinical Commissioning Group • East London Foundation Trust • Saffron Health Centre, Biggleswade • The Vale Surgery, Lewisham • Forest Hill Health Visiting • Safeguarding Children Partnerships for Lewisham and Enfield Key areas of focus: In responding to our Rapid Review, the National Panel noted ‘the helpful focus on ritual abuse but thought that the consideration could have extended into a more intersectional analysis into race, disability, and health conditions. We also questioned whether it would have been relevant to consider the role of the father given previous incidents related to assault, stalking, as well as coercive and controlling behaviour.’ We will bring together practitioners, knowledgeable stakeholders and panel members to explore learning from key time periods and learning themes. The impact of COVID will be explored as a golden thread throughout the themes. Time periods • Pre-pregnancy; agencies may share relevant information and learning prior to the pregnancy. • Pregnancy (Sept 2020-April 2021) • Periods of residence in Central Bedfordshire (April– Oct 2021) and London Borough (Oct 2021 onwards) • Return to Central Bedfordshire and death of Baby Euan (November- December 2021) Learning themes • Voice of the Child • Mobile Families Page | 20 Final • Domestic Abuse/ Coercive Control • Invisible/ Hidden Males • Culture and Ethnicity, including a focus on intersectional analysis into race, disability, and health conditions. Timescales for completion: 22nd June- 22nd December 2022 Written Documents to be requested: • Individual Management Reviews (IMR) to be completed. Reviews to include critical analysis and reflection of engagement with Euan and his family, identifying learning and recommendations to take forward. • Chronologies: existing chronologies will be reviewed as part of the IMR process and updated as required. Practitioner learning event: Once all information has been received and reviewed a panel meeting will be held to review all information and identify key learning themes before holding a practitioner event. Process for engaging family: TBC- Criminal Investigation in progress. |
NC52257 | Significant injuries to an 11-month-old boy. Alex was admitted to hospital with cardiac and respiratory failure from suspected non-accidental injuries. Medical investigations found bleeding, including bleeding in the brain, an old rib fracture and extensive bruising. These diagnoses resulted in significant disabilities for Alex leading to care in a children's hospice. Alex had been placed into foster care following his birth, as his parents had significant previous involvement with children's social care. At the time of his hospitalisation Alex had been living with connected carers, who were an extended family member and her partner. His connected carer mother had five other children, and did not live with connected carer father. There were no previous concerns regarding the connected carer family. Alex's ethnicity or nationality are not stated. Learning includes: expediting social work assessment timescales may impact the quality of assessments; children who are looked after may be at risk of harm, and that being in foster or connected care does not automatically mean safety; professionals should recognise the difference between various fostering arrangements and prioritise visits and reviews accordingly. Recommendations include: assessments for connected carers include a thorough review of family dynamics and explore motivations to care for children; unannounced visits of connected carer placements are undertaken during the assessment phase and post placement; when children are placed in another local authority, social workers should seek support from where the child has been placed and reciprocate arrangements with other local authorities; that recommendations are raised with the Family Justice Board and the Department for Education.
| Title: Serious case review: Case 11: Alex (assigned pseudonym): overview report. LSCB: Walsall Safeguarding Partnership Author: Karen Rees Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Case 11 Alex (Assigned Pseudonym) Overview Report (FINAL May 2020) Author: Karen Rees Presented to Walsall Safeguarding Partnership (WSP) 4 December 2019 This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with the WSP. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved. 2 CONTENTS Glossary 3 1 Introduction & Circumstances Leading to the Review 5 2 Methodology and Scope 5 3 Family Engagement 6 4 Background prior to the scoping period 6 5 Key Phases 6 6 Family and Friends’ Care 10 7 Thematic Analysis 11 8 Good Practice 22 9 Conclusion 22 10 Recommendations 24 Appendices Appendix 1: Terms of Reference (Redacted for publication) 27 3 GLOSSARY A child who has been in the care of their local authority for more than 24 hours is known as a looked after child. Looked after children are also often referred to as children in care, a term which many children and young people prefer. The Looked After Children’s system includes terminology and acronyms that may not be understood. A Glossary is therefore provided. Birth parents Biological parents, sometimes referred to as 'natural parents'. Care by family and friends Care provided by friends and relatives for a looked-after child or young person. Previously referred to as 'kinship care'. Government guidance also uses the term 'connected care'. Care plan A document that sets out the actions to be taken to meet the child's needs and records the person responsible for taking each identified action. The local authority is responsible for ensuring that it is regularly reviewed and that the identified actions happen. The local authority that looks after the child must arrange for them to have a health assessment as required by The Care Planning, Placement and Case Review (England) Regulations 2010. The initial health assessment must be done by a registered medical practitioner. Review health assessments may be carried out by a registered nurse or registered midwife and must be undertaken every six months where a child is under five. Independent reviewing officer (IRO) The person who makes sure that the health and welfare of looked-after children and young people are prioritised, that they have completed and accurate care plans in place (which are regularly reviewed and updated), that any physical, emotional health or wellbeing needs or assessments identified by their care plans are met or completed, and that their views and wishes, and those of their families, are heard. A looked-after child review is a regular meeting that brings together those people who are closely concerned with the care of the child. It is an opportunity to: review the child’s care plan discuss the child’s progress make plans for the future. A parallel plan, also referred to as a twin track plan, is a term used when a contingency plan for a looked after child is being explored at the same time as the primary plan for the child. As part of permanence planning for looked after children, parallel plans must be drawn up to ensure that alternative plans have been explored and are available without delay if the preferred permanent outcome proves unachievable. 4 The supervising social worker provides both supervision and support, and acts as the conduit between the fostering household and the fostering service and is separate from the role of the foster child's social worker. 5 1. Introduction and Circumstances Leading to the Review 1.1. Alex was 11 months old and living with connected carers in Area B subject to a Full Care Order placed by Area A. Alex was taken to Area B Hospital by ambulance and admitted with cardiac and respiratory failure from suspected non accidental injuries. 1.2. Medical Investigations found that Alex had a bleed to the right side of the brain, which was causing pressure, a bleed within an adrenal gland, an old rib fracture, and evidence of a past bleed in the lungs, which could have been injury or past infection. Added to this Alex also had extensive bruising reaching from forehead, body, arms, legs and sole of a foot. 1.3. These diagnoses resulted in significant disabilities for Alex leading to a requirement for care in a Children’s Hospice. 2. Methodology and Scope 2.1. The request for a Serious Case Review was agreed by the Independent Chair of Walsall Safeguarding Children Board (under previous arrangements) following a Rapid Review meeting on 11/02/2019. 2.2. Full Terms of Reference, rationale for the scope and methodology of the review etc. for this SCR can be found in Appendix 1. 2.3. This review takes into account interagency involvement covering the six months prior to the date that Alex presented at hospital. This period covers just prior to placement with the connected carers until the date that Alex became critically ill at home. Key background information will also form part of the review that will inform the more contemporary elements for analysis and learning. 2.4. For the purposes of this review, Area A is the placing authority where Alex’s birth family live, and Area B is the area where Alex went to live with the connected carers. 2.5. In order to differentiate between the different carers for Alex and parental relationships the following coding system will be used. Family member: To be called: Birth Mother Mother Birth Father Father Foster Carer Mother FCM Foster Carer Father FCF Connected Carer Mother CCM Connected Carer Father CCF Older Children of Connected Carers Child 1, 2, 3 etc (Oldest =1) 6 3. Family Engagement 3.1. A key part of undertaking a SCR is to gather the views of the family regarding the services they received from agencies and share findings of the review with them prior to publication. Due to the nature of the family circumstances and the scope of the review, the independent reviewer met with the connected carers prior to the first professionals’ workshop. Their views have been incorporated as appropriate throughout this report. Arrangements will be made to feed back the learning to Alex’s birth mother and father as well as the connected carers on conclusion of the review. 4. Background Prior to Scoping Period 4.1. Alex was the eighth born child to parents who have significant previous involvement with children’s social care. When Mother was pregnant with Alex, pre-birth planning commenced, Alex was placed into local authority foster care immediately following birth. An extended family member of Alex’s mother was identified as a possible connected carer for Alex in order that Alex could stay within the family. Following a positive viability assessment, CCM, and later, CCF were accepted to go forward with full assessments to become permanent carers of Alex. CCM had three children with her previous husband and had two children with CCF. CCM had moved from another county, where she had lived with her husband, to move back with her mother when her marriage ended. CCM and CCF did not live locally to Alex’s immediate birth family. At the time of writing this review CCM and CCF had been in a relationship for nine years. They did not live together. 4.2. The assessment was commenced when Alex was three months old. 5. Key Phases 5.1. For the purposes of setting out the story related to Alex’s life from foster care to connected carers, key phases will be used to identify the factual information available to the review. This will then form the basis of the analysis that will then generate key themes for learning and recommendations. Phase one: pre-placement 5.2. Whilst CCM and CCF were being assessed, Alex remained in the care of local authority foster carers who were described by the local authority as extremely experienced. Alex was seen by the health visitor monthly, as is required for a child who is looked after. Alex was taken to all routine appointments by FCM and received all the usual childhood immunisations. The health visitor had expressed no concerns about Alex’s care, growth or development. At Alex’s adoption medical (parallel planning was underway) the paediatrician identified that 7 Alex was developing appropriately and had reached all developmental milestones expected of a four-month-old baby. 5.3. The assessment of CCF and CCM was very positive. Positive references were received from CCM’s previous partner, and the children’s schools. GPs for both CCM and CCF provided reports. It was not possible to get a reference from CCF's previous partner, but an additional reference was received from a friend who knew CCF when he was with his previous partner. All statutory checks were undertaken and no contra indications to continuing with the assessment were found. Albeit that the assessing social worker was concerned regarding the number of children already in the household, the assessment found that CCM was someone who was organised, proud to be a mother and very family orientated. CCM’s own children were described as happy, positive about family life and looking forward to Alex joining them. 5.4. Assessments and observational visits pointed to CCM being a very capable and caring mother who put the needs of her children first, was able to provide a child friendly environment, a wide range of outdoor and indoor activities to suit the ages of the children, and a healthy diet. 5.5. There was less contact with CCF but the assessing social worker observed that he was very good with the children and he responded appropriately to them. CCM and CCF were seen together as a couple and no concerns were identified. They were also seen individually and again this was very positive. 5.6. Three months after the assessment began, CCM and CCF presented to the foster panel and were approved as connected carers for Alex. The next day the agency decision maker endorsed the panel decision. Two weeks later transition planning commenced. The transition plan was approved a week later when the local authority was granted a Full Care Order in respect of Alex. 5.7. Nine days later the introductions to Alex commenced. Phase Two: transition to connected carers; the first six weeks 5.8. CCM and CCF had not met Alex during the assessment process. The introduction took place at the home of FCM and FCF. FCM supervised the visit. CCM and CCF told the author that they spent a few hours playing and giving Alex dinner. Having stayed in a hotel overnight they returned the next morning and again spent some time getting to know Alex. 5.9. Four days later, FCM and FCF travelled to Area B to the home of CCM. CCM and CCF spent some time caring for Alex. Alex was included in the usual routines of the household and was then got ready for bed. FCM and FCF then arrived, collected Alex and returned the next day 8 having spent the night in a hotel. The next day Alex spent the day with the family (it was school holidays) and Alex also spent the night with them. The next day the social worker visited for an hour for a statutory visit. It was agreed that as the introduction had gone so well that Alex’s full-time placement with CCM and CCF would commence from that point. FCF and FCM returned to say goodbye to Alex. 5.10. The notification to Area B health and social care partners was not received by the Area B social work department, although there is evidence that it was sent. CCM registered Alex with the family GP six days post placement and made contact with the health visiting team two weeks later. 5.11. A notification was received by Area A health visiting services of a movement out of area for Alex via routine tracking as a result of Alex being registered with a new GP. Area B health visitors indicated that they would not require Alex’s records due to being a paper light service. The following day, the previous health visitor made contact with Area B’s health visiting single point of access service and spoke to a health visitor to verbally hand over to the new area. The Area A health visitor was again told that the records were not required due to being a paper light service. 5.12. Visits took place by Area A Children’s Social Care as expected; there was a handover visit from the assessing social worker to the supervising social worker two weeks after placement (CCM and all children were seen) and a routine post placement visit one month later by the supervising social worker. At the later visit CCM was seen with the youngest of her two children and Alex (the older children were now back at school). In between both of these visits a Looked After Child Review was undertaken with a visit by the Independent Reviewing Officer and Alex’s Social Worker. CCM was present, CCF was at work. 5.13. A week later, CCM took Alex to the health visiting clinic, Alex was noted to be a looked after child, weighed and the attendance was recorded in the clinic book. Nothing else is recorded about this contact. The contact is not recorded in Alex’s electronic record. The health visitor in this clinic was not Alex’s allocated health visitor. 5.14. The allocated health visitor telephoned CCM the next day to arrange a home visit. The visit took place 11 days later. As Alex was a looked after child, the family were assessed as having needs at Universal Partnership Plus (UPP) level of service delivery in line with organisational policy and the Healthy Child Programme (HCP)1 . This would have meant monthly contacts. The home visit by the health visitor took place just under six weeks after Alex was placed with 1 The HCP offers every family a programme of screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing. Healthy Child Programme - Gov.uk 9 CCM and CCF. CCM gave the health visitor a family history of why Alex had been placed with her as a connected carer, that Alex had settled well into the family and that she would be applying for special guardianship. The health visitor noted no concerns; the family were well known to the health visiting service locally due to the number of CCM’s children that they had contact with. The health visitor planned to review Alex monthly and to attend all looked after review meetings. Phase Three: post placement; the last four months 5.15. There was a delay in the looked after health review being set up as the consent form on file was related to the previous foster care placement. A new consent form was signed and sent to the Area B health visiting team. This delay lengthened as there was a backlog of health assessments for looked after children in Area B, and despite a chase being sent from the Area A looked after children nursing team, this remained outstanding at the time that Alex presented to hospital. 5.16. An invitation was sent the following month for Alex to be brought to clinic for a 9-11month developmental review in three weeks’ time. This was an oversight as, for a looked after child, this should have been a home visit. 5.17. The allocated health visitor then coincidentally telephoned CCM as part of a routine contact to ask her to bring Alex to clinic the following week as part of the routine monthly contact. CCM made contact on the day of the planned clinic visit to say that she could not attend as one of her own children was unwell. The appointment was rearranged for two weeks later. This appointment was not kept and there was no follow up arranged by the health visitor. 5.18. Alex was brought to the clinic as planned for the 9-11 month developmental review at 10 months old. No concerns were expressed by CCM. Alex was observed by the health visitor to be very vocal. Alex’s development was showing some delay in three areas, gross motor, social and problem-solving skills. There was a plan in place to review this in 3 months. 5.19. Three weeks later the allocated health visitor, handed over to a new health visitor due to the existing health visitor moving to a new area. Two weeks later, the new health visitor contacted CCM to arrange an introductory visit. CCM reported that Alex was recovering from chicken pox, so the visit was arranged for the following week. The telephone call had been made on the same day that Alex later became critically ill. 5.20. During this phase there were a few visits from Area A social workers. CCM telephoned the social worker to cancel a statutory visit that have been planned. This was six weeks after the previous visit. There was then a change of allocated social worker, who contacted CCM to arrange an introductory visit. The visit took place ten weeks after the last statutory visit. 10 There were no concerns noted; the environment was reported to be similar to others had found and that Alex was making progress. The next visit from the supervising social worker was cancelled by CCM as she had an appointment at the school related to one of the other children. Alex was then seen the following week for a Looked After Child Review and a statutory visit the same day. 5.21. The supervising social worker then visited the following week and saw Alex with the two younger children. 5.22. Four weeks later CCM phoned to cancel the statutory visit as one child had chicken pox and Alex and another child were ‘under the weather’. A week later CCM cancelled a further visit as Alex now had chicken pox, the visit for the supervising social worker was also cancelled the same day for the same reason. It was the next day that Alex became critically ill. 6. FAMILY AND FRIENDS CARE 6.1. In order to understand the learning from this review more fully it is important to consider some aspects of family and friends care (placement with connected carers). 6.2. Over 8,000 looked after children are placed with family members who have been approved as their foster carers2. Family and friends’ carers provide a way for a child to stay within a family if their parent/s cannot care for them. Many of these carers are close relatives of the parent e.g. grandparent, aunt, uncle etc. In the case of Alex, CCM was an extended family member of mother. 6.3. There are some important differences noted in the Statutory Guidance document3 that make family and friends carers suitable for placing children with family or a connected person when compared with an unrelated foster carer. The benefits are that the child may already be known to the identified carers and already have a strong bond and relationship with the carers. This was not the case for Alex as there was not an existing relationship with Alex; CCM and CCF had never met Alex. 6.4. The guidance identifies that legislation promotes the finding of a placement within a family where it may be safe to do so, as a preferred option to unrelated foster care. The decision to assess and place Alex with connected carers was therefore best practice and in accordance with legislation and statutory guidance. 2 8,830 on 31 March 2017. Department for Education Statistical First Release September 2017, Table A2. 3 Department for Education (2010) Family and Friends Care: Statutory Guidance for Local Authorities (Also in Draft under consultation May 2018 update) 11 6.5. A recent systematic review4 of the research into this type of care highlighted benefits and improved outcomes when compared to those in registered foster care (i.e. unrelated and unknown to the child). The research does conclude that connected persons placements often require additional support and training for those carers. 6.6. For several of the partners involved in the review, there was a recognition that the significant differences between a looked after child in registered foster care and a looked after child in the care of connected carers was not fully appreciated. 6.7. The Area B GP practice had recorded that CCM had registered Alex as a foster child. It is not clear at that point if the practice understood that this was not a placement with trained foster carers in the way that placement with registered foster carers would be. In discussion, health visitors questioned whether there is still a view amongst professionals that once a child is placed in foster care, that they are hence out of danger and safe. 6.8. A report by the NSPCC in 2014 based on research by the University of York5 concluded that: “The care system generally provides a safe environment for children, and many children and young people say that they think that their care is good. Despite the efforts of social workers and other professionals to remove children from abusive environments, there is nevertheless a risk that they may inadvertently place them at risk of abuse or neglect within the care system.” P35 6.9. Alex was being placed into a new family who were a well-established family unit and it was therefore going to take a period of adjustment for all family members and Alex. It is important to understand the differences, motivations, and family dynamics that may be involved in such arrangements. 7. THEMATIC ANALYSIS Assessment and understanding of connected carers 7.1. There were only two agencies involved in this review i.e. Health and Social Care albeit that health involved three organisations; GP in Area B, Area A and Area B Community Health 4 Winokur, M A. Holtan, A. & Batchelder, K.E. (2018) Systematic Review of Kinship Care Effects on Safety, Permanency, and Well-Being Outcomes. Research on Social Work Practice 2018, Vol. 28(1) 19-32 available at https://journals.sagepub.com/doi/pdf/10.1177/1049731515620843 Accessed 18 September 2019 5 Nina Biehal,N. et al (2014) Keeping children safe: allegations concerning the abuse or neglect of children in care. Final report. NSPCC Impact and Evidence Series 12 Trusts. 7.2. The review spent some time looking at the robustness of the assessment. Albeit the assessment process on initial view appeared comprehensive and followed statutory guidance, there were some areas identified where learning has been found. 7.3. One of the first issues that was highlighted was the engagement of CCF in the assessment process. When he spoke to the author, he indicated that he took quite some time to come around to the idea of taking Alex into the family. He was concerned that they already had five children and he wasn’t sure that it was right for him to take on another. CCF told the author that his resistance to the idea changed when he suffered a personal issue that made him rethink his life and made a decision that he wanted to give something back. It is important to note that once he changed his mind, he was fully supportive of taking Alex into the family. 7.4. CCM had a very different view and told the author that she was very keen to take on Alex right from the start. She had been already contacted by Alex’s Birth Grandmother encouraging her to consider taking Alex before she had received the call from social care. It is of note that CCM had previously commenced assessment to take a previous child of Mother but had then become pregnant herself and withdrew. It is of note that a previous child of Mother had been adopted as there were no identified family carers available to offer a home. This had had an impact on the family and CCM was clear that she did not want this to happen to another child within the family. 7.5. Whilst these issues were known about within the assessment, it was agreed during the review, that more exploration of the resistance from CCF could have been explored and further assessed. 7.6. CCF was not present for the first two assessment visits undertaken by the assessing social worker. On the first occasion that he was not present due to being at work, CCM was reminded that the assessment was for both of them and therefore he needed to be present. On the second occasion he was again absent as he was at work, so the social worker returned later in the day when he had finished work and spent some time talking with him, the social worker reiterated the importance of his involvement in the assessment and there were no further issues of non-engagement. 7.7. When CCF was observed with the children on the following occasion, there were no concerns. He related well to all children, his stepchildren as well as his own with no differing treatment noted. The issues raised above regarding CCF were known to the panel and were not identified to be an ongoing concern due to the above positive observations. 13 7.8. Another issue that arose during the review was any family dynamics that may place pressure on connected carers to be put forward for assessment. Motivation to undertake care of Alex was explored during assessment. It was clear that right from the time that Mother became pregnant that she would not be able to care for Alex. The experience of having one of the previous children adopted had upset the family and there was a determination not to let this happen again. CCM may well have felt pressured as the only viable option for keeping Alex within the family. CCM, however indicated that even if she did not take on the care of Alex, she would go on to have a further baby of her own. 7.9. It was noted by Alex’s IRO, that there was two other IRO’s for the other children of Mother. This would not be best practice but does happen on occasion due to either oversight or workload issues for IRO’s. This situation could have meant that family dynamics that may have had an impact on the decision to place within the family were not analysed further. Since this review, the IRO’s in question have been meeting together and with the children’s social workers. This will lead to recommendations for future practice. 7.10. The general assessment observations were very positive with the family appearing to be a happy one with lots of child friendly evidence and comments from CCM very positive in the way she approached parenting. CCM was described as an ‘earth mother’ type parent who had breastfed all her children for lengthy periods and wanted her children to experience the outdoors and nature. Growing vegetables in the garden and harvesting them and preparing them to eat were some of the activities CCM described to the author. 7.11. All the references that were received were positive. Although there were no issues with the people that had been approached for references, there were possibly some omissions of note. There was no recorded response from school nurse for the older children CCF was a football coach for a local children’s football team; no reference was sought from the club It was not possible to get a response from CCF’s previous partner due to there being no up to date contact details 7.12. Whilst there is little that could be done about contacting the previous partner, the other two references should have been pursued. 7.13. In trying to gather reasons why the above issues had not been more fully explored there were several explanations. The distance from Area A to the connected carers address was 225 miles round trip; this resulted in less visits than would be usual 14 The positiveness of other aspects of the assessment resulted in an optimistic view of family life. Both connected carers were being assessed as a couple. Although CCM would be providing the majority of care, as CCF did not live in the household, she was reported to be well supported by her own mother. 7.14. Those at the workshop who were involved in the assessment recognised that there may be occasions where there could be a self-challenge when an assessment appears to provide evidence of an exceptional family life. Professionals questioned whether this presentation was ‘too good to be true’. It is important not to use hindsight bias here; there is no suggestion that the assessment outcome should have resulted in a different placement decision. It is, however, an opportunity to consider learning based on reflection. 7.15. There is some post incident evidence that the family may have been a more ‘normal 21st century family’ than that which was portrayed. On speaking to CCF, he told the author that the older children had hardly noticed Alex’s addition to the family as they rarely were off their gaming devices and tablets. None of the visiting professionals, before or after the placement witnessed children on tablets. It could be suggested that unannounced visits (or at least one), may have provided for a better view of a real picture. It is not part of assessment policy to undertake unannounced visits unless there are concerns. It could be argued, therefore, that families who are desperate to provide an overly optimistic view are able to depict a perfect life. The author would suggest that unannounced visits should always be undertaken during assessments. 7.16. Both connected carers commented on the speed of the assessment. From when they were approached until the time that Alex went to live with them was four months. This would not be unusual for a case of this nature where it is important to consider the needs of a baby in ensuring a permanent care placement as soon as possible. They also commented that they had a very positive experience of the assessment process with all those that they came in contact with offering support and guidance throughout. 7.17. The review noted that there is often pressure from the family courts to expedite the assessment process; there is no evidence that this was true of this case. Social work professionals stated that this has led to cases where the quality of assessments that are often complex and take time, are compromised in order to comply with court deadlines. 26 weeks is the regulated time allowed to undertake assessments; it can be argued that this not likely allow professionals time for thorough assessments, particularly where placements are a distance from the placing authority. 15 Post Placement Support 7.18. Once approval had taken place things moved quite quickly, again this was felt to be in Alex’s best interests and not contraindicated in policy and guidance. There is however more learning in this element of the review. Some of the issues that occurred post placement will be addressed in the next section as they are relevant to communication. 7.19. One of the main comments from CCF and CCM when they spoke to the author was the surprise that they had not met Alex or FCM during the assessment process. It is of note that until approval had taken place it would not have been in Alex’s best interests to be introduced to strangers who may not be approved to become carers. Once the court had granted a full care order and approved the plan for Alex, introductions began thirteen days later. 7.20. The statutory guidance and local procedures6 do not go into detail about introductions to the child. It is more usual for the child in question to be known to the family and friends’ carers who will be taking on the full-time care of a child. In this case, CCM and CCF did not know and had not met Alex. 7.21. There were two periods of time spent with Alex over a two-week period. The most notable element is that this was mostly unsupervised by social workers and was managed by the foster carers. When this was questioned in the review, it was stated that the foster carers were very experienced local authority carers. There were in fact no issues with the transition but CCF and CCM had expressed surprise at this, given the contacts and assessment process they had experienced as being quite different. Professionals involved in the review identified that this was not best practice and should have been subject to more social work oversight. 6 Walsall Children's Services Procedures Manual: Chapter 3.2.3 Placements with Connected Persons; available at https://walsallchildcare.proceduresonline.com/chapters/p_place_rels.html Accessed 18 September 2019 Learning Point 1: Distant placements can impact on assessments and visits Learning Point 2: Family dynamics may impact on motivation to care for a family child Learning Point 3: Reticence to foster a family child is an indicator that needs full exploration Learning Point 4: It is important that engagement in assessment needs clarification at assessment commencement and any non-engagement receive robust challenge Learning Point 5: Expediting assessment timescales may impact on the quality of the assessment. 16 7.22. Again, one of the reasons suggested in the review for this was the distance. It is arguable that there could have been more introductory visits in Area A before Alex was taken to Area B for any visits. It is of note that another child in the same foster placement was being prepared for a move of placement and that the timing of this impacted on the speed that Alex was moved. This was not in Alex’s best interests and should have been challenged. 7.23. It is fair to say that it would be very unsettling for Alex to have been taken back and forth between area A and B very often, but there was no other reason not to have more observation over this period by social workers, apart from the distance. Use could have been made of social workers local to Area B. As social workers are very busy professionals, there could be more use made of reciprocal arrangements to support some observational visits. This was not explored as it is not usual practice. 7.24. As a result of this review, however, the adoption and fostering team are now undertaking this and making more contact with social workers and other agencies in the placement locality to support their work with out of county placements. 7.25. There are parallels with adult services where adults with special needs are placed out of county. As a result of several high-profile reviews of adults abused in care, there have been more reciprocal arrangements for reviews to be carried out by the host authority where distances are prohibitive for regular travel. Whilst it may not be possible for all statutory visits to be of that nature, there is certainly conversations and agreements that could be had regarding localised support and visits for connected carers. 7.26. Notwithstanding the communication issues that will be discussed later, it is of note in this period that activity from professionals was reduced. The assessment had been positive and there were no concerns identified with the transition or at any point in the five months before Alex became critically ill at home. 7.27. The first couple of statutory visits, the looked after review and the visit from the supervising social worker all took place without any issues being identified and all happened as planned in the first six weeks. 7.28. CCM had been proactive in registering Alex with the GP, making contact with the health visitor and attending the health visiting clinic. 7.29. Issues of note include that CCF was never seen following Alex’s placement as he was always at work and the older children were not spoken to alone following Alex coming to live with them. The reason for this was that as there were no concerns and everything was going as expected, it was not considered necessary. Although the children were often at school it 17 may have been beneficial as part of recording post placement observations that the children remained settled in school and that there was nothing negative to note. 7.30. There were also no unannounced visits, although it is only a requirement for one in the first 12 months and again there was no reason to suspect that it was necessary to undertake one sooner. 7.31. The health visiting service made contact with CCM following her call to the service to notify them that Alex had been placed with them and a home visit was arranged. Again, there were no concerns identified; the health visiting service knew the family well and had no concerns. CCM did not raise any concerns regarding caring for Alex. 7.32. Health visiting contacts were problematic and not coordinated: When CCM took Alex to clinic the following week, the contact was recorded in the clinic attendance book but not the electronic record. The notification from Area A Looked After Child team that Health Assessment was due, did not result in a prompt assessment, in fact it was not undertaken by the time of the critical illness of Alex, due to significant backlog of reviews. Alex was unwell on an arranged clinic appointment; the rearranged appointment was not attended and there was no follow up. Alex was seen in clinic for the 9-11 month review rather than being seen at home as would be required for a child in receipt of UPP health visiting service. There was then a change of health visitor. The new health visitor made contact to arrange a home visit; Alex was admitted to hospital before this visit took place. 7.33. It can therefore be seen that Alex was only seen at home once and in clinic twice by the health visiting service in the five months in Area B. 7.34. There were a variety of reasons for these issues that were identified in the health visiting service agency review report. There were staffing issues that were largely responsible for the lack of contact from the named health visitor. It was reflected that the health visiting service knew CCM well from the other children, and that there had been no concerns. The health visitor felt that as Alex was a Looked After Child that other children on the caseload took priority as Alex was deemed to be in a place of safety that had been assessed as such. 7.35. The Looked After Child health assessment was not undertaken. The priority in clearing the backlog of assessments was for those that were initial assessments. 7.36. The areas above have all received attention from the health visiting service and recommendations have been made in the single agency review report to overcome these 18 issues. It is noted that the staffing issues in the health visiting service had been noted on the service risk register at the time. 7.37. Whilst it is acknowledged that the above has been addressed, the author would add that there is a misconception that children who are looked after are always safe. It is also the case that the case of connected carer placements should be viewed differently. 7.38. These types of placements are not from carers that have put themselves forward to become foster carers but have been identified in order to keep a child in the family. It is of note in this particular case, that CCM and CCF did not know Alex, Alex was not a close family member. The author would suggest that there could have been, (although not evidenced) a degree of pressure placed on CCM and CCF to take on the care of Alex, given that a previous baby had been adopted out of the family. There was no one else within the family who could care for Alex, therefore CCM was the only option to prevent Alex being adopted like the previous sibling. Whilst CCM appeared to be keen, the author notes that this was to be CCM’s sixth child and that CCF was initially less keen. 7.39. In relation to the looked after child health assessment, the paperwork to consent and request the assessment, does not detail the nature of the fostering arrangement. This means that it is not clear to professionals planning and undertaking assessments that this is a placement with family and friends. It also means, in prioritising the backlog of assessments, children placed with family and friends’ carers could not be identified and prioritised. The Area A Looked After Children’s Health Team have now made amendments to the paperwork to allow for type of placement so that increased understanding and support can be offered. 7.40. The developmental delay, albeit not seen as a major concern, had been noted for review in three months. The medical undertaken five months before as part of the fostering process, noted that developmental progress was on track with no concerns. At the review at 10 months there was some delay to development. Without previous records to review, it was not possible for any relevance to this delay to be picked up. The author would suggest that a follow up in the home environment sooner than three months could have been triggered based on: An assessment that is usually required at home was done in the clinic setting Information from records indicating that developmental delay had not been a feature at four months 7.41. The issues raised by CCM when she met with the author regarding significant difficulties in feeding, the way that Alex slept and the concerns with Alex constantly bumping into things 19 was not identified by the health visitor and was not mentioned to the health visitor by CCM. Visiting professionals did not note these issues when they saw Alex in placement. Coordination and Communication Within and Between Areas 7.42. This case featured a placement that was a considerable distance from the placing authority. It appears that this led to some communication issues that may not have been a problem had the placement been local. Hence there is further learning here. 7.43. The first noticeable communication issue was related to the notification of placement of a child out of area not being received by Area B social work services. 7.44. It is not clear why this was the case. The review has identified that with electronic systems being relied on more and less hard copy paperwork that there ought to be a trigger within the electronic recording system that provides for confirmation of receipt from the receiving area. This is more important in the current financial climate where administration roles have been reduced and a reliance on social workers to manage administrative tasks and therefore triggers are seen as helpful. Area A social workers have undertaken to contact the receiving area by telephone to confirm receipt due to learning from this review. 7.45. There was a change of provider of health visiting service in Area B that led to significant service changes that had been ongoing for two and a half years at this time through a planned programme of change. There is evidence that there were some issues related to that change that affected service delivery and communication both within and between services. 7.46. The health visiting service in Area A, found out about Alex’s placement through electronic systems as a result of Alex being registered with a new GP. There was a prompt telephone call to hand over to the new health visitor. This was made to the Single Point of Access (SPA) health visiting duty line. This was also a new service delivery model and a new way of working for the health visiting service. The message to Area A was that Area B health visiting Learning Point 6: Statutory visits should provide a robust assessment of ongoing placements. Unannounced visits also provide a window on the placement. Learning Point 7: Children who are Looked after may be at risk of harm; being looked later in foster or connected care situations does not automatically mean safety Learning Point 8: Children benefit from the status and type of fostering relationship being known by the professionals that they come into contact with. Learning Point 9: The nature of connected carer arrangements may lead to a better understanding of any risk. Learning Point 10: It is important that professionals recognise the difference between various fostering arrangements and prioritise visits and reviews accordingly. 20 service was paper light and therefore paper records were not required. This is not recorded as a conversation that had taken place by the SPA in Alex’s electronic records. This was a misconception by the SPA health visitor and is not the case. At the time there was a backlog of records waiting to be uploaded to the new electronic system and had been outsourced. It was not the case that paper records were not required, particularly where a child had special needs or was subject to child protection, child in need or was looked after. It appears that communication from management regarding expectations on receiving records into the new systems was not clear. This is now being rectified as a result of risks highlighted in this case. 7.47. There were further communications issues regarding the Looked After Child Health Assessment. This, in part, started because of the delay in notification. When the consent for the assessment had been completed, it was related to Area A as it had been due a month after the transfer out. There was a delay in gaining consent for the assessment in the new area. A more proactive approach by ensuring that the right consent has been completed in cases where children move placement is required and again should be part of the prompt system to ensure that human error factors are reduced. 7.48. One of the main communication factors in this case was that health visiting and social care did not communicate over the cancelled visits over the last few weeks of the placement. There were various reasons given for the cancelled visits all of which were plausible but by not having a combined picture and due to the short timeframe that this happened, it was not possible to identify a pattern. There was only one occasion where Alex was not brought for a health visiting clinic appointment with no explanation. Most of the children had suffered from chicken pox and then Alex did. This was over the Christmas period when all the children were off school. This must have been a very stressful time for the family and in particular because CCF did not live in the family home. The author would suggest that the fact that the children had chicken pox did not preclude a visit unless there was a known pregnancy or vulnerability (in a professional) that would be a contraindication to visiting. This was a family where more support might have been helpful at this time. Professional curiosity was needed to understand and question the pressures that might have been present. 7.49. It is a known issue in supporting families and recognising patterns, that having a visual simple chronology within records that is easily accessible when you open a record (paper or electronic), can help to build a picture of any emerging patterns, support assessment, aid supervision and support multi agency working. Both Professor Jay and Lord Laming’s 7, 8 reports on inquiries into child abuse identified that the lack of up to date chronologies was a 7 Jay, A (2014) Independent Inquiry into Child Sexual Exploitation in Rotherham, 1997-2013 8 Laming, H (2003) The Victoria Climbié Inquiry, London: Cmnd 5730 HMSO 21 barrier to recognising concerns. 7.50. Chronologies’ are often used retrospectively to collate historical information in order to inform inquiries and decision making after a child incident. It is also possible and necessary to have an active live chronology for the reasons stated above. Chronologies should record key changes (e.g. address, worker) events (e.g. reviews, assessments, missed appointments). In order that a chronology is effective it is important that it is not too detailed and that the full recording is still in the right place within the record. 7.51. Although there is recognised learning here, the cancelled visits and appointments with health and social care started 10 weeks before Alex was admitted to hospital. In that period Alex was seen by the IRO, the supervising social worker and the allocated social worker, Alex was also seen in clinic for the 9-11 month review. It was the three weeks after Christmas that Alex was not seen when all appointments were cancelled by CCM. This may not have been enough time to recognise any pattern of cancellations in a family where there were no previous concerns of not bringing children to appointments. 7.52. Communication regarding statutory looked after reviews was also problematic. The health visitor in Area B was not invited to the reviews and did not actively seek to understand when these were taking place. Without being a full multi agency review it could not have been robust. The indication that there was some developmental delay identified at the 10-month review was not shared with the social worker or the IRO. There was an action for the health visitor to visit monthly from the first looked after review in placement. As the health visitor did not attend and the minutes were not sent, the health visitor was not aware of this. 7.53. Area A Looked after children health team have added the name of the IRO and the date of the next Looked after Child Review to the paperwork for health assessment in order to improve communication to allocated health professionals. 7.54. Both health visiting and social care cited reasons for these errors. As previously indicated, there were health visiting vacancies impacting on the service, recent changes were still embedding and there were teething problems with new systems. Social Care have indicated that as resources have reduced, administrative support has been diminished. This means that many of the above communication issues that were previously administrative tasks are now being undertaken by social workers. 22 8. GOOD PRACTICE 8.1. It is important to note that many practitioners offer a good level of service to the families that they work with and follow policies and procedures that are provided to guide practice. Whilst recognising gaps in practice, serious case reviews can also provide evidence of good practice. 8.2. On reviewing this case, there is evidence of some very good assessments and understanding of the connected carers and the home and care that they would be able to offer Alex. Attendees at the workshop were asked to identify further good practice from their own and other agencies involvement. It is important to highlight these as areas where learning can occur. There was good communication between the assessing social worker and the child’s social worker. The fostering panel were in receipt of all reports and assessments that were undertaken in order to inform their decision. Information within the social work records indicated that when the family were seen that there was a good level of observation and interactions recorded. There was a verbal handover from Area a to Area B health visiting service. The family reported being very well supported throughout the assessment process. Where this case has identified issues in systems, agencies have already responded and made relevant changes. Alex was placed in a timely manner. Statutory Looked After Child reviews were completed in timescale. 9. CONCLUSION 9.1. Notwithstanding the good practice identified throughout this review, it can be identified in drawing together conclusions in this case, that most learning relates to the use of systems Learning Point 11: Changes to service delivery can lead to unexpected risks and challenges. A forum for identifying issues quick with a prompt response is necessary in order to safeguard children. Learning Point 12: Proactive professionals ensure that there is no service breakdown when a Looked after child moves placement Learning Point 13: Active chronologies in the front of records provide a valuable oversight tool in assessment and risk management. Learning Point 14: Communication between health and social care regarding looked after reviews and outcomes must be robust to ensure children are safe and that the Looked After Childcare plan is compiled with. 23 to support multi agency working. 9.2. The majority of connected care placements for looked after children provide a positive solution to alternative care within a family. There is, however, learning regarding the assessment and placement of children with connected persons that differs from those placed with registered foster carers, that professionals did not appreciate. 9.3. Professionals viewed the looked after status of Alex in the same way that they would have done from a registered foster carer. CCM and CCF were robustly assessed but had not undergone any of the formal training that foster carers would. Missing in the post placement ongoing observations were hearing the voices of the other children and not seeing CCF with any of the children or Alex after the placement. CCF’s initial reticence to take Alex was not completely understood by assessing professionals. 9.4. CCM and CCF had no contact with Alex prior to placement and unlike many connected care placements, Alex was not known to them. The number of visits post placement by health and social care were not in line with requirements and there were no unannounced visits either pre or post placement. The distance of the placement played its part in not making contact easy but alternative solutions could have been sought. 9.5. There was a common view that this was an excellent placement choice for Alex. Alex was being kept within the family and the assessment had been extremely positive. Despite the initial reservations that the assessing social worker and the IRO had about the number of children in the family, they found that the environment was extremely positive and child friendly with all the children looking forward to welcoming Alex into the family. 9.6. In hindsight, professionals have now questioned if this view was too good to be true and have wondered whether there should have been more professionally curious to understand whether there were any family dynamics that placed pressure on CCM and CCF to take Alex. The need to portray an environment and home for Alex that was never in question may have taken precedence over the need to be honest about any difficulties that may have ensued. The concerns that CCM discussed with the author regarding Alex’s development and behaviours were not highlighted to any professional. 9.7. Post placement, the health visiting service knew CCM well and therefore knew her to be a competent mother. The social workers were confident that this was a positive placement and did not question cancelled visits and neither did the health visitor. The health visitor and the social worker did not communicate post placement and the health visitor was not invited to, nor proactively sought attendance at Looked After Child reviews. 24 9.8. It has to be noted that even if there had been more professional curiosity regarding the seemingly perfect placement, that it may well have still been considered a satisfactory environment for Alex. The author would question whether the addition of Alex to the number of birth children that CCM already had was too much given that CCF was not resident with the family. Whilst all children were well and being well behaved it could be seen that this would not be an issue. However, when illness affects a family and usual sibling squabbles and behaviour challenges of older children and toddlers are included, parenting becomes more of a challenge and needs additional support particularly in a case where there is a looked after child added to a large family. 9.9. Nothing, however, that came to light during this review would have led to any professional being concerned regarding the care that CCM and CCF would give Alex and there was no indication that Alex would suffer significant harm whilst in their care. 9.10. There is learning, however, that can inform and improve future practice for children placed in family and friends care. 10. RECOMMENDATIONS 10.1. The findings identified above has been included in learning points throughout this report and lead to recommendations/actions for improvement for both areas’ Safeguarding Partnerships. 10.2. Where agencies have made their own recommendations in their Agency Review Reports, the relevant area Safeguarding Partnership should seek assurance that action plans are underway, and outcomes are impact assessed within those organisations. 10.3. The following multi agency recommendations/actions are made to the relevant area Safeguarding Partnership as a result of the learning in this case: 1. Assessment a. Area A Safeguarding Partnership must be assured that local practice guidance to supplement social work procedures chapter “Placements with Connected Persons’ and other relevant chapters are updated to include the following guidance and clarifications: i) Assessments for connected carers must include a thorough review of family dynamics and explore motivation to undertake the long-term care of a distant relative’s child. ii) Unannounced visits should be undertaken during the assessment phase and six-monthly post placement. 25 iii) Where children are placed a distance away, social workers should seek support from the local authority where the child has been placed and should reciprocate those arrangements with other local authorities. iv) Once approved, there should be a child centred period of introduction to the connected persons where the child is not already known to them. v) In keeping with Walsall Council’s Policy on Supervision and Support of Foster Carers, as part of Supervisory Visits to Foster Carers, children living in the household are to be consulted on a bi monthly basis. Their views should also be sought and health and well-being reviewed post placement and as part of the annual review. vi) Other approved connected persons absent at statutory/supervisory visits must be seen bimonthly. vii) Expectations for ongoing training and development of approved connected persons. viii) Rationale for not having the same IRO for all birth siblings looked after should be recorded. Where there are two or more IRO’s they must work, meet and communicate together to share information. 2. Regional and National Issue to be Raised Area A Safeguarding Partnership should raise with the Family Justice Board and the Department for Education the points highlighted in Recommendation 1 to ensure that regional and national protocols and guidance take account of the learning from this SCR. 3. Connected Persons/Family and Friends Care Understanding Area A should produce a seven-minute briefing regarding connected carers, highlighting the difference between connected carers and registered foster carers. Area B Safeguarding Partnership should determine the relevance and implementation of this learning for their area. 4. Chronologies Area B Safeguarding Partnership should determine how they can be assured that chronologies are routinely updated in records for families, subject to Universal Plus and Universal Partnership Plus Health Visiting offer. 5. Multi Agency Working Area A must seek assurance that where a child is looked after: a. All professionals relevant to the child’s care, actively seek to be involved with and/or provide information for Looked After Child Reviews. Minutes must be circulated to all even if the professional did not attend the meeting. 26 Area A Safeguarding Partnership must seek assurance that where a child is looked after: b. Notifications of placement and request for health assessment must have space to identify type of placement (differentiating family and friends care from foster care), next health assessment due date and date of next looked after child review. c. Notifications of placement must be followed up with confirmation of receipt. Area B Safeguarding Partnership will also need to determine how they should implement learning in recommendation 5a. 6. Audit Area A Safeguarding Partnership must undertake a multi-agency audit of Looked After Children placed in Family and Friends Care within 12 months based on learning in this review. This will assess practice and outcomes for those children. 27 Appendix One Terms of Reference (REDACTED) Serious Case Review Terms of Reference and Planning Document 1. Introduction: The request for a Serious Case Review was agreed by the Independent Chair of WSCB following a Rapid Review meeting. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Serious Case Reviews and other case reviews should be conducted in a way in which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. (Working Together Chapter 4 para 11, March 2015) As set out above this SCR will be undertaken in line with Working Together to Safeguard Children 2015, it will also comply with the Working Together: Transition Guidance (July 2018). Once the LSCB ceases to exist the completion of the SCR will be overseen by the new safeguarding partnership arrangements. 2. Case summary Alex was 11 months old and was placed with connected carers in Area B subject to a full Care order placed by Area A. Alex was taken to Area B Hospital by ambulance with 28 suspected non accidental injuries, where she had a CT scan of her head and a full skeletal X-ray. She was admitted with cardiac and respiratory failure. The tests found that Alex had a bleed to the right side of her brain which was causing pressure, a bleed within her adrenal gland, an old fracture of her rib, and evidence of a past bleed in her lungs, which could have been injury or past infection. Added to this Alex also had extensive bruising reaching from her forehead, now to her body arms, legs and sole of her foot. As a result of these injuries, Alex remains in hospital. Plans are underway for transfer to a Children’s Hospice. A Do Not Attempt Resuscitation order has been agreed and signed by relevant parties. 3. Terms of Reference for the SCR 3.1 Subject Alex 3.2 Scope The SCR will cover the period Just prior to placement with connected carers- Date of Incident 4. Methodology This Serious Case Review will be undertaken using a hybrid methodology that will analyse the complex circumstances that practitioners work in and provide opportunities for shared learning and lead to improvements in the way in which agencies understand their roles and responsibilities and work together to promote the safety and well-being of children. Agencies will be asked to review their own involvement with the family and to produce an Agency Review Report. This will be followed by the sharing of the written material in order that learning can be shared in and analysed taking into account the view of the professionals that were involved at the time. This process will involve 2 round table Practitioner Reflection and Learning Workshops to ensure practitioner and first line manager involvement in the review. This methodology takes into account the requirements in Sec. 1 above. 5. Areas of consideration: In addition to the scoping period, agencies are asked to provide any relevant background information that they consider will be important in setting the context for the later family situation. Also, the following questions should be addressed: Out of Scope Contextual Consideration: a. What did your service know of the plans for Alex both Pre and Post birth? How was your service involved in the assessment and planning for Alex’s placement with connected carers? If relevant, please analyse the detail of the assessments undertaken by your service? 29 In Scope considerations: b. Prior to placement of Alex, what contact did your service have with the other children of the connected carers? Did any of these contacts raise any concerns? c. How was the transition managed from foster care to placement with connected carers? What arrangements were made to ensure transition was smooth for Alex and the new family? d. Following the placement of Alex with the connected carers, how and when was your service notified? What action was taken by your service and what assessment/contact did your service have? Please include all contact and assessments from beginning of July up to date of incident. e. Did practice within your service meet the required standards set by your agency? (Please expand on your answer providing evidence). f. Please comment on liaison between professionals and record keeping in the case generally. g. Were more senior managers or other agencies/professionals involved at points where they should have been? Provide appropriate examples h. Is there evidence that this case was subject to the appropriate supervision and managerial oversight? i. Please identify examples of good practice, both single and multi-agency. 6. Family Engagement An important part of a Serious Case Review is the involvement of family members so that their thoughts and viewpoints can be incorporated both to the review itself and any learning. The overview author will make contact with relevant family members once agreed and authorised. Family members to be considered and included will be both birth parents, foster carers and connected carers. Feedback will be offered at the end of the Serious Case Review process. 7. Overview Author Walsall Safeguarding Children Board have commissioned Karen Rees, an Independent Safeguarding Consultant to undertake this SCR. 8. Organisations to be involved with the review: Area A Council Children’s Social Care 30 Area A Health and Care Trust (Midwifery, Health Visiting and Looked After Children Team) Area B CCG/GPs for both connected carers and children of connected carers Area B NHS Foundation Trust (Salisbury Hospital) Area B (Health visiting and School Nursing) Area B Police 9. Timeline for Review: The SCR will follow the following timeline: Safeguarding Board Rapid Review Meeting 11 February 2019 Letters to Agencies/Authors etc. TBC Scoping Meeting 29 April 2019 Authors’ Briefing via telephone TBC Agency Reviews submitted to WSCB 1 July 2019 Quality Assurance of Agency Reviews by Chair/Author 2-5 July 2019 Agency Reviews Reports distributed 10 July 2109 Practitioner Learning and Reflection Workshop (Whole Day) Tuesday 16th July. 1st Draft of Overview Report Distributed to all attendees 10 September 2019 (1 week before workshop) 2nd Review Learning and Reflection workshop (½ Day) 17 September 2019 V2 Overview Report Distributed to all attendees 7-9 October 2019 Comments on V2 latest by 21 October 2019 Version 3 to Subgroup members 28 October 2019 Subgroup meeting 4 November 2019 V4 to subgroup and Board 18 November 2019 Final Overview report presented to WSCB 4 December 2019 |
NC52178 | Sexual abuse of a boy under 8-years-old from January 2014 to October 2016. Freddie lived with his mother and two older half-siblings who were known to children's services due to concerns including neglect and physical abuse. Evidence of sexual abuse of Freddie's half siblings by their father. Freddie's mother started a relationship with a person posing a risk to children. The children were made subjects of Child Protection Plans under the category of sexual abuse in June 2014. Accounts of Freddie displaying sexually inappropriate behaviours at pre-school; excluded from school in June 2015 for displaying aggressive and sexualised behaviours. In March 2016, Freddie was taken into local authority care due to neglectful parenting. Whilst in care Freddie made statements about sexual abuse that had taken place within the family, and in October 2016 he was made the subject of a final Care Order. Learning includes: importance of management support and supervision when working with intra-familial child sexual abuse; the value of seeking additional input from specialised services in helping professionals remain objective and child focused; not letting biases of professionals towards parents hamper judgements and undermine decision making. Recommendations: ensure that the plans for children subject to Child Protection Plans are fit for purpose and have pace; to examine blocks and barriers to effective multi-agency work around the issue of child sexual abuse; and increase the knowledge and confidence of practitioners in assessing and working with cases involving child sexual abuse.
| Title: Serious case review: Freddie: review report. LSCB: Southampton Safeguarding Children Partnership Author: Kevin Ball Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Freddie Review report Independent Reviewer: Kevin Ball CONTENTS Section Page 1.Introduction to the case & synopsis of the review 1 2. Process for conducting the Serious Case Review 1 3. Family structure 2 4. Summary of relevant case history - Summary of relevant case history prior to the timeframe under review - Summary of relevant case history during the timeframe under review - Practice episode 1: Being subject to a Child Protection Plan 3 – 7 5. Findings & analysis - The quality & effectiveness of multi-agency working & child protection processes - The use of family history to inform assessments & decision making - The recognition & response by professionals to actual or potential harm - The assessment of the grandparents to provide a safe place for Freddie - Current practice challenges raised relating to the findings of this case 7 - 23 6. Family contribution to the review 23 7. Good practice 24 8. Conclusion 24 9. Recommendations 25 1 1. Introduction to the case & synopsis of the review 1.1. Based on statutory guidance1 Southampton Safeguarding Children Board concluded that it was appropriate to conduct a Serious Case Review examining the circumstances of agency involvement with a child under eight years old who, for the purposes of this report, will be known as Freddie. 1.2. Freddie had a long history of contact and involvement with statutory services due to concerns about neglect and harmful sexual behaviours. As a result of these concerns Freddie was judged as no longer safe to remain living with his family and was taken into local authority care. Whilst in care, Freddie made a number of statements about sexual abuse by family members, as well as providing information about other sexual abuse that had taken place within the family. Given the involvement of a number of statutory agencies at the time of this alleged abuse taking place, the decision to conduct a serious case review was deemed appropriate due to the abuse or neglect of a child being known about or suspected at that time, and that a child had been seriously harmed and there were concerns about the way in which agencies had worked together. The Police initiated a criminal investigation into these matters however at this stage no further action was to be taken. 1.3. By way of a summary, the review has highlighted a number of lessons for the safeguarding partnership. These include; - Freddie was subject to a Child Protection Plan; this was mostly ineffective, offered little additional safety to Freddie and siblings. There was considerable drift, a lack of pace and purpose and ineffective multi-agency working. - There were a number of contributory factors to the drift. The most notable include there being a collective uncertainty across the professional network about how to best manage the risks to Freddie, delays in assessment work being completed, sympathy for the Mother’s situation distracting the professional view about the children’s safety and welfare, and inadequate management oversight from Children’s Services. - Challenge and escalation by professionals across the partnership was limited. - The ability of Children’s Services and to effectively fulfil their statutory functions as the lead agency were compromised due to multiple systemic challenges during the critical time period of Freddie being subject to a Child Protection Plan. 1.4. The review has also highlighted ongoing challenges and opportunities as services improve for the professional network in responding to cases that have a similar profile as this case. 1.5. This review has benefitted from the contributions of a number of agencies and professionals that were involved with the children, gained Freddie’s mother’s perspective, captured a number of points for learning and improvement and concluded with recommendations for the Safeguarding Partnership to take forward. 2. Process for conducting the Serious Case Review 2.1. Southampton Safeguarding Children Board commissioned Kevin Ball as the Independent Reviewer2. The approach taken has adhered to the principles set out in statutory guidance3 and has applied systems thinking ideas to the findings and analysis. As such, the process has been able to capture and identify opportunities for professionals and organisations to learn and improve safeguarding practices from a whole system perspective. 1 Working Together to Safeguard Children, HM Government, 2015. 2 Kevin Ball is an experienced independent safeguarding consultant from a children’s services background, an independent Scrutineer and has specific experience of chairing & authoring case reviews. 3 Working Together to Safeguard Children, HM Government, 2015. 2 2.3. At the time of the decision in July 2018 by the Independent Chair of the Board to commission this review there was a Police investigation into the statements made by Freddie. As a result, there was an agreed delay by the LSCB initiating the review. Consequently, the review did not begin until January 2019. The following steps were then taken; - Terms of reference for conducting the Review were then set by the Case Review Sub-Group4, - Single agency reports and chronology were requested and submitted5. This process provided each agency with the opportunity to reflect on their involvement with Freddie and his family, from both a single agency viewpoint but also from a wider, and more interactive systemic perspective. As a result, agencies have been able to consider actions required of themselves in order to make improvements to practice, - The contribution of practitioners that had contact with Freddie and his family has been gathered through the process of completing each single agency report. Given the course of time a number of practitioners, managers and relevant personnel are no longer in post. Practitioner contribution to this review has therefore been limited and best efforts have been made where-ever possible. - The LSCB Case Review Sub-Group determined that the approach to this review should be proportionate especially given the passage of time and the need to position learning and findings within current practice. On this basis, the review has comprised mainly of a documentary review and analysis by the Independent Reviewer following the receipt of single agency reports. 2.4. It was agreed that the timeframe for the Review would be from January 2014 through to Freddie being made the subject of a final Care Order in October 2016. Relevant information prior to this timeframe is also included. 2.5. Limitations to this review: - The focus of this review is to examine the quality and effectiveness of multi-agency arrangements in respect of Freddie. This report does refer to Freddie's siblings, notably Sibling 2, however he is not the subject of the review. - Information was submitted to this review that explicitly described some of the sexualised behaviours that Freddie is reported to have been subject to and which he disclosed to professionals at the time whilst he was in his mother's care. On balance, recognising that this report will be placed in the public domain, and the need to be respectful and sensitive to Freddie and not cause further harm, the general consensus of those responsible for commissioning the review, was that the explicit references should not be used. On this basis, Freddie's voice is lessened and potentially limits the impact of the review. 3. Family structure 3.1. For the purpose of conducting this review the following individuals are relevant; Individual Identified as Individual Identified as Subject child Freddie Mother to Freddie Mother Older half-sibling Sibling 1 Father to Freddie Father Older half-sibling Sibling 2 Father to Siblings 1 & 2 Father 2 4 The Case Review Sub-Group is a sub group of the Southampton Safeguarding Children Board. 5 Single agency reports were submitted from the following agencies; - Southampton City Council Children’s Services - Hampshire Constabulary - Southampton City Council Education SEND Service - Southampton City Clinical Commissioning Group - University Hospital Southampton Foundation Trust - Southampton City Council Legal Services - Primary School A - Solent NHS Trust - Behaviour Resource Service (Health/Children’s Services service) 3 4. Summary of relevant case history 4.1. Summary of relevant case history prior to the timeframe under review (prior to January 2014) 4.1.1. Sibling 1 and 2 had been known to Southampton Children’s Services since 1999 due to concerns about neglect, physical abuse and punitive parenting, social relations and harassment of the Mother from an ex-partner. 4.1.2. In 2004 the Mother and Father 2 separated, and the Police investigated a report by the Mother that Sibling 1 and Sibling 2 had experienced inappropriate sexual behaviours from their father. This information was shared with Children’s Services. As no forensic evidence of sexual abuse was available it was agreed the matters were filed and remain on record. 4.1.3. In 2007 there was an allegation of indecent assault on Sibling 2 perpetrated by his father, Father 2. There was insufficient evidence to pursue this matter. 4.1.4. In 2008 the Mother entered into a relationship with a Schedule One offender6. The offender was spending most of his time at the family home, which resulted in a Child Protection Plan being agreed in August 2008 as the Mother initially chose to continue her relationship with the offender above that of her children’s safety. Sibling 1 went on to make an allegation of sexual assault by the offender, which was proven by medical evidence. The Child Protection Plan ended in March 2009 on the basis that the Mother had subsequently ended the relationship and the offender had been charged and remanded for offences. 4.1.5. During 2011 there were 17 contacts to Children’s Services reporting the Mother as struggling to manage Siblings 1 and 2 and Freddie. In 2012 there were a further seven contacts, including directly from the Mother who was struggling to manage the children. A CAF7 was completed identifying the need for support for the family; but with no role for Southampton Children’s Services. 4.1.6. In 2013 the Mother requested further help with Sibling 2. The Child & Adolescent Mental Health Service (CAMHS) noted the following factors; the inconsistency of the Mother’s parenting; not managing boundaries; being reliant on Sibling 2 to parent the younger siblings; blaming Sibling 2 for Freddie’s behaviours; and lack of concern about the individuals Sibling 2 was associating with and his potential drug use. In November 2013, when Freddie’s Pre-School provision contacted Southampton Children’s Services concerned about his behaviour and pre-occupation with genitals (aged 4 years), commenting on the inappropriate sexualised behaviour by his father towards him. 4.1.7. In 2014 Sibling 2 was charged and convicted of rape offence however this conviction was successfully appealed with a lesser offence substituted. 4.1.8. From 2013 - 2014 the Police responded to a high volume of reports from the Mother relating to anti-social behaviour, assaults and criminal damage. Seven referrals were made to CAMHS at the request of the Mother, insisting that Sibling 2 had a mental health issue or learning disability. He was later diagnosed with ADHD and ODD8. 4.2. Summary of relevant case history during the timeframe under review (January 2014 – October 2016) 4.2.1. Accounts of Freddie displaying sexually inappropriate behaviours whilst at Pre-School and then into school continued throughout the timeframe. Throughout the time period under review there were reports and incidents of 6 A Schedule One offender is someone who is convicted of an offence listed in the first schedule of the Children and Young Persons Act 1933. The term Schedule One offender has now been replaced and is now known as a ‘person posing a risk to children’. 7 CAF – Common Assessment Framework which provides an opportunity to assess a child/family circumstances. 8 ADHD - attention deficit hyperactivity disorder, and ODD - Oppositional Defiant Disorder. 4 anti-social behaviour from the local neighbourhood, common assaults relating to Sibling 2, and public order incidents. Sibling 2 was also reported as going missing for short periods of time on a number of occasions. 4.2.2. In April 2014 Children’s Services confirmed that there was no role for them but that an early help (Families Matter) worker would continue to offer support and advice to the family. However later in April 2014 there was a section 479 investigation, following referral from the Families Matter worker due to further concerns Freddie was displaying inappropriate sexualised behaviour in Pre-School. This resulted in a single agency investigation by Children’s Services and then Freddie and Sibling 1 being managed via Child in Need10 procedures. Following a consultation by the Behaviour Resource Service (BRS)11 it was concluded that Freddie’s behaviour was judged as ‘normal and exploratory’ however the assessment expressed concern about the frequency and persisting nature of the sexualised behaviours, that they may become harmful and that services with statutory responsibility should take action, as necessary, to safeguard Freddie if judged appropriate. 4.2.3. In June 2014 there was a section 47 investigation due to Freddie making statements about both his mother and father behaving towards him in an inappropriate sexual manner. Freddie was also reported as behaving inappropriately with a Social Worker. The school had a catalogue of incidents where Freddie had touched or tried to touch children. There was no clear disclosure to pursue a criminal investigation however there was agreement for an Initial Child Protection Conference (ICPC) in respect of all three children. Also in June 2014 there was a further rape allegation against Sibling 2. No further action was taken by the Police in this matter due to the evidential threshold not being met. As part of the investigation taking place in June 2014 concerning Freddie, BRS agreed to undertaken an AIM assessment12 of Freddie and the Youth Offending Service to complete an assessment of Sibling 2. 4.2.4. All three children were made subjects of Child Protection Plans under the category of sexual abuse in June 2014. Date Comment June 2014 Initial Child Protection Conference All children were made subjects of Child Protection Plans under the category of sexual abuse13. The Chair noted that ‘… it is important to recognise that it is not known where the risk is coming from and it is a crucial part of the plan that this is explored quickly …’14. All relevant professionals were present at the ICPC other than the Health Visitor and GP, but both sent reports. 9 A strategy discussion is held under Section 47 of the Children Act 1989 which provides the local authority with a duty to make enquiries as considered necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare, where there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm 10 Child in Need - Section 17 of the Children Act 1989 imposes a general duty on the Local Authority to safeguard and promote the welfare of children who are ‘in need’ and to promote the upbringing of children in need by their families by providing a range and level of services to meet those children’s needs. A child in need is defined as a child: i) who is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision of services; ii) or a child whose health or development is likely to be significantly impaired, or further impaired, without the provision of services; iii) or a child who is disabled. 11 The Behaviour Resource Service is a jointly funded health/children’s services resource that (at the time) offered a service to high risk and complex cases. 12 AIM assessment is a specific assessment tool for understanding sexually harmful behaviours towards other children. 13 Sexual abuse is defined as ‘ … forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example, rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children …’. Working together to safeguard children, 2015, HM Government. 14 Southampton Children’s Services: documents submitted to the review. 5 July 2014 Core Group Freddie’s new school, and the School Nurse were absent from this initial meeting; there was no allocated Social Worker. Exchanges between Children’s Services and BRS suggest that a referral to the BRS was expected but that safeguarding concerns should be pursued as a priority given the significant risks identified about possible sexual abuse. August 2014 Core Group Records indicate the Core Group meeting did not go ahead. In August 2014 a MAPPA15 meeting assessed Sibling 2 as high risk, with ongoing risks identified. As a result of concerns a decision was made in September 2014 that Sibling 2 could be accommodated16. A placement became available however records indicate that this was never pursued by Children’s Services. No suitable alternative placements were found for Sibling 2 and he remained in the family home. Sibling 2 was however found a more appropriate school placement. In August an adolescent female with learning difficulties, reported to the Police that she had been inappropriately touched by Sibling 2. Despite attempts, it was not possible to take the matter any further. September 2014 Review Child Protection Conference 1 The Chair commented ‘… there has been very little progress since the ICPC … there has only been one Core Group meeting … and visits within every ten working days have not been achieved … specific protective work is still required to be carried out by the parents … assessments specified in the CP plan have not yet been undertaken …’17. November 2014 Core Group No minutes available – it is unclear whether this meeting took place. The Police received information that a registered sex offender had been having sexual contact with Sibling 1 breaching his SOPO18. The individual was arrested and charged. In October it was agreed that BRS would become involved with Freddie despite him not meeting the criteria for the service (the risk was judged as high). This may have been endorsed at Director level. December 2014 Core Group This meeting highlighted that the Social Worker had not visited in four weeks due to absence, protective parenting work had not started and Freddie was on a waiting list for CAMHS. The referral information relating to the BRS work, despite being requested in October, was not received until December. January 2015 Core Group Meeting cancelled due to Social Worker sickness; the school were reporting incidents of Freddie displaying sexualised behaviour. The Health Visiting Service were not invited to this meeting. February 2015 Core Group Core group held in family home, which school attended but no other professionals. Delays in the BRS receiving information from the Social Worker were identified. In February 2015 there were allegations by an adolescent female that Sibling 2 had touched her inappropriately. Due to lack of evidence no further action was taken. March 2015 Review Child Protection Conference 2 The children remain subject to a Child Protection Plan. A family assessment was being undertaken by the BRS however they awaited outstanding information before the assessment could be completed. The Mother was engaging with professionals, no concerns identified by the Social Worker regarding the home conditions or supervision of Freddie. No protective parenting work or post abuse work with Sibling 1 had started, no progress in assessing Freddie or identifying the source of sexualised behaviours. 15 MAPPA – Multi-Agency Public Protection Arrangements. 16 Section 20 of the Children Act 1989 - Every local authority shall provide accommodation for any child in need within their area who appears to them to require accommodation as a result of (a) there being no person who has parental responsibility for him; (b) his being lost or having been abandoned; or (c) the person who has been caring for him being prevented (whether or not permanently, and for whatever reason) from providing him with suitable accommodation or care. 17 Southampton Children’s Services: documents submitted to the review. 18 SOPO – Sexual Offences Prevention Order. 6 April 2015 Core Group Highlights that the Youth Offending Service and Family Matters were no longer part of the Core Group. Some progress identified in respect of Sibling 1. May 2015 Core Group Progress was reported about statutory visiting, the Mother engaging with services, yet no update on protective parenting work. School maintain concerns about Freddie’s sexualised behaviour. June 2015 Core Group Freddie had been excluded from school having displayed aggressive and sexualised behaviours. The Mother never mentioned Freddie’s sexualised behaviour when attending support sessions. July 2015 Core Group There was no representative at the meeting to discuss Siblings 1 or 2. Despite still waiting for outstanding information, some details of the BRS assessment were shared during this meeting; there is no indication of how this information was used by members of the Core Group. In July 2015 during a contact session with his Father, Freddie (aged under 6 years) was sexually inappropriate with a three year old child. This was reported to the Police, the Father minimised the incident and Freddie made comments about sexually inappropriate behaviour with his mother. The Police made attempts to discuss this information with the Emergency Duty Team of Children’s Services however it was stated that there was no manager available and the matter was never followed through. September 2015 Review Child Protection Conference 3 No Social Worker for 5 weeks. Freddie continued to display sexualised behaviour and services were still waiting for the final BRS report. The Chair remarked ‘… I can’t see the changes in the family that have been impacting on any improvement of Freddie’s behaviour. The aggressive and sexualised behaviour of Freddie is a massive concern. If things can’t change in the family home to improve this situation we are going to be here is three or four years’ time. We need to consider whether home continues to be protective for Freddie …’19. The children remained subject to Child Protection Plans but the decision was divided about Sibling 1 and 2; the Chair made the decision to maintain the Plan due to ongoing allegations and lack of progress. An emphasis was placed on the need to conduct a formal review of Freddie as there had been no progress for Freddie; Freddie’s behaviour was becoming increasingly worrying. November 2015 Core Group The outcome of the Family Day assessment report are reported as still outstanding (conflicting with the report from July). The BRS were due to start holding play sessions for Freddie. January 2016 Core Group Concerns persisted about Freddie’s sexualised behaviour. Sibling 1 disclosed that her ex-boyfriend sexually assaulted her but due to lack of evidence the matter was not pursued. February 2016 Review Child Protection Conference 4 This RCPC involved a different Chair and new Social Worker. The BRS report was completed however it was viewed as not addressing the issues that needed exploring. The Chair identified that ‘… despite being subject to child protection planning for 2 years (a third of his life) it is still unclear what the root causes of Freddie’s sexualised and aggressive behaviours were …’20. Siblings 1 & 2 were stepped down to Child in Need; Freddie remained subject to a Child Protection Plan. May 2016 Freddie was accommodated section 20 and an Independent Reviewing Officer was allocated. 4.2.5. In March 2016 the Mother reported that she no longer felt able to manage Freddie; the Maternal Grandparents had been supportive over the last few weeks and had offered to care for Freddie. This resulted in a decision the following month to issue legal proceedings to take Freddie into local authority care – it appears this was due to neglectful parenting and not risks associated with sexual abuse. A fostering placement was deemed necessary whilst considering extended family members as possible carers. In early June 2016 a care planning meeting was held where 19 Southampton Children’s Services: documents submitted to the review. 20 Southampton Children’s Services: documents submitted to the review. 7 it was noted that ‘… no sexual abuse assessment has been done on the family. BRS did a family day assessment last year but work was outstanding …’. A final Care Order was granted four months later on Freddie. He was unable to stay in foster care due to sexualised behaviour and was moved to a specialist placement; from this point he began to talk about his experiences. Given their ages, Siblings 1 and 2 remained in the family home with the Mother. 5. Findings & analysis 1. As outlined in section 2.3, by providing each agency with the opportunity to submit an individual report it has allowed agencies the chance to examine their own practice against the terms of reference. In turn, agencies have identified learning for themselves, and made recommendations to strengthen practice. The following sections provide an analysis of multi-agency involvement and, as such, provide us with the greatest insight into the quality and effectiveness of the response to Freddie. Where possible, an explanation of why events occurred as they did, has been provided. Learning points for use by all practitioners and trainers have been emphasised. 2. The report will examine five key areas in order to better understand the quality and effectiveness of safeguarding arrangements across the partnership, these are; - The quality & effectiveness of multi-agency working and child protection processes. - The use of family history to inform assessments & decision making. - The recognition and response by professionals to actual or potential harm. - The assessment of the grandparents to provide a safe place for Freddie. - Practice challenges raised relating to the findings of this case. 3. By way of a summary, the following features have been identified as contributing to agencies not working together as effectively as required in order to safeguard and promote Freddie’s welfare; - Whilst subject to a Child Protection Plan there was considerable drift in progressing actions that may have offered safeguards to Freddie. The lack of pace and purpose resulted in Freddie’s continued exposure to harm. - The drift was influenced by multiple factors which included; staff changes resulting in a lack of continuity; inadequate oversight of case progression; delays in initiating and completing assessment work; and a collective professional uncertainty about how to manage the risks to Freddie and respond to the whole family situation. - A wholesale lack of effective challenge and escalation across the partnership allowed the situation to drift. - Some professionals felt sympathetic towards the Mother, thereby losing focus on the children’s day to day experience and their safety and welfare. - Children’s Services experienced multiple systemic challenges during the time period which impacted on their capacity to effectively fulfil their responsibilities as the lead agency responsible for the Child Protection Plan. 5.1. The quality & effectiveness of multi-agency working & child protection processes 5.1.1. Statutory guidance relevant at the time21 states of assessment and analysis ‘ … decision points and review points involving the child and family and relevant professionals should be used to keep the assessment on track. This is to ensure that help is given in a timely and appropriate way …’. Freddie, and both his older siblings were subject to a multi-agency Child Protection Plan for two years from June 2014 until July 2016. This two year window allows us an opportunity to focus on the quality and effectiveness of multi-agency working arrangements. 5.1.2. Local procedures in Southampton set out the expectations of a Child Protection Plan with the purpose being ‘… to facilitate and make explicit a co-ordinated approach to: a) Ensure that each child in the household is safe and prevent them from suffering further harm; b) Promote the child's welfare, health and development; c) Provided it is in the best interests of the child, to support the family and wider family members to safeguard and promote the welfare of their 21 Working together to safeguard children, 2015, HM Government 8 child …’22. The lead agency, in all cases of children subject to a Child Protection Plan is the local authority Children’s Services, with a named Social Worker. The Social Worker has a pivotal role in coordinating and facilitating the multi-agency protection plan. 5.1.3. Analysis of the review and decision points, as detailed above, over this two year period reveal significant problems; - Four Review Child Protection Conferences were held within expected procedural timescales but documentation consistently reflects a lack of pace and purposeful activity between each Review. - 13 Core Group meetings were held and which appear to be within expected procedural timescales. Records indicate however that the first five Core Groups encountered significant problems (July 2014 – February 2015), which included; cancellation, no Social Worker allocated or attending, and lack of attendance by other agency representatives and no minutes being available (suggestive of either the meeting not going ahead, minutes not being distributed or taken). The effectiveness of the Core Group as a mechanism for driving forward the multi-agency Child Protection Plan, in the first eight months, is therefore negligible. - The first RCPC highlighted that statutory visits to see the children had not happened in accordance to expected practice standards. Subsequent RCPCs make no reference to statutory visiting patterns. The effectiveness of having a lead professional offering oversight of day to day protection arrangements for the three children is also negligible given there is no evidence to support any other way of thinking. - Records highlight that at each Conference an outline Plan had been documented. At each subsequent RCPC there appears no explicit reference to checking progress against previously agreed actions, and the Plan shifting each time despite limited identifiable progress. There is an emphasis on a narrative update between the intervening period of time since the last Conference; in effect more story telling rather than scrutiny and action tracking. The effectiveness of RCPCs acting as an opportunity to keep assessments on track is very limited. - Over the course of two years, four different Chairs lead the five Conferences, with three different Social Workers attending. Representation from the School Nursing Service and the Police is inconsistent; however this has to be balanced with the agreed protocol that School Nurse and Police attendance at RCPCs is only likely if there is an ongoing Police investigation or significant new information and significant relevant health needs requiring the involvement of School Nurses. Representation from these two services will therefore always be inconsistent given the operational demands23. Attendees from other agencies fluctuated, most notably around September 2015 and February 2016. As the consistency of agency representation is often lacking it follows that each new person attending will have to familiarise themselves with the case history and form an opinion on the basis of the information presented on the day whilst at the Conference. - Throughout both Conferences and Core Groups there are several references to progress not being made, with the Chair of the September 2015 Conference stating ‘ … there continues to be evidence of extreme behaviour from Freddie and a display of sexualised behaviour which has no apparent root cause. Sibling 2 is also known to show sexualised behaviour and remains of Police bail for an alleged sexual assault … The risk for all children exposed to potential risk of harm of a sexual nature continues to be evident in the home, school and in public. It is a significant issue of which professionals continue to express their concern for Freddie in particular. No progress has been made since the ICPC and observations indicate that behaviour from Freddie is increasingly worrying …’24. During the February 2016 School A report to the RCPC that ‘… This is an extreme area of concern. We do not believe that the support from social care has been robust enough in order to address any of the issues in the family home. The issues which are on-going have been issues since [Freddie] joined in 2014 and do not show any signs of 22 Southampton LSCB procedures: Child Protection Plans 23 The Hampshire Constabulary receive an average of 165 invitations to Child Protection Conferences per week. 24 Southampton Children’s Services: documents submitted to the review. 9 improvement …’25. Records indicate this being the strongest and clearest challenge to date by any agency represented in the two year process. - Other than the challenge in February 2016 by School A about the lack of progress, there is no other obvious evidence to indicate any challenge or escalation about the lack of progress, other than statements of frustration by various professionals attending including the Chair. There is reference in the September 2015 to Siblings 1 & 2 being stepped down and managed via a Child in Need Plan rather than via a Child Protection Plan. This is however not agreed until the February 2016 with the following statement ‘ … a Child in Need plan for Sibling 2 and Sibling 1 which needs to be well thought through particularly regarding the sexual risk ...’. A Child Protection Plan remained in place for Freddie. The assessment of Siblings 1 & 2 being managed via a Child in Need plan conflicts with information presented at the Conference highlighting ongoing risks. The idea of a ‘… well thought through plan …’ fails to acknowledge that this was precisely what was needed in the preceding two years. 5.1.4. Whilst the formal RCPC may be more procedurally driven the Core Group can support opportunities for closer working relationships with professionals and parents. Evidence submitted confirms that the effectiveness of the Core Group as being limited, lacking pace, purpose and authority. Learning point: As a mechanism for protecting children, the child protection conferencing process and associated Core Group activity relies on procedural compliance but also relationships and human interaction. When either aspects are dysfunctional the risks to the child are highly likely to increase thereby rendering the multi-agency plan less effective. The assertive use of challenge and escalation outside of the dysfunctional dynamic in which professionals may find themselves unwittingly trapped is always an appropriate step for any professional to take. 5.1.5. There is evidence within the records from Solent NHS Trust of health agencies ‘ … working in apparent silo, such as CAMHS documenting no contact from social care for child protection meetings without any plans to address this. Frequently health practitioners recorded outcomes from child protection proceedings without considering and therefore challenging the length of time or lack of change for the children. An example being Freddie’s sexualised behaviour in preschool, with no apparent escalation or conversation from health to social care ...’26. 5.1.6. A further example of agencies not working effectively together can be seen by the Police’s response to Sibling 2’s episodes of going missing – which were frequent. Review of records shows that although incidents were appropriately dealt with as a single agency, information was not shared with partner agencies in a systematic way alongside a broader consideration of holistic risk management i.e. alongside information about concerns for Sibling 1 being exploited and concerns about Freddie. Operating context is important. At the time the multi-agency response to children going missing and exploitation was not as well developed in Southampton as it might be now. Alongside these concerns was intelligence about the family increasingly becoming linked to a number of concerning individuals know to the Police as perpetrators of child sexual exploitation. Using Police intelligence to feed into contextual safeguarding issues and working with partner agencies was still evolving practice. The ability to effectively use Police intelligence and share with partner agencies was also compromised due to local arrangements limiting capacity. This episode does show that a considerable amount of activity and knowledge was held by Police and there were missed opportunities for the professional network to join up and consider information holistically. Developments in contextual safeguarding27 is an area worth exploring to support more timely and effective interventions. Learning point: Creating local arrangements that bring professionals together, and reduce silo working, can be beneficial when working with complex cases where there is extra-familial risk. Assessing the family context and 25 Southampton Children’s Services: documents submitted to the review. 26 Solent NHS Trust submission to this review. 27 Contextual Safeguarding Network 10 exploring issues around exploitation, peer on peer abuse, neighbourhood violence and criminality, relationships and other risk factors can feed into other professional forums, thereby creating a more holistic approach to intervention 5.1.7. The professional network clearly debated and understood the implications of the information being presented to the Initial Child Protection Conference, judging abuse to have taken place. When working with cases of child sexual abuse, Furniss28discusses the importance of the professional network surrounding the family to work in a tight and coordinated manner. He refers to mirroring where ‘ … the professional network enacts the family dynamics; for example showing splitting and fragmentation and reflecting in the professional network the way the family sees itself … [with] … case conferences [being] the most typical places in which mirroring of the family process is enacted visibly in the professional network …[where] we often find ourselves locked into mirroring the family’s dysfunctional ways of relating and their inability at problem solving and conflict resolution … ’. It is possible to see potential of the professional network being split in the decision making notes from the ICPC in June 2014 and then the September 2015 RCPC where differences of opinion about how the case could be managed are apparent. Given the fragmented follow through by the Core Groups there was little opportunity for the professional network to reconcile their differences, come together as a tight unit and consider their tactics and strategy for working with this family. 5.1.8. This is also somewhat brought to light in a Children’s Service management oversight note from July 2015 ‘… it is possible that Freddie is being abused within the home by a number of people or it is possible that Freddie is not being sexually abused but is being subject to inappropriate sexual content via a number of outlets … there is no clear evidence either way, and no disclosures have been made by Freddie or any other party … it is very difficult to accurately assess the risk … the social worker has raised that professional anxiety in this case is a driving factor in how agencies respond to this family and this response could well be perpetuating the situation …’. Importantly, Furniss goes on to state that ‘… mirroring does not happen because of incompetent professional conduct. Mirroring is the result of the striking influence families are able to exert even on very competent and highly skilled professional networks …’. This dynamic (including professional anxiety) is an inevitable consequence of working with complexity in families where child sexual abuse features and emphasises the importance of good quality supervision and support, and high performing child protection processes. Records and discussions confirm that there was sufficient professional suspicion about Freddie being sexually abused. The direct statements by him of inappropriate behaviour from family members offered a clear opportunity to form a view that he was not being protected by a Child Protection Plan and that his current care arrangements were ineffective in keeping him safe. On the basis of the evidence available in August 2014 a more assertive plan could have been adopted earlier. Learning point: Receiving regular high quality management support and supervision is important when working with intra-familial child sexual abuse. Seeking additional input from specialised services can be of equal value in helping professionals remain objective, child focused and attentive to unconscious processes which may impact on assessment and decision making. 5.1.9. Placing the above findings of this review in context of the wider system in which professionals were operating at the time is important; this allows us to better understand the behaviours of individuals in context. In 2012 Ofsted29 highlighted some aspects of inadequate practice by Southampton Children’s Services particularly relating to the quality of safeguarding work i.e. social work and management turnover, the quality of assessments and Core Group activity. A self-assessment conducted the following year, in 2013, highlighted insufficient progress had been made on some of these areas despite efforts to make improvements. In 2014 Ofsted30 noted positive improvements in respect of the 28 Furniss, T., The multi-professional handbook of child sexual abuse: Integrated management, therapy & legal intervention, p.81, 1995, Routledge 29 Ofsted & the Care Quality Commission, Inspection of safeguarding and looked after children services Southampton, 2012. 30 Ofsted, Southampton Council Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the local safeguarding children board, Inspection date: 8 July 2014 - 30 July 2014 Report published: 15 September 2014 11 Council’s work with children subject to Child Protection Plans and Conferences and a 2018 inspection31 noted further improvements across the system. Appreciating the contextual journey that spans the timeframe under review is an important aspect to understanding the quality and effectiveness of the response to Freddie. This highlights systemic problems that have taken a number of years to identify and address, and which has included significant changes in managers, re-structuring and transformations – all of which have impacted on front-line practice. Learning point: An effective safeguarding partnership is more than a collection of representatives, organisational structures, systems, processes and procedures. It is also a combination of complex relationships between individual professionals and leaders and the combined efforts of organisations. Partnerships require time, effort and investment in order to become, and remain, effective. 5.1.10. From a system thinking perspective the concept of emergence is relevant. Emergence32 is a key property of complex systems – of which the multi-agency child protection mechanism is one example. The strength of a complex system can often be tested against its ability to respond to emerging issues which cannot be controlled, predicted or easily managed. Emergence as a concept is therefore relevant as it allows us, often with the benefit of hindsight, to better examine system weaknesses – rather than purely concentrating on the efforts, or errors, of individual practitioners. Research about other case reviews33 confirms that this can have a negative impact of front line practice. It is clear that practices had emerged prior to the timeframe under review which had become embedded in the wider multi-agency working arrangements in Southampton. The earlier Ofsted reports confirm this. Evidence submitted by Southampton Children’s Services, Solent NHS Trust and the Police supports the fact that at those times when information could have been brought together to inform a holistic assessment and safety planning for Freddie, it was not. Some of these emergent practices created what might be described as organisational pathways to harm34 or failure. The combined effect was that the multi-agency response, in the form of Child Protection Conferences and Core Group activity for Freddie, was not an effective mechanism to offer protection. Learning point: Research into other Serious Case Reviews highlights ‘ … the child protection conference can be a crucial, pivotal point in the overall child protection process, facilitating analysis of information, appraisal of risks, decision making and planning for intervention. As with any pivot, its effectiveness is dependent not just on the structure and function of the conference itself, but on the processes on either side …’35. 5.1.11. For those children that are subject of a Child Protection Plan for more than 18 months questions are often raised about the effectiveness of the plan in bringing about change and improvement. In the 2015 - 2016 period Southampton City Council had 3.9% or 13 children of the total cohort of children (333) subject to Child Protection Plans on Plans for two years or more36. In 2016 - 2017 this had dropped to 2.2% or 6 children of the total cohort (276). During the 2016 – 2017 reporting period Freddie and his two siblings would have accounted for 3 of this total number. Whilst the number of children being subject to a Child Protection Plan for longer than two years is not necessarily indicative of a deeper problem in a local area, it can provide a useful proxy measure about the quality, pace and 31 Ofsted: Children's Services focused visit - Southampton - 2018 32 Seel, R., Emergence in organisations, 2006. 33 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 149, University of Warwick & University of East Anglia, May 2016 34 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 24, University of Warwick & University of East Anglia, May 2016 35 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 175, University of Warwick & University of East Anglia, May 2016 36 Department for Education statistics, 2015 – 2016, Characteristics of children in need: 2015 - 2016 12 purpose to multi-agency child protection work being undertaken with individual children and families. Typically such cases may reflect situations whereby child maltreatment and neglect are entrenched and difficult to un-stick; they may however also reflect a lack of assertive assessment, intervention and decision making. In this particular context, it has already been highlighted that there were embedded system wide challenges being tackled during the timeframe under review – highlighting testing times for multi-agency safeguarding practices. This case has highlighted a lack of pace and purpose to assessment work whilst known, and knowable risks, were in plain sight. This is reflected somewhat by a comment from the Mother during RCPC in February 2016 noting that ‘… the Mother recognises that she has lost focus on what the issues around her children are any more – including the purpose behind the CP process and the work undertaken and how it all links …’. Learning point: When working with children and families, irrespective of which process is being followed, if parents/carers state that they no longer understand why professionals are involved in their lives or what the issues are then it is time to pause, re-group and re-examine the quality and purposefulness of professional contact. Keeping parents/carers on board with change is critical to successful intervention. 5.1.12. In summary, notwithstanding the challenges associated with assessing and intervening in this case due to the uncertainty about the origins of child sexual abuse there is strong evidence of the multi-agency machinery around formal child protection processes being ineffective. The complexity of relationships within the family and then between the family and professionals impacted on the ability of the professional network operating as a coherent whole. When coupled with the wider system challenges faced by services in Southampton during this timeframe, as outlined above it is possible to understand cause and effect of drift and the pathway to ongoing harm for Freddie. Had the partnership’s decision making and interventions been more effective the strength of the response by the safeguarding partnership may have resulted in a more robust intervention in Freddie’s life .i.e. consistent attendance at meetings by all agencies, consistency in those who had oversight and scrutiny roles, greater professional curiosity, information sharing, challenge and escalation, and the timely follow-through on actions. 5.2. The use of family history to inform assessments & decision making 5.2.1. Given the breadth and extent of worrying history outlined in section 4, which has purely been extracted from agency records, it would be reasonable to conclude that it is likely to represent the very tip of professional awareness about Freddie’s day to day experiences in the family home. 5.2.2. Section 4.1 has outlined information about family history which was relevant and of interest to the professional network during the timeframe under review. When conducting assessments and making decisions the use of historical information is critical to effective safety planning. 5.2.3. Risk can be categorised into those factors that are currently presenting themselves as a concern, for which it may be possible to manage i.e. situational risks, and those where there is less likelihood of effecting change and which occurred prior to the current concerns and circumstances i.e. pre-disposing risks. For Freddie there were a significant number of pre-disposing risks that formed part of his family history, which the professional network had no control or influence over, but were known or knowable. These included; - Information about concerns about parenting of Siblings 1 and 2 since 1999, - Verbal statements of a sexual nature by Siblings 1 and 2 in 2004 and 2007, - The Mother’s concerning relationships or associates. - Concerns about the Mother’s ongoing ability to manage all three children, - Sibling 2 being charged with rape/sexual assault in 2013, - Police persistently being called out to anti-social behaviour, assaults and criminal damage incidents. 5.2.4. Therefore, when the professional network was faced with the emerging concerns about Freddie’s sexualised behaviours in 2013 awareness and consideration of this history would have been highly relevant in helping them 13 manage risk and make decisions. Research37 relating to childhood adversity and trauma highlights maltreatment (including abuse or neglect), violence and coercion, and household or family adversity as potential pathways to further harm that can impact negatively on development and life chances. For Freddie to benefit from a safe pathway through childhood and into adulthood, the time given by the professional network to recognising the weight and significance of his family history and family functioning would have been critical. Learning point: Taking the time to be curious, analyse information and forming a set of working hypotheses about the impact of adverse events that have occurred in a child’s earlier life can be an important step in setting the professional network on a pathway that offers protection to the child. Learning point: When concerns emerge about a child’s safety and welfare, it is always good practice to review previous chronological involvement with the child and family and apply professional judgement about current needs and risks in the context of known history and relevant research about child development. Statutory guidance38 states ‘… a high quality assessment is one in which evidence is built and revised throughout the process and takes account of family history and the child’s experience of cumulative abuse …’. 5.2.5. From a Children’s Services perspective it has been noted that the previous interventions, concerns and sexual risks including the child protection planning from August 2008 until March 2009 were not consistently referred to within decision making and management oversight later on. Whilst it is mentioned in some single assessments undertaken, the Mother’s failure to protect is not weighed against the current concerns due to her perceived engagement with the professional network. Despite the Mother embarking on new relationships in 2013 and 2014, some of which resulted in the male partner residing in the family home leading to child protection concerns, the Mother’s ‘ … lack of capacity to safeguard and prioritise the safety of the children is not discussed. Instead, decision making is based on Mother mainly being able to meet the basic needs of the children ...This decision does not appear to take into account that Sibling 2 is being investigated for sexually assaulting a peer, or the risks this poses for Sibling 1 and Freddie, and whether Mother is equipped to manage this ...’39. This is reflected by a management oversight note at the time in April 2014 that highlights a level of sympathy for the Mother rather than a focus on the children’s welfare ‘… It is clear from the assessment although there are ongoing issues regarding the children and their behaviour their mother does her best to offer the best care to all of them’. 5.2.6. Further examples of where family history is inconsistently applied to inform assessment and decision making includes a) when the family are re-referred in April 2014 following Sibling 2 being found guilty of rape of a peer, b) the sexual abuse of Sibling 1 by Mother’s partner in 2008, and c) the allegations the children made about Father 2, which occurred in 2007. Additionally, the disclosure that Freddie had been sexually touched by the Mother and Father is clearly stated in one document but is then not referred to throughout the rest of the involvement by Children’s Services, even during discussion about where the sexualised behaviour may have stemmed from. 5.2.7. The inconsistent consideration and use of history by Children’s Services is worrying given that for two years Freddie and his Siblings were subject to a multi-agency Child Protection Plan, for which the local authority Children’s Services were the lead and responsible agency. This information was known and there is no evidence to indicate it was extracted in a coherent way to inform multi-agency decision making or early advice being sought from Legal Services (see section 5.3). 5.2.8. From a Solent NHS Trust perspective, who were responsible for the provision of health visiting, school nursing, speech & language therapy services, paediatric and child mental health services, a similar inconsistent picture 37 Young Minds & NHS Health Education England: Addressing childhood adversity and trauma 38 Working together to safeguard children, 2018, HM Government. 39 Southampton Children’s Services submission to the review. 14 emerges. This review has highlighted that there was considerable historical information held within the electronic records which could have informed practice, such as Sibling 2’s convictions and Sibling 1’s involvement with an older man, Mother’s partners and their history. The Trust has acknowledged that there was inconsistent recording, which resulted in unreliable analysis on which to base planning and intervention, noting that with the benefit of hindsight ‘ … it could be seen that lack of detailed analysis and plans potentially contributed to the longevity of the abuse suffered by all three children ...’. The Trust has also noted that ‘… family history was referred to within many of the assessments undertaken within the time frame of the review however it would appear that these were not analysed regularly or adequately, such as; the noted sexualised behaviours and history of older brother’s offences. These are known indicators of sexual abuse but there is little reference made within the records that would evidence that practitioners were concerned enough that these children had, or possibly were being sexually abused …’40. 5.2.9. As with Children’s Services, Solent NHS Trust also note a professional empathy for the Mother above the focus needing to be on the children. One example cited relates to decision making being more about the mothers needs based on the perceptions of some professionals about community harassment in February 2016 and seeing the ‘ … children as perpetrators rather than victims … suggesting it was the children’s behaviour as the cause, and therefore no questions were raised as to the underlining reason for this behaviour ...’41. Research into other Serious Case Reviews42 examines the need for authoritative practice when dealing with complexity and ambiguity in individual cases ‘… the quality of empathy embraces considering both the voice of the child and the needs of the family. It must be grounded in the centrality of the rights and needs of the child, while being sensitive but not colluding with the needs and views of the parents …’. Learning point: It is important that the feelings and biases of professionals and managers towards parents do not hamper judgements, prevent challenge and undermine decision making. Balancing support with authoritative scrutiny is a key requirement when making decisions about a child’s best interests. 5.2.10. One reason cited for this inconsistent practice and deficits by Solent NHS Trust relates to recording systems which, at the time were continuing to change from paper to electronic records. Information contained about Siblings 1 and 2 in paper records is likely to have been lost at the point of transfer. This is an issue that has been identified in other local Serious Case Reviews conducted recently. 5.2.11. From Primary School A’s perspective, which Freddie began attending in 2014, it is noted that there is limited evidence of history in the chronology on record. They recall that there was no contact from the Social Worker at the point that Freddie transferred from the Pre-School. 5.2.12. The Clinical Commissioning Group has noted, on behalf of the GPs involved with Freddie and his family, that there are significant gaps in the GP’s understanding – or at least their capacity to understand – family history due to the inconsistent use of electronic database systems, but also limitations of its use at the time. They have reflected that ‘… there is no reference made in Freddie’s notes to his mother’s history as a victim of sexual and domestic abuse, nor to her capacity to protect her children from abuse as perceived by other agencies. There is also no reference made to Sibling 2’s history of sexual assault, nor Sibling 1 having been a victim of sexual assault which resulted in them both being on a Child Protection Plan …’43. A contributing factor to these deficits relates to the cross referencing of significant issues within a family across the individual family members medical notes. In this case, there was no information cross referenced linking, for example, the Mother’s notes to Freddie’s. Prior to 2014 it was not compulsory 40 Solent NHS Trust submission to the review. 41 Solent NHS Trust submission to the review. 42 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 202, University of Warwick & University of East Anglia, May 2016 43 Clinical Commissioning Group submission to the review. 15 for GP Practices to scan whole documents relating to safeguarding issues into the records of the index child i.e. in this case Freddie. Information, potentially pertinent, could be stored separately to the medical record but accessible to staff if needed. Best practice guidance44 produced by the Royal College of General Practitioner and the NSPCC advises that children’s records should be linked in some way to parents (even if at different addresses), siblings and others in the household. It recommends that safeguarding information received by the Practice should be handled by a designated, administrative, member of staff who should scan CPC reports into the child’s records with an appropriate coding system to flag safeguarding issues. The local GP Practice supports the use of this guidance and best practice toolkit including the expectation that a GP should read and have oversight of relevant information. The CCG have noted that in this case ‘… it is evident in Freddie’s medical record that safeguarding documents were scanned by an administrator but no GP comments were associated with them. [The CCG] is … assured by the interim Practice Safeguarding Lead that, since the Practices merged in April 2015, all documents are coded by a trained and competent administrator and seen by a GP …’45. 5.2.13. Notwithstanding the lack of historical information about the family in the GP records, there was information available about Freddie following the section 47 enquires and information relating to Sibling 2’s arrest on the rape charge. Freddie was seen by a GP shortly after this information came to light as the Mother took Freddie for a routine consultation. Not unreasonably, information about the wider safeguarding issues was not discussed given the distinct nature of the issues being consulted about. Later in 2014 information was received by the GP Practice regarding the children being subject to Child Protection Plans. This information was coded correctly and resulted in a telephone call between the GP and Health Visitor in October 2014 regarding a rejected CAMHS referral and ongoing concerns about his mental health and emotional well-being. There is no information that indicates this pro-active step taken by the GP in discussing the concerns with the Health Visitor resulted in a change of decision by CAMHS. 5.2.14. When the Mother attended an appointment with Freddie in January 2015 feeling exhausted due to his sleeping difficulties the GP Practice at that time, was unable to offer a permanent GP for patients. On the basis of the presenting concerns, but with the benefit of hindsight, this might have provided the GP with an opportunity to probe further and be more curious about family history and circumstances. Given that the issues to be discussed were sensitive it is reasonable to argue that it was not appropriate for this to be achieved in one single, short consultation. However a follow-up consultation could have been suggested to explore underlying contributory factors and make a more thorough assessment of the family and household structure, and other adults or partners involved. A similar opportunity presented itself in April 2016 when the Mother saw the GP, concerned about Freddie and how she was coping and requesting another CAMHS referral. GP records for Freddie do not document what other agencies were involved with the family, how Freddie was being supported, and how the Mother’s ability to protect Freddie was being assessed or managed. These episodes reflect an inherent challenge GPs for who may see patients on an intermittent basis for very short slots of time and are often forced to focus on the immediate and presenting issue. 5.2.15. From a system thinking perspective, the challenges faced by the GP can be described as a trade-off46. Trade-offs are a system thinking concept. Work in complex systems is impossible to assign, predict and prescribe completely. Demand fluctuates, resources are often limited and goals often conflict. Frequently, the choices available to us are not ideal and we are forced to make trade-offs and choose sub-optimal courses of action. Trade-offs, such as these, help us understand system behaviour and system outcomes. The trade-off in this case was that the GP chose to respond to the presenting physical health related issue in the short consultation slot, over pursuing enquiring into the mire of dysfunctional family dynamics and possible sexual abuse. 44 RCGP & NSPCC - 2014: Safeguarding children toolkit for General Practitioners 45 Clinical Commissioning Group submission to the review. 46 Trade-off - as cited a) Learning into Practice: improving the quality and use of serious case reviews, Masterclass 2: Systems thinking, SCIE & NSPCC, 2016 and b) Systems thinking for safety: Ten principles – A White Paper, Eurocontrol, 2014. 16 5.3. The recognition & response by professionals to actual or potential harm 5.3.1. Recognising actual or potential harm to a child or children is the first step to responding. Harm arises in many forms, and in this case the focus is on sexual harm; however emotional harm and neglect are also important to consider and were known worries for professionals at the time. The consequence of the professional network not effectively intervening with children who have been sexually abused are likely to be severe and enduring for those individual children47. The assessment and response to child sexual abuse can be challenging for professionals who may face a series of perplexing problems; ‘ … child sexual abuse is a minefield for all concerned … it is genuinely a multidisciplinary problem, requiring the close co-operation of a wide range of professionals with different skills …’48. 5.3.2. Research49 by the NSPCC highlights that 90% of sexually abused children were abused by someone they knew and children who have been abused or neglected in the past are more likely to be open to re-victimisation and experience further abuse. Further research shows that the majority of allegations of sexual abuse are against fathers, stepfathers or new male partners’50. Bentovim51 discusses some of the specific challenges associated with safeguarding children who have been sexually abused, specifically highlighting that for interventions to be effective any therapeutic work needs to take place in a context of safety for the child. 5.3.2. From Southampton Children’s Services perspective, Freddie had explicitly informed the staff at school, Police and Social Workers in 2013 and 2014 that his Mother and Father were behaving in a sexually inappropriate way towards him. This review has been unable to identify any evidence to indicate that the risk of sexual harm by either parents was discussed any further by the Social Worker in supervision, strategy discussions or elsewhere during the timeframe. When the Mother suggested that Freddie’s Father may be the cause of these problems, there is very limited recognition that he had supervised contact fortnightly, for which the Mother was responsible for supervising. The origins of Freddie’s and Sibling 2’s sexualised behaviour is never established, and decisions appear to focus on how to manage or change this behaviour rather than understand the origins. Understanding the origins of Freddie’s sexual abuse (as best as possible) was critical to creating an effective safety plan given the high possibility that Freddie continued to live in the same household as his abuser. The possibility of any therapeutic work taking place in a context of safety was therefore impossible at this time for Freddie. 5.3.3 The September 2015 RCPC minutes lists strengths/protective factors with one being ‘… family … assessment in March 2015 … no clear outcome as yet from this assessment …’. This form of words or what it describes cannot be viewed, at-all, as a strength or protective factor as it refers to not knowing the outcome. The outcome of this family assessment was clearly not known about by the professional network attending the RCPC and therefore could not be considered and used to inform safety planning. It is not until the February 2016 RCPC, almost two years after the children first became subject to a Child Protection Plan, that the minutes refer to this assessment of Freddie but of it being of limited value. The RCPC record goes on to state that ‘… there is no understanding as to why all three children have displayed inappropriate sexualised behaviours (aside from the fact that it is known that Sibling 1 was sexually abused by the Mother’s previous partner …’. Records indicate that it was not until March 2016 when a different Social 47 NSPCC Signs, symptoms and effects of child abuse 48 Furniss, T., The multi-professional handbook of child sexual abuse: Integrated management, therapy & legal intervention, p. xvi, 1995, Routledge. 49 NSPCC Sexual abuse research 50 Parkinson, P., Child sexual abuse: assessing the risk, 2014, Paper for the Independent Children’s Lawyers Conference, Independent Children’s Lawyers, Child sexual abuse: assessing the risk, and accessed 29/04/19. 51 Bentovim, A., Safeguarding and promoting the welfare of children who have been sexually abused: The assessment challenges, in Horwath, J., The Child’s World, second edition, 2010, Jessica Kingsley. 17 Worker was allocated that there was a conversation with Mother about the possibility that Sibling 2 has been sexually abused; something that the Mother is reported to have stated she had not considered previously. 5.3.4. Practice from Southampton Children’s Services appears to have been one where the focus was on the Mother’s needs with a failure to respond to the risks of sexual harm faced by Freddie. Given the explicit lack of recognition of actual, or likely, sexual harm to Freddie it follows that the response was equally lacking. This is evidenced by comments such as … Despite consistent concerns in the quality of information provided by mother to the professional network, the social worker believes Mother when she reports that she is “in a better place” (November 2015) and reports there are “no concerns about her care of the children, only her behaviour management”52. This further reinforces the point made above about professional empathy for the Mother, and a loss of focus on the child’s day to day experiences. 5.3.5. Throughout the timeframe under review records indicate there was management oversight or supervision by Children’s Services, however it appears to collude with the circumstances at the time and offer no challenge or direction. This is evidenced by frequent references to the fact that the Child Protection Plan had not achieved any changes for the children. A further contributing factor was the frequency and quality of management supervision for the Social Worker; ‘… The social worker allocated to Freddie and his family in July 2014 did not received case supervision until April 2015. This supervision is poor quality and does not explore the risks for Freddie or the work plan required to assess and create an effective safety plan for him. Following a change in team manager, it was noted that there was a significant improvement in the quality of recording of supervision and the content of discussions ...’’53. This however continued to result in a lack of authoritative social work practice and drift. Significant practice issues were identified with the management oversight and supervision at this time, accounting for the quality of management oversight not being to the standard expected. Issues connected to this are being addressed via a separate single agency process. Learning point: Management oversight offers the opportunity to exercise quality assurance, scrutiny of professional standards, sense check risk management and safety planning and provide a ‘one-step’ removed perspective. It is important for managers to have the time and space to provide reflective feedback on these issues. 5.3.6. There is further evidence of collusive practices between professionals and the Mother which, albeit unwittingly, resulted in a loss of focus on the children. There is also evidence of limited curiosity and a lack of challenge across the professional network. Examples of this include: - A letter sent to the GP from CAMHS in January 2014 suggesting that the children were the instigators rather than the victims of their behaviours and circumstances. - During a telephone call in early 2014 between CAMHS and the Mother, the emphasis was on the impact of the children’s actions on the Mother. - The Mother was often given the opportunity to speak on behalf of the children rather than practitioners seeing and allowing the children to speak for themselves. - In May 2014, continuing sexualised behaviours were noted, but plans and actions focused on parenting programs/support for the Mother. - In Core Group meetings Freddie’s behaviours were rarely challenged or explored. - Practitioners recording not being invited to child protection meetings but no evidence of a plan, or no attempt to contact social work team to correct this, or open the channels of communication. This lack of challenge and escalation colluded with ineffective multi-agency arrangements. - The Mother continued to be seen as a protective factor for the children with nothing to indicate that any practitioners were considering the family members, or known and unknown associates, as potential abusers. 52 Southampton Children’s Service submission to the review. 53 Southampton Children’s Services submission to the review. 18 5.3.7. Potential signs of neglect are also frequently reflected in the records of all three children held by Solent NHS Trust. These include; - Freddie’s constant dribbling which was discussed in an assessment by Speech therapy in June 2014, advice was provided on two separate occasions, with no apparent recorded consideration of dental health forming part of that assessment. Since coming into local authority care Freddie has required several dental extractions due to decay – one indicator of long term neglect. - In April 2015 where Sibling 1 presented with poor hygiene, being visibly dirty, and having head lice. Sibling 1 was referred to the School Nurse who was also informed by the school and Social Worker that Sibling 1 was in a relationship with an older man who was a registered sex offender. The School Nurse promptly saw Sibling 1 the next day in school, where the focus was on self-care and personal hygiene. This could have been a good opportunity for the School Nurse to explore with Sibling 1 her relationship and risk of sexual exploitation. There is also little documentation about her presentation at this contact, or any discussion regarding her being vulnerable to abuse. There is no recorded communication back to the Social Worker regarding the outcome of this contact. The significance of Sibling 1’s relationship and her vulnerability to abuse and neglect is not fully considered within the health records. - At the Core Group meeting in June 2015, the School Nurse identified that Sibling 2 had hit Freddie, and that the Mother had brought charges against Sibling 2 as a result. There is no obvious curiosity about the approach taken by the Mother to criminalise her son. 5.3.9. It is clear from the above findings that over the duration of there being a multi-agency safety plan in place, there was a limited use of information and an over-optimistic mind-set to safety planning. There is no evidence of a multi-agency chronology, for example, making its way into the Initial or Review Child Protection Conferences. This resulted in safeguarding partners not having access to full information. Concerted attempts to make sense of the origins of sexual abuse for Siblings 1 and 2 and Freddie are not evident and continue to remain a mystery throughout the timeframe under review despite potential lines of enquiry being exposed; this resulted in the creation of an un-workable safety plan. References in the Initial and Review Child Protection Conferences to the children ‘needing to feel safe’ and the need for therapeutic work are misguided given that there was no certainty that the children were free from further abuse. 5.3.10. Records do however indicate that the Health Visitor made clear reference within their child protection report about needing to consider why Freddie was presenting with sexualised behaviour, alluding to the fact that remained at risk of sexual harm. This sensible contribution had no impact on outcomes or arrangements. 5.3.11. Solent NHS Trust have advised that safeguarding supervision is offered on a regular basis to practitioners who work with children i.e. Health Visitors, School Nurses and CAMHS practitioners. During the timeframe under review there are no supervision sessions recorded by those practitioners working with the family. This suggests an inconsistent understanding about recognising indicators of actual or potential harm to children. Given that all three children were subject to a Child Protection Plan it is concerning to think that the use of worrying information was not taken advantage of and explored in a safe and supportive environment such as that which could be provided by safeguarding supervision. One of the contributing factors to this not happening was that during the timeframe under review the model of safeguarding supervision arrangements for Health Visitors changed from 1:1 to being a mixture of 1:1 and being in a group setting. No group supervision is recorded as being sought either. A high proportion of the caseloads held by Health Visitors at the time had safeguarding concerns and the change in arrangements meant that workers had to prioritise which cases they brought to group supervision. The need to select cases inevitably meant that those with the most pressing, immediate and identifiable worries were prioritised. A factor which will have impacted on prioritising will have been the knowledge that Freddie’s case was open to Children’s Services; which would have been perceived as a reassuring factor. 19 5.3.12. Southampton City Council’s Legal Services had four episodes of contact with the professional network during the timeframe under review. Their contributions are important when exploring the quality and effectiveness of actions taken by Southampton Children’s Services in recognising and responding to indicators of actual or potential harm. These episodes include; 5.3.13. August 2014 MAPPA meeting – A Legal Services representative was asked to attend a MAPPA meeting in response to a request by Southampton Youth Offending Service regarding Sibling 2. The advice back from attending this meeting was that a legal planning meeting should be convened in respect of Sibling 2 as a matter of urgency. This clearly demonstrated that Legal Services at the time recognised and responded to indicators of actual or potential harm. This advice was followed. 5.3.14. August 2014 legal planning meeting – An initial legal planning meeting was convened and attended by representatives from Children’s Services. Records indicate that those attending the meeting were aware of the issues with Sibling 2 and that Pre-School had raised concerns that Freddie was exhibiting sexualised behaviour. Given the attendance at the MAPPA meeting it was known that MAPPA were very concerned and that Sibling 2 had been described as a ‘ … predatory and dangerous man …’. The concerns at this legal planning meeting focused on Sibling 2, the risk he posed to others and the Mother’s difficulty in controlling him. Whilst there is reference to the current concern about Freddie’s sexualised behaviour records show that Freddie was not the main focus of the legal advice sought. The outcome of this meeting was for the children to ‘… remain subject to CP planning. CAHMS referral for Freddie regarding sexualised behaviour. Options need to be explored to keep both himself and others safe …’. The advice given also included ‘ … plan - possible issue on Sibling 2 - ICO plan to place in a residential … assessment of the mother- capacity to care/change assessment to be undertaken … and the Social Worker to continue weekly visits …’54. The fact that the legal advice acknowledged that legal proceedings could be initiated in respect of Sibling 2 and to seek an Interim Care Order indicates that there was a legal opinion that the threshold of actual, or likely, significant harm had been met and that this was attributable to the current care arrangements. Records indicate that details of residential placements were considered (pending management agreement) and one suitable placement was found however there was a lack of follow-through on pursuing the matter, with no response to questions posed to the Fostering Placements Team and no further management oversight, decision or escalation. As well as highlighting potential shortage of suitable placements (which is known to be a persisting national issue55), this episode highlights a system issue which created a pathway to failure; emails were not responded to and there was no checking back to seek a response nor any management oversight of this. 5.3.15. July 2015 legal planning meeting – This meeting was requested by Children’s Services. Records indicate that the meeting had been called as there had been a lack of progress under a Child Protection Plan. Case history was also presented at this meeting including further information about Freddie’s sexualised behaviours. Importantly the notes highlight that the recommendations from the legal planning meeting held in 2014 had not been pursued, that the Social Worker was confident that the Mother was not allowing unsupervised contact between Freddie and Sibling 2 and that the Mother was engaging with services “ … and doing everything asked of her…”. On this occasion, Legal Services advised against legal proceedings in respect of Sibling 1 and 2 in 2015, a year after they had advised that there may be grounds to seek an Interim Care Order in respect of Sibling 2 – it seems the rationale behind this decision was based on their ages (16 & 15 years at the time) and potential for disruption. Again, there was no challenge at this second legal planning meeting about why the actions in respect of Sibling 2 had not been followed through in 2014. 5.3.16. February 2016 and issuing of legal proceedings – A legal case note refers to a Legal Planning Meeting being held in February 2016; records of this Legal Planning Meeting cannot be found despite efforts. The case note indicates 54 Southampton City Legal Services submission to the review. 55 ADCS: What is Care For – Alternative Models of Care for Adolescents, April 2013, b) ADCS press release 9 August 2017, c) ADCS press release 13 June 2018 20 that the Public Law Outline process should have been initiated in February 2016 but was not because the Social Worker went on extended sick leave. A similar pattern is repeated with a further request for a Legal Planning Meeting in April 2016 in relation to Freddie. Freddie was not then accommodated using section 20 of the Children Act 1989 until May 20016 and legal proceedings were not issued until June 2016 with Freddie being initially placed in foster care before then moving on to a residential placement. The reason given for this delay and drift is that the Social Worker went on an extended period of sick leave and there was no re-allocation of the case. The drift is worrying and was not child focused especially given that the management oversight at that time was consistent. 5.3.17. On the basis of records examined the advice provided by Legal Services was clear and sound. It advised a systematic and evidenced based pathway for Children’s Services to follow so as to build a case to support legal intervention into safeguarding Freddie’s welfare. Clear advice was given that a further meeting should be convened once the required actions and recommendations had been completed. The legal advice was not followed through for either Sibling 2 or Freddie in a timely way, and this was not pursued or challenged. At the time of the advice being sought in 2014 the focus was on Sibling 2, however it later shifted to include a focus on Freddie; there is little consideration about Sibling 1 who continued to live in the household. This may be due to gender bias – being the only other female in the household and her behaviours somehow seeming more acceptable, her appearing to pose no risk compared to Sibling 2, and her being viewed as contributing to the household in a caring role as opposed to a perpetrating role. 5.3.18. Monitoring of whether legal advice and agreed actions were followed is an important learning point of this review. The responsibility for this rests across two parties; Legal Services but also Children’s Services management. Learning point: Gaining legal advice offers the opportunity to seek a fresh perspective about how to manage concerns about a child’s safety and welfare. In cases that are particularly entrenched or complex a legal perspective may be invaluable to assist with untangling what may be viewed as messy and thorny problems faced by the professional network. It is crucial that legal advice is properly recorded and that a clear rational is also recorded when the advice given is not followed. 5.3.19. The Clinical Commissioning Group, on behalf of the GPs have considered their contribution to the recognition and response to indicators of actual or potential harm to any children in the household. They have usefully reflected that although the concerns about Freddie and the family were well documented in correspondence the GPs received (as outlined in section 5.1) gaining a sense of the Mother’s parenting style, her interactions with the children and her parenting ability was not something that was easily extracted from the various documents held. The Mother had told her GP that she had attended parenting courses but that they had not helped; the reasons for this lack of improvement do not appear to have been evidenced by any agency in documentation. This is a helpful reflection highlighting the importance of good minute taking but also the need to produce a coherent record of a meeting that can be shared with those professionals unable to attend. 5.3.20. A further example where there is limited recognition of Freddie’s worrying sexualised behaviour can be seen in June 2014 when there was a request for a specialist assessment to be undertaken by BRS, a multi-agency team within Children’s Services. This is a service that is part funded by health and Children’s Services where specialist services such a child-psychologist and psychiatrists can be accessed and that specifically works with children who are Looked After. The initial meeting concluded that only Sibling 2 would benefit from a specialist assessment and that it would not be appropriate to assess Freddie however the Service would review documentary information about Freddie in order to then make a recommendation about what might be appropriate for him. Records suggest a level of concern so high that access to a service ordinarily provided solely to Looked after Children is disregarded because of the risk levels. The September 2014 RCPC states that the referral to CAMHS was rejected but that the BRS may be able to assist – reflecting drift between June and September 2014 when the original request was submitted. The RCPC record of March 2015 then states that there had been a family assessment by the BRS but the outcome was not yet known – reflecting further drift from the original point that some action was agreed nine months earlier. The account 21 given by the BRS for the delay in producing a final assessment report is that they were waiting for information to be submitted which would enable them to correctly complete their assessment work, alongside staff sickness for an extended period of time. This drift appears unchallenged resulting in no pace and little purposeful activity. The BRS did not escalate their concerns about missing information at any time and given their own views about the levels of risk this was a missed opportunity. Nor was there any escalation by the Child Protection Chairs or other members of the professional network responsible for the Child Protection Plan; this too, was a missed opportunity. Records indicate that a year after the original request was submitted (July 2014) the Service had in fact completed an assessment and report but that it had not been shared with the Social Worker. It is not until the February 2016 RCPC that we see reference to the BRS assessment and comments that it did not address the issues that needed to be explored. This reflects a mismatch in expectations about what such an assessment might be able to achieve and what it might have been able to offer the wider professional network. Learning point: When any specific type of assessment has been commissioned it is reasonable to expect professional challenge and escalation when it is not completed or if agreed processes have not been followed in terms of information exchange or commissioning arrangements. 5.3.21. Whilst the recommendations from the BRS focus on gaining more understanding, management strategies and support it does make reference to the Mother not accepting responsibility for Freddie’s sexualised behaviour and instead blaming Sibling 2 or the Father. The Mother also minimises Sibling 2’s offences and behaviours and appeared happy to criminalise them. Shifting the responsibility for the root causes deflects attention away from the Mother and further complicates the professional network’s search for trying to understand the origins of Freddie’s sexualised behaviours. This may account for some of the frustration and disappointment expressed by the network in that the BRS assessment did not pinpoint the origins of abuse, does not provide them with the magic solution and perpetuates a notion of the situation having to be maintained through management strategies rather than endorsing a view that a more interventionist approach could be followed. Furniss56 discusses the use of the ‘expert’ in such situations which is how the BRS was perceived ‘… to accept the notion of experts in child sexual abuse creates the false expectation that somebody who knows could tell others who do not know …the debate is not between the ones who can see and the ones who cannot … the tasks, the skills and the responsibilities in the overall intervention are larger than any single professional or agency can cover …’. The BRS’s report concludes, correctly so, with a recommendation that ‘ Freddie is also subject to a Child Protection Plan and within this framework consideration should be given to whether [the Mother’s] parenting is good enough and is meeting Freddie’s needs …’. Learning point: When seeking specialist input into cases where there are child protection concerns it is important to remember that sitting behind the need for specialist input is a statutory framework requiring agencies to safeguard children’s welfare. When cases have already reached a child protection threshold this means being mindful of the options open to professionals. Specialist input therefore has to be seen in the context of statutory intervention and one which still requires the professional network to keep children safe. 5.4. The assessment of the grandparents to provide a safe place for Freddie 5.4.1. It is understood that Freddie had been cared for by his Maternal Grandparents on a regular basis from around January 2016 onwards. This informal arrangement is one that evolved over time and towards the latter part of the timeframe under review became one whereby the Maternal Grandparents took on a greater role. On this basis it would be reasonable to expect to see some reference to an assessment of the situation as it evolved by Children’s Services, but also an assessment of the Maternal Grandparents’ ability to care for Freddie. Given that the entire professional network had not formed a view, or obtained any evidence, about the origins of any sexual abuse it would be reasonable to take a view that anyone with unsupervised contact with Freddie could be viewed as a potential 56 Furniss, T., The multi-professional handbook of child sexual abuse: Integrated management, therapy & legal intervention, p.260, 1995, Routledge. 22 perpetrator. Keeping the possibility of inter-generational abuse in mind at this point should have been an important consideration57. 5.4.2. There is no evidence of a formal viability assessment58 or referral for a full assessment of the maternal grandparents, or any other family members to be considered for looking after Freddie until May 2016 – some five months after it was known that they had taken on a greater role in Freddie’s life. This indicates there was little focus or grasp of what was really happening for Freddie by Children’s Services at this time. 5.4.3. Much of the groundwork for this assessment work could have been achieved whilst Freddie was subject to a Child Protection Plan. Exploring family networks and support would ordinarily form part of the assessment process when a child becomes subject to a Child Protection Plan, and certainly ongoing assessment work whilst on such a Plan. Exploring options about who might be best placed to care for Freddie would have been an entirely appropriate course of action as part of a coherent and systematic plan; as the notes of the legal planning meeting cannot be found it is impossible to comment on whether it was an option explored by Legal Services with Children’s Services in February 2016 but it would have been a reasonable recommendation from the July 2015 legal advice given. 5.4.4. The September 2015 RCPC makes a cursory reference to the grandparents and great grandparents being a good support to the whole family. Other than this, extended family members are not referenced at-all over the duration of the timeframe under review in any of the Conferences records and there is no reference to the Maternal Grandparents being involved in Freddie’s care at the February 2016 RCPC (when one might expect to see something). 5.4.5. The lack of assessment by Children’s Services is confirmed by Solent NHS Trust who have very little reference to the Maternal Grandparents in their records. Good practice standards expect assessment work to consider information from other agencies and professionals and there is no evidence to indicate that health professionals involved with Freddie at the time were contacted to consider the Maternal Grandparents capacity to care for a young and vulnerable child. Health professionals only became aware of the Maternal Grandparents involvement towards the end of the timeframe under review. There had been no known statements by the children of the Maternal Grandparents being abusive or inappropriate with them. 5.4.6. It is not until May 2016 when there is reference to the Maternal Grandparents being considered for long term care does any assessment work take shape. The conclusion reached was that although they cared a great deal for Freddie they would not be able to meet his complex needs. 5.4.7. It has not been possible to ascertain any specific reasons for the lack of assessment work on the grandparents other than those factors which have already been identified in the preceding pages. 5.5. Current practice challenges raised relating to the findings of this case 5.5.1. In order for this review to assist with learning and improvement activity it is helpful to place the findings in the current operating context for practitioners. On this basis the review has had access to the findings of recent audit activity which have examined many of the practice issues highlighted in this report. Whilst it is important to not draw conclusions about the quality of practice across all cases which may have a similar profile to this case there is value in noting that some themes remain a significant challenge for the safeguarding partnership. The following evidence supports this; - An audit was conducted in April 2018 of concerns raised about cases of intra-familial sexual abuse between January 2017 and April 2018. Findings were made about the quality of protective parenting work, sexual abuse 57 Intergenerational Patterns of Child Maltreatment: What the Evidence Shows, August 2016, U.S. Department of Health and Human Services & Children’s Bureau. 58 A viability assessment is a formal and specific type of assessment to consider the suitability of alternative carers when a child is unable to remain with the parent and members of the extended family have put themselves forward as carers. 23 had been missed with professionals focusing on other forms of abuse, and the quality of assessment work completed. These issues are reflective of what occurred in this case. - An audit of referrals and case progression was conducted in March 2018 looking at cases at the three month and nine month Child Protection Review Conferences. Findings were made about core group activity at three months ‘… core groups were more likely to occur than not, but there were cases where no multi-agency core groups occurred, and some where only one occurred during the 12 week period of planning. When core groups do occur, the success depends of the professionals and family attending and the quality of the recording and tracking of progress in the plan. On the cases where there has been drift, no core group minutes reflected how this had been challenged or discussed …’ noting that ‘ … the first three months of a child protection plan is a key time to engage and effect change within a family … [and] the delay in starting key pieces of work to achieve the outcomes in the CP plan has a fundamental impact on the effectiveness and therefore duration of the plan ...’ The finding at nine months was ‘ … there is still a pattern of core groups not occurring or not being recorded …’. Again, the issues are reflective of this case. - An audit was conducted in September 2018 of cases where children were subject to a Child Protection Plan for more than 18 months. Findings concluded that there was a lack of clear and adequate assessment of the circumstances and parents ability and motivation to make and sustain change, plus most of the cases had periods of drift and delay due to social worker absences or the Plan not being progressed, and that RCPCs were more effective when there is a consistent Chair. The findings are similar to those of this review. - An audit was conducted in January 2019 about children that come off a Child Protection Plan after more than 12 months. The findings concluded that risk assessments were often not completed in appropriate timescales with no clear explanation why, protective parenting work not being undertaken within agreed timescales and there being a lack of analysis in assessment work. - In discussion with workers from CAMHS it was noted that during the timeframe under review CAMHS were often not invited to Child Protection Conferences; reports suggest that this still remains an issue with short notice often being a barrier and CAMHS needing to find cover for scheduled clinic appointments. - The quality of management oversight and supervision in Children’s Services has come under the spotlight in this case. Whilst it may be possible to place the findings of this review against rogue practice current concerns remain about the overall quality and consistency of this important area. This is an area that is currently under review in the broader programme of improvement activity. 5.5.2. The audit work and examples cited above clearly demonstrate ongoing challenges around some of the core aspects of child protection work and the effectiveness of the multi-agency machinery around formal child protection processes. From the audit activity it is unclear what specific recommendations and actions have been taken forward to drive improvement activity. 5.5.3. Also of note, the time taken to initiate and conduct this case review has been a concern to the Independent Reviewer. The decision to conduct a review was taken in July 2018 yet there were delays in beginning the review of over six months despite it being possible to run case review processes in parallel to criminal proceedings. Further delays in receiving information were then experienced, in part due to staff sickness but also delays in information being submitted. Case reviews can be a valuable mechanism to provide feedback into the safeguarding system however in order to be effective there has to be an element of pace and momentum. The issues highlighted in this case, when placed alongside the findings of audit activity illustrate the high value of reviewing those cases where learning and improvements can be captured and then responded to in a timely manner; the danger being otherwise the system has no effective feedback loop to reduce the likelihood of recurrence. 6. Family contribution to the review 6.1. Seeking the contribution of family members has been an important consideration. The Independent Reviewer met with Freddie’s mother towards the end of the review process despite good efforts to engage her earlier. The mother 24 continues to have statutory agencies involved in her life but spoke about some of her frustrations with the professional contact during the time frame under review. These included; - Not understanding why a decision had been made to find alternative accommodation for Sibling 2 in 2014 but then not pursuing the matter further and Sibling 2 remaining in the family home. - Despite having many professionals involved with her, and the children, feeling like that she was not actually receiving any support, or at least not the right kind of support. The mother expressed a view that she would have valued further advice and guidance about how to be a more protective parent to Freddie. - During the time when Freddie was subject to a two year Child Protection Plan the mother was unclear what it was achieving and often felt it to be very messy; in part she confirmed that she was not finding life easy around that time herself, which fits with the offer of support not feeling enough for her. - During meetings, the mother expressed a view that she often felt intimidated by professionals, sometimes not knowing who people were or what they did. - A strong theme for the mother was her frustrations that professionals were not listening to her, especially when she was struggling to manage Sibling 2 and being worried about the impact of his behaviour on Freddie. Examples of her feeling like she was not being listened to include during meetings, professionals using information from the past and basing judgements on what this will mean for the future, and not being given sufficient time to make changes and professionals not hearing how challenging it was to make those changes. - The mother was complimentary about a Family Support Worker and one of the more recent Social Workers; due to them taking the time to understand her situation, spend time with Freddie and make good decisions. She was also complimentary about some of the actions of the Police in trying to manage Sibling 2’s behaviours. 7. Good practice 7.1. The focus of this Review is to learn and improve services. As such, it is important to capture good practice which supports positive outcomes for children. The following aspects of good practice have been captured. - It is evident that the Health Visitor understood the family’s complexities and had a focus on the impact of this on Freddie. - School A held a detailed chronology and notes regarding a range of incidents. There is evidence of positive attendance at statutory meetings such as Core Groups and Child Protection Conferences with shared reports highlighting concerns. Staff commented in interview that they allocated support to Freddie; he was happy in school; the staff worked as a team and shared concerns with each other; and that Freddie had made progress. - The GP Practice communicated with other agencies (Health visitor, Social worker) in a timely and useful manner to further discuss what was known about the family, and these contacts were well documented. This Practice currently holds monthly Safeguarding Meetings with Health Visitors in attendance. - GPs continued to refer Freddie to CAMHS when the Mother continued to have concerns about his behaviour. - The Police use of Out of Court Disposals for dealing with Sibling 2 was a positive approach to responding to his behaviour. - The Police use of the Neighbourhood Police Team single point of contact for engaging with the family - Pro-active multi-agency working by the Police via the MAPPA arrangements which recognised Sibling 2 as both an offender but also a vulnerable child. - The clear advice given by Legal Services to Children’s Services. 8. Conclusion 8.1. This Serious Case Review has examined the circumstances of agency involvement with an eight year old child who is suspected of being sexually abused in his family. The review has highlighted that the family were well known to 25 agencies and professionals and that all the children in the family were subject to a multi-agency Child Protection Plan for two years. 8.2. The review has benefitted from the contributions of agencies involved with the child and highlighted that work undertaken by professionals involved was largely ineffective in reducing the risks to the child. Attempts were made to gain the contribution of the Mother and children to the review however these offers were not taken. 8.3. The ineffectiveness of this work was due to a number of factors. These include; - The multi-agency Child Protection Plan had no pace and had little purpose. - There were a number of contributory factors to the drift. The most notable include there being a collective uncertainty across the professional network about how to best manage the risks to Freddie, delays in assessment work being completed, sympathy for the Mother’s situation distracting the professional view about the children’s safety and welfare, and inadequate management oversight from Children’s Services – who held lead responsibility for the Child Protection Plan. - Challenge and escalation by professionals across the partnership was limited. - The ability of Children’s Services to effectively fulfil their statutory functions as the lead agency were compromised due to multiple system issues whilst Freddie was subject to a Child Protection Plan. 8.4. The review has also exposed information that indicates ongoing challenges for the professional network in responding to cases that have a similar profile as this case. 8.5. The review has captured points for learning and improvement and concludes with recommendations for the Safeguarding Partnership to take forward. 9. Recommendations 9.1. As a result of this review agencies that have contributed have been able to identify learning that can be taken forward internally, and as such have submitted single agency action plans reflecting their internal learning and recommendations for improvement. It is the role and responsibility of the Safeguarding Partnership to scrutinise and challenge progress against single agency action plans. The following recommendations are for Southampton Safeguarding Partnership. 1. To ensure the learning from this Review is disseminated across the multi-agency safeguarding partnership to practitioners and managers. 2. To seek assurance that the actions identified by each partner agency, as a result of this Review, have been managed, implemented and embedded in a timely manner. 3. To request information about the consistency of Chairs for Child Protection Conferences over the last 12 months, and, where there has been inconsistency i.e. more than one Chair, seek assurance that the Plans for children subject to Child Protection Plans are fit for purpose and have pace. 4. To seek assurance about the quality, effectiveness and compliance with Core Groups when children are subject to Child Protection Plans and an update on actions taken to remedy the points raised in the March 2018 audit conducted by Children’s Services. 5. To seek an update about progress on actions arising from the April 2018 audit conducted by Children’s Services which looked at cases of intra-familial child sexual abuse, and to examine blocks and barriers to effective multi-agency work around the issue of child sexual abuse. 6. Southampton Children’s Services to assure the Safeguarding Partnership that there is a robust system for seeking legal advice, sharing information, recording legal planning meetings and tracking outputs – all on a timely manner. 26 This should include a process for monitoring any gatekeeping which may act as a barrier to gaining a legal perspective on a case where there may be threshold disagreements. 7. To ensure the commissioning arrangements for specialist services such as the Building Resilience Service (formerly the Behaviour Resource Service) are unambiguous and that all potential referrers are clear about expectations of what the service can offer. This should include a clear set of expectations about the need for professional escalation to be built in to contractual arrangements particularly when there are concerns about child protection, risk and safeguarding. Assurances should also be provided to the Safeguarding Partnership about the timeliness, pace and purpose of assessments and reports commissioned. 8. To raise awareness of the professional challenge and escalation protocol. 9. To increase the knowledge and confidence of front-line practitioners, in particular social workers, school nurses, and police in assessing and working with cases where child sexual abuse and exploitation may be a feature. 10. To seek assurance from Southampton Children’s Services about the quality of management supervision and employee welfare, plus management scrutiny and oversight in Children’s Services for cases where child sexual abuse and exploitation are features. 11. To seek assurance from Southampton Children’s Services that the decision making process and practice around viability assessments is robust and that decisions and assessments are completed in a timely manner. 12. The Safeguarding Partnership to review the systems and procedures around decision making, commissioning and business processes for conducting statutory reviews. This would be with a view to ensuring the necessary agility, rigour and pace and whilst confirming that learning from case reviews is implemented and embedded in a timely manner. |
NC50541 | Sexual assault of a 14-year-old male, by a 20-year-old male care leaver (YPA) in June 2016. The assault took place whilst the two males were being housed in temporary accommodation by the local District Council who were unaware of YPA's harmful sexual behaviour. Child Z had been placed in temporary accommodation with his mother and sister in January 2016 after eviction from previous rented accommodation in November 2015. YPA had been taken into care after a difficult and unsettling early childhood. He developed inappropriate sexualised behaviour in early adolescence and in 2011, aged 14, was placed in residential care. In December 2015 he was arrested for assault of an 11-year-old boy and bailed with conditions that he should not be alone with a person under 16. Lessons learned include: Children's Services should ensure its leaving care service is fit for purpose; the need to put in place effective early intervention services for young people, including care leavers, who exhibit HSB; unaccompanied children under 16 years of age must not be placed in temporary accommodation; Police child sexual exploitation perpetrators' risk assessments must result in effective and timely multi-agency planning of suspected individuals. Recommendations: that HSB procedures are fit for purpose and up to date; to disseminate and embed HSB policies and procedures; to widely disseminate and implement findings and learning from this SCR; for the Sexual Abuse Referral Centre (SARC) to report to the LSCB on the feasibility of expanding the service remit to include children and young people who have suffered non-penetrative sexual abuse.
| Title: Executive summary: Norfolk SCR Case Z. LSCB: Norfolk Safeguarding Children Board Author: Norfolk Safeguarding Children Board Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Executive Summary Norfolk SCR Case Z This Serious Case Review (SCR) is concerned with the sexual assault of Child Z, a 14-year-old male, by a 20-year-old male care leaver (YPA) in June 2016 and the learning to be gained from an understanding of how and why this happened. The assault took place whilst the two males were being housed in temporary accommodation by a local District Council who was unaware of YPA’s harmful sexual behaviour. Child Z had been placed at the accommodation along with his mother and sister in January 2016 having been evicted from their previous rented accommodation by their landlord in November 2015. They were waiting to be rehoused in June 2016 and were eventually found suitable long-term accommodation in July of that year. There had been two referrals to the Norfolk MASH (Multi-Agency Safeguarding Hub) in 2014 but these had not needed any intervention by Norfolk Children’s Social Care (NCSC). YPA and his younger sister had experienced unsettling and difficult early childhoods which had resulted in both of them being taken into the care of Norfolk County Council when young. They were brought up together as Looked After children in a long term foster placement until YPA reached the age of fourteen. By all accounts, the placement met the children’s long term needs for security, emotional attachment and stability. Unfortunately, it broke down for YPA who experienced the move to another placement as a traumatic life event, seemingly impacting quite significantly on his sense of security and vulnerability. Whilst having good general health he had developed Attention Deficit Hyperactivity Disorder (ADHD) for which he received appropriate medication. YPA developed inappropriate sexualised behaviour in early adolescence and in 2011, aged 14, was placed in a residential setting run by a private provider. He started to show signs of Harmful Sexual Behaviour (HSB) towards younger boys and in 2014 received psychological intervention to address the behaviour that included a risk assessment. The Norfolk Police and NCS were involved with YPA on several occasions in 2014-15 regarding HSB incidents. YPA was subject to regular Looked After Child (LAC) Reviews up to his 18th birthday in January 2015, when he became a Care Leaver. As part of his pathway plan YPA moved into supported accommodation (a two-bedroomed flat) overseen by the residential home. He left the home on his own volition in the Spring of 2015 with no suitable accommodation and spent the rest of the year ‘sofa surfing’ with friends in North Norfolk. Regarding health matters, there is currently no dedicated health service commissioned for Norfolk’s care leavers, who receive their last health assessment as they approach their eighteenth birthday. Given YPA’s diagnosis of ADHD, ongoing health input beyond the age of eighteen would have been beneficial to support his pathway planning. In this case, the health services played a small part in the lives of both boys, both before and after the sexual assault incident. Health services were not aware of the sexual abuse incident in relation to either of the boys and Health was not included in any multi-agency decision making forums, such as the strategy discussions (see below). YPA was arrested in December 2015 for the sexual assault of an 11-year-old boy and bailed with conditions that he should not have any contact with the victim and not be alone with a person under 16. The Police informed his Personal Adviser (PA1) of the bail conditions. YPA and PA1 attended an interview with a young person’s accommodation agency (AA1) in February 2016. His application for accommodation was refused due to the risks he presented to young people. YPA informed his personal adviser (PA1) in early May that he was homeless and needed somewhere to live. He duly registered in mid-May with NNDC/Housing Options as homeless who made enquiries with NCS about his housing status. They were not informed of his bail conditions and placed him at the temporary accommodation on the 24.05.16 where there were several vulnerable children and young people resident with their families, including Child Z and his family. YPA had been subject to a Child Sexual Exploitation (CSE) Perpetrator’s Risk Assessment by Norfolk Police on the 12 April 2016 and graded as Medium risk. On the10 June, the Police became aware that YPA was living in temporary accommodation and spoke to NCS about their concerns regarding the potential abuse of children living there. NCS agreed to contact the District Council/Housing Options and obtain the name of the staff member who had dealt with YPA’s homeless application and provide this to the Police. Unfortunately, due to a set of mistaken assumptions by both the Police and NCS, each agency thought that the other was taking primary responsibility with the housing agency for moving YPA. This resulted in a delay in moving him which eventually happened on the 24 June 2016. Unfortunately, this was not in time to prevent the sexual abuse of Child Z sometime between the 16 -19 June. The District Council Housing Options service only became aware of YPA’s bail conditions and the ongoing Police enquiry from Children’s Services (Leaving Care Team) on the 24 June 2016, which prompted the move out of temporary accommodation. YPA was moved by the District Council from temporary accommodation on the 24 June. On the same day, Child Z’s mother became aware of her son’s abuse and made a complaint to the Police who arrested YPA that night. He was subsequently charged with the sexual assaults of an 11-year-old boy (the December 2015 arrest) and Child Z in late June and early July respectively. YPA pleaded guilty to the charges and was given a custodial sentence in May 2017. Child Z was risk assessed for Child Sexual Exploitation by the Multi-Agency Safeguarding Hub (MASH) on the 27 June and graded as ‘Standard Risk’ and referred to Early Help. Subsequently, no support was offered. The family moved into new accommodation in July 2016. The SCR resulted in one recommendation for the Board to take action to ensure that: The HSB procedures are fit for purpose and up to date. That there is a robust strategy to disseminate and embed the HSB policies and procedures, including the need for early risk assessments and management plans for children and young people identified as presenting HSB, across the safeguarding partnership that includes the Care Leaving Service, the MASH, and relevant sections of the Police service. That the findings and learning from this SCR will be widely disseminated and implemented across the NSCB partnership so as to make an evidenced and demonstrable improvement to the safeguarding outcomes for children and young people. In addition, the report identified the following areas for improvement: a joint recommendation for Norfolk Children’s Services and Norfolk Constabulary assure the NSCB that, in cases of extra- familial child sexual abuse, arrangements (when appropriate) are made by the MASH to convene strategy meetings and initiate joint S.47 CSC/Police/EDT enquiries, in compliance with NSCB safeguarding procedures a recommendation to the Sexual Abuse Referral Centre (SARC) to report to the NSCB on the feasibility of expanding the service remit to include children and young people who have suffered non-penetrative sexual abuse. a number of single agency recommendations as below: Agency Summary recommendation Children’s Services To assure the NSCB that the NSCB that the Leaving Care service continues to make progress to the point where it is rated as, ‘Good’, by Ofsted and achieves high quality outcomes for care leavers a service is in place for early intervention regarding the assessment, treatment and risk planning of young people, including care leavers, who exhibit HSB. Local District Council To assure the NSCB that children under 16 who are in need of temporary accommodation are found placements which maximise their safety and well-being by reference to the learning in this SCR Norfolk Constabulary To assure the NSCB that the CSE Perpetrators’ Scheme is operating effectively a safeguarding referral is made to the Children’s Services on arrest of an individual suspected of being a perpetrator in extra-familial sexual abuse of a child. Health and Voluntary sector To advise the NSCB on any services outside of the SARC that can provide support to children and young people who have been sexually abused so that the Board can promote these services and address any commissioning gaps. |
NC047003 | Sexual exploitation of children in Oxfordshire. Focuses on the experiences of six girls aged 12-16-years-old who were the victims of offences between May 2004 and June 2012. Nine men were charged with offences, of which seven were convicted on 14 May 2013. Girls targeted had complex needs and many were known to children's services or were in care. They were groomed by older men who supplied them with drugs and alcohol. Broad multi-agency learning points identified include, lack of understanding of child sexual exploitation; insufficient use of child protection processes; lack of organisational overview; difficulty managing missing children; and a focus on young people's behaviour rather than their risk of being harmed. Recommendations include: all agencies should review escalation procedures; Oxfordshire Safeguarding Children Board should ensure inter-agency clarity about child protection roles; all agencies should raise awareness of guidance around children's ability to consent to sexual activity; and the Department for Education should review national guidance to ensure it gives sufficient weight to the use of disruption techniques in safeguarding children.
| Title: Serious case review into child sexual exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F. LSCB: Oxfordshire Safeguarding Children Board Author: Alan Bedford Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F Approved by the OSCB February 26th 2015 Independent Reviewer: Alan Bedford MA (Social Work), Dip.Crim FOREWORD i. What happened to the child victims of the sexual exploitation in Oxfordshire was indescribably awful, and a number of perpetrators are serving long periods of imprisonment following the investigation known as ‘Operation Bullfinch’. The child victims and their families feel very let down. Their accounts of how they perceived professional work are disturbing and chastening. There is clearly a demand to find out how such extensive abuse could have continued for so long before it was properly identified, and why there was not speedier action. There was a strong public reaction last year and this year to two Rotherham inquiries (which were not Serious Case Reviews) and to similar concerns reported elsewhere, and there have been calls in such cases for individuals to be held to account. ii. The Serious Case Review (SCR) has seen no evidence of wilful professional neglect or misconduct by organisations, but there was at times a worrying lack of curiosity and follow through, and much work should have been considerably different and better. There is little evidence that the local understanding of child sexual exploitation (CSE), or how to tackle it once identified, was significantly different from many parts of the country. iii. On the surface, many of the illustrations described in the report can seem like professional ineptitude, unconcern, or inaction. They become more understandable when put in the context of the knowledge and processes at the time, practical difficulties around evidence, and a professional mind-set which could not grasp that the victims’ ability to say ‘no’ had been totally eroded. However, understanding it does not make what happened right. The analysis of ‘why’, on the surface, there was inexplicable behaviour by organisations is to explain, not excuse. It is in understanding the context in which professional work took place, and what impacted on the thought processes and actions of staff, that there can be learning for individuals and organisations. This is the prime purpose of an SCR. The answers to ‘why’ cannot be reduced to a few simple sound bites, as there are many complex interlocking issues, which are described in detail in the Review. iv. The County Council and Police have apologised for not preventing or stopping the exploitation, (and some agency and multidisciplinary arrangements should indeed have been better). The Chief Constable apologised that it took so long to bring the offenders to justice, and said she was “sorry that we did not identify the systematic nature of the abuse sooner, and that we were too reliant on victims supporting criminal proceedings”. The Chief Executive for the County Council said that, “we would like to publically apologise for not stopping this abuse sooner and to reassure everybody listening that we have learnt a huge number of lessons in terms of how to tackle this type of abuse and that we are now taking decisive action to stop it happening in Oxfordshire”. The attitude seen by the Review is not one of denying the scale of abuse or the errors, but an acceptance of what was missed and a determination to ensure things are better. v. This SCR is not an ‘inquiry’, but does identify where there is evidence that things were not good enough. The fact that scores of professionals from numerous disciplines, and tens of organisations or departments, took a long time to recognise CSE, used language that appeared at least in part to blame victims and see them as adults, and had a view that little could be done in the face of ‘no cooperation’ demonstrates that the failures were common to organisational systems. There have been similar cases to those in Oxfordshire, most notably in Rochdale, Derby, Bristol and Rotherham. The same patterns of abuse are seen, the same views of victims and parents, and similar long lead-ins before effective intervention. For all this everywhere to be the result of inept, uncaring and weak staff, and leaders who need to go, seems highly improbable. The overall failings were those of a lack of knowledge and understanding around a concept (of CSE) that few understood and where few knew how it could be tackled, but also of organisational weaknesses which prevented the true picture from being seen. It is important this is recognised so organisations can, and can continue to, get it right on CSE, and can respond better when the next new challenge occurs. vi. There were many errors. Some organisations and some staff should have acted with more sensitivity, rigour, imagination or indeed common sense. Some processes and procedures should have been implemented much better, and the collective agency work around safeguarding before 2011 should have been much stronger. Over a number of years there were many signs of CSE of the type revealed in the Bullfinch trial, and whilst they were not recognised as ‘CSE’, the extreme nature of those signs required concerns to be escalated to top managers, but this did not happen. Even if what had been happening were unconnected individual cases, the effectiveness of professional work was not good enough. The abuse, as a result, continued for longer than could have been the case. vii. The issue in Oxfordshire was not very top management and governing bodies knowing about CSE and not acting, but that they didn’t know there were cases being dealt with that were showing indications of CSE, even if not defined or recognised as such. viii. While much should have been better, professionals working with the families concerned, over many years, worked relentlessly (if not always very effectively) to fulfil their professional duties to the victims and their families. Ultimately, it was the efforts of staff on the ground, and their observations and persistence, which was the main driver in the eventual identification of CSE. ix. Five of the seven convicted perpetrators were of Pakistani heritage. No evidence has been seen of any agency not acting when they should have done because of racial sensitivities. The victims were all white British girls. x. The vast majority of the information for this SCR has come from the agencies’ own internal reviews, so the accounts of any deficits in performance have come from the agencies themselves voluntarily, and reflect a laudable willingness to be open about the past. They were equally forthcoming when the author made additional inquiries. The learning in Oxfordshire has already been significant, with much good practice now in place, and a professional mind-set now attuned to CSE, with children seen as children, however they behave. There is a growing arsenal of tools to identify, prevent, disrupt and prosecute CSE. Operation Bullfinch and subsequent prosecutions have shown concerted and rigorous action. xi. This Review focuses on what can be concluded and learned for the system overall and about the period leading up to Operation Bullfinch, and includes an overview of progress since. In an associated document, ‘CSE in Oxfordshire: agency responses since 2011’ the detailed learning identified by each agency is set out, together with key actions taken and points of contact for further learning. Alan Bedford, Independent Reviewer February 2015 Para Page Foreword 1 SUMMARY AND INTRODUCTION 1 1.1 Summary of findings 1 1.11 The need for a Serious Case Review 2 1.13 Terms of reference 3 1.18 Independent Reviewer 3 1.19 Review process 4 1.23 Anonymity 5 1.26 Report structure 6 1.28 Definition of CSE 6 1.29 Terminology around ethnicity 7 2 BACKGROUND 8 3 THE EXPERIENCE OF VICTIMS AND THEIR FAMILIES 11 3.1 Introduction 11 3.8 Vulnerability 12 3.9 Experiences after grooming 12 3.10 The victims’ experience of professionals 13 3.12 The parents’ experience 15 4 IMPROVEMENTS IN OXFORDSHIRE 19 4.5 OSCB overview 19 4.6 Leadership commitment 20 4.15 Countywide service improvement 22 4.20 Investigation, disruption, prosecution 24 4.25 Community relations 24 4.26 Involved agency progress 25 4.34 The views of girls currently at risk 29 4.38 Moving on – an apology 31 5 WHY THE DELAYED INDENTIFICATION AND ACTION ON CSE? 32 5.1 Introduction 32 5.4 Why the delays? 32 5.6 5.13 5.19 5.26 5.38 5.46 5.60 5.68 5.72 5.85 5.88 5.103 5.111 5.112 5.114 5.115 Knowledge Language Consent and age The nature of the families Levels of cooperation Crime/No crime and evidence Lack of curiosity and rigour Disruption Escalation ‘Nothing can be done’ Missing persons management Pressures in Children’s Social Care Supervision Working with the parents ‘Professionalism’ Looked After Children processes 32 34 35 36 39 40 44 46 46 50 50 54 57 57 58 58 5.128 5.130 5.135 5.136 5.139 5.144 5.146 5.149 5.150 5.151 Assessments Use of Child Protection procedures Minutes and meetings Donnington Doorstep School-related issues Drug and alcohol issues Summary of health issues Taxis The whole multi-agency team Ethnicity 61 61 63 63 63 64 65 66 66 67 5.154 Summary 67 6 WHAT MIGHT HAVE BEEN KNOWN ABOUT CSE? 68 6.1 Introduction 68 6.2 Guidance 68 7 ORGANISATIONAL AND LEADERSHIP AWARENESS 74 7.1 Introduction 74 7.2 Priorities 74 7.5 Oxfordshire’s journey 75 7.6 7.25 7.66 7.71 The Oxfordshire Safeguarding Children Board (OSCB) The growing awareness in Oxfordshire Top of the office knowledge Operation Bullfinch 75 79 88 89 7.73 Comment 90 8 APPRAISAL AND LEARNING 91 8.1 Introduction 91 8.3 Learning points 91 8.4 Were mistakes made? 91 8.6 Could CSE have been identified or prevented earlier? 93 8.7 8.24 8.37 8.40 8.51 8.59 8.64 8.74 Missed opportunities What was missing organisationally in Oxfordshire? Knowledge Escalation Tolerance Staff attitudes and rigour Investigations Going missing 93 97 100 101 103 105 106 108 8.78 The impact of ethnicity 109 9 CONCLUDING SUMMARY AND RECOMMENDATIONS 111 9.14 Recommendations 113 App 1 Collated SCR learning points i App 2 Terms of reference vi App 3 CSE numbers- methodology ix App 4 Ofsted Inspection 2014: key findings x App 5 Acronyms xii App 6 Oxfordshire Safeguarding Children Board members at 26.2.15 xiii 1 1 SUMMARY AND INTRODUCTION 1.1 Summary of the findings: This Review is about the sexual exploitation of children in Oxfordshire, using as background the experiences of six girls who were the victims in the Operation Bullfinch trial. It important to recognise that the time when most of the abuse took place was when there was almost no knowledge of group or gang related CSE nationally, and it is only in hindsight that the full picture is obvious. The Review concludes that many errors were made, and identifies what lay behind the errors (listed fully in section 8). 1.2 Lack of understanding led to insufficient inquiry. That the girls had lost the ability to consent or make their own decisions due to grooming was not realised, and instead they were seen as very difficult girls making bad choices. This, and that most of their families were seen as also having many problems, deflected attention from who was drawing them away from their homes - their own or in Care. The language used by professionals was one which saw the girls as the source not the victims of their extreme behaviour, and they received much less sympathy as a result. They were often in Care for their own protection, and frequent episodes of going missing were again put in the context of them being extremely difficult children. 1.3 The law around consent was not properly understood, and the Review finds confusion related to a national culture where children are sexualised at an ever younger age and deemed able to consent to, say, contraception long before they are able legally to have sex. A professional tolerance to knowing young teenagers were having sex with adults seems to have developed. 1.4 The victims almost never cooperated with investigations (again caused by the grooming) and there was a sense that nothing could be done as evidence was therefore weak. The need for disruption, covert surveillance and comprehensive intelligence gathering, despite no formal evidence from victims, was not understood. In fact, there was limited understanding of guidance related to the exploitation of children, although this has been seen nationwide. The lack of cooperation, and attitudes of the victims, sometimes led to crimes against them not being recorded as such 1.5 Regardless of levels of technical knowledge about CSE, there was a lack of curiosity across agencies about the visible suffering of the children and the information that did emerge from girls, parents, or carers, or some very worried staff. Also, a failure to recognise that the very extreme circumstances around the victims were so bad as to need referral upwards to board/governing body level, and a strategic response. Instead, the cases were seen more in isolation, with the focus mainly on protecting and containing the girls rather than tackling the perpetrators. There was no evidence that the ethnic origin of the perpetrators played a part in the delayed identification of the group CSE. The Review shows that from 2005-10 there was sufficient known about the girls, drugs, prostitution and association with adult men to have generated a more rigorous and strategic response, but this did not happen – and mostly the information did not reach strategic levels. 1.6 In part, the findings above are not new, or unique to Oxfordshire. Much research had shown that few areas were prepared for this type of abuse. However, there were reasons why in Oxfordshire the group abuse was not recognised earlier, when there were opportunities to do so. The predecessor body to the Oxfordshire Safeguarding Children Board (OSCB), and OSCB in its early years, did not show sufficient grip or curiosity when some early signs were presented, and the topic drifted off the agenda. Children’s Social Care (CSC) was at the time 2 of much of the abuse rated as only adequate by Ofsted, and an external review showed the OSCB needed to improve. Social worker numbers were at one point amongst the lowest in the country (leading to high caseloads), and supervision of staff was not strong. Child protection processes were not always robust. Crucially, insufficient value was placed on escalating extreme cases for top consideration, and this must reflect the then management culture. The Police, then, had limited processes in place that pulled together force-wide patterns. The important role of the City District Council in terms of local knowledge and regulation was not understood. 1.7 There are indications that top-level commitment from agencies to the OSCB and its predecessor was variable, and the Board members did not create a Board which rigorously followed things through. Crucial national guidance on 2009 CSE was overlooked, and there was no strategic overview. 1.8 As a result, the discovery of what later emerged in the Bullfinch inquiry and trial was led not by leaders and strategic bodies but by more junior staff working nearer the coalface. A drugs worker for the City Council, a social worker, and a detective inspector, on their own initiative, and in the absence of any strategic work, each led a number of meetings which were unknown to the OSCB or top managers. Their efforts eventually culminated in a shared recognition that there was group-related exploitation of multiple girls. Action from this point became coordinated and successful. 1.9 Since this turning point in early 2011, Oxfordshire has responded comprehensively to the challenge, is rated as ‘good’, and is held as an exemplar of how CSE should be tackled. There is no denial of either the errors or the scale of abuse, and top-level apologies have been made to the victims and their families. 1.10 The Review identifies around 60 learning points that will help agencies understand why and what needs to happen to be sure CSE continues to be tackled well. 1.11 The need for a Serious Case Review: Concerns were identified about children in Oxfordshire being sexually exploited. The collective picture from local agencies, and the intelligence that emerged about those individual children, led to ‘Operation Bullfinch’. This complex investigation was led by the Police and involved other OSCB partners. A significant number of children were identified as victims of serious sexual exploitation. Nine men stood trial at The Old Bailey in January 2013, seven of whom were convicted and received substantial custodial sentences. The charges related to six individual girls – four cases of historic abuse and two which were more recent. The abuse was described by the trial Judge as a ‘series of sexual crimes of the utmost depravity’. 1.12 A decision was made by the OSCB to convene a Serious Case Review (SCR) on 26 September 2012. The cases of the six victims known as Children A, B, C, D, E, F (referred to in this report as A-F) met the criteria for an SCR as defined in the then national guidance.1 Children had been seriously harmed and there were concerns about the way agencies had worked together. This guidance was superseded in March 2013 but this would also have justified the decision to conduct an SCR. 1 Working Together to Safeguard Children (DfE 2010), chapter 8 paras 8.9 – 8.12. 3 1.13 Terms of reference (TOR): The 2013 guidance no longer provides core terms of reference for SCRs, but says that final SCR reports should provide a sound analysis of what happened in the case and why, and what needs to happen in order to reduce the risk of recurrence. The TOR are given in Appendix 2. The period covered is mainly 2005-11 (when the multi-agency Operation Bullfinch started), with older history considered where relevant. For four of the girls their abuse by the mainly Pakistani heritage group ended 2-5 years before Operation Bullfinch started in 2011. For the other two, it was still current, but near its end, by the time Bullfinch started. (In all cases the impact of the abuse has continued for them after the abuse itself stopped.) 1.14 This Review, which needs to identify ‘why’, was asked to look at the following two key questions: To what extent was the child sexual exploitation experienced in Oxfordshire preventable? What can be learned from the Review’s appraisal of the quality of agency work, and the experiences of the victims and their families? 1.15 To answer these questions the review will need to explore: What was known about child sexual exploitation and how it could be tackled? If it was not identified quickly enough, why not? What, including the quality of agency work, contributed to the vulnerability of the victims to abuse? How did agencies respond to the growing awareness of child sexual exploitation? What have agencies already learned and done as a result of Operation Bullfinch? What still needs to be done? 1.16 The Review should identify where agency performance could have been better, but also explain the context in which that performance occurred so that the contributory factors provide learning for OSCB and its member agencies. 1.17 To fulfil these terms of reference the views of the six girls and their families were sought and reported, and they had pre-publication opportunity to hear and discuss the findings. 1.18 Independent Reviewer: The original reviewer was David Spicer, a barrister, and formerly Head of Legal Services to Nottingham County Council, who in recent years had undertaken 16 SCRs mainly for Welsh local authorities. When David Spicer stepped down for health reasons, Alan Bedford was appointed by the OSCB from July 2014 and is the author of this report. He has a background in child protection social work with the NSPCC, where he was also National Training Manager. Following this he spent 18 years in the NHS, the majority of the time as a CEO in Trusts and Health Authorities. Through Alan Bedford Consulting he has worked on a range of issues, from infection control to emergency healthcare, and now mainly safeguarding. From 2009-11, he was Director of Safeguarding Improvement for NHS London, leading a London-wide peer review programme, and from 2009-13 was an LSCB Chair. He led on SCRs for the Association of Independent LSCB Chairs 2102-13. He has conducted a number of SCRs, is accredited as a SCIE Systems Reviewer, and has completed the 2010 and 2013 national training for SCR authors. 4 1.19 Review process: A Serious Case Review Panel was set up to oversee the SCR, and met in 15 occasions. It had the following membership Role/Name Organisation Chair Paul Kerswell SCR Independent Chair Members Lucy Butler Deputy Director, Children’s Social Care and Youth Offending Service, Oxfordshire County Council Hannah Farncombe Safeguarding Manager, Children’s Social Care, Oxfordshire County Council Peter Clark Head of Law and Governance, County Solicitor, Oxfordshire County Council Frances Craven (to Sept 14) Deputy Director Education and Early Intervention, Oxfordshire County Council Margaret Dennison (Sept to Oct 14) Deputy Director Education and Early Intervention, Oxfordshire County Council Melanie Pearce Area Service Manager, Adult Social Care, Oxfordshire County Council Rob Mason Detective Chief Superintendent, Thames Valley Police Adrian Roberts (Aug to Oct 2014) Head of the Complex Casework Unit, CPS Thames and Chiltern Adrian Foster (from Nov 2014) Chief Crown Prosecutor, CPS Thames and Chiltern Jane Bell (to June 2013) Designated Nurse and Safeguarding Lead, Oxfordshire Clinical Commissioning Group Alison Chapman (from June 2013) Designated Nurse and Safeguarding Lead, Oxfordshire Clinical Commissioning Group Christine Simm (from May 2013) Chair of the Management Committee, Donnington Doorstep Clare Robertson Designated Doctor for Safeguarding, Oxfordshire Clinical Commissioning Group, and Oxfordshire Hospitals NHS Trust Di Batchelor Chair, OSCB Education Subgroup Kate Riddle Acting Head of Nursing Children and Families Division, Oxford Health NHS Foundation Trust Kevin Gibbs Head of Service, South West England & Thames Valley, Cafcass Tim Sadler (from Sept 14) Executive Director, Community Services, Oxford City Council Critical Friend Bina Parmar Specialist Team Member, NWG Network LSCB Staff OSCB Business Manager OSCB Business Officer 1.20 As the SCR started in September 2012, it had to follow a much prescribed methodology under the then statutory guidance, and the Panel decided to continue with that model when in March 2013 successor guidance introduced local flexibility on method. A core part of the traditional methodology was the production of Individual Management Reviews (IMRs), and these were commissioned from the following organisations, several of whom used independent authors. 5 NHS Oxford Health NHS FT Oxford University Hospitals NHS Trust Oxfordshire Clinical Commissioning Group Health Overview Oxfordshire Clinical Commissioning Group Oxfordshire County Council Early Years/Education Children’s Social Care Adult Social Care Public Health – Drugs and Alcohol Youth Offending Service Legal Services Oxford City Council Oxford City Justice Services Cafcass Thames Valley Police Crown Prosecution Service (Briefing Report not IMR) Voluntary Services Donnington Doorstep OSCB Oxfordshire Safeguarding Children Board 1.21 These IMRs and the combined agency chronologies amounted to around 6,000 pages of information and analysis, and the extent of agency involvement described explains in part the length of time it took for contributory documents to be finalised before the report itself could be started. Each agency IMR made recommendations and organisations have been working on their own action plans. The majority of evidence in this SCR comes from IMRs, but in the narrative it may simply say ‘(the agency) said’ or ‘(the agency) told the SCR,’ etc. This will include information from follow up queries from the SCR author to agencies. The author was given full cooperation with any further inquiries he felt appropriate to supplement that from IMRs. 1.22 The Panel met with the IMR authors for a two-day exploration of the key issues, and the new Independent Reviewer (the author) held a one day workshop with the IMR authors. The original reviewer met five of the six children and several parents, who provided a rich contribution to the SCR. The author met four of the victims and spoke to parents of three. He also met them again, with the OSCB Independent Chair to brief them on findings before publication. The author also interviewed a number of chief officers past and present, the former Lead Member for Children’s Services, and a number of staff who had played a significant part in identifying the child sexual exploitation. 1.23 Anonymity: When the Review started, the national guidance required reports to be fully anonymised, and it was on this basis that most staff and family contributions were made. Working Together 2013 no longer requires anonymity but asks the Local Safeguarding Children Board (LSCB) to consider the impact on those involved in determining publication. The OSCB believes it is important to preserve the identity of the children and families. This Review will not therefore describe the families in detail. This is also necessary to comply with the legal requirement not to publish the identity of victims of sexual offences. Members of staff are referred to by job title, and anonymity is also important if maximum learning is to be achieved through staff contribution to SCRs. 1.24 The case illustrations in this report are not associated with a specific victim, even anonymously, but as an account of the sorts of experiences and feelings experienced by the six victims and those working with them. This avoids risking a loss of confidentiality, and 6 allows mention of some detail which could not be used if there was a risk of linkage with a particular family. The law says that no matter likely to identify a person against whom a sexual offence has been committed shall be published during the victim’s lifetime. 1.25 The Review has had to weigh up two risks when referring to the specific experiences. If the initials A-F are used, and in some way identities are revealed, it would be unfair on those involved. On the other hand, if illustrations are reported as typical, common or even ‘in one case’ then something might be seen to apply to any or all of the victims/families, which might also be or be seen to be indiscriminative. The author has decided, on balance, not to align experiences to victims or families by specific initials. 1.26 Report structure: The first Annual Report of the National Panel of Independent Experts on SCRs (which oversees the quality of reviews to ensure appropriate action is taken from the learning) comments on SCRs being produced now. It has expressed concern about undue length. It warns against a level of detail that would make publication difficult (and hence learning limited). It calls for a ‘sharp focus’ and ‘concise accounts’. This SCR therefore uses the case detail to illustrate findings rather than describing all the very significant history, which would lead to a report of such length as to render its aim of being read and learned from impractical and unsuccessful. The SCR uses the six cases to illustrate the findings, but wherever possible findings relate to the whole system not only those cases 1.27 The report describes what happened in the words of the victims and families, and identifies the reasons why agency responses were insufficient for some time to intervene in a protective way. It goes on to look at what guidance was available to organisations and professionals, and then appraises the quality of agency work. It identifies learning points and key recommendations. Early in the report there is an account of how child sexual exploitation is addressed now and the improvements already made. 1.28 Definition of CSE: This Review is about child sexual exploitation (CSE) defined by government as follows: “Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. Child sexual exploitation can occur through the use of technology without the child’s immediate recognition; for example being persuaded to post sexual images on the Internet/mobile phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social/economic and/or emotional vulnerability.” 2 This accurately describes what happened in Oxfordshire. 1.29 Terminology around ethnicity: The perpetrators in this case were predominantly of Pakistani heritage. (Five were of Pakistani and one of North African heritage and the other has said he was born in Saudi Arabia.) In this report the word ‘Asian’ is used more than ’Pakistani’. This is 2 Safeguarding Children and Young People from Sexual Exploitation: supplementary guidance to Working Together to Safeguard Children 9DCSF, 2009). 7 not to hide any specific ethnic origin, but because this was the description mainly used by the victims and in agency case records. It is believed that when the term ‘Asian’ was used it did very often refer to those of Pakistani heritage, but ‘Asian’ seems to be the word used in common professional parlance. 1.30 The victims were white British girls. 1.31 This Report was in final draft stage before the Report of Inspection of Rotherham Metropolitan Borough Council by Louise Casey was published on 4 February 2015.3 3 Report of Inspection of Rotherham Metropolitan Borough Council, House of Commons, HC1050 (February 2015). 8 2 BACKGROUND 2.1 This section is necessarily frank about what the exploitation involved. It is the recognition of just how awful it was that focuses the mind on the suffering and how well agencies acted and reacted. It was so bad that, for a time, it was hard for staff to grasp the reality of what was happening. Concerns were identified about young people in Oxfordshire who were being sexually exploited. The collective picture from local agencies and intelligence that emerged about those individual young people led to ‘Operation Bullfinch’. This complex investigation was led by the Police and involved key OSCB partners. 2.2 In Operation Bulfinch over 20 young people were identified as potential victims. Nine men were charged with offences against six children (Children A-F) and committed to trial at the Central Criminal Court in London. As a result, seven of the nine defendants were convicted on 14 May 2013. Five life sentences were given, with minimum terms ranging from 12 to 20 years. The two others were jailed for seven years, with Sexual Offence Prevention Orders. Further investigations and trials continue. 2.3 The six children whose cases illustrate this Review were the victims of between one and 24 of the convicted offences, although the testimony they have given to court, professionals and this Review makes clear that this would only be a very small fraction of the offences likely to have been committed against them. The Prosecution said the charges were “not intended to reflect each and every act of sexual abuse performed on each of the complainants. Rather, the indictment is intended to reflect the different types of conduct inflicted on the complainants and their ages at the time that conduct was inflicted.” The offences took place between May 2004 and June 2012 when the children were between 12 and 16. For the seven convicted perpetrators, the guilty verdicts related to the following offences: 19 convictions for rape 10 convictions for conspiracy to rape 5 convictions for rape of a child under 13 4 convictions for conspiracy to rape a child under 13 8 convictions for arranging or facilitating prostitution 5 convictions for trafficking for sexual exploitation 4 convictions for sexual activity with a child 1 conviction for conspiracy to commit a sexual assault of a child 1 conviction for sexual assault of a child under 13 by penetration 1 conviction for using an instrument to procure a miscarriage 1 convictions for supplying a class A drug 2.4 The Prosecution’s opening speech at the Operation Bullfinch trial began by saying, “These defendants, and others not before the court, used and abused the six complainants persistently, over long periods of time, sometimes in groups, for their own sexual gratification and the sexual gratification of others. The depravity of what was done to the complainants was extreme… The facts in the case will make you uncomfortable. Much of what the girls were forced to endure was perverted in the extreme.” 2.5 The Review finds extracts from the remainder of the Prosecution speech a clear summary of the children’s experiences. Some acts of abuse in the speech were too graphic to be repeated here. 9 “… these men, sometimes acting in groups and at other times separately, actively targeted vulnerable young girls from the age of about the ages of 11 or 12. Sometimes the men would come across the girls while the girls were out drinking or playing truant. There is evidence that the men deliberately targeted children who were out of control. They also targeted children who had been sent to live in care homes for precisely that reason. Sometimes girls already being abused by the group(s) were tasked to find other girls for the group(s). The girls who were chosen generally had troubled upbringings and unsettled home lives which made it less likely that anyone would be exercising any normal parental control over them or looking out for them. The girls were then groomed in a variety of ways such as being given gifts or simply by being shown the care and attention that they craved. The attention lavished on the girls at the outset was of course entirely insincere as it was merely a device to exploit their vulnerability. Having secured their confidence the men would ply the girls with alcohol and introduce them to drugs such as cannabis, cocaine, ‘crack’ and sometimes heroin. The girls became addicted to certain of the drugs and felt unable to live without them. This made them even more dependent on the men. Sometimes the men would also exercise extreme physical and sexual violence on the girls and threaten them that should they ever seek to free themselves from the grasp of the group they and/or their families would suffer serious harm. In such ways the men came to exercise control over the girls who they knew: - Were therefore likely to subject themselves to sexual exploitation and abuse; - Unlikely to ever be able to extract themselves from it let alone complain about it; - And if they were to complain, it is unlikely they would be believed in view of what others would perceive as their delinquent conduct. It was a lifestyle described by one of the complainants as a “living hell” from which they could not extricate themselves. The overall period covered on the indictment is from May 2004 to early 2012… The defendants took the girls to other places, usually hotels / guest houses or empty private dwellings, for other men to have sex with them, again often in groups and often in return for money which was paid to the men and not the girls. Most of the men were engaged in the sexual abuse of the young girls did so over many years. Each was much older than any of the girls and of an age to know precisely what he was doing; the harm he was inflicting on the girls; the fact of their suffering and that their activity was illegal and in many instances depraved. In short, their conduct was intentional and persistent. Many of the sexual acts committed on the girls were extreme in their depravity. The girls were usually given so many drugs that they were barely aware of what was going on. Indeed, they say that it was the only way they could cope with what was going on. The sexual abuse included vaginal, anal and oral rape and also involved the use of a variety of objects such as knives, meat cleavers, baseball bats… sex toys … It was often accompanied by humiliating and degrading conduct such as biting, scratching, acts of urinating, being… 10 suffocated, tied up. They were also beaten and burnt. This sexual activity was often carried out by groups of men; sometimes it would go on for days on end. The places to which the girls were taken were often private houses and guest houses in Oxford. Some of the private houses appeared to be empty and used solely for the purposes of the abuse. The men who came to pay to have sex with the girls were not always from Oxford; many travelled from far afield, places such as Bradford, Leeds, London and Slough. It seems they came specifically to sexually abuse young girl, often by appointment with the men in Oxford who had dominated the girls. Between acts of abuse sometimes stretching over a number of days, the Oxford men ensured girls were guarded so that they could not escape. In addition to being abused in various locations in Oxford, some of the girls were taken to other towns and cities such as London and Bournemouth for the same purpose.” 2.6 Assessing the scale of CSE is a very difficult task and there is no nationally agreed means of doing this. The Police and CSC were commissioned by the SCR Panel to try to produce robust figure. Adding cases where there was some certainty to those where there was a formal conviction of offences against them, there are grounds for believing that over the last 15 years around 370 girls may have been exploited in the ways covered by this SCR. The total will be a reasonable figure from the collective research of Police and CSC, although not precise because figures, by definition, were not formally collated until the pattern was finally recognised. (See Appendix 3 for methodology.) Original Bullfinch investigation 39 Ongoing Bullfinch investigation 58 Others from CSC records 21 Children with whom Kingfisher have worked to Dec 2014 255 Total 373 2.7 The author and SCR Panel are conscious that these numbers may seem low given the higher (estimated) figures in Rotherham, but the work was carefully done and was debated and agreed by Panel members. It is not reasonable to extrapolate from the 255 children worked with in 2011-14 back to 1999 because many of these will refer to abuse which took place before 2011. 2.8 There was a commercial aspect to the exploitation, with some of the girls forced to work as prostitutes, hired out for up to hundreds of pounds, and trafficked and sold for sex. The police officer who led Operation Bullfinch characterised the crimes as ‘organised’. 2.9 The Prosecution opening speech refers to the areas men came from to abuse these girls. It says in various statements that the girls were trafficked for sex or being abused in London, Slough, Manchester, Coventry, Torbay, and Wycombe, and accounts of men coming from a range of cities including Leeds and Bradford to have sex with the girls. In February 2014, West Yorkshire Police charged 25 men from Halifax, Bradford, Shipley, Nantwich, Huddersfield, Derby and Newport in relation to sexual exploitation. Together with other high-profile cases of CSE across the country, the spread of places suggests that CSE is a nationwide issue. 11 3. THE EXPERIENCE OF THE VICTIMS AND THEIR FAMILIES 3.1 Introduction: The stories of the children whose cases are covered by this Review are shocking. The accounts here are as told to the original reviewer, the author, or from documents seen by the Review. Little comment is made on the views given in this section as it is important to know what the victims (and families) experienced and how it made them feel, both as a result of perpetrator action and in their dealings with professionals. In later sections, the perspective of staff is described and analysed for learning, and any differences of view discussed. As explained in Section 1, no comment is attributed to a specific victim or family. 3.2 The victims’ voices are reflected through this report. The bulleted comments and views in this section are mainly taken from the previous reviewer’s detailed notes of discussions with them, from the author’s agreed interview notes with victims and parents, and some from other documents seen by the Review. 3.3 This Review will not tell individual stories as they become easily identifiable. The Prosecution speech in Section 2 has given a powerful overview of what happened to the girls. Their views, and parents’ views, are given in three sections. Firstly, there is the period when, for most of the girls, a degree of vulnerability made them more susceptible to the attention of older men and the excitement that went with being found attractive, having money spent on them, a sense of drama and of ‘living’, probably the buzz from doing something on the edge, and alcohol and drugs. The families would be puzzled by the absence of the girls, who they were with, the gifts the girls came home with – and, if there were no problems with school attendance, there soon would be. Some of the children were already in Care or under Social Services care for a variety of reasons. Going missing from home or Care became common , . 3.4 Secondly, there were the results of the grooming. The more extreme behaviour, the longer periods of being missing, the effects of drink and drugs, looking gaunt, non-cooperation with anyone in authority. Longer periods in Care, sometimes being locked up in secure accommodation for their own safety. And despite what any professionals did (and the sum total of their effort was massive, if not too effective), the girls were unable to break away from the men who were by then using them for sex, offering them to others, selling them for sex, and keeping them hooked in by generating dependence on alcohol and drugs, which the girls paid for through sex. They were unable to reveal, in any usable way in court, detail of what was happening to them. During this period, some parents’ entire lives would be dominated by searching for the girls, or trying to get agencies to act in a proactive protective way. The more vulnerable parents had less focus on protection. 3.5 The impression given in the history as told to the Review or the Police investigation was one of remorseless drama, chaos, violence, drink, hard drugs, violent and utterly unloving sex, and of not being able to escape – even to the point that the grooming was so successful that there was ambivalence about whether to escape or not. 3.6 Thirdly, there is how the girls and parents viewed the work of staff. Whilst it must be remembered that these cases were amongst the most difficult most staff would ever face, in general, family views were not positive. They saw staff as not taking concerns seriously enough, not believing the girls, not picking up the hints that they were giving about their abuse, and not being inquisitive enough about what was happening to them. The girls saw staff as critical of them and (while all the girls spoken to acknowledged how ‘difficult’ they were) felt 12 staff were not able to make a real human connection with them. Understanding the staff perception of this dynamic is an important part of the learning later in this Review. There is more on the parents’ experience in 3.12 below. 3.7 The bulleted remarks below are powerful, relevant, and no doubt will be easy headlines which could lead to superficial conclusions. It is important that they are considered in the context of the whole Review. Words in brackets are added by the author to aid clarity. 3.8 Vulnerability: These are descriptions by the children after the abuse. Their acknowledgement of their vulnerability does not imply they were responsible for what happened to them. It was a bit exciting They gave us more than my Mum could Dad was violent to me. I thought it was normal I had no male love, my father was an alcoholic, he hit me I was already off the rails before [meeting the men] Other children have a parent who they can talk to and rely on My birth father was alcoholic and violent I have always been aware of my problems, I was a brat My poor early life made me vulnerable School was bad for me – I was made fun of as a foster child. So I bunked off Suddenly the guys were bringing me stuff. They said how lovely I was They would buy us things I used to run away before [the grooming] They made me trust them for months, and I was their friend. I was flattered It was exciting – Asian boys with flash cars I wanted an exciting life: after 5-6 months I was involved – it was too late For a while he was my friend – just the two of us I used to moan about my home life – I was flattered they listened I believed they were my friends, nothing was more important They paid for drinks and gave us drugs I went missing every week – I thought it was normal When the grooming started they were so kind and nice. They were a lot older. It was flattering. It was attractive – then things started to change. I was already into drugs The Asian men felt they ran Oxford. That was exciting. People were afraid of them. I felt protected. People respected them 3.9 Experiences after grooming: There is no need to repeat here some of the very graphic illustrations given by the Prosecutor in 2.4-5 above. Suffice to say, as horrendous as that description is, seeing/hearing about it in the girl’s words, for example in statements, is indescribably awful. The victims were describing things happening to them across ages 12-15: It all began when I was about 12 years old It started with men taking an interest in me The next thing it isn’t nice anymore… they gave us weed and drink to make us feel better They started nice on the first day, on the second they wanted sex – still being nice. We drank vodka 13 They took us to a field where there were other men who had come to have sex with us. I tried not to do it. There were five of them They threatened to blow up my house with my Mum in it I was expected to do things – if I didn’t they said they would come to my house and burn me alive. I had a baby brother I took so many drugs – it was just a mish-mash Now I feel I was raped – I didn’t have any choice I wouldn’t ever have said no – they’d have beaten the shit out of me It was always Asian men I got deeper and deeper into this group Sometimes I was driven into alleys and woods and men would have sex with me I wouldn’t have done this if I was sober. That’s why the men gave us so much to drink Both men had sex with me lots of times – oral and vaginal I hate them... all they do is rape you… all they want is sex… it’s happened to girls I know, not me before you ask, I not like that When we were at the flats I knew I was there to have sex which whichever men were brought there. He urinated on me I was spit roasted [made to have sex simultaneously with two men] I didn’t want to go to the places to do what I did, but it was my job I went to London on my own to have sex with men they arranged The fear is still very real for me – though they are in jail I still check the cars It wasn’t until the trial that I realised the organised nature of the abuse 3.10 The victims’ experience of professionals: At the time, the power of the grooming and the fear was so strong that there was an inability to cooperate with caring and justice agencies. Nevertheless, the victims have a great sense that they still gave enough indication verbally and non-verbally of what was happening for agencies to have intervened – even when they would have said they did not want such intervention. Allegations were frequently withdrawn, or details not given. Later in the report this dynamic is analysed in more detail. The comments relate to being missing as well as the absence of intervention. 3.11 Many comments are not attributed to specific agencies, as the learning from what is said applies across all organisations: I was found in the presence of the men constantly. Why were they not pulled in? Police… didn’t find me except once… I didn’t hide – I told people where I was If a perpetrator can spot the vulnerable children, why can’t professionals? Social workers asked me questions which showed they knew They could have followed us [On why not more inquiring questions] We wouldn’t have told them but it would have showed they cared Why would a 13-year-old make it up? They didn’t stop to think ‘why?’ They did not look on me as a child. In my head I was older, but really truly I wasn’t People were reluctant to see what was clearly in front of them 14 Social Services knew what was going on – they always asked questions that showed that they knew The only person who was any good was [the support worker]. She took me to MacDonald’s or Costa Coffee to talk. I wasn’t confident enough to tell her... but she was taking to me and listening The support worker was great. She was an adult… she was firm and there for me... she talked about ‘we’, ie me and her The social worker just wanted to hear what [the worker] wanted to hear so there was no need to do anything… [A police officer] tried to get people to listen, but she was banging her head against a brick wall The same officer was kind, supportive and showed the humanity and respect that so many officers seemed to lack at the time No one believes me, no one cares They knew where I was, they didn’t care when I came back I couldn’t sleep or eat The Police never asked me why – they just took me home They left you in a house with Asian men and didn’t even ask my age I thought if I told the Police what was really happening they would not believe me, and they would not arrest them and then… they did not do anything and that made me think that nothing could be done I was put in a secure unit because I kept going missing – I thought I was being punished. They did nothing to the men that made me go missing They should have done something to the men, not me Staff would see you get picked up by adult males in cars so they knew what you were doing [On returning from London] No one spoke to me about the men in London. There were hundreds of them – untouched I never told anyone what I was going through Taking me away from my Mum was bad I said, ‘I will get burned alive’. She said come round for a coffee I made a complaint about a man who trafficked me from a children’s home. He was arrested, released and trafficked me again If someone had taken the trouble to ask me I would have told them Oxford and another council argued about me to try and avoid doing anything. It wasn’t my fault I was abused The old sergeant was great. He has a cigarette with you, and chatted about anything, He didn’t make me feel bad about myself and treated me like a person The social worker didn’t understand the extent or seriousness of what was happening. She didn’t understand why I wasn’t telling them [about the exploitation] I turned up at the police station at 2/3am, blood all over me, soaked through my trousers to the crotch. They dismissed it as me being naughty, a nuisance. I was bruised and bloody Social services washed their hands – ‘it’s your choice’ I was told A WPC found me drunk with men. I said I was ok and she went away and left me with them. I was abused that night Ms X at the school – she had no idea what to do. She just listened and didn’t say do this, do that. She was a rock… … She did speak to the police. It meant I was whacked around the head with a crowbar 15 The staff in the Secure Units were good. They knew how to deal with hard cases. If you told them to f-off 20 times, they would still ask if you were ok and wanted a cup of tea There were a number of very negative comments from victims about one children’s home, Dell Quay in Henley (closed 2008), suggesting poorly trained and inexperienced staff who set a poor example to the girls. 3.12 The parents’ experience: The SCR Panel decided to approach only those parents where the victims agreed they could be approached. Four parents of three victims agreed to speak to the Review, so the views below do not necessarily reflect those of all parents, but it would be surprising if there were not some similarities. As will be seen later, a number of parents created strong reactions in professionals who might have a different take on some of what is reproduced below. Regardless of how ’difficult’ any parents were (either innately, or as a result of the anxieties of caring for exploited children, or their frustrations with agencies), their experiences of having children who, for example, went missing up to hundreds of time, who seemed so distressed and hurt, and who would often act in a self-defeating way was truly exceptional. Any parent whose 12- to 15-year-old has gone missing even once, or had an inappropriate sexual relationship, or been attacked will recall the chaos and upset this caused and have this emblazoned on their mind for ever. These parents dealt with worrying incidents up to daily for years. They were naturally frustrated that agencies did not provide quick solutions to protection, prevention, or discovery. It shows that there was a long period when no one knew exactly what was happening, but the parents knew ‘something’ serious was awry. 3.13 The bulleted comments are in no special order, but aim to illustrate the range of views. The quotation below seems to sum up what it was like to be a parent of a child caught up in grooming and CSE. 3.14 “… we... have a situation where [the daughter] is virtually living on the streets and no service or individual has been able to engage with her at all, most have not even tried. She is absolutely alone in the world apart from me and she refuses to allow me to have any influence on her. I have reached the reluctant conclusion that [her] home here is of absolutely no benefit to her and that the toll that trying to preserve it is taking on my physical and mental health and to a lesser extent the well-being of family and friends and neighbours and the police is all for nothing.” Parental comments included: Police wouldn’t pursue anyone unless they had a cast iron case No one thought about us – what it would be like if it was their daughter She always said she was with friends but would surface, often in A&E, anywhere – usually in London but also Essex Coventry and Gloucester She would be dirty, hungry, not in her own clothes, very distressed and clearly coming down off some substance Police wouldn’t tell us addresses so we could go and bring her home She was a minor but we were told it wasn’t our business We thought she was just a rebellious teenager bunking off to smoke and drink in the park – no one said we need to know where she goes I tried to tell social services about the evidence – but they weren’t interested. It was obvious it was something sexual All this – it has ripped the family apart 16 I keep emphasising ‘she is a minor’. Why would other vulnerable groups be protected from themselves, but she was allowed to make the wrong choices A big chunk of her life has been taken away – when she should have been at the youth club or skating or the school prom – all that went missing because of them: the perpetrators and the police/social services for not stopping it when they knew I put window locks on and kept the key... but in the morning found someone had helped her chisel open the sashes It’s in my mind all the time – what happened to my ‘baby’ and what I did because I didn’t understand what was happening to me They knew what was happening to her and didn’t tell me Every day I deal with it – dread the phone ringing in case it’s something bad Why did they let it go on during the long investigation No one spoke to us about dealing with the people responsible The social worker was very abrupt, said it was my duty to look after her. I said I was not capable of dealing with it There were lots of meetings. I got very angry and said it was a load of bull shit - no one was doing anything The police said she didn’t appear in danger, they said she was happy to be there, and refused to tell me where she was If I had known I would have fetched her out of [named address] – I didn’t learn about it till the trial The Guardian Ad Litem never spoke to me at all, or discussed with me how to protect her They threatened to kill me and behead my daughter’s baby She was missing for ten days Because she came home [from missing] they thought she was safe now Giving her a cuddle and taking her to MacDonald’s was the [worker’s] solution One manager said [before the exploitation was understood] ‘She’s streetwise, and loves it’ [After a theft was investigated where a girl was with older men] The issue for the police was the burglary, not a 13-year-old with older men At interagency meetings attended no one kept any records/minutes, and there were never agendas The Children’s Home didn’t tell me when she went missing I despaired of ever getting an appropriate response that stood alongside us and didn’t try to blame and shame us 3.15 One parent submitted a written paper to the Review, extracts from which are included above and below: “I don’t blame Social Services for not understanding exactly what went on- the street grooming by groups was an ‘unknown unknown’, but I would criticise them for… - Only working with one model of abuse – intra-familial - Having no empathy - Not adequately acknowledging my concerns - Appearing to have no interest in what was happening when she was placed out of county, and being indifferent to her being trafficked 250 miles from one care home - Not having the interest and skills to engage an angry troubled child –all bar one excellent down-to-earth support worker 17 On the whole the Police were the only service who tried to get a grip, or which offered interest empathy but… - Even the police back then didn’t see organised abuse as the main reason the girls went missing - There was a lack of curiosity - Too many accepted her explanation of being with friends - I was asked the same questions each time on the scores of occasions I reported her missing, and they would search the house and gardens each time – a waste of everyone’s time. The police were always apologetic and sympathetic Health - Wonderful empathetic support from our GP - In mental health no one really had the skills to engage her as she didn’t have a diagnosable illness and she was too challenging - They did arrange review conferences using the care programme approach Education Although some individuals tried to support her, education as a whole failed her… the response was to exclude her as soon as at 12 she started exhibiting difficult behaviour and truanting… which meant she had nothing else to do except hang around the square where she was first approached and groomed by predatory men. The lack of education also further reduced her self-esteem, isolated her from peers and… made her extra vulnerable to the blandishments of the child groomers. Multi-agency meetings convened by the mental health trust became good at general information sharing, but the elephant in the room for all of us was the fact she was being groomed and exploited. I think we all knew it but no service had the language, understanding and tools to acknowledge it, yet alone deal with it. 3.16 The parent also described the impact on the daughter – “now ultra-fearful and cautious and unable to enjoy age appropriate activities. She suffers nightmares, flashbacks and is depressed. She lost her childhood and education…” The parent described “hunting the streets of SE England night after night taking its toll on health”, and “having to move to escape ongoing threats…” The parent set out some recommendations which will be referred to later in the report. 3.17 Two parents provided some feedback on staff work through listing their expectations that were not met. They gave the previous reviewer and the author a number of illustrations of these points. They made huge efforts to find their daughter when missing. “We expected… - To have our concerns listened to and believed… to be taken seriously - Not to be patronised - To have information about our daughter shared with us - Police and Social Workers to work together... not passing the buck to each other while we got more scared and frustrated about what was happening - To be told what was happening to the intelligence we gave them - To get intervention sooner, especially when it as so painful to have to ask for help (as it meant we had failed to keep her safe) - Social Services to listen to recommendations by other professional bodies making sound assessments- they didn’t and our daughter’s would go back to old ways 18 - We didn’t expect to have to do all the chasing ourselves 19 4 IMPROVEMENTS IN OXFORDSHIRE 4.1 The views from families as seen in Section 3, and the analysis in Sections 5 onwards, show that there were indeed missed opportunities to identify CSE and many areas where services could and should have responded better. It is tragic that families had to go through the experiences they described before services made the improvements that are in place now. Since that time (four to ten years ago) there has been much improvement. This does not mean that everything is likely to be perfect, but that the critique later in the Report of what happened in the past can be read with the knowledge that many lessons have already been learned, and that services for children vulnerable to CSE have been improved considerably. 4.2 This will not be a time when known numbers will reduce. Almost certainly the opposite will be the case due to the joined-up rigour with which CSE is now identified and pursued, However, the chances of it being prevented, disrupted or punished are far higher due to the commitment and skill now being shown. 4.3 In light of the strengthened multi-agency work across Oxfordshire to protect children at risk of sexual exploitation, it is likely that children will now experience a persistence and continuity in the services they receive. Those services will be much more coordinated between agencies with staff who are now well trained about the signs of abuse and understand why the victims behave as they do. Perpetrators will now be actively pursued by all available means, regardless of the degree of victim cooperation. That determination, and the persistence of staff who are trained to ‘never give up on a child’, will give more confidence to victims to disclose and give evidence, and also provide better support for victims and their families. 4.4 This section only gives headline changes. A more complete account is given in the associated document prepared by the OSCB and its members, ‘CSE in Oxfordshire: Agency Responses since 2011’, which describes the system-wide and agency progress in greater detail so that more learning is available. The source of the information below is agency reports commissioned for the SCR Panel. The improvements are those reported by the OSCB and its member agencies, and confirmed by SCR Panel members. Personally quality assuring these submissions was beyond the author’s remit. Recent external inspections have been positive. 4.5 OSCB overview: This account of OSCB action may on the surface sound rather bureaucratic, but as will be seen in following sections, the absence of such a framework and focus on CSE played a part in the delayed recognition of CSE. The following arrangements are now in place and monitored by the OSCB: The new (2014) OSCB Chair has assured the Review that compliance against the 2009 CSE guidance was last reviewed satisfactorily in November 2014 There has been a subgroup of the Board focusing on CSE since 2011. It is currently chaired by a Police Superintendent, with membership from the City District Council, County Council, NHS, Police and voluntary sector The subgroup scrutinises and challenges prevalence and missing persons reports, oversees the ongoing development of procedures, and acts as steering group over the multi-agency specialist CSE team ‘Kingfisher’. (See 4.8-9 and 4.15-17.) Progress in addressing CSE in Oxfordshire was last reported in the 2013-14 OSCB Annual Report (July 2014) 20 The Board’s Annual Conference in 2012 was themed on CSE (before the Bullfinch convictions) and its 2015 conference is to be focused on older children at risk The OSCB has comprehensive procedures on CSE as part of the overall Child Protection procedures which are on its website There is a ‘Tackling CSE: Professional’s Handbook: Never Give Up On a Child’ covering all aspects of the understanding and management of CSE, including the CSE Screening Tool “to be used by all professionals working with children and young people aged 10 plus” (or younger if necessary). If the tool identifies a certain degree of risk, then referral to CSC is mandatory Since 2011 in excess of 7,500 Oxfordshire staff have received training on CSE, including all front line staff and those working with children. Take-up of training is monitored by the OSCB Training subgroup to ensure good compliance There is a very extensive multi-agency OSCB Action Plan covering five main themes: - Raising awareness - Improving statutory responses and provision of services - Improving evidence - Improving prosecution procedures - Improving disruption The new OSCB Chair has introduced a Chief Officer Forum on Safeguarding, and has met regularly with the County Council Full Council, Cabinet and Scrutiny Committee In the 2014 Ofsted inspection4 the OCSB’s effectiveness was rated as ‘good’, which means that the OSCB “coordinates the activity of statutory partners and monitors the effectiveness of local arrangements. Multi-agency training in the protection and care of children is effective and evaluated regularly for impact. The LSCB provides robust and rigorous evaluation and analysis of local performance that identifies areas for improvement and influences the planning and delivery of high-quality services.” The Ofsted summary of why Oxfordshire and the LSCB were rated ‘good’ is in Appendix 4. 4.6 Leadership commitment: The SCR will show how top leaders had little influence on what turned out to be CSE by groups of adult males of Pakistani heritage because, for reasons explored below, early concerns were not escalated to them – a pattern that crossed all agencies. It is fair to say that they were shocked by the discoveries, and since Operation Bullfinch there has been an impressive focus, drive and commitment from the top leaders from all agencies – in terms of personal interest, political engagement and resource commitment. In September 2014 the County, City, Thames Valley Police (TVP) and the OSCB co-hosted a major briefing session for all County and District councillors, and equivalent stakeholders. The author attended, and there was a frank assessment of what did not go well together with a positive account of across-the-board improvements. MPs have also been regularly briefed. Both County and TVP Chief Officers have given a number of national presentations on Oxfordshire’s learning, and various national leaders/politicians have been to see local progress. Summaries are given for the County, City and TVP. 4.7 County Council: In the County Council (which is the local authority for social services and education), the Cabinet receives regular updates on CSE against national expectations, and the CEO describes CSE as her “number one personal priority”. The OSCB Annual Report is discussed at full Council, Scrutiny Committee, and Cabinet. Children’s Services budgets have 4 Oxfordshire County Council: Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the LSCB (Ofsted, 30.6.14). 21 increased by 80% in real terms between 2007 and 2014, and an estimated £8m was committed to the Bullfinch investigation and the response to CSE, including additional social workers. For example, in 2013-14, £1.4m enabled the recruitment of 21 child protection social workers. Capital resources have been agreed to build new children’s homes in-county to allow vulnerable children to be placed nearer home. After the Bullfinch trial in 2013 there was a cross-party Cabinet Advisory Group to consider arrangements for safeguarding assurance. A Cabinet review considered and accepted, in May 2014, 14 recommendations to strengthen the governance and quality assurance of safeguarding.5 In 2014, Ofsted rated the local authority’s services to children as ‘good’, “…leading effective services that help, protect and care for children and young people and those who are looked after and care leavers have their welfare safeguarded and promoted”. 4.8 On CSE specifically, the Ofsted June 2014 inspection (reporting on partnership work, not just the Council) concluded that “Work done by the Kingfisher service, a specialist team working with young people who have suffered or are at risk of child sexual exploitation (CSE), is of high quality. It focuses both on reducing risks and meeting wider needs for young people, as well as providing good consideration of the young person’s holistic needs. Large numbers of professionals have been effectively trained to identify potential indicators of child sexual exploitation. The consistently high use of a child sexual exploitation screening tool by professionals who are concerned about possible CSE is leading to more young people being helped earlier. The Kingfisher team provides good quality consultation and advice to a wide range of professionals on child sexual exploitation. Excellent awareness-raising activity takes place with young people on a continual cycle and is now taking place with parents and carers.” 4.9 And on missing children that “Good arrangements are in place to respond when children go missing from home and care. The police undertake a ‘safe and well’ visit when children return home and provide very prompt reports to the local authority. Social workers visit promptly after each missing episode of a child known to the service. They complete a return interview with the young person to understand the reasons for the missing episode. All missing episodes are effectively recorded and risk assessed, with appropriate plans to reduce the risk of future missing episodes. The authority has effective systems for identifying, monitoring and responding to those children who are missing from education and those who are educated at home. Officers provide support and, where necessary, challenge to ensure the quality of the education provided in this way.” 4.10 The Rotherham reports have highlighted the role of Council leaders. The 2014 Ofsted report said, “Services for children and families are given a high priority by senior leaders and elected members. The local authority knows its strengths and weaknesses well. Strategic priorities are identified and informed by feedback from children, young people, parents, carers and staff. Leadership is strong and effective and services make a demonstrable difference in improving the life chances of some of the most vulnerable children in Oxfordshire. Elected members have high aspirations for looked after children and young people in Oxfordshire and have prioritised continued investment, for example in additional social worker and team manager posts. They hold senior officers to account for the quality of services.” 5 Recommendations of the Cabinet Advisory Group on the Strategic Assurance Framework for safeguarding children and young people (Oxfordshire County Council, 13 May 2014). 22 4.11 The Police: Since 2011, the Police have had a new structure which enables force-wide briefing and identification of new issues. CSE is a strategic priority in the Police and Crime Commissioners Police and Crime Plan and in the TVP Delivery Plan, and a CSE Oversight Group provides strategic oversight to the more significant investigations and intelligence development operations. There has also been significant investment in line with their commitment to prevent, disrupt and prosecute CSE. The Chief Constable’s Management Team approved the recruitment of five dedicated CSE officers and, for the Child Abuse and Investigation Unit, 18 detective constables, three detective sergeants, a detective inspector and a detective chief inspector. A DVD of the Chief Constable speaking with one victim and another’s parent about their experiences of CSE and feedback on TVP staff has been incorporated in staff training across the force. In 2014 TVP was rated as follows by HMIC offending, is good at investigating crime and good at tackling anti-social behaviour; the:6 ‘In terms of its effectiveness, in general, the force is good at reducing crime and preventing offending, is good at investigating crime and good at tackling anti-social behaviour; the efficiency with which the force carries out its responsibilities is good; and the force is acting to achieve fairness and legitimacy in most of the practices that were examined this year’. 4.12 The OSCB Annual Report is reported formally to the Police and Crime Commissioner, and TVP’s Chief Officer team engage regularly with the OSCB Independent Chair. 4.13 The Superintendent, who is the TVP Area Commander for Oxford, said in February 2015,“If you ask any of my staff their number one priority they would say tackling child sexual exploitation.” 4.14 City Council: The City (in which most of the CSE occurred) is a District Council and does not manage child safeguarding, but provides a range of services and regulatory functions which support vulnerable children and their families. In 2013, the City CEO commissioned an external review which confirmed its self-assessment that it complied with its safeguarding responsibilities under the Children Act. Four service heads act as designated officers to coordinate the Council’s approach to safeguarding, within each service area there are named safeguarding officers. A Director now takes the overall lead, and has recently become a member of the OSCB. Investment has included a significant input to the Youth Ambition and Educational Attainment Programme, which aims to boost the resilience and confidence of young people, and a new safeguarding coordinator. City staff wrote the OSCB CSE training materials. Work is ongoing to clarify the interrelationships between the various community safety partnerships and safeguarding through a new community engagement work stream of the OSCB CSE subgroup. 4.15 Countywide service improvement: The SCR shows that coordination of work and the sharing of information around the safety of children (so that a wider picture on CSE might emerge) were not optimal in the years before group CSE was identified in Oxfordshire. There have been two major developments. From September 2014 there has been a Multi-agency Safeguarding Hub (MASH), which ensures that referrals about children are considered from the beginning on a multi-agency basis and that information is shared quickly. The Oxfordshire MASH was planned by a multi-agency steering group, chaired by the Assistant Chief Constable of Thames Valley Police. The MASH is based at Cowley Police Station and includes staff from Children’s Social Care, Adult Social Care, Early Intervention, the 6 ‘Police effectiveness, efficiency and legitimacy programme (PEEL) assessment of TVP’ (HMIC, 2014). 23 Emergency Duty Team, Thames Valley Police, and safeguarding experts from Oxford Health, Oxford University Hospitals and the Clinical Commissioning Group (CCG). There will also be input from other agencies on a 'virtual basis' such as South Central Ambulance Service, Youth Offending Service, Fire and Rescue Service, Trading Standards and Probation. The hub is a link between universal services such as schools and GPs, and statutory services such as police and social care. Oxford City is piloting MASH links on behalf of other Districts. 4.16 Specifically on CSE, there is the Kingfisher Team, a TVP, Oxford Health and Oxfordshire County Council joint team set up in November 2012 to tackle CSE. The initiative has already won two national awards for its work – for innovative partnership work to protect children at risk of CSE, and for having “successfully linked with different services and partners in innovative and constructive ways and created forward thinking services for children, young people and families”. The Team has developed a CSE Screening Tool, which helps build a picture of concerns around the county. Care plans are designed to support and protect those children identified by Kingfisher as being at risk. The team has a strong focus on achieving successful prosecutions as a key way to safeguard and protect children, and also plans disruption activity. 4.17 The Kingfisher Team and the OSCB also coordinated and supported a theatre production (Chelsea’s Choice) to raise awareness of CSE, which has been shown in numerous secondary schools across the county. Kingfisher also works closely with parents to raise awareness of the grooming process. The team has a full time CSE health nurse who provides one-to-one support for children who are Kingfisher cases. The nurse has specialist training in recognising signs and symptoms of sexual exploitation, and can fast-track referrals to specialist health services. 4.18 The range of services that were provided by Kingfisher can be illustrated by one teenage girl, who was very much like the girls described in Section 3, Social Worker – regular visits, befriending, family work, building trust, CSE recognition and safeguarding Specialist Nurse – general health assessment, sexual health screening, contraception, relationships, self-esteem and building trust Police – gathering intelligence from all aspects surrounding (the girl). Offering support and guidance throughout the ongoing investigation Child Protection Plan in place – regular multi-agency meetings and core groups gathering information Good communication within the Kingfisher team, sharing information quickly so that there can be a quick response to concerns Escalation of concern – (the girl) requested to be taken into care of local authority. Continues to be at risk of CSE Further placement found out of county in a therapeutic residential placement Statement submitted by (the girl) to the police describing extensive CSE... Police Operation ongoing Work continues with same social worker, nurse and police officers 24 4.19 This shows a level of expertise and coordination that was not present before Bullfinch, and strong multi-agency commitment. Around 255 children have been referred to Kingfisher since it began in late 2012. 4.20 Investigation, disruption and prosecution: Among the problems before the Bullfinch case, and the expertise gained through it, were insufficient disruption activity, insufficient focus on potential abusers, and difficulties in getting to prosecution given the evidential difficulties these cases threw up. The Bullfinch operation itself was a major exercise with the Police and CSC working together on intelligence gathering and to support the victims through the most challenging process of agreeing to give evidence and them maintaining that commitment through court. The Police used innovative covert investigative tactics. Seven men were found guilty and imprisoned for 60 offences. There were three further, related convictions in June 2014. In February 2015, a man was convicted of five offences related to sexual exploitation of two girls. Further trials are imminent. 4.21 In the autumn of 2014 the Chief Constable reported 16 live CSE operations across the TVP area, with 35 arrested as a result of current operations and a total of 78 charges made. For example, in June 2014, seven men were arrested with 25 charges against girls of 13-16 in Banbury. It took over 12 months of intensive work by Kingfisher with a number of girls to get to the point where they felt sufficiently safe and trusting to make disclosures. This included two seeking reception into Local Authority care as they did not feel safe disclosing from home. In September, eight men were charged for offences linked to CSE in Aylesbury. 4.22 There is also a wide use of disruption process such as Abduction Notices and work with other regulatory bodies such as District Councils on matters such as housing, nuisance, licensing of premises and taxis to provide concerted action to disrupt. 4.23 There is now updated guidance on prosecuting cases,7 which used some of the Bullfinch learning. This introduces a range of approaches which make it more possible to use the sort of evidence that girls subject to grooming may be able to give, and make it easier for such evidence to be given. For example, changing evidence or matters which might be seen to undermine a girl’s credibility are now put forward as possible confirmation of exploitation. 4.24 The collective approach to prosecution and protection can be seen in one recent exploitation case where a long jail term was given. The victims were looked after children (LAC). Carers concerned about one girl followed her and immediately called the Police when an adult male was involved. The man was arrested immediately and served with an Abduction Warning Notice. The victim soon disclosed a range of abuse and other victims identified. 4.25 Community relations: With the known perpetrators of group CSE being significantly of Pakistani heritage, there is considerable work to build relationships with these communities (and others), increase their understanding of CSE and help build a preventative approach. Some examples: The Children’s Society runs 12-week induction programmes for young unaccompanied asylum seekers, on which CSC and the Police provide input on CSE and age of consent issues 7 Guidance on Prosecuting Case of Child Sexual Abuse (Crown Prosecution Service, 2013). 25 The City Council is appointing a Pakistani Father Support project worker, and has developed a new mentoring programme to prevent CSE amongst at risk BME/South Asian males The Superintendent in charge of the Oxford Police (who also chairs the OSCB CSE subgroup) meets Mosque leaders every two months, with for example discussions on CSE warning signs. In 2015 it is planned to extend this to include the City and County Councils The Superintendent also has a bi-monthly Independent Advisory Group which includes all faiths. CSE is always on the agenda, and the Group is briefed for example on disruption operations Police officers attend the Mosque Friday Prayers weekly The OSCB’s revised CSE Strategy will have a major new section on community engagement The Local Authority Designated Officer (LADO) has led work with the Oxfordshire Mosques and their linked Madrassas on safeguarding children and has worked to ensure safeguarding arrangements are in place including DBS checks, basic training and a safeguarding policy Seven faith leaders attended a top-level briefing on CSE progress in September 2014 In October 2014, Muslim representatives attended a CSC/TVP meeting, discussing trafficking and CSE with other religious leaders A meeting was held in February 2015 between Police, City and County representatives and the OSCB Chair with Muslim community leaders 4.26 Involved agency progress: Full details on progress can be found in the associated ‘CSE in Oxfordshire: Agency Responses since 2011’ but brief extracts are given here to show developments in agencies (on top of the progress described above). 4.27 Oxford City Council All staff audited for safeguarding training needs Internal safeguarding expectations now explicit The Community Safety Team (with Public Health funding support) has commissioned a range of CSE-related activities in Oxfordshire including: - A human trafficking conference for front line professionals and members of the BME community - A scoping exercise on ‘at risk’ communities - A CSE awareness conference for hotels and B&Bs - Revision of guidance for new taxi drivers to include trafficking Joint operations targeting premises involved in CSE Landlords used to place vulnerable persons subject to fit and proper persons tests and intelligence sharing with TVP The City Council’s taxi licencing policies on ‘warnings, offences, cautions and convictions’, and its application pack for licencing are published by the National Working Group on CSE as exemplars, as is their training materials. The City has a website on ‘Taxi and Private Hire – Safeguarding children and vulnerable people’ There is an information-sharing arrangement with Oxfordshire County Council’s School and Social Care Transport team who will provide details to us of any concerns they have regarding a driver licensed by Oxford City Council 26 4.28 Oxfordshire County Council: Adult Social Care Joining the MASH from April 2015 Reinforcement of escalation procedures for CSE identified by staff working with adults Focus on work with parents with disabilities and young carers (issues in this review) Adult Social Care now represented on the Community Safety Partnerships Children’s Social Care Commitment to funding the ten staff in Kingfisher Use of Troubled Families funding to support, with the voluntary sector, work with parents of children at risk of CSE Jointly funding a new Kingfisher post to engage South Asian communities’ girls and women Joint work with Police and NHS on coordinating responses to girls with serious injuries Taking part in a national trafficking pilot about identifying and supporting CSE victims Monthly extended team meetings now operating across the county, led by Kingfisher and involving a wide range of partners including schools and the voluntary sector. These are proving effective in implementing the CSE Screening Tool in the early identification of children at risk and enable targeting of new ‘hot spot’ areas Independent Reviewing Officers and Independent Chairs of Child Protection conferences have worked through a programme of quality assurance audits, observations of chairing practice and team development focused on improving the quality of children’s Care and Protection Plans and raising the standard of their scrutiny role. Challenges made by independent Reviewing Officers/Independent Chairs to social workers are recorded on children’s files and entered on a tracking system that ensures challenges have impact on social work practice CSC used its IMR’s critical analysis to run challenging practice development sessions with 360-plus staff and managers Education and Early Intervention Service (EIS) EIS organises or conducts return from missing interviews for children not open cases Safeguarding on the agenda of the termly Heads/Chair of Governors meetings with the Director of Children’s Services, eg dynamics of grooming, impact of absence Bespoke training for 250-plus staff in schools and FE colleges All state school year 8 and 9 shown the play Chelsea’s Choice, a powerful drama about grooming, and year 10s will be shown Somebody’s Sister, Somebody’s Daughter Senior EIS managers are involved with the OSCB, and its CSE and Quality Assurance/Audit groups, the Missing Persons Panel, and three staff are seconded to Kingfisher Centralised easy access list of children missing from education Transfer of records, including safeguarding concerns, between schools to be audited Greater information sharing about exclusions from school Directory of alternative quality provision completed Youth Offending Service All staff have received CSE training CSE Screening Tool core part of YOS assessment files Safeguarding a standard item for all team meetings Any significant risks for a child are escalated to the Chair of the YOS Management Board 27 Legal Services Improved process for monitoring the completion of actions following decisions Legal advisers more aware of the wider powers, beyond the Children Act, that can be used to protect children Public Health School health nurse provision enhanced to be available for all secondary schools CSE expectation of providers more explicit, including school nurse joint work with CAMHS and sexual health services New drug and alcohol education programmes for year 8/9 in all secondary schools Permanent drug and alcohol worker seconded to MASH Safeguarding audit of adult case files on parental drug/alcohol use, with findings fed back to the OSCB to improve joint planning of services 4.29 NHS: Clinical Commissioning Group/NHS England Providers are now contractually required to use the CSE Screening Tool, provide CSE training and have agreed referral pathways. This is monitored through contract meetings for relevant services Providers are required to have clear internal escalation processes that link to OSCB escalation procedures. A specialist practitioner has been commissioned for Kingfisher to enable health assessments and referrals to be made in a timely way. This service is provided by Oxford Health The Designated Nurse and Doctor delivered CSE training to all GP localities as soon as the learning emerged of the extent of CSE in Oxfordshire. This is being sustained through a rolling training programme. As a result, GPs are increasingly requesting support and advice on CSE from the CCG Safeguarding team A review of healthcare provision in the LAC (looked after children) system has been undertaken. The intention is to identify where improvements can be made Oxford University Hospitals NHS Trust CSE is included in all child safeguarding delivered to Trust staff. Targeted Level 3 CSE training has been provided for genito-urinary medicine (GUM), paediatrics, emergency department, psychology, obstetrics and midwifery. As a result of training, the Safeguarding team is now receiving regular enquiries from a wide variety of professionals for advice on possible cases of CSE Teenage pregnancy pathways have been updated to include the CSE Screening Tool. Sexual health services have a new pro-forma for assessment of CSE and use the CSE toolkit. They have weekly multidisciplinary team meetings to review notes of all under 16s seen, and flag records of potentially vulnerable young people. They have regular meetings with the specialist nurse from the Kingfisher team and where relevant share information with her, the OUH Safeguarding team, school health nurses and make referrals to the MASH 28 Professionals are better at considering CSE as a possibility in young people who are admitted with self-harm and/or challenging behaviour. Where there are concerns, an MDT meeting is held before the young person is discharged The criteria for referring concerns to CSC have been reinforced, and professionals have been made aware of how to escalate concerns Oxford Health NHS Foundation Trust The Trust provides the specialist Kingfisher nurse. The nurse undertakes health assessments and facilitates information sharing across health providers to ensure that health needs are met and attends the Missing Children’s Panel Since 2010 the Trust has provided a specialist nurse for looked after children who works with children in residential settings and harder to reach young people, and will attend LAC reviews All Looked After Children have full access to CAMHS, including access to 24/7 outreach service for crisis support. The CAMHs service is now routinely considering Dialectical Behavioural Theory (DBT) for children who are looked after and who are open to the Kingfisher team Looked After Children’s Initial Health Assessments are now completed by dedicated doctors. This results in an improved assessment which is informed by social care histories and the GP records, leading to better healthcare plans All young people under 16 (or older if at risk) accessing contraceptive or sexual health advice from the school nursing service have a risk assessment for sexual abuse/exploitation CSE is embedded in the Trust safeguarding training. Health visitors, school health nurses, college nurses, CAMHS and inpatient adolescent mental health unit have been trained in the use of the CSE Screening Tool New Trust escalation guidance is in place and compliance is audited 4.30 Thames Valley Police (TVP): TVP has six dedicated CSE officers in the Kingfisher Team (based at Cowley Police station), including the Detective Inspector, who leads the team, and a Missing Persons Coordinator One office of the Major Crime Unit is dedicated to ongoing CSE investigations in Oxfordshire with 24 police officers, including a Detective Chief Inspector lead and five Police staff Each of the remaining three Major Crime Offices is conducting CSE investigations across the Force with officers and staff seconded to these investigations The Force has ensured clarity around the ownership of CSE investigations through allocation to the Child Abuse Investigation Unit (CAIU), Crime Investigation Department (CID) or Major Crime teams based on complexity All front line officers and staff, including constables, PCSOs and sergeants, have been attending bespoke CSE training since 2013, and control room staff are now trained in recognition of CSE signs; all officers have a CSE ‘aide memoire’ Bespoke guidance, ‘Be confident in your powers to protect children – you may be the last chance that child has’, about powers of entry and reasonable force, has been developed 29 Bespoke missing persons (CSE) training for all inspectors, detective inspectors and chief inspectors since 2013, and all staff have also completed the College of Policing e-learning package, which further reinforces the link between missing children and CSE All officers had a laminated card with guidance on ‘safe and well’ checks for missing persons Full array of disruption tools used including, for example, Abduction Warning Notices Covert investigation guidance as a core tool in building cases against perpetrators (adopted as national good practice) Numerous actions to improve the recording and management of crime Four flags have been added to the Police National Computer System to ensure alerts on potential victims of CSE, repeat missing persons, the presence of Child Abduction Warning Notices (and the associated children) 4.31 The Children and Family Court Advisory and Support Service (Cafcass): Managerial oversight within Cafcass was assessed by Ofsted as ‘good’ in 2014 Cafcass now has a CSE strategy In response to the SCR Cafcass has significantly increased training on CSE, including for self-employed assessors who are contracted in Cafcass will be able to collate information about cases from its national caseload with connections to CSE from March 2015 4.32 Crown Prosecution Service: A dedicated CSE specialist lawyer within the Complex Casework Unit, who is part of a national network of specialists A dedicated Rape and Serious Sexual Offences (RASSO) team of lawyers and paralegals has been established working across the area, handling early investigative advice to the Police, decisions on charging and prosecutions of rape, serious sexual offences and child abuse New guidance on the handling of child sexual abuse cases was issued to all lawyers in 2013 A real focus on the credibility of the allegation rather than that of the victim 4.33 Donnington Doorstep: (voluntary organisation) Supervision arrangements for staff have been substantially improved Recording systems have been improved Runs (since 2011) the Step Out project providing casework support for girls and young women at risk of CSE; a staff member is part of the Missing Persons Panel Funding from local agencies has extended casework from the City to the County, to include boys and parents Donnington Doorstep’s Board regularly monitors its work with CSE 4.34 The views of girls currently at risk: Some girls working with the Kingfisher team helped make a DVD which was shared in September 2014 at a major event hosted by the County and TVP with County councillors, City councillors, Oxfordshire MPs, Oxfordshire CCG, Oxford Health, Oxford University Hospitals Trust, the Deputy Police and Crime Commissioner, nine Chairs of Neighbourhood Action Groups, seven local religious leaders including from three mosques, eight Chairs of Independent Advisory Groups, three head teachers of local schools, and members of the OSCB. Some extracts are given. 30 4.35 On proactivity and support: “Someone was involved with CSE and she mentioned my name to them. So Kingfisher came and found me, they came and spoke to me and asked me some questions about certain people.” On building trust to get special help, three views: “I started talking to my social worker more, started having 1-1 time with her and then I went on the Kingfisher team” … “‘I got put in foster care and I quickly got close to my foster carer. Then I got closer to my social worker and I started telling her more on a 1-1 sort of thing” … “I feel like they [Kingfisher] are my family and they like me for me. I just get on with everyone, it’s a nice environment and everyone is nice and stuff.” On the skill needed to engage potential victims: “I got told it [the Kingfisher team] was for girls who were being exploited. I didn’t think I was being exploited. I thought I was in trouble for things I hadn’t done or anything and then the more they talked about things the more I realised I was in a wrong situation. The more they talked about it [exploitation] happening to other people the more I wanted to let them know that things were actually happening to me.” On advice for social workers: “Just wait. Different people trust people quickly and others take long to trust people. Just wait until they get used to you. You shouldn’t just assume stuff.” And from another girl: “This woman [a social worker] came to my house and talked to me for about ten minutes and asked lots of questions, then they talked to my parents a lot. The social worker came to see me at school. She kept asking me questions and trying to talk to me but at first I didn’t talk back. It was like she was talking to a brick wall at first. It was very hard because I wouldn’t give out any information about my friends.” The girl went on to say, “It was nice to have the company of the social worker, to have someone come and see me, to talk to me and be interested in what I was doing on a daily basis.” On the balance between caring and controlling: “I just felt she [the social worker] was really there for me, as if she was a friend. It was like having a mum, a mum who cared… but someone who would leave you alone at the same time, someone that wasn’t in your face but was there.” (See 5.114 on Professionalism.) 4.36 And Kingfisher social workers also noted these comments about a departing Police case investigator and a PC attached to the team, showing the contrast from victims in the past” A girl: “I’m sorry he is going, he is really good and I liked speaking to him… he is really approachable and easy to talk to.” And a social worker said : “He took one of the statements from [a name] and she really liked him and felt comfortable with him, she was happy to see him as he made her feel safe... all the girls liked him and they remembered him.” On the PC: “[She] made me feel really comfortable during the trial.” 4.37 The remainder of this Review will show that it was not always like this across the County, and that opportunities to identify and act on exploitation were missed, although Oxfordshire was not alone. The progress described above has come from a willingness in organisations working with children to learn and change – which should be acknowledged. 31 4.38 Moving on – an apology: One of the children, now an adult, takes part in regular training for a range of Police staff on CSE. She told the Review that after one session an officer approached her and said, “I feel I need to apologise to you for all the girls I treated wrongly.” This was hugely appreciated by the victim concerned. 32 5 WHY THE DELAYED IDENTIFICATION AND ACTION ON CSE? 5.1 Introduction: The identification of CSE and robust action to intervene was delayed in the sense that it was going on for some years before it was truly recognised, and before concerted action was taken. This section looks in the context of the time at what will seem, in hindsight, to be glaringly missed opportunities, and offers some explanation. It also identifies underlying issues of practice that did not relate specifically to CSE, but which hampered progress. The explanations that follow do not excuse the inexcusable, but describe the complexities of work in this area. The section does not go into all the detail (which would take hundreds of pages), but describes the general reasons for the late response. This section is for describing ‘why’, rather than giving judgement. It describes the period before the very successful investigation that was Operation Bullfinch and the improvements described earlier in Section 4. 5.2 The explorations of ‘why’ given below do not imply that this Review finds what is described as acceptable. Section 8 gives an appraisal of the work. The points discussed are often not discrete and feed off, or into, other points. Most of what is described below has been addressed by agencies. 5.3 To prevent this report becoming unreadably long, the causes of the delays are rarely specifically dated, and some will have varied in strength or even presence over the pre-Bullfinch period. This SCR is not saying it was like this everywhere all the time, but is describing the ‘sorts of things’ that conspired to create the delays in action. It also needs to be said that most of what is described occurred before there was a real national understanding of ‘group-related CSE’ as we now understand it. 5.4 Why the delays: What follows are summaries of the main findings from the agency Individual Management Reviews (IMRs) which, in the opinion of the author, have described performance in very honest detail. The Police and CSC IMRs (which, for example, are 1,000 pages between them) describe and explain what happened frankly in a way that has allowed the SCR Panel and author to draw conclusions, and they do not shy from drawing robust conclusions of their own. The issues described may be focused on one agency more than another, but in most cases are not described under an agency heading as there is so much overlap. 5.5 In the most simplified of summaries, a combination of not grasping the extent of exploitation, the focus on the girls and their families as the source of the problems, the corresponding lack of focus on perpetrators, and a host of administrative and management issues all worked together to lead to CSE being identified later than it might have been. 5.6 Knowledge: Although there was an increasing literature from the 1990s about what we might know now as CSE, and patterns of abuse through control, the phrase ‘child sexual exploitation’ did not appear in the core national guidance of safeguarding management ‘Working Together to Safeguard Children’ 2006 (HM Govt). However, it did say: “The identification of a child involved in prostitution, or at risk of being drawn into prostitution, should always trigger the agreed local procedures to ensure the child’s safety and welfare, and to enable the police to gather evidence about abusers and coercers. The strong links that have been identified between prostitution, running away from home, human trafficking and substance misuse should be borne in mind in the development of protocols.” But the language was mainly about prostitution. The government did produce, in 2009, supplementary guidance to Working 33 Together called Safeguarding Children and Young People from Sexual Exploitation,8 which set out the framework for what is now understood to be a more modern approach to concerted action. Several national reports have shown that this guidance did not catch on uniformly across the country. 5.7 The House of Commons Home Affairs Committee report, ‘CSE and the response to localised grooming’ (June 2013), said that “The failure of these cases has been both systemic and cultural. Rules and guidelines existed which were not followed. People employed as public servants appeared to lack human compassion when dealing with victims. Children have only one chance at childhood. For too long, victims of child sexual exploitation have been deprived of that childhood without society challenging their abusers. Such a situation must never happen again.” (This was, of course, written after Operation Bullfinch had indeed ‘challenged the abusers’ and gained numerous convictions, which was only possible because of highly skilled, determined and rigorous local work.) The key to understanding ‘why’ therefore rests in an earlier period, which in Oxfordshire would be around 2005-10, when there were indeed indications of children suffering, but limited understanding and little intervention that could have inhibited the abuse. 5.8 It cannot be denied that there was much existing guidance (and there were some reports about the growing awareness of exploitation) but that is not the same as front line staff or even their immediate managers knowing it, absorbing it, understanding it, or feeling confidant to use it – especially when it cuts across traditional ways of interpreting or doing things. As one parent said, “no service had the language, understanding and tools to acknowledge it, yet alone deal with it”. 5.9 The overall problem was not grasping the nature of the abuse – the grooming, the ‘pull’ from home, the erosion of consent, the inability to escape and the sheer horror of what the girls were going through – but of seeing it as something done more voluntarily. Something that the girls did as opposed to something done to them. 5.10 This lack of knowledge crossed all organisations and professions. The Education IMR put it well. “It was clear to… through conversations with a range of professionals for this review, including a focus group with head-teachers and designated school safeguarding leads, that there was little understanding of child sexual exploitation and any indicators to suggest that any of the girls might be subject to or at risk of it, at the time. Certainly there was significant anxiety about their safety and well-being, but this tended to be focused on their home situation, the domestic violence they were living with and the lifestyles of their parents. The girls were labelled as promiscuous, at risk of prostitution, out of control and certainly not viewed as victims of CSE.” 5.11 The lack of knowledge also, for example, affected the therapeutic care given to the girls as risks were not identified, clues not picked up, and the presenting issue was the focus. “Primary care [and a listed range of sexual health and pregnancy services] failed to recognise that these girls were at ‘high on-going risk’ and failed to protect them from pregnancy and sexually transmitted diseases (STDs) and failed to work together to safeguard them.” 8 Children and Young People from Sexual Exploitation: Supplementary Guidance to Working Together (HM Govt, 2009). 34 5.12 One social worker, who played an important role in identifying the CSE in the lead up to Operation Bullfinch said in 2014, “Even now I still can hardly believe that adult males would do what they did to children – too awful to believe it could happen in the city I live in.” 5.13 Language: The language used demonstrated the lack of full understanding of CSE at the time. It described the girls getting themselves ‘into trouble’. Other examples quoted by the Police as from the Missing Persons database (two of which were recording referrals from a parent) included “[The missing person] is believed to be prostituting herself… to pay for drugs’, ‘putting themselves at risk” “She is a streetwise girl who is wilful…” “She associates with adults who have warnings for firearms and drugs. It is possible she is prostituting herself” “... Deliberately puts herself as risk as she goes off with older men that are strangers” 5.14 In some senses, parts of these examples were literally true. There was seldom from the victims an overt sense of helping agencies to affect change, but the language had a consequence which delayed the protection which the girls covertly wanted, and the parents very clearly wanted. This was because the words were judgemental and focused on the victim and their contribution, and deflected from the more proper perpetrator focus. 5.15 As the CSC Review says, “This labelling followed the child and became a barrier to understanding their situation.” This Review does not believe that this indicated a general callous disregard of the needs of young teenagers, more that this was the longstanding way for describing children of that age who led a wild, risky life of premature sex and early excesses of drink and drugs. The problem was that the prevailing understanding of it being wayward youth tended to blind staff to something serious when it happened, and continue to see the victim as the author of their own downfall. Some of the examples quoted in the Police IMR of events that were not investigated make the point powerfully. 5.16 The IMR for the NHS Trust which provides community and mental health services describes how partner agencies reported a girl ‘hanging out’ with older men, and a social worker described to the school nurse men in their 20s as ‘lads’. School health records used the words “prostituting herself”. The IMR said, “The word ‘lad’ may have influenced practitioners to minimise the potential seriousness of the situation because the term is suggestive of someone who is much younger. The School Health Nurse records also state that there is a concern that (the child) was ‘prostituting herself’. This raises a concern that [the child] may have been viewed as active perpetrator of criminal offences such as prostitution and as a challenging young person who creates risk and rather than being seen as a victim of abuse. These views will/may have affected how she was supported by professionals.” 5.17 There were other ways the use of words had a counter-productive impact. In particular, the use of the word ‘boyfriend’ deflected from the awfulness of what was happening by implying a benign or acceptable relationship. This compounded the girls’ use of the word, which, as it usually applied to a much older (sometimes very much older) man, was more a sign of the grooming than fond acquaintance. ‘Boyfriend’ was used even when referring to a 13- to 15-year-old and males in their late teens, even to their thirties. This is not to say that ‘boyfriend’ was used to deliberately condone illegal relationships, but that its use did not help and at times hindered. It also conveyed confusion about what was and was not consensual and lawful. 35 5.18 The use of the word ‘prostitution’ also had the effect of deflecting from the extreme youth of the victims and the phrase sometimes heard of ‘prostituting themselves’ deflected attention from their groomers. Referrals to the Police from say social care settings also used language which, in the positive interests of information sharing, compounded the impression that the victim lacked credibility by detailing their difficult behaviour. 5.19 Consent and age: Related to the language of wilfully participating was the understanding of consent to sexual activity, and the relevance of age. In law, no one under 16 can consent to sexual activity, although, if the child is aged between 13 and 16, no offence is committed if the adult reasonably believed the child to be 16 or over.9 There is no such defence if the child is under 13. The Police IMR found a number of occasions where ‘unlawful sexual activity’ offences were brought to Police attention, recorded and subject to initial investigations, adding that “it was evident [to the IMR] that investigators were repeatedly wrestling with the challenge of age”, and for example described where, in an allegation of sex with a 13-year-old, the detective said, “she is a 13 year old girl who could easily be mistaken for being 16 years old”. The Crown Prosecution Service (CPS) reviewed the evidence and decided against a prosecution for sex with a 13-year-old girl, as her appearance, actions and saying she was 16 would, in their view, have meant there was no realistic prospect of conviction. 5.20 A CID sergeant reported that one 14-year-old appeared 18 or 19, and “by her own admission initiated the sexual intercourse with both named males… and said she told then she was 19”. The victim refused to cooperate with any means of investigation, so a combination of issues relating to cooperation, consent, and age came together to hamper any protective action. The Police review suggested that “… decisions being made throughout … were often tainted with the perception of these children having consented to the sexual activity. This was evidently an opinion shared amongst professionals that was only reinforced further by the way the children were presenting to them. As can be seen throughout this [IMR] the national awareness of CSE and the impact on the victims ability to consent at this time was, at best, described as ‘patchy’ and certainly does not appear to have been embedded amongst agencies within Oxfordshire. As such these views… had a significant impact on many of the investigations undertaken during this time.” One of the victims found with several Asian adult males told the author that the Police did not even ask her age. 5.21 This was not just an issue for Police. CSC concluded that, “throughout this [IMR], there are recorded instances of young girls having sexual relationships with older males. There appears to have been a tolerance of underage sexual activity and no recognition of factors such as abuse of power and coercion and the fact that this was against the law. At interview most members of staff disputed they tolerated underage sex and they did try to talk to the girls about this but that often the most they felt they could do was to stress that it was inappropriate, to ask the girls why they thought older men would be interested in young girls and to talk about safe sex.” This brief but powerful summary shows the debilitating uncertainty about the ability to take action, and the sense of powerlessness. While there is usually some understanding of sex between underage children and peers a little older, what CSC called ‘tolerance’ also seemed to apply to relationships with those much older. The CSC IMR was concerned to find in one record on a 13-year-old the phrase, “an age 9 Sexual Offences Act 2003, section 5-15. 36 appropriate sexual relationship… [which]... evidenced a lack of understanding the law and/or an unsafe acceptance of young teenagers being sexually active”. 5.22 The Health Overview points out: “Skilled questioning is required to establish whether a relationship is consensual, when victims do not see themselves as victims and perceive that they are consenting to a relationship, to explore potential power imbalances. Whilst Contraception and Sexual Health (CASH) clinics established that these young people were able to give consent to sexual activity it was not specifically considered within an exploitative relationship. The Genito-urinary Medicine (GUM) service did explore potential power imbalances but from the answers given did not detect potential vulnerabilities or exploitation at the time, although in retrospect and with current knowledge can see that in some cases indicators were present.” 5.23 The IMRs which contributed to this SCR very openly describe illustrations or suggestions of terrible abuse to children, where reading them generates the immediate question of “why wasn’t something done?” The author’s conclusion is that there was, beyond any lack of knowledge or clarity, an acceptance of a degree of underage sexual activity that reflects a wider societal reluctance to consider something ‘wrong’. This involves ascribing to young teenagers a degree of self-determining choice which should be respected. This is not altogether surprising when in Health (looked at more below) the national guidance involves an assessment of the child’s ability to give true consent to receiving contraceptive advice or treatment without the involvement of parents. In a nutshell, a child may be judged mature enough to get contraceptives to have sex with an adult at an age when they are deemed in law unable to give consent to the sex itself. It is no wonder there was confusion and a lack of confidence in taking action. 5.24 What all this was not grasping was that the ability to consent had been eroded. The CPS’s submission on consent in the Bullfinch trial pointed out that, regardless of perceived or stated age, there was no exercise in free choice.10 It described the orchestrated ‘incremental steps’ by which any wish of the girls was squashed by the men through a progression of gifts and attention, getting physical for sex, pestering, threats, orders and “doing by force despite protestation – despite physically being incapable through drink, drugs, or despite an unwilling body and fatigued beyond endurance”. The Crown argued that the lack of true consent was clear, or why would the groups escalate their tactics to ever more controlling, threatening methods? 5.25 The judgemental language about the girls/families, the confusion over consent and age and the lack of knowledge led to a lack of focus on what was being done to the girls, and to the lack of the mental leap to focus instead on the perpetrators. The more determinedly self-assertive, disruptive or extreme the child’s behaviour, the more self-determination they were assumed to have. In fact, the opposite was true. 5.26 The nature of the families: This is a very hard section to write without risking being misleading or unfair. It describes the nature of the families with which numerous professionals from numerous agencies worked. It runs the risk of being seen as deflecting blame from professional weaknesses, but this is not the intention. The reason is that if the statutory 10 Section 74 of the Sexual Offences Act 2003 defines consent in the following terms: “For the purposes of this Part, a person consents if he agrees by choice, and has the freedom and capacity to make that choice”. 37 requirement of SCRs is to understand ‘why’, it is important to describe what professionals saw in front of them, and whether it was understood properly or not. Describing this is not blaming the victims or their families. Indeed, this report is critical of how parents were sometimes treated. It is important to put professional work in context where its quality is being reviewed if learning is to be obtained. It is also important in terms of allocating professional effort to be clear that most victims will be those with most vulnerability. 5.27 Managing the cases concerned was not at all easy. Most (but not all) of the children and parents concerned did have a predisposition to difficulties or challenges in childcare and growing up. This does not mean that family members were responsible for the CSE; they were not. The perpetrators (or at least a number of them) who were responsible are in jail. It does mean that the children were vulnerable to grooming, and that many parents (just like many professionals) did not have the knowledge and understanding, skills or strength to intervene and protect. Some families had had involvement with the statutory agencies for many years before CSE happened. The Review summarises some of this below – but only in broad terms in order to protect victims and their families from unintended identification. 5.28 The offences against the children were not of a lesser magnitude because they may have been ‘troublesome’ and/or may have experienced abuse before. In some senses it makes it worse as it added, in a most horrible way, to any experiences they may have already been through. 5.29 Most of the victims had experienced parental domestic violence at home or in their birth families. Police attended one family for domestic abuse 74 times in one two-year period. There was considerable experience of family instability. Two children were removed from their homes for their own protection long before the CSE. One of these had experienced three different LAC placements and a broken-down adoption placement in another part of the country before the age of ten. 5.30 CSC says that there is information suggesting that three of the victims had experience of sexual abuse in their families of origin. One was sexually abused when looked after (not related to Oxfordshire). One parent was an “offender who has been identified as posing a risk, or potential risk, to children”,11 and three children were exposed to such offenders in their home environment. For a number of the six there was wide experience of drug/and or alcohol problems in their birth or subsequent families, and drug/alcohol services had dealings with three of the families. One parent died of drug-related illnesses. Two had parents with criminal records, and in one of those families the parents had nearly 150 convictions. Statutory agencies had been involved with several of the families for the whole life of the girls concerned. Parental ill health or disability was prominent in two families, and in one the child was regarded as carer from a young age. 5.31 The CSC Individual Management Review (IMR) summarised: “… girls experienced home lives which contributed to their vulnerability to abuse [and] sexual exploitation. With the… exception of [one girl] the girls experienced varying levels of neglect linked to their parents’ own issues taking precedence over the needs of the child. These are ‘Push Factors’ which contribute to 11 Formerly known as ‘schedule 1 offenders’ under Schedule 1 to the Children and Young Persons Act 1933 (CYPA), which lists a wide range of offences against children and young persons under the age of 18, from murder to cruelty or neglect, and offences resulting in bodily injury to the victim. 38 pushing the child away from where they should be safe and protected from harm.” It also made them very vulnerable to the ‘pull’ of grooming and their inability to escape once groomed. “It is likely that their low self-esteem and experience of domestic abuse, parental drugs and alcohol use and physical and sexual abuse will have desensitised the girls to the grooming and CSE model making them very vulnerable victims…” 5.32 There were, in addition to the above, challenges created or partially by the CSE itself. The six girls were reported missing between one and 193 times in their early teenage years. Five of the six girls had from one to 18 periods of being Looked After including spells in secure units for their own protection. The majority of ‘missing’ reports for the girls who had spells in care were while the children were accommodated in care. 5.33 The majority of the girls were investigated for offences ranging from acquisitive crime, drugs offences to damage and violence – including some against parents. Four were known to the YOS. These offences should be seen in the context of what they were required to do by the perpetrators, the chaotic and violent environment in which the exploitation took place, and reacting to those wanting to stop their behaviour before they themselves were able or ready to. 5.34 As an example of the crossover between underlying vulnerability and signs of the exploitation, CSC reported that, “The six girls lived within a culture of acceptance of very early sexual activity and in some of the cases this was accepted and condoned by their parents and in others it was tolerated… The girls were attending sexual health clinics for tests and treatment and were being prescribed contraception from an early age, in most cases with their parent’s knowledge.” 5.35 There was also health involvement through mental health services for four of the children. And of course the girls were in education. This extract from the Education submission to this Review shows both the challenges, but also the lost opportunities to take advantage of innate ability. “From the educational settings’ point of view… the persistent disruptive behaviour of the girls and the challenges that they posed were not easy for any setting to manage and, at times, they were at a loss to know what to do. These were girls that staff told the [IMR] author they had remembered for years, they stuck in their minds and had a significant impact on them. They were also girls that, even with all the challenges they posed, had academic ability. Staff spoke with affection about them and it should be noted that some tried really hard to support them when at school, and now feel a huge sadness at now knowing more about the reality of what was actually happening to them at the time.” 5.36 The scale of professional involvement with the families, going back many years was vast. The chronologies from agencies of their involvement provided for the Review amount to 3,900 pages. The Police had 1,561 recorded contacts with the girls during the Review period. The sheer scale of agency involvement in itself demonstrates the complexity of the task of inter-agency collaboration, and that if it were easy and obvious to identify CSE or effect change at the time, given the cumulated brainpower being applied, it would have been done earlier. 5.37 This section is not emphasising the difficulties emanating from the nature of those who needed help to deflect attention from agency performance, nor is it suggesting anything unique about A-F. The challenge remains the same now even for those with real expertise. At a conference in 2014 attended by the author, the Kingfisher team of CSE experts (with the most up-to-date knowledge of CSE and how to approach it) said of today’s potential victims: “They are the 39 most difficult children to deal with”, and illustrated with a case example: “Poor school attendance, behavioural concerns dysfunctional family relationships… difficult to engage, missing episodes, attendance at sexual health clinics and third party information regarding X being seen at parties and parks with older males.” This statement was not blaming the children but simply describing the reality of trying to help exploited children, which is incredibly difficult. 5.38 Levels of cooperation: The victims were not able to cooperate with the authorities for three main reasons. Firstly, for a while, they felt they were getting something of what they wanted from the perpetrators. Secondly, they were groomed into a misplaced sense of loyalty to their abusers. Thirdly, they were trapped by fear of punishment by the perpetrators, and by the cycle of having to repay, through sex, the cost of drink, drugs and so on into which they had been skilfully led. 5.39 A senior Police officer in Operation Bullfinch said that “The girls were ‘the most difficult victims [that officer] had ever had to deal with… as a direct result of their grooming/conditioning. They were isolated so much by their abusers they trusted no one except them – so ‘helping’ agencies or any adult were not to be trusted or cooperated with.” An illustration was given which illustrated the hold over the victims by the perpetrators. The officer described how one girl was punished by being taken to a wood and humiliated and raped in different ways by seven men. Left alone, hurt, crying, naked and covered with semen, the person she called for help was not the parents, social worker, police or ambulance but one of the abusers who had just raped her. 5.40 The case illustrations from IMRs are full of examples of the victims, we know now because of the grooming, refusing to be interviewed or make statements, refusing to identify perpetrators, demanding that no action be taken on their behalf, and sometimes criticising any action that was taken. They did from time to time make specific allegations, and were often found in a condition when it was obvious ‘something’ had happened. But whilst it is the case that police investigations were not adequate by current methods, it is also the case that victims seldom assisted seeing anything through because of what we now know was fear, intimidation or misguided loyalty to the abusers. 5.41 This was compounded by the experience of one child who was prepared to give evidence in a 2006 trial but who withdrew from the case (leading to its collapse) in the face of what was to her a brutal and humiliating defence cross-examination. Also, by the victims’ sense that the police were powerless to control/contain the perpetrators thus making it very risky to reveal anything in case it led to their ordeal at the hands of the offenders getting worse. While the reasons for no action against the perpetrators were extremely complex, understanding that would not have prevented the victims feeling exceedingly vulnerable. 5.42 As seen in Section 3, the parents went through the most worrying of times, could be exasperated with the inability to tackle their children’s vulnerability, and felt that professionals showed insufficient tenacity or concern. But to some agencies, some parents were seen as uncooperative, collusive and even obstructive. CSC, which worked with the families on child protection processes, care proceedings, investigations and so on, reported to the Review that one parent was aggressive and difficult with the social worker, another was convicted for threatening a worker, another ‘manhandled’ the social worker, another was ‘verbally aggressive and abusive’. Five of the six parents, CSC said, did not at times report their 40 children missing. There was evidence of some of the girls having sex with adult males in their family homes, seemingly with parental knowledge. 5.43 Some of the parental hostility to social work staff may have reflected the extreme frustration with ‘inaction’, or feeling overwhelmed by the challenges posed by their children. Some lack of cooperation by, for example, removing children against advice from children’s homes may indeed have reflected their deep ambivalence about the need for care or, as the CSC IMR acknowledges, the lack of safety that care provided. 5.44 But whatever its cause, the antagonism to professionals added to the complexity of managing these cases. But, to repeat, it was not the families who committed the CSE. 5.45 The author consulted the girls he interviewed about his intention to describe their background and the four he met were all in agreement. They were all very open about how difficult anyone would have found them at that time. 5.46 Crime/No crime and evidence: Whereas now good practice is followed and perpetrators are investigated through a variety of means, regardless of victim cooperation, and CSE is well understood, during the period before the Bullfinch convictions, the Police IMR identified how only a proportion of what was reported became logged officially as a crime. The Police had only 26 recorded offences related to the six girls on the main database of ‘crimes’, but the Bullfinch inquiry and the IMR identified many more recorded in other ways which, in the Police view now, should have been responded to as ‘crimes’. This was for a variety of reasons, which did not seem to be for reasons of deliberate disregard but because of confusing processes and many of the other issues described in this section. 5.47 There is evidence that not recording crimes as crimes, or declassifying an event as no crime inappropriately, is a national issue. Her Majesty’s Inspectorate of Constabularies (HMIC)12 in 2014 reported that its national inspection on crime data found that over 800,000 crimes reported to the police had gone unrecorded each year, “representing a national average under-recording of 19 percent”. Also, in 20% of the cases studied, where something was reclassified from crime to no crime, that the change was inappropriate. The examples given here of Oxfordshire cases up to a decade ago, whilst regrettable, were almost certainly not unique to the County. (A 2014 review13 of TVP’s crime recording says that “the force’s approach to ‘no-criming’ is generally acceptable… and found that frontline officers saw the no-crime process as rigorous”.) 5.48 One example was when a mother reported her daughter being persuaded to deal drugs. The child did not want police to visit in case the men “f…..g kill me”. Later, the mother said the girl was out armed with a knife for protection dealing drugs in a named place, and later still said that the Police should not miss this chance to get information from the girl. This was not investigated, nor any attempt made to speak to the (unwilling) child. It is unlikely that CSC was told. In another case, at a ‘safe and well’ check after a child returned from being missing, a PC heard that she had been overnight with older men, drinking all night and taking heroin. The child was described as uncooperative, regarding it all as funny. Nothing 12 State of Policing: The Annual Assessment of Policing in England and Wales 2013/2014 (HMIC, 2014). 13 Crime Data Integrity: Inspection of Thames Valley Police (HMIC, 2014). 41 was investigated and the officer submitted an intelligence report “in the hope another department who knew more about her could have taken more action”. On another occasion, after another child returned home, the flat where a girl had stayed with an adult was visited, and the man (who denied sex had taken place) was warned she was under 16 and “told he was lucky not to be arrested”. Another officer noted on an intelligence report, rather than formally as a crime, a named man attempting to prostitute two of the girls (aged 14 and 15), plying them with alcohol to get sex, the fear of the girls who could not resist the man’s demands that they run off from their children’s home, and how the man was attracted to their extreme youth. That officer is clear that now a crime report would be created. 5.49 There were other examples, including when Police were told of an old rape allegedly committed by a (partially) named man. When a parent reported a ‘rape’ and the child confirmed then denied it, the case was closed without full investigation due to a view that the original claim was manipulative, the parent agreeing the story was made up, and verbal abuse of officers by the child. This was before the current understanding that the story and denial may in themselves actually indicate CSE, which needs thorough inquiry, and at the time no ‘crime’ was logged. The Police IMR said that “by not treating the reports they received as crimes, it is evident that TVP staff did not bring the necessary investigative mindset to what they were being told”. The officer then in charge of Oxford CID says cases would have been investigated if referred (within the practice of the day) and was very frustrated to find from the IMR that there were many incidents not treated as crimes, so not passed to CID. 5.50 The Police review for this SCR also identified that even if there was a ‘crime’ there was, at the time, lack of clarity about which branch led the investigation – from the attending officer through to CID and the Child Abuse Investigation Unit (CAIU). This meant sometimes that the necessary understanding or skills for such complex work might not be there. 5.51 In addition to the ‘no crime’ issue, there was a difficulty in proceeding without victim disclosure. A national CEOP report14 said: “Overall, victims are unlikely to disclose exploitation voluntarily as a result of fear of exploiters, loyalty to perpetrators, a failure to recognise that they have been exploited and a negative perception or fear of authorities.” Of the 26 reports the Police had of offences against the six girls, evidential statements were made in seven. Of the other 19, six were made by third parties, so the police had ‘only’ 13 disclosures. In no case where the report was from a third party did the victim support the police investigation. 5.52 The Police describe one process in relation to underage sex with three men encouraged by money, and reported by a children’s home after one of the children returned from several periods of being missing. It was not originally recorded as a crime. The IMR identified over 24 recorded investigative actions over four months (mostly related to multi-agency liaison including several meetings). At an early stage the officer in charge said that “there is no victim as such as she is not willing to give police a statement”. Later an Inspector recorded that “the aggrieved is indicating that she does not wish to speak with the police and so this matter may not be progressed as a criminal investigation”. Sometimes opportunities were lost as evidence gathering was delayed for the outcome of multi-agency meetings, when it is clearer these days that there are occasions when ‘now’ is the only time something might be disclosed. 14 Out of Mind, Out of Sight: Breaking Down the Barriers to Understanding CSE (CEOP, 2011). 42 5.53 Even where there was some disclosure, getting anything to a successful prosecution was far from easy. The updated CPS guidance,15 which takes a helpful approach about using the weaknesses or contradictions in evidence as signs that courts could consider as demonstrating sexual abuse, was not published until 2013. In a speech used in many settings, including to the Home Secretary, the Detective Chief Superintendent currently overseeing CSE work in Oxfordshire said: “The picture is not as simple as these children were completely ignored. They were not. There were attempts at investigation throughout the period but they were not sustained or coordinated or prioritised and each attempt faced almost insurmountable odds in a criminal justice system that had no real idea how to present evidence from difficult young victims (with) a whole baggage load of complex disclosure issues and problems.” 5.54 The Police also identified what was described as ‘tunnel vision’, whereby investigations before Bullfinch tended to look at the presenting issue only, and not ‘join the dots’ to other reports to the Police. They re-assembled over 40 pieces of information available about two 14-year-old girls in 2006 from the Missing Persons database, interview statements, crime and intelligence records, etc. This included information from third parties as well as from the girls. It included information about being held against their will, hard drug use, ‘consenting’ sex with a number of males, several accounts of sex with up to seven men, sex with a named man at 13, and a number of named men. Whilst there were a number of arrests for offences up to rape, there were no prosecutions (for the sorts of reasons given earlier, including lack of victim support). The IMR concluded that there was a lot of potential evidence that was not pursued beyond intelligence or missing persons reports, and that investigators did not make the connection – such as one girl being found at the same address where another had been the previous week, or linking names. Saying this does not necessarily imply that making the connections could, at that time, have led to successful prosecutions in the light of, say, the absence of victim evidence, but the chances would have been higher, and disruption could have been undertaken. 5.55 The Police IMR also identified that there was a risk that information recorded on intelligence systems might not get to the relevant safeguarding teams. It illustrated this with a 2007 account of a 13-year-old girl found hiding in a car with an adult Asian male, with condoms in the car. The officer also suspected drugs. Their account of being ‘friends’, and him not knowing she was 13 seems to have deflected focus on the risks. The man was advised and ‘sent on his way’, and the girl taken home. Only an intelligence report was submitted. The officer’s open comments many years later to the IMR are repeated here as they are a useful indication of front line mind-set and how hard it was to grasp the extent of what might be happening. “That was probably the first time I thought – what is going on here, this is a bit odd. At the time from a beat officer’s point of view you don’t have the knowledge and the know how to know what to do. I had 25 years’ service but didn’t have the experience to deal with it... my mind was that would go to a department or someone that would be more suitable to deal with it… a department or someone that would be more suitable to deal with it.” The IMR could not trace that any action was picked up. It was assessed as a ‘non-crime incident’, which means, says the IMR, it may not have been passed on to CSC. (However, the police officer concerned attended a professionals’ meeting two days after the incident where it was discussed, so CSC was informed.). The combined agency chronology about 15 Guidance on Prosecuting Case of Child Sexual Abuse (CPS, 2013). 43 this child shows over 80 entries during the month of this event, including major legal and multi-agency considerations, and the City Council was expressing serious concerns about the girl’s wellbeing. 5.56 The CSC IMR describes how at times social work or residential staff might report concerns to locally based front line police officers who might make some preliminary inquiries but not forward to the Police CAIU, thus preventing the safeguarding team considering more formal steps. It is possible that the informal conversations were not seen as ‘referrals’ but might have been meant as such. 5.57 There were some unsuccessful early attempts at prosecuting or convicting men who may well have been involved in activities akin to the Bullfinch offences. Four allegations were referred to the CPS for charging advice. One case of rape against three men did get to court in 2006, but was discontinued when the victim refused to give further evidence, distressed by the cross-examination. The CPS explained to the SCR the reasons why other potential cases involving these children (not necessarily all with Pakistani group members) did not get even this far. In some respects, there is overlap with the issues around knowledge, language and consent discussed earlier. In one case, where one of the victims was 12, there were concerns about voluntary actions by the girls, a refused medical examination, and the credibility of the victims in light of their behaviour. (The CPS describes the police investigation as ‘thorough’.) In another, the problems were given as poor credibility as the victim was ‘out of control’, no corroborating forensics, and that the police officer in charge was ‘shocked’ the girl was only 13 (so there might be a defence on perceived age). This shows that the way of thinking about these victims was, in the mid-2000s, similar across agencies including courts. There was, at that time, a failure to focus on the actions of the perpetrators. 5.58 The author has seen CPS correspondence about a number of cases involving children from A-F and the reasons given for not taking court action. Whilst the wording may indicate that the girls’ behaviour was a relevant factor, and there was no more understanding than anywhere else about how consent was eroded, the CPS arguments were in the author’s view merely reflecting accurately how the defence and juries at the time would see the weaknesses in any prosecution. 5.59 It is important to show that there was indeed effort to obtain convictions for offences against the girls during 2005-8, so this was not a period of doing ‘nothing,’ although the hoped-for outcome was usually thwarted. The children are not identified by A-F to avoid inadvertent identification. The first chart includes any alleged perpetrator, not necessarily the group later convicted in Bullfinch. Only three investigations resulted in a conviction (italics) for the reasons given. CHILD OFFENCE OUTCOME 1 Sexual activity/child under 16 CPS decided insufficient evidence/cooperation Sexual assault on a female 13+ 4 arrested (2 later Bullfinch suspects), but victim denied assault. Men released 2 Rape of female under 13 Case discontinued by CPS on evidential grounds, although child was believed Rape of female under 16 2 men arrested but not charged as no cooperation with medical or statement Sexual activity/child under 16 No statement from victim – case filed 44 Sexual activity/child under 16 Man in 30s convicted and jailed Rape of female over 16 Victim made statements but then withdrew them. Not pursued as a crime 3 Sexual activity/child under 16 Man guilty on 3 counts and jailed 4 Rape of female under 16 Victim would not support proceedings or have medical. CPS advised no further action Rape of female under 16 3 men charged, but acquitted when victim withdrew in face of cross-examination Rape of female under 16 Cooperation with medical and video but DNA evidence led to no further action against later Bullfinch suspect 4 and 1 Sexual activity/child under 16 Victims withdraw cooperation, and CPS decide no public interest in proceeding (a young alleged perpetrator) The second chart records arrests of Bullfinch suspects against girls other than A-F in the period 2007-10. Offender OFFENCE OUTCOME 1 Insulting words causing harassment/alarm/distress (encouraging 11- to 12-year-olds into his car) Fined Rape of adult Arrested but inconsistent victim evidence 2 Sexual assault of adult Case dismissed at court 3 Rape of adult Case filed as inconsistencies in victim account 4 plus 1 Rape of two 17-year-olds Two men arrested – no further action due to consent and evidential issues 5.60 Lack of curiosity and rigour: CSC staff at times did not follow through some information that in hindsight needed investigation. The CSC IMR says that four of the six children alleged they were hit by their parents but, whether the allegations were true or not, none led to formal investigations. “The girls learned that adults could hit them and nothing would happen and this added to their de-sensitisation and vulnerability, with managers signing off assessments without ensuring the allegations had been addressed.” 5.61 In another illustration, in a CSC Initial Assessment, “an opportunity to pick up on the concerns about a thirteen year old child associating with older males and being sexually active was missed. It also failed to take full account of the information that her father was a Schedule 1 offender [now known as an ‘offender who has been identified as posing a risk, or potential risk, to children]. The Team Manager should not have signed off the assessment as – no further action as a ‘team around the child’ in place – given this information.” There were other references to two partners of parents who were such offenders who were not assessed. 5.62 A lack of professional curiosity was described as ‘a theme’ which ran through the CSC internal management review. “There [were] unanswered questions in relation to several of the girls, for example, them associating with unknown adults… Team Managers needed to be challenging this in supervision but rarely did so.” It gave examples, asking why there seemed to be no exploration of why a girl in a deeply troubled family was using contraceptives at 12. The IMR concluded that “what was lacking was a real sense of 45 professional curiosity and the wish to really get underneath the behaviours and identify the issues. The fact that assessments were not routinely reviewed and updated compounded this issue. Team Managers should also have been picking this up and helping the case holding social workers manage the complex cases and ensure appropriate plans were in place to address all the identified issues.” This is a good example of how issues described in this section relate to each other. 5.63 The lack of curiosity was not restricted to certain agencies. A senior social work manager said the Police were similarly uncurious. “The police response lacked curiosity – they would pick the child up, give them a telling off and drop them back at the children’s home”, and the Police IMR confirms this with its own illustrations. In Health, children accessing Sexual Health Services were also subject to a lack of curiosity. The Oxford University Hospitals (OUH) IMR gives a good example about an admission for excess alcohol. “… the team did not review (the child’s) sexual history other than at first presentation at a time when she was still intoxicated, when she told the admitting junior doctor that she ‘regularly has sex for alcohol and drugs’ – but describes those she has intercourse with as ‘friends’. This information was taken at face value: at that time there was limited knowledge of potential Child Sexual Exploitation amongst clinical staff.” 5.64 “The fact that she described those with whom she had sex as ‘friends’ gave the impression that she was talking of young people of a similar age. However, at a different point in the history she had explained (to the medical student who was the first person to see her) that she had run away and was staying with ‘people she knows in Cowley’ who she describes as much older – and uncertain of their ages. This comment is completely separate from the one about having sex with ‘friends’ and further questions should have been asked when the effects of the alcohol had worn off. This subject was not revisited in detail when she was sober.” 5.65 Sometimes the lack of curiosity was tactical. OUH described the concerns of staff in sensitive areas such as GUM clinics: “If they are seen to pry too much the children might not stay, or fail to re-attend: this compromises staff’s ability to give best medical treatment so there is a fine line between what staff perceive as an appropriate degree of professional curiosity and what a young person perceives as simply too nosey or intrusive.” Oxford Health also found a lack of curiosity in substance misuse services and health visiting about what was really going on behind the presenting issues. “Although staff had significant concerns about the behaviour and disclosures of Children A-F there was a lack of professional curiosity in establishing the nature of these relationships and the identity of the individuals they were associating with…” 5.66 The lack of follow up of concerns was also related to assumptions. Oxford Health describes how, with all the children being Looked After Children (LAC) or having a social worker, Health staff assumed that they knew about and were managing ongoing concerns. Oxford University Hospitals also said its clinical staff would assume that statutory agencies already knew about what they were hearing from their patients. 5.67 The apparent lack of rigour also related to uncertainties about Police powers – for example the right to enter property to search for a child, or the appropriateness of following children covertly to try to identify possible perpetrators. The Police look-back at the cases said that 46 while covert operations were used in 2007, they were not then used again until 2011. (From Operation Bullfinch onwards there was much greater clarity on this.) 5.68 Disruption: Whilst the idea of disrupting the activity of individuals and groups that are exploiting children is now a core part of practice, during the years leading up to the Bullfinch investigation and trial it was uncommon and the Police have concluded it was indeed under-used. This included not using various legal orders which had been available for many years. Disruption runs alongside safeguarding and investigation, and may protect children but also build evidence of a propensity to behave in a particular way that can be used in later proceedings. For example, Child Abduction Notices, which do not need a complaint from a victim, have been available since 1984 for under-16s, and since 1989 for under-18s. It is an offence to take a child away without legal authority. Such a notice might warn a suspect that a child was less than 16 years old, so removing belief of being older if eventually charged. The person can be arrested if the warning is breached. 5.69 The Police review showed many records of the consideration or decision to use such notices. “However whilst this [IMR] found numerous directions to make use of these notices, there is very little evidence of them actually being served on people,” and found only three in relation to A-F. The Police did note that it was not easy to ascertain from records if such notices had been issued, but concluded “this may have been down to a lack of knowledge amongst the front-line staff”, quoting interviews with staff who were working on cases at the time, and there was no specific training on the use of these orders in the mid/late 2000s. It is also likely that the views discussed above about the girls being seen as voluntarily getting involved would lessen the sense of there being an ‘abduction’. 5.70 Risk of Sexual Harm Orders were also available from 2003. They can be imposed on an offender who has demonstrated behaviour that suggests he may be at risk of committing a sexual offence against children, where the court is satisfied that the order is necessary to protect children from harm from the defendant. There have to be at least two specified incidents of concern but there does not need to be a previous conviction. There is no record of such orders being used. 5.71 Disruption can also include targeted surveillance, gathering of information about, say, the use of specific taxi firms, stop-checks and so on. There was an increasing use of these tactics over the years of this Review, but the Police conclude that they were uncoordinated. Looking back, the Police say they should have involved other agencies more in Police ‘tactical’ meetings around these cases “to have ensured all of the information they held was made available to support the development of robust investigation and disruption plans. As it was, the professionals involved seem to have repeatedly fallen in to the same trap... relying on an approach that was doomed to fail as the children were unable to support the criminal prosecutions.” 5.72 Escalation: The CSC IMR found that, whilst casework decisions on these girls (and others like them) were escalated from the front line, both in social work and residential care, to their managers, this was not always shared with more senior managers. This meant that concerns about what might be happening (before CSE was properly recognised) were not discussed in the higher reaches of the Council (or Police), but it also affected the front line staff. CSC told the SCR that the non-escalation “became part of the culture of the service and meant senior managers were not providing challenge and support on these complex cases’. The extent to 47 which the top of agencies was aware, or should have been aware, of the exploitation of girls in the County is explored in Sections 7 and 8. Here the focus is more on those involved in operational work. 5.73 In the middle of the first decade of the 2000s, despite the formal existence of processes which would allow reports of concerns to reach high-level managers, middle managers told the CSC Review that “staff and managers have described children’s social care as being ‘extraordinarily self-sufficient’. In addition middle managers said that their experience was if they took issues to senior managers it would result in criticism and blame and so they learned not to escalate but to try and manage things themselves.” The IMR says: “One example which some managers have cited is that asking for a placement for a child to become looked after was seen as a failure on the part of the social work team, asking for an out-of-county placement was seen as a failure and an unacceptable demand on budgets... The panels were also seen as very challenging and distressing for some social workers and so they began to avoid them until absolutely necessary.” The IMR also recorded middle management concerns about an oppressive culture around 2010,16 “which led to them retrenching and avoiding raising concerns because to do so led to blame”. Whilst, if correct, the atmosphere at certain points would not be conducive to the maximum management of the most difficult cases, caution needs to be exercised in assuming a connection between this and specific issues about CSE, especially as middle managers may not have grasped its magnitude anyway. All that can be said is that, to find an understanding of CSE, a means to protect from it and a solution for it, systems needed to be working very smoothly indeed. 5.74 Escalation also did not happen across agencies. For example, the Drugs and Alcohol IMR says that a drugs service, hearing very worrying things from a 14-year-old, should have escalated to CSC management when there was sustained non-response to calls made to a front line CSC worker. 5.75 In the Police, there were some illustrations of more junior staff formally informing senior officers about their concerns. In 2006, the then Missing Persons Coordinator (a constable) wrote to the Detective Chief Inspector, copying in the Oxford and Oxfordshire Commanders, about a lack of inquiry into where two girls were or giving them due priority. The Police said this led to better multi-agency planning and a Police visit to Lancashire where there was more experience of sexual exploitation. In 2010, a sergeant wrote to the CAIU Detective Inspector in charge of Missing Persons describing many of the features now known as CSE, and this was fed into subsequent meetings of the Missing Persons Panel. 5.76 There is also an example where a City Crime and Neighbourhood Nuisance Officer was hugely concerned about a particular child and escalated to senior staff in other agencies, but not within his own. His Chief Executive was unaware of it until this SCR, despite the work being subject to a director-level complaint from the County Council. The Nuisance Officer was a former Detective Sergeant and acting Detective Inspector with experience in child protection sections of the Police. In 2007-8, he repeatedly raised concerns with senior CSC and Police staff (including the then Director of Children’s Services, but not above his own 16 The DCS at the time says she and the Interim Deputy, not long after their arrival, had drawn safeguarding shortfalls to the attention of County CEO and Lead Members for Children and Education and “had to lead rapid improvements in safeguarding arrangements that required constructive challenge, challenge which I considered some managers were unused to”. 48 City team leader) about a particular family and child (one of A-F who was at times looked after), describing her behaviour and associates which today would lead to a speedy recognition that something bigger might be happening, but which at the time led to rather harsh disregard and criticism. For example, in February 2007, he reported “men going into the flat every night and leaving in the early hours of morning” and seeing the 13-year-old lying under a cover with an adult male (which led to a Police Protection Order). He also sought a child protection case conference after a rape allegation but this was turned down. He and a colleague told the OSCB City subgroup about the risks to children from massage parlours and reminded the meeting that his team was continuing to pass to the Police information about 14 and 15 year olds being seen in cars with older men. 5.77 This episode is one that agencies must learn from. The Nuisance Officer concerned was helping manage a situation with a very difficult challenging family where the behaviour of adults was the prime focus, but where the behaviour of one child in this review was also a serious issue. The officer gathered very significant information about the girl, her association with much older adults, and her general access to risky situations – having argued in 2007 against her coming off the Child Protection Register, as she was going missing so often.17 He resorted to sending emails to many senior Police and CSC staff such was his concern (which seem from what is known about the child and exploitation quite justified). The SCR has seen correspondence with Police and Social Services about the girl with adult males late at night in January, February, March, June 2007 and February March and May 2008 (when she was 13 or 14 and was under Council supervision or formally in Care) 5.78 Whilst Police responses were calm and aimed at reassuring him (and implicitly supported the officer’s intentions, once encouraging him to continue his communications with the County Council), responses from a CSC senior manager were, in the author’s opinion, rather hostile and demeaning. The Nuisance Officer’s emails included phrases like “can we all live with risk that this young girl is exposed to in view of the intelligence we have of her association with Males”. He referred to both ‘Asian’ and ‘black’ males on several occasions. The child was subject to a Care Order and the risks being described were at times when resident in Council care. One CSC response to concerns about sexual association with adults said: “The innuendo relating to her alleged associates I find a little presumptive and unsavoury, and does not in my view indicate a significant prima facie risk of harm…” Another email said that “the evidence beyond innuendo remains thin”. (By this point there were numerous reports collated by the Nuisance Officer of association by the then 14-year-old, late at night, with adult men.) The writer of those messages accepts that their tone was wrong, but at the time believed the course of action the Police and CSC were taking to focus on reducing missing episodes was right. 5.79 CSC, who knew the Nuisance Officer had good connections with the Police, thought the officer had unreasonable access to confidential police information about the case, but the Police IMR saw this more as good liaison between agencies. A police officer was embedded in CANACT (Crime and Nuisance Action Team), so close liaison was the norm. The County’s Head of Adult Social Services was asked by the CSC Head of Service, through his contacts 17 A view was put to the SCR that, if the child was Looked After, a Child Protection Plan was not needed, but there is nothing to this effect in the 2006 Working Together, which actually described the process when both were in effect. The criterion for being on a Plan was ‘if the child is at continuing risk of significant harm’, and is hard to argue this was not the case given what was known about her and adult males, whether the child was at home or placed with a relative or in a children’s home. 49 with the City, to complain about the Nuisance Officer’s emails and style, and the City senior manager apologised for “the attitude of the staff member and for the unprofessional way he has acted. I am most upset that an officer under my control could act in this matter, and apologise to your staff unreservedly. Please be assured I have taken strong action to ensure this does not happen again.” The author understands that the worker was asked to stop emailing, but not told that his concerns were inappropriate. It is likely though that his managers assumed that the Police and CSC would be doing the right thing as it was their responsibility, and so did not take up the issues themselves. Only his team leader, and no one more senior, spoke to the Nuisance Officer, who said that he was told the County did not like senior staff being criticised by a junior person. 5.80 Whatever the style of the Nuisance Officer concerned, he was trying to get a child protected, and responses received (including turning down a case conference request) show one reason why the full picture of CSE was delayed. There is no evidence that the very top managers in the City knew about this disagreement but, according to CSC, “At one stage in this correspondence the Directors of Social Services18 and Education were copied in to the City Council employee’s correspondence – the Director of Education because (the Child) was not in school. Both asked their direct reports to respond.” He also describes being so frustrated he went to the County Council and demanded to see a senior manager, and was seen, he says, by the Head of Adult Social Services19 to whom, he says, he relayed all his concerns. 5.81 In 2008, the then Lead Member for Children’s Services was copied into some of the correspondence and asked the CSC senior manager with whom the City officer was corresponding to draft a reply. The Nuisance Officer also says he spoke to the Lead Member and briefed her on the whole picture, including the association with adult black males. The Lead Member for Children made personal inquiries. “She also met with the staff at the residential children’s home, without a senior manager present, to ask them herself about the child and she was also assured that the males [the child] was being seen with were young asylum seeking males. She accepted this explanation.” 5.82 The correspondence was concerning (or the Lead Member would not have made personal inquiries) but it must be noted that was no indication of group-related CSE, but rather concerns about one child/family. However, the Lead Member also told the CSC IMR about a meeting with the CSC Head of Service, other senior managers and staff from two Homes. No minutes have been found but it seems probable the Lead Member had two meetings. The Lead Member recalls her prime concern being girls in care being out late at night and the risks that must follow that from men, rather than specific examples, and says she was unaware of abuse by Pakistani heritage men of multiple girls until 2011. She says that the County Corporate Parenting Panel saw that the missing statistics had recurring names and was concerned about the risks, but says the Panel would not have known what was happening to them when away. 5.83 The former CSC manager who had some of the correspondence with the Nuisance Officer now accepts that the strategy of trying to support the girl to learn how to cope with her 18 The emails into which the then DCS or the Director of Adult Social Care were copied did not mention anything specific about adult males or sexual activity. 19 It may well have been another senior manager who reported to the Head of Adult Services. 50 complex family situation rather than removing her from the risks was wrong, but believes it was followed with good intentions. 5.84 The Bullfinch perpetrators were found guilty of 25 offences against this child. The girl was reported missing from Council Care 69 times in 2007 and 79 times in 2008. 5.85 ‘Nothing can be done’: The perceived difficulty in prosecuting and the lack of investigation on occasions led to a vicious circle whereby victims would either not disclose, or make only a partial disclosure, or withdraw support for the Police, because they could see that there was no guarantee of sufficient action to be safe from perpetrators if they did support the Police. Victims can describe circumstances, some quite dreadful, when they made allegations or were found in dire straits after abuse yet ‘nothing happened’. Although there might be understanding now about why nothing (much) happened to end the abuse, for victims who were scared, hurt and trapped, this must have merely reinforced their sense of isolation and lack of choices. Exasperation might then reduce further cooperation or lead to withdrawal of cooperation, which would then enhance the sense amongst police and others that this was all too hard. One detective said of the pre-Bullfinch period that “if a child did not disclose it was a matter for social services as we needed to move on to the next job”. This showed the then absence of other measures such as disruption and covert surveillance. 5.86 The limitation to investigation was reflected on by a very senior police officer looking back at that period. He told the SCR that at the time of the illustration above there was real pessimism about whether cases could successfully get to court due to evidential constraints and lack of evidence from victims, and that was a disincentive to further investigation without victim support. Attention was instead focused on a strategic approach to managing ‘missing persons’ and multi-agency safeguarding plans, rather than what were expected to be fruitless investigations. This was acknowledged, in hindsight, as clearly being the wrong approach with this form of CSE. 5.87 CSC/residential homes staff, felt frustrated that ‘nothing was done’ with information they provided. CSC say that “the prevailing culture became, if the police can’t do anything there is nothing we can do, and this became a source of frustration and anxiety for some social care professionals”. But there is also evidence in IMRs of Social Care and Health staff at times being reluctant to tell police all they knew or heard in case it undermined their relationship with the girls. Police were also frustrated by the sorts of issue described earlier, such as evidential issues and cooperation. As will be seen below, there was a growing level of shared concern at the end of the 2000s and which culminated in the excellent Bullfinch initiative, but for a period (despite vast public sector involvement) the understanding and skills were insufficient to solve that frustration. 5.88 Missing persons management: ‘Missing persons’ was a powerful and complex issue running through these cases and the developing understanding of CSE. The Police IMR alone took 176 pages to describe, analyse and pull out the learning from the management of those who went missing. There are 450 Police Missing Reports held on the six children in this SCR, and there were further episodes not reported. The 450 represented only 4% of the 10,600 total under-18 missing episodes in the County in 2005-13. And the 10,600 Missing Children reports were only just over half of all Missing reports, which averaged 2,450 per year. Oxfordshire figures were around a third of the TVP area overall. However, for children missing from being Looked After, Oxfordshire had a much higher proportion in 2006-9, which 51 may reflect the pernicious effect of the exploitation, and a reducing proportion thereafter, reflecting the increased local focus and awareness and improved joint agency systems. For the six children concerned, the episodes increased from ages 12-14 and decreased to almost none at 16, which was associated with the perpetrators losing interest as the girls got older. Five of the six girls started going missing from home, so this was an established pattern before spells as Looked After Children. 5.89 The obvious questions are – was it not obvious that these girls were being exploited in a major way, and why were they not stopped from running away to danger? An extract from the Oxford University Hospitals IMR shows one of the main causes, but also the link with other issues in this section. A 14-year-old girl was admitted with excess alcohol and there was a lot of interagency liaison. “OUH staff accepted the view of those professionals in police, the Care Home and CAMHS that this was simply another episode in the life of a girl with significant behavioural difficulties rather than exercising a higher level of professional curiosity about what was causing this. Specifically, her comment while intoxicated about having sex with friends for drugs and alcohol was taken at face value: mainly because of an assumption that this was simply part of the ‘bad behaviour’ but also because of lack of knowledge amongst health professionals about grooming, and the significance of missing episodes as one possible indicator of Child Sexual Exploitation as this was not a widely publicised factor at that time.” 5.90 There was a sense of exasperation about so many missing episodes, and for too long staff found it easier to try to control those episodes rather than work on the perpetrators to weaken the ‘pull’ factors. One senior social worker said, “We would get missing reports most days. I guess the view [then] was that the children were just playing up. It was always the same children.” There was also the traditional view of those who run away as running ‘from’ something (e.g. abuse at home or the control of a children’s home). With some of the families this could be a tempting thought, and it took some time before the enormity and power of the pull from grooming was grasped. 5.91 There was also an assumption that the children were better off in Care, and even safer in secure accommodation. This proved not to be the case as the very numerous missing episodes from Care showed. Only official secure accommodation is allowed to lock doors or windows, and even when one girl had round-the-clock 2:1 staffing in a residential care home, windows were used to get away. More distant homes proved no barrier, as some girls would find their way back to Oxford. Whilst the girls could not get away from secure accommodation and were safe for that time, the fact that their perpetrators were untouched by such a placement meant that the abuse resumed on their discharge (unless they had become too old to be attractive to the men in the meantime). The CSC IMR was concerned about one child in the mid-2000s who was in a local children’s home after two spells in secure accommodation. It said it was well known that she was being hurt when missing from the (not secure) home, and that it was “a serious error of judgement” when senior managers indicated that a third spell in secure would not be agreed. (Although it must be said that secure was a respite from abuse and not a solution.) 5.92 Physical restraint can be authorised, but it was virtually never granted as the social work managers who had to deal with such a request apparently regarded restraint as a sign of failure, and it could not in any case have been a continuous action. (Every parent knows there is a point beyond which it becomes impractical or unreasonable to physically control teenagers.) Removing or disrupting the perpetrators is now the solution. It was some time after Children’s Homes began reporting names they knew or had heard, car registration 52 plates, visits by perpetrators, etc before such action against perpetrators was consistently and successfully taken by the Police. 5.93 There were a number of procedural issues that fed into the pattern of insufficient action to make a difference. A sample of those is described below. The Police told the SCR that whilst most missing reports were correctly graded for an ‘urgent’ response, there were some that should have been ‘immediate’, where for example the operator noted that the caller (a parent) “thinks [the daughter] is being held against her will by Asian males” or “at risk of sexual exploitation, harassed by a group of Asian males”. The Police tried to establish why staff were not recognising vulnerability issues, and identified some confusing wording in the risk assessment questionnaire, but concluded that overall the cause of misclassification was: “It is evident throughout this review that TVP staff did not have a sufficient understanding of CSE to be able to readily identify this as a form of child abuse and a factor that increased the young person’s vulnerability. This was not surprising given the national awareness of CSE at this time, with both national guidance and TVP policy regarding missing persons not overtly recognising this link and its impact on risk. It certainly did not feature in TVP staff training nor within the force policies that….staff were following.” 5.94 Such were the numbers of missing episodes, of which A-F were a small proportion, that processes were agreed that allowed a differential approach, and the IMR found that some officers read the lack of requirement to attend as meaning they should not attend rather than use case-by-case judgement. This had the impact of lessening the impact of oft repeated (and oft returned from) spells of being missing and the Police quoted one duty sergeant: “I do not agree that she is high risk. She has many friends who she stays with. She regularly goes missing to return in the following day. Due to her age she is of concern due to her choice of people that she associates with. This is not something that we can control. Neither can we prevent her choice of boyfriend.” The IMR commented that “this entry highlights the impact the frequent missing person reports made by staff at the home had had on this supervisor’s perception of [the 14-year-old and 21-year-old male), to the point that potential risk factors and child protection concerns appear to have gone un-noticed.” This view is enhanced by illustrations that the more a child went and came back, the lower the level of risk perceived, while it is realised now that the opposite is the case and risk of CSE is very high with more episodes. One Inspector updated a report on a frequently missing child by writing: “Risk category changed from high to medium. Regular misper who is streetwise.” 5.95 Although Association of Chief Police officers’ guidance emphasised the need to ‘investigate’ missing persons, and that failure to do so may leave an individual at risk, the Police identified many situations where the Missing Persons report was seen as a process, not a need to investigate. This should not be read to indicate that police officers were not in most cases attending the place from where the child was missing, checking the children were safe on their return, and so on. One mother told the SCR about their politeness and apologies for asking the same questions and searching the house yet again. She also gave fulsome praise for the Police Missing Persons Coordinator. However, the volume of reports – not just for A-F – desensitised people to the risks involved. Also, resources would have been overwhelmed by actively investigating every episode. As a result of the learning from the experience in Oxfordshire, there are significant increases in staffing, which were not there in the time of this Review. Whilst it is not hard to understand the impact of complex processes, that ‘CSE’ was a barely understood concept, and that the hundreds of missing episodes could have had a 53 wearying and desensitising effect, it is also true that there were very serious descriptions of harm or potential harm to the children, which were not investigated. 5.96 All missing children were supposed to have a ‘safe and well’ check by the police and also an independent ‘return interview’. In the middle of the previous decade there was an agreement between the Police and the County Council that, to avoid duplication and so that the ‘right person’ spoke to a child, Care Homes would do many of the checks and interviews. The Police concluded in hindsight that, whilst this plan was understood, it reduced the opportunity for the Police to identify the possibility of a crime against the girls and lessened the potential linking of incidents. It also lessened the chance of another possible decision – that the Police should do all return interviews for a specific child owing to the risks involved. An example was given where there was an apparent risk to a child from a member of the children’s home staff. In another case, a Missing Persons staff member saw on a child’s return to a Children’s Home that the 14-year-old girl had a pashmina and silver ring from a named Asian man, and had mentioned that her abuse started at 13. This never moved from an intelligence report to any investigation or inquiry. 5.97 Paragraph 5.75 described how the Missing Persons Coordinator wrote in 2006 to a number of senior officers, including her DCI and some Superintendents, seeking more action on missing children, including the following: “The sad thing is, is that I’m not at all shocked or surprised at this lack of response as both girls appear to be labelled – repeat Mispers, Streetwise, too much trouble, not worth the effort of finding them as they will run off again... The staff at [the children’s home] give plenty of information as to the vulnerability of these girls and I don’t know what more can be done to ensure that these vulnerable Mispers are treated as a priority enquiry until one of them is found dead!... I know that you share my concern about these girls and I apologise for sounding off but I would like some help in both raising awareness and to try to track the people responsible for abusing these girls on a regular basis. Thanks for your time.” This did lead to some improvements, but more about Missing Persons organisation than seeing the wider picture the coordinator was trying to get across and the need for more investigatory action. 5.98 The DCI in charge of the Missing Persons Coordinator asked her and her Inspector to visit Lancashire as it was known that it was more advanced on missing persons. The report brought back to the DCI led to discussions with many agencies and to the creation of the multi-agency Missing Children and Families Panel, which went live in 2007. 5.99 At these Panels up to 38 children (August 2010) were discussed at such meetings. This was positive process but, as concerns in various agencies grew about CSE, other multi-agency meetings began and decision-making processes became unclear – who was ‘doing’ what and where authority lay. The YOS IMR says the meetings appeared “to be unclear about purpose and function: was it there to agree action plans, just report, or look for patterns of behaviour for individuals and or groups?” Oxford Health made a similar point: “During the time frame of the review there is no evidence in the clinical records that any liaison took place with staff regarding any missing episodes a child or young person had or that relevant information was entered on to the clinical record to alert staff. Interview with the Designated Nurse for LAC (who was a member of the Missing Persons Panel) clarified the focus of the meeting was to share information with partner agencies rather than individual practitioners.” This suggests that front line staff in health may not have been in the loop on missing children. 54 5.100 If anything, the duplication was a ‘good fault’, as it represented a drive from involved staff to finally understand and act on CSE, but the Police say it led to inactivity through assumptions that others were acting. The Police looked back at the membership, and while the Police and CSC attended nearly all meetings and the key children’s home (Home A) 88%, the PCT (which at the time provided the LAC health service) attended a third, and Education 6%. There was no attendance from the City Council and it is unlikely they were asked, nor from the voluntary sector. From November 2010 the Police provided CSC with daily lists of all children reported missing in the last 24 hours, up from weekly, in accordance with government direction. 5.101 The Detective Chief Superintendent now in charge of crime investigation says: “In retrospect it wasn’t ‘our’ problem. It was up to our local authority partners in CSC to solve it. So we set up the Panel in the hope we could find a solution down the safeguarding route... ‘control your children!’… but now we know that even when our partners pressed their ‘nuclear’ option... secure accommodation... even that failed to make the children safe as they often returned to the same areas and continued to be abused.” While this doesn’t do justice to the efforts of Police Missing Persons staff, it does show a frank recognition that there was insufficient understanding at the time. 5.102 The TVP Prostitution Strategy of 2008-11 was very clear. “The possibility of grooming must always be considered as part of the missing person risk assessment and investigation, particularly in cases of frequently missing young persons from care settings. Regardless of the background to the grooming process, and any apparent willingness to participate on the part of the child, any young person involved in, or at risk of becoming involved in prostitution must be regarded as a victim.” The associated standard and policing guidance document was equally clear: “Any missing person enquiry involving a young person, particularly those from care settings, should consider the possibility that the individual is being groomed or becoming involved in prostitution as part of the risk assessment and investigation procedure.” 5.103 Pressures in Children’s Social Care: The issues which follow relate more to CSC. Some are related to CSE itself and some to general performance which might have an undue impact on the very complex cases around CSE. This SCR makes a number of references to management arrangements around CSC, and acknowledges that most of the information has come from the way in which CSC has contributed frankly to the SCR. In some respects, it would not be surprising if there were some problems in the way services operated as reviews, including a Joint Area Review (JAR)20 (a multi-agency external review), reported some concerns in public reports. The author’s summaries below are aimed at explaining any problems identified, not the whole report. 2005: Children’s Services were ‘good’, although one team was struggling, with assessments behind time, and there needed to be more local placement choice of looked after children (LAC). 2006: Adequate. Too many children placed too far from home; reviews for children who are looked after need to be done on time; and the lack of placement choice on occasions puts children and young people in less appropriate placements. 20 Joint Area Review – Oxfordshire (Ofsted, April 2008). 55 2007: Adequate. Weaknesses with the referral, assessment and child protection systems. Increases in children being de-registered and re-registered (suggesting hasty de-registration). A need to improve the timeliness of LAC reviews. 2008: Adequate. Management of referrals and assessment raised for third time. Re-arranging processes had led to ‘referrals’ doubling. The JAR (Ofsted plus Police and the Healthcare Commission among others) also judged Children’s Services as adequate and had concerns about the public sector partnership overall, with QA underdeveloped and the LSCB needing to improve monitoring: “Insufficiently rigorous management structures and procedures within the partnership to ensure comprehensive management oversight of processes and outcomes.” 2009: The Annual Statement said, ‘Performs well’. There remained concerns about the timeliness of child protection inquiries, poor timeliness for assessments, and problems with prompt allocation to the long-term team. 2009: The unannounced inspection, which was reported after the 2009 Annual Statement, described 11 areas of satisfactory performance in the contact assessment and referral service, and five ‘strengths’ including the management oversight of complex cases. There were six areas for development including that some child protection inquiries had insufficient management oversight. There was one area for priority action: “Staff turnover within one of the contact, referral and assessment teams has had a recent but marked adverse impact on its performance, particularly on the timeliness and quality of assessments and management oversight of contacts held on duty.” 2010: Performs well over the year. The unannounced inspection had some concern about supervision and support for staff, and about overly optimistic assessments that needed more attention to the background circumstances. 2011: Good overall. Ofsted asked for more involvement from Adult Services in Child Protection Case Conferences, for Child Protection Plans to be improved, and all children to be interviewed after going missing. 2014: Child Protection, LAC services, and Management were all rated ‘good’, as was the LSCB. 5.104 Although the external assessments improved over time, the Director of Children’s Services (DCS) from 2010-11 identified issues with safeguarding, organisational structure and culture, capacity and quality of management, policy, performance management, business processes and systems and practice. The Director told the CSC IMR that there was a lack of performance information on which to judge services, and lack of compliance, for example with missing procedures. Her concerns were shared with the County CEO and Lead Members. 5.105 The years before the Bullfinch investigation had been one of considerable leadership change at the top of CSC, which had been merged with Education in 2006. From 2004-11 there were five substantive Directors, and three periods of interim directorship. Under the Director, the operational management of CSC was under a Head of Service. From a similar period (to 2012) there were four Heads of Service and at least seven spells of interim leadership. However hard anyone tried, this degree of change would have an impact on consistency and 56 clarity of direction.21 This also applied to the Safeguarding Board. For example, between June 2006 and March 2008, before the first Independent Chair was appointed, six different Council officers chaired meetings of that Board. As seen at the end of that period, the external JAR inspection said there were “insufficiently rigorous management structures and procedures within the partnership to ensure comprehensive management oversight of processes and outcomes” (a responsibility of course shared with its members from all other agencies). 5.106 Three former Directors, speaking with CSC for this SCR, found (to one degree or another) Oxfordshire CSC to be insufficiently well organised, weak at performance management, inclined to overrate its own performance and resistant to change. It was also commented that if CSC did not do well on any national performance indicators, the view was always that the indicators were inappropriate. One “felt the culture… was really trying to avoid the issues and pretend they weren’t there and no sense of urgency, that people were not open with me…” Directors felt the need to address some of these issues vigorously and this was at times seen as unsympathetic or over-firm leadership. The merger with Education also had an impact, with interviewees saying that CSC was the poor relation in terms of resources, and some staff saying that having no Director until 2010 with a social work background was not helpful. (Education interviewees also found this period difficult.) One CSC Head of Service said that not having a social work professional as line manager meant that one did not get professional supervision, or professional challenge. If this contributed to the lack of escalation to the top described earlier, that would not have been appropriate. 5.107 There were recurrent financial challenges impacting on, say, placement budgets but that is far from uncommon in local government, and new resources were successfully sought by the CSC Head of Service in the process described in the Cabinet paper below. 5.108 The SCR is not suggesting a direct connection between the delayed identification of CSE and the tensions and changes within CSC, but that it must have been harder for such a difficult topic to get the right attention with so much else happening. 5.109 Another issue may have been a new 2006 CSC strategy, which seems laudable but may have had unintended consequences. The model is not ideal for dealing with CSE where consent in the victims is eroded, and CSC and others need to take tough decisions to protect the children regardless of a child’s, or at times their family’s, wishes. For children tied up by CSE, the concept of ‘choice’ is not a real one. It also, in a quite unintended way, kept focus away from the non-family perpetrators by its (otherwise praiseworthy) focus on the family. A 2006 Council Cabinet paper22 said: “A key recommendation concerns the establishment of services and decision-making structures that replace the existing, professionally-dominated models, with mechanisms that enable and empower families and kinship networks to find solutions for, and meet the needs of, their children: the role of the public services becomes that of supporting families to take decisions and make plans for their children, ensuring that through such an approach children are better safeguarded and enjoy better outcomes as a consequence... Such an approach has a strong research and evidence base to support that outcomes improve, that families can and do make safe and secure arrangements for their 21 The Association of Directors of Children’s Services in its DCS analysis March 2007 – March 2014 reported that, in that seven-year period, 63% of authorities had the three DCSs that Oxfordshire had. The average tenure of a substantive DCS nationally was only 32 months. 22 External Review: Children’s Social Care Service and Strategy Action Plan (Oxfordshire County Council Cabinet, 11 November 2006). 57 children, and that numbers in the Public Care and formal child protection systems fall as a consequence of child-focused, family-centred practice and management models.” This may also give context to the philosophical approach to decisions about accommodating teenagers. 5.110 The same Cabinet paper, describing the position from which improvements were to be made, said that Oxfordshire was a low spender on CSC services, in the bottom quarter nationally although overspent, (i.e. underfunded). It was 132nd lowest of 150 authorities nationally, and the number of social workers was the tenth lowest in the country, with 14.7 per 10,000 population compared to 27.2 nationally and 19.1 in the most comparable authorities. 5.111 Supervision: Anyone working on abuse needs to be supervised so their work is supported, reviewed, and challenged. This is because working in such an emotive and at times scary way increases the chance of objectivity being weakened, or finding judgement is affected. One learning point from CSC said: “In most cases supervision took place at reasonable frequency although one manager did not provide supervision. The quality of supervision was generally poor with the focus being on updating the manager and checking that processes such as reviews were being completed in timescale. There is insufficient evidence of managerial decision making and little if anything to show that supervision was focused on reflective practice.” These cases were so hard that they needed the very best supervision. The Police IMR also points out that their supervisory processes were not always robust around cases like those in this Review. 5.112 Working with the parents: Social workers (and other professionals) found dealing with the parents very hard. This is not unique and is challenging everywhere. This took a variety of forms which CSC has identified in its own review. In two cases it appears that decisions were made to reduce the risk status around Child Protection planning because of strong parental opposition, when retaining the higher status may have been in the child’s best interests. With another child, a case was (in the current opinion of CSC) wrongly closed as a mother would not cooperate. One parent was not allowed to attend LAC reviews “as a result of... abusive and threatening behaviour”. In another case, workers could not visit alone owing to aggression. CSC concludes that this did impact on professionals’ ability to work with and plan for the child. Not gaining cooperation limited the ability to conduct assessments that would illuminate the situation. 5.113 The SCR author, from the family interviews and detailed IMRs, wonders whether the dynamic was more subtle than this and, just as language suggested that the children were the author of their own downfall, workers came to see some parents too as partly responsible for the mayhem actually created by the abusers. In a multi-agency meeting in 2006 discussing two children, a CSC worker is recorded as saying that the father of one “is obsessed with finding her when she goes missing”. The author would be worried if any parent was not obsessed with finding a 13-year-old girl who has been subject to rapes, excessive drug taking and alcohol, or who was running from Council Care. Later the minutes say that “there was a discussion about the parents who moan about social services and police and that (the child) does this as well… her behaviour is a reflection of her parents”. The parents’ ‘moans’ were about the public services not seeming able to assure the safety of their daughter. The child had gone missing from Council Care 12 times in the 10 weeks before the meeting for a total of more than 26 days. 58 5.114 ‘Professionalism’: The girls to whom the author spoke acknowledged just how difficult they were with professionals and did not think the author should disguise this. They would not deny that they gave staff (they were talking mainly about social workers, but also the Police) a very hard time, but they said the more someone acted like a ‘professional’ the more they found it difficult to relate, and the less likely they were to disclose. They talked of staff coolness, a dispassionate approach, or not being prepared to talk about themselves, and about a sense that they did not feel they were being related to as people. In contrast, they said that unqualified staff were more down to earth, prepared to act as if they were on an equal footing, and would share something of themselves. Of course, being objective, measured and preserving professional boundaries is the basis of being professional, but it seems that with these girls (who had more dealings with adults than most, even if inappropriately) needed someone more ‘ordinary’ to stick with them. The professional approach, which cannot in itself be criticised, may have inadvertently acted as a barrier. (This seems to be different now, see current quotes in 4.34 onwards.) 5.115 Some staff understandably found it hard to stay dispassionate in face of behaviour that they saw as at least partly self-determined, frustrating and self-defeating. Some girls told the author of demeaning comments by some police officers (‘snide’ said one victim) and these again acted to prevent trust. It was interesting that secure accommodation staff (who almost by definition are used to the most difficult children) were praised by the girls for remaining polite and nice however they behaved 5.116 It is important when reading the above to consider the girls’ views in the context of most staff members investing a huge amount of attention and care into what they did, in very difficult circumstances – even if those efforts were not always effective. 5.117 Looked After Children processes: Five of the girls were accommodated in the Looked After system at varying points. After 2005, Oxfordshire had an increasingly lower proportion of children in care. In some respects this might be a good achievement but CSC has identified that, in the mid to late 2000s, there was a prevailing culture at senior operational manager level described by staff as contributing to the IMR. Various panels were put in place to gate-keep entry to LAC status, and many staff told the IMR that when seeking such a placement they felt ‘attacked’ or they were told there were no placements with nothing else being offered. One manager said, “I started to go with social workers to protect them.” The figures do show a small reduction in children looked after in 2007 and 2008, but a big rise in 2009, so there is little evidence of policy induced drops in placements. (By 2011 Ofsted was praising the decision-making process around placements.) 5.118 In relation to the reported discouragement of placements, the County Council Legal IMR said that whilst to that point social workers had unfettered access to in-house solicitors to discuss risks and justification for statutory action, the clamp down on placements led to social work being stopped from direct access as legal services was seen as a source of encouraging care proceedings leading to additional requirements for accommodation/placements. A Panel was instituted and, although Legal say that in most cases social work managers and lawyers agreed, “… such formality… may well have meant that legal advice was sought late on in the working of a case when earlier advice might have led to less delay and a more informed decision”. This IMR, and CSC’s, also said that the use of voluntary receptions into care, as opposed to Care Proceedings (particularly when the focus was trying to maintain parental cooperation and engagement), “resulted in a weakening of robust long term planning”. The 59 CSC IMR identified that at the time there was no process of performance managing decisions made in legal planning meetings, so if a conclusion to take certain action was not implemented it might not be picked up. 5.119 A senior manager at the time says that the stance on placements (which he saw as getting the right placement for a child) was not only to address serious financial issues, but also because being accommodated did not seem to benefit all teenagers, and there needed to be a rigorous decision-making process that examined all alternatives to residential care. The manager told the SCR he was committed to finding creative alternatives to residential care and implemented an innovative scheme to help teenagers. To some extent the manager may have been right as the victims in this case were not protected as a result of being in Care, but the CSC IMR concluded that the “unintended consequences of attempts to manage pressure on budgets and to reduce the numbers of teenagers in care and the culture brought by senior managers meant that some of these very vulnerable girls were left in unacceptable family situations for too long”. There is some evidence to support this, but more from trying to follow good principles about supporting families and trying to avoid residential care if possible than any thoughtless approach. However, it is clear from the IMR that there was some tension with the management approach, tension between social workers and those managing placements, and limited choice of where a troubled teenager could be placed (including inappropriate co-placements with other girls who might influence each other and increase risk). CSC told the SCR, “There was a lack of effective strategic planning as to how the local authority would meet its sufficiency duty and place looked after children close to home. This resulted in ad hoc placements which were not always matched to the child’s needs and where the quality was uncertain.” Several of the girls were placed in distant homes, for example in Devon, Cheshire and East Anglia, and it appears they were not safe there either. One girl was trafficked several times from a Devon home, and according to a parent had the same staff attitudes from residential staff and Police, which suggests again that Oxfordshire was far from unique. 5.120 Caution needs to be exercised when considering the above. The girls appeared to be just as vulnerable to the abusers when in residential care, and at least one parent thought that, for all the struggles, the daughter was safer at home than in residential care. It is also, sadly, the case that three of the five girls who were looked after made allegations of sexual abuse by carers whilst in care (one was before she was living in the County). One of the children may have been the victim of two different men within Care. As CSC says, “All three of these girls had been or are suspected to have been sexually abused within their birth family before becoming looked after and it is very worrying that they then suffered abuse when they should have been safe in care”. It is interesting that investigations into these concerns showed similar patterns to allegations against the exploiters: allegations made and withdrawn, sometimes made several times over years, sometimes the investigation was poor. With a recent concern the author has seen evidence of a very thorough assessment of risk by the Council. 5.121 There was also concern about one private children’s home (long since closed) where it appears there were serious problems concerning the quality and training of staff, poor boundaries between staff and children, and a recorded instruction to staff not to share information about the girls with social worker or parents. Ofsted has confirmed to the County Council that appropriate safeguards have been put in place to identify any inappropriate future applications to lead care establishments. Despite the very high levels of going missing 60 from Home A, this in-county home was generally praised by the IMR for its care, effort and collation of information about predatory males. 5.122 Another issue was the review/plan for Looked After children. CSC says that LAC reviews tended to be planning forward, and missed the opportunity to re-assess risk by piecing together prior patterns of behaviour or harm. “The overall quality of reviews was variable. Sometimes there was a failure to consider the presenting concerns, including absconding, allegations of rape and sexual assault, inappropriate calls to the homes etc. The Independent Reviewing Officers interviewed as part of this review have explained that the LAC review is seen as ‘looking forwards’ not backwards and this results in a failure to undertake a meaningful review of the child’s placement and whether and how their assessed needs are being met.” Oxford Health said that Health staff contributing to LAC reviews were not invited to review meetings, so limiting the interchange of information between professionals, and that Health staff might do assessments with little knowledge of preceding history. 5.123 The Council Legal Department submission to the SCR points out that the legislative framework with regards to secure placements (under Section 25 of the Children Act 1989) creates significant practical difficulties for those responsible for the children. One of the main grounds for such secure accommodation is that the young person has a history of absconding and a likelihood of absconding and that when absconding they are likely to cause significant harm to themselves or to others. However, once a person is securely accommodated, the immediate risk of absconding goes and through a good response to any therapeutic input they may be able to evidence a reduced risk of significant harm. These restrictions on liberties are subject to stringent review with a strong independent element, and if the grounds are no longer met the young person must be immediately released. The focus, says Legal, is therefore on the child’s current behaviour but, of course, that creates difficulties in relation to assessing the risk and likelihood of absconding from other types of placements. Cooperation and becoming more settled might be seen as a positive development of the therapy but might actually lead to the risk of premature discharge. Frequent returns to Court can also cause destabilisation within the placement. 5.124 The SCR heard that reviews of children in secure accommodation did not include wider plans for disrupting or stopping the exploitation from which they were locked up for their own safety, so nothing changed on discharge. The absence of any clear purpose and outcome of such a serious placement was not set out, so it became hard to justify its continuance. 5.125 One of the children was adopted in Oxfordshire after being placed by another authority. When there were issues (ten years ago) that needed dealing with about that child and family, there was a long debate between the authorities as to whose job it was to respond or to fund care. There was an incident where the child was found by a parent dishevelled, partially clothed, drunk in a room with seven adults, and later, after a brief spell in a police station until sober, taken by the mother to hospital (and admitted) with after-effects and injuries. The chronology suggests that debating which authority should be doing what took energy that might better have been used inquiring into what happened to her. This was distressing for the family concerned and did not get relationships within Oxfordshire off to a good start. Interestingly, the police made no inquiries as to what had happened, and when the child was admitted to A&E two weeks later complaining of assault, no link was made to the recent inpatient spell and no referral was made to Social Services. The County Council told the Review they accepted the case, so that the child’s needs were met. 61 5.126 The Children and Families Court Advisory and Support Service (Cafcass), which provides independent support to children going through various Family Court proceedings, also found in its own review that its staff had a similar lack of knowledge about CSE and the erosion of consent. Signs that would now be seen as evidence of likely abuse were not seen as such and there was insufficient discussion of child protection issues with supervisors. 5.127 General Practices involved had little knowledge about their patients in the LAC system. The CCG IMR said, “For all the girls in care, except (one), the registered GPs never knew anything about them. They had no background information about why they were in care, who had parental responsibility, no information about their needs and no important contact details, like the name and phone number of their social worker. This could lead to less than ideal care.” The Health Overview noted the following having looked at all the Health IMRs: “Whilst the statutory assessments were happening, the health review has identified them occurring as single episodes and there being a lack of continuity of care following these assessments. There was no identified health professional that knew the child in a holistic way and co-ordinated health care or followed up on needs identified within the assessments. There also seemed to be a lack of multi-agency working at reviews with school health nurses not being involved in LAC meetings. There was some involvement of CAMHS with LAC reviews, when they were involved but many reviews were found to involve no health professionals.” 5.128 Assessments: As well as assessments whilst Looked After, there were of course many assessments and plans for children living at home. The CSC IMR has looked at them all and, bearing in mind some are a decade old, found that, linked to weaknesses in supervision and management decision-making, they did not make effective use of Child Protection planning or legal proceedings to bring about improved safety for the children. Social workers showed commitment and care in their dealings with young people, but plans were of limited quality, with drift, not changing direction with information about risks that were external to the family, nor leading to wider inquiries or the coordinated engagement of police. 5.129 The County’s Adult Social Care service was also involved with one family which has a wide range of problems. Details are not given to preserve the identity of the family concerned. Although in the same organisation, its IMR described how at the time (many years ago) paper files in CSC meant that progress on a child could only be tracked through personal contact with other professionals, and that case conference minutes would be too late to serve an updating purpose. It also recommended a single ‘case coordinator’ when a case involved two or more County departments. 5.130 Use of Child Protection procedures: Throughout the pre-Bullfinch period, IMRs identify that there was a patchy use of Child Protection procedures. There was a period when, even within the Police CAIU, what the girls were experiencing (before the full situation was known) was seen as not really for ‘Child Protection’ as it was occurring outside the family. The lack of Section 47 inquiries into the potential offences against children as a result of ‘crime’ not being properly identified, or a sort of tolerance developing to what was happening, or the notion that the girls were the initiator of their abuse led to relatively few case conferences, and indeed not many ‘strategy meetings’. These statutorily backed meetings are supposed to be held (to use words in 2006 guidance) “Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm, there should be a strategy 62 discussion involving LA children’s social care and the police, and other bodies as appropriate (e.g. children’s centre/school and health), in particular any referring agency. The strategy discussion should be convened by LA children’s social care, and those participating should be sufficiently senior and able, therefore, to contribute to the discussion of available information and to make decisions on behalf of their agencies.” 5.131 Its purpose included “to share available information, agree the conduct and timing of any criminal investigation, decide whether a core assessment under s47 of the Children Act 1989 (s47 inquiries) should be initiated, or continued if it has already begun to plan how the s47 enquiry should be undertaken (if one is to be initiated), including the need for medical treatment, and who will carry out what actions, by when and for what purpose, agree what action is required immediately to safeguard and promote the welfare of the child, and/or provide interim services and support. If the child is in hospital, decisions should also be made about how to secure the safe discharge of the child”. 5.132 The Police can only identify around 20 such discussions across all six children over many years, ranging from none to eight per child. None made any direct reference to CSE for reasons discussed at length above. It is clear now, although not always recognised at the time, that there were many more occasions when there was reasonable cause to suspect the presence or likelihood of serious harm. The Police give several examples where there was no strategy discussion (eg after S46 Police Protection Powers were used) and no Section 47 joint inquiry with CSC, including an extreme example, ten years ago, when a child of 15 said she was raped (by a man later convicted in Bullfinch). There was a criminal investigation, but one can see from the previous paragraph that without the strategy meeting the degree of joint-ness, information sharing, and obtaining or a joint plan of action is severely limited. There were a several ‘professionals’ meetings’ which discussed a number of children together. These were held for the best of reasons, and were part of the movement that eventually led to the true picture of local CSE being recognised, but although they were sometimes called strategy meetings they were not. They were often not minuted. They often led to confusion about what was decided and who was responsible for actions, and confusions with other meetings discussing multiple children, such as the Missing Persons Panel. CSC has found that even when there were minutes they were not placed on each child’s records – showing a blurring of meetings about an emerging pattern of abuse and decision-making meetings. 5.133 Only half of the six children were made subject to a Child Protection Plan (formerly known as ‘on the register’), and CSC believes that on two occasions “child protection processes were not used because of the hostility of the parents”, which does not seem to be child-focused decision-making, but does illustrate the challenges faced by staff. CSC says that “professionals became aware that the parents were failing to report the child missing but this did not trigger a strategy meeting to consider the risk and implications and how these should be addressed with the parents. This failure to report should have been seen as a safeguarding issue and the appropriate child protection processes should have been triggered.” Those who were on a plan were so for reasons other than the CSE, but when events happened that were typical of what is now understood to be grooming and exploitation, plans were not changed. “Child protection processes were ineffective in protecting the girls from CSE because CSE was not recognised as a safeguarding issue and so not included in their child protection plans. Since 2013 there has been a child protection plan category ‘at risk of CSE’ which was not available to workers during the timescale for this review.” 63 5.134 One of the benefits of being on a Child Protection Plan is that details are usually kept in A&E departments, and attendance can trigger more rigorous scrutiny or interagency checks. Lists of Looked After children are not kept by hospitals (although a call to CSC would discover LAC status). 5.135 Minutes and meetings: For both IMRs and this SCR the collation of minutes (a key record of decisions) has been a hard task. The SCR has looked in particular at those meetings called about multiple girls or to get more strategic interest. A number of meetings were not minuted or, if minuted, noted in a rather informal way. It was hard to work out where such meetings fitted into decision-making structures. Some meetings changed titles, and others were assumed to be ‘strategy meetings’ when they were really something else. There were indications of delays in circulating minutes, and the Police referred to a recent inspection where their files could not be updated promptly for decisions as minutes were late arriving – so it may still be an issue. The lack of clarity around minutes did not help the shared understanding of growing concerns. 5.136 Donnington Doorstep (DD): This is a voluntary organisation that worked with several of the girls and with others who have been exploited or at risk of exploitation. It has provided a wide range of support services for children, young people and families since the 1980s. It started to identify CSE in 2009 and more recently has provided specific services in support of children vulnerable to CSE. It worked with two of the six girls (not specifically for ‘CSE’) whose experiences illustrate this SCR, and had second-hand knowledge of a third through a parent who assisted the organisation. It played a significant part in raising concerns about the emerging picture that was finally recognised in Bullfinch. One of the features of a voluntary organisation is that it is not an organisation with statutory powers or duties, and so has a different relationship with its clients. This throws up issues of confidentiality, what to report, and what it should be told by other agencies. 5.137 An example is that on a number of occasions DD discussed very worrying concerns with CSC on a ‘no names consultation’ basis, as was allowed by multi-agency procedures, to enable a discussion without having to make a ‘referral’. On one occasion it was recorded that this was due to the relationship between one child and DD being the only protective factor. The author agrees with the CSC IMR that such a process is risky and inappropriate. In this case, although very well intentioned, it meant that the statutory agencies could not either add the information to what else they held, or intervene. To some extent, the hesitation about being open is the same as seen in the girls themselves – being open is very risky without a guarantee of protection and abusers being halted. 5.138 DD did pass on much information to Police community support officers and social workers, and participated in many meetings. It experienced difficulties in tracking through decisions made, and frequently received no minutes of meetings about children. (It is not clear if this reflected a general weakness in minuting or something specific to DD.) It also found different meetings uncoordinated or not linked, which was also mentioned by the Police. 5.139 School-related issues: Education reported to the SCR that, “The reality is that the secondary educational experiences of the six girls were in the main poor. They appear to have been responded to either through detention or exclusion and had long periods of absence from school. Alternative provision was limited, with little evidence of cross-checking against alternative provision registers and school registers, leaving young people vulnerable as 64 schools were not aware as to whether they were actually attending alternative provision.” It also said that many staff saw the period after 2005, when Education and CSC were theoretically merged but in their view operating separately, as one of low morale and ‘chaotic reorganisations’. The IMR said that before 2008 there was view that the “educational needs of Looked After Children (LAC) were just not seen as important as there was so much structural and leadership change”, and that “from 2008–2010 children’s homes’ response to home tuition was not consistent”. This may not be directly related to CSE but if it had been better could have contributed to the alternative to the groups being a little more attractive. 5.140 As with other agencies, Education says that its staff, including its Social Inclusion Officers who advised on children likely to be excluded, had no real understanding of CSE. Exclusion decisions were based on children’s behaviour and attainment issues rather than wellbeing, and Heads who contributed to the Education IMR said they still see this as the national agenda. It is not surprising, given how all the other professions were seeing the girls’ behaviour, that education professionals also saw the solutions as lying with the children (or excluding them), or pressing the parents to improve their children’s attendance, rather than seeing the girls as victims. 5.141 The Education IMR described how a panel determined alternative arrangements after exclusion, but if the exclusion happened a day after a panel, nothing was done until the next panel. Now alternatives for Looked After children are planned promptly but, in the past (and all of A-F required alternative education provision), they “often had to wait some time before it was provided. Some of the parents or carers of the girls were at times left trying to negotiate provision and appeared to get caught up in the administrative processes and bureaucracy of meeting thresholds and choosing from the limited range of provision on offer. This was particularly evident for [three of the girls] when they were returning from residential or secure placements to mainstream school.” 5.142 Education says that, at the time (but now improved), the transfer of education records between schools was poor, which would have affected these children more than most because of the moves and exclusions. In another administrative issue, children could be recorded as present if they were known to be receiving alternative education elsewhere, but reported that there was no real system to be sure of actual attendance elsewhere, so absences could be missed when considering a child’s progress. Like Donnington Doorstep, schools used the no names consultation process, and the Education IMR says that staff found this confusing, and actual referrals were ‘low’. 5.143 It summarised the position before Bullfinch: “At no time did it appear that professionals were really aware of the increased risk and vulnerability to CSE that being out of school posed or the implications of delay in finding alterative provision. At the same time, it has highlighted that the level of disruptive behaviour that the girls mostly displayed was something that the schools were at a loss to deal with and the support available to them was minimal.” 5.144 Drug and alcohol issues: Drug and alcohol services were provided by a range of NHS and voluntary organisations. Specialist services were provided to a relative/s of three of the children. The use of alcohol and drugs, initially as a gift, then to weaken the resistance of children, and probably taken thereafter to anaesthetise their trauma, was a common feature of the exploitation. One girl who was being helped at 14 by a specialist service told of daily cannabis use, cocaine at parties, and drinking up to forty five (45) units of alcohol in one night. 65 She also talked about her 19-year-old ‘boyfriend’. Workers tried to speak to the CSC family support worker (who had referred the girl with reference to CSE) a number of times without an answer or call back. The IMR said that the drugs worker should also have found out more about the CSE before seeing the girl to aid the forthcoming conversations. 5.145 The Drug and Alcohol IMR author, from scrutinising the combined chronology, points to the lack of referral to specialist services despite drug and alcohol use/misuse being so frequently referred to. “Even when a social care or health record talks about excessive alcohol use, or worrying use, it is not followed up with an action to make a referral to drug and alcohol services or to work with the young person around their use. This suggests many missed opportunities to support and advice the girls about the risk associated with it, and to get them support from appropriate services.” The Oxford Health IMR says that Child Mental Health Services should have taken more initiative about drug and alcohol use revealed by the girls, with referrals to specialist services and been more curious about the source of access to it given the girls’ young age. 5.146 Summary of health issues: A summary overview of health-related issues has been provided to the SCR by the Designated Nurse and Designated Doctor for Safeguarding. The issues of knowledge, language, lack of curiosity and so on are seen in health as in other sectors. There have been a number of references to Health IMRs above. The Health Overview identified that the degree to which patients were assessed to check vulnerability varied. For example, Genitourinary Medicine (GUM) used the Vulnerable Persons Questionnaire, but the Contraceptive and Sexual Health Clinic (CASH) did not (although they followed Fraser guidelines and service protocols). Records show that whilst the particular pattern of abuse in this Review was not known, there are many entries describing elements of such abuse. The Overview also pointed out that there a multiple of access points for confidential Sexual Health Services, so accessing one of them might remain unknown to others or mainstream health services. 5.147 Health notes recorded being told by girls of pregnancy terminations, but none had a termination performed by services commissioned by the Oxfordshire NHS (unless with false names). The complexities of information sharing across multiple health services was described in the Health Overview. “The review of health information demonstrated that the GP record was not a repository of all health information and emphasised the need for dialogue and better sharing of information by all involved in a child’s care to ensure understanding. Services did not consistently inform or involve the GP, often the information was incomplete or provided to them retrospectively. There were services such as sexual health services who only notified the GP when patients gave consent, resulting in gaps within the records. Communications from other professionals was generally only summarised and although added to records and reviewed by the GP who assumed that the professional sending the information was acting appropriately on it.” When other agencies are added into the matrix one can see the difficulty in getting an overall picture on one child. 5.148 The Health Overview summarised well a pattern seen everywhere else about not recognising the patterns of abuse, and added how symptoms rather than causes were the focus. “Health care staff recognised unusual and challenging behaviours that were beyond normal parameters but did not see them as indicators that raised concern about CSE. Managing behaviour changes when identified was found to be an area of challenge for health care staff. In some situations the behaviours were treated as the diagnosis rather than as a symptom 66 e.g. PTSD. Interventions and treatment often related to resolving the behaviour not asking why the behaviours were occurring.” 5.149 Taxis: Oxford City Council is the licensing authority (although national rules allow someone licensed elsewhere to operate anywhere). The Review understands that one of the Bullfinch defendants held a licence for a year, but not at the time of Bullfinch. No drivers licensed elsewhere have been implicated. There have been concerns about links between the perpetrators and certain firms, but no evidence about this was presented at the trial. If a licence holder is arrested for a sexual offence there is Police-City liaison and the driver suspended. The City says that to date there has been no conviction of a named licensed driver. From June 2010 to April 2014 there were nine complaints about sexual assault, all but one by adults. In four cases, the driver has not had the licence re-issued, but in five cases the licence has been reinstated after no prosecution or acquittal. The City’s well-regarded practices on taxis were described in 4.27. The Police told the Review that recently a taxi driver drove a girl to a Police station, worried that she was being sexually exploited, which they said suggested the training was effective. 5.150 The whole multi-agency team: Many illustrations in this section describe issues which are within one agency or profession, but in practice success with such complex cases comes from the whole group of professionals or other staff, each doing their bit. The girls might be involved with social workers, police, doctors, sexual health clinics, voluntary organisations, mental health services, schools, and so on. There is much focus on Police and CSC in this Review, but for cases of this complexity, unless every agency plays its part sharing a similar approach to and understanding about children at risk of CSE, the work of those agencies with the statutory powers to intervene will not be effective. As the 2009 statutory CSE guidance says, “Safeguarding and promoting the welfare of children and young people in this context, like safeguarding children more generally, depends on effective joint working between different agencies and professionals that work with children and young people... Their full involvement is vital if children and young people are to be effectively supported and action is to be taken against perpetrators of sexual exploitation. All agencies should be alert to the risks of sexual exploitation and be able to take action and work together when an issue is identified.” 5.151 Ethnicity: Only one reference was made, either in family interviews or in agency evidence, to the SCR that suggested any reticence related to ethnicity. A parent told a police station about information provided by the daughter and queried why no immediate arrests were being made. The parent says the desk officer responded by saying that such arrests could not simply be made on such information and that the Police were also under pressure not to appear institutionally racist. (The incident is likely to have been around nine years ago.) No other information has come to this SCR to suggest that any processes of identifying CSE or taking action against it was delayed due to the ethnicity of the perpetrators. In 2,000 pages of IMRs, there is barely a mention of ethnic issues. 5.152 The frankness of the IMRs suggests that, had there been indication of any ‘go easy’ to avoid an appearance of racism, it would have been uncovered and reported. The SCR Panel (representing all involved agencies), when considering the draft SCR and this section, confirmed no knowledge of indications of perpetrator ethnicity dampening concerns about children. In subsequent similar operations to Bullfinch, both in terms of prosecution and 67 disruption, the perpetrators or alleged perpetrators have mainly been from BME groups, which would again suggest no holding back on grounds of ethnicity. 5.153 The Police IMR (in 550 pages), when referring to official records and family/staff quotes, does not use ‘Pakistani’ and, in a similar size IMR, CSC uses it nine times. This compares to 54 and 126 uses respectively of ‘Asian’. When referring to possible perpetrators, the Police IMR uses ‘black’ twice and CSC uses ‘black’ about 15 times. The Police say they would not use ‘Pakistani’, a nationality, in their reports, as the perpetrators of Pakistani heritage were of British nationality. It would seem that ‘Asian’ is the phrase predominantly used by professionals and victims in documents and interviews. The offenders of Pakistani heritage gave their ethnicity to Court and the prison as ‘Asian’. One of the others, who says he came from Saudi Arabia, described himself as ‘British Asian’. Whilst the terminology used is interesting, the author can find no evidence of ‘Asian’ being used to hide the predominance of Pakistani heritage involvement. 5.154 Summary: This section has described a multiplicity of reasons why CSE as in Bullfinch was not recognised for a long time after it had started to occur. An explanation does not, of course, make it ‘all right’. Agency work is appraised in Section 8. The issue is not only about how much agencies and professionals knew/understood about the Bullfinch type of organised exploitation by groups. The question is also whether they did well enough with what they did know was happening. 68 6 WHAT MIGHT HAVE BEEN KNOWN ABOUT CSE? 6.1 Introduction: This section looks at what organisations might have known about child sexual exploitation from guidance in the years before the Bullfinch investigation in order to help assess organisational action. There was much published from the late 1990s that might be deemed relevant to CSE. However, it was not specifically about the Bullfinch type of abuse, and was generally couched around ‘prostitution’. If ‘trafficking’ was used, it meant trafficking from abroad. The notion of sexual exploitation of young teenagers by groups in local towns was not something many people saw, or something of which they were even aware. However, although the labels were different, the signs of it were indeed covered by guidance over many years – but it was not to the forefront of thought in the public sector. This section also looks at how guidance was received nationally. 6.2 Guidance: The 1999 version of the statutory Child Protection guidance Working Together23 had only half a page amid its 128 pages on prostitution, other forms of commercial exploitation and pornography/internet grooming, but it did list some of the cornerstones of today’s management of CSE: - treat the child primarily as a victim of abuse; - safeguard the children involved and promote their welfare; - provide children with strategies to leave prostitution; and - investigate and prosecute those who coerce, exploit and abuse children. 6.3 In 2000, the government published, Safeguarding Children Involved in Prostitution: Supplementary Guidance to Working Together to Safeguard Children.24 It repeated the above bullets and again identified key ways of thinking which were missing in Oxfordshire before Operation Bullfinch a decade later. For example, “Although not always prominent or visible, children are involved in prostitution… It is a tragedy for any child to become involved... It exposes them to abuse and assault, and may even threaten their lives. It deprives them of their childhood, self-esteem and opportunities for good health, education and training. It results in their social exclusion. Children involved in prostitution should be treated primarily as the victims of abuse, and their needs require careful assessment. They are likely to require…in many cases, protection under the Children Act 1989… the vast majority of children do not voluntarily enter prostitution: they are coerced, enticed or are utterly desperate. We need to ensure that local agencies act quickly and sensitively in the best interests of the children concerned. It is important that proper prevention, protection and re-integration strategies are put in place to ensure good outcomes for these children. All services… should treat such children as children in need, who may be suffering, or may be likely to suffer, significant harm.” What the Oxfordshire girls were involved in was very akin to this; some were literally involved in prostitution and some were trafficked for sex. 6.4 In 2001, the government published a National Plan for Safeguarding Children from Commercial Sexual Exploitation.25 Again, it had many echoes of the current form of CSE. “The causes of children’s involvement in commercial sexual exploitation… cannot easily be 23 Working Together to Safeguard Children: A Guide to Inter-agency Working to Safeguard and Promote the Welfare of Children (Department of Health, Home Office, Department for Education and Employment, 1999). 24 Department of Health (2000). 25 Department of Health (2001), but jointly with the Home Office. 69 disentangled from the wider problems of poverty, family conflict and breakdown, child abuse, domestic violence and homelessness. All commercial sexual exploitation of children is utterly unacceptable. It takes away children’s self-respect and dignity. It exposes them to great danger and it takes away their childhood. Tackling this evil trade needs determination, clarity of purpose and an ongoing partnership between a wide variety of organisations in the public, private and voluntary sectors… The term commercial sexual exploitation is interpreted widely in this document to include the prostitution of children and young people; the production, sale, marketing and possession of pornographic material involving children; the distribution of pornographic pictures of children over the internet; trafficking in children; and sex tourism involving children.” 6.8 It also had guidance for ACPCs26 (the predecessors of today’s LSCBs): “… It also falls within [ACPC’s] remit to ensure that appropriate protective services exist to support children caught up in such exploitation or who have been abused… there is a need for the ACPC to raise awareness of the nature and scale of harm with agencies before taking action. Action is then best targeted simultaneously on the investigation and prosecution of abusers and the support of the children involved.” Note the emphasis on investigating the abusers, which was missing for too long. 6.9 The 2006 ‘Working Together’, in a document twice as long as its 1999 predecessor, again still had half a page on ‘children abused through prostitution’, but it did have a larger section on trafficking – largely about trafficking from abroad. In 2006, after ‘Working Together’ 2006 was published, the OSCB agreed ‘Guidance for Professionals Working with Sexually Active Young People under the Age of 18 in Oxfordshire’. This gave clear guidance on consent, and how to assess the risk to the young person, and included the following pointers which describe the process later identified on Bullfinch: The nature of the relationship between those involved, particularly if there are age or power imbalances… Whether overt aggression, coercion or bribery was involved including misuse of substances/alcohol as a disinhibitor Whether the young person’s own behaviour, for example through misuse of substances, including alcohol, places them in a position where they are unable to make an informed choice about the activity Any attempts to secure secrecy by the sexual partner beyond what would be considered usual in a teenage relationship Whether sex has been used to gain favours (e.g. swap sex for cigarettes, clothes, CDs, trainers, alcohol, drugs etc.) The young person has a lot of money or other valuable things, which cannot be accounted for Whether methods used to secure compliance and/or secrecy by the sexual partner are consistent with behaviours considered to be ‘grooming’ 6.10 If a young child “may be at risk of sexual exploitation through prostitution, a referral should be made to CSC (and if an emergency) the Police should be contacted immediately”. Oddly, this guidance, whilst having a ‘presumption’ of referral, allowed for a referral not to be made even if an under 13-year-old was having sex, but this is no longer in current guidance. Whilst the reference is to exploitation ‘through prostitution’, the bullets above describe exploitation in general. This 2006 OSCB guidance was very appropriate, and relevant to what the girls were 26 Area Child Protection Committee. 70 going through, but the links between the cases and what the guidance was describing were not made. 6.11 In 2008, the University of Bedfordshire published a government-commissioned paper, ‘Gathering evidence of the sexual exploitation of children and young people: a scoping exercise’. This could not have been clearer about the key principles of preventing, disrupting and prosecuting CSE which would be advocated today. It is unlikely that it was seen widely. 6.12 In 2009, there was major supplementary guidance to Working Together 2006 on child sexual exploitation – Safeguarding Children and Young People from Sexual Exploitation.27 This was the first guidance to use the phrase ‘child sexual exploitation’ and, like others in this section, described the sorts of abuse experienced by the six children in this SCR- other than the ethnic origin of the perpetrators. 6.13 There is very little missing in it from what guidance written today would say. It uses the definition of CSE still used (see 1.28 above). It refers to criminal groups. It emphasises the child-centred approach required of professionals and warns that professionals “should be aware that children and young people do not always acknowledge what may be an exploitative and abusive situation” and that “Sexual exploitation of children and young people should not be regarded as criminal behaviour on the part of the child or young person, but as child sexual abuse”. It describes how to manage individual cases, the roles and responsibilities of the LSCB and agencies (requiring an LSCB CSE subgroup and a lead professional in each agency),28 and has a detailed chapter on ‘Identifying and prosecuting perpetrators’. This described most of the techniques which came to be used in Bullfinch around disruption, evidence gathering, and so on. It is all there. 6.14 The 2010 edition of Working Together, the last before the Bullfinch convictions, required LSCBs to include in their annual reports (a statutory requirement) “progress on priority issues (for example, child trafficking, sexual exploitation and domestic violence)”. It also said: “Every Local Safeguarding Children Board (LSCB) should assume that sexual exploitation occurs within its area unless there is clear evidence to the contrary, and should put in place systems to monitor prevalence and responses.” 6.15 It also left little doubt that it was talking about the sort of abuse that came to be understood in Oxfordshire. “The guidance states that LSCBs should ensure that specific local procedures are in place covering the sexual exploitation of children and young people. The procedures should be a subset of the LSCB procedures for safeguarding and promoting the welfare of children, and be consistent with local youth offending protocols. The identification of a child who is being sexually exploited, or at risk of being sexually exploited, should always trigger the agreed local procedures to ensure the child’s safety and welfare and to enable the police to gather evidence about abusers and coercers… The strong links that have been identified between different forms of sexual exploitation, running away from home, group activity, child trafficking and substance misuse should be borne in mind in the development of procedures. These should include identifying signs of sexual exploitation, routes for referring concerns, 27 HM Govt, 2009. 28 It is an interesting illustration of the vagaries of national guidance that only two years later this statutory guidance ‘should’ had been downgraded by a new government to “the DoE can help LSCBs to consider if it is appropriate to…”. Tackling Child Exploitation: Action Plan (DfE, 2011). 71 advice on working with other professionals to disrupt sexual exploitation and support victims, gathering and preserving evidence about perpetrators, as well as how to deal with more complex issues such as those relating to the increasing use of the internet in sexual exploitation.” 6.16 On complex case management and trafficking it said, “Children do not have to be trafficked across international borders to be exploited in this way. There is evidence that some UK resident children, mainly young girls, are being groomed, coerced and moved around between towns and cities within the UK for the purposes of sexual exploitation.” (This was happening to some of the girls.) “Relevant agencies should remain alert to the possibility that this can happen, and work together to address it.” 6.17 The Police have identified eleven items of guidance on missing children from 1997-2010. In 2009, there was ‘Statutory guidance on children who run away and go missing from home or care’,29 which very accurately describes what was found in Bullfinch. “Grooming for potential sexual exploitation: In some cases, young people may run away or go missing following grooming by adults who will seek to exploit them sexually. Evidence suggests that 90 per cent of children subjected to sexual grooming go missing at some point. The supply of drugs and alcohol or the offering of gifts may be used to entice and coerce young people into associations with inappropriate adults. Both girls and boys are at risk of sexual exploitation. Looked-after children may also be targeted by those wishing to abuse and sexually exploit them, and encouraging these children to run in order to disrupt their placement is often part of this abuse. Young people living within residential care units are particularly vulnerable to being directly targeted in this way.” 6.18 In November 2010, there was some publicity (but not to the later Rochdale or Rotherham level) about the convictions of a number of Asian men in Derby and the associated SCR. The circumstances of the cases were very similar to what was happening in Oxfordshire. In early January 2011, The Times published a series of articles, which promoted significant media and top-level political comment, about the sequence of convictions in recent years, the overwhelming predominance of Pakistani heritage men as convicted perpetrators, and suggesting blind eyes were being turned. 6.19 In November 2011, there was a further government publication, Tackling Child Sexual Exploitation – Action Plan,30 which had strong ministerial backing. Although it mentioned nowhere that group CSE had actually been identified, there can be little doubt it was talking about the sort of abuse discovered in Oxfordshire, with strong messages for LSCBs: “LSCBs… have a central role in overseeing much of the work set out in this action plan. The University of Bedfordshire research, however, found that many LSCBs have not identified child sexual exploitation as a priority issue in their area… The Government believes that LSCBs will want to assure themselves that local services are based on a robust assessment of need in the locality, taking account of the statement in the statutory guidance that every LSCB ‘should assume that sexual exploitation occurs within its area unless there is clear evidence to the contrary’. They will also want to assure themselves that local services are designed and delivered effectively to tackle the issue where it arises.” The Oxfordshire LSCB had already set 29 Department of Children Schools and Families, July 2009. 30 Tackling CSE – Action Plan (Department of Education, 2011). 72 up its CSE subgroup, and Operation Bullfinch had already been underway many months when this came out. 6.20 In November 2012 the Office of the Children’s Commissioner produced “I thought I was the only one the only one in the world”: the Interim Inquiry into Child Sexual Exploitation in Groups and Groups, which LSCBs would have wanted to see as they contributed to the research. 6.21 Looked at now, there is little doubt that national guidance and reports across the early years of the 2000s, and especially around the end of the decade, were giving clear indications of the approach to exploitation, describing it well (even if in different words) and requiring action. The problem was that the guidance, especially that published more than two or three years ago, just did not have the required impact across the country – whether in towns that had a major challenge from CSE or other places. Subsequent inquiries by the University of Bedfordshire31 and the Children’s Commissioner found that only a minority of LSCBs had introduced key elements of the guidance. In 2013 (after Oxfordshire had successfully implemented Bullfinch), the Office of the Children’s Commissioner32 reported very patchy take up of the guidance. That suggests a problem across systems nationwide in grasping what was happening and needed, rather than individual failings – something about the process of issuing and responding to the guidance, and how guidance may not be absorbed if one thinks the problem described is rare and is occurring somewhere else. The notion that such widespread organisational poor response is down to most professionals or responsible organisations deliberately disregarding a known problem is not one the author finds credible. It seems mostly to be connected to organisations thinking such abuse happened somewhere else. 6.22 Even in November 2014, Ofsted33 was still finding that “Until very recently, child sexual exploitation has not been treated as the priority that events in Rotherham and elsewhere strongly suggest it should have been. As a result, local arrangements to tackle the problem are often insufficiently developed and the leadership required in this crucial area of child protection work is frequently lacking…” In Oxfordshire, there has been a very robust response since 2011 – see Section 4. 6.23 In addition to guidance, there were also prosecutions on CSE. Before the main Rochdale convictions brought CSE to un-missable attention in 2012, there had been some convictions in Bradford, Blackpool, Oldham, Sheffield, Blackburn, Rochdale, Manchester, Skipton and Nelson. None of these registered CSE in the national consciousness until, to some extent, the convictions in Derby in late 2010 and then very significantly with the main Rochdale convictions, which were in 2012. If anyone was aware of any of the convictions before the very end of 2010, they would have had the impression this was a ‘northern problem’. 6.24 The author recalls a common reaction to the 2009 guidance and requirements for CSE, which was outside most people’s area of knowledge: ‘who can we find to lead a CSE subgroup, who knows anything about it; group-related CSE doesn’t happen here, does it?’, etc. Any new large-scale requirement can be difficult for LSCBs, with actions having to rely on agencies volunteering time when they have numerous competing requirements. Independent Chairs 31 ‘What’s going on to safeguard children and young people from sexual exploitation?’ (University of Bedfordshire, November 2011). 32 If Only They had Listened: Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation in Groups and Groups. Final report (November 2013). 33 The Sexual Exploitation of Children: It Couldn’t Happen Here, Could It? (Ofsted, November 2014). 73 may only have half a day a week. It is likely that, in many areas, the assumption that group-related CSE was something others had led to insufficient attention being given. This assumption and reaction, while regrettable and wrong, is not the same as knowing about local CSE and not acting. This SCR tells of a small number of relatively junior staff in two or three agencies who began to see the risks and increasingly knew about CSE; the learning came from the bottom up and not down from leaders. It was the grassroots knowledge of vulnerable children by a small number of determined staff which eventually led to system-changing action. 6.25 In summary, two factors seemed to prevent the guidance being used in recognising and dealing with CSE before 2011. For many years, guidance, whilst describing the signs of CSE, did so in the context of prostitution and trafficking rather than the language of the group CSE later identified. But, anyway, the prostitution was not recognised either. Secondly, even when the guidance became more explicit, group CSE was thought of as something that happened somewhere else. Nevertheless, there was a lot in the guidance that would have been very helpful, and much of it remains very apt. 74 7 ORGANISATIONAL AND LEADERSHIP AWARENESS 7.1 Introduction: When there is a period when performance across agencies does not have the required outcome, it is appropriate to ask whether the leadership of the agencies was doing all it could, or whether it had knowingly not responded to CSE issues. This section will describe the level of knowledge organisations and top leaders had and, if they had little or no knowledge, why this was the case. There is no evidence of governing bodies in the major agencies being aware of the CSE in terms of organised grooming and exploitation by groups of Asian males until at least early 2011 (the year in which Operation Bullfinch was formed) and reasons for this are examined. This is different, therefore, from Rotherham, where the inquiries concluded that warnings had been disregarded at the top. The SCR benefited from detailed reviews of the national context in the Police and CSC IMRs, and the author also commissioned additional reports from each agency analysing what was known at their higher levels in the period under review, to which all responded. SCRs, especially those commissioned under Working Together 2010, are not ‘inquiries’, so rely largely on self-report, but the author’s own inquiries (which were responded to openly) have found no reason to challenge agency submissions. 7.1 Parts of this section may seem in places to be rather dense and bureaucratic, but the detail will aid professional readers who can see the impact of structures and processes on outcomes for children. However, it also sets out what was known about the children’s suffering. The section is structured as follows: The headline priorities for the Police and CSC Oxfordshire’s journey towards identifying CSE - The OSCB - The growing awareness in the County - The knowledge at the top of organisations - Operation Bullfinch Overarching comment 7.2 Priorities: Whilst the protection of children can always be said to be a ‘priority’, and there has been a major focus on child protection activities since Maria Colwell in the 1970s, that is different from saying the protection of vulnerable people was always in formal priorities set by government, and on which organisations and their leaders are performance managed. If an organisation does not meet those formal priorities (often known as targets), there are serious penalties to be paid. This point should not be exaggerated, as a hurt child is a hurt child whatever the target of the day, but as far as the Police and Social Services are concerned it is interesting to consider the issues for which they were under pressure. The author has looked at all Ofsted reports on Oxfordshire Children’s Services from 2004 to 2014 and the words ‘sexual exploitation’ do not appear until after the Bullfinch case. There is no evidence therefore that Ofsted was looking to see how the County was dealing with CSE, even after statutory guidance was issued in 2009. This suggests that the notion that it could happen anywhere so everyone needed to be well prepared was not one that was inspected in practice; rather, it was something that only happened in particular places. 7.3 The Police IMR does not hide behind the fact that sexual exploitation, or even protecting vulnerable people, was not a national priority during the pre-Bullfinch years and 75 acknowledges openly that many mistakes were made. Nevertheless, it does point out that the key aspects of performance on which TVP was being judged did not include an emphasis on vulnerable people. It describes how the statutory performance indicators in the National Delivery Plan 2006-9 were mainly about rates of acquisitive and life-threatening crime, gun crime and violent offences per 1,000 population. There was no mention of child abuse in the Delivery Plan. The IMR says: “The Home Secretary’s ‘National Policing Plan 2006-2009’ guided local priorities particularly in relation to their performance target” and described some local plans. “It is also notable that like the National Policing Plan neither child protection nor missing persons featured in the performance data produced for this document, suggesting at this time neither were seen as a specific [local] priority, something reflected across the Force.” 7.4 This does not mean that staff who were working on, for example, missing persons did not work extremely hard at what they were doing, but does indicate the challenge to devote priority time to activity that might prove lengthy – and often fruitless as investigations were unlikely to lead to convictions. There was, however, no evidence of a knowing decision not to pay attention to potentially exploited or otherwise vulnerable children because of priorities. Again, not using this as an excuse but to illustrate the context, the County Council showed the SCR how intensive the external performance management culture was with, say, in 2008-9, 115 different targets for children and young people that had to be accounted for – none specifically related to sexual exploitation and one for missing children. 7.5 Oxfordshire’s journey: This section goes into detail, as local agencies will learn from seeing how the knowledge developed in the uncoordinated way it did. There is no evidence that the overall position of readiness in Oxfordshire differed substantially from that in many other areas, but it is the case that from the mid-2000s there were girls (and more than A-F) who were sexually active with much older men, getting involved with drink and drugs and some associated crime, sometimes hurt, and often missing for substantial periods – so Oxfordshire may have had a greater chance than some areas to identify CSE. As will be seen, what is hard to explain is that, with many professionals very worried about the girls, with considerable resources being used to keep them safe (for example, in distant secure facilities) and ‘missing’ statistics which were unusually high, why the full picture did not emerge and the issue never percolated through to governing body level such as CEOs, Boards, or Committees. The ‘journey’ is described firstly by looking at the OSCB, which had a statutory oversight of child protection work, and secondly how things unfolded across the County over time. 7.6 The Oxfordshire Safeguarding Children Board (OSCB): The 2002 Oxfordshire ACPC (the predecessor body of the OSCB) procedures echoed recent national guidance and included “Entry into prostitution usually involves a complex set of factors often including a strongly dependent relationship with a coercer or an abuser. Helping a young person to leave prostitution will therefore be complex, involving winning trust and overcoming fear, and may therefore take time… Children and young people living in and leaving care, especially residential care, are particularly vulnerable and those who run away even more so. Joint local authority/police procedures must be followed when young people go missing and when they return.” 7.7 The first reference to young people involved in prostitution in ACPC minutes was in 2005, where it was agreed that police and CSC would work on ‘a piece of action research’. At the next meeting, it said that “a member of the CSC’s City team was working with the Police Child 76 Protection Unit to identify incidents of ‘sexual exploitation’ with a view to further analysis”, with the action allocated to the interim Head of CSC. The OSCB says there are no subsequent references to this. 7.8 In 2007, there were several mentions at the Board or its subgroups. In March 2007, the minutes of the OSCB (chaired by the CSC Head of Service) referring to its City sub-group noted ‘... concerns about 14-15 year old girls in relation to drugs/prostitution/going missing, a problem which seems to be increasing. It was agreed that the Board needs to address this. Action is in hand locally”. (At interview, the then City subgroup chair said that local action meant “We were dealing with the individual children’s cases and managing the risk”.) In May 2007, the OSCB Core Group (a subgroup which monitored OSCB business), chaired by the Head of Service for CSC, agreed to a future agenda item, the ”role of child protection process in protecting young people exhibiting risky behaviour (drug abuse, prostitution etc) for July agenda”. (At the next two meetings of the OSCB Core Group, discussion was postponed twice due to the absence of the Police member, with any references then stopping after August 2007). 7.9 Parallel to this, the OSCB City subgroup met in June 2007 and recorded “continued concern regarding cases of 14-15 year old girls exhibiting out of control behaviour and possible involvement in prostitution and drug use within Oxford”. There was a case discussion about two girls, one of whom from initials used was one of A-F. “… Police are feeling equally as ‘stuck’ as any other agency in how the negative influences for these cases can be addressed (i.e. Drug Dealing, Possible Prostitution, Missing Persons and high risk out of control behavior). Subgroup members agreed, at last meeting, that this required a wider/ joint response, but issues still appear to be being considered on a case by case basis. There is a serious concern that there is an organised abuse ring within Oxford and that a Complex (organised or multiple) abuse investigation should be considered”. 7.10 The action was for the subgroup chair, a CSC officer, to brief his two senior CSC safeguarding and quality assurance colleagues. There was no mention of this item at the next City subgroup meeting. There is no indication that a “complex abuse investigation” was held or actively considered. The Review understands that the County Head of Safeguarding wrote to social workers to try to obtain more evidence about CSE, but had a “poor response”, and it was not thought that complex abuse procedures should be implemented. There should have been follow-through to a formal conclusion. The point the subgroup minute made about things being looked at on a case-by-case basis, and it needing a wider, joint response, was exactly right and stayed the position until early 2011. 7.11 The OSCB, a week later in mid-June, had a verbal report of the City subgroup and minuted ‘There are concerns about a number of young women coming into contact with statutory agencies who may be victims of organised prostitution. (A CSC service manager) is pulling together what information is known with a view to making a judgment about likely connections and the need for these cases to be addressed other than on a case-by-case basis.” The minutes made no reference to its City subgroup’s view that “there is a serious concern that there is an organised abuse ring within Oxford and that a Complex (organised or multiple) abuse investigation should be considered”. There is nothing in subsequent minutes. The OSCB IMR says that, at the time, there was no process in place to pick up items that dropped off the agenda. 77 7.12 In September 2007, the OSCB City subgroup met again and, as mentioned earlier, the City Nuisance Officer and a colleague warned about the risks to children from massage parlours and reminded the meeting that his team was continuing to pass to the Police information about 14 and 15 year olds being seen in cars with older men. 7.13 No further reference to the mix of drugs/prostitution/young teenagers has been identified in OSCB and subgroup minutes until the Bullfinch investigation. 7.14 In September 2008, the OSCB’s Monitoring and Evaluation subgroup noted the increase in children going missing, and at its March 2009 meeting a member of the Missing Persons Panel said there were “no specific concerns”. That year, following a Joint Area Review34 (a multi-agency external review), an OSCB Business Manager was appointed full-time for the first time to address the deficiencies in business administration. The OSCB says there are several recorded minute entries about insufficiently regular or senior attendance leading to insufficient “promotion of child protection issues and disseminating information within their agencies”. (The March 2009 review35 of progress after the Joint Area Review rated the OSCB as good, as has Ofsted since then.) 7.15 The 2009 statutory guidance was not picked up in any meaningful way. The OSCB explained to the SCR, “From 2008 to 2010 there is an increase in the number of guidance documents raised at Board level, as evidenced by the Board minutes and associated papers. At the time the role of Business Manager… included producing an overview of recently published guidance and proposing recommendations to the Board for further action… this appears to have been left for the Business Manager to assign follow-up actions. There is no evidence these actions were arrived at in conjunction with the Chair… or any Board Member. This reliance on the Business Manager appears to have led to complacency amongst the members in challenging whether these decisions were the most appropriate ones.” 7.16 The Board members were not sent a copy of the guidance but alerted to its existence in a September 2009 agenda paper, which listed another 11 items of guidance from the previous six months. The recommended action in the paper was “OSCB procedures to be reviewed against guidance. Put on website”. The minutes make no reference to it, so one presumes the fact that it contained much beyond simply ‘procedures’ was not noticed by members or Board officers. In fact, nothing happened until the January 2010 OSCB meeting, when a ‘Sexual Abuse Mapping’ paper went to the Board. It said that the Oxfordshire Safer Communities Partnership had set up a Sexual Violence and Abuse Group to “drive forward the agenda”. Noting that a senior CSC manager had not been able to attend, the paper (which made no reference to CSE in the narrative) recommended that the OSCB “require that a senior manager from Children’s Social Care become an active part of the sexual abuse strategy group to ensure the needs of children are included in this strategy… This member to feedback to the OSCB on a 6 monthly basis the progress to date… ensure this member also pick up the work from the Government’s Guidance on Children who are Sexually Exploited…” A strategy was delivered for July 2010, but did not cover most requirements of the statutory guidance. 7.17 A senior safeguarding nurse on the OSCB told the Review that it was not that there was no consideration of CSE, but that it was “simply not believed to be a local issue”. 34 Joint Area Review – Oxfordshire (Ofsted, April 2008). 35 Final Evaluation of OSCB (DCSF, March 2009). 78 7.18 The Sexual Violence and Abuse Group to which the OSCB passed the statutory guidance was not actually part of the OSCB, but was under the Oxfordshire Safer Communities Partnership, another multi-agency partnership, facilitated by the County Council. This was not or not wholly appropriate as the guidance contained statutory requirements for the OSCB itself. 7.19 In January 2011, the OSCB Chair and Business Manager received from the chair of the Board’s City subgroup a City Council report on CSE. It was referred on to the Sexual Abuse Strategy Group (see previous paragraph) and seems never to have been put to the Board. The City report, which had been drawn up after surveying agencies’ knowledge of the signs of CSE in their work, summarised national guidance, gave the results of the survey, highlighted the shortcomings in local services, referred to the recent major CSE case and SCR in Derby (Operation Retriever), and made many recommendations. 7.20 It came from the City’s Drug Strategy Coordinator, but was the sort of report that should (under national guidance) have been prepared by Safeguarding Boards, or certainly given higher-level consideration. It was done because “In late 2009 concerns were raised in Oxford by a professional that young school girls had disclosed that they were in receipt of high priced gifts in exchange for sexual favours”, and it identified that “No data collection of children & young people who are 'at risk' or who are affected by sexual exploitation, No specific child sexual exploitation training for professionals, care pathways are generic and do not address specific concerns for children & young people who are being sexual exploited, and no specialist service who can offer support to those at risk, victims and/or parents/carer.” It was a useful review of national knowledge, organisational and training needs locally, staff perceptions of local risk from CSE, etc, but it did not identify the CSE as it was later understood. At the end of January 2011, the Drug Strategy Coordinator asked the OSCB City Safeguarding subgroup Chair if the report had gone to the OSCB Executive. The response was that it was understood the matter was to be put to an existing sexual violence group and asked whether the Drug Strategy worker knew the Chair of that group. “I will discuss with [the Business Manager] as you must be linked in!” 7.21 It was June 2011 before that report’s author joined the Sexual Abuse Strategy Group and the minute does not indicate that her report was received. In any case, this was not an OSCB subgroup. By this time, Operation Bullfinch had started, although few people, for reasons of operational secrecy, knew the details. In the summer, as a result of some knowing what was being investigated, the Sexual Abuse Strategy Group was disbanded and replaced by the CSE Task and Finish Group, which, this time, was a subgroup of the OSCB. Invitations were issued in August 2011 and it had met before it was formally approved by the OSCB. The City Drug Strategy Coordinator was a member. 7.22 It is clear that failing to follow or to follow fully the 2009 national guidance was initially widespread in England, and the OSCB did go through a period when it was less than thorough on CSE, with no strategic oversight of the topic. It was not that it was ignoring messages about local concerns, but that, other than in 2007, such messages did not get to the Safeguarding Board itself until 2011. 7.23 Some former top CSC managers were critical of OSCB organisation/proactivity in their interviews with CSC. Before 2008 there was no Independent Chair. Other than the very part-time Independent Chair from 2008, all LSCBs consisted only of the senior representatives 79 from each agency, and the critics were some of the most senior and influential members. This raises questions about how much members of the OSCB fulfilled their statutory duties as members. 7.24 Safeguarding Board Annual Reports were statutorily required from 2010-11. The first contained no reference to CSE, but did include an article about missing children by the Detective Inspector in charge of the Police CAIU. It did not refer to CSE being a possible cause. This may have been because Operation Bullfinch had just started and great discretion was being used until arrests were made. In contrast, the 2011-12 report has tackling CSE as a priority. There is a CSE subgroup. It identifies there is CSE in the County, reports a July 2011 OSCB conference on CSE, and announces the forthcoming CSE strategy and the introduction on the Kingfisher specialist multiagency CSE team. The then Chair said that “CSE has become a key focus for the Board…” 7.25 The growing awareness in Oxfordshire: This part looks at how awareness grew across the agencies working with the families. The detail here highlights not only great effort in some quarters, but also who knew what, and learning about inter-agency connections. The awareness in the County came from those who worked with these children and families or in their communities and who had a growing sense, despite the girls’ frequent denials and lack of cooperation, that there was something really awful happening. Many signs could have been seen, and the girls and families would at times give sufficient information for conclusions to be drawn. The headline milestones in the journey should not be taken to mean that nothing else was happening, as the 3,900 pages of agency chronologies testify. Many entries are the same event described by different agencies, but there would probably be up to 10,000 contacts and events. The momentum grew strongly in 2010 as various groups took the initiative, although not in a coordinated way, and staff who led those strands of discovery should be applauded for their determination and concern. 7.26 The paragraphs above on the OSCB describe some mentions of child prostitution from 2005, with nothing further on this or exploitation until 2007. However, there was growing awareness in 2005-6 of very serious cases and extreme behaviour associated with going missing, drugs, older men and prostitution that do not seem to have been addressed by the OSCB, its local subgroups or top managers – or, more accurately, not brought to their attention. With one of A-F, the following references could be found in her chronology of agency records in one period of less than three weeks in 2005. - 13 years old - Drug use – crack - Symptoms of cannabis dependence - Delivering cocaine/admits drug dealing - ‘They sprinkle coke on weed’ - Associating with ‘older inappropriate males’ - Not eating when missing - Frequently missing - Returns home dehydrated and in neglected state - Emaciated in police station - Mother complains over 3 weeks is too long to wait for a multi-agency meeting - Child left a note about 2 rapes – charges followed - Blood soaked jeans and underwear 80 - May have been ‘prostituting herself’ - Says she will be dead by 20 - Receives phone call with accented black man – she is in debt to men. Number given to police - Being driven in and driving cars - At risk of sexual exploitation - Sexually assaulted by 2 males 7.27 There was very considerable agency activity in this period, but one wonders if this case was typical of many and did not stand out, or was so extreme that it should have warranted very top attention. In the same year, there were concerns about at least three of the other girls around going missing, adult men, drugs, coming back from missing with money, etc. One girl was branded. Despite this, there was no recognition of a Bulfinch-type coordinated and wide-scale abuse. 7.28 In 2006, there was the abandoned trial when a child refused to give further evidence under tough cross-examination. There was also concern about the management of missing children, especially from Care, as seen in the plea from the Police Missing Persons Coordinator to her superiors up to head of Oxfordshire level in September 2006, and there were meetings about individual children with good level multi-agency involvement. This included a Police DCI-led ‘Tactical Meeting’ (which may in part have been a response to the coordinator’s email) with County and City staff present, as well as the private home where the girls were placed. It discussed multiple offenders described as a “paedophile ring” being arrested for offences against one of A-F. It was agreed that TVP would consult other forces about the subject in general and the child concerned (which led to the creation of the Missing Persons Panel). 7.29 The minutes show that, as well intentioned as the meeting was, much of what the child was saying was disbelieved, even though the notes showed that many signs of being abused were known. There was a discussion on using ASBOs and other control measures with “the males”. This indicates an awareness of the possibility of group exploitation in 2006. There was also a very high level of concern for several of the girls across 2006. This is discussed further under ‘Missed opportunities’ in Section 8. 7.30 In 2007 the OSCB, as described earlier, twice recorded concerns by its City subgroup. In June 2007, after concerns were raised about a possible ‘organised abuse ring’, the County Head of Safeguarding tried to find supporting evidence and decided not to introduce complex abuse procedures, it is understood because he thought there was insufficient evidence. At the end of 2007 a strategy meeting was held about one child and her involvement with an adult Asian male (referring to violence from a man later convicted in Bullfinch). A few days later, cross-references to other children began to emerge when, at a strategy meeting with at least CSC middle managers present (but no police), others in A-F were mentioned. The notes say: “Concerns regarding the association between a number of girls LAC/leaving care and adult men from the Asian Community”. Three from A-F were listed. The content of the meeting, although relating to different girls, was very similar to the meeting almost three years to the day later, which led to the first complex abuse meeting being called. It told of groups of men, sex with adults, drugs, drink, named men, and disclosures from a child. 7.31 A CSC chronology comment wondered whether this was the first strategy meeting where multiple victims were discussed. It may have been for three or more girls, but the September 81 2006 Tactical Meeting was about two girls and multiple men. However, earlier in 2007, the City Drug Strategy Coordinator, part of the City’s Community Safety Team, attended the daily morning briefing of the Oxford Police as usual and heard about two of A-F absconding from Care and being with two adult males (later convicted in Bullfinch). She corresponded with a Police managerial colleague: saying “There are a number of females in social services care and the missing persons who are going missing on a regular basis. Care Plans are in place for some but there seems to be little done about the males involved.” She asked if the care homes could stop the children or test for drugs on return. “If all else fails note the details of the car, occupants and pass them onto the Police. Letters can be sent to the registered owner advising if found with the females again or in the area of the Home legal proceedings will be considered...” The Police colleague replied saying she had told a senior officer about “possible tactics that could be used against perpetrators” in order to tell more senior staff. 7.32 The City worker forwarded the correspondence to the Missing Persons Coordinator who, in response, reported positive links with residential homes. “I have spent many an hour with social services at the children's homes with reference to keeping their children safe. They are powerless to prevent them from leaving and are VERY well aware of the risks the children are exposing themselves to. I’ve a fairly good relationship with the staff and have been given some info re males, vehicles etc, which has all been submitted on 72s.”36 This suggests that, by spring 2007, there was a degree of knowledge about multiple victims and perpetrators at least amongst those involved in the management of missing persons. This adds to the similar conclusion about 2006. 7.33 Across 2007 and 2008, the City Crime and Nuisance Action Team’s (Canact) Nuisance Officer was repeatedly trying to alert CSC (and the Police) to concerns about the vulnerability of one Bulfinch victim. In March 2008, he alerted the senior Police officer in charge of Oxford, copying in a CSC social worker and the safeguarding manager concerned that a 13-year-old was connected to prostitution, was associating with adult Asian males, and was unprotected. (There was indeed very considerable Police and CSC activity around this child, but the gist of his concerns was that protection was not nearly robust enough and specific risks were being tolerated.) The records show he submitted personal sightings of the child in compromising situations with adults, and numerous intelligence reports gathered through his work about her late night contact with adult men despite being in Care. 7.34 In January 2008, a CSC manager told the Missing Persons Panel that one of A-F “had been disclosing to her social worker her involvement in the past with groups of young Asian males from the [named] area and named other girls involved. [The social worker] described how [the girl] would provide information up to a point but was afraid to stand alone.” CSC says that a “strategy meeting was to be held on February 5th at Oxfordshire County Council to look at girls with common stories/males for mapping. Details/minutes of meeting not located”. A few days after that, the County Council Safeguarding Panel (which looked at complaints raised by Looked After children) discussed three of girls A-F. In two cases, the ‘complaint against’ was logged as “Asian men’ including X” (a well-known Asian who had allegedly raped one of the girls at 11). The ‘Concern’ was listed as “sexual exploitation”. The action was logged as “strategy meeting held... intelligence being collated… names of other girls… registration of numbers of cars”. At interview for the CSC IMR, the Director of Children’s Services at the time had no recollection of this and the Head of Safeguarding was “not aware”. The Head of 36 An internal Police intelligence document on which information is shared and assessed. 82 Looked After Children services was aware, as was the CSC QA manager for safeguarding who was keeping a list of girls to be followed up at the monthly meetings. 7.35 In 2008, the Police Prostitution Strategy 2008-11 (which had been contributed to by the Drug Strategy and Domestic and Sexual Abuse Coordinators from the City Council) was produced, with good guidance on missing persons, grooming and so on – but it is clear at that point that there was no awareness of abuse on the scale later revealed, as it refers to only “small pockets” of prostitution. 7.36 The City Drug Strategy Coordinator chaired the multi-agency Sex Workers Intervention Panel, which began to hear about much younger females being involved. The Detective Inspector who later led the Bullfinch inquiry, on the back of a successful trafficking trial, and was keen to understand more about CSE, also encouraged her to explore further. She decided, in consultation with her manager, to set up a youth version of that Panel and in March 2010 the Prostitution Strategy Youth Group met with representation from 12 staff from the City, County and Health, with apologies from a Police schools officer. The minutes said that “anecdotal evidence had come to light of young girls who were being groomed by much older men in Oxford. The men were buying expensive gifts for the girls who believed them to be their 'boyfriend'. This has raised concern and this scoping meeting has been set up to determine if other agencies are aware of young people, boys and girls, who are being sexually exploited. If they are then how prevalent is it and how are they responding. If it is agreed that there is an issue then how do we tackle it?” 7.37 Interestingly, it said that “all agencies reported cases of young people engaged in some form of exploitation”. (By ‘all agencies’, it meant the relatively junior staff with whom inquiries had been made.) The minutes say the form of the abuse included the following – a near perfect description of what was described three years later in the Bullfinch trial: Older 'boyfriends' who buy expensive gifts for girls under the age of 16 Girls granting sexual favours in return for somewhere to sleep for the night Girls selling their bodies to pay for a drug habit Girls being collected and taken to London Family member actively facilitating sex with their child Grooming solely to sexually exploit Abusive same age relationships, where the females believe that they cannot say no Young girls actively targeting older men to establish a 'father figure' relationship that is missing from their lives Young people going through the care system increasing the likelihood of being sexually exploited Young girls proactively engaging in sexual activity with older men for complex reasons Rape being used as a punishment within groups “In all of the cases reported there is professional involvement but the majority of the females do not see themselves as victims at this point and are not ready to listen to advice… It was agreed that there does appear to be a problem in this area but as there is no formal monitoring the number of girls being sexually exploited is impossible to quantify.” The minutes say they needed to continue to develop a strategy to tackle CSE and bring the Police and some other agencies into the group. The pooled information at this meeting suggests considerable awareness of sexual exploitation a year before the Bullfinch investigation started, but the 83 minutes were not seen in any senior setting. 7.38 The day before this meeting, the Missing Children Panel, with no overlapping membership, had met and noted the 57 missing episodes from Home A in the previous three months. A month later, the OSCB (also with no overlap with those who were working on identifying the problem) appears from its minutes not to have a related item on the agenda. 7.39 The next meeting of the Prostitution group was at the end of April 2010 – this time described as the Youth Sexual Exploitation (YSE) Group, with senior police attendance. The group was working hard on a terms of reference and clearly, and to their personal credit, saw it as the setting in which the problem was to be tackled on a strategic basis. A subgroup of the YSE group met in May to map out all the tasks that needed doing, and was concerned how they could demonstrate there really was a problem so they could argue for funding support. A “risk” noted gave a view that senior management was “reluctant” and was nervous of funding issues – but about what request and which management was not specified. It was from this work that the City Drug Strategy Coordinator did the research and produced the December 2010 CSE Scoping Report, which is discussed above in relation to the OSCB. 7.40 While this was happening, concern was growing in the Police. In February 2010, a CAIU Sergeant was raising concerns about three girls who had gone missing 53 times from Home A in three months and a request was made for this to be discussed at the Missing Children Panel in March. In May, a PC in the East Oxford Neighbourhood Policing Team became aware of several girls being involved with older Asian males regarding prostitution and underage sex, and another PC logged 31 intelligence reports about the same thing. In June, a DC in the CAIU reported attending a meeting about seven girls (two from A-F) called by CSC. No minutes have been located but notes suggest useful exchange about involved places and names of adults. Donnington Doorstep also attended. This was one of three such meetings that were key in piecing the scale of the abuse together 7.41 The meeting above was called and chaired by a CSC specialist practitioner (senior front line worker) who worked in the CSC referral/assessment team, where she was “seeing all new referrals at the assessment team, talking to colleagues at the office, and especially with the ex Home A colleague... the same names kept cropping up. I also picked up more as locality senior for East Oxford which included Donnington Doorstep, relevant schools and children’s centres… There were three girls [two of girls A-F and another]. There was something else – we didn’t understand what.” 7.42 Although often referred to in records as strategy meetings (statutory meetings to determine investigative steps on a child), they were not. Rather, they were ‘professionals meetings’, which are informal information exchange meetings. The chair’s team leader was aware of the first and the area manager from the second. Minutes have only been located for one of the first three meetings, although one attendee kept personal notes seen by the Review 7.43 After that first meeting, the CSC Service Manager for Strategy, Performance and Development contacted the Youth Exploitation chair (the City Drug Strategy Coordinator) to ask whether she had any figures on child exploitation to assist with the sexual violence and abuse strategy she was working on with a colleague, also from the City. In a long response, she explained about the Youth Exploitation Group, the impending survey, youth workers’ concerns about girls and older men, how youth workers felt they needed more 84 training, and her thoughts on how she could go about making links to take the work forward. The reply was that the Service Manager would raise this with the Service Manager for Safeguarding and the Chair of the Sexual Violence and Abuse Group: “However, I agree if this is a growing concern, more strategic action will be needed.” (The CSC head of safeguarding told the CSC IMR he was unaware of concerns until 2011.) The same month, the City ran a conference on human trafficking “especially women and girls into prostitution” attended by 100 people. 7.44 The OSCB met at the beginning of July 2010 and approved the Sexual Violence and Abuse Strategy, which had some reference to CSE but was not a CSE strategy. Also in July, whilst conducting inquiries on one of the girls, officers were told by her social worker about four men she was believed to be associated with. Two days later there was a “child protection (non-crime incident) report” which said confusingly, “This crime report has been created to collate information/intelligence/referrals etc in relation to a number of young females [including two of A-F] in the Oxford area who are suspected of being involved in the sex trade. To date there is a number of crime reports in existence. A number of the females concerned are also regular missing persons.” 7.45 A few days later two neighbourhood PCs attended the second professionals meeting chaired by the CSC Senior Practitioner about nine girls who were or might be involved with sexual exploitation, including the same two from A-F. Again, a number of males were named, with at least one later convicted in Bullfinch. The Drug Strategy Coordinator who chaired the youth exploitation meetings was there and recalls feeling concerned that the group was not meeting again until after the holidays and there appeared to be no plan in place to address what was being discussed about the girls. (The concern was not escalated.) 7.46 The Sexual Violence and Abuse Group to which was referred the City CSE report was another stream of meetings, in addition to those led by the City/Youth Exploitation and CSC, and the developing thinking by the Police. In October 2009, a multi-agency meeting of the Sexual Violence and Abuse Strategy Group (SCASG), occurred “under the auspices” of the Oxfordshire Domestic Abuse Steering Group (ODASG), itself a subset of the Crime and Disorder Reduction Partnership (CDRP). It said that “reports will go to the Oxfordshire Safer Communities Partnership and CDRPs via OSDAG”. (The SCR understands that, while Community Safety Partnerships sit statutorily under Districts, the Oxfordshire Safer Communities Partnership sits under the County Council.) One of the Strategy Group’s functions was to “drive the Sexual Violence and Abuse Strategy”. Its place in the structure of meetings was unclear as the minutes say that “SVASG would be a stand-alone strategic group but will be reviewed in future to determine if it would be better placed in ODASG”. It met again in early 2010 with an OSCB officer present and began to refer to children, noting that the OSCB had no sexual abuse strategy. 7.47 Despite this rather vague positioning, the group did do important work and created the Sexual Violence and Abuse Strategy that was presented to the OSCB on 1 July 2010 by a County Council Strategy Manager who had been part of the process. The strategy did have a children’s section. The lack of clarity about structure was shown in the City IMR, which said the SVASG belonged to the Safeguarding Board, while also saying that when the Drug Strategy Manager went to her first meeting of the group in April 2011 it was “convened as a development group rather than established partnership and will look for a longer strategic ‘home’ for this work”. This demonstrates that the process was not clearly ‘owned’. 85 7.48 In August 2010, an intelligence PC prepared a report about children running away from care. “Most were regular missing persons and intelligence suggested that they were being collected from the Oxford area and taken to addresses in the West London/Slough/Reading areas where they were supplied with alcohol and drugs and were then used for sex with groups of older Asian males. This report raises concerns that the males had returned and a ‘new generation’ of young girls were being involved in the same activity.” In another report, a CAIU Detective Constable told the Detective Inspector that she had visited all four girls (two from A-F) some several times, including “one last time with their social worker”. Three of them denied any involvement in prostitution, and the fourth subsequently denied it. The Police had been conducting “high visibility patrols/stop checks”, the PC had researched Facebook, mobile phone records were being examined. It concluded: “I do not believe we are in a position to progress this investigation further at this time In my opinion, the only way… would be to conduct a covert operation in order to identity possible offenders and gather intelligence”. This shows much work by the Police in association with CSC, even if it concluded they could not act against offenders then. 7.49 In September 2010, the third of the CSC professionals meetings chaired by the Senior Practitioner (now an Assistant Team Manager) was held. The Police reported that all the relevant girls had been seen but there had been no disclosures. Six days later, the fourth youth sexual exploitation meeting took place with a range of City, County and Health staff, and the Detective Inspector for the CAIU. Like the previous meetings, it was chaired by the Drug Strategy Coordinator. Only a City Community Partnership Manager was at both meetings. It discussed the results of the survey the City worker had done. The numbers of cases reported by the respondents was more than had been referred to CSC. It was wondered whether they were referred without use of the word ‘exploitation’. It was suggested the group contact the Chair of the OSCB. The Inspector suggested a presentation at the OSCB to include gaps in return interviews of missing children 7.50 In October 2010, at an Oxford City Police meeting, another Detective Inspector discussed one of the children who was missing being involved in prostitution, and the CAIU met with the Children and Families Assessment Team regarding a number of girls. The Police note that there was a “joint decision that without further actionable intelligence or disclosures this could not be progressed any further”. Later in the month, a CAIU report showed that there had been 204 missing episodes from Home A in the first ten months of 2010. 7.51 In the autumn the Youth Exploitation Chair (and two other City colleagues) joined the National Working Group (NWG) on Child Sexual Exploitation – a network of projects, practitioners and policymakers. “It gave me a huge amount of knowledge, contacts, resources – and access to the lead of the NWG.” She informed the Oxford DCI of the Leicestershire Police model and “obtained copies at his request including the policy which was currently being reviewed by the National Police Improvement Agency (NPIA) for adoption of good practice nationally”. 7.52 In November 2010, the CID Detective Inspector who later initiated the Bullfinch plan first “recognised the potential for wide scale abuse and began work to identify the full details of the offending”, a view which he further confirmed in January 2011. Also in November, there was a Child Exploitation Project meeting chaired by the City’s Drug Strategy Coordinator to discuss how to take forward the findings of the survey and resulting report. This had more senior presence, with the Chair of the OSCB’s City subgroup and the Designated Nurse for 86 Safeguarding (who was to forward the report to the OSCB), the District Council’s representative on the OSCB, as well as the County lead on teenage pregnancy. In December 2010, the City CSE report described above was sent to the OSCB, although with little apparent response. 7.53 In December 2010, concerns were mounting, on top of considerable ongoing casework by CSC. Mid-month, the City Drug Strategy Coordinator wrote to CSC, the Police and Donnington Doorstep: “I have been informed that the two girls are linked to a well-known sex worker… maybe introducing them into the ways of working. It is believed that the girls have been in her company whilst getting into a vehicle. They have also been seen at hanging around a known sex worker's address on the X Road… is believed to be out all night staying at her boyfriend's who is believed to be 21 years old [later found guilty of nine offences at the Bullfinch trial]. Mum seems to know where he lives and the relationship that [the child] has with him, may have been in this relationship for a number of years… You may already have this information but I am very worried about what is happening to these girls. The girls refer to themselves as prostitutes but in reality they are abused children as they cannot give consent. Is there any way that the girls can be removed from Oxford and found a place of safety? I am really scared that something serious will happen to these girls. I am trying not to be too dramatic but I really do have concerns and would recommend a case conference with all the agencies who have any contact with the girls to talk, with the girls present and their parents and explain what could, would, will happen if this continues… It would be helpful if the police could, where-ever possible, engage with the girls and give warnings to adults present about their involvement with these children. It maybe that the police consider issuing warning/harbouring notices to these adults.” 7.54 It appears that, in response to this, CSC called a strategy meeting for the following day which included City, County, Police and Donnington Doorstep staff. Again, names of victims, perpetrators and addresses were pooled. The chair was the senior practitioner’s team manager, and included Police and the CSC area manager who invited her Assistant Director. The notes, discussing one of A-F, said: “…sex exploitation – discuss with (CSC head of safeguarding) we need to focus on this”. And also, “Report being prepared for [the Chair of the City OSCB subgroup] to take to the OSCB”. 7.55 As a result of that meeting, and the worrying information being mapped about a number of girls, the CSC Assistant Director immediately wrote a briefing note to the then Deputy DCS (and Head of Service for CSC) referring to the information pulled together by City, County, Police and other professionals saying, “… there are at least [five] girls known to social care who would appear to sexually expolited by much older men, a network of girls… (some are care leavers) linked to both adult sex workers schedule 1 offenders and half way houses for offenders… This was eye opening and as you can imagine extremely concerning.” It referred to three of the girls associating with Asian/Afghani men. A response is not in the documents provided, and there is no record of a follow-up meeting (given the level of concern) for six weeks, when CSC invited, at the end of January, a large multi-agency group to a ‘highly confidential’ Complex Abuse meeting on 9 February 2011. (There had been work in CSC on mapping information which had led to calling this meeting.) 7.56 Also in December 2010, the Greater Manchester Police (GMP) came across an Oxford girl in their Rochdale inquiries. She indicated a similar pattern in Oxford. There was communication 87 between GMP and TVP and the girl’s Oxford social worker and the Police. The social worker’s notes stated that a GMP email had said there had been “an email from police in Oxford to say that there is a similar enquiry happening in Oxford… regarding child sexual exploitation”. 7.57 The CSC Assistant Team Manager called a ‘planning meeting’ around two of the girls for 17 January 2011. No minutes or attendance have been identified, other than a brief note by one attendee. The following day a decision was taken to call a Complex Abuse Strategy meeting. 7.58 On 20 January 2011 the OSCB Executive discussed the annual Missing Children Report. The Chair of the OSCB City subgroup, and the senior manager who had alerted the Deputy DCS in December to the sexual exploitation were there. “Missing Children – There is more work to do in this area. There appears to be an issue with regard to the approach taken when dealing with frequent runaways. Each instance needs to be as thoroughly looked at as the first. Why they went, where they went and who they were with should be fully explored through return interviews as we need to know more about who they are with when they’re gone. Within Oxfordshire most of the missing children reports come from the same few children.The Missing Children Panel is a case discussion panel and does not have sufficient strategic oversight of Missing Children. There needs to be a formal strategy... The Terms of Reference for the Missing Children Panel need to be checked to see if this is a function they could also pick up and if it would be suitable for that group. The Thames Valley guidance on Missing Children has yet to be signed off by all authorities. When it has been Oxfordshire need to ensure they are compliant.” There was no reference at that OSCB Executive to any of the concerns about CSE discussed at professional, strategy, Police or youth expoloitation meetings held over the previous year. 7.59 The same day the local CID Detective Inspector chaired a CSE scoping meeting, which included seven Police staff and the author of the City CSE Report, although the minutes incorrectly say she was from the County Council. This was essentially an operational meeting about tactics and information gathering – largely around girls missing from Home A. The meeting Chair told the Review that this was the point at which he decided that real action now had to be taken. 7.60 As a result of this meeting, the DCI for Intelligence and Protecting Vulnerable People wrote to the Deputy Director of Children’s Services at the beginning of February 2011 to say “There is significant intelligence to suggest that the national trend of local Asian males targeting our most vulnerable girls is occurring in the city. A number of these girls are housed within your institutions and we have particular intelligence relating to (Home A)... There are a number of options and tactics available to (the Oxford DCI) when considering long and short term solutions all of which need careful consideration. As some of these tactics are quite sensitive it is important we consider the appropriate engagement with yourselves as a starting point. This is particularly prudent in light of ( the service manager for safeguarding’s) work around grooming, prostitution and exploitation… What would be a good start is for the 5 of us to get together to discuss the situation and agree a way forward.” The Vulnerable Persons DCI was informed of the impending Complex Abuse meeting and asked the senior officer who had led the 20 January scoping meeting to attend. 7.61 Eight days later, on 9 February 2011, there was the first strategy meeting held under the ‘Potential Complex Abuse Case’ heading with a large attendance from CSC, health (the designated nurse) , the City, the voluntary sector and the Police (both the Oxford DCI and 88 CAIU DIs). The 28 January email invitation from CSC said that “Family Support Teams in Oxford City have identified some potential links between children… that may indicate a grooming network for CSC.” The meeting discussed a number of girls, including three from A-F. It was chaired by the CSC Service Manager for Safeguarding. The Chair’s pre-minutes note of the meeting said, “During December and Jan 2011 social workers in the family support teams in the city noted continuing concerns relating to [five girls]. On January 18th the area service manager for the city and service manager for safeguarding met, a complex abuse strategy meeting was arranged to continue mapping out the concerns and inform the need for complex abuse investigation.” There was no mention of the 1 February top-level approach from the Police about group CSE being identified in the City, but three of the recipients of the 1 February email were there. It was a very detailed meeting sharing information, including 26 suspect addresses and health concerns. 7.62 The meeting concluded that there were “some very worrying concerns… and… several participants remarked on the worry that this had been going on for some time”. It was also recorded that the police investigation so far had “met a wall of silence”. The meeting concluded the need for “absolute confidentiality” to ensure no possible offenders were alerted. A large range of operational actions were agreed, and the Head of Safeguarding for CSC agreed to brief the DCS, with the intention of setting up a senior management group by 18 February 2011 “to drive the investigations forward” as per the Complex Abuse Protocol. 7.63 The Police have described the 9 February meeting as “a critical meeting where for the first time all agencies involved acknowledged the extent of the potential abuse and in effect identified that child sexual exploitation was occurring”. After this meeting, the CSC Head of Safeguarding discussed it with the Interim Deputy Director who briefed the then DCS. The DCS informed the CEO and Lead Member for Children, and the CEO briefed the Council Leader. The next day, the City IMR says, “the [Chair of the Youth Exploitation meetings] met with police to discuss issues and allocate tasks”. 7.64 The SCR has seen a helpful briefing note about the analysis and proposed investigatory work from the Interim Deputy DCS (who became DCS in November 2011), which it is believed was sent to the OSCB Chair (and top County officials), again urging confidentiality. For reasons which are not fully understood, the City Council CEO was not briefed for a further year, in March 2012, by either the Police or CSC. 7.65 In March 2011, the CID DI communicated with Oxford staff about the Home A girls being targeted, directed staff to pay particular attention to the males they were with, and provided guidance on Abduction and Harbouring Notices. The Assistant Chief Constable and then the Chief Constable were briefed in April. 7.66 Top of the office knowledge: A key issue in this Review is how long it took for concerns across the field to be coordinated and then reach the highest reaches of organisations. In the NHS there is no evidence that anything went to a board-level manager until after Operation Bullfinch had started. (One parent in 2004-6 did copy the Social Services Director into several letters to an MP, worried about the care and management of the daughter. One of the six letters did refer to the child being trafficked to London from another area where she was Looked After. The traffickers were not connected to Oxfordshire). At Donnington Doorstep the management was aware of individual cases from 2007, and was part of the meetings across 2010 which began to build the collective picture which Doorstep was itself seeing. 89 7.67 In the City Council, the Chair of the Community Safety Partnership (a Director, not a member) and the Partnership were aware of the national cases of CSE. It was from the Community Partnership arena that the work done leading to the City’s December 2010 CSE Report emanated. The City CEO was not briefed on this work, but was briefed by the County DCS in March 2012 about Operation Bullfinch and recalls that he was shocked to hear what was happening, as was the City Council Leader who the CEO immediately briefed. The City says that “was [the CEOs] first knowledge of the cases involving the children and also to the prevalence of Child Sexual Exploitation in the city”. This raises issues about inter-agency communication and internal escalation, as City staff were aware of at least the generality of Bullfinch. It is possible that those staff followed the Police request for complete confidentiality and did not even have discussions internally, but the Police, the SCR was told, assumed staff in the know would tell their seniors! The author is surprised that the City CEO was not taken into the inner fold of Bullfinch at the beginning, given that the offences were mainly in the City, its community safety role, and the role played by his staff in raising awareness of CSE. 7.68 At the County Council, there were long periods when concerns did not seem to be escalated above Head of Service level, or even at times to that level. The CEO said that she was first formally informed in writing about CSE in February 2011. She says: “I was immediately alerted by the then DCS as soon as she herself had been briefed by her Interim Deputy Director... I also have a clear recollection of the deputy... [giving] me a heads up and saying words to the effect that he thought we might have a group operating similar to one of those in the north... Prior to this I had no knowledge of the concerns about CSE in Oxfordshire... I was subsequently made aware of concerns about a number of girls, some of whom were looked after but others who were living at home, who were suspected of being abused by adult Asian males. I was also made aware that there were concerns of historical abuse of a similar nature. At that stage we did not know the extent of the alleged abuse but obviously we quickly began work to identify this and thereafter I was regularly kept informed of progress... No previous Director had ever raised concerns about this issue with me. I had therefore not raised the issue previously with the Leader of the Council, the Lead Member or any other Elected Member.” 7.69 As the Deputy Director overseeing CSC was aware of pretty serious concerns from at least mid-December, it is surprising that neither the DCS nor CEO and Lead Member were briefed until after the Complex Abuse meeting nearly two months later. Escalation also did not happen to very top Police officers for some time after the pattern began to be recognised, which is also surprising. 7.70 The Chief Constable summarised the position for the SCR. “The first time the issues, that were to become Bullfinch, were taken beyond the Police area occurred was when (the CID DI) highlighted his concerns to the Head of Crime, Detective Chief Superintendent… early 2011. Initial inquiries continued until the matter was taken to the appropriate Assistant Chief Constable who was responsible for both Oxfordshire and Force Crime... who then briefed me on Operation Bullfinch in April 2011.” 7.71 Operation Bullfinch: In May 2011 Operation Bullfinch formally commenced following preparatory work and resource commitment by both the Police and Children’s Social Care from Oxfordshire County Council. The joint Police and County investigation team comprised Police officers and staff and two senior social work managers seconded from CSC. This 90 ensured an aligned approach to the management of victims and eased the ability to share information. The investigation progressed identifying suspects and liaising with potential victims to obtain disclosures of sexual abuse. It proved very challenging to obtain disclosures from the victims as most were, understandably, mistrusting of any form of authority and the relationships were particularly difficult to maintain. Innovative but challenging tactics were used to secure forensic evidence which would prove critical at Court. 7.72 In April 2012, over twenty males were arrested in connection with the disclosures made by the victims and forensic evidence. Nine men were charged with various serious offences. Throughout this period the most challenging part of the investigation remained the ongoing management and support of the victims. Extensive work was undertaken with the CPS to overcome significant legal disclosure issues. The scale of this task required the CPS to employ two dedicated ‘disclosure barristers’ in addition to the prosecution barristers. The trial began in early 2013 and after several weeks the jury found the majority of the defendants guilty. 7.73 Comment: In many respects, organisational knowledge and reaction to guidance in Oxfordshire was similar to elsewhere, as national surveys have shown. There was the same slowness to grasp what was happening, and similar limitations in skill in how to tackle group-related CSE, as has been seen elsewhere – and not just in places with notable trials. What was to some extent different was that in the County, and mainly the City within it, there were more signs pointing in the direction of exploitation than would have been seen somewhere where there was no group-related CSE. In other words, there was an opportunity. In each year from 2005-10, there were discussions in one setting or another in Oxfordshire about sexual exploitation, but hardly any of this was at a level that could have made a strategic difference. 7.74 The author is not sure that the fact that seeing what was happening as prostitution, out-of-control teenagers, the result of home problems or whatever is sufficient to explain how it was so many years before there was concerted action and top leaders became involved. It might not have been understood as CSE, but there was little doubt the girls were suffering badly – even if it was thought to be self-induced. Not knowing the full picture does not explain some of the individual case management. The girls were only 12-15 years old. 7.75 It must raise a question about the culture of escalation in Oxfordshire, where top leaders seem never to have been briefed or consulted about what many of their staff were struggling with, or even interagency disputes. Also, about the effectiveness of the OSCB which appeared fairly peripheral at the time to the growing awareness of CSE. The report about CSE from the City was not put to the Board. It also raises questions about the working relationship between the County Council and the City Council, especially given that most of the abuse was in the City. 7.76 If important information does not reach the very top, it must be a combination of issues which relate to both escalating and receiving escalation. The OSCB and its member agencies will need to be assured that there are, now, more effective systems of escalation for concerns about abuse (both within and between agencies), that the OSCB is managed so it effectively implements national requirements and indeed holds the safeguarding ring in the County, and that there are open effective relationships around safeguarding, especially sexual exploitation between major agencies. 91 8 APPRAISAL AND LEARNING 8.1 Introduction: This section makes an appraisal of how agencies worked in Oxfordshire, looking at the context and explanations from previous sections, and forms a view on their performance back to 2005. Professional responsibilities for keeping children safe are both agency and collective. It is important to acknowledge the vast amount of work by professionals in all agencies with the girls and their families. Reference has already been made to the nearly 4,000 pages of chronology itemising agency dealings with the six girls, and the author could see evidence of daily work over long periods of time of a very challenging nature. This is not a story about not trying, but the degree to which the effort was effective in preventing or intervening to stop exploitation. Looking back now, even if there was enough information to indicate something very bad was happening, the CSC IMR author, referring to the full horrors of what emerged in Bullfinch, commented that “It was striking at interview that all the social workers and managers had been shocked when they found out via internal briefings and external media reporting what had actually happened to the girls with whom they worked.” 8.1 As far as CSE is concerned, Oxfordshire has made very significant progress from the time in 2011 it was finally realised there was a pattern of organised CSE and multiple victims (see Section 4). It now uses modern methods of perpetrator-focused intelligence gathering, disruption and prosecution. The old attitude of the victims being responsible for their own plight has gone. Top leaders have shown high levels of personal commitment to tackling CSE, as well as the commitment of their agencies. People now visit Oxfordshire to see how things should be done. Nevertheless, it is right to see what can be learned from the period where arrangements were not nearly as good as they are now. 8.2 Learning points: Some ‘learning points’ from the SCR are itemised under each heading. Asking in these points for something to be checked against current practice does not be mean that it is necessarily not now in place, but emphasises the importance of agencies assuring themselves that it is. Some learning points may seem bland when compared to the dramatic stories in this Review, but they are about creating the environment within which front line work with the most difficult cases can be nurtured. This Review is being written up to four years after the corner was turned in Oxfordshire, and many learning points itemised below are already subject to work, for example in the OSCB CSE Action Plan. Where that is the case, these points act as further confirmation of their priority. A much more detailed description of the rich learning points for each agency can be seen in the CSE in Oxfordshire: Agency Responses since 2011 report published alongside this SCR. 8.3 Were mistakes made? This SCR tries to understand why agencies responded as they did in order to learn from it. Although much of the response is understandable in the context of the time, it is clear that mistakes were made. There has been no attempt to deny this and the two most involved agencies have issued clear apologies. The Chief Constable apologised that it took so long to bring the offenders to justice and was sorry that “we did not identify the systematic nature of the abuse sooner and that we were too reliant on victims supporting criminal proceeding”. At the time, she wrote to all six victims and apologised, and met with three of the girls to make the apology in person. The County Council CEO was “deeply sorry we were not able to stop the abuse sooner” and said, ‘We would like to publically apologise for not stopping this abuse sooner.” The DCS met four of the victims personally. It is clear to the author how shocking agencies and professionals have found the full revelation of the abuse, 92 and that opportunities to intervene were missed or belated. The author has encountered no efforts to deny the scale of abuse or that there were errors. The County Council offered and provided the children with (where accepted) a range of practical and material support in relation to post-trial normalisation of their lives. This recognised that victims lost a lot of normal opportunities earlier during their abuse, for example by not being able to complete their education. 8.4 Section 5 described in some detail the agency-based delays, and a summary of errors is as follows. Some were agency specific, some system wide. Many of the issues have been seen wherever else CSE has come to light, but some were more Oxford specific. Lack of understanding led to insufficient inquiry National guidance was not widely understood or followed The behaviour of the girls was interpreted through eyes, and a language, which saw them as young adults rather than children, and therefore assumed they had control of their actions At times, their accounts were disbelieved or thought to be exaggerated What happened to the girls was not recognised as being as terrible as it was because of the view that saw them as consenting, or bringing problems upon themselves, and the victims were often hostile to and dismissive of staff As a result, the girls were sometimes treated without common courtesies, and as one victim described it by “snide remarks” There was insufficient understanding of the law around consent, and an apparent tolerance of (or failure to be alarmed by) unlawful sexual activity There was insufficient understanding of parental reaction to their children’s behaviour and going missing, so distraught, desperate and terrified parents were sometimes seen as part of the problem There was insufficient curiosity about what was happening to the girls, or to investigate further incidents or concerns which on review now appear to be crimes or something for formal child protection investigation Although there were very few formal disclosures, there were many, often stark, indications that what was happening to them was extreme and out of the ordinary There was insufficient attention to investigating and disrupting the activities of the alleged perpetrators (compared to the effort to contain the girls behaviour), and various available legal tools were not used There was insufficient understanding of how the City Council’s community safety function could contribute to the prevention and management of CSE Day-to-day processes were not strong enough Insufficient use was made of Child Protection processes, and staff sometimes allowed parental reaction to prevent Child Protection processes being used Processes in CSC, such as supervision and the quality of reviews, were not strong, especially in 2006-9 Minutes of multi-agency meetings and review were largely of low quality or missing, which weakened planning and information sharing Recording of ‘crimes’ was inconsistent Transfer of educational records between schools was poor 93 The provision of alternative education after exclusion, or of post-secure placement education, was slow In Health, there was insufficient sharing of information heard from or about the girls (often for ‘confidentiality’) and LAC medicals were often done without full knowledge of history and context The organisational response in Oxfordshire was weak and lacked overview Escalation about serious concerns about looked after children and emerging patterns did not reach governing body level or chief officers for several years after they had begun to emerge in 2005, and again 2006-10 When some signs reached the ACPC and OSCB in 2005 and 2007 respectively there was insufficient curiosity and no follow through The OSCB, before late 2011, did not lead the scoping, understanding and prevention of CSE after the 2009 statutory guidance, and member agencies comprising the OSCB share that responsibility Whilst before 2010 there was much less recognition of the connectedness of cases, or the organised nature of perpetrators, both within and across agencies the growing awareness in 2010 still did not reach top management or the OSCB Before 2011, there were fewer processes in place to help form a force-wide Police view of developing problems There was a gap of one to two months between senior managers being aware of the bigger picture, or at least the strong likelihood of a bigger picture, in late 2010 and very top management being informed 8.5 Could CSE have been identified or prevented earlier? The simple answer is yes. In practice, identifying CSE has proved difficult in many parts of the country, and it is likely that there will be more discovered elsewhere. Wherever it has appeared and led to convictions, there seem to have been warning signs not picked up earlier, a difficulty in believing such things could happen, and an attitude that looked more at victims than perpetrators as the source of the problem. This has been regardless of guidance, which has (even if using different terminology) for many years described the signs of child sexual exploitation and offered guidance on action. The issues contributing to the delay are appraised below. 8.6 Missed opportunities: There was a window within which a number opportunities to recognise what was happening were lost. Given the general level of knowledge at the time, the then evidential requirements and the then lack of experience elsewhere, it would be wrong to conclude that Operation Bullfinch would definitely have happened earlier, but it might have done. In 2005-8, there were some significant concerns about multiple victims and abusers to a level very similar to that which, in 2010-11, led to Operation Bullfinch. 8.7 In 2005, there was considerable concern about some girls who we now know were being exploited. A detailed illustration is given in 7.23 above. There was similar knowledge in 2006 with the plea from the Police Missing Persons Coordinator, only a constable, to quite senior colleagues about the need for more action in relation to two girls, the need to go after the perpetrators, and expressing a fear that even death might occur. The same month (September) the police-led, multi-agency ‘tactical meeting’ discussed multiple offenders using the phrase “paedophile ring” and hearing allegations of rape by multiple men. 94 8.8 The coordinator’s concern and the focus of the meeting were two girls in particular, one of from the 2005 example. The purpose of the table below is not to criticise action by front line staff – their work was dominated by these girls daily, and there were investigations, arrests of six men for offences against one child, residential staff out searching, medical care provided, Police visiting other areas to learn more, and very little consistent evidence was given. The purpose is to argue that what was happening was so extreme that it required attention by the highest levels of management, who, with their greater distance, may have been able to bring a more strategic approach to the problem and may have been able to identify patterns. It is also to query why these concerns were not reported to governing level. 8.9 The table shows extracts from agency chronologies of two girls in a period of around six weeks around the time of the tactical meeting, so both Police and CSC staff were aware of the detail (and doing a lot of work around these children). It would be hard not to conclude by this point that there was an organised element to the abuse. However, to put this in context, in 2006 there was little experience anywhere in the country of identifying, let alone getting convictions for, CSE and cases were still being seen as relatively isolated, with little chance of successful prosecution. First girl, age 14/15 Second girl, age 14 Frequently missing from care home Frequently missing from care home Gave addresses where abuse happened Gave same addresses as first girl Admitted ‘underage sex’ with a group of Asian males Advised police that she and the first girl had stayed the previous night in a multi-occupancy dwelling where there was drug taking. She showed police several addresses … described that the occupants at one address had two firearms Drank a bottle of Jack Daniels Said she had sex with four men one night, two the next and one the night after – in their 20s and 30s Admitted to hospital, alcohol poisoning Reported an oral rape Tells hospital her friends have sex with her Found by police with several Asian men who she said she had had sex with. Men later convicted in Bullfinch also arrived Describes rape by two men convicted in Bullfinch six years later Multiple arrests of Asian men Told residential home staff she had sex with at least seven Asian men aged 17-33, with two older Told police she had oral sex with eight men in return for alcohol ‘These men are my protectors’ In a crack den with Asian males Strategy meeting planned but did not happen Eventual meeting talks of ‘paedophile ring’ Thought to be having sex for drink drugs, lifts Tells police she has had sex with several Asian men Twice stopped by Police with an Asian male later convicted in Bullfinch. Told Police she was afraid of him, and that he and her friends knew her age 95 Found with same man a week later and alleged rape 8.10 There was a recognition that the management of missing children needed to be better, advice was taken, and the Missing Persons Panel introduced. But it was still not recognised that the prime focus on managing the girls was not the right approach. 8.11 In 2007 the OSCB was twice alerted to concerns from its City subgroup. The Board minutes in March noted, concern about an ‘increasing’ problem of 14-15 year olds going missing, agreeing the Board needed to deal with it, and action was ‘in hand locally. In June, the Board noted its City group’s concern that girls could be victims of ‘organised prostitution’ (the subgroup minutes called it an ‘organised abuse ring’). The Board minute did not refer to the subgroup’s view that a “complex abuse investigation” may be needed, or the “need for a wider/joint response” (rather than just tackling it on a case by case basis). The subgroup had agreed these views would be passed to County safeguarding managers. There is no evidence of significant action as a result of these concerns. 8.12 In 2007, the minutes of six OSCB and subgroup meetings refer to risks to young teenagers including from drugs, prostitution, and associated risky behaviour with men. Either attending, or seeing, minutes would be a range of senior managers and safeguarding staff (below director level). However, concerns were never revisited, and did not reappear in minutes for four years. The SCR has seen no evidence of this being in anyway a deliberate suppression, but it is clear that the OSCB and its member agencies should have taken it more seriously and reached minuted conclusions on any necessary action. For context, CSE by Asian groups as it later emerged was an unknown issue in 2007. 8.13 Also in 2007 (and 2008), there was the concern expressed by the City Nuisance Worker around one child aged 13-14, with numerous reports of association whilst in care with adult males late at night. In December 2007 there was a strategy meeting about one child about a missing girl marked by a man later convicted in Bullfinch, and threats from this man’s family members. Eight days later, there was a very significant strategy meeting, which noted: “Concerns regarding the association between a number of girls LAC/leaving care and adult men from the Asian community”. The meeting discussed groups of men, sex with adults, drugs, drink, named men, and disclosures from a child. It also discussed an incident for which there were convictions six years later in the Bullfinch trial. 8.14 The statistics on ‘missing’ in this period were also worrying. From 2005 to 2007, three of the girls went missing a total of 359 times, with 161 of those occasions being from Council care. In 2006 and 2007, Oxfordshire had almost half the missing from care episodes in the TVP area with only a third of the population. Half of all Oxfordshire missing from Care episodes in 2006 and 2007 were for two girls from A-F, so it is hard to argue that these were not exceptional cases. (The missing from care episodes in Oxfordshire continued to grow in 2007-8 and 2007-9, although the contribution from A-F was much smaller, which suggests the possibility of more girls being trapped by groomers.) 8.15 In 2008 the Missing Persons Panel, the County Safeguarding Panel and the Nuisance Officer’s referrals all discussed exploitation by adult Asian males. In 2009, Donnington Doorstep was sharing concerns about girls and adult men. Early in 2010, the junior respondents from ‘all agencies’ reported to the Youth Exploitation Group a full range of signs 96 of CSE, and professionals meetings began to put the picture together around specific girls. The first any of this got to Director level was December 2010. The OSCB and agencies must make sure that there are processes in place so this could not happen again 8.16 There were also in 2005-8, for just four of A-F, 12 reported sexual assaults by some of the men later convicted in Bullfinch. Only two led to convictions, mainly due to evidential weaknesses, but this only led to a sense that little could be done, and the sequence did not seem to be discussed in any forum where the pattern could be recognised. 8.17 From what was recorded over these years, at least a partial picture of a group of girls, links with being LAC, multiple Asian abusers and real harm to those girls could have been formed. The component parts of that picture were seen to some extent by operational staff and some more senior staff in the CSC and the Police, but they did not trigger, in their un-joined-up state, a collective high-level managerial and strategic response, as occurred in early 2011. In the author’s view, the level of information known by 2007 was not dissimilar to that which was sufficient in 2011 to trigger the discussions that led to Bullfinch, so opportunities were indeed missed. 8.18 The CSC IMR came to a similar conclusion about the depth of knowledge from 2005. It said: “There can be no doubt that from 2005 onwards there was knowledge of these and other young girls being involved with older Asian males.” It gave many examples of girls being found with men convicted years later in Bullfinch, of events which were not fully investigated, for which there were convictions later in Bullfinch, and of where it would have be possible for staff to make connections. It said that the four older girls being managed in separate CSC area teams “did not aid social workers to make connections”. 8.19 It is not just that the bigger picture was not grasped but that the individual cases, which by and large were not linked, were so extreme in their circumstances that greater protection should have been given – regardless of whether there was an abusing group or not. It is important that this is not overlooked by just focusing on the missed bigger picture. 8.20 Ofsted rated CSC only as adequate in 2006, 2007 and 2008, raising issues including too many children placed too far from home, reviews for children that are Looked After need to be done on time, and the lack of placement choice on occasions putting children and young people in less appropriate placements (2006); Weaknesses with the referral, assessment and child protection systems. Increases in children being de-registered and re-register (suggesting hasty de-registration) and a need to improve the timeliness of LAC reviews; and the management of referrals and assessment raised for third time (2007); Rearranging processes had led to ‘referrals’ doubling (2008). The JAR in early 2008 described Council services saying, “Oxfordshire’s performance is often below that in similar authorities and the track record of improvement in services has been variable.” 8.21 A former DCS in post in 2006 and 2007 said: “My perception of children’s social care was of a service under very considerable pressure, high demand, significant overspends and I suppose in response to that it seemed like it had been constantly reviewed and there was a view that things needed to be different. Pressure points appeared to me to be: – entering care/LAC/Assessments …” The CSC IMR described supervision as generally poor in these cases. Such cases, which are so hard, create powerful feelings and emotions in staff, and 97 good case supervision is essential so staff can be as insightful, objective and effective as possible. 8.22 Many authorities were ‘adequate’ at the time, so there is no necessarily direct correlation between this and CSE-related weaknesses. However, the key weaknesses listed by Ofsted and the JAR are those which may well have made it less likely that trends would be picked up, that risks that needed escalating would be identified, that children’s progress would be reviewed well, and that children in Care would have been placed optimally. The tensions (not restricted to Oxfordshire) described above where DCSs did not have a social work background may have contributed (wrongly) to attitudes to escalation in CSC. 8.23 What was missing organisationally in Oxfordshire? Whilst there was much, looking back, which was not helpful, was ill-informed or even seemed uncaring, the general patterns seen in this Review were not unique, and there is no evidence of top managers or governing bodies failing to respond to what was later subject to many convictions at the Bullfinch trial – they did not know about it. What needs to be learned from locally is the picture (that did not fully emerge until the SCR) of parallel streams of work on what is called, in Section 7, ‘Oxfordshire’s journey’ of discovery about CSE. The local consensus is that there are now substantially better inter-agency connections, joint working arrangements, a well-functioning OSCB, and Bullfinch itself is said to have drawn professions and organisations together in an unprecedented way. But this SCR offers the opportunity to take steps to be sure that what is described under this heading has indeed been addressed or will be. 8.24 What was seen in Oxfordshire was a range of concerns, some very high, about the risks to which a number of girls, mainly LAC, were exposed by their association with much older men, drink/drugs and generally ‘difficult’ behaviour. For a whole host of reasons described earlier, responses were not what they would be now, the signs of CSE were not recognised or, even if suspected, were not drawn together in a way that led to collective top-level action. 8.25 In 2010 the several parallel strands of discovery began in earnest: the more strategic approach by City staff, the case-focused approach by County staff, and the growing concerns by City Police. And, across the whole period, the most intense work by CSC staff to manage the most difficult of cases. The key question is, why it was not pulled together earlier? 8.26 There are the simple answers about lacking knowledge, the inability to grasp that something so dreadful could be happening in Oxford or the County, and the nationwide attitudes which failed to see such difficult children as victims, and so on. However, there seemed to have been weaknesses in the collective work across the child protection partnership. The author would not want to imply that this was all unique to Oxfordshire, but it is what the OSCB and other strategic partnerships must make really sure has been addressed now. 8.27 The OSCB, although seen as good for some years, was not well developed by the time of the JAR in 2008: “Underdeveloped operational and monitoring arrangements for the OSCB”. And although improvements were put in place with a new Independent Chair that year, it is clear that reaching a good level of functioning took some time, as evidenced by the non-response to the 2009 statutory guidance or not utilising the 2010 City report on CSE. That new and first Independent Chair reported that she found it hard to get deadlines met and to improve the performance management rigour found wanting earlier. She also felt that 98 meetings with senior council officers only happened at her instigation. (It would be fair to say that many councils found it hard to adapt to their first Independent Chair.) That Chair says her first priority was to improve the level and commitment of agency membership and develop the governance arrangements of the Board. The DCS appointed in 2010 says she instituted regular meetings with the OSCB Chair, and between the OSCB Chair and the County CEO. 8.28 Also, it has often proved hard for agencies, even senior staff, to appreciate that, other than the Independent Chair, who then would have worked maybe half a day a week, the LSCB does not exist other than as a collective of members. The only ‘independent’ professional on any Board is that very part-time Chair. This means that, largely, challenge and scrutiny of performance has to be on a peer basis. Indeed, at the time of Bullfinch, national guidance37 required members to act independently of their agencies. “The individual members of LSCBs have a duty as members to contribute to the effective work of the LSCB, for example, in making the LSCB’s assessment of performance as objective as possible, and in recommending or deciding upon the necessary steps to put right any problems. This should take precedence, if necessary, over their role as a representative of their organisation.” (This was removed from national guidance in 2013, and it is unclear whether government still expects the spirit to be adhered to.) Before Bullfinch, the OSCB was not as proactive as it should have been. Certainly the work the City Drug Strategy Coordinator and colleagues did in 2010 to try to scope CSE and join agencies together to address growing concerns was what the OSCB should have been doing following the 2009 guidance, and doing more thoroughly in a CSE strategy. 8.29 There are indications that, before Bullfinch, the influence on the OSCB from top managers varied. This contributed to the OSCB not operating in a way that was picking up growing levels of concern, or exercising its statutory duty to have led collectively on CSE from 2009. National research would suggest this was not an uncommon picture. This, and the fact that concerns across all agencies never reached the most influential decision-makers, meant that those leaders were not driving a strategic approach and this contributed to the delay in identifying the CSR. The OSCB has been working well on CSE since 2011. 8.30 Secondly, there were also issues across agency boundaries. Oxfordshire has a two-tier local authority arrangement. Districts have community safety responsibilities, whilst the County have the statutory child protection role. It has taken Bullfinch for there to be a realisation of just how related are these two service areas. Without that understanding, the connections between the two in the City (the only District specifically looked at) were not close enough at middle management tier, whilst there is evidence of much closer working at field level. Although there is a much better mutual understanding now, pre-Bullfinch there was a degree to which it appears that in some quarters the City was seen as a rather small player. The correspondence about the Nuisance Officer’s concerns did not show due respect for the views being put forward; not taking the City CEO into full confidence about Operation Bullfinch for a year seems remarkable. The only involved major agency not invited to join the overseeing Panel for this SCR when formed in 2012 was the City. City staff did as much as if not more than any to understand and identify responses to CSE when this was actually a collective duty, but this good contribution was not generally known until it emerged during this SCR – which makes the point. 37 Working Together to Safeguard Children (HM Govt, 2010). 99 8.31 It is clear now that, within the County, CSE is not just in the City. One district used to represent all five on the OSCB. (The previous OSCB Chair told the Review that this was their choice). This has been addressed by the new Independent Chair, who has secured both resource and senior management commitment to the OSCB from all the districts. All districts understand the importance of membership. The need for greater understanding and clarity about the link between various strategic partnerships was confirmed in a 2013 external review38 of OSCB effectiveness, commissioned by the OSCB, which listed as an area for development: “Specifically clarify the respective roles and inter-relationships between the OSCB and the Health and Well-Being Board, the Children and Young People’s Partnership Board, the Community Safety Partnership and the Safeguarding Vulnerable Adults Group”. 8.32 Thirdly, there is an issue for agency governing bodies. In the evidence received for the SCR, there was almost no reference to governing bodies such as Boards or Council Committees (which in all cases involve lay people). The absence of concerns getting to directors would be the main reason for governing bodies not addressing CSE before Bullfinch. It would be a good exercise for governing bodies to consider whether, in hindsight, there is information, which, looking back, should have got to member/non-executive level – and if so to make such expectations clear now. Related to this, they should consider whether existing performance management processes are identifying significant causes for concern at an early enough stage: for example, the very worrying missing from care figures and what was happening to the young people concerned. If this was a new issue today, are there processes which would ensure governing bodies have the opportunity to contribute to a robust response and determine priority? 8.33 Fourthly (and great credit should go to the mainly junior and middle ranking staff who pursued the implications of what they saw and heard until eventually there was some joined up action), there was something that prevented those concerns being either passed upwards or put into a more strategic arena by those who were aware. It is hard now, many years later, to be clear what that ‘something’ was. It is known, for example, that in CSC there was a climate of trying to deal with things at a senior operational level rather than at a more corporate County level. TVP is a very large organisation, which, before 2011, had fewer processes in place than it has now to see things on a force-wide basis. 8.34 The minutes of meetings seen by the SCR seem to support the notion of a lack of grip. Most were multi-agency, although ‘owned’ by one agency. IMR authors and this author found it difficult to find minutes of many meetings (for 2011 and earlier) referred to in the SCR. All except OSCB minutes were devoid of logos or other headings to distinguish the agency responsible for them. A number did not indicate who chaired them. In many, it was hard to follow what happened, and as many of these meetings were subgroups it was hard to see to whom they were accountable. The impression was of informality and a lack of either clarity about or understanding of the importance of ‘governance’. This is not to say that the meetings were not doing good work, but that minuting during that period needed to be a much more valued exercise. This comment applies both to agencies preparing them and agencies receiving them. . 38 Independent Review of the Effectiveness of the OSCB (Paul Burnett, August 2013). Note: the current OSCB Chair told the Review she was ‘comfortable’ that all the recommendations in this report had been achieved. 100 8.35 Learning points: Rather than trying to be definitive about why inter-agency arrangements did not lead to greater awareness at the top, and why it was left (not consciously) to junior staff to scope and identify the CSE when there were requirements for this be done at a higher level, the relevant learning points below can be used as a guide against which current ways of working can be assessed: The risks an OSCB runs if it does not have robust processes for: - acting on new guidance - performance monitoring to ensure actions are seen through - ensuring there are routes in for fieldwork concerns to be heard - its role being widely understood by staff at all levels The OSCB, other than the part-time presence of an Independent Chair, has no existence other than as a collective unit. This means that governing bodies must be sure their organisations and leaders actively share in leadership and shaping the Board The importance of the District Council community safety role being proactively understood by partners, and appropriate links with County Children’s Services being strong at operational and more strategic level The need to be sure that all Districts continue to be represented on the OSCB Governing bodies need to be sure they are clear on what they expect reported to them by way of early warning, so they have an opportunity to reflect on an issue as early as is useful Governing bodies need to be sure that performance management arrangements identify key measures of child safety, including those around looked after children The benefits of relatively junior staff using their initiative to take forward discussions and explorations about concerns on child safety, but… ... there is also a need for their managers to ensure such important work makes the right links inside and across agencies, and also what is the governance framework for the work 8.36 Knowledge: In general terms, Oxfordshire would not stand out from many other parts of the country in its amount of accumulated knowledge about the concept of CSE, or in terms of implementing guidance. The Review has described national research in 2011, and even in 2013 (by which time Oxfordshire was doing well), which showed low uptake of national guidance. On the other hand, the OSCB at the time of the major national statutory guidance in 2009 did not have a very robust process in place to ensure that new guidance was always dealt with at the right level. Also, many OSCB member agencies would have known of the guidance but did not raise it with the Board as a shortcoming, so responsibility must be shared. Although there were some concerns over the years, the evidence for the SCR shows only some City staff making determined efforts to learn more about CSE – notably through the Community Safety Team which should be applauded for its efforts – and, associated with this, the Police also began making inquiries elsewhere. 8.37 The Oxfordshire experience (and that of others) shows how long inappropriate views can remain entrenched if there are not good processes of learning from national good practice guidance and robust multi-agency oversight 8.38 Learning points: OSCB member agencies also receive such guidance and need to share responsibility for it being considered both internally and collectively by the Board 101 The value of more widely and proactively seeking out learning and good practice, as shown by the City and the Police There may be an assumption that the focus on CSE is so high now that the old, less unhelpful attitudes to the victims have gone. This needs ongoing monitoring 8.39 Escalation: In this Review, the evidence was of very limited escalation to top decision-makers, so no Directors/Chief Officers or governing bodies were aware of anything akin to organised Asian groups and multiple young victims until very late 2010, 2011 or even 2012. The reasons varied. Some organisations like the Police and County are so large or have such a range of services that the individual cases (as they were seen) might not reach the very top. In other cases, staff were trying to be sure there was something especially unusual before pushing it up the line. 8.40 Whether they should have realised it or not, there is little evidence of anyone having a clear picture of group-related CSE and not escalating it, although the IMRs have identified evidence that might have supported such a picture in 2005-8. It took from mid-December 2010, when the Deputy DCS was briefed in writing about growing concerns, to mid-February 2011 before the DCS and then CEO/Lead Member were briefed, a point two weeks after the Police identified to CSC concerns about the group sexual exploitation of children in care of a very significant nature. This should have been done quicker. It was April 2011 before the Assistant Chief Constable, and then Chief Constable, were briefed about awareness of local group CSE. Again this should have been quicker. 8.41 Given how long, due to the complexity, it took Operation Bullfinch to get even to the point of arrest (a year), it is unlikely these delays made much difference but the speedier upward briefings would have been appropriate. By this point, there was some national awareness about Asian-led group abuse of multiple children, and the Directors/Chief Officers should have been given the opportunity to consider the implications both practically and politically and be sure action was at the appropriate level. It is important to emphasise that this was in no sense ‘hiding’ the issue but staff not seeing the need to brief chief officers (wrongly in the author’s opinion). 8.42 It is also important to avoid hindsight when assessing how soon the chief officers needed to know. The Rochdale and Rotherham publicity is now etched on the public consciousness, but the beginning of 2011, when it was realised Oxfordshire had a pattern locally, was over a year before the main Rochdale trial concluded and over three years before Rotherham became news. Only the far less publicised Derby case might have been known by then. 8.43 Over the years, the issue is whether concerns should have been escalated and, had they done so, would there have been more strategic and concerted action. (See also ‘Tolerance’ below). The Chief Constable, talking to the SCR, was asked about expectations of escalation, and illustrated the above point about hindsight: “Knowing what I know now about the significance of the operation and the court case for Thames Valley Police I would have wanted to know sooner. However I do not think that my knowing would have affected the outcome of the investigation. The question is whether it is reasonable for the officers involved, knowing what they did at the time, to have begun to deal with the case without escalating it to chief officers. In early 2011 they were establishing the team in partnership with Social Services from within resources they controlled and had no need at that time to seek additional help or permission to begin to develop the intelligence and gather evidence.” 102 8.44 What is clear is that the pattern of limited escalation of whatever was known at the time was more or less the same across all agencies, despite leaders feeling they were open to hearing staff concerns. To some extent, this was because staff did not know that something uniquely awful was happening, or could not believe it, so thought they were dealing with the difficult end of the spectrum of cases which they were expected to get on with. On the other hand, this Review has shown that there was enough information about the signs (as a opposed to the recognition of the overall pattern) of abuse of linked children by multiple men of mainly Pakistani heritage for many years before Bullfinch began, which would have benefited from the consideration of top managers and governing bodies. 8.45 Chief officers were never told of any of the concerns during 2005-10, neither were Directors of Children’s Services. (CSC had its first Escalation Policy in 2010.) Even the City Council did not agenda its own December 2010 CSE scoping report at any internal meeting or even at the Community Safety Partnership where it was lead agency. One former DCS said: “In previous jobs if a social worker had concerns they would want it to get to the top of it asap and get it dealt with…” That DCS said that in OCC (Social Work and Education), there was a sense of “people not wanting to deal with things” and “letting it go” if the manager above was perceived as not being interested. 8.46 The author, in discussions with senior staff and the new independent OSCB Chair about draft findings, has found there is still a degree to which the value of top managers/governing bodies being briefed is not grasped. This suggests a public sector culture within Oxfordshire where middle or even senior management feel a need to solve problems themselves, rather than considering the wider corporate governance issues, and in doing so deny the top the opportunity to have influence. This means that top management/governing bodies must consider how open and welcoming they are to early warning, and indicate their need to know about extreme matters being handled by their staff. Those with whom the author has spoken believe they have always been open, so the cause of the non-escalation will need to be understood, and current improvements tested. 8.47 Agencies and the OSCB need to consider whether, should another ‘new’ topic emerge now, it would find its way up the line more easily and more quickly, so there could be a more corporate response. Agencies should review how clear it is what their staff and junior managers are expected to escalate, and the OSCB should review its committee and other arrangements so that it gets to hear of worrying concerns early enough to use its collective influence well. Many local agencies will have looked at this in recent years as a result of Bullfinch (and CSC has an updated ‘Need to Know’ policy on escalation) so the task will be to test out new arrangements to make sure they are robust, that the ‘top of the office’ is indeed told what it would expect to hear, and that staff are quite clear what they need to share. 8.48 Disputes between agencies about case handling may at the time seem unnecessary, but they may well contain issues of real concern that can be submerged in irritation across agencies or professions. The 2007-8 tension described around one child and family, given the nature of concerns expressed, could have been handled much better, and would have benefited from, in both City and County, higher managers considering the childcare implications. In this case, the resolution at the time seemed more tactical than child focused. 103 When there were concerns about child protection processes (eg case conferences) not being used, there was no sign of disputes processes being used. 8.49 Learning points: OSCBs are strategic, but must also be sure that they have processes that allow them to hear of operational concerns at an early stage, so there can be a decision as to whether the Board needs a collective response/action Agencies should satisfy themselves that formal escalation processes work in practice, from the perspective of both front line staff and top managers Also, that there is a culture which promotes the sharing of concerns and reacts positively rather than negatively to service concerns There need to be clear processes that are understood and followed regarding resolving differences of opinion about cases or groups of cases both internally and across agencies 8.50 Tolerance: Other reviews have found it hard to get over to the public how incidents in which children have been hurt or exposed to major risk have not always led to ‘something being done’ and the whole pattern not recognised. One does not need training in CSE to know that a 12-year-old sleeping with a 25-year-old is not right, or that you don’t come back drunk bruised, half naked and bleeding from seeing your ‘friends’, etc. 8.51 It is not the role of the SCR to examine each individual incident and judge whether a professional acted in a culpable way (that lies with agency processes separate from SCRs), but it can summarise some of the reasons and suggest the impact of national culture. The Police are clear that, where a specific allegation reached investigators, cases were indeed investigated – although success was mostly limited for evidential reasons and insufficient focus on perpetrators. However, the Police review also identified reports of many incidents that were crimes but not regarded as such, and where judgements on future action were coloured by attitudes which saw action as futile due to non-cooperation or self-induced harm. The SCR has also described CSC’s reports of incidents that merited, at the least, further thought and at times statutory inquiry, which received neither. There were also times where it seems that confidentiality was put before protection (with the intention of maintaining relationships with staff who could offer ongoing help). 8.52 The result was that inappropriate or illegal sexual activity by children who were clients, patients or looked after children was subject to a higher tolerance threshold than would be the case than, say, the average parent. This may have been because professionals could not find a way to stop the girls going where they were at risk; it may have been from trying to avoid being too ‘controlling’ and risking more alienation, and from the wide sense that ‘nothing could be done’. However, for some, it may also relate to a reluctance to take a moral stance on right and wrong, and seeing being non-judgemental as the overriding principle. What is right and wrong about youthful sexuality is anyway a rather blurred issue. Paragraph 5.43 referred to health guidance which determines a child’s ability to consent to sexual health advice and get contraception for an act which the child might be legally unable to consent to. The law regards underage sex between peers over 13 as not something that should have any intervention, and it is not much more of a step to see sex between say a 14-year-old and a young adult as ‘one of those things’. And, in this Review, sex with older adults did not always lead to what might colloquially be called bringing in the cavalry to intervene come what may. The benign word ‘boyfriend’ disguised age-inappropriate relationships. 104 8.53 This is more than a policy debate. It affected practical steps. Missing children in care were in the main reported missing, but it was some of the parents who scoured the streets trying to find them, not generally the corporate parent (the Council), although there were some notable exceptions of residential staff doing just that. The logistical difficulty in council staff doing what a parent beside themselves with terror about a child might do is understood, but it is interesting to consider the comparison. 8.54 There can be little doubt that the earlier sexualisation of children, the age of perceived self-determination and ability to consent creeping lower, and the reluctance in many places, both political and professional, to have any firm statements about something being ‘wrong’, creates an environment where it is easier for vulnerable young people/children to be exploited. It also makes it harder for professionals to have the confidence and bravery to be more proactive on prevention and intervention. This is an issue reaching way beyond Oxfordshire and requires a national debate. 8.55 There is also the tolerance that comes from dealing with the extreme ends of human activity, which can happen to any professional. The author has an impression from reading the evidence that because the girls faced so many problems, were missing so often, caused concern so often, that any one incident would be regarded less seriously than a single incident would if it were the only occurrence. This is a natural reaction, but one which can have serious consequences if it results in downplaying the level of harm a child is experiencing. Reading the chronology of events around the child subject to the longstanding concern of the City Nuisance Officer, described earlier, it is disturbing to see how, despite very clear accounts of her late-night lifestyle at 13 with adult men, she was ‘protected’ by being placed with a relative from where the activity continued, as it did when in residential care. 8.56 Whatever the reasons for the higher professional tolerance levels for these children, it was one of the factors that prevented sufficient weight being given to the key task of stopping the abuse. 8.57 Learning points: Staff at all levels need to be clear about the law of consent (to sex and healthcare) Verbal consent does not mean it is free consent, or sensible consent Across agencies, supervisors should test out with staff making decisions about how they see the threshold for action with sexually active children Supervisors (and their managers) need to be aware of the tendency for the impact of an incidence of abuse or risk to lessen when such incidents happen frequently In the tension between action to be non-judgemental and action to prevent harm because an activity is wrong or inappropriate, the latter should be the overriding principle with children Agencies which act as parent or share parental care should, when determining what is appropriate action in the face of risky behaviour, consider what a good parent caring for a child at home would do There needs to be a rethink of the national guidance regarding sexually active children, to ensure that well-intentioned policies to support the vulnerable young do not inadvertently add to a climate that facilitates exploitation 105 8.58 Staff attitudes and rigour: Although the impact of staff attitudes on the handling of CSE has been written about in guidance and several other SCRs or similar, it is worth repeating here as this is at the heart of messages from victims and their families. A number of illustrations were given in their own words in Section 3. While there is no doubt that the grooming, threats and abuse made the victims unable to support investigations, and unable on most occasions to give what would be good evidence, it is also the case that there were plenty of signs that something serious was wrong. One victim, in a Police training video, has described very lucidly signs that she thought were visible and should have meant more to staff. Extreme stories of sex or violence that 12- or 13-year-olds “could surely not make up”, about marks on her that were not pursued, about the ravaging by drugs at such a young age, about being dishevelled and bleeding and not feeling cared for, about no one asking if she was ok, about leaving disturbed pictures around for people to see, and of not being believed. She talked of ‘snide comments’ and an attitude that it was her fault. She would admit she was very difficult to deal with, but thought there were enough clues. (The context of these remarks was about the police, but the CSC IMR details a number of illustrations where CSC did not pursue signs of harm, and Health staff also heard worrying stories and assumed others were dealing with it.) 8.59 These reactions often stemmed from the belief that the girls were being difficult, badly behaved and putting themselves in harm’s way. This in turn made it easier for staff not to be inquisitive, not to pursue every allegation or sign of harm, not to deal with the girls in a way likely to encourage them to be more open, and not to pick up the hints and signs that were there. Whilst in the absence of understanding the grooming process the reactions might be understood, they were not right, fed into the delays, and unintentionally added to the girls’ isolation and sense of vulnerability to the abusers 8.60 Although some of the parents were far from easy to deal with, there was insufficient recognition of how they were affected by their child’s grooming inspired behaviour. Illustrations were given in 5.112. One can see that, in some cases, social work staff became quite exasperated by parents and in these situations staff need the highest level of support and supervision to help tease out what might be an inherent parental reaction, what might be from dealing with the nightmare scenario of a child as a victim of CSE, and what might be a reaction to how they are being treated by staff. Some parents also found the Police at times insufficiently sensitive to their desperation. 8.61 The girls’ comments about how they trusted and felt most at ease with unqualified staff (see section 3 and 5.113), finding some professionals hard to relate to and cool/distant/boundaried, is food for thought for those involved with professional training and practitioners. Professionals were no doubt, by and large, acting as they had been trained, and the depth of dysfunction, the risks, and statutory roles all need professionals’ skills, but the victims are saying that they would have shown more trust and be more likely to disclose (after some time) if some key staff had been more ordinary. They did not use this word, but it sounded like they meant more like ‘friends’. It would seem that to be successful with girls at risk of or suffering CSE that at least one person in the team needs to be like this. 8.62 Learning points: Some of the learning points have used words given by victims and parents However difficult they may appear, children need to be treated as children Ask if they are ok 106 Use the basic niceties Start with the basic assumption that what the child says is to be believed Don’t make snide remarks to possible victims (however they behave) which undermine them more It is important that, just as the victims are not blamed for their exploitation, parents are not blamed for their children’s exploitation Signs of drug and alcohol use at a very young age are not normal and need real inquiry Signs of physical harm must always be investigated If you have any suspicions that a child may be being abused, do not be frightened to ask them about it … and keep asking Go with your instincts if something seems wrong Children do not go missing on numerous occasions without there being a reason. That reason must be explored rigorously Beware in case being more ‘professional’ makes it less likely that the victims will engage 8.63 Investigations: The Police have been very open in their review for this SCR that, on many occasions and for a host of reasons, incidents which needed to be logged as crimes and investigated as such were not, or that incidents initially classified as crimes were reclassified. The HMIC 2014 report shows that this is still a national issue, and the findings in this SCR may well reflect a national position rather than just local. Also, many of the mistaken classifications reflected the level of understanding and the attitudes about CSE prevalent at the time. Nevertheless, the decisions now seen in retrospect to be wrong did mean that victims were sometimes denied their right to a full investigation of crimes against them (even if they might not have been helpful to that investigation). It also meant that it was less likely that patterns and links would be identified. The Police also identified issues about a lack of clarity around the ‘ownership’ of investigations, and confusion around consent. The cases were hard enough and any lack of clarity could not have helped. 8.64 It was not only in the Police that processes led to no or inadequate investigations. CSC’s own review showed alleged assaults by parents not being investigated, information revealed in strategy meetings not looked at quickly, strategy meetings not being called when Police were investigating, and the presence of known offenders with a risk to children in children’s lives not being explored. There were also illustrations of multi-agency investigations delayed to await meetings, and the ‘moment’ when disclosure may have happened was lost. 8.65 In their work for the SCR, both the Police and CSC have emphasised the importance of supervision and review processes in being assured that proper decisions and appropriate action are being taken. In both organisations, there was the involvement, at least at some point, of more senior managers/officers in most of the examples where it is now deemed that an inappropriate decision was taken. This emphasises the importance of a corporate understanding about how processes are working in practice, and of how CSE should be managed. 8.66 Alongside the lack of evidence gathering around offenders until late 2010 and 2011, there was also a lack of disruption activity – which is now a central part of the armoury in tackling CSE. The tools (such as Child Abduction Notices) were available throughout the period under review, and in guidance, but TVP, alongside most other forces, made little to no use of them. The impact was that when the victims were not protected through 107 prosecution/conviction, they were also not protected through the disruption of offender lifestyles in the way one would be today. As an indication of the newness of disruption techniques, Birmingham City Council gained significant national publicity in November 2014 for using civil injunctions to restrict risky men when prosecutions seemed not possible, even though orders with similar powers have been available since the 1980s. 8.67 There was also the focus on the abused and their evidence, rather than getting evidence about the abusers. Although guidance pointed to the necessary focus on the alleged perpetrators, the need to put in major effort was not grasped, and many offences could not be pursued due to weak victim evidence. Not using this approach delayed both the full identification of this sort of CSE and successful prosecutions. But relying almost solely on victim evidence was not unique to the County, and it is only in the most recent years that more offender-focused approach has been accepted as national good practice. The Police IMR has two summary learning points which make the point well: “Moving away from victim disclosure led investigations towards the evidence based approach taken in domestic abuse cases. Building the case without the victim generates disruption/enforcement opportunities and ultimately creates a better environment for them to provide their evidence (Example -The investigation may identify other victims, forensic and/or CCTV evidence that corroborates the victim’s account and reduces the reliance/pressure on them). Recognising that unlike interfamilial abuse the safeguarding of CSE victims relies more heavily on the police led criminal justice interventions as opposed to the social care led ‘Working Together’ processes. This is because these traditional safeguarding approaches cannot protect against offenders outside the family setting, particularly as these will often be unidentified.” 8.68 This was echoed by the CPS: “At the heart of any investigation into child sex or grooming must be a ‘what is happening’ or ‘what happened’ to the victim as opposed to simple evaluation of the quality of victim and his/her account as a witness. The CPS has adopted this approach so that the focus rest on the credibility of the allegation rather than the credibility of the complainant… What is required is an investigation both with the co-operation of the victim if the victim is prepared to co-operate and also an investigation independent of the victim, whether or not the victim is prepared to co-operate.” It gives as an example the Oxford Police obtaining forensic evidence from victim’s clothing without their knowledge. Also the use of phone evidence, care homes and families keeping contemporaneous records of victims’ comings and goings, their appearance, descriptions of those they meet, and vehicle details. The combined effort in Oxfordshire to do all this in the Bullfinch investigation and since is to be applauded, although some family members and care staff did provide information like this years before Bullfinch. 8.69 The CPS also said, “The investigation team did a remarkably good job in encouraging the victims to give evidence and thereafter, keeping in contact with them in the run up to the trial. That is a lesson well learned and should be repeated. The idea of having a dedicated flat for the use of each victim as she gave her evidence was extremely sensible and worked extremely well.” (This involved Police and CSC working together.) 8.70 The Police think greater emphasis on the wider investigative aspects of CSE could be given in the statutory ‘Working Together’ guidance. For example, the section beginning “Professionals should, in particular, be alert to the potential need for early help for a child who…” does not refer to sexual exploitation (which is not mentioned in the core text of the 108 guidance). The guidance on assessment is all about the child and their family, when it might be better also to include the key points of dealing with abuse from outside the family. 8.71 In Oxfordshire, it has been clear since 2011 that it is only the combination of disruption, investigation, intelligence gathering, prosecution and safeguarding the children which leads to successful prevention or intervention, and these method have been or are being used since Bullfinch across the whole Thames Valley area. 8.72 Learning points: How attitudes and understanding of CSE, or indeed ‘difficult’ teenagers and families can impact on what is recorded as and acted upon as a crime How attitudes and understanding of CSE, or indeed ‘difficult’ teenagers and families, can impact on decisions about fulfilling statutory duties in CSC Any allegation of abuse must be investigated formally, even if it does seem to be part of teenager/parent disputes Strategy meetings must always be used to agree the multi-agency roles on inquiries when the criteria are met. The crucial importance of supervisory and review processes to ensure that staff near the front line are making sound and objective decisions The need to recognise that evidence around the ‘bad character’ of offenders can back up vulnerable evidence by victims, and the presence of such evidence can give victims more confidence to give and stick to evidence themselves The need to investigate regardless of the cooperation of the child The need to ensure that there are robust processes in place to make links between victims and between perpetrators – including the use of covert actions and intelligence gathering Disruption of abuser activity is an essential protective process, regardless of whether a criminal case can be brought 8.73 Going missing: The scale of missing episodes was vast. From 2005-10 the six girls were reported missing around 500 times, with around half of the episodes being from Council care. Bearing in mind that no one child was went missing in more than three of those years, one was never in care and several were unable to be missing for long periods as they were in secure accommodation, the intensity of these episodes was high. There was a multi-agency Missing Persons Panel in place from 2007 and the Police’s Missing Persons Coordinator is widely seen (by staff and families) as one of those who should be strongly praised for the personal commitment shown. Paragraphs 5.88 onwards describe a number of weaknesses in the overall process and, despite the coordinator escalating concerns upwards, a focus on managing the girls rather than blocking whatever was being done to them. 8.74 Many of the things that should have been done better are covered above – about crime/no crime, not being sufficiently curious, seeing the girls as at fault, and so on. What is striking to this Review is the scale of going missing and the scale for individuals about whom there was particular concern about health and well-being and sexual activity with older men. This is another confirmation that, over a period of years, processes were not in place which might have brought such issues to the highest attention (managerial or political leaders) so that a major, system-wide response or inquiry could be made to address it. 109 8.75 Care must be taken in making this point. From April 2006 to March 2010 (when the journey of discovery was just beginning to gather pace), there were over 17,000 episodes of being missing in the TVP area, and over 5,800 of these were from Oxfordshire, so going missing was not an unusual occurrence. However, had it been known at the time by higher management or the OSCB that Oxfordshire’s missing from Care figures in 2006-9 were disproportionately large in the Thames Valley, or that half their missing from care episodes related to girls with many recorded concerns about adult males, etc, there may have been a quicker, higher-level response. For example, the OSCB Monitoring and Evaluation Subgroup received missing statistics twice yearly, with a one-line minute in September 2008 and March 2009 saying, “Group to note numbers, with significant numbers of episodes and trends and review over time”, and then “No specific concerns from [Missing Persons] Panel. Very positive re work of Panel.” In the year ending March 2009, the Police recorded the highest numbers missing in Oxfordshire under 18 years, both overall and from Care. There should have been more challenge at this point. Indeed, the CSCs IMR concluded that their own “Performance management systems should have picked up the issue of large numbers of incidents of children missing from care and triggered further challenge about what was happening and why”. 8.76 Learning points: This Review does not intend to go into detail about how managing missing children is best managed. Recent government statutory guidance covers this well,39 and more detailed local agency learning is in the associated publication, ‘Agency Responses since 2011’. Going missing does not always but may well indicate the child concerned is being exploited and therefore has eroded consent Going missing from residential care is an even bigger indicator, as there may well be an inherent vulnerability that can attract perpetrators Because of this vulnerability it can be easy to see the children as running from somewhere, so inquiries must be made as to what they are running to There is now a statutorily required for local authorities to ensure a discussion with the child, the family or both after two or more episodes, and also a requirement to ensure that previous episodes and actions are always taken into account The OSCB, relevant Council committees (or equivalent), including the lead member for Children’s Services, and senior police performance management meetings need not only receive the Missing Persons information regularly, but actively consider and interrogate it to make sure that high volumes are seen as significant rather than downplayed by their commonality Secure accommodation may solve the problem temporarily, but is ineffective beyond the period in secure unless the groomers are disrupted or removed from the scene through conviction 8.77 The impact of ethnicity: As noted above, the material submitted to this SCR makes little reference to ethnicity. This Review has considered whether this reflects the deliberate ignoring of the ethnic aspect to protect sensitivities (which has been suggested elsewhere in the country), or any failure to consider it when to do so would be helpful. The answer, within the limits of time and methodology, is that the author has identified neither, and reports and 39 Statutory guidance on children who run away or go missing from home or care and Flowchart showing roles and responsibilities when a child goes missing from care (DFE, January 2014). 110 interviews suggest that the perpetrators were seen as just that, and not treated differently because of their background. The members of the SCR Panel also specifically discussed this in December 2014, and assured the author that no one was aware of evidence of any holding back due to ethnicity. 8.78 This does not mean that investigators might not have found working with tight-knit groups of a different culture, and at times language, hard. But that does not imply any ‘going easy’ to avoid offending cultural sensitivities or seeming politically incorrect. However, as has been found wherever this type of organised group abuse has been uncovered, the perpetrators have been mainly from an Asian heritage, with some from Africa or south east European countries, and with a mainly Muslim culture. This has continued with the Thames Valley cases post-Bullfinch, and in the very recent convictions in Bristol. 8.79 This SCR, in one county, is not the place to attempt a definitive analysis of why this is, and this needs to be researched and understood at a national level given both its importance and the sensitivities of any conclusions. It cannot be parked as too potentially sensitive or inflammatory to pursue openly at that level. 8.80 The association (not of all CSE, but group-based CSE) with mainly Pakistan heritage is undeniable, and prevention will need both national understanding, communication and debate, and also work with faith groups at a local level. A national recommendation is made below. Section 4 described some of the work around developing community relationships and resilience in Oxfordshire. 8.81 Learning points: The importance of agencies individually and collectively developing strong links with faith groups to share understanding about CSE and to assist with each community’s own efforts to protect children and prevent CSE 111 9 CONCLUDING SUMMMARY AND RECOMMENDATIONS 9.1 This conclusion summarises the facts and findings of the Serous Case Review and makes some recommendations. These recommendations do not aim to repeat the agency-specific recommendations contained in IMRs and being worked on by agencies, nor the OSCB’s collated Action Plan. These can be seen in the associated ‘Agency Responses since 2011’. Rather this Review focuses on overarching, system-wide issues, or those for national consideration. 9.2 A group of approximately 370 girls and young women have been identified as possible victims of sexual exploitation within the last 16 years. Since 2011, there have been a large number of investigations and convictions, the most significant of which was Operation Bullfinch, which culminated in seven men being convicted of around 60 offences against six children. This investigation used a multi-agency approach and innovative tactics to bring together victim statements and intelligence about the lifestyle of the offenders. The core of this SCR is whether this point could have been reached earlier, and if so why. 9.3 The agencies involved have made comprehensive reviews of their own services, and have openly identified many things that could have gone better. The author has been impressed by the candour of agencies (as well as their huge commitment to make things better now). However, there were clearly many things done which are clearly seen now as mistakes or mistaken approaches. The author has seen little that has not been replicated in other SCRs on CSE, or in national reviews which have identified over and again the slow progress in responding to guidance, and a poor understanding of CSE and its wide geographical spread. That slow progress was often related to three things – thinking group based CSE happened somewhere else, an inability to grasp that something as horrible could really be happening, and seeing the victims as placing themselves at risk rather than understanding the grooming process. 9.4 The fact that the most of the patterns of agency and professional response seen in Oxfordshire were not unusual is both true and sad. But the fact that the lack of knowledge and understanding of CSE and attitudes to the most difficult teenagers were common nationally does not mean no one was responsible: all agencies and professionals in the country share the responsibility of protecting children. This is why this Review has gone to some length in describing what happened and the long process to discovery. As most information about what happened has diligently and openly come from agencies, it is also to show that Oxfordshire has recognised what could and should have been different, and is not hiding its own mistakes. 9.5 There were three other attitudes which also lay behind the failure to recognise more quickly that group CSE was occurring to multiple girls. Firstly, the girls’ precocious and difficult behaviour was seen to be something that they decided to adopt, with harm coming because of their decisions to place themselves in situations of great risk. The fact that most of the children came from families with other problems enhanced the belief that the problem and the solution lay with the family or the girl concerned. Secondly, there was a failure to recognise that the girls’ ability to consent had been eroded by a process of grooming escalating to violent control. These two issues sometimes resulted in responses to the girls or parents which compounded the lack of trust in agencies instilled by the grooming. Thirdly, 112 there was pessimism about the prospect of criminal investigations being successful. Very strong evidence was needed and, through the impact of the grooming and fear, hardly any evidence was obtained that was not withdrawn or later denied. 9.6 Overlaying this, and partly related to the attitudes in the previous paragraph, were confusions about what should be recorded as a crime and investigated, a lack of curiosity, and a failure to look into worrying events, was seen in several agencies. This in turn was enhanced by weaknesses in supervision. There was also an apparent tolerance of inappropriate sexual activity, which was partly created and partly fuelled by societal ambivalence (and lack of understanding) around consent. 9.7 There was very little use of disruption tactics before Bullfinch; although several such tactics were known and available, these were also not widely used elsewhere. Neither were the covert surveillance and rigorous intelligence gathering now seen to be essential. This meant that taking something forward rested almost wholly on victim evidence – which in CSE can rarely be expected to be forthcoming or maintained. Whilst Oxfordshire now has a nationally renowned level of expertise in how to approach the multi-agency investigation of CSE, the approaches it uses now were not widely known and understood before 2011. 9.8 The patterns seen above are likely to have been seen anywhere where CSE has been a challenge, but there were in addition issues that seemed to be more local to Oxfordshire. Whilst the fact that the OSCB regrettably did not respond adequately to the 2009 statutory guidance on CSE was not uncommon amongst LSCBs, it did seem to reflect a pattern in Oxfordshire in the years leading up to Bullfinch of weaknesses in the way agencies collectively worked together around safeguarding. External inspection showed the OSCB to need improvement in 2008, and the fact that it did not get a grip of CSE until 2011 suggests it took some time to work well, although it was externally rated as good from 2010 so must have been making improvements. The Safeguarding Board consists almost entirely of Oxfordshire agencies. There is no indication that any of them challenged the delay in responding to the statutory guidance, or indeed the earlier dropping off the agenda of concerns expressed in 2007 about girls and ‘organised prostitution’. 9.9 Despite there being very worrying case illustrations over a number of years involving more than one girl, multiple alleged perpetrators, usually Pakistani, with a very strong association with children in care, the highest levels of management were not briefed until 2011. This included Directors of Children’s Services. Whilst it must be pointed out that, until the end of 2010, there was little knowledge of the CSE that had happened elsewhere in the country, this Review concludes that the circumstances described, regardless of the name given to them, were so extreme that top management and indeed governing bodies should have been given the opportunity to bring their unique perspective to the issue earlier. 9.10 There are, of course, differing cultures of escalation in different agencies, but the fact that there was no exception to this pattern of non-escalation suggests something that leaders in Oxfordshire must make sure is not present now. It is true that the way this Review has tabulated series of events over short periods to illustrate what was known is a type of collation not done until late 2010, so staff never saw the picture as starkly. That in itself provides a learning point about continually taking history into account. 113 9.11 This lack of overview is regrettable, as the information, for example across 2005-8, was very similar to that which triggered Bullfinch in 2011. The position in Oxfordshire was not therefore of clear warnings to top decision-makers but the absence of such warnings. 9.12 The various strands of thinking about CSE which eventually culminated in the Bullfinch investigation were led by dedicated and enthusiastic staff, some quite junior, in the City and County Councils and the Police (with support from other agencies), and their work must be applauded. It was the combined impact of their work which in the end led to the investigation, convictions and modern ways of tackling CSE. However, the fact that this work was essentially done in a governance vacuum, without strategic oversight, provides a clear lesson for agencies about what was missing, and about what they must be sure is in place now. 9.13 The contribution to the Review by victims and parents has been extensive and hugely valuable. Their perspectives about the grooming process, their interaction with staff, and what they think would have made things better have had a big impact on this Review, for which the author and the OSCB is most grateful. 9.14 Recommendations: The recommendations from this Review are aimed at the system. The learning points, set out in collated form in Appendix 1, provide a more detailed set of points for OSCB and agency consideration – for use as a checklist against which to assess current practice. There are three recommendations for national consideration. The local recommendations below are set out for OSCB consideration, either for direct action or to oversee in its assurance role. Such assurance needs to be ongoing. They are worded that the OSCB has flexibility in how it achieves them. Where there is reference to ‘member agencies’, this should be deemed to include educational establishments that are not actual members, nor under OCC management, and the OSCB will need to be sure how it seeks assurances from them For national consideration i. The DfE should review ‘Working Together’ 2013 to ensure it gives sufficient weight to investigation and disruption aspect of safeguarding children at risk from CSE ii. Relevant government departments should consider the impact of current guidance on consent to ensure what seems to be the ever-lower age at which a child can be deemed to consent (for example to treatment) and attitudes to underage sex are not making it easier for perpetrators to succeed iii. With a significant proportion of those found guilty nationally of group CSE being from a Pakistani and/or Muslim heritage, relevant government departments should research why this is the case, in order to guide prevention strategies. For the Oxfordshire Safeguarding Children Board The Board should (if it has not done so already): i. Ask each member agency to review its escalation procedures, and provide assurance to the Board that they are understood and complied with 114 ii. Review the interrelationships with other multi-agency partnerships, such as District Community Safety Partnerships and the County Safer Community Partnership, to ensure there is mutual clarity about each other’s roles and appropriate cross-representation iii. Ask each agency to provide evidence of its supervision policies and how the agencies ensure they are effective iv. Be assured that the lessons from this Review and IMRs are embedded in OSCB and single agency training v. Ensure that the messages from victims and their families given to this review are embedded in training vi. Seek evidence that minutes of multi-agency meetings are clear about ownership, have consistent titles, and can be seen by their content and appearance to be of high value vii. Seek assurance from TVP about progress on recording crime relating to sexual offences viii. Seek assurance from OCC that there is appropriate access to the necessary range of LAC placements ix. Ensure that reports on missing children statistics for the Board are fully interrogated to identify any emerging patterns x. Seek assurance from Oxfordshire County Council that there are good arrangements for the transfer of information between schools about child vulnerability, and that decisions around exclusion from school and its management (risk assessments and plans) take into account that the behaviour is or may be related to exploitation xi. Seek assurance from NHS bodies, including general practice, that staff include the consideration that consent has been eroded through exploitation when assessing a child’s ability to consent to treatment and that referrals to statutory agencies will be made appropriately xii. Seek assurance from all member agencies that staff are aware of the guidance around consent to sexual activity, and relationships xiii. Continue to undertake rigorous multi-agency case audits where CSE is suspected i APPENDIX 1: COLLATED SCR LEARNING POINTS From ‘Were mistakes made?’ Lack of understanding led to insufficient inquiry National guidance was not widely understood or followed The behaviour of the girls was interpreted through eyes, and a language, which saw them as young adults rather than children, and therefore assumed they had control of their actions At times, their accounts were disbelieved or thought to be exaggerated What happened to the girls was not recognised as being as terrible as it was because of the view that saw them as consenting, or bringing problems upon themselves, and the victims were often hostile to and dismissive of staff As a result the girls were sometimes treated without common courtesies, and as one victim described it by ‘snide remarks’ There was insufficient understanding of the law around consent, and an apparent tolerance of (or failure to be alarmed by) unlawful sexual activity There was insufficient understanding of parental reaction to their children’s behaviour and missing, so distraught, desperate and terrified parents were sometimes seen as part of the problem There was insufficient curiosity about what was happening to the girls, or to investigate further incidents or concerns which, on review, now appear to be crimes or something for formal child protection investigation Although there were very few formal disclosures, there were many, often stark, indications that what was happening to them was extreme and out of the ordinary There was insufficient attention to investigating and disrupting the activities of the alleged perpetrators (compared to the effort to contain the girls behaviour), and various available legal tools were not used. There was insufficient understanding of how the City Council’s community safety function could contribute to the prevention and management of CSE Day-to-day processes were not strong enough Insufficient use was made of Child Protection processes, and staff sometimes allowed parental reaction to prevent Child Protection processes being used Processes in CSC, such as supervision and the quality of reviews, were not strong, especially 2006-9 Minutes of multi-agency meetings and review were largely of low quality or missing, which weakened planning and information sharing Recording of ‘crimes’ was inconsistent Transfer of educational records between schools was poor The provision of alternative education after exclusion, or of post-secure placement education, was slow In health, there was insufficient sharing of information heard from or about the girls (often for ‘confidentiality’) and LAC medicals were often done without full knowledge of history and context ii The organisational response in Oxfordshire was weak and lacked overview Escalation about serious concerns about looked after children and emerging patterns did not reach governing body level or Chief Officers for several years after they had begun to emerge in 2005, and again 2006-10 When some signs reached the ACPC and OSCB in 2005 and 2007 respectively there was insufficient curiosity and no follow through The OSCB, before late 2011, did not lead the scoping, understanding and prevention of CSE after the 2009 statutory guidance, and member agencies who comprise the OSCB share that responsibility Whilst before 2010 there was much less recognition of the connectedness of cases, or the organised nature of perpetrators, both within and across agencies, the growing awareness in 2010 still did not reach top management or the OSCB Before 2011 there were fewer processes in place to help form a force-wide Police view of developing problems There was a gap of one to two months between senior managers being aware of the bigger picture, or at least the strong likelihood of a bigger picture in late 2010, and very top management being informed From ‘What was missing organisationally in Oxfordshire’ The risks an OSCB runs if it does not have robust processes for - acting on new guidance - performance monitoring to ensure actions are seen through - ensuring there are routes in for fieldwork concerns to be heard - its role being widely understood by staff at all levels The OSCB, other than the part-time presence of an Independent Chair, has no existence other than as a collective unit. This means governing bodies must be sure their organisations and leaders actively share in leadership and shaping the Board The importance of the District Council community safety role being proactively understood by partners, and appropriate links with County children’s services being strong at operational and more strategic level The need to reconsider how Districts are represented on the OSCB Governing bodies need to be sure they are clear on what they expect to be reported to them by way of early warning, so they have an opportunity to reflect on an issue as early as is useful Governing bodies need to be sure that performance management arrangements identify key measures of child safety, including those around looked after children The benefits of relatively junior staff using their initiative to take forward discussions and explorations about concerns on child safety, but… … there is also a need for their managers to ensure such important work makes the right links inside and across agencies, and also what the governance framework is for the work From ‘Knowledge’ OSCB member agencies also receive such guidance and need to share responsibility for it being considered both internally and collectively by the Board iii The value of more widely and proactively seeking out learning and good practice, as shown by the City and the Police There may be an assumption that the focus on CSE is so high now that the old, less unhelpful attitudes to the victims have gone. This needs ongoing monitoring From ‘Escalation’ LSCBs are strategic, but must also be sure that they have processes that allow them to hear of operational concerns at an early stage, so there can be a decision as to whether the Board needs a collective response/action Agencies should satisfy themselves that formal escalation processes work in practice, from the perspective of both front line staff and top managers Also, that there is a culture which promotes the sharing of concerns and reacts positively rather than negatively to service concerns There need to be clear processes that are understood and followed about resolving differences of opinion about cases or groups of cases, both internally and across agencies From ‘Tolerance’ Staff at all levels need to be clear about the law of consent (to sex and healthcare) Verbal consent does not mean it is free consent, or sensible consent Across agencies, supervisors should test out with staff making decisions how they see the threshold for action with sexually active children Supervisors (and their managers) need to be aware of the tendency for the impact of an incidence of abuse or risk to lessen when such incidents happen frequently In the tension between inaction to be non-judgemental and action to prevent harm because an activity is wrong or inappropriate, the latter should be the overriding principle with children Agencies which act as parent or share parental care should, when determining what is appropriate action in the face of risky behaviour, consider what a good parent caring for a child at home would do. There needs to be a rethink of the national guidance regarding sexually active children, to ensure that well-intentioned policies to support the vulnerable young do not inadvertently add to a climate that facilitates exploitation From ‘Staff attitudes and rigour’ However difficult they may appear, children need to be treated as children Ask if they are ok Use the basic niceties Start with the basic assumption that what the child says is to be believed Don’t make snide remarks to possible victims (however they behave) which undermine them more It is important that, just as the victims are not blamed for their exploitation, parents are not blamed for their children’s exploitation Signs of drug and alcohol use at a very young age are not normal and need real inquiry Signs of physical harm must always be investigated If you have any suspicions that a child may be being abused, do not be frightened to ask them about it… and keep asking Go with your instincts if something seems wrong iv Children do not go missing on numerous occasions without there being a reason. That reason must be explored rigorously Beware in case being more ‘professional’ makes it less likely that the victims will engage From ‘Investigation’ How attitudes and understanding of CSE, or indeed ‘difficult’ teenagers and families, can impact on what is recorded as and acted upon as a crime How attitudes and understanding of CSE, or indeed ‘difficult’ teenagers and families, can impact on decisions about fulfilling statutory duties in CSC Any allegation of abuse must be investigated formally, even if it does seem to be part of teenager/parent disputes Strategy meetings must always be used to agree the multi-agency roles on inquiries when the criteria are met. The crucial importance of supervisory and review processes to ensure that staff near the front line are making sound and objective decisions The need to recognise that evidence around the ‘bad character’ of offenders can back up evidence by victims, and the presence of such evidence can give victims more confidence to give and stick to evidence themselves The need to investigate regardless of the cooperation of the child The need to ensure that there are robust processes in place to make links between victims and between perpetrators – including the use of covert actions and intelligence gathering Disruption of abuser activity is an essential protective process, regardless of whether a criminal case can be brought From ‘Going missing’ Going missing does not always but may well indicate the child concerned is being exploited and therefore has eroded consent Going missing from residential care is an even bigger indicator as there may well be an inherent vulnerability that can attract perpetrators Because of this vulnerability it can be easy to see the children as running from somewhere, so inquiries must be made as to what they are running to There is now a statutorily requirement for local authorities to ensure a discussion with the child family or both after two or more episodes, and also a requirement to ensure previous episodes and actions are always taken into account The OSCB, relevant Council committees (or equivalent), including the lead member for Children’s Services, and senior police performance management meetings need to not only receive the Missing Persons information regularly, but to actively consider and interrogate it to make sure that high volumes are seen as significant rather than downplayed by their commonality Secure accommodation may solve the problem temporarily, but is ineffective beyond the period in secure unless the groomers are disrupted or removed from the scene through conviction v From the Impact of ethnicity The importance of agencies individually and collectively to develop strong links with faith groups, to share understanding about CSE and to assist with each community’s own efforts to protect children and prevent CSE vi APPENDIX 2: SCR TERMS OF REFERENCE Note: The Terms of Reference are those agreed by the SCR Panel on 11.9.14 to update them for revised national expectations following new guidelines published in March 2013, and to guide the production of the final report. They were originally prepared in November 2012. TERMS OF REFERENCE FOR THE SERIOUS CASE REVIEW OF CHILD SEXUAL EXPLOITATION IN OXFORDSHIRE (CHILDREN A-F) 1. Decision to hold the Serious Case Review Following the review of circumstances relating to the cases of Children A,B,C,D,E,F from Operation Bulfinch, a decision was made by Oxfordshire Safeguarding Board to convene a Serious Case Review (SCR) on 26 September 2012. The cases met the criteria for a SCR as defined in chapter 8 paragraphs 8.9–8.12 of ‘Working Together 2010’. This draft of the Terms of Reference is a working document and will be subject to amendment by the SCR Panel. 2. Background and scope of the review Background: Concerns were identified about young people in Oxfordshire who were being sexually exploited. The collective picture from local agencies and the intelligence that emerged about those individual young people led to ‘Operation Bullfinch’. This complex investigation was led by the Police and involved other OSCB partners. Over 20 young people were identified as victims of serious sexual exploitation. Nine men stood trial at The Old Bailey in January 2013, seven of whom received substantial custodial sentences. The charges related to six individual girls: four cases of historic abuse and two which were current. The abuse was described by Judge Rook as a “series of sexual crimes of the utmost depravity”. Scope: This review is on child sexual exploitation in Oxfordshire and using the cases of the six victims, reviews the work of agencies, the extent to which they were aware of the abuse, and how they responded to it. The six had suffered abuse over a long period of time and they were a representative group of a wider cohort of known young people. The complexities of their circumstances led to a thematic review in order to build on what was already understood by 2012 and to maximise learning. The report will describe the background to and experiences of the girls’ journey through exploitation. This process will draw out the themes that show the strengths and weaknesses of the safeguarding system and aims to understand not only ‘what’ happened but ‘why’. The first annual report of the National Panel of Independent Experts on SCRs (which oversees the quality of reviews and that appropriate action is being taken from the learning) comments on SCRs being produced now. It has expressed concern about undue length. It warns against a level of detail that would make publication difficult (and hence learning is limited). It calls for a ‘sharp focus’ and ‘concise accounts’. This SCR will take this into vii account by using the case detail to illustrate findings rather than attempt to describe all the very significant history. 3. Key themes for study Although this review was commence under the national guidance, ‘Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, 2010’, these terms of reference are now also guided by the successor guidance, ‘Working Together, 2013’. This guidance captures the purpose: when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm… These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved locally in cases. Everyone across the country has an interest in understanding both what works well and also why things can go wrong. ‘Working Together, 2013’ goes on to say: reviews look at what happened in a case, and why, and what action will be taken to learn from the review findings; action results in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and there is transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final reports of Serious Case Reviews (SCRs) with the public. SCRs... should be conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. This Review will explore any avenue necessary to fulfil these statutory requirements, and will look at the following two key questions: To what extent was the child sexual exploitation experienced in Oxfordshire preventable? What can be learned from the reviews appraisal of the quality of agency work, and the experiences of the victims and their families? To answer these questions the review will need to explore: What was known about child sexual exploitation and how it could be tackled If it was not identified quickly enough, why not? What, including the quality of agency work, contributed to the vulnerability if the victims to abuse? viii How did agencies respond to the growing awareness of child sexual exploitation? What have agencies already learned and done as a result of Operation Bullfinch? What still needs to be done? The Review should identify where agency performance could have been better, but also explain the context in which that performance occurred, so that the contributory factors provide learning for OSCB and its member agencies. To fulfil these Terms of Reference, the views of the six girls and their families must be sought and reported, and they should have an early opportunity to hear and discuss the findings. SCR Panel 11.9.14 Report author: The Report author from July 2014 is Alan Bedford, who has a background in child protection social work, senior leadership of NHS Trusts and Health Authorities (13 years as a CEO), as an LSCB Chair and is the author of many SCRs. ix APPENDIX 3: CSE NUMBERS – METHODOLOGY ‘A group of approximately 370 girls and young women have been identified as possible victims of sexual exploitation within the last 15 years’ This is the method used in reaching the figures as assessed by Children’s Social Care and Thames Valley Police These figures have been derived from TV Police and OCC records. Individual children have been cross-matched to avoid duplication and to ensure that both agencies are agreed as to the appropriate category for the child. Children’s Social Care records cover the period 1999-2012. TVP records cover the period from the period subject to the Operation Bullfinch investigation (2005) to date. Kingfisher figures (joint CSC and TVP) cover its referrals since it started November 2012 to December 2014. From a Children’s Social Care perspective, the figures were arrived at following work during Operation Bullfinch. All the girls of interest to Bullfinch were identified with the police team and a search done to identify those with whom CSC had had any contact. A file review was then undertaken looking at each of those girls to identify any issues and concerns which may have been an indicator of CSE, including missing episodes, allegations, and information such as having an older boyfriend or associating with other girls at risk. Some of the girls were active Bullfinch cases and information from the police team was used to prioritise the review work. That information was collated on a simple pro-forma and then analysed and the girls categorised into the following groups: Disclosed to the police, either before or as part of Operation Bullfinch, or possibly a clear disclosure to a social worker or other professional, even where that did not result in a formal statement or charges Evidence but no disclosure = strong evidence of grooming/CSE noted by either the Bullfinch investigation or in CSC records, which includes a ‘third party’ disclosure by a friend or family member but where the girl herself (at the time of writing) had declined to make a disclosure Probable = examination of these cases show clear indications of grooming or CSE as would currently be identified in the CSE Screening Tool, including information that the child had been with other victims and/or at addresses where other victims were believed to have been abused Possible = less clear than the previous group, but case records indicate some of the signs of CSE/grooming which would currently be identified in the Screening Tool No Evidence = these girls names were raised through Bullfinch but analysis of records does not give any clear indications of grooming/CSE Girls specifically linked to a (named) case which has since been dropped An additional four girls were added to the list following a review of a children’s residential unit which identified them as likely victims, ie they would have fallen into group two. In 2013, the police in the Bullfinch Team were provided by CSC’s reviewer with a full report setting out details of all the girls where concerns had been identified. A meeting was held with the senior officer within the team, a second police officer, the CSC reviewer, the manager of Kingfisher and the Area Social Care Manager to discuss the report. It is understood that the Bullfinch Team would consider those cases as part of their ongoing investigations. x APPENDIX 4: OFSTED INSPECTION 2014: KEY FINDINGS Section 1: The local authority Summary of key findings This local authority is good because: 1. When agencies are concerned about children, they know how to get the right level of help for them. Thresholds for the different levels of help, including social care, are clear and understood by professionals. 2. Agencies work well together. Early help services are well coordinated and have clear thresholds for support. The Troubled Families programme, Thriving Families, is well targeted and responsive, with good take-up by those families in most need. When children are referred to children’s social care they almost always receive a prompt response and the right help. The large majority of social work assessments are good. Children are always seen and asked about their life and what they need to improve it. Assessments analyse risk carefully and what needs to be done to reduce it. Hospital-based social workers complete good assessments that result in effective planning and discharge arrangements for newborn babies who may be in need of help or protection. 3. The large majority of child protection enquiries are carefully planned by children’s social care with the police and other agencies and investigated thoroughly. Social work action to protect children when they need it is decisive and proportionate. 4. Consultation and advice are readily available to professionals who are concerned about possible child sexual exploitation. The Kingfisher team provides a consistent service for children identified as at risk of sexual exploitation. Their work is clearly focused on reducing risks as well as on meeting children’s and young people’s wider needs. 5. A stable workforce in children’s social care means that most children experience consistency of social worker and say they have a significant, sustained relationship with them. 6. Decisions about whether children should become or remain looked after are timely and based on evidence about the child’s needs. When necessary, care proceedings are initiated quickly to ensure that children are not exposed to harm for extended periods. 7. The Family Placement Support Service is a particular strength. It works effectively with families to prevent the need for children to become looked after. It also supports families when a child returns home after being looked after. 8. Long-term planning to secure stable futures for children is given a high priority. The search for suitable alternative families starts at the earliest possible stage. The contribution made by the adoption service is good. The number of children placed for adoption has increased over the last two years and includes improved adoption rates for older children. 9. Young people are well supported when they leave care. The quality of most pathway plans is good and, whilst some lack detail, most reflect clear and timely actions to help young people make the transition to independence. Most care leavers feel well supported by their xi social workers and describe effective and consistent relationships that enable them to develop trusting relationships. 10. A ‘Staying Put’ scheme has enabled a growing number of care leavers to remain with their carers beyond the age of 18. This is bringing demonstrable improvements to the life chances of most care leavers, for example in increased emotional stability as well as a secure base while in education. 11. Services for children and families are given a high priority by senior leaders and elected members. The local authority knows its strengths and weaknesses well. Strategic priorities are identified and informed by feedback from children, young people, parents, carers and staff. Leadership is strong and effective and services make a demonstrable difference in improving the life chances of some of the most vulnerable children in Oxfordshire. 12. Elected members have high aspirations for looked after children and young people in Oxfordshire and have prioritised continued investment, for example in additional social worker and team manager posts. They hold senior officers to account for the quality of services. 13. Management oversight of practice is good. Performance data are used effectively to inform change and drive improvement. This learning culture is further supported by the effective identification and dissemination of lessons from audits and serious case reviews. xii APPENDIX 5 ACRONYMS ACPC Area Child Protection Committee ASBO Anti Social Behaviour Order BME Black and Minority Ethnic CAIU Child Abuse Investigation Unit CEOP Child Exploitation and Online Protection Centre CID Criminal Investigation Department CSC Children’s Social Care CSE Child Sexual Exploitation DC Detective Constable DCS Director of Children’s Services DfE Department for Education DI/DCI Detective Inspector/Detective Chief Inspector FT NHS Foundation Trust GP General Practitioner IMR Individual Management Review JAR Joint Area Review LAC Looked After Child/ren, ie in Council Care LSCB Local Safeguarding Children Board MP Member of Parliament NWG National Working Group on CSE OCC Oxfordshire County Council OCyC Oxford City Council OH Oxford Health NHS FT OUH Oxford University Hospitals NHS Trust OSCB Oxfordshire Safeguarding Children Board PC Police Constable PCT NHS Primary Care Trust SCR Serious Case Review xiii APPENDIX 6: OXFORDSHIRE SAFEGUARDING CHILDREN BOARD MEMBERS As of 26.2.15 when it accepted this SCR and approved it for publication Name Job title Organisation Maggie Blyth Independent Chair Independent Jim Leivers Director for Children’s Services Children Education and Families Oxfordshire County Council Christian Bunt Superintendent Thames Valley Police Stephen Czajewski Director Thames Valley Community Rehabilitation Company Katy Barrow-Grint Detective Chief Inspector Thames Valley Police - Protecting Vulnerable People Unit Peter Clark Monitoring Officer and Head of Law & Governance Legal, Oxfordshire County Council Clare Robertson Designated Doctor Safeguarding Oxfordshire Clinical Commissioning Group Sula Wiltshire Director of Quality and Innovation Oxfordshire Clinical Commissioning Group Pauline Scully Director of Children and Families Division Oxford Health NHS Foundation Trust Ros Alstead Director of Nursing and Clinical Standards Oxford Health NHS Foundation Trust Lucy Butler Deputy Director Children’s Social Care & Youth Offending Service Oxfordshire County Council Rebecca Matthews Interim Deputy Director for Education and Early Intervention Children Education and Families Oxfordshire County Council Seona Douglas Deputy Director for Social & Community Services (adults) Social & Community Services Oxfordshire County Council Clare Edwards Lay member Modupe Adefala Lay member Alison Chapman Designated Child Protection Nurse Safeguarding Oxfordshire Clinical Commissioning Group Julia Grant Acting Lead Nurse, Safeguarding Children Services Oxford Health NHS Foundation Trust Tracy Toohey Safeguarding Children Lead and Patient Experience Oxford University Hospitals NHS Trust Debra White Senior Probation Officer Oxford Probation Service Gareth Davies Brigade Welfare Support Officer Army Welfare Service 11Bde xiv Hannah Farncombe Safeguarding Manager Children Education and Families Oxfordshire County Council Penny Browne Area Social Care Manager Central Area Children Education and Families Oxfordshire County Council Tan Lea Early Intervention Manager Children Education and Families Oxfordshire County Council David Heycock GM Home and Community Safety Manager Fire and Rescue – Oxfordshire County Council Catherine Stoddart Deputy Chief Nurse Oxford University Hospitals NHS Trust Julie Kerry Thames Valley Area Team Manager NHS England Tony McDonald Divisional General Manager – Children & Women’s Division Oxford University Hospitals Trust Gerry Stevens Social Work Team Manager SSAFA Personal Support and Social Work Service RAF Amrik Panaser County Manager Youth Offending Service Children Education and Families Oxfordshire County Council Sally Thomas Service Manager Oxford CAFCASS Sally Truman Shared Policy and Partnerships Manager South and Vale District Council Tim Sadler Executive Director, Community Safety Oxford City Council Val Johnson Partnership Development Manager Oxford City Council Nicola Riley Shared Interim Community, Partnerships and Recreation Manager Cherwell and Northants District Council Diana Shelton Head of Leisure and Tourism West Oxfordshire District Council Jo Melling Head of Commissioning - Drugs & Alcohol Team (DAAT) Public Health – Oxfordshire County Council Romy Briant Voluntary rep Reducing the Risk of Domestic Abuse Emma Lawley Head teacher Springfield School Annabel Kay Head teacher Warriner School Lynn Knapp Head teacher Windmill School Melinda Tilley Councillor and Lead Member for Children Oxfordshire County Council Alan Bedford Final. OSCB approved 26.2.15 BRIEF SUMMARY OF THE SERIOUS CASE REVIEW This review is about the sexual exploitation of children in Oxfordshire. It uses as background the experiences of six girls who were the victims in the Operation Bullfinch trial. When most of the abuse took place there was almost no knowledge of group or gang related Child Sexual Exploitation anywhere in the country. While it is easy looking back to say “it was obvious”, at the time it was something organisations did not understand. The Review says many errors were made, and shows what lay behind them. Organisations had a weak understanding of government guidance related to the exploitation of children. This was the case all over the country, not just locally. This lack of understanding meant that police and social workers did not look hard enough at what was happening to the girls. The girls were not able to make their own decisions because of the grooming, but staff tended to see them as difficult girls making bad choices. This mistaken conclusion meant that staff did not look enough at what was drawing them away from their homes (their own homes or care placements). There was not enough investigation. The language used by professionals described the girls’ behaviour as caused by them, not their situation with the groomers. As a result, the girls received much less sympathy than they should have received. They were often in care for their own protection, but their frequent episodes of going missing were seen to be because they were difficult children. The law around consent was not properly understood. There was confusion around the fact that young teenagers can consent to use contraception to have sex that might be illegal. This makes it easier for the exploiters. Young teenagers were seen too much as young adults rather than as children. Some professionals seemed to get used to knowing the girls were having sex with men, rather than having a clear view that it was wrong, full stop. The victims almost never cooperated with investigations. This was caused by the grooming and fear. There was a sense that nothing could be done as evidence was weak. The need for disruption, investigation and careful information-gathering, even when there is no formal evidence from victims, was not understood as it is now. The lack of cooperation and behaviour of the victims sometimes led to crimes against them not being recorded as crimes, when clearly they were. This was wrong. There was a lack of curiosity across agencies about the visible suffering of the children and information given by girls, parents, carers, and worried staff. Also, there was a failure to recognise that the situation was so bad it should be reported to top managers, so they could start a county-wide response. Instead, the cases were seen more in isolation, with the focus mainly on protecting and containing the girls, rather than tackling the perpetrators. There was no evidence that the race and ethnic background of the exploiters stopped the professionals from identifying the child sexual exploitation earlier. The Review shows that from 2005-10 there was enough known about the girls, drugs, sexual exploitation, and association with adult men to start a more serious response. But this did not happen – and mostly the information did not reach high levels. As well as the errors seen in other places, there were reasons why in Oxfordshire the group abuse was not recognised earlier, when there were opportunities to do so. The Oxfordshire Safeguarding Children Board, and the committee which was there before it, did not show sufficient grip or curiosity when some early signs were presented, and child sexual exploitation drifted off the agenda. Children’s Social Care was at the time of much of the abuse regarded as only “adequate” by Ofsted. Another review showed the Oxfordshire Safeguarding Children Board needed to improve. Social worker numbers were at one point amongst the lowest in the country, leading to high caseloads, and supervision of staff was not strong. Child protection processes were not always strong. These extremely worrying cases were not reported to top bosses. The Police, at that time, did not have good systems for seeing patterns across the force so did not piece together the different cases. There are signs that top level commitment from the different organisations to the Oxfordshire Safeguarding Children Board varied, and that the Board did not follow things through properly. Really important national guidance on child sexual exploitation published in 2009 was overlooked. As a result, the Child Sexual Exploitation that later emerged in the Bullfinch inquiry and trial was led, not by top managers and committees, but by more junior staff working nearer the families. A drugs worker for the City Council, a social worker, and a detective inspector, on their own initiative, each led a number of meetings which were unknown to the Oxfordshire Safeguarding Children Board or top managers. Their efforts discovered there was group exploitation of multiple girls. Action from this point became coordinated and successful leading to many convictions. Since this turning point in early 2011, Oxfordshire has responded very well indeed to the challenge, is rated as ‘good’, and is held up as a good example of how Child Sexual Exploitation should be tackled. There is no denial by local organisations of either the errors made, or the scale of abuse, and top level apologies have been made to the victims and their families. The Review identifies around 60 learning points that will help agencies understand why and what needs to happen to be sure Child Sexual Exploitation continues to be tackled well. |
NC50663 | Attempted suicide of a 17-years-6-month-old young person in December 2016 resulting in significant and life changing injuries. The young person Darry exhibited behavioural and language concerns at secondary school which led to a move to a school for children and young people with special educational needs at age 15. From the beginning of Year 12 the school became concerned about Darry with evidence of increased anxiety, low mood, lack of interaction with peers and self-harm and referred Darry to CAMHS Learning Disability Team. A meeting with CAMHS, Special Educational Needs, school staff and mother in November 2016 summarised Darry's recent deteriorating mental state and mother's views regarding long term bullying, family losses and domestic abuse. Findings: young people with deteriorating mental health require a holistic multi-agency response which takes account of all factors and does not focus on the young person as the problem; self-harm is a serious issue which needs robust multi-professional action; referrals to children's social care need to make clear the concerns to enable a decision to be made on the best available information; there is professional confusion about the Mental Capacity Act as it relates to 16 and 17-year olds, particularly in the context of parental decision making and professional advocacy. Uses a hybrid version of a systems process. There are no recommendations in this overview.
| Serious Case Review No: 2018/C7429 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Serious Case Review “Darry” QQQQQ 2 CONTENTS Page Number Introduction and process of the Serious Case review (SCR) Why this Serious Case Review (SCR) was undertaken? Family Background Background circumstances of Darry Process of the Review Family Involvement in the Review 2. Chronology of professional involvement over a 15-month period 3. The Findings Finding 1: Professionals need to evaluate the most appropriate action to take to address parents/carers reluctance to accept services designed to improve the circumstances of children and young people. Finding 2: Young people with poor or deteriorating mental health require a holistic multi-agency response which takes account of all the factors that might have caused their difficulties, rather than a focus on the individual young person as the problem. Finding 3: Self-harm is a serious issue which needs robust multi-professional action, management and clarity about who should be the Lead agency Finding 4: Referrals to Children’s Social Care (CSC) need to make clear the concerns to enable a decision to be made on the best available information. CSC need to provide feedback when concerns are not clear to help the multi-agency network improve. Where it is agreed that referrals do not meet the threshold for CSC services there should be a discussion about alternative courses of action such as an early help response to ensure that children and young people’s needs are met. Finding 5: There is Professional confusion about the Mental Capacity Act (MCA) as it relates to 16-17 year, particularly in the context of parental decision making and professional advocacy. 3 1. Introduction and process of the Serious Case review (SCR) Why this Serious Case Review (SCR) was undertaken? 1.1 This SCR has been commissioned by QQQQQ Safeguarding Children’s Board (QQQQQ). This SCR was initiated as a result of Young Person D (known in this report as Darry1) attempted suicide at the age of 17 years and 6 months sustaining significant and life changing injuries. This attempt came after escalating concerns about previous self-harm, running away from home and low mood/isolation. The purpose of the SCR is to reflect on the professional response to Darry and the family over a 15-month period and considers what lessons can be learned to improve future practice. Family Background 1.2 Darry lives with Mother; Father left the family home 6 months into the review period. Darry is one of four siblings. Two siblings are older; the oldest, sibling 1, left home at age 18, the next sibling attended university and the youngest sibling is at secondary school. Darry has a very close extended family who support the family. The family is White British. The family were under acute financial pressure during the time under review, Mother had two jobs and worked long hours as a result of this. When father left the family home, these financial pressures were exacerbated. Background circumstances of Darry 1.3 Darry attended mainstream junior and transferred in 2011 to secondary school with no school concerns. Darry exhibited some behavioural concerns initially and mother and Darry later reported widespread bullying, but the school were not told about this at the time. The parents asked for a statutory assessment of special education needs to be undertaken but were told that the criteria had not been met and that the current school met Darry’s needs. Speech and Language support was provided to address Darry’s communication skills difficulties. A Community Paediatric Assessment was planned regarding possible Autism but Mother declined the appointment because she was not clear what this was for. 1.4 There were growing concerns about Darry behaviour and language at secondary school, and many meetings were held with the parents. A 1 All names hav e been anonymised 4 behavioural and pastoral contract was set up and support provided. Darry’s engagement in learning began to further decline and she was unhappy; in September 2014 an Education Health and Care Assessment (EHCR) was started and this led to the move at aged 15 to a school for children and young people with special educational needs. Darry was assessed as having a mild learning disability at this time. Process of the Review 1.5 This review has been undertaken using a hybrid version of a systems process and this was agreed in the frame of reference during the commissioning process. Chronologies of agency involvement with single agency reflections on practice were commissioned (see appendix 1 for a full list of agencies) and face to face and follow up telephone interviews were conducted with most of the professionals involved with the family; it was not possible to interview all as some professionals had left their posts, but these people had only brief contact with Darry and the family. Many of the core records, assessments and reports/email correspondence held by agencies were also reviewed. Several conference calls were conducted to clarify key information. The Findings of the review were drawn from an analysis of the knowledge of those professionals involved with Darry, the chronologies and records provided and information regarding best practice and research. The review team is grateful for all those who contributed to the SCR process. 1.6 This SCR was overseen by an independent reviewer (see appendix 2) and her work has been assisted by a panel of multi-agency senior safeguarding professionals (see appendix 3). The panel met three times over a 9-month period and helped with the initial analysis and development of key themes/Findings and then commented on 4 draft reports and approved the final version. 1.7 The Final report was presented to the safeguarding Child’s Board/Adult Board in March and June 2018. Family Involvement in the review 1.8 The independent reviewer met with mother, Darry and maternal aunt twice as part of the review and maternal grandmother attended the second meeting. These meetings were facilitated by the current social worker. Darry did not feel able to speak but agreed to listen to what others said. The family’s views are incorporated into the body of the 5 report. The independent reviewer is grateful for their contribution. The siblings were offered the opportunity to contribute to the review but did not feel able to. 6 2. Chronology of professional involvement over a 15-month period Emerging Concerns about Darry’ emotional wellbeing 2.1 From the beginning of Year 12 school became concerned about Darry whose behaviour began to deteriorate; there was evidence of increased anxiety, low mood, complete lack of interaction with peers and a need to be with only a few trusted adults. There were incidents of verbal abuse, leaving the class, absconding from the school site and generally being disruptive on an almost daily basis. There were meetings with the parents in October 2015 and a comprehensive school pastoral support programme was put in place. The school were particularly concerned regarding escalating incidents of self-harm. A referral to Child and Adolescent Mental Health Services (CAMHS)2 and the Community Team for people with Learning disabilities (CTLD) was suggested, but Mother refused this support. She said that Darry did not trust professionals and Mother also expressed distrust because she felt she had been asking for help for years without success. This contradiction, between mother requesting support, but refusing services and support for Darry was a theme across the review and is discussed in Finding 1. 2.2 The school completed the Education, Health and Care (EHC) plan 3 and developed an individual timetable with a few trusted adults to support Darry. There were regular school reviews, EHC4 reviews and meetings/contact with the parents, and in February 2016 as a result of the further escalation of concerns, mother agreed to a referral to Child and Adolescent Mental Health Services (CAMHS) to address Darry’s deteriorating mental health and self-harm, and a referral to the Adult Community Learning Disability Team (CLDT) for support; Darry was not known to the Children with Disability Team. School Referral for Support: February 2016 2 CAMHS stands for Child and Adolescent Mental Health Services. CAMHS are the NHS serv ices that assesses and treat young people with emotional, behavioural or mental health difficulties. There are local NHS CAMHS services around the UK, with teams made up of nurses, therapists, psychologists, support workers and social workers, as well as other professionals. 3 On 1 September 2014, the law for special educational needs (SEN) changed. The Children and Families Act (‘The Act’) introduced a more holistic approach to meeting the needs of a child or young person with SEN, with a mandate for councils to replace Statements of SEN with Education, Health and Care (EHC) plans. 4 On 1 September 2014, the law for special educational needs (SEN) changed. The Children and Families Act (‘The Act’) introduced a more holistic approach to meeting the needs of a child or young person with SEN, with a mandate for councils to replace Statements of SEN with Education, Health and Care (EHC) plans. 7 2.3 The CLDT referral was accepted, and Darry was placed on a waiting list for an assessment. This assessment would not take place for another 9 months, though other agencies were in contact with this team on a regular basis; there was general confusion, disagreement and debate about the role they might play and regular discussion about which team (adult or children’s) was responsible for providing Darry and family with an assessment and possible support. This is discussed further Finding 2. The issue of the uncertainty about which agencies, individually or collectively, could and should provide services to address the complex needs of Darry and family and how a multi-agency plan could be devised using the best of what all agencies could offer is discussed in Finding 2. 2.4 The referral to CAMHS by the school was comprehensive and focussed on Darry’s deteriorating mental state, low mood, depression, complete isolation in school, self-harm and suicidal ideation. The CAMHS Learning Disability Team started their assessment two weeks after the referral was received; this was a prompt response which demonstrated effective practice. This assessment included meeting with the school, mother and the extended family, time with Darry who felt unable to say very much and the completion by Darry and Mother of the Revised Children’s Anxiety and Depression Scale (RCADS5 ). 2.5 The assessment process was completed in May 2016 and was communicated to Darry and the family via letter; this highlighted that there were concerns about self-harm and suicidal ideation/family history of suicide, physical and emotional abuse by father and a history of unreported bullying at school. However, the assessment did not provide a formulation or holistic analysis of the possible causes of Darry’s current difficulties incorporating all the known information about the wider factors which were likely to be impacting on Darry’s wellbeing. Without these broader factors being directly linked to an understanding of any young persons’ difficulties, there is an unintended consequence that the focus of professional concern can become about the young person as the problem, potentially reinforcing feelings of low self-esteem. This is discussed further in Finding 2. Within the assessment there was no specific consideration of the concerns about 5 The Rev ised Children’s Anxiety and Depression Scale (RCADS) and the RCADS – Parent Version (RCADS-P) are 47-item questionnaires that measure the reported frequency of v arious symptoms of anxiety and low mood. They produce a total anxiety and low mood score and separate scores for each of the follow sub-scales: separation anxiety; social phobia; generalised anxiety; panic; obsessive compulsive; total anxiety; and, low mood. 8 self-harm, the possible cause, a risk assessment and a specific plan of action. It was unclear which was the agency that would lead on this issue. This is discussed in Finding 3. The CAMHS plan was to provide Darry with Dance Therapy for an exploration of feelings non-verbally and to build a therapeutic relationship over time; mother and the family were also offered regular support. This plan was regularly reviewed by the CAMHS team. 2.6 The Dance therapy started and would provide regular and predictable weekly support for Darry over the next six months. The CAMHS team met with mother, Darry and Maternal Grandmother (MGM) in June 2016 and they provided the team with more details about the physical and emotional abuse experienced by Darry at the hands of father in the past. Mother also reported being domestically abused. CAMHS professionals were appropriately concerned about Darry and the other sibling’s safety and they made a verbal referral to Children’s Social Care(CSC). This was in line with both QQQQQ Think Family approach and the Children’s safeguarding procedures. The CAMHS professional was informed by CSC that they needed to seek consent from Mother to discuss the referral6; this was in line with current procedures but it would have been expected that advice would have been given about what the next steps should be if consent was not given, such as convening an early help meeting and process or discussing whether the concerns were so serious that consent could be dispensed with. The issue of differences of professional opinion regarding the nature of concerns for a child or young person and ensuring that this does not lead to no multi-agency response is discussed in Finding 2. Mother said she did not wish to give consent because she was worried about the impact this might have on the family. The available information about significant physical abuse by father suggested that the threshold for a safeguarding response had been met and there should have been a strategy meeting/discussion. The lack of a written referral or written record of the conversation held meant that it is not clear what information was shared between the two agencies. The issue of the importance of providing written referrals, which are clear about concerns regarding likely significant harm to a child/young person is addressed in Finding 4. 6 The parents' permission should be sought before discussing a referral about them with other agencies unless permission-seeking may itself place a child at risk of significant harm. Where a professional decides not to seek parental permission before making a referral to Children's social care, the decision must be recorded in the child's file with reasons, dated and signed and confirmed in the referral to Children's social care. http://www.proceduresonline.com/swcpp/QQQQQ 9 2.7 CAMHS appropriately sought advice from the named nurse for safeguarding about next steps and it was suggested that a CAADA/DASH7 risk assessment be completed with mother to assess current risks. Mother initially refused, but the CAMHS professional persevered with engaging mother CAADA/DASH risk assessment was completed and the conclusion was that there were low level risks for mother and she was appropriately signposted to support services. The issue of the potential impact of domestic abuse on Darry and the siblings was not explicitly addressed by any agency. The issue of the importance of ensuring that the impact of domestic abuse on children and young people is considered as part of a wider analysis of needs is discussed in Finding 2. 2.8 At the beginning of September 2016 CAMHS met with mother and Darry for the regular review of progress of the CAMHS plan. Mother reported a difficult summer; father had left home and had been aggressive and violent, Paternal Grandmother (PGM) had died and the family dog (who Darry was very close to) had died. The Dance therapy sessions were discussed and it was agreed that the sessions would continue with the aim of building a therapeutic relationship and through this to work for Darry to begin trusting others and talking about feelings. This was an appropriate plan of action for individual work for Darry who continued not to feel able to talk to any professionals. Escalation of concerns about Darry 2.9 In the middle of September 2016, the school reported to CAMHS an escalation in Darry’s self-harming behaviour. The school were concerned about Mother’s negative attitude to the self-harm which indicated high levels of stress for the family and a lack of understanding or empathy for the distress that Darry was exhibiting; see Finding 4 regarding a discussion of the importance of enabling parents or family figures to be supportive and understanding in the context of self-harm. CAMHS advised ensuring that Darry did not have access to sharp objects and to contact children’ social care if the school remained concerned. There was insufficient discussion between the agencies of what needed to be done to address the escalating self-harm, whether a multi-agency meeting was required or who should take the lead role. This is also discussed in Finding 3. 10 2.10 The school contacted children’s social care (CSC) who said they could not accept a referral without consent being sought from mother. Given the concerns shared this advice was consistent with the existing safeguarding thresholds; it would have been expected that advice would have been provided, about other steps to take, although this happened the next day. School continued to be worried and they contacted CSC again the next day and were advised to convene a Team around the Child meeting (TAC). The school felt this was a positive opportunity to bring all involved professionals together and it was organised for a week later and attended by school staff, and a CAMHS team member. The concerns about Darry self-harming, continuing to express ideas about wanting to die and mother’s negative and unempathetic attitude were discussed; there was concern that the family were not coping. 2.11 Mother joined the meeting late and was described as angry, emotional and expressing that she had been asking for help for years and remained unsupported. Mother talked about family losses and suicides. She asked that the school email her rather than telephone because she could no longer cope. There was no discussion about what needed to be put in place to support the family (for the benefit of Darry) and who would provide this. There was no multi-agency plan developed, no minutes and no Lead Professional nominated. Each agency continued with their own work and individual plans. The importance of clear early help processes and plan is discussed in Finding 2. 2.12 The school were tasked with contacting the Community Learning Disability team to clarify when the assessment of Darry would take place. The Community Learning Disability team said they would be undertaking an assessment but whilst Darry was still not 18 suggested a referral to the Children with Disability Team, despite being told that contact had already been made. Once again, each agency questioned who was responsible for providing a service to the family, ending in no further action and a lack of support. See Finding 2. Darry runs away overnight 2.13 At the beginning of October 2016 Darry ran away from home threatening to commit suicide. The police were informed and engaged in an extensive search in the early hours of the morning. Darry was found and taken to hospital. Darry had a number of injuries which were likely self-inflicted; bruising to the face, bumps to the head, cuts 11 to the hand and a possible sprained wrist. Darry was initially assessed by an adult psychiatrist who concluded that Darry lacked capacity, without a formal mental capacity assessment being conducted; this is discussed in Finding 5. 2.14 Darry was also assessed by the hospital on-call child and adolescent psychiatrist who concluded after advice from a more senior colleague (Consultant Child Psychiatrist) that inpatient psychiatric care would not meet Darry’s current needs and that support in the community should continue; this made good clinical sense, but the lack of a crisis/assertive outreach service meant there was a lack of appropriate community resources available8. Initially mother was unhappy with the decision to return home because she said the family felt unable to cope. The family were persuaded on the basis that there would be further discussion about increased support. They were advised verbally and by letter that Darry should stay with Maternal Grandmother (MGM), that the doors and windows should be locked, knives, scissors and tablets to be locked away and Darry to have close supervision. The family reported during this review process that they felt a responsibility to keep to this advice for the next few months. This was in fact a short-term plan and the intention was that a more robust multi-agency plan would be developed but this intention was not made explicit. This raises issues regarding whether this advice amounted to a deprivation of Darry’s liberty; this was the least restrictive option in the short term, but a review of this plan was necessary in the longer term and a consideration of the requirements of the MCA 2005; something that was never sufficiently addressed for Darry. This is discussed in Finding 5. 2.15 The school were concerned about Darry’s safety after this recent incident and sought advice from CAMHS who reassured them that the school was a safe place. School contacted the Disabled Children’s Team and provided the first written referral. This outlined recent events but could have been clearer about the concerns and the risk of significant harm; this is discussed in Finding 4. The Disabled Children’s team (DCT) agreed a social worker would attend the next school review planned for the following week to see if support was required. T 8 The CAMHS team had sought funding for a crisis/ assertiv e outreach team from the transformation funding held by the CCG but this was not granted despite this having been highlighted as a priority nationally. This meant that clinicians were having to manage the needs of children and young people with very complex needs without this community-based service. 12 2.16 The school meeting took place as planned the following week and was attended by school staff, DCT social worker and a CAMHS professional. Recent events were discussed, and it was agreed that the CAMHS review was to be expedited, there would be clarification of the progress of the Autism assessment and the educational psychologist assessment would also be brought forward. This was tagged as a school review but was actually more like a follow on to the multi-agency Team Around the Child Meeting (TAC) previously held. This lack of clarity meant that no formal TAC plan to address the needs of either Darry or the family was developed and no Lead Professional nominated. There were no TAC minutes and each agency recorded a slightly different version of the meeting and its outcomes. The importance of a robust early help response to address the needs of vulnerable adolescents is discussed in Finding 2. 2.17 The duty social worker from the disabled children’s team contacted the community learning disability team two weeks later who confirmed that they would be completing an assessment in the next month (this was 9 months after the original referral; this delay was caused by lack of resources in the team). It was agreed therefore that the disabled children’s team would not start an assessment or be involved in considering whether Darry or the family were in need of services or support because this would require Darry and the family to engage with too many new professionals. This was a considered discussion which did not take account of the purpose of the referral and the school were not informed of this decision and advised about next steps. 2.18 Darry was seen for review at CAMHS on the 18th October with Mother and MGM. It was agreed that the autism assessment would be started. Darry did not feel able to speak. It was suggested that anti-depressants might help Darry, but mother was not happy with this, reporting a history of family concerns about their use. It was agreed that the current approach to building a therapeutic relationship with Darry, using the non-verbal approach of dance therapy would continue and the use of medication would be discussed in the future if necessary. 2.19 A summary of this meeting was sent to the family and the community learning disability team; this noted that the current problems for Darry were mild to moderate learning disabilities, low mood and self-harm and possible communication difficulties. The wider concerns regarding school and home were not incorporated into a more holistic analysis. 13 Darry taken to hospital 2.20 At the beginning of November, after half term, school had considerable concerns about Darry, particularly self-harming and running away from school. On one occasion Darry would not return to the school and the maternal Grandparents came to collect Darry. Darry was observed to be expressing anger and aggression and refused to return to school or listen to the grandparents or school staff. Eventually the police were called and they were able to help get Darry into the grandparent’s car and they escorted the family home. 2.21 The police made a referral to children’s social care team and shared information with CAMHS because they were so concerned. The police concerns were passed to the disabled children’s team who contacted school and information was shared; once again it was proposed that contact be made with the adult community learning disability team. This team said they were planning an assessment but because Darry was not yet 18 it would be more appropriate for the disabled children’s team to be involved; contradicting the advice provided a week earlier. Once again, the debate about which team was responsible for the care of a vulnerable adolescent meant no action was taken. This was the fifth referral (verbal and written) that the children’s social care had received regarding Darry and should have prompted a discussion about what would be an appropriate response. This lack of response did not fulfil the ambitions of the QQQQQ Think Family Approach with the emphasis on there should be no ‘wrong door’ to services9. 2.22 Aunt contacted the CAMHS team for help and support after this incident. It was agreed that medication (risperidone10 and diazepam11 PRN12) would be prescribed for Darry. This medication was reviewed three weeks later when Darry was seen in hospital. There should have been a formal Mental Capacity Assessment completed for Darry at this time to consider whether she had the capacity to consent to the prescription of the medication or, if she lacked capacity, whether it 9 file:///C:/QQQQ 10 Risperidone is antipsychotic medication. These medicines work on the balance of chemical substances in the brain. It is prescribed to reliev e the symptoms of schizophrenia, autism, learning disability or a similar mental health problem/psychosis. It is also giv en to treat aggressiv e behaviour problems in some people where these could become a danger to self or to others. 11 This drug is used in the short term to treat sev ere anxiety, it relaxes patients – mentally as well as physically – and prev ents anxiety. 12 Abbrev iation for pro re nata, a Latin phrase meaning "as needed." The administration times are determined by the patient's needs. 14 was in her best interests for this medication to be prescribed. This is discussed in Finding 5. 2.23 School were concerned about whether Darry could be in school safely and they organised a meeting. This was attended by CAMHS staff, Special Educational Needs service (SEN) representative, school staff and Mother and MGM. The meeting summarised the recent history of Darry’s deteriorating mental state and mother’s views regarding long term bullying, family losses and domestic abuse. More information was provided about the previous level of violence at home. There was still no multi-agency plan or a lead professional identified. Darry returned to school with the agreement that there would be further discussion about what setting Darry would attend in the future and school would progress this. Darry taken to hospital 2.24 On the morning of the 23rd November 2016 Mother contacted CAMHS to report that Darry had run away again and expressed suicidal thoughts. Mother was advised to call the police who found Darry in a distressed state with self-harm cuts to the hand. Darry refused to speak and would not go with the police. The police detained Darry under Section 136 of the Mental Health Act 13 and took Darry to hospital. Darry was assessed under the Mental Health Act by a child and adult Psychiatrist and a mental health social worker (AHMP14). Darry refused to speak and stayed curled up in a ball in the corridor of the Place of safety15. Darry was assessed as lacking capacity and it was agreed that Darry would be re-assessed the next day with mother present to see if this would help Darry feel more comfortable and able to talk. The mental health social worker spoke to mother on the phone who was described as low in mood and reported that the family could not cope 13 Section 136 is part of the 1983 Mental Health Act. The police can use Section 136 when they think an individual has a mental illness and needs care or control. They will take the individual to a place of safety which could someone’s home, a friend’s or relative’s home, a hospital or a police station. The individual will have a mental health assessment whilst on this section and can be kept on this section for up to 24 hours. This can be extended for 12 hours. 14 Approved Mental Health Professional (AMHP): an AMHP is a mental health professional who is trained to use the Mental Health Act. This can be a psychologist, nurse, social worker or occupational therapist. They be involved in bringing you to hospital under a section of the Mental Health Act. 15 The place of safety is a specialist four bedded unit designed specifically for people in extreme mental distress who are detained for their own safety and the safety of others under section 136 of the mental health act. 15 with Darry at home, but she was unsure of the best option available. She agreed to come to the meeting the next day. 2.25 Mother arrived for the meeting/assessment the next day, without knowing that it had been cancelled. There was confusion about next steps and the ward staff expressed concern about the lack of a plan given that it was Friday lunchtime. The hospital social worker did a lot of work to develop a short-term plan. She contacted children’s services duty team, the children with disability team and the adult community learning disability team. All said that they could not see what role they might play and the lack of a local crisis/assertive outreach team meant that it was agreed that support would be provided by the Intensive Support Team (IST) from the adult mental health services team, despite this not being within their remit. This was good practice to meet Darry and the family’s current needs. 2.26 Professionals from the IST visited the next day. Darry refused to speak but agreed to sit in the kitchen and listen whilst mother and maternal aunt shared the recent family history and that Darry had been physically and emotionally abused by father. The subsequent written record has a question mark next to a query about whether Darry had been sexually abused, but it is not clear whether this was discussed with the family or was a professional hypothesis of the team. It has not been possible to establish this. The intensive support team had no further contact with Darry or the family. The provided verbal feedback to the CAMHS team about their involvement, but it is unclear whether the issue of possible sexual abused was discussed. The IST sent over all the records of all the hospital’s recent involvement with Darry rather than a summary of their work. This full set of records provided minimal information about the query of sexual abuse (the records just say sexual abuse?). The IST did not take any action to address concerns about sexual abuse, and it is unclear whether this concern was understood by other agencies. It would have been expected that action would have been taken to explore this serious concern further. 2.27 The plan was for support to continue in the community. Darry was seen for a dance therapy appointment and was described as slightly chattier, talking about school and feeling worried about a potential new educational placement. The family were seen by the CAMHS team at home but the current support was not reviewed in response to this further crisis. The community learning disability team undertook their assessment at the end of November (9 months after the original 16 referral) and further contact was planned for early January 2017. This assessment took place in isolation from all the other work. 2.28 School contacted CAMHS in the second week of December 2016 at the end of term as they remained significantly concerned about Darry. CAMHS confirmed that they were continuing their plan of support. 2.29 Immediately after Christmas Darry ran away from home again. Darry was found by the police in a distressed state and unwilling to speak and they brought Darry home. The police liaised with the hospital where Darry had recently been seen and the police reported that Darry was refusing to take medication. The hospital provided information about CAMHS involvement and the CAMHS team offered an appointment for the next day. Darry was brought to the appointment by mother, maternal grandmother and maternal aunt. During the interview Darry ran off and engaged in a serious self-injurious act/suicide attempt which Darry survived, but now has life changing physical injuries. 2.30 Darry was in hospital for some time. Members of The CAMHS team visited Darry in hospital, provided support and advocated for Darry with other professionals. Darry was assessed by the adult social care learning Disability Team and a full package of support put in place. Darry has now returned home with support from the family, hospital staff and the adult social worker. Independent advocacy has been put in place for Darry. 17 3. The Findings 3.1 The aim of any serious case review is to review the circumstances of one young person (Darry) and their family to explore the professional response to their needs and circumstances and to use this information as a ‘window on the system’; to uncover more general strengths and weaknesses in the safeguarding system. The aim is to establish learning or findings which can contribute to improving practice in the future. 3.2 At the heart of Darry’s story is a question about the most appropriate way of addressing, assessing and meeting the needs of young people who have experienced abuse, witnessed domestic violence who have deteriorating mental health, learning disabilities and for whom self-harm is a means of communication. The Findings that follow largely focus on these big issues. The Findings 1. Professionals need to evaluate the most appropriate action to take to address parents/carers reluctance to accept services designed to improve the circumstances of children and young people 2. Young people with poor or deteriorating mental health require a holistic multi-agency response which takes account of all the factors that might have caused their difficulties, rather than a focus on the individual young person as the problem. 3. Self-harm is a serious issue which needs robust multi-professional action, management and clarity about who should be the Lead agency. 4. Referrals to Children’s Social Care (CSC) need to make clear the concerns to enable a decision to be made on the best available information. CSC need to provide feedback when concerns are not clear to help the multi-agency network improve. Where it is agreed that referrals do not meet the threshold for CSC services there should be a discussion about alternative courses of action such as an early help response to ensure that children and young people’s needs are met. 5. There is Professional confusion about the Mental Capacity Act (MCA) as it relates to 16-17 year, particularly in the context of parental decision making and professional advocacy. 18 Finding 1: Professionals need to evaluate the most appropriate action to take to address parents/carers reluctance to accept services designed to improve the circumstances of children and young people 3.3 This finding is about the discrepancy noted in this review that mother and family members often talked about feeling unsupported by professionals, and at the same time often refused to engage with services and support offered, both for Darry and the other siblings. This meant that services designed to improve Darry’s circumstances or ensure safety and wellbeing were not always implemented. This issue was not sufficiently discussed, assessed or analysed by professionals; there was a lack of clarity about why this discrepancy occurred and what was the best approach to address it. 3.4 It is not unusual for adults/family members to be reluctant or resistant to engage with specialist services. This has been a key theme of serious case reviews for the last 20 years and there have been a number of national research reviewsi commissioned by policy makers and the Children’s Commissionerii to try and make sense of this and consider how this can be addressed. What emerges is that a reluctance or resistance to engage with services is complex and requires careful analysis to ensure that children, young people and their family’s needs for support and safeguarding are met. 3.5 Poor engagement with services can be caused by parents own needs such as learning disabilities, poor mental health, previous negative experiences of services and lack of understanding of what is being offered. It can also be caused by a poor professional response, which lacks empathy, poor clarity of role and responsibility and a lack of acknowledgement of power dynamics. Poor engagement can also be an important indicator of child and adolescent neglect. 3.6 Mother did share that she did not always trust professionals and worried about the impact of some services on the family. During discussions with her and the family during the serious case review process it emerged that mother felt that all the professionals that she had contact with were helpful and supportive but that she did not always understand professional language or what some services were or how they might help Darry or the family. 3.7 It is important that professionals work respectfully and in partnership with families, seek to understand resistance or reluctance and address concerns. They need to reflect whether they have been clear what services are, check that they are using appropriate language and 19 ensuring that adults and children understand the support being offered, or concerns being raised. 3.8 It is also important that professionals consider what lack of engagement might mean for the well-being and safety of children and young people. Professionals must feel equipped to be able to challenge adult family members about creating barriers for their children and young people to access appropriate services to children and young people. Finding 2: Young people with poor or deteriorating mental health require a coordinated multi-agency holistic response which takes account of all the factors that might have caused their difficulties, rather than a focus on the individual young person as the problem. 3.9 This Finding looks at the extent to which Darry’s deteriorating mental health was understood and addressed with a holistic and coordinated multi-agency approach. 3.10 Good mental health is the foundation of healthy development in the long term for children and adolescents. Mental health problems, whether these are subject of a formal diagnosis or not, have a significantly adverse impact on children and young peoples’ outcomesiii. 3.11 In order to address mental health difficulties in children and adolescents it is important to try and understand what causes those difficulties. These will vary for each individual, but researchiv suggest that the risk of developing a mental health problem is strongly influenced by social disadvantage, adverse childhood experiences such as abuse or neglect, severe bullying, experiencing and witnessing domestic abuse as well as individual factors such as learning disabilities or autism spectrum disorders. 3.12 This multiplicity of causal factors requires a holistic or ecological approach where risk factors at the societal level, community level, family and individual level are considered and the negative interaction of these factors and the cumulative impact of multiple disadvantage over time is understood. Good holistic assessment lies at the heart of this, alongside a clear formulationv, a written understanding of causal factors which takes account of all these variables. 3.13 If the wider context or trauma and abuse in which poor mental health develops for young people is not explicitly assessed and does not become part of a holistic formulation leading to a plan of action and 20 understanding, then the focus can become on “what is wrong with you” as opposed to “what has happened to you” and moving towards “how are we going to make things better for you”. This individual problem focussed approach is inevitably self-reinforcing. Young people can feel responsible for the abuse and harm they have experienced and this can contribute to feelings of low worth and self-esteem; if the assessment and intervention response focusses only on there being something wrong with the individual, rather than the abuse they have experienced this can exacerbate mental health difficulties. Young people’s self-esteem and depression can deepen. 3.14 The multiplicity of causal factors impacting on a young person’s mental health also requires a multi-agency response. Although there were a number of agencies involved with Darry and the family who communicated with each other, a pattern emerged over time of silo working. Each agency undertook its own assessment of Darry, the school, CAMHS, and on two occasions the hospital. These all considered Darry and the family, but these different assessment processes happened in isolation from each other, the assessments were not shared or asked for by other agencies. These assessments led to individual agency plans but at no point was a multi-agency plan developed. This was in part caused by the lack of clarity about an early help response. The school were advised to convene a Team around the Child meeting when they made a referral to children’s social care. This happened and was attended by mother and all agencies involved at that time with Darry. Key issues and future plans were discussed, but no lead professional was agreed and no holistic multi-agency plan formulated. The lack of a Lead Professional or agency also meant the family were often unclear who to contact when there was a crisis and they often had contact with a number of different professionals. There were several follow-on meetings, which were called school reviews, but were actually follow on team around the child meetings. 3.15 This lack of clarity was further exacerbated by those agencies involved with Darry seeking additional help and support from children’s social care and adult services as Darry’s mental health deteriorated. CAMHS made a safeguarding referral and were asked to seek consent, which was not agreed by mother. The school made three referrals to children’s social care and the hospital and police made one referral each. These often led to a link with the children with disability team, who would then ask the adult community learning disability to expedite 21 their involvement. Other agencies also tried to involve the adult community learning disability team. These discussions often focussed on age, or threshold criteria, but none focussed on the needs of Darry or the family. Far from fulfilling the first principle of the QQQQQ Think Family approach and guidance “There should be no ‘wrong door’ t o services”16 the constant discussion between agencies suggested there was no “right door” for Darry and the family. 3.16 There appears to have been a number of factors at play here. Agencies working in silos, carrying out their own assessments and constructing their own plans, without these being shared/coordinated or being asked for by others; confusion about an early help response in the context of a young person’s deteriorating mental health, agencies seeking the involvement of children and adult services, perhaps believing that this was the way that a coordinated approach could be achieved and children and adult services focussing on age eligibility as a way of limiting services rather than Thinking Family and thinking what was the “right door” for Darry and the family. This left Darry and the family without a coordinated and holistic multi-agency plan which addressed the many causal factors. This lack of a holistic assessment and plan meant that the issues of domestic abuse and its impact on Darry and the Sibling was not addressed nor the historic abuse Darry and the siblings were subjected to by father. Finding 3: Self-harm is a serious issue which needs robust multi-professional action, management and clarity about who should be the Lead agency 3.17 There were considerable concerns about Darry self-harming over the period of this serious case review. This Finding looks at the professional response to self-harm and the of the need for a specific response to address this very serious issue. Over the period under review there was a lack of clarity regarding who should take the lead role in assessing and managing Darry’s self-harming behaviour, who should undertake a risk assessment, put an overarching risk plan in place and assess and treat causal factors. This confusion meant that the self-harm was not explicitly addressed. 3.18 Clarity regarding the multi-agency response to self-harm locally is essential because of the serious nature of the issue. One in twelve young people self-harmv i and there is a 50 – to 100 times greater likelihood that a young person who self-harms will attempt suicidev ii. Self-harm is defined as any behaviour that causes harm or injury to someway as a way to deal with difficult emotions caused by something 16 file:///C:/Users/QQQQQ 22 that is currently happening to the young person or has happened in the past. Self-harm can start as a way to relieve the build-up of pressure from distressing thoughts and feelings. This might give temporary relief from the emotional pain the person is feeling; however, this relief is only temporary because the underlying reasons still remain. Soon after young people might experience feelings of guilt and shame, which can continue the cycle. For this reason, a sensitive and non-stigmatising response to self-harm is required from family members and professionals. 3.19 It is essential that the underlying causes of self harm are addressed to create change for the young person. Self-harm in young people is largely caused by a range of issues such as physical, emotional or sexual abuse and neglect, domestic abuse, bereavement, significant bullying and is often accompanied by depression, anxiety and unresolved angerv iii. There is considerable guidance regarding the management of self-harm and advice about possible interventions. It is essential that a psycho-social assessment of needs is carried out ix and a careful risk assessment focused specifically on the self-harmx. This should lead to an integrated care and risk management plan with a joined-up multi-disciplinary approach. 3.20 This integrated approach did not happen for Darry. There was no risk assessment focussed on the self-harm, there was no multi-disciplinary care plan and no Lead agency or professional. All these were essential. Meetings were organised, but these did not focus on what needed to be in place to address Darry’s self-harming behaviour. This was despite reassurance to the family that support would be provided in the community when Darry returned after being in hospital. 3.21 There were concerns that mother and family members were very negative and dismissive about Darry’s self-harm behaviour indicating that they saw it as possibly attention seeking and linked to personal difficulties. The connections to the experience of abuse and trauma were not made for them or for Darry and they were not signposted to some of the written resources available or helplines. 3.22 The lack of a risk and care plan meant that when the police found Darry wandering in the community they were not clear what their response should be to Darry. 3.23 Children’s Social Care were made aware of these issues through referrals from the school, the police and the hospital but did not see that these concerns alongside allegations of abuse might indicate a 23 need for an assessment, despite the Safeguarding Children Board Procedures Manual highlighting that this should be considered. The child safeguarding procedures say that “any child or young person, who self -harms or expresses t houghts about this or about suicide, must be t aken seriously and appropriate help and int ervention should be offered at the earliest point 17. 3.24 The periods of hospitalisation and link back to the community were an opportunity to think about what was in place and whether this was helpful to Darry. This review did not happen clearly enough, and the links between crisis care and support in the community was insufficient, leaving the family and Darry feeling they were in constant crisis. The care and risk plan could have helped with this. 3.25 The NICE Guidelines on the management of self-harm in young people proposes that Tier 3 Mental health service should generally be responsible for the needs and risk assessments, overseeing the longer-term care plan and should fulfil the Lead Professionals role for the coordination of the required mulita-agency services18. Locally there is a need for clarity about the multi-agency response to self-harm who should lead this work and how it will be resourced. Finding 4: Referrals to Children’s Social Care (CSC) need to make clear the concerns and enable a decision to be made on the best available information. CSC need to provide feedback when concerns are not clear to help the multi-agency network improve and to ensure that children and young people are safeguarded It is important not to conflate information sharing with communication. Communication is t he process by which information is t ransferred from one person t o anot her and is underst ood by bot h parties (Reder and Duncan, 2003xi;) 3.26 Serious case reviews have highlighted the importance of effective communication between agenciesxii to ensure that children and young people’s needs and well-being are assured. This is particularly important when agencies are making a referral to children’s social care about either a child or young person being in need or at risk of harm. Researchxiii suggest that there can be problems in the interface between those making a referral and those receiving a referral. 17 http://www.proceduresonline.com/QQQQQ 18 Mental health services (including community mental health teams and liaison psychiatry teams) should generally be responsible for the routine assessment and the longer-term treatment and management of self-harm. In children and young people this should be the responsibility of tier 2 and 3 CAMHS . https://www.nicQQQQQ 24 3.27 CAMHS were appropriately concerned about information that Darry was being physically and emotionally abused by father and decided to contact children’s social care. They did not discuss this with mother to make clear why they were concerned and why a referral to Children’s Social Care might help. Telephone contact was made and the absence of a written referral makes it hard to be clear what information was actually shared. The advice given was that consent needed to be sought and when this was done mother refused for the referral to be made. This required more discussion and gentle challenge to mother about the wellbeing of Darry and the other siblings. If this challenge had been unsuccessful the referral could still have been made if the belief was that the abuse had gone unaddressed. Given the level of concern about current physical abuse, mother described father dragging Darry across the floor by the hair, this referral should have led to a strategy discussion. It appears that the concern regarding possible significant harm got lost in the interface between the referrer and the receiver of the referral. This should have led to more challenge to children’s social care in the context of their stated and agreed multi-agency thresholds. 3.28 The school also made a written referral to children’s Social Care about their concerns for Darry. This was prompted by concerns regarding mother’s very negative and punitive attitude towards Darry’s self-harming. They were right to be concerned about the impact on Darry. This primary concern got lost in the detail of the referral. School had not sought consent because they were concerned about mother’s attitude, but they were asked to do so. At this stage mother had disengaged from communicating with the school because she reported feeling overwhelmed and unsupported. This all needed untangling to establish whether the reasons for mother’s reluctance and how this could be addressed. 3.29 There should have been a discussion between the agencies about what next steps would be for Darry and the family if a referral was not accepted; this happened once and was helpful. The principles of the Think Family approach suggest that it is all agencies responsibility to think carefully about what services would help. 3.30 Good quality written referrals need to make clear the likelihood or reality of the harm being experienced by the child or young person giving a succinct, but clear summary and analysis making use of the QQQQQ Threshold Guidance and the descriptors of harm and abuse 25 contained in Working Together 2015. Information should be provided about the reason for the referral, why the child or young person is at risk or in need, what action has already been taken and why this has not addressed the concerns. It is important that an overall professional analysis and judgement of the concerns is provided to enable an appropriate decision to be made. This means moving beyond the provision of facts but making sense of the information in the context of what the agency knows about the child and what the current concerns mean for their well-being and safety. 3.31 If these concerns are not clear, there is a responsibility on children’s Social Care to provide appropriate feedback. It is then the responsibility of the referrer to appropriately question decisions that they believe do not meet the needs of the child or young person and to use the escalation policy where professional discussions are unsuccessful. 3.32 This finding serves as a reminder of getting this interface right for children and young people. Finding 5: Professional understanding of the Mental Capacity Act (MCA) as it relates to 16- 17 year, particularly in the context of parental decision making and professional advocacy “The focus of t he Mental Capacity Act 2005 (MCA) is not about how t o make decisions for young people, but it is about developing a cult ure of care t hat serves t o maximise young people’s capacit y, support t heir decision making and advocat e for t hem so t heir voice is heard” 3.33 This Finding looks at the application of the principles and practice of the Mental Capacity Act 2005 for Darry who was aged 17. The Mental Capacity Act 2005 came into force in 2007 and applies to anyone in England and Wales who is aged 16 or over. The MCA is primarily about people’s rights to make decisions and choices for themselves with the assumption that they have the capacity to do so; it is also about the right to have decisions and choices made in a person best interests if they lack the mental capacity to be able to make those decisions for themselves. 3.34 For young people aged 16/17 the underpinning assumption is the same; that they will have capacity to make decisions about their care and treatment and will be provided with all possible support to do so. It is the responsibility of professionals to determine whether a young person does not have capacity to make a decision or give consent to 26 treatment/interventions and to make an explicit assessment of this which is recorded on each occasion it is required. In regards to young people aged 16/17 those with Parental Responsibility (PR19) can make decisions on behalf of a young person as long as they are seen to sit within the zone of parental control (ZPC20). There is no statement about which decisions come into the ZPC but the Mental Health Act 1983 code of practice21 suggest that there are three key principles for professionals to bear in mind. “Is t he decision one t hat a parent could be expect ed t o make: are t here any indications that the parent might not act in the young person’s interests and t he nature/invasiveness of what is being proposed.” 3.35 When Darry came to the attention of CAMHS and hospital services Darry refused to speak or engage with professionals. This was why non-verbal therapy was proposed. This lack of engagement meant that mother made many of the decisions about treatment choices and plans. The first decision mother made regarding services for Darry was about a possible referral to children’s services regarding allegations of physical and emotional abuse by father. Mother refused consent; this should have prompted an assessment of Darry’s mental capacity, and if Darry was found to lack capacity a consideration of whether this referral was in Darry’s best interests. The point here is that professionals needed to explicitly note whether Darry could consent to the referral, whether it fell within the zone of parental control and what could be done to advocate for Darry. 3.36 In October 2016 Darry ran away from home and was found by the police in a dishevelled state. Darry was taken to hospital and refused to speak to professionals. Mental Capacity was not explicitly assessed and the decision was made that Darry should return home. Mother and family members were advised to lock the windows and doors and supervise closely. There was no timescale put on this and this plan was never discussed with those providing support in the community. Mother and family members believed that this was a permanent decision rather than a short-term crisis plan to keep Darry safe over the 19 Parental responsibility is defined in law as “all the rights, duties, powers, responsibilities and authority, which by law a parent has in relation to the child and the administration of his/her property.” 20 The 2007 amendments to the Mental Health Act 1983 and their accompanying Code of Practice produced new guidance on the limits of parental influence over young people's ability to consent. The 2007 amendments to the 1983 Act has formalised what was previously left open to balanced professional interpretation of the implications of Parental responsibility and the Mental Capacity legislation. 21 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/435512/MHA_Code_of_Practice.PDF 27 weekend because in-patient care would not be appropriate for her needs. In the short term this plan was in legal terms the least restriction option to keep Darry safe. In the longer term this amounted to a possible Deprivation of Liberty for Darry which needed more discussion in the context of Darry’s Mental Capacity. 3.37 The Cheshire West ruling in 2014 provided the acid test for definition of Deprivation of Liberty, namely the need to ask the question “is the person under continuous supervision and control and not free to leave”; if this is so then it is a Deprivation of liberty. The Legal Framework in place at the time did not allow parents to deprive 16/17-year olds of their liberty through the zone of parental control, though this ruling has subsequently changed. In this context at the time this incident took place mother had no authority to carry out the instructions to prevent Darry from leaving the house or closely supervising Darry. (In June 2015 the High Court ruled in Re D1 that a person with parental responsibility may consent to the deprivation of their child’s liberty where it falls within the ‘zone of parental control’22). 3.38 The application of the principles and practice of the Mental Capacity Act 2005 to the world of 16/17 year olds is very important. Issues of autonomy and control over decision making and choices regarding care and intervention for this age group are essential, particularly where these young people have been abused and where by definition control and autonomy have been undermined. This Finding recognises the complexity of decision making for young people, but highlights the importance of routine Mental Capacity Assessments, an informed approach to what comes within the zone of parental control and when advocacy or a best interests meeting/discussion is required. 22 https://www.rlb-law.com/briefings/healthcare/the-zone-of-parental-control-deprivation-of-liberty/ 28 Appendix 1: Chronologies were sought from and received from: Schools attended by Darry QQQQQ Council Children’s services QQQQQ Council Adult Services QQQQQ Health Trust QQQQQ Police SEND QQQQQ Community Partnership GP QQQQQ Partnership NHS Trust 29 Appendix 2: About the Independent Reviewer and overview author: QQQQQ, is accredited in systems learning and the SCIE “Learning Together” model and is an experienced independent investigator and safeguarding lead who has undertaken many Serious Case Reviews nationally over the last XXXXX years. QQQQQ has a professional background in social work, training and policy development. XXX has never worked for any agency in QQQQQ and is completely independent. 30 Appendix 3: Review Panel Organisation Title Independent Author QQQQQ Local Safeguarding Children’s Board Independent Chair QQQQQ Assistant Director, Support and Safeguarding Children QQQQQ Council Service Leader, Strategic Safeguarding and Quality Assurance QQQQQ Council Prevention and Re-engagement Service Leader and Virtual School Head teacher QQQQQ Council Safeguarding in Education Training Officer QQQQQ Council Safeguarding Adults Manager QQQQQ Designated Nurse for QQQQQ QQQQQ Health Area Trust Designated Nurse QQQQQ Police Chief Inspector 31 References: i Fauth, R. et al (2010) Effective practice to protect children living in 'highly resistant' families: knowledge review 1. C4EO ii QQQQQ iii DOH (2015) Future in mind: promoting, protecting and improving our children and young people’s mental health and wellbeing file:///C:/Users/richa/Documents/QQQQQMental_Health.pdf iv Professor Dame Sally C Davies Chief Medical Officer annual report 2012: children and young people’s health; Chapter 10 Mental health problems in children and young people; Murphy and Peter Fonagy https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/252660/33571_2901304_CMO_Chapter_10.pdf vMacneil et al (2012) Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice Craig A BMC Medicine 2012, 10:111 file:///C:/Users/richa/Documents/QQQQQpdf v i Young Minds: Self Harm Your guide to self-harm and getting the help you needhttps://youngminds.org.uk/media/1519/youngminds-self-harm.pdf v ii Royal College of Psychiatry (2010) Self-harm, suicide and risk: a summary: https://www.rcpsych.ac.uk/pdf/PS03-2010x.pdf v iii https://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/self-harm.aspx ix https://www.nice.org.uk/guidance/CG133/chapter/1-Guidance#psychosocial-assessment-in-community-mental-health-services-and-other-specialist-mental-health x https://www.nice.org.uk/guidance/CG133/chapter/1-Guidance#psychosocial-assessment-in-community-mental-health-services-and-other-specialist-mental-health xi Reder, P and Duncan, S (2003) Understanding communication in child protection networks. Child Abuse Review. Volume12, Issue2 xii Sidebotham et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014; Department for Education https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/53382 6/Triennial_Analysis_of_SCRs_2011-2014___Pathways_to_harm_and_protection.pdf xiii Broadhurst, K et al (2010) Ten pitfalls and how to avoid them: What research tells us. NSPCC https://www.nspcc.org.uk/globalassets/documents/research-reports/10-pitfalls-initial-assessments-report.pdf |
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